# Patient Protection and Affordable Care Act/Title III/Subtitle B/Part I
## PART I—ENSURING BENEFICIARY ACCESS TO PHYSICIAN CARE AND OTHER SERVICES
### SEC. 3101. INCREASE IN THE PHYSICIAN PAYMENT UPDATE.

Section 1848(d) of the Social Security Act (42 U.S.C. 1395w-4(d)) is amended by adding at the end the following new paragraph:
                `(10) UPDATE FOR 2010-
                   `(A) IN GENERAL- Subject to paragraphs (7)(B), (8)(B), and (9)(B), in lieu of the update to the single conversion factor established in paragraph (1)(C) that would otherwise apply for 2010, the update to the single conversion factor shall be 0.5 percent.
                   `(B) NO EFFECT ON COMPUTATION OF CONVERSION FACTOR FOR 2011 AND SUBSEQUENT YEARS- The conversion factor under this subsection shall be computed under paragraph (1)(A) for 2011 and subsequent years as if subparagraph (A) had never applied.'.

### SEC. 3102. EXTENSION OF THE WORK GEOGRAPHIC INDEX FLOOR AND REVISIONS TO THE PRACTICE EXPENSE GEOGRAPHIC ADJUSTMENT UNDER THE MEDICARE PHYSICIAN FEE SCHEDULE.

    (a) Extension of Work GPCI Floor- Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-4(e)(1)(E)) is amended by striking `before January 1, 2010' and inserting `before January 1, 2011'.
    (b) Practice Expense Geographic Adjustment for 2010 and Subsequent Years- Section 1848(e)(1) of the Social Security Act (42 U.S.C. 1395w4(e)(1)) is amended--
       (1) in subparagraph (A), by striking `and (G)' and inserting `(G), and (H)'; and
       (2) by adding at the end the following new subparagraph:
                   `(H) PRACTICE EXPENSE GEOGRAPHIC ADJUSTMENT FOR 2010 AND SUBSEQUENT YEARS-
                      `(i) FOR 2010- Subject to clause (iii), for services furnished during 2010, the employee wage and rent portions of the practice expense geographic index described in subparagraph (A)(i) shall reflect 3/4 of the difference between the relative costs of employee wages and rents in each of the different fee schedule areas and the national average of such employee wages and rents.
                      `(ii) FOR 2011- Subject to clause (iii), for services furnished during 2011, the employee wage and rent portions of the practice expense geographic index described in subparagraph (A)(i) shall reflect 1/2 of the difference between the relative costs of employee wages and rents in each of the different fee schedule areas and the national average of such employee wages and rents.
                      `(iii) HOLD HARMLESS- The practice expense portion of the geographic adjustment factor applied in a fee schedule area for services furnished in 2010 or 2011 shall not, as a result of the application of clause (i) or (ii), be reduced below the practice expense portion of the geographic adjustment factor under subparagraph (A)(i) (as calculated prior to the application of such clause (i) or (ii), respectively) for such area for such year.
                      `(iv) ANALYSIS- The Secretary shall analyze current methods of establishing practice expense geographic adjustments under subparagraph (A)(i) and evaluate data that fairly and reliably establishes distinctions in the costs of operating a medical practice in the different fee schedule areas. Such analysis shall include an evaluation of the following:
                         `(I) The feasibility of using actual data or reliable survey data developed by medical organizations on the costs of operating a medical practice, including office rents and non-physician staff wages, in different fee schedule areas.
                         `(II) The office expense portion of the practice expense geographic adjustment described in subparagraph (A)(i), including the extent to which types of office expenses are determined in local markets instead of national markets.
                         `(III) The weights assigned to each of the categories within the practice expense geographic adjustment described in subparagraph (A)(i).
                      `(v) REVISION FOR 2012 AND SUBSEQUENT YEARS- As a result of the analysis described in clause (iv), the Secretary shall, not later than January 1, 2012, make appropriate adjustments to the practice expense geographic adjustment described in subparagraph (A)(i) to ensure accurate geographic adjustments across fee schedule areas, including--
                         `(I) basing the office rents component and its weight on office expenses that vary among fee schedule areas; and
                         `(II) considering a representative range of professional and non-professional personnel employed in a medical office based on the use of the American Community Survey data or other reliable data for wage adjustments.
          Such adjustments shall be made without regard to adjustments made pursuant to clauses (i) and (ii) and shall be made in a budget neutral manner.'.

### SEC. 3103. EXTENSION OF EXCEPTIONS PROCESS FOR MEDICARE THERAPY CAPS.

Section 1833(g)(5) of the Social Security Act (42 U.S.C. 1395l(g)(5)) is amended by striking `December 31, 2009' and inserting `December 31, 2010'.

### SEC. 3104. EXTENSION OF PAYMENT FOR TECHNICAL COMPONENT OF CERTAIN PHYSICIAN PATHOLOGY SERVICES.

Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (as enacted into law by section 1(a)(6) of Public Law 106-554), as amended by section 732 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 U.S.C. 1395w-4 note), section 104 of division B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395w-4 note), section 104 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173), and section 136 of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275), is amended by striking `and 2009' and inserting `2009, and 2010'.

### SEC. 3105. EXTENSION OF AMBULANCE ADD-ONS.

    (a) Ground Ambulance- Section 1834(l)(13)(A) of the Social Security Act (42 U.S.C. 1395m(l)(13)(A)) is amended--
       (1) in the matter preceding clause (i)--
          (A) by striking `2007, and for' and inserting `2007, for'; and
          (B) by striking `2010' and inserting `2010, and for such services furnished on or after April 1, 2010, and before January 1, 2011,'; and
       (2) in each of clauses (i) and (ii), by inserting `, and on or after April 1, 2010, and before January 1, 2011' after `January 1, 2010' each place it appears.
    (b) Air Ambulance- Section 146(b)(1) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275) is amended by striking `December 31, 2009' and inserting `December 31, 2009, and during the period beginning on April 1, 2010, and ending on January 1, 2011'.
    (c) Super Rural Ambulance- Section 1834(l)(12)(A) of the Social Security Act (42 U.S.C. 1395m(l)(12)(A)) is amended by striking `2010' and inserting `2010, and on or after April 1, 2010, and before January 1, 2011'.

### SEC. 3106. EXTENSION OF CERTAIN PAYMENT RULES FOR LONG-TERM CARE HOSPITAL SERVICES AND OF MORATORIUM ON THE ESTABLISHMENT OF CERTAIN HOSPITALS AND FACILITIES.

    (a) Extension of Certain Payment Rules- Section 114(c) of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395ww note), as amended by section 4302(a) of the American Recovery and Reinvestment Act (Public Law 111-5), is further amended by striking `3-year period' each place it appears and inserting `4-year period'.
    (b) Extension of Moratorium- Section 114(d)(1) of such Act (42 U.S.C. 1395ww note), in the matter preceding subparagraph (A), is amended by striking `3-year period' and inserting `4-year period'.

### SEC. 3107. EXTENSION OF PHYSICIAN FEE SCHEDULE MENTAL HEALTH ADD-ON.

Section 138(a)(1) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275) is amended by striking `December 31, 2009' and inserting `December 31, 2010'.

### SEC. 3108. PERMITTING PHYSICIAN ASSISTANTS TO ORDER POST-HOSPITAL EXTENDED CARE SERVICES.

    (a) Ordering Post-Hospital Extended Care Services-
       (1) IN GENERAL- Section 1814(a)(2) of the Social Security Act (42 U.S.C. 1395f(a)(2)), in the matter preceding subparagraph (A), is amended by striking `or clinical nurse specialist' and inserting `, a clinical nurse specialist, or a physician assistant (as those terms are defined in section 1861(aa)(5))' after `nurse practitioner'.
       (2) CONFORMING AMENDMENT- Section 1814(a) of the Social Security Act (42 U.S.C. 1395f(a)) is amended, in the second sentence, by striking `or clinical nurse specialist' and inserting `clinical nurse specialist, or physician assistant' after `nurse practitioner,'.
    (b) Effective Date- The amendments made by this section shall apply to items and services furnished on or after January 1, 2011.

### SEC. 3109. EXEMPTION OF CERTAIN PHARMACIES FROM ACCREDITATION REQUIREMENTS.

    (a) In General- Section 1834(a)(20) of the Social Security Act (42 U.S.C. 1395m(a)(20)), as added by section 154(b)(1)(A) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 100-275), is amended--
       (1) in subparagraph (F)(i)--
          (A) by inserting `and subparagraph (G)' after `clause (ii)'; and
          (B) by inserting `, except that the Secretary shall not require a pharmacy to have submitted to the Secretary such evidence of accreditation prior to January 1, 2011' before the semicolon at the end; and
       (2) by adding at the end the following new subparagraph:
                   `(G) APPLICATION OF ACCREDITATION REQUIREMENT TO CERTAIN PHARMACIES-
                      `(i) IN GENERAL- With respect to items and services furnished on or after January 1, 2011, in implementing quality standards under this paragraph--
                         `(I) subject to subclause (II), in applying such standards and the accreditation requirement of subparagraph (F)(i) with respect to pharmacies described in clause (ii) furnishing such items and services, such standards and accreditation requirement shall not apply to such pharmacies; and
                         `(II) the Secretary may apply to such pharmacies an alternative accreditation requirement established by the Secretary if the Secretary determines such alternative accreditation requirement is more appropriate for such pharmacies.
                      `(ii) PHARMACIES DESCRIBED- A pharmacy described in this clause is a pharmacy that meets each of the following criteria:
                         `(I) The total billings by the pharmacy for such items and services under this title are less than 5 percent of total pharmacy sales, as determined based on the average total pharmacy sales for the previous 3 calendar years, 3 fiscal years, or other yearly period specified by the Secretary.
                         `(II) The pharmacy has been enrolled under section 1866(j) as a supplier of durable medical equipment, prosthetics, orthotics, and supplies, has been issued (which may include the renewal of) a provider number for at least 5 years, and for which a final adverse action (as defined in section 424.57(a) of title 42, Code of Federal Regulations) has not been imposed in the past 5 years.
                         `(III) The pharmacy submits to the Secretary an attestation, in a form and manner, and at a time, specified by the Secretary, that the pharmacy meets the criteria described in subclauses (I) and (II). Such attestation shall be subject to section 1001 of title 18, United States Code.
                         `(IV) The pharmacy agrees to submit materials as requested by the Secretary, or during the course of an audit conducted on a random sample of pharmacies selected annually, to verify that the pharmacy meets the criteria described in subclauses (I) and (II). Materials submitted under the preceding sentence shall include a certification by an accountant on behalf of the pharmacy or the submission of tax returns filed by the pharmacy during the relevant periods, as requested by the Secretary.'.
    (b) Administration- Notwithstanding any other provision of law, the Secretary may implement the amendments made by subsection (a) by program instruction or otherwise.
    (c) Rule of Construction- Nothing in the provisions of or amendments made by this section shall be construed as affecting the application of an accreditation requirement for pharmacies to qualify for bidding in a competitive acquisition area under section 1847 of the Social Security Act (42 U.S.C. 1395w-3).

### SEC. 3110. PART B SPECIAL ENROLLMENT PERIOD FOR DISABLED TRICARE BENEFICIARIES.

    (a) In General-
       (1) IN GENERAL- Section 1837 of the Social Security Act (42 U.S.C. 1395p) is amended by adding at the end the following new subsection:
             `(l)(1) In the case of any individual who is a covered beneficiary (as defined in section 1072(5) of title 10, United States Code) at the time the individual is entitled to part A under section 226(b) or section 226A and who is eligible to enroll but who has elected not to enroll (or to be deemed enrolled) during the individual's initial enrollment period, there shall be a special enrollment period described in paragraph (2).
                `(2) The special enrollment period described in this paragraph, with respect to an individual, is the 12-month period beginning on the day after the last day of the initial enrollment period of the individual or, if later, the 12-month period beginning with the month the individual is notified of enrollment under this section.
                `(3) In the case of an individual who enrolls during the special enrollment period provided under paragraph (1), the coverage period under this part shall begin on the first day of the month in which the individual enrolls, or, at the option of the individual, the first month after the end of the individual's initial enrollment period.
                `(4) An individual may only enroll during the special enrollment period provided under paragraph (1) one time during the individual's lifetime.
                `(5) The Secretary shall ensure that the materials relating to coverage under this part that are provided to an individual described in paragraph (1) prior to the individual's initial enrollment period contain information concerning the impact of not enrolling under this part, including the impact on health care benefits under the TRICARE program under chapter 55 of title 10, United States Code.
                `(6) The Secretary of Defense shall collaborate with the Secretary of Health and Human Services and the Commissioner of Social Security to provide for the accurate identification of individuals described in paragraph (1). The Secretary of Defense shall provide such individuals with notification with respect to this subsection. The Secretary of Defense shall collaborate with the Secretary of Health and Human Services and the Commissioner of Social Security to ensure appropriate follow up pursuant to any notification provided under the preceding sentence.'.
       (2) EFFECTIVE DATE- The amendment made by paragraph (1) shall apply to elections made with respect to initial enrollment periods that end after the date of the enactment of this Act.
    (b) Waiver of Increase of Premium- Section 1839(b) of the Social Security Act (42 U.S.C. 1395r(b)) is amended by striking `section 1837(i)(4)' and inserting `subsection (i)(4) or (l) of section 1837'.

### SEC. 3111. PAYMENT FOR BONE DENSITY TESTS.

    (a) Payment-
       (1) IN GENERAL- Section 1848 of the Social Security Act (42 U.S.C. 1395w-4) is amended--
          (A) in subsection (b)--
             (i) in paragraph (4)(B), by inserting `, and for 2010 and 2011, dual-energy x-ray absorptiometry services (as described in paragraph (6))' before the period at the end; and
             (ii) by adding at the end the following new paragraph:
                `(6) TREATMENT OF BONE MASS SCANS- For dual-energy x-ray absorptiometry services (identified in 2006 by HCPCS codes 76075 and 76077 (and any succeeding codes)) furnished during 2010 and 2011, instead of the payment amount that would otherwise be determined under this section for such years, the payment amount shall be equal to 70 percent of the product of--
                   `(A) the relative value for the service (as determined in subsection (c)(2)) for 2006;
                   `(B) the conversion factor (established under subsection (d)) for 2006; and
                   `(C) the geographic adjustment factor (established under subsection (e)(2)) for the service for the fee schedule area for 2010 and 2011, respectively.'; and
          (B) in subsection (c)(2)(B)(iv)--
             (i) in subclause (II), by striking `and' at the end;
             (ii) in subclause (III), by striking the period at the end and inserting `; and'; and
             (iii) by adding at the end the following new subclause:
                         `(IV) subsection (b)(6) shall not be taken into account in applying clause (ii)(II) for 2010 or 2011.'.
       (2) IMPLEMENTATION- Notwithstanding any other provision of law, the Secretary may implement the amendments made by paragraph (1) by program instruction or otherwise.
    (b) Study and Report by the Institute of Medicine-
       (1) IN GENERAL- The Secretary of Health and Human Services is authorized to enter into an agreement with the Institute of Medicine of the National Academies to conduct a study on the ramifications of Medicare payment reductions for dual-energy x-ray absorptiometry (as described in section 1848(b)(6) of the Social Security Act, as added by subsection (a)(1)) during 2007, 2008, and 2009 on beneficiary access to bone mass density tests.
       (2) REPORT- An agreement entered into under paragraph (1) shall provide for the Institute of Medicine to submit to the Secretary and to Congress a report containing the results of the study conducted under such paragraph.

### SEC. 3112. REVISION TO THE MEDICARE IMPROVEMENT FUND.

Section 1898(b)(1)(A) of the Social Security Act (42 U.S.C. 1395iii) is amended by striking `$22,290,000,000' and inserting `$0'.

### SEC. 3113. TREATMENT OF CERTAIN COMPLEX DIAGNOSTIC LABORATORY TESTS.

    (a) Demonstration Project-
       (1) IN GENERAL- The Secretary of Health and Human Services (in this section referred to as the `Secretary') shall conduct a demonstration project under part B title XVIII of the Social Security Act under which separate payments are made under such part for complex diagnostic laboratory tests provided to individuals under such part. Under the demonstration project, the Secretary shall establish appropriate payment rates for such tests.
       (2) COVERED COMPLEX DIAGNOSTIC LABORATORY TEST DEFINED- In this section, the term `complex diagnostic laboratory test' means a diagnostic laboratory test--
          (A) that is an analysis of gene protein expression, topographic genotyping, or a cancer chemotherapy sensitivity assay;
          (B) that is determined by the Secretary to be a laboratory test for which there is not an alternative test having equivalent performance characteristics;
          (C) which is billed using a Health Care Procedure Coding System (HCPCS) code other than a not otherwise classified code under such Coding System;
          (D) which is approved or cleared by the Food and Drug Administration or is covered under title XVIII of the Social Security Act; and
          (E) is described in section 1861(s)(3) of the Social Security Act (42 U.S.C. 1395x(s)(3)).
       (3) SEPARATE PAYMENT DEFINED- In this section, the term `separate payment' means direct payment to a laboratory (including a hospital-based or independent laboratory) that performs a complex diagnostic laboratory test with respect to a specimen collected from an individual during a period in which the individual is a patient of a hospital if the test is performed after such period of hospitalization and if separate payment would not otherwise be made under title XVIII of the Social Security Act by reason of sections 1862(a)(14) and 1866(a)(1)(H)(i) of the such Act (42 U.S.C. 1395y(a)(14); 42 U.S.C. 1395cc(a)(1)(H)(i)).
    (b) Duration- Subject to subsection (c)(2), the Secretary shall conduct the demonstration project under this section for the 2-year period beginning on July 1, 2011.
    (c) Payments and Limitation- Payments under the demonstration project under this section shall--
       (1) be made from the Federal Supplemental Medical Insurance Trust Fund under section 1841 of the Social Security Act (42 U.S.C. 1395t); and
       (2) may not exceed $100,000,000.
    (d) Report- Not later than 2 years after the completion of the demonstration project under this section, the Secretary shall submit to Congress a report on the project. Such report shall include--
       (1) an assessment of the impact of the demonstration project on access to care, quality of care, health outcomes, and expenditures under title XVIII of the Social Security Act (including any savings under such title); and
       (2) such recommendations as the Secretary determines appropriate.
    (e) Implementation Funding- For purposes of administering this section (including preparing and submitting the report under subsection (d)), the Secretary shall provide for the transfer, from the Federal Supplemental Medical Insurance Trust Fund under section 1841 of the Social Security Act (42 U.S.C. 1395t), to the Centers for Medicare & Medicaid Services Program Management Account, of $5,000,000. Amounts transferred under the preceding sentence shall remain available until expended.

### SEC. 3114. IMPROVED ACCESS FOR CERTIFIED NURSE-MIDWIFE SERVICES.

Section 1833(a)(1)(K) of the Social Security Act (42 U.S.C. 1395l(a)(1)(K)) is amended by inserting `(or 100 percent for services furnished on or after January 1, 2011)' after `1992, 65 percent'.