H.R. 3200/Division B/Title III

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America's Affordable Health Choices Act of 2009
Division B - Medicare and Medicaid Improvements
Title III - Promoting Primary Care, Mental Health Services, and Coordinated Care

==TITLE III — PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND COORDINATED CARE==

Sec. 1301. Accountable Care Organization Pilot Program.[edit]

Title XVIII of the Social Security Act is amended by inserting after section 1866C the following new section:
``Sec. 1866D. Accountable Care Organization Pilot Program.
``(a) In general.—The Secretary shall conduct a pilot program (in this section referred to as the ‘pilot program’) to test different payment incentive models, including (to the extent practicable) the specific payment incentive models described in subsection (c), designed to reduce the growth of expenditures and improve health outcomes in the provision of items and services under this title to applicable beneficiaries (as defined in subsection (d)) by qualifying accountable care organizations (as defined in subsection (b)(1)) in order to—
``(1) promote accountability for a patient population and coordinate items and services under parts A and B;
``(2) encourage investment in infrastructure and redesigned care processes for high quality and efficient service delivery; and
``(3) reward physician practices and other physician organizational models for the provision of high quality and efficient health care services.
``(b) Qualifying Accountable care organizations (ACOs).—
``(1) Qualifying ACO defined.—In this section:
``(A) In general.—The terms ‘qualifying accountable care organization’ and ‘qualifying ACO’ mean a group of physicians or other physician organizational model (as defined in subparagraph (D)) that—
``(i) is organized at least in part for the purpose of providing physicians’ services; and
``(ii) meets such criteria as the Secretary determines to be appropriate to participate in the pilot program, including the criteria specified in paragraph (2).
``(B) Inclusion of other providers.—Nothing in this subsection shall be construed as preventing a qualifying ACO from including a hospital or any other provider of services or supplier furnishing items or services for which payment may be made under this title that is affiliated with the ACO under an arrangement structured so that such provider or supplier participates in the pilot program and shares in any incentive payments under the pilot program.
``(C) Physician.—The term ‘physician’ includes, except as the Secretary may otherwise provide, any individual who furnishes services for which payment may be made as physicians’ services.
``(D) Other physician organizational model.—The term ‘other physician organization model’ means, with respect to a qualifying ACO any model of organization under which physicians enter into agreements with other providers for the purposes of participation in the pilot program in order to provide high quality and efficient health care services and share in any incentive payments under such program.
``(E) Other services.—Nothing in this paragraph shall be construed as preventing a qualifying ACO from furnishing items or services, for which payment may not be made under this title, for purposes of achieving performance goals under the pilot program.
``(2) Qualifying criteria.—The following are criteria described in this paragraph for an organized group of physicians to be a qualifying ACO:
``(A) The group has a legal structure that would allow the group to receive and distribute incentive payments under this section.
``(B) The group includes a sufficient number of primary care physicians for the applicable beneficiaries for whose care the group is accountable (as determined by the Secretary).
``(C) The group reports on quality measures in such form, manner, and frequency as specified by the Secretary (which may be for the group, for providers of services and suppliers, or both).
``(D) The group reports to the Secretary (in a form, manner and frequency as specified by the Secretary) such data as the Secretary determines appropriate to monitor and evaluate the pilot program.
``(E) The group provides notice to applicable beneficiaries regarding the pilot program (as determined appropriate by the Secretary).
``(F) The group contributes to a best practices network or website, that shall be maintained by the Secretary for the purpose of sharing strategies on quality improvement, care coordination, and efficiency that the groups believe are effective.
``(G) The group utilizes patient-centered processes of care, including those that emphasize patient and caregiver involvement in planning and monitoring of ongoing care management plan.
``(H) The group meets other criteria determined to be appropriate by the Secretary.
``(c) Specific payment incentive models.—The specific payment incentive models described in this subsection are the following:
``(1) Performance target model.—Under the performance target model under this paragraph (in this paragraph referred to as the ‘performance target model’):
``(A) In general.—A qualifying ACO qualifies to receive an incentive payment if expenditures for applicable beneficiaries are less than a target spending level or a target rate of growth. The incentive payment shall be made only if savings are greater than would result from normal variation in expenditures for items and services covered under parts A and B.
``(B) Computation of performance target.—
``(i) In general.—The Secretary shall establish a performance target for each qualifying ACO comprised of a base amount (described in clause (ii)) increased to the current year by an adjustment factor (described in clause (iii)). Such a target may be established on a per capita basis, as the Secretary determines to be appropriate.
``(ii) Base amount.—For purposes of clause (i), the base amount in this subparagraph is equal to the average total payments (or allowed charges) under parts A and B (and may include part D, if the Secretary determines appropriate) for applicable beneficiaries for whom the qualifying ACO furnishes items and services in a base period determined by the Secretary. Such base amount may be determined on a per capita basis.
``(iii) Adjustment factor.—For purposes of clause (i), the adjustment factor in this clause may equal an annual per capita amount that reflects changes in expenditures from the period of the base amount to the current year that would represent an appropriate performance target for applicable beneficiaries (as determined by the Secretary). Such adjustment factor may be determined as an amount or rate, may be determined on a national, regional, local, or organization-specific basis, and may be determined on a per capita basis. Such adjustment factor also may be adjusted for risk as determined appropriate by the Secretary.
``(iv) Rebasing.—Under this model the Secretary shall periodically rebase the base expenditure amount described in clause (ii).
``(C) Meeting target.—
``(i) In general.—Subject to clause (ii), a qualifying ACO that meet or exceeds annual quality and performance targets for a year shall receive an incentive payment for such year equal to a portion (as determined appropriate by the Secretary) of the amount by which payments under this title for such year relative are estimated to be below the performance target for such year, as determined by the Secretary. The Secretary may establish a cap on incentive payments for a year for a qualifying ACO.
``(ii) Limitation.—The Secretary shall limit incentive payments to each qualifying ACO under this paragraph as necessary to ensure that the aggregate expenditures with respect to applicable beneficiaries for such ACOs under this title (inclusive of incentive payments described in this subparagraph) do not exceed the amount that the Secretary estimates would be expended for such ACO for such beneficiaries if the pilot program under this section were not implemented.
``(D) Reporting and other requirements.—In carrying out such model, the Secretary may (as the Secretary determines to be appropriate) incorporate reporting requirements, incentive payments, and penalties related to the physician quality reporting initiative (PQRI), electronic prescribing, electronic health records, and other similar initiatives under section 1848, and may use alternative criteria than would otherwise apply under such section for determining whether to make such payments. The incentive payments described in this subparagraph shall not be included in the limit described in subparagraph (C)(ii) or in the performance target model described in this paragraph.
``(2) Partial capitation model.—
``(A) In general.—Subject to subparagraph (B), a partial capitation model described in this paragraph (in this paragraph referred to as a ‘partial capitation model’) is a model in which a qualifying ACO would be at financial risk for some, but not all, of the items and services covered under parts A and B, such as at risk for some or all physicians’ services or all items and services under part B. The Secretary may limit a partial capitation model to ACOs that are highly integrated systems of care and to ACOs capable of bearing risk, as determined to be appropriate by the Secretary.
``(B) No additional program expenditures.—Payments to a qualifying ACO for applicable beneficiaries for a year under the partial capitation model shall be established in a manner that does not result in spending more for such ACO for such beneficiaries than would otherwise be expended for such ACO for such beneficiaries for such year if the pilot program were not implemented, as estimated by the Secretary.
``(3) Other payment models.—
``(A) In general.—Subject to subparagraph (B), the Secretary may develop other payment models that meet the goals of this pilot program to improve quality and efficiency.
``(B) No additional program expenditures.—Subparagraph (B) of paragraph (2) shall apply to a payment model under subparagraph (A) in a similar manner as such subparagraph (B) applies to the payment model under paragraph (2).
``(d) Applicable beneficiaries.—
``(1) In general.—In this section, the term ‘applicable beneficiary’ means, with respect to a qualifying ACO, an individual who—
``(A) is enrolled under part B and entitled to benefits under part A;
``(B) is not enrolled in a Medicare Advantage plan under part C or a PACE program under section 1894; and
``(C) meets such other criteria as the Secretary determines appropriate, which may include criteria relating to frequency of contact with physicians in the ACO.
``(2) Following applicable beneficiaries.—The Secretary may monitor data on expenditures and quality of services under this title after an applicable beneficiary discontinues receiving services under this title through a qualifying ACO.
``(e) Implementation.—
``(1) Starting date.—The pilot program shall begin no later than January 1, 2012. An agreement with a qualifying ACO under the pilot program may cover a multi-year period of between 3 and 5 years.
``(2) Waiver.—The Secretary may waive such provisions of this title (including section 1877) and title XI in the manner the Secretary determines necessary in order implement the pilot program.
``(3) Performance results reports.—The Secretary shall report performance results to qualifying ACOs under the pilot program at least annually.
``(4) Limitations on review.—There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of—
``(A) the elements, parameters, scope, and duration of the pilot program;
``(B) the selection of qualifying ACOs for the pilot program;
``(C) the establishment of targets, measurement of performance, determinations with respect to whether savings have been achieved and the amount of savings;
``(D) determinations regarding whether, to whom, and in what amounts incentive payments are paid; and
``(E) decisions about the extension of the program under subsection (g), expansion of the program under subsection (h) or extensions under subsection (i).
``(5) Administration.—Chapter 35 of title 44, United States Code shall not apply to this section.
``(f) Evaluation; monitoring.—
``(1) In general.—The Secretary shall evaluate the payment incentive model for each qualifying ACO under the pilot program to assess impacts on beneficiaries, providers of services, suppliers and the program under this title. The Secretary shall make such evaluation publicly available within 60 days of the date of completion of such report.
``(2) Monitoring.—The Inspector General of the Department of Health and Human Services shall provide for monitoring of the operation of ACOs under the pilot program with regard to violations of section 1877 (popularly known as the ‘Stark law’).
``(g) Extension of pilot agreement with successful organizations.—
``(1) Reports to congress.—Not later than 2 years after the date the first agreement is entered into under this section, and biennially thereafter for six years, the Secretary shall submit to Congress and make publicly available a report on the use of authorities under the pilot program. Each report shall address the impact of the use of those authorities on expenditures, access, and quality under this title.
``(2) Extension.—Subject to the report provided under paragraph (1), with respect to a qualifying ACO, the Secretary may extend the duration of the agreement for such ACO under the pilot program as the Secretary determines appropriate if—
``(A) the ACO receives incentive payments with respect to any of the first 4 years of the pilot agreement and is consistently meeting quality standards; or
``(B) the ACO is consistently exceeding quality standards and is not increasing spending under the program.
``(3) Termination.—The Secretary may terminate an agreement with a qualifying ACO under the pilot program if such ACO did not receive incentive payments or consistently failed to meet quality standards in any of the first 3 years under the program.
``(h) Expansion to additional ACOs.—
``(1) Testing and refinement of payment incentive models.—Subject to the evaluation described in subsection (f), the Secretary may enter into agreements under the pilot program with additional qualifying ACOs to further test and refine payment incentive models with respect to qualifying ACOs.
``(2) Expanding use of successful models to program implementation.—
``(A) In general.—Subject to subparagraph (B), the Secretary may issue regulations to implement, on a permanent basis, 1 or more models if, and to the extent that, such models are beneficial to the program under this title, as determined by the Secretary.
``(B) Certification.—The Chief Actuary of the Centers for Medicare & Medicaid Services shall certify that 1 or more of such models described in subparagraph (A) would result in estimated spending that would be less than what spending would otherwise be estimated to be in the absence of such expansion.
``(i) Treatment of physician group practice demonstration.—
``(1) Extension.—The Secretary may enter in to an agreement with a qualifying ACO under the demonstration under section 1866A, subject to rebasing and other modifications deemed appropriate by the Secretary, until the pilot program under this section is operational.
``(2) Transition.—For purposes of extension of an agreement with a qualifying ACO under subsection (g)(2), the Secretary shall treat receipt of an incentive payment for a year by an organization under the physician group practice demonstration pursuant to section 1866A as a year for which an incentive payment is made under such subsection, as long as such practice group practice organization meets the criteria under subsection (b)(2).
``(j) Additional provisions.—
``(1) Authority for separate incentive arrangements.—The Secretary may create separate incentive arrangements (including using multiple years of data, varying thresholds, varying shared savings amounts, and varying shared savings limits) for different categories of qualifying ACOs to reflect natural variations in data availability, variation in average annual attributable expenditures, program integrity, and other matters the Secretary deems appropriate.
``(2) Encouragement of participation of smaller organizations.—In order to encourage the participation of smaller accountable care organizations under the pilot program, the Secretary may limit a qualifying ACO’s exposure to high cost patients under the program.
``(3) Involvement in private payer arrangements.—Nothing in this section shall be construed as preventing qualifying ACOs participating in the pilot program from negotiating similar contracts with private payers.
``(4) Antidiscrimination limitation.—The Secretary shall not enter into an agreement with an entity to provide health care items or services under the pilot program, or with an entity to administer the program, unless such entity guarantees that it will not deny, limit, or condition the coverage or provision of benefits under the program, for individuals eligible to be enrolled under such program, based on any health status-related factor described in section 2702(a)(1) of the Public Health Service Act.
``(5) Construction.—Nothing in this section shall be construed to compel or require an organization to use an organization-specific target growth rate for an accountable care organization under this section for purposes of section 1848.
``(6) Funding.—For purposes of administering and carrying out the pilot program, other than for payments for items and services furnished under this title and incentive payments under subsection (c)(1), in addition to funds otherwise appropriated, there are appropriated to the Secretary for the Center for Medicare & Medicaid Services Program Management Account $25,000,000 for each of fiscal years 2010 through 2014 and $20,000,000 for fiscal year 2015. Amounts appropriated under this paragraph for a fiscal year shall be available until expended.´´.


Sec. 1302. Medical Home Pilot Program.[edit]

(a) In General.—
Title XVIII of the Social Security Act is amended by inserting after section 1866D, as inserted by section 1301, the following new section:
``Sec. 1866E. Medical Home Pilot Program.
``(a) Establishment and medical home models.—
``(1) Establishment of pilot program.—The Secretary shall establish a medical home pilot program (in this section referred to as the ‘pilot program’) for the purpose of evaluating the feasibility and advisability of reimbursing qualified patient-centered medical homes for furnishing medical home services (as defined under subsection (b)(1)) to high need beneficiaries (as defined in subsection (d)(1)(C)) and to targeted high need beneficiaries (as defined in subsection (c)(1)(C)).
``(2) Scope.—Subject to subsection (g), the pilot program shall include urban, rural, and underserved areas.
``(3) Models of medical homes in the pilot program.—The pilot program shall evaluate each of the following medical home models:
``(A) Independent patient-centered medical home model.—Independent patient-centered medical home model under subsection (c).
``(B) Community-based medical home model.—Community-based medical home model under subsection (d).
``(4) Participation of nurse practitioners and physician assistants.—
``(A) Nothing in this section shall be construed as preventing a nurse practitioner from leading a patient centered medical home so long as—
``(i) all the requirements of this section are met; and
``(ii) the nurse practitioner is acting consistently with State law.
``(B) Nothing in this section shall be construed as preventing a physician assistant from participating in a patient centered medical home so long as—
``(i) all the requirements of this section are met; and
``(ii) the physician assistant is acting consistently with State law.
``(b) Definitions.—For purposes of this section:
``(1) Patient-centered medical home services.—The term ‘patient-centered medical home services’ means services that—
``(A) provide beneficiaries with direct and ongoing access to a primary care or principal care by a physician or nurse practitioner who accepts responsibility for providing first contact, continuous and comprehensive care to such beneficiary;
``(B) coordinate the care provided to a beneficiary by a team of individuals at the practice level across office, institutional and home settings led by a primary care or principal care physician or nurse practitioner, as needed and appropriate;
``(C) provide for all the patient’s health care needs or take responsibility for appropriately arranging care with other qualified providers for all stages of life;
``(D) provide continuous access to care and communication with participating beneficiaries;
``(E) provide support for patient self-management, proactive and regular patient monitoring, support for family caregivers, use patient-centered processes, and coordination with community resources;
``(F) integrate readily accessible, clinically useful information on participating patients that enables the practice to treat such patients comprehensively and systematically; and
``(G) implement evidence-based guidelines and apply such guidelines to the identified needs of beneficiaries over time and with the intensity needed by such beneficiaries.
``(2) Primary care.—The term ‘primary care’ means health care that is provided by a physician or nurse practitioner who practices in the field of family medicine, general internal medicine, geriatric medicine, or pediatric medicine.
``(3) Principal care.—The term ‘principal care’ means integrated, accessible health care that is provided by a physician who is a medical subspecialist that addresses the majority of the personal health care needs of patients with chronic conditions requiring the subspecialist’s expertise, and for whom the subspecialist assumes care management.
``(c) Independent patient-Centered medical home model.—
``(1) In general.—
``(A) Payment authority.—Under the independent patient-centered medical home model under this subsection, the Secretary shall make payments for medical home services furnished by an independent patient-centered medical home (as defined in subparagraph (B)) pursuant to paragraph (3)(B) for a targeted high need beneficiaries (as defined in subparagraph (C)).
``(B) Independent patient-centered medical home defined.—In this section, the term ‘independent patient-centered medical home’ means a physician-directed or nurse-practitioner-directed practice that is qualified under paragraph (2) as—
``(i) providing beneficiaries with patient-centered medical home services; and
``(ii) meets such other requirements as the Secretary may specify.
``(C) Targeted high need beneficiary defined.—For purposes of this subsection, the term ‘targeted high need beneficiary’ means a high need beneficiary who, based on a risk score as specified by the Secretary, is generally within the upper 50th percentile of Medicare beneficiaries.
``(D) Beneficiary election to participate.—The Secretary shall determine an appropriate method of ensuring that beneficiaries have agreed to participate in the pilot program.
``(E) Implementation.—The pilot program under this subsection shall begin no later than 6 months after the date of the enactment of this section.
``(2) Standard setting and qualification process for patient-centered medical homes.—The Secretary shall review alternative models for standard setting and qualification, and shall establish a process—
``(A) to establish standards to enable medical practices to qualify as patient-centered medical homes; and
``(B) to initially provide for the review and certification of medical practices as meeting such standards.
``(3) Payment.—
``(A) Establishment of methodology.—The Secretary shall establish a methodology for the payment for medical home services furnished by independent patient-centered medical homes. Under such methodology, the Secretary shall adjust payments to medical homes based on beneficiary risk scores to ensure that higher payments are made for higher risk beneficiaries.
``(B) Per beneficiary per month payments.—Under such payment methodology, the Secretary shall pay independent patient-centered medical homes a monthly fee for each targeted high need beneficiary who consents to receive medical home services through such medical home.
``(C) Prospective payment.—The fee under subparagraph (B) shall be paid on a prospective basis.
``(D) Amount of payment.—In determining the amount of such fee, the Secretary shall consider the following:
``(i) The clinical work and practice expenses involved in providing the medical home services provided by the independent patient-centered medical home (such as providing increased access, care coordination, population disease management, and teaching self-care skills for managing chronic illnesses) for which payment is not made under this title as of the date of the enactment of this section.
``(ii) Allow for differential payments based on capabilities of the independent patient-centered medical home.
``(iii) Use appropriate risk-adjustment in determining the amount of the per beneficiary per month payment under this paragraph in a manner that ensures that higher payments are made for higher risk beneficiaries.
``(4) Encouraging participation of variety of practices.—The pilot program under this subsection shall be designed to include the participation of physicians in practices with fewer than 10 full-time equivalent physicians, as well as physicians in larger practices, particularly in underserved and rural areas, as well as federally qualified community health centers, and rural health centers.
``(5) No duplication in pilot participation.—A physician in a group practice that participates in the accountable care organization pilot program under section 1866D shall not be eligible to participate in the pilot program under this subsection, unless the pilot program under this section has been implemented on a permanent basis under subsection (e)(3).
``(d) Community-Based medical home model.—
``(1) In general.—
``(A) Authority for payments.—Under the community-based medical home model under this subsection (in this section referred to as the ‘CBMH model’), the Secretary shall make payments for the furnishing of medical home services by a community-based medical home (as defined in subparagraph (B)) pursuant to paragraph (5)(B) for high need beneficiaries.
``(B) Community-based medical home defined.—In this section, the term ‘community-based medical home’ means a nonprofit community-based or State-based organization that is certified under paragraph (2) as meeting the following requirements:
``(i) The organization provides beneficiaries with medical home services.
``(ii) The organization provides medical home services under the supervision of and in close collaboration with the primary care or principal care physician or nurse practitioner designated by the beneficiary as his or her community-based medical home provider.
``(iii) The organization employs community health workers, including nurses or other non-physician practitioners, lay health workers, or other persons as determined appropriate by the Secretary, that assist the primary or principal care physician or nurse practitioner in chronic care management activities such as teaching self-care skills for managing chronic illnesses, transitional care services, care plan setting, medication therapy management services for patients with multiple chronic diseases, or help beneficiaries access the health care and community-based resources in their local geographic area.
``(iv) The organization meets such other requirements as the Secretary may specify.
``(C) High need beneficiary.—In this section, the term ‘high need beneficiary’ means an individual who requires regular medical monitoring, advising, or treatment.
``(2) Qualification process for community-based medical homes.—The Secretary shall establish a process—
``(A) for the initial qualification of community-based or State-based organizations as community-based medical homes; and
``(B) to provide for the review and qualification of such community-based and State-based organizations pursuant to criteria established by the Secretary.
``(3) Duration.—The pilot program for community-based medical homes under this subsection shall start no later than 2 years after the date of the enactment of this section. Each demonstration site under the pilot program shall operate for a period of up to 5 years after the initial implementation phase, without regard to the receipt of a initial implementation funding under subsection (i).
``(4) Preference.—In selecting sites for the CBMH model, the Secretary may give preference to—
``(A) applications from geographic areas that propose to coordinate health care services for chronically ill beneficiaries across a variety of health care settings, such as primary care physician practices with fewer than 10 physicians, specialty physicians, nurse practitioner practices, Federally qualified health centers, rural health clinics, and other settings;
``(B) applications that include other payors that furnish medical home services for chronically ill patients covered by such payors; and
``(C) applications from States that propose to use the medical home model to coordinate health care services for individuals enrolled under this title, individuals enrolled under title XIX, and full-benefit dual eligible individuals (as defined in section 1935(c)(6)) with chronic diseases across a variety of health care settings.
``(5) Payments.—
``(A) Establishment of methodology.—The Secretary shall establish a methodology for the payment for medical home services furnished under the CBMH model.
``(B) Per beneficiary per month payments.—Under such payment methodology, the Secretary shall make two separate monthly payments for each high need beneficiary who consents to receive medical home services through such medical home, as follows:
``(i) Payment to community-based organization.—One monthly payment to a community-based or State-based organization.
``(ii) Payment to primary or principal care practice.—One monthly payment to the primary or principal care practice for such beneficiary.
``(C) Prospective payment.—The payments under subparagraph (B) shall be paid on a prospective basis.
``(D) Amount of payment.—In determining the amount of such payment, the Secretary shall consider the following:
``(i) The clinical work and practice expenses involved in providing the medical home services provided by the community-based medical home (such as providing increased access, care coordination, care plan setting, population disease management, and teaching self-care skills for managing chronic illnesses) for which payment is not made under this title as of the date of the enactment of this section.
``(ii) Use appropriate risk-adjustment in determining the amount of the per beneficiary per month payment under this paragraph.
``(6) Initial implementation funding.—The Secretary may make available initial implementation funding to a community based or State-based organization or a State that is participating in the pilot program under this subsection. Such organization shall provide the Secretary with a detailed implementation plan that includes how such funds will be used.
``(e) Expansion of program.—
``(1) Evaluation of cost and quality.—The Secretary shall evaluate the pilot program to determine—
``(A) the extent to which medical homes result in—
``(i) improvement in the quality and coordination of health care services, particularly with regard to the care of complex patients;
``(ii) improvement in reducing health disparities;
``(iii) reductions in preventable hospitalizations;
``(iv) prevention of readmissions;
``(v) reductions in emergency room visits;
``(vi) improvement in health outcomes, including patient functional status where applicable;
``(vii) improvement in patient satisfaction;
``(viii) improved efficiency of care such as reducing duplicative diagnostic tests and laboratory tests; and
``(ix) reductions in health care expenditures; and
``(B) the feasability and advisability of reimbursing medical homes for medical home services under this title on a permanent basis.
``(2) Report.—Not later than 60 days after the date of completion of the evaluation under paragraph (1), the Secretary shall submit to Congress and make available to the public a report on the findings of the evaluation under paragraph (1).
``(3) Expansion of program.—
``(A) In general.—Subject to the results of the evaluation under paragraph (1) and subparagraph (B), the Secretary may issue regulations to implement, on a permanent basis, one or more models, if, and to the extent that such model or models, are beneficial to the program under this title, including that such implementation will improve quality of care, as determined by the Secretary.
``(B) Certification requirement.—The Secretary may not issue such regulations unless the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that the expansion of the components of the pilot program described in subparagraph (A) would result in estimated spending under this title that would be no more than the level of spending that the Secretary estimates would otherwise be spent under this title in the absence of such expansion.
``(f) Administrative provisions.—
``(1) No duplication in payments.—During any month, the Secretary may not make payments under this section under more than one model or through more than one medical home under any model for the furnishing of medical home services to an individual.
``(2) No effect on payment for evaluation and management services.—Payments made under this section are in addition to, and have no effect on the amount of, payment for evaluation and management services made under this title.
``(3) Administration.—Chapter 35 of title 44, United States Code shall not apply to this section.
``(g) Funding.—
``(1) Operational costs.—For purposes of administering and carrying out the pilot program (including the design, implementation, technical assistance for and evaluation of such program), in addition to funds otherwise available, there shall be transferred from the Federal Supplementary Medical Insurance Trust Fund under section 1841 to the Secretary for the Centers for Medicare & Medicaid Services Program Management Account $6,000,000 for each of fiscal years 2010 through 2014. Amounts appropriated under this paragraph for a fiscal year shall be available until expended.
``(2) Patient-centered medical home services.—In addition to funds otherwise available, there shall be available to the Secretary for the Centers for Medicare & Medicaid Services, from the Federal Supplementary Medical Insurance Trust Fund under section 1841—
``(A) $200,000,000 for each of fiscal years 2010 through 2014 for payments for medical home services under subsection (c)(3); and
``(B) $125,000,000 for each of fiscal years 2012 through 2016, for payments under subsection (d)(5).
``Amounts available under this paragraph for a fiscal year shall be available until expended.
``(3) Initial implementation.—In addition to funds otherwise available, there shall be available to the Secretary for the Centers for Medicare & Medicaid Services, from the Federal Supplementary Medical Insurance Trust Fund under section 1841, $2,500,000 for each of fiscal years 2010 through 2012, under subsection (d)(6). Amounts available under this paragraph for a fiscal year shall be available until expended.
``(h) Treatment of TRHCA medicare medical home demonstration funding.—
``(1) In addition to funds otherwise available for payment of medical home services under subsection (c)(3), there shall also be available the amount provided in subsection (g) of section 204 of division B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395b–1 note).
``(2) Notwithstanding section 1302(c) of the America’s Affordable Health Choices Act of 2009, in addition to funds provided in paragraph (1) and subsection (g)(2)(A), the funding for medical home services that would otherwise have been available if such section 204 medical home demonstration had been implemented (without regard to subsection (g) of such section) shall be available to the independent patient-centered medical home model described in subsection (c).´´.


(b) Effective Date.—
The amendment made by this section shall apply to services furnished on or after the date of the enactment of this Act.
(c) Conforming Repeal.—
Section 204 of division B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395b–1 note), as amended by section 133(a)(2) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275), is repealed.

Sec. 1303. Payment Incentive for Selected Primary Care Services.[edit]

(a) In General.—
Section 1833 of the Social Security Act is amended by inserting after subsection (o) the following new subsection:


``(p) Primary care payment incentives.—
``(1) In general.—In the case of primary care services (as defined in paragraph (2)) furnished on or after January 1, 2011, by a primary care practitioner (as defined in paragraph (3)) for which amounts are payable under section 1848, in addition to the amount otherwise paid under this part there shall also be paid to the practitioner (or to an employer or facility in the cases described in clause (A) of section 1842(b)(6)) (on a monthly or quarterly basis) from the Federal Supplementary Medical Insurance Trust Fund an amount equal 5 percent (or 10 percent if the practitioner predominately furnishes such services in an area that is designated (under section 332(a)(1)(A) of the Public Health Service Act) as a primary care health professional shortage area.
``(2) Primary care services defined.—In this subsection, the term ‘primary care services’—
``(A) means services which are evaluation and management services as defined in section 1848(j)(5)(A); and
``(B) includes services furnished by another health care professional that would be described in subparagraph (A) if furnished by a physician.
``(3) Primary care practitioner defined.—In this subsection, the term ‘primary care practitioner’—
``(A) means a physician or other health care practitioner (including a nurse practitioner) who—
``(i) specializes in family medicine, general internal medicine, general pediatrics, geriatrics, or obstetrics and gynecology; and
``(ii) has allowed charges for primary care services that account for at least 50 percent of the physician’s or practitioner’s total allowed charges under section 1848, as determined by the Secretary for the most recent period for which data are available; and
``(B) includes a physician assistant who is under the supervision of a practitioner described in subparagraph (A).
``(4) Limitation on review.—There shall be no administrative or judicial review under section 1869, section 1878, or otherwise, respecting—
``(A) any determination or designation under this subsection;
``(B) the identification of services as primary care services under this subsection; and
``(C) the identification of a practitioner as a primary care practitioner under this subsection.
``(5) Coordination with other payments.—
``(A) With other primary care incentives.—The provisions of this subsection shall not be taken into account in applying subsections (m) and (u) and any payment under such subsections shall not be taken into account in computing payments under this subsection.
``(B) With quality incentives.—Payments under this subsection shall not be taken into account in determining the amounts that would otherwise be paid under this part for purposes of section 1834(g)(2)(B).´´.


(b) Conforming Amendments.—
(1) Section 1833 of such Act (42 U.S.C. 1395l(m)) is amended by redesignating paragraph (4) as paragraph (5) and by inserting after paragraph (3) the following new paragraph:


``(4) The provisions of this subsection shall not be taken into account in applying subsections (m) or (u) and any payment under such subsections shall not be taken into account in computing payments under this subsection.´´.


(2) Section 1848(m)(5)(B) of such Act (42 U.S.C. 1395w–4(m)(5)(B)) is amended by inserting ``, (p),´´ after ::::::``(m)´´.
(3) Section 1848(o)(1)(B)(iv) of such Act (42 U.S.C. 1395w–4(o)(1)(B)(iv)) is amended by inserting ``primary care´´ before ``health professional shortage area´´.


Sec. 1304. Increased Reimbursement Rate for Certified Nurse-Midwives.[edit]

(a) In General.—
Section 1833(a)(1)(K) of the Social Security Act (42 U.S.C.1395l(a)(1)(K)) is amended by striking ``(but in no event´´ and all that follows through ``performed by a physician)´´.
(b) Effective Date.—
The amendment made by subsection (a) shall apply to services furnished on or after January 1, 2011.


Sec. 1305. Coverage and Waiver of Cost-Sharing for Preventive Services.[edit]

(a) Medicare Covered Preventive Services Defined.—
Section 1861 of the Social Security Act (42 U.S.C. 1395x), as amended by section 1235(a)(2), is amended by adding at the end the following new subsection:


``(iii) Medicare Covered Preventive Services
``(1) Subject to the succeeding provisions of this subsection, the term ‘Medicare covered preventive services’ means the following:
``(A) Prostate cancer screening tests (as defined in subsection (oo)).
``(B) Colorectal cancer screening tests (as defined in subsection (pp) and when applicable as described in section 1305).
``(C) Diabetes outpatient self-management training services (as defined in subsection (qq)).
``(D) Screening for glaucoma for certain individuals (as described in subsection (s)(2)(U)).
``(E) Medical nutrition therapy services for certain individuals (as described in subsection (s)(2)(V)).
``(F) An initial preventive physical examination (as defined in subsection (ww)).
``(G) Cardiovascular screening blood tests (as defined in subsection (xx)(1)).
``(H) Diabetes screening tests (as defined in subsection (yy)).
``(I) Ultrasound screening for abdominal aortic aneurysm for certain individuals (as described in described in subsection (s)(2)(AA)).
``(J) Pneumococcal and influenza vaccines and their administration (as described in subsection (s)(10)(A)) and hepatitis B vaccine and its administration for certain individuals (as described in subsection (s)(10)(B)).
``(K) Screening mammography (as defined in subsection (jj)).
``(L) Screening pap smear and screening pelvic exam (as defined in subsection (nn)).
``(M) Bone mass measurement (as defined in subsection (rr)).
``(N) Kidney disease education services (as defined in subsection (ggg)).
``(O) Additional preventive services (as defined in subsection (ddd)).
``(2) With respect to specific Medicare covered preventive services, the limitations and conditions described in the provisions referenced in paragraph (1) with respect to such services shall apply.´´.


(b) Payment and Elimination of Cost-sharing.—
(1) In General.—
(A) In General.—
Section 1833(a) of the Social Security Act (42 U.S.C. 1395l(a)) is amended by adding after and below paragraph (9) the following:


``With respect to Medicare covered preventive services, in any case in which the payment rate otherwise provided under this part is computed as a percent of less than 100 percent of an actual charge, fee schedule rate, or other rate, such percentage shall be increased to 100 percent.´´.


(B) Application to Sigmoidoscopies and Colonoscopies.—
Section 1834(d) of such Act (42 U.S.C. 1395m(d)) is amended—
(i) in paragraph (2)(C), by amending clause (ii) to read as follows:


``(ii) No coinsurance.—In the case of a beneficiary who receives services described in clause (i), there shall be no coinsurance applied.´´; and


(ii) in paragraph (3)(C), by amending clause (ii) to read as follows:


``(ii) No coinsurance.—In the case of a beneficiary who receives services described in clause (i), there shall be no coinsurance applied.´´.


(2) Elimination of Coinsurance in Outpatient Hospital Settings.—
(A) Exclusion from Opd Fee Schedule.—
Section 1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. 1395l(t)(1)(B)(iv)) is amended by striking ``screening mammography (as defined in section 1861(jj)) and diagnostic mammography´´ and inserting ``diagnostic mammograms and Medicare covered preventive services (as defined in section 1861(iii)(1))´´.
(B) Conforming Amendments.—
Section 1833(a)(2) of the Social Security Act (42 U.S.C. 1395l(a)(2)) is amended—
(i) in subparagraph (F), by striking ``and´´ after the semicolon at the end;
(ii) in subparagraph (G)(ii), by adding ``and´´ at the end; and
(iii) by adding at the end the following new subparagraph:


``(H) with respect to additional preventive services (as defined in section 1861(ddd)) furnished by an outpatient department of a hospital, the amount determined under paragraph (1)(W);´´.


(3) Waiver of Application of Deductible for All Preventive Services.—
The first sentence of section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)) is amended—
(A) in clause (1), by striking ``items and services described in section 1861(s)(10)(A)´´ and inserting ``Medicare covered preventive services (as defined in section 1861(iii))´´;
(B) by inserting ``and´´ before ``(4)´´; and
(C) by striking clauses (5) through (8).
(4) Application to Providers of Services.—
Section 1866(a)(2)(A)(ii) of such Act (42 U.S.C. 1395cc(a)(2)(A)(ii)) is amended by inserting ``other than for Medicare covered preventive services and´´ after ``for such items and services (´´.
(c) Effective Date.—
The amendments made by this section shall apply to services furnished on or after January 1, 2011.


Sec. 1306. Waiver of Deductible for Colorectal cancer Screening Tests Regardless of Coding, Subsequent Diagnosis, or Ancillary tissue Removal.[edit]

(a) In General.—
Section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)), as amended by section 1305(b)(3), is amended by adding at the end the following new sentence: ``Clause (1) of the first sentence of this subsection shall apply with respect to a colorectal cancer screening test regardless of the code that is billed for the establishment of a diagnosis as a result of the test, or for the removal of tissue or other matter or other procedure that is furnished in connection with, as a result of, and in the same clinical encounter as, the screening test.´´.
(b) Effective Date.—
The amendment made by subsection (a) shall apply to items and services furnished on or after January 1, 2011.


Sec. 1307. Excluding Clinical Social Worker Services From Coverage Under the Medicare Skilled Nursing Facility Prospective Payment System and Consolidated Payment.[edit]

(a) In General.—
Section 1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting ``clinical social worker services,´´ after ``qualified psychologist services,´´.
(b) Conforming Amendment.—
Section 1861(hh)(2) of the Social Security Act (42 U.S.C. 1395x(hh)(2)) is amended by striking ``and other than services furnished to an inpatient of a skilled nursing facility which the facility is required to provide as a requirement for participation´´.
(c) Effective Date.—
The amendments made by this section shall apply to items and services furnished on or after July 1, 2010.


Sec. 1308. Coverage of Marriage and Family Therapist Services and Mental Health Counselor Services.[edit]

(a) Coverage of Marriage and Family Therapist Services.—
(1) Coverage of Services.—
Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)), as amended by section 1235, is amended—
(A) in subparagraph (EE), by striking ``and´´ at the end;
(B) in subparagraph (FF), by adding ``and´´ at the end; and
(C) by adding at the end the following new subparagraph:


``(GG) marriage and family therapist services (as defined in subsection (jjj));´´.


(2) Definition.—
Section 1861 of the Social Security Act (42 U.S.C. 1395x), as amended by sections 1235 and 1305, is amended by adding at the end the following new subsection:


``(jjj) Marriage and Family Therapist Services
``(1) The term ‘marriage and family therapist services’ means services performed by a marriage and family therapist (as defined in paragraph (2)) for the diagnosis and treatment of mental illnesses, which the marriage and family therapist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) of the State in which such services are performed, as would otherwise be covered if furnished by a physician or as incident to a physician’s professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services.
``(2) The term ‘marriage and family therapist’ means an individual who—
``(A) possesses a master’s or doctoral degree which qualifies for licensure or certification as a marriage and family therapist pursuant to State law;
``(B) after obtaining such degree has performed at least 2 years of clinical supervised experience in marriage and family therapy; and
``(C) is licensed or certified as a marriage and family therapist in the State in which marriage and family therapist services are performed.´´.


(3) Provision for Payment Under PART B.—
Section 1832(a)(2)(B) of the Social Security Act (42 U.S.C. 1395k(a)(2)(B)) is amended by adding at the end the following new clause:


``(v) marriage and family therapist services;´´.


(4) Amount of Payment.—
(A) In General.—
Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended—
(i) by striking ``and´´ before ``(W)´´; and
(ii) by inserting before the semicolon at the end the following: ``, and (X) with respect to marriage and family therapist services under section 1861(s)(2)(GG), the amounts paid shall be 80 percent of the lesser of the actual charge for the services or 75 percent of the amount determined for payment of a psychologist under clause (L)´´.
(B) Development of criteria with respect to consultation with a health care professional.—
The Secretary of Health and Human Services shall, taking into consideration concerns for patient confidentiality, develop criteria with respect to payment for marriage and family therapist services for which payment may be made directly to the marriage and family therapist under part B of title XVIII of the Social Security Act (42 U.S.C. 1395j et seq.) under which such a therapist must agree to consult with a patient’s attending or primary care physician or nurse practitioner in accordance with such criteria.
(5) Exclusion of Marriage and Family Therapist Services From Skilled Nursing Facility Prospective Payment System.—
Section 1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)), as amended by section 1307(a), is amended by inserting ``marriage and family therapist services (as defined in subsection (jjj)(1)),´´ after ``clinical social worker services,´´.
(6) Coverage of Marriage and Family Therapist Services Provided in Rural Health Clinics and Federally Qualified Health Centers.—
Section 1861(aa)(1)(B) of the Social Security Act (42 U.S.C. 1395x(aa)(1)(B)) is amended by striking ``or by a clinical social worker (as defined in subsection (hh)(1)),´´ and inserting ``, by a clinical social worker (as defined in subsection (hh)(1)), or by a marriage and family therapist (as defined in subsection (jjj)(2)),´´.
(7) Inclusion of Marriage and Family Therapists as Practitioners for Assignment of Claims.—
Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)) is amended by adding at the end the following new clause:


``(vii) A marriage and family therapist (as defined in section 1861(jjj)(2)).´´.


(b) Coverage of Mental Health Counselor Services.—
(1) Coverage of Services.—
Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)), as previously amended, is further amended—
(A) in subparagraph (FF), by striking ``and´´ at the end;
(B) in subparagraph (GG), by inserting ``and´´ at the end; and
(C) by adding at the end the following new subparagraph:


``(HH) mental health counselor services (as defined in subsection (kkk)(1));´´.


(2) Definition.—
Section 1861 of the Social Security Act (42 U.S.C. 1395x), as previously amended, is amended by adding at the end the following new subsection:


``(kkk) Mental Health Counselor Services
``(1) The term ‘mental health counselor services’ means services performed by a mental health counselor (as defined in paragraph (2)) for the diagnosis and treatment of mental illnesses which the mental health counselor is legally authorized to perform under State law (or the State regulatory mechanism provided by the State law) of the State in which such services are performed, as would otherwise be covered if furnished by a physician or as incident to a physician’s professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services.
``(2) The term ‘mental health counselor’ means an individual who—
``(A) possesses a master’s or doctor’s degree which qualifies the individual for licensure or certification for the practice of mental health counseling in the State in which the services are performed;
``(B) after obtaining such a degree has performed at least 2 years of supervised mental health counselor practice; and
``(C) is licensed or certified as a mental health counselor or professional counselor by the State in which the services are performed.´´.


(3) Provision for Payment Under PART B.—
Section 1832(a)(2)(B) of the Social Security Act (42 U.S.C. 1395k(a)(2)(B)), as amended by subsection (a)(3), is further amended—
(A) by striking ``and´´ at the end of clause (iv);
(B) by adding ``and´´ at the end of clause (v); and
(C) by adding at the end the following new clause:


``(vi) mental health counselor services;´´.


(4) Amount of Payment.—
(A) In General.—
Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), as amended by subsection (a), is further amended—
(i) by striking ``and´´before ``(X)´´; and
(ii) by inserting before the semicolon at the end the following: ``, and (Y), with respect to mental health counselor services under section 1861(s)(2)(HH), the amounts paid shall be 80 percent of the lesser of the actual charge for the services or 75 percent of the amount determined for payment of a psychologist under clause (L)´´.
(B) Development of criteria with respect to consultation with a physician.—
The Secretary of Health and Human Services shall, taking into consideration concerns for patient confidentiality, develop criteria with respect to payment for mental health counselor services for which payment may be made directly to the mental health counselor under part B of title XVIII of the Social Security Act (42 U.S.C. 1395j et seq.) under which such a counselor must agree to consult with a patient’s attending or primary care physician in accordance with such criteria.
(5) Exclusion of Mental Health Counselor Services From Skilled Nursing Facility Prospective Payment System.—
Section 1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)), as amended by section 1307(a) and subsection (a), is amended by inserting ``mental health counselor services (as defined in section 1861(kkk)(1)),´´ after ``marriage and family therapist services (as defined in subsection (jjj)(1)),´´.
(6) Coverage of Mental Health Counselor Services Provided in Rural Health Clinics and Federally Qualified Health Centers.—
Section 1861(aa)(1)(B) of the Social Security Act (42 U.S.C. 1395x(aa)(1)(B)), as amended by subsection (a), is amended by striking ``or by a marriage and family therapist (as defined in subsection (jjj)(2)),´´ and inserting ``by a marriage and family therapist (as defined in subsection (jjj)(2)), or a mental health counselor (as defined in subsection (kkk)(2)),´´.
(7) Inclusion of Mental Health Counselors as Practitioners for Assignment of Claims.—
Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)), as amended by subsection (a)(7), is amended by adding at the end the following new clause:


``(viii) A mental health counselor (as defined in section 1861(kkk)(2)).´´.


(c) Effective Date.—
The amendments made by this section shall apply to items and services furnished on or after January 1, 2011.

Sec. 1309. Extension of Physician Fee Schedule Mental Health Add-on.[edit]

Section 138(a)(1) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275) is amended by striking ``December 31, 2009´´ and inserting ``December 31, 2011´´.

Sec. 1310. Expanding Access to Vaccines.[edit]

(a) In General.—
Paragraph (10) of section 1861(s) of the Social Security Act (42 U.S.C. 1395w(s)) is amended to read as follows:


``(10) federally recommended vaccines (as defined in subsection (lll)) and their respective administration;´´.


(b) Federally Recommended Vaccines Defined.—
Section 1861 of such Act is further amended by adding at the end the following new subsection:


``(lll) Federally Recommended Vaccines
``The term ‘federally recommended vaccine’ means an approved vaccine recommended by the Advisory Committee on Immunization Practices (an advisory committee established by the Secretary, acting through the Director of the Centers for Disease Control and Prevention).´´.


(c) Conforming Amendments.—
(1) Section 1833 of such Act (42 U.S.C. 1395l) is amended, in each of subsections (a)(1)(B), (a)(2)(G), (a)(3)(A), and (b)(1) (as amended by section 1305(b)), by striking ``1861(s)(10)(A)´´ or ``1861(s)(10)(B)´´ and inserting ``1861(s)(10)´´ each place it appears.
(2) Section 1842(o)(1)(A)(iv) of such Act (42 U.S.C. 1395u(o)(1)(A)(iv)) is amended—
(A) by striking ``subparagraph (A) or (B) of´´; and
(B) by inserting before the period the following: ``and before January 1, 2011, and influenza vaccines furnished on or after January 1, 2011´´.
(3) Section 1847A(c)(6) of such Act (42 U.S.C. 1395w–3a(c)(6)) is amended by striking subparagraph (G) and inserting the following:


``(G) Implementation.—Chapter 35 of title 44, United States Code shall not apply to manufacturer provision of information pursuant to section 1927(b)(3)(A)(iii) for purposes of implementation of this section.´´.


(4) Section 1860D–2(e)(1)(B) of such Act (42 U.S.C. 1395w–102(e)(1)(B)) is amended by striking ``such term includes a vaccine´´ and all that follows through ``its administration) and´´.
(5) Section 1861(ww)(2)(A) of such Act (42 U.S.C. 1395x(ww)(2)(A))) is amended by striking ``Pneumococcal, influenza, and hepatitis B and administration´´ and inserting ``Federally recommended vaccines (as defined in subsection (lll)) and their respective administration´´.
(6) Section 1861(iii)(1) of such Act, as added by section 1305(a), is amended by amending subparagraph (J) to read as follows:


``(J) Federally recommended vaccines (as defined in subsection (lll)) and their respective administration.´´.


(7) Section 1927(b)(3)(A)(iii) of such Act (42 U.S.C. 1396r–8(b)(3)(A)(iii)) is amended, in the matter following subclause (III), by inserting ``(A)(iv) (including influenza vaccines furnished on or after January 1, 2011),´´ after ``described in subparagraph.´´
(d) Effective Dates.—
The amendments made by—
(1) this section (other than by subsection (c)(7)) shall apply to vaccines administered on or after January 1, 2011; and
(2) by subsection (c)(7) shall apply to calendar quarters beginning on or after January 1, 2010.