II 

Calendar No. 330 

113TH CONGRESS 

2D SESSION S. 2122 

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

Medicare sustainable growth rate and to improve Medicare and Medicaid 

payments, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

MARCH 12, 2014 

Mr. HATCH (for himself, Mr. MCCONNELL, and Mr. CORNYN) introduced the 

following bill; which was read the first time 

MARCH 13, 2014 

Read the second time and placed on the calendar 

A BILL 

To amend titles XVIII and XIX of the Social Security Act 

to repeal the Medicare sustainable growth rate and to 

improve Medicare and Medicaid payments, and for other 

purposes. 

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


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1 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

3 ‘‘Responsible Medicare SGR Repeal and Beneficiary Ac4 cess Improvement Act of 2014’’. 

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

6 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—MEDICARE PAYMENT FOR PHYSICIANS’ SERVICES 

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

payment for physicians’ services. 

Sec. 102. Priorities and funding for measure development. 

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

needs. 

Sec. 104. Ensuring accurate valuation of services under the physician fee 

schedule. 

Sec. 105. Promoting evidence-based care. 

Sec. 106. Empowering beneficiary choices through access to information on 

physicians’ services. 

Sec. 107. Expanding availability of Medicare data. 

Sec. 108. Reducing administrative burden and other provisions. 

TITLE II—EXTENSIONS 

Subtitle A—Medicare Extensions 

Sec. 201. Work geographic adjustment. 

Sec. 202. Medicare payment for therapy services. 

Sec. 203. Medicare ambulance services. 

Sec. 204. Revision of the Medicare-dependent hospital (MDH) program. 

Sec. 205. Revision of Medicare inpatient hospital payment adjustment for lowvolume hospitals. 

Sec. 206. Specialized Medicare Advantage plans for special needs individuals. 

Sec. 207. Reasonable cost reimbursement contracts. 

Sec. 208. Quality measure endorsement and selection. 

Sec. 209. Permanent extension of funding outreach and assistance for low-income programs. 

Subtitle B—Medicaid and Other Extensions 

Sec. 211. Qualifying individual program. 

Sec. 212. Transitional Medical Assistance. 

Sec. 213. Express lane eligibility. 

Sec. 214. Pediatric quality measures. 

Sec. 215. Special diabetes programs. 

Subtitle C—Human Services Extensions 

Sec. 221. Abstinence education grants. 


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Sec. 222. Personal responsibility education program. 

Sec. 223. Family-to-family health information centers. 

Sec. 224. Health workforce demonstration project for low-income individuals. 

TITLE III—MEDICARE AND MEDICAID PROGRAM INTEGRITY 

Sec. 301. Reducing improper Medicare payments. 

Sec. 302. Authority for Medicaid fraud control units to investigate and prosecute complaints of abuse and neglect of Medicaid patients in 

home and community-based settings. 

Sec. 303. Improved use of funds received by the HHS Inspector General from 

oversight and investigative activities. 

Sec. 304. Preventing and reducing improper Medicare and Medicaid expenditures. 

TITLE IV—OTHER PROVISIONS 

Sec. 401. Commission on Improving Patient Directed Health Care. 

Sec. 402. Expansion of the definition of inpatient hospital services for certain 

cancer hospitals. 

Sec. 403. Quality measures for certain post-acute care providers relating to notice and transfer of patient health information and patient care 

preferences. 

Sec. 404. Criteria for medically necessary, short inpatient hospital stays. 

Sec. 405. Transparency of reasons for excluding additional procedures from the 

Medicare ambulatory surgical center (ASC) approved list. 

Sec. 406. Supervision in critical access hospitals. 

Sec. 407. Requiring State licensure of bidding entities under the competitive acquisition program for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). 

Sec. 408. Recognition of attending physician assistants as attending physicians 

To serve hospice patients. 

Sec. 409. Remote patient monitoring pilot projects. 

Sec. 410. Community-Based Institutional Special Needs Plan Demonstration 

Program. 

Sec. 411. Applying CMMI waiver authority to PACE in order to foster innovations. 

Sec. 412. Improve and modernize Medicaid data systems and reporting. 

Sec. 413. Fairness in Medicaid supplemental needs trusts. 

Sec. 414. Helping Ensure Life- and Limb-Saving Access to Podiatric Physicians. 

Sec. 415. Demonstration programs to improve community mental health services. 

Sec. 416. Annual Medicaid DSH report. 

Sec. 417. Implementation. 

TITLE V—RESTORING INDIVIDUAL LIBERTY 

Sec. 501. Restoring individual liberty. 


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1 TITLE I—MEDICARE PAYMENT 

2 FOR PHYSICIANS’ SERVICES 

3 SEC. 101. REPEALING THE SUSTAINABLE GROWTH RATE 

4 (SGR) AND IMPROVING MEDICARE PAYMENT 

5 FOR PHYSICIANS’ SERVICES. 

6 (a) STABILIZING FEE UPDATES.— 

7 (1) REPEAL OF SGR PAYMENT METHOD8 OLOGY.—Section 1848 of the Social Security Act 

9 (42 U.S.C. 1395w–4) is amended— 

10 (A) in subsection (d)— 

11 (i) in paragraph (1)(A), by inserting 

12 ‘‘or a subsequent paragraph’’ after ‘‘para13 graph (4)’’; and 

14 (ii) in paragraph (4)— 

15 (I) in the heading, by inserting 

16 ‘‘AND ENDING WITH 2013’’ after 

17 ‘‘YEARS BEGINNING WITH 2001’’; and 

18 (II) in subparagraph (A), by in19 serting ‘‘and ending with 2013’’ after 

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

21 (B) in subsection (f)— 

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

23 ‘‘through 2013’’ after ‘‘of each succeeding 

24 year’’; and 


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

2 preceding subparagraph (A), by inserting 

3 ‘‘and ending with 2013’’ after ‘‘beginning 

4 with 2000’’. 

5 (2) UPDATE OF RATES FOR APRIL THROUGH

6 DECEMBER OF 2014, 2015, AND SUBSEQUENT

7 YEARS.—Subsection (d) of section 1848 of the Social 

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

9 striking paragraph (15) and inserting the following 

10 new paragraphs: 

11 ‘‘(15) UPDATE FOR 2014 THROUGH 2018.—The 

12 update to the single conversion factor established in 

13 paragraph (1)(C) for 2014 and each subsequent 

14 year through 2018 shall be 0.5 percent. 

15 ‘‘(16) UPDATE FOR 2019 THROUGH 2023.—The 

16 update to the single conversion factor established in 

17 paragraph (1)(C) for 2019 and each subsequent 

18 year through 2023 shall be zero percent. 

19 ‘‘(17) UPDATE FOR 2024 AND SUBSEQUENT

20 YEARS.—The update to the single conversion factor 

21 established in paragraph (1)(C) for 2024 and each 

22 subsequent year shall be— 

23 ‘‘(A) for items and services furnished by a 

24 qualifying APM participant (as defined in sec25 tion 1833(z)(2)) for such year, 1.0 percent; and 


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1 ‘‘(B) for other items and services, 0.5 per2 cent.’’. 

3 (3) MEDPAC REPORTS.— 

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

5 1, 2016, the Medicare Payment Advisory Com6 mission shall submit to Congress a report on 

7 the relationship between— 

8 (i) physician and other health profes9 sional utilization and expenditures (and the 

10 rate of increase of such utilization and ex11 penditures) of items and services for which 

12 payment is made under section 1848 of the 

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

14 and 

15 (ii) total utilization and expenditures 

16 (and the rate of increase of such utilization 

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

18 of title XVIII of such Act. 

19 Such report shall include a methodology to de20 scribe such relationship and the impact of 

21 changes in such physician and other health pro22 fessional practice and service ordering patterns 

23 on total utilization and expenditures under 

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


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

2 1, 2020, the Medicare Payment Advisory Com3 mission shall submit to Congress a report on 

4 the relationship described in subparagraph (A), 

5 including the results determined from applying 

6 the methodology included in the report sub7 mitted under such subparagraph. 

8 (C) REPORT ON UPDATE TO PHYSICIANS’ 

9 SERVICES UNDER MEDICARE.—Not later than 

10 July 1, 2018, the Medicare Payment Advisory 

11 Commission shall submit to Congress a report 

12 on— 

13 (i) the payment update for profes14 sional services applied under the Medicare 

15 program under title XVIII of the Social 

16 Security Act for the period of years 2014 

17 through 2018; 

18 (ii) the effect of such update on the 

19 efficiency, economy, and quality of care 

20 provided under such program; 

21 (iii) the effect of such update on en22 suring a sufficient number of providers to 

23 maintain access to care by Medicare bene24 ficiaries; and 


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1 (iv) recommendations for any future 

2 payment updates for professional services 

3 under such program to ensure adequate 

4 access to care is maintained for Medicare 

5 beneficiaries. 

6 (b) CONSOLIDATION OF CERTAIN CURRENT LAW

7 PERFORMANCE PROGRAMS WITH NEW MERIT-BASED IN8 CENTIVE PAYMENT SYSTEM.— 

9 (1) EHR MEANINGFUL USE INCENTIVE PRO10 GRAM.— 

11 (A) SUNSETTING SEPARATE MEANINGFUL

12 USE PAYMENT ADJUSTMENTS.—Section 

13 1848(a)(7)(A) of the Social Security Act (42 

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

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

16 any subsequent payment year’’ and insert17 ing ‘‘2015, 2016, or 2017’’; 

18 (ii) in clause (ii)— 

19 (I) in the matter preceding sub20 clause (I), by striking ‘‘Subject to 

21 clause (iii), for’’ and inserting ‘‘For’’; 

22 and 

23 (II) in subclause (III), by strik24 ing ‘‘and each subsequent year’’; and 

25 (iii) by striking clause (iii). 


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1 (B) CONTINUATION OF MEANINGFUL USE

2 DETERMINATIONS FOR MIPS.—Section 

3 1848(o)(2) of the Social Security Act (42 

4 U.S.C. 1395w–4(o)(2)) is amended— 

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

6 preceding clause (i)— 

7 (I) by striking ‘‘For purposes of 

8 paragraph (1), an’’ and inserting 

9 ‘‘An’’; and 

10 (II) by inserting ‘‘, or pursuant 

11 to subparagraph (D) for purposes of 

12 subsection (q), for a performance pe13 riod under such subsection for a year’’ 

14 after ‘‘under such subsection for a 

15 year’’; and 

16 (ii) by adding at the end the following 

17 new subparagraph: 

18 ‘‘(D) CONTINUED APPLICATION FOR PUR19 POSES OF MIPS.—With respect to 2018 and 

20 each subsequent payment year, the Secretary 

21 shall, for purposes of subsection (q) and in ac22 cordance with paragraph (1)(F) of such sub23 section, determine whether an eligible profes24 sional who is a MIPS eligible professional (as 

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


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1 a meaningful EHR user under this paragraph 

2 for the performance period under subsection (q) 

3 for such year.’’. 

4 (2) QUALITY REPORTING.— 

5 (A) SUNSETTING SEPARATE QUALITY RE6 PORTING INCENTIVES.—Section 1848(a)(8)(A) 

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

8 4(a)(8)(A)) is amended— 

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

10 any subsequent year’’ and inserting ‘‘2015, 

11 2016, or 2017’’; and 

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

13 each subsequent year’’ and inserting ‘‘and 

14 2017’’. 

15 (B) CONTINUATION OF QUALITY MEAS16 URES AND PROCESSES FOR MIPS.—Section 

17 1848 of the Social Security Act (42 U.S.C. 

18 1395w–4) is amended— 

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

20 end the following new paragraph: 

21 ‘‘(9) CONTINUED APPLICATION FOR PURPOSES

22 OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN23 TEERING TO REPORT.—The Secretary shall, in ac24 cordance with subsection (q)(1)(F), carry out the 

25 provisions of this subsection— 


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

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

3 MIPS eligible professionals (as defined in sub4 section (q)(1)(C)) for the year involved.’’; and 

5 (ii) in subsection (m)— 

6 (I) by redesignating paragraph 

7 (7) added by section 10327(a) of Pub8 lic Law 111–148 as paragraph (8); 

9 and 

10 (II) by adding at the end the fol11 lowing new paragraph: 

12 ‘‘(9) CONTINUED APPLICATION FOR PURPOSES

13 OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN14 TEERING TO REPORT.—The Secretary shall, in ac15 cordance with subsection (q)(1)(F), carry out the 

16 processes under this subsection— 

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

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

19 MIPS eligible professionals (as defined in sub20 section (q)(1)(C)) for the year involved.’’. 

21 (3) VALUE-BASED PAYMENTS.— 

22 (A) SUNSETTING SEPARATE VALUE-BASED

23 PAYMENTS.—Clause (iii) of section 

24 1848(p)(4)(B) of the Social Security Act (42 


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

2 as follows: 

3 ‘‘(iii) APPLICATION.—The Secretary 

4 shall apply the payment modifier estab5 lished under this subsection for items and 

6 services furnished on or after January 1, 

7 2015, but before January 1, 2018, with re8 spect to specific physicians and groups of 

9 physicians the Secretary determines appro10 priate. Such payment modifier shall not be 

11 applied for items and services furnished on 

12 or after January 1, 2018.’’. 

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

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

16 1395w–4(p)) is amended— 

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

18 end the following new subparagraph: 

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

22 subparagraph (B) for purposes of subsection 

23 (q).’’; and 

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

25 end the following: ‘‘With respect to 2018 


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1 and each subsequent year, the Secretary 

2 shall, in accordance with subsection 

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

4 purposes of subsection (q).’’. 

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

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

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

8 adding at the end the following new subsection: 

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

10 ‘‘(1) ESTABLISHMENT.— 

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

14 Merit-based Incentive Payment System (in this 

15 subsection referred to as the ‘MIPS’) under 

16 which the Secretary shall— 

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

21 performance period (as established under 

22 paragraph (4)) for a year; 

23 ‘‘(ii) using such methodology, provide 

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


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1 professional for each performance period; 

2 and 

3 ‘‘(iii) use such composite performance 

4 score of the MIPS eligible professional for 

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

7 (and, as applicable, an additional MIPS 

8 adjustment factor) under paragraph (6) to 

9 the professional for the year. 

10 ‘‘(B) PROGRAM IMPLEMENTATION.—The 

11 MIPS shall apply to payments for items and 

12 services furnished on or after January 1, 2018. 

13 ‘‘(C) MIPS ELIGIBLE PROFESSIONAL DE14 FINED.— 

15 ‘‘(i) IN GENERAL.—For purposes of 

16 this subsection, subject to clauses (ii) and 

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

18 means— 

19 ‘‘(I) for the first and second 

20 years for which the MIPS applies to 

21 payments (and for the performance 

22 period for such first and second year), 

23 a physician (as defined in section 

24 1861(r)), a physician assistant, nurse 

25 practitioner, and clinical nurse speVerDate Mar 15 2010 01:32 Mar 14, 2014 Jkt 039200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\S2122.PCS S2122

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1 cialist (as such terms are defined in 

2 section 1861(aa)(5)), and a certified 

3 registered nurse anesthetist (as de4 fined in section 1861(bb)(2)) and a 

5 group that includes such profes6 sionals; and 

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

8 the MIPS applies to payments (and 

9 for the performance period for such 

10 third year) and for each succeeding 

11 year (and for the performance period 

12 for each such year), the professionals 

13 described in subclause (I) and such 

14 other eligible professionals (as defined 

15 in subsection (k)(3)(B)) as specified 

16 by the Secretary and a group that in17 cludes such professionals. 

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

19 clause (i), the term ‘MIPS eligible profes20 sional’ does not include, with respect to a 

21 year, an eligible professional (as defined in 

22 subsection (k)(3)(B)) who— 

23 ‘‘(I) is a qualifying APM partici24 pant (as defined in section 

25 1833(z)(2)); 


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

2 partial qualifying APM participant (as 

3 defined in clause (iii)) for the most re4 cent period for which data are avail5 able and who, for the performance pe6 riod with respect to such year, does 

7 not report on applicable measures and 

8 activities described in paragraph 

9 (2)(B) that are required to be re10 ported by such a professional under 

11 the MIPS; or 

12 ‘‘(III) for the performance period 

13 with respect to such year, does not ex14 ceed the low-volume threshold meas15 urement selected under clause (iv). 

16 ‘‘(iii) PARTIAL QUALIFYING APM PAR17 TICIPANT.—For purposes of this subpara18 graph, the term ‘partial qualifying APM 

19 participant’ means, with respect to a year, 

20 an eligible professional for whom the Sec21 retary determines the minimum payment 

22 percentage (or percentages), as applicable, 

23 described in paragraph (2) of section 

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1 fying APM participant (as defined in such 

2 paragraph) for such year if— 

3 ‘‘(I) with respect to 2018 and 

4 2019, the reference in subparagraph 

5 (A) of such paragraph to 25 percent 

6 was instead a reference to 20 percent; 

7 ‘‘(II) with respect to 2020 and 

8 2021— 

9 ‘‘(aa) the reference in sub10 paragraph (B)(i) of such para11 graph to 50 percent was instead 

12 a reference to 40 percent; and 

13 ‘‘(bb) the references in sub14 paragraph (B)(ii) of such para15 graph to 50 percent and 25 per16 cent of such paragraph were in17 stead references to 40 percent 

18 and 20 percent, respectively; and 

19 ‘‘(III) with respect to 2022 and 

20 subsequent years— 

21 ‘‘(aa) the reference in sub22 paragraph (C)(i) of such para23 graph to 75 percent was instead 

24 a reference to 50 percent; and 


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1 ‘‘(bb) the references in sub2 paragraph (C)(ii) of such para3 graph to 75 percent and 25 per4 cent of such paragraph were in5 stead references to 50 percent 

6 and 20 percent, respectively. 

7 ‘‘(iv) SELECTION OF LOW-VOLUME

8 THRESHOLD MEASUREMENT.—The Sec9 retary shall select a low-volume threshold 

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

11 which may include one or more or a com12 bination of the following: 

13 ‘‘(I) The minimum number (as 

14 determined by the Secretary) of indi15 viduals enrolled under this part who 

16 are treated by the eligible professional 

17 for the performance period involved. 

18 ‘‘(II) The minimum number (as 

19 determined by the Secretary) of items 

20 and services furnished to individuals 

21 enrolled under this part by such pro22 fessional for such performance period. 

23 ‘‘(III) The minimum amount (as 

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1 sional under this part for such per2 formance period. 

3 ‘‘(v) TREATMENT OF NEW MEDICARE

4 ENROLLED ELIGIBLE PROFESSIONALS.—In 

5 the case of a professional who first be6 comes a Medicare enrolled eligible profes7 sional during the performance period for a 

8 year (and had not previously submitted 

9 claims under this title such as a person, an 

10 entity, or a part of a physician group or 

11 under a different billing number or tax 

12 identifier), such professional shall not be 

13 treated under this subsection as a MIPS 

14 eligible professional until the subsequent 

15 year and performance period for such sub16 sequent year. 

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

18 items and services furnished during a year 

19 by an individual who is not a MIPS eligible 

20 professional (including pursuant to clauses 

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

22 case shall a MIPS adjustment factor (or 

23 additional MIPS adjustment factor) under 

24 paragraph (6) apply to such individual for 

25 such year. 


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1 ‘‘(vii) PARTIAL QUALIFYING APM PAR2 TICIPANT CLARIFICATIONS.— 

3 ‘‘(I) TREATMENT AS MIPS ELIGI4 BLE PROFESSIONAL.—In the case of 

5 an eligible professional who is a par6 tial qualifying APM participant, with 

7 respect to a year, and who for the 

8 performance period for such year re9 ports on applicable measures and ac10 tivities described in paragraph (2)(B) 

11 that are required to be reported by 

12 such a professional under the MIPS, 

13 such eligible professional is considered 

14 to be a MIPS eligible professional 

15 with respect to such year. 

16 ‘‘(II) NOT ELIGIBLE FOR QUALI17 FYING APM PARTICIPANT PAY18 MENTS.—In no case shall an eligible 

19 professional who is a partial quali20 fying APM participant, with respect 

21 to a year, be considered a qualifying 

22 APM participant (as defined in para23 graph (2) of section 1833(z)) for such 

24 year or be eligible for the additional 


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1 payment under paragraph (1) of such 

2 section for such year. 

3 ‘‘(D) APPLICATION TO GROUP PRAC4 TICES.— 

5 ‘‘(i) IN GENERAL.—Under the MIPS: 

6 ‘‘(I) QUALITY PERFORMANCE

7 CATEGORY.—The Secretary shall es8 tablish and apply a process that in9 cludes features of the provisions of 

10 subsection (m)(3)(C) for MIPS eligi11 ble professionals in a group practice 

12 with respect to assessing performance 

13 of such group with respect to the per14 formance category described in clause 

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

16 ‘‘(II) OTHER PERFORMANCE CAT17 EGORIES.—The Secretary may estab18 lish and apply a process that includes 

19 features of the provisions of sub20 section (m)(3)(C) for MIPS eligible 

21 professionals in a group practice with 

22 respect to assessing the performance 

23 of such group with respect to the per24 formance categories described in 


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1 clauses (ii) through (iv) of such para2 graph. 

3 ‘‘(ii) ENSURING COMPREHENSIVENESS

4 OF GROUP PRACTICE ASSESSMENT.—The 

5 process established under clause (i) shall to 

6 the extent practicable reflect the range of 

7 items and services furnished by the MIPS 

8 eligible professionals in the group practice 

9 involved. 

10 ‘‘(iii) CLARIFICATION.—MIPS eligible 

11 professionals electing to be a virtual group 

12 under paragraph (5)(I) shall not be consid13 ered MIPS eligible professionals in a group 

14 practice for purposes of applying this sub15 paragraph. 

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

17 MIPS, the Secretary shall encourage the use of 

18 qualified clinical data registries pursuant to 

19 subsection (m)(3)(E) in carrying out this sub20 section. 

21 ‘‘(F) APPLICATION OF CERTAIN PROVI22 SIONS.—In applying a provision of subsection 

23 (k), (m), (o), or (p) for purposes of this sub24 section, the Secretary shall— 


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1 ‘‘(i) adjust the application of such 

2 provision to ensure the provision is con3 sistent with the provisions of this sub4 section; and 

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

6 extent that the provision is duplicative with 

7 a provision of this subsection. 

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

9 ‘‘(i) RISK FACTORS.—Taking into ac10 count the relevant studies conducted and 

11 recommendations made in reports under 

12 section 101(f)(1) of the Responsible Medi13 care SGR Repeal and Beneficiary Access 

14 Improvement Act of 2014, the Secretary, 

15 on an ongoing basis, shall estimate how an 

16 individual’s health status and other risk 

17 factors affect quality and resource use out18 come measures and, as feasible, shall in19 corporate information from quality and re20 source use outcome measurement (includ21 ing care episode and patient condition 

22 groups) into the MIPS. 

23 ‘‘(ii) ACCOUNTING FOR OTHER FAC24 TORS IN PAYMENT ADJUSTMENTS.—Tak25 ing into account the studies conducted and 


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1 recommendations made in reports under 

2 section 101(f)(1) of the Responsible Medi3 care SGR Repeal and Beneficiary Access 

4 Improvement Act of 2014 and other infor5 mation as appropriate, the Secretary shall 

6 account for identified factors with an effect 

7 on quality and resource use outcome meas8 ures when determining payment adjust9 ments, composite performance scores, 

10 scores for performance categories, or 

11 scores for measures or activities under the 

12 MIPS. 

13 ‘‘(2) MEASURES AND ACTIVITIES UNDER PER14 FORMANCE CATEGORIES.— 

15 ‘‘(A) PERFORMANCE CATEGORIES.—Under 

16 the MIPS, the Secretary shall use the following 

17 performance categories (each of which is re18 ferred to in this subsection as a performance 

19 category) in determining the composite per20 formance score under paragraph (5): 

21 ‘‘(i) Quality. 

22 ‘‘(ii) Resource use. 

23 ‘‘(iii) Clinical practice improvement 

24 activities. 


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1 ‘‘(iv) Meaningful use of certified EHR 

2 technology. 

3 ‘‘(B) MEASURES AND ACTIVITIES SPECI4 FIED FOR EACH CATEGORY.—For purposes of 

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

6 (C), measures and activities specified for a per7 formance period (as established under para8 graph (4)) for a year are as follows: 

9 ‘‘(i) QUALITY.—For the performance 

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

11 the quality measures included in the final 

12 measures list published under subpara13 graph (D)(i) for such year and the list of 

14 quality measures described in subpara15 graph (D)(vi) used by qualified clinical 

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

17 ‘‘(ii) RESOURCE USE.—For the per18 formance category described in subpara19 graph (A)(ii), the measurement of resource 

20 use for such period under subsection 

21 (p)(3), using the methodology under sub22 section (r) as appropriate, and, as feasible 

23 and applicable, accounting for the cost of 

24 drugs under part D. 


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1 ‘‘(iii) CLINICAL PRACTICE IMPROVE2 MENT ACTIVITIES.—For the performance 

3 category described in subparagraph 

4 (A)(iii), clinical practice improvement ac5 tivities (as defined in subparagraph 

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

7 by the Secretary for such period, which 

8 shall include at least the following: 

9 ‘‘(I) The subcategory of expanded 

10 practice access, which shall include ac11 tivities such as same day appoint12 ments for urgent needs and after 

13 hours access to clinician advice. 

14 ‘‘(II) The subcategory of popu15 lation management, which shall in16 clude activities such as monitoring 

17 health conditions of individuals to pro18 vide timely health care interventions 

19 or participation in a qualified clinical 

20 data registry. 

21 ‘‘(III) The subcategory of care 

22 coordination, which shall include ac23 tivities such as timely communication 

24 of test results, timely exchange of 

25 clinical information to patients and 


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1 other providers, and use of remote 

2 monitoring or telehealth. 

3 ‘‘(IV) The subcategory of bene4 ficiary engagement, which shall in5 clude activities such as the establish6 ment of care plans for individuals 

7 with complex care needs, beneficiary 

8 self-management assessment and 

9 training, and using shared decision10 making mechanisms. 

11 ‘‘(V) The subcategory of patient 

12 safety and practice assessment, such 

13 as through use of clinical or surgical 

14 checklists and practice assessments 

15 related to maintaining certification. 

16 ‘‘(VI) The subcategory of partici17 pation in an alternative payment 

18 model (as defined in section 

19 1833(z)(3)(C)). 

20 In establishing activities under this clause, 

21 the Secretary shall give consideration to 

22 the circumstances of small practices (con23 sisting of 15 or fewer professionals) and 

24 practices located in rural areas and in 

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1 ignated under section 332(a)(1)(A) of the 

2 Public Health Service Act). 

3 ‘‘(iv) MEANINGFUL EHR USE.—For 

4 the performance category described in sub5 paragraph (A)(iv), the requirements estab6 lished for such period under subsection 

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

8 professional is a meaningful EHR user. 

9 ‘‘(C) ADDITIONAL PROVISIONS.— 

10 ‘‘(i) EMPHASIZING OUTCOME MEAS11 URES UNDER THE QUALITY PERFORMANCE

12 CATEGORY.—In applying subparagraph 

13 (B)(i), the Secretary shall, as feasible, em14 phasize the application of outcome meas15 ures. 

16 ‘‘(ii) APPLICATION OF ADDITIONAL

17 SYSTEM MEASURES.—The Secretary may 

18 use measures used for a payment system 

19 other than for physicians, such as meas20 ures for inpatient hospitals, for purposes of 

21 the performance categories described in 

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

23 For purposes of the previous sentence, the 

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1 pital outpatient departments, except in the 

2 case of emergency physicians. 

3 ‘‘(iii) GLOBAL AND POPULATION4 BASED MEASURES.—The Secretary may 

5 use global measures, such as global out6 come measures, and population-based 

7 measures for purposes of the performance 

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

9 ‘‘(iv) APPLICATION OF MEASURES AND

10 ACTIVITIES TO NON-PATIENT-FACING PRO11 FESSIONALS.—In carrying out this para12 graph, with respect to measures and activi13 ties specified in subparagraph (B) for per14 formance categories described in subpara15 graph (A), the Secretary— 

16 ‘‘(I) shall give consideration to 

17 the circumstances of professional 

18 types (or subcategories of those types 

19 determined by practice characteris20 tics) who typically furnish services 

21 that do not involve face-to-face inter22 action with a patient; and 

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

24 and appropriate, take into account 

25 such circumstances and apply under 


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1 this subsection with respect to MIPS 

2 eligible professionals of such profes3 sional types or subcategories, alter4 native measures or activities that ful5 fill the goals of the applicable per6 formance category. 

7 In carrying out the previous sentence, the 

8 Secretary shall consult with professionals 

9 of such professional types or subcategories. 

10 ‘‘(v) CLINICAL PRACTICE IMPROVE11 MENT ACTIVITIES.— 

12 ‘‘(I) REQUEST FOR INFORMA13 TION.—In initially applying subpara14 graph (B)(iii), the Secretary shall use 

15 a request for information to solicit 

16 recommendations from stakeholders to 

17 identify activities described in such 

18 subparagraph and specifying criteria 

19 for such activities. 

20 ‘‘(II) CONTRACT AUTHORITY FOR

21 CLINICAL PRACTICE IMPROVEMENT

22 ACTIVITIES PERFORMANCE CAT23 EGORY.—In applying subparagraph 

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


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1 with entities to assist the Secretary 

2 in— 

3 ‘‘(aa) identifying activities 

4 described in subparagraph 

5 (B)(iii); 

6 ‘‘(bb) specifying criteria for 

7 such activities; and 

8 ‘‘(cc) determining whether a 

9 MIPS eligible professional meets 

10 such criteria. 

11 ‘‘(III) CLINICAL PRACTICE IM12 PROVEMENT ACTIVITIES DEFINED.— 

13 For purposes of this subsection, the 

14 term ‘clinical practice improvement 

15 activity’ means an activity that rel16 evant eligible professional organiza17 tions and other relevant stakeholders 

18 identify as improving clinical practice 

19 or care delivery and that the Sec20 retary determines, when effectively ex21 ecuted, is likely to result in improved 

22 outcomes. 

23 ‘‘(D) ANNUAL LIST OF QUALITY MEASURES

24 AVAILABLE FOR MIPS ASSESSMENT.— 


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1 ‘‘(i) IN GENERAL.—Under the MIPS, 

2 the Secretary, through notice and comment 

3 rulemaking and subject to the succeeding 

4 clauses of this subparagraph, shall, with 

5 respect to the performance period for a 

6 year, establish an annual final list of qual7 ity measures from which MIPS eligible 

8 professionals may choose for purposes of 

9 assessment under this subsection for such 

10 performance period. Pursuant to the pre11 vious sentence, the Secretary shall— 

12 ‘‘(I) not later than November 1 

13 of the year prior to the first day of 

14 the first performance period under the 

15 MIPS, establish and publish in the 

16 Federal Register a final list of quality 

17 measures; and 

18 ‘‘(II) not later than November 1 

19 of the year prior to the first day of 

20 each subsequent performance period, 

21 update the final list of quality meas22 ures from the previous year (and pub23 lish such updated final list in the Fed24 eral Register), by— 


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1 ‘‘(aa) removing from such 

2 list, as appropriate, quality meas3 ures, which may include the re4 moval of measures that are no 

5 longer meaningful (such as meas6 ures that are topped out); 

7 ‘‘(bb) adding to such list, as 

8 appropriate, new quality meas9 ures; and 

10 ‘‘(cc) determining whether 

11 or not quality measures on such 

12 list that have undergone sub13 stantive changes should be in14 cluded in the updated list. 

15 ‘‘(ii) CALL FOR QUALITY MEAS16 URES.— 

17 ‘‘(I) IN GENERAL.—Eligible pro18 fessional organizations and other rel19 evant stakeholders shall be requested 

20 to identify and submit quality meas21 ures to be considered for selection 

22 under this subparagraph in the an23 nual list of quality measures published 

24 under clause (i) and to identify and 

25 submit updates to the measures on 


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1 such list. For purposes of the previous 

2 sentence, measures may be submitted 

3 regardless of whether such measures 

4 were previously published in a pro5 posed rule or endorsed by an entity 

6 with a contract under section 1890(a). 

7 ‘‘(II) ELIGIBLE PROFESSIONAL

8 ORGANIZATION DEFINED.—In this 

9 subparagraph, the term ‘eligible pro10 fessional organization’ means a pro11 fessional organization as defined by 

12 nationally recognized multispecialty 

13 boards of certification or equivalent 

14 certification boards. 

15 ‘‘(iii) REQUIREMENTS.—In selecting 

16 quality measures for inclusion in the an17 nual final list under clause (i), the Sec18 retary shall— 

19 ‘‘(I) provide that, to the extent 

20 practicable, all quality domains (as 

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

22 addressed by such measures; and 

23 ‘‘(II) ensure that such selection 

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1 lection of measures under subsections 

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

3 ‘‘(iv) PEER REVIEW.—Before includ4 ing a new measure or a measure described 

5 in clause (i)(II)(cc) in the final list of 

6 measures published under clause (i) for a 

7 year, the Secretary shall submit for publi8 cation in applicable specialty-appropriate 

9 peer-reviewed journals such measure and 

10 the method for developing and selecting 

11 such measure, including clinical and other 

12 data supporting such measure. 

13 ‘‘(v) MEASURES FOR INCLUSION.— 

14 The final list of quality measures published 

15 under clause (i) shall include, as applica16 ble, measures under subsections (k), (m), 

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

18 from among— 

19 ‘‘(I) measures endorsed by a con20 sensus-based entity; 

21 ‘‘(II) measures developed under 

22 subsection (s); and 

23 ‘‘(III) measures submitted under 

24 clause (ii)(I). 


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1 Any measure selected for inclusion in such 

2 list that is not endorsed by a consensus3 based entity shall have a focus that is evi4 dence-based. 

5 ‘‘(vi) EXCEPTION FOR QUALIFIED

6 CLINICAL DATA REGISTRY MEASURES.— 

7 Measures used by a qualified clinical data 

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

9 not be subject to the requirements under 

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

11 shall publish the list of measures used by 

12 such qualified clinical data registries on 

13 the Internet website of the Centers for 

14 Medicare & Medicaid Services. 

15 ‘‘(vii) EXCEPTION FOR EXISTING

16 QUALITY MEASURES.—Any quality meas17 ure specified by the Secretary under sub18 section (k) or (m), including under sub19 section (m)(3)(E), and any measure of 

20 quality of care established under sub21 section (p)(2) for the reporting period 

22 under the respective subsection beginning 

23 before the first performance period under 

24 the MIPS— 


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1 ‘‘(I) shall not be subject to the 

2 requirements under clause (i) (except 

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

4 (II) of such clause) or to the require5 ment under clause (iv); and 

6 ‘‘(II) shall be included in the 

7 final list of quality measures pub8 lished under clause (i) unless removed 

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

10 ‘‘(viii) CONSULTATION WITH REL11 EVANT ELIGIBLE PROFESSIONAL ORGANI12 ZATIONS AND OTHER RELEVANT STAKE13 HOLDERS.—Relevant eligible professional 

14 organizations and other relevant stake15 holders, including State and national med16 ical societies, shall be consulted in carrying 

17 out this subparagraph. 

18 ‘‘(ix) OPTIONAL APPLICATION.—The 

19 process under section 1890A is not re20 quired to apply to the selection of meas21 ures under this subparagraph. 

22 ‘‘(3) PERFORMANCE STANDARDS.— 

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

24 the Secretary shall establish performance stand25 ards with respect to measures and activities 


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1 specified under paragraph (2)(B) for a perform2 ance period (as established under paragraph 

3 (4)) for a year. 

4 ‘‘(B) CONSIDERATIONS IN ESTABLISHING

5 STANDARDS.—In establishing such performance 

6 standards with respect to measures and activi7 ties specified under paragraph (2)(B), the Sec8 retary shall consider the following: 

9 ‘‘(i) Historical performance standards. 

10 ‘‘(ii) Improvement. 

11 ‘‘(iii) The opportunity for continued 

12 improvement. 

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

14 shall establish a performance period (or periods) for 

15 a year (beginning with the year described in para16 graph (1)(B)). Such performance period (or periods) 

17 shall begin and end prior to the beginning of such 

18 year and be as close as possible to such year. In this 

19 subsection, such performance period (or periods) for 

20 a year shall be referred to as the performance period 

21 for the year. 

22 ‘‘(5) COMPOSITE PERFORMANCE SCORE.— 

23 ‘‘(A) IN GENERAL.—Subject to the suc24 ceeding provisions of this paragraph and taking 

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1 graph (1)(G), the Secretary shall develop a 

2 methodology for assessing the total performance 

3 of each MIPS eligible professional according to 

4 performance standards under paragraph (3) 

5 with respect to applicable measures and activi6 ties specified in paragraph (2)(B) with respect 

7 to each performance category applicable to such 

8 professional for a performance period (as estab9 lished under paragraph (4)) for a year. Using 

10 such methodology, the Secretary shall provide 

11 for a composite assessment (using a scoring 

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

13 the performance period for such year. In this 

14 subsection such a composite assessment for 

15 such a professional with respect to a perform16 ance period shall be referred to as the ‘com17 posite performance score’ for such professional 

18 for such performance period. 

19 ‘‘(B) INCENTIVE TO REPORT; ENCOUR20 AGING USE OF CERTIFIED EHR TECHNOLOGY

21 FOR REPORTING QUALITY MEASURES.— 

22 ‘‘(i) INCENTIVE TO REPORT.—Under 

23 the methodology established under sub24 paragraph (A), the Secretary shall provide 

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1 sional who fails to report on an applicable 

2 measure or activity that is required to be 

3 reported by the professional, the profes4 sional shall be treated as achieving the 

5 lowest potential score applicable to such 

6 measure or activity. 

7 ‘‘(ii) ENCOURAGING USE OF CER8 TIFIED EHR TECHNOLOGY AND QUALIFIED

9 CLINICAL DATA REGISTRIES FOR REPORT10 ING QUALITY MEASURES.—Under the 

11 methodology established under subpara12 graph (A), the Secretary shall— 

13 ‘‘(I) encourage MIPS eligible 

14 professionals to report on applicable 

15 measures with respect to the perform16 ance category described in paragraph 

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

18 EHR technology and qualified clinical 

19 data registries; and 

20 ‘‘(II) with respect to a perform21 ance period, with respect to a year, 

22 for which a MIPS eligible professional 

23 reports such measures through the 

24 use of such EHR technology, treat 

25 such professional as satisfying the 


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1 clinical quality measures reporting re2 quirement described in subsection 

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

4 ‘‘(C) CLINICAL PRACTICE IMPROVEMENT

5 ACTIVITIES PERFORMANCE SCORE.— 

6 ‘‘(i) RULE FOR ACCREDITATION.—A 

7 MIPS eligible professional who is in a 

8 practice that is certified as a patient-cen9 tered medical home or comparable spe10 cialty practice pursuant to subsection 

11 (b)(8)(B)(i) with respect to a performance 

12 period shall be given the highest potential 

13 score for the performance category de14 scribed in paragraph (2)(A)(iii) for such 

15 period. 

16 ‘‘(ii) APM PARTICIPATION.—Partici17 pation by a MIPS eligible professional in 

18 an alternative payment model (as defined 

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

20 performance period shall earn such eligible 

21 professional a minimum score of one-half 

22 of the highest potential score for the per23 formance category described in paragraph 

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


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1 ‘‘(iii) SUBCATEGORIES.—A MIPS eli2 gible professional shall not be required to 

3 perform activities in each subcategory 

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

5 in an alternative payment model in order 

6 to achieve the highest potential score for 

7 the performance category described in 

8 paragraph (2)(A)(iii). 

9 ‘‘(D) ACHIEVEMENT AND IMPROVE10 MENT.— 

11 ‘‘(i) TAKING INTO ACCOUNT IMPROVE12 MENT.—Beginning with the second year to 

13 which the MIPS applies, in addition to the 

14 achievement of a MIPS eligible profes15 sional, if data sufficient to measure im16 provement is available, the methodology 

17 developed under subparagraph (A)— 

18 ‘‘(I) in the case of the perform19 ance score for the performance cat20 egory described in clauses (i) and (ii) 

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

22 account the improvement of the pro23 fessional; and 

24 ‘‘(II) in the case of performance 

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1 egories, may take into account the im2 provement of the professional. 

3 ‘‘(ii) ASSIGNING HIGHER WEIGHT FOR

4 ACHIEVEMENT.—Beginning with the 

5 fourth year to which the MIPS applies, 

6 under the methodology developed under 

7 subparagraph (A), the Secretary may as8 sign a higher scoring weight under sub9 paragraph (F) with respect to the achieve10 ment of a MIPS eligible professional than 

11 with respect to any improvement of such 

12 professional applied under clause (i) with 

13 respect to a measure, activity, or category 

14 described in paragraph (2). 

15 ‘‘(E) WEIGHTS FOR THE PERFORMANCE

16 CATEGORIES.— 

17 ‘‘(i) IN GENERAL.—Under the meth18 odology developed under subparagraph (A), 

19 subject to subparagraph (F)(i) and clauses 

20 (ii) and (iii), the composite performance 

21 score shall be determined as follows: 

22 ‘‘(I) QUALITY.— 

23 ‘‘(aa) IN GENERAL.—Sub24 ject to item (bb), thirty percent 

25 of such score shall be based on 


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1 performance with respect to the 

2 category described in clause (i) of 

3 paragraph (2)(A). In applying 

4 the previous sentence, the Sec5 retary shall, as feasible, encour6 age the application of outcome 

7 measures within such category. 

8 ‘‘(bb) FIRST 2 YEARS.—For 

9 the first and second years for 

10 which the MIPS applies to pay11 ments, the percentage applicable 

12 under item (aa) shall be in13 creased in a manner such that 

14 the total percentage points of the 

15 increase under this item for the 

16 respective year equals the total 

17 number of percentage points by 

18 which the percentage applied 

19 under subclause (II)(bb) for the 

20 respective year is less than 30 

21 percent. 

22 ‘‘(II) RESOURCE USE.— 

23 ‘‘(aa) IN GENERAL.—Sub24 ject to item (bb), thirty percent 

25 of such score shall be based on 


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1 performance with respect to the 

2 category described in clause (ii) 

3 of paragraph (2)(A). 

4 ‘‘(bb) FIRST 2 YEARS.—For 

5 the first year for which the MIPS 

6 applies to payments, not more 

7 than 10 percent of such score 

8 shall be based on performance 

9 with respect to the category de10 scribed in clause (ii) of para11 graph (2)(A). For the second 

12 year for which the MIPS applies 

13 to payments, not more than 15 

14 percent of such score shall be 

15 based on performance with re16 spect to the category described in 

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

18 ‘‘(III) CLINICAL PRACTICE IM19 PROVEMENT ACTIVITIES.—Fifteen 

20 percent of such score shall be based 

21 on performance with respect to the 

22 category described in clause (iii) of 

23 paragraph (2)(A). 

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1 five percent of such score shall be 

2 based on performance with respect to 

3 the category described in clause (iv) of 

4 paragraph (2)(A). 

5 ‘‘(ii) AUTHORITY TO ADJUST PER6 CENTAGES IN CASE OF HIGH EHR MEAN7 INGFUL USE ADOPTION.—In any year in 

8 which the Secretary estimates that the pro9 portion of eligible professionals (as defined 

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

11 EHR users (as determined under sub12 section (o)(2)) is 75 percent or greater, the 

13 Secretary may reduce the percent applica14 ble under clause (i)(IV), but not below 15 

15 percent. If the Secretary makes such re16 duction for a year, subject to subclauses 

17 (I)(bb) and (II)(bb) of clause (i), the per18 centages applicable under one or more of 

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

20 for such year shall be increased in a man21 ner such that the total percentage points 

22 of the increase under this clause for such 

23 year equals the total number of percentage 

24 points reduced under the preceding sen25 tence for such year. 


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1 ‘‘(F) CERTAIN FLEXIBILITY FOR

2 WEIGHTING PERFORMANCE CATEGORIES, MEAS3 URES, AND ACTIVITIES.—Under the method4 ology under subparagraph (A), if there are not 

5 sufficient measures and clinical practice im6 provement activities applicable and available to 

7 each type of eligible professional involved, the 

8 Secretary shall assign different scoring weights 

9 (including a weight of 0)— 

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

11 weights specified in subparagraph (E), for 

12 each performance category based on the 

13 extent to which the category is applicable 

14 to the type of eligible professional involved; 

15 and 

16 ‘‘(ii) for each measure and activity 

17 specified under paragraph (2)(B) with re18 spect to each such category based on the 

19 extent to which the measure or activity is 

20 applicable and available to the type of eli21 gible professional involved. 

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

23 performance category described in paragraph 

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1 ology described in subsection (r)(5), as appro2 priate. 

3 ‘‘(H) INCLUSION OF QUALITY MEASURE

4 DATA FROM OTHER PAYERS.—In applying sub5 sections (k), (m), and (p) with respect to meas6 ures described in paragraph (2)(B)(i), analysis 

7 of the performance category described in para8 graph (2)(A)(i) may include data submitted by 

9 MIPS eligible professionals with respect to 

10 items and services furnished to individuals who 

11 are not individuals entitled to benefits under 

12 part A or enrolled under part B. 

13 ‘‘(I) USE OF VOLUNTARY VIRTUAL GROUPS

14 FOR CERTAIN ASSESSMENT PURPOSES.— 

15 ‘‘(i) IN GENERAL.—In the case of 

16 MIPS eligible professionals electing to be a 

17 virtual group under clause (ii) with respect 

18 to a performance period for a year, for 

19 purposes of applying the methodology 

20 under subparagraph (A)— 

21 ‘‘(I) the assessment of perform22 ance provided under such methodology 

23 with respect to the performance cat24 egories described in clauses (i) and 

25 (ii) of paragraph (2)(A) that is to be 


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1 applied to each such professional in 

2 such group for such performance pe3 riod shall be with respect to the com4 bined performance of all such profes5 sionals in such group for such period; 

6 and 

7 ‘‘(II) the composite score pro8 vided under this paragraph for such 

9 performance period with respect to 

10 each such performance category for 

11 each such MIPS eligible professional 

12 in such virtual group shall be based 

13 on the assessment of the combined 

14 performance under subclause (I) for 

15 the performance category and per16 formance period. 

17 ‘‘(ii) ELECTION OF PRACTICES TO BE

18 A VIRTUAL GROUP.—The Secretary shall, 

19 in accordance with clause (iii), establish 

20 and have in place a process to allow an in21 dividual MIPS eligible professional or a 

22 group practice consisting of not more than 

23 10 MIPS eligible professionals to elect, 

24 with respect to a performance period for a 

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1 fessional or all such MIPS eligible profes2 sionals in such group practice, respectively, 

3 to be a virtual group under this subpara4 graph with at least one other such indi5 vidual MIPS eligible professional or group 

6 practice making such an election. Such a 

7 virtual group may be based on geographic 

8 areas or on provider specialties defined by 

9 nationally recognized multispecialty boards 

10 of certification or equivalent certification 

11 boards and such other eligible professional 

12 groupings in order to capture classifica13 tions of providers across eligible profes14 sional organizations and other practice 

15 areas or categories. 

16 ‘‘(iii) REQUIREMENTS.—The process 

17 under clause (ii)— 

18 ‘‘(I) shall provide that an election 

19 under such clause, with respect to a 

20 performance period, shall be made be21 fore or during the beginning of such 

22 performance period and may not be 

23 changed during such performance pe24 riod; 


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1 ‘‘(II) shall provide that a practice 

2 described in such clause, and each 

3 MIPS eligible professional in such 

4 practice, may elect to be in no more 

5 than one virtual group for a perform6 ance period; and 

7 ‘‘(III) may provide that a virtual 

8 group may be combined at the tax 

9 identification number level. 

10 ‘‘(6) MIPS PAYMENTS.— 

11 ‘‘(A) MIPS ADJUSTMENT FACTOR.—Tak12 ing into account paragraph (1)(G), the Sec13 retary shall specify a MIPS adjustment factor 

14 for each MIPS eligible professional for a year. 

15 Such MIPS adjustment factor for a MIPS eligi16 ble professional for a year shall be in the form 

17 of a percent and shall be determined— 

18 ‘‘(i) by comparing the composite per19 formance score of the eligible professional 

20 for such year to the performance threshold 

21 established under subparagraph (D)(i) for 

22 such year; 

23 ‘‘(ii) in a manner such that the ad24 justment factors specified under this sub25 paragraph for a year result in differential 


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1 payments under this paragraph reflecting 

2 that— 

3 ‘‘(I) MIPS eligible professionals 

4 with composite performance scores for 

5 such year at or above such perform6 ance threshold for such year receive 

7 zero or positive incentive payment ad8 justment factors for such year in ac9 cordance with clause (iii), with such 

10 professionals having higher composite 

11 performance scores receiving higher 

12 adjustment factors; and 

13 ‘‘(II) MIPS eligible professionals 

14 with composite performance scores for 

15 such year below such performance 

16 threshold for such year receive nega17 tive payment adjustment factors for 

18 such year in accordance with clause 

19 (iv), with such professionals having 

20 lower composite performance scores 

21 receiving lower adjustment factors; 

22 ‘‘(iii) in a manner such that MIPS eli23 gible professionals with composite scores 

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

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1 graph (F), receive a zero or positive ad2 justment factor on a linear sliding scale 

3 such that an adjustment factor of 0 per4 cent is assigned for a score at the perform5 ance threshold and an adjustment factor of 

6 the applicable percent specified in subpara7 graph (B) is assigned for a score of 100; 

8 and 

9 ‘‘(iv) in a manner such that— 

10 ‘‘(I) subject to subclause (II), 

11 MIPS eligible professionals with com12 posite performance scores described in 

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

14 negative payment adjustment factor 

15 on a linear sliding scale such that an 

16 adjustment factor of 0 percent is as17 signed for a score at the performance 

18 threshold and an adjustment factor of 

19 the negative of the applicable percent 

20 specified in subparagraph (B) is as21 signed for a score of 0; and 

22 ‘‘(II) MIPS eligible professionals 

23 with composite performance scores 

24 that are equal to or greater than 0, 

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1 formance threshold specified under 

2 subparagraph (D)(i) for such year, re3 ceive a negative payment adjustment 

4 factor that is equal to the negative of 

5 the applicable percent specified in 

6 subparagraph (B) for such year. 

7 ‘‘(B) APPLICABLE PERCENT DEFINED.— 

8 For purposes of this paragraph, the term ‘ap9 plicable percent’ means— 

10 ‘‘(i) for 2018, 4 percent; 

11 ‘‘(ii) for 2019, 5 percent; 

12 ‘‘(iii) for 2020, 7 percent; and 

13 ‘‘(iv) for 2021 and subsequent years, 

14 9 percent. 

15 ‘‘(C) ADDITIONAL MIPS ADJUSTMENT FAC16 TORS FOR EXCEPTIONAL PERFORMANCE.— 

17 ‘‘(i) IN GENERAL.—In the case of a 

18 MIPS eligible professional with a com19 posite performance score for a year at or 

20 above the additional performance threshold 

21 under subparagraph (D)(ii) for such year, 

22 in addition to the MIPS adjustment factor 

23 under subparagraph (A) for the eligible 

24 professional for such year, subject to the 

25 availability of funds under clause (ii), the 


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1 Secretary shall specify an additional posi2 tive MIPS adjustment factor for such pro3 fessional and year. Such additional MIPS 

4 adjustment factors shall be determined by 

5 the Secretary in a manner such that pro6 fessionals having higher composite per7 formance scores above the additional per8 formance threshold receive higher addi9 tional MIPS adjustment factors. 

10 ‘‘(ii) ADDITIONAL FUNDING POOL.— 

11 For 2018 and each subsequent year 

12 through 2023, there is appropriated from 

13 the Federal Supplementary Medical Insur14 ance Trust Fund $500,000,000 for MIPS 

15 payments under this paragraph resulting 

16 from the application of the additional 

17 MIPS adjustment factors under clause (i). 

18 ‘‘(D) ESTABLISHMENT OF PERFORMANCE

19 THRESHOLDS.— 

20 ‘‘(i) PERFORMANCE THRESHOLD.— 

21 For each year of the MIPS, the Secretary 

22 shall compute a performance threshold 

23 with respect to which the composite per24 formance score of MIPS eligible profes25 sionals shall be compared for purposes of 


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1 determining adjustment factors under sub2 paragraph (A) that are positive, negative, 

3 and zero. Such performance threshold for 

4 a year shall be the mean or median (as se5 lected by the Secretary) of the composite 

6 performance scores for all MIPS eligible 

7 professionals with respect to a prior period 

8 specified by the Secretary. The Secretary 

9 may reassess the selection under the pre10 vious sentence every 3 years. 

11 ‘‘(ii) ADDITIONAL PERFORMANCE

12 THRESHOLD FOR EXCEPTIONAL PERFORM13 ANCE.—In addition to the performance 

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

15 the MIPS, the Secretary shall compute an 

16 additional performance threshold for pur17 poses of determining the additional MIPS 

18 adjustment factors under subparagraph 

19 (C)(i). For each such year, the Secretary 

20 shall apply either of the following methods 

21 for computing such additional performance 

22 threshold for such a year: 

23 ‘‘(I) The threshold shall be the 

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1 posite performance scores above the 

2 performance threshold with respect to 

3 the prior period described in clause 

4 (i). 

5 ‘‘(II) The threshold shall be the 

6 score that is equal to the 25th per7 centile of the actual composite per8 formance scores for MIPS eligible 

9 professionals with composite perform10 ance scores at or above the perform11 ance threshold with respect to the 

12 prior period described in clause (i). 

13 ‘‘(iii) SPECIAL RULE FOR INITIAL 2

14 YEARS.—With respect to each of the first 

15 two years to which the MIPS applies, the 

16 Secretary shall, prior to the performance 

17 period for such years, establish a perform18 ance threshold for purposes of determining 

19 MIPS adjustment factors under subpara20 graph (A) and a threshold for purposes of 

21 determining additional MIPS adjustment 

22 factors under subparagraph (C)(i). Each 

23 such performance threshold shall— 

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

25 such performance periods; and 


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1 ‘‘(II) take into account— 

2 ‘‘(aa) data available with re3 spect to performance on meas4 ures and activities that may be 

5 used under the performance cat6 egories under subparagraph 

7 (2)(B); and 

8 ‘‘(bb) other factors deter9 mined appropriate by the Sec10 retary. 

11 ‘‘(E) APPLICATION OF MIPS ADJUSTMENT

12 FACTORS.—In the case of items and services 

13 furnished by a MIPS eligible professional dur14 ing a year (beginning with 2018), the amount 

15 otherwise paid under this part with respect to 

16 such items and services and MIPS eligible pro17 fessional for such year, shall be multiplied by— 

18 ‘‘(i) 1, plus 

19 ‘‘(ii) the sum of— 

20 ‘‘(I) the MIPS adjustment factor 

21 determined under subparagraph (A) 

22 divided by 100, and 

23 ‘‘(II) as applicable, the additional 

24 MIPS adjustment factor determined 


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1 under subparagraph (C)(i) divided by 

2 100. 

3 ‘‘(F) AGGREGATE APPLICATION OF MIPS

4 ADJUSTMENT FACTORS.— 

5 ‘‘(i) APPLICATION OF SCALING FAC6 TOR.— 

7 ‘‘(I) IN GENERAL.—With respect 

8 to positive MIPS adjustment factors 

9 under subparagraph (A)(ii)(I) for eli10 gible professionals whose composite 

11 performance score is above the per12 formance threshold under subpara13 graph (D)(i) for such year, subject to 

14 subclause (II), the Secretary shall in15 crease or decrease such adjustment 

16 factors by a scaling factor in order to 

17 ensure that the budget neutrality re18 quirement of clause (ii) is met. 

19 ‘‘(II) SCALING FACTOR LIMIT.— 

20 In no case may be the scaling factor 

21 applied under this clause exceed 3.0. 

22 ‘‘(ii) BUDGET NEUTRALITY REQUIRE23 MENT.— 

24 ‘‘(I) IN GENERAL.—Subject to 

25 clause (iii), the Secretary shall ensure 


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1 that the estimated amount described 

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

3 the estimated amount described in 

4 subclause (III) for such year. 

5 ‘‘(II) AGGREGATE INCREASES.— 

6 The amount described in this sub7 clause is the estimated increase in the 

8 aggregate allowed charges resulting 

9 from the application of positive MIPS 

10 adjustment factors under subpara11 graph (A) (after application of the 

12 scaling factor described in clause (i)) 

13 to MIPS eligible professionals whose 

14 composite performance score for a 

15 year is above the performance thresh16 old under subparagraph (D)(i) for 

17 such year. 

18 ‘‘(III) AGGREGATE DE19 CREASES.—The amount described in 

20 this subclause is the estimated de21 crease in the aggregate allowed 

22 charges resulting from the application 

23 of negative MIPS adjustment factors 

24 under subparagraph (A) to MIPS eli25 gible professionals whose composite 


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1 performance score for a year is below 

2 the performance threshold under sub3 paragraph (D)(i) for such year. 

4 ‘‘(iii) EXCEPTIONS.— 

5 ‘‘(I) In the case that all MIPS el6 igible professionals receive composite 

7 performance scores for a year that are 

8 below the performance threshold 

9 under subparagraph (D)(i) for such 

10 year, the negative MIPS adjustment 

11 factors under subparagraph (A) shall 

12 apply with respect to such MIPS eligi13 ble professionals and the budget neu14 trality requirement of clause (ii) shall 

15 not apply for such year. 

16 ‘‘(II) In the case that, with re17 spect to a year, the application of 

18 clause (i) results in a scaling factor 

19 equal to the maximum scaling factor 

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

21 factor shall apply and the budget neu22 trality requirement of clause (ii) shall 

23 not apply for such year. 

24 ‘‘(iv) ADDITIONAL INCENTIVE PAY25 MENT ADJUSTMENTS.—In specifying the 


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1 MIPS additional adjustment factors under 

2 subparagraph (C)(i) for each applicable 

3 MIPS eligible professional for a year, the 

4 Secretary shall ensure that the estimated 

5 increase in payments under this part re6 sulting from the application of such addi7 tional adjustment factors for MIPS eligible 

8 professionals in a year shall be equal (as 

9 estimated by the Secretary) to the addi10 tional funding pool amount for such year 

11 under subparagraph (C)(ii). 

12 ‘‘(7) ANNOUNCEMENT OF RESULT OF ADJUST13 MENTS.—Under the MIPS, the Secretary shall, not 

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

15 involved, make available to MIPS eligible profes16 sionals the MIPS adjustment factor (and, as appli17 cable, the additional MIPS adjustment factor) under 

18 paragraph (6) applicable to the eligible professional 

19 for items and services furnished by the professional 

20 for such year. The Secretary may include such infor21 mation in the confidential feedback under paragraph 

22 (12). 

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

24 MIPS adjustment factors and additional MIPS ad25 justment factors under paragraph (6) shall apply 


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1 only with respect to the year involved, and the Sec2 retary shall not take into account such adjustment 

3 factors in making payments to a MIPS eligible pro4 fessional under this part in a subsequent year. 

5 ‘‘(9) PUBLIC REPORTING.— 

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

7 in an easily understandable format, make avail8 able on the Physician Compare Internet website 

9 of the Centers for Medicare & Medicaid Serv10 ices the following: 

11 ‘‘(i) Information regarding the per12 formance of MIPS eligible professionals 

13 under the MIPS, which— 

14 ‘‘(I) shall include the composite 

15 score for each such MIPS eligible pro16 fessional and the performance of each 

17 such MIPS eligible professional with 

18 respect to each performance category; 

19 and 

20 ‘‘(II) may include the perform21 ance of each such MIPS eligible pro22 fessional with respect to each measure 

23 or activity specified in paragraph 

24 (2)(B). 


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1 ‘‘(ii) The names of eligible profes2 sionals in eligible alternative payment mod3 els (as defined in section 1833(z)(3)(D)) 

4 and, to the extent feasible, the names of 

5 such eligible alternative payment models 

6 and performance of such models. 

7 ‘‘(B) DISCLOSURE.—The information 

8 made available under this paragraph shall indi9 cate, where appropriate, that publicized infor10 mation may not be representative of the eligible 

11 professional’s entire patient population, the va12 riety of services furnished by the eligible profes13 sional, or the health conditions of individuals 

14 treated. 

15 ‘‘(C) OPPORTUNITY TO REVIEW AND SUB16 MIT CORRECTIONS.—The Secretary shall pro17 vide for an opportunity for a professional de18 scribed in subparagraph (A) to review, and sub19 mit corrections for, the information to be made 

20 public with respect to the professional under 

21 such subparagraph prior to such information 

22 being made public. 

23 ‘‘(D) AGGREGATE INFORMATION.—The 

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1 mation on the MIPS, including the range of 

2 composite scores for all MIPS eligible profes3 sionals and the range of the performance of all 

4 MIPS eligible professionals with respect to each 

5 performance category. 

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

7 consult with stakeholders in carrying out the MIPS, 

8 including for the identification of measures and ac9 tivities under paragraph (2)(B) and the methodolo10 gies developed under paragraphs (5)(A) and (6) and 

11 regarding the use of qualified clinical data registries. 

12 Such consultation shall include the use of a request 

13 for information or other mechanisms determined ap14 propriate. 

15 ‘‘(11) TECHNICAL ASSISTANCE TO SMALL PRAC16 TICES AND PRACTICES IN HEALTH PROFESSIONAL

17 SHORTAGE AREAS.— 

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

19 enter into contracts or agreements with appro20 priate entities (such as quality improvement or21 ganizations, regional extension centers (as de22 scribed in section 3012(c) of the Public Health 

23 Service Act), or regional health collaboratives) 

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1 fessionals (with priority given to such practices 

2 located in rural areas, health professional short3 age areas (as designated under in section 

4 332(a)(1)(A) of such Act), and medically under5 served areas, and practices with low composite 

6 scores) with respect to— 

7 ‘‘(i) the performance categories de8 scribed in clauses (i) through (iv) of para9 graph (2)(A); or 

10 ‘‘(ii) how to transition to the imple11 mentation of and participation in an alter12 native payment model as described in sec13 tion 1833(z)(3)(C). 

14 ‘‘(B) FUNDING FOR IMPLEMENTATION.— 

15 ‘‘(i) IN GENERAL.—For purposes of 

16 implementing subparagraph (A), the Sec17 retary shall provide for the transfer from 

18 the Federal Supplementary Medical Insur19 ance Trust Fund established under section 

20 1841 to the Centers for Medicare & Med21 icaid Services Program Management Ac22 count of $40,000,000 for each of fiscal 

23 years 2015 through 2019. Amounts trans24 ferred under this subparagraph for a fiscal 

25 year shall be available until expended. 


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1 ‘‘(ii) TECHNICAL ASSISTANCE.—Of 

2 the amounts transferred pursuant to clause 

3 (i) for each of fiscal years 2015 through 

4 2019, not less than $10,000,000 shall be 

5 made available for each such year for tech6 nical assistance to small practices in health 

7 professional shortage areas (as so des8 ignated) and medically underserved areas. 

9 ‘‘(12) FEEDBACK AND INFORMATION TO IM10 PROVE PERFORMANCE.— 

11 ‘‘(A) PERFORMANCE FEEDBACK.— 

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

13 2016, the Secretary— 

14 ‘‘(I) shall make available timely 

15 (such as quarterly) confidential feed16 back to MIPS eligible professionals on 

17 the performance of such professionals 

18 with respect to the performance cat19 egories under clauses (i) and (ii) of 

20 paragraph (2)(A); and 

21 ‘‘(II) may make available con22 fidential feedback to each such profes23 sional on the performance of such 

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1 formance categories under clauses (iii) 

2 and (iv) of such paragraph. 

3 ‘‘(ii) MECHANISMS.—The Secretary 

4 may use one or more mechanisms to make 

5 feedback available under clause (i), which 

6 may include use of a web-based portal or 

7 other mechanisms determined appropriate 

8 by the Secretary. With respect to the per9 formance category described in paragraph 

10 (2)(A)(i), feedback under this subpara11 graph shall, to the extent an eligible pro12 fessional chooses to participate in a data 

13 registry for purposes of this subsection (in14 cluding registries under subsections (k) 

15 and (m)), be provided based on perform16 ance on quality measures reported through 

17 the use of such registries. With respect to 

18 any other performance category described 

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

20 encourage provision of feedback through 

21 qualified clinical data registries as de22 scribed in subsection (m)(3)(E)). 

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

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

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1 sional, from periods prior to the current 

2 performance period and may use rolling 

3 periods in order to make illustrative cal4 culations about the performance of such 

5 professional. 

6 ‘‘(iv) DISCLOSURE EXEMPTION.— 

7 Feedback made available under this sub8 paragraph shall be exempt from disclosure 

9 under section 552 of title 5, United States 

10 Code. 

11 ‘‘(v) RECEIPT OF INFORMATION.— 

12 The Secretary may use the mechanisms es13 tablished under clause (ii) to receive infor14 mation from professionals, such as infor15 mation with respect to this subsection. 

16 ‘‘(B) ADDITIONAL INFORMATION.— 

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

18 2017, the Secretary shall make available to 

19 each MIPS eligible professional informa20 tion, with respect to individuals who are 

21 patients of such MIPS eligible professional, 

22 about items and services for which pay23 ment is made under this title that are fur24 nished to such individuals by other sup25 pliers and providers of services, which may 


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1 include information described in clause (ii). 

2 Such information may be made available 

3 under the previous sentence to such MIPS 

4 eligible professionals by mechanisms deter5 mined appropriate by the Secretary, which 

6 may include use of a web-based portal. 

7 Such information may be made available in 

8 accordance with the same or similar terms 

9 as data are made available to accountable 

10 care organizations participating in the 

11 shared savings program under section 

12 1899, including a beneficiary opt-out. 

13 ‘‘(ii) TYPE OF INFORMATION.—For 

14 purposes of clause (i), the information de15 scribed in this clause, is the following: 

16 ‘‘(I) With respect to selected 

17 items and services (as determined ap18 propriate by the Secretary) for which 

19 payment is made under this title and 

20 that are furnished to individuals, who 

21 are patients of a MIPS eligible profes22 sional, by another supplier or provider 

23 of services during the most recent pe24 riod for which data are available (such 

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1 riod), such as the name of such pro2 viders furnishing such items and serv3 ices to such patients during such pe4 riod, the types of such items and serv5 ices so furnished, and the dates such 

6 items and services were so furnished. 

7 ‘‘(II) Historical data, such as 

8 averages and other measures of the 

9 distribution if appropriate, of the 

10 total, and components of, allowed 

11 charges (and other figures as deter12 mined appropriate by the Secretary). 

13 ‘‘(13) REVIEW.— 

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

15 shall establish a process under which a MIPS 

16 eligible professional may seek an informal re17 view of the calculation of the MIPS adjustment 

18 factor applicable to such eligible professional 

19 under this subsection for a year. The results of 

20 a review conducted pursuant to the previous 

21 sentence shall not be taken into account for 

22 purposes of paragraph (6) with respect to a 

23 year (other than with respect to the calculation 

24 of such eligible professional’s MIPS adjustment 

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1 ment factor for such year) after the factors de2 termined in subparagraph (A) and subpara3 graph (C) of such paragraph have been deter4 mined for such year. 

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

6 in subparagraph (A), there shall be no adminis7 trative or judicial review under section 1869, 

8 section 1878, or otherwise of the following: 

9 ‘‘(i) The methodology used to deter10 mine the amount of the MIPS adjustment 

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

12 amount of the additional MIPS adjustment 

13 factor under paragraph (6)(C)(i) and the 

14 determination of such amounts. 

15 ‘‘(ii) The establishment of the per16 formance standards under paragraph (3) 

17 and the performance period under para18 graph (4). 

19 ‘‘(iii) The identification of measures 

20 and activities specified under paragraph 

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

22 posted on the Physician Compare Internet 

23 website of the Centers for Medicare & 

24 Medicaid Services under paragraph (9). 


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1 ‘‘(iv) The methodology developed 

2 under paragraph (5) that is used to cal3 culate performance scores and the calcula4 tion of such scores, including the weighting 

5 of measures and activities under such 

6 methodology.’’. 

7 (2) GAO REPORTS.— 

8 (A) EVALUATION OF ELIGIBLE PROFES9 SIONAL MIPS.—Not later than October 1, 2019, 

10 and October 1, 2022, the Comptroller General 

11 of the United States shall submit to Congress 

12 a report evaluating the eligible professional 

13 Merit-based Incentive Payment System under 

14 subsection (q) of section 1848 of the Social Se15 curity Act (42 U.S.C. 1395w–4), as added by 

16 paragraph (1). Such report shall— 

17 (i) examine the distribution of the 

18 composite performance scores and MIPS 

19 adjustment factors (and additional MIPS 

20 adjustment factors) for MIPS eligible pro21 fessionals (as defined in subsection 

22 (q)(1)(c) of such section) under such pro23 gram, and patterns relating to such scores 

24 and adjustment factors, including based on 


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1 type of provider, practice size, geographic 

2 location, and patient mix; 

3 (ii) provide recommendations for im4 proving such program; 

5 (iii) evaluate the impact of technical 

6 assistance funding under section 

7 1848(q)(11) of the Social Security Act, as 

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

9 professionals to improve within such pro10 gram or successfully transition to an alter11 native payment model (as defined in sec12 tion 1833(z)(3) of the Social Security Act, 

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

14 for such evaluation given to practices lo15 cated in rural areas, health professional 

16 shortage areas (as designated in section 

17 332(a)(1)(a) of the Public Health Service 

18 Act), and medically underserved areas; and 

19 (iv) provide recommendations for opti20 mizing the use of such technical assistance 

21 funds. 

22 (B) STUDY TO EXAMINE ALIGNMENT OF

23 QUALITY MEASURES USED IN PUBLIC AND PRI24 VATE PROGRAMS.— 


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1 (i) IN GENERAL.—Not later than 18 

2 months after the date of the enactment of 

3 this Act, the Comptroller General of the 

4 United States shall submit to Congress a 

5 report that— 

6 (I) compares the similarities and 

7 differences in the use of quality meas8 ures under the original Medicare fee9 for-service program under parts A and 

10 B of title XVIII of the Social Security 

11 Act, the Medicare Advantage program 

12 under part C of such title, selected 

13 State Medicaid programs under title 

14 XIX of such Act, and private payer 

15 arrangements; and 

16 (II) makes recommendations on 

17 how to reduce the administrative bur18 den involved in applying such quality 

19 measures. 

20 (ii) REQUIREMENTS.—The report 

21 under clause (i) shall— 

22 (I) consider those measures ap23 plicable to individuals entitled to, or 

24 enrolled for, benefits under such part 


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1 A, or enrolled under such part B and 

2 individuals under the age of 65; and 

3 (II) focus on those measures that 

4 comprise the most significant compo5 nent of the quality performance cat6 egory of the eligible professional 

7 MIPS incentive program under sub8 section (q) of section 1848 of the So9 cial Security Act (42 U.S.C. 1395w– 

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

11 (C) STUDY ON ROLE OF INDEPENDENT

12 RISK MANAGERS.—Not later than January 1, 

13 2016, the Comptroller General of the United 

14 States shall submit to Congress a report exam15 ining whether entities that pool financial risk 

16 for physician practices, such as independent 

17 risk managers, can play a role in supporting 

18 physician practices, particularly small physician 

19 practices, in assuming financial risk for the 

20 treatment of patients. Such report shall exam21 ine barriers that small physician practices cur22 rently face in assuming financial risk for treat23 ing patients, the types of risk management enti24 ties that could assist physician practices in par25 ticipating in two-sided risk payment models, 


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1 and how such entities could assist with risk 

2 management and with quality improvement ac3 tivities. Such report shall also include an anal4 ysis of any existing legal barriers to such ar5 rangements. 

6 (D) STUDY TO EXAMINE RURAL AND

7 HEALTH PROFESSIONAL SHORTAGE AREA AL8 TERNATIVE PAYMENT MODELS.—Not later than 

9 October 1, 2020, and October 1, 2022, the 

10 Comptroller General of the United States shall 

11 submit to Congress a report that examines the 

12 transition of professionals in rural areas, health 

13 professional shortage areas (as designated in 

14 section 332(a)(1)(A) of the Public Health Serv15 ice Act), or medically underserved areas to an 

16 alternative payment model (as defined in sec17 tion 1833(z)(3) of the Social Security Act, as 

18 added by subsection (e)). Such report shall 

19 make recommendations for removing adminis20 trative barriers to practices, including small 

21 practices consisting of 15 or fewer profes22 sionals, in rural areas, health professional 

23 shortage areas, and medically underserved areas 

24 to participation in such models. 


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1 (3) FUNDING FOR IMPLEMENTATION.—For 

2 purposes of implementing the provisions of and the 

3 amendments made by this section, the Secretary of 

4 Health and Human Services shall provide for the 

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

6 Medical Insurance Trust Fund established under 

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

8 1395t) to the Centers for Medicare & Medicaid Pro9 gram Management Account for each of the fiscal 

10 years 2014 through 2018. Amounts transferred 

11 under this paragraph shall be available until ex12 pended. 

13 (d) IMPROVING QUALITY REPORTING FOR COM14 POSITE SCORES.— 

15 (1) CHANGES FOR GROUP REPORTING OP16 TION.— 

17 (A) IN GENERAL.—Section 

18 1848(m)(3)(C)(ii) of the Social Security Act 

19 (42 U.S.C. 1395w–4(m)(3)(C)(ii)) is amended 

20 by inserting ‘‘and, for 2015 and subsequent 

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

22 (B) CLARIFICATION OF QUALIFIED CLIN23 ICAL DATA REGISTRY REPORTING TO GROUP

24 PRACTICES.—Section 1848(m)(3)(D) of the So25 cial Security Act (42 U.S.C. 1395w– 


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1 4(m)(3)(D)) is amended by inserting ‘‘and, for 

2 2015 and subsequent years, subparagraph (A) 

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

4 (2) CHANGES FOR MULTIPLE REPORTING PERI5 ODS AND ALTERNATIVE CRITERIA FOR SATISFAC6 TORY REPORTING.—Section 1848(m)(5)(F) of the 

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

8 is amended— 

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

10 and inserting ‘‘through reporting periods occur11 ring in 2014’’; and 

12 (B) by inserting ‘‘and, for reporting peri13 ods occurring in 2015 and subsequent years, 

14 the Secretary may establish’’ following ‘‘shall 

15 establish’’. 

16 (3) PHYSICIAN FEEDBACK PROGRAM REPORTS

17 SUCCEEDED BY REPORTS UNDER MIPS.—Section 

18 1848(n) of the Social Security Act (42 U.S.C. 

19 1395w–4(n)) is amended by adding at the end the 

20 following new paragraph: 

21 ‘‘(11) REPORTS ENDING WITH 2016.—Reports 

22 under the Program shall not be provided after De23 cember 31, 2016. See subsection (q)(12) for reports 

24 under the eligible professionals Merit-based Incentive 

25 Payment System.’’. 


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1 (4) COORDINATION WITH SATISFYING MEANING2 FUL EHR USE CLINICAL QUALITY MEASURE REPORT3 ING REQUIREMENT.—Section 1848(o)(2)(A)(iii) of 

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

5 4(o)(2)(A)(iii)) is amended by inserting ‘‘and sub6 section (q)(5)(B)(ii)(II)’’ after ‘‘Subject to subpara7 graph (B)(ii)’’. 

8 (e) PROMOTING ALTERNATIVE PAYMENT MODELS.— 

9 (1) INCREASING TRANSPARENCY OF PHYSICIAN

10 FOCUSED PAYMENT MODELS.—Section 1868 of the 

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

12 by adding at the end the following new subsection: 

13 ‘‘(c) PHYSICIAN FOCUSED PAYMENT MODELS.— 

14 ‘‘(1) TECHNICAL ADVISORY COMMITTEE.— 

15 ‘‘(A) ESTABLISHMENT.—There is estab16 lished an ad hoc committee to be known as the 

17 ‘Payment Model Technical Advisory Committee’ 

18 (referred to in this subsection as the ‘Com19 mittee’). 

20 ‘‘(B) MEMBERSHIP.— 

21 ‘‘(i) NUMBER AND APPOINTMENT.— 

22 The Committee shall be composed of 11 

23 members appointed by the Comptroller 

24 General of the United States. 


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1 ‘‘(ii) QUALIFICATIONS.—The member2 ship of the Committee shall include indi3 viduals with national recognition for their 

4 expertise in payment models and related 

5 delivery of care. No more than 5 members 

6 of the Committee shall be providers of 

7 services or suppliers, or representatives of 

8 providers of services or suppliers. 

9 ‘‘(iii) PROHIBITION ON FEDERAL EM10 PLOYMENT.—A member of the Committee 

11 shall not be an employee of the Federal 

12 Government. 

13 ‘‘(iv) ETHICS DISCLOSURE.—The 

14 Comptroller General shall establish a sys15 tem for public disclosure by members of 

16 the Committee of financial and other po17 tential conflicts of interest relating to such 

18 members. Members of the Committee shall 

19 be treated as employees of Congress for 

20 purposes of applying title I of the Ethics 

21 in Government Act of 1978 (Public Law 

22 95–521). 

23 ‘‘(v) DATE OF INITIAL APPOINT24 MENTS.—The initial appointments of mem25 bers of the Committee shall be made by 


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1 not later than 180 days after the date of 

2 enactment of this subsection. 

3 ‘‘(C) TERM; VACANCIES.— 

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

5 the Committee shall be for 3 years except 

6 that the Comptroller General shall des7 ignate staggered terms for the members 

8 first appointed. 

9 ‘‘(ii) VACANCIES.—Any member ap10 pointed to fill a vacancy occurring before 

11 the expiration of the term for which the 

12 member’s predecessor was appointed shall 

13 be appointed only for the remainder of that 

14 term. A member may serve after the expi15 ration of that member’s term until a suc16 cessor has taken office. A vacancy in the 

17 Committee shall be filled in the manner in 

18 which the original appointment was made. 

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

20 as needed, to provide comments and rec21 ommendations to the Secretary, as described in 

22 paragraph (2)(C), on physician-focused pay23 ment models. 

24 ‘‘(E) COMPENSATION OF MEMBERS.— 


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1 ‘‘(i) IN GENERAL.—Except as pro2 vided in clause (ii), a member of the Com3 mittee shall serve without compensation. 

4 ‘‘(ii) TRAVEL EXPENSES.—A member 

5 of the Committee shall be allowed travel 

6 expenses, including per diem in lieu of sub7 sistence, at rates authorized for an em8 ployee of an agency under subchapter I of 

9 chapter 57 of title 5, United States Code, 

10 while away from the home or regular place 

11 of business of the member in the perform12 ance of the duties of the Committee. 

13 ‘‘(F) OPERATIONAL AND TECHNICAL SUP14 PORT.— 

15 ‘‘(i) IN GENERAL.—The Assistant 

16 Secretary for Planning and Evaluation 

17 shall provide technical and operational sup18 port for the Committee, which may be by 

19 use of a contractor. The Office of the Ac20 tuary of the Centers for Medicare & Med21 icaid Services shall provide to the Com22 mittee actuarial assistance as needed. 

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

24 provide for the transfer, from the Federal 

25 Supplementary Medical Insurance Trust 


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1 Fund under section 1841, such amounts as 

2 are necessary to carry out clause (i) (not 

3 to exceed $5,000,000) for fiscal year 2014 

4 and each subsequent fiscal year. Any 

5 amounts transferred under the preceding 

6 sentence for a fiscal year shall remain 

7 available until expended. 

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

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

10 App.) shall not apply to the Committee. 

11 ‘‘(2) CRITERIA AND PROCESS FOR SUBMISSION

12 AND REVIEW OF PHYSICIAN-FOCUSED PAYMENT

13 MODELS.— 

14 ‘‘(A) CRITERIA FOR ASSESSING PHYSICIAN15 FOCUSED PAYMENT MODELS.— 

16 ‘‘(i) RULEMAKING.—Not later than 

17 November 1, 2015, the Secretary shall, 

18 through notice and comment rulemaking, 

19 following a request for information, estab20 lish criteria for physician-focused payment 

21 models, including models for specialist phy22 sicians, that could be used by the Com23 mittee for making comments and rec24 ommendations pursuant to paragraph 

25 (1)(D). 


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1 ‘‘(ii) MEDPAC SUBMISSION OF COM2 MENTS.—During the comment period for 

3 the proposed rule described in clause (i), 

4 the Medicare Payment Advisory Commis5 sion may submit comments to the Sec6 retary on the proposed criteria under such 

7 clause. 

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

9 update the criteria established under this 

10 subparagraph through rulemaking. 

11 ‘‘(B) STAKEHOLDER SUBMISSION OF PHY12 SICIAN FOCUSED PAYMENT MODELS.—On an 

13 ongoing basis, individuals and stakeholder enti14 ties may submit to the Committee proposals for 

15 physician-focused payment models that such in16 dividuals and entities believe meet the criteria 

17 described in subparagraph (A). 

18 ‘‘(C) TAC REVIEW OF MODELS SUB19 MITTED.—The Committee shall, on a periodic 

20 basis, review models submitted under subpara21 graph (B), prepare comments and recommenda22 tions regarding whether such models meet the 

23 criteria described in subparagraph (A), and 

24 submit such comments and recommendations to 

25 the Secretary. 


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1 ‘‘(D) SECRETARY REVIEW AND RE2 SPONSE.—The Secretary shall review the com3 ments and recommendations submitted by the 

4 Committee under subparagraph (C) and post a 

5 detailed response to such comments and rec6 ommendations on the Internet Website of the 

7 Centers for Medicare & Medicaid Services. 

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

9 this subsection shall be construed to impact the de10 velopment or testing of models under this title or ti11 tles XI, XIX, or XXI.’’. 

12 (2) INCENTIVE PAYMENTS FOR PARTICIPATION

13 IN ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 

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

15 1395l) is amended by adding at the end the fol16 lowing new subsection: 

17 ‘‘(z) INCENTIVE PAYMENTS FOR PARTICIPATION IN

18 ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 

19 ‘‘(1) PAYMENT INCENTIVE.— 

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

21 professional services furnished by an eligible 

22 professional during a year that is in the period 

23 beginning with 2018 and ending with 2023 and 

24 for which the professional is a qualifying APM 

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1 ment that would otherwise be made for such 

2 covered professional services under this part for 

3 such year, there also shall be paid to such pro4 fessional an amount equal to 5 percent of the 

5 payment amount for the covered professional 

6 services under this part for the preceding year. 

7 For purposes of the previous sentence, the pay8 ment amount for the preceding year may be an 

9 estimation for the full preceding year based on 

10 a period of such preceding year that is less than 

11 the full year. The Secretary shall establish poli12 cies to implement this subparagraph in cases 

13 where payment for covered professional services 

14 furnished by a qualifying APM participant in 

15 an alternative payment model is made to an en16 tity participating in the alternative payment 

17 model rather than directly to the qualifying 

18 APM participant. 

19 ‘‘(B) FORM OF PAYMENT.—Payments 

20 under this subsection shall be made in a lump 

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

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

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


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1 payment model and for purposes of determining 

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

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

5 additional payment for an item or service under 

6 this subsection or subsection (m) shall be deter7 mined without regard to any additional pay8 ment for the item or service under subsection 

9 (m) and this subsection, respectively. The 

10 amount of the additional payment for an item 

11 or service under this subsection or subsection 

12 (x) shall be determined without regard to any 

13 additional payment for the item or service 

14 under subsection (x) and this subsection, re15 spectively. The amount of the additional pay16 ment for an item or service under this sub17 section or subsection (y) shall be determined 

18 without regard to any additional payment for 

19 the item or service under subsection (y) and 

20 this subsection, respectively. 

21 ‘‘(2) QUALIFYING APM PARTICIPANT.—For pur22 poses of this subsection, the term ‘qualifying APM 

23 participant’ means the following: 

24 ‘‘(A) 2018 AND 2019.—With respect to 

25 2018 and 2019, an eligible professional for 


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1 whom the Secretary determines that at least 25 

2 percent of payments under this part for covered 

3 professional services furnished by such profes4 sional during the most recent period for which 

5 data are available (which may be less than a 

6 year) were attributable to such services fur7 nished under this part through an entity that 

8 participates in an eligible alternative payment 

9 model with respect to such services. 

10 ‘‘(B) 2020 AND 2021.—With respect to 

11 2020 and 2021, an eligible professional de12 scribed in either of the following clauses: 

13 ‘‘(i) MEDICARE REVENUE THRESHOLD

14 OPTION.—An eligible professional for 

15 whom the Secretary determines that at 

16 least 50 percent of payments under this 

17 part for covered professional services fur18 nished by such professional during the 

19 most recent period for which data are 

20 available (which may be less than a year) 

21 were attributable to such services furnished 

22 under this part through an entity that par23 ticipates in an eligible alternative payment 

24 model with respect to such services. 


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1 ‘‘(ii) COMBINATION ALL-PAYER AND

2 MEDICARE REVENUE THRESHOLD OP3 TION.—An eligible professional— 

4 ‘‘(I) for whom the Secretary de5 termines, with respect to items and 

6 services furnished by such professional 

7 during the most recent period for 

8 which data are available (which may 

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

10 percent of the sum of— 

11 ‘‘(aa) payments described in 

12 clause (i); and 

13 ‘‘(bb) all other payments, re14 gardless of payer (other than 

15 payments made by the Secretary 

16 of Defense or the Secretary of 

17 Veterans Affairs under chapter 

18 55 of title 10, United States 

19 Code, or title 38, United States 

20 Code, or any other provision of 

21 law, and other than payments 

22 made under title XIX in a State 

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1 able under the State program 

2 under that title), 

3 meet the requirement described in 

4 clause (iii)(I) with respect to pay5 ments described in item (aa) and meet 

6 the requirement described in clause 

7 (iii)(II) with respect to payments de8 scribed in item (bb); 

9 ‘‘(II) for whom the Secretary de10 termines at least 25 percent of pay11 ments under this part for covered pro12 fessional services furnished by such 

13 professional during the most recent 

14 period for which data are available 

15 (which may be less than a year) were 

16 attributable to such services furnished 

17 under this part through an entity that 

18 participates in an eligible alternative 

19 payment model with respect to such 

20 services; and 

21 ‘‘(III) who provides to the Sec22 retary such information as is nec23 essary for the Secretary to make a de24 termination under subclause (I), with 

25 respect to such professional. 


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1 ‘‘(iii) REQUIREMENT.—For purposes 

2 of clause (ii)(I)— 

3 ‘‘(I) the requirement described in 

4 this subclause, with respect to pay5 ments described in item (aa) of such 

6 clause, is that such payments are 

7 made under an eligible alternative 

8 payment model; and 

9 ‘‘(II) the requirement described 

10 in this subclause, with respect to pay11 ments described in item (bb) of such 

12 clause, is that such payments are 

13 made under an arrangement in 

14 which— 

15 ‘‘(aa) quality measures com16 parable to measures under the 

17 performance category described 

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

19 ‘‘(bb) certified EHR tech20 nology is used; and 

21 ‘‘(cc) the eligible profes22 sional (AA) bears more than 

23 nominal financial risk if actual 

24 aggregate expenditures exceeds 

25 expected aggregate expenditures; 


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1 or (BB) is a medical home (with 

2 respect to beneficiaries under 

3 title XIX) that meets criteria 

4 comparable to medical homes ex5 panded under section 1115A(c). 

6 ‘‘(C) BEGINNING IN 2022.—With respect to 

7 2022 and each subsequent year, an eligible pro8 fessional described in either of the following 

9 clauses: 

10 ‘‘(i) MEDICARE REVENUE THRESHOLD

11 OPTION.—An eligible professional for 

12 whom the Secretary determines that at 

13 least 75 percent of payments under this 

14 part for covered professional services fur15 nished by such professional during the 

16 most recent period for which data are 

17 available (which may be less than a year) 

18 were attributable to such services furnished 

19 under this part through an entity that par20 ticipates in an eligible alternative payment 

21 model with respect to such services. 

22 ‘‘(ii) COMBINATION ALL-PAYER AND

23 MEDICARE REVENUE THRESHOLD OP24 TION.—An eligible professional— 


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1 ‘‘(I) for whom the Secretary de2 termines, with respect to items and 

3 services furnished by such professional 

4 during the most recent period for 

5 which data are available (which may 

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

7 percent of the sum of— 

8 ‘‘(aa) payments described in 

9 clause (i); and 

10 ‘‘(bb) all other payments, re11 gardless of payer (other than 

12 payments made by the Secretary 

13 of Defense or the Secretary of 

14 Veterans Affairs under chapter 

15 55 of title 10, United States 

16 Code, or title 38, United States 

17 Code, or any other provision of 

18 law, and other than payments 

19 made under title XIX in a State 

20 in which no medical home or al21 ternative payment model is avail22 able under the State program 

23 under that title), 

24 meet the requirement described in 

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1 ments described in item (aa) and meet 

2 the requirement described in clause 

3 (iii)(II) with respect to payments de4 scribed in item (bb); 

5 ‘‘(II) for whom the Secretary de6 termines at least 25 percent of pay7 ments under this part for covered pro8 fessional services furnished by such 

9 professional during the most recent 

10 period for which data are available 

11 (which may be less than a year) were 

12 attributable to such services furnished 

13 under this part through an entity that 

14 participates in an eligible alternative 

15 payment model with respect to such 

16 services; and 

17 ‘‘(III) who provides to the Sec18 retary such information as is nec19 essary for the Secretary to make a de20 termination under subclause (I), with 

21 respect to such professional. 

22 ‘‘(iii) REQUIREMENT.—For purposes 

23 of clause (ii)(I)— 

24 ‘‘(I) the requirement described in 

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1 ments described in item (aa) of such 

2 clause, is that such payments are 

3 made under an eligible alternative 

4 payment model; and 

5 ‘‘(II) the requirement described 

6 in this subclause, with respect to pay7 ments described in item (bb) of such 

8 clause, is that such payments are 

9 made under an arrangement in 

10 which— 

11 ‘‘(aa) quality measures com12 parable to measures under the 

13 performance category described 

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

15 ‘‘(bb) certified EHR tech16 nology is used; and 

17 ‘‘(cc) the eligible profes18 sional (AA) bears more than 

19 nominal financial risk if actual 

20 aggregate expenditures exceeds 

21 expected aggregate expenditures; 

22 or (BB) is a medical home (with 

23 respect to beneficiaries under 

24 title XIX) that meets criteria 


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1 comparable to medical homes ex2 panded under section 1115A(c). 

3 ‘‘(3) ADDITIONAL DEFINITIONS.—In this sub4 section: 

5 ‘‘(A) COVERED PROFESSIONAL SERV6 ICES.—The term ‘covered professional services’ 

7 has the meaning given that term in section 

8 1848(k)(3)(A). 

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

10 ‘eligible professional’ has the meaning given 

11 that term in section 1848(k)(3)(B). 

12 ‘‘(C) ALTERNATIVE PAYMENT MODEL

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

14 means any of the following: 

15 ‘‘(i) A model under section 1115A 

16 (other than a health care innovation 

17 award). 

18 ‘‘(ii) The shared savings program 

19 under section 1899. 

20 ‘‘(iii) A demonstration under section 

21 1866C. 

22 ‘‘(iv) A demonstration required by 

23 Federal law. 

24 ‘‘(D) ELIGIBLE ALTERNATIVE PAYMENT

25 MODEL (APM).— 


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1 ‘‘(i) IN GENERAL.—The term ‘eligible 

2 alternative payment model’ means, with re3 spect to a year, an alternative payment 

4 model— 

5 ‘‘(I) that requires use of certified 

6 EHR technology (as defined in sub7 section (o)(4)); 

8 ‘‘(II) that provides for payment 

9 for covered professional services based 

10 on quality measures comparable to 

11 measures under the performance cat12 egory described in section 

13 1848(q)(2)(B)(i); and 

14 ‘‘(III) that satisfies the require15 ment described in clause (ii). 

16 ‘‘(ii) ADDITIONAL REQUIREMENT.— 

17 For purposes of clause (i)(III), the require18 ment described in this clause, with respect 

19 to a year and an alternative payment 

20 model, is that the alternative payment 

21 model— 

22 ‘‘(I) is one in which one or more 

23 entities bear financial risk for mone24 tary losses under such model that are 

25 in excess of a nominal amount; or 


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1 ‘‘(II) is a medical home expanded 

2 under section 1115A(c). 

3 ‘‘(4) LIMITATION.—There shall be no adminis4 trative or judicial review under section 1869, 1878, 

5 or otherwise, of the following: 

6 ‘‘(A) The determination that an eligible 

7 professional is a qualifying APM participant 

8 under paragraph (2) and the determination 

9 that an alternative payment model is an eligible 

10 alternative payment model under paragraph 

11 (3)(D). 

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

13 the 5 percent payment incentive under para14 graph (1)(A), including any estimation as part 

15 of such determination.’’. 

16 (3) COORDINATION CONFORMING AMEND17 MENTS.—Section 1833 of the Social Security Act 

18 (42 U.S.C. 1395l) is further amended— 

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

20 end the following new sentence: ‘‘The amount 

21 of the additional payment for a service under 

22 this subsection and subsection (z) shall be de23 termined without regard to any additional pay24 ment for the service under subsection (z) and 

25 this subsection, respectively.’’; and 


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

2 end the following new sentence: ‘‘The amount 

3 of the additional payment for a service under 

4 this subsection and subsection (z) shall be de5 termined without regard to any additional pay6 ment for the service under subsection (z) and 

7 this subsection, respectively.’’. 

8 (4) ENCOURAGING DEVELOPMENT AND TEST9 ING OF CERTAIN MODELS.—Section 1115A(b)(2) of 

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

11 amended— 

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

13 end the following new clauses: 

14 ‘‘(xxi) Focusing primarily on physi15 cians’ services (as defined in section 

16 1848(j)(3)) furnished by physicians who 

17 are not primary care practitioners. 

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

19 fewer professionals. 

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

21 for small physician practices which may in22 volve two-sided risk and prospective patient 

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1 pital readmissions rates, and other relevant 

2 and appropriate clinical measures. 

3 ‘‘(xxiv) Focusing primarily on title 

4 XIX, working in conjunction with the Cen5 ter for Medicaid and CHIP Services.’’; and 

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

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

8 and inserting ‘‘other public sector payers, pri9 vate sector payers, or Statewide payment mod10 els’’. 

11 (5) CONSTRUCTION REGARDING TELEHEALTH

12 SERVICES.—Nothing in the provisions of, or amend13 ments made by, this Act shall be construed as pre14 cluding an alternative payment model or a qualifying 

15 APM participant (as those terms are defined in sec16 tion 1833(z) of the Social Security Act, as added by 

17 paragraph (1)) from furnishing a telehealth service 

18 for which payment is not made under section 

19 1834(m) of the Social Security Act (42 U.S.C. 

20 1395m(m)). 

21 (6) INTEGRATING MEDICARE ADVANTAGE AL22 TERNATIVE PAYMENT MODELS.—Not later than July 

23 1, 2015, the Secretary of Health and Human Serv24 ices shall submit to Congress a study that examines 

25 the feasibility of integrating alternative payment 


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1 models in the Medicare Advantage payment system. 

2 The study shall include the feasibility of including a 

3 value-based modifier and whether such modifier 

4 should be budget neutral. 

5 (7) STUDY AND REPORT ON FRAUD RELATED

6 TO ALTERNATIVE PAYMENT MODELS UNDER THE

7 MEDICARE PROGRAM.— 

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

9 Human Services, in consultation with the In10 spector General of the Department of Health 

11 and Human Services, shall conduct a study 

12 that— 

13 (i) examines the applicability of the 

14 Federal fraud prevention laws to items and 

15 services furnished under title XVIII of the 

16 Social Security Act for which payment is 

17 made under an alternative payment model 

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

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

20 (ii) identifies aspects of such alter21 native payment models that are vulnerable 

22 to fraudulent activity; and 

23 (iii) examines the implications of waiv24 ers to such laws granted in support of such 

25 alternative payment models, including 


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1 under any potential expansion of such 

2 models. 

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

4 the date of the enactment of this Act, the Sec5 retary shall submit to Congress a report con6 taining the results of the study conducted under 

7 subparagraph (A). Such report shall include 

8 recommendations for actions to be taken to re9 duce the vulnerability of such alternative pay10 ment models to fraudulent activity. Such report 

11 also shall include, as appropriate, recommenda12 tions of the Inspector General for changes in 

13 Federal fraud prevention laws to reduce such 

14 vulnerability. 

15 (f) IMPROVING PAYMENT ACCURACY.— 

16 (1) STUDIES AND REPORTS OF EFFECT OF CER17 TAIN INFORMATION ON QUALITY AND RESOURCE

18 USE.— 

19 (A) STUDY USING EXISTING MEDICARE

20 DATA.— 

21 (i) STUDY.—The Secretary of Health 

22 and Human Services (in this subsection re23 ferred to as the ‘‘Secretary’’) shall conduct 

24 a study that examines the effect of individ25 uals’ socioeconomic status on quality and 


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1 resource use outcome measures for individ2 uals under the Medicare program (such as 

3 to recognize that less healthy individuals 

4 may require more intensive interventions). 

5 The study shall use information collected 

6 on such individuals in carrying out such 

7 program, such as urban and rural location, 

8 eligibility for Medicaid (recognizing and ac9 counting for varying Medicaid eligibility 

10 across States), and eligibility for benefits 

11 under the supplemental security income 

12 (SSI) program. The Secretary shall carry 

13 out this paragraph acting through the As14 sistant Secretary for Planning and Evalua15 tion. 

16 (ii) REPORT.—Not later than 2 years 

17 after the date of the enactment of this Act, 

18 the Secretary shall submit to Congress a 

19 report on the study conducted under clause 

20 (i). 

21 (B) STUDY USING OTHER DATA.— 

22 (i) STUDY.—The Secretary shall con23 duct a study that examines the impact of 

24 risk factors, such as those described in sec25 tion 1848(p)(3) of the Social Security Act 


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1 (42 U.S.C. 1395w–4(p)(3)), race, health 

2 literacy, limited English proficiency (LEP), 

3 and patient activation, on quality and re4 source use outcome measures under the 

5 Medicare program (such as to recognize 

6 that less healthy individuals may require 

7 more intensive interventions). In con8 ducting such study the Secretary may use 

9 existing Federal data and collect such ad10 ditional data as may be necessary to com11 plete the study. 

12 (ii) REPORT.—Not later than 5 years 

13 after the date of the enactment of this Act, 

14 the Secretary shall submit to Congress a 

15 report on the study conducted under clause 

16 (i). 

17 (C) EXAMINATION OF DATA IN CON18 DUCTING STUDIES.—In conducting the studies 

19 under subparagraphs (A) and (B), the Sec20 retary shall examine what non-Medicare data 

21 sets, such as data from the American Commu22 nity Survey (ACS), can be useful in conducting 

23 the types of studies under such paragraphs and 

24 how such data sets that are identified as useful 

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1 tive data in order to improve the overall data 

2 set available to do such studies and for the ad3 ministration of the Medicare program. 

4 (D) RECOMMENDATIONS TO ACCOUNT FOR

5 INFORMATION IN PAYMENT ADJUSTMENT

6 MECHANISMS.—If the studies conducted under 

7 subparagraphs (A) and (B) find a relationship 

8 between the factors examined in the studies and 

9 quality and resource use outcome measures, 

10 then the Secretary shall also provide rec11 ommendations for how the Centers for Medicare 

12 & Medicaid Services should— 

13 (i) obtain access to the necessary data 

14 (if such data is not already being collected) 

15 on such factors, including recommenda16 tions on how to address barriers to the 

17 Centers in accessing such data; and 

18 (ii) account for such factors in deter19 mining payment adjustments based on 

20 quality and resource use outcome measures 

21 under the eligible professional Merit-based 

22 Incentive Payment System under section 

23 1848(q) of the Social Security Act (42 

24 U.S.C. 1395w–4(q)) and, as the Secretary 


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1 determines appropriate, other similar pro2 visions of title XVIII of such Act. 

3 (E) FUNDING.—There are hereby appro4 priated from the Federal Supplementary Med5 ical Insurance Trust Fund under section 1841 

6 of the Social Security Act to the Secretary to 

7 carry out this paragraph $6,000,000, to remain 

8 available until expended. 

9 (2) CMS ACTIVITIES.— 

10 (A) HIERARCHAL CONDITION CATEGORY

11 (HCC) IMPROVEMENT.—Taking into account the 

12 relevant studies conducted and recommenda13 tions made in reports under paragraph (1), the 

14 Secretary, on an ongoing basis, shall, as the 

15 Secretary determines appropriate, estimate how 

16 an individual’s health status and other risk fac17 tors affect quality and resource use outcome 

18 measures and, as feasible, shall incorporate in19 formation from quality and resource use out20 come measurement (including care episode and 

21 patient condition groups) into provisions of title 

22 XVIII of the Social Security Act that are simi23 lar to the eligible professional Merit-based In24 centive Payment System under section 1848(q) 

25 of such Act. 


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1 (B) ACCOUNTING FOR OTHER FACTORS IN

2 PAYMENT ADJUSTMENT MECHANISMS.— 

3 (i) IN GENERAL.—Taking into ac4 count the studies conducted and rec5 ommendations made in reports under para6 graph (1) and other information as appro7 priate, the Secretary shall, as the Sec8 retary determines appropriate, account for 

9 identified factors with an effect on quality 

10 and resource use outcome measures when 

11 determining payment adjustment mecha12 nisms under provisions of title XVIII of 

13 the Social Security Act that are similar to 

14 the eligible professional Merit-based Incen15 tive Payment System under section 

16 1848(q) of such Act. 

17 (ii) ACCESSING DATA.—The Secretary 

18 shall collect or otherwise obtain access to 

19 the data necessary to carry out this para20 graph through existing and new data 

21 sources. 

22 (iii) PERIODIC ANALYSES.—The Sec23 retary shall carry out periodic analyses, at 

24 least every 3 years, based on the factors 


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1 referred to in clause (i) so as to monitor 

2 changes in possible relationships. 

3 (C) FUNDING.—There are hereby appro4 priated from the Federal Supplementary Med5 ical Insurance Trust Fund under section 1841 

6 of the Social Security Act to the Secretary to 

7 carry out this paragraph and the application of 

8 this paragraph to the Merit-based Incentive 

9 Payment System under section 1848(q) of such 

10 Act $10,000,000, to remain available until ex11 pended. 

12 (3) STRATEGIC PLAN FOR ACCESSING RACE

13 AND ETHNICITY DATA.—Not later than 18 months 

14 after the date of the enactment of this Act, the Sec15 retary shall develop and report to Congress on a 

16 strategic plan for collecting or otherwise accessing 

17 data on race and ethnicity for purposes of carrying 

18 out the eligible professional Merit-based Incentive 

19 Payment System under section 1848(q) of the Social 

20 Security Act and, as the Secretary determines ap21 propriate, other similar provisions of title XVIII of 

22 such Act. 

23 (g) COLLABORATING WITH THE PHYSICIAN, PRACTI24 TIONER, AND OTHER STAKEHOLDER COMMUNITIES TO

25 IMPROVE RESOURCE USE MEASUREMENT.—Section 1848 


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

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

3 at the end the following new subsection: 

4 ‘‘(r) COLLABORATING WITH THE PHYSICIAN, PRAC5 TITIONER, AND OTHER STAKEHOLDER COMMUNITIES TO

6 IMPROVE RESOURCE USE MEASUREMENT.— 

7 ‘‘(1) IN GENERAL.—In order to involve the phy8 sician, practitioner, and other stakeholder commu9 nities in enhancing the infrastructure for resource 

10 use measurement, including for purposes of the 

11 Merit-based Incentive Payment System under sub12 section (q) and alternative payment models under 

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

14 steps described in the succeeding provisions of this 

15 subsection. 

16 ‘‘(2) DEVELOPMENT OF CARE EPISODE AND PA17 TIENT CONDITION GROUPS AND CLASSIFICATION

18 CODES.— 

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

20 similar patients into care episode groups and 

21 patient condition groups, the Secretary shall 

22 undertake the steps described in the succeeding 

23 provisions of this paragraph. 

24 ‘‘(B) PUBLIC AVAILABILITY OF EXISTING

25 EFFORTS TO DESIGN AN EPISODE GROUPER.— 


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1 Not later than 120 days after the date of the 

2 enactment of this subsection, the Secretary 

3 shall post on the Internet website of the Cen4 ters for Medicare & Medicaid Services a list of 

5 the episode groups developed pursuant to sub6 section (n)(9)(A) and related descriptive infor7 mation. 

8 ‘‘(C) STAKEHOLDER INPUT.—The Sec9 retary shall accept, through the date that is 60 

10 days after the day the Secretary posts the list 

11 pursuant to subparagraph (B), suggestions 

12 from physician specialty societies, applicable 

13 practitioner organizations, and other stake14 holders for episode groups in addition to those 

15 posted pursuant to such subparagraph, and 

16 specific clinical criteria and patient characteris17 tics to classify patients into— 

18 ‘‘(i) care episode groups; and 

19 ‘‘(ii) patient condition groups. 

20 ‘‘(D) DEVELOPMENT OF PROPOSED CLAS21 SIFICATION CODES.— 

22 ‘‘(i) IN GENERAL.—Taking into ac23 count the information described in sub24 paragraph (B) and the information reVerDate Mar 15 2010 01:32 Mar 14, 2014 Jkt 039200 PO 00000 Frm 00111 Fmt 6652 Sfmt 6201 E:\BILLS\S2122.PCS S2122

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1 ceived under subparagraph (C), the Sec2 retary shall— 

3 ‘‘(I) establish care episode groups 

4 and patient condition groups, which 

5 account for a target of an estimated 

2 6 ⁄3 of expenditures under parts A and 

7 B; and 

8 ‘‘(II) assign codes to such 

9 groups. 

10 ‘‘(ii) CARE EPISODE GROUPS.—In es11 tablishing the care episode groups under 

12 clause (i), the Secretary shall take into ac13 count— 

14 ‘‘(I) the patient’s clinical prob15 lems at the time items and services 

16 are furnished during an episode of 

17 care, such as the clinical conditions or 

18 diagnoses, whether or not inpatient 

19 hospitalization is anticipated or oc20 curs, and the principal procedures or 

21 services planned or furnished; and 

22 ‘‘(II) other factors determined 

23 appropriate by the Secretary. 

24 ‘‘(iii) PATIENT CONDITION GROUPS.— 

25 In establishing the patient condition 


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1 groups under clause (i), the Secretary shall 

2 take into account— 

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

4 at the time of each medical visit, such 

5 as the patient’s combination of chron6 ic conditions, current health status, 

7 and recent significant history (such as 

8 hospitalization and major surgery dur9 ing a previous period, such as 3 

10 months); and 

11 ‘‘(II) other factors determined 

12 appropriate by the Secretary, such as 

13 eligibility status under this title (in14 cluding eligibility under section 

15 226(a), 226(b), or 226A, and dual eli16 gibility under this title and title XIX). 

17 ‘‘(E) DRAFT CARE EPISODE AND PATIENT

18 CONDITION GROUPS AND CLASSIFICATION

19 CODES.—Not later than 180 days after the end 

20 of the comment period described in subpara21 graph (C), the Secretary shall post on the 

22 Internet website of the Centers for Medicare & 

23 Medicaid Services a draft list of the care epi24 sode and patient condition codes established 


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1 under subparagraph (D) (and the criteria and 

2 characteristics assigned to such code). 

3 ‘‘(F) SOLICITATION OF INPUT.—The Sec4 retary shall seek, through the date that is 60 

5 days after the Secretary posts the list pursuant 

6 to subparagraph (E), comments from physician 

7 specialty societies, applicable practitioner orga8 nizations, and other stakeholders, including rep9 resentatives of individuals entitled to benefits 

10 under part A or enrolled under this part, re11 garding the care episode and patient condition 

12 groups (and codes) posted under subparagraph 

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

14 shall use one or more mechanisms (other than 

15 notice and comment rulemaking) that may in16 clude use of open door forums, town hall meet17 ings, or other appropriate mechanisms. 

18 ‘‘(G) OPERATIONAL LIST OF CARE EPI19 SODE AND PATIENT CONDITION GROUPS AND

20 CODES.—Not later than 180 days after the end 

21 of the comment period described in subpara22 graph (F), taking into account the comments 

23 received under such subparagraph, the Sec24 retary shall post on the Internet website of the 

25 Centers for Medicare & Medicaid Services an 


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1 operational list of care episode and patient con2 dition codes (and the criteria and characteris3 tics assigned to such code). 

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

5 than November 1 of each year (beginning with 

6 2017), the Secretary shall, through rulemaking, 

7 make revisions to the operational lists of care 

8 episode and patient condition codes as the Sec9 retary determines may be appropriate. Such re10 visions may be based on experience, new infor11 mation developed pursuant to subsection 

12 (n)(9)(A), and input from the physician spe13 cialty societies, applicable practitioner organiza14 tions, and other stakeholders, including rep15 resentatives of individuals entitled to benefits 

16 under part A or enrolled under this part. 

17 ‘‘(3) ATTRIBUTION OF PATIENTS TO PHYSI18 CIANS OR PRACTITIONERS.— 

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

20 the attribution of patients and episodes (in 

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

22 applicable practitioners furnishing items and 

23 services, the Secretary shall undertake the steps 

24 described in the succeeding provisions of this 

25 paragraph. 


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1 ‘‘(B) DEVELOPMENT OF PATIENT RELA2 TIONSHIP CATEGORIES AND CODES.—The Sec3 retary shall develop patient relationship cat4 egories and codes that define and distinguish 

5 the relationship and responsibility of a physi6 cian or applicable practitioner with a patient at 

7 the time of furnishing an item or service. Such 

8 patient relationship categories shall include dif9 ferent relationships of the physician or applica10 ble practitioner to the patient (and the codes 

11 may reflect combinations of such categories), 

12 such as a physician or applicable practitioner 

13 who— 

14 ‘‘(i) considers themself to have the 

15 primary responsibility for the general and 

16 ongoing care for the patient over extended 

17 periods of time; 

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

19 physician or practitioner and who furnishes 

20 items and services and coordinates care 

21 furnished by other physicians or practi22 tioners for the patient during an acute epi23 sode; 

24 ‘‘(iii) furnishes items and services to 

25 the patient on a continuing basis during an 


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1 acute episode of care, but in a supportive 

2 rather than a lead role; 

3 ‘‘(iv) furnishes items and services to 

4 the patient on an occasional basis, usually 

5 at the request of another physician or 

6 practitioner; or 

7 ‘‘(v) furnishes items and services only 

8 as ordered by another physician or practi9 tioner. 

10 ‘‘(C) DRAFT LIST OF PATIENT RELATION11 SHIP CATEGORIES AND CODES.—Not later than 

12 270 days after the date of the enactment of this 

13 subsection, the Secretary shall post on the 

14 Internet website of the Centers for Medicare & 

15 Medicaid Services a draft list of the patient re16 lationship categories and codes developed under 

17 subparagraph (B). 

18 ‘‘(D) STAKEHOLDER INPUT.—The Sec19 retary shall seek, through the date that is 60 

20 days after the Secretary posts the list pursuant 

21 to subparagraph (C), comments from physician 

22 specialty societies, applicable practitioner orga23 nizations, and other stakeholders, including rep24 resentatives of individuals entitled to benefits 

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1 garding the patient relationship categories and 

2 codes posted under subparagraph (C). In seek3 ing such comments, the Secretary shall use one 

4 or more mechanisms (other than notice and 

5 comment rulemaking) that may include open 

6 door forums, town hall meetings, or other ap7 propriate mechanisms. 

8 ‘‘(E) OPERATIONAL LIST OF PATIENT RE9 LATIONSHIP CATEGORIES AND CODES.—Not 

10 later than 180 days after the end of the com11 ment period described in subparagraph (D), 

12 taking into account the comments received 

13 under such subparagraph, the Secretary shall 

14 post on the Internet website of the Centers for 

15 Medicare & Medicaid Services an operational 

16 list of patient relationship categories and codes. 

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

18 than November 1 of each year (beginning with 

19 2017), the Secretary shall, through rulemaking, 

20 make revisions to the operational list of patient 

21 relationship categories and codes as the Sec22 retary determines appropriate. Such revisions 

23 may be based on experience, new information 

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

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1 plicable practitioner organizations, and other 

2 stakeholders, including representatives of indi3 viduals entitled to benefits under part A or en4 rolled under this part. 

5 ‘‘(4) REPORTING OF INFORMATION FOR RE6 SOURCE USE MEASUREMENT.—Claims submitted for 

7 items and services furnished by a physician or appli8 cable practitioner on or after January 1, 2017, shall, 

9 as determined appropriate by the Secretary, in10 clude— 

11 ‘‘(A) applicable codes established under 

12 paragraphs (2) and (3); and 

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

14 ordering physician or applicable practitioner (if 

15 different from the billing physician or applicable 

16 practitioner). 

17 ‘‘(5) METHODOLOGY FOR RESOURCE USE ANAL18 YSIS.— 

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

20 the resources used to treat patients (with re21 spect to care episode and patient condition 

22 groups), the Secretary shall— 

23 ‘‘(i) use the patient relationship codes 

24 reported on claims pursuant to paragraph 

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


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1 part) to one or more physicians and appli2 cable practitioners; 

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

4 condition codes reported on claims pursu5 ant to paragraph (4) as a basis to compare 

6 similar patients and care episodes and pa7 tient condition groups; and 

8 ‘‘(iii) conduct an analysis of resource 

9 use (with respect to care episodes and pa10 tient condition groups of such patients), as 

11 the Secretary determines appropriate. 

12 ‘‘(B) ANALYSIS OF PATIENTS OF PHYSI13 CIANS AND PRACTITIONERS.—In conducting the 

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

15 respect to patients attributed to physicians and 

16 applicable practitioners, the Secretary shall, as 

17 feasible— 

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

19 such patients by patient condition codes 

20 during a common period, such as 12 

21 months; and 

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

23 such patients by care episode codes— 

24 ‘‘(I) in the case of episodes with25 out a hospitalization, during periods 


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1 of time (such as the number of days) 

2 determined appropriate by the Sec3 retary; and 

4 ‘‘(II) in the case of episodes with 

5 a hospitalization, during periods of 

6 time (such as the number of days) be7 fore, during, and after the hospitaliza8 tion. 

9 ‘‘(C) MEASUREMENT OF RESOURCE USE.— 

10 In measuring such resource use, the Sec11 retary— 

12 ‘‘(i) shall use per patient total allowed 

13 charges for all services under part A and 

14 this part (and, if the Secretary determines 

15 appropriate, part D) for the analysis of pa16 tient resource use, by care episode codes 

17 and by patient condition codes; and 

18 ‘‘(ii) may, as determined appropriate, 

19 use other measures of allowed charges 

20 (such as subtotals for categories of items 

21 and services) and measures of utilization of 

22 items and services (such as frequency of 

23 specific items and services and the ratio of 

24 specific items and services among attrib25 uted patients or episodes). 


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1 ‘‘(D) STAKEHOLDER INPUT.—The Sec2 retary shall seek comments from the physician 

3 specialty societies, applicable practitioner orga4 nizations, and other stakeholders, including rep5 resentatives of individuals entitled to benefits 

6 under part A or enrolled under this part, re7 garding the resource use methodology estab8 lished pursuant to this paragraph. In seeking 

9 comments the Secretary shall use one or more 

10 mechanisms (other than notice and comment 

11 rulemaking) that may include open door fo12 rums, town hall meetings, or other appropriate 

13 mechanisms. 

14 ‘‘(6) IMPLEMENTATION.—To the extent that 

15 the Secretary contracts with an entity to carry out 

16 any part of the provisions of this subsection, the 

17 Secretary may not contract with an entity or an en18 tity with a subcontract if the entity or subcon19 tracting entity currently makes recommendations to 

20 the Secretary on relative values for services under 

21 the fee schedule for physicians’ services under this 

22 section. 

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

25 1878, or otherwise of— 


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1 ‘‘(A) care episode and patient condition 

2 groups and codes established under paragraph 

3 (2); 

4 ‘‘(B) patient relationship categories and 

5 codes established under paragraph (3); and 

6 ‘‘(C) measurement of, and analyses of re7 source use with respect to, care episode and pa8 tient condition codes and patient relationship 

9 codes pursuant to paragraph (5). 

10 ‘‘(8) ADMINISTRATION.—Chapter 35 of title 44, 

11 United States Code, shall not apply to this section. 

12 ‘‘(9) DEFINITIONS.—In this section: 

13 ‘‘(A) PHYSICIAN.—The term ‘physician’ 

14 has the meaning given such term in section 

15 1861(r)(1). 

16 ‘‘(B) APPLICABLE PRACTITIONER.—The 

17 term ‘applicable practitioner’ means— 

18 ‘‘(i) a physician assistant, nurse prac19 titioner, and clinical nurse specialist (as 

20 such terms are defined in section 

21 1861(aa)(5)), and a certified registered 

22 nurse anesthetist (as defined in section 

23 1861(bb)(2)); and 

24 ‘‘(ii) beginning January 1, 2018, such 

25 other eligible professionals (as defined in 


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1 subsection (k)(3)(B)) as specified by the 

2 Secretary. 

3 ‘‘(10) CLARIFICATION.—The provisions of sec4 tions 1890(b)(7) and 1890A shall not apply to this 

5 subsection.’’. 

6 SEC. 102. PRIORITIES AND FUNDING FOR MEASURE DEVEL7 OPMENT. 

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

9 1395w–4), as amended by subsections (c) and (g) of sec10 tion 101, is further amended by inserting at the end the 

11 following new subsection: 

12 ‘‘(s) PRIORITIES AND FUNDING FOR MEASURE DE13 VELOPMENT.— 

14 ‘‘(1) PLAN IDENTIFYING MEASURE DEVELOP15 MENT PRIORITIES AND TIMELINES.— 

16 ‘‘(A) DRAFT MEASURE DEVELOPMENT

17 PLAN.—Not later than January 1, 2015, the 

18 Secretary shall develop, and post on the Inter19 net website of the Centers for Medicare & Med20 icaid Services, a draft plan for the development 

21 of quality measures for application under the 

22 applicable provisions (as defined in paragraph 

23 (5)). Under such plan the Secretary shall— 

24 ‘‘(i) address how measures used by 

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1 tems could be incorporated under title 

2 XVIII; 

3 ‘‘(ii) describe how coordination, to the 

4 extent possible, will occur across organiza5 tions developing such measures; and 

6 ‘‘(iii) take into account how clinical 

7 best practices and clinical practice guide8 lines should be used in the development of 

9 quality measures. 

10 ‘‘(B) QUALITY DOMAINS.—For purposes of 

11 this subsection, the term ‘quality domains’ 

12 means at least the following domains: 

13 ‘‘(i) Clinical care. 

14 ‘‘(ii) Safety. 

15 ‘‘(iii) Care coordination. 

16 ‘‘(iv) Patient and caregiver experience. 

17 ‘‘(v) Population health and preven18 tion. 

19 ‘‘(C) CONSIDERATION.—In developing the 

20 draft plan under this paragraph, the Secretary 

21 shall consider— 

22 ‘‘(i) gap analyses conducted by the en23 tity with a contract under section 1890(a) 

24 or other contractors or entities; 


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1 ‘‘(ii) whether measures are applicable 

2 across health care settings; 

3 ‘‘(iii) clinical practice improvement ac4 tivities submitted under subsection 

5 (q)(2)(C)(iv) for identifying possible areas 

6 for future measure development and identi7 fying existing gaps with respect to such 

8 measures; and 

9 ‘‘(iv) the quality domains applied 

10 under this subsection. 

11 ‘‘(D) PRIORITIES.—In developing the draft 

12 plan under this paragraph, the Secretary shall 

13 give priority to the following types of measures: 

14 ‘‘(i) Outcome measures, including pa15 tient reported outcome and functional sta16 tus measures. 

17 ‘‘(ii) Patient experience measures. 

18 ‘‘(iii) Care coordination measures. 

19 ‘‘(iv) Measures of appropriate use of 

20 services, including measures of over use. 

21 ‘‘(E) STAKEHOLDER INPUT.—The Sec22 retary shall accept through March 1, 2015, 

23 comments on the draft plan posted under para24 graph (1)(A) from the public, including health 


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1 care providers, payers, consumers, and other 

2 stakeholders. 

3 ‘‘(F) FINAL MEASURE DEVELOPMENT

4 PLAN.—Not later than May 1, 2015, taking 

5 into account the comments received under this 

6 subparagraph, the Secretary shall finalize the 

7 plan and post on the Internet website of the 

8 Centers for Medicare & Medicaid Services an 

9 operational plan for the development of quality 

10 measures for use under the applicable provi11 sions. Such plan shall be updated as appro12 priate. 

13 ‘‘(2) CONTRACTS AND OTHER ARRANGEMENTS

14 FOR QUALITY MEASURE DEVELOPMENT.— 

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

16 enter into contracts or other arrangements with 

17 entities for the purpose of developing, improv18 ing, updating, or expanding in accordance with 

19 the plan under paragraph (1) quality measures 

20 for application under the applicable provisions. 

21 Such entities shall include organizations with 

22 quality measure development expertise. 

23 ‘‘(B) PRIORITIZATION.— 

24 ‘‘(i) IN GENERAL.—In entering into 

25 contracts or other arrangements under 


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1 subparagraph (A), the Secretary shall give 

2 priority to the development of the types of 

3 measures described in paragraph (1)(D). 

4 ‘‘(ii) CONSIDERATION.—In selecting 

5 measures for development under this sub6 section, the Secretary shall consider— 

7 ‘‘(I) whether such measures 

8 would be electronically specified; and 

9 ‘‘(II) clinical practice guidelines 

10 to the extent that such guidelines 

11 exist. 

12 ‘‘(3) ANNUAL REPORT BY THE SECRETARY.— 

13 ‘‘(A) IN GENERAL.—Not later than May 1, 

14 2016, and annually thereafter, the Secretary 

15 shall post on the Internet website of the Cen16 ters for Medicare & Medicaid Services a report 

17 on the progress made in developing quality 

18 measures for application under the applicable 

19 provisions. 

20 ‘‘(B) REQUIREMENTS.—Each report sub21 mitted pursuant to subparagraph (A) shall in22 clude the following: 

23 ‘‘(i) A description of the Secretary’s 

24 efforts to implement this paragraph. 


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1 ‘‘(ii) With respect to the measures de2 veloped during the previous year— 

3 ‘‘(I) a description of the total 

4 number of quality measures developed 

5 and the types of such measures, such 

6 as an outcome or patient experience 

7 measure; 

8 ‘‘(II) the name of each measure 

9 developed; 

10 ‘‘(III) the name of the developer 

11 and steward of each measure; 

12 ‘‘(IV) with respect to each type 

13 of measure, an estimate of the total 

14 amount expended under this title to 

15 develop all measures of such type; and 

16 ‘‘(V) whether the measure would 

17 be electronically specified. 

18 ‘‘(iii) With respect to measures in de19 velopment at the time of the report— 

20 ‘‘(I) the information described in 

21 clause (ii), if available; and 

22 ‘‘(II) a timeline for completion of 

23 the development of such measures. 

24 ‘‘(iv) A description of any updates to 

25 the plan under paragraph (1) (including 


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1 newly identified gaps and the status of pre2 viously identified gaps) and the inventory 

3 of measures applicable under the applicable 

4 provisions. 

5 ‘‘(v) Other information the Secretary 

6 determines to be appropriate. 

7 ‘‘(4) STAKEHOLDER INPUT.—With respect to 

8 paragraph (1), the Secretary shall seek stakeholder 

9 input with respect to— 

10 ‘‘(A) the identification of gaps where no 

11 quality measures exist, particularly with respect 

12 to the types of measures described in paragraph 

13 (1)(D); 

14 ‘‘(B) prioritizing quality measure develop15 ment to address such gaps; and 

16 ‘‘(C) other areas related to quality measure 

17 development determined appropriate by the Sec18 retary. 

19 ‘‘(5) DEFINITION OF APPLICABLE PROVI20 SIONS.—In this subsection, the term ‘applicable pro21 visions’ means the following provisions: 

22 ‘‘(A) Subsection (q)(2)(B)(i). 

23 ‘‘(B) Section 1833(z)(2)(C). 

24 ‘‘(6) FUNDING.—For purposes of carrying out 

25 this subsection, the Secretary shall provide for the 


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1 transfer, from the Federal Supplementary Medical 

2 Insurance Trust Fund under section 1841, of 

3 $15,000,000 to the Centers for Medicare & Medicaid 

4 Services Program Management Account for each of 

5 fiscal years 2014 through 2018. Amounts trans6 ferred under this paragraph shall remain available 

7 through the end of fiscal year 2021.’’. 

8 SEC. 103. ENCOURAGING CARE MANAGEMENT FOR INDI9 VIDUALS WITH CHRONIC CARE NEEDS. 

10 (a) IN GENERAL.—Section 1848(b) of the Social Se11 curity Act (42 U.S.C. 1395w–4(b)) is amended by adding 

12 at the end the following new paragraph: 

13 ‘‘(8) ENCOURAGING CARE MANAGEMENT FOR

14 INDIVIDUALS WITH CHRONIC CARE NEEDS.— 

15 ‘‘(A) IN GENERAL.—In order to encourage 

16 the management of care by an applicable pro17 vider (as defined in subparagraph (B)) for indi18 viduals with chronic care needs the Secretary 

19 shall— 

20 ‘‘(i) establish one or more HCPCS 

21 codes for chronic care management serv22 ices for such individuals; and 

23 ‘‘(ii) subject to subparagraph (D), 

24 make payment (as the Secretary deter25 mines to be appropriate) under this section 


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1 for such management services furnished on 

2 or after January 1, 2015, by an applicable 

3 provider. 

4 ‘‘(B) APPLICABLE PROVIDER DEFINED.— 

5 For purposes of this paragraph, the term ‘ap6 plicable provider’ means a physician (as defined 

7 in section 1861(r)(1)), physician assistant or 

8 nurse practitioner (as defined in section 

9 1861(aa)(5)(A)), or clinical nurse specialist (as 

10 defined in section 1861(aa)(5)(B)) who fur11 nishes services as part of a patient-centered 

12 medical home or a comparable specialty practice 

13 that— 

14 ‘‘(i) is recognized as such a medical 

15 home or comparable specialty practice by 

16 an organization that is recognized by the 

17 Secretary for purposes of such recognition 

18 as such a medical home or practice; or 

19 ‘‘(ii) meets such other comparable 

20 qualifications as the Secretary determines 

21 to be appropriate. 

22 ‘‘(C) BUDGET NEUTRALITY.—The budget 

23 neutrality provision under subsection 

24 (c)(2)(B)(ii)(II) shall apply in establishing the 

25 payment under subparagraph (A)(ii). 


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1 ‘‘(D) POLICIES RELATING TO PAYMENT.— 

2 In carrying out this paragraph, with respect to 

3 chronic care management services, the Sec4 retary shall— 

5 ‘‘(i) make payment to only one appli6 cable provider for such services furnished 

7 to an individual during a period; 

8 ‘‘(ii) not make payment under sub9 paragraph (A) if such payment would be 

10 duplicative of payment that is otherwise 

11 made under this title for such services 

12 (such as in the case of hospice care or 

13 home health services); and 

14 ‘‘(iii) not require that an annual 

15 wellness visit (as defined in section 

16 1861(hhh)) or an initial preventive phys17 ical examination (as defined in section 

18 1861(ww)) be furnished as a condition of 

19 payment for such management services.’’. 

20 (b) EDUCATION AND OUTREACH.— 

21 (1) CAMPAIGN.— 

22 (A) IN GENERAL.—The Secretary of 

23 Health and Human Services (in this subsection 

24 referred to as the ‘‘Secretary’’) shall conduct an 

25 education and outreach campaign to inform 


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1 professionals who furnish items and services 

2 under part B of title XVIII of the Social Secu3 rity Act and individuals enrolled under such 

4 part of the benefits of chronic care management 

5 services described in section 1848(b)(8) of the 

6 Social Security Act, as added by subsection (a), 

7 and encourage such individuals with chronic 

8 care needs to receive such services. 

9 (B) REQUIREMENTS.—Such campaign 

10 shall— 

11 (i) be directed by the Office of Rural 

12 Health Policy of the Department of Health 

13 and Human Services and the Office of Mi14 nority Health of the Centers for Medicare 

15 & Medicaid Services; and 

16 (ii) focus on encouraging participation 

17 by underserved rural populations and ra18 cial and ethnic minority populations. 

19 (2) REPORT.— 

20 (A) IN GENERAL.—Not later than Decem21 ber 31, 2017, the Secretary shall submit to 

22 Congress a report on the use of chronic care 

23 management services described in such section 

24 1848(b)(8) by individuals living in rural areas 


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1 and by racial and ethnic minority populations. 

2 Such report shall— 

3 (i) identify barriers to receiving chron4 ic care management services; and 

5 (ii) make recommendations for in6 creasing the appropriate use of chronic 

7 care management services. 

8 SEC. 104. ENSURING ACCURATE VALUATION OF SERVICES 

9 UNDER THE PHYSICIAN FEE SCHEDULE. 

10 (a) AUTHORITY TO COLLECT AND USE INFORMA11 TION ON PHYSICIANS’ SERVICES IN THE DETERMINATION

12 OF RELATIVE VALUES.— 

13 (1) IN GENERAL.—Section 1848(c)(2) of the 

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

15 amended by adding at the end the following new 

16 subparagraph: 

17 ‘‘(M) AUTHORITY TO COLLECT AND USE

18 INFORMATION ON PHYSICIANS’ SERVICES IN

19 THE DETERMINATION OF RELATIVE VALUES.— 

20 ‘‘(i) COLLECTION OF INFORMATION.— 

21 Notwithstanding any other provision of 

22 law, the Secretary may collect or obtain in23 formation on the resources directly or indi24 rectly related to furnishing services for 

25 which payment is made under the fee 


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1 schedule established under subsection (b). 

2 Such information may be collected or ob3 tained from any eligible professional or any 

4 other source. 

5 ‘‘(ii) USE OF INFORMATION.—Not6 withstanding any other provision of law, 

7 subject to clause (v), the Secretary may 

8 (as the Secretary determines appropriate) 

9 use information collected or obtained pur10 suant to clause (i) in the determination of 

11 relative values for services under this sec12 tion. 

13 ‘‘(iii) TYPES OF INFORMATION.—The 

14 types of information described in clauses 

15 (i) and (ii) may, at the Secretary’s discre16 tion, include any or all of the following: 

17 ‘‘(I) Time involved in furnishing 

18 services. 

19 ‘‘(II) Amounts and types of prac20 tice expense inputs involved with fur21 nishing services. 

22 ‘‘(III) Prices (net of any dis23 counts) for practice expense inputs, 

24 which may include paid invoice prices 

25 or other documentation or records. 


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1 ‘‘(IV) Overhead and accounting 

2 information for practices of physicians 

3 and other suppliers. 

4 ‘‘(V) Any other element that 

5 would improve the valuation of serv6 ices under this section. 

7 ‘‘(iv) INFORMATION COLLECTION

8 MECHANISMS.—Information may be col9 lected or obtained pursuant to this sub10 paragraph from any or all of the following: 

11 ‘‘(I) Surveys of physicians, other 

12 suppliers, providers of services, manu13 facturers, and vendors. 

14 ‘‘(II) Surgical logs, billing sys15 tems, or other practice or facility 

16 records. 

17 ‘‘(III) Electronic health records. 

18 ‘‘(IV) Any other mechanism de19 termined appropriate by the Sec20 retary. 

21 ‘‘(v) TRANSPARENCY OF USE OF IN22 FORMATION.— 

23 ‘‘(I) IN GENERAL.—Subject to 

24 subclauses (II) and (III), if the Sec25 retary uses information collected or 


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1 obtained under this subparagraph in 

2 the determination of relative values 

3 under this subsection, the Secretary 

4 shall disclose the information source 

5 and discuss the use of such informa6 tion in such determination of relative 

7 values through notice and comment 

8 rulemaking. 

9 ‘‘(II) THRESHOLDS FOR USE.— 

10 The Secretary may establish thresh11 olds in order to use such information, 

12 including the exclusion of information 

13 collected or obtained from eligible pro14 fessionals who use very high resources 

15 (as determined by the Secretary) in 

16 furnishing a service. 

17 ‘‘(III) DISCLOSURE OF INFORMA18 TION.—The Secretary shall make ag19 gregate information available under 

20 this subparagraph but shall not dis21 close information in a form or manner 

22 that identifies an eligible professional 

23 or a group practice, or information 

24 collected or obtained pursuant to a 

25 nondisclosure agreement. 


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1 ‘‘(vi) INCENTIVE TO PARTICIPATE.— 

2 The Secretary may provide for such pay3 ments under this part to an eligible profes4 sional that submits such solicited informa5 tion under this subparagraph as the Sec6 retary determines appropriate in order to 

7 compensate such eligible professional for 

8 such submission. Such payments shall be 

9 provided in a form and manner specified 

10 by the Secretary. 

11 ‘‘(vii) ADMINISTRATION.—Chapter 35 

12 of title 44, United States Code, shall not 

13 apply to information collected or obtained 

14 under this subparagraph. 

15 ‘‘(viii) DEFINITION OF ELIGIBLE PRO16 FESSIONAL.—In this subparagraph, the 

17 term ‘eligible professional’ has the meaning 

18 given such term in subsection (k)(3)(B). 

19 ‘‘(ix) FUNDING.—For purposes of car20 rying out this subparagraph, in addition to 

21 funds otherwise appropriated, the Sec22 retary shall provide for the transfer, from 

23 the Federal Supplementary Medical Insur24 ance Trust Fund under section 1841, of 

25 $2,000,000 to the Centers for Medicare & 


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1 Medicaid Services Program Management 

2 Account for each fiscal year beginning with 

3 fiscal year 2014. Amounts transferred 

4 under the preceding sentence for a fiscal 

5 year shall be available until expended.’’. 

6 (2) LIMITATION ON REVIEW.—Section 

7 1848(i)(1) of the Social Security Act (42 U.S.C. 

8 1395w–4(i)(1)) is amended— 

9 (A) in subparagraph (D), by striking 

10 ‘‘and’’ at the end; 

11 (B) in subparagraph (E), by striking the 

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

13 (C) by adding at the end the following new 

14 subparagraph: 

15 ‘‘(F) the collection and use of information 

16 in the determination of relative values under 

17 subsection (c)(2)(M).’’. 

18 (b) AUTHORITY FOR ALTERNATIVE APPROACHES TO

19 ESTABLISHING PRACTICE EXPENSE RELATIVE VAL20 UES.—Section 1848(c)(2) of the Social Security Act (42 

21 U.S.C. 1395w–4(c)(2)), as amended by subsection (a), is 

22 amended by adding at the end the following new subpara23 graph: 

24 ‘‘(N) AUTHORITY FOR ALTERNATIVE AP25 PROACHES TO ESTABLISHING PRACTICE EXVerDate Mar 15 2010 01:32 Mar 14, 2014 Jkt 039200 PO 00000 Frm 00140 Fmt 6652 Sfmt 6201 E:\BILLS\S2122.PCS S2122

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1 PENSE RELATIVE VALUES.—The Secretary may 

2 establish or adjust practice expense relative val3 ues under this subsection using cost, charge, or 

4 other data from suppliers or providers of serv5 ices, including information collected or obtained 

6 under subparagraph (M).’’. 

7 (c) REVISED AND EXPANDED IDENTIFICATION OF

8 POTENTIALLY MISVALUED CODES.—Section 

9 1848(c)(2)(K)(ii) of the Social Security Act (42 U.S.C. 

10 1395w–4(c)(2)(K)(ii)) is amended to read as follows: 

11 ‘‘(ii) IDENTIFICATION OF POTEN12 TIALLY MISVALUED CODES.—For purposes 

13 of identifying potentially misvalued codes 

14 pursuant to clause (i)(I), the Secretary 

15 shall examine codes (and families of codes 

16 as appropriate) based on any or all of the 

17 following criteria: 

18 ‘‘(I) Codes that have experienced 

19 the fastest growth. 

20 ‘‘(II) Codes that have experi21 enced substantial changes in practice 

22 expenses. 

23 ‘‘(III) Codes that describe new 

24 technologies or services within an ap25 propriate time period (such as 3 


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1 years) after the relative values are ini2 tially established for such codes. 

3 ‘‘(IV) Codes which are multiple 

4 codes that are frequently billed in con5 junction with furnishing a single serv6 ice. 

7 ‘‘(V) Codes with low relative val8 ues, particularly those that are often 

9 billed multiple times for a single treat10 ment. 

11 ‘‘(VI) Codes that have not been 

12 subject to review since implementation 

13 of the fee schedule. 

14 ‘‘(VII) Codes that account for 

15 the majority of spending under the 

16 physician fee schedule. 

17 ‘‘(VIII) Codes for services that 

18 have experienced a substantial change 

19 in the hospital length of stay or proce20 dure time. 

21 ‘‘(IX) Codes for which there may 

22 be a change in the typical site of serv23 ice since the code was last valued. 

24 ‘‘(X) Codes for which there is a 

25 significant difference in payment for 


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1 the same service between different 

2 sites of service. 

3 ‘‘(XI) Codes for which there may 

4 be anomalies in relative values within 

5 a family of codes. 

6 ‘‘(XII) Codes for services where 

7 there may be efficiencies when a serv8 ice is furnished at the same time as 

9 other services. 

10 ‘‘(XIII) Codes with high intra11 service work per unit of time. 

12 ‘‘(XIV) Codes with high practice 

13 expense relative value units. 

14 ‘‘(XV) Codes with high cost sup15 plies. 

16 ‘‘(XVI) Codes as determined ap17 propriate by the Secretary.’’. 

18 (d) TARGET FOR RELATIVE VALUE ADJUSTMENTS

19 FOR MISVALUED SERVICES.— 

20 (1) IN GENERAL.—Section 1848(c)(2) of the 

21 Social Security Act (42 U.S.C. 1395w–4(c)(2)), as 

22 amended by subsections (a) and (b), is amended by 

23 adding at the end the following new subparagraph: 

24 ‘‘(O) TARGET FOR RELATIVE VALUE AD25 JUSTMENTS FOR MISVALUED SERVICES.—With 


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1 respect to fee schedules established for each of 

2 2015 through 2018, the following shall apply: 

3 ‘‘(i) DETERMINATION OF NET REDUC4 TION IN EXPENDITURES.—For each year, 

5 the Secretary shall determine the esti6 mated net reduction in expenditures under 

7 the fee schedule under this section with re8 spect to the year as a result of adjust9 ments to the relative values established 

10 under this paragraph for misvalued codes. 

11 ‘‘(ii) BUDGET NEUTRAL REDISTRIBU12 TION OF FUNDS IF TARGET MET AND

13 COUNTING OVERAGES TOWARDS THE TAR14 GET FOR THE SUCCEEDING YEAR.—If the 

15 estimated net reduction in expenditures de16 termined under clause (i) for the year is 

17 equal to or greater than the target for the 

18 year— 

19 ‘‘(I) reduced expenditures attrib20 utable to such adjustments shall be 

21 redistributed for the year in a budget 

22 neutral manner in accordance with 

23 subparagraph (B)(ii)(II); and 

24 ‘‘(II) the amount by which such 

25 reduced expenditures exceeds the tarVerDate Mar 15 2010 01:32 Mar 14, 2014 Jkt 039200 PO 00000 Frm 00144 Fmt 6652 Sfmt 6201 E:\BILLS\S2122.PCS S2122

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1 get for the year shall be treated as a 

2 reduction in expenditures described in 

3 clause (i) for the succeeding year, for 

4 purposes of determining whether the 

5 target has or has not been met under 

6 this subparagraph with respect to that 

7 year. 

8 ‘‘(iii) EXEMPTION FROM BUDGET

9 NEUTRALITY IF TARGET NOT MET.—If the 

10 estimated net reduction in expenditures de11 termined under clause (i) for the year is 

12 less than the target for the year, reduced 

13 expenditures in an amount equal to the 

14 target recapture amount shall not be taken 

15 into account in applying subparagraph 

16 (B)(ii)(II) with respect to fee schedules be17 ginning with 2015. 

18 ‘‘(iv) TARGET RECAPTURE AMOUNT.— 

19 For purposes of clause (iii), the target re20 capture amount is, with respect to a year, 

21 an amount equal to the difference be22 tween— 

23 ‘‘(I) the target for the year; and 


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1 ‘‘(II) the estimated net reduction 

2 in expenditures determined under 

3 clause (i) for the year. 

4 ‘‘(v) TARGET.—For purposes of this 

5 subparagraph, with respect to a year, the 

6 target is calculated as 0.5 percent of the 

7 estimated amount of expenditures under 

8 the fee schedule under this section for the 

9 year.’’. 

10 (2) CONFORMING AMENDMENT.—Section 

11 1848(c)(2)(B)(v) of the Social Security Act (42 

12 U.S.C. 1395w–4(c)(2)(B)(v)) is amended by adding 

13 at the end the following new subclause: 

14 ‘‘(VIII) REDUCTIONS FOR

15 MISVALUED SERVICES IF TARGET NOT

16 MET.—Effective for fee schedules be17 ginning with 2015, reduced expendi18 tures attributable to the application of 

19 the target recapture amount described 

20 in subparagraph (O)(iii).’’. 

21 (e) PHASE-IN OF SIGNIFICANT RELATIVE VALUE

22 UNIT (RVU) REDUCTIONS.— 

23 (1) IN GENERAL.—Section 1848(c) of the So24 cial Security Act (42 U.S.C. 1395w–4(c)) is amendVerDate Mar 15 2010 01:32 Mar 14, 2014 Jkt 039200 PO 00000 Frm 00146 Fmt 6652 Sfmt 6201 E:\BILLS\S2122.PCS S2122

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1 ed by adding at the end the following new para2 graph: 

3 ‘‘(7) PHASE-IN OF SIGNIFICANT RELATIVE

4 VALUE UNIT (RVU) REDUCTIONS.—Effective for fee 

5 schedules established beginning with 2015, if the 

6 total relative value units for a service for a year 

7 would otherwise be decreased by an estimated 

8 amount equal to or greater than 20 percent as com9 pared to the total relative value units for the pre10 vious year, the applicable adjustments in work, prac11 tice expense, and malpractice relative value units 

12 shall be phased-in over a 2-year period.’’. 

13 (2) CONFORMING AMENDMENTS.—Section 

14 1848(c)(2) of the Social Security Act (42 U.S.C. 

15 1395w–4(c)(2)) is amended— 

16 (A) in subparagraph (B)(ii)(I), by striking 

17 ‘‘subclause (II)’’ and inserting ‘‘subclause (II) 

18 and paragraph (7)’’; and 

19 (B) in subparagraph (K)(iii)(VI)— 

20 (i) by striking ‘‘provisions of subpara21 graph (B)(ii)(II)’’ and inserting ‘‘provi22 sions of subparagraph (B)(ii)(II) and para23 graph (7)’’; and 


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1 (ii) by striking ‘‘under subparagraph 

2 (B)(ii)(II)’’ and inserting ‘‘under subpara3 graph (B)(ii)(I)’’. 

4 (f) AUTHORITY TO SMOOTH RELATIVE VALUES

5 WITHIN GROUPS OF SERVICES.—Section 1848(c)(2)(C) of 

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

7 amended— 

8 (1) in each of clauses (i) and (iii), by striking 

9 ‘‘the service’’ and inserting ‘‘the service or group of 

10 services’’ each place it appears; and 

11 (2) in the first sentence of clause (ii), by insert12 ing ‘‘or group of services’’ before the period. 

13 (g) GAO STUDY AND REPORT ON RELATIVE VALUE

14 SCALE UPDATE COMMITTEE.— 

15 (1) STUDY.—The Comptroller General of the 

16 United States (in this subsection referred to as the 

17 ‘‘Comptroller General’’) shall conduct a study of the 

18 processes used by the Relative Value Scale Update 

19 Committee (RUC) to provide recommendations to 

20 the Secretary of Health and Human Services regard21 ing relative values for specific services under the 

22 Medicare physician fee schedule under section 1848 

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

24 (2) REPORT.—Not later than 1 year after the 

25 date of the enactment of this Act, the Comptroller 


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1 General shall submit to Congress a report containing 

2 the results of the study conducted under paragraph 

3 (1). 

4 (h) ADJUSTMENT TO MEDICARE PAYMENT LOCAL5 ITIES.— 

6 (1) IN GENERAL.—Section 1848(e) of the So7 cial Security Act (42 U.S.C. 1395w–4(e)) is amend8 ed by adding at the end the following new para9 graph: 

10 ‘‘(6) USE OF MSAS AS FEE SCHEDULE AREAS IN

11 CALIFORNIA.— 

12 ‘‘(A) IN GENERAL.—Subject to the suc13 ceeding provisions of this paragraph and not14 withstanding the previous provisions of this 

15 subsection, for services furnished on or after 

16 January 1, 2017, the fee schedule areas used 

17 for payment under this section applicable to 

18 California shall be the following: 

19 ‘‘(i) Each Metropolitan Statistical 

20 Area (each in this paragraph referred to as 

21 an ‘MSA’), as defined by the Director of 

22 the Office of Management and Budget as 

23 of December 31 of the previous year, shall 

24 be a fee schedule area. 


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1 ‘‘(ii) All areas not included in an MSA 

2 shall be treated as a single rest-of-State 

3 fee schedule area. 

4 ‘‘(B) TRANSITION FOR MSAS PREVIOUSLY

5 IN REST-OF-STATE PAYMENT LOCALITY OR IN

6 LOCALITY 3.— 

7 ‘‘(i) IN GENERAL.—For services fur8 nished in California during a year begin9 ning with 2017 and ending with 2021 in 

10 an MSA in a transition area (as defined in 

11 subparagraph (D)), subject to subpara12 graph (C), the geographic index values to 

13 be applied under this subsection for such 

14 year shall be equal to the sum of the fol15 lowing: 

16 ‘‘(I) CURRENT LAW COMPO17 NENT.—The old weighting factor (de18 scribed in clause (ii)) for such year 

19 multiplied by the geographic index 

20 values under this subsection for the 

21 fee schedule area that included such 

22 MSA that would have applied in such 

23 area (as estimated by the Secretary) 

24 if this paragraph did not apply. 


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1 ‘‘(II) MSA-BASED COMPO2 NENT.—The MSA-based weighting 

3 factor (described in clause (iii)) for 

4 such year multiplied by the geographic 

5 index values computed for the fee 

6 schedule area under subparagraph (A) 

7 for the year (determined without re8 gard to this subparagraph). 

9 ‘‘(ii) OLD WEIGHTING FACTOR.—The 

10 old weighting factor described in this 

11 clause— 

‘‘(I) for 2017, is 5 12 ⁄6; and 

13 ‘‘(II) for each succeeding year, is 

14 the old weighting factor described in 

15 this clause for the previous year 

minus 1 16 ⁄6. 

17 ‘‘(iii) MSA-BASED WEIGHTING FAC18 TOR.—The MSA-based weighting factor 

19 described in this clause for a year is 1 

20 minus the old weighting factor under 

21 clause (ii) for that year. 

22 ‘‘(C) HOLD HARMLESS.—For services fur23 nished in a transition area in California during 

24 a year beginning with 2017, the geographic 

25 index values to be applied under this subsection 


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1 for such year shall not be less than the cor2 responding geographic index values that would 

3 have applied in such transition area (as esti4 mated by the Secretary) if this paragraph did 

5 not apply. 

6 ‘‘(D) TRANSITION AREA DEFINED.—In 

7 this paragraph, the term ‘transition area’ 

8 means each of the following fee schedule areas 

9 for 2013: 

10 ‘‘(i) The rest-of-State payment local11 ity. 

12 ‘‘(ii) Payment locality 3. 

13 ‘‘(E) REFERENCES TO FEE SCHEDULE

14 AREAS.—Effective for services furnished on or 

15 after January 1, 2017, for California, any ref16 erence in this section to a fee schedule area 

17 shall be deemed a reference to a fee schedule 

18 area established in accordance with this para19 graph.’’. 

20 (2) CONFORMING AMENDMENT TO DEFINITION

21 OF FEE SCHEDULE AREA.—Section 1848(j)(2) of the 

22 Social Security Act (42 U.S.C. 1395w–4(j)(2)) is 

23 amended by striking ‘‘The term’’ and inserting ‘‘Ex24 cept as provided in subsection (e)(6)(D), the term’’. 


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1 (i) DISCLOSURE OF DATA USED TO ESTABLISH

2 MULTIPLE PROCEDURE PAYMENT REDUCTION POLICY.— 

3 The Secretary of Health and Human Services shall make 

4 publicly available the information used to establish the 

5 multiple procedure payment reduction policy to the profes6 sional component of imaging services in the final rule pub7 lished in the Federal Register, v. 77, n. 222, November 

8 16, 2012, pages 68891–69380 under the physician fee 

9 schedule under section 1848 of the Social Security Act (42 

10 U.S.C. 1395w–4). 

11 SEC. 105. PROMOTING EVIDENCE-BASED CARE. 

12 (a) IN GENERAL.—Section 1834 of the Social Secu13 rity Act (42 U.S.C. 1395m) is amended by adding at the 

14 end the following new subsection: 

15 ‘‘(p) RECOGNIZING APPROPRIATE USE CRITERIA FOR

16 CERTAIN IMAGING SERVICES.— 

17 ‘‘(1) PROGRAM ESTABLISHED.— 

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

19 establish a program to promote the use of ap20 propriate use criteria (as defined in subpara21 graph (B)) for applicable imaging services (as 

22 defined in subparagraph (C)) furnished in an 

23 applicable setting (as defined in subparagraph 

24 (D)) by ordering professionals and furnishing 


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1 professionals (as defined in subparagraphs (E) 

2 and (F), respectively). 

3 ‘‘(B) APPROPRIATE USE CRITERIA DE4 FINED.—In this subsection, the term ‘appro5 priate use criteria’ means criteria, only devel6 oped or endorsed by national professional med7 ical specialty societies or other provider-led enti8 ties, to assist ordering professionals and fur9 nishing professionals in making the most appro10 priate treatment decision for a specific clinical 

11 condition. To the extent feasible, such criteria 

12 shall be evidence-based. 

13 ‘‘(C) APPLICABLE IMAGING SERVICE DE14 FINED.—In this subsection, the term ‘applicable 

15 imaging service’ means an advanced diagnostic 

16 imaging service (as defined in subsection 

17 (e)(1)(B)) for which the Secretary determines— 

18 ‘‘(i) one or more applicable appro19 priate use criteria specified under para20 graph (2) apply; 

21 ‘‘(ii) there are one or more qualified 

22 clinical decision support mechanisms listed 

23 under paragraph (3)(C); and 

24 ‘‘(iii) one or more of such mechanisms 

25 is available free of charge. 


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1 ‘‘(D) APPLICABLE SETTING DEFINED.—In 

2 this subsection, the term ‘applicable setting’ 

3 means a physician’s office, a hospital outpatient 

4 department (including an emergency depart5 ment), an ambulatory surgical center, and any 

6 other provider-led outpatient setting determined 

7 appropriate by the Secretary. 

8 ‘‘(E) ORDERING PROFESSIONAL DE9 FINED.—In this subsection, the term ‘ordering 

10 professional’ means a physician (as defined in 

11 section 1861(r)) or a practitioner described in 

12 section 1842(b)(18)(C) who orders an applica13 ble imaging service for an individual. 

14 ‘‘(F) FURNISHING PROFESSIONAL DE15 FINED.—In this subsection, the term ‘fur16 nishing professional’ means a physician (as de17 fined in section 1861(r)) or a practitioner de18 scribed in section 1842(b)(18)(C) who furnishes 

19 an applicable imaging service for an individual. 

20 ‘‘(2) ESTABLISHMENT OF APPLICABLE APPRO21 PRIATE USE CRITERIA.— 

22 ‘‘(A) IN GENERAL.—Not later than No23 vember 15, 2015, the Secretary shall through 

24 rulemaking, and in consultation with physi25 cians, practitioners, and other stakeholders, 


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1 specify applicable appropriate use criteria for 

2 applicable imaging services only from among 

3 appropriate use criteria developed or endorsed 

4 by national professional medical specialty soci5 eties or other provider-led entities. 

6 ‘‘(B) CONSIDERATIONS.—In specifying ap7 plicable appropriate use criteria under subpara8 graph (A), the Secretary shall take into account 

9 whether the criteria— 

10 ‘‘(i) have stakeholder consensus; 

11 ‘‘(ii) are scientifically valid and evi12 dence based; and 

13 ‘‘(iii) are based on studies that are 

14 published and reviewable by stakeholders. 

15 ‘‘(C) REVISIONS.—The Secretary shall re16 view, on an annual basis, the specified applica17 ble appropriate use criteria to determine if 

18 there is a need to update or revise (as appro19 priate) such specification of applicable appro20 priate use criteria and make such updates or 

21 revisions through rulemaking. 

22 ‘‘(D) TREATMENT OF MULTIPLE APPLICA23 BLE APPROPRIATE USE CRITERIA.—In the case 

24 where the Secretary determines that more than 

25 one appropriate use criteria applies with respect 


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1 to an applicable imaging service, the Secretary 

2 shall permit one or more applicable appropriate 

3 use criteria under this paragraph for the serv4 ice. 

5 ‘‘(3) MECHANISMS FOR CONSULTATION WITH

6 APPLICABLE APPROPRIATE USE CRITERIA.— 

7 ‘‘(A) IDENTIFICATION OF MECHANISMS TO

8 CONSULT WITH APPLICABLE APPROPRIATE USE

9 CRITERIA.— 

10 ‘‘(i) IN GENERAL.—The Secretary 

11 shall specify qualified clinical decision sup12 port mechanisms that could be used by or13 dering professionals to consult with appli14 cable appropriate use criteria for applicable 

15 imaging services. 

16 ‘‘(ii) CONSULTATION.—The Secretary 

17 shall consult with physicians, practitioners, 

18 health care technology experts, and other 

19 stakeholders in specifying mechanisms 

20 under this paragraph. 

21 ‘‘(iii) INCLUSION OF CERTAIN MECHA22 NISMS.—Mechanisms specified under this 

23 paragraph may include any or all of the 

24 following that meet the requirements de25 scribed in subparagraph (B)(ii): 


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1 ‘‘(I) Use of clinical decision sup2 port modules in certified EHR tech3 nology (as defined in section 

4 1848(o)(4)). 

5 ‘‘(II) Use of private sector clin6 ical decision support mechanisms that 

7 are independent from certified EHR 

8 technology, which may include use of 

9 clinical decision support mechanisms 

10 available from medical specialty orga11 nizations. 

12 ‘‘(III) Use of a clinical decision 

13 support mechanism established by the 

14 Secretary. 

15 ‘‘(B) QUALIFIED CLINICAL DECISION SUP16 PORT MECHANISMS.— 

17 ‘‘(i) IN GENERAL.—For purposes of 

18 this subsection, a qualified clinical decision 

19 support mechanism is a mechanism that 

20 the Secretary determines meets the re21 quirements described in clause (ii). 

22 ‘‘(ii) REQUIREMENTS.—The require23 ments described in this clause are the fol24 lowing: 


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1 ‘‘(I) The mechanism makes avail2 able to the ordering professional appli3 cable appropriate use criteria specified 

4 under paragraph (2) and the sup5 porting documentation for the applica6 ble imaging service ordered. 

7 ‘‘(II) In the case where there are 

8 more than one applicable appropriate 

9 use criteria specified under such para10 graph for an applicable imaging serv11 ice, the mechanism indicates the cri12 teria that it uses for the service. 

13 ‘‘(III) The mechanism determines 

14 the extent to which an applicable im15 aging service ordered is consistent 

16 with the applicable appropriate use 

17 criteria so specified. 

18 ‘‘(IV) The mechanism generates 

19 and provides to the ordering profes20 sional a certification or documentation 

21 that documents that the qualified clin22 ical decision support mechanism was 

23 consulted by the ordering professional. 

24 ‘‘(V) The mechanism is updated 

25 on a timely basis to reflect revisions 


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1 to the specification of applicable ap2 propriate use criteria under such 

3 paragraph. 

4 ‘‘(VI) The mechanism meets pri5 vacy and security standards under ap6 plicable provisions of law. 

7 ‘‘(VII) The mechanism performs 

8 such other functions as specified by 

9 the Secretary, which may include a re10 quirement to provide aggregate feed11 back to the ordering professional. 

12 ‘‘(C) LIST OF MECHANISMS FOR CON13 SULTATION WITH APPLICABLE APPROPRIATE

14 USE CRITERIA.— 

15 ‘‘(i) INITIAL LIST.—Not later than 

16 April 1, 2016, the Secretary shall publish 

17 a list of mechanisms specified under this 

18 paragraph. 

19 ‘‘(ii) PERIODIC UPDATING OF LIST.— 

20 The Secretary shall identify on an annual 

21 basis the list of qualified clinical decision 

22 support mechanisms specified under this 

23 paragraph. 

24 ‘‘(4) CONSULTATION WITH APPLICABLE APPRO25 PRIATE USE CRITERIA.— 


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1 ‘‘(A) CONSULTATION BY ORDERING PRO2 FESSIONAL.—Beginning with January 1, 2017, 

3 subject to subparagraph (C), with respect to an 

4 applicable imaging service ordered by an order5 ing professional that would be furnished in an 

6 applicable setting and paid for under an appli7 cable payment system (as defined in subpara8 graph (D)), an ordering professional shall— 

9 ‘‘(i) consult with a qualified decision 

10 support mechanism listed under paragraph 

11 (3)(C); and 

12 ‘‘(ii) provide to the furnishing profes13 sional the information described in clauses 

14 (i) through (iii) of subparagraph (B). 

15 ‘‘(B) REPORTING BY FURNISHING PROFES16 SIONAL.—Beginning with January 1, 2017, 

17 subject to subparagraph (C), with respect to an 

18 applicable imaging service furnished in an ap19 plicable setting and paid for under an applica20 ble payment system (as defined in subpara21 graph (D)), payment for such service may only 

22 be made if the claim for the service includes the 

23 following: 

24 ‘‘(i) Information about which qualified 

25 clinical decision support mechanism was 


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1 consulted by the ordering professional for 

2 the service. 

3 ‘‘(ii) Information regarding— 

4 ‘‘(I) whether the service ordered 

5 would adhere to the applicable appro6 priate use criteria specified under 

7 paragraph (2); 

8 ‘‘(II) whether the service ordered 

9 would not adhere to such criteria; or 

10 ‘‘(III) whether such criteria was 

11 not applicable to the service ordered. 

12 ‘‘(iii) The national provider identifier 

13 of the ordering professional (if different 

14 from the furnishing professional). 

15 ‘‘(C) EXCEPTIONS.—The provisions of sub16 paragraphs (A) and (B) and paragraph (6)(A) 

17 shall not apply to the following: 

18 ‘‘(i) EMERGENCY SERVICES.—An ap19 plicable imaging service ordered for an in20 dividual with an emergency medical condi21 tion (as defined in section 1867(e)(1)). 

22 ‘‘(ii) INPATIENT SERVICES.—An appli23 cable imaging service ordered for an inpa24 tient and for which payment is made under 

25 part A. 


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1 ‘‘(iii) ALTERNATIVE PAYMENT MOD2 ELS.—An applicable imaging service or3 dered by an ordering professional with re4 spect to an individual attributed to an al5 ternative payment model (as defined in 

6 section 1833(z)(3)(C)). 

7 ‘‘(iv) SIGNIFICANT HARDSHIP.—An 

8 applicable imaging service ordered by an 

9 ordering professional who the Secretary 

10 may, on a case-by-case basis, exempt from 

11 the application of such provisions if the 

12 Secretary determines, subject to annual re13 newal, that consultation with applicable ap14 propriate use criteria would result in a sig15 nificant hardship, such as in the case of a 

16 professional who practices in a rural area 

17 without sufficient Internet access. 

18 ‘‘(D) APPLICABLE PAYMENT SYSTEM DE19 FINED.—In this subsection, the term ‘applicable 

20 payment system’ means the following: 

21 ‘‘(i) The physician fee schedule estab22 lished under section 1848(b). 

23 ‘‘(ii) The prospective payment system 

24 for hospital outpatient department services 

25 under section 1833(t). 


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1 ‘‘(iii) The ambulatory surgical center 

2 payment systems under section 1833(i). 

3 ‘‘(5) IDENTIFICATION OF OUTLIER ORDERING

4 PROFESSIONALS.— 

5 ‘‘(A) IN GENERAL.—With respect to appli6 cable imaging services furnished beginning with 

7 2017, the Secretary shall determine, on an an8 nual basis, no more than five percent of the 

9 total number of ordering professionals who are 

10 outlier ordering professionals. 

11 ‘‘(B) OUTLIER ORDERING PROFES12 SIONALS.—The determination of an outlier or13 dering professional shall— 

14 ‘‘(i) be based on low adherence to ap15 plicable appropriate use criteria specified 

16 under paragraph (2), which may be based 

17 on comparison to other ordering profes18 sionals; and 

19 ‘‘(ii) include data for ordering profes20 sionals for whom prior authorization under 

21 paragraph (6)(A) applies. 

22 ‘‘(C) USE OF TWO YEARS OF DATA.—The 

23 Secretary shall use two years of data to identify 

24 outlier ordering professionals under this para25 graph. 


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1 ‘‘(D) PROCESS.—The Secretary shall es2 tablish a process for determining when an 

3 outlier ordering professional is no longer an 

4 outlier ordering professional. 

5 ‘‘(E) CONSULTATION WITH STAKE6 HOLDERS.—The Secretary shall consult with 

7 physicians, practitioners and other stakeholders 

8 in developing methods to identify outlier order9 ing professionals under this paragraph. 

10 ‘‘(6) PRIOR AUTHORIZATION FOR ORDERING

11 PROFESSIONALS WHO ARE OUTLIERS.— 

12 ‘‘(A) IN GENERAL.—Beginning January 1, 

13 2020, subject to paragraph (4)(C), with respect 

14 to services furnished during a year, the Sec15 retary shall, for a period determined appro16 priate by the Secretary, apply prior authoriza17 tion for applicable imaging services that are or18 dered by an outlier ordering professional identi19 fied under paragraph (5). 

20 ‘‘(B) APPROPRIATE USE CRITERIA IN

21 PRIOR AUTHORIZATION.—In applying prior au22 thorization under subparagraph (A), the Sec23 retary shall utilize only the applicable appro24 priate use criteria specified under this sub25 section. 


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1 ‘‘(C) FUNDING.—For purposes of carrying 

2 out this paragraph, the Secretary shall provide 

3 for the transfer, from the Federal Supple4 mentary Medical Insurance Trust Fund under 

5 section 1841, of $5,000,000 to the Centers for 

6 Medicare & Medicaid Services Program Man7 agement Account for each of fiscal years 2019 

8 through 2021. Amounts transferred under the 

9 preceding sentence shall remain available until 

10 expended. 

11 ‘‘(7) CONSTRUCTION.—Nothing in this sub12 section shall be construed as granting the Secretary 

13 the authority to develop or initiate the development 

14 of clinical practice guidelines or appropriate use cri15 teria.’’. 

16 (b) CONFORMING AMENDMENT.—Section 

17 1833(t)(16) of the Social Security Act (42 U.S.C. 

18 1395l(t)(16)) is amended by adding at the end the fol19 lowing new subparagraph: 

20 ‘‘(E) APPLICATION OF APPROPRIATE USE

21 CRITERIA FOR CERTAIN IMAGING SERVICES.— 

22 For provisions relating to the application of ap23 propriate use criteria for certain imaging serv24 ices, see section 1834(p).’’. 


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1 (c) REPORT ON EXPERIENCE OF IMAGING APPRO2 PRIATE USE CRITERIA PROGRAM.—Not later than 18 

3 months after the date of the enactment of this Act, the 

4 Comptroller General of the United States shall submit to 

5 Congress a report that includes a description of the extent 

6 to which appropriate use criteria could be used for other 

7 services under part B of title XVIII of the Social Security 

8 Act (42 U.S.C. 1395j et seq.), such as radiation therapy 

9 and clinical diagnostic laboratory services. 

10 SEC. 106. EMPOWERING BENEFICIARY CHOICES THROUGH 

11 ACCESS TO INFORMATION ON PHYSICIANS’ 

12 SERVICES. 

13 (a) IN GENERAL.—The Secretary shall make publicly 

14 available on Physician Compare the information described 

15 in subsection (b) with respect to eligible professionals. 

16 (b) INFORMATION DESCRIBED.—The following infor17 mation, with respect to an eligible professional, is de18 scribed in this subsection: 

19 (1) Information on the number of services fur20 nished by the eligible professional under part B of 

21 title XVIII of the Social Security Act (42 U.S.C. 

22 1395j et seq.), which may include information on the 

23 most frequent services furnished or groupings of 

24 services. 


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1 (2) Information on submitted charges and pay2 ments for services under such part. 

3 (3) A unique identifier for the eligible profes4 sional that is available to the public, such as a na5 tional provider identifier. 

6 (c) SEARCHABILITY.—The information made avail7 able under this section shall be searchable by at least the 

8 following: 

9 (1) The specialty or type of the eligible profes10 sional. 

11 (2) Characteristics of the services furnished, 

12 such as volume or groupings of services. 

13 (3) The location of the eligible professional. 

14 (d) DISCLOSURE.—The information made available 

15 under this section shall indicate, where appropriate, that 

16 publicized information may not be representative of the 

17 eligible professional’s entire patient population, the variety 

18 of services furnished by the eligible professional, or the 

19 health conditions of individuals treated. 

20 (e) IMPLEMENTATION.— 

21 (1) INITIAL IMPLEMENTATION.—Physician 

22 Compare shall include the information described in 

23 subsection (b)— 

24 (A) with respect to physicians, by not later 

25 than July 1, 2015; and 


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1 (B) with respect to other eligible profes2 sionals, by not later than July 1, 2016. 

3 (2) ANNUAL UPDATING.—The information 

4 made available under this section shall be updated 

5 on Physician Compare not less frequently than on 

6 an annual basis. 

7 (f) OPPORTUNITY TO REVIEW AND SUBMIT CORREC8 TIONS.—The Secretary shall provide for an opportunity 

9 for an eligible professional to review, and submit correc10 tions for, the information to be made public with respect 

11 to the eligible professional under this section prior to such 

12 information being made public. 

13 (g) DEFINITIONS.—In this section: 

14 (1) ELIGIBLE PROFESSIONAL; PHYSICIAN; SEC15 RETARY.—The terms ‘‘eligible professional’’, ‘‘physi16 cian’’, and ‘‘Secretary’’ have the meaning given such 

17 terms in section 10331(i) of Public Law 111–148. 

18 (2) PHYSICIAN COMPARE.—The term ‘‘Physi19 cian Compare’’ means the Physician Compare Inter20 net website of the Centers for Medicare & Medicaid 

21 Services (or a successor website). 

22 SEC. 107. EXPANDING AVAILABILITY OF MEDICARE DATA. 

23 (a) EXPANDING USES OF MEDICARE DATA BY

24 QUALIFIED ENTITIES.— 

25 (1) ADDITIONAL ANALYSES.— 


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1 (A) IN GENERAL.—Subject to subpara2 graph (B), to the extent consistent with appli3 cable information, privacy, security, and disclo4 sure laws (including paragraph (3)), notwith5 standing paragraph (4)(B) of section 1874(e) of 

6 the Social Security Act (42 U.S.C. 1395kk(e)) 

7 and the second sentence of paragraph (4)(D) of 

8 such section, beginning July 1, 2015, a quali9 fied entity may use the combined data described 

10 in paragraph (4)(B)(iii) of such section received 

11 by such entity under such section, and informa12 tion derived from the evaluation described in 

13 such paragraph (4)(D), to conduct additional 

14 non-public analyses (as determined appropriate 

15 by the Secretary) and provide or sell such anal16 yses to authorized users for non-public use (in17 cluding for the purposes of assisting providers 

18 of services and suppliers to develop and partici19 pate in quality and patient care improvement 

20 activities, including developing new models of 

21 care). 

22 (B) LIMITATIONS WITH RESPECT TO ANAL23 YSES.— 

24 (i) EMPLOYERS.—Any analyses pro25 vided or sold under subparagraph (A) to 


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1 an employer described in paragraph 

2 (9)(A)(iii) may only be used by such em3 ployer for purposes of providing health in4 surance to employees and retirees of the 

5 employer. 

6 (ii) HEALTH INSURANCE ISSUERS.—A 

7 qualified entity may not provide or sell an 

8 analysis to a health insurance issuer de9 scribed in paragraph (9)(A)(iv) unless the 

10 issuer is providing the qualified entity with 

11 data under section 1874(e)(4)(B)(iii) of 

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

13 1395kk(e)(4)(B)(iii)). 

14 (2) ACCESS TO CERTAIN DATA.— 

15 (A) ACCESS.—To the extent consistent 

16 with applicable information, privacy, security, 

17 and disclosure laws (including paragraph (3)), 

18 notwithstanding paragraph (4)(B) of section 

19 1874(e) of the Social Security Act (42 U.S.C. 

20 1395kk(e)) and the second sentence of para21 graph (4)(D) of such section, beginning July 1, 

22 2015, a qualified entity may— 

23 (i) provide or sell the combined data 

24 described in paragraph (4)(B)(iii) of such 

25 section to authorized users described in 


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1 clauses (i), (ii), and (v) of paragraph 

2 (9)(A) for non-public use, including for the 

3 purposes described in subparagraph (B); 

4 or 

5 (ii) subject to subparagraph (C), pro6 vide Medicare claims data to authorized 

7 users described in clauses (i), (ii), and (v), 

8 of paragraph (9)(A) for non-public use, in9 cluding for the purposes described in sub10 paragraph (B). 

11 (B) PURPOSES DESCRIBED.—The purposes 

12 described in this subparagraph are assisting 

13 providers of services and suppliers in developing 

14 and participating in quality and patient care 

15 improvement activities, including developing 

16 new models of care. 

17 (C) MEDICARE CLAIMS DATA MUST BE

18 PROVIDED AT NO COST.—A qualified entity may 

19 not charge a fee for providing the data under 

20 subparagraph (A)(ii). 

21 (3) PROTECTION OF INFORMATION.— 

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

23 subparagraph (B), an analysis or data that is 

24 provided or sold under paragraph (1) or (2) 


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1 shall not contain information that individually 

2 identifies a patient. 

3 (B) INFORMATION ON PATIENTS OF THE

4 PROVIDER OF SERVICES OR SUPPLIER.—To the 

5 extent consistent with applicable information, 

6 privacy, security, and disclosure laws, an anal7 ysis or data that is provided or sold to a pro8 vider of services or supplier under paragraph 

9 (1) or (2) may contain information that individ10 ually identifies a patient of such provider or 

11 supplier, including with respect to items and 

12 services furnished to the patient by other pro13 viders of services or suppliers. 

14 (C) PROHIBITION ON USING ANALYSES OR

15 DATA FOR MARKETING PURPOSES.—An author16 ized user shall not use an analysis or data pro17 vided or sold under paragraph (1) or (2) for 

18 marketing purposes. 

19 (4) DATA USE AGREEMENT.—A qualified entity 

20 and an authorized user described in clauses (i), (ii), 

21 and (v) of paragraph (9)(A) shall enter into an 

22 agreement regarding the use of any data that the 

23 qualified entity is providing or selling to the author24 ized user under paragraph (2). Such agreement shall 

25 describe the requirements for privacy and security of 


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1 the data and, as determined appropriate by the Sec2 retary, any prohibitions on using such data to link 

3 to other individually identifiable sources of informa4 tion. If the authorized user is not a covered entity 

5 under the rules promulgated pursuant to the Health 

6 Insurance Portability and Accountability Act of 

7 1996, the agreement shall identify the relevant regu8 lations, as determined by the Secretary, that the 

9 user shall comply with as if it were acting in the ca10 pacity of such a covered entity. 

11 (5) NO REDISCLOSURE OF ANALYSES OR

12 DATA.— 

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

14 subparagraph (B), an authorized user that is 

15 provided or sold an analysis or data under 

16 paragraph (1) or (2) shall not redisclose or 

17 make public such analysis or data or any anal18 ysis using such data. 

19 (B) PERMITTED REDISCLOSURE.—A pro20 vider of services or supplier that is provided or 

21 sold an analysis or data under paragraph (1) or 

22 (2) may, as determined by the Secretary, redis23 close such analysis or data for the purposes of 

24 performance improvement and care coordination 


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1 activities but shall not make public such anal2 ysis or data or any analysis using such data. 

3 (6) OPPORTUNITY FOR PROVIDERS OF SERV4 ICES AND SUPPLIERS TO REVIEW.—Prior to a quali5 fied entity providing or selling an analysis to an au6 thorized user under paragraph (1), to the extent 

7 that such analysis would individually identify a pro8 vider of services or supplier who is not being pro9 vided or sold such analysis, such qualified entity 

10 shall provide such provider or supplier with the op11 portunity to appeal and correct errors in the manner 

12 described in section 1874(e)(4)(C)(ii) of the Social 

13 Security Act (42 U.S.C. 1395kk(e)(4)(C)(ii)). 

14 (7) ASSESSMENT FOR A BREACH.— 

15 (A) IN GENERAL.—In the case of a breach 

16 of a data use agreement under this section or 

17 section 1874(e) of the Social Security Act (42 

18 U.S.C. 1395kk(e)), the Secretary shall impose 

19 an assessment on the qualified entity both in 

20 the case of— 

21 (i) an agreement between the Sec22 retary and a qualified entity; and 

23 (ii) an agreement between a qualified 

24 entity and an authorized user. 


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1 (B) ASSESSMENT.—The assessment under 

2 subparagraph (A) shall be an amount up to 

3 $100 for each individual entitled to, or enrolled 

4 for, benefits under part A of title XVIII of the 

5 Social Security Act or enrolled for benefits 

6 under part B of such title— 

7 (i) in the case of an agreement de8 scribed in subparagraph (A)(i), for whom 

9 the Secretary provided data on to the 

10 qualified entity under paragraph (2); and 

11 (ii) in the case of an agreement de12 scribed in subparagraph (A)(ii), for whom 

13 the qualified entity provided data on to the 

14 authorized user under paragraph (2). 

15 (C) DEPOSIT OF AMOUNTS COLLECTED.— 

16 Any amounts collected pursuant to this para17 graph shall be deposited in Federal Supple18 mentary Medical Insurance Trust Fund under 

19 section 1841 of the Social Security Act (42 

20 U.S.C. 1395t). 

21 (8) ANNUAL REPORTS.—Any qualified entity 

22 that provides or sells an analysis or data under 

23 paragraph (1) or (2) shall annually submit to the 

24 Secretary a report that includes— 


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1 (A) a summary of the analyses provided or 

2 sold, including the number of such analyses, the 

3 number of purchasers of such analyses, and the 

4 total amount of fees received for such analyses; 

5 (B) a description of the topics and pur6 poses of such analyses; 

7 (C) information on the entities who re8 ceived the data under paragraph (2), the uses 

9 of the data, and the total amount of fees re10 ceived for providing, selling, or sharing the 

11 data; and 

12 (D) other information determined appro13 priate by the Secretary. 

14 (9) DEFINITIONS.—In this subsection and sub15 section (b): 

16 (A) AUTHORIZED USER.—The term ‘‘au17 thorized user’’ means the following: 

18 (i) A provider of services. 

19 (ii) A supplier. 

20 (iii) An employer (as defined in sec21 tion 3(5) of the Employee Retirement In22 surance Security Act of 1974). 

23 (iv) A health insurance issuer (as de24 fined in section 2791 of the Public Health 

25 Service Act). 


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1 (v) A medical society or hospital asso2 ciation. 

3 (vi) Any entity not described in 

4 clauses (i) through (v) that is approved by 

5 the Secretary (other than an employer or 

6 health insurance issuer not described in 

7 clauses (iii) and (iv), respectively, as deter8 mined by the Secretary). 

9 (B) PROVIDER OF SERVICES.—The term 

10 ‘‘provider of services’’ has the meaning given 

11 such term in section 1861(u) of the Social Se12 curity Act (42 U.S.C. 1395x(u)). 

13 (C) QUALIFIED ENTITY.—The term ‘‘quali14 fied entity’’ has the meaning given such term in 

15 section 1874(e)(2) of the Social Security Act 

16 (42 U.S.C. 1395kk(e)). 

17 (D) SECRETARY.—The term ‘‘Secretary’’ 

18 means the Secretary of Health and Human 

19 Services. 

20 (E) SUPPLIER.—The term ‘‘supplier’’ has 

21 the meaning given such term in section 1861(d) 

22 of the Social Security Act (42 U.S.C. 

23 1395x(d)). 


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1 (b) ACCESS TO MEDICARE DATA BY QUALIFIED

2 CLINICAL DATA REGISTRIES TO FACILITATE QUALITY

3 IMPROVEMENT.— 

4 (1) ACCESS.— 

5 (A) IN GENERAL.—To the extent con6 sistent with applicable information, privacy, se7 curity, and disclosure laws, beginning July 1, 

8 2015, the Secretary shall, at the request of a 

9 qualified clinical data registry under section 

10 1848(m)(3)(E) of the Social Security Act (42 

11 U.S.C. 1395w–4(m)(3)(E)), provide the data 

12 described in subparagraph (B) (in a form and 

13 manner determined to be appropriate) to such 

14 qualified clinical data registry for purposes of 

15 linking such data with clinical outcomes data 

16 and performing risk-adjusted, scientifically valid 

17 analyses and research to support quality im18 provement or patient safety, provided that any 

19 public reporting of such analyses or research 

20 that identifies a provider of services or supplier 

21 shall only be conducted with the opportunity of 

22 such provider or supplier to appeal and correct 

23 errors in the manner described in subsection 

24 (a)(6). 


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1 (B) DATA DESCRIBED.—The data de2 scribed in this subparagraph is— 

3 (i) claims data under the Medicare 

4 program under title XVIII of the Social 

5 Security Act; and 

6 (ii) if the Secretary determines appro7 priate, claims data under the Medicaid 

8 program under title XIX of such Act and 

9 the State Children’s Health Insurance Pro10 gram under title XXI of such Act. 

11 (2) FEE.—Data described in paragraph (1)(B) 

12 shall be provided to a qualified clinical data registry 

13 under paragraph (1) at a fee equal to the cost of 

14 providing such data. Any fee collected pursuant to 

15 the preceding sentence shall be deposited in the Cen16 ters for Medicare & Medicaid Services Program 

17 Management Account. 

18 (c) EXPANSION OF DATA AVAILABLE TO QUALIFIED

19 ENTITIES.—Section 1874(e) of the Social Security Act 

20 (42 U.S.C. 1395kk(e)) is amended— 

21 (1) in the subsection heading, by striking 

22 ‘‘MEDICARE’’; and 

23 (2) in paragraph (3)— 

24 (A) by inserting after the first sentence the 

25 following new sentence: ‘‘Beginning July 1, 


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1 2015, if the Secretary determines appropriate, 

2 the data described in this paragraph may also 

3 include standardized extracts (as determined by 

4 the Secretary) of claims data under titles XIX 

5 and XXI for assistance provided under such ti6 tles for one or more specified geographic areas 

7 and time periods requested by a qualified enti8 ty.’’; and 

9 (B) in the last sentence, by inserting ‘‘or 

10 under titles XIX or XXI’’ before the period at 

11 the end. 

12 (d) REVISION OF PLACEMENT OF FEES.—Section 

13 1874(e)(4)(A) of the Social Security Act (42 U.S.C. 

14 1395kk(e)(4)(A)) is amended, in the second sentence— 

15 (1) by inserting ‘‘, for periods prior to July 1, 

16 2015,’’ after ‘‘deposited’’; and 

17 (2) by inserting the following before the period 

18 at the end: ‘‘, and, beginning July 1, 2015, into the 

19 Centers for Medicare & Medicaid Services Program 

20 Management Account’’. 

21 SEC. 108. REDUCING ADMINISTRATIVE BURDEN AND 

22 OTHER PROVISIONS. 

23 (a) MEDICARE PHYSICIAN AND PRACTITIONER OPT24 OUT TO PRIVATE CONTRACT.— 


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1 (1) INDEFINITE, CONTINUING AUTOMATIC EX2 TENSION OF OPT OUT ELECTION.— 

3 (A) IN GENERAL.—Section 1802(b)(3) of 

4 the Social Security Act (42 U.S.C. 1395a(b)(3)) 

5 is amended— 

6 (i) in subparagraph (B)(ii), by strik7 ing ‘‘during the 2-year period beginning on 

8 the date the affidavit is signed’’ and insert9 ing ‘‘during the applicable 2-year period 

10 (as defined in subparagraph (D))’’; 

11 (ii) in subparagraph (C), by striking 

12 ‘‘during the 2-year period described in sub13 paragraph (B)(ii)’’ and inserting ‘‘during 

14 the applicable 2-year period’’; and 

15 (iii) by adding at the end the fol16 lowing new subparagraph: 

17 ‘‘(D) APPLICABLE 2-YEAR PERIODS FOR

18 EFFECTIVENESS OF AFFIDAVITS.—In this sub19 section, the term ‘applicable 2-year period’ 

20 means, with respect to an affidavit of a physi21 cian or practitioner under subparagraph (B), 

22 the 2-year period beginning on the date the af23 fidavit is signed and includes each subsequent 

24 2-year period unless the physician or practi25 tioner involved provides notice to the Secretary 


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1 (in a form and manner specified by the Sec2 retary), not later than 30 days before the end 

3 of the previous 2-year period, that the physician 

4 or practitioner does not want to extend the ap5 plication of the affidavit for such subsequent 2- 

6 year period.’’. 

7 (B) EFFECTIVE DATE.—The amendments 

8 made by subparagraph (A) shall apply to affi9 davits entered into on or after the date that is 

10 60 days after the date of the enactment of this 

11 Act. 

12 (2) PUBLIC AVAILABILITY OF INFORMATION ON

13 OPT-OUT PHYSICIANS AND PRACTITIONERS.—Section 

14 1802(b) of the Social Security Act (42 U.S.C. 

15 1395a(b)) is amended— 

16 (A) in paragraph (5), by adding at the end 

17 the following new subparagraph: 

18 ‘‘(D) OPT-OUT PHYSICIAN OR PRACTITIONER.— 

19 The term ‘opt-out physician or practitioner’ means 

20 a physician or practitioner who has in effect an affi21 davit under paragraph (3)(B).’’; 

22 (B) by redesignating paragraph (5) as 

23 paragraph (6); and 

24 (C) by inserting after paragraph (4) the 

25 following new paragraph: 


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1 ‘‘(5) POSTING OF INFORMATION ON OPT-OUT

2 PHYSICIANS AND PRACTITIONERS.— 

3 ‘‘(A) IN GENERAL.—Beginning not later 

4 than February 1, 2015, the Secretary shall 

5 make publicly available through an appropriate 

6 publicly accessible website of the Department of 

7 Health and Human Services information on the 

8 number and characteristics of opt-out physi9 cians and practitioners and shall update such 

10 information on such website not less often than 

11 annually. 

12 ‘‘(B) INFORMATION TO BE INCLUDED.— 

13 The information to be made available under 

14 subparagraph (A) shall include at least the fol15 lowing with respect to opt-out physicians and 

16 practitioners: 

17 ‘‘(i) Their number. 

18 ‘‘(ii) Their physician or professional 

19 specialty or other designation. 

20 ‘‘(iii) Their geographic distribution. 

21 ‘‘(iv) The timing of their becoming 

22 opt-out physicians and practitioners, rel23 ative to when they first entered practice 

24 and with respect to applicable 2-year peri25 ods. 


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1 ‘‘(v) The proportion of such physi2 cians and practitioners who billed for 

3 emergency or urgent care services.’’. 

4 (b) GAINSHARING STUDY AND REPORT.—Not later 

5 than 6 months after the date of the enactment of this Act, 

6 the Secretary of Health and Human Services, in consulta7 tion with the Inspector General of the Department of 

8 Health and Human Services, shall submit to Congress a 

9 report with legislative recommendations to amend existing 

10 fraud and abuse laws, through exceptions, safe harbors, 

11 or other narrowly targeted provisions, to permit 

12 gainsharing or similar arrangements between physicians 

13 and hospitals that improve care while reducing waste and 

14 increasing efficiency. The report shall— 

15 (1) consider whether such provisions should 

16 apply to ownership interests, compensation arrange17 ments, or other relationships; 

18 (2) describe how the recommendations address 

19 accountability, transparency, and quality, including 

20 how best to limit inducements to stint on care, dis21 charge patients prematurely, or otherwise reduce or 

22 limit medically necessary care; and 

23 (3) consider whether a portion of any savings 

24 generated by such arrangements should accrue to 


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1 the Medicare program under title XVIII of the So2 cial Security Act. 

3 (c) PROMOTING INTEROPERABILITY OF ELECTRONIC

4 HEALTH RECORD SYSTEMS.— 

5 (1) RECOMMENDATIONS FOR ACHIEVING WIDE6 SPREAD EHR INTEROPERABILITY.— 

7 (A) OBJECTIVE.—As a consequence of a 

8 significant Federal investment in the implemen9 tation of health information technology through 

10 the Medicare and Medicaid EHR incentive pro11 grams, Congress declares it a national objective 

12 to achieve widespread exchange of health infor13 mation through interoperable certified EHR 

14 technology nationwide by December 31, 2017. 

15 (B) DEFINITIONS.—In this paragraph: 

16 (i) WIDESPREAD INTEROPER17 ABILITY.—The term ‘‘widespread inter18 operability’’ means interoperability between 

19 certified EHR technology systems em20 ployed by meaningful EHR users under 

21 the Medicare and Medicaid EHR incentive 

22 programs and other clinicians and health 

23 care providers on a nationwide basis. 

24 (ii) INTEROPERABILITY.—The term 

25 ‘‘interoperability’’ means the ability of two 


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1 or more health information systems or 

2 components to exchange clinical and other 

3 information and to use the information 

4 that has been exchanged using common 

5 standards as to provide access to longitu6 dinal information for health care providers 

7 in order to facilitate coordinated care and 

8 improved patient outcomes. 

9 (C) ESTABLISHMENT OF METRICS.—Not 

10 later than July 1, 2015, and in consultation 

11 with stakeholders, the Secretary shall establish 

12 metrics to be used to determine if and to the 

13 extent that the objective described in subpara14 graph (A) has been achieved. 

15 (D) RECOMMENDATIONS IF OBJECTIVE

16 NOT ACHIEVED.—If the Secretary of Health 

17 and Human Services determines that the objec18 tive described in subparagraph (A) has not been 

19 achieved by December 31, 2017, then the Sec20 retary shall submit to Congress a report, by not 

21 later than December 31, 2018, that identifies 

22 barriers to such objective and recommends ac23 tions that the Federal Government can take to 

24 achieve such objective. Such recommended ac25 tions may include recommendations— 


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1 (i) to adjust payments for not being 

2 meaningful EHR users under the Medicare 

3 EHR incentive programs; and 

4 (ii) for criteria for decertifying cer5 tified EHR technology products. 

6 (2) PREVENTING BLOCKING THE SHARING OF

7 INFORMATION.— 

8 (A) FOR MEANINGFUL EHR PROFES9 SIONALS.—Section 1848(o)(2)(A)(ii) of the So10 cial Security Act (42 U.S.C. 1395w– 

11 4(o)(2)(A)(ii)) is amended by inserting before 

12 the period at the end the following: ‘‘, and the 

13 professional demonstrates (through a process 

14 specified by the Secretary, such as the use of an 

15 attestation) that the professional has not know16 ingly and willfully taken any action to limit or 

17 restrict the compatibility or interoperability of 

18 the certified EHR technology’’. 

19 (B) FOR MEANINGFUL EHR HOSPITALS.— 

20 Section 1886(n)(3)(A)(ii) of the Social Security 

21 Act (42 U.S.C. 1395ww(n)(3)(A)(ii)) is amend22 ed by inserting before the period at the end the 

23 following: ‘‘, and the hospital demonstrates 

24 (through a process specified by the Secretary, 

25 such as the use of an attestation) that the hosVerDate Mar 15 2010 01:32 Mar 14, 2014 Jkt 039200 PO 00000 Frm 00188 Fmt 6652 Sfmt 6201 E:\BILLS\S2122.PCS S2122

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1 pital has not knowingly and willfully taken any 

2 action to limit or restrict the compatibility or 

3 interoperability of the certified EHR tech4 nology’’. 

5 (C) EFFECTIVE DATE.—The amendments 

6 made by this subsection shall apply to meaning7 ful EHR users as of the date that is one year 

8 after the date of the enactment of this Act. 

9 (3) STUDY AND REPORT ON THE FEASIBILITY

10 OF ESTABLISHING A WEBSITE TO COMPARE CER11 TIFIED EHR TECHNOLOGY PRODUCTS.— 

12 (A) STUDY.—The Secretary shall conduct 

13 a study to examine the feasibility of estab14 lishing mechanisms that includes aggregated re15 sults of surveys of meaningful EHR users on 

16 the functionality of certified EHR technology 

17 products to enable such users to directly com18 pare the functionality and other features of 

19 such products. Such information may be made 

20 available through contracts with physician, hos21 pital, or other organizations that maintain such 

22 comparative information. 

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

24 the date of the enactment of this Act, the Sec25 retary shall submit to Congress a report on the 


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1 website. The report shall include information on 

2 the benefits of, and resources needed to develop 

3 and maintain, such a website. 

4 (4) DEFINITIONS.—In this subsection: 

5 (A) The term ‘‘certified EHR technology’’ 

6 has the meaning given such term in section 

7 1848(o)(4) of the Social Security Act (42 

8 U.S.C. 1395w–4(o)(4)). 

9 (B) The term ‘‘meaningful EHR user’’ has 

10 the meaning given such term under the Medi11 care EHR incentive programs. 

12 (C) The term ‘‘Medicare and Medicaid 

13 EHR incentive programs’’ means— 

14 (i) in the case of the Medicare pro15 gram under title XVIII of the Social Secu16 rity Act, the incentive programs under sec17 tion 1814(l)(3), section 1848(o), sub18 sections (l) and (m) of section 1853, and 

19 section 1886(n) of the Social Security Act 

20 (42 U.S.C. 1395f(l)(3), 1395w–4(o), 

21 1395w–23, 1395ww(n)); and 

22 (ii) in the case of the Medicaid pro23 gram under title XIX of such Act, the in24 centive program under subsections 


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1 (a)(3)(F) and (t) of section 1903 of such 

2 Act (42 U.S.C. 1396b). 

3 (D) The term ‘‘Secretary’’ means the Sec4 retary of Health and Human Services. 

5 (d) GAO STUDIES AND REPORTS ON THE USE OF

6 TELEHEALTH UNDER FEDERAL PROGRAMS AND ON RE7 MOTE PATIENT MONITORING SERVICES.— 

8 (1) STUDY ON TELEHEALTH SERVICES.—The 

9 Comptroller General of the United States shall con10 duct a study on the following: 

11 (A) How the definition of telehealth across 

12 various Federal programs and Federal efforts 

13 can inform the use of telehealth in the Medicare 

14 program under title XVIII of the Social Secu15 rity Act (42 U.S.C. 1395 et seq.). 

16 (B) Issues that can facilitate or inhibit the 

17 use of telehealth under the Medicare program 

18 under such title, including oversight and profes19 sional licensure, changing technology, privacy 

20 and security, infrastructure requirements, and 

21 varying needs across urban and rural areas. 

22 (C) Potential implications of greater use of 

23 telehealth with respect to payment and delivery 

24 system transformations under the Medicare 

25 program under such title XVIII and the MedVerDate Mar 15 2010 01:32 Mar 14, 2014 Jkt 039200 PO 00000 Frm 00191 Fmt 6652 Sfmt 6201 E:\BILLS\S2122.PCS S2122

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1 icaid program under title XIX of such Act (42 

2 U.S.C. 1396 et seq.). 

3 (D) How the Centers for Medicare & Med4 icaid Services conducts oversight of payments 

5 made under the Medicare program under such 

6 title XVIII to providers for telehealth services. 

7 (2) STUDY ON REMOTE PATIENT MONITORING

8 SERVICES.— 

9 (A) IN GENERAL.—The Comptroller Gen10 eral of the United States shall conduct a 

11 study— 

12 (i) of the dissemination of remote pa13 tient monitoring technology in the private 

14 health insurance market; 

15 (ii) of the financial incentives in the 

16 private health insurance market relating to 

17 adoption of such technology; 

18 (iii) of the barriers to adoption of 

19 such services under the Medicare program 

20 under title XVIII of the Social Security 

21 Act; 

22 (iv) that evaluates the patients, condi23 tions, and clinical circumstances that could 

24 most benefit from remote patient moni25 toring services; and 


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1 (v) that evaluates the challenges re2 lated to establishing appropriate valuation 

3 for remote patient monitoring services 

4 under the Medicare physician fee schedule 

5 under section 1848 of the Social Security 

6 Act (42 U.S.C. 1395w–4) in order to accu7 rately reflect the resources involved in fur8 nishing such services. 

9 (B) DEFINITIONS.—For purposes of this 

10 paragraph: 

11 (i) REMOTE PATIENT MONITORING

12 SERVICES.—The term ‘‘remote patient 

13 monitoring services’’ means services fur14 nished through remote patient monitoring 

15 technology. 

16 (ii) REMOTE PATIENT MONITORING

17 TECHNOLOGY.—The term ‘‘remote patient 

18 monitoring technology’’ means a coordi19 nated system that uses one or more home20 based or mobile monitoring devices that 

21 automatically transmit vital sign data or 

22 information on activities of daily living and 

23 may include responses to assessment ques24 tions collected on the devices wirelessly or 

25 through a telecommunications connection 


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1 to a server that complies with the Federal 

2 regulations (concerning the privacy of indi3 vidually identifiable health information) 

4 promulgated under section 264(c) of the 

5 Health Insurance Portability and Account6 ability Act of 1996, as part of an estab7 lished plan of care for that patient that in8 cludes the review and interpretation of that 

9 data by a health care professional. 

10 (3) REPORTS.—Not later than 24 months after 

11 the date of the enactment of this Act, the Comp12 troller General shall submit to Congress— 

13 (A) a report containing the results of the 

14 study conducted under paragraph (1); and 

15 (B) a report containing the results of the 

16 study conducted under paragraph (2). 

17 A report required under this paragraph shall be sub18 mitted together with recommendations for such leg19 islation and administrative action as the Comptroller 

20 General determines appropriate. The Comptroller 

21 General may submit one report containing the re22 sults described in subparagraphs (A) and (B) and 

23 the recommendations described in the previous sen24 tence. 


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1 (e) RULE OF CONSTRUCTION REGARDING

2 HEALTHCARE PROVIDER STANDARDS OF CARE.— 

3 (1) MAINTENANCE OF STATE STANDARDS.— 

4 The development, recognition, or implementation of 

5 any guideline or other standard under any Federal 

6 health care provision shall not be construed— 

7 (A) to establish the standard of care or 

8 duty of care owed by a health care provider to 

9 a patient in any medical malpractice or medical 

10 product liability action or claim; or 

11 (B) to preempt any standard of care or 

12 duty of care, owed by a health care provider to 

13 a patient, duly established under State or com14 mon law. 

15 (2) DEFINITIONS.—For purposes of this sub16 section: 

17 (A) FEDERAL HEALTH CARE PROVISION.— 

18 The term ‘‘Federal health care provision’’ 

19 means any provision of the Patient Protection 

20 and Affordable Care Act (Public Law 111– 

21 148), title I or subtitle B of title II of the 

22 Health Care and Education Reconciliation Act 

23 of 2010 (Public Law 111–152), or title XVIII 

24 or XIX of the Social Security Act. 


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1 (B) HEALTH CARE PROVIDER.—The term 

2 ‘‘health care provider’’ means any individual or 

3 entity— 

4 (i) licensed, registered, or certified 

5 under Federal or State laws or regulations 

6 to provide health care services; or 

7 (ii) required to be so licensed, reg8 istered, or certified but that is exempted 

9 by other statute or regulation. 

10 (C) MEDICAL MALPRACTICE OR MEDICAL

11 PRODUCT LIABILITY ACTION OR CLAIM.—The 

12 term ‘‘medical malpractice or medical product 

13 liability action or claim’’ means a medical mal14 practice action or claim (as defined in section 

15 431(7) of the Health Care Quality Improve16 ment Act of 1986 (42 U.S.C. 11151(7))) and 

17 includes a liability action or claim relating to a 

18 health care provider’s prescription or provision 

19 of a drug, device, or biological product (as such 

20 terms are defined in section 201 of the Federal 

21 Food, Drug, and Cosmetic Act or section 351 

22 of the Public Health Service Act). 

23 (D) STATE.—The term ‘‘State’’ includes 

24 the District of Columbia, Puerto Rico, and any 


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1 other commonwealth, possession, or territory of 

2 the United States. 

3 (3) PRESERVATION OF STATE LAW.—No provi4 sion of the Patient Protection and Affordable Care 

5 Act (Public Law 111–148), title I or subtitle B of 

6 title II of the Health Care and Education Reconcili7 ation Act of 2010 (Public Law 111–152), or title 

8 XVIII or XIX of the Social Security Act shall be 

9 construed to preempt any State or common law gov10 erning medical professional or medical product liabil11 ity actions or claims. 

12 TITLE II—EXTENSIONS 

13 Subtitle A—Medicare Extensions 

14 SEC. 201. WORK GEOGRAPHIC ADJUSTMENT. 

15 Section 1848(e)(1)(E) of the Social Security Act (42 

16 U.S.C. 1395w–4(e)(1)(E)) is amended by striking ‘‘and 

17 before April 1, 2014,’’. 

18 SEC. 202. MEDICARE PAYMENT FOR THERAPY SERVICES. 

19 (a) REPEAL OF THERAPY CAP AND 1-YEAR EXTEN20 SION OF THRESHOLD FOR MANUAL MEDICAL REVIEW.— 

21 Section 1833(g) of the Social Security Act (42 U.S.C. 

22 1395l(g)) is amended— 

23 (1) in paragraph (4)— 


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1 (A) by striking ‘‘This subsection’’ and in2 serting ‘‘Except as provided in paragraph 

3 (5)(C)(iii), this subsection’’; and 

4 (B) by inserting the following before the 

5 period at the end: ‘‘or with respect to services 

6 furnished on or after the date of enactment of 

7 the Responsible Medicare SGR Repeal and Ben8 eficiary Access Improvement Act of 2014’’; and 

9 (2) in paragraph (5)(C), by adding at the end 

10 the following new clause: 

11 ‘‘(iii) Beginning on the date of enactment of the Re12 sponsible Medicare SGR Repeal and Beneficiary Access 

13 Improvement Act of 2014 and ending on the day before 

14 the date that is 12 months after such date of enactment, 

15 the manual medical review process described in clause (i) 

16 shall apply with respect to expenses incurred in a year for 

17 services described in paragraphs (1) and (3) that exceed 

18 the threshold described in clause (ii) for the year.’’. 

19 (b) MEDICAL REVIEW OF OUTPATIENT THERAPY

20 SERVICES.— 

21 (1) MEDICAL REVIEW OF OUTPATIENT THER22 APY SERVICES.—Section 1833 of the Social Security 

23 Act (42 U.S.C. 1395l), as amended by section 

24 101(e)(2), is amended by adding at the end the fol25 lowing new subsection: 


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1 ‘‘(aa) MEDICAL REVIEW OF OUTPATIENT THERAPY

2 SERVICES.— 

3 ‘‘(1) IN GENERAL.— 

4 ‘‘(A) PROCESS FOR MEDICAL REVIEW.— 

5 The Secretary shall implement a process for the 

6 medical review (as described in paragraph (2)) 

7 of outpatient therapy services (as defined in 

8 paragraph (10)) and, subject to paragraph 

9 (12), apply such process to such services fur10 nished on or after the date that is 12 months 

11 after the date of enactment of the Responsible 

12 Medicare SGR Repeal and Beneficiary Access 

13 Improvement Act of 2014, focusing on services 

14 identified under subparagraph (B). 

15 ‘‘(B) IDENTIFICATION OF SERVICES FOR

16 REVIEW.—Under the process, the Secretary 

17 shall identify services for medical review, using 

18 such factors as the Secretary determines appro19 priate, which may include the following: 

20 ‘‘(i) Services furnished by a therapy 

21 provider (as defined in paragraph (10)) 

22 whose pattern of billing is aberrant com23 pared to peers. 

24 ‘‘(ii) Services furnished by a therapy 

25 provider who, in a prior period, has a high 


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1 claims denial percentage or is less compli2 ant with other applicable requirements 

3 under this title. 

4 ‘‘(iii) Services furnished by a therapy 

5 provider that is newly enrolled under this 

6 title. 

7 ‘‘(iv) Services furnished by a therapy 

8 provider who has questionable billing prac9 tices, such as billing medically unlikely 

10 units of services in a day. 

11 ‘‘(v) Services furnished to treat a type 

12 of medical condition. 

13 ‘‘(vi) Services identified by use of the 

14 standardized data elements required to be 

15 reported under section 1834(p). 

16 ‘‘(vii) Services furnished by a single 

17 therapy provider or a group that includes 

18 a therapy provider identified by factors de19 scribed in this subparagraph. 

20 ‘‘(viii) Other services as determined 

21 appropriate by the Secretary. 

22 ‘‘(2) MEDICAL REVIEW.— 

23 ‘‘(A) PRIOR AUTHORIZATION MEDICAL RE24 VIEW.— 


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1 ‘‘(i) IN GENERAL.—Subject to the 

2 succeeding provisions of this subparagraph, 

3 the Secretary shall use prior authorization 

4 medical review for outpatient therapy serv5 ices furnished to an individual above one 

6 or more thresholds established by the Sec7 retary, such as a dollar threshold or a 

8 threshold based on other factors. 

9 ‘‘(ii) ENDING APPLICATION OF PRIOR

10 AUTHORIZATION FOR A THERAPY PRO11 VIDER.—The Secretary shall end the appli12 cation of prior authorization medical re13 view to outpatient therapy services fur14 nished by a therapy provider if the Sec15 retary determines that the provider has a 

16 low denial rate under such prior authoriza17 tion. The Secretary may subsequently re18 apply prior authorization medical review to 

19 such therapy provider if the Secretary de20 termines it to be appropriate. 

21 ‘‘(iii) PRIOR AUTHORIZATION OF MUL22 TIPLE SERVICES.—The Secretary shall, 

23 where practicable, provide for prior author24 ization medical review for multiple services 

25 at a single time, such as services in a therVerDate Mar 15 2010 01:32 Mar 14, 2014 Jkt 039200 PO 00000 Frm 00201 Fmt 6652 Sfmt 6201 E:\BILLS\S2122.PCS S2122

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1 apy plan of care described in section 

2 1861(p)(2). 

3 ‘‘(B) OTHER TYPES OF MEDICAL RE4 VIEW.—The Secretary may use pre-payment re5 view or post-payment review for services identi6 fied under paragraph (1)(B) that are not sub7 ject to prior authorization medical review under 

8 subparagraph (A). 

9 ‘‘(C) LIMITATION FOR LAW ENFORCEMENT

10 ACTIVITIES.—The Secretary may determine 

11 that medical review under this subsection does 

12 not apply in the case where potential fraud may 

13 be involved. 

14 ‘‘(3) REVIEW CONTRACTORS.—The Secretary 

15 shall conduct prior authorization medical review of 

16 outpatient therapy services under this subsection 

17 using medicare administrative contractors (as de18 scribed in section 1874A) or other review contrac19 tors (other than contractors under section 1893(h) 

20 or contractors paid on a contingent basis). 

21 ‘‘(4) NO PAYMENT WITHOUT PRIOR AUTHORIZA22 TION.—With respect to an outpatient therapy service 

23 for which prior authorization medical review under 

24 this subsection applies, the following shall apply: 


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1 ‘‘(A) PRIOR AUTHORIZATION DETERMINA2 TION.—The Secretary shall make a determina3 tion, prior to the service being furnished, of 

4 whether the service would or would not meet 

5 the applicable requirements of section 

6 1862(a)(1)(A). 

7 ‘‘(B) DENIAL OF PAYMENT.—Subject to 

8 paragraph (6), no payment shall be made under 

9 this part for the service unless the Secretary 

10 determines pursuant to subparagraph (A) that 

11 the service would meet the applicable require12 ments of such section. 

13 ‘‘(5) SUBMISSION OF INFORMATION.—A ther14 apy provider may submit the information necessary 

15 for medical review by fax, by mail, or by electronic 

16 means. The Secretary shall make available the elec17 tronic means described in the preceding sentence as 

18 soon as practicable, but not later than 24 months 

19 after the date of enactment of this subsection. 

20 ‘‘(6) TIMELINESS.—If the Secretary does not 

21 make a prior authorization determination under 

22 paragraph (4)(A) within 10 business days of the 

23 date of the Secretary’s receipt of medical docu24 mentation needed to make such determination, para25 graph (4)(B) shall not apply. 


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1 ‘‘(7) CONSTRUCTION.—With respect to an out2 patient therapy service that has been affirmed by 

3 medical review under this subsection, nothing in this 

4 subsection shall be construed to preclude the subse5 quent denial of a claim for such service that does 

6 not meet other applicable requirements under this 

7 Act. 

8 ‘‘(8) BENEFICIARY PROTECTIONS.—With re9 spect to services furnished on or after January 1, 

10 2015, where payment may not be made as a result 

11 of application of medical review under this sub12 section, section 1879 shall apply in the same manner 

13 as such section applies to a denial that is made by 

14 reason of section 1862(a)(1). 

15 ‘‘(9) IMPLEMENTATION.— 

16 ‘‘(A) AUTHORITY.—The Secretary may im17 plement the provisions of this subsection by in18 terim final rule with comment period. 

19 ‘‘(B) ADMINISTRATION.—Chapter 35 of 

20 title 44, United States Code, shall not apply to 

21 medical review under this subsection. 

22 ‘‘(C) LIMITATION.—There shall be no ad23 ministrative or judicial review under section 

24 1869, section 1878, or otherwise of the identi25 fication of services for medical review or the 


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1 process for medical review under this sub2 section. 

3 ‘‘(10) DEFINITIONS.—For purposes of this sub4 section: 

5 ‘‘(A) OUTPATIENT THERAPY SERVICES.— 

6 The term ‘outpatient therapy services’ means 

7 the following services for which payment is 

8 made under section 1848, 1834(g), or 1834(k): 

9 ‘‘(i) Physical therapy services of the 

10 type described in section 1861(p). 

11 ‘‘(ii) Speech-language pathology serv12 ices of the type described in such section 

13 though the application of section 

14 1861(ll)(2). 

15 ‘‘(iii) Occupational therapy services of 

16 the type described in section 1861(p) 

17 through the operation of section 1861(g). 

18 ‘‘(B) THERAPY PROVIDER.—The term 

19 ‘therapy provider’ means a provider of services 

20 (as defined in section 1861(u)) or a supplier (as 

21 defined in section 1861(d)) who submits a claim 

22 for outpatient therapy services. 

23 ‘‘(11) FUNDING.—For purposes of imple24 menting this subsection, the Secretary shall provide 

25 for the transfer, from the Federal Supplementary 


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1 Medical Insurance Trust Fund under section 1841, 

2 of $35,000,000 to the Centers for Medicare & Med3 icaid Services Program Management Account for 

4 each fiscal year (beginning with fiscal year 2014). 

5 Amounts transferred under this paragraph shall re6 main available until expended. 

7 ‘‘(12) SCALING BACK.— 

8 ‘‘(A) PERIODIC DETERMINATIONS.—Begin9 ning with 2017, and every two years thereafter, 

10 the Secretary shall— 

11 ‘‘(i) make a determination of the im12 proper payment rate for outpatient therapy 

13 services for a 12-month period; and 

14 ‘‘(ii) make such determination publicly 

15 available. 

16 ‘‘(B) SCALING BACK.—If the improper 

17 payment rate for outpatient therapy services de18 termined for a 12-month period under subpara19 graph (A) is 50 percent or less of the Medicare 

20 fee-for-service improper payment rate for such 

21 period, the Secretary shall— 

22 ‘‘(i) reduce the amount and extent of 

23 medical review conducted for a prospective 

24 year under the process established in this 

25 subsection; and 


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1 ‘‘(ii) return an appropriate portion of 

2 the funding provided for such year under 

3 paragraph (11).’’. 

4 (2) GAO STUDY AND REPORT.— 

5 (A) STUDY.—The Comptroller General of 

6 the United States shall conduct a study on the 

7 effectiveness of medical review of outpatient 

8 therapy services under section 1833(aa) of the 

9 Social Security Act, as added by paragraph (1). 

10 Such study shall include an analysis of— 

11 (i) aggregate data on— 

12 (I) the number of individuals, 

13 therapy providers, and claims subject 

14 to such review; and 

15 (II) the number of reviews con16 ducted under such section; and 

17 (ii) the outcomes of such reviews. 

18 (B) REPORT.—Not later than 3 years after 

19 the date of enactment of this Act, the Comp20 troller General shall submit to Congress a re21 port containing the results of the study 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 (c) COLLECTION OF STANDARDIZED DATA ELE2 MENTS FOR OUTPATIENT THERAPY SERVICES.— 

3 (1) COLLECTION OF STANDARDIZED DATA ELE4 MENTS FOR OUTPATIENT THERAPY SERVICES.—Sec5 tion 1834 of the Social Security Act (42 U.S.C. 

6 1395m) is amended by adding at the end the fol7 lowing new subsection: 

8 ‘‘(p) COLLECTION OF STANDARDIZED DATA ELE9 MENTS FOR OUTPATIENT THERAPY SERVICES.— 

10 ‘‘(1) STANDARDIZED DATA ELEMENTS.— 

11 ‘‘(A) IN GENERAL.—Not later than 6 

12 months after the date of enactment of this sub13 section, the Secretary shall post on the Internet 

14 website of the Centers for Medicare & Medicaid 

15 Services a draft list of standardized data ele16 ments for individuals receiving outpatient ther17 apy services. 

18 ‘‘(B) DOMAINS.—Such standardized data 

19 elements shall include information with respect 

20 to the following domains, as determined appro21 priate by the Secretary: 

22 ‘‘(i) Demographic information. 

23 ‘‘(ii) Diagnosis. 

24 ‘‘(iii) Severity. 


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1 ‘‘(iv) Affected body structures and 

2 functions. 

3 ‘‘(v) Limitations with activities of 

4 daily living and participation. 

5 ‘‘(vi) Functional status. 

6 ‘‘(vii) Other domains determined to be 

7 appropriate by the Secretary. 

8 ‘‘(C) SOLICITATION OF INPUT.—The Sec9 retary shall accept comments from stakeholders 

10 through the date that is 60 days after the date 

11 the Secretary posts the draft list of standard12 ized data elements pursuant to subparagraph 

13 (A). In seeking such comments, the Secretary 

14 shall use one or more mechanisms to solicit 

15 input from stakeholders that may include use of 

16 open door forums, town hall meetings, requests 

17 for information, or other mechanisms deter18 mined appropriate by the Secretary. 

19 ‘‘(D) OPERATIONAL LIST OF STANDARD20 IZED DATA ELEMENTS.—Not later than 120 

21 days after the end of the comment period de22 scribed in subparagraph (C), the Secretary, tak23 ing into account such comments, shall post on 

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1 care & Medicaid Services an operational list of 

2 standardized data elements. 

3 ‘‘(E) SUBSEQUENT REVISIONS.—Subse4 quent revisions to the operational list of stand5 ardized data elements shall be made through 

6 rulemaking. Such revisions may be based on ex7 perience and input from stakeholders. 

8 ‘‘(2) SYSTEM TO REPORT STANDARDIZED DATA

9 ELEMENTS.— 

10 ‘‘(A) IN GENERAL.—Not later than 18 

11 months after the date the Secretary posts the 

12 operational list of standardized data elements 

13 pursuant to paragraph (1)(D), the Secretary 

14 shall develop and implement an electronic sys15 tem (which may be a web portal) for therapy 

16 providers to report the standardized data ele17 ments for individuals with respect to outpatient 

18 therapy services. 

19 ‘‘(B) CONSULTATION.—The Secretary 

20 shall seek comments from stakeholders regard21 ing the best way to report the standardized 

22 data elements. 

23 ‘‘(3) REPORTING.— 

24 ‘‘(A) FREQUENCY OF REPORTING.—The 

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1 ing standardized data elements. The Secretary 

2 shall seek comments from stakeholders regard3 ing the frequency of the reporting of such data 

4 elements. 

5 ‘‘(B) REPORTING REQUIREMENT.—Begin6 ning on the date the system to report standard7 ized data elements under this subsection is 

8 operational, no payment shall be made under 

9 this part for outpatient therapy services fur10 nished to an individual unless a therapy pro11 vider reports the standardized data elements for 

12 such individual. 

13 ‘‘(4) REPORT ON NEW PAYMENT SYSTEM FOR

14 OUTPATIENT THERAPY SERVICES.— 

15 ‘‘(A) IN GENERAL.—Not later than 24 

16 months after the date described in paragraph 

17 (3)(B), the Secretary shall submit to Congress 

18 a report on the design of a new payment system 

19 for outpatient therapy services. The report shall 

20 include an analysis of the standardized data ele21 ments collected and other appropriate data and 

22 information. 

23 ‘‘(B) FEATURES.—Such report shall con24 sider— 


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1 ‘‘(i) appropriate adjustments to pay2 ment (such as case mix and outliers); 

3 ‘‘(ii) payments on an episode of care 

4 basis; and 

5 ‘‘(iii) reduced payment for multiple 

6 episodes. 

7 ‘‘(C) CONSULTATION.—The Secretary shall 

8 consult with stakeholders regarding the design 

9 of such a new payment system. 

10 ‘‘(5) IMPLEMENTATION.— 

11 ‘‘(A) FUNDING.—For purposes of imple12 menting this subsection, the Secretary shall 

13 provide for the transfer, from the Federal Sup14 plementary Medical Insurance Trust Fund 

15 under section 1841, of $7,000,000 to the Cen16 ters for Medicare & Medicaid Services Program 

17 Management Account for each of fiscal years 

18 2014 through 2018. Amounts transferred under 

19 this subparagraph shall remain available until 

20 expended. 

21 ‘‘(B) ADMINISTRATION.—Chapter 35 of 

22 title 44, United States Code, shall not apply to 

23 specification of the standardized data elements 

24 and implementation of the system to report 


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1 such standardized data elements under this 

2 subsection. 

3 ‘‘(C) LIMITATION.—There shall be no ad4 ministrative or judicial review under section 

5 1869, section 1878, or otherwise of the speci6 fication of standardized data elements required 

7 under this subsection or the system to report 

8 such standardized data elements. 

9 ‘‘(D) DEFINITION OF OUTPATIENT THER10 APY SERVICES AND THERAPY PROVIDER.—In 

11 this subsection, the terms ‘outpatient therapy 

12 services’ and ‘therapy provider’ have the mean13 ing given those term in section 1833(aa).’’. 

14 (2) SUNSET OF CURRENT CLAIMS-BASED COL15 LECTION OF THERAPY DATA.—Section 3005(g)(1) of 

16 the Middle Class Tax Extension and Job Creation 

17 Act of 2012 (42 U.S.C. 1395l note) is amended, in 

18 the first sentence, by inserting ‘‘and ending on the 

19 date the system to report standardized data ele20 ments under section 1834(p) of the Social Security 

21 Act (42 U.S.C. 1395m(p)) is implemented,’’ after 

22 ‘‘January 1, 2013,’’. 

23 (d) REPORTING OF CERTAIN INFORMATION.—Sec24 tion 1842(t) of the Social Security Act (42 U.S.C. 


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1 1395u(t)) is amended by adding at the end the following 

2 new paragraph: 

3 ‘‘(3) Each request for payment, or bill submitted, by 

4 a therapy provider (as defined in section 1833(aa)(10)) 

5 for an outpatient therapy service (as defined in such sec6 tion) furnished by a therapy assistant on or after January 

7 1, 2015, shall include (in a form and manner specified 

8 by the Secretary) an indication that the service was fur9 nished by a therapy assistant.’’. 

10 SEC. 203. MEDICARE AMBULANCE SERVICES. 

11 (a) EXTENSION OF CERTAIN AMBULANCE ADD-ON

12 PAYMENTS.— 

13 (1) GROUND AMBULANCE.—Section 

14 1834(l)(13)(A) of the Social Security Act (42 U.S.C. 

15 1395m(l)(13)(A)) is amended by striking ‘‘April 1, 

16 2014’’ and inserting ‘‘January 1, 2019’’ each place 

17 it appears. 

18 (2) SUPER RURAL AMBULANCE.—Section 

19 1834(l)(12)(A) of the Social Security Act (42 U.S.C. 

20 1395m(l)(12)(A)) is amended, in the first sentence, 

21 by striking ‘‘April 1, 2014’’ and inserting ‘‘January 

22 1, 2019’’. 

23 (b) REQUIRING AMBULANCE PROVIDERS TO SUBMIT

24 COST AND OTHER INFORMATION.—Section 1834(l) of the 


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1 Social Security Act (42 U.S.C. 1395m(l)) is amended by 

2 adding at the end the following new paragraph: 

3 ‘‘(16) SUBMISSION OF COST AND OTHER INFOR4 MATION.— 

5 ‘‘(A) DEVELOPMENT OF DATA COLLECTION

6 SYSTEM.—The Secretary shall develop a data 

7 collection system (which may include use of a 

8 cost survey and standardized definitions) for 

9 providers and suppliers of ambulance services to 

10 collect cost, revenue, utilization, and other in11 formation determined appropriate by the Sec12 retary. Such system shall be designed to submit 

13 information— 

14 ‘‘(i) needed to evaluate the appro15 priateness of payment rates under this 

16 subsection; 

17 ‘‘(ii) on the utilization of capital 

18 equipment and ambulance capacity; and 

19 ‘‘(iii) on different types of ambulance 

20 services furnished in different geographic 

21 locations, including rural areas and low 

22 population density areas described in para23 graph (12). 

24 ‘‘(B) SPECIFICATION OF DATA COLLEC25 TION SYSTEM.— 


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1 ‘‘(i) IN GENERAL.—Not later than 

2 July 1, 2015, the Secretary shall— 

3 ‘‘(I) specify the data collection 

4 system under subparagraph (A) and 

5 the time period during which such 

6 data is required to be submitted; and 

7 ‘‘(II) identify the providers and 

8 suppliers of ambulance services who 

9 would be required to submit the infor10 mation under such data collection sys11 tem. 

12 ‘‘(ii) RESPONDENTS.—Subject to sub13 paragraph (D)(ii), the Secretary shall de14 termine an appropriate sample of providers 

15 and suppliers of ambulance services to sub16 mit information under the data collection 

17 system for each period for which reporting 

18 of data is required. 

19 ‘‘(C) PENALTY FOR FAILURE TO REPORT

20 COST AND OTHER INFORMATION.—Beginning 

21 on July 1, 2016, a 5 percent reduction to pay22 ments under this part shall be made for a 1- 

23 year prospective period specified by the Sec24 retary to a provider or supplier of ambulance 

25 services who— 


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1 ‘‘(i) is identified under subparagraph 

2 (B)(i)(II) as being required to submit the 

3 information under the data collection sys4 tem; and 

5 ‘‘(ii) does not submit such information 

6 during the period specified under subpara7 graph (B)(i)(I). 

8 ‘‘(D) ONGOING DATA COLLECTION.— 

9 ‘‘(i) REVISION OF DATA COLLECTION

10 SYSTEM.—The Secretary may, as deter11 mined appropriate, periodically revise the 

12 data collection system. 

13 ‘‘(ii) SUBSEQUENT DATA COLLEC14 TION.—In order to continue to evaluate 

15 the appropriateness of payment rates 

16 under this subsection, the Secretary shall, 

17 for years after 2016 (but not less often 

18 than once every 3 years), require providers 

19 and suppliers of ambulance services to sub20 mit information for a period the Secretary 

21 determines appropriate. The penalty de22 scribed in subparagraph (C) shall apply to 

23 such subsequent data collection periods. 

24 ‘‘(E) CONSULTATION.—The Secretary shall 

25 consult with stakeholders in carrying out the 


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1 development of the system and collection of in2 formation under this paragraph, including the 

3 activities described in subparagraphs (A) and 

4 (D). Such consultation shall include the use of 

5 requests for information and other mechanisms 

6 determined appropriate by the Secretary. 

7 ‘‘(F) ADMINISTRATION.—Chapter 35 of 

8 title 44, United States Code, shall not apply to 

9 the collection of information required under this 

10 subsection. 

11 ‘‘(G) LIMITATIONS ON REVIEW.—There 

12 shall be no administrative or judicial review 

13 under section 1869, section 1878, or otherwise 

14 of the data collection system or identification of 

15 respondents under this paragraph. 

16 ‘‘(H) FUNDING FOR IMPLEMENTATION.— 

17 For purposes of carrying out subparagraph (A), 

18 the Secretary shall provide for the transfer, 

19 from the Federal Supplementary Medical Insur20 ance Trust Fund under section 1841, of 

21 $1,000,000 to the Centers for Medicare & Med22 icaid Services Program Management Account 

23 for fiscal year 2014. Amounts transferred under 

24 this subparagraph shall remain available until 

25 expended.’’. 


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1 SEC. 204. REVISION OF THE MEDICARE-DEPENDENT HOS2 PITAL (MDH) PROGRAM. 

3 (a) PERMANENT EXTENSION OF PAYMENT METHOD4 OLOGY.— 

5 (1) IN GENERAL.—Section 1886(d)(5)(G) of 

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

7 1395ww(d)(5)(G)) is amended— 

8 (A) in clause (i), by striking ‘‘and before 

9 April 1, 2014,’’; and 

10 (B) in clause (ii)(II), by striking ‘‘and be11 fore April 1, 2014,’’. 

12 (2) CONFORMING AMENDMENTS.— 

13 (A) TARGET AMOUNT.—Section 

14 1886(b)(3)(D) of the Social Security Act (42 

15 U.S.C. 1395ww(b)(3)(D)) is amended— 

16 (i) in the matter preceding clause (i), 

17 by striking ‘‘and before April 1, 2014,’’; 

18 and 

19 (ii) in clause (iv), by striking 

20 ‘‘through fiscal year 2013 and the portion 

21 of fiscal year 2014 before April 1, 2014’’ 

22 and inserting ‘‘or a subsequent fiscal 

23 year’’. 

24 (B) HOSPITAL VALUE-BASED PURCHASING

25 PROGRAM.—Section 1886(o)(7)(D)(ii)(I) of the 

26 Social Security Act (42 U.S.C. 


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1 1395ww(o)(7)(D)(ii)(I)) is amended by striking 

2 ‘‘(with respect to discharges occurring during 

3 fiscal year 2012 and 2013)’’. 

4 (C) HOSPITAL READMISSION REDUCTION

5 PROGRAM.—Section 1886(q)(2)(B)(i) of the So6 cial Security Act (42 U.S.C. 

7 1395ww(q)(2)(B)(i)) is amended by striking 

8 ‘‘(with respect to discharges occurring during 

9 fiscal years 2012 and 2013)’’. 

10 (D) PERMITTING HOSPITALS TO DECLINE

11 RECLASSIFICATION.—Section 13501(e)(2) of 

12 the Omnibus Budget Reconciliation Act of 1993 

13 (42 U.S.C. 1395ww note) is amended by strik14 ing ‘‘fiscal year 1998, fiscal year 1999, or fiscal 

15 year 2000 through the first 2 quarters of fiscal 

16 year 2014’’ and inserting ‘‘or fiscal year 1998 

17 or a subsequent fiscal year’’. 

18 (b) GAO STUDY AND REPORT ON MEDICARE-DE19 PENDENT HOSPITALS.— 

20 (1) STUDY.—The Comptroller General of the 

21 United States shall conduct a study on the following: 

22 (A) The payor mix of medicare-dependent, 

23 small rural hospitals (as defined in section 

24 1886(d)(5)(G)(iv)), how such mix will trend in 

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1 ment under subclause (IV) of such section 

2 should be revised. 

3 (B) The characteristics of medicare-de4 pendent, small rural hospitals that meet the re5 quirement of such subclause (IV) through the 

6 application of paragraph (a)(iii)(A) or 

7 (a)(iii)(B) of section 412.108 of the Code of 

8 Federal Regulations, including Medicare inpa9 tient and outpatient utilization, payor mix, and 

10 financial status, including Medicare and total 

11 margins, and whether or not Medicare pay12 ments for such hospitals should be revised. 

13 (C) Such other items related to medicare14 dependent, small rural hospitals as the Comp15 troller General determines appropriate. 

16 (2) REPORT.—Not later than 12 months after 

17 the date of the enactment of this Act, the Comp18 troller General of the United States shall submit to 

19 Congress a report on the study conducted under 

20 paragraph (1), together with recommendations for 

21 such legislation and administrative action as the 

22 Comptroller General determines appropriate. 

23 (c) IMPLEMENTATION.—Notwithstanding any other 

24 provision of law, for purposes of fiscal year 2014, the Sec25 retary of Health and Human Services may implement the 


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1 provisions of, and the amendments made by, this section 

2 through program instruction or otherwise. 

3 SEC. 205. REVISION OF MEDICARE INPATIENT HOSPITAL 

4 PAYMENT ADJUSTMENT FOR LOW-VOLUME 

5 HOSPITALS. 

6 (a) IN GENERAL.—Section 1886(d)(12) of the Social 

7 Security Act (42 U.S.C. 1395ww(d)(12)) is amended— 

8 (1) in subparagraph (B)— 

9 (A) in the subparagraph heading, by in10 serting ‘‘FOR FISCAL YEARS 2005 THROUGH

11 2010’’ after ‘‘INCREASE’’; and 

12 (B) in the matter preceding clause (i), by 

13 striking ‘‘and for discharges occurring in the 

14 portion of fiscal year 2014 beginning on April 

15 1, 2014, fiscal year 2015, and subsequent 

16 years’’; 

17 (2) in subparagraph (C)(i)— 

18 (A) by striking ‘‘fiscal years 2011, 2012, 

19 and 2013, and the portion of fiscal year 2014 

20 before’’ and inserting ‘‘fiscal year 2011 and 

21 subsequent fiscal years,’’ each place it appears; 

22 and 

23 (B) by striking ‘‘or portion of fiscal year’’ 

24 after ‘‘during the fiscal year’’; and 

25 (3) in subparagraph (D)— 


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1 (A) in the heading, by striking ‘‘TEM2 PORARY APPLICABLE PERCENTAGE INCREASE’’ 

3 and inserting ‘‘APPLICABLE PERCENTAGE IN4 CREASE FOR FISCAL YEAR 2011 AND SUBSE5 QUENT FISCAL YEARS’’; 

6 (B) by striking ‘‘fiscal years 2011, 2012, 

7 and 2013, and the portion of fiscal year 2014 

8 before April 1, 2014’’ and inserting ‘‘fiscal year 

9 2011 or a subsequent fiscal year’’; and 

10 (C) by striking ‘‘or the portion of fiscal 

11 year’’ after ‘‘in the fiscal year’’. 

12 (b) IMPLEMENTATION.—Notwithstanding any other 

13 provision of law, for purposes of fiscal year 2014, the Sec14 retary of Health and Human Services may implement the 

15 provisions of, and the amendments made by, this section 

16 through program instruction or otherwise. 

17 SEC. 206. SPECIALIZED MEDICARE ADVANTAGE PLANS FOR 

18 SPECIAL NEEDS INDIVIDUALS. 

19 (a) EXTENSION.—Section 1859(f)(1) of the Social 

20 Security Act (42 U.S.C. 1395w–28(f)(1)) is amended— 

21 (1) by striking ‘‘ENROLLMENT.—In the case’’ 

22 and inserting ‘‘ENROLLMENT.— 

23 ‘‘(A) IN GENERAL.—Subject to subpara24 graphs (B) and (C), in the case’’; 


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1 (2) in subparagraph (A), as added by para2 graph (1), by striking ‘‘and for periods before Janu3 ary 1, 2016’’; and 

4 (3) by adding at the end the following new sub5 paragraphs: 

6 ‘‘(B) APPLICATION TO DUAL SNPS.—Sub7 paragraph (A) shall only apply to a specialized 

8 MA plan for special needs individuals described 

9 in subsection (b)(6)(B)(ii) for periods before 

10 January 1, 2021. 

11 ‘‘(C) APPLICATION TO SEVERE OR DIS12 ABLING CHRONIC CONDITION SNPS.—Subpara13 graph (A) shall only apply to a specialized MA 

14 plan for special needs individuals described in 

15 subsection (b)(6)(B)(iii) for periods before Jan16 uary 1, 2018.’’. 

17 (b) INCREASED INTEGRATION OF DUAL SNPS.— 

18 (1) IN GENERAL.—Section 1859(f) of the Social 

19 Security Act (42 U.S.C. 1395w–28(f)) is amended— 

20 (A) in paragraph (3), by adding at the end 

21 the following new subparagraph: 

22 ‘‘(F) The plan meets the requirements ap23 plicable under paragraph (8).’’; and 

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

25 paragraph: 


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1 ‘‘(8) INCREASED INTEGRATION OF DUAL

2 SNPS.— 

3 ‘‘(A) DESIGNATED CONTACT.—The Sec4 retary, acting through the Federal Coordinated 

5 Health Care Office (Medicare-Medicaid Coordi6 nation Office) established under section 2602 of 

7 the Patient Protection and Affordable Care Act 

8 (in this paragraph referred to as the ‘MMCO’), 

9 shall serve as a dedicated point of contact for 

10 States to address misalignments that arise with 

11 the integration of specialized MA plans for spe12 cial needs individuals described in subsection 

13 (b)(6)(B)(ii) under this paragraph. Consistent 

14 with such role, the MMCO shall— 

15 ‘‘(i) establish a uniform process for 

16 disseminating to State Medicaid agencies 

17 information under this title impacting con18 tracts between such agencies and such 

19 plans under this subsection; and 

20 ‘‘(ii) establish basic resources for 

21 States interested in exploring such plans 

22 as a platform for integration. 

23 ‘‘(B) UNIFIED GRIEVANCES AND APPEALS

24 PROCESS.— 


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1 ‘‘(i) IN GENERAL.—Not later than 

2 April 1, 2015, the Secretary shall establish 

3 procedures unifying the grievances and ap4 peals procedures under sections 1852(f), 

5 1852(g), 1902(a)(3), and 1902(a)(5) for 

6 items and services provided by specialized 

7 MA plans for special needs individuals de8 scribed in subsection (b)(6)(B)(ii) under 

9 this title and title XIX. The Secretary 

10 shall solicit comment in developing such 

11 procedures from States, plans, beneficiary 

12 representatives, and other relevant stake13 holders. 

14 ‘‘(ii) PROCEDURES.—The procedures 

15 established under clause (i) shall— 

16 ‘‘(I) adopt the most protective 

17 provisions for the enrollee under cur18 rent law, including continuation of 

19 benefits under title XIX pending ap20 peal if an appeal is filed in a timely 

21 manner; 

22 ‘‘(II) take into account dif23 ferences in State plans under title 

24 XIX; 


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1 ‘‘(III) be easily navigable by an 

2 enrollee; and 

3 ‘‘(IV) include the elements de4 scribed in clause (iii). 

5 ‘‘(iii) ELEMENTS DESCRIBED.—The 

6 following elements are described in this 

7 clause: 

8 ‘‘(I) Single notification of all ap9 plicable grievances and appeal rights 

10 under this title and title XIX. 

11 ‘‘(II) Notices written in plain lan12 guage and available in a language and 

13 format that is accessible to the en14 rollee. 

15 ‘‘(III) Unified timeframes for in16 ternal and external grievances and ap17 peals processes, such as an individ18 ual’s filing of a grievance or appeal, a 

19 plan’s acknowledgment and resolution 

20 of a grievance or appeal, and notifica21 tion of decisions with respect to a 

22 grievance or appeal. 

23 ‘‘(IV) Guidelines to allow the 

24 plan to process, track, and resolve 

25 grievances and appeals, to ensure 


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1 beneficiaries are notified on a timely 

2 basis of decisions that are made 

3 throughout the grievance or appeals 

4 process and are able to easily deter5 mine the status of a grievance or ap6 peal. 

7 ‘‘(C) REQUIREMENT FOR UNIFIED GRIEV8 ANCES AND APPEALS.— 

9 ‘‘(i) IN GENERAL.—For 2016 and 

10 subsequent years, the contract of a special11 ized MA plan for special needs individuals 

12 described in subsection (b)(6)(B)(ii) with a 

13 State Medicaid agency under this sub14 section shall require the use of unified 

15 grievances and appeals procedures as de16 scribed in subparagraph (B). 

17 ‘‘(ii) CONSIDERATION OF APPLICA18 TION FOR OTHER SNPS.—The Secretary 

19 shall consider applying the unified griev20 ances and appeals process described in 

21 subparagraph (B) to specialized MA plans 

22 for special needs individuals described in 

23 subsection (b)(6)(B)(i) and subsection 

24 (b)(6)(B)(iii) that have a substantial por25 tion of enrollees who are dually eligible for 


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1 benefits under this title and title XIX and 

2 are at risk for full benefits under title 

3 XIX. 

4 ‘‘(D) REQUIREMENT FOR FULL INTEGRA5 TION FOR CERTAIN DUAL SNPS.— 

6 ‘‘(i) REQUIREMENT.—Subject to the 

7 succeeding provisions of this subparagraph, 

8 for 2018 and subsequent years, a special9 ized MA plan for special needs individuals 

10 described in subsection (b)(6)(B)(ii) 

11 shall— 

12 ‘‘(I) integrate all benefits under 

13 this title and title XIX; and 

14 ‘‘(II) meet the requirements of a 

15 fully integrated plan described in sec16 tion 1853(a)(1)(B)(iv)(II) (other than 

17 the requirement that the plan have 

18 similar average levels of frailty, as de19 termined by the Secretary, as the 

20 PACE program), including with re21 spect to long-term care services or be22 havioral health services to the extent 

23 State law permits capitation of those 

24 services under such plan. 


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1 ‘‘(ii) INITIAL SANCTIONS FOR FAIL2 URE TO MEET REQUIREMENT FOR 2018 OR

3 2019.—For each of 2018 and 2019, if the 

4 Secretary determines that a plan has failed 

5 to meet the requirement described in 

6 clause (i), the Secretary shall impose one 

7 of the following on the plan: 

8 ‘‘(I) A reduction in payment to 

9 the plan under this part in an amount 

10 at least equal to the portion of the 

11 monthly rebate computed under sec12 tion 1854(b)(1)(C)(i) for the plan and 

13 year that would otherwise be kept by 

14 the plan after application of the bene15 ficiary rebate rule under section 

16 1854(b)(1)(C). 

17 ‘‘(II) Closing enrollment in the 

18 plan. 

19 ‘‘(III) Sanctioning the plan in ac20 cordance with section 1857(g). 

21 ‘‘(IV) Other reasonable action 

22 (other than the sanction described in 

23 clause (iii)) the Secretary determines 

24 appropriate. 


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1 ‘‘(iii) SANCTIONS FOR FAILURE TO

2 MEET REQUIREMENT FOR 2020 AND SUBSE3 QUENT YEARS.—For 2020 and subsequent 

4 years, if the Secretary determines that a 

5 plan has failed to meet the requirement de6 scribed in clause (i), the plan shall be 

7 deemed to no longer meet the definition of 

8 a specialized MA plan for special needs in9 dividuals described in subsection 

10 (b)(6)(B)(ii). 

11 ‘‘(iv) LIMITATION.—This subpara12 graph shall not apply to a specialized MA 

13 plan for special needs individuals described 

14 in subsection (b)(6)(B)(ii) that only enrolls 

15 individuals for whom the only medical as16 sistance to which the individuals are enti17 tled under the State plan is medicare cost 

18 sharing described in section 

19 1905(p)(3)(A)(ii).’’. 

20 (2) CONFORMING AMENDMENT TO RESPON21 SIBILITIES OF FEDERAL COORDINATED HEALTH

22 CARE OFFICE (MMCO).—Section 2602(d) of the Pa23 tient Protection and Affordable Care Act (42 U.S.C. 

24 1315b(d)) is amended by adding at the end the fol25 lowing new paragraph: 


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1 ‘‘(6) To act as a designated contact for States 

2 under subsection (f)(8)(A) of section 1859 of the So3 cial Security Act (42 U.S.C. 1395w–28) with respect 

4 to the integration of specialized MA plans for special 

5 needs individuals described in subsection 

6 (b)(6)(B)(ii) of such section.’’. 

7 (c) IMPROVEMENTS TO SEVERE OR DISABLING

8 CHRONIC CONDITION SNPS.—Section 1859(f)(5) of the 

9 Social Security Act (42 U.S.C. 1395w–28(f)(5)) is amend10 ed— 

11 (1) by striking ‘‘ALL SNPS.—The requirements’’ 

12 and inserting ‘‘ALL SNPS.— 

13 ‘‘(A) IN GENERAL.—Subject to subpara14 graph (B), the requirements’’; 

15 (2) by redesignating subparagraphs (A) and 

16 (B) as clauses (i) and (ii), respectively, and indent17 ing appropriately; 

18 (3) in clause (ii), as redesignated by paragraph 

19 (2), by redesignating clauses (i) through (iii) as sub20 clauses (I) through (III), respectively, and indenting 

21 appropriately; and 

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

24 ‘‘(B) IMPROVEMENTS TO CARE MANAGE25 MENT REQUIREMENTS FOR SEVERE OR DISVerDate Mar 15 2010 01:32 Mar 14, 2014 Jkt 039200 PO 00000 Frm 00232 Fmt 6652 Sfmt 6201 E:\BILLS\S2122.PCS S2122

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1 ABLING CHRONIC CONDITION SNPS.—For 2016 

2 and subsequent years, in the case of a special3 ized MA plan for special needs individuals de4 scribed in subsection (b)(6)(B)(iii), the require5 ments described in this paragraph include the 

6 following: 

7 ‘‘(i) The interdisciplinary team under 

8 subparagraph (A)(ii)(III) includes a team 

9 of providers with demonstrated expertise, 

10 including training in an applicable spe11 cialty, in treating individuals similar to the 

12 targeted population of the plan. 

13 ‘‘(ii) Requirements developed by the 

14 Secretary to provide face-to-face encoun15 ters with individuals enrolled in the plan 

16 not less frequently than on an annual 

17 basis. 

18 ‘‘(iii) As part of the model of care 

19 under clause (i) of subparagraph (A), the 

20 results of the initial assessment and an21 nual reassessment under clause (ii)(I) of 

22 such subparagraph of each individual en23 rolled in the plan are addressed in the indi24 vidual’s individualized care plan under 

25 clause (ii)(II) of such subparagraph. 


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1 ‘‘(iv) As part of the annual evaluation 

2 and approval of such model of care, the 

3 Secretary shall take into account whether 

4 the plan fulfilled the previous year’s goals 

5 (as required under the model of care). 

6 ‘‘(v) The Secretary shall establish a 

7 minimum benchmark for each element of 

8 the model of care of a plan. The Secretary 

9 shall only approve a plan’s model of care 

10 under this paragraph if each element of 

11 the model of care meets the minimum 

12 benchmark applicable under the preceding 

13 sentence.’’. 

14 (d) GAO STUDY ON QUALITY IMPROVEMENT.— 

15 (1) STUDY.—The Comptroller General of the 

16 United States shall conduct a study on how the Sec17 retary of Health and Human Services could change 

18 the quality measurement system under the Medicare 

19 Advantage program under part C of title XVIII of 

20 the Social Security Act (42 U.S.C. 1395w–21 et 

21 seq.) to allow an accurate comparison of the quality 

22 of care provided by specialized MA plans for special 

23 needs individuals (as defined in section 1859(b)(6) 

24 of such Act (42 U.S.C. 1395w–28(b)(6)), both for 

25 individual plans and such plans overall, compared to 


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1 the quality of care delivered by the original Medicare 

2 fee-for-service program under parts A and B of such 

3 title and other Medicare Advantage plans under such 

4 part C across similar populations. 

5 (2) REPORT.—Not later than July 1, 2016, the 

6 Comptroller General shall submit to Congress a re7 port containing the results of the study under para8 graph (1), together with recommendations for such 

9 legislation and administrative action as the Comp10 troller General determines appropriate. 

11 (e) CHANGES TO QUALITY RATINGS AND MEASURE12 MENT OF SNPS AND DETERMINATION OF FEASABILITY

13 OF QUALITY MEASUREMENT AT THE PLAN LEVEL.—Sec14 tion 1853(o) of the Social Security Act (42 U.S.C. 1395w– 

15 23(o)) is amended by adding at the end the following new 

16 paragraphs: 

17 ‘‘(6) CHANGES TO QUALITY RATINGS OF

18 SNPS.— 

19 ‘‘(A) EMPHASIS ON IMPROVEMENT ACROSS

20 SNPS.—Subject to subparagraph (B), beginning 

21 in plan year 2016, in the case of a specialized 

22 MA plan for special needs individuals, the Sec23 retary shall increase the emphasis on the plan’s 

24 improvement or decline in performance when 


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1 determining the star rating of the plan under 

2 this subsection for the year as follows: 

3 ‘‘(i)(I) For plan year 2016, at least 

4 10 percent, but not more than 12 percent, 

5 of the total star rating of the plan shall be 

6 based on improvement or decline in per7 formance. 

8 ‘‘(II) For plan year 2017 and subse9 quent plan years, at least 12 percent, but 

10 not more than 15 percent, of the total star 

11 rating of the plan shall be based on im12 provement or decline in performance. 

13 ‘‘(ii) Improvement or decline in per14 formance under this subparagraph shall be 

15 measured based on net change in the indi16 vidual star rating measures of the plan, 

17 with appropriate weight given to specific 

18 individual star ratings measures, such as 

19 readmission rates, as determined by the 

20 Secretary. 

21 ‘‘(iii) The Secretary shall make an ap22 propriate adjustment to the improvement 

23 rating of a plan under this subparagraph 

24 if the plan has achieved a 4.5-star rating 

25 or the highest rating possible overall or for 


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1 an individual measure in order to ensure 

2 that the plan is not punished in cases 

3 where it is not possible to improve. 

4 ‘‘(B) NO APPLICATION TO CERTAIN

5 PLANS.—Subparagraph (A) shall not apply, 

6 with respect to a year, to a specialized MA plan 

7 for special needs individuals that has a rating 

8 that is less than two-and-one-half stars. 

9 ‘‘(C) QUALITY MEASUREMENT AT THE

10 PLAN LEVEL.— 

11 ‘‘(i) IN GENERAL.—The Secretary 

12 may require reporting for and apply under 

13 this subsection quality measures at the 

14 plan level for specialized MA plan for spe15 cial needs individuals instead of at the con16 tract level. 

17 ‘‘(ii) CONSIDERATION.—The Secretary 

18 shall take into consideration the minimum 

19 number of enrollees in a specialized MA 

20 plan for special needs individuals in order 

21 to determine if a statistically significant or 

22 valid measurement of quality at the plan 

23 level is possible under clause (i). 


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1 ‘‘(iii) APPLICATION.—If the Secretary 

2 applies quality measurement at the plan 

3 level under this subparagraph— 

4 ‘‘(I) such quality measurement 

5 shall include Medicare Health Out6 comes Survey (HOS), Healthcare Ef7 fectiveness Data and Information Set 

8 (HEDIS), and Consumer Assessment 

9 of Healthcare Providers and Systems 

10 (CAHPS) measures; and 

11 ‘‘(II) payment and other adminis12 trative actions linked to quality meas13 urement (including the 5-star rating 

14 system under this subsection) shall be 

15 applied at the plan level in accordance 

16 with this subparagraph. 

17 ‘‘(7) DETERMINATION OF FEASIBILITY OF

18 QUALITY MEASUREMENT AT THE PLAN LEVEL.— 

19 ‘‘(A) DETERMINATION OF FEASIBILITY.— 

20 The Secretary shall determine the feasibility of 

21 requiring reporting for and applying under this 

22 subsection quality measures at the plan level for 

23 all MA plans under this part. 

24 ‘‘(B) CONSIDERATION OF CHANGE.—After 

25 making a determination under subparagraph 


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1 (A), the Secretary shall consider requiring such 

2 reporting and applying such quality measures 

3 at the plan level as described in such subpara4 graph.’’. 

5 SEC. 207. REASONABLE COST REIMBURSEMENT CON6 TRACTS. 

7 (a) ONE-YEAR TRANSITION AND NOTICE REGARDING

8 TRANSITION.—Section 1876(h)(5)(C) of the Social Secu9 rity Act (42 U.S.C. 1395mm(h)(5)(C)) is amended— 

10 (1) in clause (ii), in the matter preceding sub11 clause (I), by striking ‘‘For any’’ and inserting 

12 ‘‘Subject to clause (iv), for any’’; and 

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

14 clauses: 

15 ‘‘(iv) In the case of an eligible organization that is 

16 offering a reasonable cost reimbursement contract that 

17 may no longer be extended or renewed because of the ap18 plication of clause (ii), the following shall apply: 

19 ‘‘(I) Notwithstanding such clause, such contract 

20 may be extended or renewed for the two years subse21 quent to the previous year described in clause (ii). 

22 The second of the two years described in the pre23 ceding sentence with respect to a contract is referred 

24 to in this subsection as the ‘last reasonable cost re25 imbursement contract year for the contract’. 


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1 ‘‘(II) The organization may not enroll any new 

2 enrollees under such contract during the last reason3 able cost reimbursement contract year for the con4 tract. 

5 ‘‘(III) Not later than a date determined appro6 priate by the Secretary prior to the beginning of the 

7 last reasonable cost reimbursement contract year for 

8 the contract, the organization shall provide notice to 

9 the Secretary as to whether or not the organization 

10 will apply to have the contract converted over and 

11 offered as a Medicare Advantage plan under part C 

12 for the year following the last reasonable cost reim13 bursement contract year for the contract. 

14 ‘‘(IV) If the organization provides the notice de15 scribed in subclause (III) that the contract will be 

16 converted, the organization shall, not later than a 

17 date determined appropriate by the Secretary, pro18 vide the Secretary with such information as the Sec19 retary determines appropriate in order to carry out 

20 sections 1851(c)(4) and 1854(a)(5), including sub21 paragraph (C) of such section. 

22 ‘‘(v) If an eligible organization that is offering a rea23 sonable cost reimbursement contract that is extended or 

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1 scribed in clause (iv)(III) that the contract will be con2 verted, the following provisions shall apply: 

3 ‘‘(I) The deemed enrollment under section 

4 1851(c)(4). 

5 ‘‘(II) The special rule for quality increases 

6 under 1853(o)(3)(A)(iv).’’. 

7 (b) DEEMED ENROLLMENT FROM REASONABLE

8 COST REIMBURSEMENT CONTRACTS CONVERTED TO

9 MEDICARE ADVANTAGE PLANS.— 

10 (1) IN GENERAL.—Section 1851(c) of the So11 cial Security Act (42 U.S.C. 1395w–21(c)) is 

12 amended— 

13 (A) in paragraph (1), by striking ‘‘Such 

14 elections’’ and inserting ‘‘Subject to paragraph 

15 (4), such elections’’; and 

16 (B) by adding at the end the following: 

17 ‘‘(4) DEEMED ENROLLMENT RELATING TO CON18 VERTED REASONABLE COST REIMBURSEMENT CON19 TRACTS.— 

20 ‘‘(A) IN GENERAL.—On the first day of 

21 the annual, coordinated election period under 

22 subsection (e)(3) for plan years beginning on or 

23 after January 1, 2017, an MA eligible indi24 vidual described in clause (i) or (ii) of subpara25 graph (B) is deemed to have elected to receive 


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1 benefits under this title through an applicable 

2 MA plan (and shall be enrolled in such plan) 

3 beginning with such plan year, if— 

4 ‘‘(i) the individual is enrolled in a rea5 sonable cost reimbursement contract under 

6 section 1876(h) in the previous plan year; 

7 ‘‘(ii) such reasonable cost reimburse8 ment contract was extended or renewed for 

9 the last reasonable cost reimbursement 

10 contract year of the contract pursuant to 

11 section 1876(h)(5)(C)(iv); 

12 ‘‘(iii) the eligible organization that is 

13 offering such reasonable cost reimburse14 ment contract provided the notice de15 scribed in subclause (III) of such section 

16 that the contract was to be converted; 

17 ‘‘(iv) the applicable MA plan— 

18 ‘‘(I) is the plan that was con19 verted from the reasonable cost reim20 bursement contract described in 

21 clause (iii); 

22 ‘‘(II) is offered by the same enti23 ty (or an organization affiliated with 

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1 ship interest of control) that entered 

2 into such contract; and 

3 ‘‘(III) is offered in the service 

4 area where the individual resides; 

5 ‘‘(v) the applicable MA plan provides 

6 benefits, premiums, and access to in-net7 work and out-of-network providers that are 

8 comparable to the benefits, premiums, and 

9 access to in-network and out-of-network 

10 providers under such reasonable cost reim11 bursement contract for the previous plan 

12 year; and 

13 ‘‘(vi) the applicable MA plan— 

14 ‘‘(I) allows enrollees transitioning 

15 from the converted reasonable cost 

16 contract to such plan to maintain cur17 rent providers and course of treat18 ment at the time of enrollment for at 

19 least 90 days after enrollment; and 

20 ‘‘(II) during such period, pays 

21 non-contracting providers for items 

22 and services furnished to the enrollee 

23 an amount that is not less than the 

24 amount of payment applicable for 

25 those items and services under the 


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1 original medicare fee-for-service pro2 gram under parts A and B. 

3 ‘‘(B) MA ELIGIBLE INDIVIDUALS DE4 SCRIBED.— 

5 ‘‘(i) WITHOUT PRESCRIPTION DRUG

6 COVERAGE.—An MA eligible individual de7 scribed in this clause, with respect to a 

8 plan year, is an MA eligible individual who 

9 is enrolled in a reasonable cost reimburse10 ment contract under section 1876(h) in the 

11 previous plan year and who does not, for 

12 such previous plan year, receive any pre13 scription drug coverage under part D, in14 cluding coverage under section 1860D–22. 

15 ‘‘(ii) WITH PRESCRIPTION DRUG COV16 ERAGE.—An MA eligible individual de17 scribed in this clause, with respect to a 

18 plan year, is an MA eligible individual who 

19 is enrolled in a reasonable cost reimburse20 ment contract under section 1876(h) in the 

21 previous plan year and who, for such pre22 vious plan year, receives prescription drug 

23 coverage under part D— 

24 ‘‘(I) through such contract; or 


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1 ‘‘(II) through a prescription drug 

2 plan, if the sponsor of such plan is the 

3 same entity (or an organization affili4 ated with such entity) that entered 

5 into such contract. 

6 ‘‘(C) APPLICABLE MA PLAN DEFINED.—In 

7 this paragraph, the term ‘applicable MA plan’ 

8 means, in the case of an individual described 

9 in— 

10 ‘‘(i) subparagraph (B)(i), an MA plan 

11 that is not an MA–PD plan; and 

12 ‘‘(ii) subparagraph (B)(ii), an MA– 

13 PD plan. 

14 ‘‘(D) IDENTIFICATION AND NOTIFICATION

15 OF DEEMED INDIVIDUALS.—Not later than 30 

16 days before the first day of the annual, coordi17 nated election period under subsection (e)(3) 

18 for plan years beginning on or after January 1, 

19 2017, the Secretary shall identify and notify the 

20 individuals who will be subject to deemed elec21 tions under subparagraph (A) on the first day 

22 of such period.’’. 

23 (2) BENEFICIARY OPTION TO DISCONTINUE OR

24 CHANGE MA PLAN OR MA–PD PLAN AFTER DEEMED

25 ENROLLMENT.— 


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1 (A) IN GENERAL.—Section 1851(e)(2) of 

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

3 21(e)(4)) is amended by adding at the end the 

4 following: 

5 ‘‘(F) SPECIAL PERIOD FOR CERTAIN

6 DEEMED ELECTIONS.— 

7 ‘‘(i) IN GENERAL.—At any time dur8 ing the period beginning after the last day 

9 of the annual, coordinated election period 

10 under paragraph (3) in which an individual 

11 is deemed to have elected to enroll in an 

12 MA plan or MA–PD plan under subsection 

13 (c)(4) and ending on the last day of Feb14 ruary of the first plan year for which the 

15 individual is enrolled in such plan, such in16 dividual may change the election under 

17 subsection (a)(1) (including changing the 

18 MA plan or MA–PD plan in which the in19 dividual is enrolled). 

20 ‘‘(ii) LIMITATION OF ONE CHANGE.— 

21 An individual may exercise the right under 

22 clause (i) only once during the applicable 

23 period described in such clause. The limita24 tion under this clause shall not apply to 

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1 nual, coordinated election period under 

2 paragraph (3) or during a special enroll3 ment period under paragraph (4).’’. 

4 (B) CONFORMING AMENDMENTS.— 

5 (i) PLAN REQUIREMENT FOR OPEN

6 ENROLLMENT.—Section 1851(e)(6)(A) of 

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

8 21(e)(6)(A)) is amended by striking ‘‘para9 graph (1),’’ and inserting ‘‘paragraph (1), 

10 during the period described in paragraph 

11 (2)(F),’’. 

12 (ii) PART D.—Section 1860D– 

13 1(b)(1)(B) of such Act (42 U.S.C. 1395w– 

14 101(b)(1)(B)) is amended— 

15 (I) in clause (ii), by adding ‘‘and 

16 paragraph (4)’’ after ‘‘paragraph 

17 (3)(A)’’; and 

18 (II) in clause (iii) by striking 

19 ‘‘and (E)’’ and inserting ‘‘(E), and 

20 (F)’’. 

21 (3) TREATMENT OF ESRD FOR DEEMED EN22 ROLLMENT.—Section 1851(a)(3)(B) of the Social 

23 Security Act (42 U.S.C. 1395w–21(a)(3)(B)) is 

24 amended by adding at the end the following flush 

25 sentence: 


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1 ‘‘An individual who develops end-stage renal 

2 disease while enrolled in a reasonable cost reim3 bursement contract under section 1876(h) shall 

4 be treated as an MA eligible individual for pur5 poses of applying the deemed enrollment under 

6 subsection (c)(4).’’. 

7 (c) INFORMATION REQUIREMENTS.—Section 

8 1851(d)(2)(B) of the Social Security Act (42 U.S.C. 

9 1395w–21(d)(2)(B)) is amended— 

10 (1) by striking the subparagraph heading and 

11 inserting the following: ‘‘(i) NOTIFICATION TO

12 NEWLY ELIGIBLE MEDICARE ADVANTAGE ELIGIBLE

13 INDIVIDUALS.—’’; and 

14 (2) by adding at the end the following: 

15 ‘‘(ii) NOTIFICATION RELATED TO CERTAIN

16 DEEMED ELECTIONS.—The Secretary shall re17 quire the converting cost plan to mail, not later 

18 than 15 days prior to the first day of the an19 nual, coordinated election period under sub20 section (e)(3) of a year, to any individual iden21 tified by the Secretary under subsection 

22 (c)(4)(D) for such year— 

23 ‘‘(I) a notification that such individual 

24 will, on such day, be deemed to have made 

25 an election to receive benefits under this 


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1 title through an MA plan or MA–PD plan 

2 (and shall be enrolled in such plan) for the 

3 next plan year under subsection (c)(4)(A), 

4 but that the individual may make a dif5 ferent election during the annual, coordi6 nated election period for such year; 

7 ‘‘(II) the information described in 

8 subparagraph (A); 

9 ‘‘(III) a description of the differences 

10 between such MA plan or MA–PD plan 

11 and the reasonable cost reimbursement 

12 contract in which the individual was most 

13 recently enrolled with respect to benefits 

14 covered under such plans, including cost15 sharing, premiums, drug coverage, and 

16 provider networks; 

17 ‘‘(IV) information about the special 

18 period for elections under subsection 

19 (e)(2)(F); and 

20 ‘‘(V) other information the Secretary 

21 may specify’’. 

22 (d) TREATMENT OF TRANSITION PLAN FOR QUALITY

23 RATING FOR PAYMENT PURPOSES.—Section 1853(o)(4) 

24 of the Social Security Act (42 U.S.C. 1395w–23(o)(4)) is 


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1 amended by adding at the end the following new subpara2 graph: 

3 ‘‘(C) SPECIAL RULE FOR FIRST 3 PLAN

4 YEARS FOR PLANS THAT WERE CONVERTED

5 FROM A REASONABLE COST REIMBURSEMENT

6 CONTRACT.—For purposes of applying para7 graph (1) and section 1854(b)(1)(C) for the 

8 first 3 plan years under this part in the case of 

9 an MA plan to which deemed enrollment applies 

10 under section 1851(c)(4)— 

11 ‘‘(i) such plan shall not be treated as 

12 a new plan (as defined in paragraph 

13 (3)(A)(iii)(II)); and 

14 ‘‘(ii) in determining the star rating of 

15 the plan under subparagraph (A), to the 

16 extent that Medicare Advantage data for 

17 such plan is not available for a measure 

18 used to determine such star rating, the 

19 Secretary shall use data from the period in 

20 which such plan was a reasonable cost re21 imbursement contract.’’. 

22 SEC. 208. QUALITY MEASURE ENDORSEMENT AND SELEC23 TION. 

24 (a) CONTRACT WITH AN ENTITY REGARDING INPUT

25 ON THE SELECTION OF MEASURES.— 


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1 (1) IN GENERAL.—Title XVIII of the Social Se2 curity Act (42 U.S.C. 1395 et seq.) is amended— 

3 (A) by redesignating section 1890A as sec4 tion 1890B; and 

5 (B) by inserting after section 1890 the fol6 lowing new section: 

7 ‘‘CONTRACT WITH AN ENTITY REGARDING INPUT ON THE

8 SELECTION OF MEASURES

9 ‘‘SEC. 1890A (a) CONTRACT.— 

10 ‘‘(1) IN GENERAL.—For purposes of activities 

11 conducted under this Act, the Secretary shall iden12 tify and have in effect a contract with an entity that 

13 meets the requirements described in subsection (c). 

14 Such contract shall provide that the entity will per15 form the duties described in subsection (b). 

16 ‘‘(2) TIMING FOR FIRST CONTRACT.—The first 

17 contract under paragraph (1) shall begin on, or as 

18 soon as practicable after, October 1, 2014. 

19 ‘‘(3) PERIOD OF CONTRACT.—A contract under 

20 paragraph (1) shall be for a period of 3 years (ex21 cept as may be renewed after a subsequent bidding 

22 process). 

23 ‘‘(4) COMPETITIVE PROCEDURES.—Competitive 

24 procedures (as defined in section 4(5) of the Office 

25 of Federal Procurement Policy Act (41 U.S.C. 


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1 403(5))) shall be used to enter into a contract under 

2 paragraph (1). 

3 ‘‘(b) DUTIES.—The duties described in this sub4 section are the following: 

5 ‘‘(c) REQUIREMENTS DESCRIBED.—The require6 ments described in this subsection are the following: 

7 ‘‘(1) PRIVATE NONPROFIT, BOARD MEMBER8 SHIP, MEMBERSHIP FEES, AND NOT A MEASURE DE9 VELOPER.—The requirements described in para10 graphs (1), (2), (7), and (8) of section 1890(c). 

11 ‘‘(2) EXPERIENCE.—The entity has at least 4 

12 years of experience working with quality and effi13 ciency measures.’’. 

14 (2) DUTIES OF ENTITY.— 

15 (A) TRANSFER OF PRIORITY SETTING

16 PROCESS.—Paragraph (1) of section 1890(b) of 

17 the Social Security Act (42 U.S.C. 1395aaa(b)) 

18 is redesignated as paragraph (1) of section 

19 1890A(b) of such Act, as added by paragraph 

20 (1). 

21 (B) TRANSFER OF MULTI-STAKEHOLDER

22 PROCESS.—Paragraphs (7) and (8) of such sec23 tion 1890(b) are redesignated as paragraphs 

24 (2) and (3), respectively, of section 1890A(b) of 


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1 such Act, as added by paragraph (1) and 

2 amended by subparagraph (A). 

3 (C) ADDITIONAL DUTIES.—Section 

4 1890A(b) of such Act, as added by paragraph 

5 (1) and amended by subparagraphs (A) and 

6 (B), is amended by adding at the end the fol7 lowing new paragraphs: 

8 ‘‘(4) FACILITATION TO BETTER COORDINATE

9 AND ALIGN PUBLIC AND PRIVATE SECTOR USE OF

10 QUALITY MEASURES.— 

11 ‘‘(A) IN GENERAL.—The entity shall facili12 tate increased coordination and alignment be13 tween the public and private sector with respect 

14 to quality and efficiency measures. 

15 ‘‘(B) REPORTS.—The entity shall prepare 

16 and make available to the public annual reports 

17 on its findings under this paragraph. Such pub18 lic availability shall include posting each report 

19 on the Internet website of the entity. 

20 ‘‘(5) GAP ANALYSIS.—The entity shall conduct 

21 an ongoing analysis of— 

22 ‘‘(A) gaps in endorsed quality and effi23 ciency measures, which shall include measures 

24 that are within priority areas identified by the 

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1 lished under section 399HH of the Public 

2 Health Service Act; and 

3 ‘‘(B) areas where quality measures are un4 available or inadequate to identify or address 

5 such gaps. 

6 ‘‘(6) ANNUAL REPORT TO CONGRESS AND THE

7 SECRETARY; SECRETARIAL PUBLICATION AND COM8 MENT.— 

9 ‘‘(A) ANNUAL REPORT.—By not later than 

10 June 1 of each year, the entity shall submit to 

11 Congress and the Secretary a report con12 taining— 

13 ‘‘(i) a description of— 

14 ‘‘(I) the recommendations made 

15 under paragraph (1); 

16 ‘‘(II) the matters described in 

17 clauses (i) and (ii) of paragraph 

18 (2)(A); 

19 ‘‘(III) the results of the analysis 

20 under paragraph (5); and 

21 ‘‘(IV) the performance by the en22 tity of the duties required under the 

23 contract entered into with the Sec24 retary under subsection (a); and 


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1 ‘‘(ii) any other items determined ap2 propriate by the Secretary. 

3 ‘‘(B) SECRETARIAL REVIEW AND PUBLICA4 TION OF ANNUAL REPORT.—Not later than 6 

5 months after receiving a report under subpara6 graph (A), the Secretary shall— 

7 ‘‘(i) review such report; and 

8 ‘‘(ii) publish such report in the Fed9 eral Register, together with any comments 

10 of the Secretary on such report.’’. 

11 (D) ADDITIONAL AMENDMENTS.—Section 

12 1890A(b) of such Act, as so added and amend13 ed, is amended— 

14 (i) in paragraph (2)— 

15 (I) in subparagraph (A)(i)— 

16 (aa) in subclause (I), by in17 serting ‘‘with a contract under 

18 section 1890’’ after ‘‘entity’’; and 

19 (bb) in subclause (II), by 

20 striking ‘‘such entity’’ and insert21 ing ‘‘the entity with a contract 

22 under section 1890’’; 

23 (II) in the heading of subpara24 graph (B) by inserting ‘‘AND EFFI25 CIENCY’’ after ‘‘QUALITY’’; 


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1 (III) in subparagraph (B)(i)(III), 

2 by striking ‘‘this Act’’ and inserting 

3 ‘‘this title’’; and 

4 (IV) by adding at the end the fol5 lowing new subparagraphs: 

6 ‘‘(E) INPUT.—In providing the input de7 scribed in subparagraph (A), the multi-stake8 holder groups— 

9 ‘‘(i) shall include a detailed descrip10 tion of the rationale for each recommenda11 tion made by the multi-stakeholder group, 

12 including in areas relating to— 

13 ‘‘(I) the expected impact that im14 plementing the measure will have on 

15 individuals; 

16 ‘‘(II) the burden on providers of 

17 services and suppliers; 

18 ‘‘(III) the expected influence over 

19 the behavior of providers of services 

20 and suppliers; 

21 ‘‘(IV) the applicability of a meas22 ure for more than one setting or pro23 gram; and 

24 ‘‘(V) other areas determined in 

25 consultation with the Secretary; and 


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1 ‘‘(ii) may consider whether it is appro2 priate to provide separate recommenda3 tions with respect to measures for internal 

4 use, public reporting, and payment provi5 sions. 

6 ‘‘(F) EQUAL REPRESENTATION.—In con7 vening multi-stakeholder groups pursuant to 

8 this paragraph, the entity shall, to the extent 

9 feasible, make every effort to ensure such 

10 groups are balanced across stakeholders.’’; and 

11 (ii) in paragraph (3), by striking ‘‘Not 

12 later’’ and all that follows through the pe13 riod at the end and inserting the following: 

14 ‘‘Not later than the applicable dates de15 scribed in section 1890B(a)(3) of each 

16 year (or, as applicable, the timeframe de17 scribed in section 1890B(a)(4)), the entity 

18 shall transmit to the Secretary the input of 

19 the multi-stakeholder groups under para20 graph (2).’’. 

21 (b) REVISIONS TO CONTRACT WITH CONSENSUS22 BASED ENTITY.— 

23 (1) CONTRACT.—Section 1890(a) of the Social 

24 Security Act (42 U.S.C. 1395aaa(a)) is amended— 


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

2 as the National Quality Forum,’’; and 

3 (B) in paragraph (3), by striking ‘‘4 

4 years’’ and inserting ‘‘3 years’’. 

5 (2) DUTIES.—Section 1890(b) of the Social Se6 curity Act (42 U.S.C. 1395aaa(b)), as amended by 

7 subsection (a)(2), is amended— 

8 (A) by redesignating paragraphs (2) and 

9 (3) as paragraphs (1) and (2), respectively; 

10 (B) in paragraph (2), as redesignated by 

11 subparagraph (A), by striking ‘‘paragraph (2)’’ 

12 and inserting ‘‘paragraph (1)’’; 

13 (C) by striking paragraphs (5) and (6); 

14 and 

15 (D) by adding at the end the following new 

16 paragraphs: 

17 ‘‘(3) FACILITATION TO BETTER COORDINATE

18 AND ALIGN PUBLIC AND PRIVATE SECTOR USE OF

19 QUALITY MEASURES.— 

20 ‘‘(A) IN GENERAL.—The entity shall facili21 tate increased coordination and alignment be22 tween the public and private sector with respect 

23 to quality and efficiency measures. 

24 ‘‘(B) REPORTS.—The entity shall prepare 

25 and make available to the public annual reports 


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1 on its findings under this paragraph. Such pub2 lic availability shall include posting each report 

3 on the Internet website of the entity. 

4 ‘‘(4) ANNUAL REPORT TO CONGRESS AND THE

5 SECRETARY; SECRETARIAL PUBLICATION AND COM6 MENT.— 

7 ‘‘(A) ANNUAL REPORT.—By not later than 

8 March 1 of each year, the entity shall submit 

9 to Congress and the Secretary a report con10 taining— 

11 ‘‘(i) a description of— 

12 ‘‘(I) the coordination of quality 

13 initiatives under this title and titles 

14 XIX and XXI with quality initiatives 

15 implemented by other payers; 

16 ‘‘(II) areas in which evidence is 

17 insufficient to support endorsement of 

18 quality measures in priority areas 

19 identified by the Secretary under the 

20 national strategy established under 

21 section 399HH of the Public Health 

22 Service Act and where targeted re23 search may address such gaps; and 

24 ‘‘(III) the performance by the en25 tity of the duties required under the 


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1 contract entered into with the Sec2 retary under subsection (a); and 

3 ‘‘(ii) any other items determined ap4 propriate by the Secretary. 

5 ‘‘(B) SECRETARIAL REVIEW AND PUBLICA6 TION OF ANNUAL REPORT.—Not later than 6 

7 months after receiving a report under subpara8 graph (A), the Secretary shall— 

9 ‘‘(i) review such report; and 

10 ‘‘(ii) publish such report in the Fed11 eral Register, together with any comments 

12 of the Secretary on such report.’’. 

13 (3) REQUIREMENTS.—Section 1890(c) of the 

14 Social Security Act (42 U.S.C. 1395aaa(c)) is 

15 amended by adding at the end the following new 

16 paragraph: 

17 ‘‘(8) NOT A MEASURE DEVELOPER.—The entity 

18 is not a measure developer.’’. 

19 (c) REVISIONS TO DUTIES OF THE SECRETARY RE20 GARDING USE OF MEASURES.— 

21 (1) IN GENERAL.—Section 1890B(a) of the So22 cial Security Act (42 U.S.C. 1395aaa–1(a)), as re23 designated by subsection (a)(1)(A), is amended— 


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1 (A) by striking ‘‘section 1890(b)(7)(B)’’ 

2 each place it appears and inserting ‘‘section 

3 1890A(b)(2)(B)’’; 

4 (B) in paragraph (1)— 

5 (i) by striking ‘‘section 1890(b)(7)’’ 

6 and inserting ‘‘section 1890A(b)(2)’’; and 

7 (ii) by striking ‘‘section 1890’’ and in8 serting ‘‘section 1890A’’; 

9 (C) by striking paragraphs (2) and (3) and 

10 inserting the following: 

11 ‘‘(2) PUBLIC AVAILABILITY OF MEASURES CON12 SIDERED FOR SELECTION.—Subject to paragraph 

13 (4), not later than October 1 or December 31 of 

14 each year (or as soon as practicable after such dates 

15 for the first year of the contract), the Secretary 

16 shall make available to the public a list of quality 

17 and efficiency measures described in section 

18 1890A(b)(2)(B) that the Secretary is considering 

19 under this title. The Secretary shall provide for an 

20 appropriate balance of the number of measures to be 

21 made available by each such date in a year. 

22 ‘‘(3) TRANSMISSION OF MULTI-STAKEHOLDER

23 INPUT.— 

24 ‘‘(A) IN GENERAL.—Subject to paragraph 

25 (4), not later than the applicable date described 


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1 in subparagraph (B) of each year, the entity 

2 with a contract under section 1890A shall, pur3 suant to subsection (b)(3) of such section, 

4 transmit to the Secretary the input of multi5 stakeholder groups described in paragraph (1). 

6 ‘‘(B) APPLICABLE DATE DESCRIBED.—The 

7 applicable date described in this subparagraph 

8 for a year is— 

9 ‘‘(i) February 1 (or as soon as prac10 ticable after such date for the first year of 

11 the contract) with respect to quality and 

12 efficiency measures made available under 

13 paragraph (2) by October 1 of the pre14 ceding year; and 

15 ‘‘(ii) April 1 (or as soon as practicable 

16 after such dates for the first year of the 

17 contract) with respect to quality and effi18 ciency measures made available under 

19 paragraph (2) by December 31 of the pre20 ceding year.’’; 

21 (D) by redesignating— 

22 (i) paragraph (6) as paragraph (8); 

23 and 

24 (ii) paragraphs (4) and (5) as para25 graphs (5) and (6), respectively; 


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1 (E) by inserting after paragraph (3) the 

2 following new paragraph: 

3 ‘‘(4) LIMITED PROCESS FOR ADDITIONAL

4 MULTI-STAKEHOLDER INPUT.—In addition to the 

5 Secretary making measures publically available pur6 suant to the dates described in paragraph (2) and 

7 multi-stakeholder groups transmitting the input pur8 suant to the applicable dates described in paragraph 

9 (3)— 

10 ‘‘(A) the Secretary may, at times that do 

11 not meet the time requirements described in 

12 paragraph (2), make available to the public a 

13 limited number of quality and efficiency meas14 ures described in section 1890A(b)(2) that the 

15 Secretary is considering under this title; and 

16 ‘‘(B) if the Secretary uses the authority 

17 under subparagraph (A), the entity with a con18 tract under section 1890A shall, pursuant to 

19 section 1890A(b)(3), transmit to the Secretary 

20 on a timely basis the input from a multi-stake21 holder group described in paragraph (1) with 

22 respect to such measures.’’; 

23 (F) in paragraph (6), as redesignated by 

24 subparagraph (D)(ii), by inserting ‘‘or that has 

25 not been recommended by the multi-stakeholder 


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1 group under section 1890A(b)(2)’’ before the 

2 period at the end; and 

3 (G) by inserting after paragraph (6) the 

4 following new paragraph: 

5 ‘‘(7) CONCORDANCE RATES.—For each year 

6 (beginning with 2015), the Secretary shall include a 

7 list of concordance rates with respect to the input 

8 provided under section 1890A(b)(2)(A) for those 

9 new measures adopted for each type of provider of 

10 services and supplier in the annual final rule appli11 cable to such type of provider or supplier.’’. 

12 (2) REVIEW.—Section 1890B(c) of the Social 

13 Security Act (42 U.S.C. 1395aaa–1(c)), as redesig14 nated by subsection (a)(1)(A), is amended— 

15 (A) in paragraph (1)(A), by striking ‘‘sec16 tion 1890(b)(7)(B)’’ and inserting ‘‘section 

17 1890A(b)(2)(B)’’; and 

18 (B) in paragraph (2)— 

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

20 ‘‘and’’ at the end; 

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

22 the period at the end and inserting ‘‘; 

23 and’’; and 

24 (iii) by adding at the end the fol25 lowing new subparagraph: 


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1 ‘‘(C) take into consideration the benefits of 

2 the alignment of measures between the public 

3 and private sector.’’. 

4 (d) FUNDING FOR QUALITY MEASURE ENDORSE5 MENT, INPUT, AND SELECTION.— 

6 (1) FISCAL YEAR 2014.—In addition to amounts 

7 transferred under section 3014(c) of the Patient 

8 Protection and Affordable Care Act (Public Law 

9 111–148), for purposes of carrying out section 1890 

10 and section 1890A (other than subsections (e) and 

11 (f)), the Secretary shall provide for the transfer, 

12 from the Federal Hospital Insurance Trust Fund 

13 under section 1817 and the Federal Supplementary 

14 Medical Insurance Trust Fund under section 1841, 

15 in such proportion as the Secretary determines ap16 propriate, to the Centers for Medicare & Medicaid 

17 Services Program Management Account of 

18 $7,000,000 for fiscal year 2014. Amounts trans19 ferred under the preceding sentence shall remain 

20 available until expended. 

21 (2) FISCAL YEARS 2015 THROUGH 2017.—Sec22 tion 1890B of the Social Security Act (42 U.S.C. 

23 1395aaa–1), as redesignated by subsection 

24 (a)(1)(A), is amended by adding at the end the fol25 lowing new subsection: 


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1 ‘‘(g) FUNDING.— 

2 ‘‘(1) IN GENERAL.—For purposes of carrying 

3 out this section (other than subsections (e) and (f)) 

4 and sections 1890 and 1890A, the Secretary shall 

5 provide for the transfer, from the Federal Hospital 

6 Insurance Trust Fund under section 1817 and the 

7 Federal Supplementary Medical Insurance Trust 

8 Fund under section 1841, in such proportion as the 

9 Secretary determines appropriate, to the Centers for 

10 Medicare & Medicaid Services Program Management 

11 Account of $25,000,000 for each of fiscal years 

12 2015 through 2017. 

13 ‘‘(2) AVAILABILITY.—Amounts transferred 

14 under paragraph (1) shall remain available until ex15 pended.’’. 

16 (3) CONFORMING AMENDMENT.—Subsection (d) 

17 of section 1890 of the Social Security Act (42 

18 U.S.C. 1395aaa) is repealed. 

19 (e) CONFORMING AMENDMENTS.—(1) Section 

20 1848(m)(3)(E)(iii) of the Social Security Act (42 U.S.C. 

21 1395w–4(m)(3)(E)(iii)) is amended by striking ‘‘section 

22 1890(b)(7) and 1890A(a)’’ and inserting ‘‘section 

23 1890A(b)(2) and 1890B(a)’’. 

24 (2) Section 1866D(b)(2)(C) of the Social Security 

25 Act (42 U.S.C. 1395cc–4(b)(2)(C)) is amended by striking 


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1 ‘‘section 1890 and 1890A’’ and inserting ‘‘sections 1890, 

2 1890A, and 1890B’’. 

3 (3) Section 1899A(n)(2)(A) of the Social Security 

4 Act (42 U.S.C. 1395cc–4(n)(2)(A)) is amended by strik5 ing ‘‘section 1890(b)(7)(B)’’ and inserting ‘‘section 

6 1890A(b)(2)(B)’’. 

7 (f) EFFECTIVE DATE.— 

8 (1) IN GENERAL.—The amendments made by 

9 this section shall take effect on October 1, 2014, 

10 and shall apply with respect to contract periods 

11 under sections 1890 and 1890A of the Social Secu12 rity Act that begin on or after such date. 

13 (2) NEW CONTRACTS.—The Secretary of 

14 Health and Human Services shall enter into a new 

15 contract under both sections 1890 and 1890A of the 

16 Social Security Act, as amended by this Act, for a 

17 contract period beginning on, or as soon as prac18 ticable after, October 1, 2014. 

19 SEC. 209. PERMANENT EXTENSION OF FUNDING OUTREACH 

20 AND ASSISTANCE FOR LOW-INCOME PRO21 GRAMS. 

22 (a) ADDITIONAL FUNDING FOR STATE HEALTH IN23 SURANCE PROGRAMS.—Subsection (a)(1)(B)(iv) of section 

24 119 of the Medicare Improvements for Patients and Pro25 viders Act of 2008 (42 U.S.C. 1395b–3 note), as amended 


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1 by section 3306 of the Patient Protection and Affordable 

2 Care Act (Public Law 111–148), section 610 of the Amer3 ican Taxpayer Relief Act of 2012 (Public Law 112–240), 

4 and section 1110 of the Pathway for SGR Reform Act 

5 of 2013 (Public Law 113–67), is amended to read as fol6 lows: 

7 ‘‘(iv) for fiscal year 2014 and for each 

8 subsequent fiscal year, $7,500,000.’’. 

9 (b) ADDITIONAL FUNDING FOR AREA AGENCIES ON

10 AGING.—Subsection (b)(1)(B)(iv) of such section 119, as 

11 so amended, is amended to read as follows: 

12 ‘‘(iv) for fiscal year 2014 and for each 

13 subsequent fiscal year, $7,500,000.’’. 

14 (c) ADDITIONAL FUNDING FOR AGING AND DIS15 ABILITY RESOURCE CENTERS.—Subsection (c)(1)(B)(iv) 

16 of such section 119, as so amended, is amended to read 

17 as follows: 

18 ‘‘(iv) for fiscal year 2014 and for each 

19 subsequent fiscal year, $5,000,000.’’. 

20 (d) ADDITIONAL FUNDING FOR CONTRACT WITH

21 THE NATIONAL CENTER FOR BENEFITS AND OUTREACH

22 ENROLLMENT.—Subsection (d)(2)(iv) of such section 119, 

23 as so amended, is amended to read as follows: 

24 ‘‘(iv) for fiscal year 2014 and for each 

25 subsequent fiscal year, $5,000,000.’’. 


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1 Subtitle B—Medicaid and Other 

2 Extensions 

3 SEC. 211. QUALIFYING INDIVIDUAL PROGRAM. 

4 (a) EXTENSION.—Section 1902(a)(10)(E)(iv) of the 

5 Social Security Act (42 U.S.C. 1396a(a)(10)(E)(iv)) is 

6 amended by striking ‘‘March 2104’’ and inserting ‘‘De7 cember 2018’’. 

8 (b) ELIMINATING LIMITATIONS ON ELIGIBILITY.— 

9 Section 1933 of the Social Security Act (42 U.S.C. 

10 1396u–3) is amended by striking subsections (b) and (e). 

11 (c) ELIMINATING ALLOCATIONS.—Section 1933 of 

12 the Social Security Act (42 U.S.C. 1396u–3) is amended 

13 by striking subsections (c) and (g). 

14 (d) CONFORMING AMENDMENTS.— 

15 (1) IN GENERAL.—Section 1933 of the Social 

16 Security Act (42 U.S.C. 1396u–3), as amended by 

17 subsections (b) and (c), is further amended— 

18 (A) by striking subsection (a) and insert19 ing the following new subsection: 

20 ‘‘(a) APPLICABLE FMAP.—With respect to assist21 ance described in section 1902(a)(10)(E)(iv) furnished in 

22 a State, the Federal medical assistance percentage shall 

23 be equal to 100 percent.’’; 

24 (B) by striking subsection (d); and 


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1 (C) by redesignating subsection (f) as sub2 section (b). 

3 (2) DEFINITION OF FMAP.—Section 1905(b) of 

4 the Social Security Act (42 U.S.C. 1396d(b)) is 

5 amended by striking ‘‘section 1933(d)’’ and insert6 ing ‘‘section 1933(a)’’. 

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

8 this section shall take effect on April 1, 2014, and shall 

9 apply with respect to calendar quarters beginning on or 

10 after such date. 

11 SEC. 212. TRANSITIONAL MEDICAL ASSISTANCE. 

12 (a) EXTENSION.—Sections 1902(e)(1)(B) and 

13 1925(f) of the Social Security Act (42 U.S.C. 

14 1396a(e)(1)(B), 1396r–6(f)) are each amended by strik15 ing ‘‘March 31, 2014’’ and inserting ‘‘December 31, 

16 2018’’. 

17 (b) OPT-OUT OPTION FOR STATES THAT EXPAND

18 ADULT COVERAGE AND PROVIDE 12-MONTH CONTINUOUS

19 ELIGIBILITY UNDER MEDICAID AND CHIP.— 

20 (1) IN GENERAL.—Section 1925 of the Social 

21 Security Act (42 U.S.C. 1396r–6), as amended by 

22 subsection (a), is further amended— 

23 (A) in subsection (a)— 


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1 (i) in paragraph (1)(A), by striking 

2 ‘‘paragraph (5)’’ and inserting ‘‘para3 graphs (5) and (6)’’; and 

4 (ii) by adding at the end the fol5 lowing: 

6 ‘‘(6) OPT-OUT OPTION FOR STATES THAT EX7 PAND ADULT COVERAGE AND PROVIDE 12-MONTH

8 CONTINUOUS ELIGIBILITY UNDER MEDICAID AND

9 CHIP.— 

10 ‘‘(A) IN GENERAL.—In the case of a State 

11 described in subparagraph (B), the State may 

12 elect through a State plan amendment to have 

13 this section and sections 408(a)(11)(A), 

14 1902(a)(52), 1902(e)(1), and 1931(c)(2) not 

15 apply to the State. 

16 ‘‘(B) STATE DESCRIBED.—A State is de17 scribed in this subparagraph if the State is one 

18 of the 50 States or the District of Columbia 

19 and— 

20 ‘‘(i) has elected to provide medical as21 sistance to individuals under subclause 

22 (VIII) of section 1902(a)(10)(A)(i); 

23 ‘‘(ii) has elected under section 

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1 tinuous eligibility for a 12-month period 

2 for individuals under 19 years of age; 

3 ‘‘(iii) has elected under section 

4 1902(e)(12)(B) the option to provide con5 tinuous eligibility for a 12-month period 

6 for all categories of individuals described in 

7 that section; and 

8 ‘‘(iv) has elected to apply section 

9 1902(e)(12)(A) to the State child health 

10 plan under title XXI.’’; and 

11 (B) in subsection (b)(1), by striking ‘‘sub12 section (a)(5)’’ and inserting ‘‘paragraphs (5) 

13 and (6) of subsection (a)’’. 

14 (2) CONFORMING AMENDMENT TO 4-MONTH RE15 QUIREMENT.—Section 1902(e)(1) of the Social Se16 curity Act (42 U.S.C. 1396a(e)(1)), as amended by 

17 subsection (a), is further amended— 

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

19 ‘‘Subparagraph (A)’’ and inserting ‘‘Subject to 

20 subparagraph (C), subparagraph (A)’’; and 

21 (B) by adding at the end the following: 

22 ‘‘(C) If a State has made an election under section 

23 1925(a)(6), subparagraph (A) and section 1925 shall not 

24 apply to the State.’’. 


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1 (c) EXTENSION OF 12-MONTH CONTINUOUS ELIGI2 BILITY OPTION TO CERTAIN ADULT ENROLLEES UNDER

3 MEDICAID; CLARIFICATION OF APPLICATION TO CHIP.— 

4 (1) IN GENERAL.—Section 1902(e)(12) of the 

5 Social Security Act (42 U.S.C. 1396a(e)(12)) is 

6 amended— 

7 (A) by redesignating subparagraphs (A) 

8 and (B) as clauses (i) and (ii), respectively; 

9 (B) by inserting ‘‘(A)’’ after ‘‘(12)’’; and 

10 (C) by adding at the end the following: 

11 ‘‘(B) At the option of the State, the plan may provide 

12 that an individual who is determined to be eligible for ben13 efits under a State plan approved under this title under 

14 any of the following eligibility categories, or who is rede15 termined to be eligible for such benefits under any of such 

16 categories, shall be considered to meet the eligibility re17 quirements met on the date of application and shall re18 main eligible for those benefits until the end of the 12– 

19 month period following the date of the determination or 

20 redetermination of eligibility: 

21 ‘‘(i) Section 1902(a)(10)(A)(i)(VIII). 

22 ‘‘(ii) Section 1931.’’. 

23 (2) APPLICATION TO CHIP.—Section 2107(e)(1) 

24 of the Social Security Act (42 U.S.C. 1397gg(e)(1)) 

25 is amended— 


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1 (A) by redesignating subparagraphs (E) 

2 through (O) as subparagraphs (F) through (P), 

3 respectively; and 

4 (B) by inserting after subparagraph (D), 

5 the following: 

6 ‘‘(E) Section 1902(e)(12)(A) (relating to 

7 the State option for 12-month continuous eligi8 bility and enrollment).’’. 

9 (d) CONFORMING AND TECHNICAL AMENDMENTS

10 RELATING TO SECTION 1931 TRANSITIONAL COVERAGE

11 REQUIREMENTS.— 

12 (1) IN GENERAL.—Section 1931(c) of the So13 cial Security Act (42 U.S.C. 1396u–1(c)) is amend14 ed— 

15 (A) in paragraph (1)— 

16 (i) in the paragraph heading, by strik17 ing ‘‘CHILD’’ and inserting ‘‘SPOUSAL’’; 

18 (ii) by striking ‘‘The provisions’’ and 

19 inserting ‘‘Subject to paragraph (3), the 

20 provisions’’; and 

21 (iii) by striking ‘‘child or’’; 

22 (B) in paragraph (2), by striking ‘‘For 

23 continued’’ and inserting ‘‘Subject to paragraph 

24 (3), for continued’’; and 

25 (C) by adding at the end the following: 


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1 ‘‘(3) OPT-OUT OPTION FOR STATES THAT EX2 PAND ADULT COVERAGE AND PROVIDE 12-MONTH

3 CONTINUOUS ELIGIBILITY UNDER MEDICAID AND

4 CHIP.— 

5 ‘‘(A) IN GENERAL.—In the case of a State 

6 described in subparagraph (B), the State may 

7 elect through a State plan amendment to have 

8 paragraphs (1) and (2) of this subsection and 

9 sections 408(a)(11), 1902(a)(52), 1902(e)(1), 

10 and 1925 not apply to the State. 

11 ‘‘(B) STATE DESCRIBED.—A State is de12 scribed in this subparagraph if the State is one 

13 of the 50 States or the District of Columbia 

14 and— 

15 ‘‘(i) has elected to provide medical as16 sistance to individuals under subclause 

17 (VIII) of section 1902(a)(10)(A)(i); 

18 ‘‘(ii) has elected under section 

19 1902(e)(12)(A) the option to provide con20 tinuous eligibility for a 12-month period 

21 for individuals under 19 years of age; 

22 ‘‘(iii) has elected under section 

23 1902(e)(12)(B) the option to provide con24 tinuous eligibility for a 12-month period 


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1 for all categories of individuals described in 

2 that section; and 

3 ‘‘(iv) has elected to apply section 

4 1902(e)(12)(A) to the State child health 

5 plan under title XXI.’’. 

6 (2) CONFORMING AMENDMENT TO SECTION

7 408.—Section 408(a)(11) of the Social Security Act 

8 (42 U.S.C. 608(a)(11) is amended— 

9 (A) in the paragraph heading, by striking 

10 ‘‘CHILD’’ and inserting ‘‘SPOUSAL’’; and 

11 (B) in subparagraph (B)— 

12 (i) in the subparagraph heading, by 

13 striking ‘‘CHILD’’ and inserting ‘‘SPOUS14 AL’’; and 

15 (ii) by striking ‘‘child or’’. 

16 (e) CONFORMING AMENDMENT RELATING TO MAIN17 TENANCE OF EFFORT FOR CHILDREN.—Section 

18 1902(gg)(4) of the Social Security Act (42 U.S.C. 

19 1396a(gg)(4)) is amended by adding at the end the fol20 lowing: 

21 ‘‘(C) STATES THAT EXPAND ADULT COV22 ERAGE AND ELECT TO OPT-OUT OF TRANSI23 TIONAL COVERAGE.— 

24 ‘‘(i) IN GENERAL.—For purposes of 

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1 ments of paragraph (2), a State which ex2 ercises the option under sections 

3 1925(a)(6) and 1931(c)(3) to provide no 

4 transitional medical assistance or other ex5 tended eligibility (as applicable) shall not, 

6 as a result of exercising such option, be 

7 considered to have in effect eligibility 

8 standards, methodologies, or procedures 

9 described in clause (ii) that are more re10 strictive than the standards, methodolo11 gies, or procedures in effect under the 

12 State plan or under a waiver of the plan 

13 on the date of enactment of the Patient 

14 Protection and Affordable Care Act. 

15 ‘‘(ii) STANDARDS, METHODOLOGIES, 

16 OR PROCEDURES DESCRIBED.—The eligi17 bility standards, methodologies, or proce18 dures described in this clause are those 

19 standards, methodologies, or procedures 

20 applicable to determining the eligibility for 

21 medical assistance of any child under 19 

22 years of age (or such higher age as the 

23 State may have elected).’’. 

24 (f) EFFECTIVE DATE.—The amendments made by 

25 this section shall take effect on April 1, 2014. 


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1 SEC. 213. EXPRESS LANE ELIGIBILITY. 

2 Section 1902(e)(13)(I) of the Social Security Act (42 

3 U.S.C. 1396a(e)(13)(I)) is amended by striking ‘‘Sep4 tember 30, 2014’’ and inserting ‘‘September 30, 2015’’. 

5 SEC. 214. PEDIATRIC QUALITY MEASURES. 

6 (a) CONTINUATION OF FUNDING FOR PEDIATRIC

7 QUALITY MEASURES FOR IMPROVING THE QUALITY OF

8 CHILDREN’S HEALTH CARE.—Section 1139B(e) of the 

9 Social Security Act (42 U.S.C. 1320b–9b(e)) is amended 

10 by adding at the end the following: ‘‘Of the funds appro11 priated under this subsection, not less than $15,000,000 

12 shall be used to carry out section 1139A(b).’’. 

13 (b) ELIMINATION OF RESTRICTION ON MEDICAID

14 QUALITY MEASUREMENT PROGRAM.—Section 

15 1139B(b)(5)(A) of the Social Security Act (42 U.S.C. 

16 1320b–9b(b)(5)(A)) is amended by striking ‘‘The aggre17 gate amount awarded by the Secretary for grants and con18 tracts for the development, testing, and validation of 

19 emerging and innovative evidence-based measures under 

20 such program shall equal the aggregate amount awarded 

21 by the Secretary for grants under section 

22 1139A(b)(4)(A)’’. 

23 SEC. 215. SPECIAL DIABETES PROGRAMS. 

24 (a) SPECIAL DIABETES PROGRAMS FOR TYPE I DIA25 BETES.—Section 330B(b)(2)(C) of the Public Health 


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1 Service Act (42 U.S.C. 254c–2(b)(2)(C)) is amended by 

2 striking ‘‘2014’’ and inserting ‘‘2019’’. 

3 (b) SPECIAL DIABETES PROGRAMS FOR INDIANS.— 

4 Section 330C(c)(2)(C) of the Public Health Service Act 

5 (42 U.S.C. 254c–3(c)(2)(C)) is amended by striking 

6 ‘‘2014’’ and inserting ‘‘2019’’. 

7 Subtitle C—Human Services 

8 Extensions 

9 SEC. 221. ABSTINENCE EDUCATION GRANTS. 

10 (a) IN GENERAL.—Section 510 of the Social Security 

11 Act (42 U.S.C. 710) is amended— 

12 (1) in subsection (a), in the matter preceding 

13 paragraph (1), by striking ‘‘2010 through 2014’’ 

14 and inserting ‘‘2015 through 2019’’; and 

15 (2) in subsection (d)— 

16 (A) by striking ‘‘2010 through 2014’’ and 

17 inserting ‘‘2015 through 2019’’; and 

18 (B) by striking the second sentence. 

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

20 this section shall take effect on October 1, 2014. 

21 SEC. 222. PERSONAL RESPONSIBILITY EDUCATION PRO22 GRAM. 

23 (a) IN GENERAL.—Section 513 of the Social Security 

24 Act (42 U.S.C. 713) is amended— 

25 (1) in subsection (a)— 


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1 (A) in paragraph (1)(A), by striking ‘‘2010 

2 through 2014’’ and inserting ‘‘2015 through 

3 2019’’; 

4 (B) in paragraph (4)— 

5 (i) in subparagraph (A)— 

6 (I) by striking ‘‘2010 or 2011’’ 

7 and inserting ‘‘2015 or 2016’’; 

8 (II) by striking ‘‘2010 through 

9 2014’’ and inserting ‘‘2015 through 

10 2019’’; and 

11 (III) by striking ‘‘2012 through 

12 2014’’ and inserting ‘‘2017 through 

13 2019’’; and 

14 (ii) in subparagraph (B)(i)— 

15 (I) by striking ‘‘2012, 2013, and 

16 2014’’ and inserting ‘‘2017, 2018, 

17 and 2019’’; and 

18 (II) by striking ‘‘2010 or 2011’’ 

19 and inserting ‘‘2015 or 2016’’; and 

20 (C) in paragraph (5), by striking ‘‘2009’’ 

21 and inserting ‘‘2014’’; 

22 (2) in subsection (b)(2)(A), in the matter pre23 ceding clause (i), by inserting ‘‘and youth at risk of 

24 becoming victims of sex trafficking (as defined in 

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1 tion Act of 2000 (22 U.S.C. 7102(10))) or victims 

2 of a severe form of trafficking in persons described 

3 in paragraph (9)(A) of that Act (22 U.S.C. 

4 7102(9)(A)’’ after ‘‘adolescents’’; 

5 (3) in subsection(c)(1), by inserting ‘‘youth at 

6 risk of becoming victims of sex trafficking (as de7 fined in section 103(10) of the Trafficking Victims 

8 Protection Act of 2000 (22 U.S.C. 7102(10))) or 

9 victims of a severe form of trafficking in persons de10 scribed in paragraph (9)(A) of that Act (22 U.S.C. 

11 7102(9)(A),’’ after ‘‘youth in foster care,’’; and 

12 (4) in subsection (f), by striking ‘‘2010 through 

13 2014’’ and inserting ‘‘2015 through 2019’’. 

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

15 this section shall take effect on October 1, 2014. 

16 SEC. 223. FAMILY-TO-FAMILY HEALTH INFORMATION CEN17 TERS. 

18 (a) IN GENERAL.—Section 501(c) of the Social Secu19 rity Act (42 U.S.C. 701(c)) is amended— 

20 (1) in paragraph (1)(A), by striking clause (iv) 

21 and inserting the following: 

22 ‘‘(iv) $6,000,000 for each of fiscal 

23 years 2014 through 2018.’’; and 

24 (2) by striking paragraph (5). 


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1 (b) PREVENTION OF DUPLICATE APPROPRIATIONS

2 FOR FISCAL YEAR 2014.—Expenditures made for fiscal 

3 year 2014 pursuant to section 501(c)(iv) of the Social Se4 curity Act (42 U.S.C. 701(c)(iv)), as amended by section 

5 1203 of division B of the Bipartisan Budget Act of 2013 

6 (Public Law 113–67), shall be charged to the appropria7 tion for that fiscal year provided by the amendments made 

8 by this section. 

9 SEC. 224. HEALTH WORKFORCE DEMONSTRATION PROJECT 

10 FOR LOW-INCOME INDIVIDUALS. 

11 Section 2008(c)(1) of the Social Security Act (42 

12 U.S.C. 1397g(c)(1)) is amended by striking ‘‘ through 

13 2014’’ and inserting ‘‘2012, and only to carry out sub14 section (a), $85,000,000 for each of fiscal years 2013 

15 through 2016’’. 

16 TITLE III—MEDICARE AND 

17 MEDICAID PROGRAM INTEGRITY 

18 SEC. 301. REDUCING IMPROPER MEDICARE PAYMENTS. 

19 (a) MEDICARE ADMINISTRATIVE CONTRACTOR IM20 PROPER PAYMENT OUTREACH AND EDUCATION PRO21 GRAM.— 

22 (1) IN GENERAL.—Section 1874A of the Social 

23 Security Act (42 U.S.C. 1395kk–1) is amended— 

24 (A) in subsection (a)(4)— 


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1 (i) by redesignating subparagraph (G) 

2 as subparagraph (H); and 

3 (ii) by inserting after subparagraph 

4 (F) the following new subparagraph: 

5 ‘‘(G) IMPROPER PAYMENT OUTREACH AND

6 EDUCATION PROGRAM.—Having in place an im7 proper payment outreach and education pro8 gram described in subsection (h).’’; and 

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

10 subsection: 

11 ‘‘(h) IMPROPER PAYMENT OUTREACH AND EDU12 CATION PROGRAM.— 

13 ‘‘(1) IN GENERAL.—In order to reduce im14 proper payments under this title, each medicare ad15 ministrative contractor shall establish and have in 

16 place an improper payment outreach and education 

17 program under which the contractor, through out18 reach, education, training, and technical assistance 

19 activities, shall provide providers of services and sup20 pliers located in the region covered by the contract 

21 under this section with the information described in 

22 paragraph (3). The activities described in the pre23 ceding sentence shall be conducted on a regular 

24 basis. 


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1 ‘‘(2) FORMS OF OUTREACH, EDUCATION, TRAIN2 ING, AND TECHNICAL ASSISTANCE ACTIVITIES.—The 

3 outreach, education, training, and technical assist4 ance activities under a payment outreach and edu5 cation program shall be carried out through any of 

6 the following: 

7 ‘‘(A) Emails and other electronic commu8 nications. 

9 ‘‘(B) Webinars. 

10 ‘‘(C) Telephone calls. 

11 ‘‘(D) In-person training. 

12 ‘‘(E) Other forms of communications de13 termined appropriate by the Secretary. 

14 ‘‘(3) INFORMATION TO BE PROVIDED THROUGH

15 ACTIVITIES.—The information to be provided to pro16 viders of services and suppliers under a payment 

17 outreach and education program shall include all of 

18 the following information: 

19 ‘‘(A) A list of the provider’s or supplier’s 

20 most frequent and expensive payment errors 

21 over the last quarter. 

22 ‘‘(B) Specific instructions regarding how to 

23 correct or avoid such errors in the future. 

24 ‘‘(C) A notice of all new topics that have 

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1 ducted by recovery audit contractors under sec2 tion 1893(h). 

3 ‘‘(D) Specific instructions to prevent fu4 ture issues related to such new audits. 

5 ‘‘(E) Other information determined appro6 priate by the Secretary. 

7 ‘‘(4) ERROR RATE REDUCTION TRAINING.— 

8 ‘‘(A) IN GENERAL.—The activities under a 

9 payment outreach and education program shall 

10 include error rate reduction training. 

11 ‘‘(B) REQUIREMENTS.— 

12 ‘‘(i) IN GENERAL.—The training de13 scribed in subparagraph (A) shall— 

14 ‘‘(I) be provided at least annu15 ally; and 

16 ‘‘(II) focus on reducing the im17 proper payments described in para18 graph (5). 

19 ‘‘(C) INVITATION.—A medicare adminis20 trative contractor shall ensure that all providers 

21 of services and suppliers located in the region 

22 covered by the contract under this section are 

23 invited to attend the training described in sub24 paragraph (A) either in person or online. 


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1 ‘‘(5) PRIORITY.—A medicare administrative 

2 contractor shall give priority to activities under the 

3 improper payment outreach and education program 

4 that will reduce improper payments for items and 

5 services that— 

6 ‘‘(A) have the highest rate of improper 

7 payment; 

8 ‘‘(B) have the greatest total dollar amount 

9 of improper payments; 

10 ‘‘(C) are due to clear misapplication or 

11 misinterpretation of Medicare policies; 

12 ‘‘(D) are clearly due to common and inad13 vertent clerical or administrative errors; or 

14 ‘‘(E) are due to other types of errors that 

15 the Secretary determines could be prevented 

16 through activities under the program. 

17 ‘‘(6) INFORMATION ON IMPROPER PAYMENTS

18 FROM RECOVERY AUDIT CONTRACTORS.— 

19 ‘‘(A) IN GENERAL.—In order to assist 

20 medicare administrative contractors in carrying 

21 out improper payment outreach and education 

22 programs, the Secretary shall provide each con23 tractor with a complete list of improper pay24 ments identified by recovery audit contractors 

25 under section 1893(h) with respect to providers 


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1 of services and suppliers located in the region 

2 covered by the contract under this section. Such 

3 information shall be provided on a quarterly 

4 basis. 

5 ‘‘(B) INFORMATION.—The information de6 scribed in subparagraph (A) shall include the 

7 following information: 

8 ‘‘(i) The providers of services and 

9 suppliers that have the highest rate of im10 proper payments. 

11 ‘‘(ii) The providers of services and 

12 suppliers that have the greatest total dollar 

13 amounts of improper payments. 

14 ‘‘(iii) The items and services furnished 

15 in the region that have the highest rates of 

16 improper payments. 

17 ‘‘(iv) The items and services furnished 

18 in the region that are responsible for the 

19 greatest total dollar amount of improper 

20 payments. 

21 ‘‘(v) Other information the Secretary 

22 determines would assist the contractor in 

23 carrying out the improper payment out24 reach and education program. 


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1 ‘‘(C) FORMAT OF INFORMATION.—The in2 formation furnished to medicare administrative 

3 contractors by the Secretary under this para4 graph shall be transmitted in a manner that 

5 permits the contractor to easily identify the 

6 areas of the Medicare program in which tar7 geted outreach, education, training, and tech8 nical assistance would be most effective. In car9 rying out the preceding sentence, the Secretary 

10 shall ensure that— 

11 ‘‘(i) the information with respect to 

12 improper payments made to a provider of 

13 services or supplier clearly displays the 

14 name and address of the provider or sup15 plier, the amount of the improper payment, 

16 and any other information the Secretary 

17 determines appropriate; and 

18 ‘‘(ii) the information is in an elec19 tronic, easily searchable database. 

20 ‘‘(7) COMMUNICATIONS.—All communications 

21 with providers of services and suppliers under a pay22 ment outreach and education program are subject to 

23 the standards and requirements of subsection (g). 

24 ‘‘(8) FUNDING.—After application of paragraph 

25 (1)(C) of section 1893(h), the Secretary shall retain 


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1 a portion of the amounts recovered by recovery audit 

2 contractors under such section which shall be avail3 able to the program management account of the 

4 Centers for Medicare & Medicaid Services for pur5 poses of carrying out this subsection and to imple6 ment corrective actions to help reduce the error rate 

7 of payments under this title. The amount retained 

8 under the preceding sentence shall not exceed an 

9 amount equal to 25 percent of the amounts recov10 ered under section 1893(h).’’. 

11 (2) FUNDING CONFORMING AMENDMENT.—Sec12 tion 1893(h)(2) of the Social Security Act (42 

13 U.S.C. 1395ddd(h)(2)) is amended by inserting ‘‘or 

14 section 1874(h)(8)’’ after ‘‘paragraph (1)(C)’’. 

15 (3) EFFECTIVE DATE.—The amendments made 

16 by this subsection take effect on January 1, 2015. 

17 (b) TRANSPARENCY.—Section 1893(h)(8) of the So18 cial Security Act (42 U.S.C. 1395ddd(h)(8)) is amended— 

19 (1) by striking ‘‘REPORT.—The Secretary’’ and 

20 inserting ‘‘REPORT.— 

21 ‘‘(A) IN GENERAL.—The Secretary’’; and 

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

24 ‘‘(B) INCLUSION OF CERTAIN INFORMA25 TION.— 


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1 ‘‘(i) IN GENERAL.—For reports sub2 mitted under this paragraph for 2015 or a 

3 subsequent year, each such report shall in4 clude the information described in clause 

5 (ii) with respect to each of the following 

6 categories of audits carried out by recovery 

7 audit contractors under this subsection: 

8 ‘‘(I) Automated. 

9 ‘‘(II) Complex. 

10 ‘‘(III) Medical necessity review. 

11 ‘‘(IV) Part A. 

12 ‘‘(V) Part B. 

13 ‘‘(VI) Durable medical equip14 ment. 

15 ‘‘(ii) INFORMATION DESCRIBED.—For 

16 purposes of clause (i), the information de17 scribed in this clause, with respect to a 

18 category of audit described in clause (i), is 

19 the result of all appeals for each individual 

20 level of appeals in such category.’’. 

21 (c) RECOVERY AUDIT CONTRACTOR DEMONSTRA22 TION PROJECT.— 

23 (1) IN GENERAL.—The Secretary shall conduct 

24 a demonstration project under title XVIII of the So25 cial Security Act that— 


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1 (A) targets audits by recovery audit con2 tractors under section 1893(h) of the Social Se3 curity Act (42 U.S.C. 1395ddd(h)) with respect 

4 to high error providers of services and suppliers 

5 identified under paragraph (3); and 

6 (B) rewards low error providers of services 

7 and suppliers identified under such paragraph. 

8 (2) SCOPE.— 

9 (A) DURATION.—The demonstration 

10 project shall be implemented not later than 

11 January 1, 2015, and shall be conducted for a 

12 period of three years. 

13 (B) DEMONSTRATION AREA.—In deter14 mining the geographic area of the demonstra15 tion project, the Secretary shall consider the 

16 following: 

17 (i) The total number of providers of 

18 services and suppliers in the region. 

19 (ii) The diversity of types of providers 

20 of services and suppliers in the region. 

21 (iii) The level and variation of im22 proper payment rates of and among indi23 vidual providers of services and suppliers 

24 in the region. 


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1 (iv) The inclusion of a mix of both 

2 urban and rural areas. 

3 (3) IDENTIFICATION OF LOW ERROR AND HIGH

4 ERROR PROVIDERS OF SERVICES AND SUPPLIERS.— 

5 (A) IN GENERAL.—In conducting the dem6 onstration project, the Secretary shall identify 

7 the following two groups of providers in accord8 ance with this paragraph: 

9 (i) Low error providers of services and 

10 suppliers. 

11 (ii) High error providers of services 

12 and suppliers. 

13 (B) ANALYSIS.—For purposes of identi14 fying the groups under subparagraph (A), the 

15 Secretary shall analyze the following as they re16 late to the total number and amount of claims 

17 submitted in the area and by each provider: 

18 (i) The improper payment rates of in19 dividual providers of services and suppliers. 

20 (ii) The amount of improper payments 

21 made to individual providers of services 

22 and suppliers. 

23 (iii) The frequency of errors made by 

24 the provider of services or supplier over 

25 time. 


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1 (iv) Other information determined ap2 propriate by the Secretary. 

3 (C) ASSIGNMENT BASED ON COMPOSITE

4 SCORE.—The Secretary shall assign selected 

5 providers of services and suppliers under the 

6 demonstration program based on a composite 

7 score determined using the analysis under sub8 paragraph (B) as follows: 

9 (i) Providers of services and suppliers 

10 with high, expensive, and frequent errors 

11 shall receive a high score and be identified 

12 as high error providers of services and sup13 pliers under subparagraph (A). 

14 (ii) Providers of services and suppliers 

15 with few, inexpensive, and infrequent er16 rors shall receive a low score and be identi17 fied as low error providers of services and 

18 suppliers under such subparagraph. 

19 (iii) Only a small proportion of the 

20 total providers of services and suppliers 

21 and individual types of providers of serv22 ices and suppliers in the geographic area 

23 of the demonstration project shall be as24 signed to either group identified under 

25 such subparagraph. 


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1 (D) TIMEFRAME OF IDENTIFICATION.— 

2 (i) IN GENERAL.—Any identification 

3 of a provider of services or a supplier 

4 under subparagraph (A) shall be for a pe5 riod of 12 months. 

6 (ii) REEVALUATION.—The Secretary 

7 shall reevaluate each such identification at 

8 the end of such period. 

9 (iii) USE OF MOST CURRENT INFOR10 MATION.—In carrying out the reevaluation 

11 under clause (ii) with respect to a provider 

12 of services or supplier, the Secretary 

13 shall— 

14 (I) consider the most current in15 formation available with respect to the 

16 provider of services or supplier under 

17 the analysis under subparagraph (B); 

18 and 

19 (II) take into account improve20 ment or regression of the provider of 

21 services or supplier. 

22 (4) ADJUSTMENT OF RECORD REQUEST MAX23 IMUM.—Under the demonstration project, the Sec24 retary shall establish procedures to— 


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1 (A) increase the maximum record request 

2 made by recovery audit contractors to providers 

3 of services and suppliers identified as high error 

4 providers of services and suppliers under para5 graph (3); and 

6 (B) decrease the maximum record request 

7 made by recovery audit contractors to providers 

8 of services and suppliers identified as low error 

9 providers of services and supplier under such 

10 paragraph. 

11 (5) ADDITIONAL ADJUSTMENTS.— 

12 (A) IN GENERAL.—Under the demonstra13 tion project, the Secretary may make additional 

14 adjustments to requirements for recovery audit 

15 contractors under section 1893(h) of the Social 

16 Security Act (42 U.S.C. 1395ddd(h)) and the 

17 conduct of audits with respect to low error pro18 viders of services and suppliers identified under 

19 paragraph (3) and high error providers of serv20 ices and suppliers identified under such para21 graph as the Secretary determines necessary in 

22 order to incentivize reductions in improper pay23 ment rates under title XVIII of such Act (42 

24 U.S.C. 1395 et seq.). 


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1 (B) LIMITATION.—The Secretary shall not 

2 exempt any group of providers of services or 

3 suppliers in the demonstration project from 

4 being subject to audit by a recovery audit con5 tractor under such section 1893(h). 

6 (6) EVALUATION AND REPORT.— 

7 (A) EVALUATION.—The Inspector General 

8 of the Department of Health and Human Serv9 ices shall conduct an evaluation of the dem10 onstration project under this subsection. The 

11 evaluation shall include an analysis of— 

12 (i) the error rates of providers of serv13 ices and suppliers— 

14 (I) identified under paragraph 

15 (3) as low error providers of services 

16 and suppliers; 

17 (II) identified under such para18 graph as high error providers of serv19 ices and suppliers; and 

20 (III) that are located in the geo21 graphic area of the demonstration 

22 project and are not identified as either 

23 a low error or high error provider of 

24 services or supplier under such para25 graph; and 


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1 (ii) any improvements in the error 

2 rates of those high error providers of serv3 ices and suppliers identified under such 

4 paragraph. 

5 (B) REPORT.—Not later than 12 months 

6 after completion of the demonstration project, 

7 the Inspector General shall submit to Congress 

8 a report containing the results of the evaluation 

9 conducted under subparagraph (A), together 

10 with recommendations on whether the dem11 onstration project should be continued or ex12 panded, including on a permanent or nation13 wide basis. 

14 (7) FUNDING.— 

15 (A) FUNDING FOR IMPLEMENTATION.— 

16 For purposes of carrying out the demonstration 

17 project under this subsection (other than the 

18 evaluation and report under paragraph (6)), the 

19 Secretary shall provide for the transfer, from 

20 the Federal Hospital Insurance Trust Fund 

21 under section 1817 (42 U.S.C. 1395i) and the 

22 Federal Supplementary Medical Insurance 

23 Trust Fund under section 1841 (42 U.S.C. 

24 1395t), in such proportion as the Secretary de25 termines appropriate, of $10,000,000 to the 


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1 Centers for Medicare & Medicaid Services Pro2 gram Management Account. 

3 (B) FUNDING FOR INSPECTOR GENERAL

4 EVALUATION AND REPORT.—For purposes of 

5 carrying out the evaluation and report under 

6 paragraph (6), the Secretary shall provide for 

7 the transfer, from the Federal Hospital Insur8 ance Trust Fund under such section 1817 and 

9 the Federal Supplementary Medical Insurance 

10 Trust Fund under such section 1841, in such 

11 proportion as the Secretary determines appro12 priate, of $245,000 to the Inspector General of 

13 the Department of Health and Human Services. 

14 (C) AVAILABILITY.—Amounts transferred 

15 under subparagraph (A) or (B) shall remain 

16 available until expended. 

17 (8) DEFINITIONS.—In this section: 

18 (A) DEMONSTRATION PROJECT.—The term 

19 ‘‘demonstration project’’ means the demonstra20 tion project under this subsection. 

21 (B) PROVIDER OF SERVICES.—The term 

22 ‘‘provider of services’’ has the meaning given 

23 that term in section 1861(u). 

24 (C) RECOVERY AUDIT CONTRACTOR.—The 

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1 tity with a contract under section 1893(h) of 

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

3 1395ddd(h)). 

4 (D) SECRETARY.—The term ‘‘Secretary’’ 

5 means the Secretary of Health and Human 

6 Services. 

7 (E) SUPPLIER.—The term ‘‘supplier’’ has 

8 the meaning given that term in section 1861(d). 

9 SEC. 302. AUTHORITY FOR MEDICAID FRAUD CONTROL 

10 UNITS TO INVESTIGATE AND PROSECUTE 

11 COMPLAINTS OF ABUSE AND NEGLECT OF 

12 MEDICAID PATIENTS IN HOME AND COMMU13 NITY-BASED SETTINGS. 

14 (a) IN GENERAL.—Section 1903(q)(4)(A) of the So15 cial Security Act (42 U.S.C. 1396b(q)(4)(A)) is amended 

16 to read as follows: 

17 ‘‘(4)(A) The entity’s function includes a state18 wide program for the— 

19 ‘‘(i) investigation and prosecution, or refer20 ral for prosecution or other action, of com21 plaints of abuse or neglect of patients in health 

22 care facilities which receive payments under the 

23 State plan under this title or under a waiver of 

24 such plan; 


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1 ‘‘(ii) at the option of the entity, investiga2 tion and prosecution, or referral for prosecution 

3 or other action, of complaints of abuse or ne4 glect of individuals in connection with any as5 pect of the provision of medical assistance and 

6 the activities of providers of such assistance in 

7 a home or community based setting that is paid 

8 for under the State plan under this title or 

9 under a waiver of such plan; and 

10 ‘‘(iii) at the option of the entity, investiga11 tion and prosecution, or referral for prosecution 

12 or other action, of complaints of abuse or ne13 glect of patients residing in board and care fa14 cilities.’’. 

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

16 subsection (a) shall take effect on January 1, 2015. 

17 SEC. 303. IMPROVED USE OF FUNDS RECEIVED BY THE HHS 

18 INSPECTOR GENERAL FROM OVERSIGHT AND 

19 INVESTIGATIVE ACTIVITIES. 

20 (a) IN GENERAL.—Section 1128C(b) of the Social 

21 Security Act (42 U.S.C. 1320a–7c(b)) is amended to read 

22 as follows: 

23 ‘‘(b) ADDITIONAL USE OF FUNDS BY INSPECTOR

24 GENERAL.— 


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1 ‘‘(1) COLLECTIONS FROM MEDICARE AND MED2 ICAID RECOVERY ACTIONS.—Notwithstanding section 

3 3302 of title 31, United States Code, or any other 

4 provision of law affecting the crediting of collections, 

5 the Inspector General of the Department of Health 

6 and Human Services may receive and retain for cur7 rent use three percent of all amounts collected pur8 suant to civil debt collection and administrative en9 forcement actions related to false claims or frauds 

10 involving the Medicare program under title XVIII or 

11 the Medicaid program under title XIX. 

12 ‘‘(2) CREDITING.—Funds received by the In13 spector General under paragraph (1) shall be depos14 ited as offsetting collections to the credit of any ap15 propriation available for oversight and enforcement 

16 activities of the Inspector General permitted under 

17 subsection (a), and shall remain available until ex18 pended.’’. 

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

20 subsection (a) shall apply to funds received from settle21 ments finalized, judgments entered, or final agency deci22 sions issued, on or after the date of the enactment of this 

23 Act. 


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1 SEC. 304. PREVENTING AND REDUCING IMPROPER MEDI2 CARE AND MEDICAID EXPENDITURES. 

3 (a) REQUIRING VALID PRESCRIBER NATIONAL PRO4 VIDER IDENTIFIERS ON PHARMACY CLAIMS.—Section 

5 1860D–4(c) of the Social Security Act (42 U.S.C. 1395w– 

6 104(c)) is amended by adding at the end the following new 

7 paragraph: 

8 ‘‘(4) REQUIRING VALID PRESCRIBER NATIONAL

9 PROVIDER IDENTIFIERS ON PHARMACY CLAIMS.— 

10 ‘‘(A) IN GENERAL.—For plan year 2015 

11 and subsequent plan years, subject to subpara12 graph (B), the Secretary shall prohibit PDP 

13 sponsors of prescription drug plans from paying 

14 claims for prescription drugs under this part 

15 that do not include a valid prescriber National 

16 Provider Identifier. 

17 ‘‘(B) PROCEDURES.—The Secretary shall 

18 establish procedures for determining the validity 

19 of prescriber National Provider Identifiers 

20 under subparagraph (A). 

21 ‘‘(C) REPORT.—Not later than January 1, 

22 2017, the Inspector General of the Department 

23 of Health and Human Services shall submit to 

24 Congress a report on the effectiveness of the 

25 procedures established under subparagraph 

26 (B).’’. 


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1 (b) REFORMING HOW CMS TRACKS AND CORRECTS

2 THE VULNERABILITIES IDENTIFIED BY RECOVERY AUDIT

3 CONTRACTORS.—Section 1893(h) of the Social Security 

4 Act (42 U.S.C. 1395ddd(h)) is amended— 

5 (1) in paragraph (8), as amended by section 

6 301, by adding at the end the following new sub7 paragraphs: 

8 ‘‘(C) INCLUSION OF IMPROPER PAYMENT

9 VULNERABILITIES IDENTIFIED.—For reports 

10 submitted under this paragraph for 2015 or a 

11 subsequent year, each such report shall in12 clude— 

13 ‘‘(i) a description of— 

14 ‘‘(I) the types and financial cost 

15 to the program under this title of im16 proper payment vulnerabilities identi17 fied by recovery audit contractors 

18 under this subsection; and 

19 ‘‘(II) how the Secretary is ad20 dressing such improper payment 

21 vulnerabilities; and 

22 ‘‘(ii) an assessment of the effective23 ness of changes made to payment policies 

24 and procedures under this title in order to 

25 address the vulnerabilities so identified. 


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1 ‘‘(D) LIMITATION.—The Secretary shall 

2 ensure that each report submitted under sub3 paragraph (A) does not include information 

4 that the Secretary determines would be sen5 sitive or would otherwise negatively impact pro6 gram integrity.’’; and 

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

8 paragraph: 

9 ‘‘(10) ADDRESSING IMPROPER PAYMENT

10 VULNERABILITIES.—The Secretary shall address im11 proper payment vulnerabilities identified by recovery 

12 audit contractors under this subsection in a timely 

13 manner, prioritized based on the risk to the program 

14 under this title.’’. 

15 (c) STRENGTHENING MEDICAID PROGRAM INTEG16 RITY THROUGH FLEXIBILITY.—Section 1936 of the Social 

17 Security Act (42 U.S.C. 1396u–6) is amended— 

18 (1) in subsection (a), by inserting ‘‘, or other19 wise,’’ after ‘‘entities’’; and 

20 (2) in subsection (e)— 

21 (A) in paragraph (1), in the matter pre22 ceding subparagraph (A), by inserting ‘‘(includ23 ing the costs of equipment, salaries and bene24 fits, and travel and training)’’ after ‘‘Program 

25 under this section’’; and 


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1 (B) in paragraph (3), by striking ‘‘by 100’’ 

2 and inserting ‘‘by 100, or such number as de3 termined necessary by the Secretary to carry 

4 out the Program under this section,’’. 

5 (d) ACCESS TO THE NATIONAL DIRECTORY OF NEW

6 HIRES.—Section 453(j) of the Social Security Act (42 

7 U.S.C. 653(j)) is amended by adding at the end the fol8 lowing new paragraph: 

9 ‘‘(12) INFORMATION COMPARISONS AND DIS10 CLOSURES TO ASSIST IN ADMINISTRATION OF THE

11 MEDICARE PROGRAM AND STATE HEALTH SUBSIDY

12 PROGRAMS.— 

13 ‘‘(A) DISCLOSURE TO THE ADMINIS14 TRATOR OF THE CENTERS FOR MEDICARE &

15 MEDICAID SERVICES.—The Administrator of 

16 the Centers for Medicare & Medicaid shall have 

17 access to the information in the National Direc18 tory of New Hires for purposes of determining 

19 the eligibility of an applicant for, or enrollee in, 

20 the Medicare program under title XVIII or an 

21 applicable State health subsidy program (as de22 fined in section 1413(e) of the Patient Protec23 tion and Affordable Care Act (42 U.S.C. 

24 18083(e)). 


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1 ‘‘(B) DISCLOSURE TO THE INSPECTOR

2 GENERAL OF THE DEPARTMENT OF HEALTH

3 AND HUMAN SERVICES.— 

4 ‘‘(i) IN GENERAL.—If the Inspector 

5 General of the Department of Health and 

6 Human Services transmits to the Secretary 

7 the names and social security account 

8 numbers of individuals, the Secretary shall 

9 disclose to the Inspector General informa10 tion on such individuals and their employ11 ers maintained in the National Directory 

12 of New Hires. 

13 ‘‘(ii) USE OF INFORMATION.—The In14 spector General of the Department of 

15 Health and Human Services may use in16 formation provided under clause (i) only 

17 for purposes of — 

18 ‘‘(I) enforcing mandatory and 

19 permissive exclusions under title XI; 

20 or 

21 ‘‘(II) evaluating the integrity of 

22 the Medicare program or an applica23 ble State health subsidy program (as 

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1 tient Protection and Affordable Care 

2 Act). 

3 The authority under this clause is in addi4 tion to any authority conferred under the 

5 Inspector General Act of 1978 (5 U.S.C. 

6 App). 

7 ‘‘(C) DISCLOSURE TO STATE AGENCIES.— 

8 ‘‘(i) IN GENERAL.—If, for purposes of 

9 determining the eligibility of an applicant 

10 for, or an enrollee in, an applicable State 

11 health subsidy program (as defined in sec12 tion 1413(e) of the Patient Protection and 

13 Affordable Care Act (42 U.S.C. 18083(e)), 

14 a State agency responsible for admin15 istering such program transmits to the 

16 Secretary the names, dates of birth, and 

17 social security account numbers of individ18 uals, the Secretary shall disclose to such 

19 State agency information on such individ20 uals and their employers maintained in the 

21 National Directory of New Hires, subject 

22 to this subparagraph. 

23 ‘‘(ii) CONDITION ON DISCLOSURE BY

24 THE SECRETARY.—The Secretary shall 

25 make a disclosure under clause (i) only to 


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1 the extent that the Secretary determines 

2 that the disclosure would not interfere with 

3 the effective operation of the program 

4 under this part. 

5 ‘‘(iii) USE AND DISCLOSURE OF IN6 FORMATION BY STATE AGENCIES.— 

7 ‘‘(I) IN GENERAL.—A State 

8 agency may not use or disclose infor9 mation provided under clause (i) ex10 cept for purposes of determining the 

11 eligibility of an applicant for, or an 

12 enrollee in, a program referred to in 

13 clause (i). 

14 ‘‘(II) INFORMATION SECURITY.— 

15 The State agency shall have in effect 

16 data security and control policies that 

17 the Secretary finds adequate to ensure 

18 the security of information obtained 

19 under clause (i) and to ensure that 

20 access to such information is re21 stricted to authorized persons for pur22 poses of authorized uses and disclo23 sures. 

24 ‘‘(III) PENALTY FOR MISUSE OF

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1 ployee of the State agency who fails to 

2 comply with this clause shall be sub3 ject to the sanctions under subsection 

4 (l)(2) to the same extent as if such of5 ficer or employee were an officer or 

6 employee of the United States. 

7 ‘‘(iv) PROCEDURAL REQUIREMENTS.— 

8 State agencies requesting information 

9 under clause (i) shall adhere to uniform 

10 procedures established by the Secretary 

11 governing information requests and data 

12 matching under this paragraph. 

13 ‘‘(v) REIMBURSEMENT OF COSTS.— 

14 The State agency shall reimburse the Sec15 retary, in accordance with subsection 

16 (k)(3), for the costs incurred by the Sec17 retary in furnishing the information re18 quested under this subparagraph.’’. 

19 (e) IMPROVING THE SHARING OF DATA BETWEEN

20 THE FEDERAL GOVERNMENT AND STATE MEDICAID PRO21 GRAMS.— 

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

23 Human Services (in this subsection referred to as 

24 the ‘‘Secretary’’) shall establish a plan to encourage 

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1 care-Medicaid Data Match Program (commonly re2 ferred to as the ‘‘Medi-Medi Program’’) under sec3 tion 1893(g) of the Social Security Act (42 U.S.C. 

4 1395ddd(g)). 

5 (2) PROGRAM REVISIONS TO IMPROVE MEDI6 MEDI DATA MATCH PROGRAM PARTICIPATION BY

7 STATES.—Section 1893(g)(1)(A) of the Social Secu8 rity Act (42 U.S.C. 1395ddd(g)(1)(A)) is amend9 ed— 

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

11 inserting ‘‘or otherwise’’ after ‘‘eligible enti12 ties’’; 

13 (B) in clause (i)— 

14 (i) by inserting ‘‘to review claims 

15 data’’ after ‘‘algorithms’’; and 

16 (ii) by striking ‘‘service, time, or pa17 tient’’ and inserting ‘‘provider, service, 

18 time, or patient’’; 

19 (C) in clause (ii)— 

20 (i) by inserting ‘‘to investigate and re21 cover amounts with respect to suspect 

22 claims’’ after ‘‘appropriate actions’’; and 

23 (ii) by striking ‘‘; and’’ and inserting 

24 a semicolon; 


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1 (D) in clause (iii), by striking the period 

2 and inserting ‘‘; and’’; and 

3 (E) by adding at end the following new 

4 clause: 

5 ‘‘(iv) furthering the Secretary’s de6 sign, development, installation, or enhance7 ment of an automated data system archi8 tecture— 

9 ‘‘(I) to collect, integrate, and as10 sess data for purposes of program in11 tegrity, program oversight, and ad12 ministration, including the Medi-Medi 

13 Program; and 

14 ‘‘(II) that improves the coordina15 tion of requests for data from 

16 States.’’. 

17 (3) PROVIDING STATES WITH DATA ON IM18 PROPER PAYMENTS MADE FOR ITEMS OR SERVICES

19 PROVIDED TO DUAL ELIGIBLE INDIVIDUALS.— 

20 (A) IN GENERAL.—The Secretary shall de21 velop and implement a plan that allows each 

22 State agency responsible for administering a 

23 State plan for medical assistance under title 

24 XIX of the Social Security Act access to rel25 evant data on improper or fraudulent payments 


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1 made under the Medicare program under title 

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

3 1395 et seq.) for health care items or services 

4 provided to dual eligible individuals. 

5 (B) DUAL ELIGIBLE INDIVIDUAL DE6 FINED.—In this paragraph, the term ‘‘dual eli7 gible individual’’ means an individual who is en8 titled to, or enrolled for, benefits under part A 

9 of title XVIII of the Social Security Act (42 

10 U.S.C. 1395c et seq.), or enrolled for benefits 

11 under part B of title XVIII of such Act (42 

12 U.S.C. 1395j et seq.), and is eligible for medical 

13 assistance under a State plan under title XIX 

14 of such Act (42 U.S.C. 1396 et seq.) or under 

15 a waiver of such plan. 

16 TITLE IV—OTHER PROVISIONS 

17 SEC. 401. COMMISSION ON IMPROVING PATIENT DIRECTED 

18 HEALTH CARE. 

19 (a) FINDINGS.—Congress finds the following: 

20 (1) In order to elevate the role of patient 

21 choices in the health care system, the American pub22 lic must engage in an informed, national, public de23 bate on how the current health care system empow24 ers and informs health care decision-making, and 


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1 what can be done to improve the likelihood patients 

2 receive the care they want and need. 

3 (2) Research suggests that patients often do 

4 not receive the care they want. As a result, the end 

5 of life is associated with a substantial burden of suf6 fering by the patient and negative health and finan7 cial consequences that extend to family members and 

8 society. 

9 (3) Patients face a complex and fragmented 

10 health care system that may decrease the likelihood 

11 that health care choices are known and carried out. 

12 The health care system should embed principles that 

13 take into account patient wishes. 

14 (4) Decisions concerning health care, including 

15 end-of-life issues, affect an increasing number of 

16 Americans. 

17 (5) Medical advances are prolonging life expect18 ancy in the United States both in acute life-threat19 ening situations and protracted battles with illness. 

20 These advances raise new challenges surrounding 

21 health care decision-making. 

22 (6) The United States health care system 

23 should promote consideration of a person’s pref24 erence in health care decision-making and end-of-life 

25 choices. 


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1 (b) COMMISSION.—The Social Security Act is amend2 ed by inserting after section 1150B (42 U.S.C. 1320b– 

3 24) the following new section: 

4 ‘‘SEC. 1150C. COMMISSION ON IMPROVING PATIENT DI5 RECTED HEALTH CARE. 

6 ‘‘(a) PURPOSES.—The purposes of this section are 

7 to— 

8 ‘‘(1) provide a forum for a nationwide public 

9 debate on improving patient self-determination in 

10 health care decision-making; 

11 ‘‘(2) identify strategies that ensure every Amer12 ican has the health care they want; and 

13 ‘‘(3) provide recommendations to Congress that 

14 result from the debate. 

15 ‘‘(b) ESTABLISHMENT.—The Secretary shall estab16 lish an entity to be known as the Commission on Improv17 ing Patient Directed Health Care (referred to in this sec18 tion as the ‘Commission’). 

19 ‘‘(c) MEMBERSHIP.— 

20 ‘‘(1) NUMBER AND APPOINTMENT.—The Com21 mission shall be composed of 15 members. One 

22 member shall be the Secretary. The Comptroller 

23 General of the United States shall appoint 14 mem24 bers. 


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1 ‘‘(2) QUALIFICATIONS.—The membership of the 

2 Commission shall include— 

3 ‘‘(A) health care consumers impacted by 

4 decision-making in advance of a health care cri5 sis, such as individuals of advanced age, indi6 viduals with chronic, terminal and mental ill7 nesses, family care givers, and individuals with 

8 disabilities; 

9 ‘‘(B) providers in settings where crucial 

10 health care decision-making occurs, such as 

11 those working in intensive care settings, emer12 gency room departments, primary care settings, 

13 nursing homes, hospice, or palliative care set14 tings; 

15 ‘‘(C) payors ensuring patients get the level 

16 of care they want; 

17 ‘‘(D) experts in advance care planning, 

18 hospice, palliative care, information technology, 

19 bioethics, aging policy, disability policy, pedi20 atric ethics, cultural sensitivity, psychology, and 

21 health care financing; 

22 ‘‘(E) individuals who represent culturally 

23 diverse perspectives on patient self-determina24 tion and end-of-life issues; and 

25 ‘‘(F) members of the faith community. 


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1 ‘‘(d) PERIOD OF APPOINTMENT.—Members of the 

2 Commission shall be appointed for the life of the Commis3 sion. Any vacancies shall not affect the power and duties 

4 of the Commission but shall be filled in the same manner 

5 as the original appointment. 

6 ‘‘(e) DESIGNATION OF THE CHAIRPERSON.—Not 

7 later than 15 days after the date on which all members 

8 of the Commission have been appointed, the Comptroller 

9 General shall designate the chairperson of the Commis10 sion. 

11 ‘‘(f) SUBCOMMITTEES.—The Commission may estab12 lish subcommittees if doing so increases the efficiency of 

13 the Commission in completing tasks. 

14 ‘‘(g) DUTIES.— 

15 ‘‘(1) HEARINGS.—Not later than 90 days after 

16 the date of designation of the chairperson under 

17 subsection (e), the Commission shall hold no fewer 

18 than 8 hearings to examine— 

19 ‘‘(A) the current state of health care deci20 sion-making and advance care planning laws in 

21 the United States at the Federal level and 

22 across the States, as well as options for improv23 ing advance care planning tools, especially with 

24 regard to use, portability, and storage; 


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1 ‘‘(B) consumer-focused approaches that 

2 educate the American public about patient 

3 choices, care planning, and other end-of-life 

4 issues; 

5 ‘‘(C) the use of comprehensive, patient-cen6 tered care plans by providers, the impact care 

7 plans have on health care delivery and spend8 ing, and methods to expand the use of high 

9 quality care planning tools in both public and 

10 private health care systems; 

11 ‘‘(D) the role of electronic medical records 

12 and other technologies in improving patient-di13 rected health care; 

14 ‘‘(E) innovative tools for improving patient 

15 experience with advanced illness, such as pallia16 tive care, hospice, and other models; 

17 ‘‘(F) the role social determinants of health, 

18 such as socio-economic status, play in patient 

19 self-direction in health care; 

20 ‘‘(G) the use of culturally-competent tools 

21 for health care decision-making; 

22 ‘‘(H) strategies for educating providers 

23 and increasing provider engagement on care 

24 planning, palliative care, hospice care, and 


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1 other issues surrounding honoring patient 

2 choices; 

3 ‘‘(I) the sociological and psychological fac4 tors that influence health care decision-making 

5 and end-of-life choices; and 

6 ‘‘(J) the role of spirituality and religion in 

7 patient self-determination in health care. 

8 ‘‘(2) ADDITIONAL HEARINGS.—The Commission 

9 may hold additional hearings on subjects other than 

10 those listed in paragraph (1) so long as such hear11 ings are determined necessary by the Commission in 

12 carrying out the purposes of this section. Such addi13 tional hearings do not have to be completed within 

14 the time period specified but shall not delay the 

15 other activities of the Commission under this sec16 tion. 

17 ‘‘(3) NUMBER AND LOCATION OF HEARINGS

18 AND ADDITIONAL HEARINGS.—The Commission shall 

19 hold no fewer than 8 hearings as indicated in para20 graph (1) and in sufficient number in order to re21 ceive information that reflects— 

22 ‘‘(A) the geographic differences throughout 

23 the United States; 

24 ‘‘(B) diverse populations; and 


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1 ‘‘(C) a balance among urban and rural 

2 populations. 

3 ‘‘(4) INTERACTIVE TECHNOLOGY.—The Com4 mission may encourage public participation in hear5 ings through interactive technology and other means 

6 as determined appropriate by the Commission. 

7 ‘‘(5) REPORT TO THE AMERICAN PEOPLE ON

8 PATIENT DIRECTED HEALTH CARE.—Not later than 

9 90 days after the hearings described in paragraphs 

10 (1) and (2) are completed, the Commission shall 

11 prepare and make available to health care consumers 

12 through the Internet and other appropriate public 

13 channels, a report to be entitled, ‘Report to the 

14 American People on Patient Directed Health Care’. 

15 Such a report shall be understandable to the general 

16 public and include— 

17 ‘‘(A) a summary of— 

18 ‘‘(i) the hearings described in such 

19 paragraphs; 

20 ‘‘(ii) how the current health care sys21 tem empowers and informs decision-mak22 ing in advance of a health care crisis; 

23 ‘‘(iii) factors that contribute to the 

24 provision of health care that does not ad25 here to patient wishes; 


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1 ‘‘(iv) the impact of care that does not 

2 follow patient choices, particularly at the 

3 end-of-life, on patients, families, providers, 

4 spending, and the health care system; 

5 ‘‘(v) the laws surrounding advance 

6 care planning and health care decision7 making including issues of portability, use, 

8 and storage; 

9 ‘‘(vi) consumer-focused approaches to 

10 education of the American public about pa11 tient choices, care planning, and other end12 of-life issues; 

13 ‘‘(vii) the role of care plans in health 

14 care decision-making; 

15 ‘‘(viii) the role of providers in ensur16 ing patients receive the care they want; 

17 ‘‘(ix) the role of electronic medical 

18 records and other technologies in improv19 ing patient directed health care; 

20 ‘‘(x) the impact of social determinants 

21 on patient self-direction in health care 

22 services; 

23 ‘‘(xi) the use of culturally competent 

24 methods for health care decision-making; 


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1 ‘‘(xii) the sociological and psycho2 logical factors that influence patient self3 determination; and 

4 ‘‘(xiii) the role of spirituality and reli5 gion in health care decision-making and 

6 end-of-life care; 

7 ‘‘(B) best practices from communities, pro8 viders, and payors that document patient wish9 es and provide health care that adheres to those 

10 wishes; and 

11 ‘‘(C) information on educating providers 

12 about health care decision-making and end-of13 life issues. 

14 ‘‘(6) INTERIM REQUIREMENTS.—Not later than 

15 180 days after the date of completion of the hear16 ings, the Commission shall prepare and make avail17 able to the public through the Internet and other ap18 propriate public channels, an interim set of rec19 ommendations on patient self-determination in 

20 health care and ways to improve and strengthen the 

21 health care system based on the information and 

22 preferences expressed at the community meetings. 

23 There shall be a 90-day public comment period on 

24 such recommendations. 


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1 ‘‘(h) RECOMMENDATIONS.—Not later than 120 days 

2 after the expiration of the public comment period de3 scribed in subsection (g)(6), the Commission shall submit 

4 to Congress and the President a final set of recommenda5 tions. The recommendations must be comprehensive and 

6 detailed. The recommendations must contain rec7 ommendations or proposals for legislative or administra8 tive action as the Commission deems appropriate, includ9 ing proposed legislative language to carry out the rec10 ommendations or proposals. 

11 ‘‘(i) ADMINISTRATION.— 

12 ‘‘(1) EXECUTIVE DIRECTOR.—There shall be an 

13 Executive Director of the Commission who shall be 

14 appointed by the chairperson of the Commission in 

15 consultation with the members of the Commission. 

16 ‘‘(2) COMPENSATION.—While serving on the 

17 business of the Commission (including travel time), 

18 a member of the Commission shall be entitled to 

19 compensation at the per diem equivalent of the rate 

20 provided for level IV of the Executive Schedule 

21 under section 5315 of title 5, United States Code, 

22 and while so serving away from home and the mem23 ber’s regular place of business, a member may be al24 lowed travel expenses, as authorized by the chair25 person of the Commission. For purposes of pay and 


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1 employment benefits, rights, and privileges, all per2 sonnel of the Commission shall be treated as if they 

3 were employees of the Senate. 

4 ‘‘(3) INFORMATION FROM FEDERAL AGEN5 CIES.—The Commission may secure directly from 

6 any Federal department or agency such information 

7 as the Commission considers necessary to carry out 

8 this section. Upon request of the Commission the 

9 head of such department or agency shall furnish 

10 such information. 

11 ‘‘(4) POSTAL SERVICES.—The Commission may 

12 use the United States mails in the same manner and 

13 under the same conditions as other departments and 

14 agencies of the Federal Government. 

15 ‘‘(j) DETAIL.—Not more than 4 Federal Government 

16 employees employed by the Department of Labor, 4 Fed17 eral Government employees employed by the Social Secu18 rity Administration, and 8 Federal Government employees 

19 employed by the Department of Health and Human Serv20 ices may be detailed to the Commission under this section 

21 without further reimbursement. Any detail of an employee 

22 shall be without interruption or loss of civil service status 

23 or privilege. 

24 ‘‘(k) TEMPORARY AND INTERMITTENT SERVICES.— 

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1 porary and intermittent services under section 3109(b) of 

2 title 5, United States Code, at rates for individuals which 

3 do not exceed the daily equivalent of the annual rate of 

4 basic pay prescribed for level V of the Executive Schedule 

5 under section 5316 of such title. 

6 ‘‘(l) ANNUAL REPORT.—Not later than 1 year after 

7 the date of enactment of this Act, and annually thereafter 

8 during the existence of the Commission, the Commission 

9 shall report to Congress and make public a detailed de10 scription of the expenditures of the Commission used to 

11 carry out its duties under this section. 

12 ‘‘(m) SUNSET OF COMMISSION.—The Commission 

13 shall terminate on the date that is 3 years after the date 

14 on which all the members of the Commission have been 

15 appointed under subsection (c)(1) and appropriations are 

16 first made available to carry out this section. 

17 ‘‘(n) ADMINISTRATION REVIEW AND COMMENTS.— 

18 Not later than 45 days after receiving the final rec19 ommendations of the Commission under subsection (h), 

20 the President shall submit a report to Congress which 

21 shall contain— 

22 ‘‘(1) additional views and comments on such 

23 recommendations; and 


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1 ‘‘(2) recommendations for such legislation and 

2 administrative action as the President considers ap3 propriate. 

4 ‘‘(o) AUTHORIZATION OF APPROPRIATIONS.— 

5 ‘‘(1) IN GENERAL.—There are authorized to be 

6 appropriated to carry out this section, $3,000,000 

7 for each of fiscal years 2014 and 2015. 

8 ‘‘(2) REPORT TO THE AMERICAN PEOPLE ON

9 PATIENT DIRECTED HEALTH CARE.—There are au10 thorized to be appropriated for the preparation and 

11 dissemination of the Report to the American People 

12 on Patient Directed Health Care described in sub13 section (g)(5), $1,000,000 for the fiscal year in 

14 which the report is required to be submitted.’’. 

15 SEC. 402. EXPANSION OF THE DEFINITION OF INPATIENT 

16 HOSPITAL SERVICES FOR CERTAIN CANCER 

17 HOSPITALS. 

18 Section 1861(b) of the Social Security Act (42 U.S.C. 

19 1395x(b)) is amended— 

20 (1) in paragraph (3)— 

21 (A) by inserting ‘‘(A)’’ after ‘‘(3)’’; 

22 (B) by adding ‘‘and’’ after the semicolon 

23 at the end; and 

24 (C) by adding at the end the following new 

25 subparagraph: 


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1 ‘‘(B) subject to the third sentence of this 

2 subsection, with respect to a hospital that— 

3 ‘‘(i) is described in section 

4 1886(d)(1)(B)(v); and 

5 ‘‘(ii) as of the date of the enactment 

6 of the Responsible Medicare SGR Repeal 

7 and Beneficiary Access Improvement Act 

8 of 2014, is located in the same building, or 

9 on the same campus, as another hospital 

10 (as described in sections 412.22(e) and 

11 412.22(f) of title 42, Code of Federal Reg12 ulations, as in effect on such date of enact13 ment ); 

14 items and services described in paragraphs (1) 

15 and (2) furnished on or after October 1, 2014, 

16 by such hospital described in section 

17 1886(d)(1)(B)(v) or by others under arrange18 ments with them made by the hospital;’’; and 

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

20 flush sentence: 

21 ‘‘Paragraph (3)(B) shall only apply to payments with re22 spect to the total number of the hospital’s patient days 

23 at any satellite of the hospital or such days at another 

24 hospital providing services under arrangements to the hos25 pital, determined as of the date of the enactment of the 


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1 Responsible Medicare SGR Repeal and Beneficiary Access 

2 Improvement Act of 2014.’’. 

3 SEC. 403. QUALITY MEASURES FOR CERTAIN POST-ACUTE 

4 CARE PROVIDERS RELATING TO NOTICE AND 

5 TRANSFER OF PATIENT HEALTH INFORMA6 TION AND PATIENT CARE PREFERENCES. 

7 (a) DEVELOPMENT.—The Secretary of Health and 

8 Human Services (in this section referred to as the ‘‘Sec9 retary’’) shall provide for the development of one or more 

10 quality measures under title XVIII of the Social Security 

11 Act (42 U.S.C. 1395 et seq.) to accurately communicate 

12 the existence and provide for the transfer of patient health 

13 information and patient care preferences when an indi14 vidual transitions from a hospital to return home or move 

15 to other post-acute care settings. 

16 (b) USE OF MEASURE DEVELOPERS.—The Secretary 

17 shall arrange for the development of such measures by ap18 propriate measure developers. 

19 (c) ENDORSEMENT.—The Secretary shall arrange for 

20 such developed measures to be submitted for endorsement 

21 to a consensus-based entity as described in section 

22 1890(a) of the Social Security Act (42 U.S.C. 

23 1395aaa(a)). 

24 (d) USE OF MEASURES.—The Secretary shall, 

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1 ures under the quality reporting programs with respect 

2 to— 

3 (1) inpatient hospitals under section 

4 1886(b)(3)(B)(viii) of the Social Security Act (42 

5 U.S.C. 1395ww(b)(3)(B)(viii)); 

6 (2) skilled nursing facilities under section 

7 1888(e) of such Act (42 U.S.C. 1395yy(e)); 

8 (3) home health services under section 

9 1895(b)(3)(B)(v) of such Act (42 U.S.C. 

10 1395fff(b)(3)(B)(v)); and 

11 (4) other providers of services (as defined in 

12 section 1861(u) of such Act) and suppliers (as de13 fined in section 1861(d) of such Act) that the Sec14 retary determines appropriate. 

15 SEC. 404. CRITERIA FOR MEDICALLY NECESSARY, SHORT 

16 INPATIENT HOSPITAL STAYS. 

17 (a) IN GENERAL.—The Secretary of Health and 

18 Human Services shall consult with, and seek input from, 

19 interested stakeholders to determine appropriate criteria 

20 for payment under the Medicare program under title 

21 XVIII of the Social Security Act of an inpatient hospital 

22 admission that— 

23 (1) is medically necessary; and 

24 (2) is an inpatient hospital stay that is less 

25 than two midnights, as described in section 412.3 of 


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1 title 42, Code of Federal Regulation, as finalized in 

2 the final rule published by the Centers for Medicare 

3 & Medicaid Services in the Federal Register on Au4 gust 19, 2013 (78 Federal Register 50496) entitled 

5 ‘‘Medicare Program; Hospital Inpatient Prospective 

6 Payment Systems for Acute Care Hospitals and the 

7 Long-Term Care Hospital Prospective Payment Sys8 tem and Fiscal Year 2014 Rates; Quality Reporting 

9 Requirements for Specific Providers; Hospital Con10 ditions of Participation; Payment Policies Related to 

11 Patient Status’’. 

12 (b) INTERESTED STAKEHOLDERS.—In subsection 

13 (a), the term ‘‘interested stakeholders’’ means the fol14 lowing: 

15 (1) Hospitals. 

16 (2) Physicians 

17 (3) Medicare administrative contractors under 

18 section 1874A of the Social Security Act (42 U.S.C. 

19 1395kk–1). 

20 (4) Recovery audit contractors under section 

21 1893(h) of such Act (42 U.S.C. 1395ddd(h)). 

22 (5) Other parties determined appropriate by the 

23 Secretary. 


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1 SEC. 405. TRANSPARENCY OF REASONS FOR EXCLUDING 

2 ADDITIONAL PROCEDURES FROM THE MEDI3 CARE AMBULATORY SURGICAL CENTER (ASC) 

4 APPROVED LIST. 

5 Section 1833(i)(1) of the Social Security Act (42 

6 U.S.C. 1395l(i)(1)) is amended by adding at the end the 

7 following: ‘‘In updating such lists for application in years 

8 beginning after December 31, 2014, for each procedure 

9 that was not proposed but was requested to be included 

10 on such lists during the public comment where the Sec11 retary does not finalize (in the final rule updating such 

12 lists) to so include, the Secretary shall describe in such 

13 final rule the specific safety criteria for not including such 

14 requested procedure on such lists.’’. 

15 SEC. 406. SUPERVISION IN CRITICAL ACCESS HOSPITALS. 

16 (a) GENERAL SUPERVISION IN CRITICAL ACCESS

17 HOSPITALS.—Section 1834(g) of the Social Security Act 

18 (42 U.S.C. 1395m(g)) is amended by adding at the end 

19 the following new paragraph: 

20 ‘‘(6) SUPERVISION.—In the case of services fur21 nished on or after the date of the enactment of this 

22 paragraph, the minimum level of supervision with re23 spect to outpatient therapeutic critical access hos24 pital services shall be general supervision (as defined 

25 by the Secretary).’’. 


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1 (b) SUPERVISION OF CARDIAC AND PULMONARY RE2 HABILITATION PROGRAMS IN CRITICAL ACCESS HOS3 PITALS.—Section 1861(eee)(2)(B) of the Social Security 

4 Act (42 U.S.C. 1395x(eee)(2)(B)) is amended by inserting 

5 ‘‘, or in the case of a critical access hospital, a physician, 

6 or (beginning on the date of enactment of Responsible 

7 Medicare SGR Repeal and Beneficiary Access Improve8 ment Act of 2014) a nurse practitioner, clinical nurse spe9 cialist, or physician assistant (as such terms are defined 

10 in subsection (aa)(5)),’’ after ‘‘a physician’’. 

11 SEC. 407. REQUIRING STATE LICENSURE OF BIDDING ENTI12 TIES UNDER THE COMPETITIVE ACQUISITION 

13 PROGRAM FOR CERTAIN DURABLE MEDICAL 

14 EQUIPMENT, PROSTHETICS, ORTHOTICS, AND 

15 SUPPLIES (DMEPOS). 

16 Section 1847(a)(1) of the Social Security Act (42 

17 U.S.C. 1395w–3(a)(1)) is amended by adding at the end 

18 the following new subparagraph: 

19 ‘‘(G) REQUIRING STATE LICENSURE OF

20 BIDDING ENTITIES.—With respect to rounds of 

21 competitions beginning on or after the date of 

22 enactment of this subparagraph, the Secretary 

23 may only accept a bid from an entity for an 

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1 sure requirements for such area for all items in 

2 such bid for a product category.’’. 

3 SEC. 408. RECOGNITION OF ATTENDING PHYSICIAN ASSIST4 ANTS AS ATTENDING PHYSICIANS TO SERVE 

5 HOSPICE PATIENTS. 

6 (a) RECOGNITION OF ATTENDING PHYSICIAN AS7 SISTANTS AS ATTENDING PHYSICIANS TO SERVE HOS8 PICE PATIENTS.— 

9 (1) IN GENERAL.—Section 1861(dd)(3)(B) of 

10 the Social Security Act (42 U.S.C. 1395x(dd)(3)(B)) 

11 is amended— 

12 (A) by striking ‘‘or nurse’’ and inserting ‘‘, 

13 the nurse’’; and 

14 (B) by inserting ‘‘, or the physician assist15 ant (as defined in such subsection)’’ after ‘‘sub16 section (aa)(5))’’. 

17 (2) CLARIFICATION OF HOSPICE ROLE OF PHY18 SICIAN ASSISTANTS.—Section 1814(a)(7)(A)(i)(I) of 

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

20 1395f(a)(7)(A)(i)(I)) is amended by inserting ‘‘or a 

21 physician assistant’’ after ‘‘a nurse practitioner’’. 

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

23 this section shall apply to items and services furnished on 

24 or after October 1, 2015. 


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1 SEC. 409. REMOTE PATIENT MONITORING PILOT 

2 PROJECTS. 

3 (a) PILOT PROJECTS.— 

4 (1) IN GENERAL.—Not later than 9 months 

5 after the date of the enactment of this Act, the Sec6 retary shall conduct pilot projects under title XVIII 

7 of the Social Security Act for the purpose of pro8 viding incentives to home health agencies to furnish 

9 remote patient monitoring services that reduce ex10 penditures under such title. 

11 (2) SITE REQUIREMENTS.— 

12 (A) URBAN AND RURAL.—The Secretary 

13 shall conduct the pilot projects under this sec14 tion in both urban and rural areas. 

15 (B) SITE IN A SMALL STATE.—The Sec16 retary shall conduct at least 1 of the pilot 

17 projects in a State with a population of less 

18 than 1,000,000. 

19 (b) MEDICARE BENEFICIARIES WITHIN THE SCOPE

20 OF PROJECTS.— 

21 (1) IN GENERAL.—The Secretary shall specify 

22 the criteria for identifying those Medicare bene23 ficiaries who shall be considered within the scope of 

24 the pilot projects under this section for purposes of 

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1 ment of the effectiveness of the home health agency 

2 in achieving the objectives of this section. 

3 (2) CRITERIA.—The criteria specified under 

4 paragraph (1)— 

5 (A) shall include conditions and clinical 

6 circumstances, including congestive heart fail7 ure, diabetes, and chronic pulmonary obstruc8 tive disease, and other conditions determined 

9 appropriate by the Secretary; and 

10 (B) may provide for the inclusion in the 

11 projects of Medicare beneficiaries who begin re12 ceiving home health services under title XVIII 

13 of the Social Security Act after the date of the 

14 implementation of the projects. 

15 (c) INCENTIVES.— 

16 (1) PERFORMANCE TARGETS.—The Secretary 

17 shall establish for each home health agency partici18 pating in a pilot project under this section a per19 formance target using one of the following meth20 odologies, as determined appropriate by the Sec21 retary: 

22 (A) ADJUSTED HISTORICAL PERFORMANCE

23 TARGET.—The Secretary shall establish for the 

24 agency— 


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1 (i) a base expenditure amount equal 

2 to the average total payments made under 

3 parts A, B, and D of title XVIII of the So4 cial Security Act for Medicare beneficiaries 

5 determined to be within the scope of the 

6 pilot project in a base period determined 

7 by the Secretary; and 

8 (ii) an annual per capita expenditure 

9 target for such beneficiaries, reflecting the 

10 base expenditure amount adjusted for risk, 

11 changes in costs, and growth rates. 

12 (B) COMPARATIVE PERFORMANCE TAR13 GET.—The Secretary shall establish for the 

14 agency a comparative performance target equal 

15 to the average total payments made under such 

16 parts A, B, and D during the pilot project for 

17 comparable individuals in the same geographic 

18 area that are not determined to be within the 

19 scope of the pilot project. 

20 (2) PAYMENT.—Subject to paragraph (3), the 

21 Secretary shall pay to each home health agency par22 ticipating in a pilot project a payment for each year 

23 under the pilot project equal to a 75 percent share 

24 of the total Medicare cost savings realized for such 


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1 year relative to the performance target under para2 graph (1). 

3 (3) LIMITATION ON EXPENDITURES.—The Sec4 retary shall limit payments under this section in 

5 order to ensure that the aggregate expenditures 

6 under title XVIII of the Social Security Act (includ7 ing payments under this subsection) do not exceed 

8 the amount that the Secretary estimates would have 

9 been expended if the pilot projects under this section 

10 had not been implemented, including any reasonable 

11 costs incurred by the Secretary in the administration 

12 of the pilot projects. 

13 (4) NO DUPLICATION IN PARTICIPATION IN

14 SHARED SAVINGS PROGRAMS.—A home health agen15 cy that participates in any of the following shall not 

16 be eligible to participate in the pilot projects under 

17 this section: 

18 (A) A model tested or expanded under sec19 tion 1115A of the Social Security Act (42 

20 U.S.C. 1315a) that involves shared savings 

21 under title XVIII of such Act or any other pro22 gram or demonstration project that involves 

23 such shared savings. 


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1 (B) The independence at home medical 

2 practice demonstration program under section 

3 1866E of such Act (42 U.S.C. 1395cc–5). 

4 (d) WAIVER AUTHORITY.—The Secretary may waive 

5 such provisions of titles XI and XVIII of the Social Secu6 rity Act as the Secretary determines to be appropriate for 

7 the conduct of the pilot projects under this section. 

8 (e) REPORT TO CONGRESS.—Not later than 3 years 

9 after the date that the first pilot project under this section 

10 is implemented, the Secretary shall submit to Congress a 

11 report on the projects. Such report shall contain— 

12 (1) a detailed description of the projects, in13 cluding any changes in clinical outcomes for Medi14 care beneficiaries under the projects, Medicare bene15 ficiary satisfaction under the projects, utilization of 

16 items and services under parts A, B, and D of title 

17 XVIII of the Social Security Act by Medicare bene18 ficiaries under the projects, and Medicare per-bene19 ficiary and Medicare aggregate spending under the 

20 projects; 

21 (2) a detailed description of issues related to 

22 the expansion of the projects under subsection (f); 

23 (3) recommendations for such legislation and 

24 administrative actions as the Secretary considers ap25 propriate; and 


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1 (4) other items considered appropriate by the 

2 Secretary. 

3 (f) EXPANSION.—If the Secretary determines that 

4 any of the pilot projects under this section enhance health 

5 outcomes for Medicare beneficiaries and reduce expendi6 tures under title XVIII of the Social Security Act, the Sec7 retary shall initiate comparable projects in additional 

8 areas. 

9 (g) PAYMENTS HAVE NO EFFECT ON OTHER MEDI10 CARE PAYMENTS TO HOME HEALTH AGENCIES.—A pay11 ment under this section shall have no effect on the amount 

12 of payments that a home health agency would otherwise 

13 receive under title XVIII of the Social Security Act for 

14 the provision of home health services. 

15 (h) STUDY AND REPORT ON THE APPROPRIATE

16 VALUATION FOR REMOTE PATIENT MONITORING SERV17 ICES UNDER THE MEDICARE PHYSICIAN FEE SCHED18 ULE.— 

19 (1) STUDY.—The Secretary shall conduct a 

20 study on the appropriate valuation for remote pa21 tient monitoring services under the Medicare physi22 cian fee schedule under section 1848 of the Social 

23 Security Act (42 U.S.C. 1395w–4) in order to accu24 rately reflect the resources involved in furnishing 

25 such services. 


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1 (2) REPORT.—Not later than 6 months after 

2 the date of the enactment of this Act, the Secretary 

3 shall submit to Congress a report on the study con4 ducted under paragraph (1), together with such rec5 ommendations as the Secretary determines appro6 priate. 

7 (i) DEFINITIONS.—In this section: 

8 (1) HOME HEALTH AGENCY.—The term ‘‘home 

9 health agency’’ has the meaning given that term in 

10 section 1861(o) of the Social Security Act (42 

11 U.S.C. 1395x(o)). 

12 (2) REMOTE PATIENT MONITORING SERV13 ICES.— 

14 (A) IN GENERAL.—The term ‘‘remote pa15 tient monitoring services’’ means services fur16 nished in the home using remote patient moni17 toring technology which— 

18 (i) shall include patient monitoring or 

19 patient assessment; and 

20 (ii) may include in-home technology21 based professional consultations, patient 

22 training services, clinical observation, 

23 treatment, and any additional services that 

24 utilize technologies specified by the Sec25 retary. 


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1 (B) LIMITATION.—The term ‘‘remote pa2 tient monitoring services’’ shall not include a 

3 telecommunication that consists solely of a tele4 phone audio conversation, facsimile, or elec5 tronic text mail between a health care profes6 sional and a patient. 

7 (3) REMOTE PATIENT MONITORING TECH8 NOLOGY.—The term ‘‘remote patient monitoring 

9 technology’’ means a coordinated system that uses 

10 one or more home-based or mobile monitoring de11 vices that automatically transmit vital sign data or 

12 information on activities of daily living and may in13 clude responses to assessment questions collected on 

14 the devices wirelessly or through a telecommuni15 cations connection to a server that complies with the 

16 Federal regulations (concerning the privacy of indi17 vidually identifiable health information) promulgated 

18 under section 264(c) of the Health Insurance Port19 ability and Accountability Act of 1996, as part of an 

20 established plan of care for that patient that in21 cludes the review and interpretation of that data by 

22 a health care professional. 

23 (4) SECRETARY.—The term ‘‘Secretary’’ means 

24 the Secretary of Health and Human Services. 


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1 SEC. 410. COMMUNITY-BASED INSTITUTIONAL SPECIAL 

2 NEEDS PLAN DEMONSTRATION PROGRAM. 

3 (a) IN GENERAL.—The Secretary of Health and 

4 Human Services (referred to in this section as the ‘‘Sec5 retary’’) shall establish a Community-Based Institutional 

6 Special Needs Plan (CBI-SNP) demonstration program to 

7 prevent and delay institutionalization under Medicaid 

8 among targeted low-income Medicare beneficiaries. 

9 (b) ESTABLISHMENT.—The Secretary shall enter into 

10 agreements with not more than 5 specialized MA plans 

11 for special needs individuals, as defined in section 

12 1859(b)(6)(B)(i) of the Social Security Act (42 U.S.C. 

13 1395w–28(b)(6)(B)(i)), to conduct the CBI-SNP dem14 onstration program. Under the CBI-SNP demonstration 

15 program, a targeted low-income Medicare beneficiary shall 

16 receive, as supplemental benefits under section 1852(a)(3) 

17 of such Act (42 U.S.C. 1395w-22(a)(3)), long-term care 

18 services or supports that— 

19 (1) the Secretary determines appropriate for 

20 the purposes of the CBI-SNP demonstration pro21 gram; and 

22 (2) for which payment may be made under the 

23 State plan under title XIX of such Act (42 U.S.C. 

24 1396 et seq.) of the State in which the targeted low25 income Medicare beneficiary is located. 


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1 (c) ELIGIBLE PLANS.—To be eligible to participate 

2 in the CBI-SNP demonstration program, a specialized MA 

3 plan for special needs individuals must— 

4 (1) serve special needs individuals (as defined 

5 in section 1859(b)(6)(B)(i) of the Social Security 

6 Act (42 U.S.C. 1395w–28(b)(6)(B)(i)); 

7 (2) have experience in offering special needs 

8 plans for nursing home-eligible, non-institutionalized 

9 Medicare beneficiaries who live in the community; 

10 (3) be located in a State that the Secretary has 

11 determined will participate in the CBI-SNP dem12 onstration program by agreeing to make available 

13 data necessary for purposes of conducting the inde14 pendent evaluation required under subsection (f); 

15 and 

16 (4) meet such other criteria as the Secretary 

17 may require. 

18 (d) TARGETED LOW-INCOME MEDICARE BENE19 FICIARY DEFINED.—In this section, the term ‘‘targeted 

20 low-income Medicare beneficiary’’ means a Medicare bene21 ficiary who— 

22 (1) is enrolled in a specialized MA plan for spe23 cial needs individuals that has been selected to par24 ticipate in the CBI-SNP demonstration program; 


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1 (2) is a subsidy eligible individual (as defined in 

2 section 1860D–14(a)(3)(A) of the Social Security 

3 Act (42 U.S.C. 1395w-114(a)(3)(A)); and 

4 (3) is unable to perform 2 or more activities of 

5 daily living (as defined in section 7702B(c)(2)(B) of 

6 the Internal Revenue Code of 1986). 

7 (e) IMPLEMENTATION DEADLINE; DURATION.—The 

8 CBI-SNP demonstration program shall be implemented 

9 not later than January 1, 2016, and shall be conducted 

10 for a period of 3 years. 

11 (f) INDEPENDENT EVALUATION AND REPORTS.— 

12 (1) INDEPENDENT EVALUATION.—Not later 

13 than 2 years after the completion of the CBI-SNP 

14 demonstration program, the Secretary shall provide 

15 for the evaluation of the CBI-SNP demonstration 

16 program by an independent third party. The evalua17 tion shall determine whether the CBI-SNP dem18 onstration program has improved patient care and 

19 quality of life for the targeted low-income Medicare 

20 beneficiaries participating in the CBI-SNP dem21 onstration program. Specifically, the evaluation shall 

22 determine if the CBI-SNP demonstration program 

23 has— 

24 (A) reduced hospitalizations or re-hos25 pitalizations; 


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1 (B) reduced Medicaid nursing home facility 

2 stays; and 

3 (C) reduced spenddown of income and as4 sets for purposes of becoming eligible for Med5 icaid. 

6 (2) REPORTS.—Not later than 3 years after the 

7 completion of the CBI-SNP demonstration program, 

8 the Secretary shall submit to Congress a report con9 taining the results of the evaluation conducted under 

10 paragraph (1), together with such recommendations 

11 for legislative or administrative action as the Sec12 retary determines appropriate. 

13 (g) FUNDING.— 

14 (1) FUNDING FOR IMPLEMENTATION.—For 

15 purposes of carrying out the demonstration program 

16 under this section (other than the evaluation and re17 port under subsection (f)), the Secretary shall pro18 vide for the transfer from the Federal Hospital In19 surance Trust Fund under section 1817 of the So20 cial Security Act (42 U.S.C. 1395i) and the Federal 

21 Supplementary Medical Insurance Trust Fund under 

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

23 proportion as the Secretary determines appropriate, 

24 of $3,000,000 to the Centers for Medicare & Med25 icaid Services Program Management Account. 


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1 (2) FUNDING FOR EVALUATION AND REPORT.— 

2 For purposes of carrying out the evaluation and re3 port under subsection (f), the Secretary shall provide 

4 for the transfer from the Federal Hospital Insurance 

5 Trust Fund under such section 1817 and the Fed6 eral Supplementary Medical Insurance Trust Fund 

7 under such section 1841, in such proportion as the 

8 Secretary determines appropriate, of $500,000. 

9 (3) AVAILABILITY.—Amounts transferred under 

10 paragraph (1) or (2) shall remain available until ex11 pended. 

12 (h) BUDGET NEUTRALITY.—In conducting the CBI13 SNP demonstration program, the Secretary shall ensure 

14 that the aggregate payments made by the Secretary do 

15 not exceed the amount which the Secretary estimates 

16 would have been expended under titles XVIII and XIX 

17 of the Social Security Act (42 U.S.C. 1395 et seq., 1396 

18 et seq.) if the CBI-SNP demonstration program had not 

19 been implemented. 

20 (i) PAPERWORK REDUCTION ACT.—Chapter 35 of 

21 title 44, United States Code, shall not apply to the testing 

22 and evaluation of the CBI-SNP demonstration program 

23 under this section. 


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1 SEC. 411. APPLYING CMMI WAIVER AUTHORITY TO PACE IN 

2 ORDER TO FOSTER INNOVATIONS. 

3 (a) CMMI WAIVER AUTHORITY.—Subsection (d)(1) 

4 of section 1115A of the Social Security Act (42 U.S.C. 

5 1315a) is amended— 

6 (1) by inserting ‘‘(other than subsections 

7 (b)(1)(A) and (c)(5) of section 1894)’’ after 

8 ‘‘XVIII’’; and 

9 (2) by striking ‘‘and 1903(m)(2)(A)(iii)’’ and 

10 inserting ‘‘1903(m)(2)(A)(iii), and 1934 (other than 

11 subsections (b)(1)(A) and (c)(5) of such section)’’. 

12 (b) SENSE OF THE SENATE.—It is the sense of the 

13 Senate that the Secretary of Health and Human Services 

14 should use the waiver authority provided under the 

15 amendments made by this section to provide, in a budget 

16 neutral manner, programs of all-inclusive care for the el17 derly (PACE programs) with increased operational flexi18 bility to support the ability of such programs to improve 

19 and innovate and to reduce technical and administrative 

20 barriers that have hindered enrollment in such programs. 

21 SEC. 412. IMPROVE AND MODERNIZE MEDICAID DATA SYS22 TEMS AND REPORTING. 

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

24 Human Services shall implement a strategic plan to in25 crease the usefulness of data about State Medicaid pro26 grams reported by States to the Centers for Medicare & 


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1 Medicaid Services. The strategic plan shall address 

2 redundancies and gaps in Medicaid data systems and re3 porting through improvements to, and modernization of, 

4 computer and data systems. Areas for improvement under 

5 the plan shall include (but not be limited to) the following: 

6 (1) The reporting of encounter data by man7 aged care plans. 

8 (2) The timeliness and quality of reported data, 

9 including enrollment data. 

10 (3) The consistency of data reported from mul11 tiple sources. 

12 (4) Information about State program policies. 

13 (b) IMPLEMENTATION STATUS REPORT.—Not later 

14 than 1 year after the date of enactment of this Act, the 

15 Secretary of Health and Human Services shall submit a 

16 report to Congress on the status of the implementation 

17 of the strategic plan required under subsection (a). 

18 (c) AUTHORIZATION OF APPROPRIATIONS.—There is 

19 authorized to be appropriated to the Secretary of Health 

20 and Human Services for the period of fiscal years 2015 

21 through 2019, such sums as may be necessary to carry 

22 out this section. 


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1 SEC. 413. FAIRNESS IN MEDICAID SUPPLEMENTAL NEEDS 

2 TRUSTS. 

3 (a) IN GENERAL.—Section 1917(d)(4)(A) of the So4 cial Security Act (42 U.S.C. 1396p(d)(4)(A)) is amended 

5 by inserting ‘‘the individual,’’ after ‘‘for the benefit of such 

6 individual by’’. 

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

8 subsection (a) shall apply to trusts established on or after 

9 the date of the enactment of this Act. 

10 SEC. 414. HELPING ENSURE LIFE- AND LIMB-SAVING AC11 CESS TO PODIATRIC PHYSICIANS. 

12 (a) INCLUDING PODIATRISTS AS PHYSICIANS UNDER

13 THE MEDICAID PROGRAM.— 

14 (1) IN GENERAL.—Section 1905(a)(5)(A) of the 

15 Social Security Act (42 U.S.C. 1396d(a)(5)(A)) is 

16 amended by striking ‘‘section 1861(r)(1)’’ and in17 serting ‘‘paragraphs (1) and (3) of section 1861(r)’’. 

18 (2) EFFECTIVE DATE.— 

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

20 subparagraph (B), the amendment made by 

21 paragraph (1) shall apply to services furnished 

22 on or after the date of enactment of this Act. 

23 (B) EXTENSION OF EFFECTIVE DATE FOR

24 STATE LAW AMENDMENT.—In the case of a 

25 State plan under title XIX of the Social Secu26 rity Act (42 U.S.C. 1396 et seq.) which the 


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1 Secretary of Health and Human Services deter2 mines requires State legislation in order for the 

3 plan to meet the additional requirement im4 posed by the amendment made by paragraph 

5 (1), the State plan shall not be regarded as fail6 ing to comply with the requirements of such 

7 title solely on the basis of its failure to meet 

8 these additional requirements before the first 

9 day of the first calendar quarter beginning after 

10 the close of the first regular session of the 

11 State legislature that begins after the date of 

12 enactment of this Act. For purposes of the pre13 vious sentence, in the case of a State that has 

14 a 2-year legislative session, each year of the ses15 sion is considered to be a separate regular ses16 sion of the State legislature. 

17 (b) MODIFICATIONS TO REQUIREMENTS FOR DIA18 BETIC SHOES TO BE INCLUDED UNDER MEDICAL AND

19 OTHER HEALTH SERVICES UNDER MEDICARE.— 

20 (1) IN GENERAL.—Section 1861(s)(12) of the 

21 Social Security Act (42 U.S.C. 1395x(s)(12)) is 

22 amended to read as follows: 

23 ‘‘(12) subject to section 4072(e) of the Omni24 bus Budget Reconciliation Act of 1987, extra-depth 

25 shoes with inserts or custom molded shoes (in this 


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1 paragraph referred to as ‘therapeutic shoes’) with 

2 inserts for an individual with diabetes, if— 

3 ‘‘(A) the physician who is managing the in4 dividual’s diabetic condition— 

5 ‘‘(i) documents that the individual has 

6 diabetes; 

7 ‘‘(ii) certifies that the individual is 

8 under a comprehensive plan of care related 

9 to the individual’s diabetic condition; and 

10 ‘‘(iii) documents agreement with the 

11 prescribing podiatrist or other qualified 

12 physician (as established by the Secretary) 

13 that it is medically necessary for the indi14 vidual to have such extra-depth shoes with 

15 inserts or custom molded shoes with in16 serts; 

17 ‘‘(B) the therapeutic shoes are prescribed 

18 by a podiatrist or other qualified physician (as 

19 established by the Secretary) who— 

20 ‘‘(i) examines the individual and de21 termines the medical necessity for the indi22 vidual to receive the therapeutic shoes; and 

23 ‘‘(ii) communicates in writing the 

24 medical necessity to the physician de25 scribed in subparagraph (A) for the indiVerDate Mar 15 2010 01:32 Mar 14, 2014 Jkt 039200 PO 00000 Frm 00350 Fmt 6652 Sfmt 6201 E:\BILLS\S2122.PCS S2122

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1 vidual to have therapeutic shoes along with 

2 findings that the individual has peripheral 

3 neuropathy with evidence of callus forma4 tion, a history of pre-ulcerative calluses, a 

5 history of previous ulceration, foot deform6 ity, previous amputation, or poor circula7 tion; and 

8 ‘‘(C) the therapeutic shoes are fitted and 

9 furnished by a podiatrist or other qualified sup10 plier (as established by the Secretary), such as 

11 a pedorthist or orthotist, who is not the physi12 cian described in subparagraph (A) (unless the 

13 Secretary finds that the physician is the only 

14 such qualified individual in the area);’’. 

15 (2) EFFECTIVE DATE.—The amendment made 

16 by paragraph (1) shall apply with respect to items 

17 and services furnished on or after January 1, 2015. 

18 SEC. 415. DEMONSTRATION PROGRAMS TO IMPROVE COM19 MUNITY MENTAL HEALTH SERVICES. 

20 (a) CRITERIA FOR CERTIFIED COMMUNITY BEHAV21 IORAL HEALTH CLINICS TO PARTICIPATE IN DEM22 ONSTRATION PROGRAMS.— 

23 (1) PUBLICATION.—Not later than September 

24 1, 2015, the Secretary shall publish criteria for a 

25 clinic to be certified by a State as a certified comVerDate Mar 15 2010 01:32 Mar 14, 2014 Jkt 039200 PO 00000 Frm 00351 Fmt 6652 Sfmt 6201 E:\BILLS\S2122.PCS S2122

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1 munity behavioral health clinic for purposes of par2 ticipating in a demonstration program conducted 

3 under subsection (d). 

4 (2) REQUIREMENTS.—The criteria published 

5 under this subsection shall include criteria with re6 spect to the following: 

7 (A) STAFFING.—Staffing requirements, in8 cluding criteria that staff have diverse discipli9 nary backgrounds, have necessary State-re10 quired license and accreditation, and are cul11 turally and linguistically trained to serve the 

12 needs of the clinic’s patient population. 

13 (B) AVAILABILITY AND ACCESSIBILITY OF

14 SERVICES.—Availability and accessibility of 

15 services, including crisis management services 

16 that are available and accessible 24 hours a 

17 day, the use of a sliding scale for payment, and 

18 no rejection for services or limiting of services 

19 on the basis of a patient’s ability to pay or a 

20 place of residence. 

21 (C) CARE COORDINATION.—Care coordina22 tion, including requirements to coordinate care 

23 across settings and providers to ensure seamless 

24 transitions for patients across the full spectrum 

25 of health services including acute, chronic, and 


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1 behavioral health needs. Care coordination re2 quirements shall include partnerships or formal 

3 contracts with the following: 

4 (i) Federally-qualified health centers 

5 (and as applicable, rural health clinics) to 

6 provide Federally-qualified health center 

7 services (and as applicable, rural health 

8 clinic services) to the extent such services 

9 are not provided directly through the cer10 tified community behavioral health clinic. 

11 (ii) Inpatient psychiatric facilities and 

12 substance use detoxification, post-detoxi13 fication step-down services, and residential 

14 programs. 

15 (iii) Other community or regional 

16 services, supports, and providers, including 

17 schools, child welfare agencies, juvenile and 

18 criminal justice agencies and facilities, In19 dian Health Service youth regional treat20 ment centers, State licensed and nationally 

21 accredited child placing agencies for thera22 peutic foster care service, and other social 

23 and human services. 

24 (iv) Department of Veterans Affairs 

25 medical centers, independent outpatient 


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1 clinics, drop-in centers, and other facilities 

2 of the Department as defined in section 

3 1801 of title 38, United States Code. 

4 (v) Inpatient acute care hospitals and 

5 hospital outpatient clinics. 

6 (D) SCOPE OF SERVICES.—Provision (in a 

7 manner reflecting person-centered care) of the 

8 following services which, if not available directly 

9 through the certified community behavioral 

10 health clinic, are provided or referred through 

11 formal relationships with other providers: 

12 (i) Crisis mental health services, in13 cluding 24-hour mobile crisis teams, emer14 gency crisis intervention services, and cri15 sis stabilization. 

16 (ii) Screening, assessment, and diag17 nosis, including risk assessment. 

18 (iii) Patient-centered treatment plan19 ning or similar processes, including risk as20 sessment and crisis planning. 

21 (iv) Outpatient mental health and 

22 substance use services. 

23 (v) Outpatient clinic primary care 

24 screening and monitoring of key health in25 dicators and health risk. 


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1 (vi) Targeted case management. 

2 (vii) Psychiatric rehabilitation serv3 ices. 

4 (viii) Peer support and counselor serv5 ices and family supports. 

6 (ix) Intensive, community-based men7 tal health care for members of the armed 

8 forces and veterans, particularly those 

9 members and veterans located in rural 

10 areas, provided the care is consistent with 

11 minimum clinical mental health guidelines 

12 promulgated by the Veterans Health Ad13 ministration including clinical guidelines 

14 contained in the Uniform Mental Health 

15 Services Handbook of such Administration. 

16 (E) QUALITY AND OTHER REPORTING.— 

17 Reporting of encounter data, clinical outcomes 

18 data, quality data, and such other data as the 

19 Secretary requires. 

20 (F) ORGANIZATIONAL AUTHORITY.—Cri21 teria that a clinic be a non-profit or part of a 

22 local government behavioral health authority or 

23 operated under the authority of the Indian 

24 Health Service, an Indian tribe or tribal organi25 zation pursuant to a contract, grant, cooperaVerDate Mar 15 2010 01:32 Mar 14, 2014 Jkt 039200 PO 00000 Frm 00355 Fmt 6652 Sfmt 6201 E:\BILLS\S2122.PCS S2122

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1 tive agreement, or compact with the Indian 

2 Health Service pursuant to the Indian Self-De3 termination Act (25 U.S.C. 450 et seq.), or an 

4 urban Indian organization pursuant to a grant 

5 or contract with the Indian Health Service 

6 under title V of the Indian Health Care Im7 provement Act (25 U.S.C. 1601 et seq.). 

8 (b) GUIDANCE ON DEVELOPMENT OF PROSPECTIVE

9 PAYMENT SYSTEM FOR TESTING UNDER DEMONSTRA10 TION PROGRAMS.— 

11 (1) IN GENERAL.—Not later than September 1, 

12 2015, the Secretary, through the Administrator of 

13 the Centers for Medicare & Medicaid Services, shall 

14 issue guidance for the establishment of a prospective 

15 payment system that shall only apply to medical as16 sistance for mental health services furnished by a 

17 certified community behavioral health clinic partici18 pating in a demonstration program under subsection 

19 (d). 

20 (2) REQUIREMENTS.—The guidance issued by 

21 the Secretary under paragraph (1) shall provide 

22 that— 

23 (A) no payment shall be made for inpatient 

24 care, residential treatment, room and board exVerDate Mar 15 2010 01:32 Mar 14, 2014 Jkt 039200 PO 00000 Frm 00356 Fmt 6652 Sfmt 6201 E:\BILLS\S2122.PCS S2122

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1 penses, or any other non-ambulatory services, 

2 as determined by the Secretary; and 

3 (B) no payment shall be made to satellite 

4 facilities of certified community behavioral 

5 health clinics if such facilities are established 

6 after the date of enactment of this Act. 

7 (c) PLANNING GRANTS.— 

8 (1) IN GENERAL.—Not later than January 1, 

9 2016, the Secretary shall award planning grants to 

10 States for the purpose of developing proposals to 

11 participate in time-limited demonstration programs 

12 described in subsection (d). 

13 (2) USE OF FUNDS.—A State awarded a plan14 ning grant under this subsection shall— 

15 (A) solicit input with respect to the devel16 opment of such a demonstration program from 

17 patients, providers, and other stakeholders; 

18 (B) certify clinics as certified community 

19 behavioral health clinics for purposes of partici20 pating in a demonstration program conducted 

21 under subsection (d); and 

22 (C) establish a prospective payment system 

23 for mental health services furnished by a cer24 tified community behavioral health clinic par25 ticipating in a demonstration program under 


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1 subsection (d) in accordance with the guidance 

2 issued under subsection (b). 

3 (d) DEMONSTRATION PROGRAMS.— 

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

5 2017, the Secretary shall select States to participate 

6 in demonstration programs that are developed 

7 through planning grants awarded under subsection 

8 (c), meet the requirements of this subsection, and 

9 represent a diverse selection of geographic areas, in10 cluding rural and underserved areas. 

11 (2) APPLICATION REQUIREMENTS.— 

12 (A) IN GENERAL.—The Secretary shall so13 licit applications to participate in demonstration 

14 programs under this subsection solely from 

15 States awarded planning grants under sub16 section (c). 

17 (B) REQUIRED INFORMATION.—An appli18 cation for a demonstration program under this 

19 subsection shall include the following: 

20 (i) The target Medicaid population to 

21 be served under the demonstration pro22 gram. 

23 (ii) A list of participating certified 

24 community behavioral health clinics. 


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1 (iii) Verification that the State has 

2 certified a participating clinic as a certified 

3 community behavioral health clinic in ac4 cordance with the requirements of sub5 section (b). 

6 (iv) A description of the scope of the 

7 mental health services available under the 

8 State Medicaid program that will be paid 

9 for under the prospective payment system 

10 tested in the demonstration program. 

11 (v) Verification that the State has 

12 agreed to pay for such services at the rate 

13 established under the prospective payment 

14 system. 

15 (vi) Such other information as the 

16 Secretary may require relating to the dem17 onstration program including with respect 

18 to determining the soundness of the pro19 posed prospective payment system. 

20 (3) NUMBER AND LENGTH OF DEMONSTRATION

21 PROGRAMS.—Not more than 8 States shall be se22 lected for 4-year demonstration programs under this 

23 subsection. 

24 (4) REQUIREMENTS FOR SELECTING DEM25 ONSTRATION PROGRAMS.— 


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1 (A) IN GENERAL.—The Secretary shall 

2 give preference to selecting demonstration pro3 grams where participating certified community 

4 behavioral health clinics— 

5 (i) provide the most complete scope of 

6 services described in subsection (a)(2)(D) 

7 to individuals eligible for medical assist8 ance under the State Medicaid program; 

9 (ii) will improve availability of, access 

10 to, and participation in, services described 

11 in subsection (a)(2)(D) to individuals eligi12 ble for medical assistance under the State 

13 Medicaid program; 

14 (iii) will improve availability of, access 

15 to, and participation in assisted outpatient 

16 mental health treatment in the State; or 

17 (iv) demonstrate the potential to ex18 pand available mental health services in a 

19 demonstration area and increase the qual20 ity of such services without increasing net 

21 Federal spending. 

22 (5) PAYMENT FOR MEDICAL ASSISTANCE FOR

23 MENTAL HEALTH SERVICES PROVIDED BY CER24 TIFIED COMMUNITY BEHAVIORAL HEALTH CLIN25 ICS.— 


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1 (A) IN GENERAL.—The Secretary shall pay 

2 a State participating in a demonstration pro3 gram under this subsection the Federal match4 ing percentage specified in subparagraph (B) 

5 for amounts expended by the State to provide 

6 medical assistance for mental health services 

7 described in the demonstration program appli8 cation in accordance with paragraph (2)(B)(iv) 

9 that are provided by certified community behav10 ioral health clinics to individuals who are en11 rolled in the State Medicaid program. Payments 

12 to States made under this paragraph shall be 

13 considered to have been under, and are subject 

14 to the requirements of, section 1903 of the So15 cial Security Act (42 U.S.C. 1396b). 

16 (B) FEDERAL MATCHING PERCENTAGE.— 

17 The Federal matching percentage specified in 

18 this subparagraph is with respect to medical as19 sistance described in subparagraph (A) that is 

20 furnished— 

21 (i) to a newly eligible individual de22 scribed in paragraph (2) of section 1905(y) 

23 of the Social Security Act (42 U.S.C. 

24 1396d(y)), the matching rate applicable 

25 under paragraph (1) of that section; and 


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1 (ii) to an individual who is not a 

2 newly eligible individual (as so described) 

3 but who is eligible for medical assistance 

4 under the State Medicaid program, the en5 hanced FMAP applicable to the State. 

6 (C) LIMITATIONS.— 

7 (i) IN GENERAL.—Payments shall be 

8 made under this paragraph to a State only 

9 for mental health services— 

10 (I) that are described in the dem11 onstration program application in ac12 cordance with paragraph (2)(B)(iv); 

13 (II) for which payment is avail14 able under the State Medicaid pro15 gram; and 

16 (III) that are provided to an indi17 vidual who is eligible for medical as18 sistance under the State Medicaid 

19 program. 

20 (ii) PROHIBITED PAYMENTS.—No 

21 payment shall be made under this para22 graph— 

23 (I) for inpatient care, residential 

24 treatment, room and board expenses, 


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1 or any other non-ambulatory services, 

2 as determined by the Secretary; or 

3 (II) with respect to payments 

4 made to satellite facilities of certified 

5 community behavioral health clinics if 

6 such facilities are established after the 

7 date of enactment of this Act. 

8 (6) WAIVER OF STATEWIDENESS REQUIRE9 MENT.—The Secretary shall waive section 

10 1902(a)(1) of the Social Security Act (42 U.S.C. 

11 1396a(a)(1)) (relating to statewideness) as may be 

12 necessary to conduct demonstration programs in ac13 cordance with the requirements of this subsection. 

14 (7) ANNUAL REPORTS.— 

15 (A) IN GENERAL.—Not later than 1 year 

16 after the date on which the first State is se17 lected for a demonstration program under this 

18 subsection, and annually thereafter, the Sec19 retary shall submit to Congress an annual re20 port on the use of funds provided under all 

21 demonstration programs conducted under this 

22 subsection. Each such report shall include— 

23 (i) an assessment of access to commu24 nity-based mental health services under the 

25 Medicaid program in the area or areas of 


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1 a State targeted by a demonstration pro2 gram compared to other areas of the State; 

3 (ii) an assessment of the quality and 

4 scope of services provided by certified com5 munity behavioral health clinics compared 

6 to community-based mental health services 

7 provided in States not participating in a 

8 demonstration program under this sub9 section and in areas of a demonstration 

10 State that are not participating in the 

11 demonstration program; and 

12 (iii) an assessment of the impact of 

13 the demonstration programs on the Fed14 eral and State costs of a full range of men15 tal health services (including inpatient, 

16 emergency and ambulatory services). 

17 (B) RECOMMENDATIONS.—Not later than 

18 December 31, 2021, the Secretary shall submit 

19 to Congress recommendations concerning 

20 whether the demonstration programs under this 

21 section should be continued, expanded, modi22 fied, or terminated. 

23 (e) DEFINITIONS.—In this section: 

24 (1) FEDERALLY-QUALIFIED HEALTH CENTER

25 SERVICES; FEDERALLY-QUALIFIED HEALTH CENTER; 


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1 RURAL HEALTH CLINIC SERVICES; RURAL HEALTH

2 CLINIC.—The terms ‘‘Federally-qualified health cen3 ter services’’, ‘‘Federally-qualified health center’’, 

4 ‘‘rural health clinic services’’, and ‘‘rural health clin5 ic’’ have the meanings given those terms in section 

6 1905(l) of the Social Security Act (42 U.S.C. 

7 1396d(l)). 

8 (2) ENHANCED FMAP.—The term ‘‘enhanced 

9 FMAP’’ has the meaning given that term in section 

10 2105(b) of the Social Security Act (42 U.S.C. 

11 1397dd(b) but without regard to the second and 

12 third sentences of that section. 

13 (3) SECRETARY.—The term ‘‘Secretary’’ means 

14 the Secretary of Health and Human Services. 

15 (4) STATE.—The term ‘‘State’’ has the mean16 ing given such term for purposes of title XIX of the 

17 Social Security Act (42 U.S.C. 1396 et seq.). 

18 (f) FUNDING.— 

19 (1) IN GENERAL.—Out of any funds in the 

20 Treasury not otherwise appropriated, there is appro21 priated to the Secretary— 

22 (A) for purposes of carrying out sub23 sections (a), (b), and (d)(7), $2,000,000 for fis24 cal year 2014; and 


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1 (B) for purposes of awarding planning 

2 grants under subsection (c), $25,000,000 for 

3 fiscal year 2016. 

4 (2) AVAILABILITY.—Funds appropriated under 

5 paragraph (1) shall remain available until expended. 

6 SEC. 416. ANNUAL MEDICAID DSH REPORT. 

7 Section 1923 of the Social Security Act (42 U.S.C. 

8 1396r–4) is amended by adding at the end the following: 

9 ‘‘(k) ANNUAL REPORT TO CONGRESS.— 

10 ‘‘(1) IN GENERAL.—Beginning January 1, 

11 2015, and annually thereafter, the Secretary shall 

12 submit a report to Congress on the program estab13 lished under this section for making payment adjust14 ments to disproportionate share hospitals for the 

15 purpose of providing Congress with information rel16 evant to determining an appropriate level of overall 

17 funding for such payment adjustments during and 

18 after the period in which aggregate reductions in the 

19 DSH allotments to States are required under para20 graphs (7) and (8) of subsection (f). 

21 ‘‘(2) REQUIRED REPORT INFORMATION.—Ex22 cept as otherwise provided, each report submitted 

23 under this subsection shall include the following: 

24 ‘‘(A) Information and data relating to 

25 changes in the number of uninsured individuals 


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1 for the most recent year for which such data 

2 are available as compared to 2013 and as com3 pared to the Congressional Budget Office esti4 mates of uninsured individuals made at the 

5 time of the enactment of the Patient Protection 

6 and Affordable Care Act (Public Law 111–148) 

7 and the Health Care and Education Reconcili8 ation Act of 2010 (Public Law 111–152). 

9 ‘‘(B) Information and data relating to the 

10 extent to which hospitals continue to incur un11 compensated care costs from providing unreim12 bursed or under-reimbursed services to individ13 uals who either are eligible for medical assist14 ance under the State plan under this title or 

15 under a waiver of such plan or who have no 

16 health insurance (or other source of third party 

17 coverage) for such services. 

18 ‘‘(C) Information and data relating to the 

19 extent to which hospitals continue to provide 

20 charity care and unreimbursed or under-reim21 bursed services, or otherwise incur bad debt, 

22 under the program established under this title, 

23 the State Children’s Health Insurance Program 

24 established under title XXI, and State or local 

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1 ports submitted under title XVIII or such other 

2 data as the Secretary determines appropriate. 

3 ‘‘(D) In the first report submitted under 

4 this section, a methodology for estimating the 

5 amount of unpaid patient deductibles, copay6 ments and coinsurance incurred by hospitals for 

7 patients enrolled in qualified health plans 

8 through an American Health Benefits Ex9 change, using existing data and minimizing the 

10 administrative burden on hospitals to the extent 

11 possible, and in subsequent reports, data re12 garding such uncompensated care costs col13 lected pursuant to such methodology. 

14 ‘‘(E) For each State, information and data 

15 relating to the difference between the DSH al16 lotment for the State for the fiscal year that 

17 began on October 1 of the year preceding the 

18 year in which the report is submitted and the 

19 aggregate amount of uncompensated care costs 

20 for all disproportionate share hospitals in the 

21 State. 

22 ‘‘(F) Information and data relating to the 

23 extent to which there are certain vital hospital 

24 systems that are disproportionately experiencing 

25 high levels of uncompensated care and that 


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1 have multiple other missions, such as a commit2 ment to graduate medical education, the provi3 sion of tertiary and trauma care services, pro4 viding public health and essential community 

5 services, and providing comprehensive, coordi6 nated care. 

7 ‘‘(G) Such other information and data rel8 evant to the determination of the level of fund9 ing for, and amount of, State DSH allotments 

10 as the Secretary determines appropriate 

11 ‘‘(3) AUTHORIZATION OF APPROPRIATIONS.— 

12 There is authorized to be appropriated to the Sec13 retary for the period of fiscal years 2015 through 

14 2109, such sums as may be necessary to carry out 

15 this subsection.’’. 

16 SEC. 417. IMPLEMENTATION. 

17 To the extent the Secretary of Health and Human 

18 Services issues a regulation to carry out the provisions of 

19 this Act, the Secretary shall, unless otherwise specified in 

20 this Act— 

21 (1) issue a notice of proposed rulemaking that 

22 includes the proposed regulation; 

23 (2) provide a period of not less than 60 cal24 endar days for comments on the proposed regula25 tion; 


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1 (3) not more than 24 months following the date 

2 of publication of the proposed rule, publish the final 

3 regulation or take alternative action (such as with4 drawing the rule or proposing a revised rule with a 

5 new comment period) on the proposed regulation; 

6 and 

7 (4) not less than 30 days before the effective 

8 date of the final regulation, publish the final regula9 tion or take alternative action (such as withdrawing 

10 the rule or proposing a revised rule with a new com11 ment period) on the proposed regulation. 

12 TITLE V—RESTORING 

13 INDIVIDUAL LIBERTY 

14 SEC. 501. RESTORING INDIVIDUAL LIBERTY. 

15 Sections 1501 and 1502 and subsections (a), (b), (c), 

16 and (d) of section 10106 of the Patient Protection and 

17 Affordable Care Act (and the amendments made by such 

18 sections and subsections) are repealed and the Internal 

19 Revenue Code of 1986 shall be applied and administered 

20 as if such provisions and amendments had never been en21 acted. 


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smartinez on DSK6TPTVN1PROD with BILLS
Calendar No. 330 

113TH CONGRESS 

2D SESSION S. 2122 

A BILL 

To amend titles XVIII and XIX of the Social Secuicaid payments, and for other purposes. growth rate and to improve Medicare and Med- rity Act to repeal the Medicare sustainable 

MARCH 13, 2014 

Read the second time and placed on the calendar 


smartinez on DSK6TPTVN1PROD with BILLS