This report describes selected health care-related provisions that are scheduled to expire during the second session of the 116th Congress (i.e., during calendar year [CY] 2020). For purposes of this report, expiring provisions are defined as portions of law that are time-limited and will lapse once a statutory deadline is reached, absent further legislative action. The expiring provisions included in this report are those related to Medicare, Medicaid, the State Children's Health Insurance Program (CHIP), and private health insurance programs and activities. The report also includes health care-related provisions enacted in the Patient Protection and Affordable Care Act (ACA; P.L. 111-148) or extended under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act; P.L. 116-136). In addition, this report describes health care-related provisions within the same scope that expired during the first session of the 116th Congress (i.e., during CY2019). Although the Congressional Research Service (CRS) has attempted to be comprehensive, it cannot guarantee that every relevant provision is included here.
This report focuses on two types of health care-related provisions within the scope discussed above. The first, and most common, type of provision provides or controls mandatory spending, meaning it provides temporary funding, temporary increases or decreases in funding (e.g., Medicare provider bonus payments), or temporary special protections that may result in changes in funding levels (e.g., Medicare funding provisions that establish a floor). The second type of provision defines the authority of government agencies or other entities to act, usually by authorizing a policy, project, or activity. Such provisions also may temporarily delay the implementation of a regulation, requirement, or deadline or establish a moratorium on a particular activity. Expiring health care provisions that are predominantly associated with discretionary spending activities—such as discretionary authorizations of appropriations and authorities for discretionary user fees—are excluded from this report.
Certain types of provisions with expiration dates that otherwise would meet the criteria set forth above are excluded from this report. Some of these provisions are excluded because they are transitional or routine in nature or have been superseded by congressional action that otherwise modifies the intent of the expiring provision. For example, statutorily required Medicare payment rate reductions and payment rate re-basings that are implemented over a specified period are not considered to require legislative attention and are excluded.
The report provides tables listing the relevant provisions that are scheduled to expire in 2020 and that expired in 2019. The report then describes each listed provision, including a legislative history. An appendix lists relevant demonstration projects and pilot programs that are scheduled to expire in 2020 or that expired in 2019.
This report describes selected health care-related provisions that are scheduled to expire during the second session of the 116th Congress (i.e., during calendar year [CY] 2020). For purposes of this report, expiring provisions are defined as portions of law that are time-limited and will lapse once a statutory deadline is reached, absent further legislative action. The expiring provisions included in this report are those related to Medicare, Medicaid, the State Children's Health Insurance Program (CHIP), and private health insurance programs and activities. The report also includes health care-related provisions enacted in the Patient Protection and Affordable Care Act (ACA; P.L. 111-148) or extended under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act; P.L. 116-136 ). This report describes health care-related provisions within the same scope that expired during the first session of the 116th Congress (i.e., during CY2019). Although the Congressional Research Service (CRS) has attempted to be comprehensive, it cannot guarantee that every relevant provision is included here.
The two types of provisions discussed in this report generally are enacted in the context of authorization laws and thus are typically within the purview of congressional authorizing committees. The duration that a provision is in effect usually is regarded as creating a timeline for legislative decisionmaking. In choosing this timeline, Congress navigates tradeoffs between the frequency of congressional review and the stability of funding or other legal requirements that pertain to the program.
Expiring health care provisions that are predominantly associated with discretionary spending activities—such as discretionary authorizations of appropriations and authorities for discretionary user fees—are excluded from this report.3
Certain types of provisions with expiration dates that otherwise would meet the criteria set forth above are also excluded from this report. Some of these provisions are excluded, because they are transitional or routine in nature or have been superseded by congressional action that otherwise modifies the intent of the expiring provision. For example, statutorily required Medicare payment rate reductions and payment rate re-basings that are implemented over a specified period are not considered to require legislative attention and are excluded.
The report is organized as follows: Table 1 lists the relevant provisions that are scheduled to expire in 2020. Table 2 lists the relevant provisions that expired during 2019. The provisions in each table are organized by expiration date and applicable health care-related program.
The report then describes each listed provision, including a legislative history. The summaries are grouped by provisions scheduled to expire in 2020 followed by those that expired in 2019.4 Appendix A lists demonstration projects and pilot programs that are scheduled to expire in 2020 or that expired in 2019 and are related to Medicare, Medicaid, CHIP, and private health insurance programs and activities or other health care-related provisions that were enacted in the ACA or last extended under the Further Consolidated Appropriations Act, 2020 (P.L. 116-94). Appendix B lists the status of provisions included in CRS Report R45781, Health Care-Related Expiring Provisions of the 116th Congress, First Session, that did not apply within the scope of this report. Appendix C lists all laws that created, modified, or extended the health care-related expiring provisions described in this report. Appendix D lists abbreviations used in the report.
|
Expires After |
Health Care-Related Program |
Provisiona |
Contact |
|
|
9/30/2020 |
CHIP |
Increase to E-FMAP |
SSA §32105(b) 42 U.S.C. §1397ee(b) |
Alison Mitchell |
|
9/30/2020 |
Medicare |
MACRA Technical Assistance to Small Practices and Practices In Health Professional Shortage Areas |
SSA §1848(q) 42 U.S.C. §1395w–4(q) |
Jim Hahn |
|
11/30/2020 |
Medicaid |
Protections for Recipients of Home and Community-Based Services against Spouse Impoverishment |
SSA §1924 42 U.S.C. 1396r-5 note |
Kirsten Colello |
|
11/30/2020 |
Medicare |
Outreach and Assistance for Low-Income Programs |
MIPPA §119 |
Kirsten Colello |
|
11/30/2020 |
Medicare |
Quality Measure Selection |
SSA §1890A 42 U.S.C. §1395aaa-1 |
Amanda Sarata |
|
11/30/2020 |
Medicare |
Contract with a Consensus-Based Entity Regarding Performance Measurement |
SSA §1890(d) 42 U.S.C. §1395aaa |
Amanda Sarata |
|
11/30/2020 |
Medicare |
Floor on Work Geographic Practice Cost Indices |
SSA §1848(e)(1) 42 U.S.C. §1395w-4(e)(1)(E) |
Jim Hahn |
|
11/30/2020 |
Other |
Sexual Risk Avoidance Education Program |
SSA §501 |
Adrienne Fernandes-Alcantara |
|
11/30/2020 |
Other |
Personal Responsibility Education Program |
SSA §513 |
Adrienne Fernandes-Alcantara |
|
11/30/2020 |
Other |
Community Health Centers Fund |
PHSA §330 42 U.S.C. §254b-2(b)(1) |
Elayne Heisler |
|
11/30/2020 |
Other |
Special Diabetes Programs for Indians |
PHSA §330C 42 U.S.C. §254c-3(b) |
Elayne Heisler |
|
11/30/2020 |
Other |
Special Diabetes Programs for Type I Diabetes |
PHSA §330B 42 U.S.C. §254c-2(b) |
Elayne Heisler |
|
11/30/2020 |
Other |
National Health Service Corps Appropriations |
PHSA §338H 42 U.S.C. §254b-2(b)(2) |
Elayne Heisler |
|
11/30/2020 |
Other |
Teaching Health Centers |
PHSA §340H 42 U.S.C. §256h |
Elayne Heisler |
|
12/31/2020 |
Medicare |
Home Health Prospective Payment System Rural Add-On for High Utilization Counties |
SSA §1895 42 U.S.C. §1395fff note |
Phoenix Voorhies |
|
12/31/2020 |
Private Health Insurance |
Health Coverage Tax Credit |
IRC §35 26 U.S.C. §35 |
Bernadette Fernandez |
Source: Congressional Research Service (CRS).
Notes: CHIP = State Children's Health Insurance Program, CY = Calendar Year, E-FMAP = Enhanced Federal Medical Assistance Percentage, IRC = Internal Revenue Code, MACRA = Medicare Access and CHIP Reauthorization Act of 2015, MIPPA = Medicare Improvements for Patients and Providers Act, PHSA = Public Health Service Act, SSA = Social Security Act, U.S.C. = U.S. Code.
a. Citations in statute and the United States Code (U.S.C.) are provided where available.
|
Health Care- Related Program |
Provisiona |
Contact |
||
|
9/30/2019 |
Other |
Pregnancy Assistance Fund |
ACA §10212 |
Adrienne Fernandes-Alcantara |
|
9/30/2019 |
Medicare |
Funding for Implementation of Section 101 of MACRA |
MACRA § 101(c)(3)) |
Jim Hahn |
|
9/30/2019 |
Medicare |
Priorities and Funding for Measure Development |
SSA §1848(s) 42 U.S.C. §1395w-4(s) |
Amanda Sarata |
|
9/30/2019 |
Medicare |
Extension of Blended Site Neutral Payment Rate For Certain LTCH Discharges |
SSA §1886(m)(6)(B)(i) 42 U.S.C. §1395ww(m)(6)(B)(i) |
Marco Villagrana |
|
9/30/2019 |
Medicare |
Temporary Exception for the Application of the Medicare LTCH Site Neutral Provisions for Certain Spinal Cord Hospitals |
SSA §1886(m)(6)(F) §1395ww(m)(6)(F) |
Marco Villagrana |
|
12/31/2019 |
Medicare |
Transitional Payment Rules for Certain Radiation Therapy Services |
SSA §1848 42 U.S.C. 1395w-4(b)(11) |
Jim Hahn |
Source: Congressional Research Service.
Notes: ACA = Patient Protection and Affordable Care Act (P.L. 111-148, as amended), CY = Calendar Year, LTCH = Long-Term Care Hospital, MACRA = Medicare Access and CHIP Reauthorization Act of 2015, SSA = Social Security Act, U.S.C. = U.S. Code.
a. Citations in statute and the United States Code (U.S.C.) are provided where available.
The Title V Sexual Risk Avoidance Education (SRAE) program, formerly known as the Abstinence Education Grants program, provides funding for education to adolescents aged 10 to 20 exclusively on abstaining from sexual activity outside of marriage.6 The Department of Health and Human Services (HHS) administers the program, and funding is provided primarily via formula grants. The 50 states, District of Columbia, and the territories are eligible to apply for funds. Jurisdictions request Title V SRAE funds as part of their request for Maternal and Child Health Block Grant funds authorized in SSA Section 501. Funds are allocated to jurisdictions based on their relative shares of low-income children. Funding is also available for eligible entities (not defined in statute) in jurisdictions that do not apply for funding.
Funding authorized under the CARES Act for the Title V SRAE program expires after November 30, 2020.
The Personal Responsibility Education Program (PREP) is a broad approach to teen pregnancy prevention that seeks to educate adolescents ages 10 through 19 and pregnant and parenting youth under age 21 on both abstinence and contraceptives to prevent pregnancy and sexually transmitted infections (STIs).7 Education services can address abstinence and/or contraceptives to prevent pregnancy and STIs. PREP includes four types of grants, which are administered by HHS: (1) State PREP grants, (2) Competitive PREP grants, (3) Tribal PREP, and (4) PREP–Innovative Strategies (PREIS). A majority of PREP funding is allocated to states and territories via the State PREP grant. The 50 states, District of Columbia, and the territories are eligible for funding. Funds are allocated by formula based on the proportion of youth aged 10 to 20 in each jurisdiction relative to other jurisdictions.
Funding authorized under the CARES Act for PREP expires after November 30, 2020.
SSA Section 1890A requires the HHS Secretary to establish a pre-rulemaking process to select quality measures for use in the Medicare program. As part of this process, the Secretary makes available to the public measures under consideration for use in Medicare quality programs and broadly disseminates the quality measures that are selected to be used, while the consensus-based entity with a contract (National Quality Form, or NQF) gathers multi-stakeholder input and annually transmits that input to the Secretary. NQF fulfills this requirement through its Measure Applications Partnership (MAP), an entity that convenes multi-stakeholder groups to provide input into the selection of quality measures for use in Medicare and other federal programs. MAP publishes annual reports with recommendations for selection of quality measures in February of each year, with the first report published in February 2012.
Funding authorized under the CARES Act to carry out the measure selection activities under SSA Section 1890A(a)-(d) expires after November 30, 2020.
Under SSA Section 1890, the HHS Secretary is required to have a contract with a consensus-based entity (e.g., NQF) to carry out specified duties related to performance improvement and measurement. These duties include, among others, priority setting, measure endorsement, measure maintenance, and annual reporting to Congress.
Funding authorized under the CARES Act to support the contract with the consensus-based entity under SSA Section 1890 expires after November 30, 2020.
MACRA made several fundamental changes to how Medicare pays for physician and practitioner services by (1) changing the methodology for determining the annual updates to the conversion factor, (2) establishing new methods for paying for professional services under Medicare Part B, including a merit-based incentive payment system (MIPS) to consolidate and replace several existing incentive programs and to apply value and quality adjustments to the Medicare physician fee schedule (MPFS), and (3) establishing the development of, and participation in, alternative payment models (APMs).9
To provide technical assistance to small practices and practices in health professional shortage areas, MACRA required the HHS Secretary to enter into contracts or agreements with appropriate entities (such as quality-improvement organizations, regional extension centers, or regional health collaboratives) to offer guidance and assistance to MIPS-eligible professionals in practices of 15 or fewer professionals. Under the technical assistance program, priority is required to be given to professionals located in rural areas, health professional shortage areas, or practices with low composite scores under the new payment system. The guidance and assistance is provided with respect to the MIPS performance categories or with respect to how to transition to the implementation of and participation in an APM.
For purposes of implementing the technical assistance program, $20 million from the SMI Trust Fund was made available to the Centers for Medicare & Medicaid Services (CMS) for each of FY2016-FY2020. These amounts are available until expended.
No funds to support the technical assistance program have been authorized beyond FY2020.
Payments under the Medicare MPFS are adjusted geographically for three factors to reflect differences in the cost of resources needed to produce physician services: physician work, practice expense, and medical malpractice insurance. The geographic adjustments are indices—known as Geographic Practice Cost Indices (GPCIs)—that reflect how each area compares to the national average in a "market basket" of goods. A value of 1.00 represents the average across all areas. These indices are used in the calculation of the payment rate under the MPFS. Several laws have established a minimum value of 1.00 (floor) for the physician work GPCI for localities where the work GPCI was less than 1.00.
The authority for the MPFS GPCI floor expires after November 30, 2020.
Federally certified home health (HH) agencies receive increased payments under the HH prospective payment system (PPS) for Medicare home health care episodes furnished to beneficiaries in rural areas. Before BBA 2018, when provided by legislation, the HH rural add-on was a fixed percentage increase to the HH PPS that was applied uniformly to Medicare home health episodes of care provided in rural counties.
Under BBA 2018, the add-on was applied unvaryingly for the first year the legislation extended the increased payment, providing a 3% rural add-on payment to Medicare home health episodes furnished in any rural county that began in CY2018. After CY2018, BBA 2018 provided home health agencies a 3%, 2%, and 1% HH PPS add-on payment for services furnished in rural counties beginning during CY2019-CY2021, respectively, unless the Medicare home health services were, or are, furnished in a rural county with one of the two below-described designations, in which case alternative add-on payments were/are provided:
Under BBA 2018, rural counties were to be categorized only once and such determination applies to payment home health episodes through CY2022.10
After December 31, 2020, home health agencies are no longer set to receive an add-on payment for services provided in rural counties designated as high utilization counties.
The Administration for Community Living (ACL) administers federal grant programs that fund outreach and assistance to older adults, individuals with disabilities, and their caregivers in accessing various health and social services. Funding for these programs is provided through discretionary budget authority in annual appropriations to the following entities:
The National Center for Benefits and Outreach Enrollment assists organizations to enroll older adults and individuals with disabilities into benefit programs that they may be eligible for, such as Medicare, Medicaid, the Supplemental Security Income (SSI) program, and the Supplemental Nutrition Assistance Program (SNAP), among others.
In addition to discretionary funding for these programs, beginning in FY2009, MIPPA provided funding for specific outreach and assistance activities to Medicare beneficiaries. This mandatory funding was extended multiple times, most recently in the CARES Act through November 30, 2020, and provided for outreach and assistance to low-income Medicare beneficiaries including those who may be eligible for the Low-Income Subsidy program, Medicare Savings Program (MSP), and the Medicare Part D Prescription Drug Program. The HHS Secretary is required to transfer specified amounts for MIPPA program activities from the Medicare Trust Funds.
Funding authorized under the CARES Act for low-income outreach and assistance programs will expire after November 30, 2020. However, funds appropriated will be available for obligation until expended.
When determining financial eligibility for Medicaid-covered long-term services and supports (LTSS), there are specific rules under SSA Section 1924 for the treatment of a married couple's assets when one spouse needs long-term care provided in an institution, such as a nursing home. Commonly referred to as "spousal impoverishment rules," these rules attempt to equitably allocate income and assets to each spouse when determining Medicaid financial eligibility and are intended to prevent the impoverishment of the non-Medicaid spouse. For example, spousal impoverishment rules require state Medicaid programs to exempt all of a non-Medicaid spouse's income in his or her name from being considered available to the Medicaid spouse. Joint income of the couple is divided in half between the spouses, and the Medicaid spouse can transfer income to bring the non-Medicaid spouse up to certain income thresholds. Assets of the couple, regardless whose name they are in, are combined and then split in half. The non-Medicaid spouse can retain assets up to an asset threshold determined by the state within certain statutory parameters.12 Prior to enactment of the ACA, spousal impoverishment rules applied only in situations where the Medicaid participant was receiving LTSS in an institution. States had the option to extend these protections to certain home and community-based services (HCBS) participants under a Section 1915(c) waiver program.13
Beginning January 1, 2014, ACA Section 2404 temporarily substituted the definition of "institutionalized spouse" under SSA Section 1924(h)(1) to include application of these spousal impoverishment protections to all married individuals who are eligible for HCBS authorized under certain specified authorities. Thus, beginning January 1, 2014, for a five-year time period, the ACA required states to apply the spousal impoverishment rules to all married individuals who are eligible for HCBS under these specified authorities, not just those receiving institutional care.14 This modified definition expired on December 31, 2018. The 116th Congress extended the authority for these protections and included a provision regarding state flexibility in the application of income or asset disregards for married individuals receiving certain HCBS.
The authority for the extension of spousal impoverishment protections for certain Medicaid HCBS recipients will expire after November 30, 2020.
The federal government's share of CHIP expenditures (including both services and administration) is determined by the enhanced federal medical assistance percentage (E-FMAP) rate. The E-FMAP rate is based on the federal medical assistance percentage (FMAP) rate, which is the federal matching rate for the Medicaid program.15 The FMAP formula compares each state's average per capita income with average U.S. per capita income. FMAP rates have a statutory minimum of 50% and a statutory maximum of 83%.
The E-FMAP rate is calculated by reducing the state share under the regular FMAP rate by 30%. Statutorily, the E-FMAP (or federal matching rate) can range from 65% to 85%. For some CHIP expenditures, the federal matching rate is different from the E-FMAP rate. For instance, the matching rate for translation and interpretation services is the higher of 75% or states' E-FMAP rate plus 5 percentage points. Also, for services provided to children with family incomes exceeding 300% of the federal poverty level (FPL) with an exception for certain states, the matching rate is the lower regular FMAP rate.
The increase to the E-FMAP expires after September 30, 2020.
The Community Health Center Fund (CHCF) provided mandatory funding for federal health centers authorized in PHSA Section 330. These centers are located in medically underserved areas and provide primary care, dental care, and other health and supportive services to individuals regardless of their ability to pay. The mandatory CHCF appropriations are provided in addition to discretionary funding for the program; however, the CHCF comprised more than 70% of health center programs' appropriations in FY2019, the last year where final appropriations data are available.
Funding authorized under the CARES Act for CHCF expires after November 30, 2020. Any unused portion of grants awarded for a given fiscal year prior to November 30, 2020, will remain available until expended.
The Special Diabetes Program for Type I Diabetes (PHSA Section 330B) provides funding for the National Institutes of Health to award grants for research into the prevention and cure of Type I diabetes. The Special Diabetes Program for Indians (PHSA Section 330C) provides funding for the Indian Health Service (IHS) to award grants for services related to the prevention and treatment of diabetes for American Indians and Alaska Natives who receive services at IHS-funded facilities.
Funding authorized under the CARES Act for the two special diabetes programs expires after November 30, 2020. Any unused portion of grants awarded for a given fiscal year prior to November 30, 2020, will remain available until expended.
The National Health Service Corps (NHSC) provides scholarships and loan repayments to certain health professionals in exchange for providing care in a health professional shortage area for a period of time that varies based on the length of the scholarship or the number of years of loan repayment received. The NHSC receives mandatory funding from the CHCF through PHSA Title III. The NHSC also received discretionary appropriations in FY2011. Between FY2012 and FY2017, the program did not receive discretionary appropriations. Beginning in FY2018 and continuing in FY2019, the program received discretionary appropriations, primarily to expand the number and type of substance abuse providers participating in the NHSC. The mandatory funding from the CHCF represents more nearly three-quarters of the program's funding in both FY2018 and FY2019, the last years where final appropriations data are available.
Funding authorized under the CARES Act for the CHCF component of the NHSC expires after November 30, 2020. Any unused portion of grants awarded for a given fiscal year prior to November 30, 2020, will remain available until expended.
The Teaching Health Center program provides direct and indirect graduate medical education (GME) payments to support medical and dental residents training at qualified teaching health centers (i.e., outpatient health care facilities that provide care to underserved patients).
Funding authorized under the CARES Act for Teaching Health Center GME payments expires after November 30, 2020, but unused funds remain available until expended.
The Health Coverage Tax Credit (HCTC) subsidizes 72.5% of the cost of qualified health insurance for eligible taxpayers and their family members. Potential eligibility for the HCTC is limited to two groups of taxpayers. One group is composed of individuals eligible for Trade Adjustment Assistance (TAA) allowances because they experienced qualifying job losses. The other group consists of individuals whose defined-benefit pension plans were taken over by the Pension Benefit Guaranty Corporation because of financial difficulties. HCTC-eligible individuals are allowed to receive the tax credit only if they either cannot enroll in certain other health coverage (e.g., Medicaid) or are not eligible for other specified coverage (e.g., Medicare Part A). To claim the HCTC, eligible taxpayers must have qualified health insurance (specific categories of coverage, as specified in statute). The credit is financed through a permanent appropriation under 31 U.S.C. §1324(b)(2); therefore, the financing of the HCTC is not subject to the annual appropriations process.
Authorization for the HCTC is scheduled to expire after December 31, 2020.
The Pregnancy Assistance Fund (PAF) program focuses on meeting the educational, social service, and health needs of vulnerable expectant and parenting individuals and their families during pregnancy and the postnatal period. The program identifies eligible populations as expectant and parenting teens, college students, and women of any age who experience domestic violence, sexual violence, sexual assault, or stalking. HHS administers the PAF program, and funding is awarded competitively to the 50 states, DC, U.S. territories, and tribal entities (hereinafter, grantees) that apply successfully. Grantees may use funds (1) to establish, operate, or maintain pregnancy or parenting services at institutions of higher education (IHEs), high schools, or community service providers; (2) to provide, in partnership with the state attorney general's office, certain legal and supportive services for women who experience domestic violence, sexual violence, sexual assault, or stalking while they are pregnant or parenting an infant; and (3) to support, either directly or through a subgrantee, public awareness about PAF services for the expectant and parenting population that is eligible for the program.
Funding authorized under the ACA expired after September 30, 2019.
Section 101 of MACRA made fundamental changes to the way Medicare payments to physicians are determined and how they are updated.16 To implement the payment modifications in Section 101 of MACRA, the law authorized the transfer of $80 million from the SMI Trust Fund for each fiscal year beginning with FY2015 and ending with FY2019. The amounts transferred are to be available until expended.
Appropriated funds to support the activities under this subsection have not been enacted for FY2020 or subsequent fiscal years.
SSA Section 1848(s) required the HHS Secretary to develop a plan for the development of quality measures for use in the MIPS program, which is to be updated as needed. The subsection also requires the Secretary to enter into contracts or other arrangements to develop, improve, update, or expand quality measures, in accordance with the plan. In entering into contracts, the Secretary must give priority to developing measures of outcomes, patient experience of care, and care coordination, among other things. The HHS Secretary, through CMS, annually reports on the progress made in developing quality measures under this subsection.
Appropriated funds to support the activities under this subsection have not been enacted for FY2020 or subsequent fiscal years. However, funds appropriated prior to FY2020 are available for obligation through the end of FY2022.
Medicare pays LTCHs for certain inpatient hospital care under the LTCH prospective payment system (LTCH PPS), which is typically higher than payments for inpatient hospital care under the inpatient prospective payment system (IPPS). PSRA amended the law so that the LTCH PPS payment is no longer available for all LTCH discharges but instead is available only for those LTCH discharges that met specific clinical criteria. Specifically, LTCHs are paid under the LTCH PPS if a Medicare beneficiary either (1) had a prior three-day intensive-care-unit stay at a hospital paid under the IPPS immediately preceding the LTCH stay or (2) is assigned to an LTCH PPS case-mix group that is based on the receipt of ventilator services for at least 96 hours and had a prior hospital stay at a hospital paid under the IPPS immediately preceding the LTCH stay. Discharges involving patients who have a principal diagnosis relating to a psychiatric diagnosis or rehabilitation do not qualify for the LTCH PPS rate. Subsequent legislation provided for other criteria to temporarily receive payment under the LTCH PPS. See section "Temporary Exception for Certain Spinal Cord Conditions from Application of the Medicare LTCH Site Neutral Payment for Certain LTCHs (SSA §1886(m)(6)(F); 42 U.S.C. §1395ww(m)(6)(F))."
For LTCH discharges that did not qualify for the LTCH PPS based on these clinical criteria, a "site neutral payment rate" similar to the PPS for inpatient acute care hospitals (IPPS) was to be phased-in. The site neutral rate is defined as the lower of an "IPPS-comparable" per diem amount, as defined in regulations, or the estimated cost of the services involved.
The extended transition period to site neutral payments during which LTCHs receive a blended payment for discharges that do not meet the patient criteria expired for discharges occurring in cost-reporting periods beginning during FY2020 and subsequent years.
Medicare pays LTCHs for inpatient hospital care under the LTCH PPS, which is typically higher than payments for inpatient hospital care under the IPPS. Effective for cost-reporting periods beginning in FY2016, LTCHS are paid the LTCH PPS rate for patients that meet one of the following two criteria: (1) had a prior three-day intensive-care-unit stay at a hospital paid under the IPPS immediately preceding the LTCH stay or (2) is assigned to an LTCH PPS case-mix group that is based on the receipt of ventilator services for at least 96 hours and had a prior hospital stay at a hospital paid under the IPPS immediately preceding the LTCH stay. Discharges involving patients who have a principal diagnosis relating to a psychiatric diagnosis or rehabilitation do not qualify for the LTCH PPS rate. For LTCH discharges that did not qualify for the LTCH PPS based on these criteria, a site neutral payment rate is being phased-in for cost-reporting periods beginning FY2016 through FY2019. Subsequent legislation provided for other criteria to temporarily receive payment under the LTCH PPS. See section "Temporary Extension of Long-Term Care Hospital (LTCH) Site Neutral Payment Policy Transition Period (SSA §1886(m)(6)(B)(i); 42 U.S.C. §1395ww(m)(6)(B)(i))" for details related to site neutral payment.
The authority for the temporary criterion related to certain spinal cord conditions to receive payment under the LTCH PPS expired for discharges occurring in cost reporting periods during FY2020 and for subsequent years.
Currently, Medicare payments for services of physicians and certain non-physician practitioners, including radiation therapy services, are made on the basis of a fee schedule.
To set payment rates under the MPFS, relative values units (RVUs) are assigned to each of more than 7,000 service codes that reflect physician work (i.e., the time, skill, and intensity it takes to provide the service), practice expenses, and malpractice costs. The relative value for a service compares the relative work and other inputs involved in performing one service with the inputs involved in providing other physicians' services. The relative values are adjusted for geographic variation in input costs. The adjusted relative values are then converted into a dollar payment amount by a conversion factor.
CMS, which is responsible for maintaining and updating the fee schedule, continually modifies and refines the methodology for estimating RVUs. CMS is required to review the RVUs no less than every five years; the ACA added the requirement that the HHS Secretary periodically identify physician services as being potentially misvalued, and make appropriate adjustments to the relative values of such services under the Medicare physician fee schedule.
In determining adjustments to RVUs used as the basis for calculating Medicare physician reimbursement under the fee schedule, the HHS Secretary has authority, under previously existing law and as augmented by the ACA, to adjust the number of RVUs for any service code to take into account changes in medical practice, coding changes, new data on relative value components, or the addition of new procedures.
Under the potentially misvalued codes authority, certain radiation therapy codes were identified as being potentially misvalued in 2015. However, because of concerns that the existing code set did not accurately reflect the radiation therapy treatments identified, CMS created several new codes during the transition toward an episodic alternative payment model.
The payment restrictions expired after December 31, 2019.
Appendix A. Demonstration Projects and Pilot Programs
This appendix lists selected health care-related demonstration projects and pilot programs that are scheduled to expire during the second session of the 116th Congress (i.e., during calendar year [CY] 2020). The expiring demonstration projects and pilot programs listed below have portions of law that are time-limited and will lapse once a statutory deadline is reached, absent further legislative action. The expiring demonstration projects and pilot programs included here are those related to Medicare, Medicaid, the State Children's Health Insurance Program (CHIP), and private health insurance programs and activities.17 This appendix also includes health care-related demonstration projects and pilot programs that were enacted in the Patient Protection and Affordable Care Act (ACA; P.L. 111-148) or extended in the Coronavirus Aid, Relief, and Economic Security Act (CARES Act; P.L. 116-136 ). No relevant demonstration projects and pilot programs within the same scope expired during the first session of the 116th Congress (i.e., during CY2019).
Although CRS has attempted to be comprehensive, it cannot guarantee that every relevant demonstration project and pilot program is included here.
Table A-1 lists the relevant demonstration projects and pilot programs that are scheduled to expire in 2020.
Table A-1. Demonstration Projects and Pilot Programs Expiring in the 116th Congress, Second Session
(CY2020)
|
Expires After |
Health Care-Related Program |
Provision |
Contact |
|
|
11/30/2020 |
Medicaid/Other |
Demonstration to Improve Community Behavioral Health Clinicsa |
PAMA §223(f) |
Alison Mitchell |
|
11/30/2020 |
Medicaid |
Money Follows the Person Rebalancing Demonstrationb |
DRA §6071 |
Kirsten Colello |
|
11/30/2020 |
Other |
Demonstration Projects to Address Health Professions Workforce Needsc |
SSA §2008(c) |
Elayne Heisler |
|
12/31/2020 |
Medicare |
Medicare Independence at Home Demonstration Programe |
SSA §1866 42 U.S.C. §1395cc–5 |
Jim Hahn |
|
12/31/2020 |
Medicare |
Medicare IVIG Access Demonstrationf |
SSA §1833 42 U.S.C. §1395l |
Cliff Binder |
Source: Congressional Research Service.
Notes: CY = Calendar Year, DRA = Deficit Reduction Act of 2005, IVIG = Intravenous Immune Globulin, PAMA = Protecting Access to Medicare Act of 2014, SSA = Social Security Act, U.S.C. = U.S. Code.
a. Extended, expanded, and amended most recently by Section 3814 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act; P.L. 116-136). For more information, see https://www.samhsa.gov/section-223.
b. Extended most recently by Section 3811 of the CARES Act. For more information, see https://www.medicaid.gov/medicaid/ltss/money-follows-the-person/index.html.
c. Extended most recently by Section 3823 of the CARES Act. For more information, see https://www.acf.hhs.gov/ofa/programs/hpog.
d. Authorization for this program is included in SSA §2008(a), and mandatory appropriations for the program are included in SSA §2008(c).
e. Extended most recently in Section 50301of the Bipartisan Budget Act of 2018 (BBA 2018; P.L. 115-123). For more information, see https://innovation.cms.gov/innovation-models/independence-at-home.
f. Extended most recently in Section 302 of the Disaster Tax Relief and Airport and Airway Extension Act of 2017 (P.L. 115-63). For more information, see https://innovation.cms.gov/innovation-models/ivig.
Appendix B. Provisions Included in the Previous CRS Health Care-Related Expiring Provisions Report
This appendix provides information on the provisions that were included in the previous CRS report on health care-related expiring provisions (CRS Report R45781, Health Care-Related Expiring Provisions of the 116th Congress, First Session) henceforth referred to as "R45781," but were not detailed in the body of this report.
As does the current report, R45781 included expiring provisions (of the same two types discussed herein) related to Medicare, Medicaid, State Children's Health Insurance Program (CHIP), and private health insurance programs and activities as well as selected other health care-related provisions. R45781 included health care-related provisions that were enacted in the Patient Protection and Affordable Care Act (ACA; P.L. 111-148) or, at the time of publication, had been extended under the Bipartisan Budget Act of 2018 (BBA 2018; P.L. 115-123). R45781 also described health care-related provisions that, at the time of publication, were set to expire during the first session of the 116th Congress (i.e., during calendar year [CY] 2019) or had expired during the 115th Congress (i.e., during CY2017 or CY2018).
Some of the provisions detailed in R45781 fell within the scope of this report. Such provisions expired in CY2019 or were extended and are set to expire in CY2020. Table B-1 includes the provisions detailed in R45781 that remain expired or were extended to dates beyond the 116th Congress (i.e., after CY2020). The third column in Table B-1 provides each provision's expiration date as it was in R45781. The fourth column reflects updated information, indicating whether the expiration date remains "unchanged" by law or providing the current expiration date for provisions extended pursuant to congressional modification.
Two private health insurance provisions were included in R45781 that did not meet the report criteria but were set to expire in 2019. These provisions modified fees and taxes established by the ACA to help fund ACA activities, including those related to private health insurance. As reflected in Table B-1, those fee and tax provisions were permanently repealed in the Further Consolidated Appropriations Act, 2020 (P.L. 116-94).
Unlike the other provisions that were included in R45781 and were extended past CY2020, the extension for the Patient-Centered Outcomes Research Trust Fund (PCORTF) was legislatively undertaken in a manner that resulted in significant revisions to the program and/or funding mechanisms detailed in R45781. Because of this, this appendix includes an updated provision summary below Table B-1. See, "Patient-Centered Outcomes Research Trust Fund (IRC §9511 and §§4375-4377, SSA §1183; 26 U.S.C. §9511; 26 U.S.C. §§4375-4377; 42 U.S.C. §1320e-2)." For more detailed background information on the other provisions included in Table B-1, see CRS Report R45781, Health Care-Related Expiring Provisions of the 116th Congress, First Session.
Table B-1 does not include demonstration projects or pilot programs. The only project or program in Appendix A of R45781 that was not included in this report is the Demonstration Program to Increase Access to Dental Health Care Service. The demonstration program expired after March 23, 2017.
Table B-1.Provisions Included in the Previous CRS Health Care-Related Expiring Provisions Report That Were Not Included in This Report
|
Health Care-Related Program |
Provision |
Expiration Date as of CRS Report R45781, Health Care-Related Expiring Provisions of the 116th Congress, First Session |
Current Expiration Date |
|
|
Medicare |
Delay in Applying the 25% Patient Threshold Payment Adjustment for Long-Term Care Hospitals |
MMSEA §114(c) 42 U.S.C. §1395ww note |
9/30/2017 |
Unchanged |
|
Medicare |
Long-Term Care Hospital Moratoria |
MMSEA §114(d) 42 U.S.C. §1395ww note |
9/30/2017 |
Unchanged |
|
Medicare |
Extension of Enforcement Instruction on Supervision Requirements for Outpatient Therapeutic Services in Critical Access and Small Rural Hospitals |
12/31/2017 |
Unchanged |
|
|
Medicare |
Temporary Exception for Certain Severe Wound Discharges from Application of the Medicare Site Neutral Payment for Certain Long Term Care Hospitals |
SSA §1886(m)(6)(E) and (G) 42 U.S.C. §1395ww(m)(6)(E)and (G) |
9/30/2018 |
Unchanged |
|
Medicare |
Exclusion of ASC Physicians from the Medicare Meaningful Use Payment Adjustment |
SSA §1848(a)(7)(D) 42 U.S.C. §1395w–4(a)(7)(D) |
12/31/2018 |
Unchanged |
|
Medicare |
Delay in Authority to Terminate Contracts for MA Plans Failing to Achieve Minimum Quality Ratings |
SSA §1857 |
12/31/2018 |
Unchanged |
|
Medicaid |
Additional Medicaid Funding for the Territories |
SSA §1108 |
9/30/2019 |
9/30/2021 |
|
Medicare |
Temporary Extension of LTCH Site Neutral Payment Policy Transition Period |
SSA §1886(m)(6)(B)(i) 42 U.S.C. §1395ww(m)(6)(B)(i) |
9/30/2019 |
Unchanged |
|
Medicare |
Patient-Centered Outcomes Research Trust Fund |
IRC §9511 and §§4375-4377, SSA §1183); 26 U.S.C. §9511; 26 U.S.C. §§4375-4377; 42 U.S.C. §1320e-2 |
9/30/2019 |
9/30/2029a |
|
Other |
Family-to-Family Health Information Centers |
SSA §501(c) |
9/30/2019 |
9/30/2024 |
|
Private Health Insurance |
Suspension of the Annual Fee on Health Insurance Providers |
ACA §9010 |
12/31/2019 |
Tax permanently repealedb |
|
Private Health Insurance |
Moratorium on the Excise Tax on Medical Device Manufacturers |
26 U.S.C. §4191 |
12/31/2019 |
Tax permanently repealedb |
Source: Congressional Research Service.
Notes: ACA = Patient Protection and Affordable Care Act (P.L. 111-148. as amended), ASC = Ambulatory Surgery Centers, IRC = Internal Revenue Code, LTCH= Long-Term Care Hospital, MA = Medicare Advantage, MMSEA = Medicare, Medicaid, and SCHIP Extension Act of 2007, SSA = Social Security Act, U.S.C. = U.S. Code.
a. Unlike the other provisions that were included in R45781 and were extended past CY2020, the extension for the Patient-Centered Outcomes Research Trust Fund was legislatively undertaken in a manner that resulted in significant revisions to the program and/or funding mechanisms detailed in R45781. Because of this, the instant appendix includes an updated provision summary below Table B-1. See, "Patient-Centered Outcomes Research Trust Fund (IRC §9511 and §§4375-4377, SSA §1183; 26 U.S.C. §9511; 26 U.S.C. §§4375-4377; 42 U.S.C. §1320e-2)." For more detailed background information on the other provisions included in Table B-1, see CRS Report R45781, Health Care-Related Expiring Provisions of the 116th Congress, First Session.
b. Two private health insurance provisions were included in R45781 that did not meet the report criteria, but the provisions were set to expire in 2019. Both provisions modify fees and taxes established by the ACA to help fund ACA activities, including those related to private health insurance. The 'Excise Tax on Medical Device Manufacturers' and the 'Annual Fee on Health Insurance Providers' were permanently repealed by sections 501 and 502 respectively of Division N of the Further Consolidated Appropriations Act, 2020 (P.L. 116-94).
Patient-Centered Outcomes Research Trust Fund (IRC §9511 and §§4375-4377, SSA §1183; 26 U.S.C. §9511; 26 U.S.C. §§4375-4377; 42 U.S.C. §1320e-2)
Background
SSA Section 1181 establishes the Patient-Centered Outcomes Research Institute (PCORI), which is responsible for coordinating and supporting comparative clinical effectiveness research. PCORI has entered into contracts with federal agencies, as well as with academic and private sector research entities for both the management of funding and conduct of research. PHSA Section 937 requires the Agency for Healthcare Research and Quality (AHRQ) to broadly disseminate research findings that are published by PCORI and other government-funded comparative effectiveness research entities.
IRC Section 9511 establishes the Patient-Centered Outcomes Research Trust Fund to support the activities of PCORI and to fund activities under PHSA Section 937. It provides annual funding to the PCORTF over the period FY2010-FY2019 from the following three sources: (1) annual appropriations, (2) fees on health insurance policies and self-insured plans, and (3) transfers from the Medicare HI and SMI Trust Funds. SSA Section 1183 provides for the transfer of the required funds from the Medicare Trust Funds. Transfers to PCORTF from the Medicare HI and SMI Trust Funds are calculated based on the number of individuals entitled to benefits under Medicare Part A or enrolled in Medicare Part B. IRC Sections 4375-4377 impose the referenced fees on applicable health insurance policies and self-insured health plans and describe the method for their calculation.
For each of FY2011 through FY2019, IRC Section 9511 requires 80% of the PCORTF funds to be made available to PCORI, and the remaining 20% of funds to be transferred to the HHS Secretary for carrying out PHSA Section 937. Of the total amount transferred to HHS, 80% is to be distributed to AHRQ, with the remainder going to the Office of the Secretary (OS)/HHS.
Relevant Legislation
Current Status
Appropriated funds to PCORTF expire after September 30, 2029. Funds transferred to the HHS Secretary under IRC Section 9511 remain available until expended. No amounts shall be available for expenditure from the PCORTF after September 30, 2029, and any amounts in the Trust Fund after such date shall be transferred to the general fund of the Treasury.
Appendix C. Laws That Created, Modified, or Extended Current Health Care-Related Expiring Provisions
|
P.L. Number |
Act Title |
|
|
PRWORA |
Personal Responsibility and Work Opportunity Reconciliation Act of 1996 |
|
|
BBA 97 |
Balanced Budget Act of 1997 |
|
|
BIPA 2000 |
Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 |
|
|
— |
The Trade Act of 2002 |
|
|
— |
An Act to Amend the Public Health Service Act with Respect to Special Diabetes Programs for Type 1 Diabetes and Indians |
|
|
WREA 2003 |
Welfare Reform Extension Act of 2003 |
|
|
— |
An Act to Extend the Temporary Assistance for Needy Families Block Grant Program, and Certain Tax and Trade Programs, and for Other Purposes |
|
|
MMA |
Medicare Prescription Drug, Improvement, and Modernization Act of 2003a |
|
|
WREA 2004 |
Welfare Reform Extension Act of 2004 |
|
|
— |
TANF and Related Programs Continuation Act of 2004 |
|
|
— |
Welfare Reform Extension Act, Part VIII |
|
|
WREA 2005 |
Welfare Reform Extension Act of 2005 |
|
|
— |
TANF Extension Act of 2005 |
|
|
— |
QI, TMA, and Abstinence Programs Extension and Hurricane Katrina Unemployment Relief Act of 2005 |
|
|
DRA |
Deficit Reduction Act of 2005 |
|
|
TRHCA |
Tax Relief and Health Care Act of 2006 |
|
|
— |
An Act to Provide for the Extension of Transitional Medical Assistance, and Other Provisions |
|
|
— |
TMA, Abstinence Education, and QI Programs Extension Act of 2007 |
|
|
MMSEA |
Medicare, Medicaid, and SCHIP Extension Act of 2007b |
|
|
MIPPA |
Medicare Improvements for Patients and Providers Act of 2008c |
|
|
ARRA |
American Recovery and Reinvestment Act of 2009e |
|
|
ACA |
Patient Protection and Affordable Care Act of 2010f |
|
|
MMEA |
Medicare and Medicaid Extenders Act of 2010 |
|
|
— |
The Trade Adjustment Assistance Extension Act of 2011 |
|
|
TPTCCA |
Temporary Payroll Tax Cut Continuation Act of 2011 |
|
|
MCTRJCA |
Middle Class Tax Relief and Job Creation Act of 2012 |
|
|
ATRA |
American Taxpayer Relief Act of 2012h |
|
|
PSRA |
Continuing Appropriations Resolution of 2014, which includes Division B, the Pathway for SGR Reform Act of 2013 |
|
|
PAMA |
Protecting Access to Medicare Act of 2014 |
|
|
MACRA |
Medicare Access and CHIP Reauthorization Act of 2015i |
|
|
— |
The Trade Preferences Extension Act of 2015 |
|
|
PAMPA |
Patient Access and Medicare Protection Act |
|
|
Cures Act |
The 21st Century Cures Act |
|
|
— |
Disaster Tax Relief and Airport and Airway Extension Act of 2017 |
|
|
— |
An Act to amend the Homeland Security Act of 2002 to require the Secretary of Homeland Security to issue Department of Homeland Security-wide guidance and develop training programs as part of the Department of Homeland Security Blue Campaign, and for other purposes |
|
|
— |
Making Further Continuing Appropriations for the Fiscal Year Ending September 30, 2018, and for Other Purposes. |
|
|
BBA 2018 |
Bipartisan Budget Act of 2018 |
|
|
— |
Medicaid Extenders Act of 2019 |
|
|
— |
Medicaid Services Investment and Accountability Act of 2019 |
|
|
— |
The Sustaining Excellence in Medicaid Act of 2019 |
|
|
— |
Continuing Appropriations Act, 2020, and Health Extenders Act of 2019 |
|
|
— |
Further Continuing Appropriations Act, 2020, and Further Health Extenders Act of 2019 |
|
|
— |
Further Consolidated Appropriations Act, 2020 |
|
|
FFCRA |
Families First Coronavirus Response Actj |
|
|
CARES Act |
Coronavirus Aid, Relief, and Economic Security Act |
Source: Congressional Research Service (CRS).
Notes:
a. See CRS Report RL31966, Overview of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, and CRS Report RL32005, Medicare Fee-for-Service Modifications and Medicaid Provisions of H.R. 1 as Enacted.
b. See CRS Report RL34360, P.L. 110-173: Provisions in the Medicare, Medicaid, and SCHIP Extension Act of 2007.
c. See CRS Report RL34592, P.L. 110-275: The Medicare Improvements for Patients and Providers Act of 2008
d. See CRS Report R40226, P.L. 111-3: The Children's Health Insurance Program Reauthorization Act of 2009.
e. The Health Information Technology for Economic and Clinical Health Act was incorporated into ARRA. A description of the Medicare provisions in that bill can be found in CRS Report R40161, The Health Information Technology for Economic and Clinical Health (HITECH) Act.
f. See CRS Report R41196, Medicare Provisions in the Patient Protection and Affordable Care Act (PPACA): Summary and Timeline, and CRS Report R41210, Medicaid and the State Children's Health Insurance Program (CHIP) Provisions in ACA: Summary and Timeline.
g. See CRS Report R41124, Medicare: Changes Made by the Reconciliation Act of 2010 to the Patient Protection and Affordable Care Act (P.L. 111-148).
h. See CRS Report R42944, Medicare, Medicaid, and Other Health Provisions in the American Taxpayer Relief Act of 2012.
i. See CRS Report R43962, The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10).
j. See CRS Report R46316, Health Care Provisions in the Families First Coronavirus Response Act, P.L. 116-127.
Appendix D. List of Abbreviations
AAA: Area Agencies on Aging
ACA: Patient Protection and Affordable Care Act (P.L. 111-148, as amended)
ACL: Administration for Community Living
ADRC: Aging and Disability Resource Center
AHRQ: Agency for Healthcare Research and Quality
APM: Alternative payment model
ARRA: American Recovery and Reinvestment Act of 2009 (P.L. 111-5)
ASC: Ambulatory Surgery Center
ATRA: American Taxpayer Relief Act of 2012 (P.L. 112-240)
BBA 97: Balanced Budget Act of 1997 (P.L. 105-33)
BBA 2018: Bipartisan Budget Act of 2018 (P.L. 115-123)
BIPA 2000: Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (P.L. 106-554)
CARES Act: Coronavirus Aid, Relief, and Economic Security Act (P.L. 116-136)
CHCF: Community Health Center Fund
CHIP: State Children's Health Insurance Program
CMS: Centers for Medicare & Medicaid Services
CRS: Congressional Research Service
CY: Calendar year
DRA: Deficit Reduction Act of 2005 (P.L. 109-171)
DRG: Diagnosis related group
E-FMAP: Enhanced federal medical assistance percentage
FFCRA: Families First Coronavirus Response Act (P.L. 116-127)
FMAP: Federal medical assistance percentage
FPL: Federal poverty level
FY: Fiscal year
GME: Graduate medical education
GPCI: Geographic Practice Cost Index
HCBS: Home and community-based services
HCTC: Health Coverage Tax Credit
HH: Home health
HHS: Department of Health and Human Services
HI: Hospital Insurance
IHE: Institution of higher education
IHS: Indian Health Service
IPPS: Medicare Inpatient Prospective Payment System
IVIG: Intravenous immune globulin
LTCH: Long-term care hospital
LTCH PPS: Long-term care hospital prospective payment system
LTSS: Long-term services and supports
MA: Medicare Advantage
MACRA: Medicare Access and CHIP Reauthorization Act of 2015 (P.L. 114-10)
MAP: Measure Applications Partnership
MCTRJCA: Middle Class Tax Relief and Job Creation Act of 2012 (P.L. 112-96)
MedPAC: Medicare Payment Advisory Commission
MIPPA: Medicare Improvements for Patients and Providers Act of 2008 (P.L. 110-275)
MIPS: Merit-based incentive payment system
MMA: Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173)
MMEA: Medicare and Medicaid Extenders Act of 2010 (P.L. 111-309)
MMSEA: Medicare, Medicaid and SCHIP Extension Act of 2007 (P.L. 110-173)
MPFS: Medicare physician fee schedule
MSP: Medicare Savings Program
NHSC: National Health Service Corps
NQF: National Quality Forum
PAF: Pregnancy Assistance Fund
PAMA: Protecting Access to Medicare Act of 2014 (P.L. 113-93)
PAMPA: Patient Access and Medicare Protection Act (P.L. 114-115 )
PCORI: Patient-Centered Outcomes Research Institute
PCORTF: Patient-Centered Outcomes Research Trust Fund
PETI: Post-eligibility treatment of income
PHSA: Public Health Service Act
PPS: Prospective payment system
PREIS: Personal Responsibility Education Program Innovative Strategies
PREP: Personal Responsibility Education Program
PRWORA: Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193)
PSRA: Pathway for SGR Reform Act of 2013 (P.L. 113-67, Division B)
RVU: Relative value unit
SHIP: State Health Insurance Assistance Program
SMI: Supplementary Medical Insurance
SNAP: Supplemental Nutrition Assistance Program
SRAE: Sexual Risk Avoidance Education
SSA: Social Security Act
SSI: Supplemental Security Income
TAA: Trade Adjustment Assistance
TANF: State Temporary Assistance for Needy Families
TPTCCA: Temporary Payroll Tax Cut Continuation Act of 2011(P.L. 112-78)
TRHCA: Tax Relief and Health Care Act of 2006 (P.L. 109-432)
U.S.C.: U.S. Code
WREA 2003: Welfare Reform Extension Act of 2003 (P.L. 108-40)
WREA 2004: Welfare Reform Extension Act of 2004 (P.L. 108-210)
WREA 2005: Welfare Reform Extension Act of 2005 (P.L. 109-4)
Author Contact Information
Acknowledgments
Jessica Tollestrup, a CRS Specialist in Social Policy, provided thoughtful review and comments. Isaac Nicchitta, a research assistant at CRS, helped structure this report.
| 1. |
"Mandatory spending' is controlled by authorization acts; "discretionary spending" is controlled by appropriations acts. For further information, see CRS Report R44582, Overview of Funding Mechanisms in the Federal Budget Process, and Selected Examples. |
| 2. |
For further information about these types of authorization provisions, see CRS Report R42098, Authorization of Appropriations: Procedural and Legal Issues. |
| 3. |
The Congressional Budget Office is required to compile this information each year under Section 202(e)(3) of the Congressional Budget Act. The most recent report, Expired and Expiring Authorizations of Appropriations: Fiscal Year 2020 (February 5, 2020), which includes provisions set to expire on or before September 30, 2020, is available at https://www.cbo.gov/publication/56082. |
| 4. |
Within each section, the provisions are further organized by Social Security Act (SSA) and Public Health Service Act (PHSA) title and section. A third category includes provisions that are found elsewhere (e.g. the Internal Revenue Code (IRC). Freestanding provisions (i.e., new laws) may be grouped in any section with related programs. |
| 5. |
Citations in statute and the U.S. Code (U.S.C.) are provided where available. |
| 6. |
A discretionary federal program has the same name, Sexual Risk Avoidance Education program. The programs are distinguished here by referring to the mandatory program as the Title V Sexual Risk Avoidance Education program. In addition, HHS refers to the discretionary program as General Departmental Management Sexual Risk Avoidance Education, named for the account from which funds are appropriated for the program. For further information about both programs, see CRS Report R45183, Teen Pregnancy: Federal Prevention Programs. |
| 7. |
For further information about PREP, see CRS Report R45183, Teen Pregnancy: Federal Prevention Programs. |
| 8. |
Medicare has two trust funds: the Hospital Insurance (HI) Trust Fund and the Supplementary Medical Insurance (SMI) Trust Fund. The HI Trust Fund finances Medicare Part A services, including hospital, home health, skilled nursing facility, and hospice care. The SMI Trust Fund finances Medicare Parts B and D, including physician and outpatient hospital services and outpatient prescription drugs. |
| 9. |
For more information on Section 101 of MACRA, see CRS Report R43962, The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10). |
| 10. |
Rural-add-on-payment designations by county can be found at CMS, Home Health Agency (HHA) Center, https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center. |
| 11. |
BBA 2018 also required ACL to electronically post on its website by April 1, 2019, and biennially thereafter, the following information with respect to SHIP state grants: (1) the amount of federal funding provided to each state and the amount of federal funding provided by each state to each entity and (2) other program information, as specified by the HHS Secretary. Publicly reported information must be presented by state as well as by entity receiving funds from the state. Note Section 50207 of BBA 2018 refers to the "Agency for Community Living." |
| 12. |
See Centers for Medicare & Medicaid Services (CMS), 2020 SSI and Spousal Impoverishment Standards, at https://www.medicaid.gov/medicaid/eligibility/downloads/spousal-impoverishment/ssi-and-spousal-impoverishment-standards.pdf. |
| 13. |
These HCBS recipients are eligible under the "special home and community-based services waiver eligibility group" or "217 Group" in reference to the specific regulatory citation for this group at 42 CFR §435.217. Prior to Section 2404 of the ACA, states that chose to apply spousal impoverishment protections as an option for the 217 Group also had the option to treat married HCBS recipients in the 217 Group as institutionalized for the purposes of post-eligibility treatment of income (PETI) rules. |
| 14. |
States that cover the 217 Group must also apply the PETI rules. |
| 15. |
Section 6008 of the Families First Coronavirus Response Act (FFCRA; P.L. 116-127) provides an increase to the FMAP rate of 6.2 percentage points for each calendar quarter occurring during the COVID-19 public health emergency period. The FFCRA-increased FMAP rates will be used to calculate the E-FMAP rates for CHIP, which will increase the E-FMAP rates but not by the same amount. |
| 16. |
For more information on Section 101 of MACRA, see CRS Report R43962, The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10). |
| 17. |
Section 3021 of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) amended Title XI of the Social Security Act (SSA) to establish the Center for Medicare and Medicaid Innovation (CMMI). CMMI is authorized to test payment and service delivery models to improve the quality of care and/or reduce spending. For more information on the Center for Medicare and Medicaid Innovation (CMMI), see https://innovation.cms.gov/, and CMS, CMMI, Report to Congress: December 2016, at https://innovation.cms.gov/Files/reports/rtc-2016.pdf. |