II 

Calendar No. 336 

113TH CONGRESS 

2D SESSION S. 2157 

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 25, 2014 

Mr. WYDEN introduced the following bill; which was read the first time 

MARCH 26, 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, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

5 ‘‘Commonsense Medicare SGR Repeal and Beneficiary Ac6 cess Improvement Act of 2014’’. 


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

2 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. 

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. 


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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—AMENDMENT TO OCO ADJUSTMENTS 

Sec. 501. Amendment to OCO adjustments. 

Sec. 502. Limitation on the use of OCO funding. 

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.— 


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1 (1) REPEAL OF SGR PAYMENT METHOD2 OLOGY.—Section 1848 of the Social Security Act 

3 (42 U.S.C. 1395w–4) is amended— 

4 (A) in subsection (d)— 

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

6 ‘‘or a subsequent paragraph’’ after ‘‘para7 graph (4)’’; and 

8 (ii) in paragraph (4)— 

9 (I) in the heading, by inserting 

10 ‘‘AND ENDING WITH 2013’’ after 

11 ‘‘YEARS BEGINNING WITH 2001’’; and 

12 (II) in subparagraph (A), by in13 serting ‘‘and ending with 2013’’ after 

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

15 (B) in subsection (f)— 

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

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

18 year’’; and 

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

20 preceding subparagraph (A), by inserting 

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

22 with 2000’’. 

23 (2) UPDATE OF RATES FOR APRIL THROUGH

24 DECEMBER OF 2014, 2015, AND SUBSEQUENT

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


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

2 striking paragraph (15) and inserting the following 

3 new paragraphs: 

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

5 update to the single conversion factor established in 

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

7 year through 2018 shall be 0.5 percent. 

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

9 update to the single conversion factor established in 

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

11 year through 2023 shall be zero percent. 

12 ‘‘(17) UPDATE FOR 2024 AND SUBSEQUENT

13 YEARS.—The update to the single conversion factor 

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

15 subsequent year shall be— 

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

17 qualifying APM participant (as defined in sec18 tion 1833(z)(2)) for such year, 1.0 percent; and 

19 ‘‘(B) for other items and services, 0.5 per20 cent.’’. 

21 (3) MEDPAC REPORTS.— 

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

23 1, 2016, the Medicare Payment Advisory Com24 mission shall submit to Congress a report on 

25 the relationship between— 


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1 (i) physician and other health profes2 sional utilization and expenditures (and the 

3 rate of increase of such utilization and ex4 penditures) of items and services for which 

5 payment is made under section 1848 of the 

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

7 and 

8 (ii) total utilization and expenditures 

9 (and the rate of increase of such utilization 

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

11 of title XVIII of such Act. 

12 Such report shall include a methodology to de13 scribe such relationship and the impact of 

14 changes in such physician and other health pro15 fessional practice and service ordering patterns 

16 on total utilization and expenditures under 

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

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

19 1, 2020, the Medicare Payment Advisory Com20 mission shall submit to Congress a report on 

21 the relationship described in subparagraph (A), 

22 including the results determined from applying 

23 the methodology included in the report sub24 mitted under such subparagraph. 


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1 (C) REPORT ON UPDATE TO PHYSICIANS’ 

2 SERVICES UNDER MEDICARE.—Not later than 

3 July 1, 2018, the Medicare Payment Advisory 

4 Commission shall submit to Congress a report 

5 on— 

6 (i) the payment update for profes7 sional services applied under the Medicare 

8 program under title XVIII of the Social 

9 Security Act for the period of years 2014 

10 through 2018; 

11 (ii) the effect of such update on the 

12 efficiency, economy, and quality of care 

13 provided under such program; 

14 (iii) the effect of such update on en15 suring a sufficient number of providers to 

16 maintain access to care by Medicare bene17 ficiaries; and 

18 (iv) recommendations for any future 

19 payment updates for professional services 

20 under such program to ensure adequate 

21 access to care is maintained for Medicare 

22 beneficiaries. 

23 (b) CONSOLIDATION OF CERTAIN CURRENT LAW

24 PERFORMANCE PROGRAMS WITH NEW MERIT-BASED IN25 CENTIVE PAYMENT SYSTEM.— 


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1 (1) EHR MEANINGFUL USE INCENTIVE PRO2 GRAM.— 

3 (A) SUNSETTING SEPARATE MEANINGFUL

4 USE PAYMENT ADJUSTMENTS.—Section 

5 1848(a)(7)(A) of the Social Security Act (42 

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

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

8 any subsequent payment year’’ and insert9 ing ‘‘2015, 2016, or 2017’’; 

10 (ii) in clause (ii)— 

11 (I) in the matter preceding sub12 clause (I), by striking ‘‘Subject to 

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

14 and 

15 (II) in subclause (III), by strik16 ing ‘‘and each subsequent year’’; and 

17 (iii) by striking clause (iii). 

18 (B) CONTINUATION OF MEANINGFUL USE

19 DETERMINATIONS FOR MIPS.—Section 

20 1848(o)(2) of the Social Security Act (42 

21 U.S.C. 1395w–4(o)(2)) is amended— 

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

23 preceding clause (i)— 


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1 (I) by striking ‘‘For purposes of 

2 paragraph (1), an’’ and inserting 

3 ‘‘An’’; and 

4 (II) by inserting ‘‘, or pursuant 

5 to subparagraph (D) for purposes of 

6 subsection (q), for a performance pe7 riod under such subsection for a year’’ 

8 after ‘‘under such subsection for a 

9 year’’; and 

10 (ii) by adding at the end the following 

11 new subparagraph: 

12 ‘‘(D) CONTINUED APPLICATION FOR PUR13 POSES OF MIPS.—With respect to 2018 and 

14 each subsequent payment year, the Secretary 

15 shall, for purposes of subsection (q) and in ac16 cordance with paragraph (1)(F) of such sub17 section, determine whether an eligible profes18 sional who is a MIPS eligible professional (as 

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

20 a meaningful EHR user under this paragraph 

21 for the performance period under subsection (q) 

22 for such year.’’. 

23 (2) QUALITY REPORTING.— 

24 (A) SUNSETTING SEPARATE QUALITY RE25 PORTING INCENTIVES.—Section 1848(a)(8)(A) 


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

2 4(a)(8)(A)) is amended— 

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

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

5 2016, or 2017’’; and 

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

7 each subsequent year’’ and inserting ‘‘and 

8 2017’’. 

9 (B) CONTINUATION OF QUALITY MEAS10 URES AND PROCESSES FOR MIPS.—Section 

11 1848 of the Social Security Act (42 U.S.C. 

12 1395w–4) is amended— 

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

14 end the following new paragraph: 

15 ‘‘(9) CONTINUED APPLICATION FOR PURPOSES

16 OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN17 TEERING TO REPORT.—The Secretary shall, in ac18 cordance with subsection (q)(1)(F), carry out the 

19 provisions of this subsection— 

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

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

22 MIPS eligible professionals (as defined in sub23 section (q)(1)(C)) for the year involved.’’; and 

24 (ii) in subsection (m)— 


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1 (I) by redesignating paragraph 

2 (7) added by section 10327(a) of Pub3 lic Law 111–148 as paragraph (8); 

4 and 

5 (II) by adding at the end the fol6 lowing new paragraph: 

7 ‘‘(9) CONTINUED APPLICATION FOR PURPOSES

8 OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN9 TEERING TO REPORT.—The Secretary shall, in ac10 cordance with subsection (q)(1)(F), carry out the 

11 processes under this subsection— 

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

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

14 MIPS eligible professionals (as defined in sub15 section (q)(1)(C)) for the year involved.’’. 

16 (3) VALUE-BASED PAYMENTS.— 

17 (A) SUNSETTING SEPARATE VALUE-BASED

18 PAYMENTS.—Clause (iii) of section 

19 1848(p)(4)(B) of the Social Security Act (42 

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

21 as follows: 

22 ‘‘(iii) APPLICATION.—The Secretary 

23 shall apply the payment modifier estab24 lished under this subsection for items and 

25 services furnished on or after January 1, 


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1 2015, but before January 1, 2018, with re2 spect to specific physicians and groups of 

3 physicians the Secretary determines appro4 priate. Such payment modifier shall not be 

5 applied for items and services furnished on 

6 or after January 1, 2018.’’. 

7 (B) CONTINUATION OF VALUE-BASED PAY8 MENT MODIFIER MEASURES FOR MIPS.—Section 

9 1848(p) of the Social Security Act (42 U.S.C. 

10 1395w–4(p)) is amended— 

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

12 end the following new subparagraph: 

13 ‘‘(C) CONTINUED APPLICATION FOR PUR14 POSES OF MIPS.—The Secretary shall, in ac15 cordance with subsection (q)(1)(F), carry out 

16 subparagraph (B) for purposes of subsection 

17 (q).’’; and 

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

19 end the following: ‘‘With respect to 2018 

20 and each subsequent year, the Secretary 

21 shall, in accordance with subsection 

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

23 purposes of subsection (q).’’. 

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


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

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

3 adding at the end the following new subsection: 

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

5 ‘‘(1) ESTABLISHMENT.— 

6 ‘‘(A) IN GENERAL.—Subject to the suc7 ceeding provisions of this subsection, the Sec8 retary shall establish an eligible professional 

9 Merit-based Incentive Payment System (in this 

10 subsection referred to as the ‘MIPS’) under 

11 which the Secretary shall— 

12 ‘‘(i) develop a methodology for assess13 ing the total performance of each MIPS el14 igible professional according to perform15 ance standards under paragraph (3) for a 

16 performance period (as established under 

17 paragraph (4)) for a year; 

18 ‘‘(ii) using such methodology, provide 

19 for a composite performance score in ac20 cordance with paragraph (5) for each such 

21 professional for each performance period; 

22 and 

23 ‘‘(iii) use such composite performance 

24 score of the MIPS eligible professional for 

25 a performance period for a year to deterVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 mine and apply a MIPS adjustment factor 

2 (and, as applicable, an additional MIPS 

3 adjustment factor) under paragraph (6) to 

4 the professional for the year. 

5 ‘‘(B) PROGRAM IMPLEMENTATION.—The 

6 MIPS shall apply to payments for items and 

7 services furnished on or after January 1, 2018. 

8 ‘‘(C) MIPS ELIGIBLE PROFESSIONAL DE9 FINED.— 

10 ‘‘(i) IN GENERAL.—For purposes of 

11 this subsection, subject to clauses (ii) and 

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

13 means— 

14 ‘‘(I) for the first and second 

15 years for which the MIPS applies to 

16 payments (and for the performance 

17 period for such first and second year), 

18 a physician (as defined in section 

19 1861(r)), a physician assistant, nurse 

20 practitioner, and clinical nurse spe21 cialist (as such terms are defined in 

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

23 registered nurse anesthetist (as de24 fined in section 1861(bb)(2)) and a 


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1 group that includes such profes2 sionals; and 

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

4 the MIPS applies to payments (and 

5 for the performance period for such 

6 third year) and for each succeeding 

7 year (and for the performance period 

8 for each such year), the professionals 

9 described in subclause (I) and such 

10 other eligible professionals (as defined 

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

12 by the Secretary and a group that in13 cludes such professionals. 

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

15 clause (i), the term ‘MIPS eligible profes16 sional’ does not include, with respect to a 

17 year, an eligible professional (as defined in 

18 subsection (k)(3)(B)) who— 

19 ‘‘(I) is a qualifying APM partici20 pant (as defined in section 

21 1833(z)(2)); 

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

23 partial qualifying APM participant (as 

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1 able and who, for the performance pe2 riod with respect to such year, does 

3 not report on applicable measures and 

4 activities described in paragraph 

5 (2)(B) that are required to be re6 ported by such a professional under 

7 the MIPS; or 

8 ‘‘(III) for the performance period 

9 with respect to such year, does not ex10 ceed the low-volume threshold meas11 urement selected under clause (iv). 

12 ‘‘(iii) PARTIAL QUALIFYING APM PAR13 TICIPANT.—For purposes of this subpara14 graph, the term ‘partial qualifying APM 

15 participant’ means, with respect to a year, 

16 an eligible professional for whom the Sec17 retary determines the minimum payment 

18 percentage (or percentages), as applicable, 

19 described in paragraph (2) of section 

20 1833(z) for such year have not been satis21 fied, but who would be considered a quali22 fying APM participant (as defined in such 

23 paragraph) for such year if— 

24 ‘‘(I) with respect to 2018 and 

25 2019, the reference in subparagraph 


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1 (A) of such paragraph to 25 percent 

2 was instead a reference to 20 percent; 

3 ‘‘(II) with respect to 2020 and 

4 2021— 

5 ‘‘(aa) the reference in sub6 paragraph (B)(i) of such para7 graph to 50 percent was instead 

8 a reference to 40 percent; and 

9 ‘‘(bb) the references in sub10 paragraph (B)(ii) of such para11 graph to 50 percent and 25 per12 cent of such paragraph were in13 stead references to 40 percent 

14 and 20 percent, respectively; and 

15 ‘‘(III) with respect to 2022 and 

16 subsequent years— 

17 ‘‘(aa) the reference in sub18 paragraph (C)(i) of such para19 graph to 75 percent was instead 

20 a reference to 50 percent; and 

21 ‘‘(bb) the references in sub22 paragraph (C)(ii) of such para23 graph to 75 percent and 25 per24 cent of such paragraph were inVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00017 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 stead references to 50 percent 

2 and 20 percent, respectively. 

3 ‘‘(iv) SELECTION OF LOW-VOLUME

4 THRESHOLD MEASUREMENT.—The Sec5 retary shall select a low-volume threshold 

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

7 which may include one or more or a com8 bination of the following: 

9 ‘‘(I) The minimum number (as 

10 determined by the Secretary) of indi11 viduals enrolled under this part who 

12 are treated by the eligible professional 

13 for the performance period involved. 

14 ‘‘(II) The minimum number (as 

15 determined by the Secretary) of items 

16 and services furnished to individuals 

17 enrolled under this part by such pro18 fessional for such performance period. 

19 ‘‘(III) The minimum amount (as 

20 determined by the Secretary) of al21 lowed charges billed by such profes22 sional under this part for such per23 formance period. 

24 ‘‘(v) TREATMENT OF NEW MEDICARE

25 ENROLLED ELIGIBLE PROFESSIONALS.—In 


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1 the case of a professional who first be2 comes a Medicare enrolled eligible profes3 sional during the performance period for a 

4 year (and had not previously submitted 

5 claims under this title such as a person, an 

6 entity, or a part of a physician group or 

7 under a different billing number or tax 

8 identifier), such professional shall not be 

9 treated under this subsection as a MIPS 

10 eligible professional until the subsequent 

11 year and performance period for such sub12 sequent year. 

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

14 items and services furnished during a year 

15 by an individual who is not a MIPS eligible 

16 professional (including pursuant to clauses 

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

18 case shall a MIPS adjustment factor (or 

19 additional MIPS adjustment factor) under 

20 paragraph (6) apply to such individual for 

21 such year. 

22 ‘‘(vii) PARTIAL QUALIFYING APM PAR23 TICIPANT CLARIFICATIONS.— 

24 ‘‘(I) TREATMENT AS MIPS ELIGI25 BLE PROFESSIONAL.—In the case of 


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1 an eligible professional who is a par2 tial qualifying APM participant, with 

3 respect to a year, and who for the 

4 performance period for such year re5 ports on applicable measures and ac6 tivities described in paragraph (2)(B) 

7 that are required to be reported by 

8 such a professional under the MIPS, 

9 such eligible professional is considered 

10 to be a MIPS eligible professional 

11 with respect to such year. 

12 ‘‘(II) NOT ELIGIBLE FOR QUALI13 FYING APM PARTICIPANT PAY14 MENTS.—In no case shall an eligible 

15 professional who is a partial quali16 fying APM participant, with respect 

17 to a year, be considered a qualifying 

18 APM participant (as defined in para19 graph (2) of section 1833(z)) for such 

20 year or be eligible for the additional 

21 payment under paragraph (1) of such 

22 section for such year. 

23 ‘‘(D) APPLICATION TO GROUP PRAC24 TICES.— 

25 ‘‘(i) IN GENERAL.—Under the MIPS: 


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1 ‘‘(I) QUALITY PERFORMANCE

2 CATEGORY.—The Secretary shall es3 tablish and apply a process that in4 cludes features of the provisions of 

5 subsection (m)(3)(C) for MIPS eligi6 ble professionals in a group practice 

7 with respect to assessing performance 

8 of such group with respect to the per9 formance category described in clause 

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

11 ‘‘(II) OTHER PERFORMANCE CAT12 EGORIES.—The Secretary may estab13 lish and apply a process that includes 

14 features of the provisions of sub15 section (m)(3)(C) for MIPS eligible 

16 professionals in a group practice with 

17 respect to assessing the performance 

18 of such group with respect to the per19 formance categories described in 

20 clauses (ii) through (iv) of such para21 graph. 

22 ‘‘(ii) ENSURING COMPREHENSIVENESS

23 OF GROUP PRACTICE ASSESSMENT.—The 

24 process established under clause (i) shall to 

25 the extent practicable reflect the range of 


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1 items and services furnished by the MIPS 

2 eligible professionals in the group practice 

3 involved. 

4 ‘‘(iii) CLARIFICATION.—MIPS eligible 

5 professionals electing to be a virtual group 

6 under paragraph (5)(I) shall not be consid7 ered MIPS eligible professionals in a group 

8 practice for purposes of applying this sub9 paragraph. 

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

11 MIPS, the Secretary shall encourage the use of 

12 qualified clinical data registries pursuant to 

13 subsection (m)(3)(E) in carrying out this sub14 section. 

15 ‘‘(F) APPLICATION OF CERTAIN PROVI16 SIONS.—In applying a provision of subsection 

17 (k), (m), (o), or (p) for purposes of this sub18 section, the Secretary shall— 

19 ‘‘(i) adjust the application of such 

20 provision to ensure the provision is con21 sistent with the provisions of this sub22 section; and 

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

24 extent that the provision is duplicative with 

25 a provision of this subsection. 


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

2 ‘‘(i) RISK FACTORS.—Taking into ac3 count the relevant studies conducted and 

4 recommendations made in reports under 

5 section 101(f)(1) of the Commonsense 

6 Medicare SGR Repeal and Beneficiary Ac7 cess Improvement Act of 2014, the Sec8 retary, on an ongoing basis, shall estimate 

9 how an individual’s health status and other 

10 risk factors affect quality and resource use 

11 outcome measures and, as feasible, shall 

12 incorporate information from quality and 

13 resource use outcome measurement (in14 cluding care episode and patient condition 

15 groups) into the MIPS. 

16 ‘‘(ii) ACCOUNTING FOR OTHER FAC17 TORS IN PAYMENT ADJUSTMENTS.—Tak18 ing into account the studies conducted and 

19 recommendations made in reports under 

20 section 101(f)(1) of the Commonsense 

21 Medicare SGR Repeal and Beneficiary Ac22 cess Improvement Act of 2014 and other 

23 information as appropriate, the Secretary 

24 shall account for identified factors with an 

25 effect on quality and resource use outcome 


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1 measures when determining payment ad2 justments, composite performance scores, 

3 scores for performance categories, or 

4 scores for measures or activities under the 

5 MIPS. 

6 ‘‘(2) MEASURES AND ACTIVITIES UNDER PER7 FORMANCE CATEGORIES.— 

8 ‘‘(A) PERFORMANCE CATEGORIES.—Under 

9 the MIPS, the Secretary shall use the following 

10 performance categories (each of which is re11 ferred to in this subsection as a performance 

12 category) in determining the composite per13 formance score under paragraph (5): 

14 ‘‘(i) Quality. 

15 ‘‘(ii) Resource use. 

16 ‘‘(iii) Clinical practice improvement 

17 activities. 

18 ‘‘(iv) Meaningful use of certified EHR 

19 technology. 

20 ‘‘(B) MEASURES AND ACTIVITIES SPECI21 FIED FOR EACH CATEGORY.—For purposes of 

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

23 (C), measures and activities specified for a per24 formance period (as established under para25 graph (4)) for a year are as follows: 


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1 ‘‘(i) QUALITY.—For the performance 

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

3 the quality measures included in the final 

4 measures list published under subpara5 graph (D)(i) for such year and the list of 

6 quality measures described in subpara7 graph (D)(vi) used by qualified clinical 

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

9 ‘‘(ii) RESOURCE USE.—For the per10 formance category described in subpara11 graph (A)(ii), the measurement of resource 

12 use for such period under subsection 

13 (p)(3), using the methodology under sub14 section (r) as appropriate, and, as feasible 

15 and applicable, accounting for the cost of 

16 drugs under part D. 

17 ‘‘(iii) CLINICAL PRACTICE IMPROVE18 MENT ACTIVITIES.—For the performance 

19 category described in subparagraph 

20 (A)(iii), clinical practice improvement ac21 tivities (as defined in subparagraph 

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

23 by the Secretary for such period, which 

24 shall include at least the following: 


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1 ‘‘(I) The subcategory of expanded 

2 practice access, which shall include ac3 tivities such as same day appoint4 ments for urgent needs and after 

5 hours access to clinician advice. 

6 ‘‘(II) The subcategory of popu7 lation management, which shall in8 clude activities such as monitoring 

9 health conditions of individuals to pro10 vide timely health care interventions 

11 or participation in a qualified clinical 

12 data registry. 

13 ‘‘(III) The subcategory of care 

14 coordination, which shall include ac15 tivities such as timely communication 

16 of test results, timely exchange of 

17 clinical information to patients and 

18 other providers, and use of remote 

19 monitoring or telehealth. 

20 ‘‘(IV) The subcategory of bene21 ficiary engagement, which shall in22 clude activities such as the establish23 ment of care plans for individuals 

24 with complex care needs, beneficiary 

25 self-management assessment and 


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1 training, and using shared decision2 making mechanisms. 

3 ‘‘(V) The subcategory of patient 

4 safety and practice assessment, such 

5 as through use of clinical or surgical 

6 checklists and practice assessments 

7 related to maintaining certification. 

8 ‘‘(VI) The subcategory of partici9 pation in an alternative payment 

10 model (as defined in section 

11 1833(z)(3)(C)). 

12 In establishing activities under this clause, 

13 the Secretary shall give consideration to 

14 the circumstances of small practices (con15 sisting of 15 or fewer professionals) and 

16 practices located in rural areas and in 

17 health professional shortage areas (as des18 ignated under section 332(a)(1)(A) of the 

19 Public Health Service Act). 

20 ‘‘(iv) MEANINGFUL EHR USE.—For 

21 the performance category described in sub22 paragraph (A)(iv), the requirements estab23 lished for such period under subsection 

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

25 professional is a meaningful EHR user. 


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1 ‘‘(C) ADDITIONAL PROVISIONS.— 

2 ‘‘(i) EMPHASIZING OUTCOME MEAS3 URES UNDER THE QUALITY PERFORMANCE

4 CATEGORY.—In applying subparagraph 

5 (B)(i), the Secretary shall, as feasible, em6 phasize the application of outcome meas7 ures. 

8 ‘‘(ii) APPLICATION OF ADDITIONAL

9 SYSTEM MEASURES.—The Secretary may 

10 use measures used for a payment system 

11 other than for physicians, such as meas12 ures for inpatient hospitals, for purposes of 

13 the performance categories described in 

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

15 For purposes of the previous sentence, the 

16 Secretary may not use measures for hos17 pital outpatient departments, except in the 

18 case of emergency physicians. 

19 ‘‘(iii) GLOBAL AND POPULATION20 BASED MEASURES.—The Secretary may 

21 use global measures, such as global out22 come measures, and population-based 

23 measures for purposes of the performance 

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


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1 ‘‘(iv) APPLICATION OF MEASURES AND

2 ACTIVITIES TO NON-PATIENT-FACING PRO3 FESSIONALS.—In carrying out this para4 graph, with respect to measures and activi5 ties specified in subparagraph (B) for per6 formance categories described in subpara7 graph (A), the Secretary— 

8 ‘‘(I) shall give consideration to 

9 the circumstances of professional 

10 types (or subcategories of those types 

11 determined by practice characteris12 tics) who typically furnish services 

13 that do not involve face-to-face inter14 action with a patient; and 

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

16 and appropriate, take into account 

17 such circumstances and apply under 

18 this subsection with respect to MIPS 

19 eligible professionals of such profes20 sional types or subcategories, alter21 native measures or activities that ful22 fill the goals of the applicable per23 formance category. 


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1 In carrying out the previous sentence, the 

2 Secretary shall consult with professionals 

3 of such professional types or subcategories. 

4 ‘‘(v) CLINICAL PRACTICE IMPROVE5 MENT ACTIVITIES.— 

6 ‘‘(I) REQUEST FOR INFORMA7 TION.—In initially applying subpara8 graph (B)(iii), the Secretary shall use 

9 a request for information to solicit 

10 recommendations from stakeholders to 

11 identify activities described in such 

12 subparagraph and specifying criteria 

13 for such activities. 

14 ‘‘(II) CONTRACT AUTHORITY FOR

15 CLINICAL PRACTICE IMPROVEMENT

16 ACTIVITIES PERFORMANCE CAT17 EGORY.—In applying subparagraph 

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

19 with entities to assist the Secretary 

20 in— 

21 ‘‘(aa) identifying activities 

22 described in subparagraph 

23 (B)(iii); 

24 ‘‘(bb) specifying criteria for 

25 such activities; and 


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1 ‘‘(cc) determining whether a 

2 MIPS eligible professional meets 

3 such criteria. 

4 ‘‘(III) CLINICAL PRACTICE IM5 PROVEMENT ACTIVITIES DEFINED.— 

6 For purposes of this subsection, the 

7 term ‘clinical practice improvement 

8 activity’ means an activity that rel9 evant eligible professional organiza10 tions and other relevant stakeholders 

11 identify as improving clinical practice 

12 or care delivery and that the Sec13 retary determines, when effectively ex14 ecuted, is likely to result in improved 

15 outcomes. 

16 ‘‘(D) ANNUAL LIST OF QUALITY MEASURES

17 AVAILABLE FOR MIPS ASSESSMENT.— 

18 ‘‘(i) IN GENERAL.—Under the MIPS, 

19 the Secretary, through notice and comment 

20 rulemaking and subject to the succeeding 

21 clauses of this subparagraph, shall, with 

22 respect to the performance period for a 

23 year, establish an annual final list of qual24 ity measures from which MIPS eligible 

25 professionals may choose for purposes of 


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1 assessment under this subsection for such 

2 performance period. Pursuant to the pre3 vious sentence, the Secretary shall— 

4 ‘‘(I) not later than November 1 

5 of the year prior to the first day of 

6 the first performance period under the 

7 MIPS, establish and publish in the 

8 Federal Register a final list of quality 

9 measures; and 

10 ‘‘(II) not later than November 1 

11 of the year prior to the first day of 

12 each subsequent performance period, 

13 update the final list of quality meas14 ures from the previous year (and pub15 lish such updated final list in the Fed16 eral Register), by— 

17 ‘‘(aa) removing from such 

18 list, as appropriate, quality meas19 ures, which may include the re20 moval of measures that are no 

21 longer meaningful (such as meas22 ures that are topped out); 

23 ‘‘(bb) adding to such list, as 

24 appropriate, new quality meas25 ures; and 


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1 ‘‘(cc) determining whether 

2 or not quality measures on such 

3 list that have undergone sub4 stantive changes should be in5 cluded in the updated list. 

6 ‘‘(ii) CALL FOR QUALITY MEAS7 URES.— 

8 ‘‘(I) IN GENERAL.—Eligible pro9 fessional organizations and other rel10 evant stakeholders shall be requested 

11 to identify and submit quality meas12 ures to be considered for selection 

13 under this subparagraph in the an14 nual list of quality measures published 

15 under clause (i) and to identify and 

16 submit updates to the measures on 

17 such list. For purposes of the previous 

18 sentence, measures may be submitted 

19 regardless of whether such measures 

20 were previously published in a pro21 posed rule or endorsed by an entity 

22 with a contract under section 1890(a). 

23 ‘‘(II) ELIGIBLE PROFESSIONAL

24 ORGANIZATION DEFINED.—In this 

25 subparagraph, the term ‘eligible proVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00033 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 fessional organization’ means a pro2 fessional organization as defined by 

3 nationally recognized multispecialty 

4 boards of certification or equivalent 

5 certification boards. 

6 ‘‘(iii) REQUIREMENTS.—In selecting 

7 quality measures for inclusion in the an8 nual final list under clause (i), the Sec9 retary shall— 

10 ‘‘(I) provide that, to the extent 

11 practicable, all quality domains (as 

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

13 addressed by such measures; and 

14 ‘‘(II) ensure that such selection 

15 is consistent with the process for se16 lection of measures under subsections 

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

18 ‘‘(iv) PEER REVIEW.—Before includ19 ing a new measure or a measure described 

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

21 measures published under clause (i) for a 

22 year, the Secretary shall submit for publi23 cation in applicable specialty-appropriate 

24 peer-reviewed journals such measure and 

25 the method for developing and selecting 


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1 such measure, including clinical and other 

2 data supporting such measure. 

3 ‘‘(v) MEASURES FOR INCLUSION.— 

4 The final list of quality measures published 

5 under clause (i) shall include, as applica6 ble, measures under subsections (k), (m), 

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

8 from among— 

9 ‘‘(I) measures endorsed by a con10 sensus-based entity; 

11 ‘‘(II) measures developed under 

12 subsection (s); and 

13 ‘‘(III) measures submitted under 

14 clause (ii)(I). 

15 Any measure selected for inclusion in such 

16 list that is not endorsed by a consensus17 based entity shall have a focus that is evi18 dence-based. 

19 ‘‘(vi) EXCEPTION FOR QUALIFIED

20 CLINICAL DATA REGISTRY MEASURES.— 

21 Measures used by a qualified clinical data 

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

23 not be subject to the requirements under 

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

25 shall publish the list of measures used by 


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1 such qualified clinical data registries on 

2 the Internet website of the Centers for 

3 Medicare & Medicaid Services. 

4 ‘‘(vii) EXCEPTION FOR EXISTING

5 QUALITY MEASURES.—Any quality meas6 ure specified by the Secretary under sub7 section (k) or (m), including under sub8 section (m)(3)(E), and any measure of 

9 quality of care established under sub10 section (p)(2) for the reporting period 

11 under the respective subsection beginning 

12 before the first performance period under 

13 the MIPS— 

14 ‘‘(I) shall not be subject to the 

15 requirements under clause (i) (except 

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

17 (II) of such clause) or to the require18 ment under clause (iv); and 

19 ‘‘(II) shall be included in the 

20 final list of quality measures pub21 lished under clause (i) unless removed 

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

23 ‘‘(viii) CONSULTATION WITH REL24 EVANT ELIGIBLE PROFESSIONAL ORGANI25 ZATIONS AND OTHER RELEVANT STAKEVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00036 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 HOLDERS.—Relevant eligible professional 

2 organizations and other relevant stake3 holders, including State and national med4 ical societies, shall be consulted in carrying 

5 out this subparagraph. 

6 ‘‘(ix) OPTIONAL APPLICATION.—The 

7 process under section 1890A is not re8 quired to apply to the selection of meas9 ures under this subparagraph. 

10 ‘‘(3) PERFORMANCE STANDARDS.— 

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

12 the Secretary shall establish performance stand13 ards with respect to measures and activities 

14 specified under paragraph (2)(B) for a perform15 ance period (as established under paragraph 

16 (4)) for a year. 

17 ‘‘(B) CONSIDERATIONS IN ESTABLISHING

18 STANDARDS.—In establishing such performance 

19 standards with respect to measures and activi20 ties specified under paragraph (2)(B), the Sec21 retary shall consider the following: 

22 ‘‘(i) Historical performance standards. 

23 ‘‘(ii) Improvement. 

24 ‘‘(iii) The opportunity for continued 

25 improvement. 


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

2 shall establish a performance period (or periods) for 

3 a year (beginning with the year described in para4 graph (1)(B)). Such performance period (or periods) 

5 shall begin and end prior to the beginning of such 

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

7 subsection, such performance period (or periods) for 

8 a year shall be referred to as the performance period 

9 for the year. 

10 ‘‘(5) COMPOSITE PERFORMANCE SCORE.— 

11 ‘‘(A) IN GENERAL.—Subject to the suc12 ceeding provisions of this paragraph and taking 

13 into account, as available and applicable, para14 graph (1)(G), the Secretary shall develop a 

15 methodology for assessing the total performance 

16 of each MIPS eligible professional according to 

17 performance standards under paragraph (3) 

18 with respect to applicable measures and activi19 ties specified in paragraph (2)(B) with respect 

20 to each performance category applicable to such 

21 professional for a performance period (as estab22 lished under paragraph (4)) for a year. Using 

23 such methodology, the Secretary shall provide 

24 for a composite assessment (using a scoring 

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


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1 the performance period for such year. In this 

2 subsection such a composite assessment for 

3 such a professional with respect to a perform4 ance period shall be referred to as the ‘com5 posite performance score’ for such professional 

6 for such performance period. 

7 ‘‘(B) INCENTIVE TO REPORT; ENCOUR8 AGING USE OF CERTIFIED EHR TECHNOLOGY

9 FOR REPORTING QUALITY MEASURES.— 

10 ‘‘(i) INCENTIVE TO REPORT.—Under 

11 the methodology established under sub12 paragraph (A), the Secretary shall provide 

13 that in the case of a MIPS eligible profes14 sional who fails to report on an applicable 

15 measure or activity that is required to be 

16 reported by the professional, the profes17 sional shall be treated as achieving the 

18 lowest potential score applicable to such 

19 measure or activity. 

20 ‘‘(ii) ENCOURAGING USE OF CER21 TIFIED EHR TECHNOLOGY AND QUALIFIED

22 CLINICAL DATA REGISTRIES FOR REPORT23 ING QUALITY MEASURES.—Under the 

24 methodology established under subpara25 graph (A), the Secretary shall— 


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1 ‘‘(I) encourage MIPS eligible 

2 professionals to report on applicable 

3 measures with respect to the perform4 ance category described in paragraph 

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

6 EHR technology and qualified clinical 

7 data registries; and 

8 ‘‘(II) with respect to a perform9 ance period, with respect to a year, 

10 for which a MIPS eligible professional 

11 reports such measures through the 

12 use of such EHR technology, treat 

13 such professional as satisfying the 

14 clinical quality measures reporting re15 quirement described in subsection 

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

17 ‘‘(C) CLINICAL PRACTICE IMPROVEMENT

18 ACTIVITIES PERFORMANCE SCORE.— 

19 ‘‘(i) RULE FOR ACCREDITATION.—A 

20 MIPS eligible professional who is in a 

21 practice that is certified as a patient-cen22 tered medical home or comparable spe23 cialty practice pursuant to subsection 

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

25 period shall be given the highest potential 


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1 score for the performance category de2 scribed in paragraph (2)(A)(iii) for such 

3 period. 

4 ‘‘(ii) APM PARTICIPATION.—Partici5 pation by a MIPS eligible professional in 

6 an alternative payment model (as defined 

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

8 performance period shall earn such eligible 

9 professional a minimum score of one-half 

10 of the highest potential score for the per11 formance category described in paragraph 

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

13 ‘‘(iii) SUBCATEGORIES.—A MIPS eli14 gible professional shall not be required to 

15 perform activities in each subcategory 

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

17 in an alternative payment model in order 

18 to achieve the highest potential score for 

19 the performance category described in 

20 paragraph (2)(A)(iii). 

21 ‘‘(D) ACHIEVEMENT AND IMPROVE22 MENT.— 

23 ‘‘(i) TAKING INTO ACCOUNT IMPROVE24 MENT.—Beginning with the second year to 

25 which the MIPS applies, in addition to the 


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1 achievement of a MIPS eligible profes2 sional, if data sufficient to measure im3 provement is available, the methodology 

4 developed under subparagraph (A)— 

5 ‘‘(I) in the case of the perform6 ance score for the performance cat7 egory described in clauses (i) and (ii) 

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

9 account the improvement of the pro10 fessional; and 

11 ‘‘(II) in the case of performance 

12 scores for other performance cat13 egories, may take into account the im14 provement of the professional. 

15 ‘‘(ii) ASSIGNING HIGHER WEIGHT FOR

16 ACHIEVEMENT.—Beginning with the 

17 fourth year to which the MIPS applies, 

18 under the methodology developed under 

19 subparagraph (A), the Secretary may as20 sign a higher scoring weight under sub21 paragraph (F) with respect to the achieve22 ment of a MIPS eligible professional than 

23 with respect to any improvement of such 

24 professional applied under clause (i) with 


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1 respect to a measure, activity, or category 

2 described in paragraph (2). 

3 ‘‘(E) WEIGHTS FOR THE PERFORMANCE

4 CATEGORIES.— 

5 ‘‘(i) IN GENERAL.—Under the meth6 odology developed under subparagraph (A), 

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

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

9 score shall be determined as follows: 

10 ‘‘(I) QUALITY.— 

11 ‘‘(aa) IN GENERAL.—Sub12 ject to item (bb), thirty percent 

13 of such score shall be based on 

14 performance with respect to the 

15 category described in clause (i) of 

16 paragraph (2)(A). In applying 

17 the previous sentence, the Sec18 retary shall, as feasible, encour19 age the application of outcome 

20 measures within such category. 

21 ‘‘(bb) FIRST 2 YEARS.—For 

22 the first and second years for 

23 which the MIPS applies to pay24 ments, the percentage applicable 

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1 creased in a manner such that 

2 the total percentage points of the 

3 increase under this item for the 

4 respective year equals the total 

5 number of percentage points by 

6 which the percentage applied 

7 under subclause (II)(bb) for the 

8 respective year is less than 30 

9 percent. 

10 ‘‘(II) RESOURCE USE.— 

11 ‘‘(aa) IN GENERAL.—Sub12 ject to item (bb), thirty percent 

13 of such score shall be based on 

14 performance with respect to the 

15 category described in clause (ii) 

16 of paragraph (2)(A). 

17 ‘‘(bb) FIRST 2 YEARS.—For 

18 the first year for which the MIPS 

19 applies to payments, not more 

20 than 10 percent of such score 

21 shall be based on performance 

22 with respect to the category de23 scribed in clause (ii) of para24 graph (2)(A). For the second 

25 year for which the MIPS applies 


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1 to payments, not more than 15 

2 percent of such score shall be 

3 based on performance with re4 spect to the category described in 

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

6 ‘‘(III) CLINICAL PRACTICE IM7 PROVEMENT ACTIVITIES.—Fifteen 

8 percent of such score shall be based 

9 on performance with respect to the 

10 category described in clause (iii) of 

11 paragraph (2)(A). 

12 ‘‘(IV) MEANINGFUL USE OF CER13 TIFIED EHR TECHNOLOGY.—Twenty14 five percent of such score shall be 

15 based on performance with respect to 

16 the category described in clause (iv) of 

17 paragraph (2)(A). 

18 ‘‘(ii) AUTHORITY TO ADJUST PER19 CENTAGES IN CASE OF HIGH EHR MEAN20 INGFUL USE ADOPTION.—In any year in 

21 which the Secretary estimates that the pro22 portion of eligible professionals (as defined 

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

24 EHR users (as determined under sub25 section (o)(2)) is 75 percent or greater, the 


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1 Secretary may reduce the percent applica2 ble under clause (i)(IV), but not below 15 

3 percent. If the Secretary makes such re4 duction for a year, subject to subclauses 

5 (I)(bb) and (II)(bb) of clause (i), the per6 centages applicable under one or more of 

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

8 for such year shall be increased in a man9 ner such that the total percentage points 

10 of the increase under this clause for such 

11 year equals the total number of percentage 

12 points reduced under the preceding sen13 tence for such year. 

14 ‘‘(F) CERTAIN FLEXIBILITY FOR

15 WEIGHTING PERFORMANCE CATEGORIES, MEAS16 URES, AND ACTIVITIES.—Under the method17 ology under subparagraph (A), if there are not 

18 sufficient measures and clinical practice im19 provement activities applicable and available to 

20 each type of eligible professional involved, the 

21 Secretary shall assign different scoring weights 

22 (including a weight of 0)— 

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

24 weights specified in subparagraph (E), for 

25 each performance category based on the 


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1 extent to which the category is applicable 

2 to the type of eligible professional involved; 

3 and 

4 ‘‘(ii) for each measure and activity 

5 specified under paragraph (2)(B) with re6 spect to each such category based on the 

7 extent to which the measure or activity is 

8 applicable and available to the type of eli9 gible professional involved. 

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

11 performance category described in paragraph 

12 (2)(A)(ii) shall include results from the method13 ology described in subsection (r)(5), as appro14 priate. 

15 ‘‘(H) INCLUSION OF QUALITY MEASURE

16 DATA FROM OTHER PAYERS.—In applying sub17 sections (k), (m), and (p) with respect to meas18 ures described in paragraph (2)(B)(i), analysis 

19 of the performance category described in para20 graph (2)(A)(i) may include data submitted by 

21 MIPS eligible professionals with respect to 

22 items and services furnished to individuals who 

23 are not individuals entitled to benefits under 

24 part A or enrolled under part B. 


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1 ‘‘(I) USE OF VOLUNTARY VIRTUAL GROUPS

2 FOR CERTAIN ASSESSMENT PURPOSES.— 

3 ‘‘(i) IN GENERAL.—In the case of 

4 MIPS eligible professionals electing to be a 

5 virtual group under clause (ii) with respect 

6 to a performance period for a year, for 

7 purposes of applying the methodology 

8 under subparagraph (A)— 

9 ‘‘(I) the assessment of perform10 ance provided under such methodology 

11 with respect to the performance cat12 egories described in clauses (i) and 

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

14 applied to each such professional in 

15 such group for such performance pe16 riod shall be with respect to the com17 bined performance of all such profes18 sionals in such group for such period; 

19 and 

20 ‘‘(II) the composite score pro21 vided under this paragraph for such 

22 performance period with respect to 

23 each such performance category for 

24 each such MIPS eligible professional 

25 in such virtual group shall be based 


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1 on the assessment of the combined 

2 performance under subclause (I) for 

3 the performance category and per4 formance period. 

5 ‘‘(ii) ELECTION OF PRACTICES TO BE

6 A VIRTUAL GROUP.—The Secretary shall, 

7 in accordance with clause (iii), establish 

8 and have in place a process to allow an in9 dividual MIPS eligible professional or a 

10 group practice consisting of not more than 

11 10 MIPS eligible professionals to elect, 

12 with respect to a performance period for a 

13 year, for such individual MIPS eligible pro14 fessional or all such MIPS eligible profes15 sionals in such group practice, respectively, 

16 to be a virtual group under this subpara17 graph with at least one other such indi18 vidual MIPS eligible professional or group 

19 practice making such an election. Such a 

20 virtual group may be based on geographic 

21 areas or on provider specialties defined by 

22 nationally recognized multispecialty boards 

23 of certification or equivalent certification 

24 boards and such other eligible professional 

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1 tions of providers across eligible profes2 sional organizations and other practice 

3 areas or categories. 

4 ‘‘(iii) REQUIREMENTS.—The process 

5 under clause (ii)— 

6 ‘‘(I) shall provide that an election 

7 under such clause, with respect to a 

8 performance period, shall be made be9 fore or during the beginning of such 

10 performance period and may not be 

11 changed during such performance pe12 riod; 

13 ‘‘(II) shall provide that a practice 

14 described in such clause, and each 

15 MIPS eligible professional in such 

16 practice, may elect to be in no more 

17 than one virtual group for a perform18 ance period; and 

19 ‘‘(III) may provide that a virtual 

20 group may be combined at the tax 

21 identification number level. 

22 ‘‘(6) MIPS PAYMENTS.— 

23 ‘‘(A) MIPS ADJUSTMENT FACTOR.—Tak24 ing into account paragraph (1)(G), the Sec25 retary shall specify a MIPS adjustment factor 


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1 for each MIPS eligible professional for a year. 

2 Such MIPS adjustment factor for a MIPS eligi3 ble professional for a year shall be in the form 

4 of a percent and shall be determined— 

5 ‘‘(i) by comparing the composite per6 formance score of the eligible professional 

7 for such year to the performance threshold 

8 established under subparagraph (D)(i) for 

9 such year; 

10 ‘‘(ii) in a manner such that the ad11 justment factors specified under this sub12 paragraph for a year result in differential 

13 payments under this paragraph reflecting 

14 that— 

15 ‘‘(I) MIPS eligible professionals 

16 with composite performance scores for 

17 such year at or above such perform18 ance threshold for such year receive 

19 zero or positive incentive payment ad20 justment factors for such year in ac21 cordance with clause (iii), with such 

22 professionals having higher composite 

23 performance scores receiving higher 

24 adjustment factors; and 


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1 ‘‘(II) MIPS eligible professionals 

2 with composite performance scores for 

3 such year below such performance 

4 threshold for such year receive nega5 tive payment adjustment factors for 

6 such year in accordance with clause 

7 (iv), with such professionals having 

8 lower composite performance scores 

9 receiving lower adjustment factors; 

10 ‘‘(iii) in a manner such that MIPS eli11 gible professionals with composite scores 

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

13 subject to clauses (i) and (ii) of subpara14 graph (F), receive a zero or positive ad15 justment factor on a linear sliding scale 

16 such that an adjustment factor of 0 per17 cent is assigned for a score at the perform18 ance threshold and an adjustment factor of 

19 the applicable percent specified in subpara20 graph (B) is assigned for a score of 100; 

21 and 

22 ‘‘(iv) in a manner such that— 

23 ‘‘(I) subject to subclause (II), 

24 MIPS eligible professionals with com25 posite performance scores described in 


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

2 negative payment adjustment factor 

3 on a linear sliding scale such that an 

4 adjustment factor of 0 percent is as5 signed for a score at the performance 

6 threshold and an adjustment factor of 

7 the negative of the applicable percent 

8 specified in subparagraph (B) is as9 signed for a score of 0; and 

10 ‘‘(II) MIPS eligible professionals 

11 with composite performance scores 

12 that are equal to or greater than 0, 

but not greater than 1 13 ⁄4 of the per14 formance threshold specified under 

15 subparagraph (D)(i) for such year, re16 ceive a negative payment adjustment 

17 factor that is equal to the negative of 

18 the applicable percent specified in 

19 subparagraph (B) for such year. 

20 ‘‘(B) APPLICABLE PERCENT DEFINED.— 

21 For purposes of this paragraph, the term ‘ap22 plicable percent’ means— 

23 ‘‘(i) for 2018, 4 percent; 

24 ‘‘(ii) for 2019, 5 percent; 

25 ‘‘(iii) for 2020, 7 percent; and 


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

2 9 percent. 

3 ‘‘(C) ADDITIONAL MIPS ADJUSTMENT FAC4 TORS FOR EXCEPTIONAL PERFORMANCE.— 

5 ‘‘(i) IN GENERAL.—In the case of a 

6 MIPS eligible professional with a com7 posite performance score for a year at or 

8 above the additional performance threshold 

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

10 in addition to the MIPS adjustment factor 

11 under subparagraph (A) for the eligible 

12 professional for such year, subject to the 

13 availability of funds under clause (ii), the 

14 Secretary shall specify an additional posi15 tive MIPS adjustment factor for such pro16 fessional and year. Such additional MIPS 

17 adjustment factors shall be determined by 

18 the Secretary in a manner such that pro19 fessionals having higher composite per20 formance scores above the additional per21 formance threshold receive higher addi22 tional MIPS adjustment factors. 

23 ‘‘(ii) ADDITIONAL FUNDING POOL.— 

24 For 2018 and each subsequent year 

25 through 2023, there is appropriated from 


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1 the Federal Supplementary Medical Insur2 ance Trust Fund $500,000,000 for MIPS 

3 payments under this paragraph resulting 

4 from the application of the additional 

5 MIPS adjustment factors under clause (i). 

6 ‘‘(D) ESTABLISHMENT OF PERFORMANCE

7 THRESHOLDS.— 

8 ‘‘(i) PERFORMANCE THRESHOLD.— 

9 For each year of the MIPS, the Secretary 

10 shall compute a performance threshold 

11 with respect to which the composite per12 formance score of MIPS eligible profes13 sionals shall be compared for purposes of 

14 determining adjustment factors under sub15 paragraph (A) that are positive, negative, 

16 and zero. Such performance threshold for 

17 a year shall be the mean or median (as se18 lected by the Secretary) of the composite 

19 performance scores for all MIPS eligible 

20 professionals with respect to a prior period 

21 specified by the Secretary. The Secretary 

22 may reassess the selection under the pre23 vious sentence every 3 years. 

24 ‘‘(ii) ADDITIONAL PERFORMANCE

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1 ANCE.—In addition to the performance 

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

3 the MIPS, the Secretary shall compute an 

4 additional performance threshold for pur5 poses of determining the additional MIPS 

6 adjustment factors under subparagraph 

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

8 shall apply either of the following methods 

9 for computing such additional performance 

10 threshold for such a year: 

11 ‘‘(I) The threshold shall be the 

12 score that is equal to the 25th per13 centile of the range of possible com14 posite performance scores above the 

15 performance threshold with respect to 

16 the prior period described in clause 

17 (i). 

18 ‘‘(II) The threshold shall be the 

19 score that is equal to the 25th per20 centile of the actual composite per21 formance scores for MIPS eligible 

22 professionals with composite perform23 ance scores at or above the perform24 ance threshold with respect to the 

25 prior period described in clause (i). 


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1 ‘‘(iii) SPECIAL RULE FOR INITIAL 2

2 YEARS.—With respect to each of the first 

3 two years to which the MIPS applies, the 

4 Secretary shall, prior to the performance 

5 period for such years, establish a perform6 ance threshold for purposes of determining 

7 MIPS adjustment factors under subpara8 graph (A) and a threshold for purposes of 

9 determining additional MIPS adjustment 

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

11 such performance threshold shall— 

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

13 such performance periods; and 

14 ‘‘(II) take into account— 

15 ‘‘(aa) data available with re16 spect to performance on meas17 ures and activities that may be 

18 used under the performance cat19 egories under subparagraph 

20 (2)(B); and 

21 ‘‘(bb) other factors deter22 mined appropriate by the Sec23 retary. 

24 ‘‘(E) APPLICATION OF MIPS ADJUSTMENT

25 FACTORS.—In the case of items and services 


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1 furnished by a MIPS eligible professional dur2 ing a year (beginning with 2018), the amount 

3 otherwise paid under this part with respect to 

4 such items and services and MIPS eligible pro5 fessional for such year, shall be multiplied by— 

6 ‘‘(i) 1, plus 

7 ‘‘(ii) the sum of— 

8 ‘‘(I) the MIPS adjustment factor 

9 determined under subparagraph (A) 

10 divided by 100, and 

11 ‘‘(II) as applicable, the additional 

12 MIPS adjustment factor determined 

13 under subparagraph (C)(i) divided by 

14 100. 

15 ‘‘(F) AGGREGATE APPLICATION OF MIPS

16 ADJUSTMENT FACTORS.— 

17 ‘‘(i) APPLICATION OF SCALING FAC18 TOR.— 

19 ‘‘(I) IN GENERAL.—With respect 

20 to positive MIPS adjustment factors 

21 under subparagraph (A)(ii)(I) for eli22 gible professionals whose composite 

23 performance score is above the per24 formance threshold under subpara25 graph (D)(i) for such year, subject to 


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1 subclause (II), the Secretary shall in2 crease or decrease such adjustment 

3 factors by a scaling factor in order to 

4 ensure that the budget neutrality re5 quirement of clause (ii) is met. 

6 ‘‘(II) SCALING FACTOR LIMIT.— 

7 In no case may be the scaling factor 

8 applied under this clause exceed 3.0. 

9 ‘‘(ii) BUDGET NEUTRALITY REQUIRE10 MENT.— 

11 ‘‘(I) IN GENERAL.—Subject to 

12 clause (iii), the Secretary shall ensure 

13 that the estimated amount described 

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

15 the estimated amount described in 

16 subclause (III) for such year. 

17 ‘‘(II) AGGREGATE INCREASES.— 

18 The amount described in this sub19 clause is the estimated increase in the 

20 aggregate allowed charges resulting 

21 from the application of positive MIPS 

22 adjustment factors under subpara23 graph (A) (after application of the 

24 scaling factor described in clause (i)) 

25 to MIPS eligible professionals whose 


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1 composite performance score for a 

2 year is above the performance thresh3 old under subparagraph (D)(i) for 

4 such year. 

5 ‘‘(III) AGGREGATE DE6 CREASES.—The amount described in 

7 this subclause is the estimated de8 crease in the aggregate allowed 

9 charges resulting from the application 

10 of negative MIPS adjustment factors 

11 under subparagraph (A) to MIPS eli12 gible professionals whose composite 

13 performance score for a year is below 

14 the performance threshold under sub15 paragraph (D)(i) for such year. 

16 ‘‘(iii) EXCEPTIONS.— 

17 ‘‘(I) In the case that all MIPS el18 igible professionals receive composite 

19 performance scores for a year that are 

20 below the performance threshold 

21 under subparagraph (D)(i) for such 

22 year, the negative MIPS adjustment 

23 factors under subparagraph (A) shall 

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1 trality requirement of clause (ii) shall 

2 not apply for such year. 

3 ‘‘(II) In the case that, with re4 spect to a year, the application of 

5 clause (i) results in a scaling factor 

6 equal to the maximum scaling factor 

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

8 factor shall apply and the budget neu9 trality requirement of clause (ii) shall 

10 not apply for such year. 

11 ‘‘(iv) ADDITIONAL INCENTIVE PAY12 MENT ADJUSTMENTS.—In specifying the 

13 MIPS additional adjustment factors under 

14 subparagraph (C)(i) for each applicable 

15 MIPS eligible professional for a year, the 

16 Secretary shall ensure that the estimated 

17 increase in payments under this part re18 sulting from the application of such addi19 tional adjustment factors for MIPS eligible 

20 professionals in a year shall be equal (as 

21 estimated by the Secretary) to the addi22 tional funding pool amount for such year 

23 under subparagraph (C)(ii). 

24 ‘‘(7) ANNOUNCEMENT OF RESULT OF ADJUST25 MENTS.—Under the MIPS, the Secretary shall, not 


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

2 involved, make available to MIPS eligible profes3 sionals the MIPS adjustment factor (and, as appli4 cable, the additional MIPS adjustment factor) under 

5 paragraph (6) applicable to the eligible professional 

6 for items and services furnished by the professional 

7 for such year. The Secretary may include such infor8 mation in the confidential feedback under paragraph 

9 (12). 

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

11 MIPS adjustment factors and additional MIPS ad12 justment factors under paragraph (6) shall apply 

13 only with respect to the year involved, and the Sec14 retary shall not take into account such adjustment 

15 factors in making payments to a MIPS eligible pro16 fessional under this part in a subsequent year. 

17 ‘‘(9) PUBLIC REPORTING.— 

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

19 in an easily understandable format, make avail20 able on the Physician Compare Internet website 

21 of the Centers for Medicare & Medicaid Serv22 ices the following: 

23 ‘‘(i) Information regarding the per24 formance of MIPS eligible professionals 

25 under the MIPS, which— 


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1 ‘‘(I) shall include the composite 

2 score for each such MIPS eligible pro3 fessional and the performance of each 

4 such MIPS eligible professional with 

5 respect to each performance category; 

6 and 

7 ‘‘(II) may include the perform8 ance of each such MIPS eligible pro9 fessional with respect to each measure 

10 or activity specified in paragraph 

11 (2)(B). 

12 ‘‘(ii) The names of eligible profes13 sionals in eligible alternative payment mod14 els (as defined in section 1833(z)(3)(D)) 

15 and, to the extent feasible, the names of 

16 such eligible alternative payment models 

17 and performance of such models. 

18 ‘‘(B) DISCLOSURE.—The information 

19 made available under this paragraph shall indi20 cate, where appropriate, that publicized infor21 mation may not be representative of the eligible 

22 professional’s entire patient population, the va23 riety of services furnished by the eligible profes24 sional, or the health conditions of individuals 

25 treated. 


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1 ‘‘(C) OPPORTUNITY TO REVIEW AND SUB2 MIT CORRECTIONS.—The Secretary shall pro3 vide for an opportunity for a professional de4 scribed in subparagraph (A) to review, and sub5 mit corrections for, the information to be made 

6 public with respect to the professional under 

7 such subparagraph prior to such information 

8 being made public. 

9 ‘‘(D) AGGREGATE INFORMATION.—The 

10 Secretary shall periodically post on the Physi11 cian Compare Internet website aggregate infor12 mation on the MIPS, including the range of 

13 composite scores for all MIPS eligible profes14 sionals and the range of the performance of all 

15 MIPS eligible professionals with respect to each 

16 performance category. 

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

18 consult with stakeholders in carrying out the MIPS, 

19 including for the identification of measures and ac20 tivities under paragraph (2)(B) and the methodolo21 gies developed under paragraphs (5)(A) and (6) and 

22 regarding the use of qualified clinical data registries. 

23 Such consultation shall include the use of a request 

24 for information or other mechanisms determined ap25 propriate. 


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1 ‘‘(11) TECHNICAL ASSISTANCE TO SMALL PRAC2 TICES AND PRACTICES IN HEALTH PROFESSIONAL

3 SHORTAGE AREAS.— 

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

5 enter into contracts or agreements with appro6 priate entities (such as quality improvement or7 ganizations, regional extension centers (as de8 scribed in section 3012(c) of the Public Health 

9 Service Act), or regional health collaboratives) 

10 to offer guidance and assistance to MIPS eligi11 ble professionals in practices of 15 or fewer pro12 fessionals (with priority given to such practices 

13 located in rural areas, health professional short14 age areas (as designated under in section 

15 332(a)(1)(A) of such Act), and medically under16 served areas, and practices with low composite 

17 scores) with respect to— 

18 ‘‘(i) the performance categories de19 scribed in clauses (i) through (iv) of para20 graph (2)(A); or 

21 ‘‘(ii) how to transition to the imple22 mentation of and participation in an alter23 native payment model as described in sec24 tion 1833(z)(3)(C). 

25 ‘‘(B) FUNDING FOR IMPLEMENTATION.— 


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1 ‘‘(i) IN GENERAL.—For purposes of 

2 implementing subparagraph (A), the Sec3 retary shall provide for the transfer from 

4 the Federal Supplementary Medical Insur5 ance Trust Fund established under section 

6 1841 to the Centers for Medicare & Med7 icaid Services Program Management Ac8 count of $40,000,000 for each of fiscal 

9 years 2015 through 2019. Amounts trans10 ferred under this subparagraph for a fiscal 

11 year shall be available until expended. 

12 ‘‘(ii) TECHNICAL ASSISTANCE.—Of 

13 the amounts transferred pursuant to clause 

14 (i) for each of fiscal years 2015 through 

15 2019, not less than $10,000,000 shall be 

16 made available for each such year for tech17 nical assistance to small practices in health 

18 professional shortage areas (as so des19 ignated) and medically underserved areas. 

20 ‘‘(12) FEEDBACK AND INFORMATION TO IM21 PROVE PERFORMANCE.— 

22 ‘‘(A) PERFORMANCE FEEDBACK.— 

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

24 2016, the Secretary— 


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1 ‘‘(I) shall make available timely 

2 (such as quarterly) confidential feed3 back to MIPS eligible professionals on 

4 the performance of such professionals 

5 with respect to the performance cat6 egories under clauses (i) and (ii) of 

7 paragraph (2)(A); and 

8 ‘‘(II) may make available con9 fidential feedback to each such profes10 sional on the performance of such 

11 professional with respect to the per12 formance categories under clauses (iii) 

13 and (iv) of such paragraph. 

14 ‘‘(ii) MECHANISMS.—The Secretary 

15 may use one or more mechanisms to make 

16 feedback available under clause (i), which 

17 may include use of a web-based portal or 

18 other mechanisms determined appropriate 

19 by the Secretary. With respect to the per20 formance category described in paragraph 

21 (2)(A)(i), feedback under this subpara22 graph shall, to the extent an eligible pro23 fessional chooses to participate in a data 

24 registry for purposes of this subsection (in25 cluding registries under subsections (k) 


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1 and (m)), be provided based on perform2 ance on quality measures reported through 

3 the use of such registries. With respect to 

4 any other performance category described 

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

6 encourage provision of feedback through 

7 qualified clinical data registries as de8 scribed in subsection (m)(3)(E)). 

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

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

11 with respect to a MIPS eligible profes12 sional, from periods prior to the current 

13 performance period and may use rolling 

14 periods in order to make illustrative cal15 culations about the performance of such 

16 professional. 

17 ‘‘(iv) DISCLOSURE EXEMPTION.— 

18 Feedback made available under this sub19 paragraph shall be exempt from disclosure 

20 under section 552 of title 5, United States 

21 Code. 

22 ‘‘(v) RECEIPT OF INFORMATION.— 

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1 mation from professionals, such as infor2 mation with respect to this subsection. 

3 ‘‘(B) ADDITIONAL INFORMATION.— 

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

5 2017, the Secretary shall make available to 

6 each MIPS eligible professional informa7 tion, with respect to individuals who are 

8 patients of such MIPS eligible professional, 

9 about items and services for which pay10 ment is made under this title that are fur11 nished to such individuals by other sup12 pliers and providers of services, which may 

13 include information described in clause (ii). 

14 Such information may be made available 

15 under the previous sentence to such MIPS 

16 eligible professionals by mechanisms deter17 mined appropriate by the Secretary, which 

18 may include use of a web-based portal. 

19 Such information may be made available in 

20 accordance with the same or similar terms 

21 as data are made available to accountable 

22 care organizations participating in the 

23 shared savings program under section 

24 1899, including a beneficiary opt-out. 


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1 ‘‘(ii) TYPE OF INFORMATION.—For 

2 purposes of clause (i), the information de3 scribed in this clause, is the following: 

4 ‘‘(I) With respect to selected 

5 items and services (as determined ap6 propriate by the Secretary) for which 

7 payment is made under this title and 

8 that are furnished to individuals, who 

9 are patients of a MIPS eligible profes10 sional, by another supplier or provider 

11 of services during the most recent pe12 riod for which data are available (such 

13 as the most recent three-month pe14 riod), such as the name of such pro15 viders furnishing such items and serv16 ices to such patients during such pe17 riod, the types of such items and serv18 ices so furnished, and the dates such 

19 items and services were so furnished. 

20 ‘‘(II) Historical data, such as 

21 averages and other measures of the 

22 distribution if appropriate, of the 

23 total, and components of, allowed 

24 charges (and other figures as deter25 mined appropriate by the Secretary). 


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1 ‘‘(13) REVIEW.— 

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

3 shall establish a process under which a MIPS 

4 eligible professional may seek an informal re5 view of the calculation of the MIPS adjustment 

6 factor applicable to such eligible professional 

7 under this subsection for a year. The results of 

8 a review conducted pursuant to the previous 

9 sentence shall not be taken into account for 

10 purposes of paragraph (6) with respect to a 

11 year (other than with respect to the calculation 

12 of such eligible professional’s MIPS adjustment 

13 factor for such year or additional MIPS adjust14 ment factor for such year) after the factors de15 termined in subparagraph (A) and subpara16 graph (C) of such paragraph have been deter17 mined for such year. 

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

19 in subparagraph (A), there shall be no adminis20 trative or judicial review under section 1869, 

21 section 1878, or otherwise of the following: 

22 ‘‘(i) The methodology used to deter23 mine the amount of the MIPS adjustment 

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

25 amount of the additional MIPS adjustment 


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

2 determination of such amounts. 

3 ‘‘(ii) The establishment of the per4 formance standards under paragraph (3) 

5 and the performance period under para6 graph (4). 

7 ‘‘(iii) The identification of measures 

8 and activities specified under paragraph 

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

10 posted on the Physician Compare Internet 

11 website of the Centers for Medicare & 

12 Medicaid Services under paragraph (9). 

13 ‘‘(iv) The methodology developed 

14 under paragraph (5) that is used to cal15 culate performance scores and the calcula16 tion of such scores, including the weighting 

17 of measures and activities under such 

18 methodology.’’. 

19 (2) GAO REPORTS.— 

20 (A) EVALUATION OF ELIGIBLE PROFES21 SIONAL MIPS.—Not later than October 1, 2019, 

22 and October 1, 2022, the Comptroller General 

23 of the United States shall submit to Congress 

24 a report evaluating the eligible professional 

25 Merit-based Incentive Payment System under 


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1 subsection (q) of section 1848 of the Social Se2 curity Act (42 U.S.C. 1395w–4), as added by 

3 paragraph (1). Such report shall— 

4 (i) examine the distribution of the 

5 composite performance scores and MIPS 

6 adjustment factors (and additional MIPS 

7 adjustment factors) for MIPS eligible pro8 fessionals (as defined in subsection 

9 (q)(1)(c) of such section) under such pro10 gram, and patterns relating to such scores 

11 and adjustment factors, including based on 

12 type of provider, practice size, geographic 

13 location, and patient mix; 

14 (ii) provide recommendations for im15 proving such program; 

16 (iii) evaluate the impact of technical 

17 assistance funding under section 

18 1848(q)(11) of the Social Security Act, as 

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

20 professionals to improve within such pro21 gram or successfully transition to an alter22 native payment model (as defined in sec23 tion 1833(z)(3) of the Social Security Act, 

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

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1 cated in rural areas, health professional 

2 shortage areas (as designated in section 

3 332(a)(1)(a) of the Public Health Service 

4 Act), and medically underserved areas; and 

5 (iv) provide recommendations for opti6 mizing the use of such technical assistance 

7 funds. 

8 (B) STUDY TO EXAMINE ALIGNMENT OF

9 QUALITY MEASURES USED IN PUBLIC AND PRI10 VATE PROGRAMS.— 

11 (i) IN GENERAL.—Not later than 18 

12 months after the date of the enactment of 

13 this Act, the Comptroller General of the 

14 United States shall submit to Congress a 

15 report that— 

16 (I) compares the similarities and 

17 differences in the use of quality meas18 ures under the original Medicare fee19 for-service program under parts A and 

20 B of title XVIII of the Social Security 

21 Act, the Medicare Advantage program 

22 under part C of such title, selected 

23 State Medicaid programs under title 

24 XIX of such Act, and private payer 

25 arrangements; and 


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1 (II) makes recommendations on 

2 how to reduce the administrative bur3 den involved in applying such quality 

4 measures. 

5 (ii) REQUIREMENTS.—The report 

6 under clause (i) shall— 

7 (I) consider those measures ap8 plicable to individuals entitled to, or 

9 enrolled for, benefits under such part 

10 A, or enrolled under such part B and 

11 individuals under the age of 65; and 

12 (II) focus on those measures that 

13 comprise the most significant compo14 nent of the quality performance cat15 egory of the eligible professional 

16 MIPS incentive program under sub17 section (q) of section 1848 of the So18 cial Security Act (42 U.S.C. 1395w– 

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

20 (C) STUDY ON ROLE OF INDEPENDENT

21 RISK MANAGERS.—Not later than January 1, 

22 2016, the Comptroller General of the United 

23 States shall submit to Congress a report exam24 ining whether entities that pool financial risk 

25 for physician practices, such as independent 


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1 risk managers, can play a role in supporting 

2 physician practices, particularly small physician 

3 practices, in assuming financial risk for the 

4 treatment of patients. Such report shall exam5 ine barriers that small physician practices cur6 rently face in assuming financial risk for treat7 ing patients, the types of risk management enti8 ties that could assist physician practices in par9 ticipating in two-sided risk payment models, 

10 and how such entities could assist with risk 

11 management and with quality improvement ac12 tivities. Such report shall also include an anal13 ysis of any existing legal barriers to such ar14 rangements. 

15 (D) STUDY TO EXAMINE RURAL AND

16 HEALTH PROFESSIONAL SHORTAGE AREA AL17 TERNATIVE PAYMENT MODELS.—Not later than 

18 October 1, 2020, and October 1, 2022, the 

19 Comptroller General of the United States shall 

20 submit to Congress a report that examines the 

21 transition of professionals in rural areas, health 

22 professional shortage areas (as designated in 

23 section 332(a)(1)(A) of the Public Health Serv24 ice Act), or medically underserved areas to an 

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1 tion 1833(z)(3) of the Social Security Act, as 

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

3 make recommendations for removing adminis4 trative barriers to practices, including small 

5 practices consisting of 15 or fewer profes6 sionals, in rural areas, health professional 

7 shortage areas, and medically underserved areas 

8 to participation in such models. 

9 (3) FUNDING FOR IMPLEMENTATION.—For 

10 purposes of implementing the provisions of and the 

11 amendments made by this section, the Secretary of 

12 Health and Human Services shall provide for the 

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

14 Medical Insurance Trust Fund established under 

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

16 1395t) to the Centers for Medicare & Medicaid Pro17 gram Management Account for each of the fiscal 

18 years 2014 through 2018. Amounts transferred 

19 under this paragraph shall be available until ex20 pended. 

21 (d) IMPROVING QUALITY REPORTING FOR COM22 POSITE SCORES.— 

23 (1) CHANGES FOR GROUP REPORTING OP24 TION.— 


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1 (A) IN GENERAL.—Section 

2 1848(m)(3)(C)(ii) of the Social Security Act 

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

4 by inserting ‘‘and, for 2015 and subsequent 

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

6 (B) CLARIFICATION OF QUALIFIED CLIN7 ICAL DATA REGISTRY REPORTING TO GROUP

8 PRACTICES.—Section 1848(m)(3)(D) of the So9 cial Security Act (42 U.S.C. 1395w– 

10 4(m)(3)(D)) is amended by inserting ‘‘and, for 

11 2015 and subsequent years, subparagraph (A) 

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

13 (2) CHANGES FOR MULTIPLE REPORTING PERI14 ODS AND ALTERNATIVE CRITERIA FOR SATISFAC15 TORY REPORTING.—Section 1848(m)(5)(F) of the 

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

17 is amended— 

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

19 and inserting ‘‘through reporting periods occur20 ring in 2014’’; and 

21 (B) by inserting ‘‘and, for reporting peri22 ods occurring in 2015 and subsequent years, 

23 the Secretary may establish’’ following ‘‘shall 

24 establish’’. 


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1 (3) PHYSICIAN FEEDBACK PROGRAM REPORTS

2 SUCCEEDED BY REPORTS UNDER MIPS.—Section 

3 1848(n) of the Social Security Act (42 U.S.C. 

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

5 following new paragraph: 

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

7 under the Program shall not be provided after De8 cember 31, 2016. See subsection (q)(12) for reports 

9 under the eligible professionals Merit-based Incentive 

10 Payment System.’’. 

11 (4) COORDINATION WITH SATISFYING MEANING12 FUL EHR USE CLINICAL QUALITY MEASURE REPORT13 ING REQUIREMENT.—Section 1848(o)(2)(A)(iii) of 

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

15 4(o)(2)(A)(iii)) is amended by inserting ‘‘and sub16 section (q)(5)(B)(ii)(II)’’ after ‘‘Subject to subpara17 graph (B)(ii)’’. 

18 (e) PROMOTING ALTERNATIVE PAYMENT MODELS.— 

19 (1) INCREASING TRANSPARENCY OF PHYSICIAN

20 FOCUSED PAYMENT MODELS.—Section 1868 of the 

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

22 by adding at the end the following new subsection: 

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

24 ‘‘(1) TECHNICAL ADVISORY COMMITTEE.— 


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1 ‘‘(A) ESTABLISHMENT.—There is estab2 lished an ad hoc committee to be known as the 

3 ‘Payment Model Technical Advisory Committee’ 

4 (referred to in this subsection as the ‘Com5 mittee’). 

6 ‘‘(B) MEMBERSHIP.— 

7 ‘‘(i) NUMBER AND APPOINTMENT.— 

8 The Committee shall be composed of 11 

9 members appointed by the Comptroller 

10 General of the United States. 

11 ‘‘(ii) QUALIFICATIONS.—The member12 ship of the Committee shall include indi13 viduals with national recognition for their 

14 expertise in payment models and related 

15 delivery of care. No more than 5 members 

16 of the Committee shall be providers of 

17 services or suppliers, or representatives of 

18 providers of services or suppliers. 

19 ‘‘(iii) PROHIBITION ON FEDERAL EM20 PLOYMENT.—A member of the Committee 

21 shall not be an employee of the Federal 

22 Government. 

23 ‘‘(iv) ETHICS DISCLOSURE.—The 

24 Comptroller General shall establish a sys25 tem for public disclosure by members of 


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1 the Committee of financial and other po2 tential conflicts of interest relating to such 

3 members. Members of the Committee shall 

4 be treated as employees of Congress for 

5 purposes of applying title I of the Ethics 

6 in Government Act of 1978 (Public Law 

7 95–521). 

8 ‘‘(v) DATE OF INITIAL APPOINT9 MENTS.—The initial appointments of mem10 bers of the Committee shall be made by 

11 not later than 180 days after the date of 

12 enactment of this subsection. 

13 ‘‘(C) TERM; VACANCIES.— 

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

15 the Committee shall be for 3 years except 

16 that the Comptroller General shall des17 ignate staggered terms for the members 

18 first appointed. 

19 ‘‘(ii) VACANCIES.—Any member ap20 pointed to fill a vacancy occurring before 

21 the expiration of the term for which the 

22 member’s predecessor was appointed shall 

23 be appointed only for the remainder of that 

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1 cessor has taken office. A vacancy in the 

2 Committee shall be filled in the manner in 

3 which the original appointment was made. 

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

5 as needed, to provide comments and rec6 ommendations to the Secretary, as described in 

7 paragraph (2)(C), on physician-focused pay8 ment models. 

9 ‘‘(E) COMPENSATION OF MEMBERS.— 

10 ‘‘(i) IN GENERAL.—Except as pro11 vided in clause (ii), a member of the Com12 mittee shall serve without compensation. 

13 ‘‘(ii) TRAVEL EXPENSES.—A member 

14 of the Committee shall be allowed travel 

15 expenses, including per diem in lieu of sub16 sistence, at rates authorized for an em17 ployee of an agency under subchapter I of 

18 chapter 57 of title 5, United States Code, 

19 while away from the home or regular place 

20 of business of the member in the perform21 ance of the duties of the Committee. 

22 ‘‘(F) OPERATIONAL AND TECHNICAL SUP23 PORT.— 

24 ‘‘(i) IN GENERAL.—The Assistant 

25 Secretary for Planning and Evaluation 


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1 shall provide technical and operational sup2 port for the Committee, which may be by 

3 use of a contractor. The Office of the Ac4 tuary of the Centers for Medicare & Med5 icaid Services shall provide to the Com6 mittee actuarial assistance as needed. 

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

8 provide for the transfer, from the Federal 

9 Supplementary Medical Insurance Trust 

10 Fund under section 1841, such amounts as 

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

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

13 and each subsequent fiscal year. Any 

14 amounts transferred under the preceding 

15 sentence for a fiscal year shall remain 

16 available until expended. 

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

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

19 App.) shall not apply to the Committee. 

20 ‘‘(2) CRITERIA AND PROCESS FOR SUBMISSION

21 AND REVIEW OF PHYSICIAN-FOCUSED PAYMENT

22 MODELS.— 

23 ‘‘(A) CRITERIA FOR ASSESSING PHYSICIAN24 FOCUSED PAYMENT MODELS.— 


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1 ‘‘(i) RULEMAKING.—Not later than 

2 November 1, 2015, the Secretary shall, 

3 through notice and comment rulemaking, 

4 following a request for information, estab5 lish criteria for physician-focused payment 

6 models, including models for specialist phy7 sicians, that could be used by the Com8 mittee for making comments and rec9 ommendations pursuant to paragraph 

10 (1)(D). 

11 ‘‘(ii) MEDPAC SUBMISSION OF COM12 MENTS.—During the comment period for 

13 the proposed rule described in clause (i), 

14 the Medicare Payment Advisory Commis15 sion may submit comments to the Sec16 retary on the proposed criteria under such 

17 clause. 

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

19 update the criteria established under this 

20 subparagraph through rulemaking. 

21 ‘‘(B) STAKEHOLDER SUBMISSION OF PHY22 SICIAN FOCUSED PAYMENT MODELS.—On an 

23 ongoing basis, individuals and stakeholder enti24 ties may submit to the Committee proposals for 

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1 dividuals and entities believe meet the criteria 

2 described in subparagraph (A). 

3 ‘‘(C) TAC REVIEW OF MODELS SUB4 MITTED.—The Committee shall, on a periodic 

5 basis, review models submitted under subpara6 graph (B), prepare comments and recommenda7 tions regarding whether such models meet the 

8 criteria described in subparagraph (A), and 

9 submit such comments and recommendations to 

10 the Secretary. 

11 ‘‘(D) SECRETARY REVIEW AND RE12 SPONSE.—The Secretary shall review the com13 ments and recommendations submitted by the 

14 Committee under subparagraph (C) and post a 

15 detailed response to such comments and rec16 ommendations on the Internet Website of the 

17 Centers for Medicare & Medicaid Services. 

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

19 this subsection shall be construed to impact the de20 velopment or testing of models under this title or ti21 tles XI, XIX, or XXI.’’. 

22 (2) INCENTIVE PAYMENTS FOR PARTICIPATION

23 IN ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 

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


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1 1395l) is amended by adding at the end the fol2 lowing new subsection: 

3 ‘‘(z) INCENTIVE PAYMENTS FOR PARTICIPATION IN

4 ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 

5 ‘‘(1) PAYMENT INCENTIVE.— 

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

7 professional services furnished by an eligible 

8 professional during a year that is in the period 

9 beginning with 2018 and ending with 2023 and 

10 for which the professional is a qualifying APM 

11 participant, in addition to the amount of pay12 ment that would otherwise be made for such 

13 covered professional services under this part for 

14 such year, there also shall be paid to such pro15 fessional an amount equal to 5 percent of the 

16 payment amount for the covered professional 

17 services under this part for the preceding year. 

18 For purposes of the previous sentence, the pay19 ment amount for the preceding year may be an 

20 estimation for the full preceding year based on 

21 a period of such preceding year that is less than 

22 the full year. The Secretary shall establish poli23 cies to implement this subparagraph in cases 

24 where payment for covered professional services 

25 furnished by a qualifying APM participant in 


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1 an alternative payment model is made to an en2 tity participating in the alternative payment 

3 model rather than directly to the qualifying 

4 APM participant. 

5 ‘‘(B) FORM OF PAYMENT.—Payments 

6 under this subsection shall be made in a lump 

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

8 ‘‘(C) TREATMENT OF PAYMENT INCEN9 TIVE.—Payments under this subsection shall 

10 not be taken into account for purposes of deter11 mining actual expenditures under an alternative 

12 payment model and for purposes of determining 

13 or rebasing any benchmarks used under the al14 ternative payment model. 

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

16 additional payment for an item or service under 

17 this subsection or subsection (m) shall be deter18 mined without regard to any additional pay19 ment for the item or service under subsection 

20 (m) and this subsection, respectively. The 

21 amount of the additional payment for an item 

22 or service under this subsection or subsection 

23 (x) shall be determined without regard to any 

24 additional payment for the item or service 

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1 spectively. The amount of the additional pay2 ment for an item or service under this sub3 section or subsection (y) shall be determined 

4 without regard to any additional payment for 

5 the item or service under subsection (y) and 

6 this subsection, respectively. 

7 ‘‘(2) QUALIFYING APM PARTICIPANT.—For pur8 poses of this subsection, the term ‘qualifying APM 

9 participant’ means the following: 

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

11 2018 and 2019, an eligible professional for 

12 whom the Secretary determines that at least 25 

13 percent of payments under this part for covered 

14 professional services furnished by such profes15 sional during the most recent period for which 

16 data are available (which may be less than a 

17 year) were attributable to such services fur18 nished under this part through an entity that 

19 participates in an eligible alternative payment 

20 model with respect to such services. 

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

22 2020 and 2021, an eligible professional de23 scribed in either of the following clauses: 

24 ‘‘(i) MEDICARE REVENUE THRESHOLD

25 OPTION.—An eligible professional for 


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1 whom the Secretary determines that at 

2 least 50 percent of payments under this 

3 part for covered professional services fur4 nished by such professional during the 

5 most recent period for which data are 

6 available (which may be less than a year) 

7 were attributable to such services furnished 

8 under this part through an entity that par9 ticipates in an eligible alternative payment 

10 model with respect to such services. 

11 ‘‘(ii) COMBINATION ALL-PAYER AND

12 MEDICARE REVENUE THRESHOLD OP13 TION.—An eligible professional— 

14 ‘‘(I) for whom the Secretary de15 termines, with respect to items and 

16 services furnished by such professional 

17 during the most recent period for 

18 which data are available (which may 

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

20 percent of the sum of— 

21 ‘‘(aa) payments described in 

22 clause (i); and 

23 ‘‘(bb) all other payments, re24 gardless of payer (other than 

25 payments made by the Secretary 


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1 of Defense or the Secretary of 

2 Veterans Affairs under chapter 

3 55 of title 10, United States 

4 Code, or title 38, United States 

5 Code, or any other provision of 

6 law, and other than payments 

7 made under title XIX in a State 

8 in which no medical home or al9 ternative payment model is avail10 able under the State program 

11 under that title), 

12 meet the requirement described in 

13 clause (iii)(I) with respect to pay14 ments described in item (aa) and meet 

15 the requirement described in clause 

16 (iii)(II) with respect to payments de17 scribed in item (bb); 

18 ‘‘(II) for whom the Secretary de19 termines at least 25 percent of pay20 ments under this part for covered pro21 fessional services furnished by such 

22 professional during the most recent 

23 period for which data are available 

24 (which may be less than a year) were 

25 attributable to such services furnished 


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1 under this part through an entity that 

2 participates in an eligible alternative 

3 payment model with respect to such 

4 services; and 

5 ‘‘(III) who provides to the Sec6 retary such information as is nec7 essary for the Secretary to make a de8 termination under subclause (I), with 

9 respect to such professional. 

10 ‘‘(iii) REQUIREMENT.—For purposes 

11 of clause (ii)(I)— 

12 ‘‘(I) the requirement described in 

13 this subclause, with respect to pay14 ments described in item (aa) of such 

15 clause, is that such payments are 

16 made under an eligible alternative 

17 payment model; and 

18 ‘‘(II) the requirement described 

19 in this subclause, with respect to pay20 ments described in item (bb) of such 

21 clause, is that such payments are 

22 made under an arrangement in 

23 which— 

24 ‘‘(aa) quality measures com25 parable to measures under the 


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1 performance category described 

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

3 ‘‘(bb) certified EHR tech4 nology is used; and 

5 ‘‘(cc) the eligible profes6 sional (AA) bears more than 

7 nominal financial risk if actual 

8 aggregate expenditures exceeds 

9 expected aggregate expenditures; 

10 or (BB) is a medical home (with 

11 respect to beneficiaries under 

12 title XIX) that meets criteria 

13 comparable to medical homes ex14 panded under section 1115A(c). 

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

16 2022 and each subsequent year, an eligible pro17 fessional described in either of the following 

18 clauses: 

19 ‘‘(i) MEDICARE REVENUE THRESHOLD

20 OPTION.—An eligible professional for 

21 whom the Secretary determines that at 

22 least 75 percent of payments under this 

23 part for covered professional services fur24 nished by such professional during the 

25 most recent period for which data are 


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1 available (which may be less than a year) 

2 were attributable to such services furnished 

3 under this part through an entity that par4 ticipates in an eligible alternative payment 

5 model with respect to such services. 

6 ‘‘(ii) COMBINATION ALL-PAYER AND

7 MEDICARE REVENUE THRESHOLD OP8 TION.—An eligible professional— 

9 ‘‘(I) for whom the Secretary de10 termines, with respect to items and 

11 services furnished by such professional 

12 during the most recent period for 

13 which data are available (which may 

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

15 percent of the sum of— 

16 ‘‘(aa) payments described in 

17 clause (i); and 

18 ‘‘(bb) all other payments, re19 gardless of payer (other than 

20 payments made by the Secretary 

21 of Defense or the Secretary of 

22 Veterans Affairs under chapter 

23 55 of title 10, United States 

24 Code, or title 38, United States 

25 Code, or any other provision of 


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1 law, and other than payments 

2 made under title XIX in a State 

3 in which no medical home or al4 ternative payment model is avail5 able under the State program 

6 under that title), 

7 meet the requirement described in 

8 clause (iii)(I) with respect to pay9 ments described in item (aa) and meet 

10 the requirement described in clause 

11 (iii)(II) with respect to payments de12 scribed in item (bb); 

13 ‘‘(II) for whom the Secretary de14 termines at least 25 percent of pay15 ments under this part for covered pro16 fessional services furnished by such 

17 professional during the most recent 

18 period for which data are available 

19 (which may be less than a year) were 

20 attributable to such services furnished 

21 under this part through an entity that 

22 participates in an eligible alternative 

23 payment model with respect to such 

24 services; and 


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

5 respect to such professional. 

6 ‘‘(iii) REQUIREMENT.—For purposes 

7 of clause (ii)(I)— 

8 ‘‘(I) the requirement described in 

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

11 clause, is that such payments are 

12 made under an eligible alternative 

13 payment model; and 

14 ‘‘(II) the requirement described 

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

17 clause, is that such payments are 

18 made under an arrangement in 

19 which— 

20 ‘‘(aa) quality measures com21 parable to measures under the 

22 performance category described 

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

24 ‘‘(bb) certified EHR tech25 nology is used; and 


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1 ‘‘(cc) the eligible profes2 sional (AA) bears more than 

3 nominal financial risk if actual 

4 aggregate expenditures exceeds 

5 expected aggregate expenditures; 

6 or (BB) is a medical home (with 

7 respect to beneficiaries under 

8 title XIX) that meets criteria 

9 comparable to medical homes ex10 panded under section 1115A(c). 

11 ‘‘(3) ADDITIONAL DEFINITIONS.—In this sub12 section: 

13 ‘‘(A) COVERED PROFESSIONAL SERV14 ICES.—The term ‘covered professional services’ 

15 has the meaning given that term in section 

16 1848(k)(3)(A). 

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

18 ‘eligible professional’ has the meaning given 

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

20 ‘‘(C) ALTERNATIVE PAYMENT MODEL

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

22 means any of the following: 

23 ‘‘(i) A model under section 1115A 

24 (other than a health care innovation 

25 award). 


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1 ‘‘(ii) The shared savings program 

2 under section 1899. 

3 ‘‘(iii) A demonstration under section 

4 1866C. 

5 ‘‘(iv) A demonstration required by 

6 Federal law. 

7 ‘‘(D) ELIGIBLE ALTERNATIVE PAYMENT

8 MODEL (APM).— 

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

10 alternative payment model’ means, with re11 spect to a year, an alternative payment 

12 model— 

13 ‘‘(I) that requires use of certified 

14 EHR technology (as defined in sub15 section (o)(4)); 

16 ‘‘(II) that provides for payment 

17 for covered professional services based 

18 on quality measures comparable to 

19 measures under the performance cat20 egory described in section 

21 1848(q)(2)(B)(i); and 

22 ‘‘(III) that satisfies the require23 ment described in clause (ii). 

24 ‘‘(ii) ADDITIONAL REQUIREMENT.— 

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1 ment described in this clause, with respect 

2 to a year and an alternative payment 

3 model, is that the alternative payment 

4 model— 

5 ‘‘(I) is one in which one or more 

6 entities bear financial risk for mone7 tary losses under such model that are 

8 in excess of a nominal amount; or 

9 ‘‘(II) is a medical home expanded 

10 under section 1115A(c). 

11 ‘‘(4) LIMITATION.—There shall be no adminis12 trative or judicial review under section 1869, 1878, 

13 or otherwise, of the following: 

14 ‘‘(A) The determination that an eligible 

15 professional is a qualifying APM participant 

16 under paragraph (2) and the determination 

17 that an alternative payment model is an eligible 

18 alternative payment model under paragraph 

19 (3)(D). 

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

21 the 5 percent payment incentive under para22 graph (1)(A), including any estimation as part 

23 of such determination.’’. 


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1 (3) COORDINATION CONFORMING AMEND2 MENTS.—Section 1833 of the Social Security Act 

3 (42 U.S.C. 1395l) is further amended— 

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

5 end the following new sentence: ‘‘The amount 

6 of the additional payment for a service under 

7 this subsection and subsection (z) shall be de8 termined without regard to any additional pay9 ment for the service under subsection (z) and 

10 this subsection, respectively.’’; and 

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

12 end the following new sentence: ‘‘The amount 

13 of the additional payment for a service under 

14 this subsection and subsection (z) shall be de15 termined without regard to any additional pay16 ment for the service under subsection (z) and 

17 this subsection, respectively.’’. 

18 (4) ENCOURAGING DEVELOPMENT AND TEST19 ING OF CERTAIN MODELS.—Section 1115A(b)(2) of 

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

21 amended— 

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

23 end the following new clauses: 

24 ‘‘(xxi) Focusing primarily on physi25 cians’ services (as defined in section 


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1 1848(j)(3)) furnished by physicians who 

2 are not primary care practitioners. 

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

4 fewer professionals. 

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

6 for small physician practices which may in7 volve two-sided risk and prospective patient 

8 assignment, and which examine risk-ad9 justed decreases in mortality rates, hos10 pital readmissions rates, and other relevant 

11 and appropriate clinical measures. 

12 ‘‘(xxiv) Focusing primarily on title 

13 XIX, working in conjunction with the Cen14 ter for Medicaid and CHIP Services.’’; and 

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

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

17 and inserting ‘‘other public sector payers, pri18 vate sector payers, or Statewide payment mod19 els’’. 

20 (5) CONSTRUCTION REGARDING TELEHEALTH

21 SERVICES.—Nothing in the provisions of, or amend22 ments made by, this Act shall be construed as pre23 cluding an alternative payment model or a qualifying 

24 APM participant (as those terms are defined in sec25 tion 1833(z) of the Social Security Act, as added by 


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1 paragraph (1)) from furnishing a telehealth service 

2 for which payment is not made under section 

3 1834(m) of the Social Security Act (42 U.S.C. 

4 1395m(m)). 

5 (6) INTEGRATING MEDICARE ADVANTAGE AL6 TERNATIVE PAYMENT MODELS.—Not later than July 

7 1, 2015, the Secretary of Health and Human Serv8 ices shall submit to Congress a study that examines 

9 the feasibility of integrating alternative payment 

10 models in the Medicare Advantage payment system. 

11 The study shall include the feasibility of including a 

12 value-based modifier and whether such modifier 

13 should be budget neutral. 

14 (7) STUDY AND REPORT ON FRAUD RELATED

15 TO ALTERNATIVE PAYMENT MODELS UNDER THE

16 MEDICARE PROGRAM.— 

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

18 Human Services, in consultation with the In19 spector General of the Department of Health 

20 and Human Services, shall conduct a study 

21 that— 

22 (i) examines the applicability of the 

23 Federal fraud prevention laws to items and 

24 services furnished under title XVIII of the 

25 Social Security Act for which payment is 


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1 made under an alternative payment model 

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

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

4 (ii) identifies aspects of such alter5 native payment models that are vulnerable 

6 to fraudulent activity; and 

7 (iii) examines the implications of waiv8 ers to such laws granted in support of such 

9 alternative payment models, including 

10 under any potential expansion of such 

11 models. 

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

13 the date of the enactment of this Act, the Sec14 retary shall submit to Congress a report con15 taining the results of the study conducted under 

16 subparagraph (A). Such report shall include 

17 recommendations for actions to be taken to re18 duce the vulnerability of such alternative pay19 ment models to fraudulent activity. Such report 

20 also shall include, as appropriate, recommenda21 tions of the Inspector General for changes in 

22 Federal fraud prevention laws to reduce such 

23 vulnerability. 

24 (f) IMPROVING PAYMENT ACCURACY.— 


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1 (1) STUDIES AND REPORTS OF EFFECT OF CER2 TAIN INFORMATION ON QUALITY AND RESOURCE

3 USE.— 

4 (A) STUDY USING EXISTING MEDICARE

5 DATA.— 

6 (i) STUDY.—The Secretary of Health 

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

9 a study that examines the effect of individ10 uals’ socioeconomic status on quality and 

11 resource use outcome measures for individ12 uals under the Medicare program (such as 

13 to recognize that less healthy individuals 

14 may require more intensive interventions). 

15 The study shall use information collected 

16 on such individuals in carrying out such 

17 program, such as urban and rural location, 

18 eligibility for Medicaid (recognizing and ac19 counting for varying Medicaid eligibility 

20 across States), and eligibility for benefits 

21 under the supplemental security income 

22 (SSI) program. The Secretary shall carry 

23 out this paragraph acting through the As24 sistant Secretary for Planning and Evalua25 tion. 


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

2 after the date of the enactment of this Act, 

3 the Secretary shall submit to Congress a 

4 report on the study conducted under clause 

5 (i). 

6 (B) STUDY USING OTHER DATA.— 

7 (i) STUDY.—The Secretary shall con8 duct a study that examines the impact of 

9 risk factors, such as those described in sec10 tion 1848(p)(3) of the Social Security Act 

11 (42 U.S.C. 1395w–4(p)(3)), race, health 

12 literacy, limited English proficiency (LEP), 

13 and patient activation, on quality and re14 source use outcome measures under the 

15 Medicare program (such as to recognize 

16 that less healthy individuals may require 

17 more intensive interventions). In con18 ducting such study the Secretary may use 

19 existing Federal data and collect such ad20 ditional data as may be necessary to com21 plete the study. 

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

23 after the date of the enactment of this Act, 

24 the Secretary shall submit to Congress a 


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1 report on the study conducted under clause 

2 (i). 

3 (C) EXAMINATION OF DATA IN CON4 DUCTING STUDIES.—In conducting the studies 

5 under subparagraphs (A) and (B), the Sec6 retary shall examine what non-Medicare data 

7 sets, such as data from the American Commu8 nity Survey (ACS), can be useful in conducting 

9 the types of studies under such paragraphs and 

10 how such data sets that are identified as useful 

11 can be coordinated with Medicare administra12 tive data in order to improve the overall data 

13 set available to do such studies and for the ad14 ministration of the Medicare program. 

15 (D) RECOMMENDATIONS TO ACCOUNT FOR

16 INFORMATION IN PAYMENT ADJUSTMENT

17 MECHANISMS.—If the studies conducted under 

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

19 between the factors examined in the studies and 

20 quality and resource use outcome measures, 

21 then the Secretary shall also provide rec22 ommendations for how the Centers for Medicare 

23 & Medicaid Services should— 

24 (i) obtain access to the necessary data 

25 (if such data is not already being collected) 


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1 on such factors, including recommenda2 tions on how to address barriers to the 

3 Centers in accessing such data; and 

4 (ii) account for such factors in deter5 mining payment adjustments based on 

6 quality and resource use outcome measures 

7 under the eligible professional Merit-based 

8 Incentive Payment System under section 

9 1848(q) of the Social Security Act (42 

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

11 determines appropriate, other similar pro12 visions of title XVIII of such Act. 

13 (E) FUNDING.—There are hereby appro14 priated from the Federal Supplementary Med15 ical Insurance Trust Fund under section 1841 

16 of the Social Security Act to the Secretary to 

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

18 available until expended. 

19 (2) CMS ACTIVITIES.— 

20 (A) HIERARCHAL CONDITION CATEGORY

21 (HCC) IMPROVEMENT.—Taking into account the 

22 relevant studies conducted and recommenda23 tions made in reports under paragraph (1), the 

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

25 Secretary determines appropriate, estimate how 


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1 an individual’s health status and other risk fac2 tors affect quality and resource use outcome 

3 measures and, as feasible, shall incorporate in4 formation from quality and resource use out5 come measurement (including care episode and 

6 patient condition groups) into provisions of title 

7 XVIII of the Social Security Act that are simi8 lar to the eligible professional Merit-based In9 centive Payment System under section 1848(q) 

10 of such Act. 

11 (B) ACCOUNTING FOR OTHER FACTORS IN

12 PAYMENT ADJUSTMENT MECHANISMS.— 

13 (i) IN GENERAL.—Taking into ac14 count the studies conducted and rec15 ommendations made in reports under para16 graph (1) and other information as appro17 priate, the Secretary shall, as the Sec18 retary determines appropriate, account for 

19 identified factors with an effect on quality 

20 and resource use outcome measures when 

21 determining payment adjustment mecha22 nisms under provisions of title XVIII of 

23 the Social Security Act that are similar to 

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1 tive Payment System under section 

2 1848(q) of such Act. 

3 (ii) ACCESSING DATA.—The Secretary 

4 shall collect or otherwise obtain access to 

5 the data necessary to carry out this para6 graph through existing and new data 

7 sources. 

8 (iii) PERIODIC ANALYSES.—The Sec9 retary shall carry out periodic analyses, at 

10 least every 3 years, based on the factors 

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

12 changes in possible relationships. 

13 (C) FUNDING.—There are hereby appro14 priated from the Federal Supplementary Med15 ical Insurance Trust Fund under section 1841 

16 of the Social Security Act to the Secretary to 

17 carry out this paragraph and the application of 

18 this paragraph to the Merit-based Incentive 

19 Payment System under section 1848(q) of such 

20 Act $10,000,000, to remain available until ex21 pended. 

22 (3) STRATEGIC PLAN FOR ACCESSING RACE

23 AND ETHNICITY DATA.—Not later than 18 months 

24 after the date of the enactment of this Act, the Sec25 retary shall develop and report to Congress on a 


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1 strategic plan for collecting or otherwise accessing 

2 data on race and ethnicity for purposes of carrying 

3 out the eligible professional Merit-based Incentive 

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

5 Security Act and, as the Secretary determines ap6 propriate, other similar provisions of title XVIII of 

7 such Act. 

8 (g) COLLABORATING WITH THE PHYSICIAN, PRACTI9 TIONER, AND OTHER STAKEHOLDER COMMUNITIES TO

10 IMPROVE RESOURCE USE MEASUREMENT.—Section 1848 

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

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

13 at the end the following new subsection: 

14 ‘‘(r) COLLABORATING WITH THE PHYSICIAN, PRAC15 TITIONER, AND OTHER STAKEHOLDER COMMUNITIES TO

16 IMPROVE RESOURCE USE MEASUREMENT.— 

17 ‘‘(1) IN GENERAL.—In order to involve the phy18 sician, practitioner, and other stakeholder commu19 nities in enhancing the infrastructure for resource 

20 use measurement, including for purposes of the 

21 Merit-based Incentive Payment System under sub22 section (q) and alternative payment models under 

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

24 steps described in the succeeding provisions of this 

25 subsection. 


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1 ‘‘(2) DEVELOPMENT OF CARE EPISODE AND PA2 TIENT CONDITION GROUPS AND CLASSIFICATION

3 CODES.— 

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

5 similar patients into care episode groups and 

6 patient condition groups, the Secretary shall 

7 undertake the steps described in the succeeding 

8 provisions of this paragraph. 

9 ‘‘(B) PUBLIC AVAILABILITY OF EXISTING

10 EFFORTS TO DESIGN AN EPISODE GROUPER.— 

11 Not later than 120 days after the date of the 

12 enactment of this subsection, the Secretary 

13 shall post on the Internet website of the Cen14 ters for Medicare & Medicaid Services a list of 

15 the episode groups developed pursuant to sub16 section (n)(9)(A) and related descriptive infor17 mation. 

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

20 days after the day the Secretary posts the list 

21 pursuant to subparagraph (B), suggestions 

22 from physician specialty societies, applicable 

23 practitioner organizations, and other stake24 holders for episode groups in addition to those 

25 posted pursuant to such subparagraph, and 


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1 specific clinical criteria and patient characteris2 tics to classify patients into— 

3 ‘‘(i) care episode groups; and 

4 ‘‘(ii) patient condition groups. 

5 ‘‘(D) DEVELOPMENT OF PROPOSED CLAS6 SIFICATION CODES.— 

7 ‘‘(i) IN GENERAL.—Taking into ac8 count the information described in sub9 paragraph (B) and the information re10 ceived under subparagraph (C), the Sec11 retary shall— 

12 ‘‘(I) establish care episode groups 

13 and patient condition groups, which 

14 account for a target of an estimated 

2 15 ⁄3 of expenditures under parts A and 

16 B; and 

17 ‘‘(II) assign codes to such 

18 groups. 

19 ‘‘(ii) CARE EPISODE GROUPS.—In es20 tablishing the care episode groups under 

21 clause (i), the Secretary shall take into ac22 count— 

23 ‘‘(I) the patient’s clinical prob24 lems at the time items and services 

25 are furnished during an episode of 


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1 care, such as the clinical conditions or 

2 diagnoses, whether or not inpatient 

3 hospitalization is anticipated or oc4 curs, and the principal procedures or 

5 services planned or furnished; and 

6 ‘‘(II) other factors determined 

7 appropriate by the Secretary. 

8 ‘‘(iii) PATIENT CONDITION GROUPS.— 

9 In establishing the patient condition 

10 groups under clause (i), the Secretary shall 

11 take into account— 

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

13 at the time of each medical visit, such 

14 as the patient’s combination of chron15 ic conditions, current health status, 

16 and recent significant history (such as 

17 hospitalization and major surgery dur18 ing a previous period, such as 3 

19 months); and 

20 ‘‘(II) other factors determined 

21 appropriate by the Secretary, such as 

22 eligibility status under this title (in23 cluding eligibility under section 

24 226(a), 226(b), or 226A, and dual eli25 gibility under this title and title XIX). 


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1 ‘‘(E) DRAFT CARE EPISODE AND PATIENT

2 CONDITION GROUPS AND CLASSIFICATION

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

4 of the comment period described in subpara5 graph (C), the Secretary shall post on the 

6 Internet website of the Centers for Medicare & 

7 Medicaid Services a draft list of the care epi8 sode and patient condition codes established 

9 under subparagraph (D) (and the criteria and 

10 characteristics assigned to such code). 

11 ‘‘(F) SOLICITATION OF INPUT.—The Sec12 retary shall seek, through the date that is 60 

13 days after the Secretary posts the list pursuant 

14 to subparagraph (E), comments from physician 

15 specialty societies, applicable practitioner orga16 nizations, and other stakeholders, including rep17 resentatives of individuals entitled to benefits 

18 under part A or enrolled under this part, re19 garding the care episode and patient condition 

20 groups (and codes) posted under subparagraph 

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

22 shall use one or more mechanisms (other than 

23 notice and comment rulemaking) that may in24 clude use of open door forums, town hall meet25 ings, or other appropriate mechanisms. 


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1 ‘‘(G) OPERATIONAL LIST OF CARE EPI2 SODE AND PATIENT CONDITION GROUPS AND

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

4 of the comment period described in subpara5 graph (F), taking into account the comments 

6 received under such subparagraph, the Sec7 retary shall post on the Internet website of the 

8 Centers for Medicare & Medicaid Services an 

9 operational list of care episode and patient con10 dition codes (and the criteria and characteris11 tics assigned to such code). 

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

13 than November 1 of each year (beginning with 

14 2017), the Secretary shall, through rulemaking, 

15 make revisions to the operational lists of care 

16 episode and patient condition codes as the Sec17 retary determines may be appropriate. Such re18 visions may be based on experience, new infor19 mation developed pursuant to subsection 

20 (n)(9)(A), and input from the physician spe21 cialty societies, applicable practitioner organiza22 tions, and other stakeholders, including rep23 resentatives of individuals entitled to benefits 

24 under part A or enrolled under this part. 


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1 ‘‘(3) ATTRIBUTION OF PATIENTS TO PHYSI2 CIANS OR PRACTITIONERS.— 

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

4 the attribution of patients and episodes (in 

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

6 applicable practitioners furnishing items and 

7 services, the Secretary shall undertake the steps 

8 described in the succeeding provisions of this 

9 paragraph. 

10 ‘‘(B) DEVELOPMENT OF PATIENT RELA11 TIONSHIP CATEGORIES AND CODES.—The Sec12 retary shall develop patient relationship cat13 egories and codes that define and distinguish 

14 the relationship and responsibility of a physi15 cian or applicable practitioner with a patient at 

16 the time of furnishing an item or service. Such 

17 patient relationship categories shall include dif18 ferent relationships of the physician or applica19 ble practitioner to the patient (and the codes 

20 may reflect combinations of such categories), 

21 such as a physician or applicable practitioner 

22 who— 

23 ‘‘(i) considers themself to have the 

24 primary responsibility for the general and 


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1 ongoing care for the patient over extended 

2 periods of time; 

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

4 physician or practitioner and who furnishes 

5 items and services and coordinates care 

6 furnished by other physicians or practi7 tioners for the patient during an acute epi8 sode; 

9 ‘‘(iii) furnishes items and services to 

10 the patient on a continuing basis during an 

11 acute episode of care, but in a supportive 

12 rather than a lead role; 

13 ‘‘(iv) furnishes items and services to 

14 the patient on an occasional basis, usually 

15 at the request of another physician or 

16 practitioner; or 

17 ‘‘(v) furnishes items and services only 

18 as ordered by another physician or practi19 tioner. 

20 ‘‘(C) DRAFT LIST OF PATIENT RELATION21 SHIP CATEGORIES AND CODES.—Not later than 

22 270 days after the date of the enactment of this 

23 subsection, the Secretary shall post on the 

24 Internet website of the Centers for Medicare & 

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1 lationship categories and codes developed under 

2 subparagraph (B). 

3 ‘‘(D) STAKEHOLDER INPUT.—The Sec4 retary shall seek, through the date that is 60 

5 days after the Secretary posts the list pursuant 

6 to subparagraph (C), 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 patient relationship categories and 

12 codes posted under subparagraph (C). In seek13 ing such comments, the Secretary shall use one 

14 or more mechanisms (other than notice and 

15 comment rulemaking) that may include open 

16 door forums, town hall meetings, or other ap17 propriate mechanisms. 

18 ‘‘(E) OPERATIONAL LIST OF PATIENT RE19 LATIONSHIP CATEGORIES AND CODES.—Not 

20 later than 180 days after the end of the com21 ment period described in subparagraph (D), 

22 taking into account the comments received 

23 under such subparagraph, the Secretary shall 

24 post on the Internet website of the Centers for 


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1 Medicare & Medicaid Services an operational 

2 list of patient relationship categories and codes. 

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

4 than November 1 of each year (beginning with 

5 2017), the Secretary shall, through rulemaking, 

6 make revisions to the operational list of patient 

7 relationship categories and codes as the Sec8 retary determines appropriate. Such revisions 

9 may be based on experience, new information 

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

11 input from the physician specialty societies, ap12 plicable practitioner organizations, and other 

13 stakeholders, including representatives of indi14 viduals entitled to benefits under part A or en15 rolled under this part. 

16 ‘‘(4) REPORTING OF INFORMATION FOR RE17 SOURCE USE MEASUREMENT.—Claims submitted for 

18 items and services furnished by a physician or appli19 cable practitioner on or after January 1, 2017, shall, 

20 as determined appropriate by the Secretary, in21 clude— 

22 ‘‘(A) applicable codes established under 

23 paragraphs (2) and (3); and 

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

25 ordering physician or applicable practitioner (if 


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1 different from the billing physician or applicable 

2 practitioner). 

3 ‘‘(5) METHODOLOGY FOR RESOURCE USE ANAL4 YSIS.— 

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

6 the resources used to treat patients (with re7 spect to care episode and patient condition 

8 groups), the Secretary shall— 

9 ‘‘(i) use the patient relationship codes 

10 reported on claims pursuant to paragraph 

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

12 part) to one or more physicians and appli13 cable practitioners; 

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

15 condition codes reported on claims pursu16 ant to paragraph (4) as a basis to compare 

17 similar patients and care episodes and pa18 tient condition groups; and 

19 ‘‘(iii) conduct an analysis of resource 

20 use (with respect to care episodes and pa21 tient condition groups of such patients), as 

22 the Secretary determines appropriate. 

23 ‘‘(B) ANALYSIS OF PATIENTS OF PHYSI24 CIANS AND PRACTITIONERS.—In conducting the 

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


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1 respect to patients attributed to physicians and 

2 applicable practitioners, the Secretary shall, as 

3 feasible— 

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

5 such patients by patient condition codes 

6 during a common period, such as 12 

7 months; and 

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

9 such patients by care episode codes— 

10 ‘‘(I) in the case of episodes with11 out a hospitalization, during periods 

12 of time (such as the number of days) 

13 determined appropriate by the Sec14 retary; and 

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

16 a hospitalization, during periods of 

17 time (such as the number of days) be18 fore, during, and after the hospitaliza19 tion. 

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

21 In measuring such resource use, the Sec22 retary— 

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

24 charges for all services under part A and 

25 this part (and, if the Secretary determines 


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1 appropriate, part D) for the analysis of pa2 tient resource use, by care episode codes 

3 and by patient condition codes; and 

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

5 use other measures of allowed charges 

6 (such as subtotals for categories of items 

7 and services) and measures of utilization of 

8 items and services (such as frequency of 

9 specific items and services and the ratio of 

10 specific items and services among attrib11 uted patients or episodes). 

12 ‘‘(D) STAKEHOLDER INPUT.—The Sec13 retary shall seek comments from the physician 

14 specialty societies, applicable practitioner orga15 nizations, and other stakeholders, including rep16 resentatives of individuals entitled to benefits 

17 under part A or enrolled under this part, re18 garding the resource use methodology estab19 lished pursuant to this paragraph. In seeking 

20 comments the Secretary shall use one or more 

21 mechanisms (other than notice and comment 

22 rulemaking) that may include open door fo23 rums, town hall meetings, or other appropriate 

24 mechanisms. 


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1 ‘‘(6) IMPLEMENTATION.—To the extent that 

2 the Secretary contracts with an entity to carry out 

3 any part of the provisions of this subsection, the 

4 Secretary may not contract with an entity or an en5 tity with a subcontract if the entity or subcon6 tracting entity currently makes recommendations to 

7 the Secretary on relative values for services under 

8 the fee schedule for physicians’ services under this 

9 section. 

10 ‘‘(7) LIMITATION.—There shall be no adminis11 trative or judicial review under section 1869, section 

12 1878, or otherwise of— 

13 ‘‘(A) care episode and patient condition 

14 groups and codes established under paragraph 

15 (2); 

16 ‘‘(B) patient relationship categories and 

17 codes established under paragraph (3); and 

18 ‘‘(C) measurement of, and analyses of re19 source use with respect to, care episode and pa20 tient condition codes and patient relationship 

21 codes pursuant to paragraph (5). 

22 ‘‘(8) ADMINISTRATION.—Chapter 35 of title 44, 

23 United States Code, shall not apply to this section. 

24 ‘‘(9) DEFINITIONS.—In this section: 


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1 ‘‘(A) PHYSICIAN.—The term ‘physician’ 

2 has the meaning given such term in section 

3 1861(r). 

4 ‘‘(B) APPLICABLE PRACTITIONER.—The 

5 term ‘applicable practitioner’ means— 

6 ‘‘(i) a physician assistant, nurse prac7 titioner, and clinical nurse specialist (as 

8 such terms are defined in section 

9 1861(aa)(5)), and a certified registered 

10 nurse anesthetist (as defined in section 

11 1861(bb)(2)); and 

12 ‘‘(ii) beginning January 1, 2018, such 

13 other eligible professionals (as defined in 

14 subsection (k)(3)(B)) as specified by the 

15 Secretary. 

16 ‘‘(10) CLARIFICATION.—The provisions of sec17 tions 1890(b)(7) and 1890A shall not apply to this 

18 subsection.’’. 

19 SEC. 102. PRIORITIES AND FUNDING FOR MEASURE DEVEL20 OPMENT. 

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

22 1395w–4), as amended by subsections (c) and (g) of sec23 tion 101, is further amended by inserting at the end the 

24 following new subsection: 


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1 ‘‘(s) PRIORITIES AND FUNDING FOR MEASURE DE2 VELOPMENT.— 

3 ‘‘(1) PLAN IDENTIFYING MEASURE DEVELOP4 MENT PRIORITIES AND TIMELINES.— 

5 ‘‘(A) DRAFT MEASURE DEVELOPMENT

6 PLAN.—Not later than January 1, 2015, the 

7 Secretary shall develop, and post on the Inter8 net website of the Centers for Medicare & Med9 icaid Services, a draft plan for the development 

10 of quality measures for application under the 

11 applicable provisions (as defined in paragraph 

12 (5)). Under such plan the Secretary shall— 

13 ‘‘(i) address how measures used by 

14 private payers and integrated delivery sys15 tems could be incorporated under title 

16 XVIII; 

17 ‘‘(ii) describe how coordination, to the 

18 extent possible, will occur across organiza19 tions developing such measures; and 

20 ‘‘(iii) take into account how clinical 

21 best practices and clinical practice guide22 lines should be used in the development of 

23 quality measures. 


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1 ‘‘(B) QUALITY DOMAINS.—For purposes of 

2 this subsection, the term ‘quality domains’ 

3 means at least the following domains: 

4 ‘‘(i) Clinical care. 

5 ‘‘(ii) Safety. 

6 ‘‘(iii) Care coordination. 

7 ‘‘(iv) Patient and caregiver experience. 

8 ‘‘(v) Population health and preven9 tion. 

10 ‘‘(C) CONSIDERATION.—In developing the 

11 draft plan under this paragraph, the Secretary 

12 shall consider— 

13 ‘‘(i) gap analyses conducted by the en14 tity with a contract under section 1890(a) 

15 or other contractors or entities; 

16 ‘‘(ii) whether measures are applicable 

17 across health care settings; 

18 ‘‘(iii) clinical practice improvement ac19 tivities submitted under subsection 

20 (q)(2)(C)(iv) for identifying possible areas 

21 for future measure development and identi22 fying existing gaps with respect to such 

23 measures; and 

24 ‘‘(iv) the quality domains applied 

25 under this subsection. 


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1 ‘‘(D) PRIORITIES.—In developing the draft 

2 plan under this paragraph, the Secretary shall 

3 give priority to the following types of measures: 

4 ‘‘(i) Outcome measures, including pa5 tient reported outcome and functional sta6 tus measures. 

7 ‘‘(ii) Patient experience measures. 

8 ‘‘(iii) Care coordination measures. 

9 ‘‘(iv) Measures of appropriate use of 

10 services, including measures of over use. 

11 ‘‘(E) STAKEHOLDER INPUT.—The Sec12 retary shall accept through March 1, 2015, 

13 comments on the draft plan posted under para14 graph (1)(A) from the public, including health 

15 care providers, payers, consumers, and other 

16 stakeholders. 

17 ‘‘(F) FINAL MEASURE DEVELOPMENT

18 PLAN.—Not later than May 1, 2015, taking 

19 into account the comments received under this 

20 subparagraph, the Secretary shall finalize the 

21 plan and post on the Internet website of the 

22 Centers for Medicare & Medicaid Services an 

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1 sions. Such plan shall be updated as appro2 priate. 

3 ‘‘(2) CONTRACTS AND OTHER ARRANGEMENTS

4 FOR QUALITY MEASURE DEVELOPMENT.— 

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

6 enter into contracts or other arrangements with 

7 entities for the purpose of developing, improv8 ing, updating, or expanding in accordance with 

9 the plan under paragraph (1) quality measures 

10 for application under the applicable provisions. 

11 Such entities shall include organizations with 

12 quality measure development expertise. 

13 ‘‘(B) PRIORITIZATION.— 

14 ‘‘(i) IN GENERAL.—In entering into 

15 contracts or other arrangements under 

16 subparagraph (A), the Secretary shall give 

17 priority to the development of the types of 

18 measures described in paragraph (1)(D). 

19 ‘‘(ii) CONSIDERATION.—In selecting 

20 measures for development under this sub21 section, the Secretary shall consider— 

22 ‘‘(I) whether such measures 

23 would be electronically specified; and 


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1 ‘‘(II) clinical practice guidelines 

2 to the extent that such guidelines 

3 exist. 

4 ‘‘(3) ANNUAL REPORT BY THE SECRETARY.— 

5 ‘‘(A) IN GENERAL.—Not later than May 1, 

6 2016, and annually thereafter, the Secretary 

7 shall post on the Internet website of the Cen8 ters for Medicare & Medicaid Services a report 

9 on the progress made in developing quality 

10 measures for application under the applicable 

11 provisions. 

12 ‘‘(B) REQUIREMENTS.—Each report sub13 mitted pursuant to subparagraph (A) shall in14 clude the following: 

15 ‘‘(i) A description of the Secretary’s 

16 efforts to implement this paragraph. 

17 ‘‘(ii) With respect to the measures de18 veloped during the previous year— 

19 ‘‘(I) a description of the total 

20 number of quality measures developed 

21 and the types of such measures, such 

22 as an outcome or patient experience 

23 measure; 

24 ‘‘(II) the name of each measure 

25 developed; 


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1 ‘‘(III) the name of the developer 

2 and steward of each measure; 

3 ‘‘(IV) with respect to each type 

4 of measure, an estimate of the total 

5 amount expended under this title to 

6 develop all measures of such type; and 

7 ‘‘(V) whether the measure would 

8 be electronically specified. 

9 ‘‘(iii) With respect to measures in de10 velopment at the time of the report— 

11 ‘‘(I) the information described in 

12 clause (ii), if available; and 

13 ‘‘(II) a timeline for completion of 

14 the development of such measures. 

15 ‘‘(iv) A description of any updates to 

16 the plan under paragraph (1) (including 

17 newly identified gaps and the status of pre18 viously identified gaps) and the inventory 

19 of measures applicable under the applicable 

20 provisions. 

21 ‘‘(v) Other information the Secretary 

22 determines to be appropriate. 

23 ‘‘(4) STAKEHOLDER INPUT.—With respect to 

24 paragraph (1), the Secretary shall seek stakeholder 

25 input with respect to— 


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1 ‘‘(A) the identification of gaps where no 

2 quality measures exist, particularly with respect 

3 to the types of measures described in paragraph 

4 (1)(D); 

5 ‘‘(B) prioritizing quality measure develop6 ment to address such gaps; and 

7 ‘‘(C) other areas related to quality measure 

8 development determined appropriate by the Sec9 retary. 

10 ‘‘(5) DEFINITION OF APPLICABLE PROVI11 SIONS.—In this subsection, the term ‘applicable pro12 visions’ means the following provisions: 

13 ‘‘(A) Subsection (q)(2)(B)(i). 

14 ‘‘(B) Section 1833(z)(2)(C). 

15 ‘‘(6) FUNDING.—For purposes of carrying out 

16 this subsection, the Secretary shall provide for the 

17 transfer, from the Federal Supplementary Medical 

18 Insurance Trust Fund under section 1841, of 

19 $15,000,000 to the Centers for Medicare & Medicaid 

20 Services Program Management Account for each of 

21 fiscal years 2014 through 2018. Amounts trans22 ferred under this paragraph shall remain available 

23 through the end of fiscal year 2021.’’. 


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1 SEC. 103. ENCOURAGING CARE MANAGEMENT FOR INDI2 VIDUALS WITH CHRONIC CARE NEEDS. 

3 (a) IN GENERAL.—Section 1848(b) of the Social Se4 curity Act (42 U.S.C. 1395w–4(b)) is amended by adding 

5 at the end the following new paragraph: 

6 ‘‘(8) ENCOURAGING CARE MANAGEMENT FOR

7 INDIVIDUALS WITH CHRONIC CARE NEEDS.— 

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

9 the management of care by an applicable pro10 vider (as defined in subparagraph (B)) for indi11 viduals with chronic care needs the Secretary 

12 shall— 

13 ‘‘(i) establish one or more HCPCS 

14 codes for chronic care management serv15 ices for such individuals; and 

16 ‘‘(ii) subject to subparagraph (D), 

17 make payment (as the Secretary deter18 mines to be appropriate) under this section 

19 for such management services furnished on 

20 or after January 1, 2015, by an applicable 

21 provider. 

22 ‘‘(B) APPLICABLE PROVIDER DEFINED.— 

23 For purposes of this paragraph, the term ‘ap24 plicable provider’ means a physician (as defined 

25 in section 1861(r)(1)), physician assistant or 

26 nurse practitioner (as defined in section 


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1 1861(aa)(5)(A)), or clinical nurse specialist (as 

2 defined in section 1861(aa)(5)(B)) who fur3 nishes services as part of a patient-centered 

4 medical home or a comparable specialty practice 

5 that— 

6 ‘‘(i) is recognized as such a medical 

7 home or comparable specialty practice by 

8 an organization that is recognized by the 

9 Secretary for purposes of such recognition 

10 as such a medical home or practice; or 

11 ‘‘(ii) meets such other comparable 

12 qualifications as the Secretary determines 

13 to be appropriate. 

14 ‘‘(C) BUDGET NEUTRALITY.—The budget 

15 neutrality provision under subsection 

16 (c)(2)(B)(ii)(II) shall apply in establishing the 

17 payment under subparagraph (A)(ii). 

18 ‘‘(D) POLICIES RELATING TO PAYMENT.— 

19 In carrying out this paragraph, with respect to 

20 chronic care management services, the Sec21 retary shall— 

22 ‘‘(i) make payment to only one appli23 cable provider for such services furnished 

24 to an individual during a period; 


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1 ‘‘(ii) not make payment under sub2 paragraph (A) if such payment would be 

3 duplicative of payment that is otherwise 

4 made under this title for such services 

5 (such as in the case of hospice care or 

6 home health services); and 

7 ‘‘(iii) not require that an annual 

8 wellness visit (as defined in section 

9 1861(hhh)) or an initial preventive phys10 ical examination (as defined in section 

11 1861(ww)) be furnished as a condition of 

12 payment for such management services.’’. 

13 (b) EDUCATION AND OUTREACH.— 

14 (1) CAMPAIGN.— 

15 (A) IN GENERAL.—The Secretary of 

16 Health and Human Services (in this subsection 

17 referred to as the ‘‘Secretary’’) shall conduct an 

18 education and outreach campaign to inform 

19 professionals who furnish items and services 

20 under part B of title XVIII of the Social Secu21 rity Act and individuals enrolled under such 

22 part of the benefits of chronic care management 

23 services described in section 1848(b)(8) of the 

24 Social Security Act, as added by subsection (a), 


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1 and encourage such individuals with chronic 

2 care needs to receive such services. 

3 (B) REQUIREMENTS.—Such campaign 

4 shall— 

5 (i) be directed by the Office of Rural 

6 Health Policy of the Department of Health 

7 and Human Services and the Office of Mi8 nority Health of the Centers for Medicare 

9 & Medicaid Services; and 

10 (ii) focus on encouraging participation 

11 by underserved rural populations and ra12 cial and ethnic minority populations. 

13 (2) REPORT.— 

14 (A) IN GENERAL.—Not later than Decem15 ber 31, 2017, the Secretary shall submit to 

16 Congress a report on the use of chronic care 

17 management services described in such section 

18 1848(b)(8) by individuals living in rural areas 

19 and by racial and ethnic minority populations. 

20 Such report shall— 

21 (i) identify barriers to receiving chron22 ic care management services; and 

23 (ii) make recommendations for in24 creasing the appropriate use of chronic 

25 care management services. 


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1 SEC. 104. ENSURING ACCURATE VALUATION OF SERVICES 

2 UNDER THE PHYSICIAN FEE SCHEDULE. 

3 (a) AUTHORITY TO COLLECT AND USE INFORMA4 TION ON PHYSICIANS’ SERVICES IN THE DETERMINATION

5 OF RELATIVE VALUES.— 

6 (1) IN GENERAL.—Section 1848(c)(2) of the 

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

8 amended by adding at the end the following new 

9 subparagraph: 

10 ‘‘(M) AUTHORITY TO COLLECT AND USE

11 INFORMATION ON PHYSICIANS’ SERVICES IN

12 THE DETERMINATION OF RELATIVE VALUES.— 

13 ‘‘(i) COLLECTION OF INFORMATION.— 

14 Notwithstanding any other provision of 

15 law, the Secretary may collect or obtain in16 formation on the resources directly or indi17 rectly related to furnishing services for 

18 which payment is made under the fee 

19 schedule established under subsection (b). 

20 Such information may be collected or ob21 tained from any eligible professional or any 

22 other source. 

23 ‘‘(ii) USE OF INFORMATION.—Not24 withstanding any other provision of law, 

25 subject to clause (v), the Secretary may 

26 (as the Secretary determines appropriate) 


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1 use information collected or obtained pur2 suant to clause (i) in the determination of 

3 relative values for services under this sec4 tion. 

5 ‘‘(iii) TYPES OF INFORMATION.—The 

6 types of information described in clauses 

7 (i) and (ii) may, at the Secretary’s discre8 tion, include any or all of the following: 

9 ‘‘(I) Time involved in furnishing 

10 services. 

11 ‘‘(II) Amounts and types of prac12 tice expense inputs involved with fur13 nishing services. 

14 ‘‘(III) Prices (net of any dis15 counts) for practice expense inputs, 

16 which may include paid invoice prices 

17 or other documentation or records. 

18 ‘‘(IV) Overhead and accounting 

19 information for practices of physicians 

20 and other suppliers. 

21 ‘‘(V) Any other element that 

22 would improve the valuation of serv23 ices under this section. 

24 ‘‘(iv) INFORMATION COLLECTION

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1 lected or obtained pursuant to this sub2 paragraph from any or all of the following: 

3 ‘‘(I) Surveys of physicians, other 

4 suppliers, providers of services, manu5 facturers, and vendors. 

6 ‘‘(II) Surgical logs, billing sys7 tems, or other practice or facility 

8 records. 

9 ‘‘(III) Electronic health records. 

10 ‘‘(IV) Any other mechanism de11 termined appropriate by the Sec12 retary. 

13 ‘‘(v) TRANSPARENCY OF USE OF IN14 FORMATION.— 

15 ‘‘(I) IN GENERAL.—Subject to 

16 subclauses (II) and (III), if the Sec17 retary uses information collected or 

18 obtained under this subparagraph in 

19 the determination of relative values 

20 under this subsection, the Secretary 

21 shall disclose the information source 

22 and discuss the use of such informa23 tion in such determination of relative 

24 values through notice and comment 

25 rulemaking. 


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1 ‘‘(II) THRESHOLDS FOR USE.— 

2 The Secretary may establish thresh3 olds in order to use such information, 

4 including the exclusion of information 

5 collected or obtained from eligible pro6 fessionals who use very high resources 

7 (as determined by the Secretary) in 

8 furnishing a service. 

9 ‘‘(III) DISCLOSURE OF INFORMA10 TION.—The Secretary shall make ag11 gregate information available under 

12 this subparagraph but shall not dis13 close information in a form or manner 

14 that identifies an eligible professional 

15 or a group practice, or information 

16 collected or obtained pursuant to a 

17 nondisclosure agreement. 

18 ‘‘(vi) INCENTIVE TO PARTICIPATE.— 

19 The Secretary may provide for such pay20 ments under this part to an eligible profes21 sional that submits such solicited informa22 tion under this subparagraph as the Sec23 retary determines appropriate in order to 

24 compensate such eligible professional for 

25 such submission. Such payments shall be 


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1 provided in a form and manner specified 

2 by the Secretary. 

3 ‘‘(vii) ADMINISTRATION.—Chapter 35 

4 of title 44, United States Code, shall not 

5 apply to information collected or obtained 

6 under this subparagraph. 

7 ‘‘(viii) DEFINITION OF ELIGIBLE PRO8 FESSIONAL.—In this subparagraph, the 

9 term ‘eligible professional’ has the meaning 

10 given such term in subsection (k)(3)(B). 

11 ‘‘(ix) FUNDING.—For purposes of car12 rying out this subparagraph, in addition to 

13 funds otherwise appropriated, the Sec14 retary shall provide for the transfer, from 

15 the Federal Supplementary Medical Insur16 ance Trust Fund under section 1841, of 

17 $2,000,000 to the Centers for Medicare & 

18 Medicaid Services Program Management 

19 Account for each fiscal year beginning with 

20 fiscal year 2014. Amounts transferred 

21 under the preceding sentence for a fiscal 

22 year shall be available until expended.’’. 

23 (2) LIMITATION ON REVIEW.—Section 

24 1848(i)(1) of the Social Security Act (42 U.S.C. 

25 1395w–4(i)(1)) is amended— 


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1 (A) in subparagraph (D), by striking 

2 ‘‘and’’ at the end; 

3 (B) in subparagraph (E), by striking the 

4 period at the end and inserting ‘‘, and’’; and 

5 (C) by adding at the end the following new 

6 subparagraph: 

7 ‘‘(F) the collection and use of information 

8 in the determination of relative values under 

9 subsection (c)(2)(M).’’. 

10 (b) AUTHORITY FOR ALTERNATIVE APPROACHES TO

11 ESTABLISHING PRACTICE EXPENSE RELATIVE VAL12 UES.—Section 1848(c)(2) of the Social Security Act (42 

13 U.S.C. 1395w–4(c)(2)), as amended by subsection (a), is 

14 amended by adding at the end the following new subpara15 graph: 

16 ‘‘(N) AUTHORITY FOR ALTERNATIVE AP17 PROACHES TO ESTABLISHING PRACTICE EX18 PENSE RELATIVE VALUES.—The Secretary may 

19 establish or adjust practice expense relative val20 ues under this subsection using cost, charge, or 

21 other data from suppliers or providers of serv22 ices, including information collected or obtained 

23 under subparagraph (M).’’. 

24 (c) REVISED AND EXPANDED IDENTIFICATION OF

25 POTENTIALLY MISVALUED CODES.—Section 


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1 1848(c)(2)(K)(ii) of the Social Security Act (42 U.S.C. 

2 1395w–4(c)(2)(K)(ii)) is amended to read as follows: 

3 ‘‘(ii) IDENTIFICATION OF POTEN4 TIALLY MISVALUED CODES.—For purposes 

5 of identifying potentially misvalued codes 

6 pursuant to clause (i)(I), the Secretary 

7 shall examine codes (and families of codes 

8 as appropriate) based on any or all of the 

9 following criteria: 

10 ‘‘(I) Codes that have experienced 

11 the fastest growth. 

12 ‘‘(II) Codes that have experi13 enced substantial changes in practice 

14 expenses. 

15 ‘‘(III) Codes that describe new 

16 technologies or services within an ap17 propriate time period (such as 3 

18 years) after the relative values are ini19 tially established for such codes. 

20 ‘‘(IV) Codes which are multiple 

21 codes that are frequently billed in con22 junction with furnishing a single serv23 ice. 

24 ‘‘(V) Codes with low relative val25 ues, particularly those that are often 


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1 billed multiple times for a single treat2 ment. 

3 ‘‘(VI) Codes that have not been 

4 subject to review since implementation 

5 of the fee schedule. 

6 ‘‘(VII) Codes that account for 

7 the majority of spending under the 

8 physician fee schedule. 

9 ‘‘(VIII) Codes for services that 

10 have experienced a substantial change 

11 in the hospital length of stay or proce12 dure time. 

13 ‘‘(IX) Codes for which there may 

14 be a change in the typical site of serv15 ice since the code was last valued. 

16 ‘‘(X) Codes for which there is a 

17 significant difference in payment for 

18 the same service between different 

19 sites of service. 

20 ‘‘(XI) Codes for which there may 

21 be anomalies in relative values within 

22 a family of codes. 

23 ‘‘(XII) Codes for services where 

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1 ice is furnished at the same time as 

2 other services. 

3 ‘‘(XIII) Codes with high intra4 service work per unit of time. 

5 ‘‘(XIV) Codes with high practice 

6 expense relative value units. 

7 ‘‘(XV) Codes with high cost sup8 plies. 

9 ‘‘(XVI) Codes as determined ap10 propriate by the Secretary.’’. 

11 (d) TARGET FOR RELATIVE VALUE ADJUSTMENTS

12 FOR MISVALUED SERVICES.— 

13 (1) IN GENERAL.—Section 1848(c)(2) of the 

14 Social Security Act (42 U.S.C. 1395w–4(c)(2)), as 

15 amended by subsections (a) and (b), is amended by 

16 adding at the end the following new subparagraph: 

17 ‘‘(O) TARGET FOR RELATIVE VALUE AD18 JUSTMENTS FOR MISVALUED SERVICES.—With 

19 respect to fee schedules established for each of 

20 2015 through 2018, the following shall apply: 

21 ‘‘(i) DETERMINATION OF NET REDUC22 TION IN EXPENDITURES.—For each year, 

23 the Secretary shall determine the esti24 mated net reduction in expenditures under 

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1 spect to the year as a result of adjust2 ments to the relative values established 

3 under this paragraph for misvalued codes. 

4 ‘‘(ii) BUDGET NEUTRAL REDISTRIBU5 TION OF FUNDS IF TARGET MET AND

6 COUNTING OVERAGES TOWARDS THE TAR7 GET FOR THE SUCCEEDING YEAR.—If the 

8 estimated net reduction in expenditures de9 termined under clause (i) for the year is 

10 equal to or greater than the target for the 

11 year— 

12 ‘‘(I) reduced expenditures attrib13 utable to such adjustments shall be 

14 redistributed for the year in a budget 

15 neutral manner in accordance with 

16 subparagraph (B)(ii)(II); and 

17 ‘‘(II) the amount by which such 

18 reduced expenditures exceeds the tar19 get for the year shall be treated as a 

20 reduction in expenditures described in 

21 clause (i) for the succeeding year, for 

22 purposes of determining whether the 

23 target has or has not been met under 

24 this subparagraph with respect to that 

25 year. 


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1 ‘‘(iii) EXEMPTION FROM BUDGET

2 NEUTRALITY IF TARGET NOT MET.—If the 

3 estimated net reduction in expenditures de4 termined under clause (i) for the year is 

5 less than the target for the year, reduced 

6 expenditures in an amount equal to the 

7 target recapture amount shall not be taken 

8 into account in applying subparagraph 

9 (B)(ii)(II) with respect to fee schedules be10 ginning with 2015. 

11 ‘‘(iv) TARGET RECAPTURE AMOUNT.— 

12 For purposes of clause (iii), the target re13 capture amount is, with respect to a year, 

14 an amount equal to the difference be15 tween— 

16 ‘‘(I) the target for the year; and 

17 ‘‘(II) the estimated net reduction 

18 in expenditures determined under 

19 clause (i) for the year. 

20 ‘‘(v) TARGET.—For purposes of this 

21 subparagraph, with respect to a year, the 

22 target is calculated as 0.5 percent of the 

23 estimated amount of expenditures under 

24 the fee schedule under this section for the 

25 year.’’. 


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1 (2) CONFORMING AMENDMENT.—Section 

2 1848(c)(2)(B)(v) of the Social Security Act (42 

3 U.S.C. 1395w–4(c)(2)(B)(v)) is amended by adding 

4 at the end the following new subclause: 

5 ‘‘(VIII) REDUCTIONS FOR

6 MISVALUED SERVICES IF TARGET NOT

7 MET.—Effective for fee schedules be8 ginning with 2015, reduced expendi9 tures attributable to the application of 

10 the target recapture amount described 

11 in subparagraph (O)(iii).’’. 

12 (e) PHASE-IN OF SIGNIFICANT RELATIVE VALUE

13 UNIT (RVU) REDUCTIONS.— 

14 (1) IN GENERAL.—Section 1848(c) of the So15 cial Security Act (42 U.S.C. 1395w–4(c)) is amend16 ed by adding at the end the following new para17 graph: 

18 ‘‘(7) PHASE-IN OF SIGNIFICANT RELATIVE

19 VALUE UNIT (RVU) REDUCTIONS.—Effective for fee 

20 schedules established beginning with 2015, if the 

21 total relative value units for a service for a year 

22 would otherwise be decreased by an estimated 

23 amount equal to or greater than 20 percent as com24 pared to the total relative value units for the pre25 vious year, the applicable adjustments in work, pracVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00146 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 tice expense, and malpractice relative value units 

2 shall be phased-in over a 2-year period.’’. 

3 (2) CONFORMING AMENDMENTS.—Section 

4 1848(c)(2) of the Social Security Act (42 U.S.C. 

5 1395w–4(c)(2)) is amended— 

6 (A) in subparagraph (B)(ii)(I), by striking 

7 ‘‘subclause (II)’’ and inserting ‘‘subclause (II) 

8 and paragraph (7)’’; and 

9 (B) in subparagraph (K)(iii)(VI)— 

10 (i) by striking ‘‘provisions of subpara11 graph (B)(ii)(II)’’ and inserting ‘‘provi12 sions of subparagraph (B)(ii)(II) and para13 graph (7)’’; and 

14 (ii) by striking ‘‘under subparagraph 

15 (B)(ii)(II)’’ and inserting ‘‘under subpara16 graph (B)(ii)(I)’’. 

17 (f) AUTHORITY TO SMOOTH RELATIVE VALUES

18 WITHIN GROUPS OF SERVICES.—Section 1848(c)(2)(C) of 

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

20 amended— 

21 (1) in each of clauses (i) and (iii), by striking 

22 ‘‘the service’’ and inserting ‘‘the service or group of 

23 services’’ each place it appears; and 

24 (2) in the first sentence of clause (ii), by insert25 ing ‘‘or group of services’’ before the period. 


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1 (g) GAO STUDY AND REPORT ON RELATIVE VALUE

2 SCALE UPDATE COMMITTEE.— 

3 (1) STUDY.—The Comptroller General of the 

4 United States (in this subsection referred to as the 

5 ‘‘Comptroller General’’) shall conduct a study of the 

6 processes used by the Relative Value Scale Update 

7 Committee (RUC) to provide recommendations to 

8 the Secretary of Health and Human Services regard9 ing relative values for specific services under the 

10 Medicare physician fee schedule under section 1848 

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

12 (2) REPORT.—Not later than 1 year after the 

13 date of the enactment of this Act, the Comptroller 

14 General shall submit to Congress a report containing 

15 the results of the study conducted under paragraph 

16 (1). 

17 (h) ADJUSTMENT TO MEDICARE PAYMENT LOCAL18 ITIES.— 

19 (1) IN GENERAL.—Section 1848(e) of the So20 cial Security Act (42 U.S.C. 1395w–4(e)) is amend21 ed by adding at the end the following new para22 graph: 

23 ‘‘(6) USE OF MSAS AS FEE SCHEDULE AREAS IN

24 CALIFORNIA.— 


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1 ‘‘(A) IN GENERAL.—Subject to the suc2 ceeding provisions of this paragraph and not3 withstanding the previous provisions of this 

4 subsection, for services furnished on or after 

5 January 1, 2017, the fee schedule areas used 

6 for payment under this section applicable to 

7 California shall be the following: 

8 ‘‘(i) Each Metropolitan Statistical 

9 Area (each in this paragraph referred to as 

10 an ‘MSA’), as defined by the Director of 

11 the Office of Management and Budget as 

12 of December 31 of the previous year, shall 

13 be a fee schedule area. 

14 ‘‘(ii) All areas not included in an MSA 

15 shall be treated as a single rest-of-State 

16 fee schedule area. 

17 ‘‘(B) TRANSITION FOR MSAS PREVIOUSLY

18 IN REST-OF-STATE PAYMENT LOCALITY OR IN

19 LOCALITY 3.— 

20 ‘‘(i) IN GENERAL.—For services fur21 nished in California during a year begin22 ning with 2017 and ending with 2021 in 

23 an MSA in a transition area (as defined in 

24 subparagraph (D)), subject to subpara25 graph (C), the geographic index values to 


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1 be applied under this subsection for such 

2 year shall be equal to the sum of the fol3 lowing: 

4 ‘‘(I) CURRENT LAW COMPO5 NENT.—The old weighting factor (de6 scribed in clause (ii)) for such year 

7 multiplied by the geographic index 

8 values under this subsection for the 

9 fee schedule area that included such 

10 MSA that would have applied in such 

11 area (as estimated by the Secretary) 

12 if this paragraph did not apply. 

13 ‘‘(II) MSA-BASED COMPO14 NENT.—The MSA-based weighting 

15 factor (described in clause (iii)) for 

16 such year multiplied by the geographic 

17 index values computed for the fee 

18 schedule area under subparagraph (A) 

19 for the year (determined without re20 gard to this subparagraph). 

21 ‘‘(ii) OLD WEIGHTING FACTOR.—The 

22 old weighting factor described in this 

23 clause— 

‘‘(I) for 2017, is 5 24 ⁄6; and 


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1 ‘‘(II) for each succeeding year, is 

2 the old weighting factor described in 

3 this clause for the previous year 

minus 1 4 ⁄6. 

5 ‘‘(iii) MSA-BASED WEIGHTING FAC6 TOR.—The MSA-based weighting factor 

7 described in this clause for a year is 1 

8 minus the old weighting factor under 

9 clause (ii) for that year. 

10 ‘‘(C) HOLD HARMLESS.—For services fur11 nished in a transition area in California during 

12 a year beginning with 2017, the geographic 

13 index values to be applied under this subsection 

14 for such year shall not be less than the cor15 responding geographic index values that would 

16 have applied in such transition area (as esti17 mated by the Secretary) if this paragraph did 

18 not apply. 

19 ‘‘(D) TRANSITION AREA DEFINED.—In 

20 this paragraph, the term ‘transition area’ 

21 means each of the following fee schedule areas 

22 for 2013: 

23 ‘‘(i) The rest-of-State payment local24 ity. 

25 ‘‘(ii) Payment locality 3. 


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1 ‘‘(E) REFERENCES TO FEE SCHEDULE

2 AREAS.—Effective for services furnished on or 

3 after January 1, 2017, for California, any ref4 erence in this section to a fee schedule area 

5 shall be deemed a reference to a fee schedule 

6 area established in accordance with this para7 graph.’’. 

8 (2) CONFORMING AMENDMENT TO DEFINITION

9 OF FEE SCHEDULE AREA.—Section 1848(j)(2) of the 

10 Social Security Act (42 U.S.C. 1395w–4(j)(2)) is 

11 amended by striking ‘‘The term’’ and inserting ‘‘Ex12 cept as provided in subsection (e)(6)(D), the term’’. 

13 (i) DISCLOSURE OF DATA USED TO ESTABLISH

14 MULTIPLE PROCEDURE PAYMENT REDUCTION POLICY.— 

15 The Secretary of Health and Human Services shall make 

16 publicly available the information used to establish the 

17 multiple procedure payment reduction policy to the profes18 sional component of imaging services in the final rule pub19 lished in the Federal Register, v. 77, n. 222, November 

20 16, 2012, pages 68891–69380 under the physician fee 

21 schedule under section 1848 of the Social Security Act (42 

22 U.S.C. 1395w–4). 


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1 SEC. 105. PROMOTING EVIDENCE-BASED CARE. 

2 (a) IN GENERAL.—Section 1834 of the Social Secu3 rity Act (42 U.S.C. 1395m) is amended by adding at the 

4 end the following new subsection: 

5 ‘‘(p) RECOGNIZING APPROPRIATE USE CRITERIA FOR

6 CERTAIN IMAGING SERVICES.— 

7 ‘‘(1) PROGRAM ESTABLISHED.— 

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

9 establish a program to promote the use of ap10 propriate use criteria (as defined in subpara11 graph (B)) for applicable imaging services (as 

12 defined in subparagraph (C)) furnished in an 

13 applicable setting (as defined in subparagraph 

14 (D)) by ordering professionals and furnishing 

15 professionals (as defined in subparagraphs (E) 

16 and (F), respectively). 

17 ‘‘(B) APPROPRIATE USE CRITERIA DE18 FINED.—In this subsection, the term ‘appro19 priate use criteria’ means criteria, only devel20 oped or endorsed by national professional med21 ical specialty societies or other provider-led enti22 ties, to assist ordering professionals and fur23 nishing professionals in making the most appro24 priate treatment decision for a specific clinical 

25 condition. To the extent feasible, such criteria 

26 shall be evidence-based. 


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1 ‘‘(C) APPLICABLE IMAGING SERVICE DE2 FINED.—In this subsection, the term ‘applicable 

3 imaging service’ means an advanced diagnostic 

4 imaging service (as defined in subsection 

5 (e)(1)(B)) for which the Secretary determines— 

6 ‘‘(i) one or more applicable appro7 priate use criteria specified under para8 graph (2) apply; 

9 ‘‘(ii) there are one or more qualified 

10 clinical decision support mechanisms listed 

11 under paragraph (3)(C); and 

12 ‘‘(iii) one or more of such mechanisms 

13 is available free of charge. 

14 ‘‘(D) APPLICABLE SETTING DEFINED.—In 

15 this subsection, the term ‘applicable setting’ 

16 means a physician’s office, a hospital outpatient 

17 department (including an emergency depart18 ment), an ambulatory surgical center, and any 

19 other provider-led outpatient setting determined 

20 appropriate by the Secretary. 

21 ‘‘(E) ORDERING PROFESSIONAL DE22 FINED.—In this subsection, the term ‘ordering 

23 professional’ means a physician (as defined in 

24 section 1861(r)) or a practitioner described in 


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1 section 1842(b)(18)(C) who orders an applica2 ble imaging service for an individual. 

3 ‘‘(F) FURNISHING PROFESSIONAL DE4 FINED.—In this subsection, the term ‘fur5 nishing professional’ means a physician (as de6 fined in section 1861(r)) or a practitioner de7 scribed in section 1842(b)(18)(C) who furnishes 

8 an applicable imaging service for an individual. 

9 ‘‘(2) ESTABLISHMENT OF APPLICABLE APPRO10 PRIATE USE CRITERIA.— 

11 ‘‘(A) IN GENERAL.—Not later than No12 vember 15, 2015, the Secretary shall through 

13 rulemaking, and in consultation with physi14 cians, practitioners, and other stakeholders, 

15 specify applicable appropriate use criteria for 

16 applicable imaging services only from among 

17 appropriate use criteria developed or endorsed 

18 by national professional medical specialty soci19 eties or other provider-led entities. 

20 ‘‘(B) CONSIDERATIONS.—In specifying ap21 plicable appropriate use criteria under subpara22 graph (A), the Secretary shall take into account 

23 whether the criteria— 

24 ‘‘(i) have stakeholder consensus; 


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1 ‘‘(ii) are scientifically valid and evi2 dence based; and 

3 ‘‘(iii) are based on studies that are 

4 published and reviewable by stakeholders. 

5 ‘‘(C) REVISIONS.—The Secretary shall re6 view, on an annual basis, the specified applica7 ble appropriate use criteria to determine if 

8 there is a need to update or revise (as appro9 priate) such specification of applicable appro10 priate use criteria and make such updates or 

11 revisions through rulemaking. 

12 ‘‘(D) TREATMENT OF MULTIPLE APPLICA13 BLE APPROPRIATE USE CRITERIA.—In the case 

14 where the Secretary determines that more than 

15 one appropriate use criteria applies with respect 

16 to an applicable imaging service, the Secretary 

17 shall permit one or more applicable appropriate 

18 use criteria under this paragraph for the serv19 ice. 

20 ‘‘(3) MECHANISMS FOR CONSULTATION WITH

21 APPLICABLE APPROPRIATE USE CRITERIA.— 

22 ‘‘(A) IDENTIFICATION OF MECHANISMS TO

23 CONSULT WITH APPLICABLE APPROPRIATE USE

24 CRITERIA.— 


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1 ‘‘(i) IN GENERAL.—The Secretary 

2 shall specify qualified clinical decision sup3 port mechanisms that could be used by or4 dering professionals to consult with appli5 cable appropriate use criteria for applicable 

6 imaging services. 

7 ‘‘(ii) CONSULTATION.—The Secretary 

8 shall consult with physicians, practitioners, 

9 health care technology experts, and other 

10 stakeholders in specifying mechanisms 

11 under this paragraph. 

12 ‘‘(iii) INCLUSION OF CERTAIN MECHA13 NISMS.—Mechanisms specified under this 

14 paragraph may include any or all of the 

15 following that meet the requirements de16 scribed in subparagraph (B)(ii): 

17 ‘‘(I) Use of clinical decision sup18 port modules in certified EHR tech19 nology (as defined in section 

20 1848(o)(4)). 

21 ‘‘(II) Use of private sector clin22 ical decision support mechanisms that 

23 are independent from certified EHR 

24 technology, which may include use of 

25 clinical decision support mechanisms 


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1 available from medical specialty orga2 nizations. 

3 ‘‘(III) Use of a clinical decision 

4 support mechanism established by the 

5 Secretary. 

6 ‘‘(B) QUALIFIED CLINICAL DECISION SUP7 PORT MECHANISMS.— 

8 ‘‘(i) IN GENERAL.—For purposes of 

9 this subsection, a qualified clinical decision 

10 support mechanism is a mechanism that 

11 the Secretary determines meets the re12 quirements described in clause (ii). 

13 ‘‘(ii) REQUIREMENTS.—The require14 ments described in this clause are the fol15 lowing: 

16 ‘‘(I) The mechanism makes avail17 able to the ordering professional appli18 cable appropriate use criteria specified 

19 under paragraph (2) and the sup20 porting documentation for the applica21 ble imaging service ordered. 

22 ‘‘(II) In the case where there are 

23 more than one applicable appropriate 

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1 ice, the mechanism indicates the cri2 teria that it uses for the service. 

3 ‘‘(III) The mechanism determines 

4 the extent to which an applicable im5 aging service ordered is consistent 

6 with the applicable appropriate use 

7 criteria so specified. 

8 ‘‘(IV) The mechanism generates 

9 and provides to the ordering profes10 sional a certification or documentation 

11 that documents that the qualified clin12 ical decision support mechanism was 

13 consulted by the ordering professional. 

14 ‘‘(V) The mechanism is updated 

15 on a timely basis to reflect revisions 

16 to the specification of applicable ap17 propriate use criteria under such 

18 paragraph. 

19 ‘‘(VI) The mechanism meets pri20 vacy and security standards under ap21 plicable provisions of law. 

22 ‘‘(VII) The mechanism performs 

23 such other functions as specified by 

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1 quirement to provide aggregate feed2 back to the ordering professional. 

3 ‘‘(C) LIST OF MECHANISMS FOR CON4 SULTATION WITH APPLICABLE APPROPRIATE

5 USE CRITERIA.— 

6 ‘‘(i) INITIAL LIST.—Not later than 

7 April 1, 2016, the Secretary shall publish 

8 a list of mechanisms specified under this 

9 paragraph. 

10 ‘‘(ii) PERIODIC UPDATING OF LIST.— 

11 The Secretary shall identify on an annual 

12 basis the list of qualified clinical decision 

13 support mechanisms specified under this 

14 paragraph. 

15 ‘‘(4) CONSULTATION WITH APPLICABLE APPRO16 PRIATE USE CRITERIA.— 

17 ‘‘(A) CONSULTATION BY ORDERING PRO18 FESSIONAL.—Beginning with January 1, 2017, 

19 subject to subparagraph (C), with respect to an 

20 applicable imaging service ordered by an order21 ing professional that would be furnished in an 

22 applicable setting and paid for under an appli23 cable payment system (as defined in subpara24 graph (D)), an ordering professional shall— 


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1 ‘‘(i) consult with a qualified decision 

2 support mechanism listed under paragraph 

3 (3)(C); and 

4 ‘‘(ii) provide to the furnishing profes5 sional the information described in clauses 

6 (i) through (iii) of subparagraph (B). 

7 ‘‘(B) REPORTING BY FURNISHING PROFES8 SIONAL.—Beginning with January 1, 2017, 

9 subject to subparagraph (C), with respect to an 

10 applicable imaging service furnished in an ap11 plicable setting and paid for under an applica12 ble payment system (as defined in subpara13 graph (D)), payment for such service may only 

14 be made if the claim for the service includes the 

15 following: 

16 ‘‘(i) Information about which qualified 

17 clinical decision support mechanism was 

18 consulted by the ordering professional for 

19 the service. 

20 ‘‘(ii) Information regarding— 

21 ‘‘(I) whether the service ordered 

22 would adhere to the applicable appro23 priate use criteria specified under 

24 paragraph (2); 


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1 ‘‘(II) whether the service ordered 

2 would not adhere to such criteria; or 

3 ‘‘(III) whether such criteria was 

4 not applicable to the service ordered. 

5 ‘‘(iii) The national provider identifier 

6 of the ordering professional (if different 

7 from the furnishing professional). 

8 ‘‘(C) EXCEPTIONS.—The provisions of sub9 paragraphs (A) and (B) and paragraph (6)(A) 

10 shall not apply to the following: 

11 ‘‘(i) EMERGENCY SERVICES.—An ap12 plicable imaging service ordered for an in13 dividual with an emergency medical condi14 tion (as defined in section 1867(e)(1)). 

15 ‘‘(ii) INPATIENT SERVICES.—An appli16 cable imaging service ordered for an inpa17 tient and for which payment is made under 

18 part A. 

19 ‘‘(iii) ALTERNATIVE PAYMENT MOD20 ELS.—An applicable imaging service or21 dered by an ordering professional with re22 spect to an individual attributed to an al23 ternative payment model (as defined in 

24 section 1833(z)(3)(C)). 


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1 ‘‘(iv) SIGNIFICANT HARDSHIP.—An 

2 applicable imaging service ordered by an 

3 ordering professional who the Secretary 

4 may, on a case-by-case basis, exempt from 

5 the application of such provisions if the 

6 Secretary determines, subject to annual re7 newal, that consultation with applicable ap8 propriate use criteria would result in a sig9 nificant hardship, such as in the case of a 

10 professional who practices in a rural area 

11 without sufficient Internet access. 

12 ‘‘(D) APPLICABLE PAYMENT SYSTEM DE13 FINED.—In this subsection, the term ‘applicable 

14 payment system’ means the following: 

15 ‘‘(i) The physician fee schedule estab16 lished under section 1848(b). 

17 ‘‘(ii) The prospective payment system 

18 for hospital outpatient department services 

19 under section 1833(t). 

20 ‘‘(iii) The ambulatory surgical center 

21 payment systems under section 1833(i). 

22 ‘‘(5) IDENTIFICATION OF OUTLIER ORDERING

23 PROFESSIONALS.— 

24 ‘‘(A) IN GENERAL.—With respect to appli25 cable imaging services furnished beginning with 


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1 2017, the Secretary shall determine, on an an2 nual basis, no more than five percent of the 

3 total number of ordering professionals who are 

4 outlier ordering professionals. 

5 ‘‘(B) OUTLIER ORDERING PROFES6 SIONALS.—The determination of an outlier or7 dering professional shall— 

8 ‘‘(i) be based on low adherence to ap9 plicable appropriate use criteria specified 

10 under paragraph (2), which may be based 

11 on comparison to other ordering profes12 sionals; and 

13 ‘‘(ii) include data for ordering profes14 sionals for whom prior authorization under 

15 paragraph (6)(A) applies. 

16 ‘‘(C) USE OF TWO YEARS OF DATA.—The 

17 Secretary shall use two years of data to identify 

18 outlier ordering professionals under this para19 graph. 

20 ‘‘(D) PROCESS.—The Secretary shall es21 tablish a process for determining when an 

22 outlier ordering professional is no longer an 

23 outlier ordering professional. 

24 ‘‘(E) CONSULTATION WITH STAKE25 HOLDERS.—The Secretary shall consult with 


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1 physicians, practitioners and other stakeholders 

2 in developing methods to identify outlier order3 ing professionals under this paragraph. 

4 ‘‘(6) PRIOR AUTHORIZATION FOR ORDERING

5 PROFESSIONALS WHO ARE OUTLIERS.— 

6 ‘‘(A) IN GENERAL.—Beginning not later 

7 than January 1, 2020, subject to paragraph 

8 (4)(C), with respect to services furnished during 

9 a year, the Secretary shall, for a period deter10 mined appropriate by the Secretary, apply prior 

11 authorization for applicable imaging services 

12 that are ordered by an outlier ordering profes13 sional identified under paragraph (5). 

14 ‘‘(B) APPROPRIATE USE CRITERIA IN

15 PRIOR AUTHORIZATION.—In applying prior au16 thorization under subparagraph (A), the Sec17 retary shall utilize only the applicable appro18 priate use criteria specified under this sub19 section. 

20 ‘‘(C) FUNDING.—For purposes of carrying 

21 out this paragraph, the Secretary shall provide 

22 for the transfer, from the Federal Supple23 mentary Medical Insurance Trust Fund under 

24 section 1841, of $5,000,000 to the Centers for 

25 Medicare & Medicaid Services Program ManVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00165 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 agement Account for each of fiscal years 2019 

2 through 2021. Amounts transferred under the 

3 preceding sentence shall remain available until 

4 expended. 

5 ‘‘(7) CONSTRUCTION.—Nothing in this sub6 section shall be construed as granting the Secretary 

7 the authority to develop or initiate the development 

8 of clinical practice guidelines or appropriate use cri9 teria.’’. 

10 (b) CONFORMING AMENDMENT.—Section 

11 1833(t)(16) of the Social Security Act (42 U.S.C. 

12 1395l(t)(16)) is amended by adding at the end the fol13 lowing new subparagraph: 

14 ‘‘(E) APPLICATION OF APPROPRIATE USE

15 CRITERIA FOR CERTAIN IMAGING SERVICES.— 

16 For provisions relating to the application of ap17 propriate use criteria for certain imaging serv18 ices, see section 1834(p).’’. 

19 (c) REPORT ON EXPERIENCE OF IMAGING APPRO20 PRIATE USE CRITERIA PROGRAM.—Not later than 18 

21 months after the date of the enactment of this Act, the 

22 Comptroller General of the United States shall submit to 

23 Congress a report that includes a description of the extent 

24 to which appropriate use criteria could be used for other 

25 services under part B of title XVIII of the Social Security 


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1 Act (42 U.S.C. 1395j et seq.), such as radiation therapy 

2 and clinical diagnostic laboratory services. 

3 SEC. 106. EMPOWERING BENEFICIARY CHOICES THROUGH 

4 ACCESS TO INFORMATION ON PHYSICIANS’ 

5 SERVICES. 

6 (a) IN GENERAL.—The Secretary shall make publicly 

7 available on Physician Compare the information described 

8 in subsection (b) with respect to eligible professionals. 

9 (b) INFORMATION DESCRIBED.—The following infor10 mation, with respect to an eligible professional, is de11 scribed in this subsection: 

12 (1) Information on the number of services fur13 nished by the eligible professional under part B of 

14 title XVIII of the Social Security Act (42 U.S.C. 

15 1395j et seq.), which may include information on the 

16 most frequent services furnished or groupings of 

17 services. 

18 (2) Information on submitted charges and pay19 ments for services under such part. 

20 (3) A unique identifier for the eligible profes21 sional that is available to the public, such as a na22 tional provider identifier. 

23 (c) SEARCHABILITY.—The information made avail24 able under this section shall be searchable by at least the 

25 following: 


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1 (1) The specialty or type of the eligible profes2 sional. 

3 (2) Characteristics of the services furnished, 

4 such as volume or groupings of services. 

5 (3) The location of the eligible professional. 

6 (d) DISCLOSURE.—The information made available 

7 under this section shall indicate, where appropriate, that 

8 publicized information may not be representative of the 

9 eligible professional’s entire patient population, the variety 

10 of services furnished by the eligible professional, or the 

11 health conditions of individuals treated. 

12 (e) IMPLEMENTATION.— 

13 (1) INITIAL IMPLEMENTATION.—Physician 

14 Compare shall include the information described in 

15 subsection (b)— 

16 (A) with respect to physicians, by not later 

17 than July 1, 2015; and 

18 (B) with respect to other eligible profes19 sionals, by not later than July 1, 2016. 

20 (2) ANNUAL UPDATING.—The information 

21 made available under this section shall be updated 

22 on Physician Compare not less frequently than on 

23 an annual basis. 

24 (f) OPPORTUNITY TO REVIEW AND SUBMIT CORREC25 TIONS.—The Secretary shall provide for an opportunity 


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1 for an eligible professional to review, and submit correc2 tions for, the information to be made public with respect 

3 to the eligible professional under this section prior to such 

4 information being made public. 

5 (g) DEFINITIONS.—In this section: 

6 (1) ELIGIBLE PROFESSIONAL; PHYSICIAN; SEC7 RETARY.—The terms ‘‘eligible professional’’, ‘‘physi8 cian’’, and ‘‘Secretary’’ have the meaning given such 

9 terms in section 10331(i) of Public Law 111–148. 

10 (2) PHYSICIAN COMPARE.—The term ‘‘Physi11 cian Compare’’ means the Physician Compare Inter12 net website of the Centers for Medicare & Medicaid 

13 Services (or a successor website). 

14 SEC. 107. EXPANDING AVAILABILITY OF MEDICARE DATA. 

15 (a) EXPANDING USES OF MEDICARE DATA BY

16 QUALIFIED ENTITIES.— 

17 (1) ADDITIONAL ANALYSES.— 

18 (A) IN GENERAL.—Subject to subpara19 graph (B), to the extent consistent with appli20 cable information, privacy, security, and disclo21 sure laws (including paragraph (3)), notwith22 standing paragraph (4)(B) of section 1874(e) of 

23 the Social Security Act (42 U.S.C. 1395kk(e)) 

24 and the second sentence of paragraph (4)(D) of 

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1 fied entity may use the combined data described 

2 in paragraph (4)(B)(iii) of such section received 

3 by such entity under such section, and informa4 tion derived from the evaluation described in 

5 such paragraph (4)(D), to conduct additional 

6 non-public analyses (as determined appropriate 

7 by the Secretary) and provide or sell such anal8 yses to authorized users for non-public use (in9 cluding for the purposes of assisting providers 

10 of services and suppliers to develop and partici11 pate in quality and patient care improvement 

12 activities, including developing new models of 

13 care). 

14 (B) LIMITATIONS WITH RESPECT TO ANAL15 YSES.— 

16 (i) EMPLOYERS.—Any analyses pro17 vided or sold under subparagraph (A) to 

18 an employer described in paragraph 

19 (9)(A)(iii) may only be used by such em20 ployer for purposes of providing health in21 surance to employees and retirees of the 

22 employer. 

23 (ii) HEALTH INSURANCE ISSUERS.—A 

24 qualified entity may not provide or sell an 

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1 scribed in paragraph (9)(A)(iv) unless the 

2 issuer is providing the qualified entity with 

3 data under section 1874(e)(4)(B)(iii) of 

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

5 1395kk(e)(4)(B)(iii)). 

6 (2) ACCESS TO CERTAIN DATA.— 

7 (A) ACCESS.—To the extent consistent 

8 with applicable information, privacy, security, 

9 and disclosure laws (including paragraph (3)), 

10 notwithstanding paragraph (4)(B) of section 

11 1874(e) of the Social Security Act (42 U.S.C. 

12 1395kk(e)) and the second sentence of para13 graph (4)(D) of such section, beginning July 1, 

14 2015, a qualified entity may— 

15 (i) provide or sell the combined data 

16 described in paragraph (4)(B)(iii) of such 

17 section to authorized users described in 

18 clauses (i), (ii), and (v) of paragraph 

19 (9)(A) for non-public use, including for the 

20 purposes described in subparagraph (B); 

21 or 

22 (ii) subject to subparagraph (C), pro23 vide Medicare claims data to authorized 

24 users described in clauses (i), (ii), and (v), 

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1 cluding for the purposes described in sub2 paragraph (B). 

3 (B) PURPOSES DESCRIBED.—The purposes 

4 described in this subparagraph are assisting 

5 providers of services and suppliers in developing 

6 and participating in quality and patient care 

7 improvement activities, including developing 

8 new models of care. 

9 (C) MEDICARE CLAIMS DATA MUST BE

10 PROVIDED AT NO COST.—A qualified entity may 

11 not charge a fee for providing the data under 

12 subparagraph (A)(ii). 

13 (3) PROTECTION OF INFORMATION.— 

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

15 subparagraph (B), an analysis or data that is 

16 provided or sold under paragraph (1) or (2) 

17 shall not contain information that individually 

18 identifies a patient. 

19 (B) INFORMATION ON PATIENTS OF THE

20 PROVIDER OF SERVICES OR SUPPLIER.—To the 

21 extent consistent with applicable information, 

22 privacy, security, and disclosure laws, an anal23 ysis or data that is provided or sold to a pro24 vider of services or supplier under paragraph 

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1 ually identifies a patient of such provider or 

2 supplier, including with respect to items and 

3 services furnished to the patient by other pro4 viders of services or suppliers. 

5 (C) PROHIBITION ON USING ANALYSES OR

6 DATA FOR MARKETING PURPOSES.—An author7 ized user shall not use an analysis or data pro8 vided or sold under paragraph (1) or (2) for 

9 marketing purposes. 

10 (4) DATA USE AGREEMENT.—A qualified entity 

11 and an authorized user described in clauses (i), (ii), 

12 and (v) of paragraph (9)(A) shall enter into an 

13 agreement regarding the use of any data that the 

14 qualified entity is providing or selling to the author15 ized user under paragraph (2). Such agreement shall 

16 describe the requirements for privacy and security of 

17 the data and, as determined appropriate by the Sec18 retary, any prohibitions on using such data to link 

19 to other individually identifiable sources of informa20 tion. If the authorized user is not a covered entity 

21 under the rules promulgated pursuant to the Health 

22 Insurance Portability and Accountability Act of 

23 1996, the agreement shall identify the relevant regu24 lations, as determined by the Secretary, that the 


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1 user shall comply with as if it were acting in the ca2 pacity of such a covered entity. 

3 (5) NO REDISCLOSURE OF ANALYSES OR

4 DATA.— 

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

6 subparagraph (B), an authorized user that is 

7 provided or sold an analysis or data under 

8 paragraph (1) or (2) shall not redisclose or 

9 make public such analysis or data or any anal10 ysis using such data. 

11 (B) PERMITTED REDISCLOSURE.—A pro12 vider of services or supplier that is provided or 

13 sold an analysis or data under paragraph (1) or 

14 (2) may, as determined by the Secretary, redis15 close such analysis or data for the purposes of 

16 performance improvement and care coordination 

17 activities but shall not make public such anal18 ysis or data or any analysis using such data. 

19 (6) OPPORTUNITY FOR PROVIDERS OF SERV20 ICES AND SUPPLIERS TO REVIEW.—Prior to a quali21 fied entity providing or selling an analysis to an au22 thorized user under paragraph (1), to the extent 

23 that such analysis would individually identify a pro24 vider of services or supplier who is not being pro25 vided or sold such analysis, such qualified entity 


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1 shall provide such provider or supplier with the op2 portunity to appeal and correct errors in the manner 

3 described in section 1874(e)(4)(C)(ii) of the Social 

4 Security Act (42 U.S.C. 1395kk(e)(4)(C)(ii)). 

5 (7) ASSESSMENT FOR A BREACH.— 

6 (A) IN GENERAL.—In the case of a breach 

7 of a data use agreement under this section or 

8 section 1874(e) of the Social Security Act (42 

9 U.S.C. 1395kk(e)), the Secretary shall impose 

10 an assessment on the qualified entity both in 

11 the case of— 

12 (i) an agreement between the Sec13 retary and a qualified entity; and 

14 (ii) an agreement between a qualified 

15 entity and an authorized user. 

16 (B) ASSESSMENT.—The assessment under 

17 subparagraph (A) shall be an amount up to 

18 $100 for each individual entitled to, or enrolled 

19 for, benefits under part A of title XVIII of the 

20 Social Security Act or enrolled for benefits 

21 under part B of such title— 

22 (i) in the case of an agreement de23 scribed in subparagraph (A)(i), for whom 

24 the Secretary provided data on to the 

25 qualified entity under paragraph (2); and 


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1 (ii) in the case of an agreement de2 scribed in subparagraph (A)(ii), for whom 

3 the qualified entity provided data on to the 

4 authorized user under paragraph (2). 

5 (C) DEPOSIT OF AMOUNTS COLLECTED.— 

6 Any amounts collected pursuant to this para7 graph shall be deposited in Federal Supple8 mentary Medical Insurance Trust Fund under 

9 section 1841 of the Social Security Act (42 

10 U.S.C. 1395t). 

11 (8) ANNUAL REPORTS.—Any qualified entity 

12 that provides or sells an analysis or data under 

13 paragraph (1) or (2) shall annually submit to the 

14 Secretary a report that includes— 

15 (A) a summary of the analyses provided or 

16 sold, including the number of such analyses, the 

17 number of purchasers of such analyses, and the 

18 total amount of fees received for such analyses; 

19 (B) a description of the topics and pur20 poses of such analyses; 

21 (C) information on the entities who re22 ceived the data under paragraph (2), the uses 

23 of the data, and the total amount of fees re24 ceived for providing, selling, or sharing the 

25 data; and 


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1 (D) other information determined appro2 priate by the Secretary. 

3 (9) DEFINITIONS.—In this subsection and sub4 section (b): 

5 (A) AUTHORIZED USER.—The term ‘‘au6 thorized user’’ means the following: 

7 (i) A provider of services. 

8 (ii) A supplier. 

9 (iii) An employer (as defined in sec10 tion 3(5) of the Employee Retirement In11 surance Security Act of 1974). 

12 (iv) A health insurance issuer (as de13 fined in section 2791 of the Public Health 

14 Service Act). 

15 (v) A medical society or hospital asso16 ciation. 

17 (vi) Any entity not described in 

18 clauses (i) through (v) that is approved by 

19 the Secretary (other than an employer or 

20 health insurance issuer not described in 

21 clauses (iii) and (iv), respectively, as deter22 mined by the Secretary). 

23 (B) PROVIDER OF SERVICES.—The term 

24 ‘‘provider of services’’ has the meaning given 


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1 such term in section 1861(u) of the Social Se2 curity Act (42 U.S.C. 1395x(u)). 

3 (C) QUALIFIED ENTITY.—The term ‘‘quali4 fied entity’’ has the meaning given such term in 

5 section 1874(e)(2) of the Social Security Act 

6 (42 U.S.C. 1395kk(e)). 

7 (D) SECRETARY.—The term ‘‘Secretary’’ 

8 means the Secretary of Health and Human 

9 Services. 

10 (E) SUPPLIER.—The term ‘‘supplier’’ has 

11 the meaning given such term in section 1861(d) 

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

13 1395x(d)). 

14 (b) ACCESS TO MEDICARE DATA BY QUALIFIED

15 CLINICAL DATA REGISTRIES TO FACILITATE QUALITY

16 IMPROVEMENT.— 

17 (1) ACCESS.— 

18 (A) IN GENERAL.—To the extent con19 sistent with applicable information, privacy, se20 curity, and disclosure laws, beginning July 1, 

21 2015, the Secretary shall, at the request of a 

22 qualified clinical data registry under section 

23 1848(m)(3)(E) of the Social Security Act (42 

24 U.S.C. 1395w–4(m)(3)(E)), provide the data 

25 described in subparagraph (B) (in a form and 


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1 manner determined to be appropriate) to such 

2 qualified clinical data registry for purposes of 

3 linking such data with clinical outcomes data 

4 and performing risk-adjusted, scientifically valid 

5 analyses and research to support quality im6 provement or patient safety, provided that any 

7 public reporting of such analyses or research 

8 that identifies a provider of services or supplier 

9 shall only be conducted with the opportunity of 

10 such provider or supplier to appeal and correct 

11 errors in the manner described in subsection 

12 (a)(6). 

13 (B) DATA DESCRIBED.—The data de14 scribed in this subparagraph is— 

15 (i) claims data under the Medicare 

16 program under title XVIII of the Social 

17 Security Act; and 

18 (ii) if the Secretary determines appro19 priate, claims data under the Medicaid 

20 program under title XIX of such Act and 

21 the State Children’s Health Insurance Pro22 gram under title XXI of such Act. 

23 (2) FEE.—Data described in paragraph (1)(B) 

24 shall be provided to a qualified clinical data registry 

25 under paragraph (1) at a fee equal to the cost of 


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1 providing such data. Any fee collected pursuant to 

2 the preceding sentence shall be deposited in the Cen3 ters for Medicare & Medicaid Services Program 

4 Management Account. 

5 (c) EXPANSION OF DATA AVAILABLE TO QUALIFIED

6 ENTITIES.—Section 1874(e) of the Social Security Act 

7 (42 U.S.C. 1395kk(e)) is amended— 

8 (1) in the subsection heading, by striking 

9 ‘‘MEDICARE’’; and 

10 (2) in paragraph (3)— 

11 (A) by inserting after the first sentence the 

12 following new sentence: ‘‘Beginning July 1, 

13 2015, if the Secretary determines appropriate, 

14 the data described in this paragraph may also 

15 include standardized extracts (as determined by 

16 the Secretary) of claims data under titles XIX 

17 and XXI for assistance provided under such ti18 tles for one or more specified geographic areas 

19 and time periods requested by a qualified enti20 ty.’’; and 

21 (B) in the last sentence, by inserting ‘‘or 

22 under titles XIX or XXI’’ before the period at 

23 the end. 


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1 (d) REVISION OF PLACEMENT OF FEES.—Section 

2 1874(e)(4)(A) of the Social Security Act (42 U.S.C. 

3 1395kk(e)(4)(A)) is amended, in the second sentence— 

4 (1) by inserting ‘‘, for periods prior to July 1, 

5 2015,’’ after ‘‘deposited’’; and 

6 (2) by inserting the following before the period 

7 at the end: ‘‘, and, beginning July 1, 2015, into the 

8 Centers for Medicare & Medicaid Services Program 

9 Management Account’’. 

10 SEC. 108. REDUCING ADMINISTRATIVE BURDEN AND 

11 OTHER PROVISIONS. 

12 (a) MEDICARE PHYSICIAN AND PRACTITIONER OPT13 OUT TO PRIVATE CONTRACT.— 

14 (1) INDEFINITE, CONTINUING AUTOMATIC EX15 TENSION OF OPT OUT ELECTION.— 

16 (A) IN GENERAL.—Section 1802(b)(3) of 

17 the Social Security Act (42 U.S.C. 1395a(b)(3)) 

18 is amended— 

19 (i) in subparagraph (B)(ii), by strik20 ing ‘‘during the 2-year period beginning on 

21 the date the affidavit is signed’’ and insert22 ing ‘‘during the applicable 2-year period 

23 (as defined in subparagraph (D))’’; 

24 (ii) in subparagraph (C), by striking 

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1 paragraph (B)(ii)’’ and inserting ‘‘during 

2 the applicable 2-year period’’; and 

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

5 ‘‘(D) APPLICABLE 2-YEAR PERIODS FOR

6 EFFECTIVENESS OF AFFIDAVITS.—In this sub7 section, the term ‘applicable 2-year period’ 

8 means, with respect to an affidavit of a physi9 cian or practitioner under subparagraph (B), 

10 the 2-year period beginning on the date the af11 fidavit is signed and includes each subsequent 

12 2-year period unless the physician or practi13 tioner involved provides notice to the Secretary 

14 (in a form and manner specified by the Sec15 retary), not later than 30 days before the end 

16 of the previous 2-year period, that the physician 

17 or practitioner does not want to extend the ap18 plication of the affidavit for such subsequent 2- 

19 year period.’’. 

20 (B) EFFECTIVE DATE.—The amendments 

21 made by subparagraph (A) shall apply to affi22 davits entered into on or after the date that is 

23 60 days after the date of the enactment of this 

24 Act. 


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1 (2) PUBLIC AVAILABILITY OF INFORMATION ON

2 OPT-OUT PHYSICIANS AND PRACTITIONERS.—Section 

3 1802(b) of the Social Security Act (42 U.S.C. 

4 1395a(b)) is amended— 

5 (A) in paragraph (5), by adding at the end 

6 the following new subparagraph: 

7 ‘‘(D) OPT-OUT PHYSICIAN OR PRACTITIONER.— 

8 The term ‘opt-out physician or practitioner’ means 

9 a physician or practitioner who has in effect an affi10 davit under paragraph (3)(B).’’; 

11 (B) by redesignating paragraph (5) as 

12 paragraph (6); and 

13 (C) by inserting after paragraph (4) the 

14 following new paragraph: 

15 ‘‘(5) POSTING OF INFORMATION ON OPT-OUT

16 PHYSICIANS AND PRACTITIONERS.— 

17 ‘‘(A) IN GENERAL.—Beginning not later 

18 than February 1, 2015, the Secretary shall 

19 make publicly available through an appropriate 

20 publicly accessible website of the Department of 

21 Health and Human Services information on the 

22 number and characteristics of opt-out physi23 cians and practitioners and shall update such 

24 information on such website not less often than 

25 annually. 


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1 ‘‘(B) INFORMATION TO BE INCLUDED.— 

2 The information to be made available under 

3 subparagraph (A) shall include at least the fol4 lowing with respect to opt-out physicians and 

5 practitioners: 

6 ‘‘(i) Their number. 

7 ‘‘(ii) Their physician or professional 

8 specialty or other designation. 

9 ‘‘(iii) Their geographic distribution. 

10 ‘‘(iv) The timing of their becoming 

11 opt-out physicians and practitioners, rel12 ative to when they first entered practice 

13 and with respect to applicable 2-year peri14 ods. 

15 ‘‘(v) The proportion of such physi16 cians and practitioners who billed for 

17 emergency or urgent care services.’’. 

18 (b) GAINSHARING STUDY AND REPORT.—Not later 

19 than 6 months after the date of the enactment of this Act, 

20 the Secretary of Health and Human Services, in consulta21 tion with the Inspector General of the Department of 

22 Health and Human Services, shall submit to Congress a 

23 report with legislative recommendations to amend existing 

24 fraud and abuse laws, through exceptions, safe harbors, 

25 or other narrowly targeted provisions, to permit 


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1 gainsharing or similar arrangements between physicians 

2 and hospitals that improve care while reducing waste and 

3 increasing efficiency. The report shall— 

4 (1) consider whether such provisions should 

5 apply to ownership interests, compensation arrange6 ments, or other relationships; 

7 (2) describe how the recommendations address 

8 accountability, transparency, and quality, including 

9 how best to limit inducements to stint on care, dis10 charge patients prematurely, or otherwise reduce or 

11 limit medically necessary care; and 

12 (3) consider whether a portion of any savings 

13 generated by such arrangements should accrue to 

14 the Medicare program under title XVIII of the So15 cial Security Act. 

16 (c) PROMOTING INTEROPERABILITY OF ELECTRONIC

17 HEALTH RECORD SYSTEMS.— 

18 (1) RECOMMENDATIONS FOR ACHIEVING WIDE19 SPREAD EHR INTEROPERABILITY.— 

20 (A) OBJECTIVE.—As a consequence of a 

21 significant Federal investment in the implemen22 tation of health information technology through 

23 the Medicare and Medicaid EHR incentive pro24 grams, Congress declares it a national objective 

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1 mation through interoperable certified EHR 

2 technology nationwide by December 31, 2017. 

3 (B) DEFINITIONS.—In this paragraph: 

4 (i) WIDESPREAD INTEROPER5 ABILITY.—The term ‘‘widespread inter6 operability’’ means interoperability between 

7 certified EHR technology systems em8 ployed by meaningful EHR users under 

9 the Medicare and Medicaid EHR incentive 

10 programs and other clinicians and health 

11 care providers on a nationwide basis. 

12 (ii) INTEROPERABILITY.—The term 

13 ‘‘interoperability’’ means the ability of two 

14 or more health information systems or 

15 components to exchange clinical and other 

16 information and to use the information 

17 that has been exchanged using common 

18 standards as to provide access to longitu19 dinal information for health care providers 

20 in order to facilitate coordinated care and 

21 improved patient outcomes. 

22 (C) ESTABLISHMENT OF METRICS.—Not 

23 later than July 1, 2015, and in consultation 

24 with stakeholders, the Secretary shall establish 

25 metrics to be used to determine if and to the 


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1 extent that the objective described in subpara2 graph (A) has been achieved. 

3 (D) RECOMMENDATIONS IF OBJECTIVE

4 NOT ACHIEVED.—If the Secretary of Health 

5 and Human Services determines that the objec6 tive described in subparagraph (A) has not been 

7 achieved by December 31, 2017, then the Sec8 retary shall submit to Congress a report, by not 

9 later than December 31, 2018, that identifies 

10 barriers to such objective and recommends ac11 tions that the Federal Government can take to 

12 achieve such objective. Such recommended ac13 tions may include recommendations— 

14 (i) to adjust payments for not being 

15 meaningful EHR users under the Medicare 

16 EHR incentive programs; and 

17 (ii) for criteria for decertifying cer18 tified EHR technology products. 

19 (2) PREVENTING BLOCKING THE SHARING OF

20 INFORMATION.— 

21 (A) FOR MEANINGFUL EHR PROFES22 SIONALS.—Section 1848(o)(2)(A)(ii) of the So23 cial Security Act (42 U.S.C. 1395w– 

24 4(o)(2)(A)(ii)) is amended by inserting before 

25 the period at the end the following: ‘‘, and the 


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1 professional demonstrates (through a process 

2 specified by the Secretary, such as the use of an 

3 attestation) that the professional has not know4 ingly and willfully taken any action to limit or 

5 restrict the compatibility or interoperability of 

6 the certified EHR technology’’. 

7 (B) FOR MEANINGFUL EHR HOSPITALS.— 

8 Section 1886(n)(3)(A)(ii) of the Social Security 

9 Act (42 U.S.C. 1395ww(n)(3)(A)(ii)) is amend10 ed by inserting before the period at the end the 

11 following: ‘‘, and the hospital demonstrates 

12 (through a process specified by the Secretary, 

13 such as the use of an attestation) that the hos14 pital has not knowingly and willfully taken any 

15 action to limit or restrict the compatibility or 

16 interoperability of the certified EHR tech17 nology’’. 

18 (C) EFFECTIVE DATE.—The amendments 

19 made by this subsection shall apply to meaning20 ful EHR users as of the date that is one year 

21 after the date of the enactment of this Act. 

22 (3) STUDY AND REPORT ON THE FEASIBILITY

23 OF ESTABLISHING A WEBSITE TO COMPARE CER24 TIFIED EHR TECHNOLOGY PRODUCTS.— 


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1 (A) STUDY.—The Secretary shall conduct 

2 a study to examine the feasibility of estab3 lishing mechanisms that includes aggregated re4 sults of surveys of meaningful EHR users on 

5 the functionality of certified EHR technology 

6 products to enable such users to directly com7 pare the functionality and other features of 

8 such products. Such information may be made 

9 available through contracts with physician, hos10 pital, or other organizations that maintain such 

11 comparative information. 

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

13 the date of the enactment of this Act, the Sec14 retary shall submit to Congress a report on the 

15 website. The report shall include information on 

16 the benefits of, and resources needed to develop 

17 and maintain, such a website. 

18 (4) DEFINITIONS.—In this subsection: 

19 (A) The term ‘‘certified EHR technology’’ 

20 has the meaning given such term in section 

21 1848(o)(4) of the Social Security Act (42 

22 U.S.C. 1395w–4(o)(4)). 

23 (B) The term ‘‘meaningful EHR user’’ has 

24 the meaning given such term under the Medi25 care EHR incentive programs. 


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1 (C) The term ‘‘Medicare and Medicaid 

2 EHR incentive programs’’ means— 

3 (i) in the case of the Medicare pro4 gram under title XVIII of the Social Secu5 rity Act, the incentive programs under sec6 tion 1814(l)(3), section 1848(o), sub7 sections (l) and (m) of section 1853, and 

8 section 1886(n) of the Social Security Act 

9 (42 U.S.C. 1395f(l)(3), 1395w–4(o), 

10 1395w–23, 1395ww(n)); and 

11 (ii) in the case of the Medicaid pro12 gram under title XIX of such Act, the in13 centive program under subsections 

14 (a)(3)(F) and (t) of section 1903 of such 

15 Act (42 U.S.C. 1396b). 

16 (D) The term ‘‘Secretary’’ means the Sec17 retary of Health and Human Services. 

18 (d) GAO STUDIES AND REPORTS ON THE USE OF

19 TELEHEALTH UNDER FEDERAL PROGRAMS AND ON RE20 MOTE PATIENT MONITORING SERVICES.— 

21 (1) STUDY ON TELEHEALTH SERVICES.—The 

22 Comptroller General of the United States shall con23 duct a study on the following: 

24 (A) How the definition of telehealth across 

25 various Federal programs and Federal efforts 


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1 can inform the use of telehealth in the Medicare 

2 program under title XVIII of the Social Secu3 rity Act (42 U.S.C. 1395 et seq.). 

4 (B) Issues that can facilitate or inhibit the 

5 use of telehealth under the Medicare program 

6 under such title, including oversight and profes7 sional licensure, changing technology, privacy 

8 and security, infrastructure requirements, and 

9 varying needs across urban and rural areas. 

10 (C) Potential implications of greater use of 

11 telehealth with respect to payment and delivery 

12 system transformations under the Medicare 

13 program under such title XVIII and the Med14 icaid program under title XIX of such Act (42 

15 U.S.C. 1396 et seq.). 

16 (D) How the Centers for Medicare & Med17 icaid Services conducts oversight of payments 

18 made under the Medicare program under such 

19 title XVIII to providers for telehealth services. 

20 (2) STUDY ON REMOTE PATIENT MONITORING

21 SERVICES.— 

22 (A) IN GENERAL.—The Comptroller Gen23 eral of the United States shall conduct a 

24 study— 


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1 (i) of the dissemination of remote pa2 tient monitoring technology in the private 

3 health insurance market; 

4 (ii) of the financial incentives in the 

5 private health insurance market relating to 

6 adoption of such technology; 

7 (iii) of the barriers to adoption of 

8 such services under the Medicare program 

9 under title XVIII of the Social Security 

10 Act; 

11 (iv) that evaluates the patients, condi12 tions, and clinical circumstances that could 

13 most benefit from remote patient moni14 toring services; and 

15 (v) that evaluates the challenges re16 lated to establishing appropriate valuation 

17 for remote patient monitoring services 

18 under the Medicare physician fee schedule 

19 under section 1848 of the Social Security 

20 Act (42 U.S.C. 1395w–4) in order to accu21 rately reflect the resources involved in fur22 nishing such services. 

23 (B) DEFINITIONS.—For purposes of this 

24 paragraph: 


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1 (i) REMOTE PATIENT MONITORING

2 SERVICES.—The term ‘‘remote patient 

3 monitoring services’’ means services fur4 nished through remote patient monitoring 

5 technology. 

6 (ii) REMOTE PATIENT MONITORING

7 TECHNOLOGY.—The term ‘‘remote patient 

8 monitoring technology’’ means a coordi9 nated system that uses one or more home10 based or mobile monitoring devices that 

11 automatically transmit vital sign data or 

12 information on activities of daily living and 

13 may include responses to assessment ques14 tions collected on the devices wirelessly or 

15 through a telecommunications connection 

16 to a server that complies with the Federal 

17 regulations (concerning the privacy of indi18 vidually identifiable health information) 

19 promulgated under section 264(c) of the 

20 Health Insurance Portability and Account21 ability Act of 1996, as part of an estab22 lished plan of care for that patient that in23 cludes the review and interpretation of that 

24 data by a health care professional. 


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1 (3) REPORTS.—Not later than 24 months after 

2 the date of the enactment of this Act, the Comp3 troller General shall submit to Congress— 

4 (A) a report containing the results of the 

5 study conducted under paragraph (1); and 

6 (B) a report containing the results of the 

7 study conducted under paragraph (2). 

8 A report required under this paragraph shall be sub9 mitted together with recommendations for such leg10 islation and administrative action as the Comptroller 

11 General determines appropriate. The Comptroller 

12 General may submit one report containing the re13 sults described in subparagraphs (A) and (B) and 

14 the recommendations described in the previous sen15 tence. 

16 (e) RULE OF CONSTRUCTION REGARDING

17 HEALTHCARE PROVIDER STANDARDS OF CARE.— 

18 (1) MAINTENANCE OF STATE STANDARDS.— 

19 The development, recognition, or implementation of 

20 any guideline or other standard under any Federal 

21 health care provision shall not be construed— 

22 (A) to establish the standard of care or 

23 duty of care owed by a health care provider to 

24 a patient in any medical malpractice or medical 

25 product liability action or claim; or 


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1 (B) to preempt any standard of care or 

2 duty of care, owed by a health care provider to 

3 a patient, duly established under State or com4 mon law. 

5 (2) DEFINITIONS.—For purposes of this sub6 section: 

7 (A) FEDERAL HEALTH CARE PROVISION.— 

8 The term ‘‘Federal health care provision’’ 

9 means any provision of the Patient Protection 

10 and Affordable Care Act (Public Law 111– 

11 148), title I or subtitle B of title II of the 

12 Health Care and Education Reconciliation Act 

13 of 2010 (Public Law 111–152), or title XVIII 

14 or XIX of the Social Security Act. 

15 (B) HEALTH CARE PROVIDER.—The term 

16 ‘‘health care provider’’ means any individual or 

17 entity— 

18 (i) licensed, registered, or certified 

19 under Federal or State laws or regulations 

20 to provide health care services; or 

21 (ii) required to be so licensed, reg22 istered, or certified but that is exempted 

23 by other statute or regulation. 

24 (C) MEDICAL MALPRACTICE OR MEDICAL

25 PRODUCT LIABILITY ACTION OR CLAIM.—The 


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1 term ‘‘medical malpractice or medical product 

2 liability action or claim’’ means a medical mal3 practice action or claim (as defined in section 

4 431(7) of the Health Care Quality Improve5 ment Act of 1986 (42 U.S.C. 11151(7))) and 

6 includes a liability action or claim relating to a 

7 health care provider’s prescription or provision 

8 of a drug, device, or biological product (as such 

9 terms are defined in section 201 of the Federal 

10 Food, Drug, and Cosmetic Act or section 351 

11 of the Public Health Service Act). 

12 (D) STATE.—The term ‘‘State’’ includes 

13 the District of Columbia, Puerto Rico, and any 

14 other commonwealth, possession, or territory of 

15 the United States. 

16 (3) PRESERVATION OF STATE LAW.—No provi17 sion of the Patient Protection and Affordable Care 

18 Act (Public Law 111–148), title I or subtitle B of 

19 title II of the Health Care and Education Reconcili20 ation Act of 2010 (Public Law 111–152), or title 

21 XVIII or XIX of the Social Security Act shall be 

22 construed to preempt any State or common law gov23 erning medical professional or medical product liabil24 ity actions or claims. 


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1 TITLE II—EXTENSIONS 

2 Subtitle A—Medicare Extensions 

3 SEC. 201. WORK GEOGRAPHIC ADJUSTMENT. 

4 Section 1848(e)(1)(E) of the Social Security Act (42 

5 U.S.C. 1395w–4(e)(1)(E)) is amended by striking ‘‘and 

6 before April 1, 2014,’’. 

7 SEC. 202. MEDICARE PAYMENT FOR THERAPY SERVICES. 

8 (a) REPEAL OF THERAPY CAP AND 1-YEAR EXTEN9 SION OF THRESHOLD FOR MANUAL MEDICAL REVIEW.— 

10 Section 1833(g) of the Social Security Act (42 U.S.C. 

11 1395l(g)) is amended— 

12 (1) in paragraph (4)— 

13 (A) by striking ‘‘This subsection’’ and in14 serting ‘‘Except as provided in paragraph 

15 (5)(C)(iii), this subsection’’; and 

16 (B) by inserting the following before the 

17 period at the end: ‘‘or with respect to services 

18 furnished on or after the date of enactment of 

19 the Commonsense Medicare SGR Repeal and 

20 Beneficiary Access Improvement Act of 2014’’; 

21 and 

22 (2) in paragraph (5)(C), by adding at the end 

23 the following new clause: 

24 ‘‘(iii) Beginning on the date of enactment of the Com25 monsense Medicare SGR Repeal and Beneficiary Access 


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1 Improvement Act of 2014 and ending on the day before 

2 the date that is 12 months after such date of enactment, 

3 the manual medical review process described in clause (i) 

4 shall apply with respect to expenses incurred in a year for 

5 services described in paragraphs (1) and (3) that exceed 

6 the threshold described in clause (ii) for the year.’’. 

7 (b) MEDICAL REVIEW OF OUTPATIENT THERAPY

8 SERVICES.— 

9 (1) MEDICAL REVIEW OF OUTPATIENT THER10 APY SERVICES.—Section 1833 of the Social Security 

11 Act (42 U.S.C. 1395l), as amended by section 

12 101(e)(2), is amended by adding at the end the fol13 lowing new subsection: 

14 ‘‘(aa) MEDICAL REVIEW OF OUTPATIENT THERAPY

15 SERVICES.— 

16 ‘‘(1) IN GENERAL.— 

17 ‘‘(A) PROCESS FOR MEDICAL REVIEW.— 

18 The Secretary shall implement a process for the 

19 medical review (as described in paragraph (2)) 

20 of outpatient therapy services (as defined in 

21 paragraph (10)) and, subject to paragraph 

22 (12), apply such process to such services fur23 nished on or after the date that is 12 months 

24 after the date of enactment of the Common25 sense Medicare SGR Repeal and Beneficiary 


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1 Access Improvement Act of 2014, focusing on 

2 services identified under subparagraph (B). 

3 ‘‘(B) IDENTIFICATION OF SERVICES FOR

4 REVIEW.—Under the process, the Secretary 

5 shall identify services for medical review, using 

6 such factors as the Secretary determines appro7 priate, which may include the following: 

8 ‘‘(i) Services furnished by a therapy 

9 provider (as defined in paragraph (10)) 

10 whose pattern of billing is aberrant com11 pared to peers. 

12 ‘‘(ii) Services furnished by a therapy 

13 provider who, in a prior period, has a high 

14 claims denial percentage or is less compli15 ant with other applicable requirements 

16 under this title. 

17 ‘‘(iii) Services furnished by a therapy 

18 provider that is newly enrolled under this 

19 title. 

20 ‘‘(iv) Services furnished by a therapy 

21 provider who has questionable billing prac22 tices, such as billing medically unlikely 

23 units of services in a day. 

24 ‘‘(v) Services furnished to treat a type 

25 of medical condition. 


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1 ‘‘(vi) Services identified by use of the 

2 standardized data elements required to be 

3 reported under section 1834(p). 

4 ‘‘(vii) Services furnished by a single 

5 therapy provider or a group that includes 

6 a therapy provider identified by factors de7 scribed in this subparagraph. 

8 ‘‘(viii) Other services as determined 

9 appropriate by the Secretary. 

10 ‘‘(2) MEDICAL REVIEW.— 

11 ‘‘(A) PRIOR AUTHORIZATION MEDICAL RE12 VIEW.— 

13 ‘‘(i) IN GENERAL.—Subject to the 

14 succeeding provisions of this subparagraph, 

15 the Secretary shall use prior authorization 

16 medical review for outpatient therapy serv17 ices furnished to an individual above one 

18 or more thresholds established by the Sec19 retary, such as a dollar threshold or a 

20 threshold based on other factors. 

21 ‘‘(ii) ENDING APPLICATION OF PRIOR

22 AUTHORIZATION FOR A THERAPY PRO23 VIDER.—The Secretary shall end the appli24 cation of prior authorization medical re25 view to outpatient therapy services furVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00200 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 nished by a therapy provider if the Sec2 retary determines that the provider has a 

3 low denial rate under such prior authoriza4 tion. The Secretary may subsequently re5 apply prior authorization medical review to 

6 such therapy provider if the Secretary de7 termines it to be appropriate. 

8 ‘‘(iii) PRIOR AUTHORIZATION OF MUL9 TIPLE SERVICES.—The Secretary shall, 

10 where practicable, provide for prior author11 ization medical review for multiple services 

12 at a single time, such as services in a ther13 apy plan of care described in section 

14 1861(p)(2). 

15 ‘‘(B) OTHER TYPES OF MEDICAL RE16 VIEW.—The Secretary may use pre-payment re17 view or post-payment review for services identi18 fied under paragraph (1)(B) that are not sub19 ject to prior authorization medical review under 

20 subparagraph (A). 

21 ‘‘(C) LIMITATION FOR LAW ENFORCEMENT

22 ACTIVITIES.—The Secretary may determine 

23 that medical review under this subsection does 

24 not apply in the case where potential fraud may 

25 be involved. 


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1 ‘‘(3) REVIEW CONTRACTORS.—The Secretary 

2 shall conduct prior authorization medical review of 

3 outpatient therapy services under this subsection 

4 using medicare administrative contractors (as de5 scribed in section 1874A) or other review contrac6 tors (other than contractors under section 1893(h) 

7 or contractors paid on a contingent basis). 

8 ‘‘(4) NO PAYMENT WITHOUT PRIOR AUTHORIZA9 TION.—With respect to an outpatient therapy service 

10 for which prior authorization medical review under 

11 this subsection applies, the following shall apply: 

12 ‘‘(A) PRIOR AUTHORIZATION DETERMINA13 TION.—The Secretary shall make a determina14 tion, prior to the service being furnished, of 

15 whether the service would or would not meet 

16 the applicable requirements of section 

17 1862(a)(1)(A). 

18 ‘‘(B) DENIAL OF PAYMENT.—Subject to 

19 paragraph (6), no payment shall be made under 

20 this part for the service unless the Secretary 

21 determines pursuant to subparagraph (A) that 

22 the service would meet the applicable require23 ments of such section. 

24 ‘‘(5) SUBMISSION OF INFORMATION.—A ther25 apy provider may submit the information necessary 


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1 for medical review by fax, by mail, or by electronic 

2 means. The Secretary shall make available the elec3 tronic means described in the preceding sentence as 

4 soon as practicable, but not later than 24 months 

5 after the date of enactment of this subsection. 

6 ‘‘(6) TIMELINESS.—If the Secretary does not 

7 make a prior authorization determination under 

8 paragraph (4)(A) within 10 business days of the 

9 date of the Secretary’s receipt of medical docu10 mentation needed to make such determination, para11 graph (4)(B) shall not apply. 

12 ‘‘(7) CONSTRUCTION.—With respect to an out13 patient therapy service that has been affirmed by 

14 medical review under this subsection, nothing in this 

15 subsection shall be construed to preclude the subse16 quent denial of a claim for such service that does 

17 not meet other applicable requirements under this 

18 Act. 

19 ‘‘(8) BENEFICIARY PROTECTIONS.—With re20 spect to services furnished on or after January 1, 

21 2015, where payment may not be made as a result 

22 of application of medical review under this sub23 section, section 1879 shall apply in the same manner 

24 as such section applies to a denial that is made by 

25 reason of section 1862(a)(1). 


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1 ‘‘(9) IMPLEMENTATION.— 

2 ‘‘(A) AUTHORITY.—The Secretary may im3 plement the provisions of this subsection by in4 terim final rule with comment period. 

5 ‘‘(B) ADMINISTRATION.—Chapter 35 of 

6 title 44, United States Code, shall not apply to 

7 medical review under this subsection. 

8 ‘‘(C) LIMITATION.—There shall be no ad9 ministrative or judicial review under section 

10 1869, section 1878, or otherwise of the identi11 fication of services for medical review or the 

12 process for medical review under this sub13 section. 

14 ‘‘(10) DEFINITIONS.—For purposes of this sub15 section: 

16 ‘‘(A) OUTPATIENT THERAPY SERVICES.— 

17 The term ‘outpatient therapy services’ means 

18 the following services for which payment is 

19 made under section 1848, 1834(g), or 1834(k): 

20 ‘‘(i) Physical therapy services of the 

21 type described in section 1861(p). 

22 ‘‘(ii) Speech-language pathology serv23 ices of the type described in such section 

24 though the application of section 

25 1861(ll)(2). 


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1 ‘‘(iii) Occupational therapy services of 

2 the type described in section 1861(p) 

3 through the operation of section 1861(g). 

4 ‘‘(B) THERAPY PROVIDER.—The term 

5 ‘therapy provider’ means a provider of services 

6 (as defined in section 1861(u)) or a supplier (as 

7 defined in section 1861(d)) who submits a claim 

8 for outpatient therapy services. 

9 ‘‘(11) FUNDING.—For purposes of imple10 menting this subsection, the Secretary shall provide 

11 for the transfer, from the Federal Supplementary 

12 Medical Insurance Trust Fund under section 1841, 

13 of $35,000,000 to the Centers for Medicare & Med14 icaid Services Program Management Account for 

15 each fiscal year (beginning with fiscal year 2014). 

16 Amounts transferred under this paragraph shall re17 main available until expended. 

18 ‘‘(12) SCALING BACK.— 

19 ‘‘(A) PERIODIC DETERMINATIONS.—Begin20 ning with 2017, and every two years thereafter, 

21 the Secretary shall— 

22 ‘‘(i) make a determination of the im23 proper payment rate for outpatient therapy 

24 services for a 12-month period; and 


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1 ‘‘(ii) make such determination publicly 

2 available. 

3 ‘‘(B) SCALING BACK.—If the improper 

4 payment rate for outpatient therapy services de5 termined for a 12-month period under subpara6 graph (A) is 50 percent or less of the Medicare 

7 fee-for-service improper payment rate for such 

8 period, the Secretary shall— 

9 ‘‘(i) reduce the amount and extent of 

10 medical review conducted for a prospective 

11 year under the process established in this 

12 subsection; and 

13 ‘‘(ii) return an appropriate portion of 

14 the funding provided for such year under 

15 paragraph (11).’’. 

16 (2) GAO STUDY AND REPORT.— 

17 (A) STUDY.—The Comptroller General of 

18 the United States shall conduct a study on the 

19 effectiveness of medical review of outpatient 

20 therapy services under section 1833(aa) of the 

21 Social Security Act, as added by paragraph (1). 

22 Such study shall include an analysis of— 

23 (i) aggregate data on— 


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1 (I) the number of individuals, 

2 therapy providers, and claims subject 

3 to such review; and 

4 (II) the number of reviews con5 ducted under such section; and 

6 (ii) the outcomes of such reviews. 

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

8 the date of enactment of this Act, the Comp9 troller General shall submit to Congress a re10 port containing the results of the study under 

11 subparagraph (A), together with recommenda12 tions for such legislation and administrative ac13 tion as the Comptroller General determines ap14 propriate. 

15 (c) COLLECTION OF STANDARDIZED DATA ELE16 MENTS FOR OUTPATIENT THERAPY SERVICES.— 

17 (1) COLLECTION OF STANDARDIZED DATA ELE18 MENTS FOR OUTPATIENT THERAPY SERVICES.—Sec19 tion 1834 of the Social Security Act (42 U.S.C. 

20 1395m) is amended by adding at the end the fol21 lowing new subsection: 

22 ‘‘(p) COLLECTION OF STANDARDIZED DATA ELE23 MENTS FOR OUTPATIENT THERAPY SERVICES.— 

24 ‘‘(1) STANDARDIZED DATA ELEMENTS.— 


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1 ‘‘(A) IN GENERAL.—Not later than 6 

2 months after the date of enactment of this sub3 section, the Secretary shall post on the Internet 

4 website of the Centers for Medicare & Medicaid 

5 Services a draft list of standardized data ele6 ments for individuals receiving outpatient ther7 apy services. 

8 ‘‘(B) DOMAINS.—Such standardized data 

9 elements shall include information with respect 

10 to the following domains, as determined appro11 priate by the Secretary: 

12 ‘‘(i) Demographic information. 

13 ‘‘(ii) Diagnosis. 

14 ‘‘(iii) Severity. 

15 ‘‘(iv) Affected body structures and 

16 functions. 

17 ‘‘(v) Limitations with activities of 

18 daily living and participation. 

19 ‘‘(vi) Functional status. 

20 ‘‘(vii) Other domains determined to be 

21 appropriate by the Secretary. 

22 ‘‘(C) SOLICITATION OF INPUT.—The Sec23 retary shall accept comments from stakeholders 

24 through the date that is 60 days after the date 

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1 ized data elements pursuant to subparagraph 

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

3 shall use one or more mechanisms to solicit 

4 input from stakeholders that may include use of 

5 open door forums, town hall meetings, requests 

6 for information, or other mechanisms deter7 mined appropriate by the Secretary. 

8 ‘‘(D) OPERATIONAL LIST OF STANDARD9 IZED DATA ELEMENTS.—Not later than 120 

10 days after the end of the comment period de11 scribed in subparagraph (C), the Secretary, tak12 ing into account such comments, shall post on 

13 the Internet website of the Centers for Medi14 care & Medicaid Services an operational list of 

15 standardized data elements. 

16 ‘‘(E) SUBSEQUENT REVISIONS.—Subse17 quent revisions to the operational list of stand18 ardized data elements shall be made through 

19 rulemaking. Such revisions may be based on ex20 perience and input from stakeholders. 

21 ‘‘(2) SYSTEM TO REPORT STANDARDIZED DATA

22 ELEMENTS.— 

23 ‘‘(A) IN GENERAL.—Not later than 18 

24 months after the date the Secretary posts the 

25 operational list of standardized data elements 


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1 pursuant to paragraph (1)(D), the Secretary 

2 shall develop and implement an electronic sys3 tem (which may be a web portal) for therapy 

4 providers to report the standardized data ele5 ments for individuals with respect to outpatient 

6 therapy services. 

7 ‘‘(B) CONSULTATION.—The Secretary 

8 shall seek comments from stakeholders regard9 ing the best way to report the standardized 

10 data elements. 

11 ‘‘(3) REPORTING.— 

12 ‘‘(A) FREQUENCY OF REPORTING.—The 

13 Secretary shall specify the frequency of report14 ing standardized data elements. The Secretary 

15 shall seek comments from stakeholders regard16 ing the frequency of the reporting of such data 

17 elements. 

18 ‘‘(B) REPORTING REQUIREMENT.—Begin19 ning on the date the system to report standard20 ized data elements under this subsection is 

21 operational, no payment shall be made under 

22 this part for outpatient therapy services fur23 nished to an individual unless a therapy pro24 vider reports the standardized data elements for 

25 such individual. 


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1 ‘‘(4) REPORT ON NEW PAYMENT SYSTEM FOR

2 OUTPATIENT THERAPY SERVICES.— 

3 ‘‘(A) IN GENERAL.—Not later than 24 

4 months after the date described in paragraph 

5 (3)(B), the Secretary shall submit to Congress 

6 a report on the design of a new payment system 

7 for outpatient therapy services. The report shall 

8 include an analysis of the standardized data ele9 ments collected and other appropriate data and 

10 information. 

11 ‘‘(B) FEATURES.—Such report shall con12 sider— 

13 ‘‘(i) appropriate adjustments to pay14 ment (such as case mix and outliers); 

15 ‘‘(ii) payments on an episode of care 

16 basis; and 

17 ‘‘(iii) reduced payment for multiple 

18 episodes. 

19 ‘‘(C) CONSULTATION.—The Secretary shall 

20 consult with stakeholders regarding the design 

21 of such a new payment system. 

22 ‘‘(5) IMPLEMENTATION.— 

23 ‘‘(A) FUNDING.—For purposes of imple24 menting this subsection, the Secretary shall 

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1 plementary Medical Insurance Trust Fund 

2 under section 1841, of $7,000,000 to the Cen3 ters for Medicare & Medicaid Services Program 

4 Management Account for each of fiscal years 

5 2014 through 2018. Amounts transferred under 

6 this subparagraph shall remain available until 

7 expended. 

8 ‘‘(B) ADMINISTRATION.—Chapter 35 of 

9 title 44, United States Code, shall not apply to 

10 specification of the standardized data elements 

11 and implementation of the system to report 

12 such standardized data elements under this 

13 subsection. 

14 ‘‘(C) LIMITATION.—There shall be no ad15 ministrative or judicial review under section 

16 1869, section 1878, or otherwise of the speci17 fication of standardized data elements required 

18 under this subsection or the system to report 

19 such standardized data elements. 

20 ‘‘(D) DEFINITION OF OUTPATIENT THER21 APY SERVICES AND THERAPY PROVIDER.—In 

22 this subsection, the terms ‘outpatient therapy 

23 services’ and ‘therapy provider’ have the mean24 ing given those term in section 1833(aa).’’. 


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1 (2) SUNSET OF CURRENT CLAIMS-BASED COL2 LECTION OF THERAPY DATA.—Section 3005(g)(1) of 

3 the Middle Class Tax Extension and Job Creation 

4 Act of 2012 (42 U.S.C. 1395l note) is amended, in 

5 the first sentence, by inserting ‘‘and ending on the 

6 date the system to report standardized data ele7 ments under section 1834(p) of the Social Security 

8 Act (42 U.S.C. 1395m(p)) is implemented,’’ after 

9 ‘‘January 1, 2013,’’. 

10 (d) REPORTING OF CERTAIN INFORMATION.—Sec11 tion 1842(t) of the Social Security Act (42 U.S.C. 

12 1395u(t)) is amended by adding at the end the following 

13 new paragraph: 

14 ‘‘(3) Each request for payment, or bill submitted, by 

15 a therapy provider (as defined in section 1833(aa)(10)) 

16 for an outpatient therapy service (as defined in such sec17 tion) furnished by a therapy assistant on or after January 

18 1, 2015, shall include (in a form and manner specified 

19 by the Secretary) an indication that the service was fur20 nished by a therapy assistant.’’. 

21 SEC. 203. MEDICARE AMBULANCE SERVICES. 

22 (a) EXTENSION OF CERTAIN AMBULANCE ADD-ON

23 PAYMENTS.— 

24 (1) GROUND AMBULANCE.—Section 

25 1834(l)(13)(A) of the Social Security Act (42 U.S.C. 


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1 1395m(l)(13)(A)) is amended by striking ‘‘April 1, 

2 2014’’ and inserting ‘‘January 1, 2019’’ each place 

3 it appears. 

4 (2) SUPER RURAL AMBULANCE.—Section 

5 1834(l)(12)(A) of the Social Security Act (42 U.S.C. 

6 1395m(l)(12)(A)) is amended, in the first sentence, 

7 by striking ‘‘April 1, 2014’’ and inserting ‘‘January 

8 1, 2019’’. 

9 (b) REQUIRING AMBULANCE PROVIDERS TO SUBMIT

10 COST AND OTHER INFORMATION.—Section 1834(l) of the 

11 Social Security Act (42 U.S.C. 1395m(l)) is amended by 

12 adding at the end the following new paragraph: 

13 ‘‘(16) SUBMISSION OF COST AND OTHER INFOR14 MATION.— 

15 ‘‘(A) DEVELOPMENT OF DATA COLLECTION

16 SYSTEM.—The Secretary shall develop a data 

17 collection system (which may include use of a 

18 cost survey and standardized definitions) for 

19 providers and suppliers of ambulance services to 

20 collect cost, revenue, utilization, and other in21 formation determined appropriate by the Sec22 retary. Such system shall be designed to submit 

23 information— 


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1 ‘‘(i) needed to evaluate the appro2 priateness of payment rates under this 

3 subsection; 

4 ‘‘(ii) on the utilization of capital 

5 equipment and ambulance capacity; and 

6 ‘‘(iii) on different types of ambulance 

7 services furnished in different geographic 

8 locations, including rural areas and low 

9 population density areas described in para10 graph (12). 

11 ‘‘(B) SPECIFICATION OF DATA COLLEC12 TION SYSTEM.— 

13 ‘‘(i) IN GENERAL.—Not later than 

14 July 1, 2015, the Secretary shall— 

15 ‘‘(I) specify the data collection 

16 system under subparagraph (A) and 

17 the time period during which such 

18 data is required to be submitted; and 

19 ‘‘(II) identify the providers and 

20 suppliers of ambulance services who 

21 would be required to submit the infor22 mation under such data collection sys23 tem. 

24 ‘‘(ii) RESPONDENTS.—Subject to sub25 paragraph (D)(ii), the Secretary shall deVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00215 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 termine an appropriate sample of providers 

2 and suppliers of ambulance services to sub3 mit information under the data collection 

4 system for each period for which reporting 

5 of data is required. 

6 ‘‘(C) PENALTY FOR FAILURE TO REPORT

7 COST AND OTHER INFORMATION.—Beginning 

8 on July 1, 2016, a 5 percent reduction to pay9 ments under this part shall be made for a 1- 

10 year prospective period specified by the Sec11 retary to a provider or supplier of ambulance 

12 services who— 

13 ‘‘(i) is identified under subparagraph 

14 (B)(i)(II) as being required to submit the 

15 information under the data collection sys16 tem; and 

17 ‘‘(ii) does not submit such information 

18 during the period specified under subpara19 graph (B)(i)(I). 

20 ‘‘(D) ONGOING DATA COLLECTION.— 

21 ‘‘(i) REVISION OF DATA COLLECTION

22 SYSTEM.—The Secretary may, as deter23 mined appropriate, periodically revise the 

24 data collection system. 


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1 ‘‘(ii) SUBSEQUENT DATA COLLEC2 TION.—In order to continue to evaluate 

3 the appropriateness of payment rates 

4 under this subsection, the Secretary shall, 

5 for years after 2016 (but not less often 

6 than once every 3 years), require providers 

7 and suppliers of ambulance services to sub8 mit information for a period the Secretary 

9 determines appropriate. The penalty de10 scribed in subparagraph (C) shall apply to 

11 such subsequent data collection periods. 

12 ‘‘(E) CONSULTATION.—The Secretary shall 

13 consult with stakeholders in carrying out the 

14 development of the system and collection of in15 formation under this paragraph, including the 

16 activities described in subparagraphs (A) and 

17 (D). Such consultation shall include the use of 

18 requests for information and other mechanisms 

19 determined appropriate by the Secretary. 

20 ‘‘(F) ADMINISTRATION.—Chapter 35 of 

21 title 44, United States Code, shall not apply to 

22 the collection of information required under this 

23 subsection. 

24 ‘‘(G) LIMITATIONS ON REVIEW.—There 

25 shall be no administrative or judicial review 


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1 under section 1869, section 1878, or otherwise 

2 of the data collection system or identification of 

3 respondents under this paragraph. 

4 ‘‘(H) FUNDING FOR IMPLEMENTATION.— 

5 For purposes of carrying out subparagraph (A), 

6 the Secretary shall provide for the transfer, 

7 from the Federal Supplementary Medical Insur8 ance Trust Fund under section 1841, of 

9 $1,000,000 to the Centers for Medicare & Med10 icaid Services Program Management Account 

11 for fiscal year 2014. Amounts transferred under 

12 this subparagraph shall remain available until 

13 expended.’’. 

14 SEC. 204. REVISION OF THE MEDICARE-DEPENDENT HOS15 PITAL (MDH) PROGRAM. 

16 (a) PERMANENT EXTENSION OF PAYMENT METHOD17 OLOGY.— 

18 (1) IN GENERAL.—Section 1886(d)(5)(G) of 

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

20 1395ww(d)(5)(G)) is amended— 

21 (A) in clause (i), by striking ‘‘and before 

22 April 1, 2014,’’; and 

23 (B) in clause (ii)(II), by striking ‘‘and be24 fore April 1, 2014,’’. 

25 (2) CONFORMING AMENDMENTS.— 


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1 (A) TARGET AMOUNT.—Section 

2 1886(b)(3)(D) of the Social Security Act (42 

3 U.S.C. 1395ww(b)(3)(D)) is amended— 

4 (i) in the matter preceding clause (i), 

5 by striking ‘‘and before April 1, 2014,’’; 

6 and 

7 (ii) in clause (iv), by striking 

8 ‘‘through fiscal year 2013 and the portion 

9 of fiscal year 2014 before April 1, 2014’’ 

10 and inserting ‘‘or a subsequent fiscal 

11 year’’. 

12 (B) HOSPITAL VALUE-BASED PURCHASING

13 PROGRAM.—Section 1886(o)(7)(D)(ii)(I) of the 

14 Social Security Act (42 U.S.C. 

15 1395ww(o)(7)(D)(ii)(I)) is amended by striking 

16 ‘‘(with respect to discharges occurring during 

17 fiscal year 2012 and 2013)’’. 

18 (C) HOSPITAL READMISSION REDUCTION

19 PROGRAM.—Section 1886(q)(2)(B)(i) of the So20 cial Security Act (42 U.S.C. 

21 1395ww(q)(2)(B)(i)) is amended by striking 

22 ‘‘(with respect to discharges occurring during 

23 fiscal years 2012 and 2013)’’. 

24 (D) PERMITTING HOSPITALS TO DECLINE

25 RECLASSIFICATION.—Section 13501(e)(2) of 


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1 the Omnibus Budget Reconciliation Act of 1993 

2 (42 U.S.C. 1395ww note) is amended by strik3 ing ‘‘fiscal year 1998, fiscal year 1999, or fiscal 

4 year 2000 through the first 2 quarters of fiscal 

5 year 2014’’ and inserting ‘‘or fiscal year 1998 

6 or a subsequent fiscal year’’. 

7 (b) GAO STUDY AND REPORT ON MEDICARE-DE8 PENDENT HOSPITALS.— 

9 (1) STUDY.—The Comptroller General of the 

10 United States shall conduct a study on the following: 

11 (A) The payor mix of medicare-dependent, 

12 small rural hospitals (as defined in section 

13 1886(d)(5)(G)(iv)), how such mix will trend in 

14 future years, and whether or not the require15 ment under subclause (IV) of such section 

16 should be revised. 

17 (B) The characteristics of medicare-de18 pendent, small rural hospitals that meet the re19 quirement of such subclause (IV) through the 

20 application of paragraph (a)(iii)(A) or 

21 (a)(iii)(B) of section 412.108 of the Code of 

22 Federal Regulations, including Medicare inpa23 tient and outpatient utilization, payor mix, and 

24 financial status, including Medicare and total 


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1 margins, and whether or not Medicare pay2 ments for such hospitals should be revised. 

3 (C) Such other items related to medicare4 dependent, small rural hospitals as the Comp5 troller General determines appropriate. 

6 (2) REPORT.—Not later than 12 months after 

7 the date of the enactment of this Act, the Comp8 troller General of the United States shall submit to 

9 Congress a report on the study conducted under 

10 paragraph (1), together with recommendations for 

11 such legislation and administrative action as the 

12 Comptroller General determines appropriate. 

13 (c) IMPLEMENTATION.—Notwithstanding any other 

14 provision of law, for purposes of fiscal year 2014, the Sec15 retary of Health and Human Services may implement the 

16 provisions of, and the amendments made by, this section 

17 through program instruction or otherwise. 

18 SEC. 205. REVISION OF MEDICARE INPATIENT HOSPITAL 

19 PAYMENT ADJUSTMENT FOR LOW-VOLUME 

20 HOSPITALS. 

21 (a) IN GENERAL.—Section 1886(d)(12) of the Social 

22 Security Act (42 U.S.C. 1395ww(d)(12)) is amended— 

23 (1) in subparagraph (B)— 


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1 (A) in the subparagraph heading, by in2 serting ‘‘FOR FISCAL YEARS 2005 THROUGH

3 2010’’ after ‘‘INCREASE’’; and 

4 (B) in the matter preceding clause (i), by 

5 striking ‘‘and for discharges occurring in the 

6 portion of fiscal year 2014 beginning on April 

7 1, 2014, fiscal year 2015, and subsequent 

8 years’’; 

9 (2) in subparagraph (C)(i)— 

10 (A) by striking ‘‘fiscal years 2011, 2012, 

11 and 2013, and the portion of fiscal year 2014 

12 before’’ and inserting ‘‘fiscal year 2011 and 

13 subsequent fiscal years,’’ each place it appears; 

14 and 

15 (B) by striking ‘‘or portion of fiscal year’’ 

16 after ‘‘during the fiscal year’’; and 

17 (3) in subparagraph (D)— 

18 (A) in the heading, by striking ‘‘TEM19 PORARY APPLICABLE PERCENTAGE INCREASE’’ 

20 and inserting ‘‘APPLICABLE PERCENTAGE IN21 CREASE FOR FISCAL YEAR 2011 AND SUBSE22 QUENT FISCAL YEARS’’; 

23 (B) by striking ‘‘fiscal years 2011, 2012, 

24 and 2013, and the portion of fiscal year 2014 


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1 before April 1, 2014’’ and inserting ‘‘fiscal year 

2 2011 or a subsequent fiscal year’’; and 

3 (C) by striking ‘‘or the portion of fiscal 

4 year’’ after ‘‘in the fiscal year’’. 

5 (b) IMPLEMENTATION.—Notwithstanding any other 

6 provision of law, for purposes of fiscal year 2014, the Sec7 retary of Health and Human Services may implement the 

8 provisions of, and the amendments made by, this section 

9 through program instruction or otherwise. 

10 SEC. 206. SPECIALIZED MEDICARE ADVANTAGE PLANS FOR 

11 SPECIAL NEEDS INDIVIDUALS. 

12 (a) EXTENSION.—Section 1859(f)(1) of the Social 

13 Security Act (42 U.S.C. 1395w–28(f)(1)) is amended— 

14 (1) by striking ‘‘ENROLLMENT.—In the case’’ 

15 and inserting ‘‘ENROLLMENT.— 

16 ‘‘(A) IN GENERAL.—Subject to subpara17 graphs (B) and (C), in the case’’; 

18 (2) in subparagraph (A), as added by para19 graph (1), by striking ‘‘and for periods before Janu20 ary 1, 2016’’; and 

21 (3) by adding at the end the following new sub22 paragraphs: 

23 ‘‘(B) APPLICATION TO DUAL SNPS.—Sub24 paragraph (A) shall only apply to a specialized 

25 MA plan for special needs individuals described 


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1 in subsection (b)(6)(B)(ii) for periods before 

2 January 1, 2021. 

3 ‘‘(C) APPLICATION TO SEVERE OR DIS4 ABLING CHRONIC CONDITION SNPS.—Subpara5 graph (A) shall only apply to a specialized MA 

6 plan for special needs individuals described in 

7 subsection (b)(6)(B)(iii) for periods before Jan8 uary 1, 2018.’’. 

9 (b) INCREASED INTEGRATION OF DUAL SNPS.— 

10 (1) IN GENERAL.—Section 1859(f) of the Social 

11 Security Act (42 U.S.C. 1395w–28(f)) is amended— 

12 (A) in paragraph (3), by adding at the end 

13 the following new subparagraph: 

14 ‘‘(F) The plan meets the requirements ap15 plicable under paragraph (8).’’; and 

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

17 paragraph: 

18 ‘‘(8) INCREASED INTEGRATION OF DUAL

19 SNPS.— 

20 ‘‘(A) DESIGNATED CONTACT.—The Sec21 retary, acting through the Federal Coordinated 

22 Health Care Office (Medicare-Medicaid Coordi23 nation Office) established under section 2602 of 

24 the Patient Protection and Affordable Care Act 

25 (in this paragraph referred to as the ‘MMCO’), 


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1 shall serve as a dedicated point of contact for 

2 States to address misalignments that arise with 

3 the integration of specialized MA plans for spe4 cial needs individuals described in subsection 

5 (b)(6)(B)(ii) under this paragraph. Consistent 

6 with such role, the MMCO shall— 

7 ‘‘(i) establish a uniform process for 

8 disseminating to State Medicaid agencies 

9 information under this title impacting con10 tracts between such agencies and such 

11 plans under this subsection; and 

12 ‘‘(ii) establish basic resources for 

13 States interested in exploring such plans 

14 as a platform for integration. 

15 ‘‘(B) UNIFIED GRIEVANCES AND APPEALS

16 PROCESS.— 

17 ‘‘(i) IN GENERAL.—Not later than 

18 April 1, 2015, the Secretary shall establish 

19 procedures unifying the grievances and ap20 peals procedures under sections 1852(f), 

21 1852(g), 1902(a)(3), and 1902(a)(5) for 

22 items and services provided by specialized 

23 MA plans for special needs individuals de24 scribed in subsection (b)(6)(B)(ii) under 

25 this title and title XIX. The Secretary 


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1 shall solicit comment in developing such 

2 procedures from States, plans, beneficiaries 

3 and their representatives, and other rel4 evant stakeholders. 

5 ‘‘(ii) PROCEDURES.—The procedures 

6 established under clause (i) shall— 

7 ‘‘(I) adopt the provisions for the 

8 enrollee under current law that are 

9 most protective for the enrollee and 

10 are compatible with unified time11 frames and consolidated access to ex12 ternal review under an integrated 

13 process; 

14 ‘‘(II) take into account dif15 ferences in State plans under title 

16 XIX; 

17 ‘‘(III) be easily navigable by an 

18 enrollee; and 

19 ‘‘(IV) include the elements de20 scribed in clause (iii), as applicable, to 

21 both unified appeals and unified griev22 ance procedures. 

23 ‘‘(iii) ELEMENTS DESCRIBED.—The 

24 following elements are described in this 

25 clause: 


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1 ‘‘(I) Single notification of all ap2 plicable grievances and appeal rights 

3 under this title and title XIX. 

4 ‘‘(II) Single pathways for resolu5 tion of any grievance or appeal related 

6 to a particular item or service pro7 vided by specialized MA plans for spe8 cial needs individuals described in 

9 subsection (b)(6)(B)(ii) under this 

10 title and title XIX. 

11 ‘‘(III) Notices written in plain 

12 language and available in a language 

13 and format that is accessible to the 

14 enrollee. 

15 ‘‘(IV) Unified timeframes for 

16 grievances and appeals processes, 

17 such as an individual’s filing of a 

18 grievance or appeal, a plan’s acknowl19 edgment and resolution of a grievance 

20 or appeal, and notification of decisions 

21 with respect to a grievance or appeal. 

22 ‘‘(V) Guidelines for how the plan 

23 must process, track, and resolve griev24 ances and appeals, to ensure bene25 ficiaries are notified on a timely basis 


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1 of decisions that are made throughout 

2 the grievance or appeals process and 

3 are able to easily determine the status 

4 of a grievance or appeal. 

5 ‘‘(iv) INCORPORATION OF BENE6 FICIARY PROTECTIONS AND IMPLE7 MENTING REGULATIONS.—The unified pro8 cedures under clause (i) shall incorporate 

9 beneficiary protections under current law 

10 and implementing regulations that provide 

11 continuation of benefits pending appeal 

12 under title XIX. 

13 ‘‘(C) REQUIREMENT FOR UNIFIED GRIEV14 ANCES AND APPEALS.— 

15 ‘‘(i) IN GENERAL.—For 2017 and 

16 subsequent years, the contract of a special17 ized MA plan for special needs individuals 

18 described in subsection (b)(6)(B)(ii) with a 

19 State Medicaid agency under this sub20 section shall require the use of unified 

21 grievances and appeals procedures as de22 scribed in subparagraph (B). 

23 ‘‘(ii) CONSIDERATION OF APPLICA24 TION FOR OTHER SNPS.—The Secretary 

25 shall consider applying the unified grievVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00228 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 ances and appeals process described in 

2 subparagraph (B) to specialized MA plans 

3 for special needs individuals described in 

4 subsection (b)(6)(B)(i) and subsection 

5 (b)(6)(B)(iii) that have a substantial por6 tion of enrollees who are dually eligible for 

7 benefits under this title and title XIX and 

8 are at risk for full benefits under title 

9 XIX. 

10 ‘‘(D) REQUIREMENT FOR FULL INTEGRA11 TION FOR CERTAIN DUAL SNPS.— 

12 ‘‘(i) REQUIREMENT.—Subject to the 

13 succeeding provisions of this subparagraph, 

14 for 2018 and subsequent years, a special15 ized MA plan for special needs individuals 

16 described in subsection (b)(6)(B)(ii) 

17 shall— 

18 ‘‘(I) integrate all benefits under 

19 this title and title XIX; and 

20 ‘‘(II) meet the requirements of a 

21 fully integrated plan described in sec22 tion 1853(a)(1)(B)(iv)(II) (other than 

23 the requirement that the plan have 

24 similar average levels of frailty, as de25 termined by the Secretary, as the 


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1 PACE program), including with re2 spect to long-term care services or be3 havioral health services to the extent 

4 State law permits capitation of those 

5 services under such plan. 

6 ‘‘(ii) INITIAL SANCTIONS FOR FAIL7 URE TO MEET REQUIREMENT FOR 2018 OR

8 2019.—For each of 2018 and 2019, if the 

9 Secretary determines that a plan has failed 

10 to meet the requirement described in 

11 clause (i), the Secretary shall impose one 

12 of the following on the plan: 

13 ‘‘(I) A reduction in payment to 

14 the plan under this part in an amount 

15 at least equal to the portion of the 

16 monthly rebate computed under sec17 tion 1854(b)(1)(C)(i) for the plan and 

18 year. 

19 ‘‘(II) Closing enrollment in the 

20 plan. 

21 ‘‘(III) Sanctioning the plan in ac22 cordance with section 1857(g). 

23 ‘‘(IV) Other reasonable action 

24 (other than the sanction described in 


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1 clause (iii)) the Secretary determines 

2 appropriate. 

3 ‘‘(iii) SANCTIONS FOR FAILURE TO

4 MEET REQUIREMENT FOR 2020 AND SUBSE5 QUENT YEARS.—For 2020 and subsequent 

6 years, if the Secretary determines that a 

7 plan has failed to meet the requirement de8 scribed in clause (i), the plan shall be 

9 deemed to no longer meet the definition of 

10 a specialized MA plan for special needs in11 dividuals described in subsection 

12 (b)(6)(B)(ii).’’. 

13 (2) CONFORMING AMENDMENT TO RESPON14 SIBILITIES OF FEDERAL COORDINATED HEALTH

15 CARE OFFICE (MMCO).—Section 2602(d) of the Pa16 tient Protection and Affordable Care Act (42 U.S.C. 

17 1315b(d)) is amended by adding at the end the fol18 lowing new paragraphs: 

19 ‘‘(6) To act as a designated contact for States 

20 under subsection (f)(8)(A) of section 1859 of the So21 cial Security Act (42 U.S.C. 1395w–28) with respect 

22 to the integration of specialized MA plans for special 

23 needs individuals described in subsection 

24 (b)(6)(B)(ii) of such section. 


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1 ‘‘(7) To be responsible for developing regula2 tions and guidance related to the implementation of 

3 a unified grievance and appeals process as described 

4 in subparagraphs (B) and (C) of section 1859(f)(8) 

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

6 28(f)(8)).’’. 

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: 

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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 15 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 17 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-star rating or 

25 the highest rating possible overall or for an 


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1 individual measure in order to ensure that 

2 the plan is not punished in cases where it 

3 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 may include Medicare Health Out6 comes Survey (HOS), Healthcare Ef7 fectiveness Data and Information Set 

8 (HEDIS), Consumer Assessment of 

9 Healthcare Providers and Systems 

10 (CAHPS) measures and quality meas11 ures under part D; and 

12 ‘‘(II) payment and other adminis13 trative actions linked to quality meas14 urement (including the 5-star rating 

15 system under this subsection) shall be 

16 applied at the plan level in accordance 

17 with this subparagraph. 

18 ‘‘(7) DETERMINATION OF FEASIBILITY OF

19 QUALITY MEASUREMENT AT THE PLAN LEVEL.— 

20 ‘‘(A) DETERMINATION OF FEASIBILITY.— 

21 The Secretary shall determine the feasibility of 

22 requiring reporting for and applying under this 

23 subsection quality measures at the plan level for 

24 all MA plans under this part. 


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1 ‘‘(B) CONSIDERATION OF CHANGE.—After 

2 making a determination under subparagraph 

3 (A), the Secretary shall consider requiring such 

4 reporting and applying such quality measures 

5 at the plan level as described in such subpara6 graph.’’. 

7 SEC. 207. REASONABLE COST REIMBURSEMENT CON8 TRACTS. 

9 (a) ONE-YEAR TRANSITION AND NOTICE REGARDING

10 TRANSITION.—Section 1876(h)(5)(C) of the Social Secu11 rity Act (42 U.S.C. 1395mm(h)(5)(C)) is amended— 

12 (1) in clause (ii), in the matter preceding sub13 clause (I), by striking ‘‘For any’’ and inserting 

14 ‘‘Subject to clause (iv), for any’’; and 

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

16 clauses: 

17 ‘‘(iv) In the case of an eligible organization that is 

18 offering a reasonable cost reimbursement contract that 

19 may no longer be extended or renewed because of the ap20 plication of clause (ii), the following shall apply: 

21 ‘‘(I) Notwithstanding such clause, such contract 

22 may be extended or renewed for the two years subse23 quent to the previous year described in clause (ii). 

24 The second of the two years described in the pre25 ceding sentence with respect to a contract is referred 


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1 to in this subsection as the ‘last reasonable cost re2 imbursement contract year for the contract’. 

3 ‘‘(II) The organization may not enroll any new 

4 enrollees under such contract during the last reason5 able cost reimbursement contract year for the con6 tract. 

7 ‘‘(III) Not later than a date determined appro8 priate by the Secretary prior to the beginning of the 

9 last reasonable cost reimbursement contract year for 

10 the contract, the organization shall provide notice to 

11 the Secretary as to whether or not the organization 

12 will apply to have the contract converted over and 

13 offered as a Medicare Advantage plan under part C 

14 for the year following the last reasonable cost reim15 bursement contract year for the contract. 

16 ‘‘(IV) If the organization provides the notice de17 scribed in subclause (III) that the contract will be 

18 converted, the organization shall, not later than a 

19 date determined appropriate by the Secretary, pro20 vide the Secretary with such information as the Sec21 retary determines appropriate in order to carry out 

22 sections 1851(c)(4) and 1854(a)(5), including sub23 paragraph (C) of such section. 

24 ‘‘(v) If an eligible organization that is offering a rea25 sonable cost reimbursement contract that is extended or 


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1 renewed pursuant to clause (iv) provides the notice de2 scribed in clause (iv)(III) that the contract will be con3 verted, the following provisions shall apply: 

4 ‘‘(I) The deemed enrollment under section 

5 1851(c)(4). 

6 ‘‘(II) The special rule for quality increases 

7 under 1853(o)(3)(A)(iv).’’. 

8 (b) DEEMED ENROLLMENT FROM REASONABLE

9 COST REIMBURSEMENT CONTRACTS CONVERTED TO

10 MEDICARE ADVANTAGE PLANS.— 

11 (1) IN GENERAL.—Section 1851(c) of the So12 cial Security Act (42 U.S.C. 1395w–21(c)) is 

13 amended— 

14 (A) in paragraph (1), by striking ‘‘Such 

15 elections’’ and inserting ‘‘Subject to paragraph 

16 (4), such elections’’; and 

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

18 ‘‘(4) DEEMED ENROLLMENT RELATING TO CON19 VERTED REASONABLE COST REIMBURSEMENT CON20 TRACTS.— 

21 ‘‘(A) IN GENERAL.—On the first day of 

22 the annual, coordinated election period under 

23 subsection (e)(3) for plan years beginning on or 

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1 graph (B) is deemed to have elected to receive 

2 benefits under this title through an applicable 

3 MA plan (and shall be enrolled in such plan) 

4 beginning with such plan year, if— 

5 ‘‘(i) the individual is enrolled in a rea6 sonable cost reimbursement contract under 

7 section 1876(h) in the previous plan year; 

8 ‘‘(ii) such reasonable cost reimburse9 ment contract was extended or renewed for 

10 the last reasonable cost reimbursement 

11 contract year of the contract pursuant to 

12 section 1876(h)(5)(C)(iv); 

13 ‘‘(iii) the eligible organization that is 

14 offering such reasonable cost reimburse15 ment contract provided the notice de16 scribed in subclause (III) of such section 

17 that the contract was to be converted; 

18 ‘‘(iv) the applicable MA plan— 

19 ‘‘(I) is the plan that was con20 verted from the reasonable cost reim21 bursement contract described in 

22 clause (iii); 

23 ‘‘(II) is offered by the same enti24 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 payment errors and most expen21 sive payment errors 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 NPI or other provider identifier of the pro15 vider or supplier, the amount of the im16 proper payment, and any other information 

17 the Secretary 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 Centers for Medicare & Medicaid Services 

4 Program Management Account for purposes of car5 rying out this subsection and to implement correc6 tive actions to help reduce the error rate of pay7 ments under this title. The amount retained under 

8 the preceding sentence shall not exceed an amount 

9 equal to 25 percent of the amounts recovered under 

10 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 1874A(h)(8)’’ after ‘‘paragraph (1)(C)’’. 

15 (3) EFFECTIVE DATE.—The amendments made 

16 by this subsection take effect on the date of enact17 ment of this Act. 

18 (b) TRANSPARENCY.—Section 1893(h)(8) of the So19 cial Security Act (42 U.S.C. 1395ddd(h)(8)) is amended— 

20 (1) by striking ‘‘REPORT.—The Secretary’’ and 

21 inserting ‘‘REPORT.— 

22 ‘‘(A) IN GENERAL.—The Secretary’’; and 

23 (2) by adding at the end the following new sub24 paragraph: 


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1 ‘‘(B) INCLUSION OF CERTAIN INFORMA2 TION.— 

3 ‘‘(i) IN GENERAL.—For reports sub4 mitted under this paragraph for 2015 or a 

5 subsequent year, each such report shall in6 clude the information described in clause 

7 (ii) with respect to each of the following 

8 categories of audits carried out by recovery 

9 audit contractors under this subsection: 

10 ‘‘(I) Automated. 

11 ‘‘(II) Complex. 

12 ‘‘(III) Medical necessity review. 

13 ‘‘(IV) Part A. 

14 ‘‘(V) Part B. 

15 ‘‘(VI) Durable medical equip16 ment. 

17 ‘‘(ii) INFORMATION DESCRIBED.—For 

18 purposes of clause (i), the information de19 scribed in this clause, with respect to a 

20 category of audit described in clause (i), is 

21 the result of all appeals for each individual 

22 level of appeals in such category.’’. 

23 (c) RECOVERY AUDIT CONTRACTOR DEMONSTRA24 TION PROJECT.— 


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1 (1) IN GENERAL.—The Secretary shall conduct 

2 a demonstration project under title XVIII of the So3 cial Security Act that— 

4 (A) targets audits by recovery audit con5 tractors under section 1893(h) of the Social Se6 curity Act (42 U.S.C. 1395ddd(h)) with respect 

7 to high error providers of services and suppliers 

8 identified under paragraph (3); and 

9 (B) rewards low error providers of services 

10 and suppliers identified under such paragraph. 

11 (2) SCOPE.— 

12 (A) DURATION.—The demonstration 

13 project shall be implemented not later than 

14 January 1, 2015, and shall be conducted for a 

15 period of three years. 

16 (B) DEMONSTRATION AREA.—In deter17 mining the geographic area of the demonstra18 tion project, the Secretary shall consider the 

19 following: 

20 (i) The total number of providers of 

21 services and suppliers in the region. 

22 (ii) The diversity of types of providers 

23 of services and suppliers in the region. 

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1 vidual providers of services and suppliers 

2 in the region. 

3 (iv) The inclusion of a mix of both 

4 urban and rural areas. 

5 (3) IDENTIFICATION OF LOW ERROR AND HIGH

6 ERROR PROVIDERS OF SERVICES AND SUPPLIERS.— 

7 (A) IN GENERAL.—Subject to paragraph 

8 (5), in conducting the demonstration project, 

9 the Secretary shall identify the following two 

10 groups of providers in accordance with this 

11 paragraph: 

12 (i) Low error providers of services and 

13 suppliers. 

14 (ii) High error providers of services 

15 and suppliers. 

16 (B) ANALYSIS.—For purposes of identi17 fying the groups under subparagraph (A), the 

18 Secretary shall analyze each of the following: 

19 (i) The improper payment rates of in20 dividual providers of services and suppliers. 

21 (ii) The amount of improper payments 

22 made to individual providers of services 

23 and suppliers. 


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1 (iii) The frequency of errors made by 

2 the provider of services or supplier over 

3 time. 

4 (iv) Other information determined ap5 propriate by the Secretary. 

6 (C) ASSIGNMENT BASED ON COMPOSITE

7 SCORE.—The Secretary shall analyze the infor8 mation under subparagraph (B) and assign se9 lected providers of services and suppliers under 

10 the demonstration program as follows: 

11 (i) Providers of services and suppliers 

12 with high, expensive, and frequent errors 

13 relative to national error rates for specific 

14 items and services shall be identified as 

15 high error providers of services and sup16 pliers under subparagraph (A). 

17 (ii) Providers of services and suppliers 

18 with few, inexpensive, and infrequent er19 rors relative to national error rates for spe20 cific items and services shall be identified 

21 as low error providers of services and sup22 pliers under such subparagraph. 

23 (iii) Only a small proportion of the 

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1 ices and suppliers in the geographic area 

2 of the demonstration project shall be as3 signed to either group identified under 

4 such subparagraph. 

5 (D) TIMEFRAME OF IDENTIFICATION.— 

6 (i) IN GENERAL.—Any identification 

7 of a provider of services or a supplier 

8 under subparagraph (A) shall be for a pe9 riod of 3 months. 

10 (ii) REEVALUATION.—The Secretary 

11 shall reevaluate each such identification at 

12 the end of such period. 

13 (iii) USE OF MOST CURRENT INFOR14 MATION.—In carrying out the reevaluation 

15 under clause (ii) with respect to a provider 

16 of services or supplier, the Secretary 

17 shall— 

18 (I) consider the most current in19 formation available with respect to the 

20 provider of services or supplier under 

21 the analysis under subparagraph (B); 

22 and 

23 (II) take into account improve24 ment or regression of the provider of 

25 services or supplier. 


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1 (4) ADJUSTMENT OF RECORD REQUEST MAX2 IMUM.—Sujbect to paragraph (5), under the dem3 onstration project, the Secretary shall establish pro4 cedures to— 

5 (A) increase the maximum record request 

6 made by recovery audit contractors to providers 

7 of services and suppliers identified as high error 

8 providers of services and suppliers under para9 graph (3); and 

10 (B) decrease the maximum record request 

11 made by recovery audit contractors to providers 

12 of services and suppliers identified as low error 

13 providers of services and supplier under such 

14 paragraph. 

15 (5) FLEXIBILITY.—Notwithstanding para16 graphs (3) and (4), the Secretary may identify more 

17 than two groups of providers in a geographical area. 

18 If the Secretary identifies more than two groups of 

19 providers in a geographic area pursuant to the pre20 ceding sentence— 

21 (A) providers shall be assigned to such 

22 groups in a manner similar to the manner in 

23 which providers are assigned to a group under 

24 paragraph (3); and 


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1 (B) the maximum record request would be 

2 adjusted in a manner similar to the manner in 

3 which the maximum record request is adjusted 

4 under paragraph (4). 

5 (6) ADDITIONAL ADJUSTMENTS.— 

6 (A) IN GENERAL.—Under the demonstra7 tion project, the Secretary may make additional 

8 adjustments to requirements for recovery audit 

9 contractors under section 1893(h) of the Social 

10 Security Act (42 U.S.C. 1395ddd(h)) and the 

11 conduct of audits with respect to low error pro12 viders of services and suppliers identified under 

13 paragraph (3) (or paragraph (5), as the case 

14 may be) and high error providers of services 

15 and suppliers identified under paragraph (3) 

16 (or paragraph (5), as the case may be) as the 

17 Secretary determines necessary in order to 

18 incentivize reductions in improper payment 

19 rates under title XVIII of such Act (42 U.S.C. 

20 1395 et seq.). 

21 (B) LIMITATION.—The Secretary shall not 

22 exempt any group of providers of services or 

23 suppliers in the demonstration project, absent 

24 evidence of fraud or abuse, from being subject 


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1 to audit by a recovery audit contractor under 

2 such section 1893(h). 

3 (7) EVALUATION AND REPORT.— 

4 (A) EVALUATION.—The Inspector General 

5 of the Department of Health and Human Serv6 ices shall conduct an evaluation of the dem7 onstration project under this subsection. The 

8 evaluation shall include an analysis of— 

9 (i) the error rates of providers of serv10 ices and suppliers— 

11 (I) identified under paragraph 

12 (3) (or paragraph (5), as the case 

13 may be) as low error providers of 

14 services and suppliers; 

15 (II) identified under paragraph 

16 (3) (or paragraph (5), as the case 

17 may be) as high error providers of 

18 services and suppliers; and 

19 (III) that are located in the geo20 graphic area of the demonstration 

21 project and are not identified as either 

22 a low error or high error provider of 

23 services or supplier under such para24 graphs; 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 paragraphs. 

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 (8) FUNDING.— 

15 (A) FUNDING FOR IMPLEMENTATION.— 

16 After application of paragraph (1)(C) of section 

17 1893(h) of the Social Security Act (42 U.S.C. 

18 1395ddd(h)) and section 1874A(h)(8) of such 

19 Act (42 U.S.C. 1395kk–1(h)(8)), as added by 

20 subsection (a)(1), the Secretary shall retain 

21 $10,000,000 of the amounts recovered by recov22 ery audit contractors under such section 

23 1893(h), which shall be available to the Centers 

24 for Medicare & Medicaid Services Program 

25 Management Account for purposes of carrying 


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1 out the demonstration project under this sub2 section (other than the evaluation and report 

3 under paragraph (7)). The amount retained 

4 under the preceding sentence shall remain avail5 able until expended. 

6 (B) FUNDING FOR INSPECTOR GENERAL

7 EVALUATION AND REPORT.—After application 

8 of such paragraph (1)(C), such section 

9 1874A(h)(8), as so added, and subparagraph 

10 (A), the Secretary shall retain $245,000 of the 

11 amounts recovered by recovery audit contrac12 tors under such section 1893(h), which shall be 

13 transferred to the Inspector General of the De14 partment of Health and Human Services for 

15 purposes of carrying out the evaluation and re16 port under paragraph (7). The amount trans17 ferred under the preceding sentence shall re18 main available until expended. 

19 (C) NO REDUCTION IN PAYMENTS TO RE20 COVERY AUDIT CONTRACTORS.—Nothing in 

21 subparagraph (A) or (B) of this paragraph or 

22 such section 1874A(h)(8), as so added, shall re23 duce amounts available for payments to recov24 ery audit contractors under such section 

25 1893(h). 


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1 (D) FUNDING CONFORMING AMEND2 MENT.—Section 1893(h)(2) of the Social Secu3 rity Act (42 U.S.C. 1395ddd(h)(2)), as amend4 ed by subsection (a)(2), is amended by striking 

5 ‘‘or section 1874A(h)(8)’’ and inserting ‘‘, sec6 tion 1874A(h)(8), or subparagraphs (A) and 

7 (B) of section 301(c)(8) of the Commonsense 

8 Medicare SGR Repeal and Beneficiary Access 

9 Improvement Act of 2014’’. 

10 (9) DEFINITIONS.—In this section: 

11 (A) DEMONSTRATION PROJECT.—The term 

12 ‘‘demonstration project’’ means the demonstra13 tion project under this subsection. 

14 (B) PROVIDER OF SERVICES.—The term 

15 ‘‘provider of services’’ has the meaning given 

16 that term in section 1861(u). 

17 (C) RECOVERY AUDIT CONTRACTOR.—The 

18 term ‘‘recovery audit contractor’’ means an en19 tity with a contract under section 1893(h) of 

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

21 1395ddd(h)). 

22 (D) SECRETARY.—The term ‘‘Secretary’’ 

23 means the Secretary of Health and Human 

24 Services. 


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1 (E) SUPPLIER.—The term ‘‘supplier’’ has 

2 the meaning given that term in section 1861(d). 

3 SEC. 302. AUTHORITY FOR MEDICAID FRAUD CONTROL 

4 UNITS TO INVESTIGATE AND PROSECUTE 

5 COMPLAINTS OF ABUSE AND NEGLECT OF 

6 MEDICAID PATIENTS IN HOME AND COMMU7 NITY-BASED SETTINGS. 

8 (a) IN GENERAL.—Section 1903(q)(4)(A) of the So9 cial Security Act (42 U.S.C. 1396b(q)(4)(A)) is amended 

10 to read as follows: 

11 ‘‘(4)(A) The entity’s function includes a state12 wide program for the— 

13 ‘‘(i) investigation and prosecution, or refer14 ral for prosecution or other action, of com15 plaints of abuse or neglect of patients in health 

16 care facilities which receive payments under the 

17 State plan under this title or under a waiver of 

18 such plan; 

19 ‘‘(ii) at the option of the entity, investiga20 tion and prosecution, or referral for prosecution 

21 or other action, of complaints of abuse or ne22 glect of individuals in connection with any as23 pect of the provision of medical assistance and 

24 the activities of providers of such assistance in 

25 a home or community based setting that is paid 


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1 for under the State plan under this title or 

2 under a waiver of such plan; and 

3 ‘‘(iii) at the option of the entity, investiga4 tion and prosecution, or referral for prosecution 

5 or other action, of complaints of abuse or ne6 glect of patients residing in board and care fa7 cilities.’’. 

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

9 subsection (a) shall take effect on January 1, 2015. 

10 SEC. 303. IMPROVED USE OF FUNDS RECEIVED BY THE HHS 

11 INSPECTOR GENERAL FROM OVERSIGHT AND 

12 INVESTIGATIVE ACTIVITIES. 

13 (a) IN GENERAL.—Section 1128C(b) of the Social 

14 Security Act (42 U.S.C. 1320a–7c(b)) is amended to read 

15 as follows: 

16 ‘‘(b) ADDITIONAL USE OF FUNDS BY INSPECTOR

17 GENERAL.— 

18 ‘‘(1) COLLECTIONS FROM MEDICARE AND MED19 ICAID RECOVERY ACTIONS.—Notwithstanding section 

20 3302 of title 31, United States Code, or any other 

21 provision of law affecting the crediting of collections, 

22 the Inspector General of the Department of Health 

23 and Human Services may receive and retain for cur24 rent use three percent of all amounts collected pur25 suant to civil debt collection and administrative enVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00302 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 forcement actions related to false claims or frauds 

2 involving the Medicare program under title XVIII or 

3 the Medicaid program under title XIX. 

4 ‘‘(2) CREDITING.—Funds received by the In5 spector General under paragraph (1) shall be depos6 ited as offsetting collections to the credit of any ap7 propriation available for oversight and enforcement 

8 activities of the Inspector General permitted under 

9 subsection (a), and shall remain available until ex10 pended.’’. 

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

12 subsection (a) shall apply to funds received from settle13 ments finalized, judgments entered, or final agency deci14 sions issued, on or after the date of the enactment of this 

15 Act. 

16 SEC. 304. PREVENTING AND REDUCING IMPROPER MEDI17 CARE AND MEDICAID EXPENDITURES. 

18 (a) REQUIRING VALID PRESCRIBER NATIONAL PRO19 VIDER IDENTIFIERS ON PHARMACY CLAIMS.—Section 

20 1860D–4(c) of the Social Security Act (42 U.S.C. 1395w– 

21 104(c)) is amended by adding at the end the following new 

22 paragraph: 

23 ‘‘(4) REQUIRING VALID PRESCRIBER NATIONAL

24 PROVIDER IDENTIFIERS ON PHARMACY CLAIMS.— 


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1 ‘‘(A) IN GENERAL.—For plan year 2015 

2 and subsequent plan years, subject to subpara3 graph (B), the Secretary shall prohibit PDP 

4 sponsors of prescription drug plans from paying 

5 claims for prescription drugs under this part 

6 that do not include a valid prescriber National 

7 Provider Identifier. 

8 ‘‘(B) PROCEDURES.—The Secretary shall 

9 establish procedures for determining the validity 

10 of prescriber National Provider Identifiers 

11 under subparagraph (A). 

12 ‘‘(C) REPORT.—Not later than January 1, 

13 2017, the Inspector General of the Department 

14 of Health and Human Services shall submit to 

15 Congress a report on the effectiveness of the 

16 procedures established under subparagraph 

17 (B).’’. 

18 (b) REFORMING HOW CMS TRACKS AND CORRECTS

19 THE VULNERABILITIES IDENTIFIED BY RECOVERY AUDIT

20 CONTRACTORS.—Section 1893(h) of the Social Security 

21 Act (42 U.S.C. 1395ddd(h)) is amended— 

22 (1) in paragraph (8), as amended by section 

23 301(b), by adding at the end the following new sub24 paragraphs: 


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1 ‘‘(C) INCLUSION OF IMPROPER PAYMENT

2 VULNERABILITIES IDENTIFIED.—For reports 

3 submitted under this paragraph for 2015 or a 

4 subsequent year, each such report shall in5 clude— 

6 ‘‘(i) a description of— 

7 ‘‘(I) the types and financial cost 

8 to the program under this title of im9 proper payment vulnerabilities identi10 fied by recovery audit contractors 

11 under this subsection; and 

12 ‘‘(II) how the Secretary is ad13 dressing such improper payment 

14 vulnerabilities; and 

15 ‘‘(ii) an assessment of the effective16 ness of changes made to payment policies 

17 and procedures under this title in order to 

18 address the vulnerabilities so identified. 

19 ‘‘(D) LIMITATION.—The Secretary shall 

20 ensure that each report submitted under sub21 paragraph (A) does not include information 

22 that the Secretary determines would be sen23 sitive or would otherwise negatively impact pro24 gram integrity.’’; and 


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

2 paragraph: 

3 ‘‘(10) ADDRESSING IMPROPER PAYMENT

4 VULNERABILITIES.—The Secretary shall address im5 proper payment vulnerabilities identified by recovery 

6 audit contractors under this subsection in a timely 

7 manner, prioritized based on the risk to the program 

8 under this title.’’. 

9 (c) STRENGTHENING MEDICAID PROGRAM INTEG10 RITY THROUGH FLEXIBILITY.—Section 1936 of the Social 

11 Security Act (42 U.S.C. 1396u–6) is amended— 

12 (1) in subsection (a), by inserting ‘‘, or other13 wise,’’ after ‘‘entities’’; and 

14 (2) in subsection (e)— 

15 (A) in paragraph (1), in the matter pre16 ceding subparagraph (A), by inserting ‘‘(includ17 ing the costs of equipment, salaries and bene18 fits, and travel and training)’’ after ‘‘Program 

19 under this section’’; and 

20 (B) in paragraph (3), by striking ‘‘by 100’’ 

21 and inserting ‘‘by 100, or such number as de22 termined necessary by the Secretary to carry 

23 out the Program under this section,’’. 

24 (d) ACCESS TO THE NATIONAL DIRECTORY OF NEW

25 HIRES.—Section 453(j) of the Social Security Act (42 


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1 U.S.C. 653(j)) is amended by adding at the end the fol2 lowing new paragraph: 

3 ‘‘(12) INFORMATION COMPARISONS AND DIS4 CLOSURES TO ASSIST IN ADMINISTRATION OF THE

5 MEDICARE PROGRAM AND STATE HEALTH SUBSIDY

6 PROGRAMS.— 

7 ‘‘(A) DISCLOSURE TO THE ADMINIS8 TRATOR OF THE CENTERS FOR MEDICARE &

9 MEDICAID SERVICES.—The Administrator of 

10 the Centers for Medicare & Medicaid shall have 

11 access to the information in the National Direc12 tory of New Hires for purposes of determining 

13 the eligibility of an applicant for, or enrollee in, 

14 the Medicare program under title XVIII or an 

15 applicable State health subsidy program (as de16 fined in section 1413(e) of the Patient Protec17 tion and Affordable Care Act (42 U.S.C. 

18 18083(e)). 

19 ‘‘(B) DISCLOSURE TO THE INSPECTOR

20 GENERAL OF THE DEPARTMENT OF HEALTH

21 AND HUMAN SERVICES.— 

22 ‘‘(i) IN GENERAL.—If the Inspector 

23 General of the Department of Health and 

24 Human Services transmits to the Secretary 

25 the names and social security account 


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1 numbers of individuals, the Secretary shall 

2 disclose to the Inspector General informa3 tion on such individuals and their employ4 ers maintained in the National Directory 

5 of New Hires. 

6 ‘‘(ii) USE OF INFORMATION.—The In7 spector General of the Department of 

8 Health and Human Services may use in9 formation provided under clause (i) only 

10 for purposes of — 

11 ‘‘(I) enforcing mandatory and 

12 permissive exclusions under title XI; 

13 or 

14 ‘‘(II) evaluating the integrity of 

15 the Medicare program or an applica16 ble State health subsidy program (as 

17 defined in section 1413(e) of the Pa18 tient Protection and Affordable Care 

19 Act). 

20 The authority under this clause is in addi21 tion to any authority conferred under the 

22 Inspector General Act of 1978 (5 U.S.C. 

23 App). 

24 ‘‘(C) DISCLOSURE TO STATE AGENCIES.— 


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1 ‘‘(i) IN GENERAL.—If, for purposes of 

2 determining the eligibility of an applicant 

3 for, or an enrollee in, an applicable State 

4 health subsidy program (as defined in sec5 tion 1413(e) of the Patient Protection and 

6 Affordable Care Act (42 U.S.C. 18083(e)), 

7 a State agency responsible for admin8 istering such program transmits to the 

9 Secretary the names, dates of birth, and 

10 social security account numbers of individ11 uals, the Secretary shall disclose to such 

12 State agency information on such individ13 uals and their employers maintained in the 

14 National Directory of New Hires, subject 

15 to this subparagraph. 

16 ‘‘(ii) CONDITION ON DISCLOSURE BY

17 THE SECRETARY.—The Secretary shall 

18 make a disclosure under clause (i) only to 

19 the extent that the Secretary determines 

20 that the disclosure would not interfere with 

21 the effective operation of the program 

22 under this part. 

23 ‘‘(iii) USE AND DISCLOSURE OF IN24 FORMATION BY STATE AGENCIES.— 


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1 ‘‘(I) IN GENERAL.—A State 

2 agency may not use or disclose infor3 mation provided under clause (i) ex4 cept for purposes of determining the 

5 eligibility of an applicant for, or an 

6 enrollee in, a program referred to in 

7 clause (i). 

8 ‘‘(II) INFORMATION SECURITY.— 

9 The State agency shall have in effect 

10 data security and control policies that 

11 the Secretary finds adequate to ensure 

12 the security of information obtained 

13 under clause (i) and to ensure that 

14 access to such information is re15 stricted to authorized persons for pur16 poses of authorized uses and disclo17 sures. 

18 ‘‘(III) PENALTY FOR MISUSE OF

19 INFORMATION.—An officer or em20 ployee of the State agency who fails to 

21 comply with this clause shall be sub22 ject to the sanctions under subsection 

23 (l)(2) to the same extent as if such of24 ficer or employee were an officer or 

25 employee of the United States. 


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1 ‘‘(iv) PROCEDURAL REQUIREMENTS.— 

2 State agencies requesting information 

3 under clause (i) shall adhere to uniform 

4 procedures established by the Secretary 

5 governing information requests and data 

6 matching under this paragraph. 

7 ‘‘(v) REIMBURSEMENT OF COSTS.— 

8 The State agency shall reimburse the Sec9 retary, in accordance with subsection 

10 (k)(3), for the costs incurred by the Sec11 retary in furnishing the information re12 quested under this subparagraph.’’. 

13 (e) IMPROVING THE SHARING OF DATA BETWEEN

14 THE FEDERAL GOVERNMENT AND STATE MEDICAID PRO15 GRAMS.— 

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

17 Human Services (in this subsection referred to as 

18 the ‘‘Secretary’’) shall establish a plan to encourage 

19 and facilitate the participation of States in the Medi20 care-Medicaid Data Match Program (commonly re21 ferred to as the ‘‘Medi-Medi Program’’) under sec22 tion 1893(g) of the Social Security Act (42 U.S.C. 

23 1395ddd(g)). 

24 (2) PROGRAM REVISIONS TO IMPROVE MEDI25 MEDI DATA MATCH PROGRAM PARTICIPATION BY


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1 STATES.—Section 1893(g)(1)(A) of the Social Secu2 rity Act (42 U.S.C. 1395ddd(g)(1)(A)) is amend3 ed— 

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

5 inserting ‘‘or otherwise’’ after ‘‘eligible enti6 ties’’; 

7 (B) in clause (i)— 

8 (i) by inserting ‘‘to review claims 

9 data’’ after ‘‘algorithms’’; and 

10 (ii) by striking ‘‘service, time, or pa11 tient’’ and inserting ‘‘provider, service, 

12 time, or patient’’; 

13 (C) in clause (ii)— 

14 (i) by inserting ‘‘to investigate and re15 cover amounts with respect to suspect 

16 claims’’ after ‘‘appropriate actions’’; and 

17 (ii) by striking ‘‘; and’’ and inserting 

18 a semicolon; 

19 (D) in clause (iii), by striking the period 

20 and inserting ‘‘; and’’; and 

21 (E) by adding at end the following new 

22 clause: 

23 ‘‘(iv) furthering the Secretary’s de24 sign, development, installation, or enhanceVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00312 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 ment of an automated data system archi2 tecture— 

3 ‘‘(I) to collect, integrate, and as4 sess data for purposes of program in5 tegrity, program oversight, and ad6 ministration, including the Medi-Medi 

7 Program; and 

8 ‘‘(II) that improves the coordina9 tion of requests for data from 

10 States.’’. 

11 (3) PROVIDING STATES WITH DATA ON IM12 PROPER PAYMENTS MADE FOR ITEMS OR SERVICES

13 PROVIDED TO DUAL ELIGIBLE INDIVIDUALS.— 

14 (A) IN GENERAL.—The Secretary shall de15 velop and implement a plan that allows each 

16 State agency responsible for administering a 

17 State plan for medical assistance under title 

18 XIX of the Social Security Act access to rel19 evant data on improper or fraudulent payments 

20 made under the Medicare program under title 

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

22 1395 et seq.) for health care items or services 

23 provided to dual eligible individuals. 

24 (B) DUAL ELIGIBLE INDIVIDUAL DE25 FINED.—In this paragraph, the term ‘‘dual eliVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00313 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 gible individual’’ means an individual who is en2 titled to, or enrolled for, benefits under part A 

3 of title XVIII of the Social Security Act (42 

4 U.S.C. 1395c et seq.), or enrolled for benefits 

5 under part B of title XVIII of such Act (42 

6 U.S.C. 1395j et seq.), and is eligible for medical 

7 assistance under a State plan under title XIX 

8 of such Act (42 U.S.C. 1396 et seq.) or under 

9 a waiver of such plan. 

10 TITLE IV—OTHER PROVISIONS 

11 SEC. 401. COMMISSION ON IMPROVING PATIENT DIRECTED 

12 HEALTH CARE. 

13 (a) FINDINGS.—Congress finds the following: 

14 (1) In order to elevate the role of patient 

15 choices in the health care system, the American pub16 lic must engage in an informed, national, public de17 bate on how the current health care system empow18 ers and informs health care decision-making, and 

19 what can be done to improve the likelihood patients 

20 receive the care they want and need. 

21 (2) Research suggests that patients often do 

22 not receive the care they want. As a result, the end 

23 of life is associated with a substantial burden of suf24 fering by the patient and negative health and finanVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00314 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 cial consequences that extend to family members and 

2 society. 

3 (3) Patients face a complex and fragmented 

4 health care system that may decrease the likelihood 

5 that health care choices are known and carried out. 

6 The health care system should embed principles that 

7 take into account patient wishes. 

8 (4) Decisions concerning health care, including 

9 end-of-life issues, affect an increasing number of 

10 Americans. 

11 (5) Medical advances are prolonging life expect12 ancy in the United States both in acute life-threat13 ening situations and protracted battles with illness. 

14 These advances raise new challenges surrounding 

15 health care decision-making. 

16 (6) The United States health care system 

17 should promote consideration of a person’s pref18 erence in health care decision-making and end-of-life 

19 choices. 

20 (b) COMMISSION.—The Social Security Act is amend21 ed by inserting after section 1150B (42 U.S.C. 1320b– 

22 24) the following new section: 


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1 ‘‘SEC. 1150C. COMMISSION ON IMPROVING PATIENT DI2 RECTED HEALTH CARE. 

3 ‘‘(a) PURPOSES.—The purposes of this section are 

4 to— 

5 ‘‘(1) provide a forum for a nationwide public 

6 debate on improving patient self-determination in 

7 health care decision-making; 

8 ‘‘(2) identify strategies that ensure every Amer9 ican has the health care they want; and 

10 ‘‘(3) provide recommendations to Congress that 

11 result from the debate. 

12 ‘‘(b) ESTABLISHMENT.—The Secretary shall estab13 lish an entity to be known as the Commission on Improv14 ing Patient Directed Health Care (referred to in this sec15 tion as the ‘Commission’). 

16 ‘‘(c) MEMBERSHIP.— 

17 ‘‘(1) NUMBER AND APPOINTMENT.—The Com18 mission shall be composed of 15 members. One 

19 member shall be the Secretary. The Comptroller 

20 General of the United States shall appoint 14 mem21 bers. 

22 ‘‘(2) QUALIFICATIONS.—The membership of the 

23 Commission shall include— 

24 ‘‘(A) health care consumers impacted by 

25 decision-making in advance of a health care cri26 sis, such as individuals of advanced age, indiVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00316 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 viduals with chronic, terminal and mental ill2 nesses, family care givers, and individuals with 

3 disabilities; 

4 ‘‘(B) providers in settings where crucial 

5 health care decision-making occurs, such as 

6 those working in intensive care settings, emer7 gency room departments, primary care settings, 

8 nursing homes, hospice, or palliative care set9 tings; 

10 ‘‘(C) payors ensuring patients get the level 

11 of care they want; 

12 ‘‘(D) experts in advance care planning, 

13 hospice, palliative care, information technology, 

14 bioethics, aging policy, disability policy, pedi15 atric ethics, cultural sensitivity, psychology, and 

16 health care financing; 

17 ‘‘(E) individuals who represent culturally 

18 diverse perspectives on patient self-determina19 tion and end-of-life issues; and 

20 ‘‘(F) members of the faith community. 

21 ‘‘(d) PERIOD OF APPOINTMENT.—Members of the 

22 Commission shall be appointed for the life of the Commis23 sion. Any vacancies shall not affect the power and duties 

24 of the Commission but shall be filled in the same manner 

25 as the original appointment. 


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1 ‘‘(e) DESIGNATION OF THE CHAIRPERSON.—Not 

2 later than 15 days after the date on which all members 

3 of the Commission have been appointed, the Comptroller 

4 General shall designate the chairperson of the Commis5 sion. 

6 ‘‘(f) SUBCOMMITTEES.—The Commission may estab7 lish subcommittees if doing so increases the efficiency of 

8 the Commission in completing tasks. 

9 ‘‘(g) DUTIES.— 

10 ‘‘(1) HEARINGS.—Not later than 90 days after 

11 the date of designation of the chairperson under 

12 subsection (e), the Commission shall hold no fewer 

13 than 8 hearings to examine— 

14 ‘‘(A) the current state of health care deci15 sion-making and advance care planning laws in 

16 the United States at the Federal level and 

17 across the States, as well as options for improv18 ing advance care planning tools, especially with 

19 regard to use, portability, and storage; 

20 ‘‘(B) consumer-focused approaches that 

21 educate the American public about patient 

22 choices, care planning, and other end-of-life 

23 issues; 

24 ‘‘(C) the use of comprehensive, patient-cen25 tered care plans by providers, the impact care 


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1 plans have on health care delivery and spend2 ing, and methods to expand the use of high 

3 quality care planning tools in both public and 

4 private health care systems; 

5 ‘‘(D) the role of electronic medical records 

6 and other technologies in improving patient-di7 rected health care; 

8 ‘‘(E) innovative tools for improving patient 

9 experience with advanced illness, such as pallia10 tive care, hospice, and other models; 

11 ‘‘(F) the role social determinants of health, 

12 such as socio-economic status, play in patient 

13 self-direction in health care; 

14 ‘‘(G) the use of culturally-competent tools 

15 for health care decision-making; 

16 ‘‘(H) strategies for educating providers 

17 and increasing provider engagement on care 

18 planning, palliative care, hospice care, and 

19 other issues surrounding honoring patient 

20 choices; 

21 ‘‘(I) the sociological and psychological fac22 tors that influence health care decision-making 

23 and end-of-life choices; and 

24 ‘‘(J) the role of spirituality and religion in 

25 patient self-determination in health care. 


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1 ‘‘(2) ADDITIONAL HEARINGS.—The Commission 

2 may hold additional hearings on subjects other than 

3 those listed in paragraph (1) so long as such hear4 ings are determined necessary by the Commission in 

5 carrying out the purposes of this section. Such addi6 tional hearings do not have to be completed within 

7 the time period specified but shall not delay the 

8 other activities of the Commission under this sec9 tion. 

10 ‘‘(3) NUMBER AND LOCATION OF HEARINGS

11 AND ADDITIONAL HEARINGS.—The Commission shall 

12 hold no fewer than 8 hearings as indicated in para13 graph (1) and in sufficient number in order to re14 ceive information that reflects— 

15 ‘‘(A) the geographic differences throughout 

16 the United States; 

17 ‘‘(B) diverse populations; and 

18 ‘‘(C) a balance among urban and rural 

19 populations. 

20 ‘‘(4) INTERACTIVE TECHNOLOGY.—The Com21 mission may encourage public participation in hear22 ings through interactive technology and other means 

23 as determined appropriate by the Commission. 

24 ‘‘(5) REPORT TO THE AMERICAN PEOPLE ON

25 PATIENT DIRECTED HEALTH CARE.—Not later than 


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1 90 days after the hearings described in paragraphs 

2 (1) and (2) are completed, the Commission shall 

3 prepare and make available to health care consumers 

4 through the Internet and other appropriate public 

5 channels, a report to be entitled, ‘Report to the 

6 American People on Patient Directed Health Care’. 

7 Such a report shall be understandable to the general 

8 public and include— 

9 ‘‘(A) a summary of— 

10 ‘‘(i) the hearings described in such 

11 paragraphs; 

12 ‘‘(ii) how the current health care sys13 tem empowers and informs decision-mak14 ing in advance of a health care crisis; 

15 ‘‘(iii) factors that contribute to the 

16 provision of health care that does not ad17 here to patient wishes; 

18 ‘‘(iv) the impact of care that does not 

19 follow patient choices, particularly at the 

20 end-of-life, on patients, families, providers, 

21 spending, and the health care system; 

22 ‘‘(v) the laws surrounding advance 

23 care planning and health care decision24 making including issues of portability, use, 

25 and storage; 


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1 ‘‘(vi) consumer-focused approaches to 

2 education of the American public about pa3 tient choices, care planning, and other end4 of-life issues; 

5 ‘‘(vii) the role of care plans in health 

6 care decision-making; 

7 ‘‘(viii) the role of providers in ensur8 ing patients receive the care they want; 

9 ‘‘(ix) the role of electronic medical 

10 records and other technologies in improv11 ing patient directed health care; 

12 ‘‘(x) the impact of social determinants 

13 on patient self-direction in health care 

14 services; 

15 ‘‘(xi) the use of culturally competent 

16 methods for health care decision-making; 

17 ‘‘(xii) the sociological and psycho18 logical factors that influence patient self19 determination; and 

20 ‘‘(xiii) the role of spirituality and reli21 gion in health care decision-making and 

22 end-of-life care; 

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1 es and provide health care that adheres to those 

2 wishes; and 

3 ‘‘(C) information on educating providers 

4 about health care decision-making and end-of5 life issues. 

6 ‘‘(6) INTERIM REQUIREMENTS.—Not later than 

7 180 days after the date of completion of the hear8 ings, the Commission shall prepare and make avail9 able to the public through the Internet and other ap10 propriate public channels, an interim set of rec11 ommendations on patient self-determination in 

12 health care and ways to improve and strengthen the 

13 health care system based on the information and 

14 preferences expressed at the community meetings. 

15 There shall be a 90-day public comment period on 

16 such recommendations. 

17 ‘‘(h) RECOMMENDATIONS.—Not later than 120 days 

18 after the expiration of the public comment period de19 scribed in subsection (g)(6), the Commission shall submit 

20 to Congress and the President a final set of recommenda21 tions. The recommendations must be comprehensive and 

22 detailed. The recommendations must contain rec23 ommendations or proposals for legislative or administra24 tive action as the Commission deems appropriate, includVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00323 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 ing proposed legislative language to carry out the rec2 ommendations or proposals. 

3 ‘‘(i) ADMINISTRATION.— 

4 ‘‘(1) EXECUTIVE DIRECTOR.—There shall be an 

5 Executive Director of the Commission who shall be 

6 appointed by the chairperson of the Commission in 

7 consultation with the members of the Commission. 

8 ‘‘(2) COMPENSATION.—While serving on the 

9 business of the Commission (including travel time), 

10 a member of the Commission shall be entitled to 

11 compensation at the per diem equivalent of the rate 

12 provided for level IV of the Executive Schedule 

13 under section 5315 of title 5, United States Code, 

14 and while so serving away from home and the mem15 ber’s regular place of business, a member may be al16 lowed travel expenses, as authorized by the chair17 person of the Commission. For purposes of pay and 

18 employment benefits, rights, and privileges, all per19 sonnel of the Commission shall be treated as if they 

20 were employees of the Senate. 

21 ‘‘(3) INFORMATION FROM FEDERAL AGEN22 CIES.—The Commission may secure directly from 

23 any Federal department or agency such information 

24 as the Commission considers necessary to carry out 

25 this section. Upon request of the Commission the 


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1 head of such department or agency shall furnish 

2 such information. 

3 ‘‘(4) POSTAL SERVICES.—The Commission may 

4 use the United States mails in the same manner and 

5 under the same conditions as other departments and 

6 agencies of the Federal Government. 

7 ‘‘(j) DETAIL.—Not more than 4 Federal Government 

8 employees employed by the Department of Labor, 4 Fed9 eral Government employees employed by the Social Secu10 rity Administration, and 8 Federal Government employees 

11 employed by the Department of Health and Human Serv12 ices may be detailed to the Commission under this section 

13 without further reimbursement. Any detail of an employee 

14 shall be without interruption or loss of civil service status 

15 or privilege. 

16 ‘‘(k) TEMPORARY AND INTERMITTENT SERVICES.— 

17 The chairperson of the Commission may procure tem18 porary and intermittent services under section 3109(b) of 

19 title 5, United States Code, at rates for individuals which 

20 do not exceed the daily equivalent of the annual rate of 

21 basic pay prescribed for level V of the Executive Schedule 

22 under section 5316 of such title. 

23 ‘‘(l) ANNUAL REPORT.—Not later than 1 year after 

24 the date of enactment of this Act, and annually thereafter 

25 during the existence of the Commission, the Commission 


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1 shall report to Congress and make public a detailed de2 scription of the expenditures of the Commission used to 

3 carry out its duties under this section. 

4 ‘‘(m) SUNSET OF COMMISSION.—The Commission 

5 shall terminate on the date that is 3 years after the date 

6 on which all the members of the Commission have been 

7 appointed under subsection (c)(1) and appropriations are 

8 first made available to carry out this section. 

9 ‘‘(n) ADMINISTRATION REVIEW AND COMMENTS.— 

10 Not later than 45 days after receiving the final rec11 ommendations of the Commission under subsection (h), 

12 the President shall submit a report to Congress which 

13 shall contain— 

14 ‘‘(1) additional views and comments on such 

15 recommendations; and 

16 ‘‘(2) recommendations for such legislation and 

17 administrative action as the President considers ap18 propriate. 

19 ‘‘(o) AUTHORIZATION OF APPROPRIATIONS.— 

20 ‘‘(1) IN GENERAL.—There are authorized to be 

21 appropriated to carry out this section, $3,000,000 

22 for each of fiscal years 2014 and 2015. 

23 ‘‘(2) REPORT TO THE AMERICAN PEOPLE ON

24 PATIENT DIRECTED HEALTH CARE.—There are au25 thorized to be appropriated for the preparation and 


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1 dissemination of the Report to the American People 

2 on Patient Directed Health Care described in sub3 section (g)(5), $1,000,000 for the fiscal year in 

4 which the report is required to be submitted.’’. 

5 SEC. 402. EXPANSION OF THE DEFINITION OF INPATIENT 

6 HOSPITAL SERVICES FOR CERTAIN CANCER 

7 HOSPITALS. 

8 Section 1861(b) of the Social Security Act (42 U.S.C. 

9 1395x(b)) is amended— 

10 (1) in paragraph (3)— 

11 (A) by inserting ‘‘(A)’’ after ‘‘(3)’’; 

12 (B) by adding ‘‘and’’ after the semicolon 

13 at the end; and 

14 (C) by adding at the end the following new 

15 subparagraph: 

16 ‘‘(B) subject to the third sentence of this 

17 subsection, with respect to a hospital that— 

18 ‘‘(i) is described in section 

19 1886(d)(1)(B)(v); and 

20 ‘‘(ii) as of the date of the enactment 

21 of the Commonsense Medicare SGR Repeal 

22 and Beneficiary Access Improvement Act 

23 of 2014, is located in the same building, or 

24 on the same campus, as another hospital 

25 (as described in sections 412.22(e) and 


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1 412.22(f) of title 42, Code of Federal Reg2 ulations, as in effect on such date of enact3 ment ); 

4 items and services described in paragraphs (1) 

5 and (2) furnished on or after October 1, 2014, 

6 by such hospital described in section 

7 1886(d)(1)(B)(v) or by others under arrange8 ments with them made by the hospital;’’; and 

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

10 flush sentence: 

11 ‘‘Paragraph (3)(B) shall only apply to payments with re12 spect to the total number of the hospital’s patient days 

13 at any satellite of the hospital or such days at another 

14 hospital providing services under arrangements to the hos15 pital, determined as of the date of the enactment of the 

16 Commonsense Medicare SGR Repeal and Beneficiary Ac17 cess Improvement Act of 2014.’’. 

18 SEC. 403. QUALITY MEASURES FOR CERTAIN POST-ACUTE 

19 CARE PROVIDERS RELATING TO NOTICE AND 

20 TRANSFER OF PATIENT HEALTH INFORMA21 TION AND PATIENT CARE PREFERENCES. 

22 (a) DEVELOPMENT.—The Secretary of Health and 

23 Human Services (in this section referred to as the ‘‘Sec24 retary’’) shall provide for the development of one or more 

25 quality measures under title XVIII of the Social Security 


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1 Act (42 U.S.C. 1395 et seq.) to accurately communicate 

2 the existence and provide for the transfer of patient health 

3 information and patient care preferences when an indi4 vidual transitions from a hospital to return home or move 

5 to other post-acute care settings. 

6 (b) USE OF MEASURE DEVELOPERS.—The Secretary 

7 shall arrange for the development of such measures by ap8 propriate measure developers. 

9 (c) ENDORSEMENT.—The Secretary shall arrange for 

10 such developed measures to be submitted for endorsement 

11 to a consensus-based entity as described in section 

12 1890(a) of the Social Security Act (42 U.S.C. 

13 1395aaa(a)). 

14 (d) USE OF MEASURES.—The Secretary shall, 

15 through notice and comment rulemaking, use such meas16 ures under the quality reporting programs with respect 

17 to— 

18 (1) inpatient hospitals under section 

19 1886(b)(3)(B)(viii) of the Social Security Act (42 

20 U.S.C. 1395ww(b)(3)(B)(viii)); 

21 (2) skilled nursing facilities under section 

22 1888(e) of such Act (42 U.S.C. 1395yy(e)); 

23 (3) home health services under section 

24 1895(b)(3)(B)(v) of such Act (42 U.S.C. 

25 1395fff(b)(3)(B)(v)); and 


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1 (4) other providers of services (as defined in 

2 section 1861(u) of such Act) and suppliers (as de3 fined in section 1861(d) of such Act) that the Sec4 retary determines appropriate. 

5 SEC. 404. CRITERIA FOR MEDICALLY NECESSARY, SHORT 

6 INPATIENT HOSPITAL STAYS. 

7 (a) IN GENERAL.—The Secretary of Health and 

8 Human Services shall consult with, and seek input from, 

9 interested stakeholders to determine appropriate criteria 

10 for payment under the Medicare program under title 

11 XVIII of the Social Security Act of an inpatient hospital 

12 admission that— 

13 (1) is medically necessary; and 

14 (2) is an inpatient hospital stay that is less 

15 than two midnights, as described in section 412.3 of 

16 title 42, Code of Federal Regulation, as finalized in 

17 the final rule published by the Centers for Medicare 

18 & Medicaid Services in the Federal Register on Au19 gust 19, 2013 (78 Federal Register 50496) entitled 

20 ‘‘Medicare Program; Hospital Inpatient Prospective 

21 Payment Systems for Acute Care Hospitals and the 

22 Long-Term Care Hospital Prospective Payment Sys23 tem and Fiscal Year 2014 Rates; Quality Reporting 

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1 ditions of Participation; Payment Policies Related to 

2 Patient Status’’. 

3 (b) INTERESTED STAKEHOLDERS.—In subsection 

4 (a), the term ‘‘interested stakeholders’’ means the fol5 lowing: 

6 (1) Hospitals. 

7 (2) Physicians 

8 (3) Medicare administrative contractors under 

9 section 1874A of the Social Security Act (42 U.S.C. 

10 1395kk–1). 

11 (4) Recovery audit contractors under section 

12 1893(h) of such Act (42 U.S.C. 1395ddd(h)). 

13 (5) Other parties determined appropriate by the 

14 Secretary. 

15 SEC. 405. TRANSPARENCY OF REASONS FOR EXCLUDING 

16 ADDITIONAL PROCEDURES FROM THE MEDI17 CARE AMBULATORY SURGICAL CENTER (ASC) 

18 APPROVED LIST. 

19 Section 1833(i)(1) of the Social Security Act (42 

20 U.S.C. 1395l(i)(1)) is amended by adding at the end the 

21 following: ‘‘In updating such lists for application in years 

22 beginning after December 31, 2014, for each procedure 

23 that was not proposed but was requested to be included 

24 on such lists during the public comment where the Sec25 retary does not finalize (in the final rule updating such 


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1 lists) to so include, the Secretary shall describe in such 

2 final rule the specific safety criteria for not including such 

3 requested procedure on such lists.’’. 

4 SEC. 406. SUPERVISION IN CRITICAL ACCESS HOSPITALS. 

5 (a) GENERAL SUPERVISION IN CRITICAL ACCESS

6 HOSPITALS.—Section 1834(g) of the Social Security Act 

7 (42 U.S.C. 1395m(g)) is amended by adding at the end 

8 the following new paragraph: 

9 ‘‘(6) SUPERVISION.—In the case of services fur10 nished on or after the date of the enactment of this 

11 paragraph, the level of supervision with respect to 

12 outpatient therapeutic critical access hospital serv13 ices shall be general supervision (as defined by the 

14 Secretary) unless the Secretary specifies otherwise 

15 for a particular service.’’. 

16 (b) SUPERVISION OF CARDIAC AND PULMONARY RE17 HABILITATION PROGRAMS IN CRITICAL ACCESS HOS18 PITALS.—Section 1861(eee)(2)(B) of the Social Security 

19 Act (42 U.S.C. 1395x(eee)(2)(B)) is amended by inserting 

20 ‘‘(or, in the case of a critical access hospital, a physician, 

21 or (beginning on the date of enactment of the Common22 sense Medicare SGR Repeal and Beneficiary Access Im23 provement Act of 2014) a nurse practitioner, clinical nurse 

24 specialist, or physician assistant (as such terms are de25 fined in subsection (aa)(5)))’’ after ‘‘a physician’’. 


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1 SEC. 407. REQUIRING STATE LICENSURE OF BIDDING ENTI2 TIES UNDER THE COMPETITIVE ACQUISITION 

3 PROGRAM FOR CERTAIN DURABLE MEDICAL 

4 EQUIPMENT, PROSTHETICS, ORTHOTICS, AND 

5 SUPPLIES (DMEPOS). 

6 Section 1847(a)(1) of the Social Security Act (42 

7 U.S.C. 1395w–3(a)(1)) is amended by adding at the end 

8 the following new subparagraph: 

9 ‘‘(G) REQUIRING STATE LICENSURE OF

10 BIDDING ENTITIES.—With respect to rounds of 

11 competitions beginning on or after the date of 

12 enactment of this subparagraph, the Secretary 

13 may only accept a bid from an entity for an 

14 area if the entity meets applicable State licen15 sure requirements for such area for all items in 

16 such bid for a product category.’’. 

17 SEC. 408. RECOGNITION OF ATTENDING PHYSICIAN ASSIST18 ANTS AS ATTENDING PHYSICIANS TO SERVE 

19 HOSPICE PATIENTS. 

20 (a) RECOGNITION OF ATTENDING PHYSICIAN AS21 SISTANTS AS ATTENDING PHYSICIANS TO SERVE HOS22 PICE PATIENTS.— 

23 (1) IN GENERAL.—Section 1861(dd)(3)(B) of 

24 the Social Security Act (42 U.S.C. 1395x(dd)(3)(B)) 

25 is amended— 


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1 (A) by striking ‘‘or nurse’’ and inserting ‘‘, 

2 the nurse’’; and 

3 (B) by inserting ‘‘, or the physician assist4 ant (as defined in such subsection)’’ after ‘‘sub5 section (aa)(5))’’. 

6 (2) CLARIFICATION OF HOSPICE ROLE OF PHY7 SICIAN ASSISTANTS.—Section 1814(a)(7)(A)(i)(I) of 

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

9 1395f(a)(7)(A)(i)(I)) is amended by inserting ‘‘or a 

10 physician assistant’’ after ‘‘a nurse practitioner’’. 

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

12 this section shall apply to items and services furnished on 

13 or after October 1, 2015. 

14 SEC. 409. REMOTE PATIENT MONITORING PILOT 

15 PROJECTS. 

16 (a) PILOT PROJECTS.— 

17 (1) IN GENERAL.—Not later than 9 months 

18 after the date of the enactment of this Act, the Sec19 retary shall conduct pilot projects under title XVIII 

20 of the Social Security Act for the purpose of pro21 viding incentives to home health agencies to furnish 

22 remote patient monitoring services that reduce ex23 penditures under such title. 

24 (2) SITE REQUIREMENTS.— 


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1 (A) URBAN AND RURAL.—The Secretary 

2 shall conduct the pilot projects under this sec3 tion in both urban and rural areas. 

4 (B) SITE IN A SMALL STATE.—The Sec5 retary shall conduct at least 1 of the pilot 

6 projects in a State with a population of less 

7 than 1,000,000. 

8 (b) MEDICARE BENEFICIARIES WITHIN THE SCOPE

9 OF PROJECTS.— 

10 (1) IN GENERAL.—The Secretary shall specify 

11 the criteria for identifying those Medicare bene12 ficiaries who shall be considered within the scope of 

13 the pilot projects under this section for purposes of 

14 the application of subsection (c) and for the assess15 ment of the effectiveness of the home health agency 

16 in achieving the objectives of this section. 

17 (2) CRITERIA.—The criteria specified under 

18 paragraph (1)— 

19 (A) shall include conditions and clinical 

20 circumstances, including congestive heart fail21 ure, diabetes, and chronic pulmonary obstruc22 tive disease, and other conditions determined 

23 appropriate by the Secretary; and 

24 (B) may provide for the inclusion in the 

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1 ceiving home health services under title XVIII 

2 of the Social Security Act after the date of the 

3 implementation of the projects. 

4 (c) INCENTIVES.— 

5 (1) PERFORMANCE TARGETS.—The Secretary 

6 shall establish for each home health agency partici7 pating in a pilot project under this section a per8 formance target using one of the following meth9 odologies, as determined appropriate by the Sec10 retary: 

11 (A) ADJUSTED HISTORICAL PERFORMANCE

12 TARGET.—The Secretary shall establish for the 

13 agency— 

14 (i) a base expenditure amount equal 

15 to the average total payments made under 

16 parts A, B, and D of title XVIII of the So17 cial Security Act for Medicare beneficiaries 

18 determined to be within the scope of the 

19 pilot project in a base period determined 

20 by the Secretary; and 

21 (ii) an annual per capita expenditure 

22 target for such beneficiaries, reflecting the 

23 base expenditure amount adjusted for risk, 

24 changes in costs, and growth rates. 


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1 (B) COMPARATIVE PERFORMANCE TAR2 GET.—The Secretary shall establish for the 

3 agency a comparative performance target equal 

4 to the average total payments made under such 

5 parts A, B, and D during the pilot project for 

6 comparable individuals in the same geographic 

7 area that are not determined to be within the 

8 scope of the pilot project. 

9 (2) PAYMENT.—Subject to paragraph (3), the 

10 Secretary shall pay to each home health agency par11 ticipating in a pilot project a payment for each year 

12 under the pilot project equal to a 75 percent share 

13 of the total Medicare cost savings realized for such 

14 year relative to the performance target under para15 graph (1). 

16 (3) LIMITATION ON EXPENDITURES.—The Sec17 retary shall limit payments under this section in 

18 order to ensure that the aggregate expenditures 

19 under title XVIII of the Social Security Act (includ20 ing payments under this subsection) do not exceed 

21 the amount that the Secretary estimates would have 

22 been expended if the pilot projects under this section 

23 had not been implemented, including any reasonable 

24 costs incurred by the Secretary in the administration 

25 of the pilot projects. 


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1 (4) NO DUPLICATION IN PARTICIPATION IN

2 SHARED SAVINGS PROGRAMS.—A home health agen3 cy that participates in any of the following shall not 

4 be eligible to participate in the pilot projects under 

5 this section: 

6 (A) A model tested or expanded under sec7 tion 1115A of the Social Security Act (42 

8 U.S.C. 1315a) that involves shared savings 

9 under title XVIII of such Act or any other pro10 gram or demonstration project that involves 

11 such shared savings. 

12 (B) The independence at home medical 

13 practice demonstration program under section 

14 1866E of such Act (42 U.S.C. 1395cc–5). 

15 (d) WAIVER AUTHORITY.—The Secretary may waive 

16 such provisions of titles XI and XVIII of the Social Secu17 rity Act as the Secretary determines to be appropriate for 

18 the conduct of the pilot projects under this section. 

19 (e) REPORT TO CONGRESS.—Not later than 3 years 

20 after the date that the first pilot project under this section 

21 is implemented, the Secretary shall submit to Congress a 

22 report on the projects. Such report shall contain— 

23 (1) a detailed description of the projects, in24 cluding any changes in clinical outcomes for Medi25 care beneficiaries under the projects, Medicare beneVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00338 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 ficiary satisfaction under the projects, utilization of 

2 items and services under parts A, B, and D of title 

3 XVIII of the Social Security Act by Medicare bene4 ficiaries under the projects, and Medicare per-bene5 ficiary and Medicare aggregate spending under the 

6 projects; 

7 (2) a detailed description of issues related to 

8 the expansion of the projects under subsection (f); 

9 (3) recommendations for such legislation and 

10 administrative actions as the Secretary considers ap11 propriate; and 

12 (4) other items considered appropriate by the 

13 Secretary. 

14 (f) EXPANSION.—If the Secretary determines that 

15 any of the pilot projects under this section enhance health 

16 outcomes for Medicare beneficiaries and reduce expendi17 tures under title XVIII of the Social Security Act, the Sec18 retary shall initiate comparable projects in additional 

19 areas. 

20 (g) PAYMENTS HAVE NO EFFECT ON OTHER MEDI21 CARE PAYMENTS TO HOME HEALTH AGENCIES.—A pay22 ment under this section shall have no effect on the amount 

23 of payments that a home health agency would otherwise 

24 receive under title XVIII of the Social Security Act for 

25 the provision of home health services. 


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1 (h) STUDY AND REPORT ON THE APPROPRIATE

2 VALUATION FOR REMOTE PATIENT MONITORING SERV3 ICES UNDER THE MEDICARE PHYSICIAN FEE SCHED4 ULE.— 

5 (1) STUDY.—The Secretary shall conduct a 

6 study on the appropriate valuation for remote pa7 tient monitoring services under the Medicare physi8 cian fee schedule under section 1848 of the Social 

9 Security Act (42 U.S.C. 1395w–4) in order to accu10 rately reflect the resources involved in furnishing 

11 such services. 

12 (2) REPORT.—Not later than 6 months after 

13 the date of the enactment of this Act, the Secretary 

14 shall submit to Congress a report on the study con15 ducted under paragraph (1), together with such rec16 ommendations as the Secretary determines appro17 priate. 

18 (i) DEFINITIONS.—In this section: 

19 (1) HOME HEALTH AGENCY.—The term ‘‘home 

20 health agency’’ has the meaning given that term in 

21 section 1861(o) of the Social Security Act (42 

22 U.S.C. 1395x(o)). 

23 (2) REMOTE PATIENT MONITORING SERV24 ICES.— 


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1 (A) IN GENERAL.—The term ‘‘remote pa2 tient monitoring services’’ means services fur3 nished in the home using remote patient moni4 toring technology which— 

5 (i) shall include patient monitoring or 

6 patient assessment; and 

7 (ii) may include in-home technology8 based professional consultations, patient 

9 training services, clinical observation, 

10 treatment, and any additional services that 

11 utilize technologies specified by the Sec12 retary. 

13 (B) LIMITATION.—The term ‘‘remote pa14 tient monitoring services’’ shall not include a 

15 telecommunication that consists solely of a tele16 phone audio conversation, facsimile, or elec17 tronic text mail between a health care profes18 sional and a patient. 

19 (3) REMOTE PATIENT MONITORING TECH20 NOLOGY.—The term ‘‘remote patient monitoring 

21 technology’’ means a coordinated system that uses 

22 one or more home-based or mobile monitoring de23 vices that automatically transmit vital sign data or 

24 information on activities of daily living and may in25 clude responses to assessment questions collected on 


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1 the devices wirelessly or through a telecommuni2 cations connection to a server that complies with the 

3 Federal regulations (concerning the privacy of indi4 vidually identifiable health information) promulgated 

5 under section 264(c) of the Health Insurance Port6 ability and Accountability Act of 1996, as part of an 

7 established plan of care for that patient that in8 cludes the review and interpretation of that data by 

9 a health care professional. 

10 (4) SECRETARY.—The term ‘‘Secretary’’ means 

11 the Secretary of Health and Human Services. 

12 SEC. 410. COMMUNITY-BASED INSTITUTIONAL SPECIAL 

13 NEEDS PLAN DEMONSTRATION PROGRAM. 

14 (a) IN GENERAL.—The Secretary of Health and 

15 Human Services (referred to in this section as the ‘‘Sec16 retary’’) shall establish a Community-Based Institutional 

17 Special Needs Plan (CBI-SNP) demonstration program to 

18 prevent and delay institutionalization under Medicaid 

19 among targeted low-income Medicare beneficiaries. 

20 (b) ESTABLISHMENT.—The Secretary shall enter into 

21 agreements with not more than 5 specialized MA plans 

22 for special needs individuals, as defined in section 

23 1859(b)(6)(B)(i) of the Social Security Act (42 U.S.C. 

24 1395w–28(b)(6)(B)(i)), to conduct the CBI-SNP dem25 onstration program. Under the CBI-SNP demonstration 


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1 program, a targeted low-income Medicare beneficiary shall 

2 receive, as supplemental benefits under section 1852(a)(3) 

3 of such Act (42 U.S.C. 1395w-22(a)(3)), long-term care 

4 services or supports that— 

5 (1) the Secretary determines appropriate for 

6 the purposes of the CBI-SNP demonstration pro7 gram; and 

8 (2) for which payment may be made under the 

9 State plan under title XIX of such Act (42 U.S.C. 

10 1396 et seq.) of the State in which the targeted low11 income Medicare beneficiary is located. 

12 (c) ELIGIBLE PLANS.—To be eligible to participate 

13 in the CBI-SNP demonstration program, a specialized MA 

14 plan for special needs individuals must— 

15 (1) serve special needs individuals (as defined 

16 in section 1859(b)(6)(B)(i) of the Social Security 

17 Act (42 U.S.C. 1395w–28(b)(6)(B)(i)); 

18 (2) have experience in offering special needs 

19 plans for nursing home-eligible, non-institutionalized 

20 Medicare beneficiaries who live in the community; 

21 (3) be located in a State that the Secretary has 

22 determined will participate in the CBI-SNP dem23 onstration program by agreeing to make available 

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1 pendent evaluation required under subsection (f); 

2 and 

3 (4) meet such other criteria as the Secretary 

4 may require. 

5 (d) TARGETED LOW-INCOME MEDICARE BENE6 FICIARY DEFINED.—In this section, the term ‘‘targeted 

7 low-income Medicare beneficiary’’ means a Medicare bene8 ficiary who— 

9 (1) is enrolled in a specialized MA plan for spe10 cial needs individuals that has been selected to par11 ticipate in the CBI-SNP demonstration program; 

12 (2) is a subsidy eligible individual (as defined in 

13 section 1860D–14(a)(3)(A) of the Social Security 

14 Act (42 U.S.C. 1395w-114(a)(3)(A)); and 

15 (3) is unable to perform 2 or more activities of 

16 daily living (as defined in section 7702B(c)(2)(B) of 

17 the Internal Revenue Code of 1986). 

18 (e) IMPLEMENTATION DEADLINE; DURATION.—The 

19 CBI-SNP demonstration program shall be implemented 

20 not later than January 1, 2016, and shall be conducted 

21 for a period of 3 years. 

22 (f) INDEPENDENT EVALUATION AND REPORTS.— 

23 (1) INDEPENDENT EVALUATION.—Not later 

24 than 2 years after the completion of the CBI-SNP 

25 demonstration program, the Secretary shall provide 


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1 for the evaluation of the CBI-SNP demonstration 

2 program by an independent third party. The evalua3 tion shall determine whether the CBI-SNP dem4 onstration program has improved patient care and 

5 quality of life for the targeted low-income Medicare 

6 beneficiaries participating in the CBI-SNP dem7 onstration program. Specifically, the evaluation shall 

8 determine if the CBI-SNP demonstration program 

9 has— 

10 (A) reduced hospitalizations or re-hos11 pitalizations; 

12 (B) reduced Medicaid nursing home facility 

13 stays; and 

14 (C) reduced spenddown of income and as15 sets for purposes of becoming eligible for Med16 icaid. 

17 (2) REPORTS.—Not later than 3 years after the 

18 completion of the CBI-SNP demonstration program, 

19 the Secretary shall submit to Congress a report con20 taining the results of the evaluation conducted under 

21 paragraph (1), together with such recommendations 

22 for legislative or administrative action as the Sec23 retary determines appropriate. 

24 (g) FUNDING.— 


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1 (1) FUNDING FOR IMPLEMENTATION.—For 

2 purposes of carrying out the demonstration program 

3 under this section (other than the evaluation and re4 port under subsection (f)), the Secretary shall pro5 vide for the transfer from the Federal Hospital In6 surance Trust Fund under section 1817 of the So7 cial Security Act (42 U.S.C. 1395i) and the Federal 

8 Supplementary Medical Insurance Trust Fund under 

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

10 proportion as the Secretary determines appropriate, 

11 of $3,000,000 to the Centers for Medicare & Med12 icaid Services Program Management Account. 

13 (2) FUNDING FOR EVALUATION AND REPORT.— 

14 For purposes of carrying out the evaluation and re15 port under subsection (f), the Secretary shall provide 

16 for the transfer from the Federal Hospital Insurance 

17 Trust Fund under such section 1817 and the Fed18 eral Supplementary Medical Insurance Trust Fund 

19 under such section 1841, in such proportion as the 

20 Secretary determines appropriate, of $500,000. 

21 (3) AVAILABILITY.—Amounts transferred under 

22 paragraph (1) or (2) shall remain available until ex23 pended. 

24 (h) BUDGET NEUTRALITY.—In conducting the CBI25 SNP demonstration program, the Secretary shall ensure 


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1 that the aggregate payments made by the Secretary do 

2 not exceed the amount which the Secretary estimates 

3 would have been expended under titles XVIII and XIX 

4 of the Social Security Act (42 U.S.C. 1395 et seq., 1396 

5 et seq.) if the CBI-SNP demonstration program had not 

6 been implemented. 

7 (i) PAPERWORK REDUCTION ACT.—Chapter 35 of 

8 title 44, United States Code, shall not apply to the testing 

9 and evaluation of the CBI-SNP demonstration program 

10 under this section. 

11 SEC. 411. APPLYING CMMI WAIVER AUTHORITY TO PACE IN 

12 ORDER TO FOSTER INNOVATIONS. 

13 (a) CMMI WAIVER AUTHORITY.—Subsection (d)(1) 

14 of section 1115A of the Social Security Act (42 U.S.C. 

15 1315a) is amended— 

16 (1) by inserting ‘‘(other than subsections 

17 (b)(1)(A) and (c)(5) of section 1894)’’ after 

18 ‘‘XVIII’’; and 

19 (2) by striking ‘‘and 1903(m)(2)(A)(iii)’’ and 

20 inserting ‘‘1903(m)(2)(A)(iii), and 1934 (other than 

21 subsections (b)(1)(A) and (c)(5) of such section)’’. 

22 (b) SENSE OF THE SENATE.—It is the sense of the 

23 Senate that the Secretary of Health and Human Services 

24 should use the waiver authority provided under the 

25 amendments made by this section to provide, in a budget 


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1 neutral manner, programs of all-inclusive care for the el2 derly (PACE programs) with increased operational flexi3 bility to support the ability of such programs to improve 

4 and innovate and to reduce technical and administrative 

5 barriers that have hindered enrollment in such programs. 

6 SEC. 412. IMPROVE AND MODERNIZE MEDICAID DATA SYS7 TEMS AND REPORTING. 

8 (a) IN GENERAL.—The Secretary of Health and 

9 Human Services shall implement a strategic plan to in10 crease the usefulness of data about State Medicaid pro11 grams reported by States to the Centers for Medicare & 

12 Medicaid Services. The strategic plan shall address 

13 redundancies and gaps in Medicaid data systems and re14 porting through improvements to, and modernization of, 

15 computer and data systems. Areas for improvement under 

16 the plan shall include (but not be limited to) the following: 

17 (1) The reporting of encounter data by man18 aged care plans. 

19 (2) The timeliness and quality of reported data, 

20 including enrollment data. 

21 (3) The consistency of data reported from mul22 tiple sources. 

23 (4) Information about State program policies. 

24 (b) IMPLEMENTATION STATUS REPORT.—Not later 

25 than 1 year after the date of enactment of this Act, the 


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1 Secretary of Health and Human Services shall submit a 

2 report to Congress on the status of the implementation 

3 of the strategic plan required under subsection (a). 

4 (c) AUTHORIZATION OF APPROPRIATIONS.—There is 

5 authorized to be appropriated to the Secretary of Health 

6 and Human Services for the period of fiscal years 2015 

7 through 2019, such sums as may be necessary to carry 

8 out this section. 

9 SEC. 413. FAIRNESS IN MEDICAID SUPPLEMENTAL NEEDS 

10 TRUSTS. 

11 (a) IN GENERAL.—Section 1917(d)(4)(A) of the So12 cial Security Act (42 U.S.C. 1396p(d)(4)(A)) is amended 

13 by inserting ‘‘the individual,’’ after ‘‘for the benefit of such 

14 individual by’’. 

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

16 subsection (a) shall apply to trusts established on or after 

17 the date of the enactment of this Act. 

18 SEC. 414. HELPING ENSURE LIFE- AND LIMB-SAVING AC19 CESS TO PODIATRIC PHYSICIANS. 

20 (a) INCLUDING PODIATRISTS AS PHYSICIANS UNDER

21 THE MEDICAID PROGRAM.— 

22 (1) IN GENERAL.—Section 1905(a)(5)(A) of the 

23 Social Security Act (42 U.S.C. 1396d(a)(5)(A)) is 

24 amended by striking ‘‘section 1861(r)(1)’’ and in25 serting ‘‘paragraphs (1) and (3) of section 1861(r)’’. 


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1 (2) EFFECTIVE DATE.— 

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

3 subparagraph (B), the amendment made by 

4 paragraph (1) shall apply to services furnished 

5 on or after the date of enactment of this Act. 

6 (B) EXTENSION OF EFFECTIVE DATE FOR

7 STATE LAW AMENDMENT.—In the case of a 

8 State plan under title XIX of the Social Secu9 rity Act (42 U.S.C. 1396 et seq.) which the 

10 Secretary of Health and Human Services deter11 mines requires State legislation in order for the 

12 plan to meet the additional requirement im13 posed by the amendment made by paragraph 

14 (1), the State plan shall not be regarded as fail15 ing to comply with the requirements of such 

16 title solely on the basis of its failure to meet 

17 these additional requirements before the first 

18 day of the first calendar quarter beginning after 

19 the close of the first regular session of the 

20 State legislature that begins after the date of 

21 enactment of this Act. For purposes of the pre22 vious sentence, in the case of a State that has 

23 a 2-year legislative session, each year of the ses24 sion is considered to be a separate regular ses25 sion of the State legislature. 


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1 (b) MODIFICATIONS TO REQUIREMENTS FOR DIA2 BETIC SHOES TO BE INCLUDED UNDER MEDICAL AND

3 OTHER HEALTH SERVICES UNDER MEDICARE.— 

4 (1) IN GENERAL.—Section 1861(s)(12) of the 

5 Social Security Act (42 U.S.C. 1395x(s)(12)) is 

6 amended to read as follows: 

7 ‘‘(12) subject to section 4072(e) of the Omni8 bus Budget Reconciliation Act of 1987, extra-depth 

9 shoes with inserts or custom molded shoes (in this 

10 paragraph referred to as ‘therapeutic shoes’) with 

11 inserts for an individual with diabetes, if— 

12 ‘‘(A) the physician who is managing the in13 dividual’s diabetic condition— 

14 ‘‘(i) documents that the individual has 

15 diabetes; 

16 ‘‘(ii) certifies that the individual is 

17 under a comprehensive plan of care related 

18 to the individual’s diabetic condition; and 

19 ‘‘(iii) documents agreement with the 

20 prescribing podiatrist or other qualified 

21 physician (as established by the Secretary) 

22 that it is medically necessary for the indi23 vidual to have such extra-depth shoes with 

24 inserts or custom molded shoes with in25 serts; 


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1 ‘‘(B) the therapeutic shoes are prescribed 

2 by a podiatrist or other qualified physician (as 

3 established by the Secretary) who— 

4 ‘‘(i) examines the individual and de5 termines the medical necessity for the indi6 vidual to receive the therapeutic shoes; and 

7 ‘‘(ii) communicates in writing the 

8 medical necessity to the physician de9 scribed in subparagraph (A) for the indi10 vidual to have therapeutic shoes along with 

11 findings that the individual has peripheral 

12 neuropathy with evidence of callus forma13 tion, a history of pre-ulcerative calluses, a 

14 history of previous ulceration, foot deform15 ity, previous amputation, or poor circula16 tion; and 

17 ‘‘(C) the therapeutic shoes are fitted and 

18 furnished by a podiatrist or other qualified sup19 plier (as established by the Secretary), such as 

20 a pedorthist or orthotist, who is not the physi21 cian described in subparagraph (A) (unless the 

22 Secretary finds that the physician is the only 

23 such qualified individual in the area);’’. 


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1 (2) EFFECTIVE DATE.—The amendment made 

2 by paragraph (1) shall apply with respect to items 

3 and services furnished on or after January 1, 2015. 

4 SEC. 415. DEMONSTRATION PROGRAMS TO IMPROVE COM5 MUNITY MENTAL HEALTH SERVICES. 

6 (a) CRITERIA FOR CERTIFIED COMMUNITY BEHAV7 IORAL HEALTH CLINICS TO PARTICIPATE IN DEM8 ONSTRATION PROGRAMS.— 

9 (1) PUBLICATION.—Not later than September 

10 1, 2015, the Secretary shall publish criteria for a 

11 clinic to be certified by a State as a certified com12 munity behavioral health clinic for purposes of par13 ticipating in a demonstration program conducted 

14 under subsection (d). 

15 (2) REQUIREMENTS.—The criteria published 

16 under this subsection shall include criteria with re17 spect to the following: 

18 (A) STAFFING.—Staffing requirements, in19 cluding criteria that staff have diverse discipli20 nary backgrounds, have necessary State-re21 quired license and accreditation, and are cul22 turally and linguistically trained to serve the 

23 needs of the clinic’s patient population. 

24 (B) AVAILABILITY AND ACCESSIBILITY OF

25 SERVICES.—Availability and accessibility of 


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1 services, including crisis management services 

2 that are available and accessible 24 hours a 

3 day, the use of a sliding scale for payment, and 

4 no rejection for services or limiting of services 

5 on the basis of a patient’s ability to pay or a 

6 place of residence. 

7 (C) CARE COORDINATION.—Care coordina8 tion, including requirements to coordinate care 

9 across settings and providers to ensure seamless 

10 transitions for patients across the full spectrum 

11 of health services including acute, chronic, and 

12 behavioral health needs. Care coordination re13 quirements shall include partnerships or formal 

14 contracts with the following: 

15 (i) Federally-qualified health centers 

16 (and as applicable, rural health clinics) to 

17 provide Federally-qualified health center 

18 services (and as applicable, rural health 

19 clinic services) to the extent such services 

20 are not provided directly through the cer21 tified community behavioral health clinic. 

22 (ii) Inpatient psychiatric facilities and 

23 substance use detoxification, post-detoxi24 fication step-down services, and residential 

25 programs. 


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1 (iii) Other community or regional 

2 services, supports, and providers, including 

3 schools, child welfare agencies, juvenile and 

4 criminal justice agencies and facilities, In5 dian Health Service youth regional treat6 ment centers, State licensed and nationally 

7 accredited child placing agencies for thera8 peutic foster care service, and other social 

9 and human services. 

10 (iv) Department of Veterans Affairs 

11 medical centers, independent outpatient 

12 clinics, drop-in centers, and other facilities 

13 of the Department as defined in section 

14 1801 of title 38, United States Code. 

15 (v) Inpatient acute care hospitals and 

16 hospital outpatient clinics. 

17 (D) SCOPE OF SERVICES.—Provision (in a 

18 manner reflecting person-centered care) of the 

19 following services which, if not available directly 

20 through the certified community behavioral 

21 health clinic, are provided or referred through 

22 formal relationships with other providers: 

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1 gency crisis intervention services, and cri2 sis stabilization. 

3 (ii) Screening, assessment, and diag4 nosis, including risk assessment. 

5 (iii) Patient-centered treatment plan6 ning or similar processes, including risk as7 sessment and crisis planning. 

8 (iv) Outpatient mental health and 

9 substance use services. 

10 (v) Outpatient clinic primary care 

11 screening and monitoring of key health in12 dicators and health risk. 

13 (vi) Targeted case management. 

14 (vii) Psychiatric rehabilitation serv15 ices. 

16 (viii) Peer support and counselor serv17 ices and family supports. 

18 (ix) Intensive, community-based men19 tal health care for members of the armed 

20 forces and veterans, particularly those 

21 members and veterans located in rural 

22 areas, provided the care is consistent with 

23 minimum clinical mental health guidelines 

24 promulgated by the Veterans Health Ad25 ministration including clinical guidelines 


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1 contained in the Uniform Mental Health 

2 Services Handbook of such Administration. 

3 (E) QUALITY AND OTHER REPORTING.— 

4 Reporting of encounter data, clinical outcomes 

5 data, quality data, and such other data as the 

6 Secretary requires. 

7 (F) ORGANIZATIONAL AUTHORITY.—Cri8 teria that a clinic be a non-profit or part of a 

9 local government behavioral health authority or 

10 operated under the authority of the Indian 

11 Health Service, an Indian tribe or tribal organi12 zation pursuant to a contract, grant, coopera13 tive agreement, or compact with the Indian 

14 Health Service pursuant to the Indian Self-De15 termination Act (25 U.S.C. 450 et seq.), or an 

16 urban Indian organization pursuant to a grant 

17 or contract with the Indian Health Service 

18 under title V of the Indian Health Care Im19 provement Act (25 U.S.C. 1601 et seq.). 

20 (b) GUIDANCE ON DEVELOPMENT OF PROSPECTIVE

21 PAYMENT SYSTEM FOR TESTING UNDER DEMONSTRA22 TION PROGRAMS.— 

23 (1) IN GENERAL.—Not later than September 1, 

24 2015, the Secretary, through the Administrator of 

25 the Centers for Medicare & Medicaid Services, shall 


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1 issue guidance for the establishment of a prospective 

2 payment system that shall only apply to medical as3 sistance for mental health services furnished by a 

4 certified community behavioral health clinic partici5 pating in a demonstration program under subsection 

6 (d). 

7 (2) REQUIREMENTS.—The guidance issued by 

8 the Secretary under paragraph (1) shall provide 

9 that— 

10 (A) no payment shall be made for inpatient 

11 care, residential treatment, room and board ex12 penses, or any other non-ambulatory services, 

13 as determined by the Secretary; and 

14 (B) no payment shall be made to satellite 

15 facilities of certified community behavioral 

16 health clinics if such facilities are established 

17 after the date of enactment of this Act. 

18 (c) PLANNING GRANTS.— 

19 (1) IN GENERAL.—Not later than January 1, 

20 2016, the Secretary shall award planning grants to 

21 States for the purpose of developing proposals to 

22 participate in time-limited demonstration programs 

23 described in subsection (d). 

24 (2) USE OF FUNDS.—A State awarded a plan25 ning grant under this subsection shall— 


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1 (A) solicit input with respect to the devel2 opment of such a demonstration program from 

3 patients, providers, and other stakeholders; 

4 (B) certify clinics as certified community 

5 behavioral health clinics for purposes of partici6 pating in a demonstration program conducted 

7 under subsection (d); and 

8 (C) establish a prospective payment system 

9 for mental health services furnished by a cer10 tified community behavioral health clinic par11 ticipating in a demonstration program under 

12 subsection (d) in accordance with the guidance 

13 issued under subsection (b). 

14 (d) DEMONSTRATION PROGRAMS.— 

15 (1) IN GENERAL.—Not later than September 1, 

16 2017, the Secretary shall select States to participate 

17 in demonstration programs that are developed 

18 through planning grants awarded under subsection 

19 (c), meet the requirements of this subsection, and 

20 represent a diverse selection of geographic areas, in21 cluding rural and underserved areas. 

22 (2) APPLICATION REQUIREMENTS.— 

23 (A) IN GENERAL.—The Secretary shall so24 licit applications to participate in demonstration 

25 programs under this subsection solely from 


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1 States awarded planning grants under sub2 section (c). 

3 (B) REQUIRED INFORMATION.—An appli4 cation for a demonstration program under this 

5 subsection shall include the following: 

6 (i) The target Medicaid population to 

7 be served under the demonstration pro8 gram. 

9 (ii) A list of participating certified 

10 community behavioral health clinics. 

11 (iii) Verification that the State has 

12 certified a participating clinic as a certified 

13 community behavioral health clinic in ac14 cordance with the requirements of sub15 section (b). 

16 (iv) A description of the scope of the 

17 mental health services available under the 

18 State Medicaid program that will be paid 

19 for under the prospective payment system 

20 tested in the demonstration program. 

21 (v) Verification that the State has 

22 agreed to pay for such services at the rate 

23 established under the prospective payment 

24 system. 


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1 (vi) Such other information as the 

2 Secretary may require relating to the dem3 onstration program including with respect 

4 to determining the soundness of the pro5 posed prospective payment system. 

6 (3) NUMBER AND LENGTH OF DEMONSTRATION

7 PROGRAMS.—Not more than 8 States shall be se8 lected for 4-year demonstration programs under this 

9 subsection. 

10 (4) REQUIREMENTS FOR SELECTING DEM11 ONSTRATION PROGRAMS.— 

12 (A) IN GENERAL.—The Secretary shall 

13 give preference to selecting demonstration pro14 grams where participating certified community 

15 behavioral health clinics— 

16 (i) provide the most complete scope of 

17 services described in subsection (a)(2)(D) 

18 to individuals eligible for medical assist19 ance under the State Medicaid program; 

20 (ii) will improve availability of, access 

21 to, and participation in, services described 

22 in subsection (a)(2)(D) to individuals eligi23 ble for medical assistance under the State 

24 Medicaid program; 


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1 (iii) will improve availability of, access 

2 to, and participation in assisted outpatient 

3 mental health treatment in the State; or 

4 (iv) demonstrate the potential to ex5 pand available mental health services in a 

6 demonstration area and increase the qual7 ity of such services without increasing net 

8 Federal spending. 

9 (5) PAYMENT FOR MEDICAL ASSISTANCE FOR

10 MENTAL HEALTH SERVICES PROVIDED BY CER11 TIFIED COMMUNITY BEHAVIORAL HEALTH CLIN12 ICS.— 

13 (A) IN GENERAL.—The Secretary shall pay 

14 a State participating in a demonstration pro15 gram under this subsection the Federal match16 ing percentage specified in subparagraph (B) 

17 for amounts expended by the State to provide 

18 medical assistance for mental health services 

19 described in the demonstration program appli20 cation in accordance with paragraph (2)(B)(iv) 

21 that are provided by certified community behav22 ioral health clinics to individuals who are en23 rolled in the State Medicaid program. Payments 

24 to States made under this paragraph shall be 

25 considered to have been under, and are subject 


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1 to the requirements of, section 1903 of the So2 cial Security Act (42 U.S.C. 1396b). 

3 (B) FEDERAL MATCHING PERCENTAGE.— 

4 The Federal matching percentage specified in 

5 this subparagraph is with respect to medical as6 sistance described in subparagraph (A) that is 

7 furnished— 

8 (i) to a newly eligible individual de9 scribed in paragraph (2) of section 1905(y) 

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

11 1396d(y)), the matching rate applicable 

12 under paragraph (1) of that section; and 

13 (ii) to an individual who is not a 

14 newly eligible individual (as so described) 

15 but who is eligible for medical assistance 

16 under the State Medicaid program, the en17 hanced FMAP applicable to the State. 

18 (C) LIMITATIONS.— 

19 (i) IN GENERAL.—Payments shall be 

20 made under this paragraph to a State only 

21 for mental health services— 

22 (I) that are described in the dem23 onstration program application in ac24 cordance with paragraph (2)(B)(iv); 


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1 (II) for which payment is avail2 able under the State Medicaid pro3 gram; and 

4 (III) that are provided to an indi5 vidual who is eligible for medical as6 sistance under the State Medicaid 

7 program. 

8 (ii) PROHIBITED PAYMENTS.—No 

9 payment shall be made under this para10 graph— 

11 (I) for inpatient care, residential 

12 treatment, room and board expenses, 

13 or any other non-ambulatory services, 

14 as determined by the Secretary; or 

15 (II) with respect to payments 

16 made to satellite facilities of certified 

17 community behavioral health clinics if 

18 such facilities are established after the 

19 date of enactment of this Act. 

20 (6) WAIVER OF STATEWIDENESS REQUIRE21 MENT.—The Secretary shall waive section 

22 1902(a)(1) of the Social Security Act (42 U.S.C. 

23 1396a(a)(1)) (relating to statewideness) as may be 

24 necessary to conduct demonstration programs in ac25 cordance with the requirements of this subsection. 


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1 (7) ANNUAL REPORTS.— 

2 (A) IN GENERAL.—Not later than 1 year 

3 after the date on which the first State is se4 lected for a demonstration program under this 

5 subsection, and annually thereafter, the Sec6 retary shall submit to Congress an annual re7 port on the use of funds provided under all 

8 demonstration programs conducted under this 

9 subsection. Each such report shall include— 

10 (i) an assessment of access to commu11 nity-based mental health services under the 

12 Medicaid program in the area or areas of 

13 a State targeted by a demonstration pro14 gram compared to other areas of the State; 

15 (ii) an assessment of the quality and 

16 scope of services provided by certified com17 munity behavioral health clinics compared 

18 to community-based mental health services 

19 provided in States not participating in a 

20 demonstration program under this sub21 section and in areas of a demonstration 

22 State that are not participating in the 

23 demonstration program; and 

24 (iii) an assessment of the impact of 

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1 eral and State costs of a full range of men2 tal health services (including inpatient, 

3 emergency and ambulatory services). 

4 (B) RECOMMENDATIONS.—Not later than 

5 December 31, 2021, the Secretary shall submit 

6 to Congress recommendations concerning 

7 whether the demonstration programs under this 

8 section should be continued, expanded, modi9 fied, or terminated. 

10 (e) DEFINITIONS.—In this section: 

11 (1) FEDERALLY-QUALIFIED HEALTH CENTER

12 SERVICES; FEDERALLY-QUALIFIED HEALTH CENTER; 

13 RURAL HEALTH CLINIC SERVICES; RURAL HEALTH

14 CLINIC.—The terms ‘‘Federally-qualified health cen15 ter services’’, ‘‘Federally-qualified health center’’, 

16 ‘‘rural health clinic services’’, and ‘‘rural health clin17 ic’’ have the meanings given those terms in section 

18 1905(l) of the Social Security Act (42 U.S.C. 

19 1396d(l)). 

20 (2) ENHANCED FMAP.—The term ‘‘enhanced 

21 FMAP’’ has the meaning given that term in section 

22 2105(b) of the Social Security Act (42 U.S.C. 

23 1397dd(b) but without regard to the second and 

24 third sentences of that section. 


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1 (3) SECRETARY.—The term ‘‘Secretary’’ means 

2 the Secretary of Health and Human Services. 

3 (4) STATE.—The term ‘‘State’’ has the mean4 ing given such term for purposes of title XIX of the 

5 Social Security Act (42 U.S.C. 1396 et seq.). 

6 (f) FUNDING.— 

7 (1) IN GENERAL.—Out of any funds in the 

8 Treasury not otherwise appropriated, there is appro9 priated to the Secretary— 

10 (A) for purposes of carrying out sub11 sections (a), (b), and (d)(7), $2,000,000 for fis12 cal year 2014; and 

13 (B) for purposes of awarding planning 

14 grants under subsection (c), $25,000,000 for 

15 fiscal year 2016. 

16 (2) AVAILABILITY.—Funds appropriated under 

17 paragraph (1) shall remain available until expended. 

18 SEC. 416. ANNUAL MEDICAID DSH REPORT. 

19 Section 1923 of the Social Security Act (42 U.S.C. 

20 1396r–4) is amended by adding at the end the following: 

21 ‘‘(k) ANNUAL REPORT TO CONGRESS.— 

22 ‘‘(1) IN GENERAL.—Beginning January 1, 

23 2015, and annually thereafter, the Secretary shall 

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1 ments to disproportionate share hospitals for the 

2 purpose of providing Congress with information rel3 evant to determining an appropriate level of overall 

4 funding for such payment adjustments during and 

5 after the period in which aggregate reductions in the 

6 DSH allotments to States are required under para7 graphs (7) and (8) of subsection (f). 

8 ‘‘(2) REQUIRED REPORT INFORMATION.—Ex9 cept as otherwise provided, each report submitted 

10 under this subsection shall include the following: 

11 ‘‘(A) Information and data relating to 

12 changes in the number of uninsured individuals 

13 for the most recent year for which such data 

14 are available as compared to 2013 and as com15 pared to the Congressional Budget Office esti16 mates of uninsured individuals made at the 

17 time of the enactment of the Patient Protection 

18 and Affordable Care Act (Public Law 111–148) 

19 and the Health Care and Education Reconcili20 ation Act of 2010 (Public Law 111–152). 

21 ‘‘(B) Information and data relating to the 

22 extent to which hospitals continue to incur un23 compensated care costs from providing unreim24 bursed or under-reimbursed services to individ25 uals who either are eligible for medical assistVerDate Mar 15 2010 21:59 Mar 26, 2014 Jkt 039200 PO 00000 Frm 00368 Fmt 6652 Sfmt 6201 E:\BILLS\S2157.PCS S2157

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1 ance under the State plan under this title or 

2 under a waiver of such plan or who have no 

3 health insurance (or other source of third party 

4 coverage) for such services. 

5 ‘‘(C) Information and data relating to the 

6 extent to which hospitals continue to provide 

7 charity care and unreimbursed or under-reim8 bursed services, or otherwise incur bad debt, 

9 under the program established under this title, 

10 the State Children’s Health Insurance Program 

11 established under title XXI, and State or local 

12 indigent care programs, as reported on cost re13 ports submitted under title XVIII or such other 

14 data as the Secretary determines appropriate. 

15 ‘‘(D) In the first report submitted under 

16 this section, a methodology for estimating the 

17 amount of unpaid patient deductibles, copay18 ments and coinsurance incurred by hospitals for 

19 patients enrolled in qualified health plans 

20 through an American Health Benefits Ex21 change, using existing data and minimizing the 

22 administrative burden on hospitals to the extent 

23 possible, and in subsequent reports, data re24 garding such uncompensated care costs col25 lected pursuant to such methodology. 


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1 ‘‘(E) For each State, information and data 

2 relating to the difference between the DSH al3 lotment for the State for the fiscal year that 

4 began on October 1 of the year preceding the 

5 year in which the report is submitted and the 

6 aggregate amount of uncompensated care costs 

7 for all disproportionate share hospitals in the 

8 State. 

9 ‘‘(F) Information and data relating to the 

10 extent to which there are certain vital hospital 

11 systems that are disproportionately experiencing 

12 high levels of uncompensated care and that 

13 have multiple other missions, such as a commit14 ment to graduate medical education, the provi15 sion of tertiary and trauma care services, pro16 viding public health and essential community 

17 services, and providing comprehensive, coordi18 nated care. 

19 ‘‘(G) Such other information and data rel20 evant to the determination of the level of fund21 ing for, and amount of, State DSH allotments 

22 as the Secretary determines appropriate 

23 ‘‘(3) AUTHORIZATION OF APPROPRIATIONS.— 

24 There is authorized to be appropriated to the Sec25 retary for the period of fiscal years 2015 through 


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1 2019, such sums as may be necessary to carry out 

2 this subsection.’’. 

3 SEC. 417. IMPLEMENTATION. 

4 To the extent the Secretary of Health and Human 

5 Services issues a regulation to carry out the provisions of 

6 this Act, the Secretary shall, unless otherwise specified in 

7 this Act— 

8 (1) issue a notice of proposed rulemaking that 

9 includes the proposed regulation; 

10 (2) provide a period of not less than 60 cal11 endar days for comments on the proposed regula12 tion; 

13 (3) not more than 24 months following the date 

14 of publication of the proposed rule, publish the final 

15 regulation or take alternative action (such as with16 drawing the rule or proposing a revised rule with a 

17 new comment period) on the proposed regulation; 

18 and 

19 (4) not less than 30 days before the effective 

20 date of the final regulation, publish the final regula21 tion or take alternative action (such as withdrawing 

22 the rule or proposing a revised rule with a new com23 ment period) on the proposed regulation. 


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1 TITLE V—AMENDMENT TO OCO 

2 ADJUSTMENTS 

3 SEC. 501. AMENDMENT TO OCO ADJUSTMENTS. 

4 Section 251 of the Balanced Budget and Emergency 

5 Deficit Control Act of 1985 (2 U.S.C. 901) is amended— 

6 (1) in subsection (a), by striking paragraph (2) 

7 and inserting the following: 

8 ‘‘(2) ELIMINATING A BREACH.— 

9 ‘‘(A) IN GENERAL.—Each non-exempt ac10 count within a category shall be reduced by a 

11 dollar amount calculated by multiplying the en12 acted level of sequestrable budgetary resources 

13 in that account at that time by the uniform 

14 percentage necessary to eliminate a breach 

15 within that category. 

16 ‘‘(B) OVERSEAS CONTINGENCIES.—Any 

17 amount of budget authority designated as for 

18 Overseas Contingency Operations/Global War 

19 on Terrorism for any of fiscal years 2016 

20 through 2021 in excess of the levels set in sub21 section (b)(2)(E) shall be counted in deter22 mining whether a breach has occurred in the re23 vised security category during the fiscal year.’’; 

24 and 

25 (2) in subsection (b)(2)— 


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1 (A) in subparagraph (A)(ii), by inserting 

2 ‘‘for fiscal years 2012 through 2015,’’ before 

3 ‘‘the Congress’’; and 

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

5 ‘‘(E) OVERSEAS CONTINGENCY OPER6 ATIONS/GLOBAL WAR ON TERRORISM.—If, for 

7 fiscal years 2016 through 2021, appropriations 

8 for discretionary accounts are enacted that 

9 Congress designates for Overseas Contingency 

10 Operations/Global War on Terrorism in statute 

11 on an account by account basis and the Presi12 dent subsequently so designates, the adjustment 

13 for the fiscal year shall be the total of such ap14 propriations for the fiscal year in discretionary 

15 accounts designated as being for Overseas Con16 tingency Operations/Global War on Terrorism, 

17 but not to exceed— 

18 ‘‘(i) for fiscal year 2016, 

19 $84,937,000,000 in additional new budget 

20 authority; 

21 ‘‘(ii) for fiscal year 2017, 

22 $77,292,000,000 in additional new budget 

23 authority; 


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1 ‘‘(iii) for fiscal year 2018, 

2 $69,950,000,000 in additional new budget 

3 authority; 

4 ‘‘(iv) for fiscal year 2019, 

5 $63,304,000,000 in additional new budget 

6 authority; 

7 ‘‘(v) for fiscal year 2020, 

8 $57,227,000,000 in additional new budget 

9 authority; and 

10 ‘‘(vi) for fiscal year 2021, 

11 $51,733,000,000 in additional new budget 

12 authority.’’. 

13 SEC. 502. LIMITATION ON THE USE OF OCO FUNDING. 

14 (a) IN GENERAL.—It is the sense of Congress that— 

15 (1) the annual adjustments established under 

16 section 251(b)(2)(A)(ii) of the Balanced Budget and 

17 Emergency Deficit Control Act of 1985 (2 U.S.C. 

18 901(b)(2)(A)(ii)) to the statutory limits on discre19 tionary spending should be reserved for programs 

20 and activities in budget functions 050 and 150 nec21 essary to meet the needs of overseas contingency op22 erations; and 

23 (2) the requirements for designating funding as 

24 for overseas contingency operations provided for 

25 under such section should remain fully in effect. 


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1 (b) SAVINGS FOR DEFICIT REDUCTION.—It is the 

2 sense of the Congress that savings after the date of enact3 ment of this Act from any reductions in the annual adjust4 ments established under section 251(b)(2)(A)(ii) of the 

5 Balanced Budget and Emergency Deficit Control Act of 

6 1985 (2 U.S.C. 901(b)(2)(A)(ii)) should be reserved for 

7 deficit reduction only. 

8 (c) RULE OF CONSTRUCTION.—Nothing in this Act 

9 shall be construed to modify or eliminate any point of 

10 order that would otherwise be available against legislation 

11 that establishes or modifies any limit or adjustment to a 

12 limit on discretionary spending. 


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Calendar No. 336 

113TH CONGRESS 

2D SESSION S. 2157 

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 26, 2014 

Read the second time and placed on the calendar 


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