Overview
Title
To amend title XVIII of the Social Security Act to extend certain flexibilities and payment adjustments under the Medicare program, and for other purposes.
ELI5 AI
H. R. 8261 is a plan to make Medicare better by keeping video doctor visits, helping hospitals and ambulances, and making sure money is used carefully for medicine and care. It wants doctors to use special tools to check on people and make sure they pay the right amount, but some rules might be a bit confusing.
Summary AI
H. R. 8261 is a bill aimed at extending and enhancing certain provisions of the Medicare program, particularly concerning telehealth services, hospital care, and ambulance services. It seeks to prolong telehealth flexibilities, adjust payments for specific hospitals, and increase transparency in pharmacy benefit management. The bill also proposes studies and reports on wearables and fraud in medical billing, indicating a multi-faceted approach to healthcare improvement and cost management within the Medicare framework.
Published
Keywords AI
Sources
Bill Statistics
Size
Language
Complexity
AnalysisAI
The bill, titled "Preserving Telehealth, Hospital, and Ambulance Access Act", proposes amendments to the Social Security Act, focusing primarily on extending certain flexibilities and payment adjustments under the Medicare program. The main aim appears to be addressing the ongoing need for telehealth solutions, hospital and ambulance services, as well as program integrity within the Medicare framework.
General Summary
Telehealth and Home Care: The bill extends various telehealth services provisions that were originally set to end in 2024, now extending them to 2026. This includes removing geographic restrictions for telehealth, expanding eligible practitioners, and allowing audio-only services, particularly for mental health and hospice care.
Guidance and Reporting: It mandates the creation of guidelines on providing telehealth to individuals with limited English proficiency and requires extensive reporting and transparency regarding pharmacy benefit managers.
Hospital and Emergency Services: The bill extends several hospital-related programs and payment adjustments, such as the Medicare-dependent hospital program, and continues additional payments for ambulance services till October 1, 2025.
Significant Issues
Complexity and Oversight: The bill raises concerns due to its complexity and the lack of detailed oversight, especially in extending telehealth services (Section 101). There is no explicit financial assessment of the impact of these extensions, which could affect Medicare's budget significantly.
Administrative Burden: Section 302 introduces complex rules for pharmacy benefit managers, which may impose a heavy administrative burden due to the extensive reporting required. This could affect the transparency and effectiveness of drug pricing and cost controls.
Justification and Evidence: The extension of certain hospital care waivers and other programs lacks clear evidence of necessity. Without justification, it could lead to unwarranted spending and inefficiencies in how Medicare resources are used.
Public Impact
The bill's impact on the public hinges on its goal of maintaining and enhancing accessibility to vital healthcare services through telehealth and hospital services.
Broad Benefits: For patients, extending telehealth services can offer more flexible access to healthcare, especially essential for those in rural or underserved areas. It also aligns with growing reliance on digital solutions, spurred by recent demands.
Concerns of Quality: However, reliance on audio-only telehealth services could compromise the quality of care, as face-to-face consultations might offer more comprehensive evaluations. There is also a risk that telehealth could widen the health equity gap if not implemented with sufficient access and support for individuals with limited technology skills or language barriers.
Stakeholder Impact
Healthcare Providers and Technology Firms: Providers may benefit from an expanded pool of eligible services but might face uncertainties without clear definitions or billing guidance. Firms involved in telehealth technology stand to gain from increased demand but are tasked with ensuring secure and effective systems, especially for non-English speaking populations.
Medicare Beneficiaries: While they may experience more convenient healthcare access, beneficiaries might also face challenges with audio-only consultations or a lack of in-person evaluations for certain conditions.
Pharmacy Benefit Managers (PBM): The bill imposes significant new requirements on PBMs, increasing transparency but also potentially increasing costs and operational challenges. These firms must navigate extensive reporting, which might impact their profit margins or operational efficiency. The ultimate effect might ripple down to consumers through changes in drug availability and pricing policies.
Overall, the bill aims for broader healthcare access and enhanced Medicare services but brings with it questions about financial oversight, quality assurance, and execution feasibility amidst the complexities of healthcare provision and administration.
Financial Assessment
Summary of Financial Allocations
The bill H.R. 8261 makes several financial allocations, particularly in relation to the Medicare program's operations and transparency initiatives. Notably, Section 302 involves significant funding appropriations. It specifies that $113,000,000 is allocated to the Centers for Medicare & Medicaid Services Program Management Account and an additional $20,000,000 to the Inspector General of the Department of Health and Human Services. These funds are designated for the fiscal year 2025 and are intended to support the implementation of the subsection concerning pharmacy benefit managers.
Financial Implications in Relation to Issues
Complex Reporting Requirements for Pharmacy Benefit Managers (Section 302): The appropriated funds in Section 302 aim to enforce transparency and accountability among pharmacy benefit managers through rigorous reporting requirements. This substantial allocation highlights the legislative intent to ensure compliance and oversight, mitigating potential issues regarding the lack of enforcement mechanisms if information is withheld. However, this approach may simultaneously impose administrative burdens on these entities, as noted in the identified issues.
Potential Administrative Burden and Lack of Justification (Sections 104 and 105): While there are no direct appropriations mentioned for the extension of the acute hospital care at home waiver flexibilities (Section 104) or the report on wearable medical devices (Section 105), these sections indirectly address spending and resources. The absence of justifications or evaluations for extending certain programs can imply ongoing financial commitments without clear evidence of their benefits. The allocated funds are aimed at improving oversight and compliance, but similar financial considerations within other sections are not explicitly detailed, potentially leading to prolonged or unchecked spending.
Impacts of Financial Allocations on Medicare Payment Procedures (Section 301): The revising phase-in of Medicare clinical laboratory test payment changes can have indirect financial impacts. By allowing the Secretary of Health and Human Services to implement changes without a full regulatory process, there could be unforeseen effects on how these payments are managed financially. Although no specific appropriations are detailed here, the implications on Medicare's financial transparency are significant.
Overall, the financial references within the bill are directed towards enhancing accountability and transparency, especially regarding pharmacy benefit management. However, the broader financial implications related to extending programs and services are less explicit, potentially allowing for issues of oversight and effective use of resources within the Medicare framework.
Issues
The extension of telehealth services (Section 101) raises significant concerns about financial implications, oversight, and quality of care. The bill does not provide specific financial assessments or potential financial impacts, which could lead to budgetary issues. Additionally, the provision allowing for audio-only telehealth services might compromise the quality of care.
The section on arrangements with pharmacy benefit managers (Section 302) is complex, with extensive reporting requirements that may impose administrative burdens on the managers. There is also potential ambiguity regarding enforcement mechanisms if the required information is withheld, raising concerns about accountability.
The extension of acute hospital care at home waiver flexibilities (Section 104) from 2024 to 2029 lacks justification or evidence for the need of such an extension. This could result in prolonged spending without demonstrating clear benefits, raising concerns about the effective use of resources.
The guidance on furnishing services via telehealth to individuals with limited English proficiency (Section 102) faces potential implementation challenges due to vague terms like 'best practices', absence of metrics to evaluate efficacy, and no clear enforcement mechanisms. This could lead to inconsistent application and a lack of accountability in addressing needs of individuals with limited English proficiency.
The revising phase-in of Medicare clinical laboratory test payment changes (Section 301) may bypass formal regulatory processes with the Secretary of Health and Human Services implementing changes through program instruction or otherwise. This raises oversight concerns and could impact the transparency and financial projections of Medicare payment calculations.
The establishment of a modifier for recertifications of hospice care eligibility conducted through telehealth (Section 103) lacks clarity on specific codes or modifiers required, potentially leading to confusion and inconsistent application in claims processing.
The report on wearable medical devices (Section 105) may lack clarity on the scope and evaluation criteria, potentially leading to subjective interpretations of benefits and challenges, raising concerns about the implementability and accuracy of policy recommendations.
Sections
Sections are presented as they are annotated in the original legislative text. Any missing headers, numbers, or non-consecutive order is due to the original text.
1. Short title Read Opens in new tab
Summary AI
The first section of the bill is titled "Preserving Telehealth, Hospital, and Ambulance Access Act" and indicates that this is the short title by which the act may be formally referred to.
101. Extension of certain telehealth flexibilities Read Opens in new tab
Summary AI
The section of the bill extends certain telehealth flexibilities under the Social Security Act by changing the expiration date for many telehealth provisions from December 31, 2024, to December 31, 2026. These changes include expanding eligible practitioners, delaying in-person requirements for mental health services, and continuing the use of audio-only telehealth services and telehealth for hospice care eligibility recertification.
102. Guidance on furnishing services via telehealth to individuals with limited English proficiency Read Opens in new tab
Summary AI
The bill requires the Secretary of Health and Human Services to create guidelines for providing telehealth services to people who don't speak English well, with a focus on using interpreters, improving access to digital tools, and offering materials in multiple languages. These guidelines will be developed in consultation with different organizations, like healthcare providers, language service companies, and patient advocates.
103. Establishment of modifier for recertifications of hospice care eligibility conducted through telehealth Read Opens in new tab
Summary AI
The amendment to the Social Security Act requires that two years after the enactment of the "Preserving Telehealth, Hospital, and Ambulance Access Act," healthcare providers, like doctors or nurse practitioners, must use certain codes or modifiers in their claims when they perform hospice care recertifications via telehealth.
104. Extending acute hospital care at home waiver flexibilities Read Opens in new tab
Summary AI
The section modifies the Social Security Act to extend the "Acute Hospital Care at Home" program until 2029, and mandates two studies and reports to examine the quality of care, outcomes, and costs associated with this initiative by comparing patients admitted through emergency departments versus those from existing hospital stays.
105. Report on wearable medical devices Read Opens in new tab
Summary AI
The section requires the Comptroller General to assess and report to Congress on wearable medical devices. This report will focus on how these devices can assist in clinical decision-making, evaluating their accuracy, the role of artificial intelligence, and recommend policies to maximize benefits and address any challenges.
106. Enhancing certain program integrity requirements for DME under Medicare Read Opens in new tab
Summary AI
The bill section aims to improve monitoring of payments for Durable Medical Equipment (DME) under Medicare by including certain items on a Master List for review if they show unusual billing patterns. It also requires a report by January 1, 2026, to Congress on the risk and reduction of fraudulent claims for clinical diagnostic lab tests, identifying high-risk tests, and suggesting methods to reduce fraud.
201. Extension of increased inpatient hospital payment adjustment for certain low-volume hospitals Read Opens in new tab
Summary AI
The bill amends the section of the Social Security Act related to payment adjustments for certain low-volume hospitals, extending increased payments throughout the entirety of fiscal year 2025. It allows the Secretary of Health and Human Services to implement these changes through various means, regardless of other laws.
202. Extension of the Medicare-dependent hospital program Read Opens in new tab
Summary AI
The section extends the deadline for the Medicare-dependent hospital program and related provisions from January 1, 2025, to October 1, 2025. It also modifies the criteria for target amounts and allows hospitals the option to decline reclassification for the year 2025.
203. Extension of add-on payments for ambulance services Read Opens in new tab
Summary AI
The section amends the Social Security Act to extend the expiration date for certain additional payments for ambulance services from January 1, 2025, to October 1, 2025. It also allows the Secretary of Health and Human Services to implement these changes through program instructions or other methods.
301. Revising phase-in of Medicare clinical laboratory test payment changes Read Opens in new tab
Summary AI
The section changes the timeline for adjustments to how Medicare pays for clinical laboratory tests, specifically delaying certain payment reductions and reporting timelines by one year. It allows the Secretary of Health and Human Services to implement these changes through program instructions or other means.
302. Arrangements with pharmacy benefit managers with respect to prescription drug plans and MA–PD plans Read Opens in new tab
Summary AI
In this section, Congress introduces new rules for how pharmacy benefit managers (PBMs) should operate with prescription drug plans starting in 2027. These rules aim to ensure transparency in pricing, limit the types of income PBMs can receive, and require detailed reporting of drug costs and fees to prevent conflicts of interest and promote fair practices.
Money References
- (1) PRESCRIPTION DRUG PLANS.—Section 1860D–12 of the Social Security Act (42 U.S.C. 1395w–112) is amended by adding at the end the following new subsection: “(h) Requirements relating to pharmacy benefit managers.—For plan years beginning on or after January 1, 2027: “(1) AGREEMENTS WITH PHARMACY BENEFIT MANAGERS.—Each contract entered into with a PDP sponsor under this part with respect to a prescription drug plan offered by such sponsor shall provide that any pharmacy benefit manager acting on behalf of such sponsor has a written agreement with the PDP sponsor under which the pharmacy benefit manager, and any affiliates of such pharmacy benefit manager, as applicable, agree to meet the following requirements: “(A) NO INCOME OTHER THAN BONA FIDE SERVICE FEES.— “(i) IN GENERAL.—The pharmacy benefit manager and any affiliate of such pharmacy benefit manager shall not derive any remuneration with respect to any services provided on behalf of any entity or individual, in connection with the utilization of covered part D drugs, from any such entity or individual other than bona fide service fees, subject to clauses (ii) and (iii). “(ii) INCENTIVE PAYMENTS.—For the purposes of this subsection, an incentive payment paid by a PDP sponsor to a pharmacy benefit manager that is performing services on behalf of such sponsor shall be deemed a ‘bona fide service fee’(even if such payment does not otherwise meet the definition of such term under paragraph (7)(B)) if such payment is a flat dollar amount, is consistent with fair market value (as specified by the Secretary), is related to services actually performed by the pharmacy benefit manager or affiliate of such pharmacy benefit manager, on behalf of the entity making such payment, in connection with the utilization of covered part D drugs, and meets additional requirements, if any, as determined appropriate by the Secretary.
- Such fee must be a flat dollar amount and shall not be directly or indirectly based on, or contingent upon— “(i) drug price, such as wholesale acquisition cost or drug benchmark price (such as average wholesale price); “(ii) the amount of discounts, rebates, fees, or other direct or indirect remuneration with respect to covered part D drugs dispensed to enrollees in a prescription drug plan, except as permitted pursuant to paragraph (1)(A)(ii); “(iii) coverage or formulary placement decisions or the volume or value of any referrals or business generated between the parties to the arrangement; or “(iv) any other amounts or methodologies prohibited by the Secretary. “(C) PHARMACY BENEFIT MANAGER.—The term ‘pharmacy benefit manager’ means any person or entity that, either directly or through an intermediary, acts as a price negotiator or group purchaser on behalf of a PDP sponsor or prescription drug plan, or manages the prescription drug benefits provided by such sponsor or plan, including the processing and payment of claims for prescription drugs, the performance of drug utilization review, the processing of drug prior authorization requests, the adjudication of appeals or grievances related to the prescription drug benefit, contracting with network pharmacies, controlling the cost of covered part D drugs, or the provision of related services.
- Such term includes any person or entity that carries out one or more of the activities described in the preceding sentence, irrespective of whether such person or entity calls itself a ‘pharmacy benefit manager’.”. (2) MA–PD PLANS.—Section 1857(f)(3) of the Social Security Act (42 U.S.C. 1395w–27(f)(3)) is amended by adding at the end the following new subparagraph: “(F) REQUIREMENTS RELATING TO PHARMACY BENEFIT MANAGERS.—For plan years beginning on or after January 1, 2027, section 1860D–12(h).”. (3) NONAPPLICATION OF PAPERWORK REDUCTION ACT.—Chapter 35 of title 44, United States Code, shall not apply to the implementation of this subsection. (4) FUNDING.— (A) SECRETARY.—In addition to amounts otherwise available, there is appropriated to the Centers for Medicare & Medicaid Services Program Management Account, out of any money in the Treasury not otherwise appropriated, $113,000,000 for fiscal year 2025, to remain available until expended, to carry out this subsection. (B) OIG.—In addition to amounts otherwise available, there is appropriated to the Inspector General of the Department of Health and Human Services, out of any money in the Treasury not otherwise appropriated, $20,000,000 for fiscal year 2025, to remain available until expended, to carry out this subsection.
303. Extending the adjustment to the calculation of hospice cap amounts under the Medicare program Read Opens in new tab
Summary AI
The section amends the Social Security Act to extend the timeframe for calculating certain hospice cap amounts under the Medicare program by one year, changing the end date from 2033 to 2034.