339 
between equipment and services, and if so, how; 
and 
(F) how such payment rate compares to a 
competitively bid rate. 
(2) REPORT.—Not later than 18 months after the 
date of the enactment of this Act, the Secretary of 
Health and Human Services shall submit to Congress 
a report on the study conducted under paragraph (1). 
SEC. 610. ADJUSTMENT FOR MEDICARE MENTAL HEALTH 
SERVICES. 
(a) IN GENERAL.—For purposes of payment for serv-
ices furnished under the physician fee schedule under sec-
tion 1848 of the Social Security Act (42 U.S.C. 1395w– 
4) during the applicable period, the Secretary of Health and 
Human Services shall increase the amount otherwise pay-
able for applicable services by 5 percent. 
(b) DEFINITIONS.—For purposes of subsection (a): 
(1) APPLICABLE PERIOD.—The term ‘‘applicable 
period’’ means the period beginning on January 1, 
2008, and ending on December 31 of the year before 
the effective date of the first review after January 1, 
2008, of work relative value units conducted under 
section 1848(c)(2)(B)(i) of the Social Security Act. 
(2) APPLICABLE SERVICES.—The term ‘‘applica-
ble services’’ means procedure codes for services— 
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(A) in the categories of psychiatric thera-
peutic procedures furnished in office or other 
outpatient facility settings, or inpatient hospital, 
partial hospital or residential care facility set-
tings; and 
(B) which cover insight oriented, behavior 
modifying, or supportive psychotherapy and 
interactive 
psychotherapy 
services 
in 
the 
Healthcare Common Procedure Coding System 
established by the Secretary of Health and 
Human Services under section 1848(c)(5) of such 
Act. 
(c) IMPLEMENTATION.—Notwithstanding any other 
provision of law, the Secretary of Health and Human Serv-
ices may implement this section by program instruction or 
otherwise. 
SEC. 611. EXTENSION OF BRACHYTHERAPY SPECIAL RULE. 
Section 1833(t)(16)(C) of the Social Security Act (42 
U.S.C. 1395l(t)(16)(C)) is amended by striking ‘‘2008’’ and 
inserting ‘‘2009’’. 
SEC. 612. PAYMENT FOR PART B DRUGS. 
(a) 
APPLICATION
OF
CONSISTENT
VOLUME 
WEIGHTING IN COMPUTATION OF ASP.—In order to assure 
that payments for drugs and biologicals under section 
1847A of the Social Security Act (42 U.S.C. 1395w–3a) are 
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correct and consistent with law, the Secretary of Health and 
Human Services shall, for payment for drugs and 
biologicals furnished on or after July 1, 2008, compute the 
volume-weighted average sales price using equation #2 
(specified in appendix A of the report of the Inspector Gen-
eral of the Department of Health and Human Services on 
‘‘Calculation of Volume-Weighted Average Sales Price for 
Medicare Part B Prescription Drugs’’ (February 2006; 
OEI–03–05–00310)) used by the Office of Inspector General 
to calculate a volume-weighted ASP. 
(b) IMPROVEMENTS IN THE COMPETITIVE ACQUISITION 
PROGRAM (CAP).— 
(1) CONTINUOUS OPEN ENROLLMENT; AUTOMATIC 
REENROLLMENT
WITHOUT
NEED
FOR
REAPPLICA-
TION.—Subsection (a)(1)(A) of section 1847B of the 
Social Security Act (42 U.S.C. 1395w–3b) is amend-
ed— 
(A) in clause (ii), by striking ‘‘annually’’ 
and inserting ‘‘on an ongoing basis’’; 
(B) in clause (iii), by striking ‘‘an annual 
selection’’ and inserting ‘‘a selection (which may 
be changed on an annual basis)’’ ; and 
(C) by adding at the end the following: ‘‘An 
election and selection described in clauses (ii) 
and (iii) shall continue to be effective without 
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the need for any periodic reelection or reapplica-
tion or selection.’’. 
(2) PERMITTING VENDER TO DELIVER DRUGS TO 
SITE OF ADMINISTRATION.—Subsection (b)(4)(E) of 
such section is amended— 
(A) by striking ‘‘or’’ at the end of clause (i); 
(B) by striking the period at the end of 
clause (ii) and inserting ‘‘; or’’; and 
(C) by adding at the end the following new 
clause: 
‘‘(iii) prevent a contractor from deliv-
ering drugs and biologicals to the site in 
which the drugs or biologicals will be ad-
ministered.’’. 
(3) PHYSICIAN
OUTREACH
AND
EDUCATION.— 
Subsection (a)(1) of such section is amended by add-
ing at the end the following new subparagraph: 
‘‘(E) PHYSICIAN
OUTREACH
AND
EDU-
CATION.—The Secretary shall conduct a program 
of outreach to education physicians concerning 
the program and the ongoing opportunity of 
physicians 
to 
elect 
to 
obtain 
drugs 
and 
biologicals under the program.’’. 
(4) REBIDDING OF CONTRACTS.—The Secretary 
of Health and Human Services shall provide for the 
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rebidding of contracts under section 1847B(c) of the 
Social Security Act (42 U.S.C. 1395w-3b(c)) only for 
periods on or after the expiration of the contract in 
effect under such section as of the date of the enact-
ment of this Act. 
(c) 
TREATMENT
OF
CERTAIN
DRUGS.—Section 
1847A(b) of the Social Security Act (42 U.S.C. 1395w– 
3a(b)) is amended— 
(1) in paragraph (1), by inserting ‘‘paragraph 
(6) and’’ after ‘‘Subject to’’; and 
(2) by adding at the end the following new para-
graph: 
‘‘(6) SPECIAL
RULE.—In applying subsection 
(c)(6)(C)(ii), beginning with January 1, 2008, the av-
erage sales price for drugs or biologicals described in 
section 1842(o)(1)(G) is the lower of the average sales 
price calculated including drugs or biologicals to 
which such subsection applies and the average sales 
price that would have been calculated if such sub-
section were not applied.’’. 
(d) EFFECTIVE DATE.—Except as otherwise provided, 
the amendments made by this section shall apply to drugs 
furnished on or after January 1, 2008. 
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Subtitle B—Extension of Medicare 
Rural Access Protections 
SEC. 621. 2-YEAR EXTENSION OF FLOOR ON MEDICARE 
WORK GEOGRAPHIC ADJUSTMENT. 
Section 1848(e)(1)(E) of such Act (42 U.S.C. 1395w– 
4(e)(1)(E)) is amended by striking ‘‘2008’’ and inserting 
‘‘2010’’. 
SEC. 622. 2-YEAR EXTENSION OF SPECIAL TREATMENT OF 
CERTAIN PHYSICIAN PATHOLOGY SERVICES 
UNDER MEDICARE. 
Section 542(c) of the Medicare, Medicaid, and SCHIP 
Benefits Improvement and Protection Act of 2000, as 
amended by section 732 of the Medicare Prescription Drug, 
Improvement, and Modernization Act of 2003, and section 
104 of the Medicare Improvements and Extension Act of 
2006 (division B of Public Law 109–432), is amended by 
striking ‘‘and 2007’’ and inserting ‘‘2007, 2008, and 2009’’. 
SEC. 623. 2-YEAR EXTENSION OF MEDICARE REASONABLE 
COSTS PAYMENTS FOR CERTAIN CLINICAL DI-
AGNOSTIC LABORATORY TESTS FURNISHED 
TO HOSPITAL PATIENTS IN CERTAIN RURAL 
AREAS. 
Section 416(b) of the Medicare Prescription Drug, Im-
provement, and Modernization Act of 2003 (Public Law 
108–173; 117 Stat. 2282; 42 U.S.C. 1395l–4(b)), as amend-
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ed by section 105 of the Medicare Improvement and Exten-
sion Act of 2006 (division B of Public Law 109–432), is 
amended by striking ‘‘3-year’’ and inserting ‘‘5-year’’. 
SEC. 624. 2-YEAR EXTENSION OF MEDICARE INCENTIVE 
PAYMENT PROGRAM FOR PHYSICIAN SCAR-
CITY AREAS . 
(a) IN GENERAL.—Section 1833(u)(1) of the Social Se-
curity Act (42 U.S.C. 1395l(u)(1)) is amended by striking 
‘‘2008’’ and inserting ‘‘2010’’. 
(b) TRANSITION.—With respect to physicians’ services 
furnished during 2008 and 2009, for purposes of subsection 
(a), the Secretary of Health and Human Services shall use 
the primary care scarcity areas and the specialty care scar-
city areas (as identified in section 1833(u)(4)) that the Sec-
retary was using under such subsection with respect to phy-
sicians’ services furnished on December 31, 2007. 
SEC. 625. 2-YEAR EXTENSION OF MEDICARE INCREASE PAY-
MENTS FOR GROUND AMBULANCE SERVICES 
IN RURAL AREAS. 
Section 1834(l)(13) of the Social Security Act (42 
U.S.C. 1395m(l)(13)) is amended— 
(1) in subparagraph (A)— 
(A) in the matter before clause (i), by strik-
ing ‘‘furnished on or after July 1, 2004, and be-
fore January 1, 2007,’’; 
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(B) in clause (i), by inserting ‘‘for services 
furnished on or after July 1, 2004, and before 
January 1, 2007, and on or after January 1, 
2008, and before January 1, 2010,’’ after ‘‘in 
such paragraph,’’; and 
(C) in clause (ii), by inserting ‘‘for services 
furnished on or after July 1, 2004, and before 
January 1, 2007,’’ after ‘‘in clause (i),’’; and 
(2) in subparagraph (B)— 
(A) in the heading, by striking ‘‘AFTER 
2006’’ and inserting ‘‘FOR
SUBSEQUENT
PERI-
ODS’’; 
(B) by inserting ‘‘clauses (i) and (ii) of’’ be-
fore ‘‘subparagraph (A)’’; and 
(C) by striking ‘‘in such subparagraph’’ 
and inserting ‘‘in the respective clause’’. 
SEC. 626. EXTENDING HOLD HARMLESS FOR SMALL RURAL 
HOSPITALS UNDER THE HOPD PROSPECTIVE 
PAYMENT SYSTEM. 
Section 1833(t)(7)(D)(i)(II) of the Social Security Act 
(42 U.S.C. 1395l(t)(7)(D)(I)(II)) is amended— 
(1) by striking ‘‘January 1, 2009’’ and inserting 
‘‘January 1, 2010’’; 
(2) by striking ‘‘2007, or 2008,’’; and 
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(3) by striking ‘‘90 percent, and 85 percent, re-
spectively.’’ and inserting ‘‘and with respect to such 
services furnished after 2006 the applicable percentage 
shall be 90 percent.’’. 
Subtitle C—End Stage Renal 
Disease Program 
SEC. 631. CHRONIC KIDNEY DISEASE DEMONSTRATION 
PROJECTS. 
(a) IN GENERAL.—The Secretary of Health and 
Human Services (in this section referred to as the ‘‘Sec-
retary’’), acting through the Director of the National Insti-
tutes of Health, shall establish demonstration projects to— 
(1) increase public and medical community 
awareness (particularly of those who treat patients 
with diabetes and hypertension) about the factors that 
lead to chronic kidney disease, how to prevent it, how 
to diagnose it, and how to treat it; 
(2) increase screening and use of prevention tech-
niques for chronic kidney disease for Medicare bene-
ficiaries and the general public (particularly among 
patients with diabetes and hypertension, where pre-
vention techniques are well established and early de-
tection makes prevention possible); and 
(3) enhance surveillance systems and expand re-
search to better assess the prevalence and incidence of 
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chronic kidney disease, (building on work done by 
Centers for Disease Control and Prevention). 
(b) SCOPE AND DURATION.— 
(1) SCOPE.—The Secretary shall select at least 3 
States in which to conduct demonstration projects 
under this section. In selecting the States under this 
paragraph, the Secretary shall take into account the 
size of the population of individuals with end-stage 
renal disease who are enrolled in part B of title 
XVIII of the Social Security Act and ensure the par-
ticipation of individuals who reside in rural and 
urban areas. 
(2) DURATION.—The demonstration projects 
under this section shall be conducted for a period that 
is not longer than 5 years and shall begin on Janu-
ary 1, 2009. 
(c) EVALUATION AND REPORT.— 
(1) EVALUATION.—The Secretary shall conduct 
an evaluation of the demonstration projects conducted 
under this section. 
(2) REPORT.—Not later than 12 months after the 
date on which the demonstration projects under this 
section are completed, the Secretary shall submit to 
Congress a report on the evaluation conducted under 
paragraph (1) together with recommendations for 
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such legislation and administrative action as the Sec-
retary determines appropriate. 
SEC. 632. MEDICARE COVERAGE OF KIDNEY DISEASE PA-
TIENT EDUCATION SERVICES. 
(a) COVERAGE
OF
KIDNEY
DISEASE
EDUCATION 
SERVICES.— 
(1) COVERAGE.—Section 1861(s)(2) of the Social 
Security Act (42 U.S.C. 1395x(s)(2)), as amended by 
sections 201(a)(1), 607(a)(1), and 607(b)(1), is 
amended— 
(A) in subparagraph (CC), by striking 
‘‘and’’ after the semicolon at the end; 
(B) in subparagraph (DD), by adding 
‘‘and’’ after the semicolon at the end; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(EE) kidney disease education services (as de-
fined in subsection (ggg));’’. 
(2) SERVICES DESCRIBED.—Section 1861 of the 
Social Security Act (42 U.S.C. 1395x), as amended 
by sections 201(a)(2), 503(b)(1), 607(a)(2), and 
607(b)(2), is amended by adding at the end the fol-
lowing new subsection: 
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‘‘Kidney Disease Education Services 
‘‘(ggg)(1) The term ‘kidney disease education services’ 
means educational services that are— 
‘‘(A) furnished to an individual with stage IV 
chronic kidney disease who, according to accepted 
clinical guidelines identified by the Secretary, will re-
quire dialysis or a kidney transplant; 
‘‘(B) furnished, upon the referral of the physi-
cian managing the individual’s kidney condition, by 
a qualified person (as defined in paragraph (2)); and 
‘‘(C) designed— 
‘‘(i) to provide comprehensive information 
(consistent with the standards developed under 
paragraph (3)) regarding— 
‘‘(I) the management of comorbidities, 
including for purposes of delaying the need 
for dialysis; 
‘‘(II) the prevention of uremic com-
plications; and 
‘‘(III) each option for renal replace-
ment therapy (including hemodialysis and 
peritoneal dialysis at home and in-center as 
well as vascular access options and trans-
plantation); 
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‘‘(ii) to ensure that the individual has the 
opportunity to actively participate in the choice 
of therapy; and 
‘‘(iii) to be tailored to meet the needs of the 
individual involved. 
‘‘(2) The term ‘qualified person’ means a physician, 
physician assistant, nurse practitioner, or clinical nurse 
specialist who furnishes services for which payment may 
be made under the fee schedule established under section 
1848. Such term does not include a renal dialysis facility. 
‘‘(3) The Secretary shall set standards for the content 
of such information to be provided under paragraph 
(1)(C)(i) after consulting with physicians, other health pro-
fessionals, health educators, professional organizations, ac-
crediting organizations, kidney patient organizations, di-
alysis facilities, transplant centers, network organizations 
described in section 1881(c)(2), and other knowledgeable 
persons. To the extent possible the Secretary shall consult 
with a person or entity described in the previous sentence, 
other than a dialysis facility, that has not received industry 
funding from a drug or biological manufacturer or dialysis 
facility. 
‘‘(4) In promulgating regulations to carry out this sub-
section, the Secretary shall ensure that each individual who 
is eligible for benefits for kidney disease education services 
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under this title receives such services in a timely manner 
to maximize the benefit of those services. 
‘‘(5) The Secretary shall monitor the implementation 
of this subsection to ensure that individuals who are eligible 
for benefits for kidney disease education services receive 
such services in the manner described in paragraph (4). 
‘‘(6) No individual shall be eligible to be provided more 
than 6 sessions of kidney disease education services under 
this title.’’. 
(3) PAYMENT
UNDER
THE
PHYSICIAN
FEE 
SCHEDULE.—Section 1848(j)(3) of the Social Security 
Act (42 U.S.C. 1395w–4(j)(3)) is amended by insert-
ing ‘‘(2)(DD),’’ after ‘‘(2)(AA),’’. 
(4) LIMITATION ON NUMBER OF SESSIONS.—Sec-
tion 1862(a)(1) of the Social Security Act (42 U.S.C. 
1395y(a)(1)) is amended— 
(A) in subparagraph (M), by striking 
‘‘and’’ at the end; 
(B) in subparagraph (N), by striking the 
semicolon at the end and inserting ‘‘, and’’; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(O) in the case of kidney disease education serv-
ices (as defined in section 1861(ggg)), which are fur-
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nished in excess of the number of sessions covered 
under such section;’’. 
(5) GAO REPORT.—Not later than September 1, 
2010, the Comptroller General of the United States 
shall submit to Congress a report on the following: 
(A) The number of Medicare beneficiaries 
who are eligible to receive benefits for kidney dis-
ease education services (as defined in section 
1861(ggg) of the Social Security Act, as added 
by paragraph (2)) under title XVIII of such Act 
and who receive such services. 
(B) The extent to which there is a sufficient 
amount of physicians, physician assistants, 
nurse practitioners, and clinical nurse specialists 
to furnish kidney disease education services (as 
so defined) under such title and whether or not 
renal dialysis facilities (and appropriate em-
ployees of such facilities) should be included as 
an entity eligible under such section to furnish 
such services. 
(C) Recommendations, if appropriate, for 
renal dialysis facilities (and appropriate em-
ployees of such facilities) to structure kidney dis-
ease education services (as so defined) in a man-
ner that is objective and unbiased and that pro-
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vides a range of options and alternative loca-
tions for renal replacement therapy and manage-
ment of co-morbidities that may delay the need 
for dialysis. 
(b) EFFECTIVE DATE.—The amendments made by this 
section shall apply to services furnished on or after January 
1, 2009. 
SEC. 633. REQUIRED TRAINING FOR PATIENT CARE DIALY-
SIS TECHNICIANS. 
Section 1881 of the Social Security Act (42 U.S.C. 
1395rr) is amended by adding the following new subsection: 
‘‘(h)(1) Except as provided in paragraph (2), a pro-
vider of services or a renal dialysis facility may not use, 
for more than 12 months during 2009, or for any period 
beginning on January 1, 2010, any individual as a patient 
care dialysis technician unless the individual— 
‘‘(A) has completed a training program in the 
care and treatment of an individual with chronic kid-
ney failure who is undergoing dialysis treatment; and 
‘‘(B) has been certified by a nationally recog-
nized certification entity for dialysis technicians. 
‘‘(2)(A) A provider of services or a renal dialysis facil-
ity may permit an individual enrolled in a training pro-
gram described in paragraph (1)(A) to serve as a patient 
care dialysis technician while they are so enrolled. 
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‘‘(B) The requirements described in subparagraphs 
(A), (B), and (C) of paragraph (1) do not apply to an indi-
vidual who has performed dialysis-related services for at 
least 5 years. 
‘‘(3) For purposes of paragraph (1), if, since the most 
recent completion by an individual of a training program 
described in paragraph (1)(A), there has been a period of 
24 consecutive months during which the individual has not 
furnished dialysis-related services for monetary compensa-
tion, such individual shall be required to complete a new 
training program or become recertified as described in 
paragraph (1)(B). 
‘‘(4) A provider of services or a renal dialysis facility 
shall provide such regular performance review and regular 
in-service education as assures that individuals serving as 
patient care dialysis technicians for the provider or facility 
are competent to perform dialysis-related services.’’. 
SEC. 634. MEDPAC REPORT ON TREATMENT MODALITIES 
FOR PATIENTS WITH KIDNEY FAILURE. 
(a) EVALUATION.— 
(1) IN GENERAL.—Not later than March 1, 2009, 
the Medicare Payment Advisory Commission (estab-
lished under section 1805 of the Social Security Act) 
shall submit to the Secretary and Congress a report 
evaluating the barriers that exist to increasing the 
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number of individuals with end-stage renal disease 
who elect to receive home dialysis services under the 
Medicare program under title XVIII of the Social Se-
curity Act (42 U.S.C. 1395 et seq.). 
(2) REPORT DETAILS.—The report shall include 
the following: 
(A) A review of Medicare home dialysis 
demonstration projects initiated before the date 
of the enactment of this Act, and the results of 
such demonstration projects and recommenda-
tions for future Medicare home dialysis dem-
onstration projects or Medicare program changes 
that will test models that can improve Medicare 
beneficiary access to home dialysis. 
(B) A comparison of current Medicare home 
dialysis costs and payments with current in-cen-
ter and hospital dialysis costs and payments. 
(C) An analysis of the adequacy of Medicare 
reimbursement for patient training for home di-
alysis (including hemodialysis and peritoneal di-
alysis) and recommendations for ensuring ap-
propriate payment for such home dialysis train-
ing. 
(D) A catalogue and evaluation of the in-
centives and disincentives in the current reim-
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bursement system that influence whether patients 
receive home dialysis services or other treatment 
modalities. 
(E) An evaluation of patient education 
services and how such services impact the treat-
ment choices made by patients. 
(F) Recommendations for implementing in-
centives to encourage patients to elect to receive 
home dialysis services or other treatment modali-
ties under the Medicare program 
(3) SCOPE OF REVIEW.—In preparing the report 
under paragraph (1), the Medicare Payment Advisory 
Commission shall consider a variety of perspectives, 
including the perspectives of physicians, other health 
care professionals, hospitals, dialysis facilities, health 
plans, purchasers, and patients. 
SEC. 635. ADJUSTMENT FOR ERYTHROPOIETIN STIMU-
LATING AGENTS (ESAS). 
(a) IN GENERAL.—Subsection (b)(13) of section 1881 
of the Social Security Act (42 U.S.C. 1395rr) is amended— 
(1) in subparagraph (A)(iii), by striking ‘‘For 
such drugs’’ and inserting ‘‘Subject to subparagraph 
(C), for such drugs’’; and 
(2) by adding at the end the following new sub-
paragraph: 
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‘‘(C)(i) The payment amounts under this title for 
erythropoietin furnished during 2008 or 2009 to an indi-
vidual with end stage renal disease by a large dialysis facil-
ity (as defined in subparagraph (D)) (whether to individ-
uals in the facility or at home), in an amount equal to 
$8.75 per thousand units (rounded to the nearest 100 units) 
or, if less, 102 percent of the average sales price (as deter-
mined under section 1847A) for such drug or biological. 
‘‘(ii) The payment amounts under this title for 
darbepoetin alfa furnished during 2008 or 2009 to an indi-
vidual with end stage renal disease by a large dialysis facil-
ity (as defined in clause (iii)) (whether to individuals in 
the facility or at home), in an amount equal to $2.92 per 
microgram or, if less, 102 percent of the average sales price 
(as determined under section 1847A) for such drug or bio-
logical. 
‘‘(iii) For purposes of this subparagraph, the term 
‘large dialysis facility’ means a provider of services or renal 
dialysis facility that is owned or managed by a corporate 
entity that, as of July 24, 2007, owns or manages 300 or 
more such providers or facilities, and includes a successor 
to such a corporate entity.’’. 
(b) NO IMPACT ON DRUG ADD-ON PAYMENT.—Nothing 
in the amendments made by subsection (a) shall be con-
strued to affect the amount of any payment adjustment 
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made under section 1881(b)(12)(B)(ii) of the Social Secu-
rity Act (42 U.S.C. 1395rr(b)(12)(B)(ii)). 
SEC. 636. SITE NEUTRAL COMPOSITE RATE. 
Subsection (b)(12)(A) of section 1881 of the Social Se-
curity Act (42 U.S.C. 1395rr) is amended by adding at the 
end the following new sentence: ‘‘Under such system the 
payment rate for dialysis services furnished on or after 
January 1, 2008, by providers of such services for hospital- 
based facilities shall be the same as the payment rate (com-
puted without regard to this sentence) for such services fur-
nished by renal dialysis facilities that are not hospital- 
based, except that in applying the geographic index under 
subparagraph (D) to hospital-based facilities, the labor 
share shall be based on the labor share otherwise applied 
for such facilities.’’. 
SEC. 637. DEVELOPMENT OF ESRD BUNDLING SYSTEM AND 
QUALITY INCENTIVE PAYMENTS. 
(a) DEVELOPMENT OF ESRD BUNDLING SYSTEM.— 
Subsection (b) of section 1881 of the Social Security Act 
(42 U.S.C. 1395rr) is further amended— 
(1) in paragraph (12)(A), by striking ‘‘In lieu of 
payment’’ and inserting ‘‘Subject to paragraph (14), 
in lieu of payment’’; 
(2) in the second sentence of paragraph 
(12)(F)— 
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(A) by inserting ‘‘or paragraph (14)’’ after 
‘‘this paragraph’’; and 
(B) by inserting ‘‘or under the system under 
paragraph (14)’’ after ‘‘subparagraph (B)’’; 
(3) in paragraph (12)(H)— 
(A) by inserting ‘‘or paragraph (14)’’ after 
‘‘under this paragraph’’ the first place it ap-
pears; and 
(B) by inserting before the period at the end 
the following: ‘‘or, under paragraph (14), the 
identification of renal dialysis services included 
in the bundled payment, the adjustment for 
outliers, the identification of facilities to which 
the phase-in may apply, and the determination 
of payment amounts under subparagraph (A) 
under such paragraph, and the application of 
paragraph (13)(C)(iii)’’; 
(4) in paragraph (13)— 
(A) in subparagraph (A), by striking ‘‘The 
payment amounts’’ and inserting ‘‘subject to 
paragraph (14), the payment amounts’’; and 
(B) in subparagraph (B)— 
(i) in clause (i), by striking ‘‘(i)’’ after 
‘‘(B)’’ and by inserting ‘‘, subject to para-
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361 
graph (14)’’ before the period at the end; 
and 
(ii) by striking clause (ii); and 
(5) by adding at the end the following new para-
graph: 
‘‘(14)(A) Subject to subparagraph (E), for services fur-
nished on or after January 1, 2010, the Secretary shall im-
plement a payment system under which a single payment 
is made under this title for renal dialysis services (as de-
fined in subparagraph (B)) in lieu of any other payment 
(including a payment adjustment under paragraph 
(12)(B)(ii)) for such services and items furnished pursuant 
to paragraph (4). In implementing the system the Secretary 
shall ensure that the estimated total amount of payments 
under this title for 2010 for renal dialysis services shall 
equal 96 percent of the estimated amount of payments for 
such services, including payments under paragraph 
(12)(B)(ii), that would have been made if such system had 
not been implemented. 
‘‘(B) For purposes of this paragraph, the term ‘renal 
dialysis services’ includes— 
‘‘(i) items and services included in the com-
posite rate for renal dialysis services as of De-
cember 31, 2009; 
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‘‘(ii) erythropoietin stimulating agents fur-
nished to individuals with end stage renal dis-
ease; 
‘‘(iii) other drugs and biologicals and diag-
nostic laboratory tests, that the Secretary identi-
fies as commonly used in the treatment of such 
patients and for which payment was (before the 
application of this paragraph) made separately 
under this title, and any oral equivalent form of 
such drugs and biologicals or of drugs and 
biologicals described in clause (ii); and 
‘‘(iv) home dialysis training for which pay-
ment was (before the application of this para-
graph) made separately under this section. 
Such term does not include vaccines. 
‘‘(C) The system under this paragraph may provide 
for payment on the basis of services furnished during a week 
or month or such other appropriate unit of payment as the 
Secretary specifies. 
‘‘(D) Such system— 
‘‘(i) shall include a payment adjustment based 
on case mix that may take into account patient 
weight, body mass index, comorbidities, length of time 
on dialysis, age, race, ethnicity, and other appro-
priate factors; 
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