Sec. 2. Medicare Better Health Rewards Program
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Part B of title XVIII of the Social Security Act ( 42 U.S.C. 1395j et seq. ) is amended by adding at the end the following new section: The Secretary shall establish a Better Health Rewards Program (in this section referred to as the Program ) under which incentives are provided to Medicare beneficiaries who voluntarily agree to participate in the Program. A health professional participating in the Program shall provide their patients who are Medicare beneficiaries with a description of and an opportunity to enroll in the Program on a voluntary basis.
If a Medicare beneficiary elects to enroll in the Program, the health professional shall inform the Secretary of the individual's enrollment through a process established by the Secretary, which does not impose additional administrative requirements on the participating health professional. The Secretary shall establish standards for measuring better health targets and points for achieving such standards for participating Medicare beneficiaries, including such standards and points with respect to the following:
Annual wellness visit. Tobacco cessation. Body Mass Index (BMI). Diabetes screening test. Cardiovascular disease screening. Cholesterol level screening. Screening tests and specified vaccinations. In establishing standards and points for achieving such standards under this subsection, the Secretary— shall consult with 1 or more nationally recognized health care quality organizations, as determined appropriate by the Secretary; and may consult with physicians and other professionals experienced with wellness programs.
The number of points awarded for a year for achieving standards with respect to each of the targets described in clauses
(i)through
(vii)of subparagraph
(A)shall not exceed 5. Such points may be awarded on a sliding scale, based on standards established under this subsection, as determined appropriate by the Secretary. The Secretary may modify standards for measuring better health targets and, subject to paragraph (1)(C), points for achieving such standards for participating Medicare beneficiaries under this subsection. In modifying standards and points for achieving such standards under this paragraph, the Secretary— shall consult with 1 or more nationally recognized health care quality organizations, as determined appropriate by the Secretary; and may consult with physicians and other professionals experienced with wellness programs. Subject to subparagraph (B), the Program shall be conducted for not less than a 3-year period. The Secretary shall expand the duration and scope of the Program, to the extent determined appropriate by the Secretary, if— the Secretary determines that such expansion is expected to— reduce spending under this title without reducing the quality of care; or improve the quality of care and reduce spending; the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such expansion would reduce program spending under this title; and the Secretary determines that such expansion would not deny or limit the coverage or provision of benefits under this title for individuals. During the first year of the Program, a health professional shall establish and report to the Secretary baseline information for each participating Medicare beneficiary who is a patient of the health professional as part of that beneficiary’s first year assessment under paragraph (3)(A). The health professional shall use such data to aid in the determination of whether and to what extent the participating Medicare beneficiary is meeting the target standards under subsection
(c)in each of years 2 and 3 of the Program. During year 1 of the Program, a health professional shall furnish to each participating Medicare beneficiary that is a patient of the health professional either an annual wellness visit or an initial preventive physical examination. During each of years 2 and 3 of the Program, a health professional shall furnish to each participating Medicare beneficiary that is a patient of the health professional an annual wellness visit to determine whether and to what extent the participating Medicare beneficiary has met the target standards under subsection (c). During each of years 2 and 3 of the Program, a health professional shall— evaluate and report to the Secretary whether each participating Medicare beneficiary that is a patient of the health professional has achieved the target standards under subsection (c); and determine the total amount of points that each such participating Medicare beneficiary has achieved for the year based on the points assigned for achieving such standards under subsection (c). The Secretary shall pay to each participating Medicare beneficiary who achieves at least 20 points under paragraph (1)(B) for the year an incentive payment. Such payment shall be equal to an amount determined appropriate by the Secretary, but no case shall such amount exceed the following: Points Year 2 Payment Amount Year 3 or a Subsequent Year Payment Amount 20–24 points $100 $200 25 or more points $200 $400. The dollar amounts specified in this paragraph shall be increased, beginning with 2017, from year to year based on the percentage increase in the consumer price index for all urban consumers (all items; United States city average), rounded to the nearest $1. Under the Program, a participating health professional shall make the final determination as to whether or not a participating Medicare beneficiary has met the target standards under subsection
(c)and what screening tests and specified vaccinations, or other services, are necessary for purposes of making such determination. The Secretary shall collect relevant data, including data on claims paid under this title for services furnished to participating Medicare beneficiaries during the Program, for purposes of determining the aggregate estimated savings achieved under this title for participating Medicare beneficiaries during each of years 2 and 3 of the Program in accordance with paragraph
(2)(and for a subsequent year if the Program is expanded under subsection (d)(1)(B)). The amount of the aggregate estimated savings under this title for participating Medicare beneficiaries under paragraph (1), with respect to a year, shall be equal to— the estimated savings determined under subparagraph
(B)for the year; minus the aggregate incentive payments made under the Program during the year. For purposes of subparagraph (A)(i), the estimated savings determined under this subparagraph for a year shall be equal to— the estimated aggregate expenditures under this title (as projected under subparagraph (C)) for the year; minus the actual aggregate expenditures under this title (as determined by the Secretary and taking into account any reduction in specific health risks of the participating Medicare beneficiaries) for the year. The Secretary shall establish a benchmark base year amount of expenditures under this title for participating Medicare beneficiaries during year 1 of the Program. The Secretary shall use the benchmark base year amount established under clause
(i)to project the estimated aggregate expenditures for all participating Medicare beneficiaries during each of years 2 and 3 of the Program as if the beneficiaries were not participating in the Program. In making such projection, the Secretary may include adjustments for health status or other specific risk factors and geographic variation for the participating Medicare beneficiaries. Not later than 90 days after determining the aggregate estimated savings (if any) under subparagraph
(A)with respect to a year, the Secretary shall make available to the public a report containing a description of the amount of the savings determined, including the methodology and any other calculations or determinations involved in the determination of such amount. Such report shall include— a description of any reduction in specific health risks of participating Medicare beneficiaries identified by the Secretary; a description of— standards for measuring better health targets under subsection (c); and the points available for achieving each such standard under that subsection; and recommendations for such legislation and administrative action as the Secretary determines appropriate. During the operation of the Program, the Chief Actuary of the Centers for Medicare & Medicaid Services shall— monitor the Program to determine whether or not the Program is reducing aggregate expenditures under this title; and submit to the Secretary an annual report on the results of such monitoring. If the Secretary, taking into account the reports under paragraph (3)(B), determines that the aggregate expenditures under this title exceed the aggregate expenditures under this title that would have been made if the Program had not been implemented, the Secretary shall provide for changes to the provisions of the program in order to eliminate such excess. The Secretary may waive such requirements of titles XI and XVIII as may be necessary to carry out the purposes of the Program established under this section. In this section: The term annual wellness visit includes personalized prevention plan services (as defined in section 1861(hhh)(1)). The term health professional includes a physician (as defined in section 1861(r)(1)) and a practitioner described in clause
(i)of section 1842(b)(18)(C). The term initial preventive physical examination has the meaning given that term in section 1861(ww)(1). The term Medicare beneficiary means an individual enrolled in part B. The term participating Medicare beneficiary means a Medicare beneficiary who enrolls in the Program under subsection (b). The term screening tests means any of the following that are determined by a health professional to be appropriate for a participating Medicare beneficiary: Colorectal cancer screening tests (as defined in section 1861(pp)). Screening mammography (as described in section 1861(jj)). Screening pap smear and screening pelvic exam (as defined in section 1861(nn)). Screening for glaucoma (as defined in section 1861(uu)). Bone mass measurement (as defined in section 1861(rr)) for qualified individuals described in paragraph (2)(A) of such section. HIV screening for high-risk groups (as identified by the Secretary). The term specified vaccinations means the vaccinations described in section 1861(ww)(1) that are determined by a health professional to be appropriate for a participating Medicare beneficiary. .
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Sec. 2
Medicare Better Health Rewards Program
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