Social Security Act §1833

(22)[136]Review and revisions of paymentsfor non-opioid alternative treatments.(A)In general.With respect to paymentsmade under this subsection for covered OPD services (or groups ofservices), including covered OPD services assigned to a comprehensiveambulatory payment classification, the Secretary(i)shall, as soonas practicable, conduct a review (part of which may include a requestfor information) of payments for opioids and evidence-based non-opioidalternatives for pain management (including drugs and devices, nerveblocks, surgical injections, and neuromodulation) with a goal of ensuringthat there are not financial incentives to use opioids instead ofnon-opioid alternatives;(ii)may, as theSecretary determines appropriate, conduct subsequent reviews of suchpayments; and(iii)shall considerthe extent to which revisions under this subsection to such payments(such as the creation of additional groups of covered OPD servicesto classify separately those procedures that utilize opioids and non-opioidalternatives for pain management) would reduce payment incentivesto use opioids instead of non-opioid alternatives for pain management.(B)Priority.In conducting the review underclause (i) of subparagraph (A) and considering revisions under clause(iii) of such subparagraph, the Secretary shall focus on covered OPDservices (or groups of services) assigned to a comprehensive ambulatorypayment classification, ambulatory payment classifications that primarilyinclude surgical services, and other services determined by the Secretarywhich generally involve treatment for pain management.(C)Revisions.If the Secretary identifiesrevisions to payments pursuant to subparagraph (A)(iii), the Secretaryshall, as determined appropriate, begin making such revisions forservices furnished on or after January 1, 2020. Revisions under theprevious sentence shall be treated as adjustments for purposes ofapplication of paragraph (9)(B).(D)Rules of construction.Nothing in thisparagraph shall be construed to preclude the Secretary(i)from conductinga demonstration before making the revisions described in subparagraph(C); or(ii)prior to implementationof this paragraph, from changing payments under this subsection forcovered OPD services (or groups of services) which include opioidsor non-opioid alternatives for pain management.(u)IncentivePayments for Physician Scarcity Areas.(1)In general.In the case of physicians services furnished on or afterJanuary 1, 2005, and before July 1, 2008(A)by a primarycare physician in a primary care scarcity county (identified underparagraph (4)); or(B)by a physicianwho is not a primary care physician in a specialist care scarcitycounty (as so identified),in addition to the amount of payment that would otherwise bemade for such services under this part, there also shall be paid anamount equal to 5 percent of the payment amount for the service underthis part.(2)Determinationof ratios of physicians to medicare beneficiaries in area.Based upon available data, the Secretary shall establish foreach county or equivalent area in the United States, the following:(A)Number of physicians practicing in the area.The number of physicians who furnish physicians servicesin the active practice of medicine or osteopathy in that county orarea, other than physicians whose practice is exclusively for theFederal Government, physicians who are retired, or physicians whoonly provide administrative services. Of such number, the number ofsuch physicians who are(i)primary carephysicians; or(ii)physicianswho are not primary care physicians.(B)Number of medicare beneficiaries residing in the area.The number of individuals who are residing in the county andare entitled to benefits under part A or enrolled under this part,or both (in this subsection referred to as individuals).(C)Determination of ratios.(i)Primarycare ratio.The ratio (in this paragraphreferred to as the primary care ratio) of the numberof primary care physicians (determined under subparagraph (A)(i)),to the number of individuals determined under subparagraph (B).(ii)Specialistcare ratio.The ratio (in this paragraphreferred to as the specialist care ratio) of the numberof other physicians (determined under subparagraph (A)(ii)), to thenumber of individuals determined under subparagraph (B).(3)Rankingof counties.The Secretary shall rankeach such county or area based separately on its primary care ratioand its specialist care ratio.(4)Identificationof counties.(A)In general.The Secretary shall identify(i)those countiesand areas (in this paragraph referred to as primary care scarcitycounties) with the lowest primary care ratios that represent,if each such county or area were weighted by the number of individualsdetermined under paragraph (2)(B), an aggregate total of 20 percentof the total of the individuals determined under such paragraph; and(ii)those countiesand areas (in this subsection referred to as specialist carescarcity counties) with the lowest specialist care ratiosthat represent, if each such county or area were weighted by the numberof individuals determined under paragraph (2)(B), an aggregate totalof 20 percent of the total of the individuals determined under suchparagraph.(B)Periodic revisions.The Secretary shallperiodically revise the counties or areas identified in subparagraph(A) (but not less often than once every three years) unless the Secretarydetermines that there is no new data available on the number of physicianspracticing in the county or area or the number of individuals residingin the county or area, as identified in paragraph (2).(C)Identification of counties where service is furnished.For purposes of paying the additional amount specified in paragraph(1), if the Secretary uses the 5-digit postal ZIP Code where the serviceis furnished, the dominant county of the postal ZIP Code (as determinedby the United States Postal Service, or otherwise) shall be used todetermine whether the postal ZIP Code is in a scarcity county identifiedin subparagraph (A) or revised in subparagraph (B).(D)Special rule.With respect to physiciansservices furnished on or after January 1, 2008, and before July 1,2008, for purposes of this subsection, the Secretary shall use theprimary care scarcity counties and the speciality care scarcity counties(as identified under the preceding provisions of this paragraph) thatthe Secretary was using under this subsection with respect to physiciansservices furnished on December 31, 2007.(E)Judicial review.There shall be noadministrative or judicial review under section 1869, 1878, or otherwise, respecting(i)the identificationof a county or area;(ii)the assignmentof a specialty of any physician under this paragraph;(iii)the assignmentof a physician to a county under paragraph (2); or(iv)the assignmentof a postal ZIP Code to a county or other area under this subsection.(5)Ruralcensus tracts.To the extent feasible,the Secretary shall treat a rural census tract of a metropolitan statisticalarea (as determined under the most recent modification of the GoldsmithModification, originally published in the Federal Register on February27, 1992 (57 Fed. Reg. 6725)), as an equivalent area for purposesof qualifying as a primary care scarcity county or specialist carescarcity county under this subsection.(6)PhysicianDefined.For purposes of this paragraph,the term physician means a physician described in section 1861(r)(1) and theterm primary care physician means a physician who isidentified in the available data as a general practitioner, familypractice practitioner, general internist, or obstetrician or gynecologist.(7)Publicationof list of counties; posting on website.With respect to a year for which a county or area is identified orrevised under paragraph (4), the Secretary shall identify such countiesor areas as part of the proposed and final rule to implement the physicianfee schedule under section 1848 for the applicable year. The Secretary shall post thelist of counties identified or revised under paragraph (4) on theInternet website of the Centers for Medicare and Medicaid Services.(v)Increaseof fqhc payment limits.In the case ofservices furnished by Federally qualified health centers (as definedin section 1861(aa)(4)), theSecretary shall establish payment limits with respect to such servicesunder this part for services furnished(1)in 2010, at thelimits otherwise established under this part for such year increasedby $5; and(2)in a subsequentyear, at the limits established under this subsection for the previousyear increased by the percentage increase in the MEI (as defined insection 1842(i)(3)) for such subsequent year.(w)Methodsof payment.The Secretary may developalternative methods of payment for items and services provided underclinical trials and comparative effectiveness studies sponsored orsupported by an agency of the Department of Health and Human Services,as determined by the Secretary, to those that would otherwise applyunder this section, to the extent such alternative methods are necessaryto preserve the scientific validity of such trials or studies, suchas in the case where masking the identity of interventions from patientsand investigators is necessary to comply with the particular trialor study design.(x)IncentivePayments for Primary Care Services.(1)In general.In the case of primary care services furnished on or after January1, 2011, and before January 1, 2016, by a primary care practitioner,in addition to the amount of payment that would otherwise be madefor such services under this part, there also shall be paid (on amonthly or quarterly basis) an amount equal to 10 percent of the paymentamount for the service under this part.(2)Definitions.In this subsection:(A)Primary care practitionerThe term primary care practitioner means an individual(i)who(I)is a physician(as described in section 1861(r)(1)) who has a primary specialty designation of family medicine, internalmedicine, geriatric medicine, or pediatric medicine; or(II)is a nursepractitioner, clinical nurse specialist, or physician assistant (asthose terms are defined in section 1861(aa)(5)); and(ii)for whom primarycare services accounted for at least 60 percent of the allowed chargesunder this part for such physician or practitioner in a prior periodas determined appropriate by the Secretary(B)Primary care services.The term primary care services means services identified, as of January1, 2009, by the following HCPCS codes (and as subsequently modifiedby the Secretary):(i)99201 through99215.(ii)99304 through99340.(iii)99341 through99350.(3)Coordinationwith other payments.The amount of theadditional payment for a service under this subsection and subsection(m) shall be determined without regard to any additional payment forthe service under subsection (m) and this subsection, respectively.The amount of the additional payment for a service under this subsectionand subsection (z) shall be determined without regard to any additionalpayment for the service under subsection (z) and this subsection,respectively.[137](4)Limitationon review.There shall be no administrativeor judicial review under section 1869, 1878, or otherwise, respectingthe identification of primary care practitioners under this subsection.(y)IncentivePayments for Major Surgical Procedures Furnished in Health ProfessionalShortage Areas.(1)In general.In the case of major surgical procedures furnished on or afterJanuary 1, 2011, and before January 1, 2016, by a general surgeonin an area that is designated (under section 332(a)(1)(A) of the PublicHealth Service Act[138]) as a health professionalshortage area as identified by the Secretary prior to the beginningof the year involved, in addition to the amount of payment that wouldotherwise be made for such services under this part, there also shallbe paid (on a monthly or quarterly basis) an amount equal to 10 percentof the payment amount for the service under this part.(2)Definitions.In this subsection.(A)General surgeon.In this subsection,the term general surgeon means a physician (as describedin section 1861(r)(1)) who hasdesignated CMS specialty code 02 General Surgery as their primaryspecialty code in the physicians enrollment under section 1866(j).(B)Major surgical procedures.The term major surgical procedures means physicians serviceswhich are surgical procedures for which a 10-day or 90-day globalperiod is used for payment under the fee schedule under section 1848(b).(3)Coordinationwith others.The amount of the additionalpayment for a service under this subsection and subsection (m) shall be determined withoutregard to any additional payment for the service under subsection(m) and this subsection, respectively. The amount of the additionalpayment for a service under this subsection and subsection (z) shallbe determined without regard to any additional payment for the serviceunder subsection (z) and this subsection, respectively.[139](4)