This report describes selected health care-related provisions that are scheduled to expire during the first session of the116th Congress (i.e., during calendar year [CY] 2019). 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 health care-related provisions that were enacted in the Patient Protection and Affordable Care Act (ACA; P.L. 111-148) or last extended under the Bipartisan Budget Act of 2018 (BBA 2018; P.L. 115-123). In addition, this report describes health care-related provisions within the same scope that expired during the 115th Congress (i.e., during CY2017 or CY2018). 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 Some of these provisions are excluded because they are transitional or routine in nature or have been superseded by congressional action that otherwise modifies the intent of the expiring provision.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 legislative attention and are excluded.
The report provides tables listing the relevant provisions that are scheduled to expire in 2019 and that expired in 2018 or 2017. 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 2019 or that expired in 2018 or 2017.
This report describes selected health care-related provisions that are scheduled to expire during the first session of the116th Congress (i.e., during calendar year [CY] 2019). 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 health care-related provisions that were enacted in the Patient Protection and Affordable Care Act (ACA; P.L. 111-148) or last extended under the Bipartisan Budget Act of 2018 (BBA 2018; P.L. 115-123). In addition, this report describes health care-related provisions within the same scope that expired during the 115th Congress (i.e., during CY2017 or CY2018). 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 legislative attention and are excluded.
The report provides tables listing the relevant provisions that are scheduled to expire in 2019 and that expired in 2018 or 2017. 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 2019 or that expired in 2018 or 2017.
This report describes selected health care-related provisions that are scheduled to expire during the first session of the 116th Congress (i.e., during calendar year [CY] 2019). 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 health care-related provisions that were enacted in the Patient Protection and Affordable Care Act (ACA; P.L. 111-148) or last extended under the Bipartisan Budget Act of 2018 (BBA 2018; P.L. 115-123). In addition, this report describes health care-related provisions within the same scope that expired during the 115th Congress (i.e., during CY2017 or CY2018). 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). Mandatory spending is controlled by authorization acts; discretionary spending is controlled by appropriations acts.1 The second type of provision defines the authority of government agencies or other entities to act, usually by authorizing a policy, project, or activity.2 Such provisions also may temporarily delay the implementation of a regulation, requirement, or deadline, or establish a moratorium on a particular activity.3 Expiring health care provisions that are predominantly associated with discretionary spending activities—such as discretionary authorizations of appropriations4 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 legislative attention and are excluded.
The report is organized as follows: Table 1 lists the relevant provisions that are scheduled to expire in 2019. Table 2 lists the relevant provisions that expired during 2018 or 2017. 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 that are scheduled to expire in 2019 followed by those that expired in 2018 or 2017.5 Appendix A lists demonstration projects and pilot programs that are scheduled to expire in 2019 or that expired in 2018 or 2017 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 BBA 2018. 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 |
Contact |
|
9/30/2019 |
Medicaid |
Protections for Recipients of Home and Community-Based Services against Spouse Impoverishment |
SSA §1924 |
Kirsten Colello |
9/30/2019 |
Medicaid |
Additional Medicaid Funding for the Territories |
SSA §1108 |
Alison Mitchel |
9/30/2019 |
Medicare |
Outreach and Assistance for Low-Income Programs |
MIPPA §119 |
Kirsten Colello |
9/30/2019 |
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) |
Marco Villagrana |
9/30/2019 |
Medicare |
Temporary Exception for Certain Spinal Cord Conditions from Application of the Medicare LTCH Site Neutral Payment for Certain LTCHs |
SSA §1886(m)(6)(F) §1395ww(m)(6)(F) |
Marco Villagrana |
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) |
Amanda Sarata |
9/30/2019 |
Medicare |
Contract with a Consensus-Based Entity Regarding Performance Measurement |
SSA §1890(d) 42 U.S.C. §1395aaa |
Amanda Sarata |
9/30/2019 |
Medicare |
Quality Measure Selection |
SSA §1890A 42 U.S.C. §1395aaa-1 |
Amanda Sarata |
9/30/2019 |
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 |
Amanda Sarata |
9/30/2019 |
Other |
Family-to-Family Health Information Centers |
SSA §501(c) |
Elayne Heisler |
9/30/2019 |
Other |
Sexual Risk Avoidance Education Program |
SSA §501 |
Adrienne Fernandes-Alcantara |
9/30/2019 |
Other |
Personal Responsibility Education Program |
SSA §513 |
Adrienne Fernandes-Alcantara |
9/30/2019 |
Other |
Pregnancy Assistance Fund |
ACA §10212 42 U.S.C. §18201-18204 |
Adrienne Fernandes-Alcantara |
9/30/2019 |
Other |
Teaching Health Centers |
PHSA §340H 42 U.S.C. §256h |
Elayne Heisler |
9/30/2019 |
Other |
Community Health Centers Fund |
PHSA §330 42 U.S.C. §254b-2(b)(1) |
Elayne Heisler |
9/30/2019 |
Other |
Special Diabetes Programs |
PHSA §330B and §330C 42 U.S.C. §254c-2(b) and §254c-3(b) |
Elayne Heisler |
9/30/2019 |
Other |
National Health Service Corps Appropriations |
PHSA §338H 42 U.S.C. §254b-2(b)(2) |
Elayne Heisler |
9/30/2019 |
Other |
Teaching Health Centers |
PHSA §340H 42 U.S.C. §256h |
Elayne Heisler |
12/31/2019 |
Medicare |
Floor on Work Geographic Practice Cost Indices |
SSA §1848(e)(1) 42 U.S.C. §1395w-4(e)(1)(E) |
Jim Hahn |
12/31/2019 |
Medicare |
Transitional Payment Rules for Certain Radiation Therapy Services |
SSA §1848 42 U.S.C. 1395w-4(b)(11) |
Jim Hahn |
12/31/2019 |
Private Health Insurance |
Health Coverage Tax Credit |
IRC §35 26 U.S.C. §35 |
Bernadette Fernandez |
12/31/2019 |
Private Health Insuranceb |
Annual Fee on Health Insurance Providers |
ACA §9010 |
Ryan Rosso |
12/31/2019 |
Private Health Insuranceb |
Excise Tax on Medical Device Manufacturers |
26 U.S.C. §4191 |
Ryan Rosso |
Source: Congressional Research Service (CRS).
Notes: ACA = Patient Protection and Affordable Care Act (P.L. 111-148. as amended), CY = Calendar Year, IRC = Internal Revenue Code, LTCH= Long-Term Care Hospital, 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.
b. These two provisions did not meet the criteria for the report, but the provisions are expiring in 2019. 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.
Health Care- Related Program |
Provisiona |
Contact |
||
9/30/2017 |
Medicare |
Delay in Applying the 25% Patient Threshold Payment Adjustment for Long-Term Care Hospitals |
MMSEA §114(c) 42 U.S.C. §1395ww note |
Marco Villagrana |
9/30/2017 |
Medicare |
Long-Term Care Hospital Moratoria |
MMSEA §114(d) 42 U.S.C. §1395ww note |
Marco Villagrana |
12/31/2017 |
Medicare |
Extension of Enforcement Instruction on Supervision Requirements for Outpatient Therapeutic Services in Critical Access and Small Rural Hospitals |
Jim Hahn |
|
9/30/2018 |
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) |
Marco Villagrana |
12/31/2018 |
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) |
Jim Hahn |
12/31/2018 |
Medicare |
Delay in Authority to Terminate Contracts for MA Plans Failing to Achieve Minimum Quality Ratings |
SSA §1857 |
Paulette Morgan |
Source: Congressional Research Service.
Notes: ASC = Ambulatory Surgery Centers, CY = Calendar Year, MA = Medicare Advantage, MMSEA = Medicare, Medicaid, and SCHIP Extension Act of 2007, 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 Family-to-Family Health Information Centers program funds family-staffed and family-run centers in the 50 states, the District of Columbia, the territories, and through a tribal organization. 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 decision-making at all levels of care and service delivery. This program is administered by the Health Resources and Services Administration (HRSA).
Appropriated funds to create or maintain Family-to-Family Health Information Centers have been enacted for FY2019, but under current law no new funding will be available for FY2020 or subsequent fiscal years.
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.7 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.
Appropriated funds for the Title V SRAE program have been enacted for FY2019, but under current law no new funding will be available for FY2020 or subsequent fiscal years.
The Personal Responsibility Education Program (PREP) takes a broad approach to teen pregnancy prevention that targets adolescents aged 10 to 20 and pregnant and parenting youth under the age of 21.8 Education services can address abstinence and/or contraceptives to prevent pregnancy and sexually transmitted infections. PREP includes four types of grants: (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.
Appropriated funds for PREP have been enacted for FY2019, but under current law no new funding will be available for FY2020 or subsequent fiscal years.
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 sections "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))" and "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))" below.)
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 expires 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 expires for discharges occurring in cost reporting periods beginning during FY2020 and subsequent years.
Section 101 of MACRA made fundamental changes to the way Medicare payments to physicians are determined and how they are updated.9 To implement the payment modifications in Section 101 of MACRA, the law authorized the transfer of $80 million from the Supplementary Medical Insurance (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 Merit-based Incentive Payment System 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 the Center for Medicare & Medicaid Services (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.
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 from SSA Section 1890 have not been enacted for FY2020 or subsequent fiscal years. However, funds appropriated prior to FY2020 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. 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 (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.
Appropriated funds to carry out the measure selection activities from SSA Section 1890A(a)-(d) have not been enacted for FY2020 or subsequent fiscal years. However, funds appropriated prior to FY2020 are available for obligation until expended.
Payments under the Medicare physician fee schedule (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 will expire after December 31, 2019.
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 expire after December 31, 2019.
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 BBA 2018 through FY2019, 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.10
BBA 2018 also requires ACL11 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.
Funding authorized under BBA 2018 for low-income outreach and assistance programs will expire after September 30, 2019. However, funds appropriated will be available for obligation until expended.
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" (PCORTF) 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 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.
Appropriated funds to PCORTF have not been enacted for FY2020 or subsequent fiscal years. 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, 2019, and any amounts in the Trust Fund after such date shall be transferred to the general fund of the Treasury.
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 September 30, 2019.
Medicaid financing for the territories (i.e., America Samoa, Commonwealth of the Northern Mariana Islands, Guam, Puerto Rico, and the U.S. Virgin Islands) is different than the financing for the 50 states and the District of Columbia. Federal Medicaid funding to the states and the District of Columbia is open-ended, but the Medicaid programs in the territories are subject to annual federal capped funding.
The federal Medicaid funding for the territories comes from a few different sources. The permanent source of federal Medicaid funding for the territories is the annual capped funding. Since July 1, 2011, Medicaid funding for the territories has been supplemented by a few additional funding sources available for a limited time provided through the ACA; the Consolidated Appropriations Act, 2017 (P.L. 115-31); and BBA 2018. Prior to the availability of these additional Medicaid funding sources, all five territories typically exhausted their federal Medicaid funding prior to the end of the fiscal year.15
The $6.3 billion in additional Medicaid federal funding under ACA Section 2005 as modified and the additional funding provided to Puerto Rico and the U.S. Virgin Islands under the Consolidated Appropriations Act, 2017 and the BBA 2018 expire after September 30, 2019, and the $1.0 billion in ACA Section 1323 funding expires after December 31, 2019.
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.
Appropriated funds for CHCF have been enacted for FY2019, but under current law no new funding is provided for FY2020 or subsequent fiscal years. Any unused portion of grants awarded for a given fiscal year prior to October 1, 2019, 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 been enacted for FY2019, but under current law no new funding is provided for FY2020 or subsequent fiscal years. Any unused portion of grants awarded for a given fiscal year prior to October 1, 2019, remains 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.
Appropriated funds for CHCF funds have been enacted for FY2019, but under current law no new funding is provided for FY2020 or subsequent fiscal years. Any unused portion of grants awarded for a given fiscal year prior to October 1, 2019, remains 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).
Appropriated funds for Teaching Health Center GME payments have been enacted for FY2019. Under current law no new funding is provided for FY2020 or subsequent fiscal years.
The Pregnancy Assistance Fund (PAF) program seeks to improve the educational, health, and social outcomes of vulnerable individuals who are expectant or new parents and their children. PAF funding is awarded competitively to the 50 states, District of Columbia, the territories, and tribal entities that apply successfully. The grantees may use the funds for providing subgrants to community service providers and selected other entities that provide services during the prenatal and postnatal periods. Grantees may also provide, in partnership with the state attorney general's office, certain legal and other services for women who experience domestic violence, sexual assault, or stalking while they are pregnant or parenting an infant. Further, grant funds can be used to support public awareness efforts about PAF services for the expectant and parenting population.
Appropriated funds for the PAF program funds have been enacted for FY2019, but under current law no new funding will be available for FY2020 or subsequent fiscal years.
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, 2019.
An annual fee is imposed on certain health insurance issuers. The aggregate fee is set at $8.0 billion in CY2014, $11.3 billion in CY2015 and CY2016, $13.9 billion in CY2017, and $14.3 billion in CY2018. After CY2018, 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 calculates the fee on 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 moratorium on the collection of the fee is to end after CY2019, meaning covered entities are scheduled to be subject to the fee again beginning in CY2020.
An excise tax is imposed on the sale of certain medical devices. For the purposes of the tax, a "medical device" is defined by the Federal Food, Drug, and Cosmetic Act (21 U.S.C. §321(h)) and pertains to devices "intended for humans." Congress exempted eyeglasses, contact lenses, and hearing aids from the tax and any other medical device determined by the Secretary of the Treasury to be of the type that is "generally purchased by the general public at retail for individual use." 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 suspension of the tax is to end after CY2019, meaning the tax is to apply to sales of medical devices again beginning in CY2020.
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 temporary criterion for certain severe wound discharges for payment under the LTCH PPS expired for discharges in cost-reporting periods beginning during FY2019 and subsequent years.
Congress has passed several bills to promote the widespread adoption of health information technology (HIT) and to support the electronic sharing of clinical data among hospitals, physicians, and other health care stakeholders. HIT encompasses interoperable electronic health records (EHRs)—including computerized systems to order tests and medications, and support systems to aid clinical decision making—and the development of a national health information network to permit the secure exchange of electronic health information among providers.
The exemption as specified in the Cures Act expired December 31, 2018. Current law states that this exemption is to sunset "as of the first year that begins more than 3 years after the date on which the Secretary determines, through notice and comment rulemaking, that certified EHR technology applicable to the ambulatory surgical center setting is available." This has yet to occur.
Under Medicare Advantage (Medicare Part C, or MA) CMS pays private health plans a per-enrollee amount to provide all Medicare-covered benefits (except hospice) to beneficiaries who enroll in their plan. SSA Section 1853(o)(4) requires the HHS Secretary to use a five-star quality rating system to adjust maximum possible payments to high-performing MA plans. High star quality also results in an increase in an MA organization's rebate if its contract bid is less than the maximum amount that Medicare will pay. In addition, the five-star quality ratings are publicly reported and can be used by beneficiaries when considering which MA, Part D, or Medicare Advantage-Prescription Drug (MA-PD) plan to enroll in.
The Social Security Act authorizes the HHS Secretary to terminate a contract with an MA organization or a Perscription Drug Plan (PDP) if the HHS Secretary determines that the MA organization or PDP has failed substantially to carry out the contract, is carrying out the contract in a manner inconsistent with the efficient and effective administration of the Medicare program, or no longer meets the applicable Medicare program conditions.18 CMS amended its regulations in 2012 to include a ground for contract termination relating to an MA organization's or a PDP's rating under the five-star system. Specifically, under the regulation, CMS may terminate a contract with an MA organization or a PDP if the plan receives a "summary plan rating of less than 3 stars for 3 consecutive contract years."19 The regulation applies to plan ratings issued by CMS after September 1, 2012. CMS has terminated some MA organizations' contracts on this basis.
The HHS Secretary has the authority to terminate an organization's MA or Part D contract based solely on the organization's receipt of a Part C or Part D summary rating of less than three stars for three consecutive contract years. The Secretary issued a memorandum to MA plans indicating that the first star rating released after December 2018 is the first that could count toward termination. Star ratings are released in the fall of one year, displayed for beneficiary use the next year, and then used for payment purposes the following year. As such, the CY2020 rates (released fall CY2019 and used for payment purposes in CY2021) are the first that could apply toward potential termination. The soonest possible effective date for a CMS termination of an MA contract under this policy would be December 31, 2022.
LTCHs generally treat patients who have been discharged from acute-care hospitals but require prolonged inpatient hospital care due to their medical conditions. LTCH patients have an average length of inpatient stay longer than 25 days. LTCHs can be (1) freestanding—a hospital generally not integrated with any other hospital; (2) co-located 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 separately located facility (which may be co-located with another hospital) that operates as part of the LTCH.
Beginning in FY2005, CMS implemented a new Medicare payment regulation for LTCHs that are co-located with other hospitals and LTCH satellite facilities to limit inappropriate patient shifting driven by financial rather than clinical considerations. Under the new policy, if such an LTCH received more than 25% of its Medicare patients from any single referring hospital, the LTCH is paid the lower of the LTCH PPS or the IPPS payment for discharges that exceeded the threshold. Beginning in FY2008, CMS expanded the 25% patient threshold adjustment policy to include all LTCHs.
The statutory delay in CMS applying the 25% patient threshold adjustment to LTCHs expired after September 30, 2017. However, the HHS Secretary extended the delay through FY2018 and eliminated it beginning FY2019 through rulemaking.20
Under Medicare, LTCHs were exempt from the IPPS when it was established in 1983. Instead, LTCHs were paid 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 Balanced Budget Refinement Act of 1999 (BBRA 99; P.L. 106-113), the LTCH PPS was established, which provides a per-discharge payment based on the average costs and patient mix of LTCHs. The LTCH PPS typically provides higher Medicare payment rates for inpatient hospital care than the IPPS.
The rapid increase in both the number of LTCHs and LTCH payments led to enactment of a temporary 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 on the increase of beds in existing LTCHs expired as of September 30, 2017.
The 2009 Outpatient Prospective Payment System (OPPS) final rule required that therapeutic hospital outpatient services be furnished under the direct supervision of a physician.21 However, beginning in CY2010, CMS instructed its contractors not to evaluate or enforce the supervision requirements for therapeutic services provided to outpatients in critical access hospitals (CAHs). CMS extended this non-enforcement instruction for CY2011 and expanded it to include small rural hospitals with 100 or fewer beds. Subsequently, CMS extended the instruction for CY2012 and CY2013, The non-enforcement instruction has been extended several more times through legislation and rules.
Although the non-enforcement instruction has statutorily expired, the CY2018 OPPS/ Ambulatory Surgery Center (ASC) final rule with comment period re-established the non-enforcement policy beginning on January 1, 2018, and extended the instruction through December 31, 2019.22
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 first session of the 116th Congress (i.e., during calendar year [CY] 2019). 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.23 This appendix also includes other 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 last extended under the Bipartisan Budget Act of 2018 (BBA 2018; P.L. 115-123). In addition, this appendix lists health care-related demonstration projects and pilot programs within the same scope that expired during the 115th Congress (i.e., during CY2017 or CY2018).
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 2019. Table A-2 lists the relevant provisions that expired during 2018 or 2017.
Table A-1. Demonstration Projects and Pilot Programs Expiring in the 116th Congress, First Session
(CY2019)
Expires After |
Health Care-Related Program |
Provision |
Contact |
|
6/30/2019a |
Medicaid/ Other |
Demonstration to Improve Community Behavioral Health Clinics |
PAMA §223(f) |
Alison Mitchell |
9/30/2019 |
Medicaid |
Money Follows the Person Rebalancing Demonstrationb |
DRA §6071 |
Kirsten Colello |
9/30/2019 |
Other |
Demonstration Projects to Address Health Professions Workforce Needsc |
SSA §2008(c) |
Elayne Heisler |
Source: Congressional Research Service.
Notes: CY = Calendar Year, DRA = Deficit Reduction Act of 2005, PAMA = Protecting Access to Medicare Act of 2014, SSA = Social Security Act, U.S.C. = U.S. Code.
a. The expiration date of Demonstration to Improve Community Behavioral Health Clinics was amended in the Medicaid Services Investment and Accountability Act of 2019 (P.L. 116-16), and the expiration date is effectively June 30, 2019. For more information, see https://www.samhsa.gov/section-223.
b. Extended most recently in Section 2 of the Medicaid Extenders Act of 2019 (P.L. 116-3; additional funding provided under Section 5 of the Medicaid Services Investment and Accountability Act of 2019 (P.L. 116-16). For more information, see https://www.medicaid.gov/medicaid/ltss/money-follows-the-person/index.html.
c. 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).
Table A-2. Demonstration Projects and Pilot Programs That Expired in the 115th Congress,
(CY2017 and CY2018)
Expired After |
Health Care-Related Program |
Provision |
Contact |
|
3/23/2017 |
Other |
Demonstration Program to Increase Access to Dental Health Care Servicesa |
PHSA §340G-1 |
Elayne Heisler |
Source: Congressional Research Service.
Notes: CY = Calendar Year, PHSA = Public Health Service 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 FY2011-FY2016 and for FY2017 appropriations under continuing resolutions (P.L. 114-223 and P.L. 114-254).
Appendix B. Laws That Created, Modified, or Extended Current Health Care-Related Expiring Provisions
P.L. Number |
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 |
|
— |
Consolidated Appropriations Act of 2016 |
|
PAMPA |
Patient Access and Medicare Protection Act |
|
Cures Act |
The 21st Century Cures Act |
|
— |
Consolidated Appropriations Act, 2017 |
|
— |
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 |
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).
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
AHRQ: Agency for Healthcare Research and Quality
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 13: Bipartisan Budget Act of 2013 (P.L. 113-67, Division A)
BBA 97: Balanced Budget Act of 1997 (P.L. 105-33)
BBA 2018: Bipartisan Budget Act of 2018
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)
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
EHR: Electronic health record
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)
HIT: Health information technology
HITECH: Health Information Technology for Economic and Clinical Health Act
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
LTCH PPS: Long-term care hospital prospective payment system
LTSS: Long-term services and supports
MA: Medicare Advantage
MA-PD: Medicare Advantage-Prescription Drug
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 )
PCORI: Patient-Centered Outcomes Research Institute
PCORTF: Patient-Centered Outcomes Research Trust Fund
PDP: Prescription Drug Plan
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)
RVU: Relative value unit
SGR: Sustainable Growth Rate
SHIP: State Health Insurance Assistance Program
SMI: Supplementary Medical Insurance
SNAP: Supplemental Nutrition Assistance Program
SSA: Social Security Act
SRAE: Sexual Risk Avoidance Education
SSI: Supplemental Security Income
TAA: Trade Adjustment Assistance
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, CRS Specialist in Social Policy, provided valuable input in reviewing the report.
1. |
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. |
Two private health insurance provisions included in this report do not meet the report criteria, but the provisons are expiring in 2019. 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. |
4. |
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 2019 (March 14, 2019), which includes provisions set to expire on or before September 30, 2019, is available at https://www.cbo.gov/publication/55015. |
5. |
The 2019 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., new laws). |
6. |
Citations in statute and the U.S. Code (U.S.C.) are provided where available. |
7. |
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. For further information about both programs, see CRS Report R45183, Teen Pregnancy: Federal Prevention Programs. |
8. |
For further information about PREP, see CRS Report R45183, Teen Pregnancy: Federal Prevention Programs. |
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. |
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. |
11. |
Section 50207 of BBA 2018 refers to the "Agency for Community Living." |
12. |
See Centers for Medicare & Medicaid Services (CMS), 2019 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. |
For more information about Medicaid funding for the territories, see CRS In Focus IF11012, Medicaid Funding for the Territories. |
16. |
Because none of the territories established exchanges, the territories all received additional federal Medicaid funds. Also, the provision specified that Puerto Rico receive $925 million, and the HHS Secretary distributed the remaining funding among the other four territories. |
17. |
The certain conditions are that the HHS Secretary needs to certify that each territory (i.e., Puerto Rico and U.S. Virgin Islands) has taken steps to (1) report reliable data to the Transformed-Medicaid Statistical Information System and (2) establish a Medicaid Fraud Control Unit. |
18. |
SSA §1857(c)(2) (contract termination authority under Medicare Advantage) and §1860D-12(b)(3)(B) (contract termination authority under Medicare Part D). |
19. |
42 C.F. R. §§422.510(a)(4)(xi), 423.509(a)(4)(x) CMS, "Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year 2013 and Other Changes" 77 Federal Register 22072-22175, April 12, 2012. |
20. |
CMS, "Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2019 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs (Promoting Interoperability Programs) Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Medicare Cost Reporting Requirements; and Physician Certification and Recertification of Claims", 83 Federal Register 41144, August 17, 2018, see pages 41532-41533. |
21. |
CMS, "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 60315-60983, November 20, 2009. |
22. |
CMS, "Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs," 82 Federal Register 52356, November 11, 2017. |
23. |
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. |