This report provides descriptions of selected health care-related provisions that are scheduled to expire during the 115th Congress, first session (i.e., during calendar year [CY] 2017). 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, State Children’s Health Insurance Program (CHIP), and private health insurance programs and activities. The report also includes other health care-related provisions that were last extended under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10). Additionally, this report describes health care-related provisions within the same scope that expired during the 114th Congress, second session (i.e., during CY2016). Although the Congressional Research Service (CRS) has attempted to be comprehensive, it cannot guarantee that every relevant provision is included here.
This report generally focuses on two types of health care-related provisions within the scope discussed above. The first type of provision provides or controls mandatory spending, meaning that 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 Some of these provisions are excluded because they are transitional or routine in nature or have been superseded by congressional action that otherwise modifies the intent of the expiring provision.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 time period are not considered to require the attention of Congress and are excluded.
The report provides tables listing the relevant provisions that are scheduled to expire in 2017 and that expired in 2016. 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 2017 and that expired in 2016.
This report provides descriptions of selected health care-related provisions that are scheduled to expire during the 115th Congress, first session (i.e., during calendar year [CY] 2017). 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, State Children's Health Insurance Program (CHIP), and private health insurance programs and activities. The report also includes other health care-related provisions that were last extended under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10). Additionally, this report describes health care-related provisions within the same scope that expired during the 114th Congress, second session (i.e., during CY2016). Although the Congressional Research Service (CRS) has attempted to be comprehensive, it cannot guarantee that every relevant provision is included here.
This report generally focuses on two types of health care-related provisions within the scope discussed above. The first type of provision provides or controls mandatory spending, meaning that 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 time period are not considered to require the attention of Congress and are excluded.
The report provides tables listing the relevant provisions that are scheduled to expire in 2017 and that expired in 2016. 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 2017 and that expired in 2016.
This report provides descriptions of selected health care-related provisions that are scheduled to expire during the 115th Congress, first session (i.e., during calendar year [CY] 2017). 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, State Children's Health Insurance Program (CHIP), and private health insurance programs and activities.1 The report also includes other health care-related provisions that were last extended under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10). Additionally, this report describes health care-related provisions within the same scope that expired during the 114th Congress, second session (i.e., during CY2016). Although the Congressional Research Service (CRS) has attempted to be comprehensive, it cannot guarantee that every relevant provision is included here.
This report generally focuses on two types of health care-related provisions within the scope discussed above. The first type of provision provides or controls mandatory spending, meaning that 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).2 The second type of provision defines the authority of government agencies or other entities to act, usually by authorizing a policy, project, or activity.3 Such provisions also may temporarily delay the implementation of a regulation, requirement, or deadline, or establish a moratorium on a particular activity.4 Expiring health care provisions that are predominantly associated with discretionary spending activities—such as discretionary authorizations of appropriations and authorities for discretionary user fees5—are excluded from this report. For example, the Food and Drug Administration medical product user fee programs, which expire on September 30, 2017, are discussed in a separate CRS report.6
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 time period are not considered to require the attention of Congress and are excluded.
The report is organized as follows: Table 1, below, lists the relevant provisions that are scheduled to expire in 2017. Table 2, which follows, lists the relevant provisions that expired during 2016. The provisions in each table are organized by expiration date and applicable health care-related program.
The report then provides descriptions of each listed provision, including a legislative history. The summaries are grouped by provisions that are scheduled to expire in 2017 followed by those that expired in 2016.7 Appendix A lists demonstration projects and pilot programs that are scheduled to expire in 2017 or that expired in 2016 and are related to Medicare, Medicaid, CHIP, and private health insurance programs and activities or other health care-related provisions that were last extended under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10). Appendix B lists all laws that created, modified, or extended the health care-related expiring provisions described in this report. Appendix C lists abbreviations used in the report.
Expires After |
Health Care-Related Program |
Provisiona |
|
June 30, 2017 |
Medicare |
Non-application of Medicare Fee Schedule Adjustments for Wheelchair Accessories |
PAMPA §2 |
September 30, 2017 |
Medicare |
Outreach and Assistance for Low-Income Programs |
SSA §§1102 and 1871 42 U.S.C. §1395b–3 note |
September 30, 2017 |
Medicare |
Medicare-Dependent Hospital Program |
SSA §1886(d)(5)(G) 42 U.S.C. §1395ww(d)(5)(G) |
September 30, 2017 |
Medicare |
Low-Volume Adjustment |
SSA §1886(d)(12) 42 U.S.C. §1395ww(d)(12) |
September 30, 2017 |
Medicare |
Contract with a Consensus-Based Entity Regarding Performance Measurement |
SSA §1890(d) 42 U.S.C. §1395aaa |
September 30, 2017 |
Medicare |
Quality Measure Selection |
SSA §1890A 42 U.S.C. §1395aaa-1 |
September 30, 2017 |
Medicare |
Delay in Applying the 25% Patient Threshold Payment Adjustment for Long-Term Care Hospitals |
MMSEA §114(c) 42 U.S.C. §1395ww note |
September 30, 2017 |
Medicare |
Long-Term Care Hospital Moratoria |
MMSEA §114(d) 42 U.S.C. §1395ww note |
September 30, 2017 |
Medicaid |
Delay in Effective Date for Medicaid Amendments Relating to Beneficiary Liability Settlements |
SSA §1902(a)(25) 42 U.S.C. §1396a(a)(25)) |
September 30, 2017 |
Medicaid/CHIP |
Child Health Quality Measures |
SSA §1139A(i) 42 U.S.C. §1320b-9a(i) |
September 30, 2017 |
Medicaid/CHIP |
Medicaid and CHIP Express Lane Option |
SSA §§1902(e)(13)(A)(i) and 1902(e)(13)(I) 42 U.S.C. §1396a(e)(13) |
September 30, 2017 |
CHIP |
CHIP Appropriations |
SSA §2104(a) 42 U.S.C. §1397dd(a) |
September 30, 2017 |
CHIP |
CHIP Child Enrollment Contingency Funds |
SSA §2104(n) 42 U.S.C. §1397dd(n) |
September 30, 2017 |
CHIP |
CHIP Qualifying State Option |
SSA §2105(g)(4) 42 U.S.C. §1397ee(g)(4) |
September 30, 2017 |
CHIP |
CHIP Outreach and Enrollment Grants |
SSA §§2113(a)(1) and 2113(g)) 42 U.S.C. §1397mm |
September 30, 2017 |
Other |
Family-to-Family Health Information Centers |
SSA §501(c) 42 U.S.C. §701(c)(1)(A)(iii) |
September 30, 2017 |
Other |
Abstinence Education Grants |
SSA §510 42 U.S.C. §710 |
September 30, 2017 |
Other |
Maternal, Infant, and Early Childhood Home Visiting Program |
SSA §511 42 U.S.C. §711 |
September 30, 2017 |
Other |
Personal Responsibility Education Program |
SSA §513 42 U.S.C. §713(f) |
September 30, 2017 |
Other |
Community Health Center Fund |
PHSA §330 42 U.S.C. §254b-2(b)(1) |
September 30, 2017 |
Other |
Special Diabetes Programs |
PHSA §§330B and 330C 42 U.S.C. §254c-2(b) and 254c-3(b) |
September 30, 2017 |
Other |
National Health Service Corps Appropriations |
PHSA §338H 42 U.S.C. §254b-2(b)(2) |
September 30, 2017 |
Other |
Teaching Health Centers |
PHSA §340H 42 U.S.C. §256h |
December 31, 2017 |
Medicare |
Therapy Cap Exceptions Process |
SSA §1833(g) 42 U.S.C. §1395l(g)(5) |
December 31, 2017 |
Medicare |
Assistance for Rural Ambulance Providers in Low Population Density Areas |
SSA §1834(1)(12)(A) 42 U.S.C. §1395m(1)(12)(A) |
December 31, 2017 |
Medicare |
Temporary Increase for Ground Ambulance Services |
SSA §1834(1)(13)(A) 42 U.S.C. §1395m(1)(13)(A) |
December 31, 2017 |
Medicare |
Work Geographic Practice Cost Indices Floor |
SSA §1848(e)(1) 42 U.S.C. §1395w-4 (e)(1)(E) |
December 31, 2017 |
Medicare |
Home Health Prospective Payment System Rural Add-On |
SSA §1895 42 U.S.C. §1395fff note |
December 31, 2017 |
Private Health Insuranceb |
Annual Fee on Health Insurance Providers |
ACA §9010 |
December 31, 2017 |
Private Health Insurance |
Excise Tax on Medical Device Manufacturers |
26 U.S.C. §4191 |
Source: Congressional Research Service (CRS).
Notes: ACA = Patient Protection and Affordable Care Act (P.L. 111-148. as amended); CHIP = State Children's Health Insurance Program; MMSEA = Medicare, Medicaid and SCHIP Extension Act of 2007 (P.L. 110-173); PAMPA = Patient Access and Medicare Protection Act (P.L. 114-115); PHSA= Public Health Service Act; SSA = Social Security Act; U.S.C. = U.S. Code.
a. Citations in statute and the U.S.C. are provided where available.
b. No private health insurance provisions met the criteria for inclusion in this report. However, two provisions related to private health insurance that are expiring in 2017 are included. Both provisions modify fees and taxes established by the ACA to help fund ACA activities, including those related to private health insurance.
Expires After |
Health Care- Related Program |
Provisiona |
|
September 30, 2016 |
Medicare |
Funding to Fight Fraud, Waste, and Abuse |
SSA §1817(k)(8) 42 U.S.C. §1395i(k) |
December 31, 2016b |
Medicare |
Temporary Exception for Certain Severe Wound Discharges from Certain Long-Term Care Hospitals |
SSA §1886(m)(6) 42 U.S.C. §1395ww(m)(6) |
December 31, 2016 |
Medicare |
Moratorium on Enforcement of Supervision Requirements in CAHs |
P.L. 113-198 §1 |
Source: Congressional Research Service.
Notes: CAH = Critical Access Hospital; SSA = Social Security Act; U.S.C. = U.S. Code.
a. Citations in statute and the U.S.C. are provided where available.
b. The authority for this temporary exception expired for discharges after December 31, 2016. The 21st Century Cures Act (Cures Act; P.L. 114-255), Division C, Section 15010 temporarily reinstates, after a lapse period and with some modifications, the exception for certain severe wound long-term care hospital discharges that occur during a long-term care hospital's cost-reporting period beginning during FY2018. (See discussion of provision under "CY2016 Expired Provisions," below, for more detail.)
The Family-to-Family Health Information Centers program funds family-staffed and family-run centers in the 50 states and the District of Columbia. The Family-to-Family Health Information Centers provide information, education, technical assistance, and peer support to families of children (including youth) with special health care needs and health professionals who serve such families. They also assist in ensuring that families and health professionals are partners in decisionmaking at all levels of care and service delivery. This program is administered by the Health Resources and Services Administration (HRSA).
Appropriated funds for states to create or monitor Family-to-Family Health Information Centers have not been enacted for FY2018 or subsequent fiscal years. Any unused portions of grants for a given fiscal year that were awarded to states prior to October 1, 2017, will remain available until expended.
Abstinence Education Grants are formula grants available to states that request funding when applying for the Maternal and Child Health Block Grant funds authorized in SSA Section 501. Funds provided must be used exclusively for teaching abstinence from sexual activity outside of marriage.
Appropriated funds for Abstinence Education Grants have not been enacted for FY2018 or subsequent fiscal years. The FY2017 appropriations will no longer be available for obligation after September 30, 2017.
The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program provides grants to states, territories, and tribes for the support of evidence-based early childhood home visiting programs. These programs support in-home visits by health or social service professionals with at-risk families. Program funding also is allocated for research and evaluation (3% of appropriations) and for grants to tribal entities for home visitation services to Indian families (3% of appropriations). This program is collaboratively administered by HRSA and the Administration for Children and Families (ACF).
Appropriated funds for the MIECHV program have not been enacted for FY2018 or subsequent fiscal years. The FY2017 appropriations will no longer be available for new obligations after September 30, 2017. Any unused portions of grants for a given fiscal year that were awarded to states prior to October 1, 2017, will remain available for the second fiscal year after the funds were awarded.
The Personal Responsibility Education Program (PREP) is primarily a state formula grant program to support evidence-based programs designed to educate adolescents about abstinence, contraception, and adulthood. PREP contains five components: (1) state PREP formula grants; (2) competitive state PREP grants; (3) tribal PREP grants; (4) PREP Innovative Strategies grants to implement innovative youth pregnancy prevention strategies and to target services to high-risk populations; and (5) funding for training, technical assistance, and evaluation.
Appropriated funds for PREP have not been enacted for FY2018 or subsequent fiscal years. However, funds appropriated prior to FY2018 are available until expended. States are eligible to receive state PREP formula grants for five years in annual allotments. A state's annual allotment remains expendable by the state through the end of the second fiscal year after the funds are allotted. The Secretary of the Department of Health and Human Services (HHS) has the authority to repurpose funds that were not awarded to states and funds that were not expended during the two-year time frame for the awarding of three-year discretionary competitive state PREP grants.
The Omnibus Budget Reconciliation Act of 1990 (OBRA 90; P.L. 101-508), Section 4359, required the HHS Secretary to establish a "beneficiary assistance program" to help Medicare beneficiaries receive Medicare, Medicaid, and other health-insurance services. The beneficiary assistance program was to provide information and counseling to beneficiaries through local federal offices, community outreach programs, and toll-free telephone services. The beneficiary assistance program was later renamed the State Health Insurance Assistance Program (SHIP).
In OBRA 90 Section 4360, Congress appropriated $10 million annually for FY1991-FY1993 from the Medicare Hospital Insurance (HI) and Supplementary Medical Insurance (SMI) Trust Funds for grants to be awarded to states to implement SHIPs. 9 Congress subsequently extended SHIP appropriations.
In addition to SHIPs, the Centers for Medicare & Medicaid Services (CMS) received assistance in conducting outreach, particularly to low-income Medicare beneficiaries, from programs operated by other HHS divisions, such as the Administration for Community Living (ACL), established in 2012. Among other activities, ACL administers federal grant programs that fund Area Agencies on Aging (AAA), Aging and Disability Resource Centers (ADRCs), and the contract with the National Center for Benefits and Outreach Enrollment as well as coordination and outreach activities conducted by the Administration on Aging, a precursor agency to ACL. Congress makes annual appropriations to ACL programs. Since 2014, these appropriations have included funds for SHIPs, now administered by ACL.
Funding authorized under MACRA for low-income outreach and assistance programs has not been enacted for FY2018 or subsequent fiscal years. However, funds appropriated prior to FY2018 will be available for obligation until expended.
SSA Section 1139A established several requirements relating to child health quality measurement. The HHS Secretary was required to publish, and regularly update, a core set of child quality measures that may be used for reporting by states for Medicaid, CHIP and other programs administered under SSA Titles XIX and XXI. The section established the Pediatric Quality Measures Program (PQMP), which currently includes seven Centers of Excellence that work to identify and fill pediatric measure gaps. States are required to submit reports to the Secretary annually on children's health care quality, and the Secretary is required to collect, analyze, and make publicly available the information reported by states. The section also established a grant program for demonstration projects to evaluate ideas to improve the quality of children's health care.
Appropriated funds to carry out the child health quality measure activities in this section have not been enacted for FY2018 or subsequent fiscal years. The funds appropriated for FY2017 will no longer be available for obligation after September 30, 2017.
Medicare beneficiaries face two annual payment limits for all Medicare-covered outpatient therapy services. Established by the Balanced Budget Act of 1997 (BBA 97; P.L. 105-33), these limits initially applied to therapy services provided by nonhospital providers, to be applied separately for (1) physical therapy services and speech-language pathology services and (2) occupational therapy services. Initially set at $1,500 to apply beginning in 1999, these limits were suspended from 2000 to 2005. DRA re-implemented the limits and added an exceptions process in 2006. Should payments for therapy services furnished during a calendar year exceed the therapy caps, the exceptions process allows providers and practitioners to request an exception on a beneficiary's behalf when those services are reasonable and necessary. A series of subsequent legislative acts has extended the exceptions process, increased the limits, and modified the conditions for the application of the caps each year since.
The authority for the therapy caps exceptions process will expire after December 31, 2017.
The SSA provides for Medicare bonus payments for ground ambulance services that originate in qualified rural areas (called super-rural areas) furnished on or after July 1, 2004, and before January 1, 2018. Super-rural areas are areas that represent the lowest quartile of population density. CMS estimated and set the super-rural bonus as a 22.6% increase in the base rate for the transport.
The authority for the super-rural ambulance add-on payment will expire after December 31, 2017.
The SSA provides for a temporary increase in the Medicare ambulance fee schedule rates for ground ambulance services that otherwise are established for the year. For transports originating in a rural area, the payment increase is in addition to the super-rural add-on payment.
The temporary payment increases to Medicare's ambulance fee schedule for rural and urban ground ambulance transports will expire after December 31, 2017.
Medicare payments for services of physicians and certain nonphysician practitioners are made on the basis of a fee schedule. The Medicare physician fee schedule (MPFS) is 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 to calculate the payment rate under the MPFS.
The authority for the MPFS GPCI floor will expire after December 31, 2017.
The Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239, Section 6003(f)(1)) established criteria and payment for Medicare-dependent hospitals (MDHs) for the period April 1, 1990, through March 31, 1993. MDHs are small, rural hospitals with a high proportion of patients who are Medicare beneficiaries. MDHs receive special treatment, including higher payments, under the Medicare Inpatient Prospective Payment System (IPPS). To be eligible for the MDH program, hospitals must have no more than 100 beds and at least 60% of their acute inpatient days or discharges must be attributable to Medicare in FY1987 or in two of the three most recently audited cost-reporting periods.
The authority for the MDH program will expire after September 30, 2017.
Under the Medicare IPPS, qualifying hospitals receive increased payments to account for the higher incremental costs associated with a low volume of discharges. The HHS Secretary is required to determine an empirically appropriate percentage increase per discharge, up to a ceiling of 25%, for low-volume hospitals more than 25 road miles from an acute-care hospital. These hospitals could have as many as 800 total discharges. Based on its analysis, CMS determined that hospitals that have fewer than 200 total (Medicare and non-Medicare) discharges and that are located more than 25 road miles from another acute-care hospital qualified for a 25% increase per discharge.
The authority for the enhanced low-volume adjustment will revert to the original standards starting for discharges after September 30, 2017. The original standards are set in statute at less than 800 discharges and more than 25 road miles from another acute-care hospital.
Under SSA Section 1890, the HHS Secretary is required to have a contract with a consensus-based entity (e.g., National Quality Forum, or 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.
Appropriated funds to support the contract with the consensus-based entity in this section have not been enacted for FY2018 or subsequent fiscal years. However, funds appropriated prior to FY2018 are available for obligation until expended.
SSA Section 1890A requires the HHS Secretary to establish a pre-rulemaking process to select quality measures for use in the Medicare program. The consensus-based entity with a contract gathers multi-stakeholder input and annually transmits that input to the Secretary. 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. Through its Measure Applications Partnership (MAP), the NQF has been convening 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.
Appropriated funds to carry out the measure selection activities in this section have not been enacted for FY2018 or subsequent fiscal years. However, funds appropriated prior to FY2018 are available for obligation until expended.
Medicare provides increased payments under the home health (HH) prospective payment system (PPS) for home health care provided to beneficiaries in rural areas.
The authority for the Medicare HH PPS rural add-on will expire after December 31, 2017.
Long-term care hospitals (LTCHs) generally treat patients who have been discharged from acute-care hospitals but require prolonged inpatient hospital care due to the patients' medical conditions. LTCH patients have an average length of inpatient stay longer than 25 days. LTCHs can be (1) freestanding—a hospital that in general is not integrated with any other hospital; (2) colocated with another hospital, either located in the same building as another hospital or in a separate building on the hospital's campus; or (3) a satellite facility of an LTCH, a facility that operates as part of the LTCH but in a separate location (which may be colocated with another hospital).
Beginning in FY2005, CMS implemented a new Medicare payment regulation for LTCHs that are colocated with other hospitals and LTCH satellite facilities to limit inappropriate patient shifting driven by financial rather than clinical considerations. Under this policy, if such an LTCH received more than 25% of its Medicare patients from any single referring hospital, the LTCH would be reimbursed the lower of the LTCH PPS or the IPPS reimbursement for discharges that exceeded the threshold. (See next provision for background on the LTCH PPS.) Beginning in FY2008, CMS expanded the 25% patient threshold adjustment policy to include all LTCHs.
The delay in CMS applying the 25% patient threshold adjustment to LTCHs expires after September 30, 2017.
Under Medicare, LTCHs were exempt from the IPPS when it was established in 1983. Instead, LTCHs were reimbursed on a reasonable-cost basis subject to certain limits established by the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA; P.L. 97-248). Under the BBRA 99, the LTCH PPS was established, which would provide a per-discharge reimbursement based on the average costs and patient mix of LTCHs. The LTCH PPS typically provides higher Medicare reimbursement rates for inpatient hospital care than the IPPS.
The rapid increase in both the number of LTCHs and LTCH reimbursement led to enactment of a moratorium on the development of new LTCHs and a moratorium on new LTCH beds, with certain exceptions.
The moratorium on the development of new LTCHs and the moratorium on the increase in beds in existing LTCHs will expire after September 30, 2017.
Medicare covers a variety of durable medical equipment (DME) when the DME is medically necessary and prescribed by a physician. How much Medicare will pay for the equipment is determined in one of two ways. First, in competitive bidding geographic areas, the Medicare payments are determined for selected items based on the bids (or estimates of the cost of providing the item) submitted by winning DME suppliers. Second, outside of competitive bidding areas, payments are determined through statutorily specified formulas (fee schedules) adjusted based on information from the competitive bidding process, when information is available. Not all DME items are competitively bid; therefore, not all items outside of competitive bidding areas have their fee schedule payments adjusted based on competitive bidding information. Competitive bidding tends to result in lower payment amounts for DME, so adjusting the fee schedules based on competitive bidding results in lower payments.
Certain items of DME were statutorily excluded from competitive bidding competition, including Group 3 complex rehabilitative power wheelchairs and their accessories. Group 2 complex rehabilitative power wheelchairs and their accessories were not excluded and were competitively bid in the first round of competition. In general, the difference between Group 2 and Group 3 complex rehabilitative power wheelchairs has to do with the number of different power accessories that can be plugged into the chair and the power, durability, and performance of the chair. Certain accessories can be used with either Group 3 or Group 2 chairs and were part of the competitive bidding process. The HHS Secretary published final regulations on November 6, 2014, that would have adjusted the fee schedule payments for wheelchair accessories based on information from the competitive bidding program regardless of the type of wheelchair the accessory was used with, effective starting January 1, 2016, for areas outside of competitive bidding areas, resulting in lower payments for these accessories.
The prohibition will lapse after June 30, 2017, meaning that starting July 1, 2017, payments for accessories used with Group 3 complex rehabilitative power wheelchairs will be adjusted based on information from the competitive bidding program.
Under third-party liability (TPL) rules, Medicaid is the payer of last resort. If another insurer or payer has financial responsibility for medical services provided to Medicaid beneficiaries, generally that third party is required to pay all or part of the bill before Medicaid pays. Under federal Medicaid law applicable to TPL, states are required to determine if third parties exist and to ensure that providers bill third parties first, before billing Medicaid. DRA strengthened Medicaid TPL by clarifying what entities are considered third parties and requiring states to pass laws that stipulate third parties must comply with federal Medicaid TPL law.
States also are required under federal Medicaid TPL law to recover from judgments awarded to Medicaid beneficiaries. For example, if an individual receives medical care following an accident for which Medicaid paid, and the individual later wins a judgment against a third party responsible for that accident (e.g., another driver's auto insurance), the state must recover the amount Medicaid paid for the beneficiary's treatment from that third party. Recent court cases limited states' ability to recover from such judgments to the medical care costs, not the entire settlement or the settlement amounts attributable to lost wages or nonmedical costs.13
State Medicaid programs may recover all beneficiary liability settlements beginning on October 1, 2017.
Under this Medicaid and CHIP state plan option, states are permitted to rely on a finding from specified Express Lane agencies (e.g., agencies that administer programs such as State Temporary Assistance for Needy Families [TANF], Medicaid, CHIP, and the Supplemental Nutrition Assistance Program) for
The authority for Express Lane eligibility determinations will expire after September 30, 2017.
Federal funding for CHIP is provided with appropriation amounts in statute that are the overall annual ceiling on federal CHIP spending to the states, the District of Columbia, and the territories. CHIP was established as part of BBA 97. Since that time, other federal laws have provided additional years of appropriation amounts.
CHIP appropriations have not been enacted for FY2018 or subsequent fiscal years.
If a state's CHIP allotment for the current year, in addition to any allotment funds carried over from the prior year, is insufficient to cover the projected CHIP expenditures for the current year, a few different shortfall funding sources are potentially available. These sources include Child Enrollment Contingency Fund payments, redistribution funds, and Medicaid funds. For FY2009 through FY2015, Child Enrollment Contingency Fund payments have been available to states with both a funding shortfall (i.e., current year CHIP allotment plus any unused CHIP allotment funds from the previous year are insufficient to cover the federal share of the state's CHIP program) and CHIP enrollment for children exceeding a target level. As a result, not all states with funding shortfalls are eligible for Child Enrollment Contingency Fund payments. The contingency fund payments are based on a state's growth in CHIP enrollment and per capita spending. This means that a state may receive a payment from the fund that does not equal the state's actual shortfall in CHIP funding.
Appropriations for CHIP Child Enrollment Contingency Fund payments have not been enacted for FY2018 or subsequent fiscal years.
In a few situations, federal CHIP funding is used to finance Medicaid expenditures. For instance, certain states significantly expanded Medicaid eligibility for children prior to the enactment of CHIP in 1997. These states are allowed to use their CHIP allotment funds to fund the difference between the Medicaid and CHIP matching rates (i.e., federal medical assistance percentage [FMAP] and enhanced federal medical assistance percentage [E-FMAP] rates, respectively) to finance the cost for children above 133% of the federal poverty level in Medicaid. The following 11 states meet the definition: Connecticut, Hawaii, Maryland, Minnesota, New Hampshire, New Mexico, Rhode Island, Tennessee, Vermont, Washington, and Wisconsin. This is referred to as the qualifying state option.
The authority for the CHIP qualifying state option will expire after September 30, 2017.
CHIPRA Section 201 appropriated (out of funds in the Treasury that were not otherwise appropriated) $100 million in outreach and enrollment grants for FY2009-FY2013 to be used by eligible entities (e.g., states, local governments, community-based organizations, elementary or secondary schools) to conduct outreach and enrollment efforts that increase the participation of Medicaid and CHIP-eligible children. Of the total appropriation, 10% is directed to a national campaign to improve the enrollment of underserved child populations and 10% is targeted to outreach for Native American children. The remaining 80% is distributed among eligible entities for the purpose of conducting outreach campaigns, focusing on rural areas and underserved populations. Grant funds also are targeted at proposals that address cultural and linguistic barriers to enrollment.
Appropriated funds for CHIP outreach and enrollment grants have not been enacted for FY2018 or subsequent fiscal years.
The Community Health Center Fund (CHCF) provided mandatory funding for federal health centers authorized in the Public Health Service Act (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 approximately 70% of health center programs' appropriations in FY2016.
Appropriated funds for CHCF funds have not been enacted for FY2018 or subsequent fiscal years. Any unused portion of grants awarded for a given fiscal year prior to October 1, 2017, remains 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.
Appropriated funds for the two special diabetes programs have not been enacted for FY2018 or subsequent fiscal years. The funds appropriated for FY2017 will no longer be available for obligation after September 30, 2017.
The ACA created the CHCF, which provided mandatory funding for the National Health Service Corps (NHSC), authorized in Title III of the PHSA. The 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. This program last received discretionary appropriations in FY2011; since that time, CHCF funds have been the sole source of NHSC funding.
Appropriated funds for CHCF funds have not been enacted for FY2018 or subsequent fiscal years. Any unused portion of grants awarded for a given fiscal year prior to October 1, 2017, 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, outpatient health care facilities that provide care to underserved patients.
Appropriated funds for the Teaching Health Center GME payments have not been enacted for FY2018 or subsequent fiscal years. The funds appropriated for FY2017 will no longer be available for obligation after September 30, 2017. The program is currently funding existing Teaching Health Center programs with FY2016 MACRA funds; the program did not make awards to new programs in FY2016 and does not plan to make new awards in FY2017.
An annual fee is imposed on certain health insurance issuers. The aggregate fee is set at $8.0 billion in 2014, $11.3 billion in 2015 and 2016, $13.9 billion in 2017, and $14.3 billion in 2018. After 2018, the fee is indexed to the annual rate of U.S. premium growth. The fee is based on net health care premiums written by covered issuers during the year prior to the year in which payment is due. Each year the Internal Revenue Service apportions the fee among covered issuers based on (1) their net premiums written in the previous calendar year as a share of total net premiums written by all covered issuers and (2) their dollar value of business. Covered issuers are not subject to the fee on their first $25 million of net premiums written. The fee is imposed on 50% of net premiums above $25 million and up to $50 million and on 100% of net premiums in excess of $50 million. The fee became effective for CY2014. Collection of the fee is suspended for CY2017.
The moratorium on the collection of the fee is to end after CY2017, meaning covered entities will be subject to the fee again beginning in CY2018.
An excise tax is imposed on the sale of certain medical devices. The tax is equal to 2.3% of the device's sales price and generally is imposed on the manufacturer or importer of the device. The tax went into effect on January 1, 2013. Beginning January 1, 2016 the tax was suspended. It will apply to sales of medical devices again beginning January 1, 2018.
The suspension of the tax is to end December 31, 2017, meaning the tax is to apply to sales of medical devices again beginning January 1, 2018.
Most program integrity activities that address health care fraud, waste, and abuse are funded through the Health Care Fraud and Abuse Control (HCFAC) account, authorized by the Health Insurance Portability and Accountability Act of 1996 (HIPAA; P.L. 104-191). HCFAC was established to increase and stabilize federal funding for health care antifraud activities. The HCFAC account funds the following two programs: (1) the Health Care Fraud and Abuse Control Program and (2) the Medicare Integrity Program (MIP). The Health Care Fraud and Abuse Control Program finances HHS, the HHS Office of the Inspector General, the Department of Justice, and the Federal Bureau of Investigation administrative and operational (investigation, prosecution, audits, evaluation, and education) activities. The MIP finances CMS Medicare program integrity activities, which generally are conducted through contractors, and MIP administrative activities. Congress authorized annual mandatory appropriations from the Medicare HI Trust Fund to fund both the Health Care Fraud and Abuse Control Program and the MIP.
The additional HCFAC appropriations ($20 million in FY2016) authorized by HCERA Section 1303 have not been enacted for FY2017 or subsequent fiscal years. However, funds appropriated prior to FY2017 are available for obligation until expended.
Medicare reimburses LTCHs for inpatient hospital care under the LTCH PPS, which is typically higher than inpatient hospital care reimbursement under the IPPS. PSRA established patient criteria for reimbursement under the LTCH PPS and a site-neutral payment rate for LTCH patients who do not meet these criteria beginning in FY2016. Specifically, under the site-neutral policy, LTCHs receive reimbursement 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.
In FY2016 and FY2017, for patients who do not meet these LTCH PPS criteria, the site-neutral policy establishes that the LTCH will receive a blended payment amount based on 50% of what the LTCH would have been reimbursed under the LTCH PPS rate without the site-neutral policy and 50% of the site-neutral payment rate. Beginning in FY2018, for discharges involving patients who do not meet these LTCH PPS criteria, the LTCH will receive the site-neutral payment rate, which is equal to either 100% of the IPPS reimbursement or 100% of the estimated cost of the case, whichever is lower.
The authority for the temporary third criterion for reimbursement under the LTCH PPS expired for discharges after December 31, 2016. The reinstated exception will apply only to LTCH discharges occurring during an LTCH's cost-reporting period beginning during FY2018.
In the Medicare hospital outpatient prospective payment system (OPPS) 2009 final rule, CMS established that outpatient therapeutic services furnished in hospital outpatient departments are required to have direct physician supervision, defined as having a physician "present and on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure."15
On March 15, 2010, CMS instructed its Medicare contractors not to enforce these supervision requirements with respect to critical access hospitals (CAHs) in CY2010. As CMS continued to refine its direct supervision policy, the agency extended the moratorium on enforcement through CY2011 and expanded the scope of the moratorium to include both CAHs and small rural hospitals (which CMS defined as having 100 or fewer beds, being geographically located in a rural area, or being paid under the OPPS using a rural wage index). On November 1, 2012, CMS issued a notice that extended the moratorium through the end of CY2013.
The moratorium on enforcement of the requirement of direct supervision of outpatient therapeutic services furnished in CAHs and small rural hospitals expired after December 31, 2016.
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 115th Congress, first session (i.e., during calendar year [CY] 2017). As in the report, expiring demonstration projects and pilot programs are similarly defined as having 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 in this appendix are those related to Medicare, Medicaid, State Children's Health Insurance Program (CHIP), and private health insurance programs and activities.16 The report also includes other health care-related provisions that were last extended under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10). Additionally, this appendix lists health care-related demonstration projects and pilot programs within the same scope that expired during the 114th Congress, second session (i.e., during CY2016).
Although the Congressional Research Service (CRS) has attempted to be comprehensive, it cannot guarantee that every relevant demonstration project and pilot program is included here.
Table A-1, below, lists the relevant demonstration projects and pilot programs that are scheduled to expire in 2017. Table A-2, which follows, lists the relevant provisions that expired during 2016.
Table A-1. Demonstration Projects and Pilot Programs Expiring in the 115th Congress, First Session
(CY2017)
Expires After |
Health Care-Related Program |
Provision |
|
March 23, 2017 |
Other |
Demonstration Program to Increase Access to Dental Health Care Servicesa |
PHSA §340G-1 |
September 30, 2017 |
Medicare |
Medicare Independence at Home Demonstration Programb |
SSA §1866E(e)(1) |
September 30, 2017 |
Medicare |
Medicare IVIG Access Demonstrationc |
P.L. 112-242, §101 |
September 30, 2017 |
Other |
Funding for Childhood Obesity Demonstration Projectd |
SSA §1139A(e)(8) |
September 30, 2017 |
Other |
Demonstration Projects to Address Health Professions Workforce Needse |
SSA §2008(c) |
Source: Congressional Research Service.
Notes: CMS = Centers for Medicare & Medicaid Services; FY = fiscal year; IVIG = Intravenous Immune Globulin; PHSA = Public Health Service Act; SSA = Social Security Act; U.S.C. = U.S. Code.
a. A provision prohibiting the Health Resources and Services Administration from funding this demonstration program has been included in the Departments of Labor, Health and Human Services, Education, and Related Agencies appropriations act for each of FYs 2011-2016 and for FY2017 appropriations under continuing resolutions (P.L. 114-223 and P.L. 114-254).
b. The statute requires the demonstration program to begin no later than January 1, 2012, and authorizes provider agreements for a maximum five-year period. According to CMS, the demonstration performance period ends September 30, 2017 (CMS, Independence at Home Demonstration Fact Sheet, July 2016). For more information, see https://innovation.cms.gov/initiatives/independence-at-home/.
c. The statute requires the demonstration to begin no later than one year after the date of enactment (January 10, 2013) for a three-year period. According to CMS, the demonstration performance period ends September 30, 2017. For more information, see https://innovation.cms.gov/initiatives/ivig/.
d. For more information, see https://www.medicaid.gov/medicaid/quality-of-care/improvement-initiatives/reducing-obesity/index.html.
e. For more information, see https://www.acf.hhs.gov/ofa/programs/hpog.
Table A-2. Demonstration Projects and Pilot Programs That Expired in the 114th Congress, Second Session
(CY2016)
Expires After |
Health Care-Related Program |
Provision |
|
September 30, 2016 |
Medicaid |
Money Follows the Person Rebalancing Demonstrationa |
DRA §607 |
December 31, 2016 |
Medicaid |
Integrated Care Around a Hospitalization Demonstrationb |
ACA §2704 |
December 31, 2016 |
Medicaid |
Pediatric Accountable Care Organization Demonstration Projectc |
ACA §2706 |
Source: Congressional Research Service.
Notes: ACA = P.L. 110-148, Patient Protection and Affordable Care Act; CMS = Centers for Medicare & Medicaid Services; DRA = P.L. 109-171, Deficit Reduction Act of 2005; U.S.C. = U.S. Code.
a. For more information see https://www.medicaid.gov/medicaid/ltss/money-follows-the-person/index.html.
b. According to March 15, 2016, email correspondence with CMS, this demonstration project was never implemented, as CMS focused agency resources on other similar delivery system reform initiatives (e.g., the State Innovation Model Initiative).
c. As of the date of this report's publication, no public information regarding the demonstration project's status was located.
Appendix B. Laws That Created, Modified, or Extended Current Health Care-Related Expiring Provisions
P.L. # |
Acronym |
Act Title |
TEFRA |
Tax Equity and Fiscal Responsibility Act of 1982 |
|
— |
Omnibus Budget Reconciliation Act of 1989 |
|
OBRA 90 |
Omnibus Budget Reconciliation Act of 1990 |
|
HIPPA |
Health Insurance Portability and Protection Act of 1996 |
|
PRWORA |
Personal Responsibility and Work Opportunity Reconciliation Act of 1996 |
|
BBA 97 |
Balanced Budget Act of 1997 |
|
BBRA 99 |
Balanced Budget Refinement Act of 1999 |
|
BIPA 2000 |
Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 |
|
— |
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 |
|
— |
State Children's Health Insurance Program Allotments Extension Act |
|
— |
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 |
|
— |
National Institutes of Health Reform 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 |
|
— |
Making Continuing Appropriations for the Fiscal Year 2008, and for Other Purposes |
|
— |
Department of Defense Appropriations Act of 2008 |
|
— |
Making Further Continuing Appropriations for the Fiscal Year 2008, and for Other Purposes. |
|
— |
Making Further Continuing Appropriations for the Fiscal Year 2008, and for Other Purposes. |
|
MMSEA |
Medicare, Medicaid, and SCHIP Extension Act of 2007b |
|
MIPPA |
Medicare Improvements for Patients and Providers Act of 2008c |
|
CHIPRA |
Children's Health Insurance Program Reauthorization Act of 2009d |
|
ARRA |
American Recovery and Reinvestment Act of 2009e |
|
ACA |
Patient Protection and Affordable Care Act of 2010f |
|
HCERA |
Health Care and Education Reconciliation Act of 2010g |
|
MMEA |
Medicare and Medicaid Extenders Act of 2010 |
|
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 |
|
BBA 13/ PSRA |
Continuing Appropriations Resolution of 2014, which includes Division A, the Bipartisan Budget Act of 2013, and Division B, the Pathway for SGR Reform Act of 2013 |
|
PAMA |
Protecting Access to Medicare Act of 2014 |
|
— |
An Act to Provide for the Extension of the Enforcement Instruction on Supervision Requirements for Outpatient Therapeutic Services in Critical Access and Small Rural Hospitals Through 2014 |
|
MACRA |
Medicare Access and CHIP Reauthorization Act of 2015i |
|
— |
An Act to Provide for the Extension of the Enforcement Instruction on Supervision Requirements for Outpatient Therapeutic Services in Critical Access and Small Rural Hospitals Through 2015 |
|
CAA 16 |
Consolidated Appropriations Act of 2016 |
|
PAMPA |
Patient Access and Medicare Protection Act |
|
Cures Act |
The 21st Century Cures Actj |
Source: Congressional Research Service (CRS).
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 R44730, Increasing Choice, Access, and Quality in Health Care for Americans Act (Division C of P.L. 114-255), which describes Division C provisions referenced in this report.
Appendix C. List of Abbreviations
AAA: Area Agencies on Aging
ACA: Patient Protection and Affordable Care Act (P.L. 111-148, as amended)
ACF: Administration for Children and Families
ACL: Administration for Community Living
ADRC: Aging and Disability Resource Center
ARRA: American Recovery and Reinvestment Act of 2009 (P.L. 111-5)
ATRA: American Taxpayer Relief Act of 2012 (P.L. 112-240)
BBA 13: Bipartisan Budget Act of 2013 (P.L. 113-67, Division A)
BBA 97: Balanced Budget Act of 1997 (P.L. 105-33)
BBRA 99: Balanced Budget Refinement Act of 1999 (P.L. 106-113)
BIPA 2000: Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (P.L. 106-554)
CAA 16: Consolidated Appropriations Act of 2016 (P.L. 114-113)
CAH: Critical access hospital
CHCF: Community Health Center Fund
CHIP: State Children's Health Insurance Program
CHIPRA: Children's Health Insurance Program Reauthorization Act (P.L. 111-3)
CMS: Centers for Medicare & Medicaid Services
CPI-U: Consumer Price Index for All Urban Consumers
CRS: Congressional Research Service
CY: Calendar year
DME: Durable medical equipment
DRA: Deficit Reduction Act of 2005 (P.L. 109-171)
DSH: Disproportionate share hospital
E-FMAP: Enhanced federal medical assistance percentage
FMAP: Federal medical assistance percentage
FY: Fiscal year
GAO: Government Accountability Office
GME: Graduate medical education
GPCI: Geographic Practice Cost Index
HCERA: Health Care and Education Reconciliation Act of 2010 (P.L. 111-152)
HCFAC: Health Care Fraud and Abuse Control
HH: Home health
HHS: Department of Health and Human Services
HI: Hospital Insurance
HIPAA: Health Insurance Portability and Protection Act of 1996 (P.L. 104-191)
HPOG: Health Profession Opportunity Grants
HRSA: Health Resources and Services Administration
IHS: Indian Health Service
IPPS: Medicare Inpatient Prospective Payment System
LTCH: Long-term care hospital
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)
MEDH: Medicare-dependent hospital
MedPAC: Medicare Payment Advisory Commission
MIECHV: Maternal, Infant, and Early Childhood Home Visiting
MIP: Medicare Integrity Program
MIPPA: Medicare Improvements for Patients and Providers Act of 2008 (P.L. 110-275)
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
MSA: Metropolitan Statistical Area
NHSC: National Health Service Corps
NQF: National Quality Forum
OBRA 90: Omnibus Budget Reconciliation Act of 1990 (P.L. 101-508)
OPPS: Outpatient Prospective Payment System
PAMA: Protecting Access to Medicare Act of 2014 (P.L. 113-93)
PAMPA: Patient Access and Medicare Protection Act (P.L. 114-115)
PHSA: Public Health Service Act
PPS: Prospective payment system
PQMP: Pediatric Quality Measures Program
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)
SGR: Sustainable Growth Rate
SHIP: State Health Insurance Assistance Program
SMI: Supplementary Medical Insurance
SSA: Social Security Act
TANF: State Temporary Assistance for Needy Families
TEFRA: Tax Equity and Fiscal Responsibility Act of 1982 (P.L. 97-248)
TPL: Third-party liability
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 provided valuable input in reviewing the report. Clarissa Gregory provided valuable assistance in coordinating the report.
1. |
No private health insurance provisions met the criteria for inclusion in this report. However, two provisions related to private health insurance that are expiring in 2017 are included. Both provisions modify fees and taxes established by the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) to help fund ACA activities, including those related to private health insurance. |
2. |
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. |
3. |
For further information about these types of authorization provisions, see CRS Report R42098, Authorization of Appropriations: Procedural and Legal Issues. |
4. |
The two provisions included in the report that modify fees and taxes established by the ACA are the exceptions to this general rule. |
5. |
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 (January 13, 2017), which includes provisions set to expire as of September 30, 2017, is available at https://www.cbo.gov/publication/52368. |
6. |
For more information on the 2017 reauthorization cycle of the Food and Drug Administration user fee programs for prescription drugs, medical devices, biologics, and generic drugs, which were last reauthorized by the Food and Drug Administration Safety and Innovation Act of 2012 (FDASIA; P.L. 112-144), see CRS Report R44750, FDA Medical Product User Fee Reauthorization: In Brief. |
7. |
The 2017 expiring 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 freestanding (i.e., statutory authority that does not amend an existing statute). |
8. |
Citations in statute and the U.S. Code (U.S.C.) are provided where available. |
9. |
Medicare has two trust funds, the Hospital Insurance (HI) Trust Fund and the Supplementary Medical Insurance (SMI) Trust Fund. The HI Trust Fund covers Medicare Part A services, including hospital, home health, skilled nursing facility, and hospice care. The SMI Trust Fund covers Medicare Parts B and D, including physician and outpatient hospital services and outpatient prescription drugs. |
10. |
See U.S. Government Accountability Office, Ambulance Providers: Costs and Expected Medicare Margins Vary Greatly, GAO-07-383, May 23, 2007, at http://www.gao.gov/new.items/d07383.pdf, and U.S. Government Accountability Office, Ambulance Providers: Costs and Medicare Margins Varied Widely; Transports of Beneficiaries Have Increased, GAO 13-6, October 1, 2012, at http://www.gao.gov/assets/650/649018.pdf. |
11. |
See U.S. Department of Health and Human Services, Report to Congress: Evaluations of Hospitals' Ambulance Data on Medicare Cost Reports and Feasibility of Obtaining Cost Data from All Ambulance Providers and Suppliers, as Required by the American Taxpayer Relief Act of 2012, at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AmbulanceFeeSchedule/Downloads/Report-To-Congress-September-2015.pdf. |
12. |
The provisions in this subsection apply to Medicare but are freestanding and do not amend the SSA. |
13. |
Arkansas Dept. of Health and Human Services v. Ahlborn and Wos v. E.M.A. |
14. |
The provision in this subsection applies to Medicare but is freestanding and does not amend the SSA. |
15. |
CMS, "Final Rule: Medicare Program: Changes to the Hospital Outpatient Prospective Payment System and CY 2010 Payment Rates; Changes to the Ambulatory Surgical Center Payment System and CY 2010 Payment Rates" 74 Federal Register 60316-60983, November 20, 2009. |
16. |
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 Centers for Medicare & Medicaid Services, CMMI, Report to Congress: December 2016, at https://innovation.cms.gov/Files/reports/rtc-2016.pdf. |