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Code · BILL · 118th Congress · S. 5633 (Introduced in Senate) — To establish Medicare flex fund accounts and for other purposes. · Sec. 6

Sec. 6. Voluntary patient driven benefit flexibility

1,262 words·~6 min read·/bill/118/s/5633/is/section-6·

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Not later than 90 days after the date of enactment of this Act, the Administrator of the Centers for Medicare & Medicaid Services (referred to in this subsection as the Administrator ) shall establish a Direct Primary Care Payment Advisory Group (referred to in the subsection as the Advisory Group ). The Advisory Group shall be composed of the following individuals or the designees of those individuals: The Administrator. The Chair of the Medicare Payment Advisory Commission.
Two primary care physicians with experience in direct primary care. Two specialist physicians who provide primary care services to patients with chronic diseases with experience in direct primary care. Two representatives of Medicare Advantage plans. Two health actuaries. Two representatives of think tanks with a health policy background. Any other individual the Administrator determines appropriate. A member of the Advisory Group shall serve without compensation in addition to any compensation received for the service of the member as an officer or employee of the United States, if applicable.
The Advisory Group shall determine— a definition of primary care benefits provided under Medicare Advantage plans; and how best to calculate the amount Medicare Advantage plans would save if patients, including patients that have chronic conditions and for whom primary care is provided by a specialist physician, were to contract with providers of primary care on their own without using health insurance. Not later than 180 days after the first meeting of the Advisory Group, the Advisory Group shall submit a report to the Secretary of Health and Humans Services detailing its recommendations.
Section 1852(a)(1) of the Social Security Act ( 42 U.S.C. 1395w–22(a)(1) ) is amended— in subparagraph (A), by inserting and the patient flexibility and bundled payment requirements described in subparagraph
(C)after under section 1854(f)(1)(A)) ; and by adding at the end the following new subparagraph: Beginning with plan years beginning on or after January 1, 2027, each Medicare Advantage plan shall allow enrollees to elect to receive a direct primary care benefit payment, described in subclause (II), in lieu of receiving coverage of primary care benefits (as defined by the Secretary taking into account the recommendations of the Direct Primary Care Payment Advisory Group established under section 6(a) of the Medicare Flex Fund Accounts and Flexible Benefits Act of 2024 ) under the Medicare Advantage plan. The direct primary care benefit payment for an enrollee shall be— equal to the amount of the average per capita savings to the Medicare Advantage plan by not providing coverage of primary care benefits under such plan to such enrollee (as determined by the Secretary taking into account the recommendations of the Direct Primary Care Payment Advisory Group established under section 6(a) of the Medicare Flex Fund Accounts and Flexible Benefits Act of 2024 ); and deposited into the Medicare flex fund account (as defined in section 530A of the Internal Revenue Code of 1986 and referred to in this subparagraph as a Medicare FFA ) of such enrollee. Subject to item (bb), during the period beginning on January 1 and ending on March 31 of each plan year, an enrollee may elect to receive the direct primary care benefit payment for that year. If an enrollee makes the election described in item (aa), the enrollee may elect to stop receiving the direct primary care benefit payment and begin to receive primary care benefits under the Medicare Advantage plan for the remainder of that calendar year. If an enrollee makes the election described in item (aa), the enrollee shall continue to receive the direct primary care benefit payment until the enrollee elects to receive primary care benefits under the Medicare Advantage plan for the year during the period described in such item, the enrollee makes the election described in subitem (AA), or the enrollee changes Medicare Advantage plans. If an enrollee changes Medicare Advantage plans as described in subitem (BB), the enrollee may elect to receive the direct primary care benefit payment or to receive primary care benefits under the Medicare Advantage plan for the remainder of the year. Beginning with plan years beginning on or after January 1, 2027, each Medicare Advantage plan shall allow enrollees to receive a payment from such plan that meets the requirements of subclause
(II)and allows enrollees to receive treatment from a pre-approved alternate provider. The payment described in subclause
(I)shall— be the same amount that would have been paid to an in-network provider and include any processing costs; and be deposited in the Medicare FFA of the enrollee once a contract has been signed by the enrollee, the Medicare Advantage plan, and the alternative provider to provide treatment to the member. Each Medicare Advantage plan may develop a list of pre-approved alternate providers and information regarding the price, treatment outcomes, and customer experience of each pre-approved alternate provider for certain treatments, procedures, and episodes of care. If a Medicare Advantage plan chooses to develop such list, the Medicare Advantage plan shall provide such list to an enrollee upon the request of such enrollee. Each Medicare Advantage plan shall provide the list described in item
(aa)before the enrollee requests such list if it could result in the enrollee receiving treatment for a lesser price. No Medicare Advantage plan shall charge a provider for being on a list described in item (aa). For the purposes of this clause, the term pre-approved alternate provider means a provider of services or a supplier— located in the United States or a territory of the United States; licensed by the State or territory in which the provider furnishes services; willing to provide services on a cash basis; and that has received the review described in subclause (V). Before an enrollee has received treatment by a pre-approved alternative provider, the Medicare Advantage plan shall review any contracts or documents relating to the treatment provided by such provider to ensure that— any enrollee who elects to receive treatment by the provider will receive appropriate health quality and the desired treatment outcome; and to protect the enrollee from hidden fees or surprise bills, the cost of the service quoted by the pre-approved alternative provider will be the total price paid by the enrollee. Nothing in this subparagraph shall be construed to limit any responsibility of a Medicare Advantage plan under this part, to reduce the actuarial value of such a plan, or to change any network adequacy requirement. . Section 1860D–4 of the Social Security Act ( 42 U.S.C. 1395w–104 ) is amended by adding at the end the following new subsection: In the case of a covered part D drug on the formulary of a prescription drug plan or an MA–PD plan, the plan shall, if requested by an enrollee of such plan, provide such enrollee with a payment described in paragraph
(2)in lieu of the plan paying for such covered part D drug under the plan. The payment described in paragraph
(1)shall be an amount equal to the amount the prescription drug plan or MA–PD plan would reimburse a preferred pharmacy for such covered part D drug plus any fees that would be paid to such plan (or a subsidiary of such plan) by the manufacturer of such covered part D drug. . Section 1859 of the Social Security Act ( 42 U.S.C. 1395w–28 ) is amended by adding at the end the following new subsection: Any amount spent by an enrollee from payments made by an MA plan under section 1852(a)(1)(C) or 1860D–4(p) shall not count towards any deductible or maximum limitation on out-of-pocket expenses applicable to such MA plan. .
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3 references not yet in our index
  • 42 USC 1395w–22(a)(1)
  • 42 USC 1395w–104
  • 42 USC 1395w–28
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cites case law
Sec. 6
Voluntary patient driven benefit flexibility
Cite42 USC 1395w–22(a)(1)
Cite42 USC 1395w–104
Cite42 USC 1395w–28
Cites 3Cited by 0 across 0 sources
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