Cited Sections of the Patient Protection and Affordable Care Act

Transcription

1 Cited Sections of the Patient Protection and Affordable Care Act SEC DEMONSTRATION PROJECT TO EVALUATE INTEGRATED CARE AROUND A HOSPITALIZATION. (a) AUTHORITY TO CONDUCT PROJECT. (1) IN GENERAL. The Secretary of Health and Human Services (in this section referred to as the Secretary ) shall establish a demonstration project under title XIX of the Social Security Act to evaluate the use of bundled payments for the provision of integrated care for a Medicaid beneficiary (A) with respect to an episode of care that includes a hospitalization; and (B) for concurrent physicians services provided during a hospitalization. (2) DURATION. The demonstration project shall begin on January 1, 2012, and shall end on December 31, (b) REQUIREMENTS. The demonstration project shall be conducted in accordance with the following: (1) The demonstration project shall be conducted in up to 8 States, determined by the Secretary based on consideration of the potential to lower costs under the Medicaid program while improving care for Medicaid beneficiaries. A State selected to participate in the demonstration project may target the demonstration project to particular categories of beneficiaries, beneficiaries with particular diagnoses, or particular geographic regions of the State, but the Secretary shall insure that, as a whole, the demonstration project is, to the greatest extent possible, representative of the demographic and geographic composition of Medicaid beneficiaries nationally. (2) The demonstration project shall focus on conditions where there is evidence of an opportunity for providers of services and suppliers to improve the quality of care furnished to Medicaid beneficiaries while reducing total expenditures under the State Medicaid programs selected to participate, as determined by the Secretary. (3) A State selected to participate in the demonstration project shall specify the 1 or more episodes of care the State proposes to address in the project, the services to be included in the bundled payments, and the rationale for the selection of such episodes of care and services. The Secretary may modify the episodes of care as well as the services to be included in the bundled payments prior to or after approving the project. The Secretary may also vary such factors among the different States participating in the demonstration project. (4) The Secretary shall ensure that payments made under the demonstration project are adjusted for severity of illness and other characteristics of Medicaid beneficiaries within a category or having a diagnosis targeted as part of the demonstration project. States shall ensure that Medicaid

2 beneficiaries are not liable for any additional cost sharing than if their care had not been subject to payment under the demonstration project. (5) Hospitals participating in the demonstration project shall have or establish robust discharge planning programs to ensure that Medicaid beneficiaries requiring post-acute care are appropriately placed in, or have ready access to, postacute care settings. (6) The Secretary and each State selected to participate in the demonstration project shall ensure that the demonstration project does not result in the Medicaid beneficiaries whose care is subject to payment under the demonstration project being provided with less items and services for which medical assistance is provided under the State Medicaid program than the items and services for which medical assistance would have been provided to such beneficiaries under the State Medicaid program in the absence of the demonstration project. (c) WAIVER OF PROVISIONS. Notwithstanding section 1115(a) of the Social Security Act (42 U.S.C. 1315(a)), the Secretary may waive such provisions of titles XIX, XVIII, and XI of that Act as may be necessary to accomplish the goals of the demonstration, ensure beneficiary access to acute and post-acute care, and maintain quality of care. (d) EVALUATION AND REPORT. (1) DATA. Each State selected to participate in the demonstration project under this section shall provide to the Secretary, in such form and manner as the Secretary shall specify, relevant data necessary to monitor outcomes, costs, and quality, and evaluate the rationales for selection of the episodes of care and services specified by States under subsection (b)(3). (2) REPORT. Not later than 1 year after the conclusion of the demonstration project, the Secretary shall submit a report to Congress on the results of the demonstration project. SEC MEDICAID GLOBAL PAYMENT SYSTEM DEMONSTRATION PROJECT. (a) IN GENERAL. The Secretary of Health and Human Services (referred to in this section as the Secretary ) shall, in coordination with the Center for Medicare and Medicaid Innovation (as established under section 1115A of the Social Security Act, as added by section 3021 of this Act), establish the Medicaid Global Payment System Demonstration Project under which a participating State shall adjust the payments made to an eligible safety net hospital system or network from a fee-for-service payment structure to a global capitated payment model. (b) DURATION AND SCOPE. The demonstration project conducted under this section shall operate during a period of fiscal years 2010 through The Secretary shall select not more than 5 States to participate in the demonstration project. (c) ELIGIBLE SAFETY NET HOSPITAL SYSTEM OR NETWORK. (a) For purposes of this section, the term eligible safety net hospital system or network means a large, safety net hospital system or network (as defined by the

3 Secretary) that operates within a State selected by the Secretary under subsection (b). (d) EVALUATION. (1) TESTING. The Innovation Center shall test and evaluate the demonstration project conducted under this section to examine any changes in health care quality outcomes and spending by the eligible safety net hospital systems or networks. (2) BUDGET NEUTRALITY. During the testing period under paragraph (1), any budget neutrality requirements under section 1115A(b)(3) of the Social Security Act (as so added) shall not be applicable. (3) MODIFICATION. During the testing period under paragraph (1), the Secretary may, in the Secretary s discretion, modify or terminate the demonstration project conducted under this section. (e) REPORT. Not later than 12 months after the date of completion of the demonstration project under this section, the Secretary shall submit to Congress a report containing the results of the evaluation and testing conducted under subsection (d), together with recommendations for such legislation and administrative action as the Secretary determines appropriate. (f) AUTHORIZATION OF APPROPRIATIONS. There are authorized to be appropriated such sums as are necessary to carry out this section. SEC STREAMLINING OF PROCEDURES FOR ENROLLMENT THROUGH AN EXCHANGE AND STATE MEDICAID, CHIP, AND HEALTH SUBSIDY PROGRAMS. (a) IN GENERAL. The Secretary shall establish a system meeting the requirements of this section under which residents of each State may apply for enrollment in, receive a determination of eligibility for participation in, and continue participation in, applicable State health subsidy programs. Such system shall ensure that if an individual applying to an Exchange is found through screening to be eligible for medical assistance under the State medicaid plan under title XIX, or eligible for enrollment under a State children s health insurance program (CHIP) under title XXI of such Act, the individual is enrolled for assistance under such plan or program. (b) REQUIREMENTS RELATING TO FORMS AND NOTICE. (1) REQUIREMENTS RELATING TO FORMS. (A) IN GENERAL. The Secretary shall develop and provide to each State a single, streamlined form that (i) may be used to apply for all applicable State health subsidy programs within the State; (ii) may be filed online, in person, by mail, or by telephone; (iii) may be filed with an Exchange or with State officials operating one of the other applicable State health subsidy programs; and (iv) is structured to maximize an applicant s ability to complete the form satisfactorily, taking into account the characteristics of individuals who qualify for applicable State health subsidy programs.

4 (B) STATE AUTHORITY TO ESTABLISH FORM. A State may develop and use its own single, streamlined form as an alternative to the form developed under subparagraph (A) if the alternative form is consistent with standards promulgated by the Secretary under this section. (B) SUPPLEMENTAL ELIGIBILITY FORMS. The Secretary may allow a State to use a supplemental or alternative form in the case of individuals who apply for eligibility that is not determined on the basis of the household income (as defined in section 36B of the Internal Revenue Code of 1986). (2) NOTICE. The Secretary shall provide that an applicant filing a form under paragraph (1) shall receive notice of eligibility for an applicable State health subsidy program without any need to provide additional information or paperwork unless such information or paperwork is specifically required by law when information provided on the form is inconsistent with data used for the electronic verification under paragraph (3) or is otherwise insufficient to determine eligibility. (c) REQUIREMENTS RELATING TO ELIGIBILITY BASED ON DATA EXCHANGES. (1) DEVELOPMENT OF SECURE INTERFACES. Each State shall develop for all applicable State health subsidy programs a secure, electronic interface allowing an exchange of data (including information contained in the application forms described in subsection (b)) that allows a determination of eligibility for all such programs based on a single application. Such interface shall be compatible with the method established for data verification under section 1411(c)(4). (2) DATA MATCHING PROGRAM. Each applicable State health subsidy program shall participate in a data matching arrangement for determining eligibility for participation in the program under paragraph (3) that (A) provides access to data described in paragraph (3); (B) applies only to individuals who (i) receive assistance from an applicable State health subsidy program; or (ii) apply for such assistance (I) (II) by filing a form described in subsection (b); or by requesting a determination of eligibility and authorizing disclosure of the information described in paragraph (3) to applicable State health coverage subsidy programs for purposes of determining and = establishing eligibility; and (C) consistent with standards promulgated by the Secretary, including the privacy and data security safeguards described in section 1942 of the Social Security Act or that are otherwise applicable to such programs. (3) DETERMINATION OF ELIGIBILITY. (A) IN GENERAL. Each applicable State health subsidy program shall, to the maximum extent practicable

5 (i) establish, verify, and update eligibility for participation in the program using the data matching (a) arrangement under paragraph (2); and (ii) determine such eligibility on the basis of reliable, third party data, including information described in sections 1137, 453(i), and 1942(a) of the Social Security Act, obtained through such arrangement. (B) EXCEPTION. This paragraph shall not apply in circumstances with respect to which the Secretary determines that the administrative and other costs of use of the data matching arrangement under paragraph (2) outweigh its expected gains in accuracy, efficiency, and program participation. (4) SECRETARIAL STANDARDS. The Secretary shall, after consultation with persons in possession of the data to be matched and representatives of applicable State health subsidy programs, promulgate standards governing the timing, contents, and procedures for data matching described in this subsection. Such standards shall take into account administrative and other costs and the value of data matching to the establishment, verification, and updating of eligibility for applicable State health subsidy programs. (d) ADMINISTRATIVE AUTHORITY. (1) AGREEMENTS. Subject to section 1411 and section 6103(l)(21) of the Internal Revenue Code of 1986 and any other requirement providing safeguards of privacy and data integrity, the Secretary may establish model agreements, and enter into agreements, for the sharing of data under this section. (2) AUTHORITY OF EXCHANGE TO CONTRACT OUT. Nothing in this section shall be construed to (A) prohibit contractual arrangements through which a State medicaid agency determines eligibility for all applicable State health subsidy programs, but only if such agency complies with the Secretary s requirements ensuring reduced administrative costs, eligibility errors, and disruptions in coverage; or (B) change any requirement under title XIX that eligibility for participation in a State s medicaid program must be determined by a public agency. (e) APPLICABLE STATE HEALTH SUBSIDY PROGRAM. In this section, the term applicable State health subsidy program means (1) the program under this title for the enrollment in qualified health plans offered through an Exchange, including the premium tax credits under section 36B of the Internal Revenue Code of 1986 and cost-sharing reductions under section 1402; (2) a State medicaid program under title XIX of the Social Security Act; (3) a State children s health insurance program (CHIP) under title XXI of such Act; and (4) a State program under section 1331 establishing qualified basic health plans.

6 SEC PAYMENT ADJUSTMENT FOR HEALTH CARE-ACQUIRED CONDITIONS. (a) IN GENERAL. The Secretary of Health and Human Services (in this subsection referred to as the Secretary ) shall identify current State practices that prohibit payment for health care-acquired conditions and shall incorporate the practices identified, or elements of such practices, which the Secretary determines appropriate for application to the Medicaid program in regulations. Such regulations shall be effective as of July 1, 2011, and shall prohibit payments to States under section 1903 of the Social Security Act for any amounts expended for providing medical assistance for health care-acquired conditions specified in the regulations. The regulations shall ensure that the prohibition on payment for health care-acquired conditions shall not result in a loss of access to care or services for Medicaid beneficiaries. (b) HEALTH CARE-ACQUIRED CONDITION. In this section. The term health care-acquired condition means a medical condition for which an individual was diagnosed that could be identified by a secondary diagnostic code described in section 1886(d)(4)(D)(iv) of the Social Security Act (42 U.S.C. 1395ww(d)(4)(D)(iv)). (c) MEDICARE PROVISIONS. In carrying out this section, the Secretary shall apply to State plans (or waivers) under title XIX of the Social Security Act the regulations promulgated pursuant to section 1886(d)(4)(D) of such Act (42 U.S.C. 1395ww(d)(4)(D)) relating to the prohibition of payments based on the presence of a secondary diagnosis code specified by the Secretary in such regulations, as appropriate for the Medicaid program. The Secretary may exclude certain conditions identified under title XVIII of the Social Security Act for non-payment under title XIX of such Act when the Secretary finds the inclusion of such conditions to be inapplicable to beneficiaries under title XIX. SEC GRADUATE NURSE EDUCATION DEMONSTRATION. (a) IN GENERAL. (1) ESTABLISHMENT. (A) IN GENERAL. The Secretary shall establish a graduate nurse education demonstration under title XVIII of the Social Security Act (42 U.S.C et seq.) under which an eligible hospital may receive payment for the hospital s reasonable costs (described in paragraph (2)) for the provision of qualified clinical training to advance practice nurses. (B) NUMBER. The demonstration shall include up to 5 eligible hospitals. (C) WRITTEN AGREEMENTS. Eligible hospitals selected to participate in the demonstration shall enter into written agreements pursuant to subsection (b) in order to reimburse the eligible partners of the hospital the share of the costs attributable to each partner. (2) COSTS DESCRIBED.

7 (A) IN GENERAL. Subject to subparagraph (B) and subsection (d), the costs described in this paragraph are the reasonable costs (as described in section 1861(v) of the Social Security Act (42 U.S.C. 1395x(v))) of each eligible hospital for the clinical training costs (as determined by the Secretary) that are attributable to providing advanced practice registered nurses with qualified training. (B) LIMITATION. With respect to a year, the amount reimbursed under subparagraph (A) may not exceed the amount of costs described in subparagraph (A) that are attributable to an increase in the number of advanced practice registered nurses enrolled in a program that provides qualified training during the year and for which the hospital is being reimbursed under the demonstration, as compared to the average number of advanced practice registered nurses who graduated in each year during the period beginning on January 1, 2006, and ending on December 31, 2010 (as determined by the Secretary) from the graduate nursing education program operated by the applicable school of nursing that is an eligible partner of the hospital for purposes of the demonstration. (3) WAIVER AUTHORITY. The Secretary may waive such requirements of titles XI and XVIII of the Social Security Act as may be necessary to carry out the demonstration. (4) ADMINISTRATION. Chapter 35 of title 44, United States Code, shall not apply to the implementation of this section. (b) WRITTEN AGREEMENTS WITH ELIGIBLE PARTNERS. No payment shall be made under this section to an eligible hospital unless such hospital has in effect a written agreement with the eligible partners of the hospital. Such written agreement shall describe, at a minimum (1) the obligations of the eligible partners with respect to the provision of qualified training; and (2) the obligation of the eligible hospital to reimburse such eligible partners applicable (in a timely manner) for the costs of such qualified training attributable to partner. (c) EVALUATION. Not later than October 17, 2017, the Secretary shall submit to Congress a report on the demonstration. Such report shall include an analysis of the following: (1) The growth in the number of advanced practice registered nurses with respect to a specific base year as a result of the demonstration. (2) The growth for each of the specialties described in subparagraphs (A) through (D) of subsection (e)(1). (3) The costs to the Medicare program under title XVIII of the Social Security Act as a result of the demonstration. (4) Other items the Secretary determines appropriate and relevant. (d) FUNDING. (1) IN GENERAL. There is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $50,000,000 for each of

8 fiscal years 2012 through 2015 to carry out this section, including the design, implementation, monitoring, and evaluation of the demonstration. (2) PRORATION. If the aggregate payments to eligible hospitals under the demonstration exceed $50,000,000 for a fiscal year described in paragraph (1), the Secretary shall prorate the payment amounts to each eligible hospital in order to ensure that the aggregate payments do not exceed such amount. (3) WITHOUT FISCAL YEAR LIMITATION. Amounts appropriated under this subsection shall remain available without fiscal year limitation. (e) DEFINITIONS. In this section: (1) ADVANCED PRACTICE REGISTERED NURSE. The term advanced practice registered nurse includes the following: (A) A clinical nurse specialist (as defined in subsection (aa)(5) of section 1861 of the Social Security Act= (42 U.S.C. 1395x)). (B) A nurse practitioner (as defined in such subsection). (C) A certified registered nurse anesthetist (as defined in subsection (bb)(2) of such section). (D) A certified nurse-midwife (as defined in subsection (gg)(2) of such section). (2) APPLICABLE NON-HOSPITAL COMMUNITY-BASED CARE SETTING. The term applicable non-hospital community-based care setting means a non-hospital community-based care setting which has entered into a written agreement (as described in subsection (b)) with the eligible hospital participating in the demonstration. Such settings include Federally qualified health centers, rural health clinics, and other nonhospital settings as determined appropriate by the Secretary. (3) APPLICABLE SCHOOL OF NURSING. The term applicable school of nursing means an accredited school of nursing (as defined in section 801 of the Public Health Service Act) which has entered into a written agreement (as described in subsection (b)) with the eligible hospital participating in the demonstration. (4) DEMONSTRATION. The term demonstration means the graduate nurse education demonstration established under subsection (a). (5) ELIGIBLE HOSPITAL. The term eligible hospital means a hospital (as defined in subsection (e) of section 1861 of the Social Security Act (42 U.S.C. 1395x)) or a critical access hospital (as defined in subsection (mm)(1) of such section) that has a written agreement in place with (A) 1 or more applicable schools of nursing; and (B) 2 or more applicable non-hospital community-based care settings. (6) ELIGIBLE PARTNERS. The term eligible partners includes the following: (A) An applicable non-hospital community-based care setting. (B) An applicable school of nursing. (7) QUALIFIED TRAINING.

9 (A) IN GENERAL. The term qualified training means training (i) that provides an advanced practice registered nurse with the clinical skills necessary to provide primary care, preventive care, transitional care, chronic care management, and other services appropriate for individuals entitled to, or enrolled for, benefits under part A of title XVIII of the Social Security Act, or enrolled under part B of such title; and (ii) subject to subparagraph (B), at least half of which is provided in a non-hospital community-based care setting. (B) WAIVER OF REQUIREMENT HALF OF TRAINING BE PROVIDED IN NON-HOSPITAL COMMUNITY-BASED CARE SETTING IN CERTAIN AREAS. The Secretary may waive the requirement under subparagraph (A)(ii) with respect to eligible hospitals located in rural or medically underserved areas. (8) SECRETARY. The term Secretary means the Secretary of Health and Human Services. HCERA SEC PAYMENT FOR QUALIFYING HOSPITALS. (a) IN GENERAL. From the amount available under subsection (b), the Secretary of Health and Human Services shall provide for a payment to qualifying hospitals (as defined in subsection (d)) for fiscal years 2011 and 2012 of the amount determined under subsection (c). (b) AMOUNTS AVAILABLE. There shall be available from the Federal Hospital Insurance Trust Fund $400,000,000 for payments under this section for fiscal years 2011 and (c) PAYMENT AMOUNT. The amount of payment under this section for a qualifying hospital shall be determined, in a manner consistent with the amount available under subsection (b), in proportion to the portion of the amount of the aggregate payments under section 1886(d) of the Social Security Act to the hospital for fiscal year 2009 bears to the sum of all such payments to all qualifying hospitals for such fiscal year. (d) QUALIFYING HOSPITAL DEFINED. In this section, the term qualifying hospital means a subsection (d) hospital (as defined for purposes of section 1886(d) of the Social Security Act) that is located in a county that ranks, based upon its ranking in age, sex, and race adjusted spending for benefits under parts A and B under title XVIII of such Act per enrollee, within the lowest quartile of such counties in the United States. PPACA SEC INFRASTRUCTURE TO EXPAND ACCESS TO CARE. (a) Appropriation- There are authorized to be appropriated, and there are appropriated to the Department of Health and Human Services, $100,000,000 for fiscal year 2010, to remain available for obligation until September 30, 2011, to be used for debt service on, or direct construction or renovation of, a health care

10 facility that provides research, inpatient tertiary care, or outpatient clinical services. Such facility shall be affiliated with an academic health center at a public research university in the United States that contains a State's sole public academic medical and dental school. (b) Requirement- Amount appropriated under subsection (a) may only be made available by the Secretary of Health and Human Services upon the receipt of an application from