II 

114TH CONGRESS 

1ST SESSION H. R. 2 

IN THE SENATE OF THE UNITED STATES 

MARCH 26, 2015 

Received 

AN ACT 

To amend title XVIII of the Social Security Act to repeal 

the Medicare sustainable growth rate and strengthen 

Medicare access by improving physician payments and 

making other improvements, to reauthorize the Children’s Health Insurance Program, and for other purposes. 


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1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Medicare Access and CHIP Reauthorization Act of 

6 2015’’. 

7 (b) TABLE OF CONTENTS.—The table of contents of 

8 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—SGR REPEAL AND MEDICARE PROVIDER PAYMENT 

MODERNIZATION 

Sec. 101. Repealing the sustainable growth rate (SGR) and improving Medicare 

payment for physicians’ services. 

Sec. 102. Priorities and funding for measure development. 

Sec. 103. Encouraging care management for individuals with chronic care 

needs. 

Sec. 104. Empowering beneficiary choices through continued access to information on physicians’ services. 

Sec. 105. Expanding availability of Medicare data. 

Sec. 106. Reducing administrative burden and other provisions. 

TITLE II—MEDICARE AND OTHER HEALTH EXTENDERS 

Subtitle A—Medicare Extenders 

Sec. 201. Extension of work GPCI floor. 

Sec. 202. Extension of therapy cap exceptions process. 

Sec. 203. Extension of ambulance add-ons. 

Sec. 204. Extension of increased inpatient hospital payment adjustment for certain low-volume hospitals. 

Sec. 205. Extension of the Medicare-dependent hospital (MDH) program. 

Sec. 206. Extension for specialized Medicare Advantage plans for special needs 

individuals. 

Sec. 207. Extension of funding for quality measure endorsement, input, and selection. 

Sec. 208. Extension of funding outreach and assistance for low-income programs. 

Sec. 209. Extension and transition of reasonable cost reimbursement contracts. 

Sec. 210. Extension of home health rural add-on. 

Subtitle B—Other Health Extenders 

Sec. 211. Permanent extension of the qualifying individual (QI) program. 

Sec. 212. Permanent extension of transitional medical assistance (TMA). 


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Sec. 213. Extension of special diabetes program for type I diabetes and for Indians. 

Sec. 214. Extension of abstinence education. 

Sec. 215. Extension of personal responsibility education program (PREP). 

Sec. 216. Extension of funding for family-to-family health information centers. 

Sec. 217. Extension of health workforce demonstration project for low-income 

individuals. 

Sec. 218. Extension of maternal, infant, and early childhood home visiting programs. 

Sec. 219. Tennessee DSH allotment for fiscal years 2015 through 2025. 

Sec. 220. Delay in effective date for Medicaid amendments relating to beneficiary liability settlements. 

Sec. 221. Extension of funding for community health centers, the National 

Health Service Corps, and teaching health centers. 

TITLE III—CHIP 

Sec. 301. 2-year extension of the Children’s Health Insurance Program. 

Sec. 302. Extension of express lane eligibility. 

Sec. 303. Extension of outreach and enrollment program. 

Sec. 304. Extension of certain programs and demonstration projects. 

Sec. 305. Report of Inspector General of HHS on use of express lane option 

under Medicaid and CHIP. 

TITLE IV—OFFSETS 

Subtitle A—Medicare Beneficiary Reforms 

Sec. 401. Limitation on certain medigap policies for newly eligible Medicare 

beneficiaries. 

Sec. 402. Income-related premium adjustment for parts B and D. 

Subtitle B—Other Offsets 

Sec. 411. Medicare payment updates for post-acute providers. 

Sec. 412. Delay of reduction to Medicaid DSH allotments. 

Sec. 413. Levy on delinquent providers. 

Sec. 414. Adjustments to inpatient hospital payment rates. 

TITLE V—MISCELLANEOUS 

Subtitle A—Protecting the Integrity of Medicare 

Sec. 501. Prohibition of inclusion of Social Security account numbers on Medicare cards. 

Sec. 502. Preventing wrongful Medicare payments for items and services furnished to incarcerated individuals, individuals not lawfully 

present, and deceased individuals. 

Sec. 503. Consideration of measures regarding Medicare beneficiary smart 

cards. 

Sec. 504. Modifying Medicare durable medical equipment face-to-face encounter 

documentation requirement. 

Sec. 505. Reducing improper Medicare payments. 

Sec. 506. Improving senior Medicare patrol and fraud reporting rewards. 

Sec. 507. Requiring valid prescriber National Provider Identifiers on pharmacy 

claims. 

Sec. 508. Option to receive Medicare Summary Notice electronically. 


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Sec. 509. Renewal of MAC contracts. 

Sec. 510. Study on pathway for incentives to States for State participation in 

medicaid data match program. 

Sec. 511. Guidance on application of Common Rule to clinical data registries. 

Sec. 512. Eliminating certain civil money penalties; gainsharing study and report. 

Sec. 513. Modification of Medicare home health surety bond condition of participation requirement. 

Sec. 514. Oversight of Medicare coverage of manual manipulation of the spine 

to correct subluxation. 

Sec. 515. National expansion of prior authorization model for repetitive scheduled non-emergent ambulance transport. 

Sec. 516. Repealing duplicative Medicare secondary payor provision. 

Sec. 517. Plan for expanding data in annual CERT report. 

Sec. 518. Removing funds for Medicare Improvement Fund added by IMPACT 

Act of 2014. 

Sec. 519. Rule of construction. 

Subtitle B—Other Provisions 

Sec. 521. Extension of two-midnight PAMA rules on certain medical review activities. 

Sec. 522. Requiring bid surety bonds and State licensure for entities submitting 

bids under the Medicare DMEPOS competitive acquisition program. 

Sec. 523. Payment for global surgical packages. 

Sec. 524. Extension of Secure Rural Schools and Community Self-Determination Act of 2000. 

Sec. 525. Exclusion from PAYGO scorecards. 

1 TITLE I—SGR REPEAL AND 

2 MEDICARE PROVIDER PAY3 MENT MODERNIZATION 

4 SEC. 101. REPEALING THE SUSTAINABLE GROWTH RATE 

5 (SGR) AND IMPROVING MEDICARE PAYMENT 

6 FOR PHYSICIANS’ SERVICES. 

7 (a) STABILIZING FEE UPDATES.— 

8 (1) REPEAL OF SGR PAYMENT METHOD9 OLOGY.—Section 1848 of the Social Security Act 

10 (42 U.S.C. 1395w–4) is amended— 

11 (A) in subsection (d)— 

12 (i) in paragraph (1)(A)— 


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1 (I) by inserting ‘‘and ending with 

2 2025’’ after ‘‘beginning with 2001’’; 

3 and 

4 (II) by inserting ‘‘or a subse5 quent paragraph’’ after ‘‘paragraph 

6 (4)’’; and 

7 (ii) in paragraph (4)— 

8 (I) in the heading, by inserting 

9 ‘‘AND ENDING WITH 2014’’ after 

10 ‘‘YEARS BEGINNING WITH 2001’’; and 

11 (II) in subparagraph (A), by in12 serting ‘‘and ending with 2014’’ after 

13 ‘‘a year beginning with 2001’’; and 

14 (B) in subsection (f)— 

15 (i) in paragraph (1)(B), by inserting 

16 ‘‘through 2014’’ after ‘‘of each succeeding 

17 year’’; and 

18 (ii) in paragraph (2), in the matter 

19 preceding subparagraph (A), by inserting 

20 ‘‘and ending with 2014’’ after ‘‘beginning 

21 with 2000’’. 

22 (2) UPDATE OF RATES FOR 2015 AND SUBSE23 QUENT YEARS.—Subsection (d) of section 1848 of 

24 the Social Security Act (42 U.S.C. 1395w–4) is 

25 amended— 


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1 (A) in paragraph (1)(A), by adding at the 

2 end the following: ‘‘There shall be two separate 

3 conversion factors for each year beginning with 

4 2026, one for items and services furnished by 

5 a qualifying APM participant (as defined in 

6 section 1833(z)(2)) (referred to in this sub7 section as the ‘qualifying APM conversion fac8 tor’) and the other for other items and services 

9 (referred to in this subsection as the ‘nonquali10 fying APM conversion factor’), equal to the re11 spective conversion factor for the previous year 

12 (or, in the case of 2026, equal to the single con13 version factor for 2025) multiplied by the up14 date established under paragraph (20) for such 

15 respective conversion factor for such year.’’; 

16 (B) in paragraph (1)(D), by inserting ‘‘(or, 

17 beginning with 2026, applicable conversion fac18 tor)’’ after ‘‘single conversion factor’’; and 

19 (C) by striking paragraph (16) and insert20 ing the following new paragraphs: 

21 ‘‘(16) UPDATE FOR JANUARY THROUGH JUNE

22 OF 2015.—Subject to paragraphs (7)(B), (8)(B), 

23 (9)(B), (10)(B), (11)(B), (12)(B), (13)(B), (14)(B), 

24 and (15)(B), in lieu of the update to the single con25 version factor established in paragraph (1)(C) that 


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1 would otherwise apply for 2015 for the period begin2 ning on January 1, 2015, and ending on June 30, 

3 2015, the update to the single conversion factor 

4 shall be 0.0 percent. 

5 ‘‘(17) UPDATE FOR JULY THROUGH DECEMBER

6 OF 2015.—The update to the single conversion factor 

7 established in paragraph (1)(C) for the period begin8 ning on July 1, 2015, and ending on December 31, 

9 2015, shall be 0.5 percent. 

10 ‘‘(18) UPDATE FOR 2016 THROUGH 2019.—The 

11 update to the single conversion factor established in 

12 paragraph (1)(C) for 2016 and each subsequent 

13 year through 2019 shall be 0.5 percent. 

14 ‘‘(19) UPDATE FOR 2020 THROUGH 2025.—The 

15 update to the single conversion factor established in 

16 paragraph (1)(C) for 2020 and each subsequent 

17 year through 2025 shall be 0.0 percent. 

18 ‘‘(20) UPDATE FOR 2026 AND SUBSEQUENT

19 YEARS.—For 2026 and each subsequent year, the 

20 update to the qualifying APM conversion factor es21 tablished under paragraph (1)(A) is 0.75 percent, 

22 and the update to the nonqualifying APM conversion 

23 factor established under such paragraph is 0.25 per24 cent.’’. 

25 (3) MEDPAC REPORTS.— 


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1 (A) INITIAL REPORT.—Not later than July 

2 1, 2017, the Medicare Payment Advisory Com3 mission shall submit to Congress a report on 

4 the relationship between— 

5 (i) physician and other health profes6 sional utilization and expenditures (and the 

7 rate of increase of such utilization and ex8 penditures) of items and services for which 

9 payment is made under section 1848 of the 

10 Social Security Act (42 U.S.C. 1395w–4); 

11 and 

12 (ii) total utilization and expenditures 

13 (and the rate of increase of such utilization 

14 and expenditures) under parts A, B, and D 

15 of title XVIII of such Act. 

16 Such report shall include a methodology to de17 scribe such relationship and the impact of 

18 changes in such physician and other health pro19 fessional practice and service ordering patterns 

20 on total utilization and expenditures under 

21 parts A, B, and D of such title. 

22 (B) FINAL REPORT.—Not later than July 

23 1, 2021, the Medicare Payment Advisory Com24 mission shall submit to Congress a report on 

25 the relationship described in subparagraph (A), 


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1 including the results determined from applying 

2 the methodology included in the report sub3 mitted under such subparagraph. 

4 (C) REPORT ON UPDATE TO PHYSICIANS’ 

5 SERVICES UNDER MEDICARE.—Not later than 

6 July 1, 2019, the Medicare Payment Advisory 

7 Commission shall submit to Congress a report 

8 on— 

9 (i) the payment update for profes10 sional services applied under the Medicare 

11 program under title XVIII of the Social 

12 Security Act for the period of years 2015 

13 through 2019; 

14 (ii) the effect of such update on the 

15 efficiency, economy, and quality of care 

16 provided under such program; 

17 (iii) the effect of such update on en18 suring a sufficient number of providers to 

19 maintain access to care by Medicare bene20 ficiaries; and 

21 (iv) recommendations for any future 

22 payment updates for professional services 

23 under such program to ensure adequate 

24 access to care is maintained for Medicare 

25 beneficiaries. 


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1 (b) CONSOLIDATION OF CERTAIN CURRENT LAW

2 PERFORMANCE PROGRAMS WITH NEW MERIT-BASED IN3 CENTIVE PAYMENT SYSTEM.— 

4 (1) EHR MEANINGFUL USE INCENTIVE PRO5 GRAM.— 

6 (A) SUNSETTING SEPARATE MEANINGFUL

7 USE PAYMENT ADJUSTMENTS.—Section 

8 1848(a)(7)(A) of the Social Security Act (42 

9 U.S.C. 1395w–4(a)(7)(A)) is amended— 

10 (i) in clause (i), by striking ‘‘2015 or 

11 any subsequent payment year’’ and insert12 ing ‘‘each of 2015 through 2018’’; 

13 (ii) in clause (ii)(III), by striking 

14 ‘‘each subsequent year’’ and inserting 

15 ‘‘2018’’; and 

16 (iii) in clause (iii)— 

17 (I) in the heading, by striking 

18 ‘‘AND SUBSEQUENT YEARS’’; 

19 (II) by striking ‘‘and each subse20 quent year’’; and 

21 (III) by striking ‘‘, but in no case 

22 shall the applicable percent be less 

23 than 95 percent’’. 

24 (B) CONTINUATION OF MEANINGFUL USE

25 DETERMINATIONS FOR MIPS.—Section 


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1 1848(o)(2) of the Social Security Act (42 

2 U.S.C. 1395w–4(o)(2)) is amended— 

3 (i) in subparagraph (A), in the matter 

4 preceding clause (i)— 

5 (I) by striking ‘‘For purposes of 

6 paragraph (1), an’’ and inserting 

7 ‘‘An’’; and 

8 (II) by inserting ‘‘, or pursuant 

9 to subparagraph (D) for purposes of 

10 subsection (q), for a performance pe11 riod under such subsection for a year’’ 

12 after ‘‘under such subsection for a 

13 year’’; and 

14 (ii) by adding at the end the following 

15 new subparagraph: 

16 ‘‘(D) CONTINUED APPLICATION FOR PUR17 POSES OF MIPS.—With respect to 2019 and 

18 each subsequent payment year, the Secretary 

19 shall, for purposes of subsection (q) and in ac20 cordance with paragraph (1)(F) of such sub21 section, determine whether an eligible profes22 sional who is a MIPS eligible professional (as 

23 defined in subsection (q)(1)(C)) for such year is 

24 a meaningful EHR user under this paragraph 


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1 for the performance period under subsection (q) 

2 for such year.’’. 

3 (2) QUALITY REPORTING.— 

4 (A) SUNSETTING SEPARATE QUALITY RE5 PORTING INCENTIVES.—Section 1848(a)(8)(A) 

6 of the Social Security Act (42 U.S.C. 1395w– 

7 4(a)(8)(A)) is amended— 

8 (i) in clause (i), by striking ‘‘2015 or 

9 any subsequent year’’ and inserting ‘‘each 

10 of 2015 through 2018’’; and 

11 (ii) in clause (ii)(II), by striking ‘‘and 

12 each subsequent year’’ and inserting ‘‘, 

13 2017, and 2018’’. 

14 (B) CONTINUATION OF QUALITY MEAS15 URES AND PROCESSES FOR MIPS.—Section 

16 1848 of the Social Security Act (42 U.S.C. 

17 1395w–4) is amended— 

18 (i) in subsection (k), by adding at the 

19 end the following new paragraph: 

20 ‘‘(9) CONTINUED APPLICATION FOR PURPOSES

21 OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN22 TEERING TO REPORT.—The Secretary shall, in ac23 cordance with subsection (q)(1)(F), carry out the 

24 provisions of this subsection— 

25 ‘‘(A) for purposes of subsection (q); and 


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1 ‘‘(B) for eligible professionals who are not 

2 MIPS eligible professionals (as defined in sub3 section (q)(1)(C)) for the year involved.’’; and 

4 (ii) in subsection (m)— 

5 (I) by redesignating paragraph 

6 (7) added by section 10327(a) of Pub7 lic Law 111–148 as paragraph (8); 

8 and 

9 (II) by adding at the end the fol10 lowing new paragraph: 

11 ‘‘(9) CONTINUED APPLICATION FOR PURPOSES

12 OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN13 TEERING TO REPORT.—The Secretary shall, in ac14 cordance with subsection (q)(1)(F), carry out the 

15 processes under this subsection— 

16 ‘‘(A) for purposes of subsection (q); and 

17 ‘‘(B) for eligible professionals who are not 

18 MIPS eligible professionals (as defined in sub19 section (q)(1)(C)) for the year involved.’’. 

20 (3) VALUE-BASED PAYMENTS.— 

21 (A) SUNSETTING SEPARATE VALUE-BASED

22 PAYMENTS.—Clause (iii) of section 

23 1848(p)(4)(B) of the Social Security Act (42 

24 U.S.C. 1395w–4(p)(4)(B)) is amended to read 

25 as follows: 


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1 ‘‘(iii) APPLICATION.—The Secretary 

2 shall apply the payment modifier estab3 lished under this subsection for items and 

4 services furnished on or after January 1, 

5 2015, with respect to specific physicians 

6 and groups of physicians the Secretary de7 termines appropriate, and for services fur8 nished on or after January 1, 2017, with 

9 respect to all physicians and groups of 

10 physicians. Such payment modifier shall 

11 not be applied for items and services fur12 nished on or after January 1, 2019.’’. 

13 (B) CONTINUATION OF VALUE-BASED PAY14 MENT MODIFIER MEASURES FOR MIPS.—Section 

15 1848(p) of the Social Security Act (42 U.S.C. 

16 1395w–4(p)) is amended— 

17 (i) in paragraph (2), by adding at the 

18 end the following new subparagraph: 

19 ‘‘(C) CONTINUED APPLICATION FOR PUR20 POSES OF MIPS.—The Secretary shall, in ac21 cordance with subsection (q)(1)(F), carry out 

22 subparagraph (B) for purposes of subsection 

23 (q).’’; and 

24 (ii) in paragraph (3), by adding at the 

25 end the following: ‘‘With respect to 2019 


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1 and each subsequent year, the Secretary 

2 shall, in accordance with subsection 

3 (q)(1)(F), carry out this paragraph for 

4 purposes of subsection (q).’’. 

5 (c) MERIT-BASED INCENTIVE PAYMENT SYSTEM.— 

6 (1) IN GENERAL.—Section 1848 of the Social 

7 Security Act (42 U.S.C. 1395w–4) is amended by 

8 adding at the end the following new subsection: 

9 ‘‘(q) MERIT-BASED INCENTIVE PAYMENT SYSTEM.— 

10 ‘‘(1) ESTABLISHMENT.— 

11 ‘‘(A) IN GENERAL.—Subject to the suc12 ceeding provisions of this subsection, the Sec13 retary shall establish an eligible professional 

14 Merit-based Incentive Payment System (in this 

15 subsection referred to as the ‘MIPS’) under 

16 which the Secretary shall— 

17 ‘‘(i) develop a methodology for assess18 ing the total performance of each MIPS el19 igible professional according to perform20 ance standards under paragraph (3) for a 

21 performance period (as established under 

22 paragraph (4)) for a year; 

23 ‘‘(ii) using such methodology, provide 

24 for a composite performance score in ac25 cordance with paragraph (5) for each such 


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1 professional for each performance period; 

2 and 

3 ‘‘(iii) use such composite performance 

4 score of the MIPS eligible professional for 

5 a performance period for a year to deter6 mine and apply a MIPS adjustment factor 

7 (and, as applicable, an additional MIPS 

8 adjustment factor) under paragraph (6) to 

9 the professional for the year. 

10 Notwithstanding subparagraph (C)(ii), under 

11 the MIPS, the Secretary shall permit any eligi12 ble professional (as defined in subsection 

13 (k)(3)(B)) to report on applicable measures and 

14 activities described in paragraph (2)(B). 

15 ‘‘(B) PROGRAM IMPLEMENTATION.—The 

16 MIPS shall apply to payments for items and 

17 services furnished on or after January 1, 2019. 

18 ‘‘(C) MIPS ELIGIBLE PROFESSIONAL DE19 FINED.— 

20 ‘‘(i) IN GENERAL.—For purposes of 

21 this subsection, subject to clauses (ii) and 

22 (iv), the term ‘MIPS eligible professional’ 

23 means— 

24 ‘‘(I) for the first and second 

25 years for which the MIPS applies to 


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1 payments (and for the performance 

2 period for such first and second year), 

3 a physician (as defined in section 

4 1861(r)), a physician assistant, nurse 

5 practitioner, and clinical nurse spe6 cialist (as such terms are defined in 

7 section 1861(aa)(5)), a certified reg8 istered nurse anesthetist (as defined 

9 in section 1861(bb)(2)), and a group 

10 that includes such professionals; and 

11 ‘‘(II) for the third year for which 

12 the MIPS applies to payments (and 

13 for the performance period for such 

14 third year) and for each succeeding 

15 year (and for the performance period 

16 for each such year), the professionals 

17 described in subclause (I), such other 

18 eligible professionals (as defined in 

19 subsection (k)(3)(B)) as specified by 

20 the Secretary, and a group that in21 cludes such professionals. 

22 ‘‘(ii) EXCLUSIONS.—For purposes of 

23 clause (i), the term ‘MIPS eligible profes24 sional’ does not include, with respect to a 


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1 year, an eligible professional (as defined in 

2 subsection (k)(3)(B)) who— 

3 ‘‘(I) is a qualifying APM partici4 pant (as defined in section 

5 1833(z)(2)); 

6 ‘‘(II) subject to clause (vii), is a 

7 partial qualifying APM participant (as 

8 defined in clause (iii)) for the most re9 cent period for which data are avail10 able and who, for the performance pe11 riod with respect to such year, does 

12 not report on applicable measures and 

13 activities described in paragraph 

14 (2)(B) that are required to be re15 ported by such a professional under 

16 the MIPS; or 

17 ‘‘(III) for the performance period 

18 with respect to such year, does not ex19 ceed the low-volume threshold meas20 urement selected under clause (iv). 

21 ‘‘(iii) PARTIAL QUALIFYING APM PAR22 TICIPANT.—For purposes of this subpara23 graph, the term ‘partial qualifying APM 

24 participant’ means, with respect to a year, 

25 an eligible professional for whom the SecVerDate Sep 11 2014 21:09 Mar 27, 2015 Jkt 049200 PO 00000 Frm 00018 Fmt 6652 Sfmt 6201 E:\BILLS\H2.RDS H2

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1 retary determines the minimum payment 

2 percentage (or percentages), as applicable, 

3 described in paragraph (2) of section 

4 1833(z) for such year have not been satis5 fied, but who would be considered a quali6 fying APM participant (as defined in such 

7 paragraph) for such year if— 

8 ‘‘(I) with respect to 2019 and 

9 2020, the reference in subparagraph 

10 (A) of such paragraph to 25 percent 

11 was instead a reference to 20 percent; 

12 ‘‘(II) with respect to 2021 and 

13 2022— 

14 ‘‘(aa) the reference in sub15 paragraph (B)(i) of such para16 graph to 50 percent was instead 

17 a reference to 40 percent; and 

18 ‘‘(bb) the references in sub19 paragraph (B)(ii) of such para20 graph to 50 percent and 25 per21 cent of such paragraph were in22 stead references to 40 percent 

23 and 20 percent, respectively; and 

24 ‘‘(III) with respect to 2023 and 

25 subsequent years— 


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1 ‘‘(aa) the reference in sub2 paragraph (C)(i) of such para3 graph to 75 percent was instead 

4 a reference to 50 percent; and 

5 ‘‘(bb) the references in sub6 paragraph (C)(ii) of such para7 graph to 75 percent and 25 per8 cent of such paragraph were in9 stead references to 50 percent 

10 and 20 percent, respectively. 

11 ‘‘(iv) SELECTION OF LOW-VOLUME

12 THRESHOLD MEASUREMENT.—The Sec13 retary shall select a low-volume threshold 

14 to apply for purposes of clause (ii)(III), 

15 which may include one or more or a com16 bination of the following: 

17 ‘‘(I) The minimum number (as 

18 determined by the Secretary) of indi19 viduals enrolled under this part who 

20 are treated by the eligible professional 

21 for the performance period involved. 

22 ‘‘(II) The minimum number (as 

23 determined by the Secretary) of items 

24 and services furnished to individuals 


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1 enrolled under this part by such pro2 fessional for such performance period. 

3 ‘‘(III) The minimum amount (as 

4 determined by the Secretary) of al5 lowed charges billed by such profes6 sional under this part for such per7 formance period. 

8 ‘‘(v) TREATMENT OF NEW MEDICARE

9 ENROLLED ELIGIBLE PROFESSIONALS.—In 

10 the case of a professional who first be11 comes a Medicare enrolled eligible profes12 sional during the performance period for a 

13 year (and had not previously submitted 

14 claims under this title such as a person, an 

15 entity, or a part of a physician group or 

16 under a different billing number or tax 

17 identifier), such professional shall not be 

18 treated under this subsection as a MIPS 

19 eligible professional until the subsequent 

20 year and performance period for such sub21 sequent year. 

22 ‘‘(vi) CLARIFICATION.—In the case of 

23 items and services furnished during a year 

24 by an individual who is not a MIPS eligible 

25 professional (including pursuant to clauses 


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1 (ii) and (v)) with respect to a year, in no 

2 case shall a MIPS adjustment factor (or 

3 additional MIPS adjustment factor) under 

4 paragraph (6) apply to such individual for 

5 such year. 

6 ‘‘(vii) PARTIAL QUALIFYING APM PAR7 TICIPANT CLARIFICATIONS.— 

8 ‘‘(I) TREATMENT AS MIPS ELIGI9 BLE PROFESSIONAL.—In the case of 

10 an eligible professional who is a par11 tial qualifying APM participant, with 

12 respect to a year, and who, for the 

13 performance period for such year, re14 ports on applicable measures and ac15 tivities described in paragraph (2)(B) 

16 that are required to be reported by 

17 such a professional under the MIPS, 

18 such eligible professional is considered 

19 to be a MIPS eligible professional 

20 with respect to such year. 

21 ‘‘(II) NOT ELIGIBLE FOR QUALI22 FYING APM PARTICIPANT PAY23 MENTS.—In no case shall an eligible 

24 professional who is a partial quali25 fying APM participant, with respect 


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1 to a year, be considered a qualifying 

2 APM participant (as defined in para3 graph (2) of section 1833(z)) for such 

4 year or be eligible for the additional 

5 payment under paragraph (1) of such 

6 section for such year. 

7 ‘‘(D) APPLICATION TO GROUP PRAC8 TICES.— 

9 ‘‘(i) IN GENERAL.—Under the MIPS: 

10 ‘‘(I) QUALITY PERFORMANCE

11 CATEGORY.—The Secretary shall es12 tablish and apply a process that in13 cludes features of the provisions of 

14 subsection (m)(3)(C) for MIPS eligi15 ble professionals in a group practice 

16 with respect to assessing performance 

17 of such group with respect to the per18 formance category described in clause 

19 (i) of paragraph (2)(A). 

20 ‘‘(II) OTHER PERFORMANCE CAT21 EGORIES.—The Secretary may estab22 lish and apply a process that includes 

23 features of the provisions of sub24 section (m)(3)(C) for MIPS eligible 

25 professionals in a group practice with 


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1 respect to assessing the performance 

2 of such group with respect to the per3 formance categories described in 

4 clauses (ii) through (iv) of such para5 graph. 

6 ‘‘(ii) ENSURING COMPREHENSIVENESS

7 OF GROUP PRACTICE ASSESSMENT.—The 

8 process established under clause (i) shall to 

9 the extent practicable reflect the range of 

10 items and services furnished by the MIPS 

11 eligible professionals in the group practice 

12 involved. 

13 ‘‘(E) USE OF REGISTRIES.—Under the 

14 MIPS, the Secretary shall encourage the use of 

15 qualified clinical data registries pursuant to 

16 subsection (m)(3)(E) in carrying out this sub17 section. 

18 ‘‘(F) APPLICATION OF CERTAIN PROVI19 SIONS.—In applying a provision of subsection 

20 (k), (m), (o), or (p) for purposes of this sub21 section, the Secretary shall— 

22 ‘‘(i) adjust the application of such 

23 provision to ensure the provision is con24 sistent with the provisions of this sub25 section; and 


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1 ‘‘(ii) not apply such provision to the 

2 extent that the provision is duplicative with 

3 a provision of this subsection. 

4 ‘‘(G) ACCOUNTING FOR RISK FACTORS.— 

5 ‘‘(i) RISK FACTORS.—Taking into ac6 count the relevant studies conducted and 

7 recommendations made in reports under 

8 section 2(d) of the Improving Medicare 

9 Post-Acute Care Transformation Act of 

10 2014, and, as appropriate, other informa11 tion, including information collected before 

12 completion of such studies and rec13 ommendations, the Secretary, on an ongo14 ing basis, shall, as the Secretary deter15 mines appropriate and based on an individ16 ual’s health status and other risk factors— 

17 ‘‘(I) assess appropriate adjust18 ments to quality measures, resource 

19 use measures, and other measures 

20 used under the MIPS; and 

21 ‘‘(II) assess and implement ap22 propriate adjustments to payment ad23 justments, composite performance 

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1 egories, or scores for measures or ac2 tivities under the MIPS. 

3 ‘‘(2) MEASURES AND ACTIVITIES UNDER PER4 FORMANCE CATEGORIES.— 

5 ‘‘(A) PERFORMANCE CATEGORIES.—Under 

6 the MIPS, the Secretary shall use the following 

7 performance categories (each of which is re8 ferred to in this subsection as a performance 

9 category) in determining the composite per10 formance score under paragraph (5): 

11 ‘‘(i) Quality. 

12 ‘‘(ii) Resource use. 

13 ‘‘(iii) Clinical practice improvement 

14 activities. 

15 ‘‘(iv) Meaningful use of certified EHR 

16 technology. 

17 ‘‘(B) MEASURES AND ACTIVITIES SPECI18 FIED FOR EACH CATEGORY.—For purposes of 

19 paragraph (3)(A) and subject to subparagraph 

20 (C), measures and activities specified for a per21 formance period (as established under para22 graph (4)) for a year are as follows: 

23 ‘‘(i) QUALITY.—For the performance 

24 category described in subparagraph (A)(i), 

25 the quality measures included in the final 


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1 measures list published under subpara2 graph (D)(i) for such year and the list of 

3 quality measures described in subpara4 graph (D)(vi) used by qualified clinical 

5 data registries under subsection (m)(3)(E). 

6 ‘‘(ii) RESOURCE USE.—For the per7 formance category described in subpara8 graph (A)(ii), the measurement of resource 

9 use for such period under subsection 

10 (p)(3), using the methodology under sub11 section (r) as appropriate, and, as feasible 

12 and applicable, accounting for the cost of 

13 drugs under part D. 

14 ‘‘(iii) CLINICAL PRACTICE IMPROVE15 MENT ACTIVITIES.—For the performance 

16 category described in subparagraph 

17 (A)(iii), clinical practice improvement ac18 tivities (as defined in subparagraph 

19 (C)(v)(III)) under subcategories specified 

20 by the Secretary for such period, which 

21 shall include at least the following: 

22 ‘‘(I) The subcategory of expanded 

23 practice access, such as same day ap24 pointments for urgent needs and after 

25 hours access to clinician advice. 


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1 ‘‘(II) The subcategory of popu2 lation management, such as moni3 toring health conditions of individuals 

4 to provide timely health care interven5 tions or participation in a qualified 

6 clinical data registry. 

7 ‘‘(III) The subcategory of care 

8 coordination, such as timely commu9 nication of test results, timely ex10 change of clinical information to pa11 tients and other providers, and use of 

12 remote monitoring or telehealth. 

13 ‘‘(IV) The subcategory of bene14 ficiary engagement, such as the estab15 lishment of care plans for individuals 

16 with complex care needs, beneficiary 

17 self-management assessment and 

18 training, and using shared decision19 making mechanisms. 

20 ‘‘(V) The subcategory of patient 

21 safety and practice assessment, such 

22 as through use of clinical or surgical 

23 checklists and practice assessments 

24 related to maintaining certification. 


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1 ‘‘(VI) The subcategory of partici2 pation in an alternative payment 

3 model (as defined in section 

4 1833(z)(3)(C)). 

5 In establishing activities under this clause, 

6 the Secretary shall give consideration to 

7 the circumstances of small practices (con8 sisting of 15 or fewer professionals) and 

9 practices located in rural areas and in 

10 health professional shortage areas (as des11 ignated under section 332(a)(1)(A) of the 

12 Public Health Service Act). 

13 ‘‘(iv) MEANINGFUL EHR USE.—For 

14 the performance category described in sub15 paragraph (A)(iv), the requirements estab16 lished for such period under subsection 

17 (o)(2) for determining whether an eligible 

18 professional is a meaningful EHR user. 

19 ‘‘(C) ADDITIONAL PROVISIONS.— 

20 ‘‘(i) EMPHASIZING OUTCOME MEAS21 URES UNDER THE QUALITY PERFORMANCE

22 CATEGORY.—In applying subparagraph 

23 (B)(i), the Secretary shall, as feasible, em24 phasize the application of outcome meas25 ures. 


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1 ‘‘(ii) APPLICATION OF ADDITIONAL

2 SYSTEM MEASURES.—The Secretary may 

3 use measures used for a payment system 

4 other than for physicians, such as meas5 ures for inpatient hospitals, for purposes of 

6 the performance categories described in 

7 clauses (i) and (ii) of subparagraph (A). 

8 For purposes of the previous sentence, the 

9 Secretary may not use measures for hos10 pital outpatient departments, except in the 

11 case of items and services furnished by 

12 emergency physicians, radiologists, and an13 esthesiologists. 

14 ‘‘(iii) GLOBAL AND POPULATION15 BASED MEASURES.—The Secretary may 

16 use global measures, such as global out17 come measures, and population-based 

18 measures for purposes of the performance 

19 category described in subparagraph (A)(i). 

20 ‘‘(iv) APPLICATION OF MEASURES AND

21 ACTIVITIES TO NON-PATIENT-FACING PRO22 FESSIONALS.—In carrying out this para23 graph, with respect to measures and activi24 ties specified in subparagraph (B) for perVerDate Sep 11 2014 21:09 Mar 27, 2015 Jkt 049200 PO 00000 Frm 00030 Fmt 6652 Sfmt 6201 E:\BILLS\H2.RDS H2

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1 formance categories described in subpara2 graph (A), the Secretary— 

3 ‘‘(I) shall give consideration to 

4 the circumstances of professional 

5 types (or subcategories of those types 

6 determined by practice characteris7 tics) who typically furnish services 

8 that do not involve face-to-face inter9 action with a patient; and 

10 ‘‘(II) may, to the extent feasible 

11 and appropriate, take into account 

12 such circumstances and apply under 

13 this subsection with respect to MIPS 

14 eligible professionals of such profes15 sional types or subcategories, alter16 native measures or activities that ful17 fill the goals of the applicable per18 formance category. 

19 In carrying out the previous sentence, the 

20 Secretary shall consult with professionals 

21 of such professional types or subcategories. 

22 ‘‘(v) CLINICAL PRACTICE IMPROVE23 MENT ACTIVITIES.— 

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1 graph (B)(iii), the Secretary shall use 

2 a request for information to solicit 

3 recommendations from stakeholders to 

4 identify activities described in such 

5 subparagraph and specifying criteria 

6 for such activities. 

7 ‘‘(II) CONTRACT AUTHORITY FOR

8 CLINICAL PRACTICE IMPROVEMENT

9 ACTIVITIES PERFORMANCE CAT10 EGORY.—In applying subparagraph 

11 (B)(iii), the Secretary may contract 

12 with entities to assist the Secretary 

13 in— 

14 ‘‘(aa) identifying activities 

15 described in subparagraph 

16 (B)(iii); 

17 ‘‘(bb) specifying criteria for 

18 such activities; and 

19 ‘‘(cc) determining whether a 

20 MIPS eligible professional meets 

21 such criteria. 

22 ‘‘(III) CLINICAL PRACTICE IM23 PROVEMENT ACTIVITIES DEFINED.— 

24 For purposes of this subsection, the 

25 term ‘clinical practice improvement 


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1 activity’ means an activity that rel2 evant eligible professional organiza3 tions and other relevant stakeholders 

4 identify as improving clinical practice 

5 or care delivery and that the Sec6 retary determines, when effectively ex7 ecuted, is likely to result in improved 

8 outcomes. 

9 ‘‘(D) ANNUAL LIST OF QUALITY MEASURES

10 AVAILABLE FOR MIPS ASSESSMENT.— 

11 ‘‘(i) IN GENERAL.—Under the MIPS, 

12 the Secretary, through notice and comment 

13 rulemaking and subject to the succeeding 

14 clauses of this subparagraph, shall, with 

15 respect to the performance period for a 

16 year, establish an annual final list of qual17 ity measures from which MIPS eligible 

18 professionals may choose for purposes of 

19 assessment under this subsection for such 

20 performance period. Pursuant to the pre21 vious sentence, the Secretary shall— 

22 ‘‘(I) not later than November 1 

23 of the year prior to the first day of 

24 the first performance period under the 

25 MIPS, establish and publish in the 


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1 Federal Register a final list of quality 

2 measures; and 

3 ‘‘(II) not later than November 1 

4 of the year prior to the first day of 

5 each subsequent performance period, 

6 update the final list of quality meas7 ures from the previous year (and pub8 lish such updated final list in the Fed9 eral Register), by— 

10 ‘‘(aa) removing from such 

11 list, as appropriate, quality meas12 ures, which may include the re13 moval of measures that are no 

14 longer meaningful (such as meas15 ures that are topped out); 

16 ‘‘(bb) adding to such list, as 

17 appropriate, new quality meas18 ures; and 

19 ‘‘(cc) determining whether 

20 or not quality measures on such 

21 list that have undergone sub22 stantive changes should be in23 cluded in the updated list. 

24 ‘‘(ii) CALL FOR QUALITY MEAS25 URES.— 


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1 ‘‘(I) IN GENERAL.—Eligible pro2 fessional organizations and other rel3 evant stakeholders shall be requested 

4 to identify and submit quality meas5 ures to be considered for selection 

6 under this subparagraph in the an7 nual list of quality measures published 

8 under clause (i) and to identify and 

9 submit updates to the measures on 

10 such list. For purposes of the previous 

11 sentence, measures may be submitted 

12 regardless of whether such measures 

13 were previously published in a pro14 posed rule or endorsed by an entity 

15 with a contract under section 1890(a). 

16 ‘‘(II) ELIGIBLE PROFESSIONAL

17 ORGANIZATION DEFINED.—In this 

18 subparagraph, the term ‘eligible pro19 fessional organization’ means a pro20 fessional organization as defined by 

21 nationally recognized specialty boards 

22 of certification or equivalent certifi23 cation boards. 

24 ‘‘(iii) REQUIREMENTS.—In selecting 

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1 nual final list under clause (i), the Sec2 retary shall— 

3 ‘‘(I) provide that, to the extent 

4 practicable, all quality domains (as 

5 defined in subsection (s)(1)(B)) are 

6 addressed by such measures; and 

7 ‘‘(II) ensure that such selection 

8 is consistent with the process for se9 lection of measures under subsections 

10 (k), (m), and (p)(2). 

11 ‘‘(iv) PEER REVIEW.—Before includ12 ing a new measure in the final list of 

13 measures published under clause (i) for a 

14 year, the Secretary shall submit for publi15 cation in applicable specialty-appropriate, 

16 peer-reviewed journals such measure and 

17 the method for developing and selecting 

18 such measure, including clinical and other 

19 data supporting such measure. 

20 ‘‘(v) MEASURES FOR INCLUSION.— 

21 The final list of quality measures published 

22 under clause (i) shall include, as applica23 ble, measures under subsections (k), (m), 

24 and (p)(2), including quality measures 

25 from among— 


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1 ‘‘(I) measures endorsed by a con2 sensus-based entity; 

3 ‘‘(II) measures developed under 

4 subsection (s); and 

5 ‘‘(III) measures submitted under 

6 clause (ii)(I). 

7 Any measure selected for inclusion in such 

8 list that is not endorsed by a consensus9 based entity shall have a focus that is evi10 dence-based. 

11 ‘‘(vi) EXCEPTION FOR QUALIFIED

12 CLINICAL DATA REGISTRY MEASURES.— 

13 Measures used by a qualified clinical data 

14 registry under subsection (m)(3)(E) shall 

15 not be subject to the requirements under 

16 clauses (i), (iv), and (v). The Secretary 

17 shall publish the list of measures used by 

18 such qualified clinical data registries on 

19 the Internet website of the Centers for 

20 Medicare & Medicaid Services. 

21 ‘‘(vii) EXCEPTION FOR EXISTING

22 QUALITY MEASURES.—Any quality meas23 ure specified by the Secretary under sub24 section (k) or (m), including under sub25 section (m)(3)(E), and any measure of 


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1 quality of care established under sub2 section (p)(2) for the reporting period or 

3 performance period under the respective 

4 subsection beginning before the first per5 formance period under the MIPS— 

6 ‘‘(I) shall not be subject to the 

7 requirements under clause (i) (except 

8 under items (aa) and (cc) of subclause 

9 (II) of such clause) or to the require10 ment under clause (iv); and 

11 ‘‘(II) shall be included in the 

12 final list of quality measures pub13 lished under clause (i) unless removed 

14 under clause (i)(II)(aa). 

15 ‘‘(viii) CONSULTATION WITH REL16 EVANT ELIGIBLE PROFESSIONAL ORGANI17 ZATIONS AND OTHER RELEVANT STAKE18 HOLDERS.—Relevant eligible professional 

19 organizations and other relevant stake20 holders, including State and national med21 ical societies, shall be consulted in carrying 

22 out this subparagraph. 

23 ‘‘(ix) OPTIONAL APPLICATION.—The 

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1 quired to apply to the selection of meas2 ures under this subparagraph. 

3 ‘‘(3) PERFORMANCE STANDARDS.— 

4 ‘‘(A) ESTABLISHMENT.—Under the MIPS, 

5 the Secretary shall establish performance stand6 ards with respect to measures and activities 

7 specified under paragraph (2)(B) for a perform8 ance period (as established under paragraph 

9 (4)) for a year. 

10 ‘‘(B) CONSIDERATIONS IN ESTABLISHING

11 STANDARDS.—In establishing such performance 

12 standards with respect to measures and activi13 ties specified under paragraph (2)(B), the Sec14 retary shall consider the following: 

15 ‘‘(i) Historical performance standards. 

16 ‘‘(ii) Improvement. 

17 ‘‘(iii) The opportunity for continued 

18 improvement. 

19 ‘‘(4) PERFORMANCE PERIOD.—The Secretary 

20 shall establish a performance period (or periods) for 

21 a year (beginning with 2019). Such performance pe22 riod (or periods) shall begin and end prior to the be23 ginning of such year and be as close as possible to 

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1 riod (or periods) for a year shall be referred to as 

2 the performance period for the year. 

3 ‘‘(5) COMPOSITE PERFORMANCE SCORE.— 

4 ‘‘(A) IN GENERAL.—Subject to the suc5 ceeding provisions of this paragraph and taking 

6 into account, as available and applicable, para7 graph (1)(G), the Secretary shall develop a 

8 methodology for assessing the total performance 

9 of each MIPS eligible professional according to 

10 performance standards under paragraph (3) 

11 with respect to applicable measures and activi12 ties specified in paragraph (2)(B) with respect 

13 to each performance category applicable to such 

14 professional for a performance period (as estab15 lished under paragraph (4)) for a year. Using 

16 such methodology, the Secretary shall provide 

17 for a composite assessment (using a scoring 

18 scale of 0 to 100) for each such professional for 

19 the performance period for such year. In this 

20 subsection such a composite assessment for 

21 such a professional with respect to a perform22 ance period shall be referred to as the ‘com23 posite performance score’ for such professional 

24 for such performance period. 


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1 ‘‘(B) INCENTIVE TO REPORT; ENCOUR2 AGING USE OF CERTIFIED EHR TECHNOLOGY

3 FOR REPORTING QUALITY MEASURES.— 

4 ‘‘(i) INCENTIVE TO REPORT.—Under 

5 the methodology established under sub6 paragraph (A), the Secretary shall provide 

7 that in the case of a MIPS eligible profes8 sional who fails to report on an applicable 

9 measure or activity that is required to be 

10 reported by the professional, the profes11 sional shall be treated as achieving the 

12 lowest potential score applicable to such 

13 measure or activity. 

14 ‘‘(ii) ENCOURAGING USE OF CER15 TIFIED EHR TECHNOLOGY AND QUALIFIED

16 CLINICAL DATA REGISTRIES FOR REPORT17 ING QUALITY MEASURES.—Under the 

18 methodology established under subpara19 graph (A), the Secretary shall— 

20 ‘‘(I) encourage MIPS eligible 

21 professionals to report on applicable 

22 measures with respect to the perform23 ance category described in paragraph 

24 (2)(A)(i) through the use of certified 


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1 EHR technology and qualified clinical 

2 data registries; and 

3 ‘‘(II) with respect to a perform4 ance period, with respect to a year, 

5 for which a MIPS eligible professional 

6 reports such measures through the 

7 use of such EHR technology, treat 

8 such professional as satisfying the 

9 clinical quality measures reporting re10 quirement described in subsection 

11 (o)(2)(A)(iii) for such year. 

12 ‘‘(C) CLINICAL PRACTICE IMPROVEMENT

13 ACTIVITIES PERFORMANCE SCORE.— 

14 ‘‘(i) RULE FOR CERTIFICATION.—A 

15 MIPS eligible professional who is in a 

16 practice that is certified as a patient-cen17 tered medical home or comparable spe18 cialty practice, as determined by the Sec19 retary, with respect to a performance pe20 riod shall be given the highest potential 

21 score for the performance category de22 scribed in paragraph (2)(A)(iii) for such 

23 period. 

24 ‘‘(ii) APM PARTICIPATION.—Partici25 pation by a MIPS eligible professional in 


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1 an alternative payment model (as defined 

2 in section 1833(z)(3)(C)) with respect to a 

3 performance period shall earn such eligible 

4 professional a minimum score of one-half 

5 of the highest potential score for the per6 formance category described in paragraph 

7 (2)(A)(iii) for such performance period. 

8 ‘‘(iii) SUBCATEGORIES.—A MIPS eli9 gible professional shall not be required to 

10 perform activities in each subcategory 

11 under paragraph (2)(B)(iii) or participate 

12 in an alternative payment model in order 

13 to achieve the highest potential score for 

14 the performance category described in 

15 paragraph (2)(A)(iii). 

16 ‘‘(D) ACHIEVEMENT AND IMPROVE17 MENT.— 

18 ‘‘(i) TAKING INTO ACCOUNT IMPROVE19 MENT.—Beginning with the second year to 

20 which the MIPS applies, in addition to the 

21 achievement of a MIPS eligible profes22 sional, if data sufficient to measure im23 provement is available, the methodology 

24 developed under subparagraph (A)— 


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1 ‘‘(I) in the case of the perform2 ance score for the performance cat3 egory described in clauses (i) and (ii) 

4 of paragraph (2)(A), shall take into 

5 account the improvement of the pro6 fessional; and 

7 ‘‘(II) in the case of performance 

8 scores for other performance cat9 egories, may take into account the im10 provement of the professional. 

11 ‘‘(ii) ASSIGNING HIGHER WEIGHT FOR

12 ACHIEVEMENT.—Subject to clause (i), 

13 under the methodology developed under 

14 subparagraph (A), the Secretary may as15 sign a higher scoring weight under sub16 paragraph (F) with respect to the achieve17 ment of a MIPS eligible professional than 

18 with respect to any improvement of such 

19 professional applied under clause (i) with 

20 respect to a measure, activity, or category 

21 described in paragraph (2). 

22 ‘‘(E) WEIGHTS FOR THE PERFORMANCE

23 CATEGORIES.— 

24 ‘‘(i) IN GENERAL.—Under the meth25 odology developed under subparagraph (A), 


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1 subject to subparagraph (F)(i) and clause 

2 (ii), the composite performance score shall 

3 be determined as follows: 

4 ‘‘(I) QUALITY.— 

5 ‘‘(aa) IN GENERAL.—Sub6 ject to item (bb), thirty percent 

7 of such score shall be based on 

8 performance with respect to the 

9 category described in clause (i) of 

10 paragraph (2)(A). In applying 

11 the previous sentence, the Sec12 retary shall, as feasible, encour13 age the application of outcome 

14 measures within such category. 

15 ‘‘(bb) FIRST 2 YEARS.—For 

16 the first and second years for 

17 which the MIPS applies to pay18 ments, the percentage applicable 

19 under item (aa) shall be in20 creased in a manner such that 

21 the total percentage points of the 

22 increase under this item for the 

23 respective year equals the total 

24 number of percentage points by 

25 which the percentage applied 


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1 under subclause (II)(bb) for the 

2 respective year is less than 30 

3 percent. 

4 ‘‘(II) RESOURCE USE.— 

5 ‘‘(aa) IN GENERAL.—Sub6 ject to item (bb), thirty percent 

7 of such score shall be based on 

8 performance with respect to the 

9 category described in clause (ii) 

10 of paragraph (2)(A). 

11 ‘‘(bb) FIRST 2 YEARS.—For 

12 the first year for which the MIPS 

13 applies to payments, not more 

14 than 10 percent of such score 

15 shall be based on performance 

16 with respect to the category de17 scribed in clause (ii) of para18 graph (2)(A). For the second 

19 year for which the MIPS applies 

20 to payments, not more than 15 

21 percent of such score shall be 

22 based on performance with re23 spect to the category described in 

24 clause (ii) of paragraph (2)(A). 


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1 ‘‘(III) CLINICAL PRACTICE IM2 PROVEMENT ACTIVITIES.—Fifteen 

3 percent of such score shall be based 

4 on performance with respect to the 

5 category described in clause (iii) of 

6 paragraph (2)(A). 

7 ‘‘(IV) MEANINGFUL USE OF CER8 TIFIED EHR TECHNOLOGY.—Twenty9 five percent of such score shall be 

10 based on performance with respect to 

11 the category described in clause (iv) of 

12 paragraph (2)(A). 

13 ‘‘(ii) AUTHORITY TO ADJUST PER14 CENTAGES IN CASE OF HIGH EHR MEAN15 INGFUL USE ADOPTION.—In any year in 

16 which the Secretary estimates that the pro17 portion of eligible professionals (as defined 

18 in subsection (o)(5)) who are meaningful 

19 EHR users (as determined under sub20 section (o)(2)) is 75 percent or greater, the 

21 Secretary may reduce the percent applica22 ble under clause (i)(IV), but not below 15 

23 percent. If the Secretary makes such re24 duction for a year, subject to subclauses 

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1 centages applicable under one or more of 

2 subclauses (I), (II), and (III) of clause (i) 

3 for such year shall be increased in a man4 ner such that the total percentage points 

5 of the increase under this clause for such 

6 year equals the total number of percentage 

7 points reduced under the preceding sen8 tence for such year. 

9 ‘‘(F) CERTAIN FLEXIBILITY FOR

10 WEIGHTING PERFORMANCE CATEGORIES, MEAS11 URES, AND ACTIVITIES.—Under the method12 ology under subparagraph (A), if there are not 

13 sufficient measures and activities (described in 

14 paragraph (2)(B)) applicable and available to 

15 each type of eligible professional involved, the 

16 Secretary shall assign different scoring weights 

17 (including a weight of 0)— 

18 ‘‘(i) which may vary from the scoring 

19 weights specified in subparagraph (E), for 

20 each performance category based on the 

21 extent to which the category is applicable 

22 to the type of eligible professional involved; 

23 and 

24 ‘‘(ii) for each measure and activity 

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1 spect to each such category based on the 

2 extent to which the measure or activity is 

3 applicable and available to the type of eli4 gible professional involved. 

5 ‘‘(G) RESOURCE USE.—Analysis of the 

6 performance category described in paragraph 

7 (2)(A)(ii) shall include results from the method8 ology described in subsection (r)(5), as appro9 priate. 

10 ‘‘(H) INCLUSION OF QUALITY MEASURE

11 DATA FROM OTHER PAYERS.—In applying sub12 sections (k), (m), and (p) with respect to meas13 ures described in paragraph (2)(B)(i), analysis 

14 of the performance category described in para15 graph (2)(A)(i) may include data submitted by 

16 MIPS eligible professionals with respect to 

17 items and services furnished to individuals who 

18 are not individuals entitled to benefits under 

19 part A or enrolled under part B. 

20 ‘‘(I) USE OF VOLUNTARY VIRTUAL GROUPS

21 FOR CERTAIN ASSESSMENT PURPOSES.— 

22 ‘‘(i) IN GENERAL.—In the case of 

23 MIPS eligible professionals electing to be a 

24 virtual group under clause (ii) with respect 

25 to a performance period for a year, for 


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1 purposes of applying the methodology 

2 under subparagraph (A) with respect to 

3 the performance categories described in 

4 clauses (i) and (ii) of paragraph (2)(A)— 

5 ‘‘(I) the assessment of perform6 ance provided under such methodology 

7 with respect to such performance cat8 egories that is to be applied to each 

9 such professional in such group for 

10 such performance period shall be with 

11 respect to the combined performance 

12 of all such professionals in such group 

13 for such period; and 

14 ‘‘(II) with respect to the com15 posite performance score provided 

16 under this paragraph for such per17 formance period for each such MIPS 

18 eligible professional in such virtual 

19 group, the components of the com20 posite performance score that assess 

21 performance with respect to such per22 formance categories shall be based on 

23 the assessment of the combined per24 formance under subclause (I) for such 


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1 performance categories and perform2 ance period. 

3 ‘‘(ii) ELECTION OF PRACTICES TO BE

4 A VIRTUAL GROUP.—The Secretary shall, 

5 in accordance with the requirements under 

6 clause (iii), establish and have in place a 

7 process to allow an individual MIPS eligi8 ble professional or a group practice con9 sisting of not more than 10 MIPS eligible 

10 professionals to elect, with respect to a 

11 performance period for a year to be a vir12 tual group under this subparagraph with 

13 at least one other such individual MIPS el14 igible professional or group practice. Such 

15 a virtual group may be based on appro16 priate classifications of providers, such as 

17 by geographic areas or by provider special18 ties defined by nationally recognized spe19 cialty boards of certification or equivalent 

20 certification boards. 

21 ‘‘(iii) REQUIREMENTS.—The require22 ments for the process under clause (ii) 

23 shall— 

24 ‘‘(I) provide that an election 

25 under such clause, with respect to a 


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1 performance period, shall be made be2 fore the beginning of such perform3 ance period and may not be changed 

4 during such performance period; 

5 ‘‘(II) provide that an individual 

6 MIPS eligible professional and a 

7 group practice described in clause (ii) 

8 may elect to be in no more than one 

9 virtual group for a performance period 

10 and that, in the case of such a group 

11 practice that elects to be in such vir12 tual group for such performance pe13 riod, such election applies to all MIPS 

14 eligible professionals in such group 

15 practice; 

16 ‘‘(III) provide that a virtual 

17 group be a combination of tax identi18 fication numbers; 

19 ‘‘(IV) provide for formal written 

20 agreements among MIPS eligible pro21 fessionals electing to be a virtual 

22 group under this subparagraph; and 

23 ‘‘(V) include such other require24 ments as the Secretary determines ap25 propriate. 


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1 ‘‘(6) MIPS PAYMENTS.— 

2 ‘‘(A) MIPS ADJUSTMENT FACTOR.—Tak3 ing into account paragraph (1)(G), the Sec4 retary shall specify a MIPS adjustment factor 

5 for each MIPS eligible professional for a year. 

6 Such MIPS adjustment factor for a MIPS eligi7 ble professional for a year shall be in the form 

8 of a percent and shall be determined— 

9 ‘‘(i) by comparing the composite per10 formance score of the eligible professional 

11 for such year to the performance threshold 

12 established under subparagraph (D)(i) for 

13 such year; 

14 ‘‘(ii) in a manner such that the ad15 justment factors specified under this sub16 paragraph for a year result in differential 

17 payments under this paragraph reflecting 

18 that— 

19 ‘‘(I) MIPS eligible professionals 

20 with composite performance scores for 

21 such year at or above such perform22 ance threshold for such year receive 

23 zero or positive payment adjustment 

24 factors for such year in accordance 

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1 sionals having higher composite per2 formance scores receiving higher ad3 justment factors; and 

4 ‘‘(II) MIPS eligible professionals 

5 with composite performance scores for 

6 such year below such performance 

7 threshold for such year receive nega8 tive payment adjustment factors for 

9 such year in accordance with clause 

10 (iv), with such professionals having 

11 lower composite performance scores 

12 receiving lower adjustment factors; 

13 ‘‘(iii) in a manner such that MIPS eli14 gible professionals with composite scores 

15 described in clause (ii)(I) for such year, 

16 subject to clauses (i) and (ii) of subpara17 graph (F), receive a zero or positive ad18 justment factor on a linear sliding scale 

19 such that an adjustment factor of 0 per20 cent is assigned for a score at the perform21 ance threshold and an adjustment factor of 

22 the applicable percent specified in subpara23 graph (B) is assigned for a score of 100; 

24 and 

25 ‘‘(iv) in a manner such that— 


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1 ‘‘(I) subject to subclause (II), 

2 MIPS eligible professionals with com3 posite performance scores described in 

4 clause (ii)(II) for such year receive a 

5 negative payment adjustment factor 

6 on a linear sliding scale such that an 

7 adjustment factor of 0 percent is as8 signed for a score at the performance 

9 threshold and an adjustment factor of 

10 the negative of the applicable percent 

11 specified in subparagraph (B) is as12 signed for a score of 0; and 

13 ‘‘(II) MIPS eligible professionals 

14 with composite performance scores 

15 that are equal to or greater than 0, 

but not greater than 1 16 ⁄4 of the per17 formance threshold specified under 

18 subparagraph (D)(i) for such year, re19 ceive a negative payment adjustment 

20 factor that is equal to the negative of 

21 the applicable percent specified in 

22 subparagraph (B) for such year. 

23 ‘‘(B) APPLICABLE PERCENT DEFINED.— 

24 For purposes of this paragraph, the term ‘ap25 plicable percent’ means— 


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1 ‘‘(i) for 2019, 4 percent; 

2 ‘‘(ii) for 2020, 5 percent; 

3 ‘‘(iii) for 2021, 7 percent; and 

4 ‘‘(iv) for 2022 and subsequent years, 

5 9 percent. 

6 ‘‘(C) ADDITIONAL MIPS ADJUSTMENT FAC7 TORS FOR EXCEPTIONAL PERFORMANCE.—For 

8 2019 and each subsequent year through 2024, 

9 in the case of a MIPS eligible professional with 

10 a composite performance score for a year at or 

11 above the additional performance threshold 

12 under subparagraph (D)(ii) for such year, in 

13 addition to the MIPS adjustment factor under 

14 subparagraph (A) for the eligible professional 

15 for such year, subject to subparagraph (F)(iv), 

16 the Secretary shall specify an additional positive 

17 MIPS adjustment factor for such professional 

18 and year. Such additional MIPS adjustment 

19 factors shall be in the form of a percent and de20 termined by the Secretary in a manner such 

21 that professionals having higher composite per22 formance scores above the additional perform23 ance threshold receive higher additional MIPS 

24 adjustment factors. 


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1 ‘‘(D) ESTABLISHMENT OF PERFORMANCE

2 THRESHOLDS.— 

3 ‘‘(i) PERFORMANCE THRESHOLD.— 

4 For each year of the MIPS, the Secretary 

5 shall compute a performance threshold 

6 with respect to which the composite per7 formance score of MIPS eligible profes8 sionals shall be compared for purposes of 

9 determining adjustment factors under sub10 paragraph (A) that are positive, negative, 

11 and zero. Such performance threshold for 

12 a year shall be the mean or median (as se13 lected by the Secretary) of the composite 

14 performance scores for all MIPS eligible 

15 professionals with respect to a prior period 

16 specified by the Secretary. The Secretary 

17 may reassess the selection of the mean or 

18 median under the previous sentence every 

19 3 years. 

20 ‘‘(ii) ADDITIONAL PERFORMANCE

21 THRESHOLD FOR EXCEPTIONAL PERFORM22 ANCE.—In addition to the performance 

23 threshold under clause (i), for each year of 

24 the MIPS, the Secretary shall compute an 

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1 poses of determining the additional MIPS 

2 adjustment factors under subparagraph 

3 (C). For each such year, the Secretary 

4 shall apply either of the following methods 

5 for computing such additional performance 

6 threshold for such a year: 

7 ‘‘(I) The threshold shall be the 

8 score that is equal to the 25th per9 centile of the range of possible com10 posite performance scores above the 

11 performance threshold determined 

12 under clause (i). 

13 ‘‘(II) The threshold shall be the 

14 score that is equal to the 25th per15 centile of the actual composite per16 formance scores for MIPS eligible 

17 professionals with composite perform18 ance scores at or above the perform19 ance threshold with respect to the 

20 prior period described in clause (i). 

21 ‘‘(iii) SPECIAL RULE FOR INITIAL 2

22 YEARS.—With respect to each of the first 

23 two years to which the MIPS applies, the 

24 Secretary shall, prior to the performance 

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1 ance threshold for purposes of determining 

2 MIPS adjustment factors under subpara3 graph (A) and a threshold for purposes of 

4 determining additional MIPS adjustment 

5 factors under subparagraph (C). Each 

6 such performance threshold shall— 

7 ‘‘(I) be based on a period prior to 

8 such performance periods; and 

9 ‘‘(II) take into account— 

10 ‘‘(aa) data available with re11 spect to performance on meas12 ures and activities that may be 

13 used under the performance cat14 egories under subparagraph 

15 (2)(B); and 

16 ‘‘(bb) other factors deter17 mined appropriate by the Sec18 retary. 

19 ‘‘(E) APPLICATION OF MIPS ADJUSTMENT

20 FACTORS.—In the case of items and services 

21 furnished by a MIPS eligible professional dur22 ing a year (beginning with 2019), the amount 

23 otherwise paid under this part with respect to 

24 such items and services and MIPS eligible pro25 fessional for such year, shall be multiplied by— 


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1 ‘‘(i) 1, plus 

2 ‘‘(ii) the sum of— 

3 ‘‘(I) the MIPS adjustment factor 

4 determined under subparagraph (A) 

5 divided by 100, and 

6 ‘‘(II) as applicable, the additional 

7 MIPS adjustment factor determined 

8 under subparagraph (C) divided by 

9 100. 

10 ‘‘(F) AGGREGATE APPLICATION OF MIPS

11 ADJUSTMENT FACTORS.— 

12 ‘‘(i) APPLICATION OF SCALING FAC13 TOR.— 

14 ‘‘(I) IN GENERAL.—With respect 

15 to positive MIPS adjustment factors 

16 under subparagraph (A)(ii)(I) for eli17 gible professionals whose composite 

18 performance score is above the per19 formance threshold under subpara20 graph (D)(i) for such year, subject to 

21 subclause (II), the Secretary shall in22 crease or decrease such adjustment 

23 factors by a scaling factor in order to 

24 ensure that the budget neutrality re25 quirement of clause (ii) is met. 


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1 ‘‘(II) SCALING FACTOR LIMIT.— 

2 In no case may the scaling factor ap3 plied under this clause exceed 3.0. 

4 ‘‘(ii) BUDGET NEUTRALITY REQUIRE5 MENT.— 

6 ‘‘(I) IN GENERAL.—Subject to 

7 clause (iii), the Secretary shall ensure 

8 that the estimated amount described 

9 in subclause (II) for a year is equal to 

10 the estimated amount described in 

11 subclause (III) for such year. 

12 ‘‘(II) AGGREGATE INCREASES.— 

13 The amount described in this sub14 clause is the estimated increase in the 

15 aggregate allowed charges resulting 

16 from the application of positive MIPS 

17 adjustment factors under subpara18 graph (A) (after application of the 

19 scaling factor described in clause (i)) 

20 to MIPS eligible professionals whose 

21 composite performance score for a 

22 year is above the performance thresh23 old under subparagraph (D)(i) for 

24 such year. 


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1 ‘‘(III) AGGREGATE DE2 CREASES.—The amount described in 

3 this subclause is the estimated de4 crease in the aggregate allowed 

5 charges resulting from the application 

6 of negative MIPS adjustment factors 

7 under subparagraph (A) to MIPS eli8 gible professionals whose composite 

9 performance score for a year is below 

10 the performance threshold under sub11 paragraph (D)(i) for such year. 

12 ‘‘(iii) EXCEPTIONS.— 

13 ‘‘(I) In the case that all MIPS el14 igible professionals receive composite 

15 performance scores for a year that are 

16 below the performance threshold 

17 under subparagraph (D)(i) for such 

18 year, the negative MIPS adjustment 

19 factors under subparagraph (A) shall 

20 apply with respect to such MIPS eligi21 ble professionals and the budget neu22 trality requirement of clause (ii) and 

23 the additional adjustment factors 

24 under clause (iv) shall not apply for 

25 such year. 


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1 ‘‘(II) In the case that, with re2 spect to a year, the application of 

3 clause (i) results in a scaling factor 

4 equal to the maximum scaling factor 

5 specified in clause (i)(II), such scaling 

6 factor shall apply and the budget neu7 trality requirement of clause (ii) shall 

8 not apply for such year. 

9 ‘‘(iv) ADDITIONAL INCENTIVE PAY10 MENT ADJUSTMENTS.— 

11 ‘‘(I) IN GENERAL.—Subject to 

12 subclause (II), in specifying the MIPS 

13 additional adjustment factors under 

14 subparagraph (C) for each applicable 

15 MIPS eligible professional for a year, 

16 the Secretary shall ensure that the es17 timated aggregate increase in pay18 ments under this part resulting from 

19 the application of such additional ad20 justment factors for MIPS eligible 

21 professionals in a year shall be equal 

22 (as estimated by the Secretary) to 

23 $500,000,000 for each year beginning 

24 with 2019 and ending with 2024. 


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1 ‘‘(II) LIMITATION ON ADDI2 TIONAL INCENTIVE PAYMENT ADJUST3 MENTS.—The MIPS additional ad4 justment factor under subparagraph 

5 (C) for a year for an applicable MIPS 

6 eligible professional whose composite 

7 performance score is above the addi8 tional performance threshold under 

9 subparagraph (D)(ii) for such year 

10 shall not exceed 10 percent. The ap11 plication of the previous sentence may 

12 result in an aggregate amount of ad13 ditional incentive payments that are 

14 less than the amount specified in sub15 clause (I). 

16 ‘‘(7) ANNOUNCEMENT OF RESULT OF ADJUST17 MENTS.—Under the MIPS, the Secretary shall, not 

18 later than 30 days prior to January 1 of the year 

19 involved, make available to MIPS eligible profes20 sionals the MIPS adjustment factor (and, as appli21 cable, the additional MIPS adjustment factor) under 

22 paragraph (6) applicable to the eligible professional 

23 for items and services furnished by the professional 

24 for such year. The Secretary may include such inforVerDate Sep 11 2014 21:09 Mar 27, 2015 Jkt 049200 PO 00000 Frm 00064 Fmt 6652 Sfmt 6201 E:\BILLS\H2.RDS H2

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1 mation in the confidential feedback under paragraph 

2 (12). 

3 ‘‘(8) NO EFFECT IN SUBSEQUENT YEARS.—The 

4 MIPS adjustment factors and additional MIPS ad5 justment factors under paragraph (6) shall apply 

6 only with respect to the year involved, and the Sec7 retary shall not take into account such adjustment 

8 factors in making payments to a MIPS eligible pro9 fessional under this part in a subsequent year. 

10 ‘‘(9) PUBLIC REPORTING.— 

11 ‘‘(A) IN GENERAL.—The Secretary shall, 

12 in an easily understandable format, make avail13 able on the Physician Compare Internet website 

14 of the Centers for Medicare & Medicaid Serv15 ices the following: 

16 ‘‘(i) Information regarding the per17 formance of MIPS eligible professionals 

18 under the MIPS, which— 

19 ‘‘(I) shall include the composite 

20 score for each such MIPS eligible pro21 fessional and the performance of each 

22 such MIPS eligible professional with 

23 respect to each performance category; 

24 and 


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1 ‘‘(II) may include the perform2 ance of each such MIPS eligible pro3 fessional with respect to each measure 

4 or activity specified in paragraph 

5 (2)(B). 

6 ‘‘(ii) The names of eligible profes7 sionals in eligible alternative payment mod8 els (as defined in section 1833(z)(3)(D)) 

9 and, to the extent feasible, the names of 

10 such eligible alternative payment models 

11 and performance of such models. 

12 ‘‘(B) DISCLOSURE.—The information 

13 made available under this paragraph shall indi14 cate, where appropriate, that publicized infor15 mation may not be representative of the eligible 

16 professional’s entire patient population, the va17 riety of services furnished by the eligible profes18 sional, or the health conditions of individuals 

19 treated. 

20 ‘‘(C) OPPORTUNITY TO REVIEW AND SUB21 MIT CORRECTIONS.—The Secretary shall pro22 vide for an opportunity for a professional de23 scribed in subparagraph (A) to review, and sub24 mit corrections for, the information to be made 

25 public with respect to the professional under 


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1 such subparagraph prior to such information 

2 being made public. 

3 ‘‘(D) AGGREGATE INFORMATION.—The 

4 Secretary shall periodically post on the Physi5 cian Compare Internet website aggregate infor6 mation on the MIPS, including the range of 

7 composite scores for all MIPS eligible profes8 sionals and the range of the performance of all 

9 MIPS eligible professionals with respect to each 

10 performance category. 

11 ‘‘(10) CONSULTATION.—The Secretary shall 

12 consult with stakeholders in carrying out the MIPS, 

13 including for the identification of measures and ac14 tivities under paragraph (2)(B) and the methodolo15 gies developed under paragraphs (5)(A) and (6) and 

16 regarding the use of qualified clinical data registries. 

17 Such consultation shall include the use of a request 

18 for information or other mechanisms determined ap19 propriate. 

20 ‘‘(11) TECHNICAL ASSISTANCE TO SMALL PRAC21 TICES AND PRACTICES IN HEALTH PROFESSIONAL

22 SHORTAGE AREAS.— 

23 ‘‘(A) IN GENERAL.—The Secretary shall 

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1 ganizations, regional extension centers (as de2 scribed in section 3012(c) of the Public Health 

3 Service Act), or regional health collaboratives) 

4 to offer guidance and assistance to MIPS eligi5 ble professionals in practices of 15 or fewer pro6 fessionals (with priority given to such practices 

7 located in rural areas, health professional short8 age areas (as designated under in section 

9 332(a)(1)(A) of such Act), and medically under10 served areas, and practices with low composite 

11 scores) with respect to— 

12 ‘‘(i) the performance categories de13 scribed in clauses (i) through (iv) of para14 graph (2)(A); or 

15 ‘‘(ii) how to transition to the imple16 mentation of and participation in an alter17 native payment model as described in sec18 tion 1833(z)(3)(C). 

19 ‘‘(B) FUNDING FOR TECHNICAL ASSIST20 ANCE.—For purposes of implementing subpara21 graph (A), the Secretary shall provide for the 

22 transfer from the Federal Supplementary Med23 ical Insurance Trust Fund established under 

24 section 1841 to the Centers for Medicare & 

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1 count of $20,000,000 for each of fiscal years 

2 2016 through 2020. Amounts transferred under 

3 this subparagraph for a fiscal year shall be 

4 available until expended. 

5 ‘‘(12) FEEDBACK AND INFORMATION TO IM6 PROVE PERFORMANCE.— 

7 ‘‘(A) PERFORMANCE FEEDBACK.— 

8 ‘‘(i) IN GENERAL.—Beginning July 1, 

9 2017, the Secretary— 

10 ‘‘(I) shall make available timely 

11 (such as quarterly) confidential feed12 back to MIPS eligible professionals on 

13 the performance of such professionals 

14 with respect to the performance cat15 egories under clauses (i) and (ii) of 

16 paragraph (2)(A); and 

17 ‘‘(II) may make available con18 fidential feedback to such profes19 sionals on the performance of such 

20 professionals with respect to the per21 formance categories under clauses (iii) 

22 and (iv) of such paragraph. 

23 ‘‘(ii) MECHANISMS.—The Secretary 

24 may use one or more mechanisms to make 

25 feedback available under clause (i), which 


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1 may include use of a web-based portal or 

2 other mechanisms determined appropriate 

3 by the Secretary. With respect to the per4 formance category described in paragraph 

5 (2)(A)(i), feedback under this subpara6 graph shall, to the extent an eligible pro7 fessional chooses to participate in a data 

8 registry for purposes of this subsection (in9 cluding registries under subsections (k) 

10 and (m)), be provided based on perform11 ance on quality measures reported through 

12 the use of such registries. With respect to 

13 any other performance category described 

14 in paragraph (2)(A), the Secretary shall 

15 encourage provision of feedback through 

16 qualified clinical data registries as de17 scribed in subsection (m)(3)(E)). 

18 ‘‘(iii) USE OF DATA.—For purposes of 

19 clause (i), the Secretary may use data, 

20 with respect to a MIPS eligible profes21 sional, from periods prior to the current 

22 performance period and may use rolling 

23 periods in order to make illustrative cal24 culations about the performance of such 

25 professional. 


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1 ‘‘(iv) DISCLOSURE EXEMPTION.— 

2 Feedback made available under this sub3 paragraph shall be exempt from disclosure 

4 under section 552 of title 5, United States 

5 Code. 

6 ‘‘(v) RECEIPT OF INFORMATION.— 

7 The Secretary may use the mechanisms es8 tablished under clause (ii) to receive infor9 mation from professionals, such as infor10 mation with respect to this subsection. 

11 ‘‘(B) ADDITIONAL INFORMATION.— 

12 ‘‘(i) IN GENERAL.—Beginning July 1, 

13 2018, the Secretary shall make available to 

14 MIPS eligible professionals information, 

15 with respect to individuals who are pa16 tients of such MIPS eligible professionals, 

17 about items and services for which pay18 ment is made under this title that are fur19 nished to such individuals by other sup20 pliers and providers of services, which may 

21 include information described in clause (ii). 

22 Such information may be made available 

23 under the previous sentence to such MIPS 

24 eligible professionals by mechanisms deter25 mined appropriate by the Secretary, which 


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1 may include use of a web-based portal. 

2 Such information may be made available in 

3 accordance with the same or similar terms 

4 as data are made available to accountable 

5 care organizations participating in the 

6 shared savings program under section 

7 1899. 

8 ‘‘(ii) TYPE OF INFORMATION.—For 

9 purposes of clause (i), the information de10 scribed in this clause, is the following: 

11 ‘‘(I) With respect to selected 

12 items and services (as determined ap13 propriate by the Secretary) for which 

14 payment is made under this title and 

15 that are furnished to individuals, who 

16 are patients of a MIPS eligible profes17 sional, by another supplier or provider 

18 of services during the most recent pe19 riod for which data are available (such 

20 as the most recent three-month pe21 riod), such as the name of such pro22 viders furnishing such items and serv23 ices to such patients during such pe24 riod, the types of such items and servVerDate Sep 11 2014 21:09 Mar 27, 2015 Jkt 049200 PO 00000 Frm 00072 Fmt 6652 Sfmt 6201 E:\BILLS\H2.RDS H2

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1 ices so furnished, and the dates such 

2 items and services were so furnished. 

3 ‘‘(II) Historical data, such as 

4 averages and other measures of the 

5 distribution if appropriate, of the 

6 total, and components of, allowed 

7 charges (and other figures as deter8 mined appropriate by the Secretary). 

9 ‘‘(13) REVIEW.— 

10 ‘‘(A) TARGETED REVIEW.—The Secretary 

11 shall establish a process under which a MIPS 

12 eligible professional may seek an informal re13 view of the calculation of the MIPS adjustment 

14 factor (or factors) applicable to such eligible 

15 professional under this subsection for a year. 

16 The results of a review conducted pursuant to 

17 the previous sentence shall not be taken into ac18 count for purposes of paragraph (6) with re19 spect to a year (other than with respect to the 

20 calculation of such eligible professional’s MIPS 

21 adjustment factor for such year or additional 

22 MIPS adjustment factor for such year) after 

23 the factors determined in subparagraph (A) and 

24 subparagraph (C) of such paragraph have been 

25 determined for such year. 


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1 ‘‘(B) LIMITATION.—Except as provided for 

2 in subparagraph (A), there shall be no adminis3 trative or judicial review under section 1869, 

4 section 1878, or otherwise of the following: 

5 ‘‘(i) The methodology used to deter6 mine the amount of the MIPS adjustment 

7 factor under paragraph (6)(A) and the 

8 amount of the additional MIPS adjustment 

9 factor under paragraph (6)(C) and the de10 termination of such amounts. 

11 ‘‘(ii) The establishment of the per12 formance standards under paragraph (3) 

13 and the performance period under para14 graph (4). 

15 ‘‘(iii) The identification of measures 

16 and activities specified under paragraph 

17 (2)(B) and information made public or 

18 posted on the Physician Compare Internet 

19 website of the Centers for Medicare & 

20 Medicaid Services under paragraph (9). 

21 ‘‘(iv) The methodology developed 

22 under paragraph (5) that is used to cal23 culate performance scores and the calcula24 tion of such scores, including the weighting 


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1 of measures and activities under such 

2 methodology.’’. 

3 (2) GAO REPORTS.— 

4 (A) EVALUATION OF ELIGIBLE PROFES5 SIONAL MIPS.—Not later than October 1, 2021, 

6 the Comptroller General of the United States 

7 shall submit to Congress a report evaluating the 

8 eligible professional Merit-based Incentive Pay9 ment System under subsection (q) of section 

10 1848 of the Social Security Act (42 U.S.C. 

11 1395w–4), as added by paragraph (1). Such re12 port shall— 

13 (i) examine the distribution of the 

14 composite performance scores and MIPS 

15 adjustment factors (and additional MIPS 

16 adjustment factors) for MIPS eligible pro17 fessionals (as defined in subsection 

18 (q)(1)(c) of such section) under such pro19 gram, and patterns relating to such scores 

20 and adjustment factors, including based on 

21 type of provider, practice size, geographic 

22 location, and patient mix; 

23 (ii) provide recommendations for im24 proving such program; 


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1 (iii) evaluate the impact of technical 

2 assistance funding under section 

3 1848(q)(11) of the Social Security Act, as 

4 added by paragraph (1), on the ability of 

5 professionals to improve within such pro6 gram or successfully transition to an alter7 native payment model (as defined in sec8 tion 1833(z)(3) of the Social Security Act, 

9 as added by subsection (e)), with priority 

10 for such evaluation given to practices lo11 cated in rural areas, health professional 

12 shortage areas (as designated in section 

13 332(a)(1)(A) of the Public Health Service 

14 Act), and medically underserved areas; and 

15 (iv) provide recommendations for opti16 mizing the use of such technical assistance 

17 funds. 

18 (B) STUDY TO EXAMINE ALIGNMENT OF

19 QUALITY MEASURES USED IN PUBLIC AND PRI20 VATE PROGRAMS.— 

21 (i) IN GENERAL.—Not later than 18 

22 months after the date of the enactment of 

23 this Act, the Comptroller General of the 

24 United States shall submit to Congress a 

25 report that— 


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1 (I) compares the similarities and 

2 differences in the use of quality meas3 ures under the original Medicare fee4 for-service program under parts A and 

5 B of title XVIII of the Social Security 

6 Act, the Medicare Advantage program 

7 under part C of such title, selected 

8 State Medicaid programs under title 

9 XIX of such Act, and private payer 

10 arrangements; and 

11 (II) makes recommendations on 

12 how to reduce the administrative bur13 den involved in applying such quality 

14 measures. 

15 (ii) REQUIREMENTS.—The report 

16 under clause (i) shall— 

17 (I) consider those measures ap18 plicable to individuals entitled to, or 

19 enrolled for, benefits under such part 

20 A, or enrolled under such part B and 

21 individuals under the age of 65; and 

22 (II) focus on those measures that 

23 comprise the most significant compo24 nent of the quality performance cat25 egory of the eligible professional 


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1 MIPS incentive program under sub2 section (q) of section 1848 of the So3 cial Security Act (42 U.S.C. 1395w– 

4 4), as added by paragraph (1). 

5 (C) STUDY ON ROLE OF INDEPENDENT

6 RISK MANAGERS.—Not later than January 1, 

7 2017, the Comptroller General of the United 

8 States shall submit to Congress a report exam9 ining whether entities that pool financial risk 

10 for physician practices, such as independent 

11 risk managers, can play a role in supporting 

12 physician practices, particularly small physician 

13 practices, in assuming financial risk for the 

14 treatment of patients. Such report shall exam15 ine barriers that small physician practices cur16 rently face in assuming financial risk for treat17 ing patients, the types of risk management enti18 ties that could assist physician practices in par19 ticipating in two-sided risk payment models, 

20 and how such entities could assist with risk 

21 management and with quality improvement ac22 tivities. Such report shall also include an anal23 ysis of any existing legal barriers to such ar24 rangements. 


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1 (D) STUDY TO EXAMINE RURAL AND

2 HEALTH PROFESSIONAL SHORTAGE AREA AL3 TERNATIVE PAYMENT MODELS.—Not later than 

4 October 1, 2021, the Comptroller General of 

5 the United States shall submit to Congress a 

6 report that examines the transition of profes7 sionals in rural areas, health professional short8 age areas (as designated in section 

9 332(a)(1)(A) of the Public Health Service Act), 

10 or medically underserved areas to an alternative 

11 payment model (as defined in section 

12 1833(z)(3) of the Social Security Act, as added 

13 by subsection (e)). Such report shall make rec14 ommendations for removing administrative bar15 riers to practices, including small practices con16 sisting of 15 or fewer professionals, in rural 

17 areas, health professional shortage areas, and 

18 medically underserved areas to participation in 

19 such models. 

20 (3) FUNDING FOR IMPLEMENTATION.—For 

21 purposes of implementing the provisions of and the 

22 amendments made by this section, the Secretary of 

23 Health and Human Services shall provide for the 

24 transfer of $80,000,000 from the Supplementary 

25 Medical Insurance Trust Fund established under 


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1 section 1841 of the Social Security Act (42 U.S.C. 

2 1395t) to the Centers for Medicare & Medicaid Pro3 gram Management Account for each of the fiscal 

4 years 2015 through 2019. Amounts transferred 

5 under this paragraph shall be available until ex6 pended. 

7 (d) IMPROVING QUALITY REPORTING FOR COM8 POSITE SCORES.— 

9 (1) CHANGES FOR GROUP REPORTING OP10 TION.— 

11 (A) IN GENERAL.—Section 

12 1848(m)(3)(C)(ii) of the Social Security Act 

13 (42 U.S.C. 1395w–4(m)(3)(C)(ii)) is amended 

14 by inserting ‘‘and, for 2016 and subsequent 

15 years, may provide’’ after ‘‘shall provide’’. 

16 (B) CLARIFICATION OF QUALIFIED CLIN17 ICAL DATA REGISTRY REPORTING TO GROUP

18 PRACTICES.—Section 1848(m)(3)(D) of the So19 cial Security Act (42 U.S.C. 1395w– 

20 4(m)(3)(D)) is amended by inserting ‘‘and, for 

21 2016 and subsequent years, subparagraph (A) 

22 or (C)’’ after ‘‘subparagraph (A)’’. 

23 (2) CHANGES FOR MULTIPLE REPORTING PERI24 ODS AND ALTERNATIVE CRITERIA FOR SATISFAC25 TORY REPORTING.—Section 1848(m)(5)(F) of the 


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1 Social Security Act (42 U.S.C. 1395w–4(m)(5)(F)) 

2 is amended— 

3 (A) by striking ‘‘and subsequent years’’ 

4 and inserting ‘‘through reporting periods occur5 ring in 2015’’; and 

6 (B) by inserting ‘‘and, for reporting peri7 ods occurring in 2016 and subsequent years, 

8 the Secretary may establish’’ after ‘‘shall estab9 lish’’. 

10 (3) PHYSICIAN FEEDBACK PROGRAM REPORTS

11 SUCCEEDED BY REPORTS UNDER MIPS.—Section 

12 1848(n) of the Social Security Act (42 U.S.C. 

13 1395w–4(n)) is amended by adding at the end the 

14 following new paragraph: 

15 ‘‘(11) REPORTS ENDING WITH 2017.—Reports 

16 under the Program shall not be provided after De17 cember 31, 2017. See subsection (q)(12) for reports 

18 under the eligible professionals Merit-based Incentive 

19 Payment System.’’. 

20 (4) COORDINATION WITH SATISFYING MEANING21 FUL EHR USE CLINICAL QUALITY MEASURE REPORT22 ING REQUIREMENT.—Section 1848(o)(2)(A)(iii) of 

23 the Social Security Act (42 U.S.C. 1395w– 

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1 section (q)(5)(B)(ii)(II)’’ after ‘‘Subject to subpara2 graph (B)(ii)’’. 

3 (e) PROMOTING ALTERNATIVE PAYMENT MODELS.— 

4 (1) INCREASING TRANSPARENCY OF PHYSICIAN5 FOCUSED PAYMENT MODELS.—Section 1868 of the 

6 Social Security Act (42 U.S.C. 1395ee) is amended 

7 by adding at the end the following new subsection: 

8 ‘‘(c) PHYSICIAN-FOCUSED PAYMENT MODELS.— 

9 ‘‘(1) TECHNICAL ADVISORY COMMITTEE.— 

10 ‘‘(A) ESTABLISHMENT.—There is estab11 lished an ad hoc committee to be known as the 

12 ‘Physician-Focused Payment Model Technical 

13 Advisory Committee’ (referred to in this sub14 section as the ‘Committee’). 

15 ‘‘(B) MEMBERSHIP.— 

16 ‘‘(i) NUMBER AND APPOINTMENT.— 

17 The Committee shall be composed of 11 

18 members appointed by the Comptroller 

19 General of the United States. 

20 ‘‘(ii) QUALIFICATIONS.—The member21 ship of the Committee shall include indi22 viduals with national recognition for their 

23 expertise in physician-focused payment 

24 models and related delivery of care. No 

25 more than 5 members of the Committee 


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1 shall be providers of services or suppliers, 

2 or representatives of providers of services 

3 or suppliers. 

4 ‘‘(iii) PROHIBITION ON FEDERAL EM5 PLOYMENT.—A member of the Committee 

6 shall not be an employee of the Federal 

7 Government. 

8 ‘‘(iv) ETHICS DISCLOSURE.—The 

9 Comptroller General shall establish a sys10 tem for public disclosure by members of 

11 the Committee of financial and other po12 tential conflicts of interest relating to such 

13 members. Members of the Committee shall 

14 be treated as employees of Congress for 

15 purposes of applying title I of the Ethics 

16 in Government Act of 1978 (Public Law 

17 95–521). 

18 ‘‘(v) DATE OF INITIAL APPOINT19 MENTS.—The initial appointments of mem20 bers of the Committee shall be made by 

21 not later than 180 days after the date of 

22 enactment of this subsection. 

23 ‘‘(C) TERM; VACANCIES.— 

24 ‘‘(i) TERM.—The terms of members of 

25 the Committee shall be for 3 years except 


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1 that the Comptroller General shall des2 ignate staggered terms for the members 

3 first appointed. 

4 ‘‘(ii) VACANCIES.—Any member ap5 pointed to fill a vacancy occurring before 

6 the expiration of the term for which the 

7 member’s predecessor was appointed shall 

8 be appointed only for the remainder of that 

9 term. A member may serve after the expi10 ration of that member’s term until a suc11 cessor has taken office. A vacancy in the 

12 Committee shall be filled in the manner in 

13 which the original appointment was made. 

14 ‘‘(D) DUTIES.—The Committee shall meet, 

15 as needed, to provide comments and rec16 ommendations to the Secretary, as described in 

17 paragraph (2)(C), on physician-focused pay18 ment models. 

19 ‘‘(E) COMPENSATION OF MEMBERS.— 

20 ‘‘(i) IN GENERAL.—Except as pro21 vided in clause (ii), a member of the Com22 mittee shall serve without compensation. 

23 ‘‘(ii) TRAVEL EXPENSES.—A member 

24 of the Committee shall be allowed travel 

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1 sistence, at rates authorized for an em2 ployee of an agency under subchapter I of 

3 chapter 57 of title 5, United States Code, 

4 while away from the home or regular place 

5 of business of the member in the perform6 ance of the duties of the Committee. 

7 ‘‘(F) OPERATIONAL AND TECHNICAL SUP8 PORT.— 

9 ‘‘(i) IN GENERAL.—The Assistant 

10 Secretary for Planning and Evaluation 

11 shall provide technical and operational sup12 port for the Committee, which may be by 

13 use of a contractor. The Office of the Ac14 tuary of the Centers for Medicare & Med15 icaid Services shall provide to the Com16 mittee actuarial assistance as needed. 

17 ‘‘(ii) FUNDING.—The Secretary shall 

18 provide for the transfer, from the Federal 

19 Supplementary Medical Insurance Trust 

20 Fund under section 1841, such amounts as 

21 are necessary to carry out this paragraph 

22 (not to exceed $5,000,000) for fiscal year 

23 2015 and each subsequent fiscal year. Any 

24 amounts transferred under the preceding 


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1 sentence for a fiscal year shall remain 

2 available until expended. 

3 ‘‘(G) APPLICATION.—Section 14 of the 

4 Federal Advisory Committee Act (5 U.S.C. 

5 App.) shall not apply to the Committee. 

6 ‘‘(2) CRITERIA AND PROCESS FOR SUBMISSION

7 AND REVIEW OF PHYSICIAN-FOCUSED PAYMENT

8 MODELS.— 

9 ‘‘(A) CRITERIA FOR ASSESSING PHYSICIAN10 FOCUSED PAYMENT MODELS.— 

11 ‘‘(i) RULEMAKING.—Not later than 

12 November 1, 2016, the Secretary shall, 

13 through notice and comment rulemaking, 

14 following a request for information, estab15 lish criteria for physician-focused payment 

16 models, including models for specialist phy17 sicians, that could be used by the Com18 mittee for making comments and rec19 ommendations pursuant to paragraph 

20 (1)(D). 

21 ‘‘(ii) MEDPAC SUBMISSION OF COM22 MENTS.—During the comment period for 

23 the proposed rule described in clause (i), 

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1 retary on the proposed criteria under such 

2 clause. 

3 ‘‘(iii) UPDATING.—The Secretary may 

4 update the criteria established under this 

5 subparagraph through rulemaking. 

6 ‘‘(B) STAKEHOLDER SUBMISSION OF PHY7 SICIAN-FOCUSED PAYMENT MODELS.—On an 

8 ongoing basis, individuals and stakeholder enti9 ties may submit to the Committee proposals for 

10 physician-focused payment models that such in11 dividuals and entities believe meet the criteria 

12 described in subparagraph (A). 

13 ‘‘(C) COMMITTEE REVIEW OF MODELS

14 SUBMITTED.—The Committee shall, on a peri15 odic basis, review models submitted under sub16 paragraph (B), prepare comments and rec17 ommendations regarding whether such models 

18 meet the criteria described in subparagraph 

19 (A), and submit such comments and rec20 ommendations to the Secretary. 

21 ‘‘(D) SECRETARY REVIEW AND RE22 SPONSE.—The Secretary shall review the com23 ments and recommendations submitted by the 

24 Committee under subparagraph (C) and post a 

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1 ommendations on the Internet website of the 

2 Centers for Medicare & Medicaid Services. 

3 ‘‘(3) RULE OF CONSTRUCTION.—Nothing in 

4 this subsection shall be construed to impact the de5 velopment or testing of models under this title or ti6 tles XI, XIX, or XXI.’’. 

7 (2) INCENTIVE PAYMENTS FOR PARTICIPATION

8 IN ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 

9 Section 1833 of the Social Security Act (42 U.S.C. 

10 1395l) is amended by adding at the end the fol11 lowing new subsection: 

12 ‘‘(z) INCENTIVE PAYMENTS FOR PARTICIPATION IN

13 ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 

14 ‘‘(1) PAYMENT INCENTIVE.— 

15 ‘‘(A) IN GENERAL.—In the case of covered 

16 professional services furnished by an eligible 

17 professional during a year that is in the period 

18 beginning with 2019 and ending with 2024 and 

19 for which the professional is a qualifying APM 

20 participant with respect to such year, in addi21 tion to the amount of payment that would oth22 erwise be made for such covered professional 

23 services under this part for such year, there 

24 also shall be paid to such professional an 

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1 gregate payment amounts for such covered pro2 fessional services under this part for the pre3 ceding year. For purposes of the previous sen4 tence, the payment amount for the preceding 

5 year may be an estimation for the full pre6 ceding year based on a period of such preceding 

7 year that is less than the full year. The Sec8 retary shall establish policies to implement this 

9 subparagraph in cases in which payment for 

10 covered professional services furnished by a 

11 qualifying APM participant in an alternative 

12 payment model— 

13 ‘‘(i) is made to an eligible alternative 

14 payment entity rather than directly to the 

15 qualifying APM participant; or 

16 ‘‘(ii) is made on a basis other than a 

17 fee-for-service basis (such as payment on a 

18 capitated basis). 

19 ‘‘(B) FORM OF PAYMENT.—Payments 

20 under this subsection shall be made in a lump 

21 sum, on an annual basis, as soon as practicable. 

22 ‘‘(C) TREATMENT OF PAYMENT INCEN23 TIVE.—Payments under this subsection shall 

24 not be taken into account for purposes of deter25 mining actual expenditures under an alternative 


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1 payment model and for purposes of determining 

2 or rebasing any benchmarks used under the al3 ternative payment model. 

4 ‘‘(D) COORDINATION.—The amount of the 

5 additional payment under this subsection or 

6 subsection (m) shall be determined without re7 gard to any additional payment under sub8 section (m) and this subsection, respectively. 

9 The amount of the additional payment under 

10 this subsection or subsection (x) shall be deter11 mined without regard to any additional pay12 ment under subsection (x) and this subsection, 

13 respectively. The amount of the additional pay14 ment under this subsection or subsection (y) 

15 shall be determined without regard to any addi16 tional payment under subsection (y) and this 

17 subsection, respectively. 

18 ‘‘(2) QUALIFYING APM PARTICIPANT.—For pur19 poses of this subsection, the term ‘qualifying APM 

20 participant’ means the following: 

21 ‘‘(A) 2019 AND 2020.—With respect to 

22 2019 and 2020, an eligible professional for 

23 whom the Secretary determines that at least 25 

24 percent of payments under this part for covered 

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1 sional during the most recent period for which 

2 data are available (which may be less than a 

3 year) were attributable to such services fur4 nished under this part through an eligible alter5 native payment entity. 

6 ‘‘(B) 2021 AND 2022.—With respect to 

7 2021 and 2022, an eligible professional de8 scribed in either of the following clauses: 

9 ‘‘(i) MEDICARE PAYMENT THRESHOLD

10 OPTION.—An eligible professional for 

11 whom the Secretary determines that at 

12 least 50 percent of payments under this 

13 part for covered professional services fur14 nished by such professional during the 

15 most recent period for which data are 

16 available (which may be less than a year) 

17 were attributable to such services furnished 

18 under this part through an eligible alter19 native payment entity. 

20 ‘‘(ii) COMBINATION ALL-PAYER AND

21 MEDICARE PAYMENT THRESHOLD OP22 TION.—An eligible professional— 

23 ‘‘(I) for whom the Secretary de24 termines, with respect to items and 

25 services furnished by such professional 


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1 during the most recent period for 

2 which data are available (which may 

3 be less than a year), that at least 50 

4 percent of the sum of— 

5 ‘‘(aa) payments described in 

6 clause (i); and 

7 ‘‘(bb) all other payments, re8 gardless of payer (other than 

9 payments made by the Secretary 

10 of Defense or the Secretary of 

11 Veterans Affairs and other than 

12 payments made under title XIX 

13 in a State in which no medical 

14 home or alternative payment 

15 model is available under the 

16 State program under that title), 

17 meet the requirement described in 

18 clause (iii)(I) with respect to pay19 ments described in item (aa) and meet 

20 the requirement described in clause 

21 (iii)(II) with respect to payments de22 scribed in item (bb); 

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1 fessional services furnished by such 

2 professional during the most recent 

3 period for which data are available 

4 (which may be less than a year) were 

5 attributable to such services furnished 

6 under this part through an eligible al7 ternative payment entity; and 

8 ‘‘(III) who provides to the Sec9 retary such information as is nec10 essary for the Secretary to make a de11 termination under subclause (I), with 

12 respect to such professional. 

13 ‘‘(iii) REQUIREMENT.—For purposes 

14 of clause (ii)(I)— 

15 ‘‘(I) the requirement described in 

16 this subclause, with respect to pay17 ments described in item (aa) of such 

18 clause, is that such payments are 

19 made to an eligible alternative pay20 ment entity; and 

21 ‘‘(II) the requirement described 

22 in this subclause, with respect to pay23 ments described in item (bb) of such 

24 clause, is that such payments are 

25 made under arrangements in which— 


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1 ‘‘(aa) quality measures com2 parable to measures under the 

3 performance category described 

4 in section 1848(q)(2)(B)(i) apply; 

5 ‘‘(bb) certified EHR tech6 nology is used; and 

7 ‘‘(cc) the eligible profes8 sional participates in an entity 

9 that— 

10 ‘‘(AA) bears more than 

11 nominal financial risk if ac12 tual aggregate expenditures 

13 exceeds expected aggregate 

14 expenditures; or 

15 ‘‘(BB) with respect to 

16 beneficiaries under title 

17 XIX, is a medical home that 

18 meets criteria comparable to 

19 medical homes expanded 

20 under section 1115A(c). 

21 ‘‘(C) BEGINNING IN 2023.—With respect to 

22 2023 and each subsequent year, an eligible pro23 fessional described in either of the following 

24 clauses: 


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1 ‘‘(i) MEDICARE PAYMENT THRESHOLD

2 OPTION.—An eligible professional for 

3 whom the Secretary determines that at 

4 least 75 percent of payments under this 

5 part for covered professional services fur6 nished by such professional during the 

7 most recent period for which data are 

8 available (which may be less than a year) 

9 were attributable to such services furnished 

10 under this part through an eligible alter11 native payment entity. 

12 ‘‘(ii) COMBINATION ALL-PAYER AND

13 MEDICARE PAYMENT THRESHOLD OP14 TION.—An eligible professional— 

15 ‘‘(I) for whom the Secretary de16 termines, with respect to items and 

17 services furnished by such professional 

18 during the most recent period for 

19 which data are available (which may 

20 be less than a year), that at least 75 

21 percent of the sum of— 

22 ‘‘(aa) payments described in 

23 clause (i); and 

24 ‘‘(bb) all other payments, re25 gardless of payer (other than 


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1 payments made by the Secretary 

2 of Defense or the Secretary of 

3 Veterans Affairs and other than 

4 payments made under title XIX 

5 in a State in which no medical 

6 home or alternative payment 

7 model is available under the 

8 State program under that title), 

9 meet the requirement described in 

10 clause (iii)(I) with respect to pay11 ments described in item (aa) and meet 

12 the requirement described in clause 

13 (iii)(II) with respect to payments de14 scribed in item (bb); 

15 ‘‘(II) for whom the Secretary de16 termines at least 25 percent of pay17 ments under this part for covered pro18 fessional services furnished by such 

19 professional during the most recent 

20 period for which data are available 

21 (which may be less than a year) were 

22 attributable to such services furnished 

23 under this part through an eligible al24 ternative payment entity; and 


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1 ‘‘(III) who provides to the Sec2 retary such information as is nec3 essary for the Secretary to make a de4 termination under subclause (I), with 

5 respect to such professional. 

6 ‘‘(iii) REQUIREMENT.—For purposes 

7 of clause (ii)(I)— 

8 ‘‘(I) the requirement described in 

9 this subclause, with respect to pay10 ments described in item (aa) of such 

11 clause, is that such payments are 

12 made to an eligible alternative pay13 ment entity; and 

14 ‘‘(II) the requirement described 

15 in this subclause, with respect to pay16 ments described in item (bb) of such 

17 clause, is that such payments are 

18 made under arrangements in which— 

19 ‘‘(aa) quality measures com20 parable to measures under the 

21 performance category described 

22 in section 1848(q)(2)(B)(i) apply; 

23 ‘‘(bb) certified EHR tech24 nology is used; and 


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1 ‘‘(cc) the eligible profes2 sional participates in an entity 

3 that— 

4 ‘‘(AA) bears more than 

5 nominal financial risk if ac6 tual aggregate expenditures 

7 exceeds expected aggregate 

8 expenditures; or 

9 ‘‘(BB) with respect to 

10 beneficiaries under title 

11 XIX, is a medical home that 

12 meets criteria comparable to 

13 medical homes expanded 

14 under section 1115A(c). 

15 ‘‘(D) USE OF PATIENT APPROACH.—The 

16 Secretary may base the determination of wheth17 er an eligible professional is a qualifying APM 

18 participant under this subsection and the deter19 mination of whether an eligible professional is a 

20 partial qualifying APM participant under sec21 tion 1848(q)(1)(C)(iii) by using counts of pa22 tients in lieu of using payments and using the 

23 same or similar percentage criteria (as specified 

24 in this subsection and such section, respec25 tively), as the Secretary determines appropriate. 


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1 ‘‘(3) ADDITIONAL DEFINITIONS.—In this sub2 section: 

3 ‘‘(A) COVERED PROFESSIONAL SERV4 ICES.—The term ‘covered professional services’ 

5 has the meaning given that term in section 

6 1848(k)(3)(A). 

7 ‘‘(B) ELIGIBLE PROFESSIONAL.—The term 

8 ‘eligible professional’ has the meaning given 

9 that term in section 1848(k)(3)(B) and includes 

10 a group that includes such professionals. 

11 ‘‘(C) ALTERNATIVE PAYMENT MODEL

12 (APM).—The term ‘alternative payment model’ 

13 means, other than for purposes of subpara14 graphs (B)(ii)(I)(bb) and (C)(ii)(I)(bb) of para15 graph (2), any of the following: 

16 ‘‘(i) A model under section 1115A 

17 (other than a health care innovation 

18 award). 

19 ‘‘(ii) The shared savings program 

20 under section 1899. 

21 ‘‘(iii) A demonstration under section 

22 1866C. 

23 ‘‘(iv) A demonstration required by 

24 Federal law. 


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1 ‘‘(D) ELIGIBLE ALTERNATIVE PAYMENT

2 ENTITY.—The term ‘eligible alternative pay3 ment entity’ means, with respect to a year, an 

4 entity that— 

5 ‘‘(i) participates in an alternative pay6 ment model that— 

7 ‘‘(I) requires participants in such 

8 model to use certified EHR tech9 nology (as defined in subsection 

10 (o)(4)); and 

11 ‘‘(II) provides for payment for 

12 covered professional services based on 

13 quality measures comparable to meas14 ures under the performance category 

15 described in section 1848(q)(2)(B)(i); 

16 and 

17 ‘‘(ii)(I) bears financial risk for mone18 tary losses under such alternative payment 

19 model that are in excess of a nominal 

20 amount; or 

21 ‘‘(II) is a medical home expanded 

22 under section 1115A(c). 

23 ‘‘(4) LIMITATION.—There shall be no adminis24 trative or judicial review under section 1869, 1878, 

25 or otherwise, of the following: 


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1 ‘‘(A) The determination that an eligible 

2 professional is a qualifying APM participant 

3 under paragraph (2) and the determination 

4 that an entity is an eligible alternative payment 

5 entity under paragraph (3)(D). 

6 ‘‘(B) The determination of the amount of 

7 the 5 percent payment incentive under para8 graph (1)(A), including any estimation as part 

9 of such determination.’’. 

10 (3) COORDINATION CONFORMING AMEND11 MENTS.—Section 1833 of the Social Security Act 

12 (42 U.S.C. 1395l) is further amended— 

13 (A) in subsection (x)(3), by adding at the 

14 end the following new sentence: ‘‘The amount 

15 of the additional payment for a service under 

16 this subsection and subsection (z) shall be de17 termined without regard to any additional pay18 ment for the service under subsection (z) and 

19 this subsection, respectively.’’; and 

20 (B) in subsection (y)(3), by adding at the 

21 end the following new sentence: ‘‘The amount 

22 of the additional payment for a service under 

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1 ment for the service under subsection (z) and 

2 this subsection, respectively.’’. 

3 (4) ENCOURAGING DEVELOPMENT AND TEST4 ING OF CERTAIN MODELS.—Section 1115A(b)(2) of 

5 the Social Security Act (42 U.S.C. 1315a(b)(2)) is 

6 amended— 

7 (A) in subparagraph (B), by adding at the 

8 end the following new clauses: 

9 ‘‘(xxi) Focusing primarily on physi10 cians’ services (as defined in section 

11 1848(j)(3)) furnished by physicians who 

12 are not primary care practitioners. 

13 ‘‘(xxii) Focusing on practices of 15 or 

14 fewer professionals. 

15 ‘‘(xxiii) Focusing on risk-based models 

16 for small physician practices which may in17 volve two-sided risk and prospective patient 

18 assignment, and which examine risk-ad19 justed decreases in mortality rates, hos20 pital readmissions rates, and other relevant 

21 and appropriate clinical measures. 

22 ‘‘(xxiv) Focusing primarily on title 

23 XIX, working in conjunction with the Cen24 ter for Medicaid and CHIP Services.’’; and 


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1 (B) in subparagraph (C)(viii), by striking 

2 ‘‘other public sector or private sector payers’’ 

3 and inserting ‘‘other public sector payers, pri4 vate sector payers, or statewide payment mod5 els’’. 

6 (5) CONSTRUCTION REGARDING TELEHEALTH

7 SERVICES.—Nothing in the provisions of, or amend8 ments made by, this title shall be construed as pre9 cluding an alternative payment model or a qualifying 

10 APM participant (as those terms are defined in sec11 tion 1833(z) of the Social Security Act, as added by 

12 paragraph (1)) from furnishing a telehealth service 

13 for which payment is not made under section 

14 1834(m) of the Social Security Act (42 U.S.C. 

15 1395m(m)). 

16 (6) INTEGRATING MEDICARE ADVANTAGE AL17 TERNATIVE PAYMENT MODELS.—Not later than July 

18 1, 2016, the Secretary of Health and Human Serv19 ices shall submit to Congress a study that examines 

20 the feasibility of integrating alternative payment 

21 models in the Medicare Advantage payment system. 

22 The study shall include the feasibility of including a 

23 value-based modifier and whether such modifier 

24 should be budget neutral. 


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1 (7) STUDY AND REPORT ON FRAUD RELATED

2 TO ALTERNATIVE PAYMENT MODELS UNDER THE

3 MEDICARE PROGRAM.— 

4 (A) STUDY.—The Secretary of Health and 

5 Human Services, in consultation with the In6 spector General of the Department of Health 

7 and Human Services, shall conduct a study 

8 that— 

9 (i) examines the applicability of the 

10 Federal fraud prevention laws to items and 

11 services furnished under title XVIII of the 

12 Social Security Act for which payment is 

13 made under an alternative payment model 

14 (as defined in section 1833(z)(3)(C) of 

15 such Act (42 U.S.C. 1395l(z)(3)(C))); 

16 (ii) identifies aspects of such alter17 native payment models that are vulnerable 

18 to fraudulent activity; and 

19 (iii) examines the implications of waiv20 ers to such laws granted in support of such 

21 alternative payment models, including 

22 under any potential expansion of such 

23 models. 

24 (B) REPORT.—Not later than 2 years after 

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1 retary shall submit to Congress a report con2 taining the results of the study conducted under 

3 subparagraph (A). Such report shall include 

4 recommendations for actions to be taken to re5 duce the vulnerability of such alternative pay6 ment models to fraudulent activity. Such report 

7 also shall include, as appropriate, recommenda8 tions of the Inspector General for changes in 

9 Federal fraud prevention laws to reduce such 

10 vulnerability. 

11 (f) COLLABORATING WITH THE PHYSICIAN, PRACTI12 TIONER, AND OTHER STAKEHOLDER COMMUNITIES TO

13 IMPROVE RESOURCE USE MEASUREMENT.—Section 1848 

14 of the Social Security Act (42 U.S.C. 1395w–4), as 

15 amended by subsection (c), is further amended by adding 

16 at the end the following new subsection: 

17 ‘‘(r) COLLABORATING WITH THE PHYSICIAN, PRAC18 TITIONER, AND OTHER STAKEHOLDER COMMUNITIES TO

19 IMPROVE RESOURCE USE MEASUREMENT.— 

20 ‘‘(1) IN GENERAL.—In order to involve the phy21 sician, practitioner, and other stakeholder commu22 nities in enhancing the infrastructure for resource 

23 use measurement, including for purposes of the 

24 Merit-based Incentive Payment System under sub25 section (q) and alternative payment models under 


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1 section 1833(z), the Secretary shall undertake the 

2 steps described in the succeeding provisions of this 

3 subsection. 

4 ‘‘(2) DEVELOPMENT OF CARE EPISODE AND PA5 TIENT CONDITION GROUPS AND CLASSIFICATION

6 CODES.— 

7 ‘‘(A) IN GENERAL.—In order to classify 

8 similar patients into care episode groups and 

9 patient condition groups, the Secretary shall 

10 undertake the steps described in the succeeding 

11 provisions of this paragraph. 

12 ‘‘(B) PUBLIC AVAILABILITY OF EXISTING

13 EFFORTS TO DESIGN AN EPISODE GROUPER.— 

14 Not later than 180 days after the date of the 

15 enactment of this subsection, the Secretary 

16 shall post on the Internet website of the Cen17 ters for Medicare & Medicaid Services a list of 

18 the episode groups developed pursuant to sub19 section (n)(9)(A) and related descriptive infor20 mation. 

21 ‘‘(C) STAKEHOLDER INPUT.—The Sec22 retary shall accept, through the date that is 

23 120 days after the day the Secretary posts the 

24 list pursuant to subparagraph (B), suggestions 

25 from physician specialty societies, applicable 


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1 practitioner organizations, and other stake2 holders for episode groups in addition to those 

3 posted pursuant to such subparagraph, and 

4 specific clinical criteria and patient characteris5 tics to classify patients into— 

6 ‘‘(i) care episode groups; and 

7 ‘‘(ii) patient condition groups. 

8 ‘‘(D) DEVELOPMENT OF PROPOSED CLAS9 SIFICATION CODES.— 

10 ‘‘(i) IN GENERAL.—Taking into ac11 count the information described in sub12 paragraph (B) and the information re13 ceived under subparagraph (C), the Sec14 retary shall— 

15 ‘‘(I) establish care episode groups 

16 and patient condition groups, which 

17 account for a target of an estimated 

1 18 ⁄2 of expenditures under parts A and 

19 B (with such target increasing over 

20 time as appropriate); and 

21 ‘‘(II) assign codes to such 

22 groups. 

23 ‘‘(ii) CARE EPISODE GROUPS.—In es24 tablishing the care episode groups under 


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1 clause (i), the Secretary shall take into ac2 count— 

3 ‘‘(I) the patient’s clinical prob4 lems at the time items and services 

5 are furnished during an episode of 

6 care, such as the clinical conditions or 

7 diagnoses, whether or not inpatient 

8 hospitalization occurs, and the prin9 cipal procedures or services furnished; 

10 and 

11 ‘‘(II) other factors determined 

12 appropriate by the Secretary. 

13 ‘‘(iii) PATIENT CONDITION GROUPS.— 

14 In establishing the patient condition 

15 groups under clause (i), the Secretary shall 

16 take into account— 

17 ‘‘(I) the patient’s clinical history 

18 at the time of a medical visit, such as 

19 the patient’s combination of chronic 

20 conditions, current health status, and 

21 recent significant history (such as 

22 hospitalization and major surgery dur23 ing a previous period, such as 3 

24 months); and 


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1 ‘‘(II) other factors determined 

2 appropriate by the Secretary, such as 

3 eligibility status under this title (in4 cluding eligibility under section 

5 226(a), 226(b), or 226A, and dual eli6 gibility under this title and title XIX). 

7 ‘‘(E) DRAFT CARE EPISODE AND PATIENT

8 CONDITION GROUPS AND CLASSIFICATION

9 CODES.—Not later than 270 days after the end 

10 of the comment period described in subpara11 graph (C), the Secretary shall post on the 

12 Internet website of the Centers for Medicare & 

13 Medicaid Services a draft list of the care epi14 sode and patient condition codes established 

15 under subparagraph (D) (and the criteria and 

16 characteristics assigned to such code). 

17 ‘‘(F) SOLICITATION OF INPUT.—The Sec18 retary shall seek, through the date that is 120 

19 days after the Secretary posts the list pursuant 

20 to subparagraph (E), comments from physician 

21 specialty societies, applicable practitioner orga22 nizations, and other stakeholders, including rep23 resentatives of individuals entitled to benefits 

24 under part A or enrolled under this part, re25 garding the care episode and patient condition 


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1 groups (and codes) posted under subparagraph 

2 (E). In seeking such comments, the Secretary 

3 shall use one or more mechanisms (other than 

4 notice and comment rulemaking) that may in5 clude use of open door forums, town hall meet6 ings, or other appropriate mechanisms. 

7 ‘‘(G) OPERATIONAL LIST OF CARE EPI8 SODE AND PATIENT CONDITION GROUPS AND

9 CODES.—Not later than 270 days after the end 

10 of the comment period described in subpara11 graph (F), taking into account the comments 

12 received under such subparagraph, the Sec13 retary shall post on the Internet website of the 

14 Centers for Medicare & Medicaid Services an 

15 operational list of care episode and patient con16 dition codes (and the criteria and characteris17 tics assigned to such code). 

18 ‘‘(H) SUBSEQUENT REVISIONS.—Not later 

19 than November 1 of each year (beginning with 

20 2018), the Secretary shall, through rulemaking, 

21 make revisions to the operational lists of care 

22 episode and patient condition codes as the Sec23 retary determines may be appropriate. Such re24 visions may be based on experience, new infor25 mation developed pursuant to subsection 


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1 (n)(9)(A), and input from the physician spe2 cialty societies, applicable practitioner organiza3 tions, and other stakeholders, including rep4 resentatives of individuals entitled to benefits 

5 under part A or enrolled under this part. 

6 ‘‘(3) ATTRIBUTION OF PATIENTS TO PHYSI7 CIANS OR PRACTITIONERS.— 

8 ‘‘(A) IN GENERAL.—In order to facilitate 

9 the attribution of patients and episodes (in 

10 whole or in part) to one or more physicians or 

11 applicable practitioners furnishing items and 

12 services, the Secretary shall undertake the steps 

13 described in the succeeding provisions of this 

14 paragraph. 

15 ‘‘(B) DEVELOPMENT OF PATIENT RELA16 TIONSHIP CATEGORIES AND CODES.—The Sec17 retary shall develop patient relationship cat18 egories and codes that define and distinguish 

19 the relationship and responsibility of a physi20 cian or applicable practitioner with a patient at 

21 the time of furnishing an item or service. Such 

22 patient relationship categories shall include dif23 ferent relationships of the physician or applica24 ble practitioner to the patient (and the codes 

25 may reflect combinations of such categories), 


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1 such as a physician or applicable practitioner 

2 who— 

3 ‘‘(i) considers themself to have the 

4 primary responsibility for the general and 

5 ongoing care for the patient over extended 

6 periods of time; 

7 ‘‘(ii) considers themself to be the lead 

8 physician or practitioner and who furnishes 

9 items and services and coordinates care 

10 furnished by other physicians or practi11 tioners for the patient during an acute epi12 sode; 

13 ‘‘(iii) furnishes items and services to 

14 the patient on a continuing basis during an 

15 acute episode of care, but in a supportive 

16 rather than a lead role; 

17 ‘‘(iv) furnishes items and services to 

18 the patient on an occasional basis, usually 

19 at the request of another physician or 

20 practitioner; or 

21 ‘‘(v) furnishes items and services only 

22 as ordered by another physician or practi23 tioner. 

24 ‘‘(C) DRAFT LIST OF PATIENT RELATION25 SHIP CATEGORIES AND CODES.—Not later than 


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1 one year after the date of the enactment of this 

2 subsection, the Secretary shall post on the 

3 Internet website of the Centers for Medicare & 

4 Medicaid Services a draft list of the patient re5 lationship categories and codes developed under 

6 subparagraph (B). 

7 ‘‘(D) STAKEHOLDER INPUT.—The Sec8 retary shall seek, through the date that is 120 

9 days after the Secretary posts the list pursuant 

10 to subparagraph (C), comments from physician 

11 specialty societies, applicable practitioner orga12 nizations, and other stakeholders, including rep13 resentatives of individuals entitled to benefits 

14 under part A or enrolled under this part, re15 garding the patient relationship categories and 

16 codes posted under subparagraph (C). In seek17 ing such comments, the Secretary shall use one 

18 or more mechanisms (other than notice and 

19 comment rulemaking) that may include open 

20 door forums, town hall meetings, web-based fo21 rums, or other appropriate mechanisms. 

22 ‘‘(E) OPERATIONAL LIST OF PATIENT RE23 LATIONSHIP CATEGORIES AND CODES.—Not 

24 later than 240 days after the end of the com25 ment period described in subparagraph (D), 


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1 taking into account the comments received 

2 under such subparagraph, the Secretary shall 

3 post on the Internet website of the Centers for 

4 Medicare & Medicaid Services an operational 

5 list of patient relationship categories and codes. 

6 ‘‘(F) SUBSEQUENT REVISIONS.—Not later 

7 than November 1 of each year (beginning with 

8 2018), the Secretary shall, through rulemaking, 

9 make revisions to the operational list of patient 

10 relationship categories and codes as the Sec11 retary determines appropriate. Such revisions 

12 may be based on experience, new information 

13 developed pursuant to subsection (n)(9)(A), and 

14 input from the physician specialty societies, ap15 plicable practitioner organizations, and other 

16 stakeholders, including representatives of indi17 viduals entitled to benefits under part A or en18 rolled under this part. 

19 ‘‘(4) REPORTING OF INFORMATION FOR RE20 SOURCE USE MEASUREMENT.—Claims submitted for 

21 items and services furnished by a physician or appli22 cable practitioner on or after January 1, 2018, shall, 

23 as determined appropriate by the Secretary, in24 clude— 


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1 ‘‘(A) applicable codes established under 

2 paragraphs (2) and (3); and 

3 ‘‘(B) the national provider identifier of the 

4 ordering physician or applicable practitioner (if 

5 different from the billing physician or applicable 

6 practitioner). 

7 ‘‘(5) METHODOLOGY FOR RESOURCE USE ANAL8 YSIS.— 

9 ‘‘(A) IN GENERAL.—In order to evaluate 

10 the resources used to treat patients (with re11 spect to care episode and patient condition 

12 groups), the Secretary shall, as the Secretary 

13 determines appropriate— 

14 ‘‘(i) use the patient relationship codes 

15 reported on claims pursuant to paragraph 

16 (4) to attribute patients (in whole or in 

17 part) to one or more physicians and appli18 cable practitioners; 

19 ‘‘(ii) use the care episode and patient 

20 condition codes reported on claims pursu21 ant to paragraph (4) as a basis to compare 

22 similar patients and care episodes and pa23 tient condition groups; and 


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1 ‘‘(iii) conduct an analysis of resource 

2 use (with respect to care episodes and pa3 tient condition groups of such patients). 

4 ‘‘(B) ANALYSIS OF PATIENTS OF PHYSI5 CIANS AND PRACTITIONERS.—In conducting the 

6 analysis described in subparagraph (A)(iii) with 

7 respect to patients attributed to physicians and 

8 applicable practitioners, the Secretary shall, as 

9 feasible— 

10 ‘‘(i) use the claims data experience of 

11 such patients by patient condition codes 

12 during a common period, such as 12 

13 months; and 

14 ‘‘(ii) use the claims data experience of 

15 such patients by care episode codes— 

16 ‘‘(I) in the case of episodes with17 out a hospitalization, during periods 

18 of time (such as the number of days) 

19 determined appropriate by the Sec20 retary; and 

21 ‘‘(II) in the case of episodes with 

22 a hospitalization, during periods of 

23 time (such as the number of days) be24 fore, during, and after the hospitaliza25 tion. 


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1 ‘‘(C) MEASUREMENT OF RESOURCE USE.— 

2 In measuring such resource use, the Sec3 retary— 

4 ‘‘(i) shall use per patient total allowed 

5 charges for all services under part A and 

6 this part (and, if the Secretary determines 

7 appropriate, part D) for the analysis of pa8 tient resource use, by care episode codes 

9 and by patient condition codes; and 

10 ‘‘(ii) may, as determined appropriate, 

11 use other measures of allowed charges 

12 (such as subtotals for categories of items 

13 and services) and measures of utilization of 

14 items and services (such as frequency of 

15 specific items and services and the ratio of 

16 specific items and services among attrib17 uted patients or episodes). 

18 ‘‘(D) STAKEHOLDER INPUT.—The Sec19 retary shall seek comments from the physician 

20 specialty societies, applicable practitioner orga21 nizations, and other stakeholders, including rep22 resentatives of individuals entitled to benefits 

23 under part A or enrolled under this part, re24 garding the resource use methodology estab25 lished pursuant to this paragraph. In seeking 


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1 comments the Secretary shall use one or more 

2 mechanisms (other than notice and comment 

3 rulemaking) that may include open door fo4 rums, town hall meetings, web-based forums, or 

5 other appropriate mechanisms. 

6 ‘‘(6) IMPLEMENTATION.—To the extent that 

7 the Secretary contracts with an entity to carry out 

8 any part of the provisions of this subsection, the 

9 Secretary may not contract with an entity or an en10 tity with a subcontract if the entity or subcon11 tracting entity currently makes recommendations to 

12 the Secretary on relative values for services under 

13 the fee schedule for physicians’ services under this 

14 section. 

15 ‘‘(7) LIMITATION.—There shall be no adminis16 trative or judicial review under section 1869, section 

17 1878, or otherwise of— 

18 ‘‘(A) care episode and patient condition 

19 groups and codes established under paragraph 

20 (2); 

21 ‘‘(B) patient relationship categories and 

22 codes established under paragraph (3); and 

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1 tient condition codes and patient relationship 

2 codes pursuant to paragraph (5). 

3 ‘‘(8) ADMINISTRATION.—Chapter 35 of title 44, 

4 United States Code, shall not apply to this section. 

5 ‘‘(9) DEFINITIONS.—In this subsection: 

6 ‘‘(A) PHYSICIAN.—The term ‘physician’ 

7 has the meaning given such term in section 

8 1861(r)(1). 

9 ‘‘(B) APPLICABLE PRACTITIONER.—The 

10 term ‘applicable practitioner’ means— 

11 ‘‘(i) a physician assistant, nurse prac12 titioner, and clinical nurse specialist (as 

13 such terms are defined in section 

14 1861(aa)(5)), and a certified registered 

15 nurse anesthetist (as defined in section 

16 1861(bb)(2)); and 

17 ‘‘(ii) beginning January 1, 2019, such 

18 other eligible professionals (as defined in 

19 subsection (k)(3)(B)) as specified by the 

20 Secretary. 

21 ‘‘(10) CLARIFICATION.—The provisions of sec22 tions 1890(b)(7) and 1890A shall not apply to this 

23 subsection.’’. 


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1 SEC. 102. PRIORITIES AND FUNDING FOR MEASURE DEVEL2 OPMENT. 

3 Section 1848 of the Social Security Act (42 U.S.C. 

4 1395w–4), as amended by subsections (c) and (f) of sec5 tion 101, is further amended by inserting at the end the 

6 following new subsection: 

7 ‘‘(s) PRIORITIES AND FUNDING FOR MEASURE DE8 VELOPMENT.— 

9 ‘‘(1) PLAN IDENTIFYING MEASURE DEVELOP10 MENT PRIORITIES AND TIMELINES.— 

11 ‘‘(A) DRAFT MEASURE DEVELOPMENT

12 PLAN.—Not later than January 1, 2016, the 

13 Secretary shall develop, and post on the Inter14 net website of the Centers for Medicare & Med15 icaid Services, a draft plan for the development 

16 of quality measures for application under the 

17 applicable provisions (as defined in paragraph 

18 (5)). Under such plan the Secretary shall— 

19 ‘‘(i) address how measures used by 

20 private payers and integrated delivery sys21 tems could be incorporated under title 

22 XVIII; 

23 ‘‘(ii) describe how coordination, to the 

24 extent possible, will occur across organiza25 tions developing such measures; and 


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1 ‘‘(iii) take into account how clinical 

2 best practices and clinical practice guide3 lines should be used in the development of 

4 quality measures. 

5 ‘‘(B) QUALITY DOMAINS.—For purposes of 

6 this subsection, the term ‘quality domains’ 

7 means at least the following domains: 

8 ‘‘(i) Clinical care. 

9 ‘‘(ii) Safety. 

10 ‘‘(iii) Care coordination. 

11 ‘‘(iv) Patient and caregiver experience. 

12 ‘‘(v) Population health and preven13 tion. 

14 ‘‘(C) CONSIDERATION.—In developing the 

15 draft plan under this paragraph, the Secretary 

16 shall consider— 

17 ‘‘(i) gap analyses conducted by the en18 tity with a contract under section 1890(a) 

19 or other contractors or entities; 

20 ‘‘(ii) whether measures are applicable 

21 across health care settings; 

22 ‘‘(iii) clinical practice improvement ac23 tivities submitted under subsection 

24 (q)(2)(C)(iv) for identifying possible areas 

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1 fying existing gaps with respect to such 

2 measures; and 

3 ‘‘(iv) the quality domains applied 

4 under this subsection. 

5 ‘‘(D) PRIORITIES.—In developing the draft 

6 plan under this paragraph, the Secretary shall 

7 give priority to the following types of measures: 

8 ‘‘(i) Outcome measures, including pa9 tient reported outcome and functional sta10 tus measures. 

11 ‘‘(ii) Patient experience measures. 

12 ‘‘(iii) Care coordination measures. 

13 ‘‘(iv) Measures of appropriate use of 

14 services, including measures of over use. 

15 ‘‘(E) STAKEHOLDER INPUT.—The Sec16 retary shall accept through March 1, 2016, 

17 comments on the draft plan posted under para18 graph (1)(A) from the public, including health 

19 care providers, payers, consumers, and other 

20 stakeholders. 

21 ‘‘(F) FINAL MEASURE DEVELOPMENT

22 PLAN.—Not later than May 1, 2016, taking 

23 into account the comments received under this 

24 subparagraph, the Secretary shall finalize the 

25 plan and post on the Internet website of the 


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1 Centers for Medicare & Medicaid Services an 

2 operational plan for the development of quality 

3 measures for use under the applicable provi4 sions. Such plan shall be updated as appro5 priate. 

6 ‘‘(2) CONTRACTS AND OTHER ARRANGEMENTS

7 FOR QUALITY MEASURE DEVELOPMENT.— 

8 ‘‘(A) IN GENERAL.—The Secretary shall 

9 enter into contracts or other arrangements with 

10 entities for the purpose of developing, improv11 ing, updating, or expanding in accordance with 

12 the plan under paragraph (1) quality measures 

13 for application under the applicable provisions. 

14 Such entities shall include organizations with 

15 quality measure development expertise. 

16 ‘‘(B) PRIORITIZATION.— 

17 ‘‘(i) IN GENERAL.—In entering into 

18 contracts or other arrangements under 

19 subparagraph (A), the Secretary shall give 

20 priority to the development of the types of 

21 measures described in paragraph (1)(D). 

22 ‘‘(ii) CONSIDERATION.—In selecting 

23 measures for development under this sub24 section, the Secretary shall consider— 


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1 ‘‘(I) whether such measures 

2 would be electronically specified; and 

3 ‘‘(II) clinical practice guidelines 

4 to the extent that such guidelines 

5 exist. 

6 ‘‘(3) ANNUAL REPORT BY THE SECRETARY.— 

7 ‘‘(A) IN GENERAL.—Not later than May 1, 

8 2017, and annually thereafter, the Secretary 

9 shall post on the Internet website of the Cen10 ters for Medicare & Medicaid Services a report 

11 on the progress made in developing quality 

12 measures for application under the applicable 

13 provisions. 

14 ‘‘(B) REQUIREMENTS.—Each report sub15 mitted pursuant to subparagraph (A) shall in16 clude the following: 

17 ‘‘(i) A description of the Secretary’s 

18 efforts to implement this paragraph. 

19 ‘‘(ii) With respect to the measures de20 veloped during the previous year— 

21 ‘‘(I) a description of the total 

22 number of quality measures developed 

23 and the types of such measures, such 

24 as an outcome or patient experience 

25 measure; 


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1 ‘‘(II) the name of each measure 

2 developed; 

3 ‘‘(III) the name of the developer 

4 and steward of each measure; 

5 ‘‘(IV) with respect to each type 

6 of measure, an estimate of the total 

7 amount expended under this title to 

8 develop all measures of such type; and 

9 ‘‘(V) whether the measure would 

10 be electronically specified. 

11 ‘‘(iii) With respect to measures in de12 velopment at the time of the report— 

13 ‘‘(I) the information described in 

14 clause (ii), if available; and 

15 ‘‘(II) a timeline for completion of 

16 the development of such measures. 

17 ‘‘(iv) A description of any updates to 

18 the plan under paragraph (1) (including 

19 newly identified gaps and the status of pre20 viously identified gaps) and the inventory 

21 of measures applicable under the applicable 

22 provisions. 

23 ‘‘(v) Other information the Secretary 

24 determines to be appropriate. 


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1 ‘‘(4) STAKEHOLDER INPUT.—With respect to 

2 paragraph (1), the Secretary shall seek stakeholder 

3 input with respect to— 

4 ‘‘(A) the identification of gaps where no 

5 quality measures exist, particularly with respect 

6 to the types of measures described in paragraph 

7 (1)(D); 

8 ‘‘(B) prioritizing quality measure develop9 ment to address such gaps; and 

10 ‘‘(C) other areas related to quality measure 

11 development determined appropriate by the Sec12 retary. 

13 ‘‘(5) DEFINITION OF APPLICABLE PROVI14 SIONS.—In this subsection, the term ‘applicable pro15 visions’ means the following provisions: 

16 ‘‘(A) Subsection (q)(2)(B)(i). 

17 ‘‘(B) Section 1833(z)(2)(C). 

18 ‘‘(6) FUNDING.—For purposes of carrying out 

19 this subsection, the Secretary shall provide for the 

20 transfer, from the Federal Supplementary Medical 

21 Insurance Trust Fund under section 1841, of 

22 $15,000,000 to the Centers for Medicare & Medicaid 

23 Services Program Management Account for each of 

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1 ferred under this paragraph shall remain available 

2 through the end of fiscal year 2022. 

3 ‘‘(7) ADMINISTRATION.—Chapter 35 of title 44, 

4 United States Code, shall not apply to the collection 

5 of information for the development of quality meas6 ures.’’. 

7 SEC. 103. ENCOURAGING CARE MANAGEMENT FOR INDI8 VIDUALS WITH CHRONIC CARE NEEDS. 

9 (a) IN GENERAL.—Section 1848(b) of the Social Se10 curity Act (42 U.S.C. 1395w–4(b)) is amended by adding 

11 at the end the following new paragraph: 

12 ‘‘(8) ENCOURAGING CARE MANAGEMENT FOR

13 INDIVIDUALS WITH CHRONIC CARE NEEDS.— 

14 ‘‘(A) IN GENERAL.—In order to encourage 

15 the management of care for individuals with 

16 chronic care needs the Secretary shall, subject 

17 to subparagraph (B), make payment (as the 

18 Secretary determines to be appropriate) under 

19 this section for chronic care management serv20 ices furnished on or after January 1, 2015, by 

21 a physician (as defined in section 1861(r)(1)), 

22 physician assistant or nurse practitioner (as de23 fined in section 1861(aa)(5)(A)), clinical nurse 

24 specialist (as defined in section 


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1 1861(aa)(5)(B)), or certified nurse midwife (as 

2 defined in section 1861(gg)(2)). 

3 ‘‘(B) POLICIES RELATING TO PAYMENT.— 

4 In carrying out this paragraph, with respect to 

5 chronic care management services, the Sec6 retary shall— 

7 ‘‘(i) make payment to only one appli8 cable provider for such services furnished 

9 to an individual during a period; 

10 ‘‘(ii) not make payment under sub11 paragraph (A) if such payment would be 

12 duplicative of payment that is otherwise 

13 made under this title for such services; and 

14 ‘‘(iii) not require that an annual 

15 wellness visit (as defined in section 

16 1861(hhh)) or an initial preventive phys17 ical examination (as defined in section 

18 1861(ww)) be furnished as a condition of 

19 payment for such management services.’’. 

20 (b) EDUCATION AND OUTREACH.— 

21 (1) CAMPAIGN.— 

22 (A) IN GENERAL.—The Secretary of 

23 Health and Human Services (in this subsection 

24 referred to as the ‘‘Secretary’’) shall conduct an 

25 education and outreach campaign to inform 


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1 professionals who furnish items and services 

2 under part B of title XVIII of the Social Secu3 rity Act and individuals enrolled under such 

4 part of the benefits of chronic care management 

5 services described in section 1848(b)(8) of the 

6 Social Security Act, as added by subsection (a), 

7 and encourage such individuals with chronic 

8 care needs to receive such services. 

9 (B) REQUIREMENTS.—Such campaign 

10 shall— 

11 (i) be directed by the Office of Rural 

12 Health Policy of the Department of Health 

13 and Human Services and the Office of Mi14 nority Health of the Centers for Medicare 

15 & Medicaid Services; and 

16 (ii) focus on encouraging participation 

17 by underserved rural populations and ra18 cial and ethnic minority populations. 

19 (2) REPORT.—Not later than December 31, 

20 2017, the Secretary shall submit to Congress a re21 port on the use of chronic care management services 

22 described in such section 1848(b)(8) by individuals 

23 living in rural areas and by racial and ethnic minor24 ity populations. Such report shall— 


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1 (A) identify barriers to receiving chronic 

2 care management services; and 

3 (B) make recommendations for increasing 

4 the appropriate use of chronic care manage5 ment services. 

6 SEC. 104. EMPOWERING BENEFICIARY CHOICES THROUGH 

7 CONTINUED ACCESS TO INFORMATION ON 

8 PHYSICIANS’ SERVICES. 

9 (a) IN GENERAL.—On an annual basis (beginning 

10 with 2015), the Secretary shall make publicly available, 

11 in an easily understandable format, information with re12 spect to physicians and, as appropriate, other eligible pro13 fessionals on items and services furnished to Medicare 

14 beneficiaries under title XVIII of the Social Security Act 

15 (42 U.S.C. 1395 et seq.). 

16 (b) TYPE AND MANNER OF INFORMATION.—The in17 formation made available under this section shall be simi18 lar to the type of information in the Medicare Provider 

19 Utilization and Payment Data: Physician and Other Sup20 plier Public Use File released by the Secretary with re21 spect to 2012 and shall be made available in a manner 

22 similar to the manner in which the information in such 

23 file is made available. 


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1 (c) REQUIREMENTS.—The information made avail2 able under this section shall include, at a minimum, the 

3 following: 

4 (1) Information on the number of services fur5 nished by the physician or other eligible professional 

6 under part B of title XVIII of the Social Security 

7 Act (42 U.S.C. 1395j et seq.), which may include in8 formation on the most frequent services furnished or 

9 groupings of services. 

10 (2) Information on submitted charges and pay11 ments for services under such part. 

12 (3) A unique identifier for the physician or 

13 other eligible professional that is available to the 

14 public, such as a national provider identifier. 

15 (d) SEARCHABILITY.—The information made avail16 able under this section shall be searchable by at least the 

17 following: 

18 (1) The specialty or type of the physician or 

19 other eligible professional. 

20 (2) Characteristics of the services furnished, 

21 such as volume or groupings of services. 

22 (3) The location of the physician or other eligi23 ble professional. 

24 (e) INTEGRATION ON PHYSICIAN COMPARE.—Begin25 ning with 2016, the Secretary shall integrate the informaVerDate Sep 11 2014 21:09 Mar 27, 2015 Jkt 049200 PO 00000 Frm 00131 Fmt 6652 Sfmt 6201 E:\BILLS\H2.RDS H2

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1 tion made available under this section on Physician Com2 pare. 

3 (f) DEFINITIONS.—In this section: 

4 (1) ELIGIBLE PROFESSIONAL; PHYSICIAN; SEC5 RETARY.—The terms ‘‘eligible professional’’, ‘‘physi6 cian’’, and ‘‘Secretary’’ have the meaning given such 

7 terms in section 10331(i) of Public Law 111–148. 

8 (2) PHYSICIAN COMPARE.—The term ‘‘Physi9 cian Compare’’ means the Physician Compare Inter10 net website of the Centers for Medicare & Medicaid 

11 Services (or a successor website). 

12 SEC. 105. EXPANDING AVAILABILITY OF MEDICARE DATA. 

13 (a) EXPANDING USES OF MEDICARE DATA BY

14 QUALIFIED ENTITIES.— 

15 (1) ADDITIONAL ANALYSES.— 

16 (A) IN GENERAL.—Subject to subpara17 graph (B), to the extent consistent with appli18 cable information, privacy, security, and disclo19 sure laws (including paragraph (3)), notwith20 standing paragraph (4)(B) of section 1874(e) of 

21 the Social Security Act (42 U.S.C. 1395kk(e)) 

22 and the second sentence of paragraph (4)(D) of 

23 such section, beginning July 1, 2016, a quali24 fied entity may use the combined data described 

25 in paragraph (4)(B)(iii) of such section received 


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1 by such entity under such section, and informa2 tion derived from the evaluation described in 

3 such paragraph (4)(D), to conduct additional 

4 non-public analyses (as determined appropriate 

5 by the Secretary) and provide or sell such anal6 yses to authorized users for non-public use (in7 cluding for the purposes of assisting providers 

8 of services and suppliers to develop and partici9 pate in quality and patient care improvement 

10 activities, including developing new models of 

11 care). 

12 (B) LIMITATIONS WITH RESPECT TO ANAL13 YSES.— 

14 (i) EMPLOYERS.—Any analyses pro15 vided or sold under subparagraph (A) to 

16 an employer described in paragraph 

17 (9)(A)(iii) may only be used by such em18 ployer for purposes of providing health in19 surance to employees and retirees of the 

20 employer. 

21 (ii) HEALTH INSURANCE ISSUERS.—A 

22 qualified entity may not provide or sell an 

23 analysis to a health insurance issuer de24 scribed in paragraph (9)(A)(iv) unless the 

25 issuer is providing the qualified entity with 


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1 data under section 1874(e)(4)(B)(iii) of 

2 the Social Security Act (42 U.S.C. 

3 1395kk(e)(4)(B)(iii)). 

4 (2) ACCESS TO CERTAIN DATA.— 

5 (A) ACCESS.—To the extent consistent 

6 with applicable information, privacy, security, 

7 and disclosure laws (including paragraph (3)), 

8 notwithstanding paragraph (4)(B) of section 

9 1874(e) of the Social Security Act (42 U.S.C. 

10 1395kk(e)) and the second sentence of para11 graph (4)(D) of such section, beginning July 1, 

12 2016, a qualified entity may— 

13 (i) provide or sell the combined data 

14 described in paragraph (4)(B)(iii) of such 

15 section to authorized users described in 

16 clauses (i), (ii), and (v) of paragraph 

17 (9)(A) for non-public use, including for the 

18 purposes described in subparagraph (B); 

19 or 

20 (ii) subject to subparagraph (C), pro21 vide Medicare claims data to authorized 

22 users described in clauses (i), (ii), and (v), 

23 of paragraph (9)(A) for non-public use, in24 cluding for the purposes described in sub25 paragraph (B). 


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1 (B) PURPOSES DESCRIBED.—The purposes 

2 described in this subparagraph are assisting 

3 providers of services and suppliers in developing 

4 and participating in quality and patient care 

5 improvement activities, including developing 

6 new models of care. 

7 (C) MEDICARE CLAIMS DATA MUST BE

8 PROVIDED AT NO COST.—A qualified entity may 

9 not charge a fee for providing the data under 

10 subparagraph (A)(ii). 

11 (3) PROTECTION OF INFORMATION.— 

12 (A) IN GENERAL.—Except as provided in 

13 subparagraph (B), an analysis or data that is 

14 provided or sold under paragraph (1) or (2) 

15 shall not contain information that individually 

16 identifies a patient. 

17 (B) INFORMATION ON PATIENTS OF THE

18 PROVIDER OF SERVICES OR SUPPLIER.—To the 

19 extent consistent with applicable information, 

20 privacy, security, and disclosure laws, an anal21 ysis or data that is provided or sold to a pro22 vider of services or supplier under paragraph 

23 (1) or (2) may contain information that individ24 ually identifies a patient of such provider or 

25 supplier, including with respect to items and 


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1 services furnished to the patient by other pro2 viders of services or suppliers. 

3 (C) PROHIBITION ON USING ANALYSES OR

4 DATA FOR MARKETING PURPOSES.—An author5 ized user shall not use an analysis or data pro6 vided or sold under paragraph (1) or (2) for 

7 marketing purposes. 

8 (4) DATA USE AGREEMENT.—A qualified entity 

9 and an authorized user described in clauses (i), (ii), 

10 and (v) of paragraph (9)(A) shall enter into an 

11 agreement regarding the use of any data that the 

12 qualified entity is providing or selling to the author13 ized user under paragraph (2). Such agreement shall 

14 describe the requirements for privacy and security of 

15 the data and, as determined appropriate by the Sec16 retary, any prohibitions on using such data to link 

17 to other individually identifiable sources of informa18 tion. If the authorized user is not a covered entity 

19 under the rules promulgated pursuant to the Health 

20 Insurance Portability and Accountability Act of 

21 1996, the agreement shall identify the relevant regu22 lations, as determined by the Secretary, that the 

23 user shall comply with as if it were acting in the ca24 pacity of such a covered entity. 


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1 (5) NO REDISCLOSURE OF ANALYSES OR

2 DATA.— 

3 (A) IN GENERAL.—Except as provided in 

4 subparagraph (B), an authorized user that is 

5 provided or sold an analysis or data under 

6 paragraph (1) or (2) shall not redisclose or 

7 make public such analysis or data or any anal8 ysis using such data. 

9 (B) PERMITTED REDISCLOSURE.—A pro10 vider of services or supplier that is provided or 

11 sold an analysis or data under paragraph (1) or 

12 (2) may, as determined by the Secretary, redis13 close such analysis or data for the purposes of 

14 performance improvement and care coordination 

15 activities but shall not make public such anal16 ysis or data or any analysis using such data. 

17 (6) OPPORTUNITY FOR PROVIDERS OF SERV18 ICES AND SUPPLIERS TO REVIEW.—Prior to a quali19 fied entity providing or selling an analysis to an au20 thorized user under paragraph (1), to the extent 

21 that such analysis would individually identify a pro22 vider of services or supplier who is not being pro23 vided or sold such analysis, such qualified entity 

24 shall provide such provider or supplier with the op25 portunity to appeal and correct errors in the manner 


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1 described in section 1874(e)(4)(C)(ii) of the Social 

2 Security Act (42 U.S.C. 1395kk(e)(4)(C)(ii)). 

3 (7) ASSESSMENT FOR A BREACH.— 

4 (A) IN GENERAL.—In the case of a breach 

5 of a data use agreement under this section or 

6 section 1874(e) of the Social Security Act (42 

7 U.S.C. 1395kk(e)), the Secretary shall impose 

8 an assessment on the qualified entity both in 

9 the case of— 

10 (i) an agreement between the Sec11 retary and a qualified entity; and 

12 (ii) an agreement between a qualified 

13 entity and an authorized user. 

14 (B) ASSESSMENT.—The assessment under 

15 subparagraph (A) shall be an amount up to 

16 $100 for each individual entitled to, or enrolled 

17 for, benefits under part A of title XVIII of the 

18 Social Security Act or enrolled for benefits 

19 under part B of such title— 

20 (i) in the case of an agreement de21 scribed in subparagraph (A)(i), for whom 

22 the Secretary provided data on to the 

23 qualified entity under paragraph (2); and 

24 (ii) in the case of an agreement de25 scribed in subparagraph (A)(ii), for whom 


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1 the qualified entity provided data on to the 

2 authorized user under paragraph (2). 

3 (C) DEPOSIT OF AMOUNTS COLLECTED.— 

4 Any amounts collected pursuant to this para5 graph shall be deposited in Federal Supple6 mentary Medical Insurance Trust Fund under 

7 section 1841 of the Social Security Act (42 

8 U.S.C. 1395t). 

9 (8) ANNUAL REPORTS.—Any qualified entity 

10 that provides or sells an analysis or data under 

11 paragraph (1) or (2) shall annually submit to the 

12 Secretary a report that includes— 

13 (A) a summary of the analyses provided or 

14 sold, including the number of such analyses, the 

15 number of purchasers of such analyses, and the 

16 total amount of fees received for such analyses; 

17 (B) a description of the topics and pur18 poses of such analyses; 

19 (C) information on the entities who re20 ceived the data under paragraph (2), the uses 

21 of the data, and the total amount of fees re22 ceived for providing, selling, or sharing the 

23 data; and 

24 (D) other information determined appro25 priate by the Secretary. 


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1 (9) DEFINITIONS.—In this subsection and sub2 section (b): 

3 (A) AUTHORIZED USER.—The term ‘‘au4 thorized user’’ means the following: 

5 (i) A provider of services. 

6 (ii) A supplier. 

7 (iii) An employer (as defined in sec8 tion 3(5) of the Employee Retirement In9 surance Security Act of 1974). 

10 (iv) A health insurance issuer (as de11 fined in section 2791 of the Public Health 

12 Service Act). 

13 (v) A medical society or hospital asso14 ciation. 

15 (vi) Any entity not described in 

16 clauses (i) through (v) that is approved by 

17 the Secretary (other than an employer or 

18 health insurance issuer not described in 

19 clauses (iii) and (iv), respectively, as deter20 mined by the Secretary). 

21 (B) PROVIDER OF SERVICES.—The term 

22 ‘‘provider of services’’ has the meaning given 

23 such term in section 1861(u) of the Social Se24 curity Act (42 U.S.C. 1395x(u)). 


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1 (C) QUALIFIED ENTITY.—The term ‘‘quali2 fied entity’’ has the meaning given such term in 

3 section 1874(e)(2) of the Social Security Act 

4 (42 U.S.C. 1395kk(e)). 

5 (D) SECRETARY.—The term ‘‘Secretary’’ 

6 means the Secretary of Health and Human 

7 Services. 

8 (E) SUPPLIER.—The term ‘‘supplier’’ has 

9 the meaning given such term in section 1861(d) 

10 of the Social Security Act (42 U.S.C. 

11 1395x(d)). 

12 (b) ACCESS TO MEDICARE DATA BY QUALIFIED

13 CLINICAL DATA REGISTRIES TO FACILITATE QUALITY

14 IMPROVEMENT.— 

15 (1) ACCESS.— 

16 (A) IN GENERAL.—To the extent con17 sistent with applicable information, privacy, se18 curity, and disclosure laws, beginning July 1, 

19 2016, the Secretary shall, at the request of a 

20 qualified clinical data registry under section 

21 1848(m)(3)(E) of the Social Security Act (42 

22 U.S.C. 1395w–4(m)(3)(E)), provide the data 

23 described in subparagraph (B) (in a form and 

24 manner determined to be appropriate) to such 

25 qualified clinical data registry for purposes of 


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1 linking such data with clinical outcomes data 

2 and performing risk-adjusted, scientifically valid 

3 analyses and research to support quality im4 provement or patient safety, provided that any 

5 public reporting of such analyses or research 

6 that identifies a provider of services or supplier 

7 shall only be conducted with the opportunity of 

8 such provider or supplier to appeal and correct 

9 errors in the manner described in subsection 

10 (a)(6). 

11 (B) DATA DESCRIBED.—The data de12 scribed in this subparagraph is— 

13 (i) claims data under the Medicare 

14 program under title XVIII of the Social 

15 Security Act; and 

16 (ii) if the Secretary determines appro17 priate, claims data under the Medicaid 

18 program under title XIX of such Act and 

19 the State Children’s Health Insurance Pro20 gram under title XXI of such Act. 

21 (2) FEE.—Data described in paragraph (1)(B) 

22 shall be provided to a qualified clinical data registry 

23 under paragraph (1) at a fee equal to the cost of 

24 providing such data. Any fee collected pursuant to 

25 the preceding sentence shall be deposited in the CenVerDate Sep 11 2014 21:09 Mar 27, 2015 Jkt 049200 PO 00000 Frm 00142 Fmt 6652 Sfmt 6201 E:\BILLS\H2.RDS H2

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1 ters for Medicare & Medicaid Services Program 

2 Management Account. 

3 (c) EXPANSION OF DATA AVAILABLE TO QUALIFIED

4 ENTITIES.—Section 1874(e) of the Social Security Act 

5 (42 U.S.C. 1395kk(e)) is amended— 

6 (1) in the subsection heading, by striking 

7 ‘‘MEDICARE’’; and 

8 (2) in paragraph (3)— 

9 (A) by inserting after the first sentence the 

10 following new sentence: ‘‘Beginning July 1, 

11 2016, if the Secretary determines appropriate, 

12 the data described in this paragraph may also 

13 include standardized extracts (as determined by 

14 the Secretary) of claims data under titles XIX 

15 and XXI for assistance provided under such ti16 tles for one or more specified geographic areas 

17 and time periods requested by a qualified enti18 ty.’’; and 

19 (B) in the last sentence, by inserting ‘‘or 

20 under titles XIX or XXI’’ before the period at 

21 the end. 

22 (d) REVISION OF PLACEMENT OF FEES.—Section 

23 1874(e)(4)(A) of the Social Security Act (42 U.S.C. 

24 1395kk(e)(4)(A)) is amended, in the second sentence— 


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1 (1) by inserting ‘‘, for periods prior to July 1, 

2 2016,’’ after ‘‘deposited’’; and 

3 (2) by inserting the following before the period 

4 at the end: ‘‘, and, beginning July 1, 2016, into the 

5 Centers for Medicare & Medicaid Services Program 

6 Management Account’’. 

7 SEC. 106. REDUCING ADMINISTRATIVE BURDEN AND 

8 OTHER PROVISIONS. 

9 (a) MEDICARE PHYSICIAN AND PRACTITIONER OPT10 OUT TO PRIVATE CONTRACT.— 

11 (1) INDEFINITE, CONTINUING AUTOMATIC EX12 TENSION OF OPT OUT ELECTION.— 

13 (A) IN GENERAL.—Section 1802(b)(3) of 

14 the Social Security Act (42 U.S.C. 1395a(b)(3)) 

15 is amended— 

16 (i) in subparagraph (B)(ii), by strik17 ing ‘‘during the 2-year period beginning on 

18 the date the affidavit is signed’’ and insert19 ing ‘‘during the applicable 2-year period 

20 (as defined in subparagraph (D))’’; 

21 (ii) in subparagraph (C), by striking 

22 ‘‘during the 2-year period described in sub23 paragraph (B)(ii)’’ and inserting ‘‘during 

24 the applicable 2-year period’’; and 


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1 (iii) by adding at the end the fol2 lowing new subparagraph: 

3 ‘‘(D) APPLICABLE 2-YEAR PERIODS FOR

4 EFFECTIVENESS OF AFFIDAVITS.—In this sub5 section, the term ‘applicable 2-year period’ 

6 means, with respect to an affidavit of a physi7 cian or practitioner under subparagraph (B), 

8 the 2-year period beginning on the date the af9 fidavit is signed and includes each subsequent 

10 2-year period unless the physician or practi11 tioner involved provides notice to the Secretary 

12 (in a form and manner specified by the Sec13 retary), not later than 30 days before the end 

14 of the previous 2-year period, that the physician 

15 or practitioner does not want to extend the ap16 plication of the affidavit for such subsequent 2- 

17 year period.’’. 

18 (B) EFFECTIVE DATE.—The amendments 

19 made by subparagraph (A) shall apply to affi20 davits entered into on or after the date that is 

21 60 days after the date of the enactment of this 

22 Act. 

23 (2) PUBLIC AVAILABILITY OF INFORMATION ON

24 OPT-OUT PHYSICIANS AND PRACTITIONERS.—Section 


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1 1802(b) of the Social Security Act (42 U.S.C. 

2 1395a(b)) is amended— 

3 (A) in paragraph (5), by adding at the end 

4 the following new subparagraph: 

5 ‘‘(D) OPT-OUT PHYSICIAN OR PRACTITIONER.— 

6 The term ‘opt-out physician or practitioner’ means 

7 a physician or practitioner who has in effect an affi8 davit under paragraph (3)(B).’’; 

9 (B) by redesignating paragraph (5) as 

10 paragraph (6); and 

11 (C) by inserting after paragraph (4) the 

12 following new paragraph: 

13 ‘‘(5) POSTING OF INFORMATION ON OPT-OUT

14 PHYSICIANS AND PRACTITIONERS.— 

15 ‘‘(A) IN GENERAL.—Beginning not later 

16 than February 1, 2016, the Secretary shall 

17 make publicly available through an appropriate 

18 publicly accessible website of the Department of 

19 Health and Human Services information on the 

20 number and characteristics of opt-out physi21 cians and practitioners and shall update such 

22 information on such website not less often than 

23 annually. 

24 ‘‘(B) INFORMATION TO BE INCLUDED.— 

25 The information to be made available under 


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1 subparagraph (A) shall include at least the fol2 lowing with respect to opt-out physicians and 

3 practitioners: 

4 ‘‘(i) Their number. 

5 ‘‘(ii) Their physician or professional 

6 specialty or other designation. 

7 ‘‘(iii) Their geographic distribution. 

8 ‘‘(iv) The timing of their becoming 

9 opt-out physicians and practitioners, rel10 ative, to the extent feasible, to when they 

11 first enrolled in the program under this 

12 title and with respect to applicable 2-year 

13 periods. 

14 ‘‘(v) The proportion of such physi15 cians and practitioners who billed for 

16 emergency or urgent care services.’’. 

17 (b) PROMOTING INTEROPERABILITY OF ELECTRONIC

18 HEALTH RECORD SYSTEMS.— 

19 (1) RECOMMENDATIONS FOR ACHIEVING WIDE20 SPREAD EHR INTEROPERABILITY.— 

21 (A) OBJECTIVE.—As a consequence of a 

22 significant Federal investment in the implemen23 tation of health information technology through 

24 the Medicare and Medicaid EHR incentive pro25 grams, Congress declares it a national objective 


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1 to achieve widespread exchange of health infor2 mation through interoperable certified EHR 

3 technology nationwide by December 31, 2018. 

4 (B) DEFINITIONS.—In this paragraph: 

5 (i) WIDESPREAD INTEROPER6 ABILITY.—The term ‘‘widespread inter7 operability’’ means interoperability between 

8 certified EHR technology systems em9 ployed by meaningful EHR users under 

10 the Medicare and Medicaid EHR incentive 

11 programs and other clinicians and health 

12 care providers on a nationwide basis. 

13 (ii) INTEROPERABILITY.—The term 

14 ‘‘interoperability’’ means the ability of two 

15 or more health information systems or 

16 components to exchange clinical and other 

17 information and to use the information 

18 that has been exchanged using common 

19 standards as to provide access to longitu20 dinal information for health care providers 

21 in order to facilitate coordinated care and 

22 improved patient outcomes. 

23 (C) ESTABLISHMENT OF METRICS.—Not 

24 later than July 1, 2016, and in consultation 

25 with stakeholders, the Secretary shall establish 


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1 metrics to be used to determine if and to the 

2 extent that the objective described in subpara3 graph (A) has been achieved. 

4 (D) RECOMMENDATIONS IF OBJECTIVE

5 NOT ACHIEVED.—If the Secretary of Health 

6 and Human Services determines that the objec7 tive described in subparagraph (A) has not been 

8 achieved by December 31, 2018, then the Sec9 retary shall submit to Congress a report, by not 

10 later than December 31, 2019, that identifies 

11 barriers to such objective and recommends ac12 tions that the Federal Government can take to 

13 achieve such objective. Such recommended ac14 tions may include recommendations— 

15 (i) to adjust payments for not being 

16 meaningful EHR users under the Medicare 

17 EHR incentive programs; and 

18 (ii) for criteria for decertifying cer19 tified EHR technology products. 

20 (2) PREVENTING BLOCKING THE SHARING OF

21 INFORMATION.— 

22 (A) FOR MEANINGFUL USE EHR PROFES23 SIONALS.—Section 1848(o)(2)(A)(ii) of the So24 cial Security Act (42 U.S.C. 1395w– 

25 4(o)(2)(A)(ii)) is amended by inserting before 


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1 the period at the end the following: ‘‘, and the 

2 professional demonstrates (through a process 

3 specified by the Secretary, such as the use of an 

4 attestation) that the professional has not know5 ingly and willfully taken action (such as to dis6 able functionality) to limit or restrict the com7 patibility or interoperability of the certified 

8 EHR technology’’. 

9 (B) FOR MEANINGFUL USE EHR HOS10 PITALS.—Section 1886(n)(3)(A)(ii) of the So11 cial Security Act (42 U.S.C. 

12 1395ww(n)(3)(A)(ii)) is amended by inserting 

13 before the period at the end the following: ‘‘, 

14 and the hospital demonstrates (through a proc15 ess specified by the Secretary, such as the use 

16 of an attestation) that the hospital has not 

17 knowingly and willfully taken action (such as to 

18 disable functionality) to limit or restrict the 

19 compatibility or interoperability of the certified 

20 EHR technology’’. 

21 (C) EFFECTIVE DATE.—The amendments 

22 made by this subsection shall apply to meaning23 ful EHR users as of the date that is one year 

24 after the date of the enactment of this Act. 


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1 (3) STUDY AND REPORT ON THE FEASIBILITY

2 OF ESTABLISHING A MECHANISM TO COMPARE CER3 TIFIED EHR TECHNOLOGY PRODUCTS.— 

4 (A) STUDY.—The Secretary shall conduct 

5 a study to examine the feasibility of estab6 lishing one or more mechanisms to assist pro7 viders in comparing and selecting certified 

8 EHR technology products. Such mechanisms 

9 may include— 

10 (i) a website with aggregated results 

11 of surveys of meaningful EHR users on 

12 the functionality of certified EHR tech13 nology products to enable such users to di14 rectly compare the functionality and other 

15 features of such products; and 

16 (ii) information from vendors of cer17 tified products that is made publicly avail18 able in a standardized format. 

19 The aggregated results of the surveys described 

20 in clause (i) may be made available through 

21 contracts with physicians, hospitals, or other or22 ganizations that maintain such comparative in23 formation described in such clause. 

24 (B) REPORT.—Not later than 1 year after 

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1 retary shall submit to Congress a report on 

2 mechanisms that would assist providers in com3 paring and selecting certified EHR technology 

4 products. The report shall include information 

5 on the benefits of, and resources needed to de6 velop and maintain, such mechanisms. 

7 (4) DEFINITIONS.—In this subsection: 

8 (A) The term ‘‘certified EHR technology’’ 

9 has the meaning given such term in section 

10 1848(o)(4) of the Social Security Act (42 

11 U.S.C. 1395w–4(o)(4)). 

12 (B) The term ‘‘meaningful EHR user’’ has 

13 the meaning given such term under the Medi14 care EHR incentive programs. 

15 (C) The term ‘‘Medicare and Medicaid 

16 EHR incentive programs’’ means— 

17 (i) in the case of the Medicare pro18 gram under title XVIII of the Social Secu19 rity Act, the incentive programs under sec20 tion 1814(l)(3), section 1848(o), sub21 sections (l) and (m) of section 1853, and 

22 section 1886(n) of the Social Security Act 

23 (42 U.S.C. 1395f(l)(3), 1395w–4(o), 

24 1395w–23, 1395ww(n)); and 


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1 (ii) in the case of the Medicaid pro2 gram under title XIX of such Act, the in3 centive program under subsections 

4 (a)(3)(F) and (t) of section 1903 of such 

5 Act (42 U.S.C. 1396b). 

6 (D) The term ‘‘Secretary’’ means the Sec7 retary of Health and Human Services. 

8 (c) GAO STUDIES AND REPORTS ON THE USE OF

9 TELEHEALTH UNDER FEDERAL PROGRAMS AND ON RE10 MOTE PATIENT MONITORING SERVICES.— 

11 (1) STUDY ON TELEHEALTH SERVICES.—The 

12 Comptroller General of the United States shall con13 duct a study on the following: 

14 (A) How the definition of telehealth across 

15 various Federal programs and Federal efforts 

16 can inform the use of telehealth in the Medicare 

17 program under title XVIII of the Social Secu18 rity Act (42 U.S.C. 1395 et seq.). 

19 (B) Issues that can facilitate or inhibit the 

20 use of telehealth under the Medicare program 

21 under such title, including oversight and profes22 sional licensure, changing technology, privacy 

23 and security, infrastructure requirements, and 

24 varying needs across urban and rural areas. 


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1 (C) Potential implications of greater use of 

2 telehealth with respect to payment and delivery 

3 system transformations under the Medicare 

4 program under such title XVIII and the Med5 icaid program under title XIX of such Act (42 

6 U.S.C. 1396 et seq.). 

7 (D) How the Centers for Medicare & Med8 icaid Services monitors payments made under 

9 the Medicare program under such title XVIII to 

10 providers for telehealth services. 

11 (2) STUDY ON REMOTE PATIENT MONITORING

12 SERVICES.— 

13 (A) IN GENERAL.—The Comptroller Gen14 eral of the United States shall conduct a 

15 study— 

16 (i) of the dissemination of remote pa17 tient monitoring technology in the private 

18 health insurance market; 

19 (ii) of the financial incentives in the 

20 private health insurance market relating to 

21 adoption of such technology; 

22 (iii) of the barriers to adoption of 

23 such services under the Medicare program 

24 under title XVIII of the Social Security 

25 Act; 


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1 (iv) that evaluates the patients, condi2 tions, and clinical circumstances that could 

3 most benefit from remote patient moni4 toring services; and 

5 (v) that evaluates the challenges re6 lated to establishing appropriate valuation 

7 for remote patient monitoring services 

8 under the Medicare physician fee schedule 

9 under section 1848 of the Social Security 

10 Act (42 U.S.C. 1395w–4) in order to accu11 rately reflect the resources involved in fur12 nishing such services. 

13 (B) DEFINITIONS.—For purposes of this 

14 paragraph: 

15 (i) REMOTE PATIENT MONITORING

16 SERVICES.—The term ‘‘remote patient 

17 monitoring services’’ means services fur18 nished through remote patient monitoring 

19 technology. 

20 (ii) REMOTE PATIENT MONITORING

21 TECHNOLOGY.—The term ‘‘remote patient 

22 monitoring technology’’ means a coordi23 nated system that uses one or more home24 based or mobile monitoring devices that 

25 automatically transmit vital sign data or 


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1 information on activities of daily living and 

2 may include responses to assessment ques3 tions collected on the devices wirelessly or 

4 through a telecommunications connection 

5 to a server that complies with the Federal 

6 regulations (concerning the privacy of indi7 vidually identifiable health information) 

8 promulgated under section 264(c) of the 

9 Health Insurance Portability and Account10 ability Act of 1996, as part of an estab11 lished plan of care for that patient that in12 cludes the review and interpretation of that 

13 data by a health care professional. 

14 (3) REPORTS.—Not later than 24 months after 

15 the date of the enactment of this Act, the Comp16 troller General shall submit to Congress— 

17 (A) a report containing the results of the 

18 study conducted under paragraph (1); and 

19 (B) a report containing the results of the 

20 study conducted under paragraph (2). 

21 A report required under this paragraph shall be sub22 mitted together with recommendations for such leg23 islation and administrative action as the Comptroller 

24 General determines appropriate. The Comptroller 

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1 sults described in subparagraphs (A) and (B) and 

2 the recommendations described in the previous sen3 tence. 

4 (d) RULE OF CONSTRUCTION REGARDING HEALTH

5 CARE PROVIDERS.— 

6 (1) IN GENERAL.—Subject to paragraph (3), 

7 the development, recognition, or implementation of 

8 any guideline or other standard under any Federal 

9 health care provision shall not be construed to estab10 lish the standard of care or duty of care owed by a 

11 health care provider to a patient in any medical mal12 practice or medical product liability action or claim. 

13 (2) DEFINITIONS.—For purposes of this sub14 section: 

15 (A) FEDERAL HEALTH CARE PROVISION.— 

16 The term ‘‘Federal health care provision’’ 

17 means any provision of the Patient Protection 

18 and Affordable Care Act (Public Law 111– 

19 148), title I or subtitle B of title II of the 

20 Health Care and Education Reconciliation Act 

21 of 2010 (Public Law 111–152), or title XVIII 

22 or XIX of the Social Security Act (42 U.S.C. 

23 1395 et seq., 42 U.S.C. 1396 et seq.). 

24 (B) HEALTH CARE PROVIDER.—The term 

25 ‘‘health care provider’’ means any individual, 


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1 group practice, corporation of health care pro2 fessionals, or hospital— 

3 (i) licensed, registered, or certified 

4 under Federal or State laws or regulations 

5 to provide health care services; or 

6 (ii) required to be so licensed, reg7 istered, or certified but that is exempted 

8 by other statute or regulation. 

9 (C) MEDICAL MALPRACTICE OR MEDICAL

10 PRODUCT LIABILITY ACTION OR CLAIM.—The 

11 term ‘‘medical malpractice or medical product 

12 liability action or claim’’ means a medical mal13 practice action or claim (as defined in section 

14 431(7) of the Health Care Quality Improve15 ment Act of 1986 (42 U.S.C. 11151(7))) and 

16 includes a liability action or claim relating to a 

17 health care provider’s prescription or provision 

18 of a drug, device, or biological product (as such 

19 terms are defined in section 201 of the Federal 

20 Food, Drug, and Cosmetic Act (21 U.S.C. 321) 

21 or section 351 of the Public Health Service Act 

22 (42 U.S.C. 262)). 

23 (D) STATE.—The term ‘‘State’’ includes 

24 the District of Columbia, Puerto Rico, and any 


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1 other commonwealth, possession, or territory of 

2 the United States. 

3 (3) NO PREEMPTION.—Nothing in paragraph 

4 (1) or any provision of the Patient Protection and 

5 Affordable Care Act (Public Law 111–148), title I 

6 or subtitle B of title II of the Health Care and Edu7 cation Reconciliation Act of 2010 (Public Law 111– 

8 152), or title XVIII or XIX of the Social Security 

9 Act (42 U.S.C. 1395 et seq., 42 U.S.C. 1396 et 

10 seq.) shall be construed to preempt any State or 

11 common law governing medical professional or med12 ical product liability actions or claims. 

13 TITLE II—MEDICARE AND 

14 OTHER HEALTH EXTENDERS 

15 Subtitle A—Medicare Extenders 

16 SEC. 201. EXTENSION OF WORK GPCI FLOOR. 

17 Section 1848(e)(1)(E) of the Social Security Act (42 

18 U.S.C. 1395w–4(e)(1)(E)) is amended by striking ‘‘April 

19 1, 2015’’ and inserting ‘‘January 1, 2018’’. 

20 SEC. 202. EXTENSION OF THERAPY CAP EXCEPTIONS PROC21 ESS. 

22 (a) IN GENERAL.—Section 1833(g) of the Social Se23 curity Act (42 U.S.C. 1395l(g)) is amended— 


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1 (1) in paragraph (5)(A), in the first sentence, 

2 by striking ‘‘March 31, 2015’’ and inserting ‘‘De3 cember 31, 2017’’; and 

4 (2) in paragraph (6)(A)— 

5 (A) by striking ‘‘March 31, 2015’’ and in6 serting ‘‘December 31, 2017’’; and 

7 (B) by striking ‘‘2012, 2013, 2014, or the 

8 first three months of 2015’’ and inserting 

9 ‘‘2012 through 2017’’. 

10 (b) TARGETED REVIEWS UNDER MANUAL MEDICAL

11 REVIEW PROCESS FOR OUTPATIENT THERAPY SERV12 ICES.— 

13 (1) IN GENERAL.—Section 1833(g)(5) of the 

14 Social Security Act (42 U.S.C. 1395l(g)(5)) is 

15 amended— 

16 (A) in subparagraph (C)(i), by inserting ‘‘, 

17 subject to subparagraph (E),’’ after ‘‘manual 

18 medical review process that’’; and 

19 (B) by adding at the end the following new 

20 subparagraph: 

21 ‘‘(E)(i) In place of the manual medical review process 

22 under subparagraph (C)(i), the Secretary shall implement 

23 a process for medical review under this subparagraph 

24 under which the Secretary shall identify and conduct med25 ical review for services described in subparagraph (C)(i) 


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1 furnished by a provider of services or supplier (in this sub2 paragraph referred to as a ‘therapy provider’) using such 

3 factors as the Secretary determines to be appropriate. 

4 ‘‘(ii) Such factors may include the following: 

5 ‘‘(I) The therapy provider has had a high 

6 claims denial percentage for therapy services under 

7 this part or is less compliant with applicable require8 ments under this title. 

9 ‘‘(II) The therapy provider has a pattern of bill10 ing for therapy services under this part that is aber11 rant compared to peers or otherwise has question12 able billing practices for such services, such as bill13 ing medically unlikely units of services in a day. 

14 ‘‘(III) The therapy provider is newly enrolled 

15 under this title or has not previously furnished ther16 apy services under this part. 

17 ‘‘(IV) The services are furnished to treat a type 

18 of medical condition. 

19 ‘‘(V) The therapy provider is part of group that 

20 includes another therapy provider identified using 

21 the factors determined under this subparagraph. 

22 ‘‘(iii) For purposes of carrying out this subparagraph, 

23 the Secretary shall provide for the transfer, from the Fed24 eral Supplementary Medical Insurance Trust Fund under 

25 section 1841, of $5,000,000 to the Centers for Medicare 


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1 & Medicaid Services Program Management Account for 

2 fiscal years 2015 and 2016, to remain available until ex3 pended. Such funds may not be used by a contractor under 

4 section 1893(h) for medical reviews under this subpara5 graph. 

6 ‘‘(iv) The targeted review process under this subpara7 graph shall not apply to services for which expenses are 

8 incurred beyond the period for which the exceptions proc9 ess under subparagraph (A) is implemented.’’. 

10 (2) EFFECTIVE DATE.—The amendments made 

11 by this subsection shall apply with respect to re12 quests described in section 1833(g)(5)(C)(i) of the 

13 Social Security Act (42 U.S.C. 1395l(g)(5)(C)(i)) 

14 with respect to which the Secretary of Health and 

15 Human Services has not conducted medical review 

16 under such section by a date (not later than 90 days 

17 after the date of the enactment of this Act) specified 

18 by the Secretary. 

19 SEC. 203. EXTENSION OF AMBULANCE ADD-ONS. 

20 (a) GROUND AMBULANCE.—Section 1834(l)(13)(A) 

21 of the Social Security Act (42 U.S.C. 1395m(l)(13)(A)) 

22 is amended by striking ‘‘April 1, 2015’’ and inserting 

23 ‘‘January 1, 2018’’ each place it appears. 

24 (b) SUPER RURAL GROUND AMBULANCE.—Section 

25 1834(l)(12)(A) of the Social Security Act (42 U.S.C. 


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1 1395m(l)(12)(A)) is amended, in the first sentence, by 

2 striking ‘‘April 1, 2015’’ and inserting ‘‘January 1, 

3 2018’’. 

4 SEC. 204. EXTENSION OF INCREASED INPATIENT HOSPITAL 

5 PAYMENT ADJUSTMENT FOR CERTAIN LOW6 VOLUME HOSPITALS. 

7 Section 1886(d)(12) of the Social Security Act (42 

8 U.S.C. 1395ww(d)(12)) is amended— 

9 (1) in subparagraph (B), in the matter pre10 ceding clause (i), by striking ‘‘in fiscal year 2015 

11 (beginning on April 1, 2015), fiscal year 2016, and 

12 subsequent fiscal years’’ and inserting ‘‘in fiscal year 

13 2018 and subsequent fiscal years’’; 

14 (2) in subparagraph (C)(i), by striking ‘‘fiscal 

15 years 2011 through 2014 and fiscal year 2015 (be16 fore April 1, 2015),’’ and inserting ‘‘fiscal years 

17 2011 through 2017,’’ each place it appears; and 

18 (3) in subparagraph (D), by striking ‘‘fiscal 

19 years 2011 through 2014 and fiscal year 2015 (be20 fore April 1, 2015),’’ and inserting ‘‘fiscal years 

21 2011 through 2017,’’. 


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1 SEC. 205. EXTENSION OF THE MEDICARE-DEPENDENT HOS2 PITAL (MDH) PROGRAM. 

3 (a) IN GENERAL.—Section 1886(d)(5)(G) of the So4 cial Security Act (42 U.S.C. 1395ww(d)(5)(G)) is amend5 ed— 

6 (1) in clause (i), by striking ‘‘April 1, 2015’’ 

7 and inserting ‘‘October 1, 2017’’; and 

8 (2) in clause (ii)(II), by striking ‘‘April 1, 

9 2015’’ and inserting ‘‘October 1, 2017’’. 

10 (b) CONFORMING AMENDMENTS.— 

11 (1) EXTENSION OF TARGET AMOUNT.—Section 

12 1886(b)(3)(D) of the Social Security Act (42 U.S.C. 

13 1395ww(b)(3)(D)) is amended— 

14 (A) in the matter preceding clause (i), by 

15 striking ‘‘April 1, 2015’’ and inserting ‘‘October 

16 1, 2017’’; and 

17 (B) in clause (iv), by striking ‘‘through fis18 cal year 2014 and the portion of fiscal year 

19 2015 before April 1, 2015’’ and inserting 

20 ‘‘through fiscal year 2017’’. 

21 (2) PERMITTING HOSPITALS TO DECLINE RE22 CLASSIFICATION.—Section 13501(e)(2) of the Omni23 bus Budget Reconciliation Act of 1993 (42 U.S.C. 

24 1395ww note) is amended by striking ‘‘through the 

25 first 2 quarters of fiscal year 2015’’ and inserting 

26 ‘‘through fiscal year 2017’’. 


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1 SEC. 206. EXTENSION FOR SPECIALIZED MEDICARE ADVAN2 TAGE PLANS FOR SPECIAL NEEDS INDIVID3 UALS. 

4 Section 1859(f)(1) of the Social Security Act (42 

5 U.S.C. 1395w–28(f)(1)) is amended by striking ‘‘2017’’ 

6 and inserting ‘‘2019’’. 

7 SEC. 207. EXTENSION OF FUNDING FOR QUALITY MEASURE 

8 ENDORSEMENT, INPUT, AND SELECTION. 

9 Section 1890(d)(2) of the Social Security Act (42 

10 U.S.C. 1395aaa(d)(2)) is amended by striking ‘‘and 

11 $15,000,000 for the first 6 months of fiscal year 2015’’ 

12 and inserting ‘‘and $30,000,000 for each of fiscal years 

13 2015 through 2017’’. 

14 SEC. 208. EXTENSION OF FUNDING OUTREACH AND ASSIST15 ANCE FOR LOW-INCOME PROGRAMS. 

16 (a) ADDITIONAL FUNDING FOR STATE HEALTH IN17 SURANCE PROGRAMS.—Subsection (a)(1)(B) of section 

18 119 of the Medicare Improvements for Patients and Pro19 viders Act of 2008 (42 U.S.C. 1395b–3 note), as amended 

20 by section 3306 of the Patient Protection and Affordable 

21 Care Act (Public Law 111–148), section 610 of the Amer22 ican Taxpayer Relief Act of 2012 (Public Law 112–240), 

23 section 1110 of the Pathway for SGR Reform Act of 2013 

24 (Public Law 113–67), and section 110 of the Protecting 

25 Access to Medicare Act of 2014 (Public Law 113–93), is 

26 amended— 


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1 (1) in clause (iv), by striking ‘‘and’’ at the end; 

2 (2) by striking clause (v); and 

3 (3) by adding at the end the following new 

4 clauses: 

5 ‘‘(v) for fiscal year 2015, of 

6 $7,500,000; 

7 ‘‘(vi) for fiscal year 2016, of 

8 $13,000,000; and 

9 ‘‘(vii) for fiscal year 2017, of 

10 $13,000,000.’’. 

11 (b) ADDITIONAL FUNDING FOR AREA AGENCIES ON

12 AGING.—Subsection (b)(1)(B) of such section 119, as so 

13 amended, is amended— 

14 (1) in clause (iv), by striking ‘‘and’’ at the end; 

15 (2) by striking clause (v); and 

16 (3) by inserting after clause (iv) the following 

17 new clauses: 

18 ‘‘(v) for fiscal year 2015, of 

19 $7,500,000; 

20 ‘‘(vi) for fiscal year 2016, of 

21 $7,500,000; and 

22 ‘‘(vii) for fiscal year 2017, of 

23 $7,500,000.’’. 


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1 (c) ADDITIONAL FUNDING FOR AGING AND DIS2 ABILITY RESOURCE CENTERS.—Subsection (c)(1)(B) of 

3 such section 119, as so amended, is amended— 

4 (1) in clause (iv), by striking ‘‘and’’ at the end; 

5 (2) by striking clause (v); and 

6 (3) by inserting after clause (iv) the following 

7 new clauses: 

8 ‘‘(v) for fiscal year 2015, of 

9 $5,000,000; 

10 ‘‘(vi) for fiscal year 2016, of 

11 $5,000,000; and 

12 ‘‘(vii) for fiscal year 2017, of 

13 $5,000,000.’’. 

14 (d) ADDITIONAL FUNDING FOR CONTRACT WITH

15 THE NATIONAL CENTER FOR BENEFITS AND OUTREACH

16 ENROLLMENT.—Subsection (d)(2) of such section 119, as 

17 so amended, is amended— 

18 (1) in clause (iv), by striking ‘‘and’’ at the end; 

19 (2) by striking clause (v); and 

20 (3) by inserting after clause (iv) the following 

21 new clauses: 

22 ‘‘(v) for fiscal year 2015, of 

23 $5,000,000; 

24 ‘‘(vi) for fiscal year 2016, of 

25 $12,000,000; and 


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1 ‘‘(vii) for fiscal year 2017, of 

2 $12,000,000.’’. 

3 SEC. 209. EXTENSION AND TRANSITION OF REASONABLE 

4 COST REIMBURSEMENT CONTRACTS. 

5 (a) ONE-YEAR TRANSITION AND NOTICE REGARDING

6 TRANSITION.—Section 1876(h)(5)(C) of the Social Secu7 rity Act (42 U.S.C. 1395mm(h)(5)(C)) is amended— 

8 (1) in clause (ii), in the matter preceding sub9 clause (I), by striking ‘‘For any’’ and inserting 

10 ‘‘Subject to clause (iv), for any’’; 

11 (2) in clause (iii)(I), by inserting ‘‘cost plan 

12 service’’ after ‘‘With respect to any portion of the’’; 

13 (3) in clause (iii)(II), by inserting ‘‘cost plan 

14 service’’ after ‘‘With respect to any other portion of 

15 such’’; and 

16 (4) by adding at the end the following new 

17 clauses: 

18 ‘‘(iv) In the case of an eligible organization that is 

19 offering a reasonable cost reimbursement contract that 

20 may no longer be extended or renewed because of the ap21 plication of clause (ii), or where such contract has been 

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1 tion voluntarily plans not to seek renewal of the reasonable 

2 cost reimbursement contract, the following shall apply: 

3 ‘‘(I) Notwithstanding such clause, such contract 

4 may be extended or renewed for the two years subse5 quent to 2016. The final year in which such contract 

6 is extended or renewed is referred to in this sub7 section as the ‘last reasonable cost reimbursement 

8 contract year for the contract’. 

9 ‘‘(II) The organization may not enroll a new en10 rollee under such contract during the last reasonable 

11 cost reimbursement contract year for the contract 

12 (but may continue to enroll new enrollees through 

13 the end of the year immediately preceding such 

14 year) unless such enrollee is any of the following: 

15 ‘‘(aa) An individual who chooses enroll16 ment in the reasonable cost contract during the 

17 annual election period with respect to such last 

18 year. 

19 ‘‘(bb) An individual whose spouse, at the 

20 time of the individual’s enrollment is an enrollee 

21 under the reasonable cost reimbursement con22 tract. 

23 ‘‘(cc) An individual who is covered under 

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1 erage through the reasonable cost reimburse2 ment contract. 

3 ‘‘(dd) An individual who becomes entitled 

4 to benefits under part A, or enrolled under part 

5 B, and was enrolled in a plan offered by the eli6 gible organization immediately prior to the indi7 vidual’s enrollment under the reasonable cost 

8 reimbursement contract. 

9 ‘‘(III) Not later than a date determined appro10 priate by the Secretary prior to the beginning of the 

11 last reasonable cost reimbursement contract year for 

12 the contract, the organization shall provide notice to 

13 the Secretary as to whether the organization will 

14 apply to have the contract converted over, in whole 

15 or in part, and offered as a Medicare Advantage 

16 plan under part C for the year following the last rea17 sonable cost reimbursement contract year for the 

18 contract. 

19 ‘‘(IV) If the organization provides the notice de20 scribed in subclause (III) that the contract will be 

21 converted, in whole or in part, the organization 

22 shall, not later than a date determined appropriate 

23 by the Secretary, provide the Secretary with such in24 formation as the Secretary determines appropriate 

25 in order to carry out section 1851(c)(4) and to carry 


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1 out section 1854(a)(5), including subparagraph 

2 (C)(ii) of such section. 

3 ‘‘(V) In the case that the organization enrolls a 

4 new enrollee under such contract during the last rea5 sonable cost reimbursement contract year for the 

6 contract, the organization shall provide the indi7 vidual with a notification that such year is the last 

8 year for such contract. 

9 ‘‘(v) If an eligible organization that is offering a rea10 sonable cost reimbursement contract that is extended or 

11 renewed pursuant to clause (iv) provides the notice de12 scribed in clause (iv)(III) that the contract will be con13 verted, in whole or in part, the following shall apply: 

14 ‘‘(I) The deemed enrollment under section 

15 1851(c)(4). 

16 ‘‘(II) The special rule for quality increase under 

17 section 1853(o)(4)(C). 

18 ‘‘(III) During the last reasonable cost reim19 bursement contract year for the contract and the 

20 year immediately preceding such year, the eligible 

21 organization, or the corporate parent organization of 

22 the eligible organization, shall be permitted to offer 

23 an MA plan in the area that such contract is being 

24 offered and enroll Medicare Advantage eligible indi25 viduals in such MA plan and such cost plan.’’. 


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1 (b) DEEMED ENROLLMENT FROM REASONABLE

2 COST REIMBURSEMENT CONTRACTS CONVERTED TO

3 MEDICARE ADVANTAGE PLANS.— 

4 (1) IN GENERAL.—Section 1851(c) of the So5 cial Security Act (42 U.S.C. 1395w–21(c)) is 

6 amended— 

7 (A) in paragraph (1), by striking ‘‘Such 

8 elections’’ and inserting ‘‘Subject to paragraph 

9 (4), such elections’’; and 

10 (B) by adding at the end the following: 

11 ‘‘(4) DEEMED ENROLLMENT RELATING TO CON12 VERTED REASONABLE COST REIMBURSEMENT CON13 TRACTS.— 

14 ‘‘(A) IN GENERAL.—On the first day of 

15 the annual, coordinated election period under 

16 subsection (e)(3) for plan years beginning on or 

17 after January 1, 2017, an MA eligible indi18 vidual described in clause (i) or (ii) of subpara19 graph (B) is deemed, unless the individual 

20 elects otherwise, to have elected to receive bene21 fits under this title through an applicable MA 

22 plan (and shall be enrolled in such plan) begin23 ning with such plan year, if— 


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1 ‘‘(i) the individual is enrolled in a rea2 sonable cost reimbursement contract under 

3 section 1876(h) in the previous plan year; 

4 ‘‘(ii) such reasonable cost reimburse5 ment contract was extended or renewed for 

6 the last reasonable cost reimbursement 

7 contract year of the contract (as described 

8 in subclause (I) of section 

9 1876(h)(5)(C)(iv)) pursuant to such sec10 tion; 

11 ‘‘(iii) the eligible organization that is 

12 offering such reasonable cost reimburse13 ment contract provided the notice de14 scribed in subclause (III) of such section 

15 that the contract was to be converted; 

16 ‘‘(iv) the applicable MA plan— 

17 ‘‘(I) is the plan that was con18 verted from the reasonable cost reim19 bursement contract described in 

20 clause (iii); 

21 ‘‘(II) is offered by the same enti22 ty (or an organization affiliated with 

23 such entity that has a common owner24 ship interest of control) that entered 

25 into such contract; and 


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1 ‘‘(III) is offered in the service 

2 area where the individual resides; 

3 ‘‘(v) in the case of reasonable cost re4 imbursement contracts that provide cov5 erage under parts A and B (and, to the ex6 tent the Secretary determines it to be fea7 sible, contracts that provide only part B 

8 coverage), the difference between the esti9 mated individual costs (as determined ap10 plicable by the Secretary) for the applica11 ble MA plan and such costs for the prede12 cessor cost plan does not exceed a thresh13 old established by the Secretary; and 

14 ‘‘(vi) the applicable MA plan— 

15 ‘‘(I) provides coverage for enroll16 ees transitioning from the converted 

17 reasonable cost reimbursement con18 tract to such plan to maintain current 

19 providers of services and suppliers 

20 and course of treatment at the time of 

21 enrollment for a period of at least 90 

22 days after enrollment; and 

23 ‘‘(II) during such period, pays 

24 such providers of services and sup25 pliers for items and services furnished 


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1 to the enrollee an amount that is not 

2 less than the amount of payment ap3 plicable for such items and services 

4 under the original Medicare fee-for5 service program under parts A and B. 

6 ‘‘(B) MA ELIGIBLE INDIVIDUALS DE7 SCRIBED.— 

8 ‘‘(i) WITHOUT PRESCRIPTION DRUG

9 COVERAGE.—An MA eligible individual de10 scribed in this clause, with respect to a 

11 plan year, is an MA eligible individual who 

12 is enrolled in a reasonable cost reimburse13 ment contract under section 1876(h) in the 

14 previous plan year and who is not, for such 

15 previous plan year, enrolled in a prescrip16 tion drug plan under part D, including 

17 coverage under section 1860D–22. 

18 ‘‘(ii) WITH PRESCRIPTION DRUG COV19 ERAGE.—An MA eligible individual de20 scribed in this clause, with respect to a 

21 plan year, is an MA eligible individual who 

22 is enrolled in a reasonable cost reimburse23 ment contract under section 1876(h) in the 

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1 vious plan year, is enrolled in a prescrip2 tion drug plan under part D— 

3 ‘‘(I) through such contract; or 

4 ‘‘(II) through a prescription drug 

5 plan, if the sponsor of such plan is the 

6 same entity (or an organization affili7 ated with such entity) that entered 

8 into such contract. 

9 ‘‘(C) APPLICABLE MA PLAN DEFINED.—In 

10 this paragraph, the term ‘applicable MA plan’ 

11 means, in the case of an individual described 

12 in— 

13 ‘‘(i) subparagraph (B)(i), an MA plan 

14 that is not an MA–PD plan; and 

15 ‘‘(ii) subparagraph (B)(ii), an MA– 

16 PD plan. 

17 ‘‘(D) IDENTIFICATION AND NOTIFICATION

18 OF DEEMED INDIVIDUALS.—Not later than 45 

19 days before the first day of the annual, coordi20 nated election period under subsection (e)(3) 

21 for plan years beginning on or after January 1, 

22 2017, the Secretary shall identify and notify the 

23 individuals who will be subject to deemed elec24 tions under subparagraph (A) on the first day 

25 of such period.’’. 


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1 (2) BENEFICIARY OPTION TO DISCONTINUE OR

2 CHANGE MA PLAN OR MA–PD PLAN AFTER DEEMED

3 ENROLLMENT.— 

4 (A) IN GENERAL.—Section 1851(e)(2) of 

5 the Social Security Act (42 U.S.C. 1395w– 

6 21(e)(4)) is amended by adding at the end the 

7 following: 

8 ‘‘(F) SPECIAL PERIOD FOR CERTAIN

9 DEEMED ELECTIONS.— 

10 ‘‘(i) IN GENERAL.—At any time dur11 ing the period beginning after the last day 

12 of the annual, coordinated election period 

13 under paragraph (3) in which an individual 

14 is deemed to have elected to enroll in an 

15 MA plan or MA–PD plan under subsection 

16 (c)(4) and ending on the last day of Feb17 ruary of the first plan year for which the 

18 individual is enrolled in such plan, such in19 dividual may change the election under 

20 subsection (a)(1) (including changing the 

21 MA plan or MA–PD plan in which the in22 dividual is enrolled). 

23 ‘‘(ii) LIMITATION OF ONE CHANGE.— 

24 An individual may exercise the right under 

25 clause (i) only once during the applicable 


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1 period described in such clause. The limita2 tion under this clause shall not apply to 

3 changes in elections effected during an an4 nual, coordinated election period under 

5 paragraph (3) or during a special enroll6 ment period under paragraph (4).’’. 

7 (B) CONFORMING AMENDMENTS.— 

8 (i) PLAN REQUIREMENT FOR OPEN

9 ENROLLMENT.—Section 1851(e)(6)(A) of 

10 the Social Security Act (42 U.S.C. 1395w– 

11 21(e)(6)(A)) is amended by striking ‘‘para12 graph (1),’’ and inserting ‘‘paragraph (1), 

13 during the period described in paragraph 

14 (2)(F),’’. 

15 (ii) PART D.—Section 1860D– 

16 1(b)(1)(B) of such Act (42 U.S.C. 1395w– 

17 101(b)(1)(B)) is amended— 

18 (I) in clause (ii), by adding ‘‘and 

19 paragraph (4)’’ after ‘‘paragraph 

20 (3)(A)’’; and 

21 (II) in clause (iii) by striking 

22 ‘‘and (E)’’ and inserting ‘‘(E), and 

23 (F)’’. 

24 (3) TREATMENT OF ESRD FOR DEEMED EN25 ROLLMENT.—Section 1851(a)(3)(B) of the Social 


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1 Security Act (42 U.S.C. 1395w–21(a)(3)(B)) is 

2 amended by adding at the end the following flush 

3 sentence: ‘‘An individual who develops end-stage 

4 renal disease while enrolled in a reasonable cost re5 imbursement contract under section 1876(h) shall be 

6 treated as an MA eligible individual for purposes of 

7 applying the deemed enrollment under subsection 

8 (c)(4).’’. 

9 (c) INFORMATION REQUIREMENTS.—Section 

10 1851(d)(2)(B) of the Social Security Act (42 U.S.C. 

11 1395w–21(d)(2)(B)) is amended— 

12 (1) in the heading, by striking ‘‘NOTIFICATION

13 TO NEWLY ELIGIBLE MEDICARE ADVANTAGE ELIGI14 BLE INDIVIDUALS’’ and inserting the following: ‘‘NO15 TIFICATIONS REQUIRED.— 

16 ‘‘(i) NOTIFICATION TO NEWLY ELIGI17 BLE MEDICARE ADVANTAGE ELIGIBLE IN18 DIVIDUALS.—’’; and 

19 (2) by adding at the end the following new 

20 clause: 

21 ‘‘(ii) NOTIFICATION RELATED TO CER22 TAIN DEEMED ELECTIONS.—The Secretary 

23 shall require a Medicare Advantage organi24 zation that is offering a Medicare Advan25 tage plan that has been converted from a 


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1 reasonable cost reimbursement contract 

2 pursuant to section 1876(h)(5)(C)(iv) to 

3 mail, not later than 30 days prior to the 

4 first day of the annual, coordinated elec5 tion period under subsection (e)(3) of a 

6 year, to any individual enrolled under such 

7 contract and identified by the Secretary 

8 under subsection (c)(4)(D) for such year— 

9 ‘‘(I) a notification that such indi10 vidual will, on such day, be deemed to 

11 have made an election with respect to 

12 such plan to receive benefits under 

13 this title through an MA plan or MA– 

14 PD plan (and shall be enrolled in such 

15 plan) for the next plan year under 

16 subsection (c)(4)(A), but that the in17 dividual may make a different election 

18 during the annual, coordinated elec19 tion period for such year; 

20 ‘‘(II) the information described in 

21 subparagraph (A); 

22 ‘‘(III) a description of the dif23 ferences between such MA plan or 

24 MA–PD plan and the reasonable cost 

25 reimbursement contract in which the 


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1 individual was most recently enrolled 

2 with respect to benefits covered under 

3 such plans, including cost-sharing, 

4 premiums, drug coverage, and pro5 vider networks; 

6 ‘‘(IV) information about the spe7 cial period for elections under sub8 section (e)(2)(F); and 

9 ‘‘(V) other information the Sec10 retary may specify.’’. 

11 (d) TREATMENT OF TRANSITION PLAN FOR QUALITY

12 RATING FOR PAYMENT PURPOSES.—Section 1853(o)(4) 

13 of the Social Security Act (42 U.S.C. 1395w–23(o)(4)) is 

14 amended by adding at the end the following new subpara15 graph: 

16 ‘‘(C) SPECIAL RULE FOR FIRST 3 PLAN

17 YEARS FOR PLANS THAT WERE CONVERTED

18 FROM A REASONABLE COST REIMBURSEMENT

19 CONTRACT.—For purposes of applying para20 graph (1) and section 1854(b)(1)(C) for the 

21 first 3 plan years under this part in the case of 

22 an MA plan to which deemed enrollment applies 

23 under section 1851(c)(4)— 


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1 ‘‘(i) such plan shall not be treated as 

2 a new MA plan (as defined in paragraph 

3 (3)(A)(iii)(II)); and 

4 ‘‘(ii) in determining the star rating of 

5 the plan under subparagraph (A), to the 

6 extent that Medicare Advantage data for 

7 such plan is not available for a measure 

8 used to determine such star rating, the 

9 Secretary shall use data from the period in 

10 which such plan was a reasonable cost re11 imbursement contract.’’. 

12 SEC. 210. EXTENSION OF HOME HEALTH RURAL ADD-ON. 

13 Section 421(a) of the Medicare Prescription Drug, 

14 Improvement, and Modernization Act of 2003 (Public Law 

15 108–173; 117 Stat. 2283; 42 U.S.C. 1395fff note), as 

16 amended by section 5201(b) of the Deficit Reduction Act 

17 of 2005 (Public Law 109–171; 120 Stat. 46) and by sec18 tion 3131(c) of the Patient Protection and Affordable 

19 Care Act (Public Law 111–148; 124 Stat. 428), is amend20 ed by striking ‘‘January 1, 2016’’ and inserting ‘‘January 

21 1, 2018’’ each place it appears. 


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1 Subtitle B—Other Health 

2 Extenders 

3 SEC. 211. PERMANENT EXTENSION OF THE QUALIFYING IN4 DIVIDUAL (QI) PROGRAM. 

5 (a) PERMANENT EXTENSION.—Section 

6 1902(a)(10)(E)(iv) of the Social Security Act (42 U.S.C. 

7 1396a(a)(10)(E)(iv)) is amended by striking ‘‘(but only 

8 for premiums payable with respect to months during the 

9 period beginning with January 1998, and ending with 

10 March 2015)’’. 

11 (b) ALLOCATIONS.—Section 1933(g) of the Social Se12 curity Act (42 U.S.C. 1396u–3(g)) is amended— 

13 (1) in paragraph (2)— 

14 (A) by striking subparagraphs (A) through 

15 (H); 

16 (B) in subparagraph (V), by striking 

17 ‘‘and’’ at the end; 

18 (C) in subparagraph (W), by striking the 

19 period at the end and inserting a semicolon; 

20 (D) by redesignating subparagraphs (I) 

21 through (W) as subparagraphs (A) through 

22 (O), respectively; and 

23 (E) by adding at the end the following new 

24 subparagraphs: 


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1 ‘‘(P) for the period that begins on April 1, 

2 2015, and ends on December 31, 2015, the 

3 total allocation amount is $535,000,000; and 

4 ‘‘(Q) for 2016 and, subject to paragraph 

5 (4), for each subsequent year, the total alloca6 tion amount is $980,000,000.’’; 

7 (2) in paragraph (3), by striking ‘‘(P), (R), (T), 

8 or (V)’’ and inserting ‘‘or (P)’’; and 

9 (3) by adding at the end the following new 

10 paragraph: 

11 ‘‘(4) ADJUSTMENT TO ALLOCATIONS.—The 

12 Secretary may increase the allocation amount under 

13 paragraph (2)(Q) for a year (beginning with 2017) 

14 up to an amount that does not exceed the product 

15 of the following: 

16 ‘‘(A) MAXIMUM ALLOCATION AMOUNT FOR

17 PREVIOUS YEAR.—In the case of 2017, the allo18 cation amount for 2016, or in the case of a sub19 sequent year, the maximum allocation amount 

20 allowed under this paragraph for the previous 

21 year. 

22 ‘‘(B) INCREASE IN PART B PREMIUM.— 

23 The monthly premium rate determined under 

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1 ly premium rate determined under such section 

2 for the previous year. 

3 ‘‘(C) INCREASE IN PART B ENROLL4 MENT.—The average number of individuals (as 

5 estimated by the Chief Actuary of the Centers 

6 for Medicare & Medicaid Services in September 

7 of the previous year) to be enrolled under part 

8 B of title XVIII for months in the year divided 

9 by the average number of such individuals (as 

10 so estimated) under this subparagraph with re11 spect to enrollments in months in the previous 

12 year.’’. 

13 SEC. 212. PERMANENT EXTENSION OF TRANSITIONAL MED14 ICAL ASSISTANCE (TMA). 

15 (a) IN GENERAL.—Section 1925 of the Social Secu16 rity Act (42 U.S.C. 1396r–6) is amended— 

17 (1) by striking subsection (f); and 

18 (2) by redesignating subsection (g) as sub19 section (f). 

20 (b) CONFORMING AMENDMENT.—Section 1902(e)(1) 

21 of the Social Security Act (42 U.S.C. 1396a(e)(1)) is 

22 amended to read as follows: 

23 ‘‘(1) Beginning April 1, 1990, for provisions relating 

24 to the extension of eligibility for medical assistance for cer25 tain families who have received aid pursuant to a State 


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1 plan approved under part A of title IV and have earned 

2 income, see section 1925.’’. 

3 SEC. 213. EXTENSION OF SPECIAL DIABETES PROGRAM 

4 FOR TYPE I DIABETES AND FOR INDIANS. 

5 (a) SPECIAL DIABETES PROGRAMS FOR TYPE I DIA6 BETES.—Section 330B(b)(2)(C) of the Public Health 

7 Service Act (42 U.S.C. 254c–2(b)(2)(C)) is amended by 

8 striking ‘‘2015’’ and inserting ‘‘2017’’. 

9 (b) SPECIAL DIABETES PROGRAMS FOR INDIANS.— 

10 Section 330C(c)(2)(C) of the Public Health Service Act 

11 (42 U.S.C. 254c–3(c)(2)(C)) is amended by striking 

12 ‘‘2015’’ and inserting ‘‘2017’’. 

13 SEC. 214. EXTENSION OF ABSTINENCE EDUCATION. 

14 (a) IN GENERAL.—Section 510 of the Social Security 

15 Act (42 U.S.C. 710) is amended— 

16 (1) in subsection (a), striking ‘‘2015’’ and in17 serting ‘‘2017’’; and 

18 (2) in subsection (d), by inserting ‘‘and an ad19 ditional $75,000,000 for each of fiscal years 2016 

20 and 2017’’ after ‘‘2015’’. 

21 (b) BUDGET SCORING.—Notwithstanding section 

22 257(b)(2) of the Balanced Budget and Emergency Deficit 

23 Control Act of 1985, the baseline shall be calculated as24 suming that no grant shall be made under section 510 


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1 of the Social Security Act (42 U.S.C. 710) after fiscal year 

2 2017. 

3 (c) REALLOCATION OF UNUSED FUNDING.—The re4 maining unobligated balances of the amount appropriated 

5 for fiscal years 2016 and 2017 by section 510(d) of the 

6 Social Security Act (42 U.S.C. 710(d)) for which no appli7 cation has been received by the Funding Opportunity An8 nouncement deadline, shall be made available to States 

9 that require the implementation of each element described 

10 in subparagraphs (A) through (H) of the definition of ab11 stinence education in section 510(b)(2). The remaining 

12 unobligated balances shall be reallocated to such States 

13 that submit a valid application consistent with the original 

14 formula for this funding. 

15 SEC. 215. EXTENSION OF PERSONAL RESPONSIBILITY EDU16 CATION PROGRAM (PREP). 

17 Section 513 of the Social Security Act (42 U.S.C. 

18 713) is amended— 

19 (1) in paragraphs (1)(A) and (4)(A) of sub20 section (a), by striking ‘‘2015’’ and inserting 

21 ‘‘2017’’ each place it appears; 

22 (2) in subsection (a)(4)(B)(i), by striking ‘‘, 

23 2013, 2014, and 2015’’ and inserting ‘‘through 

24 2017’’; and 


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1 (3) in subsection (f), by striking ‘‘2015’’ and 

2 inserting ‘‘2017’’. 

3 SEC. 216. EXTENSION OF FUNDING FOR FAMILY-TO-FAMILY 

4 HEALTH INFORMATION CENTERS. 

5 Section 501(c)(1)(A) of the Social Security Act (42 

6 U.S.C. 701(c)(1)(A)) is amended— 

7 (1) by striking clause (vi); and 

8 (2) by adding after clause (v) the following new 

9 clause: 

10 ‘‘(vi) $5,000,000 for each of fiscal years 2015 

11 through 2017.’’. 

12 SEC. 217. EXTENSION OF HEALTH WORKFORCE DEM13 ONSTRATION PROJECT FOR LOW-INCOME IN14 DIVIDUALS. 

15 Section 2008(c)(1) of the Social Security Act (42 

16 U.S.C. 1397g(c)(1)) is amended by striking ‘‘2015’’ and 

17 inserting ‘‘2017’’. 

18 SEC. 218. EXTENSION OF MATERNAL, INFANT, AND EARLY 

19 CHILDHOOD HOME VISITING PROGRAMS. 

20 Section 511(j)(1) of the Social Security Act (42 

21 U.S.C. 711(j)) is amended— 

22 (1) by striking ‘‘and’’ at the end of subpara23 graph (E); 

24 (2) in subparagraph (F)— 


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1 (A) by striking ‘‘for the period beginning 

2 on October 1, 2014, and ending on March 31, 

3 2015’’ and inserting ‘‘for fiscal year 2015’’; 

4 (B) by striking ‘‘an amount equal to the 

5 amount provided in subparagraph (E)’’ and in6 serting ‘‘$400,000,000’’; and 

7 (C) by striking the period at the end and 

8 inserting a semicolon; and 

9 (3) by adding at the end the following new sub10 paragraphs: 

11 ‘‘(G) for fiscal year 2016, $400,000,000; 

12 and 

13 ‘‘(H) for fiscal year 2017, $400,000,000.’’. 

14 SEC. 219. TENNESSEE DSH ALLOTMENT FOR FISCAL YEARS 

15 2015 THROUGH 2025. 

16 Section 1923(f)(6)(A) of the Social Security Act (42 

17 U.S.C. 1396r–4(f)(6)(A)) is amended by adding at the end 

18 the following: 

19 ‘‘(vi) ALLOTMENT FOR FISCAL YEARS

20 2015 THROUGH 2025.—Notwithstanding any 

21 other provision of this subsection, any 

22 other provision of law, or the terms of the 

23 TennCare Demonstration Project in effect 

24 for the State, the DSH allotment for Ten25 nessee for fiscal year 2015, and for each 


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1 fiscal year thereafter through fiscal year 

2 2025, shall be $53,100,000 for each such 

3 fiscal year.’’. 

4 SEC. 220. DELAY IN EFFECTIVE DATE FOR MEDICAID 

5 AMENDMENTS RELATING TO BENEFICIARY 

6 LIABILITY SETTLEMENTS. 

7 Section 202(c) of the Bipartisan Budget Act of 2013 

8 (division A of Public Law 113–67; 42 U.S.C. 1396a note), 

9 as amended by section 211 of the Protecting Access to 

10 Medicare Act of 2014 (Public Law 113–93; 128 Stat. 

11 1047) is amended by striking ‘‘October 1, 2016’’ and in12 serting ‘‘October 1, 2017’’. 

13 SEC. 221. EXTENSION OF FUNDING FOR COMMUNITY 

14 HEALTH CENTERS, THE NATIONAL HEALTH 

15 SERVICE CORPS, AND TEACHING HEALTH 

16 CENTERS. 

17 (a) FUNDING FOR COMMUNITY HEALTH CENTERS

18 AND THE NATIONAL HEALTH SERVICE CORPS.— 

19 (1) COMMUNITY HEALTH CENTERS.—Section 

20 10503(b)(1)(E) of the Patient Protection and Af21 fordable Care Act (42 U.S.C. 254b–2(b)(1)(E)) is 

22 amended by striking ‘‘for fiscal year 2015’’ and in23 serting ‘‘for each of fiscal years 2015 through 

24 2017’’. 


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1 (2) NATIONAL HEALTH SERVICE CORPS.—Sec2 tion 10503(b)(2)(E) of the Patient Protection and 

3 Affordable Care Act (42 U.S.C. 254b–2(b)(2)(E)) is 

4 amended by striking ‘‘for fiscal year 2015’’ and in5 serting ‘‘for each of fiscal years 2015 through 

6 2017’’. 

7 (b) EXTENSION OF TEACHING HEALTH CENTERS

8 PROGRAM.—Section 340H(g) of the Public Health Service 

9 Act (42 U.S.C. 256h(g)) is amended by inserting ‘‘and 

10 $60,000,000 for each of fiscal years 2016 and 2017’’ be11 fore the period at the end. 

12 (c) APPLICATION.—Amounts appropriated pursuant 

13 to this section for fiscal year 2016 and fiscal year 2017 

14 are subject to the requirements contained in Public Law 

15 113–235 for funds for programs authorized under sections 

16 330 through 340 of the Public Health Service Act (42 

17 U.S.C. 254b–256). 

18 TITLE III—CHIP 

19 SEC. 301. 2-YEAR EXTENSION OF THE CHILDREN’S HEALTH 

20 INSURANCE PROGRAM. 

21 (a) FUNDING.—Section 2104(a) of the Social Secu22 rity Act (42 U.S.C. 1397dd(a)) is amended— 

23 (1) in paragraph (17), by striking ‘‘and’’ at the 

24 end; 


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1 (2) in paragraph (18)(B), by striking the period 

2 at the end and inserting a semicolon; and 

3 (3) by adding at the end the following new 

4 paragraphs: 

5 ‘‘(19) for fiscal year 2016, $19,300,000,000; 

6 and 

7 ‘‘(20) for fiscal year 2017, for purposes of mak8 ing 2 semi-annual allotments— 

9 ‘‘(A) $2,850,000,000 for the period begin10 ning on October 1, 2016, and ending on March 

11 31, 2017; and 

12 ‘‘(B) $2,850,000,000 for the period begin13 ning on April 1, 2017, and ending on Sep14 tember 30, 2017.’’. 

15 (b) ALLOTMENTS.— 

16 (1) IN GENERAL.—Section 2104(m) of the So17 cial Security Act (42 U.S.C. 1397dd(m)) is amend18 ed— 

19 (A) in the subsection heading, by striking 

20 ‘‘THROUGH 2015’’ and inserting ‘‘AND THERE21 AFTER’’; 

22 (B) in paragraph (2)— 

23 (i) in the paragraph heading, by strik24 ing ‘‘2014’’ and inserting ‘‘2016’’; and 


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1 (ii) by striking subparagraph (B) and 

2 inserting the following new subparagraph: 

3 ‘‘(B) FISCAL YEAR 2013 AND EACH SUC4 CEEDING FISCAL YEAR.—Subject to paragraphs 

5 (5) and (7), from the amount made available 

6 under paragraphs (16) through (19) of sub7 section (a) for fiscal year 2013 and each suc8 ceeding fiscal year, respectively, the Secretary 

9 shall compute a State allotment for each State 

10 (including the District of Columbia and each 

11 commonwealth and territory) for each such fis12 cal year as follows: 

13 ‘‘(i) REBASING IN FISCAL YEAR 2013

14 AND EACH SUCCEEDING ODD-NUMBERED

15 FISCAL YEAR.—For fiscal year 2013 and 

16 each succeeding odd-numbered fiscal year 

17 (other than fiscal years 2015 and 2017), 

18 the allotment of the State is equal to the 

19 Federal payments to the State that are at20 tributable to (and countable toward) the 

21 total amount of allotments available under 

22 this section to the State in the preceding 

23 fiscal year (including payments made to 

24 the State under subsection (n) for such 

25 preceding fiscal year as well as amounts 


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1 redistributed to the State in such pre2 ceding fiscal year), multiplied by the allot3 ment increase factor under paragraph (6) 

4 for such odd-numbered fiscal year. 

5 ‘‘(ii) GROWTH FACTOR UPDATE FOR

6 FISCAL YEAR 2014 AND EACH SUCCEEDING

7 EVEN-NUMBERED FISCAL YEAR.—Except 

8 as provided in clauses (iii) and (iv), for fis9 cal year 2014 and each succeeding even10 numbered fiscal year, the allotment of the 

11 State is equal to the sum of— 

12 ‘‘(I) the amount of the State al13 lotment under clause (i) for the pre14 ceding fiscal year; and 

15 ‘‘(II) the amount of any pay16 ments made to the State under sub17 section (n) for such preceding fiscal 

18 year, 

19 multiplied by the allotment increase factor 

20 under paragraph (6) for such even-num21 bered fiscal year. 

22 ‘‘(iii) SPECIAL RULE FOR 2016.—For 

23 fiscal year 2016, the allotment of the State 

24 is equal to the Federal payments to the 

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1 able toward) the total amount of allot2 ments available under this section to the 

3 State in the preceding fiscal year (includ4 ing payments made to the State under 

5 subsection (n) for such preceding fiscal 

6 year as well as amounts redistributed to 

7 the State in such preceding fiscal year), 

8 but determined as if the last two sentences 

9 of section 2105(b) were in effect in such 

10 preceding fiscal year and then multiplying 

11 the result by the allotment increase factor 

12 under paragraph (6) for fiscal year 2016. 

13 ‘‘(iv) REDUCTION IN 2018.—For fiscal 

14 year 2018, with respect to the allotment of 

15 the State for fiscal year 2017, any 

16 amounts of such allotment that remain 

17 available for expenditure by the State in 

18 fiscal year 2018 shall be reduced by one19 third.’’; 

20 (C) in paragraph (4), by inserting ‘‘or 

21 2017’’ after ‘‘2015’’; 

22 (D) in paragraph (6)— 

23 (i) in subparagraph (A), by striking 

24 ‘‘2015’’ and inserting ‘‘2017’’; and 


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1 (ii) in the second sentence, by striking 

2 ‘‘or fiscal year 2014’’ and inserting ‘‘fiscal 

3 year 2014, or fiscal year 2016’’; 

4 (E) in paragraph (8)— 

5 (i) in the paragraph heading, by strik6 ing ‘‘FISCAL YEAR 2015’’ and inserting 

7 ‘‘FISCAL YEARS 2015 AND 2017’’; and 

8 (ii) by inserting ‘‘or fiscal year 2017’’ 

9 after ‘‘2015’’; 

10 (F) by redesignating paragraphs (4) 

11 through (8) as paragraphs (5) through (9), re12 spectively; and 

13 (G) by inserting after paragraph (3) the 

14 following new paragraph: 

15 ‘‘(4) FOR FISCAL YEAR 2017.— 

16 ‘‘(A) FIRST HALF.—Subject to paragraphs 

17 (5) and (7), from the amount made available 

18 under subparagraph (A) of paragraph (20) of 

19 subsection (a) for the semi-annual period de20 scribed in such paragraph, increased by the 

21 amount of the appropriation for such period 

22 under section 301(b)(3) of the Medicare Access 

23 and CHIP Reauthorization Act of 2015, the 

24 Secretary shall compute a State allotment for 

25 each State (including the District of Columbia 


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1 and each commonwealth and territory) for such 

2 semi-annual period in an amount equal to the 

3 first half ratio (described in subparagraph (D)) 

4 of the amount described in subparagraph (C). 

5 ‘‘(B) SECOND HALF.—Subject to para6 graphs (5) and (7), from the amount made 

7 available under subparagraph (B) of paragraph 

8 (20) of subsection (a) for the semi-annual pe9 riod described in such paragraph, the Secretary 

10 shall compute a State allotment for each State 

11 (including the District of Columbia and each 

12 commonwealth and territory) for such semi-an13 nual period in an amount equal to the amount 

14 made available under such subparagraph, multi15 plied by the ratio of— 

16 ‘‘(i) the amount of the allotment to 

17 such State under subparagraph (A); to 

18 ‘‘(ii) the total of the amount of all of 

19 the allotments made available under such 

20 subparagraph. 

21 ‘‘(C) FULL YEAR AMOUNT BASED ON

22 REBASED AMOUNT.—The amount described in 

23 this subparagraph for a State is equal to the 

24 Federal payments to the State that are attrib25 utable to (and countable towards) the total 


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1 amount of allotments available under this sec2 tion to the State in fiscal year 2016 (including 

3 payments made to the State under subsection 

4 (n) for fiscal year 2016 as well as amounts re5 distributed to the State in fiscal year 2016), 

6 multiplied by the allotment increase factor 

7 under paragraph (6) for fiscal year 2017. 

8 ‘‘(D) FIRST HALF RATIO.—The first half 

9 ratio described in this subparagraph is the ratio 

10 of— 

11 ‘‘(i) the sum of— 

12 ‘‘(I) the amount made available 

13 under subsection (a)(20)(A); and 

14 ‘‘(II) the amount of the appro15 priation for such period under section 

16 301(b)(3) of the Medicare Access and 

17 CHIP Reauthorization Act of 2015; 

18 to 

19 ‘‘(ii) the sum of the— 

20 ‘‘(I) amount described in clause 

21 (i); and 

22 ‘‘(II) the amount made available 

23 under subsection (a)(20)(B).’’. 

24 (2) CONFORMING AMENDMENTS.— 


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1 (A) Section 2104(c)(1) of the Social Secu2 rity Act (42 U.S.C. 1397dd(c)(1)) is amended 

3 by striking ‘‘(m)(4)’’ and inserting ‘‘(m)(5)’’. 

4 (B) Section 2104(m) of such Act (42 

5 U.S.C. 1397dd(m)), as amended by paragraph 

6 (1), is further amended— 

7 (i) in paragraph (1)— 

8 (I) by striking ‘‘paragraph (4)’’ 

9 each place it appears in subpara10 graphs (A) and (B) and inserting 

11 ‘‘paragraph (5)’’; and 

12 (II) by striking ‘‘the allotment 

13 increase factor determined under 

14 paragraph (5)’’ each place it appears 

15 and inserting ‘‘the allotment increase 

16 factor determined under paragraph 

17 (6)’’; 

18 (ii) in paragraph (2)(A), by striking 

19 ‘‘the allotment increase factor under para20 graph (5)’’ and inserting ‘‘the allotment in21 crease factor under paragraph (6)’’; 

22 (iii) in paragraph (3)— 

23 (I) by striking ‘‘paragraphs (4) 

24 and (6)’’ and inserting ‘‘paragraphs 


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1 (5) and (7)’’ each place it appears; 

2 and 

3 (II) by striking ‘‘the allotment 

4 increase factor under paragraph (5)’’ 

5 and inserting ‘‘the allotment increase 

6 factor under paragraph (6)’’; 

7 (iv) in paragraph (5) (as redesignated 

8 by paragraph (1)(F)), by striking ‘‘para9 graph (1), (2), or (3)’’ and inserting 

10 ‘‘paragraph (1), (2), (3), or (4)’’; 

11 (v) in paragraph (7) (as redesignated 

12 by paragraph (1)(F)), by striking ‘‘subject 

13 to paragraph (4)’’ and inserting ‘‘subject 

14 to paragraph (5)’’; and 

15 (vi) in paragraph (9), (as redesignated 

16 by paragraph (1)(F)), by striking ‘‘para17 graph (3)’’ and inserting ‘‘paragraph (3) 

18 or (4)’’. 

19 (C) Section 2104(n)(3)(B)(ii) of such Act 

20 (42 U.S.C. 1397dd(n)(3)(B)(ii)) is amended by 

21 striking ‘‘subsection (m)(5)(B)’’ and inserting 

22 ‘‘subsection (m)(6)(B)’’. 

23 (D) Section 2111(b)(2)(B)(i) of such Act 

24 (42 U.S.C. 1397kk(b)(2)(B)(i)) is amended by 


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1 striking ‘‘section 2104(m)(4)’’ and inserting 

2 ‘‘section 2104(m)(5)’’. 

3 (3) ONE-TIME APPROPRIATION FOR FISCAL

4 YEAR 2017.—There is appropriated to the Secretary 

5 of Health and Human Services, out of any money in 

6 the Treasury not otherwise appropriated, 

7 $14,700,000,000 to accompany the allotment made 

8 for the period beginning on October 1, 2016, and 

9 ending on March 31, 2017, under paragraph 

10 (20)(A) of section 2104(a) of the Social Security Act 

11 (42 U.S.C. 1397dd(a)) (as added by subsection 

12 (a)(1)), to remain available until expended. Such 

13 amount shall be used to provide allotments to States 

14 under paragraph (4) of section 2104(m) of such Act 

15 (42 U.S.C. 1397dd(m)) (as amended by para16 graph(1)(G)) for the first 6 months of fiscal year 

17 2017 in the same manner as allotments are provided 

18 under subsection (a)(20)(A) of such section 2104 

19 and subject to the same terms and conditions as 

20 apply to the allotments provided from such sub21 section (a)(20)(A). 

22 (c) EXTENSION OF QUALIFYING STATES OPTION.— 

23 Section 2105(g)(4) of the Social Security Act (42 U.S.C. 

24 1397ee(g)(4)) is amended— 


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1 (1) in the paragraph heading, by striking 

2 ‘‘2015’’ and inserting ‘‘2017’’; and 

3 (2) in subparagraph (A), by striking ‘‘2015’’ 

4 and inserting ‘‘2017’’. 

5 (d) EXTENSION OF THE CHILD ENROLLMENT CON6 TINGENCY FUND.— 

7 (1) IN GENERAL.—Section 2104(n) of the So8 cial Security Act (42 U.S.C. 1397dd(n)) is amend9 ed— 

10 (A) in paragraph (2)— 

11 (i) in subparagraph (A)(ii)— 

12 (I) by striking ‘‘2010 through 

13 2014’’ and inserting ‘‘2010, 2011, 

14 2012, 2013, 2014, and 2016’’; and 

15 (II) by inserting ‘‘and fiscal year 

16 2017’’ after ‘‘2015’’; and 

17 (ii) in subparagraph (B)— 

18 (I) by striking ‘‘2010 through 

19 2014’’ and inserting ‘‘2010, 2011, 

20 2012, 2013, 2014, and 2016’’; and 

21 (II) by inserting ‘‘and fiscal year 

22 2017’’ after ‘‘2015’’; and 

23 (B) in paragraph (3)(A), in the matter 

24 preceding clause (i), by striking ‘‘fiscal year 

25 2009, fiscal year 2010, fiscal year 2011, fiscal 


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1 year 2012, fiscal year 2013, fiscal year 2014, or 

2 a semi-annual allotment period for fiscal year 

3 2015’’ and inserting ‘‘any of fiscal years 2009 

4 through 2014, fiscal year 2016, or a semi-an5 nual allotment period for fiscal year 2015 or 

6 2017’’. 

7 SEC. 302. EXTENSION OF EXPRESS LANE ELIGIBILITY. 

8 Section 1902(e)(13)(I) of the Social Security Act (42 

9 U.S.C. 1396a(e)(13)(I)) is amended by striking ‘‘2015’’ 

10 and inserting ‘‘2017’’. 

11 SEC. 303. EXTENSION OF OUTREACH AND ENROLLMENT 

12 PROGRAM. 

13 Section 2113 of the Social Security Act (42 U.S.C. 

14 1397mm) is amended— 

15 (1) in subsection (a)(1), by striking ‘‘2015’’ and 

16 inserting ‘‘2017’’; and 

17 (2) in subsection (g), by inserting ‘‘and 

18 $40,000,000 for the period of fiscal years 2016 and 

19 2017’’ after ‘‘2015’’. 

20 SEC. 304. EXTENSION OF CERTAIN PROGRAMS AND DEM21 ONSTRATION PROJECTS. 

22 (a) CHILDHOOD OBESITY DEMONSTRATION

23 PROJECT.—Section 1139A(e)(8) of the Social Security 

24 Act (42 U.S.C. 1320b–9a(e)(8)) is amended by inserting 


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1 ‘‘, and $10,000,000 for the period of fiscal years 2016 

2 and 2017’’ after ‘‘2014’’. 

3 (b) PEDIATRIC QUALITY MEASURES PROGRAM.— 

4 Section 1139A(i) of the Social Security Act (42 U.S.C. 

5 1320b–9a(i)) is amended in the first sentence by inserting 

6 before the period at the end the following: ‘‘, and there 

7 is appropriated for the period of fiscal years 2016 and 

8 2017, $20,000,000 for the purpose of carrying out this 

9 section (other than subsections (e), (f), and (g))’’. 

10 SEC. 305. REPORT OF INSPECTOR GENERAL OF HHS ON 

11 USE OF EXPRESS LANE OPTION UNDER MED12 ICAID AND CHIP. 

13 Not later than 18 months after the date of the enact14 ment of this Act, the Inspector General of the Department 

15 of Health and Human Services shall submit to the Com16 mittee on Energy and Commerce of the House of Rep17 resentatives and the Committee on Finance of the Senate 

18 a report that— 

19 (1) provides data on the number of individuals 

20 enrolled in the Medicaid program under title XIX of 

21 the Social Security Act (referred to in this section 

22 as ‘‘Medicaid’’) and the Children’s Health Insurance 

23 Program under title XXI of such Act (referred to in 

24 this section as ‘‘CHIP’’) through the use of the ExVerDate Sep 11 2014 21:09 Mar 27, 2015 Jkt 049200 PO 00000 Frm 00204 Fmt 6652 Sfmt 6201 E:\BILLS\H2.RDS H2

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1 press Lane option under section 1902(e)(13) of the 

2 Social Security Act (42 U.S.C. 1396a(e)(13)); 

3 (2) assesses the extent to which individuals so 

4 enrolled meet the eligibility requirements under Med5 icaid or CHIP (as applicable); and 

6 (3) provides data on Federal and State expendi7 tures under Medicaid and CHIP for individuals so 

8 enrolled and disaggregates such data between ex9 penditures made for individuals who meet the eligi10 bility requirements under Medicaid or CHIP (as ap11 plicable) and expenditures made for individuals who 

12 do not meet such requirements. 

13 TITLE IV—OFFSETS 

14 Subtitle A—Medicare Beneficiary 

15 Reforms 

16 SEC. 401. LIMITATION ON CERTAIN MEDIGAP POLICIES 

17 FOR NEWLY ELIGIBLE MEDICARE BENE18 FICIARIES. 

19 Section 1882 of the Social Security Act (42 U.S.C. 

20 1395ss) is amended by adding at the end the following 

21 new subsection: 

22 ‘‘(z) LIMITATION ON CERTAIN MEDIGAP POLICIES

23 FOR NEWLY ELIGIBLE MEDICARE BENEFICIARIES.— 

24 ‘‘(1) IN GENERAL.—Notwithstanding any other 

25 provision of this section, on or after January 1, 


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1 2020, a medicare supplemental policy that provides 

2 coverage of the part B deductible, including any 

3 such policy (or rider to such a policy) issued under 

4 a waiver granted under subsection (p)(6), may not 

5 be sold or issued to a newly eligible Medicare bene6 ficiary. 

7 ‘‘(2) NEWLY ELIGIBLE MEDICARE BENEFICIARY

8 DEFINED.—In this subsection, the term ‘newly eligi9 ble Medicare beneficiary’ means an individual who is 

10 neither of the following: 

11 ‘‘(A) An individual who has attained age 

12 65 before January 1, 2020. 

13 ‘‘(B) An individual who was entitled to 

14 benefits under part A pursuant to section 

15 226(b) or 226A, or deemed to be eligible for 

16 benefits under section 226(a), before January 

17 1, 2020. 

18 ‘‘(3) TREATMENT OF WAIVERED STATES.—In 

19 the case of a State described in subsection (p)(6), 

20 nothing in this section shall be construed as pre21 venting the State from modifying its alternative sim22 plification program under such subsection so as to 

23 eliminate the coverage of the part B deductible for 

24 any medical supplemental policy sold or issued under 


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1 such program to a newly eligible Medicare bene2 ficiary on or after January 1, 2020. 

3 ‘‘(4) TREATMENT OF REFERENCES TO CERTAIN

4 POLICIES.—In the case of a newly eligible Medicare 

5 beneficiary, except as the Secretary may otherwise 

6 provide, any reference in this section to a medicare 

7 supplemental policy which has a benefit package 

8 classified as ‘C’ or ‘F’ shall be deemed, as of Janu9 ary 1, 2020, to be a reference to a medicare supple10 mental policy which has a benefit package classified 

11 as ‘D’ or ‘G’, respectively. 

12 ‘‘(5) ENFORCEMENT.—The penalties described 

13 in clause (ii) of subsection (d)(3)(A) shall apply with 

14 respect to a violation of paragraph (1) in the same 

15 manner as it applies to a violation of clause (i) of 

16 such subsection.’’. 

17 SEC. 402. INCOME-RELATED PREMIUM ADJUSTMENT FOR 

18 PARTS B AND D. 

19 (a) IN GENERAL.—Section 1839(i)(3)(C)(i) of the 

20 Social Security Act (42 U.S.C. 1395r(i)(3)(C)(i)) is 

21 amended— 

22 (1) by inserting after ‘‘IN GENERAL.—’’ the fol23 lowing: 

24 ‘‘(I) Subject to paragraphs (5) 

25 and (6), for years before 2018:’’; and 


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1 (2) by adding at the end the following: 

2 ‘‘(II) Subject to paragraph (5), 

3 for years beginning with 2018: 

‘‘If the modified adjusted gross income is: The applicable 

percentage is:

More than $85,000 but not more than $107,000 ...... 35 percent

More than $107,000 but not more than $133,500 .... 50 percent

More than $133,500 but not more than $160,000 .... 65 percent

More than $160,000 ................................................... 80 percent.’’. 

4 (b) CONFORMING AMENDMENTS.—Section 1839(i) of 

5 the Social Security Act (42 U.S.C. 1395r(i)) is amended— 

6 (1) in paragraph (2)(A), by inserting ‘‘(or, be7 ginning with 2018, $85,000)’’ after ‘‘$80,000’’; 

8 (2) in paragraph (3)(A)(i), by inserting ‘‘appli9 cable’’ before ‘‘table’’; 

10 (3) in paragraph (5)(A)— 

11 (A) in the matter before clause (i), by in12 serting ‘‘(other than 2018 and 2019)’’ after 

13 ‘‘2007’’; and 

14 (B) in clause (ii), by inserting ‘‘(or, in the 

15 case of a calendar year beginning with 2020, 

16 August 2018)’’ after ‘‘August 2006’’; and 

17 (4) in paragraph (6), in the matter before sub18 paragraph (A), by striking ‘‘2019’’ and inserting 

19 ‘‘2017’’. 


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1 Subtitle B—Other Offsets 

2 SEC. 411. MEDICARE PAYMENT UPDATES FOR POST-ACUTE 

3 PROVIDERS. 

4 (a) SNFS.—Section 1888(e) of the Social Security 

5 Act (42 U.S.C. 1395yy(e))— 

6 (1) in paragraph (5)(B)— 

7 (A) in clause (i), by striking ‘‘clause (ii)’’ 

8 and inserting ‘‘clauses (ii) and (iii)’’; 

9 (B) in clause (ii), by inserting ‘‘subject to 

10 clause (iii),’’ after ‘‘each subsequent fiscal 

11 year,’’; and 

12 (C) by adding at the end the following new 

13 clause: 

14 ‘‘(iii) SPECIAL RULE FOR FISCAL

15 YEAR 2018.—For fiscal year 2018 (or other 

16 similar annual period specified in clause 

17 (i)), the skilled nursing facility market bas18 ket percentage, after application of clause 

19 (ii), is equal to 1 percent.’’; and 

20 (2) in paragraph (6)(A), by striking ‘‘paragraph 

21 (5)(B)(ii)’’ and inserting ‘‘clauses (ii) and (iii) of 

22 paragraph (5)(B)’’ each place it appears. 

23 (b) IRFS.—Section 1886(j) of the Social Security Act 

24 (42 U.S.C. 1395ww(j)) is amended— 

25 (1) in paragraph (3)(C)— 


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1 (A) in clause (i), by striking ‘‘clause (ii)’’ 

2 and inserting ‘‘clauses (ii) and (iii)’’; 

3 (B) in clause (ii), by striking ‘‘After’’ and 

4 inserting ‘‘Subject to clause (iii), after’’; and 

5 (C) by adding at the end the following new 

6 clause: 

7 ‘‘(iii) SPECIAL RULE FOR FISCAL

8 YEAR 2018.—The increase factor to be ap9 plied under this subparagraph for fiscal 

10 year 2018, after the application of clause 

11 (ii), shall be 1 percent.’’; and 

12 (2) in paragraph (7)(A)(i), by striking ‘‘para13 graph (3)(D)’’ and inserting ‘‘subparagraphs (C)(iii) 

14 and (D) of paragraph (3)’’. 

15 (c) HHAS.—Section 1895(b)(3)(B) of the Social Se16 curity Act (42 U.S.C. 1395fff(b)(3)(B)) is amended— 

17 (1) in clause (iii), by adding at the end the fol18 lowing: ‘‘Notwithstanding the previous sentence, the 

19 home health market basket percentage increase for 

20 2018 shall be 1 percent.’’; and 

21 (2) in clause (vi)(I), by inserting ‘‘(except 

22 2018)’’ after ‘‘each subsequent year’’. 

23 (d) HOSPICE.—Section 1814(i) of the Social Security 

24 Act (42 U.S.C. 1395f(i)) is amended— 

25 (1) in paragraph (1)(C)— 


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1 (A) in clause (ii)(VII), by striking ‘‘clause 

2 (iv),,’’ and inserting ‘‘clauses (iv) and (vi),’’; 

3 (B) in clause (iii), by striking ‘‘clause 

4 (iv),’’ and inserting ‘‘clauses (iv) and (vi),’’; 

5 (C) in clause (iv), by striking ‘‘After deter6 mining’’ and inserting ‘‘Subject to clause (vi), 

7 after determining’’; and 

8 (D) by adding at the end the following new 

9 clause: 

10 ‘‘(vi) For fiscal year 2018, the market basket per11 centage increase under clause (ii)(VII) or (iii), as applica12 ble, after application of clause (iv), shall be 1 percent.’’; 

13 and 

14 (2) in paragraph (5)(A)(i), by striking ‘‘para15 graph (1)(C)(iv)’’ and inserting ‘‘clauses (iv) and 

16 (vi) of paragraph (1)(C)’’. 

17 (e) LTCHS.—Section 1886(m)(3) of the Social Secu18 rity Act (42 U.S.C. 1395ww(m)(3)) is amended— 

19 (1) in subparagraph (A), in the matter pre20 ceding clause (i), by striking ‘‘In implementing’’ and 

21 inserting ‘‘Subject to subparagraph (C), in imple22 menting’’; and 

23 (2) by adding at the end the following new sub24 paragraph: 


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1 ‘‘(C) ADDITIONAL SPECIAL RULE.—For 

2 fiscal year 2018, the annual update under sub3 paragraph (A) for the fiscal year, after applica4 tion of clauses (i) and (ii) of subparagraph (A), 

5 shall be 1 percent.’’. 

6 SEC. 412. DELAY OF REDUCTION TO MEDICAID DSH ALLOT7 MENTS. 

8 Section 1923(f) of the Social Security Act (42 U.S.C. 

9 1396r–4(f)) is amended— 

10 (1) in paragraph (7)(A)— 

11 (A) in clause (i), by striking ‘‘2017 

12 through 2024’’ and inserting ‘‘2018 through 

13 2025’’; 

14 (B) by striking clause (ii) and inserting the 

15 following new clause: 

16 ‘‘(ii) AGGREGATE REDUCTIONS.—The 

17 aggregate reductions in DSH allotments 

18 for all States under clause (i)(I) shall be 

19 equal to— 

20 ‘‘(I) $2,000,000,000 for fiscal 

21 year 2018; 

22 ‘‘(II) $3,000,000,000 for fiscal 

23 year 2019; 

24 ‘‘(III) $4,000,000,000 for fiscal 

25 year 2020; 


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1 ‘‘(IV) $5,000,000,000 for fiscal 

2 year 2021; 

3 ‘‘(V) $6,000,000,000 for fiscal 

4 year 2022; 

5 ‘‘(VI) $7,000,000,000 for fiscal 

6 year 2023; 

7 ‘‘(VII) $8,000,000,000 for fiscal 

8 year 2024; and 

9 ‘‘(VIII) $8,000,000,000 for fiscal 

10 year 2025.’’; and 

11 (C) by adding at the end the following new 

12 clause: 

13 ‘‘(v) DISTRIBUTION OF AGGREGATE

14 REDUCTIONS.—The Secretary shall dis15 tribute the aggregate reductions under 

16 clause (ii) among States in accordance 

17 with subparagraph (B).’’; and 

18 (2) in paragraph (8), by striking ‘‘2024’’ and 

19 inserting ‘‘2025’’. 

20 SEC. 413. LEVY ON DELINQUENT PROVIDERS. 

21 (a) IN GENERAL.—Paragraph (3) of section 6331(h) 

22 of the Internal Revenue Code of 1986 is amended by strik23 ing ‘‘30 percent’’ and inserting ‘‘100 percent’’. 


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1 (b) EFFECTIVE DATE.—The amendment made by 

2 this section shall apply to payments made after 180 days 

3 after the date of the enactment of this Act. 

4 SEC. 414. ADJUSTMENTS TO INPATIENT HOSPITAL PAY5 MENT RATES. 

6 Section 7(b) of the TMA, Abstinence Education, and 

7 QI Programs Extension Act of 2007 (Public Law 110– 

8 90), as amended by section 631(b) of the American Tax9 payer Relief Act of 2012 (Public Law 112–240), is amend10 ed— 

11 (1) in paragraph (1)— 

12 (A) in the matter preceding subparagraph 

13 (A), by striking ‘‘, 2009, or 2010’’ and insert14 ing ‘‘or 2009’’; and 

15 (B) in subparagraph (B)— 

16 (i) in clause (i), by striking ‘‘and’’ at 

17 the end; 

18 (ii) in clause (ii), by striking the pe19 riod at the end and inserting ‘‘; and’’; and 

20 (iii) by adding at the end the fol21 lowing new clause: 

22 ‘‘(iii) make an additional adjustment to the 

23 standardized amounts under such section 

24 1886(d) of an increase of 0.5 percentage points 

25 for discharges occurring during each of fiscal 


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1 years 2018 through 2023 and not make the ad2 justment (estimated to be an increase of 3.2 

3 percent) that would otherwise apply for dis4 charges occurring during fiscal year 2018 by 

5 reason of the completion of the adjustments re6 quired under clause (ii).’’; 

7 (2) in paragraph (3)— 

8 (A) by striking ‘‘shall be construed’’ and 

9 all that follows through ‘‘providing authority’’ 

10 and inserting ‘‘shall be construed as providing 

11 authority’’; and 

12 (B) by inserting ‘‘and each succeeding fis13 cal year through fiscal year 2023’’ after 

14 ‘‘2017’’; 

15 (3) by redesignating paragraphs (3) and (4) as 

16 paragraphs (4) and (5), respectively; and 

17 (4) by inserting after paragraph (2) the fol18 lowing new paragraph: 

19 ‘‘(3) PROHIBITION.—The Secretary shall not 

20 make an additional prospective adjustment (esti21 mated to be a decrease of 0.55 percent) to the 

22 standardized amounts under such section 1886(d) to 

23 offset the amount of the increase in aggregate pay24 ments related to documentation and coding changes 

25 for discharges occurring during fiscal year 2010.’’. 


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1 TITLE V—MISCELLANEOUS 

2 Subtitle A—Protecting the 

3 Integrity of Medicare 

4 SEC. 501. PROHIBITION OF INCLUSION OF SOCIAL SECU5 RITY ACCOUNT NUMBERS ON MEDICARE 

6 CARDS. 

7 (a) IN GENERAL.—Section 205(c)(2)(C) of the Social 

8 Security Act (42 U.S.C. 405(c)(2)(C)) is amended— 

9 (1) by moving clause (x), as added by section 

10 1414(a)(2) of the Patient Protection and Affordable 

11 Care Act, 6 ems to the left; 

12 (2) by redesignating clause (x), as added by 

13 section 2(a)(1) of the Social Security Number Pro14 tection Act of 2010, and clause (xi) as clauses (xi) 

15 and (xii), respectively; and 

16 (3) by adding at the end the following new 

17 clause: 

18 ‘‘(xiii) The Secretary of Health and Human Services, 

19 in consultation with the Commissioner of Social Security, 

20 shall establish cost-effective procedures to ensure that a 

21 Social Security account number (or derivative thereof) is 

22 not displayed, coded, or embedded on the Medicare card 

23 issued to an individual who is entitled to benefits under 

24 part A of title XVIII or enrolled under part B of title 

25 XVIII and that any other identifier displayed on such card 


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1 is not identifiable as a Social Security account number (or 

2 derivative thereof).’’. 

3 (b) IMPLEMENTATION.—In implementing clause (xiii) 

4 of section 205(c)(2)(C) of the Social Security Act (42 

5 U.S.C. 405(c)(2)(C)), as added by subsection (a)(3), the 

6 Secretary of Health and Human Services shall do the fol7 lowing: 

8 (1) IN GENERAL.—Establish a cost-effective 

9 process that involves the least amount of disruption 

10 to, as well as necessary assistance for, Medicare 

11 beneficiaries and health care providers, such as a 

12 process that provides such beneficiaries with access 

13 to assistance through a toll-free telephone number 

14 and provides outreach to providers. 

15 (2) CONSIDERATION OF MEDICARE BENE16 FICIARY IDENTIFIED.—Consider implementing a 

17 process, similar to the process involving Railroad Re18 tirement Board beneficiaries, under which a Medi19 care beneficiary identifier which is not a Social Secu20 rity account number (or derivative thereof) is used 

21 external to the Department of Health and Human 

22 Services and is convertible over to a Social Security 

23 account number (or derivative thereof) for use inter24 nal to such Department and the Social Security Ad25 ministration. 


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1 (c) FUNDING FOR IMPLEMENTATION.—For purposes 

2 of implementing the provisions of and the amendments 

3 made by this section, the Secretary of Health and Human 

4 Services shall provide for the following transfers from the 

5 Federal Hospital Insurance Trust Fund under section 

6 1817 of the Social Security Act (42 U.S.C. 1395i) and 

7 from the Federal Supplementary Medical Insurance Trust 

8 Fund established under section 1841 of such Act (42 

9 U.S.C. 1395t), in such proportions as the Secretary deter10 mines appropriate: 

11 (1) To the Centers for Medicare & Medicaid 

12 Program Management Account, transfers of the fol13 lowing amounts: 

14 (A) For fiscal year 2015, $65,000,000, to 

15 be made available through fiscal year 2018. 

16 (B) For each of fiscal years 2016 and 

17 2017, $53,000,000, to be made available 

18 through fiscal year 2018. 

19 (C) For fiscal year 2018, $48,000,000, to 

20 be made available until expended. 

21 (2) To the Social Security Administration Limi22 tation on Administration Account, transfers of the 

23 following amounts: 

24 (A) For fiscal year 2015, $27,000,000, to 

25 be made available through fiscal year 2018. 


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1 (B) For each of fiscal years 2016 and 

2 2017, $22,000,000, to be made available 

3 through fiscal year 2018. 

4 (C) For fiscal year 2018, $27,000,000, to 

5 be made available until expended. 

6 (3) To the Railroad Retirement Board Limita7 tion on Administration Account, the following 

8 amount: 

9 (A) For fiscal year 2015, $3,000,000, to 

10 be made available until expended. 

11 (d) EFFECTIVE DATE.— 

12 (1) IN GENERAL.—Clause (xiii) of section 

13 205(c)(2)(C) of the Social Security Act (42 U.S.C. 

14 405(c)(2)(C)), as added by subsection (a)(3), shall 

15 apply with respect to Medicare cards issued on and 

16 after an effective date specified by the Secretary of 

17 Health and Human Services, but in no case shall 

18 such effective date be later than the date that is four 

19 years after the date of the enactment of this Act. 

20 (2) REISSUANCE.—The Secretary shall provide 

21 for the reissuance of Medicare cards that comply 

22 with the requirements of such clause not later than 

23 four years after the effective date specified by the 

24 Secretary under paragraph (1). 


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1 SEC. 502. PREVENTING WRONGFUL MEDICARE PAYMENTS 

2 FOR ITEMS AND SERVICES FURNISHED TO IN3 CARCERATED INDIVIDUALS, INDIVIDUALS 

4 NOT LAWFULLY PRESENT, AND DECEASED IN5 DIVIDUALS. 

6 (a) REQUIREMENT FOR THE SECRETARY TO ESTAB7 LISH POLICIES AND CLAIMS EDITS RELATING TO INCAR8 CERATED INDIVIDUALS, INDIVIDUALS NOT LAWFULLY

9 PRESENT, AND DECEASED INDIVIDUALS.—Section 1874 

10 of the Social Security Act (42 U.S.C. 1395kk) is amended 

11 by adding at the end the following new subsection: 

12 ‘‘(f) REQUIREMENT FOR THE SECRETARY TO ESTAB13 LISH POLICIES AND CLAIMS EDITS RELATING TO INCAR14 CERATED INDIVIDUALS, INDIVIDUALS NOT LAWFULLY

15 PRESENT, AND DECEASED INDIVIDUALS.—The Secretary 

16 shall establish and maintain procedures, including proce17 dures for using claims processing edits, updating eligibility 

18 information to improve provider accessibility, and con19 ducting recoupment activities such as through recovery 

20 audit contractors, in order to ensure that payment is not 

21 made under this title for items and services furnished to 

22 an individual who is one of the following: 

23 ‘‘(1) An individual who is incarcerated. 

24 ‘‘(2) An individual who is not lawfully present 

25 in the United States and who is not eligible for cov26 erage under this title. 


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1 ‘‘(3) A deceased individual.’’. 

2 (b) REPORT.—Not later than 18 months after the 

3 date of the enactment of this section, and periodically 

4 thereafter as determined necessary by the Office of Inspec5 tor General of the Department of Health and Human 

6 Services, such Office shall submit to Congress a report 

7 on the activities described in subsection (f) of section 1874 

8 of the Social Security Act (42 U.S.C. 1395kk), as added 

9 by subsection (a), that have been conducted since such 

10 date of enactment. 

11 SEC. 503. CONSIDERATION OF MEASURES REGARDING 

12 MEDICARE BENEFICIARY SMART CARDS. 

13 To the extent the Secretary of Health and Human 

14 Services determines that it is cost effective and techno15 logically viable to use electronic Medicare beneficiary and 

16 provider cards (such as cards that use smart card tech17 nology, including an embedded and secure integrated cir18 cuit chip), as presented in the Government Accountability 

19 Office report required by the conference report accom20 panying the Consolidated Appropriations Act, 2014 (Pub21 lic Law 113–76), the Secretary shall consider such meas22 ures as determined appropriate by the Secretary to imple23 ment such use of such cards for beneficiary and provider 

24 use under title XVIII of the Social Security Act (42 

25 U.S.C. 1395 et seq.). In the case that the Secretary conVerDate Sep 11 2014 21:09 Mar 27, 2015 Jkt 049200 PO 00000 Frm 00221 Fmt 6652 Sfmt 6201 E:\BILLS\H2.RDS H2

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1 siders measures under the preceding sentence, the Sec2 retary shall submit to the Committees on Ways and Means 

3 and Energy and Commerce of the House of Representa4 tives, and to the Committee on Finance of the Senate, a 

5 report outlining the considerations undertaken by the Sec6 retary under such sentence. 

7 SEC. 504. MODIFYING MEDICARE DURABLE MEDICAL 

8 EQUIPMENT FACE-TO-FACE ENCOUNTER 

9 DOCUMENTATION REQUIREMENT. 

10 (a) IN GENERAL.—Section 1834(a)(11)(B)(ii) of the 

11 Social Security Act (42 U.S.C. 1395m(a)(11)(B)(ii)) is 

12 amended— 

13 (1) by striking ‘‘the physician documenting 

14 that’’; and 

15 (2) by striking ‘‘has had a face-to-face encoun16 ter’’ and inserting ‘‘documenting such physician, 

17 physician assistant, practitioner, or specialist has 

18 had a face-to-face encounter’’. 

19 (b) IMPLEMENTATION.—Notwithstanding any other 

20 provision of law, the Secretary of Health and Human 

21 Services may implement the amendments made by sub22 section (a) by program instruction or otherwise. 

23 SEC. 505. REDUCING IMPROPER MEDICARE PAYMENTS. 

24 (a) MEDICARE ADMINISTRATIVE CONTRACTOR IM25 PROPER PAYMENT OUTREACH AND EDUCATION PROVerDate Sep 11 2014 21:09 Mar 27, 2015 Jkt 049200 PO 00000 Frm 00222 Fmt 6652 Sfmt 6201 E:\BILLS\H2.RDS H2

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1 GRAM.—Section 1874A of the Social Security Act (42 

2 U.S.C. 1395kk–1) is amended— 

3 (1) in subsection (a)(4)— 

4 (A) by redesignating subparagraph (G) as 

5 subparagraph (H); and 

6 (B) by inserting after subparagraph (F) 

7 the following new subparagraph: 

8 ‘‘(G) IMPROPER PAYMENT OUTREACH AND

9 EDUCATION PROGRAM.—Having in place an im10 proper payment outreach and education pro11 gram described in subsection (h).’’; and 

12 (2) by adding at the end the following new sub13 section: 

14 ‘‘(h) IMPROPER PAYMENT OUTREACH AND EDU15 CATION PROGRAM.— 

16 ‘‘(1) IN GENERAL.—In order to reduce im17 proper payments under this title, each medicare ad18 ministrative contractor shall establish and have in 

19 place an improper payment outreach and education 

20 program under which the contractor, through out21 reach, education, training, and technical assistance 

22 or other activities, shall provide providers of services 

23 and suppliers located in the region covered by the 

24 contract under this section with the information de25 scribed in paragraph (2). The activities described in 


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1 the preceding sentence shall be conducted on a reg2 ular basis. 

3 ‘‘(2) INFORMATION TO BE PROVIDED THROUGH

4 ACTIVITIES.—The information to be provided under 

5 such payment outreach and education program shall 

6 include information the Secretary determines to be 

7 appropriate, which may include the following infor8 mation: 

9 ‘‘(A) A list of the providers’ or suppliers’ 

10 most frequent and expensive payment errors 

11 over the last quarter. 

12 ‘‘(B) Specific instructions regarding how to 

13 correct or avoid such errors in the future. 

14 ‘‘(C) A notice of new topics that have been 

15 approved by the Secretary for audits conducted 

16 by recovery audit contractors under section 

17 1893(h). 

18 ‘‘(D) Specific instructions to prevent fu19 ture issues related to such new audits. 

20 ‘‘(E) Other information determined appro21 priate by the Secretary. 

22 ‘‘(3) PRIORITY.—A medicare administrative 

23 contractor shall give priority to activities under such 

24 program that will reduce improper payments that 

25 are one or more of the following: 


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1 ‘‘(A) Are for items and services that have 

2 the highest rate of improper payment. 

3 ‘‘(B) Are for items and service that have 

4 the greatest total dollar amount of improper 

5 payments. 

6 ‘‘(C) Are due to clear misapplication or 

7 misinterpretation of Medicare policies. 

8 ‘‘(D) Are clearly due to common and inad9 vertent clerical or administrative errors. 

10 ‘‘(E) Are due to other types of errors that 

11 the Secretary determines could be prevented 

12 through activities under the program. 

13 ‘‘(4) INFORMATION ON IMPROPER PAYMENTS

14 FROM RECOVERY AUDIT CONTRACTORS.— 

15 ‘‘(A) IN GENERAL.—In order to assist 

16 medicare administrative contractors in carrying 

17 out improper payment outreach and education 

18 programs, the Secretary shall provide each con19 tractor with a complete list of the types of im20 proper payments identified by recovery audit 

21 contractors under section 1893(h) with respect 

22 to providers of services and suppliers located in 

23 the region covered by the contract under this 

24 section. Such information shall be provided on 


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1 a time frame the Secretary determines appro2 priate which may be on a quarterly basis. 

3 ‘‘(B) INFORMATION.—The information de4 scribed in subparagraph (A) shall include infor5 mation such as the following: 

6 ‘‘(i) Providers of services and sup7 pliers that have the highest rate of im8 proper payments. 

9 ‘‘(ii) Providers of services and sup10 pliers that have the greatest total dollar 

11 amounts of improper payments. 

12 ‘‘(iii) Items and services furnished in 

13 the region that have the highest rates of 

14 improper payments. 

15 ‘‘(iv) Items and services furnished in 

16 the region that are responsible for the 

17 greatest total dollar amount of improper 

18 payments. 

19 ‘‘(v) Other information the Secretary 

20 determines would assist the contractor in 

21 carrying out the program. 

22 ‘‘(5) COMMUNICATIONS.—Communications with 

23 providers of services and suppliers under an im24 proper payment outreach and education program are 


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1 subject to the standards and requirements of sub2 section (g).’’. 

3 (b) USE OF CERTAIN FUNDS RECOVERED BY

4 RACS.—Section 1893(h) of the Social Security Act (42 

5 U.S.C. 1395ddd(h)) is amended— 

6 (1) in paragraph (2), by inserting ‘‘or para7 graph (10)’’ after ‘‘paragraph (1)(C)’’; and 

8 (2) by adding at the end the following new 

9 paragraph: 

10 ‘‘(10) USE OF CERTAIN RECOVERED FUNDS.— 

11 ‘‘(A) IN GENERAL.—After application of 

12 paragraph (1)(C), the Secretary shall retain a 

13 portion of the amounts recovered by recovery 

14 audit contractors for each year under this sec15 tion which shall be available to the program 

16 management account of the Centers for Medi17 care & Medicaid Services for purposes of, sub18 ject to subparagraph (B), carrying out sections 

19 1833(z), 1834(l)(16), and 1874A(a)(4)(G), car20 rying out section 514(b) of the Medicare Access 

21 and CHIP Reauthorization Act of 2015, and 

22 implementing strategies (such as claims proc23 essing edits) to help reduce the error rate of 

24 payments under this title. The amounts re25 tained under the preceding sentence shall not 


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1 exceed an amount equal to 15 percent of the 

2 amounts recovered under this subsection, and 

3 shall remain available until expended. 

4 ‘‘(B) LIMITATION.—Except for uses that 

5 support claims processing (including edits) or 

6 system functionality for detecting fraud, 

7 amounts retained under subparagraph (A) may 

8 not be used for technological-related infrastruc9 ture, capital investments, or information sys10 tems. 

11 ‘‘(C) NO REDUCTION IN PAYMENTS TO RE12 COVERY AUDIT CONTRACTORS.—Nothing in 

13 subparagraph (A) shall reduce amounts avail14 able for payments to recovery audit contractors 

15 under this subsection.’’. 

16 SEC. 506. IMPROVING SENIOR MEDICARE PATROL AND 

17 FRAUD REPORTING REWARDS. 

18 (a) IN GENERAL.—The Secretary of Health and 

19 Human Services (in this section referred to as the ‘‘Sec20 retary’’) shall develop a plan to revise the incentive pro21 gram under section 203(b) of the Health Insurance Port22 ability and Accountability Act of 1996 (42 U.S.C. 1395b– 

23 5(b)) to encourage greater participation by individuals to 

24 report fraud and abuse in the Medicare program. Such 

25 plan shall include recommendations for— 


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1 (1) ways to enhance rewards for individuals re2 porting under the incentive program, including re3 wards based on information that leads to an admin4 istrative action; and 

5 (2) extending the incentive program to the 

6 Medicaid program. 

7 (b) PUBLIC AWARENESS AND EDUCATION CAM8 PAIGN.—The plan developed under subsection (a) shall 

9 also include recommendations for the use of the Senior 

10 Medicare Patrols authorized under section 411 of the 

11 Older Americans Act of 1965 (42 U.S.C. 3032) to conduct 

12 a public awareness and education campaign to encourage 

13 participation in the revised incentive program under sub14 section (a). 

15 (c) SUBMISSION OF PLAN.—Not later than 180 days 

16 after the date of enactment of this Act, the Secretary shall 

17 submit to Congress the plan developed under subsection 

18 (a). 

19 SEC. 507. REQUIRING VALID PRESCRIBER NATIONAL PRO20 VIDER IDENTIFIERS ON PHARMACY CLAIMS. 

21 Section 1860D–4(c) of the Social Security Act (42 

22 U.S.C. 1395w–104(c)) is amended by adding at the end 

23 the following new paragraph: 

24 ‘‘(4) REQUIRING VALID PRESCRIBER NATIONAL

25 PROVIDER IDENTIFIERS ON PHARMACY CLAIMS.— 


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1 ‘‘(A) IN GENERAL.—For plan year 2016 

2 and subsequent plan years, the Secretary shall 

3 require a claim for a covered part D drug for 

4 a part D eligible individual enrolled in a pre5 scription drug plan under this part or an MA– 

6 PD plan under part C to include a prescriber 

7 National Provider Identifier that is determined 

8 to be valid under the procedures established 

9 under subparagraph (B)(i). 

10 ‘‘(B) PROCEDURES.— 

11 ‘‘(i) VALIDITY OF PRESCRIBER NA12 TIONAL PROVIDER IDENTIFIERS.—The 

13 Secretary, in consultation with appropriate 

14 stakeholders, shall establish procedures for 

15 determining the validity of prescriber Na16 tional Provider Identifiers under subpara17 graph (A). 

18 ‘‘(ii) INFORMING BENEFICIARIES OF

19 REASON FOR DENIAL.—The Secretary shall 

20 establish procedures to ensure that, in the 

21 case that a claim for a covered part D 

22 drug of an individual described in subpara23 graph (A) is denied because the claim does 

24 not meet the requirements of this para25 graph, the individual is properly informed 


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1 at the point of service of the reason for the 

2 denial. 

3 ‘‘(C) REPORT.—Not later than January 1, 

4 2018, the Inspector General of the Department 

5 of Health and Human Services shall submit to 

6 Congress a report on the effectiveness of the 

7 procedures established under subparagraph 

8 (B)(i).’’. 

9 SEC. 508. OPTION TO RECEIVE MEDICARE SUMMARY NO10 TICE ELECTRONICALLY. 

11 (a) IN GENERAL.—Section 1806 of the Social Secu12 rity Act (42 U.S.C. 1395b–7) is amended by adding at 

13 the end the following new subsection: 

14 ‘‘(c) FORMAT OF STATEMENTS FROM SECRETARY.— 

15 ‘‘(1) ELECTRONIC OPTION BEGINNING IN

16 2016.—Subject to paragraph (2), for statements de17 scribed in subsection (a) that are furnished for a pe18 riod in 2016 or a subsequent year, in the case that 

19 an individual described in subsection (a) elects, in 

20 accordance with such form, manner, and time speci21 fied by the Secretary, to receive such statement in 

22 an electronic format, such statement shall be fur23 nished to such individual for each period subsequent 

24 to such election in such a format and shall not be 

25 mailed to the individual. 


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1 ‘‘(2) LIMITATION ON REVOCATION OPTION.— 

2 ‘‘(A) IN GENERAL.—Subject to subpara3 graph (B), the Secretary may determine a max4 imum number of elections described in para5 graph (1) by an individual that may be revoked 

6 by the individual. 

7 ‘‘(B) MINIMUM OF ONE REVOCATION OP8 TION.—In no case may the Secretary determine 

9 a maximum number under subparagraph (A) 

10 that is less than one. 

11 ‘‘(3) NOTIFICATION.—The Secretary shall en12 sure that, in the most cost effective manner and be13 ginning January 1, 2017, a clear notification of the 

14 option to elect to receive statements described in 

15 subsection (a) in an electronic format is made avail16 able, such as through the notices distributed under 

17 section 1804, to individuals described in subsection 

18 (a).’’. 

19 (b) ENCOURAGED EXPANSION OF ELECTRONIC

20 STATEMENTS.—To the extent to which the Secretary of 

21 Health and Human Services determines appropriate, the 

22 Secretary shall— 

23 (1) apply an option similar to the option de24 scribed in subsection (c)(1) of section 1806 of the 

25 Social Security Act (42 U.S.C. 1395b–7) (relating to 


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1 the provision of the Medicare Summary Notice in an 

2 electronic format), as added by subsection (a), to 

3 other statements and notifications under title XVIII 

4 of such Act (42 U.S.C. 1395 et seq.); and 

5 (2) provide such Medicare Summary Notice and 

6 any such other statements and notifications on a 

7 more frequent basis than is otherwise required under 

8 such title. 

9 SEC. 509. RENEWAL OF MAC CONTRACTS. 

10 (a) IN GENERAL.—Section 1874A(b)(1)(B) of the 

11 Social Security Act (42 U.S.C. 1395kk–1(b)(1)(B)) is 

12 amended by striking ‘‘5 years’’ and inserting ‘‘10 years’’. 

13 (b) APPLICATION.—The amendments made by sub14 section (a) shall apply to contracts entered into on or 

15 after, and to contracts in effect as of, the date of the en16 actment of this Act. 

17 (c) CONTRACTOR PERFORMANCE TRANSPARENCY.— 

18 Section 1874A(b)(3)(A) of the Social Security Act (42 

19 U.S.C. 1395kk–1(b)(3)(A)) is amended by adding at the 

20 end the following new clause: 

21 ‘‘(iv) CONTRACTOR PERFORMANCE

22 TRANSPARENCY.—To the extent possible 

23 without compromising the process for en24 tering into and renewing contracts with 

25 medicare administrative contractors under 


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1 this section, the Secretary shall make 

2 available to the public the performance of 

3 each medicare administrative contractor 

4 with respect to such performance require5 ments and measurement standards.’’. 

6 SEC. 510. STUDY ON PATHWAY FOR INCENTIVES TO STATES 

7 FOR STATE PARTICIPATION IN MEDICAID 

8 DATA MATCH PROGRAM. 

9 Section 1893(g) of the Social Security Act (42 U.S.C. 

10 1395ddd(g)) is amended by adding at the end the fol11 lowing new paragraph: 

12 ‘‘(3) INCENTIVES FOR STATES.—The Secretary 

13 shall study and, as appropriate, may specify incen14 tives for States to work with the Secretary for the 

15 purposes described in paragraph (1)(A)(ii). The ap16 plication of the previous sentence may include use of 

17 the waiver authority described in paragraph (2).’’. 

18 SEC. 511. GUIDANCE ON APPLICATION OF COMMON RULE 

19 TO CLINICAL DATA REGISTRIES. 

20 Not later than one year after the date of the enact21 ment of this section, the Secretary of Health and Human 

22 Services shall issue a clarification or modification with re23 spect to the application of subpart A of part 46 of title 

24 45, Code of Federal Regulations, governing the protection 

25 of human subjects in research (and commonly known as 


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1 the ‘‘Common Rule’’), to activities, including quality im2 provement activities, involving clinical data registries, in3 cluding entities that are qualified clinical data registries 

4 pursuant to section 1848(m)(3)(E) of the Social Security 

5 Act (42 U.S.C. 1395w–4(m)(3)(E)). 

6 SEC. 512. ELIMINATING CERTAIN CIVIL MONEY PENALTIES; 

7 GAINSHARING STUDY AND REPORT. 

8 (a) ELIMINATING CIVIL MONEY PENALTIES FOR IN9 DUCEMENTS TO PHYSICIANS TO LIMIT SERVICES THAT

10 ARE NOT MEDICALLY NECESSARY.— 

11 (1) IN GENERAL.—Section 1128A(b)(1) of the 

12 Social Security Act (42 U.S.C. 1320a–7a(b)(1)) is 

13 amended by inserting ‘‘medically necessary’’ after 

14 ‘‘reduce or limit’’. 

15 (2) EFFECTIVE DATE.—The amendment made 

16 by paragraph (1) shall apply to payments made on 

17 or after the date of the enactment of this Act. 

18 (b) GAINSHARING STUDY AND REPORT.—Not later 

19 than 12 months after the date of the enactment of this 

20 Act, the Secretary of Health and Human Services, in con21 sultation with the Inspector General of the Department 

22 of Health and Human Services, shall submit to Congress 

23 a report with options for amending existing fraud and 

24 abuse laws in, and regulations related to, titles XI and 

25 XVIII of the Social Security Act (42 U.S.C. 301 et seq.), 


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1 through exceptions, safe harbors, or other narrowly tar2 geted provisions, to permit gainsharing arrangements that 

3 otherwise would be subject to the civil money penalties de4 scribed in paragraphs (1) and (2) of section 1128A(b) of 

5 such Act (42 U.S.C. 1320a–7a(b)), or similar arrange6 ments between physicians and hospitals, and that improve 

7 care while reducing waste and increasing efficiency. The 

8 report shall— 

9 (1) consider whether such provisions should 

10 apply to ownership interests, compensation arrange11 ments, or other relationships; 

12 (2) describe how the recommendations address 

13 accountability, transparency, and quality, including 

14 how best to limit inducements to stint on care, dis15 charge patients prematurely, or otherwise reduce or 

16 limit medically necessary care; and 

17 (3) consider whether a portion of any savings 

18 generated by such arrangements (as compared to an 

19 historical benchmark or other metric specified by the 

20 Secretary to determine the impact of delivery and 

21 payment system changes under such title XVIII on 

22 expenditures made under such title) should accrue to 

23 the Medicare program under title XVIII of the So24 cial Security Act. 


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1 SEC. 513. MODIFICATION OF MEDICARE HOME HEALTH 

2 SURETY BOND CONDITION OF PARTICIPA3 TION REQUIREMENT. 

4 Section 1861(o)(7) of the Social Security Act (42 

5 U.S.C. 1395x(o)(7)) is amended to read as follows: 

6 ‘‘(7) provides the Secretary with a surety 

7 bond— 

8 ‘‘(A) in a form specified by the Secretary 

9 and in an amount that is not less than the min10 imum of $50,000; and 

11 ‘‘(B) that the Secretary determines is com12 mensurate with the volume of payments to the 

13 home health agency; and’’. 

14 SEC. 514. OVERSIGHT OF MEDICARE COVERAGE OF MAN15 UAL MANIPULATION OF THE SPINE TO COR16 RECT SUBLUXATION. 

17 (a) IN GENERAL.—Section 1833 of the Social Secu18 rity Act (42 U.S.C. 1395l) is amended by adding at the 

19 end the following new subsection: 

20 ‘‘(z) MEDICAL REVIEW OF SPINAL SUBLUXATION

21 SERVICES.— 

22 ‘‘(1) IN GENERAL.—The Secretary shall imple23 ment a process for the medical review (as described 

24 in paragraph (2)) of treatment by a chiropractor de25 scribed in section 1861(r)(5) by means of manual 

26 manipulation of the spine to correct a subluxation 


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1 (as described in such section) of an individual who 

2 is enrolled under this part and apply such process to 

3 such services furnished on or after January 1, 2017, 

4 focusing on services such as— 

5 ‘‘(A) services furnished by a such a chiro6 practor whose pattern of billing is aberrant 

7 compared to peers; and 

8 ‘‘(B) services furnished by such a chiro9 practor who, in a prior period, has a services 

10 denial percentage in the 85th percentile or 

11 greater, taking into consideration the extent 

12 that service denials are overturned on appeal. 

13 ‘‘(2) MEDICAL REVIEW.— 

14 ‘‘(A) PRIOR AUTHORIZATION MEDICAL RE15 VIEW.— 

16 ‘‘(i) IN GENERAL.—Subject to clause 

17 (ii), the Secretary shall use prior author18 ization medical review for services de19 scribed in paragraph (1) that are furnished 

20 to an individual by a chiropractor de21 scribed in section 1861(r)(5) that are part 

22 of an episode of treatment that includes 

23 more than 12 services. For purposes of the 

24 preceding sentence, an episode of treat25 ment shall be determined by the underlying 


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1 cause that justifies the need for services, 

2 such as a diagnosis code. 

3 ‘‘(ii) ENDING APPLICATION OF PRIOR

4 AUTHORIZATION MEDICAL REVIEW.—The 

5 Secretary shall end the application of prior 

6 authorization medical review under clause 

7 (i) to services described in paragraph (1) 

8 by such a chiropractor if the Secretary de9 termines that the chiropractor has a low 

10 denial rate under such prior authorization 

11 medical review. The Secretary may subse12 quently reapply prior authorization medical 

13 review to such chiropractor if the Secretary 

14 determines it to be appropriate and the 

15 chiropractor has, in the time period subse16 quent to the determination by the Sec17 retary of a low denial rate with respect to 

18 the chiropractor, furnished such services 

19 described in paragraph (1). 

20 ‘‘(iii) EARLY REQUEST FOR PRIOR AU21 THORIZATION REVIEW PERMITTED.—Noth22 ing in this subsection shall be construed to 

23 prevent such a chiropractor from request24 ing prior authorization for services de25 scribed in paragraph (1) that are to be 


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1 furnished to an individual before the chiro2 practor furnishes the twelfth such service 

3 to such individual for an episode of treat4 ment. 

5 ‘‘(B) TYPE OF REVIEW.—The Secretary 

6 may use pre-payment review or post-payment 

7 review of services described in section 

8 1861(r)(5) that are not subject to prior author9 ization medical review under subparagraph (A). 

10 ‘‘(C) RELATIONSHIP TO LAW ENFORCE11 MENT ACTIVITIES.—The Secretary may deter12 mine that medical review under this subsection 

13 does not apply in the case where potential fraud 

14 may be involved. 

15 ‘‘(3) NO PAYMENT WITHOUT PRIOR AUTHORIZA16 TION.—With respect to a service described in para17 graph (1) for which prior authorization medical re18 view under this subsection applies, the following 

19 shall apply: 

20 ‘‘(A) PRIOR AUTHORIZATION DETERMINA21 TION.—The Secretary shall make a determina22 tion, prior to the service being furnished, of 

23 whether the service would or would not meet 

24 the applicable requirements of section 

25 1862(a)(1)(A). 


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1 ‘‘(B) DENIAL OF PAYMENT.—Subject to 

2 paragraph (5), no payment may be made under 

3 this part for the service unless the Secretary 

4 determines pursuant to subparagraph (A) that 

5 the service would meet the applicable require6 ments of such section 1862(a)(1)(A). 

7 ‘‘(4) SUBMISSION OF INFORMATION.—A chiro8 practor described in section 1861(r)(5) may submit 

9 the information necessary for medical review by fax, 

10 by mail, or by electronic means. The Secretary shall 

11 make available the electronic means described in the 

12 preceding sentence as soon as practicable. 

13 ‘‘(5) TIMELINESS.—If the Secretary does not 

14 make a prior authorization determination under 

15 paragraph (3)(A) within 14 business days of the 

16 date of the receipt of medical documentation needed 

17 to make such determination, paragraph (3)(B) shall 

18 not apply. 

19 ‘‘(6) APPLICATION OF LIMITATION ON BENE20 FICIARY LIABILITY.—Where payment may not be 

21 made as a result of the application of paragraph 

22 (2)(B), section 1879 shall apply in the same manner 

23 as such section applies to a denial that is made by 

24 reason of section 1862(a)(1). 


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1 ‘‘(7) REVIEW BY CONTRACTORS.—The medical 

2 review described in paragraph (2) may be conducted 

3 by medicare administrative contractors pursuant to 

4 section 1874A(a)(4)(G) or by any other contractor 

5 determined appropriate by the Secretary that is not 

6 a recovery audit contractor. 

7 ‘‘(8) MULTIPLE SERVICES.—The Secretary 

8 shall, where practicable, apply the medical review 

9 under this subsection in a manner so as to allow an 

10 individual described in paragraph (1) to obtain, at a 

11 single time rather than on a service-by-service basis, 

12 an authorization in accordance with paragraph 

13 (3)(A) for multiple services. 

14 ‘‘(9) CONSTRUCTION.—With respect to a serv15 ice described in paragraph (1) that has been af16 firmed by medical review under this subsection, 

17 nothing in this subsection shall be construed to pre18 clude the subsequent denial of a claim for such serv19 ice that does not meet other applicable requirements 

20 under this Act. 

21 ‘‘(10) IMPLEMENTATION.— 

22 ‘‘(A) AUTHORITY.—The Secretary may im23 plement the provisions of this subsection by in24 terim final rule with comment period. 


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1 ‘‘(B) ADMINISTRATION.—Chapter 35 of 

2 title 44, United States Code, shall not apply to 

3 medical review under this subsection.’’. 

4 (b) IMPROVING DOCUMENTATION OF SERVICES.— 

5 (1) IN GENERAL.—The Secretary of Health and 

6 Human Services shall, in consultation with stake7 holders (including the American Chiropractic Asso8 ciation) and representatives of medicare administra9 tive contractors (as defined in section 

10 1874A(a)(3)(A) of the Social Security Act (42 

11 U.S.C. 1395kk–1(a)(3)(A))), develop educational 

12 and training programs to improve the ability of 

13 chiropractors to provide documentation to the Sec14 retary of services described in section 1861(r)(5) in 

15 a manner that demonstrates that such services are, 

16 in accordance with section 1862(a)(1) of such Act 

17 (42 U.S.C. 1395y(a)(1)), reasonable and necessary 

18 for the diagnosis or treatment of illness or injury or 

19 to improve the functioning of a malformed body 

20 member. 

21 (2) TIMING.—The Secretary shall make the 

22 educational and training programs described in 

23 paragraph (1) publicly available not later than Janu24 ary 1, 2016. 


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1 (3) FUNDING.—The Secretary shall use funds 

2 made available under paragraph (10) of section 

3 1893(h) of the Social Security Act (42 U.S.C. 

4 1395ddd(h)), as added by section 505, to carry out 

5 this subsection. 

6 (c) GAO STUDY AND REPORT.— 

7 (1) STUDY.—The Comptroller General of the 

8 United States shall conduct a study on the effective9 ness of the process for medical review of services 

10 furnished as part of a treatment by means of man11 ual manipulation of the spine to correct a sub12 luxation implemented under subsection (z) of section 

13 1833 of the Social Security Act (42 U.S.C. 1395l), 

14 as added by subsection (a). Such study shall include 

15 an analysis of— 

16 (A) aggregate data on— 

17 (i) the number of individuals, chiro18 practors, and claims for services subject to 

19 such review; and 

20 (ii) the number of reviews conducted 

21 under such section; and 

22 (B) the outcomes of such reviews. 

23 (2) REPORT.—Not later than four years after 

24 the date of enactment of this Act, the Comptroller 

25 General shall submit to Congress a report containing 


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1 the results of the study conducted under paragraph 

2 (1), including recommendations for such legislation 

3 and administrative action with respect to the process 

4 for medical review implemented under subsection (z) 

5 of section 1833 of the Social Security Act (42 

6 U.S.C. 1395l) as the Comptroller General deter7 mines appropriate. 

8 SEC. 515. NATIONAL EXPANSION OF PRIOR AUTHORIZA9 TION MODEL FOR REPETITIVE SCHEDULED 

10 NON-EMERGENT AMBULANCE TRANSPORT. 

11 (a) INITIAL EXPANSION.— 

12 (1) IN GENERAL.—In implementing the model 

13 described in paragraph (2) proposed to be tested 

14 under subsection (b) of section 1115A of the Social 

15 Security Act (42 U.S.C. 1315a), the Secretary of 

16 Health and Human Services shall revise the testing 

17 under subsection (b) of such section to cover, effec18 tive not later than January 1, 2016, States located 

19 in medicare administrative contractor (MAC) regions 

20 L and 11 (consisting of Delaware, the District of 

21 Columbia, Maryland, New Jersey, Pennsylvania, 

22 North Carolina, South Carolina, West Virginia, and 

23 Virginia). 

24 (2) MODEL DESCRIBED.—The model described 

25 in this paragraph is the testing of a model of prior 


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1 authorization for repetitive scheduled non-emergent 

2 ambulance transport proposed to be carried out in 

3 New Jersey, Pennsylvania, and South Carolina. 

4 (3) FUNDING.—The Secretary shall allocate 

5 funds made available under section 1115A(f)(1)(B) 

6 of the Social Security Act (42 U.S.C. 

7 1315a(f)(1)(B)) to carry out this subsection. 

8 (b) NATIONAL EXPANSION.—Section 1834(l) of the 

9 Social Security Act (42 U.S.C. 1395m(l)) is amended by 

10 adding at the end the following new paragraph: 

11 ‘‘(16) PRIOR AUTHORIZATION FOR REPETITIVE

12 SCHEDULED NON-EMERGENT AMBULANCE TRANS13 PORTS.— 

14 ‘‘(A) IN GENERAL.—Beginning January 1, 

15 2017, if the expansion to all States of the 

16 model of prior authorization described in para17 graph (2) of section 515(a) of the Medicare Ac18 cess and CHIP Reauthorization Act of 2015 

19 meets the requirements described in paragraphs 

20 (1) through (3) of section 1115A(c), then the 

21 Secretary shall expand such model to all States. 

22 ‘‘(B) FUNDING.—The Secretary shall use 

23 funds made available under section 1893(h)(10) 

24 to carry out this paragraph. 


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1 ‘‘(C) CLARIFICATION REGARDING BUDGET

2 NEUTRALITY.—Nothing in this paragraph may 

3 be construed to limit or modify the application 

4 of section 1115A(b)(3)(B) to models described 

5 in such section, including with respect to the 

6 model described in subparagraph (A) and ex7 panded beginning on January 1, 2017, under 

8 such subparagraph.’’. 

9 SEC. 516. REPEALING DUPLICATIVE MEDICARE SEC10 ONDARY PAYOR PROVISION. 

11 (a) IN GENERAL.—Section 1862(b)(5) of the Social 

12 Security Act (42 U.S.C. 1395y(b)(5)) is amended by in13 serting at the end the following new subparagraph: 

14 ‘‘(E) END DATE.—The provisions of this 

15 paragraph shall not apply to information re16 quired to be provided on or after July 1, 

17 2016.’’. 

18 (b) EFFECTIVE DATE.—The amendment made by 

19 subsection (a) shall take effect on the date of the enact20 ment of this Act and shall apply to information required 

21 to be provided on or after January 1, 2016. 

22 SEC. 517. PLAN FOR EXPANDING DATA IN ANNUAL CERT 

23 REPORT. 

24 Not later than June 30, 2015, the Secretary of 

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1 mittee on Finance of the Senate, and to the Committees 

2 on Energy and Commerce and Ways and Means of the 

3 House of Representatives— 

4 (1) a plan for including, in the annual report of 

5 the Comprehensive Error Rate Testing (CERT) pro6 gram, data on services (or groupings of services) 

7 (other than medical visits) paid under the physician 

8 fee schedule under section 1848 of the Social Secu9 rity Act (42 U.S.C. 1395w–4) where the fee sched10 ule amount is in excess of $250 and where the error 

11 rate is in excess of 20 percent; and 

12 (2) to the extent practicable by such date, spe13 cific examples of services described in paragraph (1). 

14 SEC. 518. REMOVING FUNDS FOR MEDICARE IMPROVE15 MENT FUND ADDED BY IMPACT ACT OF 2014. 

16 Section 1898(b)(1) of the Social Security Act (42 

17 U.S.C. 1395iii(b)(1)), as amended by section 3(e)(3) of 

18 the IMPACT Act of 2014 (Public Law 113–185), is 

19 amended by striking ‘‘$195,000,000’’ and inserting ‘‘$0’’. 

20 SEC. 519. RULE OF CONSTRUCTION. 

21 Except as explicitly provided in this subtitle, nothing 

22 in this subtitle, including the amendments made by this 

23 subtitle, shall be construed as preventing the use of notice 

24 and comment rulemaking in the implementation of the 

25 provisions of, and the amendments made by, this subtitle. 


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1 Subtitle B—Other Provisions 

2 SEC. 521. EXTENSION OF TWO-MIDNIGHT PAMA RULES ON 

3 CERTAIN MEDICAL REVIEW ACTIVITIES. 

4 Section 111 of the Protecting Access to Medicare Act 

5 of 2014 (Public Law 113–93; 42 U.S.C. 1395ddd note) 

6 is amended— 

7 (1) in subsection (a), by striking ‘‘the first 6 

8 months of fiscal year 2015’’ and inserting ‘‘through 

9 the end of fiscal year 2015’’; 

10 (2) in subsection (b), by striking ‘‘March 31, 

11 2015’’ and inserting ‘‘September 30, 2015’’; and 

12 (3) by adding at the end the following new sub13 section: 

14 ‘‘(c) CONSTRUCTION.—Except as provided in sub15 sections (a) and (b), nothing in this section shall be con16 strued as limiting the Secretary’s authority to pursue 

17 fraud and abuse activities under such section 1893(h) or 

18 otherwise.’’. 

19 SEC. 522. REQUIRING BID SURETY BONDS AND STATE LI20 CENSURE FOR ENTITIES SUBMITTING BIDS 

21 UNDER THE MEDICARE DMEPOS COMPETI22 TIVE ACQUISITION PROGRAM. 

23 (a) BID SURETY BONDS.—Section 1847(a)(1) of the 

24 Social Security Act (42 U.S.C. 1395w–3(a)(1)) is amend25 ed by adding at the end the following new subparagraphs: 


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1 ‘‘(G) REQUIRING BID BONDS FOR BIDDING

2 ENTITIES.—With respect to rounds of competi3 tions beginning under this subsection for con4 tracts beginning not earlier than January 1, 

5 2017, and not later than January 1, 2019, an 

6 entity may not submit a bid for a competitive 

7 acquisition area unless, as of the deadline for 

8 bid submission, the entity has obtained (and 

9 provided the Secretary with proof of having ob10 tained) a bid surety bond (in this paragraph re11 ferred to as a ‘bid bond’) in a form specified by 

12 the Secretary consistent with subparagraph (H) 

13 and in an amount that is not less than $50,000 

14 and not more than $100,000 for each competi15 tive acquisition area in which the entity submits 

16 the bid. 

17 ‘‘(H) TREATMENT OF BID BONDS SUB18 MITTED.— 

19 ‘‘(i) FOR BIDDERS THAT SUBMIT BIDS

20 AT OR BELOW THE MEDIAN AND ARE OF21 FERED BUT DO NOT ACCEPT THE CON22 TRACT.—In the case of a bidding entity 

23 that is offered a contract for any product 

24 category for a competitive acquisition area, 

25 if— 


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1 ‘‘(I) the entity’s composite bid 

2 for such product category and area 

3 was at or below the median composite 

4 bid rate for all bidding entities in5 cluded in the calculation of the single 

6 payment amounts for such product 

7 category and area; and 

8 ‘‘(II) the entity does not accept 

9 the contract offered for such product 

10 category and area, 

11 the bid bond submitted by such entity for 

12 such area shall be forfeited by the entity 

13 and the Secretary shall collect on it. 

14 ‘‘(ii) TREATMENT OF OTHER BID15 DERS.—In the case of a bidding entity for 

16 any product category for a competitive ac17 quisition area, if the entity does not meet 

18 the bid forfeiture conditions in subclauses 

19 (I) and (II) of clause (i) for any product 

20 category for such area, the bid bond sub21 mitted by such entity for such area shall 

22 be returned within 90 days of the public 

23 announcement of the contract suppliers for 

24 such area.’’. 

25 (b) STATE LICENSURE.— 


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1 (1) IN GENERAL.—Section 1847(b)(2)(A) of the 

2 Social Security Act (42 U.S.C. 1395w–3(b)(2)(A)) is 

3 amended by adding at the end the following new 

4 clause: 

5 ‘‘(v) The entity meets applicable State 

6 licensure requirements.’’. 

7 (2) CONSTRUCTION.—Nothing in the amend8 ment made by paragraph (1) shall be construed as 

9 affecting the authority of the Secretary of Health 

10 and Human Services to require State licensure of an 

11 entity under the Medicare competitive acquisition 

12 program under section 1847 of the Social Security 

13 Act (42 U.S.C. 1395w–3) before the date of the en14 actment of this Act. 

15 (c) GAO REPORT ON BID BOND IMPACT ON SMALL

16 SUPPLIERS.— 

17 (1) STUDY.—The Comptroller General of the 

18 United States shall conduct a study that evaluates 

19 the effect of the bid surety bond requirement under 

20 the amendment made by subsection (a) on the par21 ticipation of small suppliers in the Medicare 

22 DMEPOS competitive acquisition program under 

23 section 1847 of the Social Security Act (42 U.S.C. 

24 1395w–3). 


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1 (2) REPORT.—Not later than 6 months after 

2 the date contracts are first awarded subject to such 

3 bid surety bond requirement, the Comptroller Gen4 eral shall submit to Congress a report on the study 

5 conducted under paragraph (1). Such report shall 

6 include recommendations for changes in such re7 quirement in order to ensure robust participation by 

8 legitimate small suppliers in the Medicare DMEPOS 

9 competition acquisition program. 

10 SEC. 523. PAYMENT FOR GLOBAL SURGICAL PACKAGES. 

11 (a) IN GENERAL.—Section 1848(c) of the Social Se12 curity Act (42 U.S.C. 1395w–4(c)) is amended by adding 

13 at the end the following new paragraph: 

14 ‘‘(8) GLOBAL SURGICAL PACKAGES.— 

15 ‘‘(A) PROHIBITION OF IMPLEMENTATION

16 OF RULE REGARDING GLOBAL SURGICAL PACK17 AGES.— 

18 ‘‘(i) IN GENERAL.—The Secretary 

19 shall not implement the policy established 

20 in the final rule published on November 

21 13, 2014 (79 Fed. Reg. 67548 et seq.), 

22 that requires the transition of all 10-day 

23 and 90-day global surgery packages to 0- 

24 day global periods. 


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1 ‘‘(ii) CONSTRUCTION.—Nothing in 

2 clause (i) shall be construed to prevent the 

3 Secretary from revaluing misvalued codes 

4 for specific surgical services or assigning 

5 values to new or revised codes for surgical 

6 services. 

7 ‘‘(B) COLLECTION OF DATA ON SERVICES

8 INCLUDED IN GLOBAL SURGICAL PACKAGES.— 

9 ‘‘(i) IN GENERAL.—Subject to clause 

10 (ii), the Secretary shall through rule11 making develop and implement a process 

12 to gather, from a representative sample of 

13 physicians, beginning not later than Janu14 ary 1, 2017, information needed to value 

15 surgical services. Such information shall 

16 include the number and level of medical 

17 visits furnished during the global period 

18 and other items and services related to the 

19 surgery and furnished during the global 

20 period, as appropriate. Such information 

21 shall be reported on claims at the end of 

22 the global period or in another manner 

23 specified by the Secretary. For purposes of 

24 carrying out this paragraph (other than 

25 clause (iii)), the Secretary shall transfer 


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1 from the Federal Supplemental Medical In2 surance Trust Fund under section 1841 

3 $2,000,000 to the Center for Medicare & 

4 Medicaid Services Program Management 

5 Account for fiscal year 2015. Amounts 

6 transferred under the previous sentence 

7 shall remain available until expended. 

8 ‘‘(ii) REASSESSMENT AND POTENTIAL

9 SUNSET.—Every 4 years, the Secretary 

10 shall reassess the value of the information 

11 collected pursuant to clause (i). Based on 

12 such a reassessment and by regulation, the 

13 Secretary may discontinue the requirement 

14 for collection of information under such 

15 clause if the Secretary determines that the 

16 Secretary has adequate information from 

17 other sources, such as qualified clinical 

18 data registries, surgical logs, billing sys19 tems or other practice or facility records, 

20 and electronic health records, in order to 

21 accurately value global surgical services 

22 under this section. 

23 ‘‘(iii) INSPECTOR GENERAL AUDIT.— 

24 The Inspector General of the Department 

25 of Health and Human Services shall audit 


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1 a sample of the information reported under 

2 clause (i) to verify the accuracy of the in3 formation so reported. 

4 ‘‘(C) IMPROVING ACCURACY OF PRICING

5 FOR SURGICAL SERVICES.—For years beginning 

6 with 2019, the Secretary shall use the informa7 tion reported under subparagraph (B)(i) as ap8 propriate and other available data for the pur9 pose of improving the accuracy of valuation of 

10 surgical services under the physician fee sched11 ule under this section.’’. 

12 (b) INCENTIVE FOR REPORTING INFORMATION ON

13 GLOBAL SURGICAL SERVICES.—Section 1848(a) of the 

14 Social Security Act (42 U.S.C. 1395w–4(a)) is amended 

15 by adding at the end the following new paragraph: 

16 ‘‘(9) INFORMATION REPORTING ON SERVICES

17 INCLUDED IN GLOBAL SURGICAL PACKAGES.—With 

18 respect to services for which a physician is required 

19 to report information in accordance with subsection 

20 (c)(8)(B)(i), the Secretary may through rulemaking 

21 delay payment of 5 percent of the amount that 

22 would otherwise be payable under the physician fee 

23 schedule under this section for such services until 

24 the information so required is reported.’’. 


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1 SEC. 524. EXTENSION OF SECURE RURAL SCHOOLS AND 

2 COMMUNITY SELF-DETERMINATION ACT OF 

3 2000. 

4 (a) PAYMENTS FOR FISCAL YEARS 2014 AND

5 2015.— 

6 (1) PAYMENTS REQUIRED.—Section 101 of the 

7 Secure Rural Schools and Community Self-Deter8 mination Act of 2000 (16 U.S.C. 7111) is amended 

9 by striking ‘‘2013’’ both places it appears and in10 serting ‘‘2015’’. 

11 (2) PROMPT PAYMENT.—Payments for fiscal 

12 year 2014 under title I of the Secure Rural Schools 

13 and Community Self-Determination Act of 2000 (16 

14 U.S.C. 7111 et seq.), as amended by this section, 

15 shall be made not later than 45 days after the date 

16 of the enactment of this Act. 

17 (3) REDUCTION IN FISCAL YEAR 2014 PAY18 MENTS ON ACCOUNT OF PREVIOUS 25- AND 50-PER19 CENT PAYMENTS.—Section 101 of the Secure Rural 

20 Schools and Community Self-Determination Act of 

21 2000 (16 U.S.C. 7111) is amended by adding at the 

22 end the following new subsection: 

23 ‘‘(c) SPECIAL RULE FOR FISCAL YEAR 2014 PAY24 MENTS.— 

25 ‘‘(1) STATE PAYMENT.—If an eligible county in 

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1 ment for fiscal year 2014 has already received, or 

2 will receive, a share of the 25-percent payment for 

3 fiscal year 2014 distributed to the State before the 

4 date of the enactment of this subsection, the amount 

5 of the State payment shall be reduced by the 

6 amount of that eligible county’s share of the 25-per7 cent payment. 

8 ‘‘(2) COUNTY PAYMENT.—If an eligible county 

9 that will receive a county payment for fiscal year 

10 2014 has already received a 50-percent payment for 

11 that fiscal year, the amount of the county payment 

12 shall be reduced by the amount of the 50-percent 

13 payment.’’. 

14 (4) SHARES OF CALIFORNIA STATE PAY15 MENT.—Section 103(d)(2) of the Secure Rural 

16 Schools and Community Self-Determination Act of 

17 2000 (16 U.S.C. 7113(d)(2)) is amended by striking 

18 ‘‘2013’’ and inserting ‘‘2015’’. 

19 (b) USE OF FISCAL YEAR 2013 ELECTIONS AND

20 RESERVATIONS FOR FISCAL YEARS 2014 AND 2015.— 

21 Section 102 of the Secure Rural Schools and Community 

22 Self-Determination Act of 2000 (16 U.S.C. 7112) is 

23 amended— 

24 (1) in subsection (b)(1), by adding at the end 

25 the following new subparagraph: 


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1 ‘‘(C) EFFECT OF LATE PAYMENT FOR FIS2 CAL YEARS 2014 AND 2015.—The election other3 wise required by subparagraph (A) shall not 

4 apply for fiscal year 2014 or 2015.’’; 

5 (2) in subsection (b)(2)— 

6 (A) in subparagraph (A), by adding at the 

7 end the following new sentence: ‘‘If such two8 fiscal year period included fiscal year 2013, the 

9 county election to receive a share of the 25-per10 cent payment or 50-percent payment, as appli11 cable, also shall be effective for fiscal years 

12 2014 and 2015.’’; and 

13 (B) in subparagraph (B), by striking 

14 ‘‘2013’’ the second place it appears and insert15 ing ‘‘2015’’; and 

16 (3) in subsection (d)— 

17 (A) by adding at the end of paragraph (1) 

18 the following new subparagraph: 

19 ‘‘(E) EFFECT OF LATE PAYMENT FOR FIS20 CAL YEAR 2014.—The election made by an eligi21 ble county under subparagraph (B), (C), or (D) 

22 for fiscal year 2013, or deemed to be made by 

23 the county under paragraph (3)(B) for that fis24 cal year, shall be effective for fiscal years 2014 

25 and 2015.’’; and 


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1 (B) by adding at the end of paragraph (3) 

2 the following new subparagraph: 

3 ‘‘(C) EFFECT OF LATE PAYMENT FOR FIS4 CAL YEAR 2014.—This paragraph does not apply 

5 for fiscal years 2014 and 2015.’’. 

6 (c) SPECIAL PROJECTS ON FEDERAL LAND.—Title 

7 II of the Secure Rural Schools and Community Self-Deter8 mination Act of 2000 (16 U.S.C. 7121 et seq.) is amend9 ed— 

10 (1) in section 203(a)(1) (16 U.S.C. 

11 7123(a)(1)), by striking ‘‘September 30 for fiscal 

12 year 2008 (or as soon thereafter as the Secretary 

13 concerned determines is practicable), and each Sep14 tember 30 thereafter for each succeeding fiscal year 

15 through fiscal year 2013’’ and inserting ‘‘September 

16 30 of each fiscal year (or a later date specified by 

17 the Secretary concerned for the fiscal year)’’; 

18 (2) in section 204(e)(3)(B)(iii) (16 U.S.C. 

19 7124(e)(3)(B)(iii)), by striking ‘‘each of fiscal years 

20 2010 through 2013’’ and inserting ‘‘fiscal year 2010 

21 and fiscal years thereafter’’; 

22 (3) in section 207(a) (16 U.S.C. 7127(a)), by 

23 striking ‘‘September 30, 2008 (or as soon thereafter 

24 as the Secretary concerned determines is prac25 ticable), and each September 30 thereafter for each 


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1 succeeding fiscal year through fiscal year 2013’’ and 

2 inserting ‘‘September 30 of each fiscal year (or a 

3 later date specified by the Secretary concerned for 

4 the fiscal year)’’; and 

5 (4) in section 208 (16 U.S.C. 7128)— 

6 (A) in subsection (a), by striking ‘‘2013’’ 

7 and inserting ‘‘2017’’; and 

8 (B) in subsection (b), by striking ‘‘2014’’ 

9 and inserting ‘‘2018’’. 

10 (d) COUNTY FUNDS.—Section 304 of the Secure 

11 Rural Schools and Community Self-Determination Act of 

12 2000 (16 U.S.C. 7144) is amended— 

13 (1) in subsection (a), by striking ‘‘2013’’ and 

14 inserting ‘‘2017’’; and 

15 (2) in subsection (b), by striking ‘‘2014’’ and 

16 inserting ‘‘2018’’. 

17 (e) AUTHORIZATION OF APPROPRIATIONS.—Section 

18 402 of the Secure Rural Schools and Community Self-De19 termination Act of 2000 (16 U.S.C. 7152) is amended by 

20 striking ‘‘for each of fiscal years 2008 through 2013’’. 

21 SEC. 525. EXCLUSION FROM PAYGO SCORECARDS. 

22 (a) STATUTORY PAY-AS-YOU-GO SCORECARDS.—The 

23 budgetary effects of this Act shall not be entered on either 

24 PAYGO scorecard maintained pursuant to section 4(d) of 

25 the Statutory Pay-As-You-Go Act of 2010. 


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1 (b) SENATE PAYGO SCORECARDS.—The budgetary 

2 effects of this Act shall not be entered on any PAYGO 

3 scorecard maintained for purposes of section 201 of S. 

4 Con. Res. 21 (110th Congress). 

Passed the House of Representatives March 26, 

2015. 

Attest: KAREN L. HAAS, 

Clerk. 


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