Modifying payment rates under the Federally qualified health center prospective payment system under the Medicare program

Section 1834(o) of the Social Security Act (42 U.S.C. 1395m(o)) is amended— (1) in paragraph (2)(B)(ii), by striking Payment and inserting Subject to paragraph (6), payment; and (2) by adding at the end the following new paragraph: (6) Adjustment of payment rates (A) In general The Secretary shall, through notice and comment rulemaking and taking into account data collected under subparagraph (B) and recommendations of the working group established under subparagraph (C)— (i) adjust payment rates determined under paragraph (2)(B) for Federally qualified health center services furnished in 2028 to account for increases in the type, intensity, duration, and amount of services furnished in a unit of service and corresponding increases in the cost of furnishing a unit of service in a manner such that the estimated aggregate amount of prospective payment rates (determined prior to the application of section 1833(a)(1)(Z)) for such services is equal to 100 percent of the estimated amount of reasonable costs (determined without the application of a per visit payment limit or productivity screen and prior to the application of section 1866(a)(2)(A)(ii)) that would have occurred for such services under this title in such year had the system established under this subsection never been implemented; and (ii) not later than 180 days after the date of the enactment of this paragraph, modify the list of services furnished to an individual at a Federally qualified health center under subparagraph (1)(A). (B) Collection of data (i) In general Not later than 90 days after the date of the enactment of this paragraph, the Secretary shall require Federally qualified health centers to submit cost reports, uniform data system reports, and any other health center program reports required by law to facilitate the adjustment described in subparagraph (A). (ii) Provision of information to the working group The Secretary shall make data required to be submitted under clause (i) available to the working group established under subparagraph (C). (C) Working group (i) In general Not later than 180 days after the date of the enactment of this paragraph, the Secretary shall convene a working group to make recommendations to the Secretary on modifications to the prospective payment system established under this subsection. (ii) Composition The working group shall be composed of such members as selected by the Secretary and shall include— (I) a patient or member of the board of a Federally qualified health center; (II) a physician, or a practitioner described in section 1842(b)(18)(C), who works at such a center; (III) at least 1 representative from a primary care association; (IV) at least 1 representative from a Health Center Controlled Network (as defined in section 330(e)(1)(C) of the Public Health Service Act); (V) a representative from a national organization that represents Federally qualified health centers; (VI) a representative from the hospital and ambulatory policy group of the Centers for Medicare & Medicaid Services; and (VII) such other individuals as the Secretary may specify. (iii) Duties The working group shall— (I) examine potential adjustments to payment rates under paragraph (2)(B) to reflect changes in the type, intensity, duration, or amount of services furnished within a unit of service, and the average cost of providing care per unit of service; (II) evaluate whether such rates capture 100 percent of the estimated amount of reasonable costs for Federally qualified health center services (determined without the application of a per visit payment limit or productivity screen and prior to the application of section 1866(a)(2)(A)(ii)) that would have occurred for such services under this title in such year had the system established under this subsection never been implemented; (III) examine which services are excluded from payment under such system and whether such services should be payable as Federally qualified health center services; (IV) evaluate the possibility of extending application of new payment and delivery system innovations developed with respect to physicians’ services under section 1848 to Federally qualified health centers; and (V) examine such other issues relating to payment for Federally qualified health centers as determined appropriate by the working group. (iv) Recommendations Not later than 1 year after the date on which the working group first convenes and after providing opportunity for public comment, such group shall make such recommendations to the Secretary regarding payment for Federally qualified health centers as determined appropriate by the working group..