II 

Calendar No. 776 

110TH CONGRESS 

2D SESSION S. 3118 

To amend titles XVIII and XIX of the Social Security Act to preserve 

beneficiary access to care by preventing a reduction in the Medicare 

physician fee schedule, to improve the quality of care by advancing 

value based purchasing, electronic health records, and electronic prescribing, and to maintain and improve access to care in rural areas, 

and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

JUNE 11, 2008 

Mr. GRASSLEY (for himself, Mr. MCCONNELL, Mr. KYL, Mr. HATCH, Mr. 

SUNUNU, Mr. BUNNING, Mr. CRAPO, Mr. BURR, Mr. ENSIGN, Mr. ENZI, 

Mr. COLEMAN, Ms. MURKOWSKI, and Mr. STEVENS) introduced the following bill; which was read the first time 

JUNE 12, 2008 

Read the second time and placed on the calendar 

A BILL 

To amend titles XVIII and XIX of the Social Security Act 

to preserve beneficiary access to care by preventing a 

reduction in the Medicare physician fee schedule, to improve the quality of care by advancing value based purchasing, electronic health records, and electronic prescribing, and to maintain and improve access to care 

in rural areas, 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 ‘‘Preserving Access to Medicare Act of 2008’’. 

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

7 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—MEDICARE 

Subtitle A—Rural Beneficiary Access Extensions and Improvements 

Sec. 100. Short title. 

Sec. 101. Temporary improvements to the Medicare inpatient hospital payment 

adjustment for low-volume hospitals. 

Sec. 102. Use of non-wage adjusted PPS rate under the Medicare-dependent 

hospital (MDH) program. 

Sec. 103. Ambulance services improvements. 

Sec. 104. Extension of authorization for FLEX grants. 

Sec. 105. Rebasing for sole community hospitals. 

Sec. 106. Extension and expansion of the Medicare hold harmless provision 

under the prospective payment system for hospital outpatient 

department (HOPD) services for certain hospitals. 

Sec. 107. Clarification of payment for clinical laboratory tests furnished by critical access hospitals. 

Sec. 108. Extension of floor on Medicare work geographic adjustment under 

the Medicare physician fee schedule. 

Sec. 109. Extension of treatment of certain physician pathology services under 

Medicare. 

Sec. 110. Adding hospital-based renal dialysis centers (including satellites) as 

originating sites for payment of telehealth services. 

Sec. 111. Adding skilled nursing facilities as originating sites for payment of 

telehealth services. 

Sec. 112. Applying rural home health add-on policy for 2009. 

Subtitle B—Other Provisions Relating to Part A 

Sec. 121. Extension of the reclassification of certain hospitals under the Medicare program. 

Sec. 122. Institute of Medicine study and report on post-acute care. 

Sec. 123. Revocation of unique deeming authority of the Joint Commission. 

Sec. 124. MedPAC study and report on payments for hospice care. 

Sec. 125. Introducing the principals of value-based health care into the Medicare program. 

Subtitle C—Other Provisions Relating to Part B 


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Sec. 131. Physician payment, efficiency, and quality improvements. 

Sec. 132. Incentives for electronic prescribing. 

Sec. 133. Increasing the number of sites for the electronic health records demonstration. 

Sec. 134. Primary care improvements. 

Sec. 135. Medicare anesthesia teaching program improvements . 

Sec. 136. Medicare coordinated care practice research network demonstration. 

Sec. 137. Imaging provisions. 

Sec. 138. Accommodation of physicians ordered to active duty in the Armed 

Services. 

Sec. 139. Extension of exceptions process for Medicare therapy caps. 

Sec. 140. Speech-language pathology services. 

Sec. 141. Coverage of items and services under a cardiac rehabilitation program 

and a pulmonary rehabilitation program. 

Sec. 142. Repeal of transfer of ownership of oxygen equipment. 

Sec. 143. Extension of payment rule for brachytherapy and therapeutic radiopharmaceuticals. 

Sec. 144. Clinical laboratory tests. 

Sec. 145. Sense of the Senate on delayed implementation of competitive bidding 

for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). 

Subtitle D—End Stage Renal Disease Program Reforms 

Sec. 151. Kidney disease education and awareness provisions. 

Sec. 152. Renal dialysis provisions. 

Subtitle E—Provisions Relating to Part C 

Sec. 161. Phase-out of indirect medical education (IME). 

Sec. 162. Revisions to quality improvement programs. 

Sec. 163. Revisions relating to specialized Medicare Advantage plans for special 

needs individuals. 

Sec. 164. Adjustment to the Medicare Advantage stabilization fund. 

Sec. 165. Access to Medicare reasonable cost contract plans. 

Sec. 166. MedPAC study and report on Medicare Advantage payments. 

Sec. 167. Marketing of Medicare Advantage plans and prescription drug plans. 

Subtitle F—Other Provisions 

Sec. 171. Contract with a consensus-based entity regarding performance measurement. 

Sec. 172. Use of part D data. 

Sec. 173. Inclusion of Medicare providers and suppliers in Federal Payment 

Levy and Administrative Offset Program. 

TITLE II—MEDICAID 

Sec. 201. Extension of transitional medical assistance (TMA) and abstinence 

education program through fiscal year 2009. 

Sec. 202. Extension of qualifying individual (QI) program through fiscal year 

2009. 

Sec. 203. Medicaid DSH extension through December 31, 2009. 

Sec. 204. Asset verification through access to information held by financial institutions. 


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Sec. 205. Application of Medicare payment adjustment for certain hospital-acquired conditions to payments for inpatient hospital services 

under Medicaid. 

Sec. 206. Reduction in payments for Medicaid administrative costs to prevent 

duplication of such payments under TANF. 

Sec. 207. Clarification treatment of regional medical center. 

Sec. 208. Grants to improve outreach and enrollment under Medicaid. 

TITLE III—MISCELLANEOUS 

Sec. 301. Extension of TANF supplemental grants through fiscal year 2009. 

Sec. 302. Special Diabetes Programs for Type I Diabetes and Indians. 

Sec. 303. Additional Funding for State Health Insurance Assistance Programs, 

Area Agencies on Aging, and Aging and Disability Resource 

Centers. 

Sec. 304. Extension of Federal reimbursement of emergency health services 

furnished to undocumented aliens. 

1 TITLE I—MEDICARE 

2 Subtitle A—Rural Beneficiary Ac3 cess Extensions and Improve4 ments 

5 SEC. 100. SHORT TITLE. 

6 This subtitle may be cited as the ‘‘Craig Thomas 

7 Rural Hospital and Provider Equity Act of 2008’’. 

8 SEC. 101. TEMPORARY IMPROVEMENTS TO THE MEDICARE 

9 INPATIENT HOSPITAL PAYMENT ADJUST10 MENT FOR LOW-VOLUME HOSPITALS. 

11 Section 1886(d)(12) of the Social Security Act (42 

12 U.S.C. 1395ww(d)(12)) is amended— 

13 (1) in subparagraph (A), by inserting ‘‘or (D) 

14 (for discharges occurring in fiscal years 2009)’’ after 

15 ‘‘subparagraph (B)’’; 


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1 (2) in subparagraph (B), by striking ‘‘The Sec2 retary’’ and inserting ‘‘Except as provided in sub3 paragraph (D), the Secretary’’; 

4 (3) in subparagraph (C)(i)— 

5 (A) by inserting ‘‘(or, with respect to fiscal 

6 years 2009, 15 road miles)’’ after ‘‘25 road 

7 miles’’; and 

8 (B) by inserting ‘‘(or, with respect to fiscal 

9 years 2009, 1,500 discharges of individuals en10 titled to, or enrolled for, benefits under part 

11 A)’’ after ‘‘800 discharges’’; and 

12 (4) by adding at the end the following new sub13 paragraph: 

14 ‘‘(D) TEMPORARY APPLICABLE PERCENT15 AGE INCREASE.—For discharges occurring in 

16 fiscal years 2009, the Secretary shall determine 

17 an applicable percentage increase for purposes 

18 of subparagraph (A) using a linear sliding scale 

19 ranging from 25 percent for low-volume hos20 pitals with fewer than an appropriate number 

21 (as determined by the Secretary) of discharges 

22 of individuals entitled to, or enrolled for, bene23 fits under part A in the fiscal year to 0 percent 

24 for low-volume hospitals with greater than 


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1 1,500 discharges of such individuals in the fis2 cal year.’’. 

3 SEC. 102. USE OF NON-WAGE ADJUSTED PPS RATE UNDER 

4 THE MEDICARE-DEPENDENT HOSPITAL 

5 (MDH) PROGRAM. 

6 (a) USE OF NON-WAGE ADJUSTED PPS RATE

7 UNDER THE MEDICARE-DEPENDENT HOSPITAL (MDH) 

8 PROGRAM.—Section 1886(d)(5)(G) of the Social Security 

9 Act (42 U.S.C. 1395ww(d)(5)(G)) is amended by adding 

10 at the end the following new clause: 

11 ‘‘(v) In the case of discharges occurring on or after 

12 October 1, 2008, and before October 1, 2009, in deter13 mining the amount under paragraph (1)(A)(iii) for pur14 poses of clauses (i) and (ii)(II), such amount shall, if it 

15 results in greater payments to the hospital, be determined 

16 without regard to any adjustment for different area wage 

17 levels under paragraph (3)(E).’’. 

18 (b) TREATMENT OF CERTAIN HOSPITALS.—Notwith19 standing any other provision of law, effective for dis20 charges occurring on or after October 1, 2008, the provi21 sions of paragraph (5)(G) of section 1886(d) of the Social 

22 Security Act (42 U.S.C. 1395ww(d)) shall apply for pur23 poses of making payments under such section to Wesley 

24 Woods Geriatric Hospital (provider number 110203) in 

25 the same manner as such provisions apply for purposes 


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1 of making payments under such section to a Medicare2 dependent, small rural hospital (as defined in paragraph 

3 (5)(G)(iv) of such section). 

4 SEC. 103. AMBULANCE SERVICES IMPROVEMENTS. 

5 (a) EXTENSION OF INCREASED MEDICARE PAY6 MENTS FOR GROUND AMBULANCE SERVICES.—Section 

7 1834(l)(13) of the Social Security Act (42 U.S.C. 

8 1395m(l)(13)) is amended— 

9 (1) in subparagraph (A)— 

10 (A) in the matter preceding clause (i), by 

11 inserting ‘‘and for such services furnished on or 

12 after July 1, 2008, and before January 1, 

13 2010’’ after ‘‘2007,’’; 

14 (B) in clause (i), by inserting ‘‘(or 3 per15 cent if such service is furnished on or after July 

16 1, 2008, and before January 1, 2010)’’ after ‘‘2 

17 percent’’; and 

18 (C) in clause (ii), by inserting ‘‘(or 2 per19 cent if such service is furnished on or after July 

20 1, 2008, and before January 1, 2010)’’ after ‘‘1 

21 percent’’; and 

22 (2) in subparagraph (B)— 

23 (A) in the heading, by striking ‘‘2006’’ and 

24 inserting ‘‘APPLICABLE PERIOD’’; and 


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1 (B) by inserting ‘‘applicable’’ before ‘‘pe2 riod’’. 

3 (b) AIR AMBULANCE PAYMENT IMPROVEMENTS.— 

4 (1) TREATMENT OF CERTAIN AREAS FOR PAY5 MENT FOR AIR AMBULANCE SERVICES UNDER THE

6 AMBULANCE FEE SCHEDULE.—Notwithstanding any 

7 other provision of law, for purposes of making pay8 ments under section 1834(l) of the Social Security 

9 Act (42 U.S.C. 1395m(l)) for air ambulance services 

10 furnished during the period beginning on July 1, 

11 2008, and ending on December 31, 2009, any area 

12 that was designated as a rural area for purposes of 

13 making payments under such section for air ambu14 lance services furnished on December 31, 2006, shall 

15 be treated as a rural area for purposes of making 

16 payments under such section for air ambulance serv17 ices furnished during such period. 

18 (2) CLARIFICATION REGARDING SATISFACTION

19 OF REQUIREMENT OF MEDICALLY NECESSARY.— 

20 (A) IN GENERAL.—Section 

21 1834(l)(14)(B)(i) of the Social Security Act (42 

22 U.S.C. 1395m(l)(14)(B)(i)) is amended by 

23 striking ‘‘reasonably determines or certifies’’ 

24 and inserting ‘‘certifies or reasonably deter25 mines’’. 


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1 (B) EFFECTIVE DATE.—The amendment 

2 made by subparagraph (A) shall apply to serv3 ices furnished on or after the date of the enact4 ment of this Act. 

5 SEC. 104. EXTENSION OF AUTHORIZATION FOR FLEX 

6 GRANTS. 

7 (a) IN GENERAL.—Section 1820(j) of the Social Se8 curity Act (42 U.S.C. 1395i–4(j)) is amended— 

9 (1) by striking ‘‘and for’’ and inserting ‘‘for’’; 

10 and 

11 (2) by inserting ‘‘, and for making grants to all 

12 States under paragraphs (1) and (2) of subsection 

13 (g), $55,000,000 in each of fiscal years 2009 and 

14 2010’’ before the period at the end. 

15 (b) MEDICARE RURAL HOSPITAL FLEXIBILITY PRO16 GRAM.—Section 1820(g)(1) of the Social Security Act (42 

17 U.S.C. 1395i–4(g)(1)) is amended— 

18 (1) in subparagraph (B), by striking ‘‘and’’ at 

19 the end; 

20 (2) in subparagraph (C), by striking the period 

21 at the end and inserting ‘‘; and’’; and 

22 (3) by adding at the end the following new sub23 paragraph: 

24 ‘‘(D) providing support for critical access 

25 hospitals for quality improvement, quality reVerDate Aug 31 2005 05:24 Jun 13, 2008 Jkt 069200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S3118.PCS S3118

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1 porting, performance improvements, and 

2 benchmarking.’’. 

3 SEC. 105. REBASING FOR SOLE COMMUNITY HOSPITALS. 

4 (a) REBASING PERMITTED.— 

5 (1) IN GENERAL.—Section 1886(b)(3) of the 

6 Social Security Act (42 U.S.C. 1395ww(b)(3)) is 

7 amended by adding at the end the following new 

8 subparagraph: 

9 ‘‘(L)(i) For cost reporting periods beginning on or 

10 after January 1, 2009, in the case of a sole community 

11 hospital there shall be substituted for the amount other12 wise determined under subsection (d)(5)(D)(i) of this sec13 tion, if such substitution results in a greater amount of 

14 payment under this section for the hospital, the subpara15 graph (L) rebased target amount. 

16 ‘‘(ii) For purposes of this subparagraph, the term 

17 ‘subparagraph (L) rebased target amount’ has the mean18 ing given the term ‘target amount’ in subparagraph (C), 

19 except that— 

20 ‘‘(I) there shall be substituted for the base cost 

21 reporting period the 12-month cost reporting period 

22 beginning during fiscal year 2006; 

23 ‘‘(II) any reference in subparagraph (C)(i) to 

24 the ‘first cost reporting period’ described in such 

25 subparagraph is deemed a reference to the first cost 


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1 reporting period beginning on or after January 1, 

2 2009; and 

3 ‘‘(III) the applicable percentage increase shall 

4 only be applied under subparagraph (C)(iv) for dis5 charges occurring on or after January 1, 2009.’’. 

6 (2) CONFORMING AMENDMENTS.—Section 

7 1886(b)(3) of the Social Security Act (42 U.S.C. 

8 1395ww(b)(3)) is amended— 

9 (A) in subparagraph (C), in the matter 

10 preceding clause (i), by striking ‘‘subparagraph 

11 (I)’’ and inserting ‘‘subparagraphs (I) and 

12 (L)’’; and 

13 (B) in subparagraph (I)(i), in the matter 

14 preceding subclause (I), by striking ‘‘For’’ and 

15 inserting ‘‘Subject to subparagraph (L), for’’. 

16 (b) RURAL REFERRAL CENTER DESIGNATION.—Not17 withstanding any other provision of law, for purposes of 

18 meeting the criteria for classification as a rural referral 

19 center under section 1886(d)(5)(C) of the Social Security 

20 Act (42 U.S.C. 1395ww(d)(5)(C)) with respect to cost re21 porting periods beginning on or after October 1, 2008, the 

22 Halifax Regional Medical Center (provider number 

23 340151) shall be deemed to satisfy the case mix require24 ment. 


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1 SEC. 106. EXTENSION AND EXPANSION OF THE MEDICARE 

2 HOLD HARMLESS PROVISION UNDER THE 

3 PROSPECTIVE PAYMENT SYSTEM FOR HOS4 PITAL OUTPATIENT DEPARTMENT (HOPD) 

5 SERVICES FOR CERTAIN HOSPITALS. 

6 Section 1833(t)(7)(D)(i) of the Social Security Act 

7 (42 U.S.C. 1395l(t)(7)(D)(i)) is amended— 

8 (1) in subclause (II)— 

9 (A) in the first sentence, by striking 

10 ‘‘2009’’ and inserting ‘‘2010’’; and 

11 (B) by striking the second sentence and in12 serting the following new sentence: ‘‘For pur13 poses of the preceding sentence, the applicable 

14 percentage shall be 95 percent with respect to 

15 covered OPD services furnished in 2006, 90 

16 percent with respect to such services furnished 

17 in 2007, and 85 percent with respect to such 

18 services furnished in 2008 or 2009.’’; and 

19 (2) by adding at the end the following new sub20 clause: 

21 ‘‘(III) In the case of a sole community 

22 hospital (as defined in section 

23 1886(d)(5)(D)(iii)) that has not more than 

24 100 beds, for covered OPD services fur25 nished on or after January 1, 2009, and 

26 before January 1, 2010, for which the 


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1 PPS amount is less than the pre-BBA 

2 amount, the amount of payment under this 

3 subsection shall be increased by 85 percent 

4 of the amount of such difference.’’. 

5 SEC. 107. CLARIFICATION OF PAYMENT FOR CLINICAL LAB6 ORATORY TESTS FURNISHED BY CRITICAL 

7 ACCESS HOSPITALS. 

8 (a) CLARIFICATION OF PAYMENT FOR CLINICAL

9 LABORATORY TESTS FURNISHED BY CRITICAL ACCESS

10 HOSPITALS.— 

11 (1) IN GENERAL.—Section 1834(g)(4) of the 

12 Social Security Act (42 U.S.C. 1395m(g)(4)) is 

13 amended— 

14 (A) in the heading, by striking ‘‘NO BENE15 FICIARY COST-SHARING FOR’’ and inserting 

16 ‘‘TREATMENT OF’’; and 

17 (B) by adding at the end the following new 

18 sentence: ‘‘For purposes of the preceding sen19 tence and section 1861(mm)(3), clinical diag20 nostic laboratory services furnished by a critical 

21 access hospital shall be treated as being fur22 nished as part of outpatient critical access serv23 ices without regard to whether the individual 

24 with respect to whom such services are fur25 nished is physically present in the critical access 


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1 hospital at the time the specimen is collected as 

2 long as the individual is present within the 

3 same county as the hospital at the time the 

4 specimen is collected.’’. 

5 (2) EFFECTIVE DATE.—The amendments made 

6 by paragraph (1) shall apply to services furnished on 

7 or after July 1, 2009. 

8 (b) MEDICARE CRITICAL ACCESS HOSPITAL DES9 IGNATIONS.—Section 405(h) of the Medicare Prescription 

10 Drug, Improvement, and Modernization Act of 2003 (Pub11 lic Law 108–173; 117 Stat. 2269) is amended by adding 

12 at the end the following new paragraph: 

13 ‘‘(3) EXCEPTION.— 

14 ‘‘(A) IN GENERAL.—The amendment made 

15 by paragraph (1) shall not apply to the certifi16 cation by the State of Alabama on or after Jan17 uary 1, 2006, under section 

18 1820(c)(2)(B)(i)(II) of the Social Security Act 

19 (42 U.S.C. 1395i–4(c)(2)(B)(i)(II)) of one hos20 pital that meets the criteria described in sub21 paragraph (B) as a necessary provider of health 

22 care services to residents in the area of the hos23 pital. 


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1 ‘‘(B) CRITERIA DESCRIBED.—A hospital 

2 meets the criteria described in this subpara3 graph if the hospital is located— 

4 ‘‘(i) in the county seat of Butler, Ala5 bama; and 

6 ‘‘(ii) a 32-mile drive from a hospital, 

7 or another facility described in section 

8 1820(c) of the Social Security Act (42 

9 U.S.C. 1395i–4(c)).’’. 

10 SEC. 108. EXTENSION OF FLOOR ON MEDICARE WORK GEO11 GRAPHIC ADJUSTMENT UNDER THE MEDI12 CARE PHYSICIAN FEE SCHEDULE. 

13 (a) IN GENERAL.—Section 1848(e)(1)(E) of the So14 cial Security Act (42 U.S.C. 1395w–4(e)(1)(E)), as 

15 amended by section 103 of the Medicare, Medicaid, and 

16 SCHIP Extension Act of 2007 (Public Law 110–173), is 

17 amended by striking ‘‘before July 1, 2008’’ and inserting 

18 ‘‘before January 1, 2010’’. 

19 (b) TREATMENT OF PHYSICIANS’ SERVICES FUR20 NISHED IN CERTAIN AREAS.—Section 1848(e)(1)(G) of 

21 the Social Security Act (42 U.S.C. 1395w–4(e)(1)(G)) is 

22 amended by adding at the end the following new sentence: 

23 ‘‘For purposes of payment for services furnished in the 

24 State described in the preceding sentence on or after Jan25 uary 1, 2009, after calculating the work geographic index 


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1 in subparagraph (A)(iii), the Secretary shall increase the 

2 work geographic index to 1.5 if such index would otherwise 

3 be less than 1.5’’. 

4 (c) TECHNICAL CORRECTION.—Section 602(1) of the 

5 Medicare Prescription Drug, Improvement, and Mod6 ernization Act of 2003 (Public Law 108–173; 117 Stat. 

7 2301) is amended to read as follows: 

8 ‘‘(1) in subparagraph (A), by striking ‘subpara9 graphs (B), (C), and (E)’ and inserting ‘subpara10 graphs (B), (C), (E), and (G)’; and’’. 

11 SEC. 109. EXTENSION OF TREATMENT OF CERTAIN PHYSI12 CIAN PATHOLOGY SERVICES UNDER MEDI13 CARE. 

14 Section 542(c) of the Medicare, Medicaid, and 

15 SCHIP Benefits Improvement and Protection Act of 2000 

16 (as enacted into law by section 1(a)(6) of Public Law 106– 

17 554), as amended by section 732 of the Medicare Prescrip18 tion Drug, Improvement, and Modernization Act of 2003 

19 (42 U.S.C. 1395w–4 note), section 104 of division B of 

20 the Tax Relief and Health Care Act of 2006 (42 U.S.C. 

21 1395w–4 note), and section 104 of the Medicare, Med22 icaid, and SCHIP Extension Act of 2007 (Public Law 

23 110–173), is amended by striking ‘‘2007, and the first 6 

24 months of 2008’’ and inserting ‘‘2007, 2008, and 2009’’. 


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1 SEC. 110. ADDING HOSPITAL-BASED RENAL DIALYSIS CEN2 TERS (INCLUDING SATELLITES) AS ORIGI3 NATING SITES FOR PAYMENT OF TELE4 HEALTH SERVICES. 

5 (a) IN GENERAL.—Section 1834(m)(4)(C)(ii) of the 

6 Social Security Act (42 U.S.C. 1395m(m)(4)(C)(ii)) is 

7 amended by adding at the end the following new sub8 clause: 

9 ‘‘(VI) A hospital-based or critical 

10 access hospital-based renal dialysis 

11 center (including satellites).’’. 

12 (b) EFFECTIVE DATE.—The amendment made by 

13 this section shall apply to services furnished on or after 

14 January 1, 2009. 

15 SEC. 111. ADDING SKILLED NURSING FACILITIES AS ORIGI16 NATING SITES FOR PAYMENT OF TELE17 HEALTH SERVICES. 

18 (a) ADDITION.— 

19 (1) IN GENERAL.—Section 1834(m)(4)(C)(ii) of 

20 the Social Security Act (42 U.S.C. 

21 1395m(m)(4)(C)(ii)), as amended by section 110, is 

22 amended by adding at the end the following new 

23 subclause: 

24 ‘‘(VII) A skilled nursing facility 

25 (as defined in section 1819(a)).’’. 


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1 (2) CONFORMING AMENDMENT.—Section 

2 1888(e)(2)(A)(ii) of the Social Security Act (42 

3 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting 

4 ‘‘telehealth services furnished under section 

5 1834(m)(4)(C)(ii)(VII),’’ after ‘‘section 

6 1861(s)(2),’’. 

7 (b) EFFECTIVE DATE.—The amendments made by 

8 subsection (a) shall apply to telehealth services furnished 

9 on or after January 1, 2009. 

10 SEC. 112. APPLYING RURAL HOME HEALTH ADD-ON POLICY 

11 FOR 2009. 

12 Section 421(a) of the Medicare Prescription Drug, 

13 Improvement, and Modernization Act of 2003 (Public Law 

14 10–173; 117 Stat. 2283), as amended by section 5201(b) 

15 of the Deficit Reduction Act of 2005 (Public Law 109– 

16 171; 120 Stat. 46), is amended— 

17 (1) by striking ‘‘, and episodes’’ and inserting 

18 ‘‘, episodes’’; and 

19 (2) by inserting ‘‘and episodes and visits ending 

20 on or after January 1, 2009, and before January 1, 

21 2010,’’ after ‘‘January 1, 2007,’’. 


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1 Subtitle B—Other Provisions 

2 Relating to Part A 

3 SEC. 121. EXTENSION OF THE RECLASSIFICATION OF CER4 TAIN HOSPITALS UNDER THE MEDICARE 

5 PROGRAM. 

6 (a) EXTENSION.— 

7 (1) IN GENERAL.—Subsection (a) of section 

8 106 of division B of the Tax Relief and Health Care 

9 Act of 2006 (42 U.S.C. 1395 note), as amended by 

10 section 117 of the Medicare, Medicaid, and SCHIP 

11 Extension Act of 2007 (Public Law 110–173), is 

12 amended by striking ‘‘September 30, 2008’’ and in13 serting ‘‘September 30, 2009’’. 

14 (2) SPECIAL EXCEPTION RECLASSIFICATIONS.— 

15 Section 117(a)(2) of the Medicare, Medicaid, and 

16 SCHIP Extension Act of 2007 (Public Law 110– 

17 173) is amended by striking ‘‘September 30, 2008’’ 

18 and inserting ‘‘September 30, 2009’’. 

19 (b) FLOOR ON MEDICARE AREA WAGE INDEX.— 

20 (1) IN GENERAL.—Notwithstanding any other 

21 provision of law, for purposes of section 

22 1886(d)(3)(E) of the Social Security Act (42 U.S.C. 

23 1395ww(d)(3)(E)), the area wage index applicable 

24 under such section to any hospital located in a State 

25 with an area described in paragraph (2) shall not be 


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1 less than the area wage index applicable under such 

2 section to such hospital during the period beginning 

3 on or after October 1, 2006, and before October 1, 

4 2007. 

5 (2) AREA DESCRIBED.—An area described in 

6 this paragraph is a rural area (as defined in para7 graph (2)(D) of section 1886(d) of the Social Secu8 rity Act (42 U.S.C. 1395ww(d))) where not less than 

9 65 percent of the wages paid by all subsection (d) 

10 hospitals (as defined in paragraph (1)(B) of such 

11 section) that are located in such area on October 1, 

12 2006, taking into account redesignations under sec13 tion 601(g) of the Social Security Amendments of 

14 1983 (Public Law 98–21) and not taking into ac15 count reclassifications or redesignations under para16 graph (8) or (10) of such section 1886(d), are at17 tributable to wages paid by one hospital. For pur18 poses of making a determination under the pre19 ceding sentence, the wages to be used are the occu20 pational mix adjusted inflated wages used to develop 

21 the wage index in effect during the period beginning 

22 on October 1, 2006 and ending on September 30, 

23 2007 (as published in the Federal Register on Octo24 ber 11, 2006 (71 Fed. Reg. 59,886)). 


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1 (3) IMPLEMENTATION.—The Secretary of 

2 Health and Human Services shall ensure that the 

3 aggregate payments made under section 1886(d) of 

4 the Social Security Act (42 U.S.C. 1395ww(d)) in a 

5 fiscal year for the operating costs of inpatient hos6 pital services are not greater or less than those 

7 which would have been made in the year if this sub8 section did not apply. 

9 (4) EFFECTIVE DATE.—The provisions of this 

10 subsection shall apply to discharges occurring on or 

11 after October 1, 2008. 

12 (c) MEDICARE HOSPITAL GEOGRAPHIC RECLASSI13 FICATIONS.— 

14 (1) RECLASSIFICATIONS.—Notwithstanding any 

15 other provision of law, effective for discharges occur16 ring during fiscal years 2009, 2010, and 2011, for 

17 purposes of making payments under section 1886(d) 

18 of the Social Security Act (42 U.S.C. 1395ww(d)) to 

19 Ball Memorial Hospital (provider number 15–0089), 

20 such hospital is deemed to be located in the Indian21 apolis-Carmel, IN Core Based Statistical Area. 

22 (2) RULES.— 

23 (A) IN GENERAL.—Except as provided in 

24 subparagraph (B), any reclassification made 

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1 sion of the Medicare Geographic Classification 

2 Review Board under section 1886(d)(10) of the 

3 Social Security Act (42 U.S.C. 1395ww(d)(10)). 

4 (B) NON-APPLICATION OF DUPLICATIVE 3- 

5 YEAR APPLICATION PROVISION.—Section 

6 1886(d)(10)(D)(v) of the Social Security Act 

7 (42 U.S.C. 1395ww(d)(10)(D)(v)), as it relates 

8 to a reclassification being effective for 3 fiscal 

9 years, shall not apply with respect to any re10 classification made under paragraph (1). 

11 SEC. 122. INSTITUTE OF MEDICINE STUDY AND REPORT ON 

12 POST-ACUTE CARE. 

13 (a) IN GENERAL.— 

14 (1) STUDY.—Not later than 6 months after the 

15 date of enactment of this Act, the Secretary of 

16 Health and Human Services shall enter into a con17 tract with the Institute of Medicine of the National 

18 Academies (in this section referred to as the ‘‘Insti19 tute’’) under which the Institute shall conduct a 

20 study on short- and long-term steps that can be 

21 taken under the Medicare program to reform the 

22 currently fragmented post-acute care payment and 

23 delivery system. Such study shall include an assess24 ment of— 


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1 (A) potential elements of an integrated 

2 continuum of care, such as— 

3 (i) a uniform assessment tool for post4 acute care patients; 

5 (ii) evidence-based admission criteria 

6 for each post-acute care setting; 

7 (iii) an integrated site-neutral pay8 ment methodology; and 

9 (iv) an integrated quality assessment 

10 system; and 

11 (B) actions necessary to establish the inte12 grated continuum of care. 

13 (2) CONSULTATION.—In conducting the study 

14 under paragraph (1), the Institute shall consult with 

15 the Administrator of the Centers for Medicare & 

16 Medicaid Services regarding the status of efforts by 

17 the Administrator to develop a common assessment 

18 instrument for post-acute care patients under the 

19 Medicare program. 

20 (3) REPORT.—Not later than 2 years after the 

21 effective date of the contract under paragraph (1), 

22 the Institute shall submit a report to the Secretary 

23 of Health and Human Services containing the re24 sults of the study conducted under paragraph (1), 

25 together with recommendations for such legislation 


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1 and administrative action as the Institute deter2 mines appropriate. 

3 (b) FUNDING.—The Secretary of Health and Human 

4 Services shall provide for the transfer, from the Federal 

5 Hospital Insurance Trust Fund established under section 

6 1817 of the Social Security Act (42 U.S.C. 1395i), of 

7 $2,700,000 for the purpose of carrying out this section. 

8 SEC. 123. REVOCATION OF UNIQUE DEEMING AUTHORITY 

9 OF THE JOINT COMMISSION. 

10 (a) REVOCATION.—Section 1865 of the Social Secu11 rity Act (42 U.S.C. 1395bb) is amended— 

12 (1) by striking subsection (a); and 

13 (2) by redesignating subsections (b), (c), (d), 

14 and (e) as subsections (a), (b), (c), and (d), respec15 tively. 

16 (b) CONFORMING AMENDMENTS.—(1) Section 1865 

17 of the Social Security Act (42 U.S.C. 1395bb) is amend18 ed— 

19 (A) in subsection (a)(1), as redesignated by 

20 subsection (a)(2), by striking ‘‘In addition, if’’ and 

21 inserting ‘‘If’’; 

22 (B) in subsection (b), as so redesignated— 

23 (i) by striking ‘‘released to him by the 

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1 pitals,’’ and inserting ‘‘released to the Secretary 

2 by’’; and 

3 (ii) by striking the comma after ‘‘Associa4 tion’’; 

5 (C) in subsection (c), as so redesignated, by 

6 striking ‘‘pursuant to subsection (a) or (b)(1)’’ and 

7 inserting ‘‘pursuant to subsection (a)(1)’’; and 

8 (D) in subsection (d), as so redesignated, by 

9 striking ‘‘pursuant to subsection (a) or (b)(1)’’ and 

10 inserting ‘‘pursuant to subsection (a)(1)’’. 

11 (2) Section 1861(e) of the Social Security Act (42 

12 U.S.C. 1395x(e)) is amended in the fourth sentence by 

13 striking ‘‘and (ii) is accredited by the Joint Commission 

14 on Accreditation of Hospitals, or is accredited by or ap15 proved by a program of the country in which such institu16 tion is located if the Secretary finds the accreditation or 

17 comparable approval standards of such program to be es18 sentially equivalent to those of the Joint Commission on 

19 Accreditation of Hospitals’’ and inserting ‘‘and (ii) is ac20 credited by a national accreditation body recognized by the 

21 Secretary under section 1865(a), or is accredited by or 

22 approved by a program of the country in which such insti23 tution is located if the Secretary finds the accreditation 

24 or comparable approval standards of such program to be 


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1 essentially equivalent to those of such a national accredita2 tion body.’’. 

3 (3) Section 1864(c) of the Social Security Act (42 

4 U.S.C. 1395aa(c)) is amended by striking ‘‘pursuant to 

5 subsection (a) or (b)(1) of section 1865’’ and inserting 

6 ‘‘pursuant to section 1865(a)(1)’’. 

7 (4) Section 1875(b) of the Social Security Act (42 

8 U.S.C. 1395ll(b)) is amended by striking ‘‘the Joint Com9 mission on Accreditation of Hospitals,’’ and inserting ‘‘na10 tional accreditation bodies under section 1865(a)’’. 

11 (5) Section 1834(a)(20)(B) of the Social Security Act 

12 (42 U.S.C. 1395m(a)(20)(B)) is amended by striking 

13 ‘‘section 1865(b)’’ and inserting ‘‘section 1865(a)’’. 

14 (6) Section 1852(e)(4)(C) of the Social Security Act 

15 (42 U.S.C. 1395w–22(e)(4)(C)) is amended by striking 

16 ‘‘section 1865(b)(2)’’ and inserting ‘‘section 1865(a)(2)’’. 

17 (c) AUTHORITY TO RECOGNIZE THE JOINT COMMIS18 SION AS A NATIONAL ACCREDITATION BODY.—The Sec19 retary of Health and Human Services may recognize the 

20 Joint Commission as a national accreditation body under 

21 section 1865 of the Social Security Act (42 U.S.C. 

22 1395bb), as amended by this section, upon such terms and 

23 conditions, and upon submission of such information, as 

24 the Secretary may require. 


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1 (d) EFFECTIVE DATE; TRANSITION RULE.—(1) Sub2 ject to paragraph (2), the amendments made by this sec3 tion shall apply with respect to accreditations of hospitals 

4 granted on or after the date that is 24 months after the 

5 date of enactment of this Act. 

6 (2) For purposes of title XVIII of the Social Security 

7 Act (42 U.S.C. 1395 et seq.), the amendments made by 

8 this section shall not effect the accreditation of a hospital 

9 by the Joint Commission, or under accreditation or com10 parable approval standards found to be essentially equiva11 lent to accreditation or approval standards of the Joint 

12 Commission, for the period of time applicable under such 

13 accreditation. 

14 SEC. 124. MEDPAC STUDY AND REPORT ON PAYMENTS FOR 

15 HOSPICE CARE. 

16 (a) STUDY.—The Medicare Payment Advisory Com17 mission shall conduct a study on payments for hospice 

18 care under the Medicare program under title XVIII of the 

19 Social Security Act. Such study shall include an analysis 

20 of potential changes in payment methodologies for hospice 

21 care under the Medicare program, including revisions to 

22 the cap amount under section 1814(i)(2) of the Social Se23 curity Act (42 U.S.C. 1395f(i)(2)), that may reflect— 

24 (1) hospice patient characteristics; 


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1 (2) variation in hospice care utilization by pa2 tient characteristics; 

3 (3) average lengths of stay in hospice care; 

4 (4) disease category; 

5 (5) geographic differences; 

6 (6) specific types of hospice care services pro7 vided; and 

8 (7) site of service. 

9 (b) REPORT.—Not later than June 15, 2009, the 

10 Medicare Payment Advisory Commission shall submit a 

11 report to Congress on the study conducted under sub12 section (a). Such report shall include recommendations for 

13 such legislation and administrative action as the Medicare 

14 Payment Advisory Commission determines appropriate. 

15 (c) HOSPICE CARE DEFINED.—In this section, the 

16 term ‘‘hospice care’’ has the meaning given such term in 

17 section 1861(dd) of the Social Security Act (42 U.S.C. 

18 1395x(dd)). 

19 SEC. 125. INTRODUCING THE PRINCIPALS OF VALUE-BASED 

20 HEALTH CARE INTO THE MEDICARE PRO21 GRAM. 

22 (a) INCENTIVES FOR PROVIDERS AND SUPPLIERS.— 

23 (1) IN GENERAL.—The Secretary of Health and 

24 Human Services (in this section referred to as the 

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1 neutral system for use in the Medicare program 

2 under title XVIII of the Social Security Act under 

3 which a portion of the payments that would other4 wise be made under such program to some or all 

5 classes of individuals and entities furnishing items 

6 or services to beneficiaries of such program would be 

7 based on the quality of their performance. 

8 (2) IMPLEMENTATION.—The Secretary shall 

9 first implement such system in hospitals. The initial 

10 focus of such efforts shall be on quality. The system 

11 shall also include incentives for reducing unwar12 ranted geographic variations in quality. 

13 (3) AUTHORITY.—The Secretary may imple14 ment the system described in this subsection without 

15 regard to any provision of title XVIII of the Social 

16 Security Act that would, in the absence of para17 graphs (1) and (2), apply with respect to payment 

18 to an individual or entity furnishing items or serv19 ices for which payment may be made under the 

20 Medicare program. 

21 (b) DEFINITION OF INFORMATION ON QUALITY OF

22 CARE.—In this section, the term ‘‘information on quality 

23 of care’’ means measures of— 

24 (1) the use of clinical processes and structures 

25 known to improve care; 


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1 (2) health outcomes; and 

2 (3) patient perceptions of their care. 

3 Subtitle C—Other Provisions 

4 Relating to Part B 

5 SEC. 131. PHYSICIAN PAYMENT, EFFICIENCY, AND QUALITY 

6 IMPROVEMENTS. 

7 (a) IN GENERAL.— 

8 (1) INCREASE IN UPDATE FOR THE SECOND

9 HALF OF 2008 AND FOR 2009.— 

10 (A) FOR THE SECOND HALF OF 2008.— 

11 Section 1848(d)(8) of the Social Security Act 

12 (42 U.S.C. 1395w–4(d)(8)), as added by section 

13 101 of the Medicare, Medicaid, and SCHIP Ex14 tension Act of 2007 (Public Law 110–173), is 

15 amended— 

16 (i) in the heading, by striking ‘‘A POR17 TION OF’’; 

18 (ii) in subparagraph (A), by striking 

19 ‘‘for the period beginning on January 1, 

20 2008, and ending on June 30, 2008,’’; and 

21 (iii) in subparagraph (B)— 

22 (I) in the heading, by striking 

23 ‘‘THE REMAINING PORTION OF 2008

24 AND’’; and 


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1 (II) by striking ‘‘for the period 

2 beginning on July 1, 2008, and end3 ing on December 31, 2008, and’’. 

4 (B) FOR 2009.—Section 1848(d) of the So5 cial Security Act (42 U.S.C. 1395w–4(d)), as 

6 amended by section 101 of the Medicare, Med7 icaid, and SCHIP Extension Act of 2007 (Pub8 lic Law 110–173), is amended by adding at the 

9 end the following new paragraph: 

10 ‘‘(9) UPDATE FOR 2009.— 

11 ‘‘(A) IN GENERAL.—Subject to paragraphs 

12 (7)(B) and (8)(B), in lieu of the update to the 

13 single conversion factor established in para14 graph (1)(C) that would otherwise apply for 

15 2009, the update to the single conversion factor 

16 shall be 1.1 percent. 

17 ‘‘(B) NO EFFECT ON COMPUTATION OF

18 CONVERSION FACTOR FOR 2010 AND SUBSE19 QUENT YEARS.—The conversion factor under 

20 this subsection shall be computed under para21 graph (1)(A) for 2010 and subsequent years as 

22 if subparagraph (A) had never applied.’’. 

23 (2) REVISION OF THE PHYSICIAN ASSISTANCE

24 AND QUALITY INITIATIVE FUND.—Section 1848(l)(2) 

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


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1 4(l)(2)), as amended by section 101(a)(2) of the 

2 Medicare, Medicaid, and SCHIP Extension Act of 

3 2007 (Public Law 110–173), is amended— 

4 (A) in subparagraph (A)— 

5 (i) in clause (i)— 

6 (I) in subclause (III), by striking 

7 ‘‘$4,960,000,000’’ and inserting 

8 ‘‘$4,090,000,000’’; 

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

11 ‘‘(IV) For expenditures during 

12 2014 through 2017, an amount equal 

13 to $30,660,000,000.’’; and 

14 (ii) in clause (ii), by adding at the end 

15 the following new subclause: 

16 ‘‘(III) 2014 THROUGH 2017.— 

17 The amount available for expenditures 

18 during 2014 through 2017 shall only 

19 be available for an adjustment to the 

20 update of the conversion factor under 

21 subsection (d) for that year.’’; and 

22 (B) in subparagraph (B)— 

23 (i) in clause (ii), by striking ‘‘and’’ at 

24 the end; 


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1 (ii) in clause (iii), by striking the pe2 riod at the end and inserting ‘‘; and’’; and 

3 (iii) by adding at the end the fol4 lowing new clause: 

5 ‘‘(iv) 2014 through 2017 for payment 

6 with respect to physicians’ services fur7 nished during 2014 through 2017.’’. 

8 (b) EXTENSION AND IMPROVEMENT OF THE QUAL9 ITY REPORTING SYSTEM.— 

10 (1) SYSTEM.—Section 1848(k)(2) of the Social 

11 Security Act (42 U.S.C. 1395w–4(k)(2)), as amend12 ed by section 101(b)(1) of the Medicare, Medicaid, 

13 and SCHIP Extension Act of 2007 (Public Law 

14 110–173), is amended by adding at the end the fol15 lowing new subparagraphs: 

16 ‘‘(C) FOR 2010 AND SUBSEQUENT

17 YEARS.— 

18 ‘‘(i) IN GENERAL.—Subject to clause 

19 (ii), for purposes of reporting data on qual20 ity measures for covered professional serv21 ices furnished during 2010 and each subse22 quent year, subject to subsection 

23 (m)(3)(C), the quality measures (including 

24 electronic prescribing quality measures) 

25 specified under this paragraph shall be 


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1 such measures selected by the Secretary 

2 from measures that have been endorsed by 

3 the entity with a contract with the Sec4 retary under section 1890(a). 

5 ‘‘(ii) EXCEPTION.—In the case of a 

6 specified area determined appropriate by 

7 the Secretary for which no measure has 

8 been endorsed by the entity with a contract 

9 under section 1890(a), the Secretary may 

10 specify a measure that is not so endorsed 

11 as long as due consideration is given to 

12 measures that have been endorsed or 

13 adopted by a consensus-based organization 

14 identified by the Secretary, such as the 

15 AQA alliance. 

16 ‘‘(D) OPPORTUNITY TO PROVIDE INPUT ON

17 MEASURES FOR 2009 AND SUBSEQUENT

18 YEARS.—For each quality measure (including 

19 an electronic prescribing quality measure) 

20 adopted by the Secretary under subparagraph 

21 (B) (with respect to 2009) or subparagraph 

22 (C), the Secretary shall ensure that eligible pro23 fessionals have the opportunity to provide input 

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1 tion of measures applicable to services they fur2 nish.’’. 

3 (2) REDESIGNATION OF REPORTING SYSTEM.— 

4 Subsection (c) of section 101 of division B of the 

5 Tax Relief and Health Care Act of 2006 (42 U.S.C. 

6 1395w–4 note), as amended by section 101(b)(2) of 

7 the Medicare, Medicaid, and SCHIP Extension Act 

8 of 2007 (Public Law 110–173), is redesignated as 

9 subsection (m) of section 1848 of the Social Security 

10 Act. 

11 (3) INCENTIVE PAYMENTS UNDER REPORTING

12 SYSTEM.—Section 1848(m) of the Social Security 

13 Act, as redesignated by paragraph (2), is amended— 

14 (A) by amending the heading to read as 

15 follows: ‘‘INCENTIVE PAYMENTS FOR QUALITY

16 REPORTING’’; 

17 (B) by striking paragraph (1) and insert18 ing the following: 

19 ‘‘(1) INCENTIVE PAYMENTS.— 

20 ‘‘(A) IN GENERAL.—For 2007 through 

21 2010, with respect to covered professional serv22 ices furnished during a reporting period by an 

23 eligible professional, if— 

24 ‘‘(i) there are any quality measures 

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1 cian reporting system that are applicable 

2 to any such services furnished by such pro3 fessional for such reporting period; and 

4 ‘‘(ii) the eligible professional satisfac5 torily submits (as determined under this 

6 subsection) to the Secretary data on such 

7 quality measures in accordance with such 

8 reporting system for such reporting period, 

9 in addition to the amount otherwise paid under 

10 this part, there also shall be paid to the eligible 

11 professional (or to an employer or facility in the 

12 cases described in clause (A) of section 

13 1842(b)(6)) or, in the case of a group practice 

14 under paragraph (3)(C), to the group practice, 

15 from the Federal Supplementary Medical Insur16 ance Trust Fund established under section 

17 1841 an amount equal to the applicable quality 

18 percent of the Secretary’s estimate (based on 

19 claims submitted not later than 2 months after 

20 the end of the reporting period) of the allowed 

21 charges under this part for all such covered 

22 professional services furnished by the eligible 

23 professional (or, in the case of a group practice 

24 under paragraph (3)(C), by the group practice) 

25 during the reporting period. 


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1 ‘‘(B) APPLICABLE QUALITY PERCENT.— 

2 For purposes of subparagraph (A), the term 

3 ‘applicable quality percent’ means— 

4 ‘‘(i) for 2007 and 2008, 1.5 percent; 

5 and 

6 ‘‘(ii) for 2009 and 2010, 2.0 per7 cent.’’; 

8 (C) by striking paragraph (3) and redesig9 nating paragraph (2) as paragraph (3); 

10 (D) in paragraph (3), as so redesignated— 

11 (i) in the matter preceding subpara12 graph (A), by striking ‘‘For purposes’’ and 

13 inserting the following: 

14 ‘‘(A) IN GENERAL.—For purposes’’; 

15 (ii) by redesignating subparagraphs 

16 (A) and (B) as clauses (i) and (ii), respec17 tively, and moving the indentation of such 

18 clauses 2 ems to the right; 

19 (iii) in subparagraph (A), as added by 

20 clause (i), by adding at the end the fol21 lowing flush sentence: 

22 ‘‘For years after 2008, quality measures for 

23 purposes of this subparagraph shall not include 

24 electronic prescribing quality measures.’’; and 


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1 (iv) by adding at the end the following 

2 new subparagraphs: 

3 ‘‘(C) SATISFACTORY REPORTING MEAS4 URES FOR GROUP PRACTICES.— 

5 ‘‘(i) IN GENERAL.—By January 1, 

6 2010, the Secretary shall establish and 

7 have in place a process under which eligi8 ble professionals in a group practice (as 

9 defined by the Secretary) shall be treated 

10 as satisfactorily submitting data on quality 

11 measures under subparagraph (A) and as 

12 meeting the requirement described in sub13 paragraph (B)(ii)) for covered professional 

14 services for a reporting period (or, for pur15 poses of subsection (a)(5), for a reporting 

16 period for a year) if, in lieu of reporting 

17 measures under subsection (k)(2)(C), the 

18 group practice reports measures deter19 mined appropriate by the Secretary, such 

20 as measures that target high-cost chronic 

21 conditions and preventive care, in a form 

22 and manner, and at a time, specified by 

23 the Secretary. 

24 ‘‘(ii) STATISTICAL SAMPLING

25 MODEL.—The process under clause (i) 


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1 shall provide for the use of a statistical 

2 sampling model to submit data on meas3 ures, such as the model used under the 

4 Physician Group Practice demonstration 

5 project under section 1866A. 

6 ‘‘(iii) NO DOUBLE PAYMENTS.—Pay7 ments to a group practice under this sub8 section by reason of the process under 

9 clause (i) shall be in lieu of the payments 

10 that would otherwise be made under this 

11 subsection to eligible professionals in the 

12 group practice for satisfactorily submitting 

13 data on quality measures. 

14 ‘‘(D) AUTHORITY TO REVISE SATISFAC15 TORILY REPORTING DATA.—For years after 

16 2009, the Secretary, in consultation with stake17 holders and experts, may revise the criteria 

18 under this subsection for satisfactorily submit19 ting data on quality measures under subpara20 graph (A) and the criteria for submitting data 

21 on electronic prescribing quality measures 

22 under subparagraph (B)(ii).’’; 

23 (E) in paragraph (5)— 


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1 (i) in subparagraph (C), by inserting 

2 ‘‘for 2007, 2008, and 2009,’’ after ‘‘provi3 sion of law,’’; 

4 (ii) in subparagraph (D)— 

5 (I) in clause (i)— 

6 (aa) by inserting ‘‘for 2007 

7 and 2008’’ after ‘‘under this sub8 section’’; and 

9 (bb) by striking ‘‘paragraph 

10 (2)’’ and inserting ‘‘this sub11 section’’; 

12 (II) in clause (ii), by striking 

13 ‘‘shall’’ and inserting ‘‘may establish 

14 procedures to’’; and 

15 (III) in clause (iii)— 

16 (aa) by inserting ‘‘(or, in the 

17 case of a group practice under 

18 paragraph (3)(C), the group 

19 practice)’’ after ‘‘an eligible pro20 fessional’’; 

21 (bb) by striking ‘‘bonus in22 centive payment’’ and inserting 

23 ‘‘incentive payment under this 

24 subsection’’; and 


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1 (cc) by adding at the end 

2 the following new sentence: ‘‘If 

3 such payments for such period 

4 have already been made, the Sec5 retary shall recoup such pay6 ments from the eligible profes7 sional (or the group practice).’’; 

8 (iii) in subparagraph (E)(i)— 

9 (I) in subclause (II), by striking 

10 ‘‘paragraph (2)’’ and inserting ‘‘this 

11 subsection’’; and 

12 (II) in subclause (IV)— 

13 (aa) by striking ‘‘the bonus’’ 

14 and inserting ‘‘any’’; and 

15 (bb) by inserting ‘‘and the 

16 payment adjustment under sub17 section (a)(5)(A)’’ before the pe18 riod at the end; 

19 (iv) in subparagraph (F)— 

20 (I) by striking ‘‘2009, paragraph 

21 (3) shall not apply, and’’ and insert22 ing ‘‘subsequent years,’’; and 

23 (II) by striking ‘‘paragraph (2)’’ 

24 and inserting ‘‘this subsection’’; and 


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1 (v) by adding at the end the following 

2 new subparagraph: 

3 ‘‘(G) POSTING ON WEBSITE.—The Sec4 retary shall post on the Internet website of the 

5 Centers for Medicare & Medicaid Services, in an 

6 easily understandable format, a list of the 

7 names of the following: 

8 ‘‘(i) The eligible professionals (or, in 

9 the case of reporting under paragraph 

10 (3)(C), the group practices) who satisfac11 torily submitted data on quality measures 

12 under this subsection. 

13 ‘‘(ii) The eligible professionals (or, in 

14 the case of reporting under paragraph 

15 (3)(C), the group practices) who are suc16 cessful electronic prescribers.’’; and 

17 (F) in paragraph (6), by striking subpara18 graph (C) and inserting the following: 

19 ‘‘(C) REPORTING PERIOD.— 

20 ‘‘(i) IN GENERAL.—Subject to clauses 

21 (ii) and (iii), the term ‘reporting period’ 

22 means— 

23 ‘‘(I) for 2007, the period begin24 ning on July 1, 2007, and ending on 

25 December 31, 2007; and 


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1 ‘‘(II) for 2008, 2009, 2010, and 

2 2011, the entire year. 

3 ‘‘(ii) AUTHORITY TO REVISE REPORT4 ING PERIOD.—For years after 2009, the 

5 Secretary may revise the reporting period 

6 under clause (i) if the Secretary deter7 mines such revision is appropriate, pro8 duces valid results on measures reported, 

9 and is consistent with the goals of maxi10 mizing scientific validity and reducing ad11 ministrative burden. If the Secretary re12 vises such period pursuant to the preceding 

13 sentence, the term ‘reporting period’ shall 

14 mean such revised period. 

15 ‘‘(iii) REFERENCE.—Any reference in 

16 this subsection to a reporting period with 

17 respect to the application of subsection 

18 (a)(5) shall be deemed a reference to the 

19 reporting period under subparagraph 

20 (D)(iii) of such subsection.’’. 

21 (4) INCLUSION OF QUALIFIED AUDIOLOGISTS

22 AS ELIGIBLE PROFESSIONALS.— 

23 (A) IN GENERAL.—Section 1848(k)(3)(B) 

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


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1 4(k)(3)(B)), is amended by adding at the end 

2 the following new clause: 

3 ‘‘(iv) Beginning with 2009, a qualified 

4 audiologist (as defined in section 

5 1861(ll)(3)(B)).’’. 

6 (B) NO CHANGE IN BILLING.—Nothing in 

7 the amendment made by subparagraph (A) 

8 shall be construed to change the way in which 

9 billing for audiology services (as defined in sec10 tion 1861(ll)(2) of the Social Security Act (42 

11 U.S.C. 1395x(ll)(2))) occurs under title XVIII 

12 of such Act as of July 1, 2008. 

13 (5) CONFORMING AMENDMENTS.—Section 

14 1848(m) of the Social Security Act, as added and 

15 amended by paragraphs (2) and (3), is amended— 

16 (A) in paragraph (5)— 

17 (i) in subparagraph (A)— 

18 (I) by striking ‘‘section 1848(k) 

19 of the Social Security Act, as added 

20 by subsection (b),’’ and inserting 

21 ‘‘subsection (k)’’; and 

22 (II) by striking ‘‘such section’’ 

23 and inserting ‘‘such subsection’’; 


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1 (ii) in subparagraph (B), by striking 

2 ‘‘of the Social Security Act (42 U.S.C. 

3 1395l)’’; 

4 (iii) in subparagraph (E)— 

5 (I) in clause (i), in the matter 

6 preceding subclause (I), by striking 

7 ‘‘1869 or 1878 of the Social Security 

8 Act or otherwise’’ and inserting 

9 ‘‘1869, section 1878, or otherwise’’; 

10 and 

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

12 the Social Security Act’’; and 

13 (iv) in subparagraph (F)— 

14 (I) by striking ‘‘paragraph (2)(B) 

15 of section 1848(k) of the Social Secu16 rity Act (42 U.S.C. 1395w–4(k))’’ and 

17 inserting ‘‘subsection (k)(2)(B)’’; and 

18 (II) by striking ‘‘paragraph (4) 

19 of such section’’ and inserting ‘‘sub20 section (k)(4)’’; 

21 (B) in paragraph (6)— 

22 (i) in subparagraph (A), by striking 

23 ‘‘section 1848(k)(3) of the Social Security 

24 Act, as added by subsection (b)’’ and in25 serting ‘‘subsection (k)(3)’’; and 


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1 (ii) in subparagraph (B), by striking 

2 ‘‘section 1848(k) of the Social Security 

3 Act, as added by subsection (b)’’ and in4 serting ‘‘subsection (k)’’; and 

5 (C) by striking paragraph (6)(D). 

6 (6) NO AFFECT ON INCENTIVE PAYMENTS FOR

7 2007 OR 2008.—Nothing in the amendments made by 

8 this subsection or section 132 shall affect the oper9 ation of the provisions of section 1848(m) of the So10 cial Security Act, as redesignated and amended by 

11 such subsection and section, with respect to 2007 or 

12 2008. 

13 (c) PHYSICIAN FEEDBACK PROGRAM TO IMPROVE

14 EFFICIENCY AND CONTROL COSTS.— 

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

16 Security Act (42 U.S.C. 1395w–4), as amended by 

17 subsection (b), is amended by adding at the end the 

18 following new subsection: 

19 ‘‘(n) PHYSICIAN FEEDBACK PROGRAM.— 

20 ‘‘(1) ESTABLISHMENT.— 

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

22 establish a Physician Feedback Program (in 

23 this subsection referred to as the ‘Program’) 

24 under which the Secretary shall use claims data 

25 under this title (and may use other data) to 


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1 provide confidential reports to physicians (and, 

2 as determined appropriate by the Secretary, to 

3 groups of physicians) that measure the re4 sources involved in furnishing care to individ5 uals under this title. If determined appropriate 

6 by the Secretary, the Secretary may include in7 formation on the quality of care furnished to in8 dividuals under this title by the physician (or 

9 group of physicians) in such reports. 

10 ‘‘(B) RESOURCE USE.—The resources de11 scribed in subparagraph (A) may be meas12 ured— 

13 ‘‘(i) on an episode basis; 

14 ‘‘(ii) on a per capita basis; or 

15 ‘‘(iii) on both an episode and a per 

16 capita basis. 

17 ‘‘(2) IMPLEMENTATION.—The Secretary shall 

18 implement the Program by not later than January 

19 1, 2009. 

20 ‘‘(3) DATA FOR REPORTS.—To the extent prac21 ticable, reports under the Program shall be based on 

22 the most recent data available. 

23 ‘‘(4) AUTHORITY TO FOCUS APPLICATION.—The 

24 Secretary may focus the application of the Program 

25 as appropriate, such as focusing the Program on— 


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1 ‘‘(A) physician specialties that account for 

2 a certain percentage of all spending for physi3 cians’ services under this title; 

4 ‘‘(B) physicians who treat conditions that 

5 have a high cost or a high volume, or both, 

6 under this title; 

7 ‘‘(C) physicians who use a high amount of 

8 resources compared to other physicians; 

9 ‘‘(D) physicians practicing in certain geo10 graphic areas; or 

11 ‘‘(E) physicians who treat a minimum 

12 number of individuals under this title. 

13 ‘‘(5) AUTHORITY TO EXCLUDE CERTAIN INFOR14 MATION IF INSUFFICIENT INFORMATION.—The Sec15 retary may exclude certain information regarding a 

16 service from a report under the Program with re17 spect to a physician (or group of physicians) if the 

18 Secretary determines that there is insufficient infor19 mation relating to that service to provide a valid re20 port on that service. 

21 ‘‘(6) ADJUSTMENT OF DATA.—To the extent 

22 practicable, the Secretary shall make appropriate ad23 justments to the data used in preparing reports 

24 under the Program, such as adjustments to take 


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1 into account variations in health status and other 

2 patient characteristics. 

3 ‘‘(7) EDUCATION AND OUTREACH.—The Sec4 retary shall provide for education and outreach ac5 tivities to physicians on the operation of, and meth6 odologies employed under, the Program. 

7 ‘‘(8) DISCLOSURE EXEMPTION.—Reports under 

8 the Program shall be exempt from disclosure under 

9 section 552 of title 5, United States Code.’’. 

10 (2) GAO STUDY AND REPORT ON THE PHYSI11 CIAN FEEDBACK PROGRAM.— 

12 (A) STUDY.—The Comptroller General of 

13 the United States shall conduct a study of the 

14 Physician Feedback Program conducted under 

15 section 1848(n) of the Social Security Act, as 

16 added by paragraph (1), including the imple17 mentation of the Program. 

18 (B) REPORT.—Not later than March 1, 

19 2011, the Comptroller General of the United 

20 States shall submit a report to Congress con21 taining the results of the study conducted under 

22 subparagraph (A), together with recommenda23 tions for such legislation and administrative ac24 tion as the Comptroller General determines ap25 propriate. 


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1 (d) PLAN FOR TRANSITION TO VALUE-BASED PUR2 CHASING PROGRAM FOR PHYSICIANS AND OTHER PRACTI3 TIONERS.— 

4 (1) IN GENERAL.—The Secretary of Health and 

5 Human Services shall develop a plan to transition to 

6 a value-based purchasing program for payment 

7 under the Medicare program for covered professional 

8 services (as defined in section 1848(k)(3)(A) of the 

9 Social Security Act (42 U.S.C. 1395w–4(k)(3)(A))). 

10 (2) REPORT.—Not later than May 1, 2010, the 

11 Secretary of Health and Human Services shall sub12 mit a report to Congress containing the plan devel13 oped under paragraph (1), together with rec14 ommendations for such legislation and administra15 tive action as the Secretary determines appropriate. 

16 (e) IMPLEMENTATION.—For purposes of carrying out 

17 the provisions of, and amendments made by, this title, in 

18 addition to any amounts otherwise provided in such provi19 sions and amendments, there are appropriated to the Cen20 ters for Medicare & Medicaid Services Program Manage21 ment Account, out of any money in the Treasury not oth22 erwise appropriated, $140,000,000 for the period of fiscal 

23 years 2009 through 2013. 


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1 SEC. 132. INCENTIVES FOR ELECTRONIC PRESCRIBING. 

2 (a) INCENTIVE PAYMENTS.—Section 1848(m) of the 

3 Social Security Act, as added and amended by section 

4 131(b), is amended— 

5 (1) by inserting after paragraph (1), the fol6 lowing new paragraph: 

7 ‘‘(2) INCENTIVE PAYMENTS FOR ELECTRONIC

8 PRESCRIBING.— 

9 ‘‘(A) IN GENERAL.—For 2009 through 

10 2013, with respect to covered professional serv11 ices furnished during a reporting period by an 

12 eligible professional, if the eligible professional 

13 is a successful electronic prescriber for such re14 porting period, in addition to the amount other15 wise paid under this part, there also shall be 

16 paid to the eligible professional (or to an em17 ployer or facility in the cases described in 

18 clause (A) of section 1842(b)(6)) or, in the case 

19 of a group practice under paragraph (3)(C), to 

20 the group practice, from the Federal Supple21 mentary Medical Insurance Trust Fund estab22 lished under section 1841 an amount equal to 

23 the applicable electronic prescribing percent of 

24 the Secretary’s estimate (based on claims sub25 mitted not later than 2 months after the end of 

26 the reporting period) of the allowed charges 


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1 under this part for all such covered professional 

2 services furnished by the eligible professional 

3 (or, in the case of a group practice under para4 graph (3)(C), by the group practice) during the 

5 reporting period. 

6 ‘‘(B) LIMITATION WITH RESPECT TO ELEC7 TRONIC PRESCRIBING QUALITY MEASURES.— 

8 The provisions of this paragraph and subsection 

9 (a)(5) shall not apply to an eligible professional 

10 (or, in the case of a group practice under para11 graph (3)(C), to the group practice) if, for the 

12 reporting period (or, for purposes of subsection 

13 (a)(5), for the reporting period for a year)— 

14 ‘‘(i) the allowed charges under this 

15 part for all covered professional services 

16 furnished by the eligible professional (or 

17 group, as applicable) for the codes to 

18 which the electronic prescribing quality 

19 measure applies (as identified by the Sec20 retary and published on the Internet 

21 website of the Centers for Medicare & 

22 Medicaid Services as of January 1, 2008, 

23 and as subsequently modified by the Sec24 retary) are less than 10 percent of the 

25 total of the allowed charges under this part 


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1 for all such covered professional services 

2 furnished by the eligible professional (or 

3 the group, as applicable); or 

4 ‘‘(ii) if determined appropriate by the 

5 Secretary, the eligible professional does not 

6 submit (including both electronically and 

7 nonelectronically) a sufficient number (as 

8 determined by the Secretary) of prescrip9 tions under part D. 

10 If the Secretary makes the determination to 

11 apply clause (ii) for a period, then clause (i) 

12 shall not apply for such period. 

13 ‘‘(C) APPLICABLE ELECTRONIC PRE14 SCRIBING PERCENT.—For purposes of subpara15 graph (A), the term ‘applicable electronic pre16 scribing percent’ means— 

17 ‘‘(i) for 2009 and 2010, 2.0 percent; 

18 ‘‘(ii) for 2011 and 2012, 1.0 percent; 

19 and 

20 ‘‘(iii) for 2013, 0.5 percent.’’; 

21 (2) in paragraph (3), as redesignated by section 

22 131(b)— 

23 (A) in the heading, by inserting ‘‘AND SUC24 CESSFUL ELECTRONIC PRESCRIBER’’ after ‘‘RE25 PORTING’’; and 


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1 (B) by inserting after subparagraph (A) 

2 the following new subparagraph: 

3 ‘‘(B) SUCCESSFUL ELECTRONIC PRE4 SCRIBER.— 

5 ‘‘(i) IN GENERAL.—For purposes of 

6 paragraph (2) and subsection (a)(5), an el7 igible professional shall be treated as a 

8 successful electronic prescriber for a re9 porting period (or, for purposes of sub10 section (a)(5), for the reporting period for 

11 a year) if the eligible professional meets 

12 the requirement described in clause (ii), or, 

13 if the Secretary determines appropriate, 

14 the requirement described in clause (iii). If 

15 the Secretary makes the determination 

16 under the preceding sentence to apply the 

17 requirement described in clause (ii) for a 

18 period, then the requirement described in 

19 clause (i) shall not apply for such period. 

20 ‘‘(ii) REQUIREMENT FOR SUBMITTING

21 DATA ON ELECTRONIC PRESCRIBING QUAL22 ITY MEASURES.—The requirement de23 scribed in this clause is that, with respect 

24 to covered professional services furnished 

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1 ing period (or, for purposes of subsection 

2 (a)(5), for the reporting period for a year), 

3 if there are any electronic prescribing qual4 ity measures that have been established 

5 under the physician reporting system and 

6 are applicable to any such services fur7 nished by such professional for the period, 

8 such professional reported each such meas9 ure under such system in at least 50 per10 cent of the cases in which such measure is 

11 reportable by such professional under such 

12 system. 

13 ‘‘(iii) REQUIREMENT FOR ELECTRONI14 CALLY PRESCRIBING UNDER PART D.—The 

15 requirement described in this clause is that 

16 the eligible professional electronically sub17 mitted a sufficient number (as determined 

18 by the Secretary) of prescriptions under 

19 part D during the reporting period (or, for 

20 purposes of subsection (a)(5), for the re21 porting period for a year). 

22 ‘‘(iv) USE OF PART D DATA.—Not23 withstanding sections 1858(c)(3)(B), 

24 1860D–15(d)(2)(B), and 1860D–15(f)(2), 

25 the Secretary may use data submitted for 


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1 purposes of part D for purposes of clause 

2 (iii) and paragraph (2)(B)(ii). Such data 

3 shall only be used for such purposes. 

4 ‘‘(v) STANDARDS FOR ELECTRONIC

5 PRESCRIBING.—To the extent practicable, 

6 in determining whether eligible profes7 sionals meet the requirements under 

8 clauses (ii) and (iii) for purposes of clause 

9 (i), the Secretary shall ensure that eligible 

10 professionals utilize electronic prescribing 

11 systems in compliance with standards es12 tablished for such systems pursuant to the 

13 Part D Electronic Prescribing Program 

14 under section 1860D–4(e).’’; and 

15 (3) in paragraph (5)(E)— 

16 (A) in clause (i), by striking subclause 

17 (III) and inserting the following new subclause: 

18 ‘‘(III) the determination of a suc19 cessful electronic prescriber under 

20 paragraph (3), the limitation under 

21 paragraph (2)(B), and the exception 

22 under subsection (a)(5)(B); and’’; and 

23 (B) in clause (ii), by inserting ‘‘or sub24 section (a)(5)’’ after ‘‘this subsection’’. 


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1 (b) INCENTIVE PAYMENT ADJUSTMENT.—Section 

2 1848(a) of the Social Security Act (42 U.S.C. 1395w– 

3 4(a)) is amended by adding at the end the following new 

4 paragraph: 

5 ‘‘(5) INCENTIVES FOR ELECTRONIC PRE6 SCRIBING.— 

7 ‘‘(A) ADJUSTMENT.— 

8 ‘‘(i) IN GENERAL.—Subject to sub9 paragraph (B) and subsection (m)(2)(B), 

10 with respect to covered professional serv11 ices furnished by an eligible professional 

12 during 2011 or any subsequent year, if the 

13 eligible professional is not a successful 

14 electronic prescriber for the reporting pe15 riod for the year (as determined under 

16 subsection (m)(3)(B)), the fee schedule 

17 amount for such services furnished by such 

18 professional during the year (including the 

19 fee schedule amount for purposes of deter20 mining a payment based on such amount) 

21 shall be equal to the applicable percent of 

22 the fee schedule amount that would other23 wise apply to such services under this sub24 section (determined after application of 


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1 paragraph (3) but without regard to this 

2 paragraph). 

3 ‘‘(ii) APPLICABLE PERCENT.—For 

4 purposes of clause (i), the term ‘applicable 

5 percent’ means— 

6 ‘‘(I) for 2011, 99 percent; 

7 ‘‘(II) for 2012, 98.5 percent; and 

8 ‘‘(III) for 2013 and each subse9 quent year, 98 percent. 

10 ‘‘(B) SIGNIFICANT HARDSHIP EXCEP11 TION.—The Secretary may exempt an eligible 

12 professional from the application of the pay13 ment adjustment under subparagraph (A) if the 

14 Secretary determines that compliance with the 

15 requirement for being a successful electronic 

16 prescriber would be a significant hardship, such 

17 as an eligible professional who practices in a 

18 rural area without sufficient Internet access 

19 and an eligible professional who frequently 

20 sends prescriptions to pharmacies that are not 

21 capable of receiving prescriptions electronically. 

22 ‘‘(C) APPLICATION.— 

23 ‘‘(i) PHYSICIAN REPORTING SYSTEM

24 RULES.—Paragraphs (5), (6), and (8) of 

25 subsection (k) shall apply for purposes of 


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1 this paragraph in the same manner as they 

2 apply for purposes of such subsection. 

3 ‘‘(ii) INCENTIVE PAYMENT VALIDA4 TION RULES.—Clauses (ii) and (iii) of sub5 section (m)(5)(D) shall apply for purposes 

6 of this paragraph in a similar manner as 

7 they apply for purposes of such subsection. 

8 ‘‘(D) DEFINITIONS.—For purposes of this 

9 paragraph: 

10 ‘‘(i) ELIGIBLE PROFESSIONAL; COV11 ERED PROFESSIONAL SERVICES.—The 

12 terms ‘eligible professional’ and ‘covered 

13 professional services’ have the meanings 

14 given such terms in subsection (k)(3). 

15 ‘‘(ii) PHYSICIAN REPORTING SYS16 TEM.—The term ‘physician reporting sys17 tem’ means the system established under 

18 subsection (k). 

19 ‘‘(iii) REPORTING PERIOD.—The term 

20 ‘reporting period’ means, with respect to a 

21 year, a period specified by the Secretary.’’. 


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1 SEC. 133. INCREASING THE NUMBER OF SITES FOR THE 

2 ELECTRONIC HEALTH RECORDS DEM3 ONSTRATION. 

4 Out of funds in the Treasury not otherwise appro5 priated, there are appropriated for the period of fiscal 

6 years 2009 through 2014, $45,000,000 to the Centers for 

7 Medicare & Medicaid Services Program Management Ac8 count for administrative costs to increase the number of 

9 sites, up to 40, in which the Electronic Health Records 

10 Demonstration is being conducted. 

11 SEC. 134. PRIMARY CARE IMPROVEMENTS. 

12 (a) INCENTIVE PAYMENT PROGRAM FOR PRIMARY

13 CARE SERVICES FURNISHED IN PHYSICIAN SCARCITY

14 AREAS.— 

15 (1) IN GENERAL.—Section 1833 of the Social 

16 Security Act (42 U.S.C. 1395l) is amended by add17 ing at the end the following new subsection: 

18 ‘‘(v) INCENTIVE PAYMENTS FOR PRIMARY CARE

19 SERVICES FURNISHED IN PHYSICIAN SCARCITY AREAS.— 

20 ‘‘(1) IN GENERAL.—In the case of primary care 

21 services furnished on or after January 1, 2011, by 

22 a primary care physician in a primary care scarcity 

23 county, in addition to the amount of payment that 

24 would otherwise be made for such services under this 

25 part, there also shall be paid (on a monthly or quarVerDate Aug 31 2005 03:52 Jun 13, 2008 Jkt 069200 PO 00000 Frm 00060 Fmt 6652 Sfmt 6201 E:\BILLS\S3118.PCS S3118

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1 terly basis) an amount equal to 5 percent of the pay2 ment amount for the service under this part. 

3 ‘‘(2) DEFINITIONS.—In this subsection: 

4 ‘‘(A) PRIMARY CARE PHYSICIAN.—The 

5 term ‘primary care physician’ means a physi6 cian (as described in section 1861(r)(1)) for 

7 whom primary care services accounted for at 

8 least a specified percent (as determined by the 

9 Secretary) of the allowed charges under this 

10 part for such physician in a prior period as de11 termined appropriate by the Secretary. 

12 ‘‘(B) PRIMARY CARE SCARCITY COUNTY.— 

13 The term ‘primary care scarcity county’ means 

14 the primary care scarcity counties that the Sec15 retary was using under subsection (u) with re16 spect to physicians’ services furnished on De17 cember 31, 2007. 

18 ‘‘(C) PRIMARY CARE SERVICES.—The term 

19 ‘primary care services’ means procedure codes 

20 for services in the category of the Healthcare 

21 Common Procedure Coding System, as estab22 lished by the Secretary under section 

23 1848(c)(5) (as of December 31, 2008 and as 

24 subsequently modified by the Secretary) con25 sisting of evaluation and management services, 


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1 but limited to such procedure codes in the cat2 egory of office or other outpatient services, and 

3 consisting of subcategories of such procedure 

4 codes for services for both new and established 

5 patients. 

6 ‘‘(3) JUDICIAL REVIEW.—There shall be no ad7 ministrative or judicial review under section 1869, 

8 1878, or otherwise, respecting the identification of 

9 primary care physicians, primary care specialty 

10 areas, or primary care services under this sub11 section.’’. 

12 (2) CONFORMING AMENDMENT.—Section 

13 1834(g)(2)(B) of the Social Security Act (42 U.S.C. 

14 1395m(g)(2)(B)) is amended by adding at the end 

15 the following sentence: ‘‘Section 1833(v) shall not be 

16 taken into account in determining the amounts that 

17 would otherwise be paid pursuant to the preceding 

18 sentence.’’. 

19 (b) REVISIONS TO THE MEDICARE MEDICAL HOME

20 DEMONSTRATION PROJECT.— 

21 (1) AUTHORITY TO EXPAND.—Section 204(b) 

22 of division B of the Tax Relief and Health Care Act 

23 of 2006 (42 U.S.C. 1395b–1 note) is amended— 


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1 (A) in paragraph (1), by striking ‘‘The 

2 project’’ and inserting ‘‘Subject to paragraph 

3 (3), the project’’; and 

4 (B) by adding at the end the following new 

5 paragraph: 

6 ‘‘(3) EXPANSION.—The Secretary may expand 

7 the duration and the scope of the project under 

8 paragraph (1), to an extent determined appropriate 

9 by the Secretary, if the Secretary determines that 

10 such expansion will result in any of the following 

11 conditions being met: 

12 ‘‘(A) The expansion of the project is ex13 pected to improve the quality of patient care 

14 without increasing spending under the Medicare 

15 program (not taking into account amounts 

16 available under subsection (g)). 

17 ‘‘(B) The expansion of the project is ex18 pected to reduce spending under the Medicare 

19 program (not taking into account amounts 

20 available under subsection (g)) without reducing 

21 the quality of patient care.’’. 

22 (2) FUNDING AND APPLICATION.—Section 204 

23 of division B of the Tax Relief and Health Care Act 

24 of 2006 (42 U.S.C. 1395b–1 note) is amended by 

25 adding at the end the following new subsections: 


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1 ‘‘(g) FUNDING FROM SMI TRUST FUND.—There 

2 shall be available, from the Federal Supplementary Med3 ical Insurance Trust Fund (under section 1841 of the So4 cial Security Act (42 U.S.C. 1395t)), the amount of 

5 $100,000,000 to carry out the project. 

6 ‘‘(h) APPLICATION.—Chapter 35 of title 44, United 

7 States Code, shall not apply to the conduct of the 

8 project.’’. 

9 (c) APPLICATION OF BUDGET-NEUTRALITY ADJUS10 TOR TO CONVERSION FACTOR.—Section 1848(c)(2)(B) of 

11 the Social Security Act (42 U.S.C. 1395w–4(c)(2)(B)) is 

12 amended by adding at the end the following new clause: 

13 ‘‘(vi) ALTERNATIVE APPLICATION OF

14 BUDGET-NEUTRALITY ADJUSTMENT.—Not15 withstanding subsection (d)(9)(A), effective 

16 for fee schedules established beginning 

17 with 2009, with respect to the 5-year re18 view of work relative value units used in 

19 fee schedules for 2007 and 2008, in lieu of 

20 continuing to apply budget-neutrality ad21 justments required under clause (ii) for 

22 2007 and 2008 to work relative value 

23 units, the Secretary shall apply such budg24 et-neutrality adjustments to the conversion 


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1 factor otherwise determined for years be2 ginning with 2009.’’. 

3 SEC. 135. MEDICARE ANESTHESIA TEACHING PROGRAM IM4 PROVEMENTS. 

5 (a) SPECIAL PAYMENT RULE FOR TEACHING ANES6 THESIOLOGISTS.—Section 1848(a) of the Social Security 

7 Act (42 U.S.C. 1395w–4(a)), as amended by section 

8 132(b), is amended— 

9 (1) in paragraph (4)(A), by inserting ‘‘except as 

10 provided in paragraph (5),’’ after ‘‘anesthesia 

11 cases,’’; and 

12 (2) by adding at the end the following new 

13 paragraph: 

14 ‘‘(6) SPECIAL RULE FOR TEACHING ANESTHE15 SIOLOGISTS.—With respect to physicians’ services 

16 furnished on or after January 1, 2010, in the case 

17 of teaching anesthesiologists involved in the training 

18 of physician residents in a single anesthesia case or 

19 two concurrent anesthesia cases, the fee schedule 

20 amount to be applied shall be 100 percent of the fee 

21 schedule amount otherwise applicable under this sec22 tion if the anesthesia services were personally per23 formed by the teaching anesthesiologist alone and 

24 paragraph (4) shall not apply if— 


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1 ‘‘(A) the teaching anesthesiologist is 

2 present during all critical or key portions of the 

3 anesthesia service or procedure involved; and 

4 ‘‘(B) the teaching anesthesiologist (or an5 other anesthesiologist with whom the teaching 

6 anesthesiologist has entered into an arrange7 ment) is immediately available to furnish anes8 thesia services during the entire procedure.’’. 

9 (b) TREATMENT OF CERTIFIED REGISTERED NURSE

10 ANESTHETISTS.—With respect to items and services fur11 nished on or after January 1, 2010, the Secretary of 

12 Health and Human Services shall make appropriate ad13 justments to payments under the Medicare program under 

14 title XVIII of the Social Security Act for teaching certified 

15 registered nurse anesthetists to implement a policy with 

16 respect to teaching certified registered nurse anesthetists 

17 that— 

18 (1) is consistent with the adjustments made by 

19 the special rule for teaching anesthesiologists under 

20 section 1848(a)(6) of the Social Security Act, as 

21 added by subsection (a); and 

22 (2) maintains the existing payment differences 

23 between teaching anesthesiologists and teaching cer24 tified registered nurse anesthetists. 


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1 SEC. 136. MEDICARE COORDINATED CARE PRACTICE RE2 SEARCH NETWORK DEMONSTRATION. 

3 (a) DEMONSTRATION PROGRAM.— 

4 (1) IN GENERAL.—Not later than October 1, 

5 2009, the Secretary shall establish a demonstration 

6 program to test best practices and new and innova7 tive coordinated care projects for Medicare bene8 ficiaries with multiple chronic conditions. 

9 (2) DEMONSTRATION PROGRAM DESIGN.— 

10 (A) INITIAL SITES.—The Secretary shall 

11 select not less than 8 organizations to partici12 pate in the demonstration program under this 

13 section initially. The organizations selected 

14 under this subparagraph shall meet the fol15 lowing requirements: 

16 (i) The organizations are highly quali17 fied direct providers of coordinated care to 

18 Medicare beneficiaries with multiple chron19 ic conditions. 

20 (ii) The organizations were partici21 pants in the Medicare Coordinated Care 

22 Demonstration under section 4016 of the 

23 Balanced Budget Act of 1997 (42 U.S.C. 

24 1395b–1 note) as of October 1, 2007. 

25 (B) ADDITIONAL SITES.—The Secretary 

26 may select organizations to participate in the 


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1 demonstration program under this section in 

2 addition to those initially selected under sub3 paragraph (A). The organizations selected 

4 under this subparagraph shall meet the fol5 lowing requirements: 

6 (i) The organizations are highly quali7 fied direct providers of coordinated care to 

8 Medicare beneficiaries with multiple chron9 ic conditions. 

10 (ii) The organizations meet such other 

11 criteria as the Secretary determines appro12 priate. 

13 (3) DURATION.— 

14 (A) IN GENERAL.—Subject to subpara15 graph (B), the demonstration program under 

16 this section shall be conducted for a 5-year pe17 riod. 

18 (B) EXPANSION OF DEMONSTRATION PRO19 GRAM; IMPLEMENTATION OF DEMONSTRATION

20 PROGRAM RESULTS.— 

21 (i) EXPANSION OF DEMONSTRATION

22 PROGRAM.—If the report under paragraph 

23 (5) contains an evaluation that the dem24 onstration program under this section— 


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1 (I) reduces expenditures under 

2 the Medicare program; or 

3 (II) does not increase expendi4 tures under the Medicare program 

5 and increases the quality of health 

6 care services provided to Medicare 

7 beneficiaries with multiple chronic 

8 conditions and satisfaction of bene9 ficiaries and health care providers; 

10 the Secretary shall continue the existing 

11 demonstration program and may expand 

12 the demonstration program. 

13 (ii) IMPLEMENTATION OF DEM14 ONSTRATION PROGRAM RESULTS.—If the 

15 report under paragraph (5) contains an 

16 evaluation described in clause (i), the Sec17 retary may issue regulations to implement, 

18 on a permanent basis, the components of 

19 the demonstration program that are bene20 ficial to the Medicare program. 

21 (4) USE OF CONTRACTOR TO FACILITATE COM22 MUNICATION AND INFORMATION SHARING.— 

23 (A) IN GENERAL.—Under the demonstra24 tion program under this section, the Secretary 

25 shall enter into a contract with a contractor to 


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1 facilitate communications and data analysis 

2 among sites participating in the demonstration 

3 program and to share information on best prac4 tices with such sites. 

5 (B) DUTIES.—The contractor shall have 

6 such duties and responsibilities as are specified 

7 by the Secretary, including ensuring, to the ex8 tent feasible, that each site participating in the 

9 demonstration program under this section re10 ceives timely and regular access to data from 

11 the other sites participating in the demonstra12 tion program to enable each site to modify, re13 fine, and evaluate current and proposed chronic 

14 care interventions and new models of care. 

15 (b) EVALUATION AND REPORT.—Not later than 4 

16 years after the establishment of the demonstration pro17 gram under this section, the Secretary shall submit a re18 port to Congress on the Medicare chronic care practice 

19 research network based on an evaluation of the dem20 onstration program. Such report shall include an evalua21 tion of the effectiveness of each site participating in the 

22 demonstration program, including the following: 

23 (1) An analysis of progress made under the 

24 demonstration program toward developing an effi25 cient and effective research infrastructure capable of 


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1 robustly testing new interventions and models of 

2 care for Medicare beneficiaries with multiple chronic 

3 conditions in a timely manner. 

4 (2) An evaluation of the impacts of the care co5 ordination models used by each site participating in 

6 the demonstration program, including the overall 

7 quality of care provided, patient satisfaction, and 

8 cost-effectiveness of the interventions tested under 

9 the demonstration program at each site. 

10 (3) An evaluation of the capability of the dem11 onstration program to define and test specifications 

12 needed to deploy successful interventions on a large 

13 geographic or nationwide scale without loss of effec14 tiveness. 

15 (4) A description of any benefits to the Medi16 care program under title XVIII of the Social Secu17 rity Act resulting from increased collaboration and 

18 partnership between participating sites under the 

19 demonstration program. 

20 (5) Any other information regarding the dem21 onstration program that the Secretary determines 

22 appropriate. 

23 (6) Recommendations for practices and guide24 lines for chronic care, including a summary of the 

25 care models found to be most effective in managing 


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1 Medicare beneficiaries with multiple chronic condi2 tions under the demonstration program under this 

3 subsection. 

4 (7) Recommendations for such legislation and 

5 administrative action as the Secretary determines 

6 appropriate. 

7 (c) FUNDING.— 

8 (1) IMPLEMENTATION FUNDING.—The Sec9 retary shall provide for the transfer from the Fed10 eral Hospital Insurance Trust Fund under section 

11 1817 of the Social Security Act (42 U.S.C. 1395i) 

12 and the Federal Supplementary Medical Insurance 

13 Trust Fund under section 1841 of such Act (42 

14 U.S.C. 1395t), in such proportion as the Secretary 

15 determines to be appropriate, of $15,000,000 to the 

16 Centers for Medicare & Medicaid Services Program 

17 Management Account to implement the demonstra18 tion program under this section. 

19 (2) ADDITIONAL FUNDING.— 

20 (A) IN GENERAL.—In addition to the im21 plementation funding under paragraph (1), the 

22 Secretary shall provide for the transfer from 

23 the Federal Hospital Insurance Trust Fund 

24 under section 1817 of the Social Security Act 

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1 mentary Medical Insurance Trust Fund under 

2 section 1841 of such Act (42 U.S.C. 1395t), in 

3 such proportion as the Secretary determines to 

4 be appropriate, of such funds as are necessary 

5 to the Centers for Medicare & Medicaid Serv6 ices Program Management Account to carry out 

7 the demonstration program under this section. 

8 (B) LIMITATION.—Except with respect to 

9 the implementation funding under paragraph 

10 (1), in conducting the demonstration program 

11 under this section, the Secretary shall ensure 

12 that the aggregate payments made by the Sec13 retary do not exceed the amount which the Sec14 retary estimates would have been paid if the 

15 demonstration program under this section were 

16 not implemented. 

17 (d) WAIVER.—The Secretary shall waive compliance 

18 with the requirements of title XVIII of the Social Security 

19 Act (42 U.S.C. 1395 et seq.) to such extent and for such 

20 period as the Secretary determines is necessary to carry 

21 out this section. 

22 SEC. 137. IMAGING PROVISIONS. 

23 (a) ACCREDITATION REQUIREMENT.— 

24 (1) ACCREDITATION REQUIREMENT.—Section 

25 1834 of the Social Security Act (42 U.S.C. 1395m) 


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1 is amended by inserting after subsection (d) the fol2 lowing new subsection: 

3 ‘‘(e) ACCREDITATION REQUIREMENT FOR ADVANCED

4 DIAGNOSTIC IMAGING SERVICES.— 

5 ‘‘(1) IN GENERAL.— 

6 ‘‘(A) IN GENERAL.—Beginning with Janu7 ary 1, 2012, with respect to the technical com8 ponent of advanced diagnostic imaging services 

9 for which payment is made under the fee sched10 ule established under section 1848(b) and that 

11 are furnished by a supplier, payment may only 

12 be made if such supplier is accredited by an ac13 creditation organization designated by the Sec14 retary under paragraph (2)(B)(i). 

15 ‘‘(B) ADVANCED DIAGNOSTIC IMAGING

16 SERVICES DEFINED.—In this subsection, the 

17 term ‘advanced diagnostic imaging services’ in18 cludes diagnostic magnetic resonance imaging, 

19 computed tomography, nuclear medicine (in20 cluding positron emission tomography), and 

21 such other diagnostic imaging services described 

22 in section 1848(b)(4)(B) (excluding X-ray, 

23 ultrasound, and fluoroscopy) as specified by the 

24 Secretary, in consultation with physician spe25 cialty organizations and other stakeholders. 


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1 ‘‘(C) SUPPLIER DEFINED.—In this sub2 section, the term ‘supplier’ has the meaning 

3 given such term in section 1861(d). 

4 ‘‘(2) ACCREDITATION ORGANIZATIONS.— 

5 ‘‘(A) FACTORS FOR DESIGNATION OF AC6 CREDITATION ORGANIZATIONS.—The Secretary 

7 shall consider the following factors in desig8 nating accreditation organizations under sub9 paragraph (B)(i) and in reviewing and modi10 fying the list of accreditation organizations des11 ignated pursuant to subparagraph (C): 

12 ‘‘(i) The ability of the organization to 

13 conduct timely reviews of accreditation ap14 plications. 

15 ‘‘(ii) Whether the organization has es16 tablished a process for the timely integra17 tion of new advanced diagnostic imaging 

18 services into the organization’s accredita19 tion program. 

20 ‘‘(iii) Whether the organization uses 

21 random site visits, site audits, or other 

22 strategies for ensuring accredited suppliers 

23 maintain adherence to the criteria de24 scribed in paragraph (3). 


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1 ‘‘(iv) The ability of the organization 

2 to take into account the capacities of sup3 pliers located in a rural area (as defined in 

4 section 1886(d)(2)(D)). 

5 ‘‘(v) Whether the organization has es6 tablished reasonable fees to be charged to 

7 suppliers applying for accreditation. 

8 ‘‘(vi) Such other factors as the Sec9 retary determines appropriate. 

10 ‘‘(B) DESIGNATION.—Not later than Janu11 ary 1, 2010, the Secretary shall designate orga12 nizations to accredit suppliers furnishing the 

13 technical component of advanced diagnostic im14 aging services. The list of accreditation organi15 zations so designated may be modified pursuant 

16 to subparagraph (C). 

17 ‘‘(C) REVIEW AND MODIFICATION OF LIST

18 OF ACCREDITATION ORGANIZATIONS.— 

19 ‘‘(i) IN GENERAL.—The Secretary 

20 shall review the list of accreditation organi21 zations designated under subparagraph (B) 

22 taking into account the factors under sub23 paragraph (A). Taking into account the re24 sults of such review, the Secretary may, by 

25 regulation, modify the list of accreditation 


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1 organizations designated under subpara2 graph (B). 

3 ‘‘(ii) SPECIAL RULE FOR ACCREDITA4 TIONS DONE PRIOR TO REMOVAL FROM

5 LIST OF DESIGNATED ACCREDITATION OR6 GANIZATIONS.—In the case where the Sec7 retary removes an organization from the 

8 list of accreditation organizations des9 ignated under subparagraph (B), any sup10 plier that is accredited by the organization 

11 during the period beginning on the date on 

12 which the organization is designated as an 

13 accreditation organization under subpara14 graph (B) and ending on the date on 

15 which the organization is removed from 

16 such list shall be considered to have been 

17 accredited by an organization designated 

18 by the Secretary under subparagraph (B) 

19 for the remaining period such accreditation 

20 is in effect. 

21 ‘‘(3) CRITERIA FOR ACCREDITATION.—The Sec22 retary shall establish procedures to ensure that the 

23 criteria used by an accreditation organization des24 ignated under paragraph (2)(B) to evaluate a sup25 plier that furnishes the technical component of adVerDate Aug 31 2005 03:52 Jun 13, 2008 Jkt 069200 PO 00000 Frm 00077 Fmt 6652 Sfmt 6201 E:\BILLS\S3118.PCS S3118

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1 vanced diagnostic imaging services for the purpose 

2 of accreditation of such supplier is specific to each 

3 imaging modality. Such criteria shall include— 

4 ‘‘(A) standards for qualifications of med5 ical personnel who are not physicians and who 

6 furnish the technical component of advanced di7 agnostic imaging services; 

8 ‘‘(B) standards for qualifications and re9 sponsibilities of medical directors and super10 vising physicians, including standards that rec11 ognize the considerations described in para12 graph (4); 

13 ‘‘(C) procedures to ensure that equipment 

14 used in furnishing the technical component of 

15 advanced diagnostic imaging services meets per16 formance specifications; 

17 ‘‘(D) standards that require the supplier 

18 have procedures in place to ensure the safety of 

19 persons who furnish the technical component of 

20 advanced diagnostic imaging services and indi21 viduals to whom such services are furnished; 

22 ‘‘(E) standards that require the establish23 ment and maintenance of a quality assurance 

24 and quality control program by the supplier 

25 that is adequate and appropriate to ensure the 


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1 reliability, clarity, and accuracy of the technical 

2 quality of diagnostic images produced by such 

3 supplier; and 

4 ‘‘(F) any other standards or procedures 

5 the Secretary determines appropriate. 

6 ‘‘(4) RECOGNITION IN STANDARDS FOR THE

7 EVALUATION OF MEDICAL DIRECTORS AND SUPER8 VISING PHYSICIANS.—The standards described in 

9 paragraph (3)(B) shall recognize whether a medical 

10 director or supervising physician— 

11 ‘‘(A) in a particular specialty receives 

12 training in advanced diagnostic imaging serv13 ices in a residency program; 

14 ‘‘(B) has attained, through experience, the 

15 necessary expertise to be a medical director or 

16 a supervising physician; 

17 ‘‘(C) has completed any continuing medical 

18 education courses relating to such services; or 

19 ‘‘(D) has met such other standards as the 

20 Secretary determines appropriate. 

21 ‘‘(5) RULE FOR ACCREDITATIONS MADE PRIOR

22 TO DESIGNATION.—In the case of a supplier that is 

23 accredited before January 1, 2010, by an accredita24 tion organization designated by the Secretary under 

25 paragraph (2)(B) as of January 1, 2010, such supVerDate Aug 31 2005 03:52 Jun 13, 2008 Jkt 069200 PO 00000 Frm 00079 Fmt 6652 Sfmt 6201 E:\BILLS\S3118.PCS S3118

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1 plier shall be considered to have been accredited by 

2 an organization designated by the Secretary under 

3 such paragraph as of January 1, 2012, for the re4 maining period such accreditation is in effect.’’. 

5 (2) CONFORMING AMENDMENTS.— 

6 (A) IN GENERAL.—Section 1862(a) of the 

7 Social Security Act (42 U.S.C. 1395y(a)) is 

8 amended— 

9 (i) in paragraph (21), by striking ‘‘or’’ 

10 at the end; 

11 (ii) in paragraph (22), by striking the 

12 period at the end and inserting ‘‘; or’’; and 

13 (iii) by inserting after paragraph (22) 

14 the following new paragraph: 

15 ‘‘(23) which are the technical component of ad16 vanced diagnostic imaging services described in sec17 tion 1834(e)(1)(B) for which payment is made under 

18 the fee schedule established under section 1848(b) 

19 and that are furnished by a supplier (as defined in 

20 section 1861(d)), if such supplier is not accredited 

21 by an accreditation organization designated by the 

22 Secretary under section 1834(e)(2)(B).’’. 

23 (B) EFFECTIVE DATE.—The amendments 

24 made by this paragraph shall apply to advanced 


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1 diagnostic imaging services furnished on or 

2 after January 1, 2012. 

3 (b) DEMONSTRATION PROJECT TO ASSESS THE AP4 PROPRIATE USE OF IMAGING SERVICES.— 

5 (1) CONDUCT OF DEMONSTRATION PROJECT.— 

6 (A) IN GENERAL.—The Secretary of 

7 Health and Human Services (in this section re8 ferred to as the ‘‘Secretary’’) shall conduct a 

9 demonstration project using the models de10 scribed in paragraph (2)(E) to collect data re11 garding physician compliance with appropriate12 ness criteria selected under paragraph (2)(D) in 

13 order to determine the appropriateness of ad14 vanced diagnostic imaging services furnished to 

15 Medicare beneficiaries. 

16 (B) ADVANCED DIAGNOSTIC IMAGING

17 SERVICES.—In this subsection, the term ‘‘ad18 vanced diagnostic imaging services’’ has the 

19 meaning given such term in section 

20 1834(e)(1)(B) of the Social Security Act, as 

21 added by subsection (a). 

22 (C) AUTHORITY TO FOCUS DEMONSTRA23 TION PROJECT.—The Secretary may focus the 

24 demonstration project with respect to certain 

25 advanced diagnostic imaging services, such as 


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1 services that account for a large amount of ex2 penditures under the Medicare program, serv3 ices that have recently experienced a high rate 

4 of growth, or services for which appropriateness 

5 criteria exists. 

6 (2) IMPLEMENTATION AND DESIGN OF DEM7 ONSTRATION PROJECT.— 

8 (A) IMPLEMENTATION AND DURATION.— 

9 (i) IMPLEMENTATION.—The Secretary 

10 shall implement the demonstration project 

11 under this subsection not later than Janu12 ary 1, 2010. 

13 (ii) DURATION.—The Secretary shall 

14 conduct the demonstration project under 

15 this subsection for a 2-year period. 

16 (B) APPLICATION AND SELECTION OF PAR17 TICIPATING PHYSICIANS.— 

18 (i) APPLICATION.—Each physician 

19 that desires to participate in the dem20 onstration project under this subsection 

21 shall submit an application to the Sec22 retary at such time, in such manner, and 

23 containing such information as the Sec24 retary may require. 


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1 (ii) SELECTION.—The Secretary shall 

2 select physicians to participate in the dem3 onstration project under this subsection 

4 from among physicians submitting applica5 tions under clause (i). The Secretary shall 

6 ensure that the physicians selected— 

7 (I) represent a wide range of geo8 graphic areas, demographic character9 istics (such as urban, rural, and sub10 urban), and practice settings (such as 

11 private and academic practices); and 

12 (II) have the capability to submit 

13 data to the Secretary (or an entity 

14 under a subcontract with the Sec15 retary) in an electronic format in ac16 cordance with standards established 

17 by the Secretary. 

18 (C) ADMINISTRATIVE COSTS AND INCEN19 TIVES.—The Secretary shall— 

20 (i) reimburse physicians for reason21 able administrative costs incurred in par22 ticipating in the demonstration project 

23 under this subsection; and 

24 (ii) provide reasonable incentives to 

25 physicians to encourage participation in 


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1 the demonstration project under this sub2 section. 

3 (D) USE OF APPROPRIATENESS CRI4 TERIA.— 

5 (i) IN GENERAL.—The Secretary, in 

6 consultation with medical specialty soci7 eties and other stakeholders, shall select 

8 criteria with respect to the clinical appro9 priateness of advanced diagnostic imaging 

10 services for use in the demonstration 

11 project under this subsection. 

12 (ii) CRITERIA SELECTED.—Any cri13 teria selected under clause (i) shall— 

14 (I) be developed or endorsed by a 

15 medical specialty society; and 

16 (II) be developed in adherence to 

17 appropriateness principles developed 

18 by a consensus organization, such as 

19 the AQA alliance. 

20 (E) MODELS FOR COLLECTING DATA RE21 GARDING PHYSICIAN COMPLIANCE WITH SE22 LECTED CRITERIA.—Subject to subparagraph 

23 (H), in carrying out the demonstration project 

24 under this subsection, the Secretary shall use 

25 each of the following models for collecting data 


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1 regarding physician compliance with appro2 priateness criteria selected under subparagraph 

3 (D): 

4 (i) A model described in subparagraph 

5 (F). 

6 (ii) A model described in subpara7 graph (G). 

8 (iii) Any other model that the Sec9 retary determines to be useful in evalu10 ating the use of appropriateness criteria 

11 for advanced diagnostic imaging services. 

12 (F) POINT OF SERVICE MODEL DE13 SCRIBED.—A model described in this subpara14 graph is a model that— 

15 (i) uses an electronic or paper intake 

16 form that— 

17 (I) contains a certification by the 

18 physician furnishing the imaging serv19 ice that the data on the intake form 

20 was confirmed with the Medicare ben21 eficiary before the service was fur22 nished; 

23 (II) contains standardized data 

24 elements for diagnosis, service or25 dered, service furnished, and such 


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1 other information determined by the 

2 Secretary, in consultation with med3 ical specialty societies and other 

4 stakeholders, to be germane to evalu5 ating the effectiveness of the use of 

6 appropriateness criteria selected under 

7 subparagraph (D); and 

8 (III) is accessible to physicians 

9 participating in the demonstration 

10 project under this subsection in a for11 mat that allows for the electronic sub12 mission of such form; and 

13 (ii) provides for feedback reports in 

14 accordance with paragraph (3)(B). 

15 (G) POINT OF ORDER MODEL DE16 SCRIBED.—A model described in this subpara17 graph is a model that— 

18 (i) uses a computerized order-entry 

19 system that requires the transmittal of rel20 evant supporting information at the time 

21 of referral for advanced diagnostic imaging 

22 services and provides automated decision23 support feedback to the referring physician 

24 regarding the appropriateness of fur25 nishing such imaging services; and 


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1 (ii) provides for feedback reports in 

2 accordance with paragraph (3)(B). 

3 (H) LIMITATION.—In no case may the 

4 Secretary use prior authorization— 

5 (i) as a model for collecting data re6 garding physician compliance with appro7 priateness criteria selected under subpara8 graph (D) under the demonstration project 

9 under this subsection; or 

10 (ii) under any model used for col11 lecting such data under the demonstration 

12 project. 

13 (I) REQUIRED CONTRACTS AND PERFORM14 ANCE STANDARDS FOR CERTAIN ENTITIES.— 

15 (i) IN GENERAL.—The Secretary shall 

16 enter into contracts with entities to carry 

17 out the model described in subparagraph 

18 (G). 

19 (ii) PERFORMANCE STANDARDS.—The 

20 Secretary shall establish and enforce per21 formance standards for such entities under 

22 the contracts entered into under clause (i), 

23 including performance standards with re24 spect to— 


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1 (I) the satisfaction of Medicare 

2 beneficiaries who are furnished ad3 vanced diagnostic imaging services by 

4 a physician participating in the dem5 onstration project; 

6 (II) the satisfaction of physicians 

7 participating in the demonstration 

8 project; 

9 (III) if applicable, timelines for 

10 the provision of feedback reports 

11 under paragraph (3)(B); and 

12 (IV) any other areas determined 

13 appropriate by the Secretary. 

14 (3) COMPARISON OF UTILIZATION OF AD15 VANCED DIAGNOSTIC IMAGING SERVICES AND FEED16 BACK REPORTS.— 

17 (A) COMPARISON OF UTILIZATION OF AD18 VANCED DIAGNOSTIC IMAGING SERVICES.—The 

19 Secretary shall consult with medical specialty 

20 societies and other stakeholders to develop 

21 mechanisms for comparing the utilization of ad22 vanced diagnostic imaging services by physi23 cians participating in the demonstration project 

24 under this subsection against— 


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1 (i) the appropriateness criteria se2 lected under paragraph (2)(D); and 

3 (ii) to the extent feasible, the utiliza4 tion of such services by physicians not par5 ticipating in the demonstration project. 

6 (B) FEEDBACK REPORTS.—The Secretary 

7 shall, in consultation with medical specialty so8 cieties and other stakeholders, develop mecha9 nisms to provide feedback reports to physicians 

10 participating in the demonstration project 

11 under this subsection. Such feedback reports 

12 shall include— 

13 (i) a profile of the rate of compliance 

14 by the physician with appropriateness cri15 teria selected under paragraph (2)(D), in16 cluding a comparison of— 

17 (I) the rate of compliance by the 

18 physician with such criteria; and 

19 (II) the rate of compliance by the 

20 physician’s peers (as defined by the 

21 Secretary) with such criteria; and 

22 (ii) to the extent feasible, a compari23 son of— 


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1 (I) the rate of utilization of ad2 vanced diagnostic imaging services by 

3 the physician; and 

4 (II) the rate of utilization of such 

5 services by the physician’s peers (as 

6 defined by the Secretary) who are not 

7 participating in the demonstration 

8 project. 

9 (4) CONDUCT OF DEMONSTRATION PROJECT

10 AND WAIVER.— 

11 (A) CONDUCT OF DEMONSTRATION

12 PROJECT.—Chapter 35 of title 44, United 

13 States Code, shall not apply to the conduct of 

14 the demonstration project under this sub15 section. 

16 (B) WAIVER.—The Secretary may waive 

17 such provisions of titles XI and XVIII of the 

18 Social Security Act (42 U.S.C. 1301 et seq.; 

19 1395 et seq.) as may be necessary to carry out 

20 the demonstration project under this sub21 section. 

22 (5) EVALUATION AND REPORT.— 

23 (A) EVALUATION.—The Secretary shall 

24 evaluate the demonstration project under this 

25 subsection to— 


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1 (i) assess the timeliness and efficacy 

2 of the demonstration project; 

3 (ii) assess the performance of entities 

4 under a contract entered into under para5 graph (2)(I)(i); 

6 (iii) analyze data— 

7 (I) on the rates of appropriate, 

8 uncertain, and inappropriate advanced 

9 diagnostic imaging services furnished 

10 by physicians participating in the 

11 demonstration project; 

12 (II) on patterns and trends in 

13 the appropriateness and inappropri14 ateness of such services furnished by 

15 such physicians; 

16 (III) on patterns and trends in 

17 national and regional variations of 

18 care with respect to the furnishing of 

19 such services; and 

20 (IV) on the correlation between 

21 the appropriateness of the services 

22 furnished and image results; and 

23 (iv) address— 

24 (I) the thresholds used under the 

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1 ceptable and outlier levels of perform2 ance with respect to the appropriate3 ness of advanced diagnostic imaging 

4 services furnished; 

5 (II) whether prospective use of 

6 appropriateness criteria could have an 

7 effect on the volume of such services 

8 furnished; 

9 (III) whether expansion of the 

10 use of appropriateness criteria with 

11 respect to such services to a broader 

12 population of Medicare beneficiaries 

13 would be advisable; 

14 (IV) whether, under such an ex15 pansion, physicians who demonstrate 

16 consistent compliance with such ap17 propriateness criteria should be ex18 empted from certain requirements; 

19 (V) the use of incident-specific 

20 versus practice-specific outlier infor21 mation in formulating future rec22 ommendations with respect to the use 

23 of appropriateness criteria for such 

24 services under the Medicare program; 

25 and 


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1 (VI) the potential for using 

2 methods (including financial incen3 tives), in addition to those used under 

4 the models under the demonstration 

5 project, to ensure compliance with 

6 such criteria. 

7 (B) REPORT.—Not later than 1 year after 

8 the completion of the demonstration project 

9 under this subsection, the Secretary shall sub10 mit to Congress a report containing the results 

11 of the evaluation of the demonstration project 

12 conducted under subparagraph (A), together 

13 with recommendations for such legislation and 

14 administrative action as the Secretary deter15 mines appropriate. 

16 (6) FUNDING.—The Secretary shall provide for 

17 the transfer from the Federal Supplementary Med18 ical Insurance Trust Fund established under section 

19 1841 of the Social Security Act (42 U.S.C. 1395t) 

20 of $10,000,000, for carrying out the demonstration 

21 project under this subsection (including costs associ22 ated with administering the demonstration project, 

23 reimbursing physicians for administrative costs and 

24 providing incentives to encourage participation under 

25 paragraph (2)(C), entering into contracts under 


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1 paragraph (2)(I), and evaluating the demonstration 

2 project under paragraph (5)). 

3 (c) DISCLOSURE REQUIREMENT FOR PHYSICIANS

4 REFERRING FOR IMAGING SERVICES.— 

5 (1) IN GENERAL.—Section 1877(b)(2) of the 

6 Social Security Act (42 U.S.C. 1395nn(b)(2)) is 

7 amended by adding at the end the following new 

8 sentence: ‘‘Such requirements shall, with respect to 

9 magnetic resonance imaging, computed tomography, 

10 positron emission tomography, and any other des11 ignated health services specified under subsection 

12 (h)(6)(D) that the Secretary determines appropriate, 

13 include a requirement that the referring physician 

14 inform the individual in writing at the time of the 

15 referral that the individual may obtain the services 

16 for which the individual is being referred from a per17 son other than a person described in subparagraph 

18 (A)(i) and provide such individual with a written list 

19 of suppliers (as defined in section 1861(d)) who fur20 nish such services in the area in which such indi21 vidual resides.’’. 

22 (2) EFFECTIVE DATE.—The amendment made 

23 by this subsection shall apply to services furnished 

24 on or after January 1, 2010. 


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1 (d) GAO STUDY AND REPORTS ON ACCREDITATION

2 REQUIREMENT FOR ADVANCED DIAGNOSTIC IMAGING

3 SERVICES.— 

4 (1) STUDY.— 

5 (A) IN GENERAL.—The Comptroller Gen6 eral of the United States (in this subsection re7 ferred to as the ‘‘Comptroller General’’) shall 

8 conduct a study, by imaging modality, on— 

9 (i) the effect of the accreditation re10 quirement under section 1834(e) of the So11 cial Security Act, as added by subsection 

12 (a); and 

13 (ii) any other relevant questions in14 volving access to, and the value of, ad15 vanced diagnostic imaging services for 

16 Medicare beneficiaries. 

17 (B) ISSUES.—The study conducted under 

18 subparagraph (A) shall examine the following: 

19 (i) The impact of such accreditation 

20 requirement on the number, type, and 

21 quality of imaging services furnished to 

22 Medicare beneficiaries. 

23 (ii) The cost of such accreditation re24 quirement, including costs to facilities of 

25 compliance with such requirement and 


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1 costs to the Secretary of administering 

2 such requirement. 

3 (iii) Access to imaging services by 

4 Medicare beneficiaries, especially in rural 

5 areas, before and after implementation of 

6 such accreditation requirement. 

7 (iv) Such other issues as the Sec8 retary determines appropriate. 

9 (2) REPORTS.— 

10 (A) PRELIMINARY REPORT.—Not later 

11 than March 1, 2013, the Comptroller General 

12 shall submit a preliminary report to Congress 

13 on the study conducted under paragraph (1). 

14 (B) FINAL REPORT.—Not later than 

15 March 1, 2014, the Comptroller General shall 

16 submit a final report to Congress on the study 

17 conducted under paragraph (1), together with 

18 recommendations for such legislation and ad19 ministrative action as the Comptroller General 

20 determines appropriate. 

21 SEC. 138. ACCOMMODATION OF PHYSICIANS ORDERED TO 

22 ACTIVE DUTY IN THE ARMED SERVICES. 

23 Section 1842(b)(6)(D)(iii) of the Social Security Act 

24 (42 U.S.C. 1395u(b)(6)(D)(iii)), as amended by section 

25 116 of the Medicare, Medicaid, and SCHIP Extension Act 


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1 of 2007 (Public Law 110–173), is amended by striking 

2 ‘‘(before July 1, 2008)’’. 

3 SEC. 139. EXTENSION OF EXCEPTIONS PROCESS FOR MEDI4 CARE THERAPY CAPS. 

5 Section 1833(g)(5) of the Social Security Act (42 

6 U.S.C. 1395l(g)(5)), as amended by section 105 of the 

7 Medicare, Medicaid, and SCHIP Extension Act of 2007 

8 (Public Law 110–173), is amended by striking ‘‘June 30, 

9 2008’’ and inserting ‘‘December 31, 2009’’. 

10 SEC. 140. SPEECH-LANGUAGE PATHOLOGY SERVICES. 

11 (a) IN GENERAL.—Section 1861(ll) of the Social Se12 curity Act (42 U.S.C. 1395x(ll)) is amended— 

13 (1) by redesignating paragraphs (2) and (3) as 

14 paragraphs (3) and (4), respectively; and 

15 (2) by inserting after paragraph (1) the fol16 lowing new paragraph: 

17 ‘‘(2) The term ‘outpatient speech-language pathology 

18 services’ has the meaning given the term ‘outpatient phys19 ical therapy services’ in subsection (p), except that in ap20 plying such subsection— 

21 ‘‘(A) ‘speech-language pathology’ shall be sub22 stituted for ‘physical therapy’ each place it appears; 

23 and 


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1 ‘‘(B) ‘speech-language pathologist’ shall be sub2 stituted for ‘physical therapist’ each place it ap3 pears.’’. 

4 (b) CONFORMING AMENDMENTS.— 

5 (1) Section 1832(a)(2)(C) of the Social Security 

6 Act (42 U.S.C. 1395k(a)(2)(C)) is amended— 

7 (A) by striking ‘‘and outpatient’’ and in8 serting ‘‘, outpatient’’; and 

9 (B) by inserting before the semicolon at 

10 the end the following: ‘‘, and outpatient speech11 language pathology services (other than services 

12 to which the second sentence of section 1861(p) 

13 applies through the application of section 

14 1861(ll)(2))’’. 

15 (2) Subparagraphs (A) and (B) of section 

16 1833(a)(8) of such Act (42 U.S.C. 1395l(a)(8)) are 

17 each amended by striking ‘‘(which includes out18 patient speech-language pathology services)’’ and in19 serting ‘‘, outpatient speech-language pathology 

20 services,’’. 

21 (3) Section 1833(g)(1) of such Act (42 U.S.C. 

22 1395l(g)(1)) is amended— 

23 (A) by inserting ‘‘and speech-language pa24 thology services of the type described in such 


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1 section through the application of section 

2 1861(ll)(2)’’ after ‘‘1861(p)’’; and 

3 (B) by inserting ‘‘and speech-language pa4 thology services’’ after ‘‘and physical therapy 

5 services’’. 

6 (4) The second sentence of section 1835(a) of 

7 such Act (42 U.S.C. 1395n(a)) is amended— 

8 (A) by striking ‘‘section 1861(g)’’ and in9 serting ‘‘subsection (g) or (ll)(2) of section 

10 1861’’ each place it appears; and 

11 (B) by inserting ‘‘or outpatient speech-lan12 guage pathology services, respectively’’ after 

13 ‘‘occupational therapy services’’. 

14 (5) Section 1861(p) of such Act (42 U.S.C. 

15 1395x(p)) is amended by striking the fourth sen16 tence. 

17 (6) Section 1861(s)(2)(D) of such Act (42 

18 U.S.C. 1395x(s)(2)(D)) is amended by inserting ‘‘, 

19 outpatient speech-language pathology services,’’ after 

20 ‘‘physical therapy services’’. 

21 (7) Section 1862(a)(20) of such Act (42 U.S.C. 

22 1395y(a)(20)) is amended— 

23 (A) by striking ‘‘outpatient occupational 

24 therapy services or outpatient physical therapy 

25 services’’ and inserting ‘‘outpatient physical 


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1 therapy services, outpatient speech-language pa2 thology services, or outpatient occupational 

3 therapy services’’; and 

4 (B) by striking ‘‘section 1861(g)’’ and in5 serting ‘‘subsection (g) or (ll)(2) of section 

6 1861’’. 

7 (8) Section 1866(e)(1) of such Act (42 U.S.C. 

8 1395cc(e)(1)) is amended— 

9 (A) by striking ‘‘section 1861(g)’’ and in10 serting ‘‘subsection (g) or (ll)(2) of section 

11 1861’’ the first two places it appears; 

12 (B) by striking ‘‘defined) or’’ and inserting 

13 ‘‘defined),’’; and 

14 (C) by inserting before the semicolon at 

15 the end the following: ‘‘, or (through the oper16 ation of section 1861(ll)(2)) with respect to the 

17 furnishing of outpatient speech-language pa18 thology’’. 

19 (9) Section 1877(h)(6) of such Act (42 U.S.C. 

20 1395nn(h)(6)) is amended by adding at the end the 

21 following new subparagraph: 

22 ‘‘(L) Outpatient speech-language pathology 

23 services.’’. 


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1 (c) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to services furnished on or after 

3 January 1, 2009. 

4 (d) CONSTRUCTION.—Nothing in this section shall be 

5 construed to affect existing regulations and policies of the 

6 Centers for Medicare & Medicaid Services that require 

7 physician oversight of care as a condition of payment for 

8 speech-language pathology services under part B of the 

9 Medicare program. 

10 SEC. 141. COVERAGE OF ITEMS AND SERVICES UNDER A 

11 CARDIAC REHABILITATION PROGRAM AND A 

12 PULMONARY REHABILITATION PROGRAM. 

13 (a) IN GENERAL.—Section 1861 of the Social Secu14 rity Act (42 U.S.C. 1395x), as amended by section 114 

15 of the Medicare, Medicaid, and SCHIP Extension Act of 

16 2007 (Public Law 110–171), is amended— 

17 (1) in subsection (s)(2)— 

18 (A) in subparagraph (Z), by striking 

19 ‘‘and’’ at the end; 

20 (B) in subparagraph (AA), by striking the 

21 period at the end and inserting ‘‘; and’’; and 

22 (C) by adding at the end the following new 

23 subparagraph: 

24 ‘‘(BB) items and services furnished under 

25 a cardiac rehabilitation program (as defined in 


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1 subsection (ddd)) or under a pulmonary reha2 bilitation program (as defined in subsection 

3 (eee)).’’; and 

4 (2) by adding at the end the following new sub5 sections: 

6 ‘‘Cardiac Rehabilitation Program 

7 ‘‘(ddd)(1) The term ‘cardiac rehabilitation program’ 

8 means a physician-supervised program (as described in 

9 paragraph (2)) that furnishes the items and services de10 scribed in paragraph (3). 

11 ‘‘(2) A program described in this paragraph is a pro12 gram under which— 

13 ‘‘(A) items and services under the program are 

14 delivered— 

15 ‘‘(i) in a physician’s office; 

16 ‘‘(ii) in a physician-directed clinic; or 

17 ‘‘(iii) in a hospital on an outpatient basis; 

18 ‘‘(B) a physician is immediately available and 

19 accessible for medical consultation and medical 

20 emergencies at all times items and services are being 

21 furnished under the program, except that, in the 

22 case of items and services furnished under such a 

23 program in a hospital, such availability shall be pre24 sumed; and 


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1 ‘‘(C) individualized treatment is furnished 

2 under a written plan established, reviewed, and 

3 signed by a physician every 30 days that describes— 

4 ‘‘(i) the individual’s diagnosis; 

5 ‘‘(ii) the type, amount, frequency, and du6 ration of the items and services furnished under 

7 the plan; and 

8 ‘‘(iii) the goals set for the individual under 

9 the plan. 

10 ‘‘(3) The items and services described in this para11 graph are— 

12 ‘‘(A) physician-prescribed exercise; 

13 ‘‘(B) cardiac risk factor modification, including 

14 education, counseling, and behavioral intervention 

15 (to the extent such education, counseling, and behav16 ioral intervention is closely related to the individual’s 

17 care and treatment and is tailored to the individual’s 

18 needs); 

19 ‘‘(C) psychosocial assessment; 

20 ‘‘(D) outcomes assessment; and 

21 ‘‘(E) such other items and services as the Sec22 retary may determine, but only if such items and 

23 services are— 


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1 ‘‘(i) reasonable and necessary for the diag2 nosis or active treatment of the individual’s 

3 condition; 

4 ‘‘(ii) reasonably expected to improve or 

5 maintain the individual’s condition and func6 tional level; and 

7 ‘‘(iii) furnished under such guidelines re8 lating to the frequency and duration of such 

9 items and services as the Secretary shall estab10 lish, taking into account accepted norms of 

11 medical practice and the reasonable expectation 

12 of improvement of the individual. 

13 ‘‘(4) The Secretary shall establish standards to en14 sure that a physician with expertise in the management 

15 of individuals with cardiac pathophysiology who is licensed 

16 to practice medicine in the State in which a cardiac reha17 bilitation program is offered— 

18 ‘‘(A) is responsible for such program; and 

19 ‘‘(B) in consultation with appropriate staff, is 

20 involved substantially in directing the progress of in21 dividual patients in the program. 

22 ‘‘Pulmonary Rehabilitation Program 

23 ‘‘(eee)(1) The term ‘pulmonary rehabilitation pro24 gram’ means a physician-supervised program (as de25 scribed in subsection (ddd)(2) with respect to a program 


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1 under this subsection) that furnishes the items and serv2 ices described in paragraph (2). 

3 ‘‘(2) The items and services described in this para4 graph are— 

5 ‘‘(A) physician-prescribed exercise; 

6 ‘‘(B) education or training (to the extent the 

7 education or training is closely and clearly related to 

8 the individual’s care and treatment and is tailored to 

9 such individual’s needs); 

10 ‘‘(C) psychosocial assessment; 

11 ‘‘(D) outcomes assessment; and 

12 ‘‘(E) such other items and services as the Sec13 retary may determine, but only if such items and 

14 services are— 

15 ‘‘(i) reasonable and necessary for the diag16 nosis or active treatment of the individual’s 

17 condition; 

18 ‘‘(ii) reasonably expected to improve or 

19 maintain the individual’s condition and func20 tional level; and 

21 ‘‘(iii) furnished under such guidelines re22 lating to the frequency and duration of such 

23 items and services as the Secretary shall estab24 lish, taking into account accepted norms of 


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1 medical practice and the reasonable expectation 

2 of improvement of the individual. 

3 ‘‘(3) The Secretary shall establish standards to en4 sure that a physician with expertise in the management 

5 of patients with respiratory pathophysiology who is li6 censed to practice medicine in the State in which a pul7 monary rehabilitation program is offered— 

8 ‘‘(A) is responsible for such program; and 

9 ‘‘(B) in consultation with appropriate staff, is 

10 involved substantially in directing the progress of in11 dividual patients in the program.’’. 

12 (b) EFFECTIVE DATE.—The amendments made by 

13 this section shall apply to items and services furnished on 

14 or after January 1, 2009. 

15 SEC. 142. REPEAL OF TRANSFER OF OWNERSHIP OF OXY16 GEN EQUIPMENT. 

17 (a) IN GENERAL.—Section 1834(a)(5)(F) of the So18 cial Security Act (42 U.S.C. 1395m(a)(5)(F)) is amend19 ed— 

20 (1) in the heading, by striking ‘‘OWNERSHIP OF

21 EQUIPMENT’’ and inserting ‘‘RENTAL CAP’’; and 

22 (2) by striking clause (ii) and inserting the fol23 lowing: 

24 ‘‘(ii) PAYMENTS AND RULES AFTER

25 RENTAL CAP.—After the 36th continuous 


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1 month during which payment is made for 

2 the equipment under this paragraph— 

3 ‘‘(I) the supplier furnishing such 

4 equipment under this subsection shall 

5 continue to furnish the equipment 

6 during any period of medical need for 

7 the remainder of the reasonable useful 

8 lifetime of the equipment, as deter9 mined by the Secretary; 

10 ‘‘(II) payments for oxygen shall 

11 continue to be made in the amount 

12 recognized for oxygen under para13 graph (9) for the period of medical 

14 need; and 

15 ‘‘(III) maintenance and servicing 

16 payments shall, if the Secretary deter17 mines such payments are reasonable 

18 and necessary, be made (for parts and 

19 labor not covered by the supplier’s or 

20 manufacturer’s warranty, as deter21 mined by the Secretary to be appro22 priate for the equipment), and such 

23 payments shall be in an amount deter24 mined to be appropriate by the Sec25 retary.’’. 


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1 (b) EFFECTIVE DATE.—The amendments made by 

2 subsection (a) shall take effect on January 1, 2009. 

3 SEC. 143. EXTENSION OF PAYMENT RULE FOR 

4 BRACHYTHERAPY AND THERAPEUTIC RADIO5 PHARMACEUTICALS. 

6 Section 1833(t)(16)(C) of the Social Security Act (42 

7 U.S.C. 1395l(t)(16)(C)), as amended by section 106 of the 

8 Medicare, Medicaid, and SCHIP Extension Act of 2007 

9 (Public Law 110–173), is amended by striking ‘‘July 1, 

10 2008’’ each place it appears and inserting ‘‘January 1, 

11 2010’’. 

12 SEC. 144. CLINICAL LABORATORY TESTS. 

13 (a) REPEAL OF MEDICARE COMPETITIVE BIDDING

14 DEMONSTRATION PROJECT FOR CLINICAL LABORATORY

15 SERVICES.— 

16 (1) IN GENERAL.—Section 1847 of the Social 

17 Security Act (42 U.S.C. 1395w–3) is amended by 

18 striking subsection (e). 

19 (2) CONFORMING AMENDMENTS.—Section 

20 1833(a)(1)(D) of the Social Security Act (42 U.S.C. 

21 1395l(a)(1)(D)) is amended— 

22 (A) by inserting ‘‘or’’ before ‘‘(ii)’’; and 

23 (B) by striking ‘‘or (iii) on the basis’’ and 

24 all that follows before the comma at the end. 


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1 (3) EFFECTIVE DATE.—The amendments made 

2 by this subsection shall take effect on the date of the 

3 enactment of this Act. 

4 (b) CLINICAL LABORATORY TEST FEE SCHEDULE

5 UPDATE ADJUSTMENT.—Section 1833(h)(2)(A)(i) of the 

6 Social Security Act (42 U.S.C. 1395l(h)(2)(A)(ii)) is 

7 amended by inserting ‘‘minus, for each of the years 2009 

8 through 2013, 0.5 percentage points’’ after ‘‘city aver9 age)’’. 

10 SEC. 145. SENSE OF THE SENATE ON DELAYED IMPLEMEN11 TATION OF COMPETITIVE BIDDING FOR DU12 RABLE MEDICAL EQUIPMENT, PROSTHETICS, 

13 ORTHOTICS, AND SUPPLIES (DMEPOS). 

14 It is the Sense of the Senate that— 

15 (1) the implementation of the durable medical 

16 equipment, prosthetics, orthotics, and supplies 

17 (DMEPOS) competitive bidding program under sec18 tion 1847 of the Social Security Act (42 U.S.C. 

19 1395w–3) should be delayed by 18 months in order 

20 to review and address ongoing concerns about the 

21 bidding process and to ensure continued access to 

22 quality medical equipment and supplies for all Medi23 care beneficiaries; and 

24 (2) such delay should be offset by a reduction 

25 in current payment rates for durable medical equipVerDate Aug 31 2005 03:52 Jun 13, 2008 Jkt 069200 PO 00000 Frm 00109 Fmt 6652 Sfmt 6201 E:\BILLS\S3118.PCS S3118

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1 ment, prosthetics, orthotics, and supplies under the 

2 Medicare program. 

3 Subtitle D—End Stage Renal 

4 Disease Program Reforms 

5 SEC. 151. KIDNEY DISEASE EDUCATION AND AWARENESS 

6 PROVISIONS. 

7 (a) CHRONIC KIDNEY DISEASE INITIATIVES.—Part 

8 P of title III of the Public Health Service Act (42 U.S.C. 

9 280g et seq.) is amended by adding at the end the fol10 lowing new section: 

11 ‘‘SEC. 399R. CHRONIC KIDNEY DISEASE INITIATIVES. 

12 ‘‘(a) IN GENERAL.—The Secretary may establish 

13 pilot projects to— 

14 ‘‘(1) increase awareness regarding chronic kid15 ney disease, focusing on prevention; 

16 ‘‘(2) increase screening for chronic kidney dis17 ease, focusing on Medicare beneficiaries at risk of 

18 chronic kidney disease; and 

19 ‘‘(3) enhance surveillance systems to better as20 sess the prevalence and incidence of chronic kidney 

21 disease. 

22 ‘‘(b) SCOPE AND DURATION.— 

23 ‘‘(1) SCOPE.—The Secretary shall select at 

24 least 3 States in which to conduct pilot projects 

25 under this section. 


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1 ‘‘(2) DURATION.—The pilot projects under this 

2 section shall be conducted for a period that is not 

3 longer than 5 years and shall begin on January 1, 

4 2009. 

5 ‘‘(c) EVALUATION AND REPORT.—The Comptroller 

6 General of the United States shall conduct an evaluation 

7 of the pilot projects conducted under this section. Not 

8 later than 12 months after the date on which the pilot 

9 projects are completed, the Comptroller General shall sub10 mit to Congress a report on the evaluation.’’. 

11 (b) MEDICARE COVERAGE OF KIDNEY DISEASE PA12 TIENT EDUCATION SERVICES.— 

13 (1) COVERAGE OF KIDNEY DISEASE EDUCATION

14 SERVICES.— 

15 (A) COVERAGE.—Section 1861(s)(2) of the 

16 Social Security Act (42 U.S.C. 1395x(s)(2)), as 

17 amended by section 141(a)(1), is amended— 

18 (i) in subparagraph (AA), by striking 

19 ‘‘and’’ after the semicolon at the end; 

20 (ii) in subparagraph (BB), by adding 

21 ‘‘and’’ after the semicolon at the end; and 

22 (iii) by adding at the end the fol23 lowing new subparagraph: 

24 ‘‘(CC) kidney disease education services (as de25 fined in subsection (fff));’’. 


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1 (B) SERVICES DESCRIBED.—Section 1861 

2 of the Social Security Act (42 U.S.C. 1395x), 

3 as amended by section 141(a)(2), is amended 

4 by adding at the end the following new sub5 section: 

6 ‘‘Kidney Disease Education Services 

7 ‘‘(fff)(1) The term ‘kidney disease education services’ 

8 means educational services that are— 

9 ‘‘(A) furnished to an individual with stage IV 

10 chronic kidney disease who, according to accepted 

11 clinical guidelines identified by the Secretary, will re12 quire dialysis or a kidney transplant; 

13 ‘‘(B) furnished, upon the referral of the physi14 cian managing the individual’s kidney condition, by 

15 a qualified person (as defined in paragraph (2)); and 

16 ‘‘(C) designed— 

17 ‘‘(i) to provide comprehensive information 

18 (consistent with the standards set under para19 graph (3)) regarding— 

20 ‘‘(I) the management of comorbidities, 

21 including for purposes of delaying the need 

22 for dialysis; 

23 ‘‘(II) the prevention of uremic com24 plications; and 


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1 ‘‘(III) each option for renal replace2 ment therapy (including hemodialysis and 

3 peritoneal dialysis at home and in-center 

4 as well as vascular access options and 

5 transplantation); 

6 ‘‘(ii) to ensure that the individual has the 

7 opportunity to actively participate in the choice 

8 of therapy; and 

9 ‘‘(iii) to be tailored to meet the needs of 

10 the individual involved. 

11 ‘‘(2) The term ‘qualified person’ means— 

12 ‘‘(A) a physician (as defined in section 

13 1861(r)(1)) or a physician assistant, nurse practi14 tioner, or clinical nurse specialist (as defined in sec15 tion 1861(aa)(5)), who furnishes services for which 

16 payment may be made under the fee schedule estab17 lished under section 1848; and 

18 ‘‘(B) a renal dialysis facility subject to the re19 quirements of section 1881(b)(1) with personnel 

20 who— 

21 ‘‘(i) provide the services described in para22 graph (1); and 

23 ‘‘(ii) meet the requirements of subpara24 graph (A). 


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1 ‘‘(3) The Secretary shall set standards for the con2 tent of such information to be provided under paragraph 

3 (1)(C)(i) after consulting with physicians, other health 

4 professionals, health educators, professional organizations, 

5 accrediting organizations, kidney patient organizations, di6 alysis facilities, transplant centers, network organizations 

7 described in section 1881(c)(2), and other knowledgeable 

8 persons. To the extent possible the Secretary shall consult 

9 with persons or entities described in the previous sentence, 

10 other than a dialysis facility, that has not received indus11 try funding from a drug or biological manufacturer or di12 alysis facility. 

13 ‘‘(4) No individual shall be furnished more than 6 

14 sessions of kidney disease education services under this 

15 title.’’. 

16 (C) PAYMENT UNDER THE PHYSICIAN FEE

17 SCHEDULE.—Section 1848(j)(3) of the Social 

18 Security Act (42 U.S.C. 1395w–4(j)(3)) is 

19 amended by inserting ‘‘(2)(CC),’’ after 

20 ‘‘(2)(AA),’’. 

21 (D) LIMITATION ON NUMBER OF SES22 SIONS.—Section 1862(a)(1) of the Social Secu23 rity Act (42 U.S.C. 1395y(a)(1)) is amended— 

24 (i) in subparagraph (M), by striking 

25 ‘‘and’’ at the end; 


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1 (ii) in subparagraph (N), by striking 

2 the semicolon at the end and inserting ‘‘, 

3 and’’; and 

4 (iii) by adding at the end the fol5 lowing new subparagraph: 

6 ‘‘(O) in the case of kidney disease education 

7 services (as defined in paragraph (1) of section 

8 1861(fff)), which are furnished in excess of the 

9 number of sessions covered under paragraph (4) of 

10 such section;’’. 

11 (2) EFFECTIVE DATE.—The amendments made 

12 by this subsection shall apply to services furnished 

13 on or after January 1, 2010. 

14 SEC. 152. RENAL DIALYSIS PROVISIONS. 

15 (a) COMPOSITE RATE.— 

16 (1) UPDATE.—Section 1881(b)(12)(G) of the 

17 Social Security Act (42 U.S.C. 1395rr(b)(12)(G)) is 

18 amended— 

19 (A) in clause (i), by striking ‘‘and’’ at the 

20 end; 

21 (B) in clause (ii)— 

22 (i) by inserting ‘‘and before January 

23 1, 2009,’’ after ‘‘April 1, 2007,’’; and 

24 (ii) by striking the period at the end 

25 and inserting ‘‘; and’’; and 


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1 (C) by adding at the end the following new 

2 clauses: 

3 ‘‘(iii) furnished on or after January 1, 2009, 

4 and before January 1, 2010, by 1.0 percent above 

5 the amount of such composite rate component for 

6 such services furnished on December 31, 2008; and 

7 ‘‘(iv) furnished on or after January 1, 2010, by 

8 1.0 percent above the amount of such composite rate 

9 component for such services furnished on December 

10 31, 2009.’’. 

11 (2) SITE NEUTRAL COMPOSITE RATE.—Section 

12 1881(b)(12)(A) of the Social Security Act (42 

13 U.S.C. 1395rr(b)(12)(A)) is amended by adding at 

14 the end the following new sentence: ‘‘Under such 

15 system, the payment rate for dialysis services fur16 nished on or after January 1, 2009, by providers of 

17 services shall be the same as the payment rate (com18 puted without regard to this sentence) for such serv19 ices furnished by renal dialysis facilities, and in ap20 plying the geographic index under subparagraph (D) 

21 to providers of services, the labor share shall be 

22 based on the labor share otherwise applied for renal 

23 dialysis facilities.’’. 

24 (b) DEVELOPMENT OF ESRD BUNDLED PAYMENT

25 SYSTEM.— 


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1 (1) IN GENERAL.—Section 1881(b) of the So2 cial Security Act (42 U.S.C. 1395rr(b)) is amended 

3 by adding at the end the following new paragraph: 

4 ‘‘(14)(A)(i) Subject to subparagraph (E), for services 

5 furnished on or after January 1, 2011, the Secretary shall 

6 implement a payment system under which a single pay7 ment is made under this title to a provider of services or 

8 a renal dialysis facility for renal dialysis services (as de9 fined in subparagraph (B)) in lieu of any other payment 

10 (including a payment adjustment under paragraph 

11 (12)(B)(ii)) and for such services and items furnished pur12 suant to paragraph (4). 

13 ‘‘(ii) In implementing the system under this para14 graph the Secretary shall ensure that the estimated total 

15 amount of payments under this title for 2011 for renal 

16 dialysis services shall equal 98 percent of the estimated 

17 total amount of payments for renal dialysis services, in18 cluding payments under paragraph (12)(B)(ii), that would 

19 have been made under this title with respect to services 

20 furnished in 2011 if such system had not been imple21 mented. In making such estimation, the Secretary shall 

22 use per patient utilization data from 2007, 2008, or 2009, 

23 whichever has the lowest per patient utilization. 

24 ‘‘(B) For purposes of this paragraph, the term ‘renal 

25 dialysis services’ includes— 


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1 ‘‘(i) items and services included in the com2 posite rate for renal dialysis services as of December 

3 31, 2010; 

4 ‘‘(ii) erythropoiesis stimulating agents and any 

5 oral form of such agents that are furnished to indi6 viduals for the treatment of end stage renal disease; 

7 ‘‘(iii) other drugs and biologicals that are fur8 nished to individuals for the treatment of end stage 

9 renal disease and for which payment was (before the 

10 application of this paragraph) made separately 

11 under this title, and any oral equivalent form of 

12 such drug or biological; and 

13 ‘‘(iv) diagnostic laboratory tests and other items 

14 and services not described in clause (i) that are fur15 nished to individuals for the treatment of end stage 

16 renal disease. 

17 Such term does not include vaccines. 

18 ‘‘(C) The system under this paragraph may provide 

19 for payment on the basis of services furnished during a 

20 week or month or such other appropriate unit of payment 

21 as the Secretary specifies. 

22 ‘‘(D) Such system— 

23 ‘‘(i) shall include a payment adjustment based 

24 on case mix that may take into account patient 


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1 weight, body mass index, comorbidities, length of 

2 time on dialysis, age, and other appropriate factors; 

3 ‘‘(ii) shall include a payment adjustment for 

4 high cost outliers due to unusual variations in the 

5 type or amount of medically necessary care, includ6 ing variations in the amount of erythropoiesis stimu7 lating agents necessary for anemia management; 

8 ‘‘(iii) shall include a payment adjustment that 

9 reflects the extent to which costs incurred by rural, 

10 low-volume providers and facilities (as defined by the 

11 Secretary) in furnishing renal dialysis services ex12 ceed the costs incurred by other providers and facili13 ties in furnishing such services, and for payment for 

14 renal dialysis services furnished on or after January 

15 1, 2011, and before January 1, 2014, such payment 

16 adjustment shall not be less than 10 percent; and 

17 ‘‘(iv) may include such other payment adjust18 ments as the Secretary determines appropriate, such 

19 as a payment adjustment— 

20 ‘‘(I) for pediatric providers of services and 

21 renal dialysis facilities; and 

22 ‘‘(II) for providers of services or renal di23 alysis facilities located in rural areas. 


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1 The Secretary shall take into consideration the unique 

2 treatment needs of children and young adults in estab3 lishing such system. 

4 ‘‘(E)(i) The Secretary shall provide for a four-year 

5 phase-in (in equal increments) of the payment amount 

6 under the payment system under this paragraph, with 

7 such payment amount being fully implemented for renal 

8 dialysis services furnished on or after January 1, 2014. 

9 ‘‘(ii) A provider of services or renal dialysis facility 

10 may make a one-time election to be excluded from the 

11 phase-in under clause (i) and be paid entirely based on 

12 the payment amount under the payment system under this 

13 paragraph. Such an election shall be made prior to Janu14 ary 1, 2011, in a form and manner specified by the Sec15 retary, and is final and may not be rescinded. 

16 ‘‘(iii) The Secretary shall make an adjustment to the 

17 payments under this paragraph for years during which the 

18 phase-in under clause (i) is applicable so that the esti19 mated total amount of payments under this paragraph, 

20 including payments under this subparagraph, shall equal 

21 the estimated total amount of payments that would other22 wise occur under this paragraph without such phase-in. 

23 ‘‘(F)(i) Subject to clause (ii), beginning in 2012, the 

24 Secretary shall annually increase payment amounts estab25 lished under this paragraph by an ESRD market basket 


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1 percentage increase factor for a bundled payment system 

2 for renal dialysis services that reflects changes over time 

3 in the prices of an appropriate mix of goods and services 

4 included in renal dialysis services minus 1.0 percentage 

5 point. 

6 ‘‘(ii) For years during which a phase-in of the pay7 ment system pursuant to subparagraph (E) is applicable, 

8 the following rules shall apply to the portion of the pay9 ment under the system that is based on the payment of 

10 the composite rate that would otherwise apply if the sys11 tem under this paragraph had not been enacted: 

12 ‘‘(I) The update under clause (i) shall not 

13 apply. 

14 ‘‘(II) The Secretary shall annually increase 

15 such composite rate by the ESRD market basket 

16 percentage increase factor described in clause (i) 

17 minus 1.0 percentage point. 

18 ‘‘(G) There shall be no administrative or judicial re19 view under section 1869, section 1878, or otherwise of the 

20 determination of payment amounts under subparagraph 

21 (A), the establishment of an appropriate unit of payment 

22 under subparagraph (C), the identification of renal dialy23 sis services included in the bundled payment, the adjust24 ments under subparagraph (D), the application of the 


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1 phase-in under subparagraph (E), and the establishment 

2 of the updates under subparagraph (F). 

3 ‘‘(H) Erythropoiesis stimulating agents and other 

4 drugs and biologicals shall be treated as prescribed and 

5 dispensed or administered and available only under part 

6 B if they are— 

7 ‘‘(i) furnished to an individual for the treatment 

8 of end stage renal disease; and 

9 ‘‘(ii) included in subparagraph (B) for purposes 

10 of payment under this paragraph.’’. 

11 (2) PROHIBITION OF UNBUNDLING.—Section 

12 1862(a) of the Social Security Act (42 U.S.C. 

13 1395y(a)), as amended by section 137(a)(2), is 

14 amended— 

15 (A) in paragraph (22), by striking ‘‘or’’ at 

16 the end; 

17 (B) in paragraph (23), by striking the pe18 riod at the end and inserting ‘‘; or’’; and 

19 (C) by inserting after paragraph (23) the 

20 following new paragraph: 

21 ‘‘(24) where such expenses are for renal dialysis 

22 services (as defined in subparagraph (B) of section 

23 1881(b)(14)) for which payment is made under such 

24 section unless such payment is made under such secVerDate Aug 31 2005 03:52 Jun 13, 2008 Jkt 069200 PO 00000 Frm 00122 Fmt 6652 Sfmt 6201 E:\BILLS\S3118.PCS S3118

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1 tion to a provider of services or a renal dialysis facil2 ity for such services.’’. 

3 (3) CONFORMING AMENDMENTS.—(A) Section 

4 1881(b) of the Social Security Act (42 U.S.C. 

5 1395rr(b)) is amended— 

6 (i) in paragraph (12)(A), by striking ‘‘In 

7 lieu of payment’’ and inserting ‘‘Subject to 

8 paragraph (14), in lieu of payment’’; 

9 (ii) in the second sentence of paragraph 

10 (12)(F)— 

11 (I) by inserting ‘‘or paragraph (14)’’ 

12 after ‘‘this paragraph’’; and 

13 (II) by inserting ‘‘or under the system 

14 under paragraph (14)’’ after ‘‘subpara15 graph (B)’’; and 

16 (iii) in paragraph (13)— 

17 (I) in subparagraph (A), in the matter 

18 preceding clause (i), by striking ‘‘The pay19 ment amounts’’ and inserting ‘‘Subject to 

20 paragraph (14), the payment amounts’’; 

21 and 

22 (II) in subparagraph (B)— 

23 (aa) in clause (i), by striking 

24 ‘‘(i)’’ after ‘‘(B)’’ and by inserting ‘‘, 


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1 subject to paragraph (14)’’ before the 

2 period at the end; and 

3 (bb) by striking clause (ii). 

4 (B) Section 1861(s)(2)(F) of the Social Secu5 rity Act (42 U.S.C. 1395x(s)(2)(F)) is amended by 

6 inserting ‘‘, and, for items and services furnished on 

7 or after January 1, 2011, renal dialysis services (as 

8 defined in section 1881(b)(14)(B))’’ before the semi9 colon at the end. 

10 (C) Section 623(e) of the Medicare Prescription 

11 Drug, Improvement, and Modernization Act of 2003 

12 (42 U.S.C. 1395rr note) is repealed. 

13 (4) RULE OF CONSTRUCTION.—Nothing in this 

14 subsection or the amendments made by this sub15 section shall be construed as authorizing or requir16 ing the Secretary of Health and Human Services to 

17 make payments under the payment system imple18 mented under paragraph (14)(A)(i) of section 

19 1881(b) of the Social Security Act (42 U.S.C. 

20 1395rr(b)), as added by paragraph (1), for any un21 recovered amount for any bad debt attributable to 

22 deductible and coinsurance on items and services not 

23 included in the basic case-mix adjusted composite 

24 rate under paragraph (12) of such section as in ef25 fect before the date of the enactment of this Act. 


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1 (c) QUALITY INCENTIVES IN THE END-STAGE RENAL

2 DISEASE PROGRAM.—Section 1881 of the Social Security 

3 Act (42 U.S.C. 1395rr) is amended by adding at the end 

4 the following new subsection: 

5 ‘‘(h) QUALITY INCENTIVES IN THE END-STAGE

6 RENAL DISEASE PROGRAM.— 

7 ‘‘(1) QUALITY INCENTIVES.— 

8 ‘‘(A) IN GENERAL.—With respect to renal 

9 dialysis services (as defined in subsection 

10 (b)(14)(B)) furnished on or after January 1, 

11 2012, in the case of a provider of services or a 

12 renal dialysis facility that does not meet the re13 quirement described in subparagraph (B) with 

14 respect to the year, payments otherwise made 

15 to such provider or facility under the system 

16 under subsection (b)(14) for such services shall 

17 be reduced by up to 2.0 percent, as determined 

18 appropriate by the Secretary. 

19 ‘‘(B) REQUIREMENT.—The requirement 

20 described in this subparagraph is that the pro21 vider or facility meets (or exceeds) the total 

22 performance score under paragraph (3) with re23 spect to performance standards established by 

24 the Secretary with respect to measures specified 

25 in paragraph (2). 


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1 ‘‘(C) NO EFFECT IN SUBSEQUENT

2 YEARS.—The reduction under subparagraph 

3 (A) shall apply only with respect to the year in4 volved, and the Secretary shall not take into ac5 count such reduction in computing the single 

6 payment amount under the system under para7 graph (14) in a subsequent year. 

8 ‘‘(2) MEASURES.— 

9 ‘‘(A) IN GENERAL.—The measures speci10 fied under this paragraph with respect to the 

11 year involved shall include— 

12 ‘‘(i) measures on anemia management 

13 that reflect the labeling approved by the 

14 Food and Drug Administration for such 

15 management and measures on dialysis ade16 quacy; 

17 ‘‘(ii) to the extent feasible, such meas18 ure (or measures) of patient satisfaction as 

19 the Secretary shall specify; and 

20 ‘‘(iii) such other measures as the Sec21 retary specifies, including, to the extent 

22 feasible, measures on— 

23 ‘‘(I) iron management; and 


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1 ‘‘(II) vascular access, including 

2 for maximizing the placement of arte3 rial venous fistula. 

4 ‘‘(B) USE OF ENDORSED MEASURES.— 

5 ‘‘(i) IN GENERAL.—Subject to clause 

6 (ii), any measure specified by the Secretary 

7 under subparagraph (A)(iii) must have 

8 been endorsed by the entity with a contract 

9 under section 1890(a). 

10 ‘‘(ii) EXCEPTION.—In the case of a 

11 specified area or medical topic determined 

12 appropriate by the Secretary for which a 

13 feasible and practical measure has not 

14 been endorsed by the entity with a contract 

15 under section 1890(a), the Secretary may 

16 specify a measure that is not so endorsed 

17 as long as due consideration is given to 

18 measures that have been endorsed or 

19 adopted by a consensus organization iden20 tified by the Secretary. 

21 ‘‘(C) UPDATING MEASURES.—The Sec22 retary shall establish a process for updating the 

23 measures specified under subparagraph (A) in 

24 consultation with interested parties. 


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1 ‘‘(D) CONSIDERATION.—In specifying 

2 measures under subparagraph (A), the Sec3 retary shall consider the availability of meas4 ures that address the unique treatment needs of 

5 children and young adults with kidney failure. 

6 ‘‘(3) PERFORMANCE SCORES.— 

7 ‘‘(A) TOTAL PERFORMANCE SCORE.— 

8 ‘‘(i) IN GENERAL.—Subject to clause 

9 (ii), the Secretary shall develop a method10 ology for assessing the total performance 

11 of each provider of services and renal di12 alysis facility based on performance stand13 ards with respect to the measures selected 

14 under paragraph (2) for a performance pe15 riod established under paragraph (4)(D) 

16 (in this subsection referred to as the ‘total 

17 performance score’). 

18 ‘‘(ii) APPLICATION.—For providers of 

19 services and renal dialysis facilities that do 

20 not meet (or exceed) the total performance 

21 score established by the Secretary, the Sec22 retary shall ensure that the application of 

23 the methodology developed under clause (i) 

24 results in an appropriate distribution of re25 ductions in payment under paragraph (1) 


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1 among providers and facilities achieving 

2 different levels of total performance scores, 

3 with providers and facilities achieving the 

4 lowest total performance scores receiving 

5 the largest reduction in payment under 

6 paragraph (1)(A). 

7 ‘‘(B) PERFORMANCE SCORE WITH RE8 SPECT TO INDIVIDUAL MEASURES.—The Sec9 retary shall also calculate separate performance 

10 scores for each measure, including for dialysis 

11 adequacy and anemia management. 

12 ‘‘(4) PERFORMANCE STANDARDS.— 

13 ‘‘(A) ESTABLISHMENT.—Subject to sub14 paragraph (E), the Secretary shall establish 

15 performance standards with respect to meas16 ures selected under paragraph (2) for a per17 formance period with respect to a year (as es18 tablished under subparagraph (D)). 

19 ‘‘(B) ACHIEVEMENT AND IMPROVE20 MENT.—The performance standards established 

21 under subparagraph (A) shall include levels of 

22 achievement and improvement, as determined 

23 appropriate by the Secretary. 

24 ‘‘(C) TIMING.—The Secretary shall estab25 lish the performance standards under subparaVerDate Aug 31 2005 03:52 Jun 13, 2008 Jkt 069200 PO 00000 Frm 00129 Fmt 6652 Sfmt 6201 E:\BILLS\S3118.PCS S3118

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1 graph (A) prior to the beginning of the per2 formance period for the year involved. 

3 ‘‘(D) PERFORMANCE PERIOD.—The Sec4 retary shall establish the performance period 

5 with respect to a year. Such performance period 

6 shall occur prior to the beginning of such year. 

7 ‘‘(5) LIMITATION ON REVIEW.—There shall be 

8 no administrative or judicial review under section 

9 1869, section 1878, or otherwise of the following: 

10 ‘‘(A) The determination of the amount of 

11 the payment reduction under paragraph (1). 

12 ‘‘(B) The establishment of the performance 

13 standards and the performance period under 

14 paragraph (4). 

15 ‘‘(C) The specification of measures under 

16 paragraph (2). 

17 ‘‘(D) The methodology developed under 

18 paragraph (3) that is used to calculate total 

19 performance scores and performance scores for 

20 individual measures. 

21 ‘‘(6) PUBLIC REPORTING.— 

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

23 establish procedures for making information re24 garding performance under this subsection 

25 available to the public, including— 


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1 ‘‘(i) the total performance score 

2 achieved by the provider of services or 

3 renal dialysis facility under paragraph (3) 

4 and appropriate comparisons of providers 

5 of services and renal dialysis facilities to 

6 the national average with respect to such 

7 scores; and 

8 ‘‘(ii) the performance score achieved 

9 by the provider or facility with respect to 

10 individual measures. 

11 ‘‘(B) OPPORTUNITY TO REVIEW.—The pro12 cedures established under subparagraph (A) 

13 shall ensure that a provider of services and a 

14 renal dialysis facility has the opportunity to re15 view the information that is to be made public 

16 with respect to the provider or facility prior to 

17 such data being made public. 

18 ‘‘(C) CERTIFICATES.— 

19 ‘‘(i) IN GENERAL.—The Secretary 

20 shall provide certificates to providers of 

21 services and renal dialysis facilities who 

22 furnish renal dialysis services under this 

23 section to display in patient areas. The 

24 certificate shall indicate the total performVerDate Aug 31 2005 03:52 Jun 13, 2008 Jkt 069200 PO 00000 Frm 00131 Fmt 6652 Sfmt 6201 E:\BILLS\S3118.PCS S3118

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1 ance score achieved by the provider or fa2 cility under paragraph (3). 

3 ‘‘(ii) DISPLAY.—Each facility or pro4 vider receiving a certificate under clause (i) 

5 shall prominently display the certificate at 

6 the provider or facility. 

7 ‘‘(D) WEB-BASED LIST.—The Secretary 

8 shall establish a list of providers of services and 

9 renal dialysis facilities who furnish renal dialy10 sis services under this section that indicates the 

11 total performance score and the performance 

12 score for individual measures achieved by the 

13 provider and facility under paragraph (3). Such 

14 information shall be posted on the Internet 

15 website of the Centers for Medicare & Medicaid 

16 Services in an easily understandable format.’’. 

17 (d) GAO REPORT ON ESRD BUNDLING SYSTEM AND

18 QUALITY INITIATIVE.—Not later than April 1, 2012, the 

19 Comptroller General of the United States shall submit to 

20 Congress a report on the implementation of the payment 

21 system under subsection (b)(14) of section 1881 of the 

22 Social Security Act (as added by subsection (b)) for renal 

23 dialysis services and related services (defined in subpara24 graph (B) of such subsection (b)(14)) and the quality ini25 tiative under subsection (h) of such section 1881 (as 


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1 added by subsection (b)). Such report shall include the fol2 lowing information: 

3 (1) The changes in utilization rates for 

4 erythropoiesis stimulating agents. 

5 (2) The mode of administering such agents, in6 cluding information on the proportion of individuals 

7 receiving such agents intravenously as compared to 

8 subcutaneously. 

9 (3) An analysis of the payment adjustment 

10 under subparagraph (D)(iii) of such subsection 

11 (b)(14), including an examination of the extent to 

12 which costs incurred by rural, low-volume providers 

13 and facilities (as defined by the Secretary) in fur14 nishing renal dialysis services exceed the costs in15 curred by other providers and facilities in furnishing 

16 such services, and a recommendation regarding the 

17 appropriateness of such adjustment. 

18 (4) Any other information or recommendations 

19 for legislative and administrative actions determined 

20 appropriate by the Comptroller General. 


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1 Subtitle E—Provisions Relating to 

2 Part C 

3 SEC. 161. PHASE-OUT OF INDIRECT MEDICAL EDUCATION 

4 (IME). 

5 (a) IN GENERAL.—Section 1853(k) of the Social Se6 curity Act (42 U.S.C. 1395w–23(k)) is amended— 

7 (1) in paragraph (1), in the matter preceding 

8 subparagraph (A), by striking ‘‘paragraph (2)’’ and 

9 inserting ‘‘paragraphs (2) and (4)’’; and 

10 (2) by adding at the end the following new 

11 paragraph: 

12 ‘‘(4) PHASE-OUT OF THE INDIRECT COSTS OF

13 MEDICAL EDUCATION FROM CAPITATION RATES.— 

14 ‘‘(A) IN GENERAL.—After determining the 

15 applicable amount for an area for a year under 

16 paragraph (1) (beginning with 2010), the Sec17 retary shall adjust such applicable amount to 

18 exclude from such applicable amount the phase19 in percentage (as defined in subparagraph 

20 (B)(i)) for the year of the Secretary’s estimate 

21 of the standardized costs for payments under 

22 section 1886(d)(5)(B) in the area for the year. 

23 Any adjustment under the preceding sentence 

24 shall be made prior to the application of para25 graph (2). 


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1 ‘‘(B) PERCENTAGES DEFINED.—For pur2 poses of this paragraph: 

3 ‘‘(i) PHASE-IN PERCENTAGE.—The 

4 term ‘phase-in percentage’ means, for an 

5 area for a year, the ratio (expressed as a 

6 percentage, but in no case greater than 

7 100 percent) of— 

8 ‘‘(I) the maximum cumulative ad9 justment percentage for the year (as 

10 defined in clause (ii)); to 

11 ‘‘(II) the standardized IME cost 

12 percentage (as defined in clause (iii)) 

13 for the area and year. 

14 ‘‘(ii) MAXIMUM CUMULATIVE ADJUST15 MENT PERCENTAGE.—The term ‘maximum 

16 cumulative adjustment percentage’ means, 

17 for— 

18 ‘‘(I) 2010, 0.6 percent; and 

19 ‘‘(II) a subsequent year, the max20 imum cumulative adjustment percent21 age for the previous year increased by 

22 0.6 percentage points. 

23 ‘‘(iii) STANDARDIZED IME COST PER24 CENTAGE.—The term ‘standardized IME 

25 cost percentage’ means, for an area for a 


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1 year, the per capita costs for payments 

2 under section 1886(d)(5)(B) (expressed as 

3 a percentage of the fee-for-service amount 

4 specified in subparagraph (C)) for the area 

5 and the year. 

6 ‘‘(C) FEE-FOR-SERVICE AMOUNT.—The 

7 fee-for-service amount specified in this subpara8 graph for an area for a year is the amount 

9 specified under subsection (c)(1)(D) for the 

10 area and the year.’’. 

11 (b) EXCLUDING ADJUSTMENT FROM THE UP12 DATE.—Section 1853(k)(1)(B)(i) of the Social Security 

13 Act (42 U.S.C. 1395w–23(k)(1)(B)(i)) is amended by 

14 striking ‘‘paragraph (2)’’ and inserting ‘‘paragraphs (2) 

15 and (4)’’. 

16 (c) HOLD HARMLESS FOR PACE PROGRAM PAY17 MENTS.—Section 1894(d) of the Social Security Act (42 

18 U.S.C. 1395eee(d)) is amended by adding at the end the 

19 following new paragraph: 

20 ‘‘(3) CAPITATION RATES DETERMINED WITH21 OUT REGARD TO THE PHASE-OUT OF THE INDIRECT

22 COSTS OF MEDICAL EDUCATION FROM THE ANNUAL

23 MEDICARE ADVANTAGE CAPITATION RATE.—Capita24 tion amounts under this subsection shall be deterVerDate Aug 31 2005 03:52 Jun 13, 2008 Jkt 069200 PO 00000 Frm 00136 Fmt 6652 Sfmt 6201 E:\BILLS\S3118.PCS S3118

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1 mined without regard to the application of section 

2 1853(k)(4).’’. 

3 SEC. 162. REVISIONS TO QUALITY IMPROVEMENT PRO4 GRAMS. 

5 (a) REQUIREMENT FOR MA PRIVATE FEE-FOR6 SERVICE AND MSA PLANS TO HAVE A QUALITY IM7 PROVEMENT PROGRAM.—Section 1852(e)(1) of the Social 

8 Security Act (42 U.S.C. 1395w–22(e)(1)) is amended by 

9 striking ‘‘(other than an MA private fee-for-service plan 

10 or an MSA plan)’’. 

11 (b) DATA COLLECTION REQUIREMENTS FOR MA RE12 GIONAL PLANS, MA PRIVATE FEE-FOR-SERVICE PLANS, 

13 AND MSA PLANS.— 

14 (1) IN GENERAL.—Section 1852(e)(3)(A) of the 

15 Social Security Act (42 U.S.C. 1395w–22(e)(3)(A)) 

16 is amended— 

17 (A) in clause (i)— 

18 (i) by striking ‘‘clauses (ii) and (iii)’’ 

19 and inserting ‘‘clause (ii)’’; and 

20 (ii) by adding at the end the following 

21 new sentence: ‘‘With respect to MA private 

22 fee-for-service plans and MSA plans, the 

23 requirements under the preceding sentence 

24 may not exceed the requirements under 

25 this subparagraph with respect to MA local 


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1 plans that are preferred provider organiza2 tion plans, except that the limitation under 

3 clause (ii) shall not apply and such re4 quirements shall apply regardless of wheth5 er or not the services are furnished by pro6 viders of services, physicians, or other 

7 health care practitioners and suppliers that 

8 have contracts with the organization offer9 ing the MA private fee-for-service plan or 

10 the MSA plan.’’ 

11 (B) by striking clause (ii); 

12 (C) by redesignating clauses (iii) and (iv) 

13 as clauses (ii) and (iii), respectively; and 

14 (D) in clause (ii), as redesignated by sub15 paragraph (C)— 

16 (i) in the heading— 

17 (I) by inserting ‘‘LOCAL’’ after 

18 ‘‘TO’’; and 

19 (II) by inserting ‘‘AND MA RE20 GIONAL PLANS’’ after ‘‘ORGANIZA21 TIONS’’; and 

22 (ii) by inserting ‘‘and to MA regional 

23 plans’’ after ‘‘organization plans’’. 


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1 (2) LIMITATION.—Section 1852(e)(3)(B) of the 

2 Social Security Act (42 U.S.C. 1395w–22(e)(3)(B)) 

3 is amended— 

4 (A) in clause (ii), by striking ‘‘subclause 

5 (iii)’’ and inserting ‘‘clauses (iii) and (iv)’’; and 

6 (B) by adding at the end the following new 

7 clause: 

8 ‘‘(iv) LIMITATION.—Notwithstanding 

9 clause (ii), with respect to MA private fee10 for-service plans and MSA plans, to the ex11 tent that services are not services fur12 nished by providers of services, physicians, 

13 or other health care practitioners and sup14 pliers that have contracts with the organi15 zation offering the plan, the data required 

16 to be collected, analyzed, and reported 

17 under subparagraph (A)(i) shall only in18 clude administrative and beneficiary survey 

19 data.’’. 

20 (c) EFFECTIVE DATE.—The amendments made by 

21 this subsection shall apply to plan years beginning on or 

22 after January 1, 2010. 


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1 SEC. 163. REVISIONS RELATING TO SPECIALIZED MEDI2 CARE ADVANTAGE PLANS FOR SPECIAL 

3 NEEDS INDIVIDUALS. 

4 (a) EXTENSION OF AUTHORITY TO RESTRICT EN5 ROLLMENT.—Section 1859(f) of the Social Security Act 

6 (42 U.S.C. 1395w–28(f)), as amended by section 108(a) 

7 of the Medicare, Medicaid, and SCHIP Extension Act of 

8 2007 (Public Law 110–173), is amended by striking 

9 ‘‘2010’’ and inserting ‘‘2011’’. 

10 (b) MORATORIUM ON AUTHORITY TO DESIGNATE

11 OTHER PLANS AS SPECIALIZED MA PLANS.—During the 

12 period beginning on January 1, 2010, and ending on De13 cember 31, 2010, the Secretary of Health and Human 

14 Services may not exercise the authority provided under 

15 section 231(d) of the Medicare Prescription Drug, Im16 provement, and Modernization Act of 2003 (42 U.S.C. 

17 1395w–21 note) to designate other plans as specialized 

18 MA plans for special needs individuals. 

19 (c) REQUIREMENTS FOR ENROLLMENT.— 

20 (1) IN GENERAL.—Section 1859 of the Social 

21 Security Act (42 U.S.C. 1395w–28) is amended— 

22 (A) in subsection (b)(6)(A), by inserting 

23 ‘‘and that meets the applicable requirements of 

24 paragraph (2), (3), or (4) of subsection (f), as 

25 the case may be’’ before the period at the end; 

26 and 


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1 (B) in subsection (f)— 

2 (i) by amending the heading to read 

3 as follows: ‘‘PROVISIONS REGARDING SPE4 CIALIZED MA PLANS FOR SPECIAL NEEDS

5 INDIVIDUALS’’; 

6 (ii) by designating the sentence begin7 ning ‘‘In the case of’’ as paragraph (1) 

8 with the heading ‘‘RESTRICTIONS ON EN9 ROLLMENT.—’’ and with appropriate in10 dentation; and 

11 (iii) by adding at the end the fol12 lowing new paragraphs: 

13 ‘‘(2) ADDITIONAL REQUIREMENTS FOR INSTI14 TUTIONAL SNPS.—In the case of a specialized MA 

15 plan for special needs individuals described in sub16 section (b)(6)(B)(i), the applicable requirements de17 scribed in this paragraph are as follows: 

18 ‘‘(A) Enrollment under the plan is re19 stricted so, of the individuals who are enrolling 

20 in the plan on or after January 1, 2009, at 

21 least 90 percent of such individuals are individ22 uals who are special needs individuals described 

23 in subsection (b)(6)(B)(i). In applying this sub24 paragraph, in order for an individual residing in 

25 a community setting but requiring an instituVerDate Aug 31 2005 03:52 Jun 13, 2008 Jkt 069200 PO 00000 Frm 00141 Fmt 6652 Sfmt 6201 E:\BILLS\S3118.PCS S3118

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1 tional level of care to be treated as an indi2 vidual described in such subsection, the indi3 vidual must be assessed and certified, using a 

4 State assessment tool of the State in which the 

5 individual resides, as requiring an institutional 

6 level of care. 

7 ‘‘(B) Effective for plan years beginning on 

8 or after January 1, 2010, the plan has in place 

9 a model of care plan described in paragraph 

10 (5). 

11 ‘‘(3) ADDITIONAL REQUIREMENTS FOR DUAL

12 SNPS.—In the case of a specialized MA plan for spe13 cial needs individuals described in subsection 

14 (b)(6)(B)(ii), the applicable requirements described 

15 in this paragraph are as follows: 

16 ‘‘(A) Enrollment under the plan is re17 stricted so, of the individuals who are enrolling 

18 in the plan on or after January 1, 2009, at 

19 least 90 percent of such individuals are individ20 uals who are special needs individuals described 

21 in subsection (b)(6)(B)(ii). 

22 ‘‘(B) Effective for plan years beginning on 

23 or after January 1, 2010, the plan has in place 

24 a model of care plan described in paragraph 

25 (5). 


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1 ‘‘(C) Effective for plan years beginning on 

2 or after January 1, 2012, the plan has docu3 mented arrangements with the State Medicaid 

4 agency that address cooperation on coordination 

5 of the operation of the plan and the State Med6 icaid plan under title XIX for such special 

7 needs individuals and that include at least the 

8 following: 

9 ‘‘(i) A means for the agency to verify 

10 an enrollee’s eligibility for medical assist11 ance under such title. 

12 ‘‘(ii) A means to identify and share 

13 information on provider participation 

14 under such title. 

15 ‘‘(iii) A means to supply the special16 ized MA plan with information on the ben17 efits to which an individual enrolled under 

18 the State Medicaid plan and eligible for 

19 medical assistance under title XIX is enti20 tled. 

21 ‘‘(D) Effective for plan years beginning on 

22 or after January 1, 2010, the plan has nec23 essary arrangements, including arrangements 

24 with providers, in order to assure that enrollees 

25 who are special needs individuals described in 


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1 subsection (b)(6)(B)(ii) are not charged or lia2 ble for cost-sharing for items and services fur3 nished through the plan and for which they are 

4 entitled to benefits under title XIX in excess of 

5 the cost-sharing that the individuals would be 

6 charged if the individuals were enrolled under 

7 the original Medicare fee-for-service program 

8 and not under the plan. 

9 ‘‘(E) Effective for enrollments made dur10 ing or after the annual open enrollment period 

11 for the plan year beginning on the earlier of 

12 January 1, 2012 or the first plan year for 

13 which the plan reaches an agreement with the 

14 state, the plan provides each prospective en15 rollee described in subsection (b)(6)(B)(ii), 

16 prior to enrollment, with an accurate and easily 

17 understandable summary comparison (using a 

18 standardized format established by the Sec19 retary) that compares— 

20 ‘‘(i) the benefits and cost-sharing that 

21 apply to individuals entitled to benefits 

22 under a State Medicaid program under 

23 title XIX if such individuals enroll in the 

24 original Medicare fee-for-service program 

25 under Parts A and B; and 


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1 ‘‘(ii) the benefits and cost-sharing 

2 that apply to individuals entitled to bene3 fits under a State Medicaid program under 

4 title XIX if such individuals enroll in the 

5 plan. 

6 Such summary comparison shall be included 

7 with any description of benefits offered by the 

8 plan. 

9 ‘‘(4) ADDITIONAL REQUIREMENTS FOR SEVERE

10 OR DISABLING CHRONIC CONDITION SNPS.—In the 

11 case of a specialized MA plan for special needs indi12 viduals described in subsection (b)(6)(B)(iii), the ap13 plicable requirements described in this paragraph 

14 are as follows: 

15 ‘‘(A) Enrollment under the plan is re16 stricted so, of the individuals who are enrolling 

17 in the plan on or after January 1, 2009, at 

18 least 90 percent of such individuals are individ19 uals who are special needs individuals described 

20 in subsection (b)(6)(B)(iii). 

21 ‘‘(B) Effective for plan years beginning on 

22 or after January 1, 2010, the plan has in place 

23 a model of care plan described in paragraph 

24 (5).’’. 


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1 (2) RESOURCES FOR STATE MEDICAID AGEN2 CIES.—The Secretary of Health and Human Serv3 ices shall provide for the designation of appropriate 

4 staff and resources that can address State inquiries 

5 with respect to the coordination of State and Fed6 eral policies for specialized MA plans for special 

7 needs individuals described in subsection 

8 (b)(6)(B)(ii) of section 1859 of the Social Security 

9 Act (42 U.S.C. 1395w–28) as described in sub10 section (f)(3) of such section, as added by this sub11 section. 

12 (3) RULE OF CONSTRUCTION.—Nothing in the 

13 provisions of, or amendments made by, this sub14 section shall be construed to require a State to enter 

15 into a contract or agreement with a Medicare Ad16 vantage organization with respect to such plans. 

17 (d) MODEL OF CARE PLAN REQUIREMENT FOR ALL

18 SNPS.— 

19 (1) IN GENERAL.—Section 1859(f) of the Social 

20 Security Act (42 U.S.C. 1395w–28(f)), as amended 

21 by subsection (c)(1), is amended by adding at the 

22 end the following new paragraph: 

23 ‘‘(5) MODEL OF CARE PLAN REQUIREMENT FOR

24 ALL SNPS.—A model of care plan described in this 

25 paragraph for a specialized MA plan is a model of 


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1 care plan that specifies how the plan will coordinate 

2 and deliver care designed for the plan’s enrollees. 

3 Such model shall include at least the following: 

4 ‘‘(A) Targeting a population of special 

5 needs enrollees for whom the plan is designed. 

6 ‘‘(B) Coordination of care for enrollees. 

7 ‘‘(C) Inclusion of a network of providers 

8 and services with clinical expertise relevant to 

9 the targeted enrollee population. 

10 ‘‘(D) Delivery of care based on appropriate 

11 protocols for the targeted enrollee population. 

12 ‘‘(E) Application of performance measures 

13 to evaluate processes and outcomes of the 

14 model. 

15 ‘‘(F) At least annually, or more often as 

16 each enrollee’s situation may require, contacting 

17 each enrollee (or the enrollee’s representative) 

18 and evaluating the enrollee in order to ensure 

19 that the model of care is being appropriately 

20 applied to such enrollee.’’. 

21 (2) REVIEW TO ENSURE COMPLIANCE WITH

22 MODEL OF CARE PLAN REQUIREMENTS.—Section 

23 1857(d) of the Social Security Act (42 U.S.C. 

24 1395w–27(d)) is amended by adding at the end the 

25 following new paragraph: 


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1 ‘‘(6) REVIEW TO ENSURE COMPLIANCE WITH

2 MODEL OF CARE PLAN REQUIREMENTS FOR SPE3 CIALIZED MEDICARE ADVANTAGE PLANS FOR SPE4 CIAL NEEDS INDIVIDUALS.—In conjunction with a 

5 general compliance audit of a specialized Medicare 

6 Advantage plan for special needs individuals under 

7 paragraph (2), the Secretary shall conduct a review 

8 to ensure that such plan is in compliance with the 

9 model of care plan requirements under section 

10 1859(f)(5).’’. 

11 (e) 1-YEAR EXTENSION OF MORATORIUM FOR

12 CHRONIC CARE SNPS.—Section 108(b)(2) of the Medi13 care, Medicaid, and SCHIP Extension Act of 2007 (Public 

14 Law 110–173) is amended by inserting after ‘‘December 

15 31, 2009’’ the following: ‘‘(or December 31, 2010, in the 

16 case of a specialized MA plan for special needs individuals 

17 described in section 1859(b)(6)(B)(iii) of the Social Secu18 rity Act)’’. 

19 SEC. 164. ADJUSTMENT TO THE MEDICARE ADVANTAGE 

20 STABILIZATION FUND. 

21 Section 1858(e)(2)(A)(i) of the Social Security Act 

22 (42 U.S.C. 1395w–27a(e)(2)(A)(i)), as amended by sec23 tion 110 of the Medicare, Medicaid, and SCHIP Extension 

24 Act of 2007 (Public Law 110–173), is amended— 


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1 (1) by striking ‘‘2013’’ and inserting ‘‘2014’’; 

2 and 

3 (2) by striking ‘‘$1,790,000,000’’ and inserting 

4 ‘‘$1’’. 

5 SEC. 165. ACCESS TO MEDICARE REASONABLE COST CON6 TRACT PLANS. 

7 (a) EXTENSION OF REASONABLE COST CON8 TRACTS.—Section 1876(h)(5)(C)(ii) of the Social Security 

9 Act (42 U.S.C. 1395mm(h)(5)(C)(ii)), as amended by sec10 tion 109 of the Medicare, Medicaid, and SCHIP Extension 

11 Act of 2007 (Public Law 110–173), is amended by strik12 ing ‘‘January 1, 2009’’ and inserting ‘‘January 1, 2010’’ 

13 in the matter preceding subclause (I). 

14 (b) REVISIONS TO LIMITATION ON EXTENSION OR

15 RENEWAL.— 

16 (1) CLARIFICATION REGARDING USE OF COUN17 TIES RATHER THAN SERVICE AREAS IN APPLICATION

18 OF PROHIBITION.—Section 1876(h)(5)(C)(ii) of the 

19 Social Security Act (42 U.S.C. 

20 1395mm(h)(5)(C)(ii)), in the matter preceding sub21 clause (I), is amended by striking ‘‘for a service 

22 area’’ and all that follows through ‘‘previous year 

23 was’’ and inserting ‘‘for a county in the service area 

24 of such contract insofar as such county during the 

25 entire previous year was entirely’’. 


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1 (2) REQUIREMENT FOR AT LEAST TWO MEDI2 CARE ADVANTAGE ORGANIZATIONS TO BE OFFERING

3 A PLAN IN AN AREA FOR THE PROHIBITION TO BE

4 APPLICABLE.—Subclauses (I) and (II) of section 

5 1876(h)(5)(C)(ii) of the Social Security Act (42 

6 U.S.C. 1395mm(h)(5)(C)(ii)) are each amended by 

7 inserting ‘‘, provided that all such plans are not of8 fered by the same Medicare Advantage organization’’ 

9 after ‘‘clause (iii)’’. 

10 (c) REVISION OF REQUIREMENTS FOR PLANS THAT

11 ARE USED TO DETERMINE IF PROHIBITION IS APPLICA12 BLE.—Section 1876(h)(5)(C)(iii) of the Social Security 

13 Act (42 U.S.C. 1395mm(h)(5)(C)(iii)) is amended— 

14 (1) in the matter preceding subclause (I)— 

15 (A) by inserting ‘‘portion of the plan’s’’ 

16 after ‘‘if the’’; and 

17 (B) by inserting ‘‘that is within the service 

18 area of a reasonable cost reimbursement con19 tract’’ after ‘‘for the year’’; and 

20 (2) in subclause (I)— 

21 (A) by inserting ‘‘that are not in another 

22 Metropolitan Statistical Area with a population 

23 of more than 250,000’’ after ‘‘such Metropoli24 tan Statistical Area’’; and 


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1 (B) by adding at the end the following new 

2 sentence: ‘‘If the service area includes a portion 

3 in more than 1 Metropolitan Statistical Area 

4 with a population of more than 250,000, the 

5 minimum enrollment determination under the 

6 preceding sentence shall be made with respect 

7 to each such Metropolitan Statistical Area (and 

8 such applicable contiguous counties to such 

9 Metropolitan Statistical Area).’’. 

10 (d) GAO STUDY AND REPORT.— 

11 (1) STUDY.—The Comptroller General of the 

12 United States shall conduct a study of the reasons 

13 (if any) why reasonable cost contracts under section 

14 1876(h) of the Social Security Act (42 U.S.C. 

15 1395mm(h)) are unable to become Medicare Advan16 tage plans under part C of title XVIII of such Act. 

17 (2) REPORT.—Not later than July 1, 2009, the 

18 Comptroller General of the United States shall sub19 mit a report to Congress containing the results of 

20 the study conducted under paragraph (1), together 

21 with recommendations for such legislation and ad22 ministrative action as the Comptroller General deter23 mines appropriate. 


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1 SEC. 166. MEDPAC STUDY AND REPORT ON MEDICARE AD2 VANTAGE PAYMENTS. 

3 (a) STUDY.—The Medicare Payment Advisory Com4 mission (in this section referred to as the ‘‘Commission’’) 

5 shall conduct a study of the following: 

6 (1) The correlation between— 

7 (A) the costs that Medicare Advantage or8 ganizations with respect to Medicare Advantage 

9 plans incur in providing coverage under the 

10 plan for items and services covered under the 

11 original Medicare fee-for-service program under 

12 parts A and B of title XVIII of the Social Secu13 rity Act, as reflected in plan bids; and 

14 (B) county-level spending under such origi15 nal Medicare fee-for-service program on a per 

16 capita basis, as calculated by the Chief Actuary 

17 of the Centers for Medicare & Medicaid Serv18 ices. 

19 The study with respect to the issue described in the 

20 preceding sentence shall include differences in cor21 relation statistics by plan type and geographic area. 

22 (2) Based on these results of the study with re23 spect to the issue described in paragraph (1), and 

24 other data the Commission determines appro25 priate— 


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1 (A) alternate approaches to achieving pay2 ment neutrality under the Medicare program 

3 with respect to a Medicare beneficiary enrolled 

4 in a Medicare Advantage plan and a Medicare 

5 beneficiary enrolled in such original Medicare 

6 fee-for-service program other than through 

7 county-level payment area equivalents, such 

8 as— 

9 (i) blends of national average per cap10 ita spending under such original Medicare 

11 fee-for-service program and local spending 

12 under such original Medicare fee-for-serv13 ice program; 

14 (ii) price adjusting national average 

15 per capita spending under such original 

16 Medicare fee-for-service program by geog17 raphy and excluding utilization factors; 

18 and 

19 (iii) blends of national average per 

20 capita spending under such original Medi21 care fee-for-service program with Medicare 

22 Advantage plan bids; and 

23 (B) the accuracy and completeness of 

24 county-level estimates of per capita spending 

25 under such original Medicare fee-for-service 


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1 program (including counties in Puerto Rico), as 

2 used to determine the annual Medicare Advan3 tage capitation rate under section 1853 of the 

4 Social Security Act (42 U.S.C. 1395w–23), and 

5 whether such estimates include— 

6 (i) expenditures with respect to Medi7 care beneficiaries at facilities of the De8 partment of Veterans Affairs; and 

9 (ii) all appropriate administrative ex10 penses, including claims processing. 

11 (3) Ways to improve the accuracy and com12 pleteness of county-level estimates of per capita 

13 spending described in paragraph (2)(B). 

14 (b) REPORT.—Not later than December 1, 2009, the 

15 Commission shall submit a report to Congress containing 

16 the results of the study conducted under subsection (a), 

17 together with recommendations for such legislation and 

18 administrative action as the Commission determines ap19 propriate. 

20 SEC. 167. MARKETING OF MEDICARE ADVANTAGE PLANS 

21 AND PRESCRIPTION DRUG PLANS. 

22 (a) PROHIBITIONS.— 

23 (1) MEDICARE ADVANTAGE PROGRAM.— 

24 (A) IN GENERAL.—Section 1851(h)(4) of 

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


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1 21(h)(4) is amended by striking subparagraph 

2 (A) and inserting the following: 

3 ‘‘(A) shall not permit a Medicare Advan4 tage organization (or the marketing representa5 tives of such an organization) to— 

6 ‘‘(i) provide cash or other remunera7 tion as an inducement for enrollment or 

8 otherwise; 

9 ‘‘(ii) offer gifts, except for gifts of 

10 nominal value (as determined by the Sec11 retary), to potential enrollees; 

12 ‘‘(iii) provide meals, regardless of 

13 value, to potential enrollees; 

14 ‘‘(iv) solicit door-to-door or through 

15 other unsolicited means of direct contact, 

16 including the telephone and personally ap17 proaching the beneficiary, unless the bene18 ficiary initiates the contact; 

19 ‘‘(v) engage in activities that mislead 

20 beneficiaries about or misrepresent the 

21 Medicare Advantage organization or the 

22 Medicare Advantage plan offered by the 

23 organization, including any activities pro24 hibited under cobranding standards estabVerDate Aug 31 2005 03:52 Jun 13, 2008 Jkt 069200 PO 00000 Frm 00155 Fmt 6652 Sfmt 6201 E:\BILLS\S3118.PCS S3118

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1 lished by the Secretary to prevent bene2 ficiaries from being misled; 

3 ‘‘(vi) market non-health care related 

4 products to potential enrollees during any 

5 Medicare Advantage sales activity or pres6 entation; 

7 ‘‘(vii) conduct a marketing appoint8 ment with a beneficiary unless the organi9 zation has a documented agreement with 

10 the beneficiary in advance of the appoint11 ment as to what health care related prod12 ucts will be discussed; 

13 ‘‘(viii) conduct sales presentations or 

14 distribute and accept Medicare Advantage 

15 plan enrollment forms in health care pro16 vider offices or, under rules provided by 

17 the Secretary, other places where health 

18 care is delivered; or 

19 ‘‘(ix) engage in any other marketing 

20 activity prohibited by the Secretary; and’’. 

21 (2) MEDICARE PRESCRIPTION DRUG PRO22 GRAM.—Section 1860D–4 of the Social Security Act 

23 (42 U.S.C. 1395w–104) is amended by adding at 

24 the end the following new subsection: 


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1 ‘‘(l) REQUIREMENTS WITH RESPECT TO MAR2 KETING.—The following provisions shall apply to a PDP 

3 sponsor in the same manner as such provisions apply to 

4 a Medicare Advantage organization: 

5 ‘‘(1) The prohibitions on the conduct of certain 

6 activities under section 1851(h)(4)(A).’’. 

7 (b) ADDITIONAL MARKETING PROTECTIONS.— 

8 (1) MEDICARE ADVANTAGE PROGRAM.—Section 

9 1851(h) of the Social Security Act (42 U.S.C. 

10 1395w–21(h)) is amended by adding at the end the 

11 following new paragraph: 

12 ‘‘(6) ADDITIONAL MARKETING PROTECTIONS.— 

13 ‘‘(A) CONFIRMATION OF MARKETING RE14 SOURCES.—Each Medicare Advantage organiza15 tion shall establish and maintain a system for 

16 confirming that individuals who are enrolled in 

17 a Medicare Advantage plan offered by the orga18 nization— 

19 ‘‘(i) have in fact enrolled in such plan; 

20 and 

21 ‘‘(ii) understand the rules applicable 

22 under such plan. 

23 ‘‘(B) LICENSING OF MARKETING REP24 RESENTATIVES.— 


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1 ‘‘(i) IN GENERAL.—Each Medicare 

2 Advantage organization shall— 

3 ‘‘(I) only conduct marketing ac4 tivities (as defined by the Secretary) 

5 in a State through marketing rep6 resentatives who are licensed by the 

7 State; and 

8 ‘‘(II) inform the State that it has 

9 appointed those individuals as mar10 keting representatives of the organiza11 tion, consistent with the State’s ap12 pointment laws, except that no ap13 pointment fees shall apply to such ap14 pointment. 

15 ‘‘(ii) MARKETING REPRESENTATIVE

16 DEFINED.—In this subsection, the term 

17 ‘marketing representative’ means an em18 ployee, agent, broker, or other third party 

19 who conducts marketing activities (as so 

20 defined) for a Medicare Advantage organi21 zation. 

22 ‘‘(C) COMPLIANCE WITH STATE REQUESTS

23 FOR INFORMATION.—Each Medicare Advantage 

24 organization shall comply with State requests 

25 for information about the performance of a liVerDate Aug 31 2005 03:52 Jun 13, 2008 Jkt 069200 PO 00000 Frm 00158 Fmt 6652 Sfmt 6201 E:\BILLS\S3118.PCS S3118

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1 censed agent or broker as part of a State inves2 tigation into the individual’s conduct.’’. 

3 (2) MEDICARE PRESCRIPTION DRUG PRO4 GRAM.—Section 1860D–4(l) of the Social Security 

5 Act, as added by subsection (a)(2), is amended by 

6 adding at the end the following new paragraph: 

7 ‘‘(2) The additional marketing protections 

8 under section 1851(h)(6).’’. 

9 (c) COMMISSIONS AND TRAINING FOR MARKETING

10 REPRESENTATIVES.— 

11 (1) MEDICARE ADVANTAGE PROGRAM.—Section 

12 1851(h) of the Social Security Act (42 U.S.C. 

13 1395w–21(h)), as amended by subsection (b)(1), is 

14 amended by adding at the end the following new 

15 paragraph: 

16 ‘‘(7) COMMISSIONS AND TRAINING FOR MAR17 KETING REPRESENTATIVES.— 

18 ‘‘(A) COMMISSIONS.—Not later than Janu19 ary 1, 2009, the Secretary shall issue rules gov20 erning commissions and, as determined appro21 priate by the Secretary, other compensation of22 fered by Medicare Advantage organizations. 

23 Such rules— 

24 ‘‘(i) shall be intended to provide mar25 keting representatives with incentives to 


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1 recommend appropriate plan options for 

2 individual beneficiaries; and 

3 ‘‘(ii) shall take effect on a date speci4 fied by the Secretary. 

5 ‘‘(B) TRAINING.—Each Medicare Advan6 tage organization shall ensure that marketing 

7 representatives who sell Medicare products are 

8 trained and tested on— 

9 ‘‘(i) rules and regulations under the 

10 program under this title; and 

11 ‘‘(ii) other information specific to the 

12 Medicare Advantage plan products the or13 ganization intends to sell.’’. 

14 (2) MEDICARE PRESCRIPTION DRUG PRO15 GRAM.—Section 1860D–4(l) of the Social Security 

16 Act, as added by subsection (a)(2) and amended by 

17 subsection (b)(2), is amended by adding at the end 

18 the following new paragraph: 

19 ‘‘(3) The requirements with respect to commis20 sions and training for marketing representatives 

21 under section 1851(h)(7).’’. 

22 (d) EFFECTIVE DATE.—Except as provided in sec23 tion 1851(h)(7)(A) of the Social Security Act, as added 

24 by subsection (c)(1), the amendments made by this section 


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1 shall apply with respect to marketing for plan years begin2 ning on or after January 1, 2009. 

3 Subtitle F—Other Provisions 

4 SEC. 171. CONTRACT WITH A CONSENSUS-BASED ENTITY 

5 REGARDING PERFORMANCE MEASUREMENT. 

6 (a) CONTRACT.— 

7 (1) IN GENERAL.—Part E of title XVIII of the 

8 Social Security Act (42 U.S.C. 1395x et seq.) is 

9 amended by inserting after section 1889 the fol10 lowing new section: 

11 ‘‘CONTRACT WITH A CONSENSUS-BASED ENTITY

12 REGARDING PERFORMANCE MEASUREMENT

13 ‘‘SEC. 1890. (a) CONTRACT.— 

14 ‘‘(1) IN GENERAL.—For purposes of activities 

15 conducted under this Act, the Secretary shall iden16 tify and have in effect a contract with a consensus17 based entity, such as the National Quality Forum, 

18 that meets the requirements described in subsection 

19 (c). Such contract shall provide that the entity will 

20 perform the duties described in subsection (b). 

21 ‘‘(2) TIMING FOR FIRST CONTRACT.—As soon 

22 as practicable after the date of the enactment of this 

23 subsection, the Secretary shall enter into the first 

24 contract under paragraph (1). 

25 ‘‘(3) PERIOD OF CONTRACT.—A contract under 

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1 cept as may be renewed after a subsequent bidding 

2 process). 

3 ‘‘(4) COMPETITIVE PROCEDURES.—Competitive 

4 procedures (as defined in section 4(5) of the Office 

5 of Federal Procurement Policy Act (41 U.S.C. 

6 403(5))) shall be used to enter into a contract under 

7 paragraph (1). 

8 ‘‘(b) DUTIES.—The duties described in this sub9 section are the following: 

10 ‘‘(1) PRIORITY SETTING PROCESS.—The entity 

11 shall synthesize evidence and convene key stake12 holders to make recommendations, with respect to 

13 activities conducted under this Act, on an integrated 

14 national strategy and priorities for health care per15 formance measurement in all applicable settings. In 

16 making such recommendations, the entity shall— 

17 ‘‘(A) ensure that priority is given to meas18 ures— 

19 ‘‘(i) that address the health care pro20 vided to patients with prevalent, high-cost 

21 chronic diseases; 

22 ‘‘(ii) with the greatest potential for 

23 improving the quality, efficiency, and pa24 tient-centeredness of health care; and 


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1 ‘‘(iii) that may be implemented rap2 idly due to existing evidence, standards of 

3 care, or other reasons; and 

4 ‘‘(B) take into account measures that— 

5 ‘‘(i) may assist consumers and pa6 tients in making informed health care deci7 sions; 

8 ‘‘(ii) address health disparities across 

9 groups and areas; and 

10 ‘‘(iii) address the continuum of care a 

11 patient receives, including services fur12 nished by multiple health care providers or 

13 practitioners and across multiple settings. 

14 ‘‘(2) ENDORSEMENT OF MEASURES.—The enti15 ty shall provide for the endorsement of standardized 

16 health care performance measures. The endorsement 

17 process under the preceding sentence shall consider 

18 whether a measure— 

19 ‘‘(A) is evidence-based, reliable, valid, 

20 verifiable, relevant to enhanced health out21 comes, actionable at the caregiver level, feasible 

22 to collect and report, and responsive to vari23 ations in patient characteristics, such as health 

24 status, language capabilities, race or ethnicity, 

25 and income level; and 


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1 ‘‘(B) is consistent across types of health 

2 care providers, including hospitals and physi3 cians. 

4 ‘‘(3) MAINTENANCE OF MEASURES.—The entity 

5 shall establish and implement a process to ensure 

6 that measures endorsed under paragraph (2) are up7 dated (or retired if obsolete) as new evidence is de8 veloped. 

9 ‘‘(4) PROMOTION OF THE DEVELOPMENT OF

10 ELECTRONIC HEALTH RECORDS.—The entity shall 

11 promote the development and use of electronic 

12 health records that contain the functionality for 

13 automated collection, aggregation, and transmission 

14 of performance measurement information. 

15 ‘‘(5) ANNUAL REPORT TO CONGRESS AND THE

16 SECRETARY; SECRETARIAL PUBLICATION AND COM17 MENT.— 

18 ‘‘(A) ANNUAL REPORT.—By not later than 

19 March 1 of each year (beginning with 2009), 

20 the entity shall submit to Congress and the Sec21 retary a report containing a description of— 

22 ‘‘(i) the implementation of quality 

23 measurement initiatives under this Act and 

24 the coordination of such initiatives with 


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1 quality initiatives implemented by other 

2 payers; 

3 ‘‘(ii) the recommendations made 

4 under paragraph (1); and 

5 ‘‘(iii) the performance by the entity of 

6 the duties required under the contract en7 tered into with the Secretary under sub8 section (a). 

9 ‘‘(B) SECRETARIAL REVIEW AND PUBLICA10 TION OF ANNUAL REPORT.—Not later than 6 

11 months after receiving a report under subpara12 graph (A) for a year, the Secretary shall— 

13 ‘‘(i) review such report; and 

14 ‘‘(ii) publish such report in the Fed15 eral Register, together with any comments 

16 of the Secretary on such report. 

17 ‘‘(c) REQUIREMENTS DESCRIBED.—The require18 ments described in this subsection are the following: 

19 ‘‘(1) PRIVATE NONPROFIT.—The entity is a pri20 vate nonprofit entity governed by a board. 

21 ‘‘(2) BOARD MEMBERSHIP.—The members of 

22 the board of the entity include— 

23 ‘‘(A) representatives of health plans and 

24 health care providers and practitioners or rep25 resentatives of groups representing such health 


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1 plans and health care providers and practi2 tioners; 

3 ‘‘(B) health care consumers or representa4 tives of groups representing health care con5 sumers; and 

6 ‘‘(C) representatives of purchasers and em7 ployers or representatives of groups rep8 resenting purchasers or employers. 

9 ‘‘(3) ENTITY MEMBERSHIP.—The membership 

10 of the entity includes persons who have experience 

11 with— 

12 ‘‘(A) urban health care issues; 

13 ‘‘(B) safety net health care issues; 

14 ‘‘(C) rural and frontier health care issues; 

15 and 

16 ‘‘(D) health care quality and safety issues. 

17 ‘‘(4) OPEN AND TRANSPARENT.—With respect 

18 to matters related to the contract with the Secretary 

19 under subsection (a), the entity conducts its business 

20 in an open and transparent manner and provides the 

21 opportunity for public comment on its activities. 

22 ‘‘(5) VOLUNTARY CONSENSUS STANDARDS SET23 TING ORGANIZATION.—The entity operates as a vol24 untary consensus standards setting organization as 

25 defined for purposes of section 12(d) of the National 


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1 Technology Transfer and Advancement Act of 1995 

2 (Public Law 104–113) and Office of Management 

3 and Budget Revised Circular A–119 (published in 

4 the Federal Register on February 10, 1998). 

5 ‘‘(6) EXPERIENCE.—The entity has at least 4 

6 years of experience in establishing national con7 sensus standards. 

8 ‘‘(7) MEMBERSHIP FEES.—If the entity re9 quires a membership fee for participation in the 

10 functions of the entity, such fees shall be reasonable 

11 and adjusted based on the capacity of the potential 

12 member to pay the fee. In no case shall membership 

13 fees pose a barrier to the participation of individuals 

14 or groups with low or nominal resources to partici15 pate in the functions of the entity. 

16 ‘‘(d) FUNDING.—For purposes of carrying out this 

17 subsection, the Secretary shall provide for the transfer, 

18 from the Federal Hospital Insurance Trust Fund under 

19 section 1817 and the Federal Supplementary Medical In20 surance Trust Fund under section 1841 (in such propor21 tion as the Secretary determines appropriate), of up to 

22 $40,000,000 to the Centers for Medicare & Medicaid Serv23 ices Program Management Account for the period of fiscal 

24 years 2009 through 2012.’’. 


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1 (2) SENSE OF THE SENATE.—It is the Sense of 

2 the Senate that the selection by the Secretary of 

3 Health and Human Services of an entity to contract 

4 with under section 1890(a) of the Social Security 

5 Act, as added by subsection (a), should not be con6 strued as diminishing the significant contributions of 

7 the Boards of Medicine, the quality alliances, and 

8 other clinical and technical experts to efforts to 

9 measure and improve the quality of health care serv10 ices. 

11 (b) GAO STUDY AND REPORTS ON THE PERFORM12 ANCE AND COSTS OF THE CONSENSUS-BASED ENTITY

13 UNDER THE CONTRACT.— 

14 (1) IN GENERAL.—The Comptroller General of 

15 the United States shall conduct a study on— 

16 (A) the performance of the entity with a 

17 contract with the Secretary of Health and 

18 Human Services under section 1890(a) of the 

19 Social Security Act, as added by subsection (a), 

20 of its duties under such contract; and 

21 (B) the costs incurred by such entity in 

22 performing such duties. 

23 (2) REPORTS.—Not later than 18 months and 

24 36 months after the effective date of the first con25 tract entered into under such section 1890(a), the 


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1 Comptroller General of the United States shall sub2 mit a report to Congress containing the results of 

3 the study conducted under paragraph (1), together 

4 with recommendations for such legislation and ad5 ministrative action as the Comptroller General deter6 mines appropriate. 

7 SEC. 172. USE OF PART D DATA. 

8 Section 1860D–12(b)(3)(D) of the Social Security 

9 Act (42 U.S.C. 1395w–112(b)(3)(D)) is amended by add10 ing at the end the following sentence: ‘‘Notwithstanding 

11 any other provision of law, information provided to the 

12 Secretary under the application of section 1857(e)(1) to 

13 contracts under this section under the preceding sentence 

14 may be used for the purposes of carrying out this part, 

15 improving public health through research on the utiliza16 tion, safety, effectiveness, quality, and efficiency of health 

17 care services (as the Secretary determines appropriate), 

18 and conducting Congressional oversight, monitoring, and 

19 analysis of the program under this title.’’. 

20 SEC. 173. INCLUSION OF MEDICARE PROVIDERS AND SUP21 PLIERS IN FEDERAL PAYMENT LEVY AND AD22 MINISTRATIVE OFFSET PROGRAM. 

23 (a) IN GENERAL.—Section 1874 of the Social Secu24 rity Act (42 U.S.C. 1395kk) is amended by adding at the 

25 end the following new subsection: 


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1 ‘‘(d) INCLUSION OF MEDICARE PROVIDER AND SUP2 PLIER PAYMENTS IN FEDERAL PAYMENT LEVY PRO3 GRAM.— 

4 ‘‘(1) IN GENERAL.—The Centers for Medicare 

5 & Medicaid Services shall take all necessary steps to 

6 participate in the Federal Payment Levy Program 

7 under section 6331(h) of the Internal Revenue Code 

8 of 1986 as soon as possible and shall ensure that— 

9 ‘‘(A) at least 50 percent of all payments 

10 under parts A and B are processed through 

11 such program beginning within 1 year after the 

12 date of the enactment of this section; 

13 ‘‘(B) at least 75 percent of all payments 

14 under parts A and B are processed through 

15 such program beginning within 2 years after 

16 such date; and 

17 ‘‘(C) all payments under parts A and B 

18 are processed through such program beginning 

19 not later than September 30, 2011. 

20 ‘‘(2) ASSISTANCE.—The Financial Management 

21 Service and the Internal Revenue Service shall pro22 vide assistance to the Centers for Medicare & Med23 icaid Services to ensure that all payments described 

24 in paragraph (1) are included in the Federal PayVerDate Aug 31 2005 03:52 Jun 13, 2008 Jkt 069200 PO 00000 Frm 00170 Fmt 6652 Sfmt 6201 E:\BILLS\S3118.PCS S3118

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1 ment Levy Program by the deadlines specified in 

2 that subsection.’’. 

3 (b) APPLICATION OF ADMINISTRATIVE OFFSET PRO4 VISIONS TO MEDICARE PROVIDER OR SUPPLIER PAY5 MENTS.—Section 3716 of title 31, United States Code, is 

6 amended— 

7 (1) by inserting ‘‘the Department of Health and 

8 Human Services,’’ after ‘‘United States Postal Serv9 ice,’’ in subsection (c)(1)(A); and 

10 (2) by adding at the end of subsection (c)(3) 

11 the following new subparagraph: 

12 ‘‘(D) This section shall apply to payments 

13 made after the date which is 90 days after the 

14 enactment of this subparagraph (or such earlier 

15 date as designated by the Secretary of Health 

16 and Human Services) with respect to claims or 

17 debts, and to amounts payable, under title 

18 XVIII of the Social Security Act.’’. 

19 (c) EFFECTIVE DATE.—The amendments made by 

20 this section shall take effect on the date of the enactment 

21 of this Act. 


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1 TITLE II—MEDICAID 

2 SEC. 201. EXTENSION OF TRANSITIONAL MEDICAL ASSIST3 ANCE (TMA) AND ABSTINENCE EDUCATION 

4 PROGRAM THROUGH FISCAL YEAR 2009. 

5 Section 401 of division B of the Tax Relief and 

6 Health Care Act of 2006 (Public Law 109–432, 120 Stat. 

7 2994), as amended by section 1 of Public Law 110–48 

8 (121 Stat. 244), section 2 of the TMA, Abstinence, Edu9 cation, and QI Programs Extension Act of 2007 (Public 

10 Law 110–90, 121 Stat. 984), and section 202 of the Medi11 care, Medicaid, and SCHIP Extension Act of 2007 (Public 

12 Law 110–173) is amended— 

13 (1) by striking ‘‘June 30, 2008’’ and inserting 

14 ‘‘September 30, 2009’’; 

15 (2) by striking ‘‘the third quarter of fiscal year 

16 2008’’ and inserting ‘‘the fourth quarter of fiscal 

17 year 2009’’; and 

18 (3) by striking ‘‘the third quarter of fiscal year 

19 2007’’ and inserting ‘‘the fourth quarter of fiscal 

20 year 2007’’. 

21 SEC. 202. EXTENSION OF QUALIFYING INDIVIDUAL (QI) 

22 PROGRAM THROUGH FISCAL YEAR 2009. 

23 (a) EXTENSION.—Section 1902(a)(10)(E)(iv) of the 

24 Social Security Act (42 U.S.C. 1396a(a)(10)(E)(iv)) is 


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1 amended by striking ‘‘June 2008’’ and inserting ‘‘Sep2 tember 2009’’. 

3 (b) EXTENDING TOTAL AMOUNT AVAILABLE FOR

4 ALLOCATION.—Section 1933(g) of such Act (42 U.S.C. 

5 1396u–3(g)) is amended— 

6 (1) in paragraph (2)— 

7 (A) by striking ‘‘and’’ at the end of sub8 paragraph (H); 

9 (B) in subparagraph (I)— 

10 (i) by striking ‘‘June 30’’ and insert11 ing ‘‘September 30’’; 

12 (ii) by striking ‘‘$200,000,000’’ and 

13 inserting ‘‘$375,000,000’’; and 

14 (iii) by striking the period at the end 

15 and inserting a semicolon; and 

16 (C) by adding at the end the following new 

17 subparagraphs: 

18 ‘‘(J) for the period that begins on October 

19 1, 2008, and ends on December 31, 2008, the 

20 total allocation amount is $150,000,000; and 

21 ‘‘(K) for the period that begins on January 

22 1, 2009, and ends on September 30, 2009, the 

23 total allocation amount is $350,000,000.’’; and 


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1 (2) in paragraph (3), in the matter preceding 

2 subparagraph (A), by striking ‘‘or (H)’’ and insert3 ing ‘‘(H), or (J)’’. 

4 SEC. 203. MEDICAID DSH EXTENSION THROUGH DECEMBER 

5 31, 2009. 

6 Section 1923(f)(6) of the Social Security Act (42 

7 U.S.C. 1396r–4(f)(6)) is amended— 

8 (1) in the heading, by striking ‘‘FOR FISCAL

9 YEAR 2007 AND PORTIONS OF FISCAL YEAR 2008’’; 

10 (2) in subparagraph (A)— 

11 (A) in clause (i)— 

12 (i) in the second sentence— 

13 (I) by striking ‘‘fiscal year 2008 

14 for the period ending on June 30, 

15 2008’’ and inserting ‘‘fiscal years 

16 2008 and 2009’’; and 

(II) by striking ‘‘3 17 ⁄4 of’’; and 

18 (ii) by adding at the end the following 

19 new sentences: ‘‘Only with respect to fiscal 

20 year 2010 for the period ending on Decem21 ber 31, 2009, the DSH allotment for Ten22 nessee for such portion of the fiscal year, 

23 notwithstanding such table or terms, shall 

be 1 24 ⁄4 of the amount specified in the first 

25 sentence for fiscal year 2007.’’; 


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1 (B) in clause (ii), by striking ‘‘or for a pe2 riod in fiscal year 2008’’ and inserting ‘‘, 2008, 

3 2009, or for a period in fiscal year 2010’’; and 

4 (C) in clause (iv)— 

5 (i) in the heading, by striking ‘‘FISCAL

6 YEAR 2007 AND FISCAL YEAR 2008’’ and in7 serting ‘‘FISCAL YEARS 2007 THROUGH 2009

8 AND THE FIRST CALENDAR QUARTER OF

9 FISCAL YEAR 2010’’; 

10 (ii) in subclause (I), by striking ‘‘or 

11 for a period in fiscal year 2008’’ and in12 serting ‘‘, 2008, 2009, or for a period in 

13 fiscal year 2010’’; and 

14 (iii) in subclause (II), by striking ‘‘or 

15 for a period in fiscal year 2008’’ and in16 serting ‘‘, 2008, 2009, or for a period in 

17 fiscal year 2010’’; and 

18 (3) in subparagraph (B)(i)— 

19 (A) in the first sentence, by striking ‘‘fiscal 

20 year 2007’’ and inserting ‘‘each of fiscal years 

21 2007 through 2009’’; and 

22 (B) by striking the second sentence and in23 serting the following: ‘‘Only with respect to fis24 cal year 2010 for the period ending on Decem25 ber 31, 2009, the DSH allotment for Hawaii 


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1 for such portion of the fiscal year, notwith2 standing the table set forth in paragraph (2), 

3 shall be $2,500,000.’’. 

4 SEC. 204. ASSET VERIFICATION THROUGH ACCESS TO IN5 FORMATION HELD BY FINANCIAL INSTITU6 TIONS. 

7 (a) ADDITION OF AUTHORITY.—Title XIX of the So8 cial Security Act is amended by inserting after section 

9 1939 the following new section: 

10 ‘‘ASSET VERIFICATION THROUGH ACCESS TO

11 INFORMATION HELD BY FINANCIAL INSTITUTIONS

12 ‘‘SEC. 1940. (a) IMPLEMENTATION.— 

13 ‘‘(1) IN GENERAL.—Subject to the provisions of 

14 this section, each State shall implement an asset 

15 verification program described in subsection (b), for 

16 purposes of determining or redetermining the eligi17 bility of an individual for medical assistance under 

18 the State plan under this title. 

19 ‘‘(2) PLAN SUBMITTAL.—In order to meet the 

20 requirement of paragraph (1), each State shall— 

21 ‘‘(A) submit not later than a deadline spec22 ified by the Secretary consistent with paragraph 

23 (3), a State plan amendment under this title 

24 that describes how the State intends to imple25 ment the asset verification program; and 


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1 ‘‘(B) provide for implementation of such 

2 program for eligibility determinations and rede3 terminations made on or after 6 months after 

4 the deadline established for submittal of such 

5 plan amendment. 

6 ‘‘(3) PHASE-IN.— 

7 ‘‘(A) IN GENERAL.— 

8 ‘‘(i) IMPLEMENTATION IN CURRENT

9 ASSET VERIFICATION DEMO STATES.—The 

10 Secretary shall require those States speci11 fied in subparagraph (C) (to which an 

12 asset verification program has been applied 

13 before the date of the enactment of this 

14 section) to implement an asset verification 

15 program under this subsection by the end 

16 of fiscal year 2009. 

17 ‘‘(ii) IMPLEMENTATION IN OTHER

18 STATES.—The Secretary shall require 

19 other States to submit and implement an 

20 asset verification program under this sub21 section in such manner as is designed to 

22 result in the application of such programs, 

23 in the aggregate for all such other States, 

24 to enrollment of approximately, but not 

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1 rollees, in the aggregate for all such other 

2 States, by the end of the fiscal year in3 volved: 

4 ‘‘(I) 12.5 percent by the end of 

5 fiscal year 2009. 

6 ‘‘(II) 25 percent by the end of 

7 fiscal year 2010. 

8 ‘‘(III) 50 percent by the end of 

9 fiscal year 2011. 

10 ‘‘(IV) 75 percent by the end of 

11 fiscal year 2012. 

12 ‘‘(V) 100 percent by the end of 

13 fiscal year 2013. 

14 ‘‘(B) CONSIDERATION.—In selecting States 

15 under subparagraph (A)(ii), the Secretary shall 

16 consult with the States involved and take into 

17 account the feasibility of implementing asset 

18 verification programs in each such State. 

19 ‘‘(C) STATES SPECIFIED.—The States 

20 specified in this subparagraph are California, 

21 New York, and New Jersey. 

22 ‘‘(D) CONSTRUCTION.—Nothing in sub23 paragraph (A)(ii) shall be construed as pre24 venting a State from requesting, and the Sec25 retary approving, the implementation of an 


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1 asset verification program in advance of the 

2 deadline otherwise established under such sub3 paragraph. 

4 ‘‘(4) EXEMPTION OF TERRITORIES.—This sec5 tion shall only apply to the 50 States and the Dis6 trict of Columbia. 

7 ‘‘(b) ASSET VERIFICATION PROGRAM.— 

8 ‘‘(1) IN GENERAL.—For purposes of this sec9 tion, an asset verification program means a program 

10 described in paragraph (2) under which a State— 

11 ‘‘(A) requires each applicant for, or recipi12 ent of, medical assistance under the State plan 

13 under this title on the basis of being aged, 

14 blind, or disabled to provide authorization by 

15 such applicant or recipient (and any other per16 son whose resources are material to the deter17 mination of the eligibility of the applicant or re18 cipient for such assistance) for the State to ob19 tain (subject to the cost reimbursement require20 ments of section 1115(a) of the Right to Finan21 cial Privacy Act but at no cost to the applicant 

22 or recipient) from any financial institution 

23 (within the meaning of section 1101(1) of such 

24 Act) any financial record (within the meaning 

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1 stitution with respect to the applicant or recipi2 ent (and such other person, as applicable), 

3 whenever the State determines the record is 

4 needed in connection with a determination with 

5 respect to such eligibility for (or the amount or 

6 extent of) such medical assistance; and 

7 ‘‘(B) uses the authorization provided under 

8 subparagraph (A) to verify the financial re9 sources of such applicant or recipient (and such 

10 other person, as applicable), in order to deter11 mine or redetermine the eligibility of such appli12 cant or recipient for medical assistance under 

13 the State plan. 

14 ‘‘(2) PROGRAM DESCRIBED.—A program de15 scribed in this paragraph is a program for verifying 

16 individual assets in a manner consistent with the ap17 proach used by the Commissioner of Social Security 

18 under section 1631(e)(1)(B)(ii). 

19 ‘‘(c) DURATION OF AUTHORIZATION.—Notwith20 standing section 1104(a)(1) of the Right to Financial Pri21 vacy Act, an authorization provided to a State under sub22 section (b)(1) shall remain effective until the earliest of— 

23 ‘‘(1) the rendering of a final adverse decision on 

24 the applicant’s application for medical assistance 

25 under the State’s plan under this title; 


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1 ‘‘(2) the cessation of the recipient’s eligibility 

2 for such medical assistance; or 

3 ‘‘(3) the express revocation by the applicant or 

4 recipient (or such other person described in sub5 section (b)(1), as applicable) of the authorization, in 

6 a written notification to the State. 

7 ‘‘(d) TREATMENT OF RIGHT TO FINANCIAL PRIVACY

8 ACT REQUIREMENTS.— 

9 ‘‘(1) An authorization obtained by the State 

10 under subsection (b)(1) shall be considered to meet 

11 the requirements of the Right to Financial Privacy 

12 Act for purposes of section 1103(a) of such Act, and 

13 need not be furnished to the financial institution, 

14 notwithstanding section 1104(a) of such Act. 

15 ‘‘(2) The certification requirements of section 

16 1103(b) of the Right to Financial Privacy Act shall 

17 not apply to requests by the State pursuant to an 

18 authorization provided under subsection (b)(1). 

19 ‘‘(3) A request by the State pursuant to an au20 thorization provided under subsection (b)(1) is 

21 deemed to meet the requirements of section 

22 1104(a)(3) of the Right to Financial Privacy Act 

23 and of section 1102 of such Act, relating to a rea24 sonable description of financial records. 


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1 ‘‘(e) REQUIRED DISCLOSURE.—The State shall in2 form any person who provides authorization pursuant to 

3 subsection (b)(1)(A) of the duration and scope of the au4 thorization. 

5 ‘‘(f) REFUSAL OR REVOCATION OF AUTHORIZA6 TION.—If an applicant for, or recipient of, medical assist7 ance under the State plan under this title (or such other 

8 person described in subsection (b)(1), as applicable) re9 fuses to provide, or revokes, any authorization made by 

10 the applicant or recipient (or such other person, as appli11 cable) under subsection (b)(1)(A) for the State to obtain 

12 from any financial institution any financial record, the 

13 State may, on that basis, determine that the applicant or 

14 recipient is ineligible for medical assistance. 

15 ‘‘(g) USE OF CONTRACTOR.—For purposes of imple16 menting an asset verification program under this section, 

17 a State may select and enter into a contract with a public 

18 or private entity meeting such criteria and qualifications 

19 as the State determines appropriate, consistent with re20 quirements in regulations relating to general contracting 

21 provisions and with section 1903(i)(2). In carrying out ac22 tivities under such contract, such an entity shall be subject 

23 to the same requirements and limitations on use and dis24 closure of information as would apply if the State were 

25 to carry out such activities directly. 


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1 ‘‘(h) TECHNICAL ASSISTANCE.—The Secretary shall 

2 provide States with technical assistance to aid in imple3 mentation of an asset verification program under this sec4 tion. 

5 ‘‘(i) REPORTS.—A State implementing an asset 

6 verification program under this section shall furnish to the 

7 Secretary such reports concerning the program, at such 

8 times, in such format, and containing such information 

9 as the Secretary determines appropriate. 

10 ‘‘(j) TREATMENT OF PROGRAM EXPENSES.—Not11 withstanding any other provision of law, reasonable ex12 penses of States in carrying out the program under this 

13 section shall be treated, for purposes of section 1903(a), 

14 in the same manner as State expenditures specified in 

15 paragraph (7) of such section.’’. 

16 (b) STATE PLAN REQUIREMENTS.—Section 1902(a) 

17 of such Act (42 U.S.C. 1396a(a)) is amended— 

18 (1) in paragraph (69) by striking ‘‘and’’ at the 

19 end; 

20 (2) in paragraph (70) by striking the period at 

21 the end and inserting ‘‘; and’’; and 

22 (3) by inserting after paragraph (70), as so 

23 amended, the following new paragraph: 


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1 ‘‘(71) provide that the State will implement an 

2 asset verification program as required under section 

3 1940.’’. 

4 (c) WITHHOLDING OF FEDERAL MATCHING PAY5 MENTS FOR NONCOMPLIANT STATES.—Section 1903(i) of 

6 such Act (42 U.S.C. 1396b(i)) is amended— 

7 (1) in paragraph (22) by striking ‘‘or’’ at the 

8 end; 

9 (2) in paragraph (23) by striking the period at 

10 the end and inserting ‘‘; or’’; and 

11 (3) by adding after paragraph (23) the fol12 lowing new paragraph: 

13 ‘‘(24) if a State is required to implement an 

14 asset verification program under section 1940 and 

15 fails to implement such program in accordance with 

16 such section, with respect to amounts expended by 

17 such State for medical assistance for individuals 

18 subject to asset verification under such section, un19 less— 

20 ‘‘(A) the State demonstrates to the Sec21 retary’s satisfaction that the State made a good 

22 faith effort to comply; 

23 ‘‘(B) not later than 60 days after the date 

24 of a finding that the State is in noncompliance, 

25 the State submits to the Secretary (and the 


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1 Secretary approves) a corrective action plan to 

2 remedy such noncompliance; and 

3 ‘‘(C) not later than 12 months after the 

4 date of such submission (and approval), the 

5 State fulfills the terms of such corrective action 

6 plan.’’. 

7 (d) REPEAL.—Section 4 of Public Law 110–90 is re8 pealed. 

9 SEC. 205. APPLICATION OF MEDICARE PAYMENT ADJUST10 MENT FOR CERTAIN HOSPITAL-ACQUIRED 

11 CONDITIONS TO PAYMENTS FOR INPATIENT 

12 HOSPITAL SERVICES UNDER MEDICAID. 

13 (a) STATE PLAN REQUIREMENT.—Section 

14 1902(a)(13)(A)(iv) of the Social Security Act (42 U.S.C. 

15 1396a(a)(13)(A)(iv)) is amended— 

16 (1) by striking ‘‘rates take’’ and inserting 

17 ‘‘rates— 

18 ‘‘(I) take’’; 

19 (2) by striking the semicolon and inserting a 

20 comma; and 

21 (3) by adding at the end the following: 

22 ‘‘(II) ensure that higher pay23 ments are not made for services re24 lated to the presence of a condition 

25 that could be identified by a secVerDate Aug 31 2005 03:52 Jun 13, 2008 Jkt 069200 PO 00000 Frm 00185 Fmt 6652 Sfmt 6201 E:\BILLS\S3118.PCS S3118

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1 ondary diagnostic code described in 

2 section 1886(d)(4)(D);’’. 

3 (b) EFFECTIVE DATE.— 

4 (1) IN GENERAL.—Except as provided in para5 graph (2), the amendments made by subsection (a) 

6 take effect on October 1, 2008. 

7 (2) EXTENSION OF EFFECTIVE DATE FOR

8 STATE LAW AMENDMENT.—In the case of a State 

9 plan under title XIX of the Social Security Act (42 

10 U.S.C. 1396 et seq.) which the Secretary of Health 

11 and Human Services determines requires State legis12 lation in order for the plan to meet the additional 

13 requirements imposed by the amendments made by 

14 this section, the State plan shall not be regarded as 

15 failing to comply with the requirements of such title 

16 solely on the basis of its failure to meet these addi17 tional requirements before the first day of the first 

18 calendar quarter beginning after the close of the 

19 first regular session of the State legislature that be20 gins after the date of enactment of this Act. For 

21 purposes of the previous sentence, in the case of a 

22 State that has a 2-year legislative session, each year 

23 of the session is considered to be a separate regular 

24 session of the State legislature. 


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1 SEC. 206. REDUCTION IN PAYMENTS FOR MEDICAID ADMIN2 ISTRATIVE COSTS TO PREVENT DUPLICATION 

3 OF SUCH PAYMENTS UNDER TANF. 

4 Section 1903 of the Social Security Act (42 U.S.C. 

5 1396b) is amended— 

6 (1) in subsection (a)(7), by striking ‘‘section 

7 1919(g)(3)(B)’’ and inserting ‘‘subsection (h)’’; 

8 (2) in subsection (a)(2)(D) by inserting ‘‘, sub9 ject to subsection (g)(3)(C) of such section’’ after 

10 ‘‘as are attributable to State activities under section 

11 1919(g)’’; and 

12 (3) by adding after subsection (g) the following 

13 new subsection: 

14 ‘‘(h) REDUCTION IN PAYMENTS FOR ADMINISTRA15 TIVE COSTS TO PREVENT DUPLICATION OF PAYMENTS

16 UNDER TITLE IV.—Beginning with the calendar quarter 

17 commencing October 1, 2008, the Secretary shall reduce 

18 the amount paid to each State under subsection (a)(7) for 

each quarter by an amount equal to 1 19 ⁄4 of the annualized 

20 amount determined for the Medicaid program under sec21 tion 16(k)(2)(B) of the Food Stamp Act of 1977 (7 U.S.C. 

22 2025(k)(2)(B)).’’. 

23 SEC. 207. CLARIFICATION TREATMENT OF REGIONAL MED24 ICAL CENTER. 

25 (a) IN GENERAL.—Nothing in section 1903(w) of the 

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1 strued by the Secretary of Health and Human Services 

2 as prohibiting a State’s use of funds as the non-Federal 

3 share of expenditures under title XIX of such Act where 

4 such funds are transferred from or certified by a publicly5 owned regional medical center located in another State 

6 and described in subsection (b), so long as the Secretary 

7 determines that such use of funds is proper and in the 

8 interest of the program under title XIX. 

9 (b) CENTER DESCRIBED.—A center described in this 

10 subsection is a publicly-owned regional medical center 

11 that— 

12 (1) provides level 1 trauma and burn care serv13 ices; 

14 (2) provides level 3 neonatal care services; 

15 (3) is obligated to serve all patients, regardless 

16 of ability to pay; 

17 (4) is located within a Standard Metropolitan 

18 Statistical Area (SMSA) that includes at least 3 

19 States; 

20 (5) provides services as a tertiary care provider 

21 for patients residing within a 125-mile radius; and 

22 (6) meets the criteria for a disproportionate 

23 share hospital under section 1923 of such Act (42 

24 U.S.C. 1396r–4) in at least one State other than the 

25 State in which the center is located. 


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1 SEC. 208. GRANTS TO IMPROVE OUTREACH AND ENROLL2 MENT UNDER MEDICAID. 

3 (a) AUTHORITY TO AWARD GRANTS.—From the 

4 amounts appropriated for a fiscal year under subsection 

5 (g), the Secretary shall award grants to eligible entities 

6 to conduct outreach and enrollment efforts that are de7 signed to increase the enrollment and participation of eli8 gible individuals under Medicaid. 

9 (b) PRIORITY FOR AWARD OF GRANTS.— 

10 (1) IN GENERAL.—In awarding grants under 

11 subsection (a), the Secretary shall give priority to el12 igible entities that— 

13 (A) propose to target geographic areas 

14 with high rates of— 

15 (i) individuals who are eligible for, but 

16 unenrolled in, Medicaid, including such in17 dividuals who reside in rural areas; or 

18 (ii) racial and ethnic minorities and 

19 health disparity populations, including 

20 those proposals that address cultural and 

21 linguistic barriers to enrollment; and 

22 (B) submit the most demonstrable evidence 

23 required under paragraphs (1) and (2) of sub24 section (c). 

25 (2) 10 PERCENT SET ASIDE FOR OUTREACH TO

26 INDIANS.—An amount equal to 10 percent of the 


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1 funds appropriated under subsection (g) for a fiscal 

2 year shall be used by the Secretary to award grants 

3 to Indian Health Service providers and urban Indian 

4 organizations receiving funds under title V of the In5 dian Health Care Improvement Act (25 U.S.C. 1651 

6 et seq.) for outreach to, and enrollment of, individ7 uals who are Indians. 

8 (c) APPLICATION.—An eligible entity that desires to 

9 receive a grant under subsection (a) shall submit an appli10 cation to the Secretary in such form and manner, and con11 taining such information, as the Secretary may decide. 

12 Such application shall include— 

13 (1) evidence demonstrating that the entity in14 cludes members who have access to, and credibility 

15 with, ethnic or low-income populations in the com16 munities in which activities funded under the grant 

17 are to be conducted; 

18 (2) evidence demonstrating that the entity has 

19 the ability to address barriers to enrollment, such as 

20 lack of awareness of eligibility, stigma concerns and 

21 punitive fears associated with receipt of benefits, 

22 and other cultural barriers to applying for and re23 ceiving medical assistance; 


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1 (3) specific quality or outcomes performance 

2 measures to evaluate the effectiveness of activities 

3 funded by a grant awarded under this section; and 

4 (4) an assurance that the eligible entity shall— 

5 (A) conduct an assessment of the effective6 ness of such activities against the performance 

7 measures; 

8 (B) cooperate with the collection and re9 porting of enrollment data and other informa10 tion in order for the Secretary to conduct such 

11 assessments; and 

12 (C) in the case of an eligible entity that is 

13 not a State, provide each State in which the eli14 gible entity conducts outreach activities with 

15 grant funds with enrollment data and other in16 formation as necessary for each such State to 

17 administer its State Medicaid program. 

18 (d) DISSEMINATION OF ENROLLMENT DATA AND IN19 FORMATION DETERMINED FROM EFFECTIVENESS AS20 SESSMENTS; ANNUAL REPORT.—The Secretary shall— 

21 (1) make publicly available the enrollment data 

22 and information collected and reported in accordance 

23 with subsection (c)(4)(B); and 

24 (2) not later than December 31, 2009, submit 

25 a report to Congress on the outreach and enrollment 


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1 activities conducted with funds appropriated under 

2 this section. 

3 (e) SUPPLEMENT, NOT SUPPLANT.—Federal funds 

4 awarded under this section shall be used to supplement, 

5 not supplant, non-Federal funds that are otherwise avail6 able for activities funded under this section. 

7 (f) DEFINITIONS.—In this section: 

8 (1) ELIGIBLE ENTITY.—The term ‘‘eligible enti9 ty’’ means any of the following: 

10 (A) A State. 

11 (B) A local government. 

12 (C) An Indian tribe or tribal consortium, a 

13 tribal organization, an urban Indian organiza14 tion receiving funds under title V of the Indian 

15 Health Care Improvement Act (25 U.S.C. 1651 

16 et seq.), or an Indian Health Service provider. 

17 (D) A Federal health safety net organiza18 tion. 

19 (E) A State, national, local, or community20 based public or nonprofit private organization. 

21 (F) A faith-based organization or con22 sortia, to the extent that a grant awarded to 

23 such an entity is consistent with the require24 ments of section 1955 of the Public Health 


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1 Service Act (42 U.S.C. 300x–65) relating to a 

2 grant award to non-governmental entities. 

3 (G) An elementary or secondary school. 

4 (2) FEDERAL HEALTH SAFETY NET ORGANIZA5 TION.—The term ‘‘Federal health safety net organi6 zation’’ means— 

7 (A) a federally-qualified health center (as 

8 defined in section 1905(l)(2)(B) of the Social 

9 Security Act (42 U.S.C. 1396d(l)(2)(B)); 

10 (B) a hospital defined as a dispropor11 tionate share hospital for purposes of section 

12 1923 of such Act (42 U.S.C. 1396r–4); 

13 (C) a covered entity described in section 

14 340B(a)(4) of the Public Health Service Act 

15 (42 U.S.C. 256b(a)(4)); and 

16 (D) any other entity or consortium that 

17 serves children under a federally-funded pro18 gram, including the special supplemental nutri19 tion program for women, infants, and children 

20 (WIC) established under section 17 of the Child 

21 Nutrition Act of 1966 (42 U.S.C. 1786), the 

22 head start and early head start programs under 

23 the Head Start Act (42 U.S.C. 9801 et seq.), 

24 the school lunch program established under the 


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1 Richard B. Russell National School Lunch Act, 

2 and an elementary or secondary school. 

3 (3) INDIANS; INDIAN TRIBE; TRIBAL ORGANIZA4 TION; URBAN INDIAN ORGANIZATION.—The terms 

5 ‘‘Indian’’, ‘‘Indian tribe’’, ‘‘tribal organization’’, and 

6 ‘‘urban Indian organization’’ have the meanings 

7 given such terms in section 4 of the Indian Health 

8 Care Improvement Act (25 U.S.C. 1603). 

9 (4) MEDICAID.—The term ‘‘Medicaid’’ means 

10 the program of medical assistance established under 

11 title XIX of the Social Security Act (42 U.S.C. 1396 

12 et seq.). 

13 (g) APPROPRIATION.—There is appropriated, out of 

14 any money in the Treasury not otherwise appropriated, 

15 for the purpose of awarding grants under this section, 

16 $25,000,000 for fiscal year 2009, to remain available until 

17 expended. Amounts appropriated and paid under the au18 thority of this section to an eligible entity that is a State 

19 shall be in addition to amounts paid to the State under 

20 section 1903(a) of the Social Security Act (42 U.S.C. 

21 1396b(a)). 


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1 TITLE III—MISCELLANEOUS 

2 SEC. 301. EXTENSION OF TANF SUPPLEMENTAL GRANTS 

3 THROUGH FISCAL YEAR 2009. 

4 (a) EXTENSION.—Section 7101(a) of the Deficit Re5 duction Act of 2005 (Public Law 109–171; 120 Stat. 135) 

6 is amended by striking ‘‘fiscal year 2008’’ and inserting 

7 ‘‘fiscal year 2009’’. 

8 (b) CONFORMING AMENDMENT.—Section 

9 403(a)(3)(H)(ii) of the Social Security Act (42 U.S.C. 

10 603(a)(3)(H)(ii)) is amended to read as follows: 

11 ‘‘(ii) subparagraph (G) shall be ap12 plied as if ‘fiscal year 2009’ were sub13 stituted for ‘fiscal year 2001’; and’’. 

14 SEC. 302. SPECIAL DIABETES PROGRAMS FOR TYPE I DIA15 BETES AND INDIANS. 

16 (a) SPECIAL DIABETES PROGRAMS FOR TYPE I DIA17 BETES.—Section 330B(b)(2)(C) of the Public Health 

18 Service Act (42 U.S.C. 254c–2(b)(2)(C)) is amended by 

19 striking ‘‘2009’’ and inserting ‘‘2011’’. 

20 (b) SPECIAL DIABETES PROGRAMS FOR INDIANS.— 

21 Section 330C(c)(2)(C) of the Public Health Service Act 

22 (42 U.S.C. 254c–3(c)(2)(C)) is amended by striking 

23 ‘‘2009’’ and inserting ‘‘2011’’. 

24 (c) REPORT ON GRANT PROGRAMS.—Section 4923(b) 

25 of the Balanced Budget Act of 1997 (42 U.S.C. 1254c– 


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1 2 note), as amended by section 931(c) of the Medicare, 

2 Medicaid, and SCHIP Benefits Improvement and Protec3 tion Act of 2000, as enacted into law by section 1(a)(6) 

4 of Public Law 106–554, and section 1(c) of Public Law 

5 107–360, is amended— 

6 (1) in paragraph (1), by striking ‘‘and’’ at the 

7 end; 

8 (2) in paragraph (2)— 

9 (A) by striking ‘‘a final report’’ and insert10 ing ‘‘a second interim report’’; and 

11 (B) by striking the period at the end and 

12 inserting ‘‘; and’’; and 

13 (3) by adding at the end the following new 

14 paragraph: 

15 ‘‘(3) a final report on such evaluation not later 

16 than January 1, 2011.’’. 

17 SEC. 303. ADDITIONAL FUNDING FOR STATE HEALTH IN18 SURANCE ASSISTANCE PROGRAMS, AREA 

19 AGENCIES ON AGING, AND AGING AND DIS20 ABILITY RESOURCE CENTERS. 

21 (a) STATE HEATH INSURANCE PROGRAMS.— 

22 (1) IN GENERAL.—Paragraph (2) of section 

23 118(a) of the Medicare, Medicaid, and SCHIP Ex24 tension Act of 2007 (Public Law 110–173) is 

25 amended by inserting ‘‘and of $19,000,000 to such 


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1 account for fiscal year 2009’’ before the period at 

2 the end. 

3 (2) AMOUNT OF GRANTS.—The amount of a 

4 grant to a State under such section 118(a) from the 

5 total amount made available under that section for 

6 fiscal year 2009 shall be equal to the sum of the 

7 amount allocated to the State under paragraph 

8 (3)(A) and the amount allocated to the State under 

9 subparagraph (3)(B). 

10 (3) ALLOCATION TO STATES.— 

11 (A) ALLOCATION BASED ON PERCENTAGE

12 OF LOW-INCOME BENEFICIARIES.—The amount 

13 allocated to a State under this subparagraph 

from 2 14 ⁄3 of the total amount made available 

15 under section 118(a) of such Act for fiscal year 

16 2009 shall be based on the number of individ17 uals who meet the requirement under sub18 section (a)(3)(A)(ii) of section 1860D–14 of the 

19 Social Security Act (42 U.S.C. 1395w–114) but 

20 who have not enrolled to receive a subsidy 

21 under such section 1860D–14 relative to the 

22 total number of individuals who meet the re23 quirement under such subsection (a)(3)(A)(ii) 

24 in each State, as estimated by the Secretary. 


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1 (B) ALLOCATION BASED ON PERCENTAGE

2 OF RURAL BENEFICIARIES.—The amount allo3 cated to a State under this subparagraph from 

1 4 ⁄3 of the total amount made available under 

5 section 118(a) of such Act for fiscal year 2009 

6 shall be based on the number of part D eligible 

7 individuals (as defined in section 1860D– 

8 1(a)(3)(A) of such Act (42 U.S.C. 1395w– 

9 101(a)(3)(A))) residing in a rural area relative 

10 to the total number of such individuals in each 

11 State, as estimated by the Secretary. 

12 (4) PORTION OF GRANT BASED ON PERCENT13 AGE OF LOW-INCOME BENEFICIARIES TO BE USED

14 TO PROVIDE OUTREACH TO INDIVIDUALS WHO MAY

15 BE SUBSIDY ELIGIBLE INDIVIDUALS OR ELIGIBLE

16 FOR THE MEDICARE SAVINGS PROGRAM.—Each 

17 grant awarded under section 118(a) of such Act 

18 with respect to amounts allocated under paragraph 

19 (3)(A) shall be used to provide outreach to individ20 uals who may be subsidy eligible individuals (as de21 fined in section 1860D–14(a)(3)(A) of the Social Se22 curity Act (42 U.S.C. 1395w–114(a)(3)(A)) or eligi23 ble for the Medicare Savings Program (as defined in 

24 subsection (c)). 


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1 (b) AREA AGENCIES ON AGING AND DISABILITY RE2 SOURCE CENTERS.— 

3 (1) IN GENERAL.—Paragraph (2) of section 

4 118(b) of the Medicare, Medicaid, and SCHIP Ex5 tension Act of 2007 (Public Law 110–173) is 

6 amended by striking ‘‘for the period of fiscal years 

7 2008 through 2009’’ and inserting ‘‘for fiscal year 

8 2008 and of $6,000,000 to such account for fiscal 

9 year 2009’’. 

10 (2) AMOUNT OF GRANT.—The amount of a 

11 grant to a State under such section 118(b) from the 

12 total amount made available under that section for 

13 fiscal year 2009 shall be determined in the same 

14 manner as the amount of a grant to a State under 

15 section 118(a) of the Medicare, Medicaid, and 

16 SCHIP Extension Act of 2007 (Public Law 110– 

17 173) is determined for fiscal year 2009. 

18 (3) ALLOCATION AND USE OF PORTION OF

19 GRANT FUNDS TO PROVIDE OUTREACH TO INDIVID20 UALS WHO MAY BE SUBSIDY ELIGIBLE INDIVIDUALS

21 OR ELIGIBLE FOR THE MEDICARE SAVINGS PRO22 GRAM.— 

23 (A) ALLOCATION.—The total amount 

24 available under section 118(b) of the Medicare, 

25 Medicaid, and SCHIP Extension Act of 2007 


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1 (Public Law 110–173) for fiscal year 2009 

2 shall be allocated to States in the same manner 

3 as the amount made available for such fiscal 

4 year under section 118(a) of such Act is allo5 cated to States under subparagraphs (A) and 

6 (B) of subsection (a)(3) of this Act. 

7 (B) USE OF PORTION OF GRANT FUNDS TO

8 PROVIDE OUTREACH TO INDIVIDUALS WHO MAY

9 BE SUBSIDY ELIGIBLE INDIVIDUALS OR ELIGI10 BLE FOR THE MEDICARE SAVINGS PROGRAM.— 

11 Paragraph (4) of subsection (a) of this Act 

12 shall apply to the amounts allocated under this 

13 paragraph in the same manner such paragraph 

14 applies to the amounts allocated under sub15 section (a)(3) of this Act. 

16 (c) MEDICARE SAVINGS PROGRAM DEFINED.—For 

17 purposes of this section, the term ‘‘Medicare Savings Pro18 gram’’ means the program of medical assistance for pay19 ment of the cost of Medicare cost-sharing under the Med20 icaid program pursuant to sections 1902(a)(10)(E) and 

21 1933 of the Social Security Act (42 U.S.C. 

22 1396a(a)(10)(E), 1396u–3). 


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1 SEC. 304. EXTENSION OF FEDERAL REIMBURSEMENT OF 

2 EMERGENCY HEALTH SERVICES FURNISHED 

3 TO UNDOCUMENTED ALIENS. 

4 Section 1011(a) of the Medicare Prescription Drug, 

5 Improvement, and Modernization Act of 2003 (42 U.S.C. 

6 13955dd note) is amended— 

7 (1) in paragraph (1), by inserting ‘‘and 

8 $200,000,000 for each of fiscal years 2009 and 

9 2010,’’ after ‘‘2008’’; 

10 (2) by redesignating paragraph (2) as para11 graph (3); and 

12 (3) by inserting after paragraph (1) the fol13 lowing new paragraph: 

14 ‘‘(2) ADMINISTRATIVE COSTS.—From the funds 

15 made available under paragraph (1) for fiscal year 

16 2009, the Secretary may use not more than 

17 $8,000,000 of such funds for the administration of 

18 this section.’’. 


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Calendar No. 776 

110TH CONGRESS 

2D SESSION S. 3118 

A BILL 

To amend titles XVIII and XIX of the Social Secuareas, and for other purposes. maintain and improve access to care in rural health records, and electronic prescribing, and to advancing value based purchasing, electronic fee schedule, to improve the quality of care by preventing a reduction in the Medicare physician rity Act to preserve beneficiary access to care by 

JUNE 12, 2008 

Read the second time and placed on the calendar 


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