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(1) in clause (i)— 
(A) by inserting ‘‘(I)’’ after ‘‘(F)(i)’’ 
(B) in subclause (I), as inserted by sub-
paragraph (A)— 
(i) by striking ‘‘clause (ii)’’ and insert-
ing ‘‘subclause (II) and clause (ii)’’; and 
(ii) by striking ‘‘minus 1.0 percentage 
point’’; and 
(C) by adding at the end the following new 
subclause: 
‘‘(II) For 2012 and each subsequent year, after deter-
mining the increase factor described in subclause (I), the 
Secretary shall reduce such increase factor by the produc-
tivity 
adjustment 
described 
in 
section 
1886(b)(3)(B)(xi)(II). The application of the preceding sen-
tence may result in such increase factor being less than 0.0 
for a year, and may result in payment rates under the pay-
ment system under this paragraph for a year being less 
than such payment rates for the preceding year.’’; and 
(2) in clause (ii)(II)— 
(A) by striking ‘‘The’’ and inserting ‘‘Sub-
ject to clause (i)(II), the’’; and 
(B) by striking ‘‘clause (i) minus 1.0 per-
centage point’’ and inserting ‘‘clause (i)(I)’’.
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(i) OUTPATIENT HOSPITALS.—Section 1833(t)(3) of 
the Social Security Act (42 U.S.C. 1395l(t)(3)) is amend-
ed— 
(1) in subparagraph (C)(iv), by inserting ‘‘and 
subparagraph (F) of this paragraph’’ after ‘‘(17)’’; 
and 
(2) by adding at the end the following new sub-
paragraphs: 
‘‘(F) PRODUCTIVITY
AND
OTHER
ADJUST-
MENT.—After determining the OPD fee schedule 
increase factor under subparagraph (C)(iv), the 
Secretary shall reduce such increase factor— 
‘‘(i) for 2012 and subsequent years, by 
the productivity adjustment described in 
section 1886(b)(3)(B)(xi)(II); and 
‘‘(ii) for each of 2010 through 2019, by 
the adjustment described in subparagraph 
(G). 
The application of this subparagraph may result 
in the increase factor under subparagraph 
(C)(iv) being less than 0.0 for a year, and may 
result in payment rates under the payment sys-
tem under this subsection for a year being less 
than such payment rates for the preceding year. 
‘‘(G) OTHER ADJUSTMENT.—
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‘‘(i) ADJUSTMENT.—For purposes of 
subparagraph (F)(ii), the adjustment de-
scribed in this subparagraph is— 
‘‘(I) for each of 2010 and 2011, 
0.25 percentage point; and 
‘‘(II) subject to clause (ii), for 
each of 2012 through 2019, 0.2 percent-
age point. 
‘‘(ii) REDUCTION OF OTHER ADJUST-
MENT.—Clause (i)(II) shall be applied with 
respect to any of 2014 through 2019 by sub-
stituting ‘0.0 percentage points’ for ‘0.2 per-
centage point’, if for such year— 
‘‘(I) the excess (if any) of— 
‘‘(aa) the total percentage of 
the non-elderly insured popu-
lation for the preceding year 
(based on the most recent esti-
mates available from the Director 
of the Congressional Budget Office 
before a vote in either House on 
the Patient Protection and Afford-
able Care Act that, if determined 
in the affirmative, would clear 
such Act for enrollment); over
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‘‘(bb) the total percentage of 
the non-elderly insured popu-
lation for such preceding year (as 
estimated by the Secretary); ex-
ceeds 
‘‘(II) 5 percentage points.’’. 
(j) AMBULANCE SERVICES.—Section 1834(l)(3) of the 
Social Security Act (42 U.S.C. 1395m(l)(3)) is amended— 
(1) in subparagraph (A), by striking ‘‘and’’ at 
the end; 
(2) in subparagraph (B)— 
(A) by inserting ‘‘, subject to subparagraph 
(C) and the succeeding sentence of this para-
graph,’’ after ‘‘increased’’; and 
(B) by striking the period at the end and 
inserting ‘‘; and’’; 
(3) by adding at the end the following new sub-
paragraph: 
‘‘(C) for 2011 and each subsequent year, 
after determining the percentage increase under 
subparagraph (B) for the year, reduce such per-
centage increase by the productivity adjustment 
described in section 1886(b)(3)(B)(xi)(II).’’; and 
(4) by adding at the end the following flush sen-
tence:
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‘‘The application of subparagraph (C) may result in 
the percentage increase under subparagraph (B) being 
less than 0.0 for a year, and may result in payment 
rates under the fee schedule under this subsection for 
a year being less than such payment rates for the pre-
ceding year.’’. 
(k) AMBULATORY SURGICAL CENTER SERVICES.—Sec-
tion 1833(i)(2)(D) of the Social Security Act (42 U.S.C. 
1395l(i)(2)(D)) is amended— 
(1) by redesignating clause (v) as clause (vi); 
and 
(2) by inserting after clause (iv) the following 
new clause: 
‘‘(v) In implementing the system de-
scribed in clause (i) for 2011 and each sub-
sequent year, any annual update under 
such system for the year, after application 
of clause (iv), shall be reduced by the pro-
ductivity adjustment described in section 
1886(b)(3)(B)(xi)(II). The application of 
the preceding sentence may result in such 
update being less than 0.0 for a year, and 
may result in payment rates under the sys-
tem described in clause (i) for a year being
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less than such payment rates for the pre-
ceding year.’’. 
(l) LABORATORY SERVICES.—Section 1833(h)(2)(A) of 
the Social Security Act (42 U.S.C. 1395l(h)(2)(A)) is 
amended— 
(1) in clause (i)— 
(A) by inserting ‘‘, subject to clause (iv),’’ 
after ‘‘year) by’’; and 
(B) by striking ‘‘through 2013’’ and insert-
ing ‘‘and 2010’’; and 
(2) by adding at the end the following new 
clause: 
‘‘(iv) After determining the adjustment 
to the fee schedules under clause (i), the Sec-
retary shall reduce such adjustment— 
‘‘(I) for 2011 and each subsequent 
year, by the productivity adjustment 
described 
in 
section 
1886(b)(3)(B)(xi)(II); and 
‘‘(II) for each of 2011 through 
2015, by 1.75 percentage points. 
Subclause (I) shall not apply in a year 
where the adjustment to the fee schedules de-
termined under clause (i) is 0.0 or a per-
centage decrease for a year. The application
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‘‘(ii) the productivity adjustment de-
scribed in section 1886(b)(3)(B)(xi)(II).’’; 
and 
(3) by adding at the end the following flush sen-
tence: 
‘‘The application of subparagraph (L)(ii) may result 
in the covered item update under this paragraph 
being less than 0.0 for a year, and may result in pay-
ment rates under this subsection for a year being less 
than such payment rates for the preceding year.’’. 
(n) PROSTHETIC DEVICES, ORTHOTICS, AND PROS-
THETICS.—Section 1834(h)(4) of the Social Security Act 
(42 U.S.C. 1395m(h)(4)) is amended— 
(1) in subparagraph (A)— 
(A) in clause (ix), by striking ‘‘and’’ at the 
end; 
(B) in clause (x)— 
(i) by striking ‘‘a subsequent year’’ 
and inserting ‘‘for each of 2007 through 
2010’’; and 
(ii) by inserting ‘‘and’’ after the semi-
colon at the end; 
(C) by adding at the end the following new 
clause:
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‘‘(xi) for 2011 and each subsequent 
year— 
‘‘(I) the percentage increase in the 
consumer price index for all urban 
consumers (United States city average) 
for the 12-month period ending with 
June of the previous year, reduced 
by— 
‘‘(II) the productivity adjustment 
described 
in 
section 
1886(b)(3)(B)(xi)(II).’’; and 
(D) by adding at the end the following flush 
sentence: 
‘‘The application of subparagraph (A)(xi)(II) may re-
sult in the applicable percentage increase under sub-
paragraph (A) being less than 0.0 for a year, and 
may result in payment rates under this subsection for 
a year being less than such payment rates for the pre-
ceding year.’’. 
(o) OTHER ITEMS.—Section 1842(s)(1) of the Social 
Security Act (42 U.S.C. 1395u(s)(1)) is amended— 
(1) in the first sentence, by striking ‘‘Subject to’’ 
and inserting ‘‘(A) Subject to’’; 
(2) by striking the second sentence and inserting 
the following new subparagraph:
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‘‘(B) Any fee schedule established under this 
paragraph for such item or service shall be up-
dated— 
‘‘(i) for years before 2011— 
‘‘(I) subject to subclause (II), by 
the percentage increase in the con-
sumer price index for all urban con-
sumers (United States city average) for 
the 12-month period ending with June 
of the preceding year; and 
‘‘(II) for items and services de-
scribed in paragraph (2)(D) for 2009, 
section 
1834(a)(14)(J) 
shall 
apply 
under this paragraph instead of the 
percentage increase otherwise applica-
ble; and 
‘‘(ii) for 2011 and subsequent years— 
‘‘(I) the percentage increase in the 
consumer price index for all urban 
consumers (United States city average) 
for the 12-month period ending with 
June of the previous year, reduced 
by—
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‘‘(II) the productivity adjustment 
described 
in 
section 
1886(b)(3)(B)(xi)(II).’’; and 
(3) by adding at the end the following flush sen-
tence: 
‘‘The application of subparagraph (B)(ii)(II) may re-
sult in the update under this paragraph being less 
than 0.0 for a year, and may result in payment rates 
under any fee schedule established under this para-
graph for a year being less than such payment rates 
for the preceding year.’’. 
(p) NO APPLICATION PRIOR TO APRIL 1, 2010.—Not-
withstanding the preceding provisions of this section, the 
amendments made by subsections (a), (c), and (d) shall not 
apply to discharges occurring before April 1, 2010. 
SEC. 3402. TEMPORARY ADJUSTMENT TO THE CALCULA-
TION OF PART B PREMIUMS. 
Section 1839(i) of the Social Security Act (42 U.S.C. 
1395r(i)) is amended— 
(1) in paragraph (2), in the matter preceding 
subparagraph (A), by inserting ‘‘subject to paragraph 
(6),’’ after ‘‘subsection,’’; 
(2) in paragraph (3)(A)(i), by striking ‘‘The ap-
plicable’’ and inserting ‘‘Subject to paragraph (6), the 
applicable’’;
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(3) by redesignating paragraph (6) as para-
graph (7); and 
(4) by inserting after paragraph (5) the fol-
lowing new paragraph: 
‘‘(6) TEMPORARY
ADJUSTMENT
TO
INCOME 
THRESHOLDS.—Notwithstanding any other provision 
of this subsection, during the period beginning on 
January 1, 2011, and ending on December 31, 
2019— 
‘‘(A) the threshold amount otherwise appli-
cable under paragraph (2) shall be equal to such 
amount for 2010; and 
‘‘(B) the dollar amounts otherwise applica-
ble under paragraph (3)(C)(i) shall be equal to 
such dollar amounts for 2010.’’. 
SEC. 3403. INDEPENDENT MEDICARE ADVISORY BOARD. 
(a) BOARD.— 
(1) IN GENERAL.—Title XVIII of the Social Se-
curity Act (42 U.S.C. 1395 et seq.), as amended by 
section 3022, is amended by adding at the end the fol-
lowing new section: 
‘‘INDEPENDENT MEDICARE ADVISORY BOARD 
‘‘SEC. 1899A. (a) ESTABLISHMENT.—There is estab-
lished an independent board to be known as the ‘Inde-
pendent Medicare Advisory Board’.
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‘‘(b) PURPOSE.—It is the purpose of this section to, 
in accordance with the following provisions of this section, 
reduce the per capita rate of growth in Medicare spend-
ing— 
‘‘(1) by requiring the Chief Actuary of the Cen-
ters for Medicare & Medicaid Services to determine in 
each year to which this section applies (in this section 
referred to as ‘a determination year’) the projected 
per capita growth rate under Medicare for the second 
year following the determination year (in this section 
referred to as ‘an implementation year’); 
‘‘(2) if the projection for the implementation 
year exceeds the target growth rate for that year, by 
requiring the Board to develop and submit during the 
first year following the determination year (in this 
section referred to as ‘a proposal year’) a proposal 
containing recommendations to reduce the Medicare 
per capita growth rate to the extent required by this 
section; and 
‘‘(3) by requiring the Secretary to implement 
such proposals unless Congress enacts legislation pur-
suant to this section. 
‘‘(c) BOARD PROPOSALS.— 
‘‘(1) DEVELOPMENT.—
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(including deductibles, coinsurance, and co-
payments), or otherwise restrict benefits or 
modify eligibility criteria. 
‘‘(iii) In the case of proposals sub-
mitted prior to December 31, 2018, the pro-
posal shall not include any recommendation 
that would reduce payment rates for items 
and services furnished, prior to December 
31, 2019, by providers of services (as de-
fined in section 1861(u)) and suppliers (as 
defined in section 1861(d)) scheduled, pur-
suant to the amendments made by section 
3401 of the Patient Protection and Afford-
able Care Act, to receive a reduction to the 
inflationary payment updates of such pro-
viders of services and suppliers in excess of 
a reduction due to productivity in a year in 
which such recommendations would take ef-
fect. 
‘‘(iv) As appropriate, the proposal 
shall include recommendations to reduce 
Medicare payments under parts C and D, 
such as reductions in direct subsidy pay-
ments to Medicare Advantage and prescrip-
tion drug plans specified under paragraph
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(1) and (2) of section 1860D–15(a) that are 
related to administrative expenses (includ-
ing profits) for basic coverage, denying high 
bids or removing high bids for prescription 
drug coverage from the calculation of the 
national average monthly bid amount 
under section 1860D–13(a)(4), and reduc-
tions in payments to Medicare Advantage 
plans under clauses (i) and (ii) of section 
1853(a)(1)(B) that are related to adminis-
trative expenses (including profits) and per-
formance bonuses for Medicare Advantage 
plans under section 1853(n). Any such rec-
ommendation shall not affect the base bene-
ficiary premium percentage specified under 
1860D–13(a). 
‘‘(v) The proposal shall include rec-
ommendations with respect to administra-
tive funding for the Secretary to carry out 
the recommendations contained in the pro-
posal. 
‘‘(vi) The proposal shall only include 
recommendations related to the Medicare 
program.
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‘‘(B) ADDITIONAL CONSIDERATIONS.—In de-
veloping and submitting each proposal under 
this section in a proposal year, the Board shall, 
to the extent feasible— 
‘‘(i) give priority to recommendations 
that extend Medicare solvency; 
‘‘(ii) include recommendations that— 
‘‘(I) improve the health care deliv-
ery system and health outcomes, in-
cluding by promoting integrated care, 
care 
coordination, 
prevention 
and 
wellness, and quality and efficiency 
improvement; and 
‘‘(II) protect and improve Medi-
care beneficiaries’ access to necessary 
and evidence-based items and services, 
including in rural and frontier areas; 
‘‘(iii) include recommendations that 
target reductions in Medicare program 
spending to sources of excess cost growth; 
‘‘(iv) consider the effects on Medicare 
beneficiaries of changes in payments to pro-
viders of services (as defined in section 
1861(u)) and suppliers (as defined in sec-
tion 1861(d));
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‘‘(v) consider the effects of the rec-
ommendations on providers of services and 
suppliers with actual or projected negative 
cost margins or payment updates; and 
‘‘(vi) consider the unique needs of 
Medicare beneficiaries who are dually eligi-
ble for Medicare and the Medicaid program 
under title XIX. 
‘‘(C) NO
INCREASE
IN
TOTAL
MEDICARE 
PROGRAM SPENDING.—Each proposal submitted 
under this section shall be designed in such a 
manner that implementation of the recommenda-
tions contained in the proposal would not be ex-
pected to result, over the 10-year period starting 
with the implementation year, in any increase 
in the total amount of net Medicare program 
spending relative to the total amount of net 
Medicare program spending that would have oc-
curred absent such implementation. 
‘‘(D) CONSULTATION
WITH
MEDPAC.—The 
Board shall submit a draft copy of each proposal 
to be submitted under this section to the Medi-
care Payment Advisory Commission established 
under section 1805 for its review. The Board
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shall submit such draft copy by not later than 
September 1 of the determination year. 
‘‘(E) REVIEW AND COMMENT BY THE SEC-
RETARY.—The Board shall submit a draft copy 
of each proposal to be submitted to Congress 
under this section to the Secretary for the Sec-
retary’s review and comment. The Board shall 
submit such draft copy by not later than Sep-
tember 1 of the determination year. Not later 
than March 1 of the submission year, the Sec-
retary shall submit a report to Congress on the 
results of such review, unless the Secretary sub-
mits a proposal under paragraph (5)(A) in that 
year. 
‘‘(F) CONSULTATIONS.—In carrying out its 
duties under this section, the Board shall engage 
in regular consultations with the Medicaid and 
CHIP Payment and Access Commission under 
section 1900. 
‘‘(3) TRANSMISSION
OF
BOARD
PROPOSAL
TO 
PRESIDENT.— 
‘‘(A) IN GENERAL.— 
‘‘(i) IN GENERAL.—Except as provided 
in clause (ii) and subsection (f)(3)(B), the 
Board shall transmit a proposal under this
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HR 3590 EAS/PP 
section to the President on January 15 of 
each year (beginning with 2014). 
‘‘(ii) EXCEPTION.—The Board shall 
not submit a proposal under clause (i) in a 
proposal year if the year is— 
‘‘(I) a year for which the Chief 
Actuary of the Centers for Medicare & 
Medicaid Services makes a determina-
tion in the determination year under 
paragraph (6)(A) that the growth rate 
described in clause (i) of such para-
graph does not exceed the growth rate 
described in clause (ii) of such para-
graph; 
‘‘(II) a year in which the Chief 
Actuary of the Centers for Medicare & 
Medicaid Services makes a determina-
tion in the determination year that the 
projected percentage increase (if any) 
for the medical care expenditure cat-
egory of the Consumer Price Index for 
All Urban Consumers (United States 
city average) for the implementation 
year is less than the projected percent-
age increase (if any) in the Consumer
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Price Index for All Urban Consumers 
(all items; United States city average) 
for such implementation year; or 
‘‘(III) for proposal year 2019 and 
subsequent proposal years, a year in 
which the Chief Actuary of the Centers 
for Medicare & Medicaid Services 
makes a determination in the deter-
mination year that the growth rate de-
scribed in paragraph (8) exceeds the 
growth rate described in paragraph 
(6)(A)(i). 
‘‘(iii) START-UP PERIOD.—The Board 
may not submit a proposal under clause (i) 
prior to January 15, 2014. 
‘‘(B) REQUIRED INFORMATION.—Each pro-
posal submitted by the Board under subpara-
graph (A)(i) shall include— 
‘‘(i) the recommendations described in 
paragraph (2)(A)(i); 
‘‘(ii) an explanation of each rec-
ommendation contained in the proposal and 
the reasons for including such recommenda-
tion;
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‘‘(iii) an actuarial opinion by the 
Chief Actuary of the Centers for Medicare & 
Medicaid Services certifying that the pro-
posal meets the requirements of subpara-
graphs (A)(i) and (C) of paragraph (2); 
‘‘(iv) a legislative proposal that imple-
ments the recommendations; and 
‘‘(v) other information determined ap-
propriate by the Board. 
‘‘(4) 
PRESIDENTIAL
SUBMISSION
TO
CON-
GRESS.—Upon receiving a proposal from the Board 
under paragraph (3)(A)(i) or the Secretary under 
paragraph (5), the President shall immediately sub-
mit such proposal to Congress. 
‘‘(5) CONTINGENT
SECRETARIAL
DEVELOPMENT 
OF PROPOSAL.—If, with respect to a proposal year, 
the Board is required, to but fails, to submit a pro-
posal to the President by the deadline applicable 
under paragraph (3)(A)(i), the Secretary shall de-
velop a detailed and specific proposal that satisfies 
the requirements of subparagraphs (A) and (C) (and, 
to the extent feasible, subparagraph (B)) of paragraph 
(2) and contains the information required paragraph 
(3)(B)). By not later than January 25 of the year, 
the Secretary shall transmit—
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‘‘(A) such proposal to the President; and 
‘‘(B) a copy of such proposal to the Medi-
care Payment Advisory Commission for its re-
view. 
‘‘(6) PER CAPITA GROWTH RATE PROJECTIONS 
BY CHIEF ACTUARY.— 
‘‘(A) IN
GENERAL.—Subject to subsection 
(f)(3)(A), not later than April 30, 2013, and an-
nually thereafter, the Chief Actuary of the Cen-
ters for Medicare & Medicaid Services shall de-
termine in each such year whether— 
‘‘(i) the projected Medicare per capita 
growth rate for the implementation year (as 
determined under subparagraph (B)); ex-
ceeds 
‘‘(ii) the projected Medicare per capita 
target growth rate for the implementation 
year (as determined under subparagraph 
(C)). 
‘‘(B) MEDICARE
PER
CAPITA
GROWTH 
RATE.— 
‘‘(i) IN
GENERAL.—For purposes of 
this section, the Medicare per capita growth 
rate for an implementation year shall be 
calculated as the projected 5-year average
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(ending with such year) of the growth in 
Medicare 
program 
spending 
per 
unduplicated enrollee. 
‘‘(ii) REQUIREMENT.—The projection 
under clause (i) shall— 
‘‘(I) to the extent that there is 
projected to be a negative update to the 
single conversion factor applicable to 
payments 
for 
physicians’ 
services 
under section 1848(d) furnished in the 
proposal year or the implementation 
year, assume that such update for such 
services is 0 percent rather than the 
negative percent that would otherwise 
apply; and 
‘‘(II) take into account any deliv-
ery system reforms or other payment 
changes that have been enacted or pub-
lished in final rules but not yet imple-
mented as of the making of such cal-
culation. 
‘‘(C) 
MEDICARE
PER
CAPITA
TARGET 
GROWTH RATE.—For purposes of this section, the 
Medicare per capita target growth rate for an 
implementation year shall be calculated as the
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projected 5-year average (ending with such year) 
percentage increase in— 
‘‘(i) with respect to a determination 
year that is prior to 2018, the average of 
the projected percentage increase (if any) 
in— 
‘‘(I) the Consumer Price Index for 
All Urban Consumers (all items; 
United States city average); and 
‘‘(II) the medical care expenditure 
category of the Consumer Price Index 
for All Urban Consumers (United 
States city average); and 
‘‘(ii) with respect to a determination 
year that is after 2017, the nominal gross 
domestic product per capita plus 1.0 per-
centage point. 
‘‘(7) SAVINGS REQUIREMENT.— 
‘‘(A) IN GENERAL.—If, with respect to a de-
termination year, the Chief Actuary of the Cen-
ters for Medicare & Medicaid Services makes a 
determination under paragraph (6)(A) that the 
growth rate described in clause (i) of such para-
graph exceeds the growth rate described in clause 
(ii) of such paragraph, the Chief Actuary shall
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establish an applicable savings target for the im-
plementation year. 
‘‘(B) APPLICABLE
SAVINGS
TARGET.—For 
purposes of this section, the applicable savings 
target for an implementation year shall be an 
amount equal to the product of— 
‘‘(i) the total amount of projected 
Medicare program spending for the proposal 
year; and 
‘‘(ii) the applicable percent for the im-
plementation year. 
‘‘(C) APPLICABLE PERCENT.—For purposes 
of subparagraph (B), the applicable percent for 
an implementation year is the lesser of— 
‘‘(i) in the case of— 
‘‘(I) implementation year 2015, 
0.5 percent; 
‘‘(II) implementation year 2016, 
1.0 percent; 
‘‘(III) implementation year 2017, 
1.25 percent; and 
‘‘(IV) implementation year 2018 
or any subsequent implementation 
year, 1.5 percent; and
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‘‘(ii) the projected excess for the imple-
mentation year (expressed as a percent) de-
termined under subparagraph (A). 
‘‘(8) PER CAPITA RATE OF GROWTH IN NATIONAL 
HEALTH
EXPENDITURES.—In each determination 
year (beginning in 2018), the Chief Actuary of the 
Centers for Medicare & Medicaid Services shall 
project the per capita rate of growth in national 
health expenditures for the implementation year. 
Such rate of growth for an implementation year shall 
be calculated as the projected 5-year average (ending 
with such year) percentage increase in national 
health care expenditures. 
‘‘(d) CONGRESSIONAL CONSIDERATION.— 
‘‘(1) INTRODUCTION.— 
‘‘(A) IN GENERAL.—On the day on which a 
proposal is submitted by the President to the 
House of Representatives and the Senate under 
subsection (c)(4), the legislative proposal (de-
scribed in subsection (c)(3)(B)(iv)) contained in 
the proposal shall be introduced (by request) in 
the Senate by the majority leader of the Senate 
or by Members of the Senate designated by the 
majority leader of the Senate and shall be intro-
duced (by request) in the House by the majority
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leader of the House or by Members of the House 
designated by the majority leader of the House. 
‘‘(B) NOT IN SESSION.—If either House is 
not in session on the day on which such legisla-
tive proposal is submitted, the legislative pro-
posal shall be introduced in that House, as pro-
vided in subparagraph (A), on the first day 
thereafter on which that House is in session. 
‘‘(C) ANY MEMBER.—If the legislative pro-
posal is not introduced in either House within 5 
days on which that House is in session after the 
day on which the legislative proposal is sub-
mitted, then any Member of that House may in-
troduce the legislative proposal. 
‘‘(D) REFERRAL.—The legislation intro-
duced under this paragraph shall be referred by 
the Presiding Officers of the respective Houses to 
the Committee on Finance in the Senate and to 
the Committee on Energy and Commerce and the 
Committee on Ways and Means in the House of 
Representatives. 
‘‘(2) 
COMMITTEE
CONSIDERATION
OF
PRO-
POSAL.— 
‘‘(A) REPORTING
BILL.—Not later than 
April 1 of any proposal year in which a pro-
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posal is submitted by the President to Congress 
under this section, the Committee on Ways and 
Means and the Committee on Energy and Com-
merce of the House of Representatives and the 
Committee on Finance of the Senate may report 
the bill referred to the Committee under para-
graph (1)(D) with committee amendments re-
lated to the Medicare program. 
‘‘(B) 
CALCULATIONS.—In 
determining 
whether a committee amendment meets the re-
quirement of subparagraph (A), the reductions 
in Medicare program spending during the 3- 
month period immediately preceding the imple-
mentation year shall be counted to the extent 
that such reductions are a result of the imple-
mentation provisions in the committee amend-
ment for a change in the payment rate for an 
item or service that was effective during such pe-
riod pursuant to such amendment. 
‘‘(C) COMMITTEE JURISDICTION.—Notwith-
standing rule XV of the Standing Rules of the 
Senate, a committee amendment described in 
subparagraph (A) may include matter not with-
in the jurisdiction of the Committee on Finance
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if that matter is relevant to a proposal contained 
in the bill submitted under subsection (c)(3). 
‘‘(D) DISCHARGE.—If, with respect to the 
House involved, the committee has not reported 
the bill by the date required by subparagraph 
(A), the committee shall be discharged from fur-
ther consideration of the proposal. 
‘‘(3) LIMITATION ON CHANGES TO THE BOARD 
RECOMMENDATIONS.— 
‘‘(A) IN GENERAL.—It shall not be in order 
in the Senate or the House of Representatives to 
consider any bill, resolution, or amendment, pur-
suant to this subsection or conference report 
thereon, that fails to satisfy the requirements of 
subparagraphs (A)(i) and (C) of subsection 
(c)(2). 
‘‘(B) LIMITATION
ON
CHANGES
TO
THE 
BOARD RECOMMENDATIONS IN OTHER LEGISLA-
TION.—It shall not be in order in the Senate or 
the House of Representatives to consider any bill, 
resolution, amendment, or conference report 
(other than pursuant to this section) that would 
repeal or otherwise change the recommendations 
of the Board if that change would fail to satisfy
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the requirements of subparagraphs (A)(i) and 
(C) of subsection (c)(2). 
‘‘(C) LIMITATION
ON
CHANGES
TO
THIS 
SUBSECTION.—It shall not be in order in the 
Senate or the House of Representatives to con-
sider any bill, resolution, amendment, or con-
ference report that would repeal or otherwise 
change this subsection. 
‘‘(D) WAIVER.—This paragraph may be 
waived or suspended in the Senate only by the 
affirmative vote of three-fifths of the Members, 
duly chosen and sworn. 
‘‘(E) APPEALS.—An affirmative vote of 
three-fifths of the Members of the Senate, duly 
chosen and sworn, shall be required in the Sen-
ate to sustain an appeal of the ruling of the 
Chair on a point of order raised under this 
paragraph. 
‘‘(4) EXPEDITED PROCEDURE.— 
‘‘(A) CONSIDERATION.—A motion to pro-
ceed to the consideration of the bill in the Senate 
is not debatable. 
‘‘(B) AMENDMENT.— 
‘‘(i) TIME LIMITATION.—Debate in the 
Senate on any amendment to a bill under
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this section shall be limited to 1 hour, to be 
equally divided between, and controlled by, 
the mover and the manager of the bill, and 
debate on any amendment to an amend-
ment, debatable motion, or appeal shall be 
limited to 30 minutes, to be equally divided 
between, and controlled by, the mover and 
the manager of the bill, except that in the 
event the manager of the bill is in favor of 
any such amendment, motion, or appeal, 
the time in opposition thereto shall be con-
trolled by the minority leader or such lead-
er’s designee. 
‘‘(ii) GERMANE.—No amendment that 
is not germane to the provisions of such bill 
shall be received. 
‘‘(iii) ADDITIONAL TIME.—The leaders, 
or either of them, may, from the time under 
their control on the passage of the bill, allot 
additional time to any Senator during the 
consideration of any amendment, debatable 
motion, or appeal. 
‘‘(iv) AMENDMENT NOT IN ORDER.—It 
shall not be in order to consider an amend-
ment that would cause the bill to result in
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a net reduction in total Medicare program 
spending in the implementation year that is 
less than the applicable savings target estab-
lished under subsection (c)(7)(B) for such 
implementation year. 
‘‘(v) WAIVER
AND
APPEALS.—This 
paragraph may be waived or suspended in 
the Senate only by the affirmative vote of 
three-fifths of the Members, duly chosen and 
sworn. An affirmative vote of three-fifths of 
the Members of the Senate, duly chosen and 
sworn, shall be required in the Senate to 
sustain an appeal of the ruling of the Chair 
on a point of order raised under this sec-
tion. 
‘‘(C) 
CONSIDERATION
BY
THE
OTHER 
HOUSE.— 
‘‘(i) IN GENERAL.—The expedited pro-
cedures provided in this subsection for the 
consideration of a bill introduced pursuant 
to paragraph (1) shall not apply to such a 
bill that is received by one House from the 
other House if such a bill was not intro-
duced in the receiving House.
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‘‘(ii) BEFORE PASSAGE.—If a bill that 
is introduced pursuant to paragraph (1) is 
received by one House from the other House, 
after introduction but before disposition of 
such a bill in the receiving House, then the 
following shall apply: 
‘‘(I) The receiving House shall 
consider the bill introduced in that 
House through all stages of consider-
ation up to, but not including, pas-
sage. 
‘‘(II) The question on passage 
shall be put on the bill of the other 
House as amended by the language of 
the receiving House. 
‘‘(iii) AFTER PASSAGE.—If a bill in-
troduced pursuant to paragraph (1) is re-
ceived by one House from the other House, 
after such a bill is passed by the receiving 
House, then the vote on passage of the bill 
that originates in the receiving House shall 
be considered to be the vote on passage of 
the bill received from the other House as 
amended by the language of the receiving 
House.
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‘‘(iv) DISPOSITION.—Upon disposition 
of a bill introduced pursuant to paragraph 
(1) that is received by one House from the 
other House, it shall no longer be in order 
to consider the bill that originates in the re-
ceiving House. 
‘‘(v) LIMITATION.—Clauses (ii), (iii), 
and (iv) shall apply only to a bill received 
by one House from the other House if the 
bill— 
‘‘(I) is related only to the pro-
gram under this title; and 
‘‘(II) satisfies the requirements of 
subparagraphs (A)(i) and (C) of sub-
section (c)(2). 
‘‘(D) SENATE LIMITS ON DEBATE.— 
‘‘(i) IN GENERAL.—In the Senate, con-
sideration of the bill and on all debatable 
motions and appeals in connection there-
with shall not exceed a total of 30 hours, 
which shall be divided equally between the 
majority and minority leaders or their des-
ignees.
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‘‘(ii) MOTION TO FURTHER LIMIT DE-
BATE.—A motion to further limit debate on 
the bill is in order and is not debatable. 
‘‘(iii) MOTION OR APPEAL.—Any de-
batable motion or appeal is debatable for 
not to exceed 1 hour, to be divided equally 
between those favoring and those opposing 
the motion or appeal. 
‘‘(iv) FINAL
DISPOSITION.—After 30 
hours of consideration, the Senate shall pro-
ceed, without any further debate on any 
question, to vote on the final disposition 
thereof to the exclusion of all amendments 
not then pending before the Senate at that 
time and to the exclusion of all motions, ex-
cept a motion to table, or to reconsider and 
one quorum call on demand to establish the 
presence of a quorum (and motions required 
to establish a quorum) immediately before 
the final vote begins. 
‘‘(E) CONSIDERATION IN CONFERENCE.— 
‘‘(i) IN
GENERAL.—Consideration in 
the Senate and the House of Representatives 
on the conference report or any messages be-
tween Houses shall be limited to 10 hours,
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equally divided and controlled by the major-
ity and minority leaders of the Senate or 
their designees and the Speaker of the 
House of Representatives and the minority 
leader of the House of Representatives or 
their designees. 
‘‘(ii) TIME LIMITATION.—Debate in the 
Senate on any amendment under this sub-
paragraph shall be limited to 1 hour, to be 
equally divided between, and controlled by, 
the mover and the manager of the bill, and 
debate on any amendment to an amend-
ment, debatable motion, or appeal shall be 
limited to 30 minutes, to be equally divided 
between, and controlled by, the mover and 
the manager of the bill, except that in the 
event the manager of the bill is in favor of 
any such amendment, motion, or appeal, 
the time in opposition thereto shall be con-
trolled by the minority leader or such lead-
er’s designee. 
‘‘(iii) FINAL
DISPOSITION.—After 10 
hours of consideration, the Senate shall pro-
ceed, without any further debate on any 
question, to vote on the final disposition
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thereof to the exclusion of all motions not 
then pending before the Senate at that time 
or necessary to resolve the differences be-
tween the Houses and to the exclusion of all 
other motions, except a motion to table, or 
to reconsider and one quorum call on de-
mand to establish the presence of a quorum 
(and motions required to establish a 
quorum) immediately before the final vote 
begins. 
‘‘(iv) LIMITATION.—Clauses (i) through 
(iii) shall only apply to a conference report, 
message or the amendments thereto if the 
conference report, message, or an amend-
ment thereto— 
‘‘(I) is related only to the pro-
gram under this title; and 
‘‘(II) satisfies the requirements of 
subparagraphs (A)(i) and (C) of sub-
section (c)(2). 
‘‘(F) VETO.—If the President vetoes the bill 
debate on a veto message in the Senate under 
this subsection shall be 1 hour equally divided 
between the majority and minority leaders or 
their designees.
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‘‘(5) RULES OF THE SENATE AND HOUSE OF 
REPRESENTATIVES.—This subsection and subsection 
(f)(2) are enacted by Congress— 
‘‘(A) as an exercise of the rulemaking power 
of the Senate and the House of Representatives, 
respectively, and is deemed to be part of the rules 
of each House, respectively, but applicable only 
with respect to the procedure to be followed in 
that House in the case of bill under this section, 
and it supersedes other rules only to the extent 
that it is inconsistent with such rules; and 
‘‘(B) with full recognition of the constitu-
tional right of either House to change the rules 
(so far as they relate to the procedure of that 
House) at any time, in the same manner, and 
to the same extent as in the case of any other 
rule of that House. 
‘‘(e) IMPLEMENTATION OF PROPOSAL.— 
‘‘(1) IN GENERAL.—Notwithstanding any other 
provision of law, the Secretary shall, except as pro-
vided in paragraph (3), implement the recommenda-
tions contained in a proposal submitted by the Presi-
dent to Congress pursuant to this section on August 
15 of the year in which the proposal is so submitted. 
‘‘(2) APPLICATION.—
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‘‘(A) IN GENERAL.—A recommendation de-
scribed in paragraph (1) shall apply as follows: 
‘‘(i) In the case of a recommendation 
that is a change in the payment rate for an 
item or service under Medicare in which 
payment rates change on a fiscal year basis 
(or a cost reporting period basis that relates 
to a fiscal year), on a calendar year basis 
(or a cost reporting period basis that relates 
to a calendar year), or on a rate year basis 
(or a cost reporting period basis that relates 
to a rate year), such recommendation shall 
apply to items and services furnished on the 
first day of the first fiscal year, calendar 
year, or rate year (as the case may be) that 
begins after such August 15. 
‘‘(ii) In the case of a recommendation 
relating to payments to plans under parts 
C and D, such recommendation shall apply 
to plan years beginning on the first day of 
the first calendar year that begins after 
such August 15. 
‘‘(iii) In the case of any other rec-
ommendation, such recommendation shall 
be addressed in the regular regulatory proc-
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ess timeframe and shall apply as soon as 
practicable. 
‘‘(B) INTERIM
FINAL
RULEMAKING.—The 
Secretary may use interim final rulemaking to 
implement any recommendation described in 
paragraph (1). 
‘‘(3) EXCEPTION.—The Secretary shall not be re-
quired to implement the recommendations contained 
in a proposal submitted in a proposal year by the 
President to Congress pursuant to this section if— 
‘‘(A) prior to August 15 of the proposal 
year, Federal legislation is enacted that includes 
the following provision: ‘This Act supercedes the 
recommendations of the Board contained in the 
proposal submitted, in the year which includes 
the date of enactment of this Act, to Congress 
under section 1899A of the Social Security Act.’; 
and 
‘‘(B) in the case of implementation year 
2020 and subsequent implementation years, a 
joint resolution described in subsection (f)(1) is 
enacted not later than August 15, 2017. 
‘‘(4) NO AFFECT ON AUTHORITY TO IMPLEMENT 
CERTAIN
PROVISIONS.—Nothing in paragraph (3) 
shall be construed to affect the authority of the Sec-
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retary to implement any recommendation contained 
in a proposal or advisory report under this section to 
the extent that the Secretary otherwise has the author-
ity to implement such recommendation administra-
tively. 
‘‘(5) LIMITATION ON REVIEW.—There shall be no 
administrative or judicial review under section 1869, 
section 1878, or otherwise of the implementation by 
the Secretary under this subsection of the rec-
ommendations contained in a proposal. 
‘‘(f) JOINT RESOLUTION REQUIRED TO DISCONTINUE 
THE BOARD.— 
‘‘(1) IN GENERAL.—For purposes of subsection 
(e)(3)(B), a joint resolution described in this para-
graph means only a joint resolution— 
‘‘(A) that is introduced in 2017 by not later 
than February 1 of such year; 
‘‘(B) which does not have a preamble; 
‘‘(C) the title of which is as follows: ‘Joint 
resolution approving the discontinuation of the 
process for consideration and automatic imple-
mentation of the annual proposal of the Inde-
pendent Medicare Advisory Board under section 
1899A of the Social Security Act’; and
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‘‘(D) the matter after the resolving clause of 
which is as follows: ‘That Congress approves the 
discontinuation of the process for consideration 
and automatic implementation of the annual 
proposal of the Independent Medicare Advisory 
Board under section 1899A of the Social Secu-
rity Act.’. 
‘‘(2) PROCEDURE.— 
‘‘(A) REFERRAL.—A joint resolution de-
scribed in paragraph (1) shall be referred to the 
Committee on Ways and Means and the Com-
mittee on Energy and Commerce of the House of 
Representatives and the Committee on Finance 
of the Senate. 
‘‘(B) DISCHARGE.—In the Senate, if the 
committee to which is referred a joint resolution 
described in paragraph (1) has not reported such 
joint resolution (or an identical joint resolution) 
at the end of 20 days after the joint resolution 
described in paragraph (1) is introduced, such 
committee may be discharged from further con-
sideration of such joint resolution upon a peti-
tion supported in writing by 30 Members of the 
Senate, and such joint resolution shall be placed 
on the calendar.
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‘‘(C) CONSIDERATION.— 
‘‘(i) IN
GENERAL.—In the Senate, 
when the committee to which a joint resolu-
tion is referred has reported, or when a 
committee is discharged (under subpara-
graph (C)) from further consideration of a 
joint resolution described in paragraph (1), 
it is at any time thereafter in order (even 
though a previous motion to the same effect 
has been disagreed to) for a motion to pro-
ceed to the consideration of the joint resolu-
tion to be made, and all points of order 
against the joint resolution (and against 
consideration of the joint resolution) are 
waived, except for points of order under the 
Congressional Budget act of 1974 or under 
budget resolutions pursuant to that Act. The 
motion is not debatable. A motion to recon-
sider the vote by which the motion is agreed 
to or disagreed to shall not be in order. If 
a motion to proceed to the consideration of 
the joint resolution is agreed to, the joint 
resolution shall remain the unfinished busi-
ness of the Senate until disposed of.
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‘‘(ii) DEBATE
LIMITATION.—In the 
Senate, consideration of the joint resolution, 
and on all debatable motions and appeals 
in connection therewith, shall be limited to 
not more than 10 hours, which shall be di-
vided equally between the majority leader 
and the minority leader, or their designees. 
A motion further to limit debate is in order 
and not debatable. An amendment to, or a 
motion to postpone, or a motion to proceed 
to the consideration of other business, or a 
motion to recommit the joint resolution is 
not in order. 
‘‘(iii) PASSAGE.—In the Senate, imme-
diately following the conclusion of the de-
bate on a joint resolution described in para-
graph (1), and a single quorum call at the 
conclusion of the debate if requested in ac-
cordance with the rules of the Senate, the 
vote on passage of the joint resolution shall 
occur. 
‘‘(iv) APPEALS.—Appeals from the de-
cisions of the Chair relating to the applica-
tion of the rules of the Senate to the proce-
dure relating to a joint resolution described
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in paragraph (1) shall be decided without 
debate. 
‘‘(D) OTHER HOUSE ACTS FIRST.—If, before 
the passage by 1 House of a joint resolution of 
that House described in paragraph (1), that 
House receives from the other House a joint reso-
lution described in paragraph (1), then the fol-
lowing procedures shall apply: 
‘‘(i) The joint resolution of the other 
House shall not be referred to a committee. 
‘‘(ii) With respect to a joint resolution 
described in paragraph (1) of the House re-
ceiving the joint resolution— 
‘‘(I) the procedure in that House 
shall be the same as if no joint resolu-
tion had been received from the other 
House; but 
‘‘(II) the vote on final passage 
shall be on the joint resolution of the 
other House. 
‘‘(E) EXCLUDED DAYS.—For purposes of de-
termining the period specified in subparagraph 
(B), there shall be excluded any days either 
House of Congress is adjourned for more than 3 
days during a session of Congress.
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‘‘(F) MAJORITY
REQUIRED
FOR
ADOP-
TION.—A joint resolution considered under this 
subsection shall require an affirmative vote of 
three-fifths of the Members, duly chosen and 
sworn, for adoption. 
‘‘(3) TERMINATION.—If a joint resolution de-
scribed in paragraph (1) is enacted not later than 
August 15, 2017— 
‘‘(A) the Chief Actuary of the Medicare & 
Medicaid Services shall not— 
‘‘(i) make any determinations under 
subsection (c)(6) after May 1, 2017; or 
‘‘(ii) provide any opinion pursuant to 
subsection (c)(3)(B)(iii) after January 16, 
2018; 
‘‘(B) the Board shall not submit any pro-
posals or advisory reports to Congress under this 
section after January 16, 2018; and 
‘‘(C) the Board and the consumer advisory 
council under subsection (k) shall terminate on 
August 16, 2018. 
‘‘(g) BOARD MEMBERSHIP; TERMS OF OFFICE; CHAIR-
PERSON; REMOVAL.— 
‘‘(1) MEMBERSHIP.—
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‘‘(A) IN
GENERAL.—The Board shall be 
composed of— 
‘‘(i) 15 members appointed by the 
President, by and with the advice and con-
sent of the Senate; and 
‘‘(ii) the Secretary, the Administrator 
of the Center for Medicare & Medicaid Serv-
ices, and the Administrator of the Health 
Resources and Services Administration, all 
of whom shall serve ex officio as nonvoting 
members of the Board. 
‘‘(B) QUALIFICATIONS.— 
‘‘(i) 
IN
GENERAL.—The 
appointed 
membership of the Board shall include indi-
viduals with national recognition for their 
expertise in health finance and economics, 
actuarial science, health facility manage-
ment, health plans and integrated delivery 
systems, reimbursement of health facilities, 
allopathic and osteopathic physicians, and 
other providers of health services, and other 
related fields, who provide a mix of different 
professionals, broad geographic representa-
tion, and a balance between urban and 
rural representatives.
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‘‘(ii) 
INCLUSION.—The 
appointed 
membership of the Board shall include (but 
not be limited to) physicians and other 
health professionals, experts in the area of 
pharmaco-economics or prescription drug 
benefit programs, employers, third-party 
payers, individuals skilled in the conduct 
and interpretation of biomedical, health 
services, and health economics research and 
expertise in outcomes and effectiveness re-
search and technology assessment. Such 
membership shall also include representa-
tives of consumers and the elderly. 
‘‘(iii) MAJORITY NONPROVIDERS.—In-
dividuals who are directly involved in the 
provision or management of the delivery of 
items and services covered under this title 
shall not constitute a majority of the ap-
pointed membership of the Board. 
‘‘(C) ETHICAL DISCLOSURE.—The President 
shall establish a system for public disclosure by 
appointed members of the Board of financial and 
other potential conflicts of interest relating to 
such members. Appointed members of the Board 
shall be treated as officers in the executive
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the annual rate of basic pay prescribed for level III 
of the Executive Schedule under section 5315 of title 
5, United States Code. The Chairperson shall be com-
pensated at a rate equal to the daily equivalent of the 
annual rate of basic pay prescribed for level II of the 
Executive Schedule under section 5315 of title 5, 
United States Code. 
‘‘(2) TRAVEL EXPENSES.—The appointed mem-
bers shall be allowed travel expenses, including per 
diem in lieu of subsistence, at rates authorized for 
employees of agencies under subchapter I of chapter 
57 of title 5, United States Code, while away from 
their homes or regular places of business in the per-
formance of services for the Board. 
‘‘(3) STAFF.— 
‘‘(A) IN GENERAL.—The Chairperson may, 
without regard to the civil service laws and regu-
lations, appoint and terminate an executive di-
rector and such other additional personnel as 
may be necessary to enable the Board to perform 
its duties. The employment of an executive direc-
tor shall be subject to confirmation by the Board. 
‘‘(B) 
COMPENSATION.—The 
Chairperson 
may fix the compensation of the executive direc-
tor and other personnel without regard to chap-
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‘‘(i) the implementation of a national 
application of Intensive Care Unit improve-
ment projects relating to the adult (includ-
ing geriatric), pediatric, and neonatal pa-
tient populations; 
‘‘(ii) practical methods for addressing 
health care associated infections, including 
Methicillin-Resistant Staphylococcus Aureus 
and Vancomycin-Resistant Entercoccus in-
fections and other emerging infections; and 
‘‘(iii) practical methods for reducing 
preventable hospital admissions and re-
admissions; 
‘‘(G) expand demonstration projects for im-
proving the quality of children’s health care and 
the use of health information technology, such as 
through 
Pediatric 
Quality 
Improvement 
Collaboratives and Learning Networks, consistent 
with provisions of section 1139A of the Social 
Security Act for assessing and improving qual-
ity, where applicable; 
‘‘(H) identify and mitigate hazards by— 
‘‘(i) analyzing events reported to pa-
tient safety reporting systems and patient 
safety organizations; and
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or contract. Such non-Federal matching funds may be pro-
vided directly or through donations from public or private 
entities and may be in cash or in-kind, fairly evaluated, 
including plant, equipment, or services. 
‘‘(e) EVALUATION.— 
‘‘(1) IN GENERAL.—The Director shall evaluate 
the performance of each entity that receives a grant 
or contract under this section. The evaluation of an 
entity shall include a study of— 
‘‘(A) the success of such entity in achieving 
the implementation, by the health care institu-
tions and providers assisted by such entity, of 
the models and practices identified in the re-
search conducted by the Center under section 
933; 
‘‘(B) the perception of the health care insti-
tutions and providers assisted by such entity re-
garding the value of the entity; and 
‘‘(C) where practicable, better patient health 
outcomes and lower cost resulting from the as-
sistance provided by such entity. 
‘‘(2) EFFECT
OF
EVALUATION.—Based on the 
outcome of the evaluation of the entity under para-
graph (1), the Director shall determine whether to