S AMDT 1262

S 1262 IS

To amend title VII of the Public Health Service Act and titles XVIII and XIX of the Social Security Act to provide additional resources for primary care services, to create new payment models for services under Medicare, to expand provision of non-institutionally-based long-term services, and for other purposes.

June 15, 2009

Ms. CANTWELL introduced the following bill; which was read twice and referred to the Committee on Finance

To amend title VII of the Public Health Service Act and titles XVIII and XIX of the Social Security Act to provide additional resources for primary care services, to create new payment models for services under Medicare, to expand provision of non-institutionally-based long-term services, and for other purposes.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the ‘Medical Efficiency and Delivery Improvement of Care Act (MEDIC) of 2009’.

SEC. 2. TABLE OF CONTENTS.

The table of contents for this Act is as follows:

Sec. 1. Short title.

Sec. 2. Table of contents.

TITLE I--LOAN PROGRAM PROVISIONS

Sec. 1001. Short title.

Sec. 1002. Hospital residency loan program.

TITLE II--PRIMARY CARE PROVISIONS

Sec. 2001. Short title.

Sec. 2002. Findings.

Sec. 2003. Definitions.

Subtitle A--Medical Education

Sec. 2101. Recruitment incentives.

Sec. 2102. Debt forgiveness, scholarships, and service obligations.

Sec. 2103. Deferment of loans during residency and internships.

Sec. 2104. Educating medical students about primary care careers.

Sec. 2105. Training in family medicine, general internal medicine, general geriatrics, general pediatrics, physician assistant education, general dentistry, and pediatric dentistry.

Sec. 2106. Increased funding for National Health Service Corps Scholarship and loan repayment programs.

Subtitle B--Medicaid Related Provisions

Sec. 2201. Transformation grants to support patient-centered medical homes under Medicaid and CHIP.

Subtitle C--Medicare Provisions

Part I--Primary Care

Sec. 2301. Reforming payment systems under Medicare to support primary care.

Sec. 2302. Coverage of patient-centered medical home services.

Sec. 2303. Medicare primary care payment equity and access provision.

Sec. 2304. Additional incentive payment program for primary care services furnished in health professional shortage areas.

Sec. 2305. Permanent extension of Medicare incentive payment program for physician scarcity areas.

Sec. 2306. HHS study and report on the process for determining relative value under the Medicare physician fee schedule.

Part II--Preventive Services

Sec. 2311. Eliminating time restriction for initial preventive physical examination.

Sec. 2312. Elimination of cost-sharing for preventive benefits under the Medicare program.

Sec. 2313. HHS study and report on facilitating the receipt of Medicare preventive services by Medicare beneficiaries.

Part III--Other Provisions

Sec. 2321. HHS study and report on improving the ability of physicians and primary care providers to assist Medicare beneficiaries in obtaining needed prescriptions under Medicare part D.

Sec. 2322. HHS study and report on improved patient care through increased caregiver and physician interaction.

Sec. 2323. Improved patient care through expanded support for limited English proficiency (LEP) services.

Sec. 2324. HHS study and report on use of real-time Medicare claims adjudication.

Sec. 2325. Ongoing assessment by MedPAC of the impact of Medicare payments on primary care access and equity.

Sec. 2326. Distribution of additional residency positions.

Sec. 2327. Counting resident time in outpatient settings.

Sec. 2328. Rules for counting resident time for didactic and scholarly activities and other activities.

Sec. 2329. Preservation of resident cap positions from closed and acquired hospitals.

Sec. 2330. Quality improvement organization assistance for physician practices seeking to be patient-centered medical home practices.

Subtitle D--Studies

Sec. 2401. Study concerning the designation of primary care as a shortage profession.

Sec. 2402. Study concerning the education debt of medical school graduates.

Sec. 2403. Study on minority representation in primary care.

TITLE III--MEDICARE PAYMENT PROVISIONS

Sec. 3001. Short title.

Sec. 3002. Findings.

Sec. 3003. Value index under the Medicare physician fee schedule.

TITLE IV--LONG-TERM SERVICES PROVISIONS

Sec. 4001. Short title.

Subtitle A--Balancing Incentives

Sec. 4101. Enhanced FMAP for expanding the provision of non-institutionally-based long-term services and supports.

Subtitle B--Strengthening the Medicaid Home and Community-Based State Plan Amendment Option

Sec. 4201. Removal of barriers to providing home and community-based services under State plan amendment option for individuals in need.

Sec. 4202. Mandatory application of spousal impoverishment protections to recipients of home and community-based services.

Sec. 4203. State authority to elect to exclude up to 6 months of average cost of nursing facility services from assets or resources for purposes of eligibility for home and community-based services.

Subtitle C--Coordination of Home and Community-Based Waivers

Sec. 4301. Streamlined process for combined waivers under subsections (b) and (c) of section 1915.

TITLE V--HOME AND COMMUNITY-BASED SERVICES PROVISIONS

Sec. 5001. Short title.

Sec. 5002. Long-term services and supports.

TITLE I--LOAN PROGRAM PROVISIONS

SEC. 1001. SHORT TITLE.

This title may be cited as the ‘Physician Workforce Enhancement Act of 2009’.

SEC. 1002. HOSPITAL RESIDENCY LOAN PROGRAM.

Subpart 2 of part E of title VII of the Public Health Service Act is amended by adding at the end the following new section:

‘SEC. 771. HOSPITAL RESIDENCY LOAN PROGRAM.

‘(a) Establishment- Not later than January 1, 2010, the Secretary, acting through the Administrator of the Health Resources and Services Administration, shall establish a loan program that provides loans to eligible hospitals to establish residency training programs.

‘(b) Application- No loan may be provided under this section to an eligible hospital except pursuant to an application that is submitted and approved in a time, manner, and form specified by the Administrator of the Health Resources and Services Administration. A loan under this section shall be on such terms and conditions and meet such requirements as the Administrator determines appropriate, in accordance with the provisions of this section.

‘(c) Eligibility; Preference for Rural and Small Urban Areas-

‘(1) ELIGIBLE HOSPITAL DEFINED- For purposes of this section, an ‘eligible hospital’ means, with respect to a loan under this section, a hospital that, as of the date of the submission of an application under subsection (b), meets, to the satisfaction of the Administrator of the Health Resources and Services Administration, each of the following criteria:

‘(A) The hospital does not operate a residency training program, has not previously operated such a program, and has not taken any significant action, such as the expenditure of a material amount of funds, before July 1, 2009, to establish such a program.

‘(B) The hospital has secured initial accreditation by the American Council for Graduate Medical Education or the American Osteopathic Association.

‘(C) The hospital provides assurances to the satisfaction of the Administrator of the Health Resources and Services Administration that such loan shall be used, consistent with subsection (d), only for the purposes of establishing and conducting an allopathic or osteopathic physician residency training program in at least one of the following medical specialties, or a combination of the following:

‘(i) Family medicine.

‘(ii) Internal medicine.

‘(iii) Emergency medicine.

‘(iv) Obstetrics or gynecology.

‘(v) General surgery.

‘(vi) Preventive Medicine.

‘(vii) Pediatrics.

‘(viii) Behavioral and Mental Health.

‘(D) The hospital enters into an agreement with the Administrator that certifies the hospital will provide for the repayment of the loan in accordance with subsection (e).

‘(2) PREFERENCE FOR RURAL AND SMALL AREAS- In making loans under this section, the Administrator of the Health Resources and Services Administration shall give preference to any applicant for such a loan that is a hospital located in a rural areas (as such term is defined in section 1886(d)(2)(D) of the Social Security Act) or an urban area that is not a large urban area (as such terms are respectively defined in such section).

‘(d) Permissible Uses of Loan Funds- A loan provided under this section shall be used, with respect to a residency training program, only for costs directly attributable to the residency training program, except as otherwise provided by the Administrator of the Health Resources and Services Administration.

‘(e) Repayment of Loans-

‘(1) REPAYMENT PLANS- For purposes of subsection (c)(1)(D), a repayment plan for an eligible hospital is in accordance with this subsection if it provides for the repayment of the loan amount in installments, in accordance with a schedule that is agreed to by the Administrator of the Health Resources and Services Administration and the hospital and that is in accordance with this subsection.

‘(2) COMMENCEMENT OF REPAYMENT- Repayment by an eligible hospital of a loan under this section shall commence not later than the date that is 18 months after the date on which the loan amount is disbursed to such hospital.

‘(3) REPAYMENT PERIOD- A loan made under this section shall be fully repaid not later than the date that is 24 months after the date on which the repayment is required to commence.

‘(4) LOAN PAYABLE IN FULL IF RESIDENCY TRAINING PROGRAM CANCELED- In the case that an eligible hospital borrows a loan under this section, with respect to a residency training program, and terminates such program before the date on which such loan has been fully repaid in accordance with a plan under paragraph (1), such loan shall be payable by the hospital not later than 45 days after the date of such termination.

‘(f) No Interest Charged- The Administrator of the Health Resources and Services Administration may not charge or collect interest on any loan made under this section.

‘(g) Limitation on Total Amount of Loan- The cumulative dollar amount of a loan made to an eligible hospital under this section may not exceed $1,000,000.

‘(h) Penalties- The Administrator of the Health Resources and Services Administration shall establish penalties to which an eligible hospital receiving a loan under this section would be subject if such hospital is in violation of any of the criteria described in subsection (c)(1).

‘(i) Reports- Not later than January 1, 2014, and annually thereafter (before January 2, 2020), the Administrator of the Health Resources and Services Administration shall submit to Congress a report on the efficacy of the program under this section in increasing the number of residents practicing in each medical specialty described in subsection (c)(1)(C) during such year and the extent to which the program resulted in an increase in the number of available practitioners in each of such medical specialties that serve medically underserved populations.

‘(j) Funding- --

‘(1) AUTHORIZATION OF APPROPRIATIONS- For the purpose of providing amounts for loans under this section, there are authorized to be appropriated $25,000,000 for the period of fiscal years 2010 through 2020.

‘(2) AVAILABILITY- Amounts appropriated under paragraph (1) shall remain available until expended.

‘(3) REPAID LOAN AMOUNTS- Any amount repaid by, or recovered from, an eligible hospital under this section on or before the date of termination described in subsection (k) shall be credited to the appropriation account from which the loan amount involved was originally paid. Any amount repaid by, or recovered from, such a hospital under this section after such date shall be credited to the general fund in the Treasury.

‘(k) Termination of Program- No loan may be made under this section after December 31, 2019.’.

TITLE II--PRIMARY CARE PROVISIONS