Hybrid payment model for primary care services

Part E of title XVIII of the Social Security Act (42 U.S.C. 1395x et seq.) is amended by inserting after section 1866G the following new section: 1866H. Hybrid payment model for primary care services (a) In general The Secretary shall, for 2027 and each subsequent year through 2031, carry out a hybrid payment model for primary care services (in this section referred to as the model) under which the Secretary shall make a monthly payment to each qualifying supplier for each individual attributed to such practice for such year in lieu of payment for any designated primary care services furnished by such supplier to such individuals during such year that would otherwise be made under the payment schedule established under section 1848 (or on the basis of such schedule). (b) Payment amount (1) In general The monthly amount payable to a qualifying supplier for a year under the model is equal to one-twelfth of the national average amount that the Secretary estimates will be payable under the payment basis established under section 1848 for designated primary care services furnished during such year (so estimated as if no cost sharing requirements applied to individuals enrolled under part B), adjusted by a geographic index determined appropriate by the Secretary and risk adjusted in a manner determined appropriate by the Secretary. (2) Nonapplication of cost sharing No cost sharing requirement shall apply with respect to a monthly payment made under the model to a qualifying supplier for an individual attributed to such supplier. (c) Attribution process (1) In general The Secretary shall establish a process under which, for each year of the model, individuals enrolled under part B who are not enrolled under an MA plan under part C may designate a qualifying supplier as such individual’s primary care provider for such year. (2) Attribution based on prior claims In the case of an individual described in paragraph (1) who fails to make a designation for a year but for whom the Secretary determines, based on claims history of items and services furnished under this title, that such individual has a primary care provider who is a qualifying supplier, the Secretary may designate such supplier as such individual’s primary care provider for such year. (3) Treated as attributed For purposes of this section, each individual who makes a designation under paragraph (1) (or for whom such a designation is made under paragraph (2)) with respect to a qualifying supplier for a year shall be treated as attributed to such supplier for such year. (d) No effect on PFS budget neutrality Section 1848(c)(2)(B) shall be applied for 2027 and each subsequent year as if the model had never applied. (e) Funding Payments under the model shall be made from the Federal Supplementary Medical Insurance Trust Fund established under section 1841. (f) Definitions In this section: (1) Designated health care practitioner The term designated health care practitioner means a physician assistant, a nurse practitioner, a clinical nurse specialist, a physical therapist, an occupational therapist, or such other health care practitioner as the Secretary may specify. (2) Designated primary care services The term designated primary care services means— (A) care management services; (B) behavioral health integration services; (C) office-based evaluation and management services (whether furnished in person or via telehealth); and (D) communications such as telephone calls, emails and patient portals between patients and their care givers. (3) Excluded practice (A) In general The term excluded practice means, subject to subparagraph (B), any practice— (i) in which any entity that is not a physician or designated health care practitioner or a professional corporation, professional association, limited liability company, or other professional body that is majority owned and controlled by physicians or designated health care practitioners has an ownership interest; (ii) in which any entity described in subparagraph (A) exercises de facto control over employment decisions (including rates of pay and terms of employment), clinical staffing levels, amount of time spent between a supplier and a patient, diagnostic or procedural coding decisions, clinical standards or policy, billing and collection, prices for items and services, contracting with third party payors, or controlling or restricting the practice’s assets; (iii) in which physicians or designated health care practitioners hold 50 percent or less of voting shares or membership interests; (iv) that has a governing board in which physicians or designated health care practitioners constitute less than 50 percent of the members; or (v) in the case such practice is a corporation or professional association, that permits the removal of directors or officers that are physicians or designated health care practitioners except by majority vote of stakeholders that are physicians or designated health care practitioners. (B) Exception The term excluded practice does not include any practice consisting of 15 or fewer designated health care practitioners. (4) Specified practitioner The term specified practitioner means— (A) a physician with a primary specialty or practice area of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or (B) a physician assistant, a nurse practitioner, or a clinical nurse specialist. (5) Qualifying supplier The term qualifying supplier means, with respect to a year, a specified practitioner— (A) who is not part of an excluded practice; (B) who furnished items and services under this title during the preceding year; (C) for whom, with respect to payments under this title for all items and services furnished by such practitioner during the preceding year, at least 60 percent of such payments were for designated primary care services; and (D) who has elected to participate in the model for such year through such process as the Secretary shall establish..