282 
(2) in clause (iv), in the heading, by inserting 
‘‘AFTER TRANSFER OF TITLE’’ after ‘‘SERVICING’’; and 
(3) by adding at the end the following new 
clause: 
‘‘(v) MAINTENANCE AND SERVICING OF 
GROUP 3 SUPPORT SURFACE IF INDIVIDUAL 
REJECTS TRANSFER OF TITLE.—In the case 
of a Group 3 Support Surface for which the 
individual has rejected transfer of title 
under subclause (ii)(II)— 
‘‘(I) during the first 6-month pe-
riod of medical need that follows the 
period of medical need during which 
payment is made under clause (i), no 
payment shall be made for rental or 
maintenance and servicing of the 
Group 3 Support Surface; and 
‘‘(II) during the first month of 
each succeeding 6-month period of 
medical need, a maintenance and serv-
icing payment may be made (for parts 
and labor not covered by the supplier’s 
or manufacturer’s warranty, as deter-
mined by the Secretary to be appro-
priate for the Group 3 Support Sur-
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00282
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
283 
face) and the amount recognized for 
each such 6-month period is the lower 
of— 
‘‘(aa) a reasonable and nec-
essary maintenance and servicing 
fee or fees established by the Sec-
retary; or 
‘‘(bb) 10 percent of the total 
of the purchase price recognized 
under paragraph (8) with respect 
to the Group 3 Support Surface.’’. 
(b) EFFECTIVE DATE.—The amendments made by this 
section shall take effect on the date of enactment of this Act. 
SEC. 
1142. 
EXTENSION 
OF 
PAYMENT 
RULE 
FOR 
BRACHYTHERAPY. 
Section 1833(t)(16)(C) of the Social Security Act (42 
U.S.C. 1395l(t)(16)(C)), as amended by section 142 of the 
Medicare Improvements for Patients and Providers Act of 
2008 (Public Law 110–275), is amended by striking, the 
first place it appears, ‘‘January 1, 2010’’ and inserting 
‘‘January 1, 2012’’. 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00283
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
284 
SEC. 1143. HOME INFUSION THERAPY REPORT TO CON-
GRESS. 
Not later than 12 months after the date of enactment 
of this Act, the Medicare Payment Advisory Commission 
shall submit to Congress a report on the following: 
(1) The scope of coverage for home infusion ther-
apy in the fee-for-service Medicare program under 
title XVIII of the Social Security Act, Medicare Ad-
vantage under part C of such title, the veteran’s 
health care program under chapter 17 of title 38, 
United States Code, and among private payers, in-
cluding an analysis of the scope of services provided 
by home infusion therapy providers to their patients 
in such programs. 
(2) The benefits and costs of providing such cov-
erage under the Medicare program, including a cal-
culation of the potential savings achieved through 
avoided or shortened hospital and nursing home stays 
as a result of Medicare coverage of home infusion 
therapy. 
(3) An assessment of sources of data on the costs 
of home infusion therapy that might be used to con-
struct payment mechanisms in the Medicare program. 
(4) Recommendations, if any, on the structure of 
a payment system under the Medicare program for 
home infusion therapy, including an analysis of the 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00284
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
285 
payment methodologies used under Medicare Advan-
tage plans and private health plans for the provision 
of home infusion therapy and their applicability to 
the Medicare program. 
SEC. 1144. REQUIRE AMBULATORY SURGICAL CENTERS 
(ASCS) TO SUBMIT COST DATA AND OTHER 
DATA. 
(a) COST REPORTING.— 
(1) IN GENERAL.—Section 1833(i) of the Social 
Security Act (42 U.S.C. 1395l(i)) is amended by add-
ing at the end the following new paragraph: 
‘‘(8) The Secretary shall require, as a condition of the 
agreement described in section 1832(a)(2)(F)(i), the submis-
sion of such cost report as the Secretary may specify, taking 
into account the requirements for such reports under section 
1815 in the case of a hospital.’’. 
(2) DEVELOPMENT OF COST REPORT.—Not later 
than 3 years after the date of the enactment of this 
Act, the Secretary of Health and Human Services 
shall develop a cost report form for use under section 
1833(i)(8) of the Social Security Act, as added by 
paragraph (1). 
(3) AUDIT REQUIREMENT.—The Secretary shall 
provide for periodic auditing of cost reports submitted 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00285
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
286 
under section 1833(i)(8) of the Social Security Act, as 
added by paragraph (1). 
(4) EFFECTIVE DATE.—The amendment made by 
paragraph (1) shall apply to agreements applicable to 
cost reporting periods beginning 18 months after the 
date the Secretary develops the cost report form under 
paragraph (2). 
(b) ADDITIONAL DATA ON QUALITY.— 
(1) IN GENERAL.—Section 1833(i)(7) of such Act 
(42 U.S.C. 1395l(i)(7)) is amended— 
(A) in subparagraph (B), by inserting ‘‘sub-
ject to subparagraph (C),’’ after ‘‘may otherwise 
provide,’’; and 
(B) by adding at the end the following new 
subparagraph: 
‘‘(C) Under subparagraph (B) the Secretary shall re-
quire the reporting of such additional data relating to qual-
ity of services furnished in an ambulatory surgical facility, 
including data on health care associated infections, as the 
Secretary may specify.’’. 
(2) EFFECTIVE DATE.—The amendment made by 
paragraph (1) shall to reporting for years beginning 
with 2012. 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00286
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
287 
SEC. 1145. TREATMENT OF CERTAIN CANCER HOSPITALS. 
Section 1833(t) of the Social Security Act (42 U.S.C. 
1395l(t)) is amended by adding at the end the following 
new paragraph: 
‘‘(18) AUTHORIZATION
OF
ADJUSTMENT
FOR 
CANCER HOSPITALS.— 
‘‘(A) STUDY.—The Secretary shall conduct 
a study to determine if, under the system under 
this subsection, costs incurred by hospitals de-
scribed in section 1886(d)(1)(B)(v) with respect 
to ambulatory payment classification groups ex-
ceed those costs incurred by other hospitals fur-
nishing services under this subsection (as deter-
mined appropriate by the Secretary). 
‘‘(B) AUTHORIZATION
OF
ADJUSTMENT.— 
Insofar as the Secretary determines under sub-
paragraph (A) that costs incurred by hospitals 
described in section 1886(d)(1)(B)(v) exceed those 
costs incurred by other hospitals furnishing serv-
ices under this subsection, the Secretary shall 
provide for an appropriate adjustment under 
paragraph (2)(E) to reflect those higher costs ef-
fective for services furnished on or after January 
1, 2011.’’. 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00287
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
288 
SEC. 1146. MEDICARE IMPROVEMENT FUND. 
Section 1898(b)(1)(A) of the Social Security Act (42 
U.S.C. 1395iii(b)(1)(A)) is amended to read as follows: 
‘‘(A) the period beginning with fiscal year 
2011 and ending with fiscal year 2019, 
$8,000,000,000; and’’. 
SEC. 1147. PAYMENT FOR IMAGING SERVICES. 
(a) ADJUSTMENT IN PRACTICE EXPENSE TO REFLECT 
HIGHER PRESUMED UTILIZATION.—Section 1848 of the 
Social Security Act (42 U.S.C. 1395w) is amended— 
(1) in subsection (b)(4)— 
(A) in subparagraph (B), by striking ‘‘sub-
paragraph (A)’’ and inserting ‘‘this paragraph’’; 
and 
(B) by adding at the end the following new 
subparagraph: 
‘‘(C) ADJUSTMENT IN PRACTICE EXPENSE 
TO REFLECT HIGHER PRESUMED UTILIZATION.— 
In computing the number of practice expense rel-
ative value units under subsection (c)(2)(C)(ii) 
with respect to advanced diagnostic imaging 
services (as defined in section 1834(e)(1)(B)) , 
the Secretary shall adjust such number of units 
so it reflects a 75 percent (rather than 50 per-
cent) presumed rate of utilization of imaging 
equipment.’’; and 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00288
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
289 
(2) in subsection (c)(2)(B)(v)(II), by inserting 
‘‘AND
OTHER
PROVISIONS’’ after ‘‘OPD PAYMENT 
CAP’’. 
(b) ADJUSTMENT IN TECHNICAL COMPONENT ‘‘DIS-
COUNT’’ ON SINGLE-SESSION IMAGING TO CONSECUTIVE 
BODY PARTS.—Section 1848(b)(4) of such Act is further 
amended by adding at the end the following new subpara-
graph: 
‘‘(D) ADJUSTMENT IN TECHNICAL COMPO-
NENT DISCOUNT ON SINGLE-SESSION IMAGING IN-
VOLVING CONSECUTIVE BODY PARTS.—The Sec-
retary shall increase the reduction in expendi-
tures attributable to the multiple procedure pay-
ment reduction applicable to the technical com-
ponent for imaging under the final rule pub-
lished by the Secretary in the Federal Register 
on November 21, 2005 (part 405 of title 42, Code 
of Federal Regulations) from 25 percent to 50 
percent.’’. 
(c) EFFECTIVE DATE.—Except as otherwise provided, 
this section, and the amendments made by this section, shall 
apply to services furnished on or after January 1, 2011. 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00289
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
290 
SEC. 1148. DURABLE MEDICAL EQUIPMENT PROGRAM IM-
PROVEMENTS. 
(a) WAIVER OF SURETY BOND REQUIREMENT.—Sec-
tion 1834(a)(16) of the Social Security Act (42 U.S.C. 
1395m(a)(16)) is amended by adding at the end the fol-
lowing: ‘‘The requirement for a surety bond described in 
subparagraph (B) shall not apply in the case of a pharmacy 
(i) that has been enrolled under section 1866(j) as a sup-
plier of durable medical equipment, prosthetics, orthotics, 
and supplies and has been issued (which may include re-
newal of) a provider number (as described in the first sen-
tence of this paragraph) for at least 5 years, and (ii) for 
which a final adverse action (as defined in section 
424.57(a) of title 42, Code of Federal Regulations) has never 
been imposed.’’. 
(b) ENSURING SUPPLY OF OXYGEN EQUIPMENT .— 
(1) IN GENERAL.—Section 1834(a)(5)(F) of the 
Social Security Act (42 U.S.C. 1395m(a)(5)(F)) is 
amended— 
(A) in clause (ii), by striking ‘‘After the’’ 
and inserting ‘‘Except as provided in clause 
(iii), after the’’; and 
(B) by adding at the end the following new 
clause: 
‘‘(iii) CONTINUATION OF SUPPLY.—In 
the case of a supplier furnishing such equip-
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00290
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
291 
ment to an individual under this subsection 
as of the 27th month of the 36 months de-
scribed in clause (i), the supplier furnishing 
such equipment as of such month shall con-
tinue to furnish such equipment to such in-
dividual (either directly or though arrange-
ments with other suppliers of such equip-
ment) during any subsequent period of med-
ical need for the remainder of the reasonable 
useful lifetime of the equipment, as deter-
mined by the Secretary, regardless of the lo-
cation of the individual, unless another sup-
plier has accepted responsibility for con-
tinuing to furnish such equipment during 
the remainder of such period.’’. 
(2) EFFECTIVE DATE.—The amendments made 
by paragraph (1) shall take effect as of the date of the 
enactment of this Act and shall apply to the fur-
nishing of equipment to individuals for whom the 
27th month of a continuous period of use of oxygen 
equipment described in section 1834(a)(5)(F) of the 
Social Security Act occurs on or after July 1, 2010. 
(c) TREATMENT OF CURRENT ACCREDITATION APPLI-
CATIONS.—Section 1834(a)(20)(F) of such Act (42 U.S.C. 
1395m(a)(20)(F)) is amended— 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00291
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
292 
(1) in clause (i)— 
(A) by striking ‘‘clause (ii)’’ and inserting 
‘‘clauses (ii) and (iii)’’; and 
(B) by striking ‘‘and’’ at the end; 
(2) by striking the period at the end of clause 
(ii)(II) and by inserting ‘‘; and’’; and 
(3) by adding at the end the following: 
‘‘(iii) the requirement for accreditation 
described in clause (i) shall not apply for 
purposes of supplying diabetic testing sup-
plies, canes, and crutches in the case of a 
pharmacy that is enrolled under section 
1866(j) as a supplier of durable medical 
equipment, prosthetics, orthotics, and sup-
plies. 
Any supplier that has submitted an application 
for accreditation before August 1, 2009, shall be 
deemed as meeting applicable standards and ac-
creditation requirement under this subparagraph 
until such time as the independent accreditation 
organization takes action on the supplier’s appli-
cation.’’. 
(d) RESTORING 36-MONTH OXYGEN RENTAL PERIOD 
IN CASE OF SUPPLIER BANKRUPTCY FOR CERTAIN INDIVID-
UALS.—Section 1834(a)(5)(F) of such Act (42 U.S.C. 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00292
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
293 
1395m(a)(5)(F)) is amended by adding at the end the fol-
lowing new clause: 
‘‘(iv) EXCEPTION FOR BANKRUPTCY.— 
If a supplier of oxygen to an individual is 
declared bankrupt and its assets are liq-
uidated and at the time of such declaration 
and liquidation more than 24 months of 
rental payments have been made, the indi-
vidual may begin under this subparagraph 
a new 36-month rental period with another 
supplier of oxygen.’’. 
(e) PAYMENT ADJUSTMENT.—Section 1834(a)(14)(K) 
of such Act (42 U.S.C. 1395m(a)(14)(K)), as amended by 
section 1131(e), is amended by inserting before the semi-
colon at the end the following: ‘‘, -0.5 percent’’. 
SEC. 1149. MEDPAC STUDY AND REPORT ON BONE MASS 
MEASUREMENT. 
(a) IN GENERAL.—The Medicare Payment Advisory 
Commission shall conduct a study regarding bone mass 
measurement, including computed tomography, duel-energy 
x-ray absorptriometry, and vertebral fracture assessment. 
The study shall focus on the following: 
(1) An assessment of the adequacy of Medicare 
payment rates for such services, taking into account 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00293
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
294 
costs of acquiring the necessary equipment, profes-
sional work time, and practice expense costs. 
(2) The impact of Medicare payment changes 
since 2006 on beneficiary access to bone mass meas-
urement benefits in general and in rural and minor-
ity communities specifically. 
(3) A review of the clinically appropriate and 
recommended use among Medicare beneficiaries and 
how usage rates among such beneficiaries compares to 
such recommendations. 
(4) In conjunction with the findings under (3), 
recommendations, if necessary, regarding methods for 
reaching appropriate use of bone mass measurement 
studies among Medicare beneficiaries. 
(b) REPORT.—The Commission shall submit a report 
to the Congress, not later than 9 months after the date of 
the enactment of this Act, containing a description of the 
results of the study conducted under subsection (a) and the 
conclusions and recommendations, if any, regarding each 
of the issues described in paragraphs (1), (2) (3) and (4) 
of such subsection. 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00294
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
295 
SEC. 1149A. EXCLUSION OF CUSTOMARY PROMPT PAY DIS-
COUNTS EXTENDED TO WHOLESALERS FROM 
MANUFACTURER’S AVERAGE SALES PRICE 
FOR 
PAYMENTS 
FOR 
DRUGS 
AND 
BIOLOGICALS UNDER MEDICARE PART B. 
Section 1847A(c)(3) of the Social Security Act (42 
U.S.C. 1395w–3a(c)(3)) is amended— 
(1) in the first sentence, by inserting after 
‘‘prompt pay discounts’’ the following: ‘‘(other than, 
for drugs and biologicals that are sold on or after 
January 1, 2011, and before January 1, 2016, cus-
tomary prompt pay discounts extended to wholesalers, 
but only to the extent such discounts do not exceed 2 
percent of the wholesale acquisition cost)’’; and 
(2) in the second sentence, by inserting after 
‘‘other price concessions’’ the following: ‘‘(other than, 
for drugs and biologicals that are sold on or after 
January 1, 2011, and before January 1, 2016, cus-
tomary prompt pay discounts extended to wholesalers, 
but only to the extent such discounts do not exceed 2 
percent of the wholesale acquisition cost)’’. 
SEC. 1149B. TIMELY ACCESS TO POSTMASTECTOMY ITEMS. 
(a) IN GENERAL.—Section 1834(h)(1) of the Social Se-
curity Act (42 U.S.C. 1395m(h)(1)) is amended— 
(1) by redesignating subparagraph (H) as sub-
paragraph (I); and 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00295
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
296 
(2) by inserting after subparagraph (G) the fol-
lowing new subparagraph: 
‘‘(H) 
SPECIAL
PAYMENT
RULE
FOR 
POSTMASTECTOMY
EXTERNAL
BREAST
PROS-
THESIS
GARMENTS.—Payment 
for 
postmastectomy external breast prosthesis gar-
ments shall be made regardless of whether such 
items are supplied to the beneficiary prior to or 
after the mastectomy procedure or other breast 
cancer surgical procedure. The Secretary shall 
develop policies to ensure appropriate beneficiary 
access and utilization safeguards for such items 
supplied to a beneficiary prior to the mastec-
tomy or other breast cancer surgical procedure.’’ 
(b) EFFECTIVE DATE.—The amendment made by sub-
section (a) shall take effect the date of the enactment of this 
Act. 
SEC. 1149C. MORATORIUM ON MEDICARE REDUCTIONS IN 
PAYMENT 
RATES 
FOR 
CERTAIN 
INTER-
VENTIONAL 
PAIN 
MANAGEMENT 
PROCE-
DURES 
COVERED 
UNDER 
THE 
ASC 
FEE 
SCHEDULE. 
(a) IN GENERAL.—Notwithstanding any other provi-
sion of law, the payment rate applied under section 
1833(i)(2) of the Social Security Act (42 U.S.C. 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00296
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
297 
13951(i)(2)) for interventional pain management proce-
dures specified in subsection (b) which are furnished on or 
after January 1, 2010, and before January 1, 2012, shall 
not be less than the payment rate applied under such sec-
tion for such procedures in effect as of January 1, 2007. 
(b) PROCEDURES SPECIFIED.—For purposes of this 
section, the interventional pain management procedures 
specified in this subsection are the following: 
(1) Epidural injections (CPT 62310, 62311, 
64483, 64484). 
(2) Facet joint injections (CPT 64470, 64472, 
64475, 64476). 
(3) Sacroiliac joint injection (CPT 27096). 
SEC. 1149D. MEDICARE COVERAGE OF SERVICES OF QUALI-
FIED RESPIRATORY THERAPISTS PERFORMED 
UNDER THE GENERAL SUPERVISION OF A 
PHYSICIAN. 
(a) IN GENERAL.—Section 1861 of the Social Security 
Act (42 U.S.C. 1395x), as amended by sections 1233(a) and 
1309, is amended— 
(1) in subsection (s)(2)— 
(A) by striking ‘‘and’’ at the end of sub-
paragraph (GG); 
(B) by adding ‘‘and’’ at the end of subpara-
graph (HH); and 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00297
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
298 
(C) by adding at the end the following new 
subparagraph: 
‘‘(II) respiratory therapy services which would 
be physicians’ services if furnished by a physician (as 
defined in subsection (r)(1)) for the diagnosis and 
treatment of respiratory illnesses and which are per-
formed by a respiratory therapist (as defined in sub-
section (mmm)) under the general supervision of a 
physician and which the respiratory therapist is le-
gally authorized to perform by the State in which the 
services are performed, but only if no facility or other 
provider charges or is paid any amounts with respect 
to the furnishing of such services;’’; and 
(2) by adding after subsection (lll) the following 
new subsection: 
‘‘Respiratory Therapist 
‘‘(mmm) For purposes of subsection (s)(2)(II) and sec-
tion 1833(a)(1)(X) only, the term ‘respiratory therapist’ 
means an individual who— 
‘‘(1) is credentialed by a national credentialing 
board recognized by the Secretary; 
‘‘(2)(A) is licensed to practice respiratory ther-
apy in the State in which the respiratory therapy 
services are performed, or 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00298
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
299 
‘‘(B) in the case of an individual in a State 
which does not provide for such licensure, is legally 
authorized to perform respiratory therapy services (in 
the State in which the individual performed such 
services) under State law (or the State regulatory 
mechanism provided by State law); 
‘‘(3) is a registered respiratory therapist; and 
‘‘(4) holds a bachelor’s degree.’’. 
(b) PAYMENT.—Section 1833(a)(1) of such Act (42 
U.S.C. 1395l(a)(1)), as amended by sections 1309(a)(4) and 
1309(b)(4), is amended— 
(1) by striking ‘‘and’’ before ‘‘(Y)’’; and 
(2) by inserting before the semicolon at the end 
the following: ‘‘, and (Z) with respect to services de-
scribed in section 1861(s)(2)(II) (relating to services 
furnished by a respiratory therapist) that are fur-
nished by a respiratory therapist (as defined in sec-
tion 1861(mmm)), the amount paid shall be equal to 
80 percent of the lesser of the actual charge for the 
services or 85 percent of the fee schedule amount pro-
vided under section 1848 for the same services if fur-
nished by a physician’’. 
(c) EFFECTIVE DATE.—The amendments made by this 
section shall apply to services furnished on or after January 
1, 2010. 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00299
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
300 
Subtitle C—Provisions Related to 
Medicare Parts A and B 
SEC. 1151. REDUCING POTENTIALLY PREVENTABLE HOS-
PITAL READMISSIONS. 
(a) HOSPITALS.— 
(1) IN GENERAL.—Section 1886 of the Social Se-
curity Act (42 U.S.C. 1395ww), as amended by sec-
tion 1103(a), is amended by adding at the end the 
following new subsection: 
‘‘(p) ADJUSTMENT TO HOSPITAL PAYMENTS FOR EX-
CESS READMISSIONS.— 
‘‘(1) IN GENERAL.—With respect to payment for 
discharges from an applicable hospital (as defined in 
paragraph (5)(C)) occurring during a fiscal year be-
ginning on or after October 1, 2011, in order to ac-
count for excess readmissions in the hospital, the Sec-
retary shall reduce the payments that would otherwise 
be made to such hospital under subsection (d) (or sec-
tion 1814(b)(3), as the case may be) for such a dis-
charge by an amount equal to the product of— 
‘‘(A) the base operating DRG payment 
amount (as defined in paragraph (2)) for the 
discharge; and 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00300
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
301 
‘‘(B) the adjustment factor (described in 
paragraph (3)(A)) for the hospital for the fiscal 
year. 
‘‘(2) BASE OPERATING DRG PAYMENT AMOUNT.— 
‘‘(A) IN GENERAL.—Except as provided in 
subparagraph (B), for purposes of this sub-
section, the term ‘base operating DRG payment 
amount’ means, with respect to a hospital for a 
fiscal year, the payment amount that would oth-
erwise be made under subsection (d) for a dis-
charge if this subsection did not apply, reduced 
by any portion of such amount that is attrib-
utable to payments under subparagraphs (B) 
and (F) of paragraph (5). 
‘‘(B) ADJUSTMENTS.—For purposes of sub-
paragraph (A), in the case of a hospital that is 
paid under section 1814(b)(3), the term ‘base op-
erating DRG payment amount’ means the pay-
ment amount under such section. 
‘‘(3) ADJUSTMENT FACTOR.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph (1), the adjustment factor under this para-
graph for an applicable hospital for a fiscal year 
is equal to the greater of— 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00301
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
302 
‘‘(i) the ratio described in subpara-
graph (B) for the hospital for the applicable 
period (as defined in paragraph (5)(D)) for 
such fiscal year; or 
‘‘(ii) the floor adjustment factor speci-
fied in subparagraph (C). 
‘‘(B) RATIO.—The ratio described in this 
subparagraph for a hospital for an applicable 
period is equal to 1 minus the ratio of— 
‘‘(i) the aggregate payments for excess 
readmissions (as defined in paragraph 
(4)(A)) with respect to an applicable hos-
pital for the applicable period; and 
‘‘(ii) the aggregate payments for all 
discharges (as defined in paragraph (4)(B)) 
with respect to such applicable hospital for 
such applicable period. 
‘‘(C) FLOOR
ADJUSTMENT
FACTOR.—For 
purposes of subparagraph (A), the floor adjust-
ment factor specified in this subparagraph for— 
‘‘(i) fiscal year 2012 is 0.99; 
‘‘(ii) fiscal year 2013 is 0.98; 
‘‘(iii) fiscal year 2014 is 0.97; or 
‘‘(iv) a subsequent fiscal year is 0.95. 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00302
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
303 
‘‘(4) AGGREGATE PAYMENTS, EXCESS READMIS-
SION
RATIO
DEFINED.—For purposes of this sub-
section: 
‘‘(A) AGGREGATE
PAYMENTS
FOR
EXCESS 
READMISSIONS.—The term ‘aggregate payments 
for excess readmissions’ means, for a hospital for 
a fiscal year, the sum, for applicable conditions 
(as defined in paragraph (5)(A)), of the product, 
for each applicable condition, of— 
‘‘(i) the base operating DRG payment 
amount for such hospital for such fiscal 
year for such condition; 
‘‘(ii) the number of admissions for such 
condition for such hospital for such fiscal 
year; and 
‘‘(iii) the excess readmissions ratio (as 
defined in subparagraph (C)) for such hos-
pital for the applicable period for such fis-
cal year minus 1. 
‘‘(B) AGGREGATE PAYMENTS FOR ALL DIS-
CHARGES.—The term ‘aggregate payments for all 
discharges’ means, for a hospital for a fiscal 
year, the sum of the base operating DRG pay-
ment amounts for all discharges for all condi-
tions from such hospital for such fiscal year. 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00303
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
304 
‘‘(C) EXCESS READMISSION RATIO.— 
‘‘(i) IN GENERAL.—Subject to clauses 
(ii) and (iii), the term ‘excess readmissions 
ratio’ means, with respect to an applicable 
condition for a hospital for an applicable 
period, the ratio (but not less than 1.0) of— 
‘‘(I) the risk adjusted readmis-
sions based on actual readmissions, as 
determined consistent with a readmis-
sion measure methodology that has 
been 
endorsed 
under 
paragraph 
(5)(A)(ii)(I), for an applicable hospital 
for such condition with respect to the 
applicable period; to 
‘‘(II) the risk adjusted expected re-
admissions (as determined consistent 
with such a methodology) for such hos-
pital for such condition with respect to 
such applicable period. 
‘‘(ii) EXCLUSION
OF
CERTAIN
RE-
ADMISSIONS.—For purposes of clause (i), 
with respect to a hospital, excess readmis-
sions shall not include readmissions for an 
applicable condition for which there are 
fewer than a minimum number (as deter-
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00304
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
305 
mined by the Secretary) of discharges for 
such applicable condition for the applicable 
period and such hospital. 
‘‘(iii) ADJUSTMENT.—In order to pro-
mote a reduction over time in the overall 
rate of readmissions for applicable condi-
tions, the Secretary may provide, beginning 
with discharges for fiscal year 2014, for the 
determination of the excess readmissions 
ratio under subparagraph (C) to be based 
on a ranking of hospitals by readmission 
ratios (from lower to higher readmission ra-
tios) normalized to a benchmark that is 
lower than the 50th percentile. 
‘‘(5) DEFINITIONS.—For purposes of this sub-
section: 
‘‘(A) APPLICABLE
CONDITION.—The term 
‘applicable condition’ means, subject to subpara-
graph (B), a condition or procedure selected by 
the Secretary among conditions and procedures 
for which— 
‘‘(i) readmissions (as defined in sub-
paragraph (E)) that represent conditions or 
procedures that are high volume or high ex-
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00305
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
306 
penditures under this title (or other criteria 
specified by the Secretary); and 
‘‘(ii) measures of such readmissions— 
‘‘(I) have been endorsed by the en-
tity with a contract under section 
1890(a); and 
‘‘(II) such endorsed measures have 
appropriate exclusions for readmis-
sions that are unrelated to the prior 
discharge (such as a planned readmis-
sion or transfer to another applicable 
hospital). 
‘‘(B) EXPANSION
OF
APPLICABLE
CONDI-
TIONS.—Beginning with fiscal year 2013, the 
Secretary shall expand the applicable conditions 
beyond the 3 conditions for which measures have 
been endorsed as described in subparagraph 
(A)(ii)(I) as of the date of the enactment of this 
subsection to the additional 4 conditions that 
have been so identified by the Medicare Payment 
Advisory Commission in its report to Congress 
in June 2007 and to other conditions and proce-
dures which may include an all-condition meas-
ure of readmissions, as determined appropriate 
by the Secretary. In expanding such applicable 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00306
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
307 
conditions, the Secretary shall seek the endorse-
ment described in subparagraph (A)(ii)(I) but 
may apply such measures without such an en-
dorsement. 
‘‘(C) APPLICABLE
HOSPITAL.—The term 
‘applicable hospital’ means a subsection (d) hos-
pital or a hospital that is paid under section 
1814(b)(3). 
‘‘(D) APPLICABLE PERIOD.—The term ‘ap-
plicable period’ means, with respect to a fiscal 
year, such period as the Secretary shall specify 
for purposes of determining excess readmissions. 
‘‘(E) READMISSION.—The term ‘readmis-
sion’ means, in the case of an individual who is 
discharged from an applicable hospital, the ad-
mission of the individual to the same or another 
applicable hospital within a time period speci-
fied by the Secretary from the date of such dis-
charge. Insofar as the discharge relates to an ap-
plicable condition for which there is an endorsed 
measure described in subparagraph (A)(ii)(I), 
such time period (such as 30 days) shall be con-
sistent with the time period specified for such 
measure. 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00307
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
308 
‘‘(6) LIMITATIONS ON REVIEW.—There shall be 
no administrative or judicial review under section 
1869, section 1878, or otherwise of— 
‘‘(A) the determination of base operating 
DRG payment amounts; 
‘‘(B) the methodology for determining the 
adjustment factor under paragraph (3), includ-
ing excess readmissions ratio under paragraph 
(4)(C), aggregate payments for excess readmis-
sions under paragraph (4)(A), and aggregate 
payments for all discharges under paragraph 
(4)(B), and applicable periods and applicable 
conditions under paragraph (5); 
‘‘(C) the measures of readmissions as de-
scribed in paragraph (5)(A)(ii); and 
‘‘(D) the determination of a targeted hos-
pital under paragraph (8)(B)(i), the increase in 
payment under paragraph (8)(B)(ii), the aggre-
gate cap under paragraph (8)(C)(i), the hospital- 
specific limit under paragraph (8)(C)(ii), and 
the form of payment made by the Secretary 
under paragraph (8)(D). 
‘‘(7) MONITORING INAPPROPRIATE CHANGES IN 
ADMISSIONS PRACTICES.—The Secretary shall mon-
itor the activities of applicable hospitals to determine 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00308
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
309 
if such hospitals have taken steps to avoid patients at 
risk in order to reduce the likelihood of increasing re-
admissions for applicable conditions. If the Secretary 
determines that such a hospital has taken such a step, 
after notice to the hospital and opportunity for the 
hospital to undertake action to alleviate such steps, 
the Secretary may impose an appropriate sanction. 
‘‘(8) ASSISTANCE TO CERTAIN HOSPITALS.— 
‘‘(A) IN GENERAL.—For purposes of pro-
viding funds to applicable hospitals to take steps 
described in subparagraph (E) to address factors 
that may impact readmissions of individuals 
who are discharged from such a hospital, for fis-
cal years beginning on or after October 1, 2011, 
the Secretary shall make a payment adjustment 
for a hospital described in subparagraph (B), 
with respect to each such fiscal year, by a per-
cent estimated by the Secretary to be consistent 
with subparagraph (C). 
‘‘(B) 
TARGETED
HOSPITALS.—Subpara-
graph (A) shall apply to an applicable hospital 
that— 
‘‘(i) received (or, in the case of an 
1814(b)(3) hospital, otherwise would have 
been eligible to receive) $10,000,000 or more 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00309
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
310 
in disproportionate share payments using 
the latest available data as estimated by the 
Secretary; and 
‘‘(ii) provides assurances satisfactory 
to the Secretary that the increase in pay-
ment under this paragraph shall be used for 
purposes described in subparagraph (E). 
‘‘(C) CAPS.— 
‘‘(i) AGGREGATE CAP.—The aggregate 
amount of the payment adjustment under 
this paragraph for a fiscal year shall not 
exceed 5 percent of the estimated difference 
in the spending that would occur for such 
fiscal year with and without application of 
the adjustment factor described in para-
graph (3) and applied pursuant to para-
graph (1). 
‘‘(ii) HOSPITAL-SPECIFIC LIMIT.—The 
aggregate amount of the payment adjust-
ment for a hospital under this paragraph 
shall not exceed the estimated difference in 
spending that would occur for such fiscal 
year for such hospital with and without ap-
plication of the adjustment factor described 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00310
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
380 
full-benefit dual eligible individual (as defined in 
paragraph (6)(A)) for which payment was made by 
a PDP sponsor under part D or a MA organization 
under part C for such period. Such rebate shall be 
paid by the manufacturer to the Secretary not later 
than 30 days after the date of receipt of the informa-
tion described in section 1860D–12(b)(7), including 
as such section is applied under section 1857(f)(3). 
‘‘(3) REBATE FOR FULL-BENEFIT DUAL ELIGIBLE 
MEDICARE DRUG PLAN ENROLLEES.— 
‘‘(A) IN GENERAL.—The amount of the re-
bate specified under this paragraph for a manu-
facturer for a rebate period, with respect to each 
dosage form and strength of any covered part D 
drug provided by such manufacturer and dis-
pensed to a full-benefit dual eligible individual, 
shall be equal to the product of— 
‘‘(i) the total number of units of such 
dosage form and strength of the drug so pro-
vided and dispensed for which payment was 
made by a PDP sponsor under part D or 
a MA organization under part C for the re-
bate period (as reported under section 
1860D–12(b)(7), including as such section 
is applied under section 1857(f)(3)); and 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00380
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
381 
‘‘(ii) the amount (if any) by which— 
‘‘(I) the Medicaid rebate amount 
(as defined in subparagraph (B)) for 
such form, strength, and period, ex-
ceeds 
‘‘(II) the average Medicare drug 
program full-benefit dual eligible re-
bate amount (as defined in subpara-
graph (C)) for such form, strength, and 
period. 
‘‘(B) MEDICAID
REBATE
AMOUNT.—For 
purposes of this paragraph, the term ‘Medicaid 
rebate amount’ means, with respect to each dos-
age form and strength of a covered part D drug 
provided by the manufacturer for a rebate pe-
riod— 
‘‘(i) in the case of a single source drug 
or an innovator multiple source drug, the 
amount specified in paragraph (1)(A)(ii) of 
section 1927(c) plus the amount, if any, 
specified in paragraph (2)(A)(ii) of such 
section, for such form, strength, and period; 
or 
‘‘(ii) in the case of any other covered 
outpatient drug, the amount specified in 
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 00381
Fmt 6652
Sfmt 6203
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS
1981 
of relocating residents to 
home 
and 
community- 
based settings or another 
facility), projects that sup-
port resident and family 
councils and other con-
sumer involvement in as-
suring quality care in fa-
cilities, and facility im-
provement initiatives ap-
proved by the Secretary 
(including joint training 
of facility staff and sur-
veyors, 
technical 
assist-
ance for facilities under 
quality 
assurance 
pro-
grams, the appointment of 
temporary 
management, 
and other activities ap-
proved by the Secretary). 
‘‘(VIII) 
PROCEDURE.—The 
provisions of section 1128A 
(other than subsections (a) 
and (b) and except to the ex-
tent that such provisions re-
VerDate Nov 24 2008 
03:16 Oct 15, 2009
Jkt 089200
PO 00000
Frm 01981
Fmt 6652
Sfmt 6202
E:\BILLS\H3200.RH
H3200
bajohnson on DSK2BSOYB1PROD with BILLS