Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Medicare Access and CHIP Reauthorization Act of 
2015’’. 
(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
TITLE I—SGR REPEAL AND MEDICARE PROVIDER PAYMENT 
MODERNIZATION 
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. Empowering beneficiary choices through continued access to informa-
tion on physicians’ services. 
Sec. 105. Expanding availability of Medicare data. 
Sec. 106. Reducing administrative burden and other provisions. 
TITLE II—MEDICARE AND OTHER HEALTH EXTENDERS 
Subtitle A—Medicare Extenders 
Sec. 201. Extension of work GPCI floor. 
Sec. 202. Extension of therapy cap exceptions process. 
Sec. 203. Extension of ambulance add-ons. 
Sec. 204. Extension of increased inpatient hospital payment adjustment for cer-
tain low-volume hospitals. 
Sec. 205. Extension of the Medicare-dependent hospital (MDH) program. 
Sec. 206. Extension for specialized Medicare Advantage plans for special needs 
individuals. 
Sec. 207. Extension of funding for quality measure endorsement, input, and se-
lection. 
Sec. 208. Extension of funding outreach and assistance for low-income pro-
grams. 
Sec. 209. Extension and transition of reasonable cost reimbursement contracts. 
Sec. 210. Extension of home health rural add-on. 
Subtitle B—Other Health Extenders 
Sec. 211. Permanent extension of the qualifying individual (QI) program. 
Sec. 212. Permanent extension of transitional medical assistance (TMA).
Sec. 213. Extension of special diabetes program for type I diabetes and for In-
dians. 
Sec. 214. Extension of abstinence education. 
Sec. 215. Extension of personal responsibility education program (PREP). 
Sec. 216. Extension of funding for family-to-family health information centers. 
Sec. 217. Extension of health workforce demonstration project for low-income 
individuals. 
Sec. 218. Extension of maternal, infant, and early childhood home visiting pro-
grams. 
Sec. 219. Tennessee DSH allotment for fiscal years 2015 through 2025. 
Sec. 220. Delay in effective date for Medicaid amendments relating to bene-
ficiary liability settlements. 
Sec. 221. Extension of funding for community health centers, the National 
Health Service Corps, and teaching health centers. 
TITLE III—CHIP 
Sec. 301. 2-year extension of the Children’s Health Insurance Program. 
Sec. 302. Extension of express lane eligibility. 
Sec. 303. Extension of outreach and enrollment program. 
Sec. 304. Extension of certain programs and demonstration projects. 
Sec. 305. Report of Inspector General of HHS on use of express lane option 
under Medicaid and CHIP. 
TITLE IV—OFFSETS 
Subtitle A—Medicare Beneficiary Reforms 
Sec. 401. Limitation on certain medigap policies for newly eligible Medicare 
beneficiaries. 
Sec. 402. Income-related premium adjustment for parts B and D. 
Subtitle B—Other Offsets 
Sec. 411. Medicare payment updates for post-acute providers. 
Sec. 412. Delay of reduction to Medicaid DSH allotments. 
Sec. 413. Levy on delinquent providers. 
Sec. 414. Adjustments to inpatient hospital payment rates. 
TITLE V—MISCELLANEOUS 
Subtitle A—Protecting the Integrity of Medicare 
Sec. 501. Prohibition of inclusion of Social Security account numbers on Medi-
care cards. 
Sec. 502. Preventing wrongful Medicare payments for items and services fur-
nished to incarcerated individuals, individuals not lawfully 
present, and deceased individuals. 
Sec. 503. Consideration of measures regarding Medicare beneficiary smart 
cards. 
Sec. 504. Modifying Medicare durable medical equipment face-to-face encounter 
documentation requirement. 
Sec. 505. Reducing improper Medicare payments. 
Sec. 506. Improving senior Medicare patrol and fraud reporting rewards. 
Sec. 507. Requiring valid prescriber National Provider Identifiers on pharmacy 
claims. 
Sec. 508. Option to receive Medicare Summary Notice electronically.
Sec. 509. Renewal of MAC contracts. 
Sec. 510. Study on pathway for incentives to States for State participation in 
medicaid data match program. 
Sec. 511. Guidance on application of Common Rule to clinical data registries. 
Sec. 512. Eliminating certain civil money penalties; gainsharing study and re-
port. 
Sec. 513. Modification of Medicare home health surety bond condition of par-
ticipation requirement. 
Sec. 514. Oversight of Medicare coverage of manual manipulation of the spine 
to correct subluxation. 
Sec. 515. National expansion of prior authorization model for repetitive sched-
uled non-emergent ambulance transport. 
Sec. 516. Repealing duplicative Medicare secondary payor provision. 
Sec. 517. Plan for expanding data in annual CERT report. 
Sec. 518. Removing funds for Medicare Improvement Fund added by IMPACT 
Act of 2014. 
Sec. 519. Rule of construction. 
Subtitle B—Other Provisions 
Sec. 521. Extension of two-midnight PAMA rules on certain medical review ac-
tivities. 
Sec. 522. Requiring bid surety bonds and State licensure for entities submitting 
bids under the Medicare DMEPOS competitive acquisition pro-
gram. 
Sec. 523. Payment for global surgical packages. 
Sec. 524. Extension of Secure Rural Schools and Community Self-Determina-
tion Act of 2000. 
Sec. 525. Exclusion from PAYGO scorecards. 
TITLE 
I—SGR 
REPEAL 
AND 
MEDICARE 
PROVIDER 
PAY-
MENT MODERNIZATION 
SEC. 101. REPEALING THE SUSTAINABLE GROWTH RATE 
(SGR) AND IMPROVING MEDICARE PAYMENT 
FOR PHYSICIANS’ SERVICES. 
(a) STABILIZING FEE UPDATES.— 
(1) REPEAL
OF
SGR
PAYMENT
METHOD-
OLOGY.—Section 1848 of the Social Security Act 
(42 U.S.C. 1395w–4) is amended— 
(A) in subsection (d)— 
(i) in paragraph (1)(A)—
(I) by inserting ‘‘and ending with 
2025’’ after ‘‘beginning with 2001’’; 
and 
(II) by inserting ‘‘or a subse-
quent paragraph’’ after ‘‘paragraph 
(4)’’; and 
(ii) in paragraph (4)— 
(I) in the heading, by inserting 
‘‘AND
ENDING
WITH
2014’’ after 
‘‘YEARS BEGINNING WITH 2001’’; and 
(II) in subparagraph (A), by in-
serting ‘‘and ending with 2014’’ after 
‘‘a year beginning with 2001’’; and 
(B) in subsection (f)— 
(i) in paragraph (1)(B), by inserting 
‘‘through 2014’’ after ‘‘of each succeeding 
year’’; and 
(ii) in paragraph (2), in the matter 
preceding subparagraph (A), by inserting 
‘‘and ending with 2014’’ after ‘‘beginning 
with 2000’’. 
(2) UPDATE OF RATES FOR 2015 AND SUBSE-
QUENT YEARS.—Subsection (d) of section 1848 of 
the Social Security Act (42 U.S.C. 1395w–4) is 
amended—
(A) in paragraph (1)(A), by adding at the 
end the following: ‘‘There shall be two separate 
conversion factors for each year beginning with 
2026, one for items and services furnished by 
a qualifying APM participant (as defined in 
section 1833(z)(2)) (referred to in this sub-
section as the ‘qualifying APM conversion fac-
tor’) and the other for other items and services 
(referred to in this subsection as the ‘nonquali-
fying APM conversion factor’), equal to the re-
spective conversion factor for the previous year 
(or, in the case of 2026, equal to the single con-
version factor for 2025) multiplied by the up-
date established under paragraph (20) for such 
respective conversion factor for such year.’’; 
(B) in paragraph (1)(D), by inserting ‘‘(or, 
beginning with 2026, applicable conversion fac-
tor)’’ after ‘‘single conversion factor’’; and 
(C) by striking paragraph (16) and insert-
ing the following new paragraphs: 
‘‘(16) UPDATE FOR JANUARY THROUGH JUNE 
OF
2015.—Subject to paragraphs (7)(B), (8)(B), 
(9)(B), (10)(B), (11)(B), (12)(B), (13)(B), (14)(B), 
and (15)(B), in lieu of the update to the single con-
version factor established in paragraph (1)(C) that
would otherwise apply for 2015 for the period begin-
ning on January 1, 2015, and ending on June 30, 
2015, the update to the single conversion factor 
shall be 0.0 percent. 
‘‘(17) UPDATE FOR JULY THROUGH DECEMBER 
OF 2015.—The update to the single conversion factor 
established in paragraph (1)(C) for the period begin-
ning on July 1, 2015, and ending on December 31, 
2015, shall be 0.5 percent. 
‘‘(18) UPDATE FOR 2016 THROUGH 2019.—The 
update to the single conversion factor established in 
paragraph (1)(C) for 2016 and each subsequent 
year through 2019 shall be 0.5 percent. 
‘‘(19) UPDATE FOR 2020 THROUGH 2025.—The 
update to the single conversion factor established in 
paragraph (1)(C) for 2020 and each subsequent 
year through 2025 shall be 0.0 percent. 
‘‘(20) UPDATE
FOR
2026
AND
SUBSEQUENT 
YEARS.—For 2026 and each subsequent year, the 
update to the qualifying APM conversion factor es-
tablished under paragraph (1)(A) is 0.75 percent, 
and the update to the nonqualifying APM conversion 
factor established under such paragraph is 0.25 per-
cent.’’. 
(3) MEDPAC REPORTS.—
(A) INITIAL REPORT.—Not later than July 
1, 2017, the Medicare Payment Advisory Com-
mission shall submit to Congress a report on 
the relationship between— 
(i) physician and other health profes-
sional utilization and expenditures (and the 
rate of increase of such utilization and ex-
penditures) of items and services for which 
payment is made under section 1848 of the 
Social Security Act (42 U.S.C. 1395w–4); 
and 
(ii) total utilization and expenditures 
(and the rate of increase of such utilization 
and expenditures) under parts A, B, and D 
of title XVIII of such Act. 
Such report shall include a methodology to de-
scribe such relationship and the impact of 
changes in such physician and other health pro-
fessional practice and service ordering patterns 
on total utilization and expenditures under 
parts A, B, and D of such title. 
(B) FINAL REPORT.—Not later than July 
1, 2021, the Medicare Payment Advisory Com-
mission shall submit to Congress a report on 
the relationship described in subparagraph (A),
including the results determined from applying 
the methodology included in the report sub-
mitted under such subparagraph. 
(C) REPORT ON UPDATE TO PHYSICIANS’ 
SERVICES UNDER MEDICARE.—Not later than 
July 1, 2019, the Medicare Payment Advisory 
Commission shall submit to Congress a report 
on— 
(i) the payment update for profes-
sional services applied under the Medicare 
program under title XVIII of the Social 
Security Act for the period of years 2015 
through 2019; 
(ii) the effect of such update on the 
efficiency, economy, and quality of care 
provided under such program; 
(iii) the effect of such update on en-
suring a sufficient number of providers to 
maintain access to care by Medicare bene-
ficiaries; and 
(iv) recommendations for any future 
payment updates for professional services 
under such program to ensure adequate 
access to care is maintained for Medicare 
beneficiaries.
(b) CONSOLIDATION
OF CERTAIN CURRENT LAW 
PERFORMANCE PROGRAMS WITH NEW MERIT-BASED IN-
CENTIVE PAYMENT SYSTEM.— 
(1) EHR MEANINGFUL USE INCENTIVE PRO-
GRAM.— 
(A) SUNSETTING SEPARATE MEANINGFUL 
USE
PAYMENT
ADJUSTMENTS.—Section 
1848(a)(7)(A) of the Social Security Act (42 
U.S.C. 1395w–4(a)(7)(A)) is amended— 
(i) in clause (i), by striking ‘‘2015 or 
any subsequent payment year’’ and insert-
ing ‘‘each of 2015 through 2018’’; 
(ii) in clause (ii)(III), by striking 
‘‘each subsequent year’’ and inserting 
‘‘2018’’; and 
(iii) in clause (iii)— 
(I) in the heading, by striking 
‘‘AND SUBSEQUENT YEARS’’; 
(II) by striking ‘‘and each subse-
quent year’’; and 
(III) by striking ‘‘, but in no case 
shall the applicable percent be less 
than 95 percent’’. 
(B) CONTINUATION OF MEANINGFUL USE 
DETERMINATIONS
FOR
MIPS.—Section
1848(o)(2) of the Social Security Act (42 
U.S.C. 1395w–4(o)(2)) is amended— 
(i) in subparagraph (A), in the matter 
preceding clause (i)— 
(I) by striking ‘‘For purposes of 
paragraph (1), an’’ and inserting 
‘‘An’’; and 
(II) by inserting ‘‘, or pursuant 
to subparagraph (D) for purposes of 
subsection (q), for a performance pe-
riod under such subsection for a year’’ 
after ‘‘under such subsection for a 
year’’; and 
(ii) by adding at the end the following 
new subparagraph: 
‘‘(D) CONTINUED APPLICATION FOR PUR-
POSES
OF
MIPS.—With respect to 2019 and 
each subsequent payment year, the Secretary 
shall, for purposes of subsection (q) and in ac-
cordance with paragraph (1)(F) of such sub-
section, determine whether an eligible profes-
sional who is a MIPS eligible professional (as 
defined in subsection (q)(1)(C)) for such year is 
a meaningful EHR user under this paragraph
for the performance period under subsection (q) 
for such year.’’. 
(2) QUALITY REPORTING.— 
(A) SUNSETTING SEPARATE QUALITY RE-
PORTING
INCENTIVES.—Section 1848(a)(8)(A) 
of the Social Security Act (42 U.S.C. 1395w– 
4(a)(8)(A)) is amended— 
(i) in clause (i), by striking ‘‘2015 or 
any subsequent year’’ and inserting ‘‘each 
of 2015 through 2018’’; and 
(ii) in clause (ii)(II), by striking ‘‘and 
each subsequent year’’ and inserting ‘‘, 
2017, and 2018’’. 
(B) CONTINUATION
OF
QUALITY
MEAS-
URES
AND
PROCESSES
FOR
MIPS.—Section 
1848 of the Social Security Act (42 U.S.C. 
1395w–4) is amended— 
(i) in subsection (k), by adding at the 
end the following new paragraph: 
‘‘(9) CONTINUED APPLICATION FOR PURPOSES 
OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN-
TEERING TO REPORT.—The Secretary shall, in ac-
cordance with subsection (q)(1)(F), carry out the 
provisions of this subsection— 
‘‘(A) for purposes of subsection (q); and
‘‘(B) for eligible professionals who are not 
MIPS eligible professionals (as defined in sub-
section (q)(1)(C)) for the year involved.’’; and 
(ii) in subsection (m)— 
(I) by redesignating paragraph 
(7) added by section 10327(a) of Pub-
lic Law 111–148 as paragraph (8); 
and 
(II) by adding at the end the fol-
lowing new paragraph: 
‘‘(9) CONTINUED APPLICATION FOR PURPOSES 
OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN-
TEERING TO REPORT.—The Secretary shall, in ac-
cordance with subsection (q)(1)(F), carry out the 
processes under this subsection— 
‘‘(A) for purposes of subsection (q); and 
‘‘(B) for eligible professionals who are not 
MIPS eligible professionals (as defined in sub-
section (q)(1)(C)) for the year involved.’’. 
(3) VALUE-BASED PAYMENTS.— 
(A) SUNSETTING SEPARATE VALUE-BASED 
PAYMENTS.—Clause 
(iii) 
of 
section 
1848(p)(4)(B) of the Social Security Act (42 
U.S.C. 1395w–4(p)(4)(B)) is amended to read 
as follows:
‘‘(iii) APPLICATION.—The Secretary 
shall apply the payment modifier estab-
lished under this subsection for items and 
services furnished on or after January 1, 
2015, with respect to specific physicians 
and groups of physicians the Secretary de-
termines appropriate, and for services fur-
nished on or after January 1, 2017, with 
respect to all physicians and groups of 
physicians. Such payment modifier shall 
not be applied for items and services fur-
nished on or after January 1, 2019.’’. 
(B) CONTINUATION OF VALUE-BASED PAY-
MENT MODIFIER MEASURES FOR MIPS.—Section 
1848(p) of the Social Security Act (42 U.S.C. 
1395w–4(p)) is amended— 
(i) in paragraph (2), by adding at the 
end the following new subparagraph: 
‘‘(C) CONTINUED APPLICATION FOR PUR-
POSES OF MIPS.—The Secretary shall, in ac-
cordance with subsection (q)(1)(F), carry out 
subparagraph (B) for purposes of subsection 
(q).’’; and 
(ii) in paragraph (3), by adding at the 
end the following: ‘‘With respect to 2019
and each subsequent year, the Secretary 
shall, 
in 
accordance 
with 
subsection 
(q)(1)(F), carry out this paragraph for 
purposes of subsection (q).’’. 
(c) MERIT-BASED INCENTIVE PAYMENT SYSTEM.— 
(1) IN GENERAL.—Section 1848 of the Social 
Security Act (42 U.S.C. 1395w–4) is amended by 
adding at the end the following new subsection: 
‘‘(q) MERIT-BASED INCENTIVE PAYMENT SYSTEM.— 
‘‘(1) ESTABLISHMENT.— 
‘‘(A) IN
GENERAL.—Subject to the suc-
ceeding provisions of this subsection, the Sec-
retary shall establish an eligible professional 
Merit-based Incentive Payment System (in this 
subsection referred to as the ‘MIPS’) under 
which the Secretary shall— 
‘‘(i) develop a methodology for assess-
ing the total performance of each MIPS el-
igible professional according to perform-
ance standards under paragraph (3) for a 
performance period (as established under 
paragraph (4)) for a year; 
‘‘(ii) using such methodology, provide 
for a composite performance score in ac-
cordance with paragraph (5) for each such
professional for each performance period; 
and 
‘‘(iii) use such composite performance 
score of the MIPS eligible professional for 
a performance period for a year to deter-
mine and apply a MIPS adjustment factor 
(and, as applicable, an additional MIPS 
adjustment factor) under paragraph (6) to 
the professional for the year. 
Notwithstanding subparagraph (C)(ii), under 
the MIPS, the Secretary shall permit any eligi-
ble professional (as defined in subsection 
(k)(3)(B)) to report on applicable measures and 
activities described in paragraph (2)(B). 
‘‘(B) PROGRAM
IMPLEMENTATION.—The 
MIPS shall apply to payments for items and 
services furnished on or after January 1, 2019. 
‘‘(C) MIPS ELIGIBLE PROFESSIONAL DE-
FINED.— 
‘‘(i) IN
GENERAL.—For purposes of 
this subsection, subject to clauses (ii) and 
(iv), the term ‘MIPS eligible professional’ 
means— 
‘‘(I) for the first and second 
years for which the MIPS applies to
payments (and for the performance 
period for such first and second year), 
a physician (as defined in section 
1861(r)), a physician assistant, nurse 
practitioner, and clinical nurse spe-
cialist (as such terms are defined in 
section 1861(aa)(5)), a certified reg-
istered nurse anesthetist (as defined 
in section 1861(bb)(2)), and a group 
that includes such professionals; and 
‘‘(II) for the third year for which 
the MIPS applies to payments (and 
for the performance period for such 
third year) and for each succeeding 
year (and for the performance period 
for each such year), the professionals 
described in subclause (I), such other 
eligible professionals (as defined in 
subsection (k)(3)(B)) as specified by 
the Secretary, and a group that in-
cludes such professionals. 
‘‘(ii) EXCLUSIONS.—For purposes of 
clause (i), the term ‘MIPS eligible profes-
sional’ does not include, with respect to a
year, an eligible professional (as defined in 
subsection (k)(3)(B)) who— 
‘‘(I) is a qualifying APM partici-
pant 
(as 
defined 
in 
section 
1833(z)(2)); 
‘‘(II) subject to clause (vii), is a 
partial qualifying APM participant (as 
defined in clause (iii)) for the most re-
cent period for which data are avail-
able and who, for the performance pe-
riod with respect to such year, does 
not report on applicable measures and 
activities 
described 
in 
paragraph 
(2)(B) that are required to be re-
ported by such a professional under 
the MIPS; or 
‘‘(III) for the performance period 
with respect to such year, does not ex-
ceed the low-volume threshold meas-
urement selected under clause (iv). 
‘‘(iii) PARTIAL QUALIFYING APM PAR-
TICIPANT.—For purposes of this subpara-
graph, the term ‘partial qualifying APM 
participant’ means, with respect to a year, 
an eligible professional for whom the Sec-
retary determines the minimum payment 
percentage (or percentages), as applicable, 
described in paragraph (2) of section 
1833(z) for such year have not been satis-
fied, but who would be considered a quali-
fying APM participant (as defined in such 
paragraph) for such year if— 
‘‘(I) with respect to 2019 and 
2020, the reference in subparagraph 
(A) of such paragraph to 25 percent 
was instead a reference to 20 percent; 
‘‘(II) with respect to 2021 and 
2022— 
‘‘(aa) the reference in sub-
paragraph (B)(i) of such para-
graph to 50 percent was instead 
a reference to 40 percent; and 
‘‘(bb) the references in sub-
paragraph (B)(ii) of such para-
graph to 50 percent and 25 per-
cent of such paragraph were in-
stead references to 40 percent 
and 20 percent, respectively; and 
‘‘(III) with respect to 2023 and 
subsequent years—
‘‘(aa) the reference in sub-
paragraph (C)(i) of such para-
graph to 75 percent was instead 
a reference to 50 percent; and 
‘‘(bb) the references in sub-
paragraph (C)(ii) of such para-
graph to 75 percent and 25 per-
cent of such paragraph were in-
stead references to 50 percent 
and 20 percent, respectively. 
‘‘(iv) SELECTION
OF
LOW-VOLUME 
THRESHOLD
MEASUREMENT.—The Sec-
retary shall select a low-volume threshold 
to apply for purposes of clause (ii)(III), 
which may include one or more or a com-
bination of the following: 
‘‘(I) The minimum number (as 
determined by the Secretary) of indi-
viduals enrolled under this part who 
are treated by the eligible professional 
for the performance period involved. 
‘‘(II) The minimum number (as 
determined by the Secretary) of items 
and services furnished to individuals
enrolled under this part by such pro-
fessional for such performance period. 
‘‘(III) The minimum amount (as 
determined by the Secretary) of al-
lowed charges billed by such profes-
sional under this part for such per-
formance period. 
‘‘(v) TREATMENT OF NEW MEDICARE 
ENROLLED ELIGIBLE PROFESSIONALS.—In 
the case of a professional who first be-
comes a Medicare enrolled eligible profes-
sional during the performance period for a 
year (and had not previously submitted 
claims under this title such as a person, an 
entity, or a part of a physician group or 
under a different billing number or tax 
identifier), such professional shall not be 
treated under this subsection as a MIPS 
eligible professional until the subsequent 
year and performance period for such sub-
sequent year. 
‘‘(vi) CLARIFICATION.—In the case of 
items and services furnished during a year 
by an individual who is not a MIPS eligible 
professional (including pursuant to clauses
(ii) and (v)) with respect to a year, in no 
case shall a MIPS adjustment factor (or 
additional MIPS adjustment factor) under 
paragraph (6) apply to such individual for 
such year. 
‘‘(vii) PARTIAL QUALIFYING APM PAR-
TICIPANT CLARIFICATIONS.— 
‘‘(I) TREATMENT AS MIPS ELIGI-
BLE PROFESSIONAL.—In the case of 
an eligible professional who is a par-
tial qualifying APM participant, with 
respect to a year, and who, for the 
performance period for such year, re-
ports on applicable measures and ac-
tivities described in paragraph (2)(B) 
that are required to be reported by 
such a professional under the MIPS, 
such eligible professional is considered 
to be a MIPS eligible professional 
with respect to such year. 
‘‘(II) NOT ELIGIBLE FOR QUALI-
FYING
APM
PARTICIPANT
PAY-
MENTS.—In no case shall an eligible 
professional who is a partial quali-
fying APM participant, with respect
to a year, be considered a qualifying 
APM participant (as defined in para-
graph (2) of section 1833(z)) for such 
year or be eligible for the additional 
payment under paragraph (1) of such 
section for such year. 
‘‘(D) APPLICATION
TO
GROUP
PRAC-
TICES.— 
‘‘(i) IN GENERAL.—Under the MIPS: 
‘‘(I) 
QUALITY
PERFORMANCE 
CATEGORY.—The Secretary shall es-
tablish and apply a process that in-
cludes features of the provisions of 
subsection (m)(3)(C) for MIPS eligi-
ble professionals in a group practice 
with respect to assessing performance 
of such group with respect to the per-
formance category described in clause 
(i) of paragraph (2)(A). 
‘‘(II) OTHER PERFORMANCE CAT-
EGORIES.—The Secretary may estab-
lish and apply a process that includes 
features of the provisions of sub-
section (m)(3)(C) for MIPS eligible 
professionals in a group practice with
respect to assessing the performance 
of such group with respect to the per-
formance 
categories 
described 
in 
clauses (ii) through (iv) of such para-
graph. 
‘‘(ii) ENSURING COMPREHENSIVENESS 
OF
GROUP
PRACTICE
ASSESSMENT.—The 
process established under clause (i) shall to 
the extent practicable reflect the range of 
items and services furnished by the MIPS 
eligible professionals in the group practice 
involved. 
‘‘(E) USE
OF
REGISTRIES.—Under the 
MIPS, the Secretary shall encourage the use of 
qualified clinical data registries pursuant to 
subsection (m)(3)(E) in carrying out this sub-
section. 
‘‘(F) APPLICATION
OF
CERTAIN
PROVI-
SIONS.—In applying a provision of subsection 
(k), (m), (o), or (p) for purposes of this sub-
section, the Secretary shall— 
‘‘(i) adjust the application of such 
provision to ensure the provision is con-
sistent with the provisions of this sub-
section; and
‘‘(ii) not apply such provision to the 
extent that the provision is duplicative with 
a provision of this subsection. 
‘‘(G) ACCOUNTING FOR RISK FACTORS.— 
‘‘(i) RISK FACTORS.—Taking into ac-
count the relevant studies conducted and 
recommendations made in reports under 
section 2(d) of the Improving Medicare 
Post-Acute Care Transformation Act of 
2014, and, as appropriate, other informa-
tion, including information collected before 
completion of such studies and rec-
ommendations, the Secretary, on an ongo-
ing basis, shall, as the Secretary deter-
mines appropriate and based on an individ-
ual’s health status and other risk factors— 
‘‘(I) assess appropriate adjust-
ments to quality measures, resource 
use measures, and other measures 
used under the MIPS; and 
‘‘(II) assess and implement ap-
propriate adjustments to payment ad-
justments, 
composite 
performance 
scores, scores for performance cat-
egories, or scores for measures or ac-
tivities under the MIPS. 
‘‘(2) MEASURES AND ACTIVITIES UNDER PER-
FORMANCE CATEGORIES.— 
‘‘(A) PERFORMANCE CATEGORIES.—Under 
the MIPS, the Secretary shall use the following 
performance categories (each of which is re-
ferred to in this subsection as a performance 
category) in determining the composite per-
formance score under paragraph (5): 
‘‘(i) Quality. 
‘‘(ii) Resource use. 
‘‘(iii) Clinical practice improvement 
activities. 
‘‘(iv) Meaningful use of certified EHR 
technology. 
‘‘(B) MEASURES
AND
ACTIVITIES
SPECI-
FIED FOR EACH CATEGORY.—For purposes of 
paragraph (3)(A) and subject to subparagraph 
(C), measures and activities specified for a per-
formance period (as established under para-
graph (4)) for a year are as follows: 
‘‘(i) QUALITY.—For the performance 
category described in subparagraph (A)(i), 
the quality measures included in the final
measures list published under subpara-
graph (D)(i) for such year and the list of 
quality measures described in subpara-
graph (D)(vi) used by qualified clinical 
data registries under subsection (m)(3)(E). 
‘‘(ii) RESOURCE USE.—For the per-
formance category described in subpara-
graph (A)(ii), the measurement of resource 
use for such period under subsection 
(p)(3), using the methodology under sub-
section (r) as appropriate, and, as feasible 
and applicable, accounting for the cost of 
drugs under part D. 
‘‘(iii) CLINICAL
PRACTICE
IMPROVE-
MENT
ACTIVITIES.—For the performance 
category 
described 
in 
subparagraph 
(A)(iii), clinical practice improvement ac-
tivities 
(as 
defined 
in 
subparagraph 
(C)(v)(III)) under subcategories specified 
by the Secretary for such period, which 
shall include at least the following: 
‘‘(I) The subcategory of expanded 
practice access, such as same day ap-
pointments for urgent needs and after 
hours access to clinician advice.
‘‘(II) The subcategory of popu-
lation management, such as moni-
toring health conditions of individuals 
to provide timely health care interven-
tions or participation in a qualified 
clinical data registry. 
‘‘(III) The subcategory of care 
coordination, such as timely commu-
nication of test results, timely ex-
change of clinical information to pa-
tients and other providers, and use of 
remote monitoring or telehealth. 
‘‘(IV) The subcategory of bene-
ficiary engagement, such as the estab-
lishment of care plans for individuals 
with complex care needs, beneficiary 
self-management 
assessment 
and 
training, and using shared decision- 
making mechanisms. 
‘‘(V) The subcategory of patient 
safety and practice assessment, such 
as through use of clinical or surgical 
checklists and practice assessments 
related to maintaining certification.
‘‘(VI) The subcategory of partici-
pation in an alternative payment 
model 
(as 
defined 
in 
section 
1833(z)(3)(C)). 
In establishing activities under this clause, 
the Secretary shall give consideration to 
the circumstances of small practices (con-
sisting of 15 or fewer professionals) and 
practices located in rural areas and in 
health professional shortage areas (as des-
ignated under section 332(a)(1)(A) of the 
Public Health Service Act). 
‘‘(iv) MEANINGFUL
EHR
USE.—For 
the performance category described in sub-
paragraph (A)(iv), the requirements estab-
lished for such period under subsection 
(o)(2) for determining whether an eligible 
professional is a meaningful EHR user. 
‘‘(C) ADDITIONAL PROVISIONS.— 
‘‘(i) EMPHASIZING
OUTCOME
MEAS-
URES UNDER THE QUALITY PERFORMANCE 
CATEGORY.—In 
applying 
subparagraph 
(B)(i), the Secretary shall, as feasible, em-
phasize the application of outcome meas-
ures.
‘‘(ii) APPLICATION
OF
ADDITIONAL 
SYSTEM
MEASURES.—The Secretary may 
use measures used for a payment system 
other than for physicians, such as meas-
ures for inpatient hospitals, for purposes of 
the performance categories described in 
clauses (i) and (ii) of subparagraph (A). 
For purposes of the previous sentence, the 
Secretary may not use measures for hos-
pital outpatient departments, except in the 
case of items and services furnished by 
emergency physicians, radiologists, and an-
esthesiologists. 
‘‘(iii) 
GLOBAL
AND
POPULATION- 
BASED
MEASURES.—The Secretary may 
use global measures, such as global out-
come 
measures, 
and 
population-based 
measures for purposes of the performance 
category described in subparagraph (A)(i). 
‘‘(iv) APPLICATION OF MEASURES AND 
ACTIVITIES TO NON-PATIENT-FACING PRO-
FESSIONALS.—In carrying out this para-
graph, with respect to measures and activi-
ties specified in subparagraph (B) for per-
formance categories described in subpara-
graph (A), the Secretary— 
‘‘(I) shall give consideration to 
the 
circumstances 
of 
professional 
types (or subcategories of those types 
determined by practice characteris-
tics) who typically furnish services 
that do not involve face-to-face inter-
action with a patient; and 
‘‘(II) may, to the extent feasible 
and appropriate, take into account 
such circumstances and apply under 
this subsection with respect to MIPS 
eligible professionals of such profes-
sional types or subcategories, alter-
native measures or activities that ful-
fill the goals of the applicable per-
formance category. 
In carrying out the previous sentence, the 
Secretary shall consult with professionals 
of such professional types or subcategories. 
‘‘(v) CLINICAL
PRACTICE
IMPROVE-
MENT ACTIVITIES.— 
‘‘(I) REQUEST
FOR
INFORMA-
TION.—In initially applying subpara-
graph (B)(iii), the Secretary shall use 
a request for information to solicit 
recommendations from stakeholders to 
identify activities described in such 
subparagraph and specifying criteria 
for such activities. 
‘‘(II) CONTRACT AUTHORITY FOR 
CLINICAL
PRACTICE
IMPROVEMENT 
ACTIVITIES
PERFORMANCE
CAT-
EGORY.—In applying subparagraph 
(B)(iii), the Secretary may contract 
with entities to assist the Secretary 
in— 
‘‘(aa) identifying activities 
described 
in 
subparagraph 
(B)(iii); 
‘‘(bb) specifying criteria for 
such activities; and 
‘‘(cc) determining whether a 
MIPS eligible professional meets 
such criteria. 
‘‘(III) CLINICAL
PRACTICE
IM-
PROVEMENT
ACTIVITIES
DEFINED.— 
For purposes of this subsection, the 
term ‘clinical practice improvement
activity’ means an activity that rel-
evant eligible professional organiza-
tions and other relevant stakeholders 
identify as improving clinical practice 
or care delivery and that the Sec-
retary determines, when effectively ex-
ecuted, is likely to result in improved 
outcomes. 
‘‘(D) ANNUAL LIST OF QUALITY MEASURES 
AVAILABLE FOR MIPS ASSESSMENT.— 
‘‘(i) IN GENERAL.—Under the MIPS, 
the Secretary, through notice and comment 
rulemaking and subject to the succeeding 
clauses of this subparagraph, shall, with 
respect to the performance period for a 
year, establish an annual final list of qual-
ity measures from which MIPS eligible 
professionals may choose for purposes of 
assessment under this subsection for such 
performance period. Pursuant to the pre-
vious sentence, the Secretary shall— 
‘‘(I) not later than November 1 
of the year prior to the first day of 
the first performance period under the 
MIPS, establish and publish in the
Federal Register a final list of quality 
measures; and 
‘‘(II) not later than November 1 
of the year prior to the first day of 
each subsequent performance period, 
update the final list of quality meas-
ures from the previous year (and pub-
lish such updated final list in the Fed-
eral Register), by— 
‘‘(aa) removing from such 
list, as appropriate, quality meas-
ures, which may include the re-
moval of measures that are no 
longer meaningful (such as meas-
ures that are topped out); 
‘‘(bb) adding to such list, as 
appropriate, new quality meas-
ures; and 
‘‘(cc) determining whether 
or not quality measures on such 
list that have undergone sub-
stantive changes should be in-
cluded in the updated list. 
‘‘(ii) 
CALL
FOR
QUALITY
MEAS-
URES.—
‘‘(I) IN GENERAL.—Eligible pro-
fessional organizations and other rel-
evant stakeholders shall be requested 
to identify and submit quality meas-
ures to be considered for selection 
under this subparagraph in the an-
nual list of quality measures published 
under clause (i) and to identify and 
submit updates to the measures on 
such list. For purposes of the previous 
sentence, measures may be submitted 
regardless of whether such measures 
were previously published in a pro-
posed rule or endorsed by an entity 
with a contract under section 1890(a). 
‘‘(II) ELIGIBLE
PROFESSIONAL 
ORGANIZATION
DEFINED.—In 
this 
subparagraph, the term ‘eligible pro-
fessional organization’ means a pro-
fessional organization as defined by 
nationally recognized specialty boards 
of certification or equivalent certifi-
cation boards. 
‘‘(iii) REQUIREMENTS.—In selecting 
quality measures for inclusion in the an-
nual final list under clause (i), the Sec-
retary shall— 
‘‘(I) provide that, to the extent 
practicable, all quality domains (as 
defined in subsection (s)(1)(B)) are 
addressed by such measures; and 
‘‘(II) ensure that such selection 
is consistent with the process for se-
lection of measures under subsections 
(k), (m), and (p)(2). 
‘‘(iv) PEER REVIEW.—Before includ-
ing a new measure in the final list of 
measures published under clause (i) for a 
year, the Secretary shall submit for publi-
cation in applicable specialty-appropriate, 
peer-reviewed journals such measure and 
the method for developing and selecting 
such measure, including clinical and other 
data supporting such measure. 
‘‘(v) MEASURES
FOR
INCLUSION.— 
The final list of quality measures published 
under clause (i) shall include, as applica-
ble, measures under subsections (k), (m), 
and (p)(2), including quality measures 
from among—
‘‘(I) measures endorsed by a con-
sensus-based entity; 
‘‘(II) measures developed under 
subsection (s); and 
‘‘(III) measures submitted under 
clause (ii)(I). 
Any measure selected for inclusion in such 
list that is not endorsed by a consensus- 
based entity shall have a focus that is evi-
dence-based. 
‘‘(vi) EXCEPTION
FOR
QUALIFIED 
CLINICAL
DATA
REGISTRY
MEASURES.— 
Measures used by a qualified clinical data 
registry under subsection (m)(3)(E) shall 
not be subject to the requirements under 
clauses (i), (iv), and (v). The Secretary 
shall publish the list of measures used by 
such qualified clinical data registries on 
the Internet website of the Centers for 
Medicare & Medicaid Services. 
‘‘(vii) 
EXCEPTION
FOR
EXISTING 
QUALITY
MEASURES.—Any quality meas-
ure specified by the Secretary under sub-
section (k) or (m), including under sub-
section (m)(3)(E), and any measure of
quality of care established under sub-
section (p)(2) for the reporting period or 
performance period under the respective 
subsection beginning before the first per-
formance period under the MIPS— 
‘‘(I) shall not be subject to the 
requirements under clause (i) (except 
under items (aa) and (cc) of subclause 
(II) of such clause) or to the require-
ment under clause (iv); and 
‘‘(II) shall be included in the 
final list of quality measures pub-
lished under clause (i) unless removed 
under clause (i)(II)(aa). 
‘‘(viii) CONSULTATION
WITH
REL-
EVANT ELIGIBLE PROFESSIONAL ORGANI-
ZATIONS
AND
OTHER
RELEVANT
STAKE-
HOLDERS.—Relevant eligible professional 
organizations and other relevant stake-
holders, including State and national med-
ical societies, shall be consulted in carrying 
out this subparagraph. 
‘‘(ix) OPTIONAL
APPLICATION.—The 
process under section 1890A is not re-
quired to apply to the selection of meas-
ures under this subparagraph. 
‘‘(3) PERFORMANCE STANDARDS.— 
‘‘(A) ESTABLISHMENT.—Under the MIPS, 
the Secretary shall establish performance stand-
ards with respect to measures and activities 
specified under paragraph (2)(B) for a perform-
ance period (as established under paragraph 
(4)) for a year. 
‘‘(B) CONSIDERATIONS IN ESTABLISHING 
STANDARDS.—In establishing such performance 
standards with respect to measures and activi-
ties specified under paragraph (2)(B), the Sec-
retary shall consider the following: 
‘‘(i) Historical performance standards. 
‘‘(ii) Improvement. 
‘‘(iii) The opportunity for continued 
improvement. 
‘‘(4) PERFORMANCE
PERIOD.—The Secretary 
shall establish a performance period (or periods) for 
a year (beginning with 2019). Such performance pe-
riod (or periods) shall begin and end prior to the be-
ginning of such year and be as close as possible to 
such year. In this subsection, such performance pe-
riod (or periods) for a year shall be referred to as 
the performance period for the year. 
‘‘(5) COMPOSITE PERFORMANCE SCORE.— 
‘‘(A) IN
GENERAL.—Subject to the suc-
ceeding provisions of this paragraph and taking 
into account, as available and applicable, para-
graph (1)(G), the Secretary shall develop a 
methodology for assessing the total performance 
of each MIPS eligible professional according to 
performance standards under paragraph (3) 
with respect to applicable measures and activi-
ties specified in paragraph (2)(B) with respect 
to each performance category applicable to such 
professional for a performance period (as estab-
lished under paragraph (4)) for a year. Using 
such methodology, the Secretary shall provide 
for a composite assessment (using a scoring 
scale of 0 to 100) for each such professional for 
the performance period for such year. In this 
subsection such a composite assessment for 
such a professional with respect to a perform-
ance period shall be referred to as the ‘com-
posite performance score’ for such professional 
for such performance period.
‘‘(B) INCENTIVE
TO
REPORT; ENCOUR-
AGING USE OF CERTIFIED EHR TECHNOLOGY 
FOR REPORTING QUALITY MEASURES.— 
‘‘(i) INCENTIVE TO REPORT.—Under 
the methodology established under sub-
paragraph (A), the Secretary shall provide 
that in the case of a MIPS eligible profes-
sional who fails to report on an applicable 
measure or activity that is required to be 
reported by the professional, the profes-
sional shall be treated as achieving the 
lowest potential score applicable to such 
measure or activity. 
‘‘(ii) ENCOURAGING
USE
OF
CER-
TIFIED EHR TECHNOLOGY AND QUALIFIED 
CLINICAL DATA REGISTRIES FOR REPORT-
ING
QUALITY
MEASURES.—Under 
the 
methodology established under subpara-
graph (A), the Secretary shall— 
‘‘(I) encourage MIPS eligible 
professionals to report on applicable 
measures with respect to the perform-
ance category described in paragraph 
(2)(A)(i) through the use of certified
EHR technology and qualified clinical 
data registries; and 
‘‘(II) with respect to a perform-
ance period, with respect to a year, 
for which a MIPS eligible professional 
reports such measures through the 
use of such EHR technology, treat 
such professional as satisfying the 
clinical quality measures reporting re-
quirement described in subsection 
(o)(2)(A)(iii) for such year. 
‘‘(C) CLINICAL
PRACTICE
IMPROVEMENT 
ACTIVITIES PERFORMANCE SCORE.— 
‘‘(i) RULE
FOR
CERTIFICATION.—A 
MIPS eligible professional who is in a 
practice that is certified as a patient-cen-
tered medical home or comparable spe-
cialty practice, as determined by the Sec-
retary, with respect to a performance pe-
riod shall be given the highest potential 
score for the performance category de-
scribed in paragraph (2)(A)(iii) for such 
period. 
‘‘(ii) APM PARTICIPATION.—Partici-
pation by a MIPS eligible professional in
an alternative payment model (as defined 
in section 1833(z)(3)(C)) with respect to a 
performance period shall earn such eligible 
professional a minimum score of one-half 
of the highest potential score for the per-
formance category described in paragraph 
(2)(A)(iii) for such performance period. 
‘‘(iii) SUBCATEGORIES.—A MIPS eli-
gible professional shall not be required to 
perform activities in each subcategory 
under paragraph (2)(B)(iii) or participate 
in an alternative payment model in order 
to achieve the highest potential score for 
the performance category described in 
paragraph (2)(A)(iii). 
‘‘(D) 
ACHIEVEMENT
AND
IMPROVE-
MENT.— 
‘‘(i) TAKING INTO ACCOUNT IMPROVE-
MENT.—Beginning with the second year to 
which the MIPS applies, in addition to the 
achievement of a MIPS eligible profes-
sional, if data sufficient to measure im-
provement is available, the methodology 
developed under subparagraph (A)—
‘‘(I) in the case of the perform-
ance score for the performance cat-
egory described in clauses (i) and (ii) 
of paragraph (2)(A), shall take into 
account the improvement of the pro-
fessional; and 
‘‘(II) in the case of performance 
scores for other performance cat-
egories, may take into account the im-
provement of the professional. 
‘‘(ii) ASSIGNING HIGHER WEIGHT FOR 
ACHIEVEMENT.—Subject 
to 
clause 
(i), 
under the methodology developed under 
subparagraph (A), the Secretary may as-
sign a higher scoring weight under sub-
paragraph (F) with respect to the achieve-
ment of a MIPS eligible professional than 
with respect to any improvement of such 
professional applied under clause (i) with 
respect to a measure, activity, or category 
described in paragraph (2). 
‘‘(E) WEIGHTS
FOR
THE
PERFORMANCE 
CATEGORIES.— 
‘‘(i) IN GENERAL.—Under the meth-
odology developed under subparagraph (A),
subject to subparagraph (F)(i) and clause 
(ii), the composite performance score shall 
be determined as follows: 
‘‘(I) QUALITY.— 
‘‘(aa) IN
GENERAL.—Sub-
ject to item (bb), thirty percent 
of such score shall be based on 
performance with respect to the 
category described in clause (i) of 
paragraph (2)(A). In applying 
the previous sentence, the Sec-
retary shall, as feasible, encour-
age the application of outcome 
measures within such category. 
‘‘(bb) FIRST 2 YEARS.—For 
the first and second years for 
which the MIPS applies to pay-
ments, the percentage applicable 
under item (aa) shall be in-
creased in a manner such that 
the total percentage points of the 
increase under this item for the 
respective year equals the total 
number of percentage points by 
which the percentage applied
under subclause (II)(bb) for the 
respective year is less than 30 
percent. 
‘‘(II) RESOURCE USE.— 
‘‘(aa) IN
GENERAL.—Sub-
ject to item (bb), thirty percent 
of such score shall be based on 
performance with respect to the 
category described in clause (ii) 
of paragraph (2)(A). 
‘‘(bb) FIRST 2 YEARS.—For 
the first year for which the MIPS 
applies to payments, not more 
than 10 percent of such score 
shall be based on performance 
with respect to the category de-
scribed in clause (ii) of para-
graph (2)(A). For the second 
year for which the MIPS applies 
to payments, not more than 15 
percent of such score shall be 
based on performance with re-
spect to the category described in 
clause (ii) of paragraph (2)(A).
‘‘(III) CLINICAL
PRACTICE
IM-
PROVEMENT
ACTIVITIES.—Fifteen 
percent of such score shall be based 
on performance with respect to the 
category described in clause (iii) of 
paragraph (2)(A). 
‘‘(IV) MEANINGFUL USE OF CER-
TIFIED
EHR
TECHNOLOGY.—Twenty- 
five percent of such score shall be 
based on performance with respect to 
the category described in clause (iv) of 
paragraph (2)(A). 
‘‘(ii) AUTHORITY
TO
ADJUST
PER-
CENTAGES IN CASE OF HIGH EHR MEAN-
INGFUL USE ADOPTION.—In any year in 
which the Secretary estimates that the pro-
portion of eligible professionals (as defined 
in subsection (o)(5)) who are meaningful 
EHR users (as determined under sub-
section (o)(2)) is 75 percent or greater, the 
Secretary may reduce the percent applica-
ble under clause (i)(IV), but not below 15 
percent. If the Secretary makes such re-
duction for a year, subject to subclauses 
(I)(bb) and (II)(bb) of clause (i), the per-
centages applicable under one or more of 
subclauses (I), (II), and (III) of clause (i) 
for such year shall be increased in a man-
ner such that the total percentage points 
of the increase under this clause for such 
year equals the total number of percentage 
points reduced under the preceding sen-
tence for such year. 
‘‘(F) 
CERTAIN
FLEXIBILITY
FOR 
WEIGHTING PERFORMANCE CATEGORIES, MEAS-
URES, AND
ACTIVITIES.—Under the method-
ology under subparagraph (A), if there are not 
sufficient measures and activities (described in 
paragraph (2)(B)) applicable and available to 
each type of eligible professional involved, the 
Secretary shall assign different scoring weights 
(including a weight of 0)— 
‘‘(i) which may vary from the scoring 
weights specified in subparagraph (E), for 
each performance category based on the 
extent to which the category is applicable 
to the type of eligible professional involved; 
and 
‘‘(ii) for each measure and activity 
specified under paragraph (2)(B) with re-
spect to each such category based on the 
extent to which the measure or activity is 
applicable and available to the type of eli-
gible professional involved. 
‘‘(G) RESOURCE
USE.—Analysis of the 
performance category described in paragraph 
(2)(A)(ii) shall include results from the method-
ology described in subsection (r)(5), as appro-
priate. 
‘‘(H) INCLUSION
OF
QUALITY
MEASURE 
DATA FROM OTHER PAYERS.—In applying sub-
sections (k), (m), and (p) with respect to meas-
ures described in paragraph (2)(B)(i), analysis 
of the performance category described in para-
graph (2)(A)(i) may include data submitted by 
MIPS eligible professionals with respect to 
items and services furnished to individuals who 
are not individuals entitled to benefits under 
part A or enrolled under part B. 
‘‘(I) USE OF VOLUNTARY VIRTUAL GROUPS 
FOR CERTAIN ASSESSMENT PURPOSES.— 
‘‘(i) IN
GENERAL.—In the case of 
MIPS eligible professionals electing to be a 
virtual group under clause (ii) with respect 
to a performance period for a year, for
purposes of applying the methodology 
under subparagraph (A) with respect to 
the performance categories described in 
clauses (i) and (ii) of paragraph (2)(A)— 
‘‘(I) the assessment of perform-
ance provided under such methodology 
with respect to such performance cat-
egories that is to be applied to each 
such professional in such group for 
such performance period shall be with 
respect to the combined performance 
of all such professionals in such group 
for such period; and 
‘‘(II) with respect to the com-
posite performance score provided 
under this paragraph for such per-
formance period for each such MIPS 
eligible professional in such virtual 
group, the components of the com-
posite performance score that assess 
performance with respect to such per-
formance categories shall be based on 
the assessment of the combined per-
formance under subclause (I) for such
performance categories and perform-
ance period. 
‘‘(ii) ELECTION OF PRACTICES TO BE 
A VIRTUAL GROUP.—The Secretary shall, 
in accordance with the requirements under 
clause (iii), establish and have in place a 
process to allow an individual MIPS eligi-
ble professional or a group practice con-
sisting of not more than 10 MIPS eligible 
professionals to elect, with respect to a 
performance period for a year to be a vir-
tual group under this subparagraph with 
at least one other such individual MIPS el-
igible professional or group practice. Such 
a virtual group may be based on appro-
priate classifications of providers, such as 
by geographic areas or by provider special-
ties defined by nationally recognized spe-
cialty boards of certification or equivalent 
certification boards. 
‘‘(iii) REQUIREMENTS.—The require-
ments for the process under clause (ii) 
shall— 
‘‘(I) provide that an election 
under such clause, with respect to a
performance period, shall be made be-
fore the beginning of such perform-
ance period and may not be changed 
during such performance period; 
‘‘(II) provide that an individual 
MIPS eligible professional and a 
group practice described in clause (ii) 
may elect to be in no more than one 
virtual group for a performance period 
and that, in the case of such a group 
practice that elects to be in such vir-
tual group for such performance pe-
riod, such election applies to all MIPS 
eligible professionals in such group 
practice; 
‘‘(III) provide that a virtual 
group be a combination of tax identi-
fication numbers; 
‘‘(IV) provide for formal written 
agreements among MIPS eligible pro-
fessionals electing to be a virtual 
group under this subparagraph; and 
‘‘(V) include such other require-
ments as the Secretary determines ap-
propriate.
‘‘(6) MIPS PAYMENTS.— 
‘‘(A) MIPS ADJUSTMENT FACTOR.—Tak-
ing into account paragraph (1)(G), the Sec-
retary shall specify a MIPS adjustment factor 
for each MIPS eligible professional for a year. 
Such MIPS adjustment factor for a MIPS eligi-
ble professional for a year shall be in the form 
of a percent and shall be determined— 
‘‘(i) by comparing the composite per-
formance score of the eligible professional 
for such year to the performance threshold 
established under subparagraph (D)(i) for 
such year; 
‘‘(ii) in a manner such that the ad-
justment factors specified under this sub-
paragraph for a year result in differential 
payments under this paragraph reflecting 
that— 
‘‘(I) MIPS eligible professionals 
with composite performance scores for 
such year at or above such perform-
ance threshold for such year receive 
zero or positive payment adjustment 
factors for such year in accordance 
with clause (iii), with such profes-
sionals having higher composite per-
formance scores receiving higher ad-
justment factors; and 
‘‘(II) MIPS eligible professionals 
with composite performance scores for 
such year below such performance 
threshold for such year receive nega-
tive payment adjustment factors for 
such year in accordance with clause 
(iv), with such professionals having 
lower composite performance scores 
receiving lower adjustment factors; 
‘‘(iii) in a manner such that MIPS eli-
gible professionals with composite scores 
described in clause (ii)(I) for such year, 
subject to clauses (i) and (ii) of subpara-
graph (F), receive a zero or positive ad-
justment factor on a linear sliding scale 
such that an adjustment factor of 0 per-
cent is assigned for a score at the perform-
ance threshold and an adjustment factor of 
the applicable percent specified in subpara-
graph (B) is assigned for a score of 100; 
and 
‘‘(iv) in a manner such that—
‘‘(I) subject to subclause (II), 
MIPS eligible professionals with com-
posite performance scores described in 
clause (ii)(II) for such year receive a 
negative payment adjustment factor 
on a linear sliding scale such that an 
adjustment factor of 0 percent is as-
signed for a score at the performance 
threshold and an adjustment factor of 
the negative of the applicable percent 
specified in subparagraph (B) is as-
signed for a score of 0; and 
‘‘(II) MIPS eligible professionals 
with composite performance scores 
that are equal to or greater than 0, 
but not greater than 1⁄4 of the per-
formance threshold specified under 
subparagraph (D)(i) for such year, re-
ceive a negative payment adjustment 
factor that is equal to the negative of 
the applicable percent specified in 
subparagraph (B) for such year. 
‘‘(B) APPLICABLE
PERCENT
DEFINED.— 
For purposes of this paragraph, the term ‘ap-
plicable percent’ means—
‘‘(i) for 2019, 4 percent; 
‘‘(ii) for 2020, 5 percent; 
‘‘(iii) for 2021, 7 percent; and 
‘‘(iv) for 2022 and subsequent years, 
9 percent. 
‘‘(C) ADDITIONAL MIPS ADJUSTMENT FAC-
TORS FOR EXCEPTIONAL PERFORMANCE.—For 
2019 and each subsequent year through 2024, 
in the case of a MIPS eligible professional with 
a composite performance score for a year at or 
above the additional performance threshold 
under subparagraph (D)(ii) for such year, in 
addition to the MIPS adjustment factor under 
subparagraph (A) for the eligible professional 
for such year, subject to subparagraph (F)(iv), 
the Secretary shall specify an additional positive 
MIPS adjustment factor for such professional 
and year. Such additional MIPS adjustment 
factors shall be in the form of a percent and de-
termined by the Secretary in a manner such 
that professionals having higher composite per-
formance scores above the additional perform-
ance threshold receive higher additional MIPS 
adjustment factors.
‘‘(D) ESTABLISHMENT OF PERFORMANCE 
THRESHOLDS.— 
‘‘(i) PERFORMANCE
THRESHOLD.— 
For each year of the MIPS, the Secretary 
shall compute a performance threshold 
with respect to which the composite per-
formance score of MIPS eligible profes-
sionals shall be compared for purposes of 
determining adjustment factors under sub-
paragraph (A) that are positive, negative, 
and zero. Such performance threshold for 
a year shall be the mean or median (as se-
lected by the Secretary) of the composite 
performance scores for all MIPS eligible 
professionals with respect to a prior period 
specified by the Secretary. The Secretary 
may reassess the selection of the mean or 
median under the previous sentence every 
3 years. 
‘‘(ii) 
ADDITIONAL
PERFORMANCE 
THRESHOLD FOR EXCEPTIONAL PERFORM-
ANCE.—In addition to the performance 
threshold under clause (i), for each year of 
the MIPS, the Secretary shall compute an 
additional performance threshold for pur-
poses of determining the additional MIPS 
adjustment factors under subparagraph 
(C). For each such year, the Secretary 
shall apply either of the following methods 
for computing such additional performance 
threshold for such a year: 
‘‘(I) The threshold shall be the 
score that is equal to the 25th per-
centile of the range of possible com-
posite performance scores above the 
performance 
threshold 
determined 
under clause (i). 
‘‘(II) The threshold shall be the 
score that is equal to the 25th per-
centile of the actual composite per-
formance scores for MIPS eligible 
professionals with composite perform-
ance scores at or above the perform-
ance threshold with respect to the 
prior period described in clause (i). 
‘‘(iii) SPECIAL RULE FOR INITIAL 2 
YEARS.—With respect to each of the first 
two years to which the MIPS applies, the 
Secretary shall, prior to the performance 
period for such years, establish a perform-
‘‘(B) LIMITATION.—Except as provided for 
in subparagraph (A), there shall be no adminis-
trative or judicial review under section 1869, 
section 1878, or otherwise of the following: 
‘‘(i) The methodology used to deter-
mine the amount of the MIPS adjustment 
factor under paragraph (6)(A) and the 
amount of the additional MIPS adjustment 
factor under paragraph (6)(C) and the de-
termination of such amounts. 
‘‘(ii) The establishment of the per-
formance standards under paragraph (3) 
and the performance period under para-
graph (4). 
‘‘(iii) The identification of measures 
and activities specified under paragraph 
(2)(B) and information made public or 
posted on the Physician Compare Internet 
website of the Centers for Medicare & 
Medicaid Services under paragraph (9). 
‘‘(iv) 
The 
methodology 
developed 
under paragraph (5) that is used to cal-
culate performance scores and the calcula-
tion of such scores, including the weighting
of measures and activities under such 
methodology.’’. 
(2) GAO REPORTS.— 
(A) EVALUATION
OF
ELIGIBLE
PROFES-
SIONAL MIPS.—Not later than October 1, 2021, 
the Comptroller General of the United States 
shall submit to Congress a report evaluating the 
eligible professional Merit-based Incentive Pay-
ment System under subsection (q) of section 
1848 of the Social Security Act (42 U.S.C. 
1395w–4), as added by paragraph (1). Such re-
port shall— 
(i) examine the distribution of the 
composite performance scores and MIPS 
adjustment factors (and additional MIPS 
adjustment factors) for MIPS eligible pro-
fessionals 
(as 
defined 
in 
subsection 
(q)(1)(c) of such section) under such pro-
gram, and patterns relating to such scores 
and adjustment factors, including based on 
type of provider, practice size, geographic 
location, and patient mix; 
(ii) provide recommendations for im-
proving such program;
gregate payment amounts for such covered pro-
fessional services under this part for the pre-
ceding year. For purposes of the previous sen-
tence, the payment amount for the preceding 
year may be an estimation for the full pre-
ceding year based on a period of such preceding 
year that is less than the full year. The Sec-
retary shall establish policies to implement this 
subparagraph in cases in which payment for 
covered professional services furnished by a 
qualifying APM participant in an alternative 
payment model— 
‘‘(i) is made to an eligible alternative 
payment entity rather than directly to the 
qualifying APM participant; or 
‘‘(ii) is made on a basis other than a 
fee-for-service basis (such as payment on a 
capitated basis). 
‘‘(B) 
FORM
OF
PAYMENT.—Payments 
under this subsection shall be made in a lump 
sum, on an annual basis, as soon as practicable. 
‘‘(C) TREATMENT
OF
PAYMENT
INCEN-
TIVE.—Payments under this subsection shall 
not be taken into account for purposes of deter-
mining actual expenditures under an alternative
233 
the provision of the Medicare Summary Notice in an 
electronic format), as added by subsection (a), to 
other statements and notifications under title XVIII 
of such Act (42 U.S.C. 1395 et seq.); and 
(2) provide such Medicare Summary Notice and 
any such other statements and notifications on a 
more frequent basis than is otherwise required under 
such title. 
SEC. 509. RENEWAL OF MAC CONTRACTS. 
(a) IN GENERAL.—Section 1874A(b)(1)(B) of the 
Social Security Act (42 U.S.C. 1395kk–1(b)(1)(B)) is 
amended by striking ‘‘5 years’’ and inserting ‘‘10 years’’. 
(b) APPLICATION.—The amendments made by sub-
section (a) shall apply to contracts entered into on or 
after, and to contracts in effect as of, the date of the en-
actment of this Act. 
(c) CONTRACTOR PERFORMANCE TRANSPARENCY.— 
Section 1874A(b)(3)(A) of the Social Security Act (42 
U.S.C. 1395kk–1(b)(3)(A)) is amended by adding at the 
end the following new clause: 
‘‘(iv) 
CONTRACTOR
PERFORMANCE 
TRANSPARENCY.—To the extent possible 
without compromising the process for en-
tering into and renewing contracts with 
medicare administrative contractors under