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United States Code (Last Updated: May 24, 2014) |
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Title 42. THE PUBLIC HEALTH AND WELFARE |
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Chapter 7. SOCIAL SECURITY |
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SubChapter XI. GENERAL PROVISIONS, PEER REVIEW, AND ADMINISTRATIVE SIMPLIFICATION |
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Part A. General Provisions |
§ 1315a. Center for Medicare and Medicaid Innovation
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(a) Center for Medicare and Medicaid Innovation established (1) In general There is created within the Centers for Medicare & Medicaid Services a Center for Medicare and Medicaid Innovation (in this section referred to as the “CMI”) to carry out the duties described in this section. The purpose of the CMI is to test innovative payment and service delivery models to reduce program expenditures under the applicable subchapters while preserving or enhancing the quality of care furnished to individuals under such subchapters. In selecting such models, the Secretary shall give preference to models that also improve the coordination, quality, and efficiency of health care services furnished to applicable individuals defined in paragraph (4)(A).
(2) Deadline The Secretary shall ensure that the CMI is carrying out the duties described in this section by not later than
January 1, 2011 .(3) Consultation In carrying out the duties under this section, the CMI shall consult representatives of relevant Federal agencies, and clinical and analytical experts with expertise in medicine and health care management. The CMI shall use open door forums or other mechanisms to seek input from interested parties.
(4) Definitions In this section: (A) Applicable individual The term “applicable individual” means— (i) an individual who is entitled to, or enrolled for, benefits under part A of subchapter XVIII or enrolled for benefits under part B of such subchapter; (ii) an individual who is eligible for medical assistance under subchapter XIX, under a State plan or waiver; or (iii) an individual who meets the criteria of both clauses (i) and (ii). (B) Applicable subchapter The term “applicable subchapter” means subchapter XVIII, subchapter XIX, or both.
(5) Testing within certain geographic areas For purposes of testing payment and service delivery models under this section, the Secretary may elect to limit testing of a model to certain geographic areas.
(b) Testing of models (phase I) (1) In general The CMI shall test payment and service delivery models in accordance with selection criteria under paragraph (2) to determine the effect of applying such models under the applicable subchapter (as defined in subsection (a)(4)(B)) on program expenditures under such subchapters and the quality of care received by individuals receiving benefits under such subchapter.
(2) Selection of models to be tested (A) In general The Secretary shall select models to be tested from models where the Secretary determines that there is evidence that the model addresses a defined population for which there are deficits in care leading to poor clinical outcomes or potentially avoidable expenditures. The Secretary shall focus on models expected to reduce program costs under the applicable subchapter while preserving or enhancing the quality of care received by individuals receiving benefits under such subchapter. The models selected under this subparagraph may include, but are not limited to, the models described in subparagraph (B).
(B) Opportunities The models described in this subparagraph are the following models: (i) Promoting broad payment and practice reform in primary care, including patient-centered medical home models for high-need applicable individuals, medical homes that address women’s unique health care needs, and models that transition primary care practices away from fee-for-service based reimbursement and toward comprehensive payment or salary-based payment. (ii) Contracting directly with groups of providers of services and suppliers to promote innovative care delivery models, such as through risk-based comprehensive payment or salary-based payment. (iii) Utilizing geriatric assessments and comprehensive care plans to coordinate the care (including through interdisciplinary teams) of applicable individuals with multiple chronic conditions and at least one of the following: (I) An inability to perform 2 or more activities of daily living. (II) Cognitive impairment, including dementia. (iv) Promote subchapter without reducing the quality of care; or (B) improve the quality of patient care without increasing spending; (2) the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such expansion would reduce (or would not result in any increase in) net program spending under applicable subchapters; and (3) the Secretary determines that such expansion would not deny or limit the coverage or provision of benefits under the applicable subchapter for applicable individuals. In determining which models or demonstration projects to expand under the preceding sentence, the Secretary shall focus on models and demonstration projects that improve the quality of patient care and reduce spending. (d) Implementation (1) Waiver authority The Secretary may waive such requirements of subchapters XI and XVIII and of sections 1396a(a)(1), 1396a(a)(13), and 1396b(m)(2)(A)(iii) of this title as may be necessary solely for purposes of carrying out this section with respect to testing models described in subsection (b).
(2) Limitations on review There shall be no administrative or judicial review under section 1395ff of this title, section 1395oo of this title, or otherwise of— (A) the selection of models for testing or expansion under this section; (B) the selection of organizations, sites, or participants to test those models selected; (C) the elements, parameters, scope, and duration of such models for testing or dissemination; (D) determinations regarding budget neutrality under subsection (b)(3); (E) the termination or modification of the design and implementation of a model under subsection (b)(3)(B); and (F) determinations about expansion of the duration and scope of a model under subsection (c), including the determination that a model is not expected to meet criteria described in paragraph (1) or (2) of such subsection. (3) Administration Chapter 35 of title 44 shall not apply to the testing and evaluation of models or expansion of such models under this section.
(e) Application to CHIP The Center may carry out activities under this section with respect to subchapter XXI in the same manner as provided under this section with respect to the program under the applicable subchapters.
(f) Funding (1) In general There are appropriated, from amounts in the Treasury not otherwise appropriated— (A) $5,000,000 for the design, implementation, and evaluation of models under subsection (b) for fiscal year 2010; (B) $10,000,000,000 for the activities initiated under this section for the period of fiscal years 2011 through 2019; and (C) the amount described in subparagraph (B) for the activities initiated under this section for each subsequent 10-year fiscal period (beginning with the 10-year fiscal period beginning with fiscal year 2020). Amounts appropriated under the preceding sentence shall remain available until expended. (2) Use of certain funds Out of amounts appropriated under subparagraphs (B) and (C) of paragraph (1), not less than $25,000,000 shall be made available each such fiscal year to design, implement, and evaluate models under subsection (b).
(g) Report to Congress Beginning in 2012, and not less than once every other year thereafter, the Secretary shall submit to Congress a report on activities under this section. Each such report shall describe the models tested under subsection (b), including the number of individuals described in subsection (a)(4)(A)(i) and of individuals described in subsection (a)(4)(A)(ii) participating in such models and payments made under applicable subchapters for services on behalf of such individuals, any models chosen for expansion under subsection (c), and the results from evaluations under subsection (b)(4). In addition, each such report shall provide such recommendations as the Secretary determines are appropriate for legislative action to facilitate the development and expansion of successful payment models.
References In Text
Section 4016 of the Balanced Budget Act of 1997, referred to in subsec. (b)(2)(B)(xx), is section 4016 of Pub. L. 105–33, which is set out as a note under section 1395b–1 of this title.
Amendments
2010—Subsec. (a)(5). Pub. L. 111–148, § 10306(1), added par. (5).
Subsec. (b)(2)(A). Pub. L. 111–148, § 10306(2)(A), inserted “The Secretary shall focus on models expected to reduce program costs under the applicable subchapter while preserving or enhancing the quality of care received by individuals receiving benefits under such subchapter.” after the first sentence and substituted “this subparagraph may include, but are not limited to,” for “the preceding sentence may include”.
Subsec. (b)(2)(B)(xix), (xx). Pub. L. 111–148, § 10306(2)(B), added cls. (xix) and (xx).
Subsec. (b)(2)(C)(viii). Pub. L. 111–148, § 10306(2)(C), added cl. (viii).
Subsec. (b)(4)(C). Pub. L. 111–148, § 10306(3), added subpar. (C).
Subsec. (c). Pub. L. 111–148, § 10306(4)(C), inserted concluding provisions.
Subsec. (c)(1)(B). Pub. L. 111–148, § 10306(4)(A), substituted “patient care without increasing spending;” for “care and reduce spending; and”.
Subsec. (c)(2). Pub. L. 111–148, § 10306(4)(B), substituted “reduce (or would not result in any increase in) net program spending under applicable subchapters; and” for “reduce program spending under applicable subchapters.”
Subsec. (c)(3). Pub. L. 111–148, § 10306(4)(C), added par. (3).
Miscellaneous
Pub. L. 111–148, title II, § 2705,