Sec. 4103: Medicare Coverage of Annual Wellness Visit Providing a Personalized Prevention Plan

This content, taken from the Affordable Care Act , is provided as a convenience.

(a) COVERAGE OF PERSONALIZED PREVENTION PLAN SERVICES.—
(1) IN GENERAL.—Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended—
(A) in subparagraph (DD), by striking ‘‘and’’ at the end;
(B) in subparagraph (EE), by adding ‘‘and’’ at the end; and
(C) by adding at the end the following new subparagraph:
‘‘(FF) personalized prevention plan services (as defined in subsection (hhh));’’.
(2) CONFORMING AMENDMENTS.—Clauses (i) and (ii) of section 1861(s)(2)(K) of the Social Security Act (42 U.S.C. 1395x(s)(2)(K)) are each amended by striking ‘‘subsection (ww)(1)’’ and inserting ‘‘subsections (ww)(1) and (hhh)’’.
(b) PERSONALIZED PREVENTION PLAN SERVICES DEFINED.—Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:

‘‘Annual Wellness Visit
‘‘(hhh)(1) The term ‘personalized prevention plan services’ means the creation of a plan for an individual—
‘‘(A) that includes a health risk assessment (that meets the guidelines established by the Secretary under paragraph (4)(A)) of the individual that is completed prior to or as part of the same visit with a health professional described in paragraph (3); and
‘‘(B) that—
‘‘(i) takes into account the results of the health risk assessment; and
‘‘(ii) may contain the elements described in paragraph (2).
‘‘(2) Subject to paragraph (4)(H), the elements described in this paragraph are the following:
‘‘(A) The establishment of, or an update to, the individual’s medical and family history.
‘‘(B) A list of current providers and suppliers that are regularly involved in providing medical care to the individual (including a list of all prescribed medications).
H. R. 3590—436
‘‘(C) A measurement of height, weight, body mass index (or waist circumference, if appropriate), blood pressure, and other routine measurements.
‘‘(D) Detection of any cognitive impairment.
‘‘(E) The establishment of, or an update to, the following:
‘‘(i) A screening schedule for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force and the Advisory Committee on Immunization Practices, and the individual’s health status, screening history, and age-appropriate preventive services covered under this title.
‘‘(ii) A list of risk factors and conditions for which primary, secondary, or tertiary prevention interventions are recommended or are underway, including any mental health conditions or any such risk factors or conditions that have been identified through an initial preventive physical examination (as described under subsection (ww)(1)), and a list of treatment options and their associated risks and benefits.
‘‘(F) The furnishing of personalized health advice and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote selfmanagement and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition.
‘‘(G) Any other element determined appropriate by the Secretary.
‘‘(3) A health professional described in this paragraph is—
‘‘(A) a physician;
‘‘(B) a practitioner described in clause (i) of section 1842(b)(18)(C); or
‘‘(C) a medical professional (including a health educator, registered dietitian, or nutrition professional) or a team of medical professionals, as determined appropriate by the Secretary, under the supervision of a physician.
‘‘(4)(A) For purposes of paragraph (1)(A), the Secretary, not later than 1 year after the date of enactment of this subsection, shall establish publicly available guidelines for health risk assessments. Such guidelines shall be developed in consultation with relevant groups and entities and shall provide that a health risk assessment—
‘‘(i) identify chronic diseases, injury risks, modifiable risk factors, and urgent health needs of the individual; and
‘‘(ii) may be furnished—
‘‘(I) through an interactive telephonic or web-based program that meets the standards established under subparagraph (B);
‘‘(II) during an encounter with a health care professional;
‘‘(III) through community-based prevention programs;
or
‘‘(IV) through any other means the Secretary determines appropriate to maximize accessibility and ease of use by beneficiaries, while ensuring the privacy of such beneficiaries.
‘‘(B) Not later than 1 year after the date of enactment of this subsection, the Secretary shall establish standards for interactive telephonic or web-based programs used to furnish health risk assessments under subparagraph (A)(ii)(I). The Secretary may utilize any health risk assessment developed under section 4004(f) of the Patient Protection and Affordable Care Act as part of the requirement to develop a personalized prevention plan to comply with this subparagraph.
‘‘(C)(i) Not later than 18 months after the date of enactment of this subsection, the Secretary shall develop and make available to the public a health risk assessment model. Such model shall meet the guidelines under subparagraph (A) and may be used to meet the requirement under paragraph (1)(A).
‘‘(ii) Any health risk assessment that meets the guidelines under subparagraph (A) and is approved by the Secretary may be used to meet the requirement under paragraph (1)(A).
‘‘(D) The Secretary may coordinate with community-based entities (including State Health Insurance Programs, Area Agencies on Aging, Aging and Disability Resource Centers, and the Administration on Aging) to—
‘‘(i) ensure that health risk assessments are accessible to beneficiaries; and
‘‘(ii) provide appropriate support for the completion of health risk assessments by beneficiaries.
‘‘(E) The Secretary shall establish procedures to make beneficiaries and providers aware of the requirement that a beneficiary complete a health risk assessment prior to or at the same time as receiving personalized prevention plan services.
‘‘(F) To the extent practicable, the Secretary shall encourage the use of, integration with, and coordination of health information technology (including use of technology that is compatible with electronic medical records and personal health records) and may experiment with the use of personalized technology to aid in the development of self-management skills and management of and adherence to provider recommendations in order to improve the health status of beneficiaries.
‘‘(G)(i) A beneficiary shall only be eligible to receive an initial preventive physical examination (as defined under subsection (ww)(1)) at any time during the 12-month period after the date that the beneficiary’s coverage begins under part B and shall be eligible to receive personalized prevention plan services under this subsection provided that the beneficiary has not received such services within the preceding 12-month period.
‘‘(ii) The Secretary shall establish procedures to make beneficiaries aware of the option to select an initial preventive physical examination or personalized prevention plan services during the period of 12 months after the date that a beneficiary’s coverage begins under part B, which shall include information regarding any relevant differences between such services.
‘‘(H) The Secretary shall issue guidance that—
‘‘(i) identifies elements under paragraph (2) that are required to be provided to a beneficiary as part of their first visit for personalized prevention plan services; and
‘‘(ii) establishes a yearly schedule for appropriate provision of such elements thereafter.’’.
(c) PAYMENT AND ELIMINATION OF COST-SHARING.—
(1) PAYMENT AND ELIMINATION OF COINSURANCE.—Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended—
(A) in subparagraph (N), by inserting ‘‘other than personalized prevention plan services (as defined in section 1861(hhh)(1))’’ after ‘‘(as defined in section 1848(j)(3))’’;
(B) by striking ‘‘and’’ before ‘‘(W)’’; and
(C) by inserting before the semicolon at the end the following: ‘‘, and (X) with respect to personalized prevention plan services (as defined in section 1861(hhh)(1)), the amount paid shall be 100 percent of the lesser of the actual charge for the services or the amount determined under the payment basis determined under section 1848’’.
(2) PAYMENT UNDER PHYSICIAN FEE SCHEDULE.—Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)) is amended by inserting ‘‘(2)(FF) (including administration of the health risk assessment) ,’’ after ‘‘(2)(EE),’’.
(3) ELIMINATION OF COINSURANCE IN OUTPATIENT HOSPITAL SETTINGS.—
(A) EXCLUSION FROM OPD FEE SCHEDULE.—Section 1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. 1395l(t)(1)(B)(iv)) is amended by striking ‘‘and diagnostic mammography’’ and inserting ‘‘, diagnostic mammography, or personalized prevention plan services (as defined in section 1861(hhh)(1))’’.
(B) CONFORMING AMENDMENTS.—Section 1833(a)(2) of the Social Security Act (42 U.S.C. 1395l(a)(2)) is amended—
(i) in subparagraph (F), by striking ‘‘and’’ at the end;
(ii) in subparagraph (G)(ii), by striking the comma at the end and inserting ‘‘; and’’; and
(iii) by inserting after subparagraph (G)(ii) the following new subparagraph:
‘‘(H) with respect to personalized prevention plan services (as defined in section 1861(hhh)(1)) furnished by an outpatient department of a hospital, the amount determined under paragraph (1)(X),’’.
(4) WAIVER OF APPLICATION OF DEDUCTIBLE.—The first sentence of section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)) is amended—
(A) by striking ‘‘and’’ before ‘‘(9)’’; and
(B) by inserting before the period the following: ‘‘, and (10) such deductible shall not apply with respect to personalized prevention plan services (as defined in section 1861(hhh)(1))’’.
(d) FREQUENCY LIMITATION.—Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is amended—
(1) in paragraph (1)—
(A) in subparagraph (N), by striking ‘‘and’’ at the end;
(B) in subparagraph (O), by striking the semicolon at the end and inserting ‘‘, and’’; and
(C) by adding at the end the following new subparagraph:
‘‘(P) in the case of personalized prevention plan services (as defined in section 1861(hhh)(1)), which are performed more frequently than is covered under such section;’’; and
(2) in paragraph (7), by striking ‘‘or (K)’’ and inserting ‘‘(K), or (P)’’.
(e) EFFECTIVE DATE.—The amendments made by this section shall apply to services furnished on or after January 1, 2011. in this title’’ and inserting ‘‘not described in subparagraph

(A) or (C) of paragraph (3)’’; and
(3) by adding at the end the following new paragraph:
‘‘(3) The term ‘preventive services’ means the following:
‘‘(A) The screening and preventive services described in subsection (ww)(2) (other than the service described in subparagraph (M) of such subsection).
‘‘(B) An initial preventive physical examination (as defined in subsection (ww)).
‘‘(C) Personalized prevention plan services (as defined in subsection (hhh)(1)).’’.
(b) COINSURANCE.—
(1) GENERAL APPLICATION.—
(A) IN GENERAL.—Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), as amended by section 4103(c)(1), is amended—
(i) in subparagraph (T), by inserting ‘‘(or 100 percent if such services are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population and are appropriate for the individual)’’ after ‘‘80 percent’’;
(ii) in subparagraph (W)—
(I) in clause (i), by inserting ‘‘(if such subparagraph were applied, by substituting ‘100 percent’ for ‘80 percent’)’’ after ‘‘subparagraph (D)’’; and
(II) in clause (ii), by striking ‘‘80 percent’’ and inserting ‘‘100 percent’’;
(iii) by striking ‘‘and’’ before ‘‘(X)’’; and
(iv) by inserting before the semicolon at the end the following: ‘‘, and (Y) with respect to preventive services described in subparagraphs (A) and (B) of section 1861(ddd)(3) that are appropriate for the individual and, in the case of such services described in subparagraph (A), are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population, the amount paid shall be 100 percent of the lesser of the actual charge for the services or the amount determined under the fee schedule that applies to such services under this part’’.
(2) ELIMINATION OF COINSURANCE IN OUTPATIENT HOSPITAL SETTINGS.—
(A) EXCLUSION FROM OPD FEE SCHEDULE.—Section 1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. H. R. 3590—440 1395l(t)(1)(B)(iv)), as amended by section 4103(c)(3)(A), is amended—
(i) by striking ‘‘or’’ before ‘‘personalized prevention plan services’’; and
(ii) by inserting before the period the following:
‘‘, or preventive services described in subparagraphs
(A) and (B) of section 1861(ddd)(3) that are appropriate for the individual and, in the case of such services described in subparagraph (A), are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population’’.
(B) CONFORMING AMENDMENTS.—Section 1833(a)(2) of the Social Security Act (42 U.S.C. 1395l(a)(2)), as amended by section 4103(c)(3)(B), is amended—
(i) in subparagraph (G)(ii), by striking ‘‘and’’ after the semicolon at the end;
(ii) in subparagraph (H), by striking the comma at the end and inserting ‘‘; and’’; and
(iii) by inserting after subparagraph (H) the following new subparagraph:
‘‘(I) with respect to preventive services described in subparagraphs (A) and (B) of section 1861(ddd)(3) that are appropriate for the individual and are furnished by an outpatient department of a hospital and, in the case of such services described in subparagraph (A), are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population, the amount determined under paragraph (1)(W) or (1)(Y),’’.
(c) WAIVER OF APPLICATION OF DEDUCTIBLE FOR PREVENTIVE SERVICES AND COLORECTAL CANCER SCREENING TESTS.—Section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)), as amended by section 4103(c)(4), is amended—
(1) in paragraph (1), by striking ‘‘items and services described in section 1861(s)(10)(A)’’ and inserting ‘‘preventive services described in subparagraph (A) of section 1861(ddd)(3) that are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population and are appropriate for the individual.’’; and
(2) by adding at the end the following new sentence: ‘‘Paragraph (1) of the first sentence of this subsection shall apply with respect to a colorectal cancer screening test regardless of the code that is billed for the establishment of a diagnosis as a result of the test, or for the removal of tissue or other matter or other procedure that is furnished in connection with, as a result of, and in the same clinical encounter as the screening test.’’.
(d) EFFECTIVE DATE.—The amendments made by this section shall apply to items and services furnished on or after January 1, 2011.