H. R. 3590—290 
and services furnished under this title and incentive payments 
under subsection (c), in addition to funds otherwise appropriated, 
there shall be transferred to the Secretary for the Center for Medi-
care & Medicaid Services Program Management Account from the 
Federal Hospital Insurance Trust Fund under section 1817 and 
the Federal Supplementary Medical Insurance Trust Fund under 
section 1841 (in proportions determined appropriate by the Sec-
retary) $5,000,000 for each of fiscal years 2010 through 2015. 
Amounts transferred under this subsection for a fiscal year shall 
be available until expended. 
‘‘(i) TERMINATION.— 
‘‘(1) MANDATORY TERMINATION.—The Secretary shall termi-
nate an agreement with an independence at home medical 
practice if— 
‘‘(A) the Secretary estimates or determines that such 
practice will not receive an incentive payment for the 
second of 2 consecutive years under the demonstration 
program; or 
‘‘(B) such practice fails to meet quality standards 
during any year of the demonstration program. 
‘‘(2) PERMISSIVE TERMINATION.—The Secretary may termi-
nate an agreement with an independence at home medical 
practice for such other reasons determined appropriate by the 
Secretary.’’. 
SEC. 3025. HOSPITAL READMISSIONS REDUCTION PROGRAM. 
(a) IN GENERAL.—Section 1886 of the Social Security Act (42 
U.S.C. 1395ww), as amended by sections 3001 and 3008, is amended 
by adding at the end the following new subsection: 
‘‘(q) HOSPITAL READMISSIONS REDUCTION PROGRAM.— 
‘‘(1) IN GENERAL.—With respect to payment for discharges 
from an applicable hospital (as defined in paragraph (5)(C)) 
occurring during a fiscal year beginning on or after October 
1, 2012, in order to account for excess readmissions in the 
hospital, the Secretary shall reduce the payments that would 
otherwise be made to such hospital under subsection (d) (or 
section 1814(b)(3), as the case may be) for such a discharge 
by an amount equal to the product of— 
‘‘(A) the base operating DRG payment amount (as 
defined in paragraph (2)) for the discharge; and 
‘‘(B) the adjustment factor (described in paragraph 
(3)(A)) for the hospital for the fiscal year. 
‘‘(2) BASE
OPERATING
DRG
PAYMENT
AMOUNT
DEFINED.— 
‘‘(A) IN GENERAL.—Except as provided in subparagraph 
(B), in this subsection, the term ‘base operating DRG pay-
ment amount’ means, with respect to a hospital for a fiscal 
year— 
‘‘(i) the payment amount that would otherwise be 
made under subsection (d) (determined without regard 
to subsection (o)) for a discharge if this subsection 
did not apply; reduced by 
‘‘(ii) any portion of such payment amount that 
is attributable to payments under paragraphs (5)(A), 
(5)(B), (5)(F), and (12) of subsection (d). 
‘‘(B) SPECIAL RULES FOR CERTAIN HOSPITALS.— 
‘‘(i) SOLE COMMUNITY HOSPITALS AND MEDICARE- 
DEPENDENT, SMALL RURAL HOSPITALS.—In the case of
H. R. 3590—291 
a medicare-dependent, small rural hospital (with 
respect to discharges occurring during fiscal years 2012 
and 2013) or a sole community hospital, in applying 
subparagraph (A)(i), the payment amount that would 
otherwise be made under subsection (d) shall be deter-
mined without regard to subparagraphs (I) and (L) 
of subsection (b)(3) and subparagraphs (D) and (G) 
of subsection (d)(5). 
‘‘(ii) HOSPITALS PAID UNDER SECTION 1814.—In the 
case of a hospital that is paid under section 1814(b)(3), 
the Secretary may exempt such hospitals provided that 
States paid under such section submit an annual report 
to the Secretary describing how a similar program 
in the State for a participating hospital or hospitals 
achieves or surpasses the measured results in terms 
of patient health outcomes and cost savings established 
herein with respect to this section. 
‘‘(3) ADJUSTMENT FACTOR.— 
‘‘(A) IN GENERAL.—For purposes of paragraph (1), the 
adjustment factor under this paragraph for an applicable 
hospital for a fiscal year is equal to the greater of— 
‘‘(i) the ratio described in subparagraph (B) for 
the hospital for the applicable period (as defined in 
paragraph (5)(D)) for such fiscal year; or 
‘‘(ii) the floor adjustment factor specified in 
subparagraph (C). 
‘‘(B) RATIO.—The ratio described in this subparagraph 
for a hospital for an applicable period is equal to 1 minus 
the ratio of— 
‘‘(i) the aggregate payments for excess readmis-
sions (as defined in paragraph (4)(A)) with respect 
to an applicable hospital for the applicable period; and 
‘‘(ii) the aggregate payments for all discharges (as 
defined in paragraph (4)(B)) with respect to such 
applicable hospital for such applicable period. 
‘‘(C) FLOOR
ADJUSTMENT
FACTOR.—For purposes of 
subparagraph (A), the floor adjustment factor specified in 
this subparagraph for— 
‘‘(i) fiscal year 2013 is 0.99; 
‘‘(ii) fiscal year 2014 is 0.98; or 
‘‘(iii) fiscal year 2015 and subsequent fiscal years 
is 0.97. 
‘‘(4) AGGREGATE
PAYMENTS, EXCESS
READMISSION
RATIO 
DEFINED.—For purposes of this subsection: 
‘‘(A) AGGREGATE
PAYMENTS
FOR
EXCESS
READMIS-
SIONS.—The term ‘aggregate payments for excess readmis-
sions’ means, for a hospital for an applicable period, the 
sum, for applicable conditions (as defined in paragraph 
(5)(A)), of the product, for each applicable condition, of— 
‘‘(i) the base operating DRG payment amount for 
such hospital for such applicable period for such condi-
tion; 
‘‘(ii) the number of admissions for such condition 
for such hospital for such applicable period; and 
‘‘(iii) the excess readmissions ratio (as defined in 
subparagraph (C)) for such hospital for such applicable 
period minus 1.
H. R. 3590—292 
‘‘(B) AGGREGATE PAYMENTS FOR ALL DISCHARGES.—The 
term ‘aggregate payments for all discharges’ means, for 
a hospital for an applicable period, the sum of the base 
operating DRG payment amounts for all discharges for 
all conditions from such hospital for such applicable period. 
‘‘(C) EXCESS READMISSION RATIO.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), the term 
‘excess readmissions ratio’ means, with respect to an 
applicable condition for a hospital for an applicable 
period, the ratio (but not less than 1.0) of— 
‘‘(I) the risk adjusted readmissions based on 
actual readmissions, as determined consistent with 
a readmission measure methodology that has been 
endorsed under paragraph (5)(A)(ii)(I), for an 
applicable hospital for such condition with respect 
to such applicable period; to 
‘‘(II) the risk adjusted expected readmissions 
(as determined consistent with such a method-
ology) for such hospital for such condition with 
respect to such applicable period. 
‘‘(ii) EXCLUSION
OF
CERTAIN
READMISSIONS.—For 
purposes of clause (i), with respect to a hospital, excess 
readmissions shall not include readmissions for an 
applicable condition for which there are fewer than 
a minimum number (as determined by the Secretary) 
of discharges for such applicable condition for the 
applicable period and such hospital. 
‘‘(5) DEFINITIONS.—For purposes of this subsection: 
‘‘(A) APPLICABLE
CONDITION.—The term ‘applicable 
condition’ means, subject to subparagraph (B), a condition 
or procedure selected by the Secretary among conditions 
and procedures for which— 
‘‘(i) readmissions (as defined in subparagraph (E)) 
that represent conditions or procedures that are high 
volume or high expenditures under this title (or other 
criteria specified by the Secretary); and 
‘‘(ii) measures of such readmissions— 
‘‘(I) have been endorsed by the entity with 
a contract under section 1890(a); and 
‘‘(II) such endorsed measures have exclusions 
for readmissions that are unrelated to the prior 
discharge (such as a planned readmission or 
transfer to another applicable hospital). 
‘‘(B) EXPANSION
OF
APPLICABLE
CONDITIONS.—Begin-
ning with fiscal year 2015, the Secretary shall, to the 
extent practicable, expand the applicable conditions beyond 
the 3 conditions for which measures have been endorsed 
as described in subparagraph (A)(ii)(I) as of the date of 
the enactment of this subsection to the additional 4 condi-
tions that have been identified by the Medicare Payment 
Advisory Commission in its report to Congress in June 
2007 and to other conditions and procedures as determined 
appropriate by the Secretary. In expanding such applicable 
conditions, the Secretary shall seek the endorsement 
described in subparagraph (A)(ii)(I) but may apply such 
measures without such an endorsement in the case of a 
specified area or medical topic determined appropriate by
H. R. 3590—293 
the Secretary for which a feasible and practical measure 
has not been endorsed by the entity with a contract under 
section 1890(a) as long as due consideration is given to 
measures that have been endorsed or adopted by a con-
sensus organization identified by the Secretary. 
‘‘(C) APPLICABLE HOSPITAL.—The term ‘applicable hos-
pital’ means a subsection (d) hospital or a hospital that 
is paid under section 1814(b)(3), as the case may be. 
‘‘(D) APPLICABLE PERIOD.—The term ‘applicable period’ 
means, with respect to a fiscal year, such period as the 
Secretary shall specify. 
‘‘(E) READMISSION.—The term ‘readmission’ means, in 
the case of an individual who is discharged from an 
applicable hospital, the admission of the individual to the 
same or another applicable hospital within a time period 
specified by the Secretary from the date of such discharge. 
Insofar as the discharge relates to an applicable condition 
for which there is an endorsed measure described in 
subparagraph (A)(ii)(I), such time period (such as 30 days) 
shall be consistent with the time period specified for such 
measure. 
‘‘(6) REPORTING HOSPITAL SPECIFIC INFORMATION.— 
‘‘(A) IN GENERAL.—The Secretary shall make informa-
tion available to the public regarding readmission rates 
of each subsection (d) hospital under the program. 
‘‘(B) OPPORTUNITY
TO
REVIEW
AND
SUBMIT
CORREC-
TIONS.—The Secretary shall ensure that a subsection (d) 
hospital has the opportunity to review, and submit correc-
tions for, the information to be made public with respect 
to the hospital under subparagraph (A) prior to such 
information being made public. 
‘‘(C) WEBSITE.—Such information shall be posted on 
the Hospital Compare Internet website in an easily under-
standable format. 
‘‘(7) LIMITATIONS ON REVIEW.—There shall be no adminis-
trative or judicial review under section 1869, section 1878, 
or otherwise of the following: 
‘‘(A) The determination of base operating DRG payment 
amounts. 
‘‘(B) The methodology for determining the adjustment 
factor under paragraph (3), including excess readmissions 
ratio under paragraph (4)(C), aggregate payments for 
excess readmissions under paragraph (4)(A), and aggregate 
payments for all discharges under paragraph (4)(B), and 
applicable periods and applicable conditions under para-
graph (5). 
‘‘(C) The measures of readmissions as described in 
paragraph (5)(A)(ii). 
‘‘(8) READMISSION RATES FOR ALL PATIENTS.— 
‘‘(A) CALCULATION
OF
READMISSION.—The Secretary 
shall calculate readmission rates for all patients (as defined 
in subparagraph (D)) for a specified hospital (as defined 
in subparagraph (D)(ii)) for an applicable condition (as 
defined in paragraph (5)(B)) and other conditions deemed 
appropriate by the Secretary for an applicable period (as 
defined in paragraph (5)(D)) in the same manner as used 
to calculate such readmission rates for hospitals with
H. R. 3590—294 
respect to this title and posted on the CMS Hospital Com-
pare website. 
‘‘(B) POSTING
OF
HOSPITAL
SPECIFIC
ALL
PATIENT 
READMISSION RATES.—The Secretary shall make informa-
tion on all patient readmission rates calculated under 
subparagraph (A) available on the CMS Hospital Compare 
website in a form and manner determined appropriate 
by the Secretary. The Secretary may also make other 
information determined appropriate by the Secretary avail-
able on such website. 
‘‘(C) HOSPITAL SUBMISSION OF ALL PATIENT DATA.— 
‘‘(i) Except as provided for in clause (ii), each speci-
fied hospital (as defined in subparagraph (D)(ii)) shall 
submit to the Secretary, in a form, manner and time 
specified by the Secretary, data and information deter-
mined necessary by the Secretary for the Secretary 
to calculate the all patient readmission rates described 
in subparagraph (A). 
‘‘(ii) Instead of a specified hospital submitting to 
the Secretary the data and information described in 
clause (i), such data and information may be submitted 
to the Secretary, on behalf of such a specified hospital, 
by a state or an entity determined appropriate by 
the Secretary. 
‘‘(D) DEFINITIONS.—For purposes of this paragraph: 
‘‘(i) The term ‘all patients’ means patients who 
are treated on an inpatient basis and discharged from 
a specified hospital (as defined in clause (ii)). 
‘‘(ii) The term ‘specified hospital’ means a sub-
section (d) hospital, hospitals described in clauses (i) 
through (v) of subsection (d)(1)(B) and, as determined 
feasible and appropriate by the Secretary, other hos-
pitals not otherwise described in this subparagraph.’’. 
(b) QUALITY IMPROVEMENT.—Part S of title III of the Public 
Health Service Act, as amended by section 3015, is further amended 
by adding at the end the following: 
‘‘SEC. 399KK. QUALITY IMPROVEMENT PROGRAM FOR HOSPITALS 
WITH A HIGH SEVERITY ADJUSTED READMISSION RATE. 
‘‘(a) ESTABLISHMENT.— 
‘‘(1) IN GENERAL.—Not later than 2 years after the date 
of enactment of this section, the Secretary shall make available 
a program for eligible hospitals to improve their readmission 
rates through the use of patient safety organizations (as defined 
in section 921(4)). 
‘‘(2) ELIGIBLE HOSPITAL DEFINED.—In this subsection, the 
term ‘eligible hospital’ means a hospital that the Secretary 
determines has a high rate of risk adjusted readmissions for 
the conditions described in section 1886(q)(8)(A) of the Social 
Security Act and has not taken appropriate steps to reduce 
such readmissions and improve patient safety as evidenced 
through historically high rates of readmissions, as determined 
by the Secretary. 
‘‘(3) RISK ADJUSTMENT.—The Secretary shall utilize appro-
priate risk adjustment measures to determine eligible hospitals. 
‘‘(b) REPORT TO THE SECRETARY.—As determined appropriate 
by the Secretary, eligible hospitals and patient safety organizations
H. R. 3590—295 
working with those hospitals shall report to the Secretary on the 
processes employed by the hospital to improve readmission rates 
and the impact of such processes on readmission rates.’’. 
SEC. 3026. COMMUNITY-BASED CARE TRANSITIONS PROGRAM. 
(a) IN GENERAL.—The Secretary shall establish a Community- 
Based Care Transitions Program under which the Secretary pro-
vides funding to eligible entities that furnish improved care transi-
tion services to high-risk Medicare beneficiaries. 
(b) DEFINITIONS.—In this section: 
(1) ELIGIBLE ENTITY.—The term ‘‘eligible entity’’ means the 
following: 
(A) A subsection (d) hospital (as defined in section 
1886(d)(1)(B) of the Social Security Act (42 U.S.C. 
1395ww(d)(1)(B))) identified by the Secretary as having 
a high readmission rate, such as under section 1886(q) 
of the Social Security Act, as added by section 3025. 
(B) An appropriate community-based organization that 
provides care transition services under this section across 
a continuum of care through arrangements with subsection 
(d) hospitals (as so defined) to furnish the services described 
in subsection (c)(2)(B)(i) and whose governing body includes 
sufficient representation of multiple health care stake-
holders (including consumers). 
(2) HIGH-RISK
MEDICARE
BENEFICIARY.—The term ‘‘high- 
risk Medicare beneficiary’’ means a Medicare beneficiary who 
has attained a minimum hierarchical condition category score, 
as determined by the Secretary, based on a diagnosis of multiple 
chronic conditions or other risk factors associated with a hos-
pital readmission or substandard transition into post-hos-
pitalization care, which may include 1 or more of the following: 
(A) Cognitive impairment. 
(B) Depression. 
(C) A history of multiple readmissions. 
(D) Any other chronic disease or risk factor as deter-
mined by the Secretary. 
(3) MEDICARE
BENEFICIARY.—The term ‘‘Medicare bene-
ficiary’’ means an individual who is entitled to benefits under 
part A of title XVIII of the Social Security Act (42 U.S.C. 
1395 et seq.) and enrolled under part B of such title, but 
not enrolled under part C of such title. 
(4) PROGRAM.—The term ‘‘program’’ means the program 
conducted under this section. 
(5) 
READMISSION.—The 
term 
‘‘readmission’’ 
has 
the 
meaning given such term in section 1886(q)(5)(E) of the Social 
Security Act, as added by section 3025. 
(6) SECRETARY.—The term ‘‘Secretary’’ means the Secretary 
of Health and Human Services. 
(c) REQUIREMENTS.— 
(1) DURATION.— 
(A) IN GENERAL.—The program shall be conducted for 
a 5-year period, beginning January 1, 2011. 
(B) EXPANSION.—The Secretary may expand the dura-
tion and the scope of the program, to the extent determined 
appropriate by the Secretary, if the Secretary determines 
(and the Chief Actuary of the Centers for Medicare & 
Medicaid Services, with respect to spending under this
H. R. 3590—296 
title, certifies) that such expansion would reduce spending 
under this title without reducing quality. 
(2) APPLICATION; PARTICIPATION.— 
(A) IN GENERAL.— 
(i) APPLICATION.—An eligible entity seeking to 
participate in the program shall submit an application 
to the Secretary at such time, in such manner, and 
containing such information as the Secretary may 
require. 
(ii) PARTNERSHIP.—If an eligible entity is a hos-
pital, such hospital shall enter into a partnership with 
a community-based organization to participate in the 
program. 
(B) INTERVENTION PROPOSAL.—Subject to subparagraph 
(C), an application submitted under subparagraph (A)(i) 
shall include a detailed proposal for at least 1 care transi-
tion intervention, which may include the following: 
(i) Initiating care transition services for a high- 
risk Medicare beneficiary not later than 24 hours prior 
to the discharge of the beneficiary from the eligible 
entity. 
(ii) Arranging timely post-discharge follow-up serv-
ices to the high-risk Medicare beneficiary to provide 
the beneficiary (and, as appropriate, the primary care-
giver of the beneficiary) with information regarding 
responding to symptoms that may indicate additional 
health problems or a deteriorating condition. 
(iii) Providing the high-risk Medicare beneficiary 
(and, as appropriate, the primary caregiver of the bene-
ficiary) with assistance to ensure productive and timely 
interactions between patients and post-acute and out-
patient providers. 
(iv) Assessing and actively engaging with a high- 
risk Medicare beneficiary (and, as appropriate, the pri-
mary caregiver of the beneficiary) through the provi-
sion of self-management support and relevant informa-
tion that is specific to the beneficiary’s condition. 
(v) Conducting comprehensive medication review 
and management (including, if appropriate, counseling 
and self-management support). 
(C) LIMITATION.—A care transition intervention pro-
posed under subparagraph (B) may not include payment 
for services required under the discharge planning process 
described in section 1861(ee) of the Social Security Act 
(42 U.S.C. 1395x(ee)). 
(3) SELECTION.—In selecting eligible entities to participate 
in the program, the Secretary shall give priority to eligible 
entities that— 
(A) participate in a program administered by the 
Administration on Aging to provide concurrent care transi-
tions interventions with multiple hospitals and practi-
tioners; or 
(B) provide services to medically underserved popu-
lations, small communities, and rural areas. 
(d) IMPLEMENTATION.—Notwithstanding any other provision of 
law, the Secretary may implement the provisions of this section 
by program instruction or otherwise.
H. R. 3590—297 
(e) WAIVER
AUTHORITY.—The Secretary may waive such 
requirements of titles XI and XVIII of the Social Security Act 
as may be necessary to carry out the program. 
(f) FUNDING.—For purposes of carrying out this section, the 
Secretary of Health and Human Services shall provide for the 
transfer, from the Federal Hospital Insurance Trust Fund under 
section 1817 of the Social Security Act (42 U.S.C. 1395i) and the 
Federal Supplementary Medical Insurance Trust Fund under sec-
tion 1841 of such Act (42 U.S.C. 1395t), in such proportion as 
the Secretary determines appropriate, of $500,000,000, to the Cen-
ters for Medicare & Medicaid Services Program Management 
Account for the period of fiscal years 2011 through 2015. Amounts 
transferred under the preceding sentence shall remain available 
until expended. 
SEC. 3027. EXTENSION OF GAINSHARING DEMONSTRATION. 
(a) IN GENERAL.—Subsection (d)(3) of section 5007 of the Deficit 
Reduction Act of 2005 (Public Law 109–171) is amended by inserting 
‘‘(or September 30, 2011, in the case of a demonstration project 
in operation as of October 1, 2008)’’ after ‘‘December 31, 2009’’. 
(b) FUNDING.— 
(1) IN
GENERAL.—Subsection (f)(1) of such section is 
amended by inserting ‘‘and for fiscal year 2010, $1,600,000,’’ 
after ‘‘$6,000,000,’’. 
(2) AVAILABILITY.—Subsection (f)(2) of such section is 
amended by striking ‘‘2010’’ and inserting ‘‘2014 or until 
expended’’. 
(c) REPORTS.— 
(1) QUALITY IMPROVEMENT AND SAVINGS.—Subsection (e)(3) 
of such section is amended by striking ‘‘December 1, 2008’’ 
and inserting ‘‘March 31, 2011’’. 
(2) FINAL
REPORT.—Subsection (e)(4) of such section is 
amended by striking ‘‘May 1, 2010’’ and inserting ‘‘March 31, 
2013’’. 
Subtitle B—Improving Medicare for 
Patients and Providers 
PART I—ENSURING BENEFICIARY ACCESS TO 
PHYSICIAN CARE AND OTHER SERVICES 
SEC. 3101. INCREASE IN THE PHYSICIAN PAYMENT UPDATE. 
Section 1848(d) of the Social Security Act (42 U.S.C. 1395w– 
4(d)) is amended by adding at the end the following new paragraph: 
‘‘(10) UPDATE FOR 2010.— 
‘‘(A) IN GENERAL.—Subject to paragraphs (7)(B), (8)(B), 
and (9)(B), in lieu of the update to the single conversion 
factor established in paragraph (1)(C) that would otherwise 
apply for 2010, the update to the single conversion factor 
shall be 0.5 percent. 
‘‘(B) NO
EFFECT
ON
COMPUTATION
OF
CONVERSION 
FACTOR FOR 2011 AND SUBSEQUENT YEARS.—The conversion 
factor under this subsection shall be computed under para-
graph (1)(A) for 2011 and subsequent years as if subpara-
graph (A) had never applied.’’.
H. R. 3590—298 
SEC. 3102. EXTENSION OF THE WORK GEOGRAPHIC INDEX FLOOR AND 
REVISIONS TO THE PRACTICE EXPENSE GEOGRAPHIC 
ADJUSTMENT UNDER THE MEDICARE PHYSICIAN FEE 
SCHEDULE. 
(a) EXTENSION OF WORK GPCI FLOOR.—Section 1848(e)(1)(E) 
of the Social Security Act (42 U.S.C. 1395w–4(e)(1)(E)) is amended 
by striking ‘‘before January 1, 2010’’ and inserting ‘‘before January 
1, 2011’’. 
(b) PRACTICE EXPENSE GEOGRAPHIC ADJUSTMENT FOR 2010 AND 
SUBSEQUENT YEARS.—Section 1848(e)(1) of the Social Security Act 
(42 U.S.C. 1395w4(e)(1)) is amended— 
(1) in subparagraph (A), by striking ‘‘and (G)’’ and inserting 
‘‘(G), and (H)’’; and 
(2) by adding at the end the following new subparagraph: 
‘‘(H) PRACTICE EXPENSE GEOGRAPHIC ADJUSTMENT FOR 
2010 AND SUBSEQUENT YEARS.— 
‘‘(i) FOR 2010.—Subject to clause (iii), for services 
furnished during 2010, the employee wage and rent 
portions of the practice expense geographic index 
described in subparagraph (A)(i) shall reflect 3⁄4 of 
the difference between the relative costs of employee 
wages and rents in each of the different fee schedule 
areas and the national average of such employee wages 
and rents. 
‘‘(ii) FOR 2011.—Subject to clause (iii), for services 
furnished during 2011, the employee wage and rent 
portions of the practice expense geographic index 
described in subparagraph (A)(i) shall reflect 1⁄2 of 
the difference between the relative costs of employee 
wages and rents in each of the different fee schedule 
areas and the national average of such employee wages 
and rents. 
‘‘(iii) HOLD HARMLESS.—The practice expense por-
tion of the geographic adjustment factor applied in 
a fee schedule area for services furnished in 2010 or 
2011 shall not, as a result of the application of clause 
(i) or (ii), be reduced below the practice expense portion 
of the geographic adjustment factor under subpara-
graph (A)(i) (as calculated prior to the application of 
such clause (i) or (ii), respectively) for such area for 
such year. 
‘‘(iv) ANALYSIS.—The Secretary shall analyze cur-
rent 
methods 
of 
establishing 
practice 
expense 
geographic adjustments under subparagraph (A)(i) and 
evaluate data that fairly and reliably establishes 
distinctions in the costs of operating a medical practice 
in the different fee schedule areas. Such analysis shall 
include an evaluation of the following: 
‘‘(I) The feasibility of using actual data or reli-
able survey data developed by medical organiza-
tions on the costs of operating a medical practice, 
including office rents and non-physician staff 
wages, in different fee schedule areas. 
‘‘(II) The office expense portion of the practice 
expense 
geographic 
adjustment 
described 
in 
subparagraph (A)(i), including the extent to which
H. R. 3590—299 
types of office expenses are determined in local 
markets instead of national markets. 
‘‘(III) The weights assigned to each of the cat-
egories within the practice expense geographic 
adjustment described in subparagraph (A)(i). 
‘‘(v) REVISION FOR 2012 AND SUBSEQUENT YEARS.— 
As a result of the analysis described in clause (iv), 
the Secretary shall, not later than January 1, 2012, 
make appropriate adjustments to the practice expense 
geographic adjustment described in subparagraph 
(A)(i) to ensure accurate geographic adjustments across 
fee schedule areas, including— 
‘‘(I) basing the office rents component and its 
weight on office expenses that vary among fee 
schedule areas; and 
‘‘(II) considering a representative range of 
professional 
and 
non-professional 
personnel 
employed in a medical office based on the use 
of the American Community Survey data or other 
reliable data for wage adjustments. 
Such adjustments shall be made without regard to 
adjustments made pursuant to clauses (i) and (ii) and 
shall be made in a budget neutral manner.’’. 
SEC. 3103. EXTENSION OF EXCEPTIONS PROCESS FOR MEDICARE 
THERAPY CAPS. 
Section 1833(g)(5) of the Social Security Act (42 U.S.C. 
1395l(g)(5)) is amended by striking ‘‘December 31, 2009’’ and 
inserting ‘‘December 31, 2010’’. 
SEC. 3104. EXTENSION OF PAYMENT FOR TECHNICAL COMPONENT OF 
CERTAIN PHYSICIAN PATHOLOGY SERVICES. 
Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits 
Improvement and Protection Act of 2000 (as enacted into law by 
section 1(a)(6) of Public Law 106–554), as amended by section 
732 of the Medicare Prescription Drug, Improvement, and Mod-
ernization Act of 2003 (42 U.S.C. 1395w–4 note), section 104 of 
division B of the Tax Relief and Health Care Act of 2006 (42 
U.S.C. 1395w–4 note), section 104 of the Medicare, Medicaid, and 
SCHIP Extension Act of 2007 (Public Law 110–173), and section 
136 of the Medicare Improvements for Patients and Providers Act 
of 2008 (Public Law 110–275), is amended by striking ‘‘and 2009’’ 
and inserting ‘‘2009, and 2010’’. 
SEC. 3105. EXTENSION OF AMBULANCE ADD-ONS. 
(a) GROUND AMBULANCE.—Section 1834(l)(13)(A) of the Social 
Security Act (42 U.S.C. 1395m(l)(13)(A)) is amended— 
(1) in the matter preceding clause (i)— 
(A) by striking ‘‘2007, and for’’ and inserting ‘‘2007, 
for’’; and 
(B) by striking ‘‘2010’’ and inserting ‘‘2010, and for 
such services furnished on or after April 1, 2010, and 
before January 1, 2011,’’; and 
(2) in each of clauses (i) and (ii), by inserting ‘‘, and on 
or after April 1, 2010, and before January 1, 2011’’ after 
‘‘January 1, 2010’’ each place it appears. 
(b) AIR
AMBULANCE.—Section 146(b)(1) of the Medicare 
Improvements for Patients and Providers Act of 2008 (Public Law
H. R. 3590—300 
110–275) is amended by striking ‘‘December 31, 2009’’ and inserting 
‘‘December 31, 2009, and during the period beginning on April 
1, 2010, and ending on January 1, 2011’’. 
(c) SUPER RURAL AMBULANCE.—Section 1834(l)(12)(A) of the 
Social Security Act (42 U.S.C. 1395m(l)(12)(A)) is amended by 
striking ‘‘2010’’ and inserting ‘‘2010, and on or after April 1, 2010, 
and before January 1, 2011’’. 
SEC. 3106. EXTENSION OF CERTAIN PAYMENT RULES FOR LONG-TERM 
CARE HOSPITAL SERVICES AND OF MORATORIUM ON 
THE ESTABLISHMENT OF CERTAIN HOSPITALS AND 
FACILITIES. 
(a) EXTENSION OF CERTAIN PAYMENT RULES.—Section 114(c) 
of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (42 
U.S.C. 1395ww note), as amended by section 4302(a) of the Amer-
ican Recovery and Reinvestment Act (Public Law 111–5), is further 
amended by striking ‘‘3-year period’’ each place it appears and 
inserting ‘‘4-year period’’. 
(b) EXTENSION OF MORATORIUM.—Section 114(d)(1) of such Act 
(42 U.S.C. 1395ww note), in the matter preceding subparagraph 
(A), is amended by striking ‘‘3-year period’’ and inserting ‘‘4-year 
period’’. 
SEC. 3107. EXTENSION OF PHYSICIAN FEE SCHEDULE MENTAL HEALTH 
ADD-ON. 
Section 138(a)(1) of the Medicare Improvements for Patients 
and Providers Act of 2008 (Public Law 110–275) is amended by 
striking ‘‘December 31, 2009’’ and inserting ‘‘December 31, 2010’’. 
SEC. 3108. PERMITTING PHYSICIAN ASSISTANTS TO ORDER POST-HOS-
PITAL EXTENDED CARE SERVICES. 
(a) ORDERING POST-HOSPITAL EXTENDED CARE SERVICES.— 
(1) IN GENERAL.—Section 1814(a)(2) of the Social Security 
Act (42 U.S.C. 1395f(a)(2)), in the matter preceding subpara-
graph (A), is amended by striking ‘‘or clinical nurse specialist’’ 
and inserting ‘‘, a clinical nurse specialist, or a physician assist-
ant (as those terms are defined in section 1861(aa)(5))’’ after 
‘‘nurse practitioner’’. 
(2) CONFORMING
AMENDMENT.—Section 1814(a) of the 
Social Security Act (42 U.S.C. 1395f(a)) is amended, in the 
second sentence, by striking ‘‘or clinical nurse specialist’’ and 
inserting ‘‘clinical nurse specialist, or physician assistant’’ after 
‘‘nurse practitioner,’’. 
(b) EFFECTIVE DATE.—The amendments made by this section 
shall apply to items and services furnished on or after January 
1, 2011. 
SEC. 3109. EXEMPTION OF CERTAIN PHARMACIES FROM ACCREDITA-
TION REQUIREMENTS. 
(a) IN GENERAL.—Section 1834(a)(20) of the Social Security 
Act (42 U.S.C. 1395m(a)(20)), as added by section 154(b)(1)(A) of 
the Medicare Improvements for Patients and Providers Act of 2008 
(Public Law 100–275), is amended— 
(1) in subparagraph (F)(i)— 
(A) by inserting ‘‘and subparagraph (G)’’ after ‘‘clause 
(ii)’’; and 
(B) by inserting ‘‘, except that the Secretary shall not 
require a pharmacy to have submitted to the Secretary
H. R. 3590—301 
such evidence of accreditation prior to January 1, 2011’’ 
before the semicolon at the end; and 
(2) by adding at the end the following new subparagraph: 
‘‘(G) APPLICATION OF ACCREDITATION REQUIREMENT TO 
CERTAIN PHARMACIES.— 
‘‘(i) IN GENERAL.—With respect to items and serv-
ices furnished on or after January 1, 2011, in imple-
menting quality standards under this paragraph— 
‘‘(I) subject to subclause (II), in applying such 
standards and the accreditation requirement of 
subparagraph (F)(i) with respect to pharmacies 
described in clause (ii) furnishing such items and 
services, such standards and accreditation require-
ment shall not apply to such pharmacies; and 
‘‘(II) the Secretary may apply to such phar-
macies an alternative accreditation requirement 
established by the Secretary if the Secretary deter-
mines such alternative accreditation requirement 
is more appropriate for such pharmacies. 
‘‘(ii) 
PHARMACIES
DESCRIBED.—A 
pharmacy 
described in this clause is a pharmacy that meets 
each of the following criteria: 
‘‘(I) The total billings by the pharmacy for 
such items and services under this title are less 
than 5 percent of total pharmacy sales, as deter-
mined based on the average total pharmacy sales 
for the previous 3 calendar years, 3 fiscal years, 
or other yearly period specified by the Secretary. 
‘‘(II) The pharmacy has been enrolled under 
section 1866(j) as a supplier of durable medical 
equipment, prosthetics, orthotics, and supplies, has 
been issued (which may include the renewal of) 
a provider number for at least 5 years, and for 
which a final adverse action (as defined in section 
424.57(a) of title 42, Code of Federal Regulations) 
has not been imposed in the past 5 years. 
‘‘(III) The pharmacy submits to the Secretary 
an attestation, in a form and manner, and at a 
time, specified by the Secretary, that the pharmacy 
meets the criteria described in subclauses (I) and 
(II). Such attestation shall be subject to section 
1001 of title 18, United States Code. 
‘‘(IV) The pharmacy agrees to submit materials 
as requested by the Secretary, or during the course 
of an audit conducted on a random sample of phar-
macies selected annually, to verify that the phar-
macy meets the criteria described in subclauses 
(I) and (II). Materials submitted under the pre-
ceding sentence shall include a certification by an 
accountant on behalf of the pharmacy or the 
submission of tax returns filed by the pharmacy 
during the relevant periods, as requested by the 
Secretary.’’. 
(b) ADMINISTRATION.—Notwithstanding any other provision of 
law, the Secretary may implement the amendments made by sub-
section (a) by program instruction or otherwise.
H. R. 3590—302 
(c) RULE OF CONSTRUCTION.—Nothing in the provisions of or 
amendments made by this section shall be construed as affecting 
the application of an accreditation requirement for pharmacies to 
qualify for bidding in a competitive acquisition area under section 
1847 of the Social Security Act (42 U.S.C. 1395w–3). 
SEC. 3110. PART B SPECIAL ENROLLMENT PERIOD FOR DISABLED 
TRICARE BENEFICIARIES. 
(a) IN GENERAL.— 
(1) IN GENERAL.—Section 1837 of the Social Security Act 
(42 U.S.C. 1395p) is amended by adding at the end the following 
new subsection: 
‘‘(l)(1) In the case of any individual who is a covered beneficiary 
(as defined in section 1072(5) of title 10, United States Code) 
at the time the individual is entitled to part A under section 
226(b) or section 226A and who is eligible to enroll but who has 
elected not to enroll (or to be deemed enrolled) during the individ-
ual’s initial enrollment period, there shall be a special enrollment 
period described in paragraph (2). 
‘‘(2) The special enrollment period described in this paragraph, 
with respect to an individual, is the 12-month period beginning 
on the day after the last day of the initial enrollment period of 
the individual or, if later, the 12-month period beginning with 
the month the individual is notified of enrollment under this section. 
‘‘(3) In the case of an individual who enrolls during the special 
enrollment period provided under paragraph (1), the coverage period 
under this part shall begin on the first day of the month in which 
the individual enrolls, or, at the option of the individual, the first 
month after the end of the individual’s initial enrollment period. 
‘‘(4) An individual may only enroll during the special enrollment 
period provided under paragraph (1) one time during the individ-
ual’s lifetime. 
‘‘(5) The Secretary shall ensure that the materials relating 
to coverage under this part that are provided to an individual 
described in paragraph (1) prior to the individual’s initial enrollment 
period contain information concerning the impact of not enrolling 
under this part, including the impact on health care benefits under 
the TRICARE program under chapter 55 of title 10, United States 
Code. 
‘‘(6) The Secretary of Defense shall collaborate with the Sec-
retary of Health and Human Services and the Commissioner of 
Social Security to provide for the accurate identification of individ-
uals described in paragraph (1). The Secretary of Defense shall 
provide such individuals with notification with respect to this sub-
section. The Secretary of Defense shall collaborate with the Sec-
retary of Health and Human Services and the Commissioner of 
Social Security to ensure appropriate follow up pursuant to any 
notification provided under the preceding sentence.’’. 
(2) EFFECTIVE DATE.—The amendment made by paragraph 
(1) shall apply to elections made with respect to initial enroll-
ment periods that end after the date of the enactment of this 
Act. 
(b) WAIVER OF INCREASE OF PREMIUM.—Section 1839(b) of the 
Social Security Act (42 U.S.C. 1395r(b)) is amended by striking 
‘‘section 1837(i)(4)’’ and inserting ‘‘subsection (i)(4) or (l) of section 
1837’’.
H. R. 3590—303 
SEC. 3111. PAYMENT FOR BONE DENSITY TESTS. 
(a) PAYMENT.— 
(1) IN GENERAL.—Section 1848 of the Social Security Act 
(42 U.S.C. 1395w–4) is amended— 
(A) in subsection (b)— 
(i) in paragraph (4)(B), by inserting ‘‘, and for 
2010 and 2011, dual-energy x-ray absorptiometry serv-
ices (as described in paragraph (6))’’ before the period 
at the end; and 
(ii) by adding at the end the following new para-
graph: 
‘‘(6) TREATMENT OF BONE MASS SCANS.—For dual-energy 
x-ray absorptiometry services (identified in 2006 by HCPCS 
codes 76075 and 76077 (and any succeeding codes)) furnished 
during 2010 and 2011, instead of the payment amount that 
would otherwise be determined under this section for such 
years, the payment amount shall be equal to 70 percent of 
the product of— 
‘‘(A) the relative value for the service (as determined 
in subsection (c)(2)) for 2006; 
‘‘(B) the conversion factor (established under subsection 
(d)) for 2006; and 
‘‘(C) the geographic adjustment factor (established 
under subsection (e)(2)) for the service for the fee schedule 
area for 2010 and 2011, respectively.’’; and 
(B) in subsection (c)(2)(B)(iv)— 
(i) in subclause (II), by striking ‘‘and’’ at the end; 
(ii) in subclause (III), by striking the period at 
the end and inserting ‘‘; and’’; and 
(iii) by adding at the end the following new sub-
clause: 
‘‘(IV) subsection (b)(6) shall not be taken into 
account in applying clause (ii)(II) for 2010 or 
2011.’’. 
(2) IMPLEMENTATION.—Notwithstanding any other provi-
sion of law, the Secretary may implement the amendments 
made by paragraph (1) by program instruction or otherwise. 
(b) STUDY AND REPORT BY THE INSTITUTE OF MEDICINE.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services is authorized to enter into an agreement with the 
Institute of Medicine of the National Academies to conduct 
a study on the ramifications of Medicare payment reductions 
for dual-energy x-ray absorptiometry (as described in section 
1848(b)(6) of the Social Security Act, as added by subsection 
(a)(1)) during 2007, 2008, and 2009 on beneficiary access to 
bone mass density tests. 
(2) REPORT.—An agreement entered into under paragraph 
(1) shall provide for the Institute of Medicine to submit to 
the Secretary and to Congress a report containing the results 
of the study conducted under such paragraph. 
SEC. 3112. REVISION TO THE MEDICARE IMPROVEMENT FUND. 
Section 1898(b)(1)(A) of the Social Security Act (42 U.S.C. 
1395iii) is amended by striking ‘‘$22,290,000,000’’ and inserting 
‘‘$0’’.