evekhm/cms_iom_500 huggingface dataset:
Social Security Act §1833
(B)Election to offer reduced copayment amount.The Secretary shall establish a procedure under which a hospital,before the beginning of a year (beginning with 1999), may elect toreduce the copayment amount otherwise established under subparagraph(A) for some or all covered OPD services to an amount that is notless than 20 percent of the medicare OPD fee schedule amount (computedunder paragraph (3)(D)) for the service involved. Under such procedures,such reduced copayment amount may not be further reduced or increasedduring the year involved and the hospital may disseminate informationon the reduction of copayment amount effected under this subparagraph.(C)Limitation on copayment amount.(i)Toinpatient hospital deductible amount.In no case shall the copayment amount for a procedure performed ina year exceed the amount of the inpatient hospital deductible establishedunder section 1813(b) for that year.(ii)Tospecified percentage.The Secretary shallreduce the national unadjusted copayment amount for a covered OPDservice (or group of such services) furnished in a year in a mannerso that the effective copayment rate (determined on a national unadjustedbasis) for that service in the year does not exceed the followingpercentage:(I)For proceduresperformed in 2001, on or after April 1, 2001, 57 percent.(II)For proceduresperformed in 2002 or 2003, 55 percent.(III)Forprocedures performed in 2004, 50 percent.(IV)For proceduresperformed in 2005, 45 percent.(V)For proceduresperformed in 2006 and thereafter, 40 percent.(D)No impact on deductibles.Nothing inthis paragraph shall be construed as affecting a hospitalsauthority to waive the charging of a deductible under section 1833(b).(E)Computation ignoring outlier and pass-through adjustments.The copayment amount shall be computed under subparagraph (A)as if the adjustments under paragraphs (5) and (6) (and any adjustmentmade under paragraph (2)(E) in relation to such adjustments) had notoccurred.(9)Periodicreview and adjustments components of prospective payment system.(A)
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(9)Periodicreview and adjustments components of prospective payment system.(A)Periodic review.The Secretary shallreview not less often than annually and revise the groups, the relativepayment weights, and the wage and other adjustments described in paragraph(2) to take into account changes in medical practice, changes in technology,the addition of new services, new cost data, and other relevant informationand factors. The Secretary shall consult with an expert outside advisorypanel composed of an appropriate selection of representatives of providersto review (and advise the Secretary concerning) the clinical integrityof the groups and weights. Such panel may use data collected or developedby entities and organizations (other than the Department of Healthand Human Services) in conducting such review.(B)Budget neutrality adjustment.If theSecretary makes adjustments under subparagraph (A), then the adjustmentsfor a year may not cause the estimated amount of expenditures underthis part for the year to increase or decrease from the estimatedamount of expenditures under this part that would have been made ifthe adjustments had not been made. In determining adjustments underthe preceding sentence for 2004 and 2005, the Secretary shall nottake into account under this subparagraph or paragraph (2)(E) anyexpenditures that would not have been made but for the applicationof paragraph (14).(C)Update factor.If the Secretary determinesunder methodologies described in paragraph (2)(F) that the volumeof services paid for under this subsection increased beyond amountsestablished through those methodologies, the Secretary may appropriatelyadjust the update to the conversion factor otherwise applicable ina subsequent year.(10)Specialrule for ambulance services.The Secretaryshall pay for hospital outpatient services that are ambulance serviceson the basis described in section 1861(v)(1)(U), or, if applicable,the fee schedule established under section 1834(l).(11)Specialrules for certain hospitals.In the caseof hospitals described in clause (iii) or (v) of section 1886(d)(1)(B)(A)the systemunder this subsection shall not apply to covered OPD services furnishedbefore January 1, 2000; and(B)the Secretarymay establish a separate conversion factor for such services in amanner that specifically takes into account the unique costs incurredby such hospitals by virtue of their patient population and serviceintensity.(12)
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(B)the Secretarymay establish a separate conversion factor for such services in amanner that specifically takes into account the unique costs incurredby such hospitals by virtue of their patient population and serviceintensity.(12)Limitationon review.There shall be no administrativeor judicial review under section 1869, 1878, or otherwise of(A)the developmentof the classification system under paragraph (2), including the establishmentof groups and relative payment weights for covered OPD services, ofwage adjustment factors, other adjustments, and methods describedin paragraph (2)(F);(B)the calculationof base amounts under paragraph (3);(C)periodicadjustments made under paragraph (6);(D)the establishmentof a separate conversion factor under paragraph (8)(B); and(E)the determinationof the fixed multiple, or a fixed dollar cutoff amount, the marginalcost of care, or applicable percentage under paragraph (5) or thedetermination of insignificance of cost, the duration of the additionalpayments, the determination and deletion of initial and new categories(consistent with subparagraphs (B) and (C) of paragraph (6)), theportion of the medicare OPD fee schedule amount associated with particulardevices, drugs, or biologicals, and the application of any pro ratareduction under paragraph (6).(13)Authorizationof adjustment for rural hospitals.(A)Study.The Secretary shall conducta study to determine if, under the system under this subsection, costsincurred by hospitals located in rural areas by ambulatory paymentclassification groups (APCs) exceed those costs incurred by hospitalslocated in urban areas.(B)Authorization of adjustment.Insofaras the Secretary determines under subparagraph (A) that costs incurredby hospitals located in rural areas exceed those costs incurred byhospitals located in urban areas, the Secretary shall provide foran appropriate adjustment under paragraph (2)(E) to reflect thosehigher costs by January 1, 2006.(14)Drugapc payment rates.(A)In general.The amount of payment underthis subsection for a specified covered outpatient drug (defined insubparagraph (B)) that is furnished as part of a covered OPD service(or group of services)(i)in 2004, inthe case of
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(i)in 2004, inthe case of(I)a solesource drug shall in no case be less than 88 percent, or exceed 95percent, of the reference average wholesale price for the drug;(II)an innovatormultiple source drug shall in no case exceed 68 percent of the referenceaverage wholesale price for the drug; or(III)a noninnovatormultiple source drug shall in no case exceed 46 percent of the referenceaverage wholesale price for the drug;(ii)in 2005, inthe case of(I)a solesource drug shall in no case be less than 83 percent, or exceed 95percent, of the reference average wholesale price for the drug;(II)an innovatormultiple source drug shall in no case exceed 68 percent of the referenceaverage wholesale price for the drug; or(III)anoninnovator multiple source drug shall in no case exceed 46 percentof the reference average wholesale price for the drug; or(iii)in a subsequentyear, shall be equal, subject to subparagraph (E)(I)to theaverage acquisition cost for the drug for that year (which, at theoption of the Secretary, may vary by hospital group (as defined bythe Secretary based on volume of covered OPD services or other relevantcharacteristics)), as determined by the Secretary taking into accountthe hospital acquisition cost survey data under subparagraph (D);or(II)ifhospital acquisition cost data are not available, the average pricefor the drug in the year established under section 1842(o), section 1847A, or section 1847B, as the casemay be, as calculated and adjusted by the Secretary as necessary forpurposes of this paragraph.(B)Specified covered outpatient drug defined.(i)Ingeneral.In this paragraph, the term specified covered outpatient drug means, subject to clause(ii), a covered outpatient drug (as defined in section 1927(k)(2)) forwhich a separate ambulatory payment classification group (APC) hasbeen established and that is(I)a radiopharmaceutical;or(II)a drugor biological for which payment was made under paragraph (6) (relatingto pass-through payments) on or before December 31, 2002.(ii)Exception.Such term does not include
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(II)a drugor biological for which payment was made under paragraph (6) (relatingto pass-through payments) on or before December 31, 2002.(ii)Exception.Such term does not include(I)a drugor biological for which payment is first made on or after January1, 2003, under paragraph (6);(II)a drugor biological for which a temporary HCPCS code has not been assigned;or(III)during2004 and 2005, an orphan drug (as designated by the Secretary).(C)Payment for designated orphan drugs during 2004 and 2005.The amount of payment under this subsection for an orphan drugdesignated by the Secretary under subparagraph (B)(ii)(III) that isfurnished as part of a covered OPD service (or group of services)during 2004 and 2005 shall equal such amount as the Secretary mayspecify.(D)Acquisition cost survey for hospital outpatient drugs.(i)AnnualGAO surveys in 2004 and 2005.(I)In general.The Comptroller Generalof the United States shall conduct a survey in each of 2004 and 2005to determine the hospital acquisition cost for each specified coveredoutpatient drug. Not later than April 1, 2005, the Comptroller Generalshall furnish data from such surveys to the Secretary for use in settingthe payment rates under subparagraph (A) for 2006.(II)Recommendations.Upon the completionof such surveys, the Comptroller General shall recommend to the Secretarythe frequency and methodology of subsequent surveys to be conductedby the Secretary under clause (ii).(ii)Subsequentsecretarial surveys.The Secretary, takinginto account such recommendations, shall conduct periodic subsequentsurveys to determine the hospital acquisition cost for each specifiedcovered outpatient drug for use in setting the payment rates undersubparagraph (A).(iii)Survey requirements.The surveys conductedunder clauses (i) and (ii) shall have a large sample of hospitalsthat is sufficient to generate a statistically significant estimateof the average hospital acquisition cost for each specified coveredoutpatient drug. With respect to the surveys conducted under clause(i), the Comptroller General shall report to Congress on the justificationfor the size of the sample used in order to assure the validity ofsuch estimates.(iv)
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(iv)Differentiationin cost.In conducting surveys underclause (i), the Comptroller General shall determine and report toCongress if there is (and the extent of any) variation in hospitalacquisition costs for drugs among hospitals based on the volume ofcovered OPD services performed by such hospitals or other relevantcharacteristics of such hospitals (as defined by the Comptroller General).(v)Commenton proposed rates.Not later than 30days after the date the Secretary promulgated proposed rules settingforth the payment rates under subparagraph (A) for 2006, the ComptrollerGeneral shall evaluate such proposed rates and submit to Congressa report regarding the appropriateness of such rates based on thesurveys the Comptroller General has conducted under clause (i).(E)Adjustment in payment rates for overhead costs.(i)Medpacreport on drug apc design.The MedicarePayment Advisory Commission shall submit to the Secretary, not laterthan July 1, 2005, a report on adjustment of payment for ambulatorypayment classifications for specified covered outpatient drugs totake into account overhead and related expenses, such as pharmacyservices and handling costs. Such report shall include(I)a descriptionand analysis of the data available with regard to such expenses;(II)a recommendationas to whether such a payment adjustment should be made; and(III)ifsuch adjustment should be made, a recommendation regarding the methodologyfor making such an adjustment.(ii)Adjustmentauthorized.The Secretary may adjustthe weights for ambulatory payment classifications for specified coveredoutpatient drugs to take into account the recommendations containedin the report submitted under clause (i).(F)Classes of drugs.For purposes of thisparagraph:(i)Solesource drugs.The term sole sourcedrug means(I)a biologicalproduct (as defined under section 1861(t)(1)); or(II)a singlesource drug (as defined in section 1927(k)(7)(A)(iv)).(ii)Innovatormultiple source drugs.The term innovator multiple source drug has the meaning given suchterm in section 1927(k)(7)(A)(ii).(iii)
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(ii)Innovatormultiple source drugs.The term innovator multiple source drug has the meaning given suchterm in section 1927(k)(7)(A)(ii).(iii)Noninnovator multiple source drugs.The term noninnovator multiple source drug has themeaning given such term in section 1927(k)(7)(A)(iii).(G)Reference average wholesale price.The term reference average wholesale price means,with respect to a specified covered outpatient drug, the average wholesaleprice for the drug as determined under section 1842(o) as of May 1, 2003.(H)Inapplicability of expenditures in determining conversion, weighting,and other adjustment factors.Additionalexpenditures resulting from this paragraph shall not be taken intoaccount in establishing the conversion, weighting, and other adjustmentfactors for 2004 and 2005 under paragraph (9), but shall be takeninto account for subsequent years.(15)Paymentfor new drugs and biologicals until hcpcs code assigned.With respect to payment under this part for an outpatient drugor biological that is covered under this part and is furnished aspart of covered OPD services for which a HCPCS code has not been assigned,the amount provided for payment for such drug or biological underthis part shall be equal to 95 percent of the average wholesale pricefor the drug or biological.(16)Miscellaneousprovisions.(A)Application of reclassification of certain hospitals.If a hospital is being treated as being located in a rural areaunder section 1886(d)(8)(E), that hospital shall be treated under this subsection as being locatedin that rural area.(B)Threshold for establishment of separate apcs for drugs.The Secretary shall reduce the threshold for the establishmentof separate ambulatory payment classification groups (APCs) with respectto drugs or biologicals to $50 per administration for drugs and biologicalsfurnished in 2005 and 2006.(C)
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(C)Payment for devices of brachytherapy and therapeutic radiopharmaceuticalsat charges adjusted to cost.Notwithstandingthe preceding provisions of this subsection, for a device of brachytherapyconsisting of a seed or seeds (or radioactive source) furnished onor after January 1, 2004, and before July 1, 2008, and for therapeuticradiopharmaceuticals furnished on or after January 1, 2008, and beforeJuly 1, 2008, the payment basis for the device or therapeutic radiopharmaceuticalunder this subsection shall be equal to the hospitals chargesfor each deviceor therapeutic radiopharmaceutical furnished, adjustedto cost. Charges for such devices or therapeutic radiopharmaceuticalsshall not be included in determining any outlier payment under thissubsection.(D)[126]Special paymentrule.(i)Ingeneral.In the case of covered OPD servicesfurnished on or after April 1, 2013, in a hospital described in clause(ii), if(I)  the payment rate that would otherwiseapply under this subsection for stereotactic radiosurgery, completecourse of treatment of cranial lesion(s) consisting of 1 session thatis multisource Cobalt 60 based (identified as of January 1, 2013,by HCPCS code 77371 (and any succeeding code) and reimbursed as ofsuch date under APC 0127 (and any succeeding classification group));exceeds(II)  the payment rate that would otherwiseapply under this subsection for linear accelerator based stereotacticradiosurgery, complete course of therapy in one session (identifiedas of January 1, 2013, by HCPCS code G0173 (and any succeeding code)and reimbursed as of such date under APC 0067 (and any succeedingclassification group)),the payment rate for the servicedescribed in subclause (I) shall be reduced to an amount equal tothe payment rate for the service described in subclause (II).(ii)Hospital described.A hospital described in this clause is a hospital that is not(I)  located in a rural area (as definedin section 1886(d)(2)(D));(II)  classified as a rural referralcenter under section 1886(d)(5)(C); or
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(I)  located in a rural area (as definedin section 1886(d)(2)(D));(II)  classified as a rural referralcenter under section 1886(d)(5)(C); or(III)  a sole community hospital (asdefined in section 1886(d)(5)(D)(iii)).(iii)Not budget neutral.In making any budget neutrality adjustments under this subsectionfor 2013 (with respect to covered OPD services furnished on or afterApril 1, 2013, and before January 1, 2014) or a subsequent year, theSecretary shall not take into account the reduced expenditures thatresult from the application of this subparagraph.(E)Application of appropriate use criteria for certain imaging services.For provisions relating to the application of appropriate usecriteria for certain imaging services, see section 1834(q).[127](17)QualityReporting.(A)Reduction in update for failure to report.(i)Ingeneral.For purposes of paragraph (3)(C)(iv)for 2009 and each subsequent year, in the case of a subsection (d)hospital (as defined in section 1886(d)(1)(B)) that does not submit,to the Secretary in accordance with this paragraph, data requiredto be submitted on measures selected under this paragraph with respectto such a year, the OPD fee schedule increase factor under paragraph(3)(C)(iv) for such year shall be reduced by 2.0 percentage points.(ii)Non-cumulativeapplication.A reduction under this subparagraphshall apply only with respect to the year involved and the Secretaryshall not take into account such reduction in computing the OPD feeschedule increase factor for a subsequent year.(B)Form and manner of submission.Eachsubsection (d) hospital shall submit data on measures selected underthis paragraph to the Secretary in a form and manner, and at a time,specified by the Secretary for purposes of this paragraph.(C)Development of outpatient measures.(i)
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(C)Development of outpatient measures.(i)Ingeneral.The Secretary shall developmeasures that the Secretary determines to be appropriate for the measurementof the quality of care (including medication errors) furnished byhospitals in outpatient settings and that reflect consensus amongaffected parties and, to the extent feasible and practicable, shallinclude measures set forth by one or more national consensus buildingentities.(ii)Construction.Nothing in this paragraph shall be construed as preventing theSecretary from selecting measures that are the same as (or a subsetof) the measures for which data are required to be submitted undersection 1886(b)(3)(B)(viii).(D)Replacement of measures.For purposesof this paragraph, the Secretary may replace any measures or indicatorsin appropriate cases, such as where all hospitals are effectivelyin compliance or the measures or indicators have been subsequentlyshown not to represent the best clinical practice.(E)Availability of data.The Secretaryshall establish procedures for making data submitted under this paragraphavailable to the public. Such procedures shall ensure that a hospitalhas the opportunity to review the data that are to be made publicwith respect to the hospital prior to such data being made public.The Secretary shall report quality measures of process, structure,outcome, patients perspectives on care, efficiency, and costsof care that relate to services furnished in outpatient settings inhospitals on the Internet website of the Centers for Medicare andMedicaid Services.(18)[128]Authorization of adjustment forcancer hospitals.(A)Study.The Secretary shall conducta study to determine if, under the system under this subsection, costsincurred by hospitals described in section 1886(d)(1)(B)(v) with respectto ambulatory payment classification groups exceed those costs incurredby other hospitals furnishing services under this subsection (as determinedappropriate by the Secretary). In conducting the study under thissubparagraph, the Secretary shall take into consideration the costof drugs and biologicals incurred by such hospitals.(B)
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(B)Authorization of adjustment.Insofaras the Secretary determines under subparagraph (A) that costs incurredby hospitals described in section 1886(d)(1)(B)(v) exceed those costs incurred by other hospitalsfurnishing services under this subsection, the Secretary shall, subjectto subparagraph (C), provide for an appropriate adjustment under paragraph(2)(E) to reflect those higher costs effective for services furnishedon or after January 1, 2011.(C)Target pcr adjustmentIn applying section 419.43(i) of title 42 of the Code of FederalRegulations to implement the appropriate adjustment under this paragraphfor services furnished on or after January 1, 2018, the Secretaryshall use a target PCR that is 1.0 percentage points less than thetarget PCR that would otherwise apply. In addition to the percentagepoint reduction under the previous sentence, the Secretary may considermaking an additional percentage point reduction to such target PCRthat takes into account payment rates for applicable items and servicesdescribed in paragraph (21)(C) other than for services furnished byhospitals described in section 1886(d)(1)(B)(v). In making any budget neutrality adjustmentsunder this subsection for 2018 or a subsequent year, the Secretaryshall not take into account the reduced expenditures that result fromthe application of this subparagraph.(19)Flooron area wage adjustment factor for hospital outpatient departmentservices in frontier states.(A)In general.Subject to subparagraph(B), with respect to covered OPD services furnished on or after January1, 2011, the area wage adjustment factor applicable under the paymentsystem established under this subsection to any hospital outpatientdepartment which is located in a frontier State (as defined in section 1886(d)(3)(E)(iii)(II)) maynot be less than 1.00. The preceding sentence shall not be appliedin a budget neutral manner.(B)Limitation.This paragraph shall notapply to any hospital outpatient department located in a State thatreceives a non-labor related share adjustment under section 1886(d)(5)(H).(20)