147 
(g) GAO STUDY AND REPORT ON RELATIVE VALUE 
SCALE UPDATE COMMITTEE.— 
(1) STUDY.—The Comptroller General of the 
United States (in this subsection referred to as the 
‘‘Comptroller General’’) shall conduct a study of the 
processes used by the Relative Value Scale Update 
Committee (RUC) to provide recommendations to 
the Secretary of Health and Human Services regard-
ing relative values for specific services under the 
Medicare physician fee schedule under section 1848 
of the Social Security Act (42 U.S.C. 1395w–4). 
(2) REPORT.—Not later than 1 year after the 
date of the enactment of this Act, the Comptroller 
General shall submit to Congress a report containing 
the results of the study conducted under paragraph 
(1). 
(h) ADJUSTMENT TO MEDICARE PAYMENT LOCAL-
ITIES.— 
(1) IN GENERAL.—Section 1848(e) of the So-
cial Security Act (42 U.S.C. 1395w–4(e)) is amend-
ed by adding at the end the following new para-
graph: 
‘‘(6) USE OF MSAS AS FEE SCHEDULE AREAS IN 
CALIFORNIA.— 
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‘‘(A) IN
GENERAL.—Subject to the suc-
ceeding provisions of this paragraph and not-
withstanding the previous provisions of this 
subsection, for services furnished on or after 
January 1, 2017, the fee schedule areas used 
for payment under this section applicable to 
California shall be the following: 
‘‘(i) Each Metropolitan Statistical 
Area (each in this paragraph referred to as 
an ‘MSA’), as defined by the Director of 
the Office of Management and Budget as 
of December 31 of the previous year, shall 
be a fee schedule area. 
‘‘(ii) All areas not included in an MSA 
shall be treated as a single rest-of-State 
fee schedule area. 
‘‘(B) TRANSITION FOR MSAS PREVIOUSLY 
IN REST-OF-STATE PAYMENT LOCALITY OR IN 
LOCALITY 3.— 
‘‘(i) IN GENERAL.—For services fur-
nished in California during a year begin-
ning with 2017 and ending with 2021 in 
an MSA in a transition area (as defined in 
subparagraph (D)), subject to subpara-
graph (C), the geographic index values to 
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149 
be applied under this subsection for such 
year shall be equal to the sum of the fol-
lowing: 
‘‘(I) 
CURRENT
LAW
COMPO-
NENT.—The old weighting factor (de-
scribed in clause (ii)) for such year 
multiplied by the geographic index 
values under this subsection for the 
fee schedule area that included such 
MSA that would have applied in such 
area (as estimated by the Secretary) 
if this paragraph did not apply. 
‘‘(II) 
MSA-BASED
COMPO-
NENT.—The 
MSA-based 
weighting 
factor (described in clause (iii)) for 
such year multiplied by the geographic 
index values computed for the fee 
schedule area under subparagraph (A) 
for the year (determined without re-
gard to this subparagraph). 
‘‘(ii) OLD WEIGHTING FACTOR.—The 
old weighting factor described in this 
clause— 
‘‘(I) for 2017, is 5⁄6; and 
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‘‘(II) for each succeeding year, is 
the old weighting factor described in 
this clause for the previous year 
minus 1⁄6. 
‘‘(iii) MSA-BASED
WEIGHTING
FAC-
TOR.—The MSA-based weighting factor 
described in this clause for a year is 1 
minus the old weighting factor under 
clause (ii) for that year. 
‘‘(C) HOLD HARMLESS.—For services fur-
nished in a transition area in California during 
a year beginning with 2017, the geographic 
index values to be applied under this subsection 
for such year shall not be less than the cor-
responding geographic index values that would 
have applied in such transition area (as esti-
mated by the Secretary) if this paragraph did 
not apply. 
‘‘(D) TRANSITION
AREA
DEFINED.—In 
this paragraph, the term ‘transition area’ 
means each of the following fee schedule areas 
for 2013: 
‘‘(i) The rest-of-State payment local-
ity. 
‘‘(ii) Payment locality 3. 
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151 
‘‘(E) REFERENCES
TO
FEE
SCHEDULE 
AREAS.—Effective for services furnished on or 
after January 1, 2017, for California, any ref-
erence in this section to a fee schedule area 
shall be deemed a reference to a fee schedule 
area established in accordance with this para-
graph.’’. 
(2) CONFORMING AMENDMENT TO DEFINITION 
OF FEE SCHEDULE AREA.—Section 1848(j)(2) of the 
Social Security Act (42 U.S.C. 1395w–4(j)(2)) is 
amended by striking ‘‘The term’’ and inserting ‘‘Ex-
cept as provided in subsection (e)(6)(D), the term’’. 
(i) DISCLOSURE
OF DATA USED TO ESTABLISH 
MULTIPLE PROCEDURE PAYMENT REDUCTION POLICY.— 
The Secretary of Health and Human Services shall make 
publicly available the information used to establish the 
multiple procedure payment reduction policy to the profes-
sional component of imaging services in the final rule pub-
lished in the Federal Register, v. 77, n. 222, November 
16, 2012, pages 68891–69380 under the physician fee 
schedule under section 1848 of the Social Security Act (42 
U.S.C. 1395w–4). 
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152 
SEC. 6. PROMOTING EVIDENCE-BASED CARE. 
(a) IN GENERAL.—Section 1834 of the Social Secu-
rity Act (42 U.S.C. 1395m) is amended by adding at the 
end the following new subsection: 
‘‘(p) RECOGNIZING APPROPRIATE USE CRITERIA FOR 
CERTAIN IMAGING SERVICES.— 
‘‘(1) PROGRAM ESTABLISHED.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
establish a program to promote the use of ap-
propriate use criteria (as defined in subpara-
graph (B)) for applicable imaging services (as 
defined in subparagraph (C)) furnished in an 
applicable setting (as defined in subparagraph 
(D)) by ordering professionals and furnishing 
professionals (as defined in subparagraphs (E) 
and (F), respectively). 
‘‘(B) APPROPRIATE
USE
CRITERIA
DE-
FINED.—In this subsection, the term ‘appro-
priate use criteria’ means criteria, only devel-
oped or endorsed by national professional med-
ical specialty societies or other provider-led enti-
ties, to assist ordering professionals and fur-
nishing professionals in making the most appro-
priate treatment decision for a specific clinical 
condition. To the extent feasible, such criteria 
shall be evidence-based. 
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‘‘(C) APPLICABLE IMAGING SERVICE DE-
FINED.—In this subsection, the term ‘applicable 
imaging service’ means an advanced diagnostic 
imaging service (as defined in subsection 
(e)(1)(B)) for which the Secretary determines— 
‘‘(i) one or more applicable appro-
priate use criteria specified under para-
graph (2) apply; 
‘‘(ii) there are one or more qualified 
clinical decision support mechanisms listed 
under paragraph (3)(C); and 
‘‘(iii) one or more of such mechanisms 
is available free of charge. 
‘‘(D) APPLICABLE SETTING DEFINED.—In 
this subsection, the term ‘applicable setting’ 
means a physician’s office, a hospital outpatient 
department (including an emergency depart-
ment), an ambulatory surgical center, and any 
other provider-led outpatient setting determined 
appropriate by the Secretary. 
‘‘(E) 
ORDERING
PROFESSIONAL
DE-
FINED.—In this subsection, the term ‘ordering 
professional’ means a physician (as defined in 
section 1861(r)) or a practitioner described in 
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section 1842(b)(18)(C) who orders an applica-
ble imaging service for an individual. 
‘‘(F) FURNISHING
PROFESSIONAL
DE-
FINED.—In this subsection, the term ‘fur-
nishing professional’ means a physician (as de-
fined in section 1861(r)) or a practitioner de-
scribed in section 1842(b)(18)(C) who furnishes 
an applicable imaging service for an individual. 
‘‘(2) ESTABLISHMENT OF APPLICABLE APPRO-
PRIATE USE CRITERIA.— 
‘‘(A) IN
GENERAL.—Not later than No-
vember 15, 2015, the Secretary shall through 
rulemaking, and in consultation with physi-
cians, practitioners, and other stakeholders, 
specify applicable appropriate use criteria for 
applicable imaging services only from among 
appropriate use criteria developed or endorsed 
by national professional medical specialty soci-
eties or other provider-led entities. 
‘‘(B) CONSIDERATIONS.—In specifying ap-
plicable appropriate use criteria under subpara-
graph (A), the Secretary shall take into account 
whether the criteria— 
‘‘(i) have stakeholder consensus; 
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‘‘(ii) are scientifically valid and evi-
dence based; and 
‘‘(iii) are based on studies that are 
published and reviewable by stakeholders. 
‘‘(C) REVISIONS.—The Secretary shall re-
view, on an annual basis, the specified applica-
ble appropriate use criteria to determine if 
there is a need to update or revise (as appro-
priate) such specification of applicable appro-
priate use criteria and make such updates or 
revisions through rulemaking. 
‘‘(D) TREATMENT OF MULTIPLE APPLICA-
BLE APPROPRIATE USE CRITERIA.—In the case 
where the Secretary determines that more than 
one appropriate use criteria applies with respect 
to an applicable imaging service, the Secretary 
shall permit one or more applicable appropriate 
use criteria under this paragraph for the serv-
ice. 
‘‘(3) MECHANISMS
FOR
CONSULTATION
WITH 
APPLICABLE APPROPRIATE USE CRITERIA.— 
‘‘(A) IDENTIFICATION OF MECHANISMS TO 
CONSULT WITH APPLICABLE APPROPRIATE USE 
CRITERIA.— 
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‘‘(i) IN
GENERAL.—The Secretary 
shall specify qualified clinical decision sup-
port mechanisms that could be used by or-
dering professionals to consult with appli-
cable appropriate use criteria for applicable 
imaging services. 
‘‘(ii) CONSULTATION.—The Secretary 
shall consult with physicians, practitioners, 
health care technology experts, and other 
stakeholders in specifying mechanisms 
under this paragraph. 
‘‘(iii) INCLUSION OF CERTAIN MECHA-
NISMS.—Mechanisms specified under this 
paragraph may include any or all of the 
following that meet the requirements de-
scribed in subparagraph (B)(ii): 
‘‘(I) Use of clinical decision sup-
port modules in certified EHR tech-
nology 
(as 
defined 
in 
section 
1848(o)(4)). 
‘‘(II) Use of private sector clin-
ical decision support mechanisms that 
are independent from certified EHR 
technology, which may include use of 
clinical decision support mechanisms 
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157 
available from medical specialty orga-
nizations. 
‘‘(III) Use of a clinical decision 
support mechanism established by the 
Secretary. 
‘‘(B) QUALIFIED CLINICAL DECISION SUP-
PORT MECHANISMS.— 
‘‘(i) IN
GENERAL.—For purposes of 
this subsection, a qualified clinical decision 
support mechanism is a mechanism that 
the Secretary determines meets the re-
quirements described in clause (ii). 
‘‘(ii) REQUIREMENTS.—The require-
ments described in this clause are the fol-
lowing: 
‘‘(I) The mechanism makes avail-
able to the ordering professional appli-
cable appropriate use criteria specified 
under paragraph (2) and the sup-
porting documentation for the applica-
ble imaging service ordered. 
‘‘(II) In the case where there are 
more than one applicable appropriate 
use criteria specified under such para-
graph for an applicable imaging serv-
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158 
ice, the mechanism indicates the cri-
teria that it uses for the service. 
‘‘(III) The mechanism determines 
the extent to which an applicable im-
aging service ordered is consistent 
with the applicable appropriate use 
criteria so specified. 
‘‘(IV) The mechanism generates 
and provides to the ordering profes-
sional a certification or documentation 
that documents that the qualified clin-
ical decision support mechanism was 
consulted by the ordering professional. 
‘‘(V) The mechanism is updated 
on a timely basis to reflect revisions 
to the specification of applicable ap-
propriate use criteria under such 
paragraph. 
‘‘(VI) The mechanism meets pri-
vacy and security standards under ap-
plicable provisions of law. 
‘‘(VII) The mechanism performs 
such other functions as specified by 
the Secretary, which may include a re-
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159 
quirement to provide aggregate feed-
back to the ordering professional. 
‘‘(C) LIST
OF
MECHANISMS
FOR
CON-
SULTATION
WITH
APPLICABLE
APPROPRIATE 
USE CRITERIA.— 
‘‘(i) INITIAL
LIST.—Not later than 
April 1, 2016, the Secretary shall publish 
a list of mechanisms specified under this 
paragraph. 
‘‘(ii) PERIODIC UPDATING OF LIST.— 
The Secretary shall identify on an annual 
basis the list of qualified clinical decision 
support mechanisms specified under this 
paragraph. 
‘‘(4) CONSULTATION WITH APPLICABLE APPRO-
PRIATE USE CRITERIA.— 
‘‘(A) CONSULTATION BY ORDERING PRO-
FESSIONAL.—Beginning with January 1, 2017, 
subject to subparagraph (C), with respect to an 
applicable imaging service ordered by an order-
ing professional that would be furnished in an 
applicable setting and paid for under an appli-
cable payment system (as defined in subpara-
graph (D)), an ordering professional shall— 
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‘‘(i) consult with a qualified decision 
support mechanism listed under paragraph 
(3)(C); and 
‘‘(ii) provide to the furnishing profes-
sional the information described in clauses 
(i) through (iii) of subparagraph (B). 
‘‘(B) REPORTING BY FURNISHING PROFES-
SIONAL.—Beginning with January 1, 2017, 
subject to subparagraph (C), with respect to an 
applicable imaging service furnished in an ap-
plicable setting and paid for under an applica-
ble payment system (as defined in subpara-
graph (D)), payment for such service may only 
be made if the claim for the service includes the 
following: 
‘‘(i) Information about which qualified 
clinical decision support mechanism was 
consulted by the ordering professional for 
the service. 
‘‘(ii) Information regarding— 
‘‘(I) whether the service ordered 
would adhere to the applicable appro-
priate use criteria specified under 
paragraph (2); 
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‘‘(II) whether the service ordered 
would not adhere to such criteria; or 
‘‘(III) whether such criteria was 
not applicable to the service ordered. 
‘‘(iii) The national provider identifier 
of the ordering professional (if different 
from the furnishing professional). 
‘‘(C) EXCEPTIONS.—The provisions of sub-
paragraphs (A) and (B) and paragraph (6)(A) 
shall not apply to the following: 
‘‘(i) EMERGENCY SERVICES.—An ap-
plicable imaging service ordered for an in-
dividual with an emergency medical condi-
tion (as defined in section 1867(e)(1)). 
‘‘(ii) INPATIENT SERVICES.—An appli-
cable imaging service ordered for an inpa-
tient and for which payment is made under 
part A. 
‘‘(iii) ALTERNATIVE
PAYMENT
MOD-
ELS.—An applicable imaging service or-
dered by an ordering professional with re-
spect to an individual attributed to an al-
ternative payment model (as defined in 
section 1833(z)(3)(C)). 
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162 
‘‘(iv) SIGNIFICANT
HARDSHIP.—An 
applicable imaging service ordered by an 
ordering professional who the Secretary 
may, on a case-by-case basis, exempt from 
the application of such provisions if the 
Secretary determines, subject to annual re-
newal, that consultation with applicable ap-
propriate use criteria would result in a sig-
nificant hardship, such as in the case of a 
professional who practices in a rural area 
without sufficient Internet access. 
‘‘(D) APPLICABLE PAYMENT SYSTEM DE-
FINED.—In this subsection, the term ‘applicable 
payment system’ means the following: 
‘‘(i) The physician fee schedule estab-
lished under section 1848(b). 
‘‘(ii) The prospective payment system 
for hospital outpatient department services 
under section 1833(t). 
‘‘(iii) The ambulatory surgical center 
payment systems under section 1833(i). 
‘‘(5) IDENTIFICATION OF OUTLIER ORDERING 
PROFESSIONALS.— 
‘‘(A) IN GENERAL.—With respect to appli-
cable imaging services furnished beginning with 
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163 
2017, the Secretary shall determine, on an an-
nual basis, no more than five percent of the 
total number of ordering professionals who are 
outlier ordering professionals. 
‘‘(B) 
OUTLIER
ORDERING
PROFES-
SIONALS.—The determination of an outlier or-
dering professional shall— 
‘‘(i) be based on low adherence to ap-
plicable appropriate use criteria specified 
under paragraph (2), which may be based 
on comparison to other ordering profes-
sionals; and 
‘‘(ii) include data for ordering profes-
sionals for whom prior authorization under 
paragraph (6)(A) applies. 
‘‘(C) USE OF TWO YEARS OF DATA.—The 
Secretary shall use two years of data to identify 
outlier ordering professionals under this para-
graph. 
‘‘(D) PROCESS.—The Secretary shall es-
tablish a process for determining when an 
outlier ordering professional is no longer an 
outlier ordering professional. 
‘‘(E) 
CONSULTATION
WITH
STAKE-
HOLDERS.—The Secretary shall consult with 
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164 
physicians, practitioners and other stakeholders 
in developing methods to identify outlier order-
ing professionals under this paragraph. 
‘‘(6) PRIOR
AUTHORIZATION
FOR
ORDERING 
PROFESSIONALS WHO ARE OUTLIERS.— 
‘‘(A) IN GENERAL.—Beginning January 1, 
2020, subject to paragraph (4)(C), with respect 
to services furnished during a year, the Sec-
retary shall, for a period determined appro-
priate by the Secretary, apply prior authoriza-
tion for applicable imaging services that are or-
dered by an outlier ordering professional identi-
fied under paragraph (5). 
‘‘(B) APPROPRIATE
USE
CRITERIA
IN 
PRIOR AUTHORIZATION.—In applying prior au-
thorization under subparagraph (A), the Sec-
retary shall utilize only the applicable appro-
priate use criteria specified under this sub-
section. 
‘‘(C) FUNDING.—For purposes of carrying 
out this paragraph, the Secretary shall provide 
for the transfer, from the Federal Supple-
mentary Medical Insurance Trust Fund under 
section 1841, of $5,000,000 to the Centers for 
Medicare & Medicaid Services Program Man-
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165 
agement Account for each of fiscal years 2019 
through 2021. Amounts transferred under the 
preceding sentence shall remain available until 
expended. 
‘‘(7) CONSTRUCTION.—Nothing in this sub-
section shall be construed as granting the Secretary 
the authority to develop or initiate the development 
of clinical practice guidelines or appropriate use cri-
teria.’’. 
(b) 
CONFORMING
AMENDMENT.—Section 
1833(t)(16) of the Social Security Act (42 U.S.C. 
1395l(t)(16)) is amended by adding at the end the fol-
lowing new subparagraph: 
‘‘(E) APPLICATION OF APPROPRIATE USE 
CRITERIA FOR CERTAIN IMAGING SERVICES.— 
For provisions relating to the application of ap-
propriate use criteria for certain imaging serv-
ices, see section 1834(p).’’. 
(c) REPORT ON EXPERIENCE OF IMAGING APPRO-
PRIATE USE CRITERIA PROGRAM.—Not later than 18 
months after the date of the enactment of this Act, the 
Comptroller General of the United States shall submit to 
Congress a report that includes a description of the extent 
to which appropriate use criteria could be used for other 
services under part B of title XVIII of the Social Security 
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Act (42 U.S.C. 1395j et seq.), such as radiation therapy 
and clinical diagnostic laboratory services. 
SEC. 7. EMPOWERING BENEFICIARY CHOICES THROUGH 
ACCESS TO INFORMATION ON PHYSICIANS’ 
SERVICES. 
(a) IN GENERAL.—The Secretary shall make publicly 
available on Physician Compare the information described 
in subsection (b) with respect to eligible professionals. 
(b) INFORMATION DESCRIBED.—The following infor-
mation, with respect to an eligible professional, is de-
scribed in this subsection: 
(1) Information on the number of services fur-
nished by the eligible professional under part B of 
title XVIII of the Social Security Act (42 U.S.C. 
1395j et seq.), which may include information on the 
most frequent services furnished or groupings of 
services. 
(2) Information on submitted charges and pay-
ments for services under such part. 
(3) A unique identifier for the eligible profes-
sional that is available to the public, such as a na-
tional provider identifier. 
(c) SEARCHABILITY.—The information made avail-
able under this section shall be searchable by at least the 
following: 
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167 
(1) The specialty or type of the eligible profes-
sional. 
(2) Characteristics of the services furnished, 
such as volume or groupings of services. 
(3) The location of the eligible professional. 
(d) DISCLOSURE.—The information made available 
under this section shall indicate, where appropriate, that 
publicized information may not be representative of the 
eligible professional’s entire patient population, the variety 
of services furnished by the eligible professional, or the 
health conditions of individuals treated. 
(e) IMPLEMENTATION.— 
(1) 
INITIAL
IMPLEMENTATION.—Physician 
Compare shall include the information described in 
subsection (b)— 
(A) with respect to physicians, by not later 
than July 1, 2015; and 
(B) with respect to other eligible profes-
sionals, by not later than July 1, 2016. 
(2) 
ANNUAL
UPDATING.—The 
information 
made available under this section shall be updated 
on Physician Compare not less frequently than on 
an annual basis. 
(f) OPPORTUNITY TO REVIEW AND SUBMIT CORREC-
TIONS.—The Secretary shall provide for an opportunity 
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for an eligible professional to review, and submit correc-
tions for, the information to be made public with respect 
to the eligible professional under this section prior to such 
information being made public. 
(g) DEFINITIONS.—In this section: 
(1) ELIGIBLE PROFESSIONAL; PHYSICIAN; SEC-
RETARY.—The terms ‘‘eligible professional’’, ‘‘physi-
cian’’, and ‘‘Secretary’’ have the meaning given such 
terms in section 10331(i) of Public Law 111–148. 
(2) PHYSICIAN COMPARE.—The term ‘‘Physi-
cian Compare’’ means the Physician Compare Inter-
net website of the Centers for Medicare & Medicaid 
Services (or a successor website). 
SEC. 8. EXPANDING AVAILABILITY OF MEDICARE DATA. 
(a) EXPANDING USES
OF MEDICARE DATA
BY 
QUALIFIED ENTITIES.— 
(1) ADDITIONAL ANALYSES.— 
(A) IN
GENERAL.—Subject to subpara-
graph (B), to the extent consistent with appli-
cable information, privacy, security, and disclo-
sure laws (including paragraph (3)), notwith-
standing paragraph (4)(B) of section 1874(e) of 
the Social Security Act (42 U.S.C. 1395kk(e)) 
and the second sentence of paragraph (4)(D) of 
such section, beginning July 1, 2015, a quali-
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169 
fied entity may use the combined data described 
in paragraph (4)(B)(iii) of such section received 
by such entity under such section, and informa-
tion derived from the evaluation described in 
such paragraph (4)(D), to conduct additional 
non-public analyses (as determined appropriate 
by the Secretary) and provide or sell such anal-
yses to authorized users for non-public use (in-
cluding for the purposes of assisting providers 
of services and suppliers to develop and partici-
pate in quality and patient care improvement 
activities, including developing new models of 
care). 
(B) LIMITATIONS WITH RESPECT TO ANAL-
YSES.— 
(i) EMPLOYERS.—Any analyses pro-
vided or sold under subparagraph (A) to 
an 
employer 
described 
in 
paragraph 
(9)(A)(iii) may only be used by such em-
ployer for purposes of providing health in-
surance to employees and retirees of the 
employer. 
(ii) HEALTH INSURANCE ISSUERS.—A 
qualified entity may not provide or sell an 
analysis to a health insurance issuer de-
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