117th CONGRESS 1st Session |
To amend title XVIII of the Social Security Act to require the inclusion of certain audio-only diagnoses in the determination of risk adjustment for Medicare Advantage plans and PACE programs, and for other purposes.
March 23, 2021
Ms. Sewell (for herself, Mr. Bilirakis, Mr. Cárdenas, Mrs. Walorski, Mr. Kind, Mr. Smith of Missouri, Ms. Houlahan, and Mr. Fitzpatrick) introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned
To amend title XVIII of the Social Security Act to require the inclusion of certain audio-only diagnoses in the determination of risk adjustment for Medicare Advantage plans and PACE programs, and for other purposes.
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,
This Act may be cited as the “Ensuring Parity in MA and PACE for Audio-Only Telehealth Act of 2021”.
SEC. 2. Requiring the inclusion of certain audio-only diagnoses in the determination of risk adjustment for Medicare Advantage plans and PACE programs.
(a) In general.—Section 1853(a)(1) of the Social Security Act (42 U.S.C. 1395w–23(a)(1)) is amended by adding at the end the following new subparagraph:
“(J) INCLUSION OF CERTAIN AUDIO-ONLY DIAGNOSES FOR PURPOSES OF RISK ADJUSTMENT.—
“(i) IN GENERAL.—For purposes of determining the appropriate adjustment for health status under subparagraph (C)(i) for plan years 2020 and 2021 (and for such other plan years determined appropriate by the Secretary), the Secretary, in determining the diseases or conditions of an individual, shall take into account diagnoses obtained through a telehealth encounter, and in the case of a qualified diagnosis (as defined in clause (ii)) made with respect to such individual by a qualified provider (as so defined), shall not require the use of video communications with respect to such telehealth encounter.
“(ii) DEFINITIONS.—For purposes of this subparagraph:
“(I) QUALIFIED DIAGNOSIS.—The term ‘qualified diagnosis’ means a diagnosis made with respect to a chronic disease or condition of an individual during a plan year if such diagnosis was also made with respect to such individual in one of the last of the 3 plan years preceding such plan year.
“(II) QUALIFIED PROVIDER.—The term ‘qualified provider’ means, with respect to a qualified diagnosis made with respect to an individual during a plan year, a provider of services, clinician or supplier that—
“(aa) furnished an item or service to such individual during the 3-year period ending on the date such diagnosis was so made; or
“(bb) is in the same practice (as determined by tax identification number) of a provider of services or supplier who furnished such an item or service to such individual during such period.”.
(b) PACE program conforming amendment.—Section 1894(d)(2) of the Social Security Act (42 U.S.C. 1395eee(d)(2)) is amended by adding at the end the following new sentence: “For purposes of applying the adjustment under subparagraph (C)(i) of section 1853(a)(1) to such amounts, subparagraph (J) of such section shall be applied as if each reference to ‘plan year’ and ‘plan years 2020 and 2021’ were instead a reference to ‘year’ and ‘2020 and 2021’, respectively.”.
SEC. 3. Requiring parity in telehealth payments during the COVID–19 emergency.
Section 1834(m) of the Social Security Act (42 U.S.C. 1395m(m)) is amended by adding at the end the following new paragraph:
“(9) SPECIAL RULE FOR TELEHEALTH PAYMENT PARITY DURING THE COVID–19 EMERGENCY.—In the case of a telehealth service furnished during the emergency period described in section 1135(g)(1)(B) for which payment may be made under this subsection (including any service for which payment may be so made due to application of a waiver made under section 1135(b)), the amount of such payment shall be equal to the amount that would have been paid for such service had such service been furnished in-person.”.