Social Security Act §1861

(C)individualizedtreatment is furnished under a written plan established, reviewed,and signed by a physician every 30 days that describes(i)the individualsdiagnosis;(ii)the type,amount, frequency, and duration of the items and services furnishedunder the plan; and(iii)the goalsset for the individual under the plan.(3)The items andservices described in this paragraph are(A)physician-prescribedexercise;(B)cardiacrisk factor modification, including education, counseling, and behavioralintervention (to the extent such education, counseling, and behavioralintervention is closely related to the individuals care andtreatment and is tailored to the individuals needs);(C)psychosocialassessment;(D)outcomesassessment; and(E)such otheritems and services as the Secretary may determine, but only if suchitems and services are(i)reasonableand necessary for the diagnosis or active treatment of the individualscondition;(ii)reasonablyexpected to improve or maintain the individuals condition andfunctional level; and(iii)furnishedunder such guidelines relating to the frequency and duration of suchitems and services as the Secretary shall establish, taking into accountaccepted norms of medical practice and the reasonable expectationof improvement of the individual.(4)(A)The term intensive cardiac rehabilitation program means a program(as described in paragraph (2)) that furnishes the items and servicesdescribed in paragraph (3) under the supervision of a physician (asdefined in subsection (r)(1)) or a physician assistant, nurse practitioner,or clinical nurse specialist (as those terms are defined in subsection(aa)(5)) and has shown, in peer-reviewed published research, thatit accomplished[539](i)one or moreof the following:(I)positivelyaffected the progression of coronary heart disease; or(II)reducedthe need for coronary bypass surgery; or(III)reducedthe need for percutaneous coronary interventions; and(ii)a statisticallysignificant reduction in 5 or more of the following measures fromtheir level before receipt of cardiac rehabilitation services to theirlevel after receipt of such services:(I)low densitylipoprotein;(II)triglycerides;(III)bodymass index;(IV)systolicblood pressure;(V)diastolicblood pressure; or(VI)theneed for cholesterol, blood pressure, and diabetes medications.(B)To be eligiblefor an intensive cardiac rehabilitation program, an individual musthave(i)had an acutemyocardial infarction within the preceding 12 months;(ii)had coronarybypass surgery;(iii)stableangina pectoris;(iv)had heartvalve repair or replacement;(v)had percutaneoustransluminal coronary angioplasty (PTCA) or coronary stenting;(vi)had a heartor heart-lung transplant;(vii)[540]stable, chronic heart failure(defined as patients with left ventricular ejection fraction of 35percent or less and New York Heart Association (NYHA) class II toIV symptoms despite being on optimal heart failure therapy for atleast 6 weeks); or(viii)any additionalcondition for which the Secretary has determined that a cardiac rehabilitationprogram shall be covered, unless the Secretary determines, using thesame process used to determine that the condition is covered for acardiac rehabilitation program, that such coverage is not supportedby the clinical evidence.(C)An intensivecardiac rehabilitation program may be provided in a series of 72 one-hoursessions (as defined in section 1848(b)(5)), up to 6 sessions perday, over a period of up to 18 weeks.(5)The Secretaryshall establish standards to ensure that a physician with expertisein the management of individuals with cardiac pathophysiology whois licensed to practice medicine in the State in which a cardiac rehabilitationprogram (or the intensive cardiac rehabilitation program, as the casemay be) is offered(A)is responsiblefor such program; and(B)in consultationwith appropriate staff, is involved substantially in directing theprogress of individual in the program.Pulmonary Rehabilitation Program(fff)(1)The term pulmonary rehabilitation program means a program (as describedin subsection (eee)(2) with respect to a program under this subsection)that furnishes the items and services described in paragraph (2) underthe supervision of a physician (as defined in subsection (r)(1)) ora physician assistant, nurse practitioner, or clinical nurse specialist(as those terms are defined in subsection (aa)(5)).[541](2)The items andservices described in this paragraph are(A)physician-prescribedexercise;(B)educationor training (to the extent the education or training is closely andclearly related to the individuals care and treatment and istailored to such individuals needs);(C)psychosocialassessment;(D)outcomesassessment; and(E)such otheritems and services as the Secretary may determine, but only if suchitems and services are(i)reasonableand necessary for the diagnosis or active treatment of the individualscondition;(ii)reasonablyexpected to improve or maintain the individuals condition andfunctional level; and(iii)furnishedunder such guidelines relating to the frequency and duration of suchitems and services as the Secretary shall establish, taking into accountaccepted norms of medical practice and the reasonable expectationof improvement of the individual.(3)The Secretaryshall establish standards to ensure that a physician with expertisein the management of individuals with respiratory pathophysiologywho is licensed to practice medicine in the State in which a pulmonaryrehabilitation program is offered(A)is responsiblefor such program; and(B)in consultationwith appropriate staff, is involved substantially in directing theprogress of individual in the program.Kidney Disease Education Services(ggg)(1)The term kidney disease education services means educational servicesthat are(A)furnishedto an individual with stage IV chronic kidney disease who, accordingto accepted clinical guidelines identified by the Secretary, willrequire dialysis or a kidney transplant;(B)furnished,upon the referral of the physician managing the individualskidney condition, by a qualified person (as defined in paragraph (2));and(C)designed(i)to providecomprehensive information (consistent with the standards set underparagraph (3)) regarding(I)the managementof comorbidities, including for purposes of delaying the need fordialysis;(II)the preventionof uremic complications; and(III)eachoption for renal replacement therapy (including hemodialysis and peritonealdialysis at home and in-center as well as vascular access optionsand transplantation);(ii)to ensurethat the individual has the opportunity to actively participate inthe choice of therapy; and(iii)to be tailoredto 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 practitioner,or clinical nurse specialist (as defined in section 1861(aa)(5)), whofurnishes services for which payment may be made under the fee scheduleestablished under section 1848; and(ii)a providerof services located in a rural area (as defined in section 1886(d)(2)(D)).(B)Such termdoes not include a provider of services (other than a provider ofservices described in subparagraph (A)(ii)) or a renal dialysis facility.(3)The Secretaryshall set standards for the content of such information to be providedunder paragraph (1)(C)(i) after consulting with physicians, otherhealth professionals, health educators, professional organizations,accrediting organizations, kidney patient organizations, dialysisfacilities, transplant centers, network organizations described insection 1881(c)(2), and other knowledgeable persons. To the extent possible the Secretaryshall consult with persons or entities described in the previous sentence,other than a dialysis facility, that has not received industry fundingfrom a drug or biological manufacturer or dialysis facility.(4)No individualshall be furnished more than 6 sessions of kidney disease educationservices under this title.Annual Wellness Visit(hhh)(1)The term personalized prevention plan services means the creationof a plan for an individual(A)that includesa health risk assessment (that meets the guidelines established bythe Secretary under paragraph (4)(A)) of the individual that is completedprior to or as part of the same visit with a health professional describedin paragraph (3); and(B)that(i)takes intoaccount the results of the health risk assessment; and(ii)may containthe elements described in paragraph (2).(2)Subject to paragraph(4)(H), the elements described in this paragraph are the following:(A)The establishmentof, or an update to, the individuals medical and family history.(B)A listof current providers and suppliers that are regularly involved inproviding medical care to the individual (including a list of allprescribed medications).(C)A measurementof height, weight, body mass index (or waist circumference, if appropriate),blood pressure, and other routine measurements.(D)Detectionof any cognitive impairment.(E)The establishmentof, or an update to, the following:(i)A screeningschedule for the next 5 to 10 years, as appropriate, based on recommendationsof the United States Preventive Services Task Force and the AdvisoryCommittee on Immunization Practices, and the individuals healthstatus, screening history, and age-appropriate preventive servicescovered under this title.(ii)A list ofrisk factors and conditions for which primary, secondary, or tertiaryprevention interventions are recommended or are underway, includingany mental health conditions or any such risk factors or conditionsthat have been identified through an initial preventive physical examination(as described under subsection (ww)(1)), and a list of treatment optionsand their associated risks and benefits.(F)The furnishingof personalized health advice and a referral, as appropriate, to healtheducation or preventive counseling services or programs aimed at reducingidentified risk factors and improving self-management, or community-basedlifestyle interventions to reduce health risks and promote self-managementand wellness, including weight loss, physical activity, smoking cessation,fall prevention, and nutrition.(G) Screening for potential substanceuse disorders and referral for treatment as appropriate.(H) The furnishing of a review ofany current opioid prescriptions (as defined in subsection (ww)(4)).[542](I)Any otherelement determined appropriate by the Secretary.(3)A health professionaldescribed in this paragraph is(A)a physician;(B)a practitionerdescribed in clause (i) of section 1842(b)(18)(C); or(C)a medicalprofessional (including a health educator, registered dietitian, ornutrition professional) or a team of medical professionals, as determinedappropriate by the Secretary, under the supervision of a physician.(4)(A)For purposesof paragraph (1)(A), the Secretary, not later than 1 year after thedate of enactment of this subsection, shall establish publicly availableguidelines for health risk assessments. Such guidelines shall be developedin consultation with relevant groups and entities and shall providethat a health risk assessment(i)identify chronicdiseases, injury risks, modifiable risk factors, and urgent healthneeds of the individual; and(ii)may be furnished(I)throughan interactive telephonic or web-based program that meets the standardsestablished under subparagraph (B);(II)duringan encounter with a health care professional;(III)throughcommunity-based prevention programs; or(IV)throughany other means the Secretary determines appropriate to maximize accessibilityand ease of use by beneficiaries, while ensuring the privacy of suchbeneficiaries.(B)Not laterthan 1 year after the date of enactment of this subsection, the Secretaryshall establish standards for interactive telephonic or web-basedprograms used to furnish health risk assessments under subparagraph(A)(ii)(I). The Secretary may utilize any health risk assessment developedunder section 4004(f) of the Patient Protection and Affordable CareAct as part of the requirement to develop a personalized preventionplan to comply with this subparagraph.(C)(i)Not later than18 months after the date of enactment of this subsection, the Secretaryshall develop and make available to the public a health risk assessmentmodel. Such model shall meet the guidelines under subparagraph (A)and may be used to meet the requirement under paragraph (1)(A).(ii)Any healthrisk assessment that meets the guidelines under subparagraph (A) andis approved by the Secretary may be used to meet the requirement underparagraph (1)(A).(D)The Secretarymay coordinate with community-based entities (including State HealthInsurance Programs, Area Agencies on Aging, Aging and Disability ResourceCenters, and the Administration on Aging) to(i)ensure thathealth risk assessments are accessible to beneficiaries; and(ii)provide appropriatesupport for the completion of health risk assessments by beneficiaries.(E)The Secretaryshall establish procedures to make beneficiaries and providers awareof the requirement that a beneficiary complete a health risk assessmentprior to or at the same time as receiving personalized preventionplan services.