157 
(B) by striking ‘‘or (iii) on the basis’’ and 
all that follows before the comma at the end. 
(3) EFFECTIVE DATE.—The amendments made 
by this subsection shall take effect on the date of the 
enactment of this Act. 
(b) CLINICAL LABORATORY TEST FEE SCHEDULE 
UPDATE ADJUSTMENT.—Section 1833(h)(2)(A)(i) of the 
Social Security Act (42 U.S.C. 1395l(h)(2)(A)(ii)) is 
amended by inserting ‘‘minus, for each of the years 2009 
through 2013, 0.5 percentage points’’ after ‘‘city aver-
age)’’. 
SEC. 147. IMPROVED ACCESS TO AMBULANCE SERVICES. 
(a) EXTENSION
OF INCREASED MEDICARE PAY-
MENTS FOR GROUND AMBULANCE SERVICES.—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 preceding clause (i), by 
inserting ‘‘and for such services furnished on or 
after July 1, 2008, and before January 1, 
2010’’ after ‘‘2007,’’; 
(B) in clause (i), by inserting ‘‘(or 3 per-
cent if such service is furnished on or after July 
1, 2008, and before January 1, 2010)’’ after ‘‘2 
percent’’; and 
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(C) in clause (ii), by inserting ‘‘(or 2 per-
cent if such service is furnished on or after July 
1, 2008, and before January 1, 2010)’’ after ‘‘1 
percent’’; and 
(2) in subparagraph (B)— 
(A) in the heading, by striking ‘‘2006’’ and 
inserting ‘‘APPLICABLE PERIOD’’; and 
(B) by inserting ‘‘applicable’’ before ‘‘pe-
riod’’. 
(b) AIR AMBULANCE PAYMENT IMPROVEMENTS.— 
(1) TREATMENT OF CERTAIN AREAS FOR PAY-
MENT FOR AIR AMBULANCE SERVICES UNDER THE 
AMBULANCE FEE SCHEDULE.—Notwithstanding any 
other provision of law, for purposes of making pay-
ments under section 1834(l) of the Social Security 
Act (42 U.S.C. 1395m(l)) for air ambulance services 
furnished during the period beginning on July 1, 
2008, and ending on December 31, 2009, any area 
that was designated as a rural area for purposes of 
making payments under such section for air ambu-
lance services furnished on December 31, 2006, shall 
be treated as a rural area for purposes of making 
payments under such section for air ambulance serv-
ices furnished during such period. 
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(2) CLARIFICATION REGARDING SATISFACTION 
OF REQUIREMENT OF MEDICALLY NECESSARY.— 
(A) 
IN
GENERAL.—Section 
1834(l)(14)(B)(i) of the Social Security Act (42 
U.S.C. 1395m(l)(14)(B)(i)) is amended by 
striking ‘‘reasonably determines or certifies’’ 
and inserting ‘‘certifies or reasonably deter-
mines’’. 
(B) EFFECTIVE
DATE.—The amendment 
made by subparagraph (A) shall apply to serv-
ices furnished on or after the date of the enact-
ment of this Act. 
SEC. 148. EXTENSION AND EXPANSION OF THE MEDICARE 
HOLD HARMLESS PROVISION UNDER THE 
PROSPECTIVE PAYMENT SYSTEM FOR HOS-
PITAL OUTPATIENT DEPARTMENT (HOPD) 
SERVICES FOR CERTAIN HOSPITALS. 
Section 1833(t)(7)(D)(i) of the Social Security Act 
(42 U.S.C. 1395l(t)(7)(D)(i)) is amended— 
(1) in subclause (II)— 
(A) in the first sentence, by striking 
‘‘2009’’ and inserting ‘‘2010’’; and 
(B) by striking the second sentence and in-
serting the following new sentence: ‘‘For pur-
poses of the preceding sentence, the applicable 
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percentage shall be 95 percent with respect to 
covered OPD services furnished in 2006, 90 
percent with respect to such services furnished 
in 2007, and 85 percent with respect to such 
services furnished in 2008 or 2009.’’; and 
(2) by adding at the end the following new sub-
clause: 
‘‘(III) In the case of a sole community 
hospital 
(as 
defined 
in 
section 
1886(d)(5)(D)(iii)) that has not more than 
100 beds, for covered OPD services fur-
nished on or after January 1, 2009, and 
before January 1, 2010, for which the 
PPS amount is less than the pre-BBA 
amount, the amount of payment under this 
subsection shall be increased by 85 percent 
of the amount of such difference.’’. 
SEC. 149. CLARIFICATION OF PAYMENT FOR CLINICAL LAB-
ORATORY TESTS FURNISHED BY CRITICAL 
ACCESS HOSPITALS. 
(a) IN GENERAL.—Section 1834(g)(4) of the Social 
Security Act (42 U.S.C. 1395m(g)(4)) is amended— 
(1) in the heading, by striking ‘‘NO
BENE-
FICIARY COST-SHARING FOR’’ and inserting ‘‘TREAT-
MENT OF’’; and 
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(2) by adding at the end the following new sen-
tence: ‘‘For purposes of the preceding sentence and 
section 1861(mm)(3), clinical diagnostic laboratory 
services furnished by a critical access hospital shall 
be treated as being furnished as part of outpatient 
critical access services without regard to whether the 
individual with respect to whom such services are 
furnished is physically present in the critical access 
hospital, or in a skilled nursing facility or a clinic 
(including a rural health clinic) that is operated by 
a critical access hospital, at the time the specimen 
is collected.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
subsection (a) shall apply to services furnished on or after 
July 1, 2009. 
SEC. 150. ADDING CERTAIN ENTITIES AS ORIGINATING 
SITES FOR PAYMENT OF TELEHEALTH SERV-
ICES. 
(a) IN GENERAL.—Section 1834(m)(4)(C)(ii) of the 
Social Security Act (42 U.S.C. 1395m(m)(4)(C)(ii)) is 
amended by adding at the end the following new sub-
clauses: 
‘‘(VI) A hospital-based or critical 
access hospital-based renal dialysis 
center (including satellites). 
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‘‘(VII) A skilled nursing facility 
(as defined in section 1819(a)). 
‘‘(VIII) A community mental 
health center (as defined in section 
1861(ff)(3)(B)).’’. 
(b) 
CONFORMING
AMENDMENT.—Section 
1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C. 
1395yy(e)(2)(A)(ii)) is amended by inserting ‘‘telehealth 
services furnished under section 1834(m)(4)(C)(ii)(VII),’’ 
after ‘‘section 1861(s)(2),’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to services furnished on or after 
January 1, 2009. 
SEC. 151. MEDPAC STUDY AND REPORT ON IMPROVING 
CHRONIC 
CARE 
DEMONSTRATION 
PRO-
GRAMS. 
(a) STUDY.—The Medicare Payment Advisory Com-
mission shall conduct a study on the feasability and advis-
ability of establishing a Medicare Chronic Care Practice 
Research Network that would serve as a standing network 
of providers testing new models of care coordination and 
other care approaches for chronically ill beneficiaries, in-
cluding the initiation, operation, evaluation, and, if appro-
priate, expansion of such models to the broader Medicare 
patient population. 
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(b) REPORT.—Not later than June 15, 2009, the 
Medicare Payment Advisory Commission shall submit to 
Congress a report containing the results of the study con-
ducted under subsection (a). 
SEC. 152. INCREASE OF FQHC PAYMENT LIMITS. 
(a) IN GENERAL.—Section 1833 of the Social Secu-
rity Act (42 U.S.C. 1395l), as amended by section 133(a), 
is amended by adding at the end the following new sub-
section: 
‘‘(w) INCREASE OF FQHC PAYMENT LIMITS.—In the 
case of services furnished by federally qualified health cen-
ters (as defined in section 1861(aa)(4)), the Secretary 
shall establish payment limits with respect to such services 
under this part for services furnished— 
‘‘(1) in 2010, at the limits otherwise established 
under this part for such year increased by $5; and 
‘‘(2) in a subsequent year, at the limits estab-
lished under this subsection for the previous year in-
creased by the percentage increase in the MEI (as 
defined in section 1842(i)(3)) for such subsequent 
year.’’. 
(b) STUDY AND REPORT ON THE EFFECTS AND ADE-
QUACY
OF
THE
MEDICARE
FEDERALLY
QUALIFIED 
HEALTH CENTER PAYMENT STRUCTURE.— 
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164 
(1) STUDY.—The Comptroller General of the 
United States shall conduct a study to determine 
whether the structure for payments for services fur-
nished by federally qualified health centers (as de-
fined in section 1861(aa)(4) of the Social Security 
Act (42 U.S.C. 1395x(aa)(4)) under part B of title 
XVIII of the Social Security Act (42 U.S.C. 1395j 
et seq.) adequately reimburses federally qualified 
health centers for the care furnished to Medicare 
beneficiaries. In conducting such study, the Comp-
troller General shall— 
(A) use the most current cost report data 
available; 
(B) examine the effects of the payment 
limits established with respect to such services 
under such part B on the ability of federally 
qualified health centers to furnish care to Medi-
care beneficiaries; and 
(C) examine the cost of furnishing services 
covered under the Medicare program as of the 
date of the enactment of this Act that were not 
covered under such program as of the date on 
which the Secretary determined the payment 
rate for federally qualified health centers in 
1991. 
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(2) REPORT.—Not later than 15 months after 
the date of the enactment of this Act, the Comp-
troller General of the United States shall submit to 
Congress a report on the study conducted under 
paragraph (1), together with recommendations for 
such legislation and administrative action the Comp-
troller General determines appropriate, taking into 
consideration the structure and adequacy of the pro-
spective payment methodology used to make pay-
ments to federally qualified health centers under the 
Medicaid program under title XIX of the Social Se-
curity Act (42 U.S.C. 1396 et seq.). 
SEC. 153. KIDNEY DISEASE EDUCATION AND AWARENESS 
PROVISIONS. 
(a) CHRONIC KIDNEY DISEASE INITIATIVES.—Part 
P of title III of the Public Health Service Act (42 U.S.C. 
280g et seq.) is amended by adding at the end the fol-
lowing new section: 
‘‘SEC. 399R. CHRONIC KIDNEY DISEASE INITIATIVES. 
‘‘(a) IN GENERAL.—The Secretary shall establish 
pilot projects to— 
‘‘(1) increase public and medical community 
awareness (particularly of those who treat patients 
with diabetes and hypertension) regarding chronic 
kidney disease, focusing on prevention; 
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‘‘(2) increase screening for chronic kidney dis-
ease, focusing on Medicare beneficiaries at risk of 
chronic kidney disease; and 
‘‘(3) enhance surveillance systems to better as-
sess the prevalence and incidence of chronic kidney 
disease. 
‘‘(b) SCOPE AND DURATION.— 
‘‘(1) SCOPE.—The Secretary shall select at 
least 3 States in which to conduct pilot projects 
under this section. 
‘‘(2) DURATION.—The pilot projects under this 
section shall be conducted for a period that is not 
longer than 5 years and shall begin on January 1, 
2009. 
‘‘(c) EVALUATION AND REPORT.—The Comptroller 
General of the United States shall conduct an evaluation 
of the pilot projects conducted under this section. Not 
later than 12 months after the date on which the pilot 
projects are completed, the Comptroller General shall sub-
mit to Congress a report on the evaluation. 
‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There 
are authorized to be appropriated such sums as may be 
necessary for the purpose of carrying out this section.’’. 
(b) MEDICARE COVERAGE OF KIDNEY DISEASE PA-
TIENT EDUCATION SERVICES.— 
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(1) COVERAGE OF KIDNEY DISEASE EDUCATION 
SERVICES.— 
(A) COVERAGE.—Section 1861(s)(2) of the 
Social Security Act (42 U.S.C. 1395x(s)(2)), as 
amended by section 144(a), is amended— 
(i) in subparagraph (BB), by striking 
‘‘and’’ after the semicolon at the end; 
(ii) in subparagraph (CC), by adding 
‘‘and’’ after the semicolon at the end; and 
(iii) by adding at the end the fol-
lowing new subparagraph: 
‘‘(DD) kidney disease education services (as de-
fined in subsection (ggg));’’. 
(B) SERVICES DESCRIBED.—Section 1861 
of the Social Security Act (42 U.S.C. 1395x), 
as amended by section 144(a), is amended by 
adding at the end the following new subsection: 
‘‘Kidney Disease Education Services 
‘‘(ggg)(1) The term ‘kidney disease education serv-
ices’ 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; 
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‘‘(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 set under para-
graph (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 
transplantation); 
‘‘(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)(A) The term ‘qualified person’ means— 
‘‘(i) 
a 
physician 
(as 
defined 
in 
section 
1861(r)(1)) or a physician assistant, nurse practi-
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tioner, or clinical nurse specialist (as defined in sec-
tion 1861(aa)(5)), who furnishes services for which 
payment may be made under the fee schedule estab-
lished under section 1848; and 
‘‘(ii) a provider of services located in a rural 
area (as defined in section 1886(d)(2)(D)). 
‘‘(B) Such term does not include a provider of serv-
ices (other than a provider of services described in sub-
paragraph (A)(ii)) or a renal dialysis facility. 
‘‘(3) The Secretary shall set standards for the con-
tent of such information to be provided under paragraph 
(1)(C)(i) after consulting with physicians, other health 
professionals, health educators, professional organizations, 
accrediting 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 persons or entities described in the previous sentence, 
other than a dialysis facility, that has not received indus-
try funding from a drug or biological manufacturer or di-
alysis facility. 
‘‘(4) No individual shall be furnished more than 6 
sessions of kidney disease education services under this 
title.’’. 
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170 
(C) 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 
inserting 
‘‘(2)(DD),’’ 
after 
‘‘(2)(AA),’’. 
(D) LIMITATION
ON
NUMBER
OF
SES-
SIONS.—Section 1862(a)(1) of the Social Secu-
rity Act (42 U.S.C. 1395y(a)(1)) is amended— 
(i) in subparagraph (M), by striking 
‘‘and’’ at the end; 
(ii) in subparagraph (N), by striking 
the semicolon at the end and inserting ‘‘, 
and’’; and 
(iii) by adding at the end the fol-
lowing new subparagraph: 
‘‘(O) in the case of kidney disease education 
services (as defined in paragraph (1) of section 
1861(ggg)), which are furnished in excess of the 
number of sessions covered under paragraph (4) of 
such section;’’. 
(2) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply to services furnished 
on or after January 1, 2010. 
SEC. 154. RENAL DIALYSIS PROVISIONS. 
(a) COMPOSITE RATE.— 
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(1) UPDATE.—Section 1881(b)(12)(G) of the 
Social Security Act (42 U.S.C. 1395rr(b)(12)(G)) is 
amended— 
(A) in clause (i), by striking ‘‘and’’ at the 
end; 
(B) in clause (ii)— 
(i) by inserting ‘‘and before January 
1, 2009,’’ after ‘‘April 1, 2007,’’; and 
(ii) by striking the period at the end 
and inserting a semicolon; and 
(C) by adding at the end the following new 
clauses: 
‘‘(iii) furnished on or after January 1, 2009, 
and before January 1, 2010, by 1.0 percent above 
the amount of such composite rate component for 
such services furnished on December 31, 2008; and 
‘‘(iv) furnished on or after January 1, 2010, by 
1.0 percent above the amount of such composite rate 
component for such services furnished on December 
31, 2009.’’. 
(2) SITE NEUTRAL COMPOSITE RATE.—Section 
1881(b)(12)(A) of the Social Security Act (42 
U.S.C. 1395rr(b)(12)(A)) is amended by adding at 
the end the following new sentence: ‘‘Under such 
system, the payment rate for dialysis services fur-
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nished on or after January 1, 2009, by providers of 
services shall be the same as the payment rate (com-
puted without regard to this sentence) for such serv-
ices furnished by renal dialysis facilities, and in ap-
plying the geographic index under subparagraph (D) 
to providers of services, the labor share shall be 
based on the labor share otherwise applied for renal 
dialysis facilities.’’. 
(b) DEVELOPMENT OF ESRD BUNDLED PAYMENT 
SYSTEM.— 
(1) IN GENERAL.—Section 1881(b) of the So-
cial Security Act (42 U.S.C. 1395rr(b)) is amended 
by adding at the end the following new paragraph: 
‘‘(14)(A)(i) Subject to subparagraph (E), for services 
furnished on or after January 1, 2011, the Secretary shall 
implement a payment system under which a single pay-
ment is made under this title to a provider of services or 
a renal dialysis facility 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)) and for such services and items furnished pur-
suant to paragraph (4). 
‘‘(ii) In implementing the system under this para-
graph the Secretary shall ensure that the estimated total 
amount of payments under this title for 2011 for renal 
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dialysis services shall equal 98 percent of the estimated 
total amount of payments for renal dialysis services, in-
cluding payments under paragraph (12)(B)(ii), that would 
have been made under this title with respect to services 
furnished in 2011 if such system had not been imple-
mented. In making the estimation under subclause (I), the 
Secretary shall use per patient utilization data from 2007, 
2008, or 2009, whichever has the lowest per patient utili-
zation. 
‘‘(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 December 
31, 2010; 
‘‘(ii) erythropoiesis stimulating agents and any 
oral form of such agents that are furnished to indi-
viduals for the treatment of end stage renal disease; 
‘‘(iii) other drugs and biologicals that are fur-
nished to individuals for the treatment of end stage 
renal disease and for which payment was (before the 
application of this paragraph) made separately 
under this title, and any oral equivalent form of 
such drug or biological; and 
‘‘(iv) diagnostic laboratory tests and other items 
and services not described in clause (i) that are fur-
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nished to individuals for the treatment of end stage 
renal disease. 
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 ap-
propriate factors; 
‘‘(ii) shall include a payment adjustment for 
high cost outliers due to unusual variations in the 
type or amount of medically necessary care, includ-
ing variations in the amount of erythropoiesis stimu-
lating agents necessary for anemia management; 
‘‘(iii) shall include a payment adjustment that 
reflects the extent to which costs incurred by low- 
volume facilities (as defined by the Secretary) in fur-
nishing renal dialysis services exceed the costs in-
curred by other facilities in furnishing such services, 
and for payment for renal dialysis services furnished 
on or after January 1, 2011, and before January 1, 
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2014, such payment adjustment shall not be less 
than 10 percent; and 
‘‘(iv) may include such other payment adjust-
ments as the Secretary determines appropriate, such 
as a payment adjustment— 
‘‘(I) for pediatric providers of services and 
renal dialysis facilities; 
‘‘(II) by a geographic index, such as the 
index referred to in paragraph (12)(D), as the 
Secretary determines to be appropriate; and 
‘‘(III) for providers of services or renal di-
alysis facilities located in rural areas. 
The Secretary shall take into consideration the unique 
treatment needs of children and young adults in estab-
lishing such system. 
‘‘(E)(i) The Secretary shall provide for a four-year 
phase-in (in equal increments) of the payment amount 
under the payment system under this paragraph, with 
such payment amount being fully implemented for renal 
dialysis services furnished on or after January 1, 2014. 
‘‘(ii) A provider of services or renal dialysis facility 
may make a one-time election to be excluded from the 
phase-in under clause (i) and be paid entirely based on 
the payment amount under the payment system under this 
paragraph. Such an election shall be made prior to Janu-
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ary 1, 2011, in a form and manner specified by the Sec-
retary, and is final and may not be rescinded. 
‘‘(iii) The Secretary shall make an adjustment to the 
payments under this paragraph for years during which the 
phase-in under clause (i) is applicable so that the esti-
mated total amount of payments under this paragraph, 
including payments under this subparagraph, shall equal 
the estimated total amount of payments that would other-
wise occur under this paragraph without such phase-in. 
‘‘(F)(i) Subject to clause (ii), beginning in 2012, the 
Secretary shall annually increase payment amounts estab-
lished under this paragraph by an ESRD market basket 
percentage increase factor for a bundled payment system 
for renal dialysis services that reflects changes over time 
in the prices of an appropriate mix of goods and services 
included in renal dialysis services minus 1.0 percentage 
point. 
‘‘(ii) For years during which a phase-in of the pay-
ment system pursuant to subparagraph (E) is applicable, 
the following rules shall apply to the portion of the pay-
ment under the system that is based on the payment of 
the composite rate that would otherwise apply if the sys-
tem under this paragraph had not been enacted: 
‘‘(I) The update under clause (i) shall not 
apply. 
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‘‘(II) The Secretary shall annually increase 
such composite rate by the ESRD market basket 
percentage increase factor described in clause (i) 
minus 1.0 percentage point. 
‘‘(G) There shall be no administrative or judicial re-
view under section 1869, section 1878, or otherwise of the 
determination of payment amounts under subparagraph 
(A), the establishment of an appropriate unit of payment 
under subparagraph (C), the identification of renal dialy-
sis services included in the bundled payment, the adjust-
ments under subparagraph (D), the application of the 
phase-in under subparagraph (E), and the establishment 
of the market basket percentage increase factors under 
subparagraph (F). 
‘‘(H) Erythropoiesis stimulating agents and other 
drugs and biologicals shall be treated as prescribed and 
dispensed or administered and available only under part 
B if they are— 
‘‘(i) furnished to an individual for the treatment 
of end stage renal disease; and 
‘‘(ii) included in subparagraph (B) for purposes 
of payment under this paragraph.’’. 
(2) PROHIBITION
OF
UNBUNDLING.—Section 
1862(a) of the Social Security Act (42 U.S.C. 
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178 
1395y(a)), as amended by section 135(a)(2), is 
amended— 
(A) in paragraph (22), by striking ‘‘or’’ at 
the end; 
(B) in paragraph (23), by striking the pe-
riod at the end and inserting ‘‘; or’’; and 
(C) by inserting after paragraph (23) the 
following new paragraph: 
‘‘(24) where such expenses are for renal dialysis 
services (as defined in subparagraph (B) of section 
1881(b)(14)) for which payment is made under such 
section unless such payment is made under such sec-
tion to a provider of services or a renal dialysis facil-
ity for such services.’’. 
(3) CONFORMING AMENDMENTS.—(A) Section 
1881(b) of the Social Security Act (42 U.S.C. 
1395rr(b)) is amended— 
(i) in paragraph (12)(A), by striking ‘‘In 
lieu of payment’’ and inserting ‘‘Subject to 
paragraph (14), in lieu of payment’’; 
(ii) in the second sentence of paragraph 
(12)(F)— 
(I) by inserting ‘‘or paragraph (14)’’ 
after ‘‘this paragraph’’; and 
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(II) by inserting ‘‘or under the system 
under paragraph (14)’’ after ‘‘subpara-
graph (B)’’; and 
(iii) in paragraph (13)— 
(I) in subparagraph (A), in the matter 
preceding clause (i), by striking ‘‘The pay-
ment amounts’’ and inserting ‘‘Subject to 
paragraph (14), the payment amounts’’; 
and 
(II) in subparagraph (B)— 
(aa) in clause (i), by striking 
‘‘(i)’’ after ‘‘(B)’’ and by inserting ‘‘, 
subject to paragraph (14)’’ before the 
period at the end; and 
(bb) by striking clause (ii). 
(B) Section 1861(s)(2)(F) of the Social Secu-
rity Act (42 U.S.C. 1395x(s)(2)(F)) is amended by 
inserting ‘‘, and, for items and services furnished on 
or after January 1, 2011, renal dialysis services (as 
defined in section 1881(b)(14)(B))’’ before the semi-
colon at the end. 
(C) Section 623(e) of the Medicare Prescription 
Drug, Improvement, and Modernization Act of 2003 
(42 U.S.C. 1395rr note) is repealed. 
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graph (A) prior to the beginning of the per-
formance period for the year involved. 
‘‘(D) PERFORMANCE
PERIOD.—The Sec-
retary shall establish the performance period 
with respect to a year. Such performance period 
shall occur prior to the beginning of such year. 
‘‘(E) SPECIAL RULE.—The Secretary shall 
initially use as the performance standard for 
the 
measures 
specified 
under 
paragraph 
(2)(A)(i) for a provider of services or a renal di-
alysis facility the lesser of— 
‘‘(i) the performance of such provider 
or facility for such measures in the year 
selected by the Secretary under the second 
sentence of subsection (b)(14)(A)(ii); or 
‘‘(ii) a performance standard based on 
the national performance rates for such 
measures in a period determined by the 
Secretary. 
‘‘(5) LIMITATION ON REVIEW.—There shall be 
no administrative or judicial review under section 
1869, section 1878, or otherwise of the following: 
‘‘(A) The determination of the amount of 
the payment reduction under paragraph (1). 
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