Starting 2014, requires 85% medical loss ratio (MLR) for MA plans, with plans effectively required to return to CMS the portion of their revenue attributable to the difference between their MLR and 85%. After three consecutive years failing to meet the MLR requirement, plans may not enroll new beneficiaries. After five years of violation, plans will be terminated.
Browse the sections of Title III
Establishes a budget neutral VBP program for inpatient hospital services applicable to 1% of base payments in FY13 and increasing to 2% in subsequent years.
Phases down incentive payments for reporting of quality measures under the Physician Quality Reporting System (PQRS) by 2015, at which time penalties for non-reporting begin, increasing to 2% of physician payments by 2016. Authorizes physicians to submit quality data to approved Maintenance of Certification (MOC) programs, with an extra 0.5% bonus for physicians who complete an MOC practice assessment.
Makes changes to the feedback program to provide reports to individual physician regarding their resource utilization rates. Requires development of episode grouper software to aggregate clinically related claims and report to physicians on their resource use by episode.
3004 - Quality Reporting for Long-Term Care Hospitals, Inpatient Rehabilitation Hospitals, and Hospice Programs
Requires CMS to implement quality reporting programs for these providers by FY14, subjecting non-compliant providers to up to a 2% reduction in payments.
Requires qualifying cancer hospitals to report on quality measures beginning in FY14. Non-compliant providers are subject to up to a 2% reimbursement penalty.
3006 - Plans for a Value-Based Purchasing Program for Skilled Nursing Facilities and Home Health Agencies
As revised by section 10301 of the Senate Manager's Amendment, stipulates that CMS develop and submit plans to Congress by January 1, 2011, for implementation of VBP programs for SNFs, HHAs and ambulatory surgical centers (ASCs). On July 8, 2013, CMS released its CY14 hospital outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) payment system proposed rule in which it contemplates...
Requires phase-in of a physician payment modifier using a composite of quality and efficiency measures. Payment adjustments begin for some physicians on January 1, 2015, and for all doctors by January 1, 2017.
Starting in FY15, applies a 1% payment reduction to hospitals with hospital-acquired condition (HAC) rates in the top quartile nationwide.
Mandates the development of a strategy to improve healthcare quality and population health nationwide. Establishes a Federal website devoted to health care quality by January 1, 2011.
Establishes a Federal Interagency working group with the goals of disseminating the national priorities under section 3011, avoiding duplication of quality improvement efforts and assessing the alignment of public and private quality-related initiatives.
Revised by sections 10303 and 10304 of the Senate Manager's Amendment, authorizes (but does not delineate a separate Congressional appropriation) $75 million per year to HHS to develop quality metrics that fill gaps in existing measure sets and include outcomes measures.
Gives new responsibilities to the National Quality Forum (NQF) to make recommendations regarding the national quality strategy (see section 3011) and to endorse quality metrics. Requires periodic review of measures by CMS. Appropriates $20 million per year for FYs 2010-2014 for these purposes.
Establishes a framework for the collection, aggregation and public dissemination of quality and resource-use related information.
Creates CMMI to test and evaluate new delivery and payment models with the intent of improving quality or reducing costs. Gives CMS authority to expand these programs, if successful, without additional congressional action. Appropriates $10 billion for this purpose. Provides several examples for CMMI to consider in establishing pilot programs.
Creates an accountable care organization (ACO) program within traditional Medicare that will allow integrated healthcare organizations to share in savings they can achieve through quality improvements and efficiency of care.
Establishes, by January 1, 2013, a new pilot program to test bundling of Medicare payments for CMS-identified episodes of care spanning three days prior to a hospital admission to 30 days after discharge. Services delivered at a variety of settings can be bundled into these episodic payments. Allows CMS to expand the program after 2016 if it is successful in...
To start by January 1, 2012, requires CMS to test a new model whereby primary care teams deliver home-based care to high-need patients.
Establishes a new program whereby inpatient hospital service payments are reduced if their preventable readmission rates exceed certain levels. Payments may be reduced by up to 1% in FY13 phasing up to 3% in FY15 and thereafter.
Requires CMS to allocate funding to hospitals with high readmission rates or community-based organizations that have arrangements in place with such hospitals to manage the care of high-risk patients as they are discharged from a hospital into the community. Authorized for five years, starting in 2011, though CMS may extend the program if it is successful.
Extends the existing Medicare gainsharing demonstration to September 30, 2011.
This section was deleted by section 30310 of the Senate Manager’s Amendment to the ACA.
3102 - Extension of Work Geographic Index Floor and Revisions to the Practice Expense Geographic Adjustment under the Medicare Physician Fee Schedule
Provides for an extension of the 1.0 work geographic practice cost index (GPCI) floor through 2010 and limits variations in the practice expense (PE) GPCI with a hold harmless for areas that would otherwise lose funding.
Provides for an extension of the exceptions process to the annual per beneficiary caps on therapy services through 2010.
Provides for an extension of the direct payment for the technical component of some pathology services to certain independent labs through 2010.
Extends the rural ground ambulance add-on (1%), the super rural ambulance add-on (2%) and the air ambulance add-on and reclassifications through 2010. On July 8, 2013, CMS released its CY14 Medicare Physician Fee Schedule (MPFS) proposed regulation, which delineates proposed payment changes to physician payments, in addition to effectuating ACA-authorized requirements consistent with these statutory provisions of the law. Comments on the underlying proposed...
3106 - Extension of Certain Payment Rules for Long-Term Care Hospital Services and of Moratorium on the Establishment of Certain Hospitals and Facilities
Extends a variety of LTCH payment provisions, including protection from the “25% Rule” and a moratorium on new LTCHs.
Increases the payment rate for psychiatric services by 5% through 2010.
Authorizes PAs to order skilled nursing facility services in Medicare starting in 2011.
Authorizes the exemption of pharmacies with less than 5% of revenues coming from durable medical equipment from accreditation requirements until pharmacy-specific standards are developed. Pharmacies participating in the competitive bidding program do not qualify for the exemption.
Establishes a special 12-month enrollment period for military retirees and their families who are eligible for Part A of Medicare but have declined Part B.
Restores Medicare payments for duel-energy x-ray absorptiometry (DXA) services to 70% of the rates paid in 2006 during 2010 and 2011.
Eliminates funding then available in the Medicare improvement Fund (MIF).
Creates a 2-year demonstration program to assess the affect on Medicare quality and costs of direct payments for certain complex laboratory tests. Requires CMS to report its findings to Congress by June 30, 2015.
Increases payment for CNM services from 65% of that paid to physicians to 100%, effective January 1, 2011.
Extends through 2010 the existing Medicare outpatient hold harmless provision for certain rural hospitals and allows Sole Community Hospitals (SCHs) with more than 100 beds to also be eligible.
3122 - Extension of Medicare Reasonable Cost Payments for Certain Clinical Diagnostic Laboratory Tests Furnished to Hospital Patients in Certain Areas
Reapplies Medicare reasonable cost payments for lab services provided by some small rural hospitals for the period July 1, 2010, to June 30, 2011.
Extends this Medicare demonstration program through FY15 while expanding it to new sites and requiring adjustments to the payment methodologies used.
Extends the MDH program through FY12 and requires CMS to study whether certain urban hospitals should qualify.
3125 - Temporary Improvements to the Medicare Inpatient Hospital Payment Adjustment for Low-Volume Hospitals
Extends this program through FY12 and modifies certain eligibility requirements relating to distances from neighboring hospitals and number of discharges.
3126 - Improvements to the Demonstration Project on Community Health Integration Models in Certain Rural Communities
Expands this Medicare demonstration program to allow additional counties to participate and also permits physician participation.
3127 - MedPAC Study on Adequacy of Medicare Payments for Health Care Providers Serving in Rural Areas
Directs the Medicare Payment Advisory Commission (MedPAC) to study the adequacy of Medicare payments made to rural healthcare providers and the impact on beneficiary access to care in these areas. Includes the impact of changes made under the Affordable Care Act (ACA).
Makes clear that CAHs can receive their 101% of costs-based payments regardless of the billing methodology they use. Also clarifies that this payment methodology applies to CAH-delivered ambulance services.
Extends the rural hospital Flex Grant program through FY12 and allows funds to be applied to delivery reform programs effective January 1, 2010.
Directs CMS to rebase Medicare home health agency (HHA) payments by 2014. Creates a 10% limit on the portion of an HHA’s reimbursement that may come from outlier payments from April 1, 2010 through 2015. Requires CMS to submit a report to Congress by March 1, 2011 making recommendations to improve the home health payment system and beneficiary access to...
Directs CMS, by January 2, 2011, to update Medicare hospice cost reports and claims forms and mandate a face-to-face encounter between a doctor (or nurse practitioner) and the patient to determine the need for recertification after 180 days, and to implement reforms to the payment system to improve payment accuracy by no earlier than FY14.
Requires CMS to adjust Medicare DSH payments to improve the accuracy in accounting for uncompensated care beginning FY14. DSH payments are to be reduced to reflect expected increases in coverage under the ACA.
Mandates review of Medicare payments for physician services, including those that have experienced rapid growth in utilization. Gives CMS authority to adjust payment rates for misvalued services.
Effective January 1, 2011, sets the utilization rate assumption for advanced diagnostic imaging services (ADIS) at 75% for the practice expense portion of Medicare physician payment. Excludes non-advanced services like x-rays and EKGs. Increases the discount to the technical component of payment for imaging performed on a contiguous body part during the same session from 25% to 50%, effective July...
Repeals the option for Medicare to purchase power-driven wheelchairs with a lump sum payment, requiring that payments be made under the traditional 13-month rental period for durable medical equipment. Does not apply to complex, rehabilitative power wheelchairs.
Extends so-called Medicare section 508 hospital reclassifications through FY10, with a requirement that CMS make recommendations to Congress by the end of 2011 regarding comprehensive reforms to the geographic wage index system. From FY11 to FY13, requires CMS to restore the thresholds used for determining hospital reclassifications to the percentage used in FY09. Clarifies that CMS may only use wage...
Mandates a CMS study regarding the degree to which inpatient prospective payment system (IPPS) exempt cancer hospitals have outpatient costs that exceed those of other hospitals. Authorizes HHS to make any appropriate adjustments to reflect those higher costs effective for services furnished on or after January 1, 2011.
Sets the Medicare payment rate for newly authorized biosimilar products at average sales price (ASP) of the biosimilar product + 6% of the corresponding branded product’s ASP.
Directs CMS to establish a three-year demonstration program allowing hospice-eligible Medicare beneficiaries to also receive all other Medicare-covered services.
3141 - Application of Budget Neutrality on a National Basis in the Calculation of the Medicare Hospital Wage Index Floor
Effective FY11, requires application of the budget neutrality policy associated with the imputed rural floor be applied on a national wage index, rather than a State-specific basis.
Mandates a CMS study regarding the need for additional Medicare payments to certain urban MDHs.
Prohibits the reduction of guaranteed home health benefits.
Repealed and replaced by section 1102 of HCERA, summarized here. Sets MA payments in 2011 at 2010 levels. Phases in plan reimbursement reductions over three, five or seven years, depending on the depth of the cuts to the plan region, with final benchmarks set at 95% in high-cost areas up to 115% in low-cost areas. Areas with high-quality plans receive...
Beginning in 2011, prohibits MA plans from imposing cost-sharing rates higher than traditional fee-for-service for chemotherapy, dialysis, skilled nursing and other services as defined by CMS.
Repealed and replaced by section 1102 of HCERA. Requires CMS to implement reductions to MA plan reimbursement to account for increases in coding intensity patterns, with cuts ramped up beginning in 2014 and again in 2019. In years 2015-2019, the cut may be no less than the previous year plus 0.25%.
Establishes an open enrollment period of 10/15 through 12/7 for MA effective for plan years 2012 and beyond. Allows MA enrollees to dis-enroll within first 45 days of the year.
Reauthorizes the MA SNP program through 2013 for beneficiaries with chronic conditions. Requires transition of non-chronically ill MA SNP enrollees to non-SNP plans or traditional Medicare by 2013. Extends SNP plans for dual eligible beneficiaries through 2012. Requires all SNPs be accredited by the National Committee for Quality Assurance (NCQA) by 2012.
Reauthorizes Medicare cost contract arrangements through 2013.
Extends the employer waiver from private fee-for-service plan network requirements, effective CY11. In a Mar. 23 letter to CMS, House Ways and Means Committee Chairman Kevin Brady (R-TX) and Energy and Commerce Committee Chairman Fred Upton (R-MI), along with other members of the Republican leadership, requested more transparency in the process for rate setting for MA Employer Group Waiver Plans...
Beginning in 2010, makes this demonstration program permanent and allows these plans to limit their services to the geographic area in which the housing facility is located.
Effective plan year 2011, provides authority to CMS to reject MA and Part D plan bids for excessive cost-sharing increases or decreases in benefits.
Directs the NAIC to revise Medigap Plans C and F to include nominal cost-sharing to encourage more appropriate use of physician services.
As amended by section 1101 of HCERA, effective 2011, phases in closure of the Part D “donut hole” by requiring 50% discounts on brand name and generic drugs to enrollees in that component of the benefit. Discount increases to 75% by 2020. Provides $250 rebate for all Medicare Part D enrollees in the donut hole in 2010.
Effective 2011, requires exclusion of beneficiary rebates or quality bonus payments from calculation of the Part D low-income subsidy (LIS).
Requires CMS to permit Part D plans to waive the monthly premium for low-income subsidy (LIS) individuals. Such plans will be included in the auto-enrollment program for LIS beneficiaries starting in 2011.
Extends the LIS eligibility determination period by one year for individuals whose spouses have died.
Effective 2011, requires CMS to provide LIS enrollees assigned to a new plan because their previous plan no longer qualified with information regarding changes in their Part D formulary and their right to request coverage reconsideration.
Provides funding from 2010 through 2012 for state health insurance programs (SHIPs), Area Agencies on Aging (AAAs), Aging and Disability Resource Centers (ADRCs) and the National Center for Benefits and Outreach and Enrollment. Up to $45 million per year is allocated for these purposes.
3307 - Improving Formulary Requirements for PDP and MA-PD Plans with Certain Categories or Classes of Drugs
Requires CMS to designate a set of protected classes of drugs for which all drugs in the class must be covered by Part D plans.
Reduces the Part D subsidy for higher-income beneficiaries in a similar manner as Part B. Accomplished through Social Security withholding.
Prohibits cost-sharing for individuals obtaining services through a home and community based services (HCBS) waiver who would otherwise qualify for institutional care, by 2012 at the earliest.
3310 - Reducing Wasteful Dispensing of Outpatient Prescription Drugs in Long-Term Care Facilities under PDP and MA-PD Plans
Effective 2012, requires Part D and MA-PD plans to reduce the dispensing cycle by pharmacies in the long-term care setting.
Mandates development of a system to collect complaints against Part D plans and requires CMS to deliver an annual report to Congress summarizing such complaints. CMS must develop a model complaint form that must be prominently displayed on the home page for Medicare.gov.
Mandates that all Part D plan sponsors utilize a single, uniform exceptions process for coverage determinations and provide instant access to decisions via toll-free phone number or the Internet by 2012.
Directs the OIG to study and report to Congress by July 1, 2011 (and annually after that), on the extent to which Part D formularies include drugs commonly used by dual eligibles. Also requires a report by October 1, 2011, regarding the prices for covered Part D drugs with an accounting of any discrepancy in price and the impact on...
3314 - Including Costs Incurred by AIDS Drug Assistance Programs and Indian Health Services in Providing Prescription Drugs Toward the Annual Out-of-Pocket Threshold under Part D
Requires inclusion of drug costs incurred by AIDS drug assistance programs and Indian Health Service on behalf of Part D enrollees toward their annual out-of-pocket cap.
Replaced HCERA section 1101. Refer to section 3301 for further details.
3401 - Revision of Certain Market Basket Updates and Incorporation of Productivity Improvements into Market Basket Updates that do not Already Incorporate such Improvements
Amended by sections 10319 of the Manager’s Amendment and 1105 of HCERA. Revises payment updates in Medicare fee-for-service as follows: Inpatient and outpatient hospitals, inpatient rehab facilities and psychiatric hospitals: -0.25% in 2010 and 2011, -0.1% in 2012 and 2013, -0.3% in 2014, -0.2% in 2015 and 2016 and 0.75% from 2017-2019. Productivity adjustment applied beginning in 2012. Long-term care...
For 2011-2019, freezes the existing income thresholds and ranges used to determine Part B premiums rather than increasing them due to changes in the consumer price index.
Amended by section 10320 of the Manager’s Amendment. Establishes a new entity that, starting in 2014, will make recommendations and develop proposals to reduce Medicare spending to meet certain targets and improve quality. The IPAB is also required to make recommendations regarding the private healthcare sector every two years, starting in 2015. Prior to 2018, target Medicare spending growth is...
Builds on the Center for Quality Improvement and Patient Safety at AHRQ to support research, technical assistance and process implementation grants. Authorizes but does not fund $20 million for grants to develop innovative approaches for quality improvement practices.
3502 - Grants or Contracts to Establish Community Health Teams to Support Patient-Centered Medical Home
Modified by section 10321 of the Manager’s amendment. Creates a new grant program to establish health teams that support care coordination services delivered at primary care practices. No funding allocated.
Creates a grant program to support medication therapy management services for certain high-risk individuals delivered by local healthcare providers. No funding appropriated.
Directs HHS to award at least four grants to state-local government partnerships to test new models of regionalized emergency medical care. No funding appropriated for these grants.
Expands an existing trauma center grant program for Indian tribal, urban Indian and Indian Health Service operated trauma centers to defray costs and improve quality. No funding appropriated for this expansion.
Creates a program at HHS to develop, test and distribute new tools to improve patient understanding of their treatment options. No funding appropriated.
Requires the FDA to evaluate whether use of drug fact boxes in advertising that would more clearly communicate their risks and benefits is warranted.
3508 - Demonstration Program to Integrate Quality Improvement and Patient Safety into Clinical Education of Health Professionals
Establishes a new grant program at AHRQ to provide grants to health professional training institutions for the development and implementation of academic programs that integrate quality improvement and patient safety in the clinical education of health professionals. No funding allocated.
Creates women’s health offices at various Federal agencies to improve the quality of care delivered to women and for related research. No funding allocated.
Extends an existing program to provide assistance to patients facing barriers in access to health services. Under these programs, patients can receive referrals, assistance with identifying support organizations, background on clinical trials and targeted outreach if in a population suffering from health-related disparities. No funding allocated.
This section authorizes funds to carry out the provisions of sections 3501-3510 of the ACA, but does not allocate such funds.
Added by section 10201 of the Manager’s Amendment. Requires GAO to deliver a report to Congress by 3/21/12 regarding any causes of action that may have been created by the ACA.
Ensures that nothing in the ACA will reduce Medicare benefits and that the savings under Medicare from the law will benefit that program.
Prohibits any provision of the ACA from reducing or eliminating any benefits otherwise required by law under the Medicare Advantage program.
Requires HHS to contract with the IOM to identify new and existing clinical practice guidelines.
Establishes Medicare eligibility for persons in Libby, Montana who were exposed to asbestos hazards prior to 6/17/09. Additional eligibility may be extended to individuals in other areas when a public health emergency is declared under the Comprehensive Environmental Response, Compensation and Liability Act of 1980.
Delays the application of the Medicare RUG-IV payment system for SNFs to FY12.
By plan year 2013, requires Part D plans to include MTM services for certain enrollees. MTM programs must include annual, comprehensive, in-person medication reviews and a process for auto-enrollment (with opt-out). Part D plans must also assess medication use of non-MTM-enrolled individuals on a quarterly basis.
Directs CMS to plan and budget means of improving provider access to data for care management purposes and to support the evaluation of delivery system reforms.
Effective January 2012, authorizes HHS to provide standardized extracts of Medicare claims data by geographic area to public and private entities that meet certain criteria for provider performance evaluation purposes.
Creates a new grant program to support groups of providers (that must include an FQHC and a Medicaid DSH-eligible hospital) to deliver coordinated care to low-income populations. No funding allocated.
Transfers the Office of Minority Health to the Office of the Secretary and establishes new minority health offices at the CDC, HRSA, SAMHSA, AHRQ, FDA and CMS, and elevates the existing office at the NIH.
Directs the Government Accountability Office (GAO) to submit a report to Congress regarding inclusion of oral-only drugs in the new bundled payment system for dialysis patients by March 23, 2011.