evekhm/cms_iom_500 huggingface dataset:
Social Security Act §1833
(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)Notbudget neutral application of reduced expenditures resulting fromquality incentives for computed tomography.The Secretary shall not take into account the reduced expendituresthat result from the application of section 1834(p) in making anybudget neutrality adjustments this subsection.[129](21)Servicesfurnished by an off-campus outpatient department of a provider[130].(A)Applicable items and services.Forpurposes of paragraph (1)(B)(v) and this paragraph, the term applicable items and services means items and services otherthan items and services furnished by a dedicated emergency department(as defined in section 489.24(b) of title 42 of the Code of FederalRegulations).(B)Off-campus outpatient department of a provider.(i)Ingeneral.[131]For purposes ofparagraph (1)(B)(v) and this paragraph, subject to the subsequentprovisions of this subparagraph, the term off- campus outpatientdepartment of a provider means a department of a provider(as defined in section 413.65(a)(2) of title 42 of the Code of FederalRegulations, as in effect as of the date of the enactment of thisparagraph) that is not located(I)on the campus(as defined in such section 413.65(a)(2)) of such provider; or(II)withinthe distance (described in such definition of campus) from a remotelocation of a hospital facility (as defined in such section 413.65(a)(2)).(ii)Exception.For purposes of paragraph (1)(B)(v) and this paragraph, theterm off-campus outpatient department of a provider shall not include a department of a provider (as so defined) thatwas billing under this subsection with respect to covered OPD servicesfurnished prior to the date of the enactment of this paragraph.(iii)
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(iii)Deemed treatment for 2017.For purposesof applying clause (ii) with respect to applicable items and servicesfurnished during 2017, a department of a provider (as so defined)not described in such clause is deemed to be billing under this subsectionwith respect to covered OPD services furnished prior to November 2,2015, if the Secretary received from the provider prior to December2, 2015, an attestation (pursuant to section 413.65(b)(3) of title42 of the Code of Federal Regulations) that such department was adepartment of a provider (as so defined).(iv)Alternativeexception beginning with 2018.For purposesof paragraph (1)(B)(v) and this paragraph with respect to applicableitems and services furnished during 2018 or a subsequent year, theterm off-campus outpatient department of a provider also shall not include a department of a provider (as so defined)that is not described in clause (ii) if(I) the Secretary receives from the provideran attestation (pursuant to such section 413.65(b)(3)) not later thanDecember 31, 2016 (or, if later, 60 days after the date of the enactmentof this clause), that such department met the requirements of a departmentof a provider specified in section 413.65 of title 42 of the Codeof Federal Regulations;(II) the provider includes such departmentas part of the provider on its enrollment form in accordance withthe enrollment process under section 1866(j); and(III) the department met the mid-buildrequirement of clause (v) and the Secretary receives, not later than60 days after the date of the enactment of this clause, from the chiefexecutive officer or chief operating officer of the provider a writtencertification that the department met such requirement.(v)Mid-buildrequirement described.The mid-buildrequirement of this clause is, with respect to a department of a provider,that before November 2, 2015, the provider had a binding written agreementwith an outside unrelated party for the actual construction of suchdepartment.
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(vi)Exclusion for certain cancerhospitals.[132]For purposes of paragraph(1)(B)(v) and this paragraph with respect to applicable items andservices furnished during 2017 or a subsequent year, the term off-campus outpatient department of a provider also shallnot include a department of a provider (as so defined) that is notdescribed in clause (ii) if the provider is a hospital described insection 1886(d)(1)(B)(v) and(I) in the case of a department thatmet the requirements of section 413.65 of title 42 of the Code ofFederal Regulations after November 1, 2015, and before the date ofthe enactment of this clause, the Secretary receives from the provideran attestation that such department met such requirements not laterthan 60 days after such date of enactment; or(II) in the case of a department thatmeets such requirements after such date of enactment, the Secretaryreceives from the provider an attestation that such department meetssuch requirements not later than 60 days after the date such requirementsare first met with respect to such department.(vii)Audit.[133]Not later than December 31, 2018, the Secretary shall auditthe compliance with requirements of clause (iv) with respect to eachdepartment of a provider to which such clause applies. Not later than2 years after the date the Secretary receives an attestation underclause (vi) relating to compliance of a department of a provider withrequirements referred to in such clause, the Secretary shall auditthe compliance with such requirements with respect to the department.and If the Secretary finds as a result of an audit under this clausethat the applicable requirements were not met with respect to suchdepartment, the department shall not be excluded from the term off- campus outpatient department of a provider under suchclause.(viii)Implementation.For purposes of implementingclauses (iii) through (vii):(I) Notwithstanding any other provisionof law, the Secretary may implement such clauses by program instructionor otherwise.(II) Subchapter I of chapter 35 of title44, United States Code, shall not apply.
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(I) Notwithstanding any other provisionof law, the Secretary may implement such clauses by program instructionor otherwise.(II) Subchapter I of chapter 35 of title44, United States Code, shall not apply.(III)[134]For purposes of carrying out this subparagraph with respectto clauses (iii) and (iv) (and clause (vii) insofar as it relatesto clause (iv)), $10,000,000 shall be available from the Federal SupplementaryMedical Insurance Trust Fund under section 1841, to remain availableuntil December 31, 2018. For purposes of carrying out this subparagraphwith respect to clause (vi) (and clause (vii) insofar as it relatesto such clause), $2,000,000 shall be available from the Federal SupplementaryMedical Insurance Trust Fund under section 1841, to remain availableuntil expended.(C)Availability of payment under other payment systems.Payments for applicable items and services furnished by an off-campusoutpatient department of a provider that are described in paragraph(1)(B)(v) shall be made under the applicable payment system underthis part (other than under this subsection) if the requirements forsuch payment are otherwise met.(D)Information needed for implementation.Each hospital shall provide to the Secretary such information asthe Secretary determines appropriate to implement this paragraph andparagraph (1)(B)(v) (which may include reporting of information ona hospital claim using a code or modifier and reporting informationabout off-campus outpatient departments of a provider on the enrollmentform described in section 1866(j)).(E)Limitations.There shall be no administrativeor judicial review under section 1869, section 1878, or otherwiseof the following:(i)The determinationof the applicable items and services under subparagraph (A) and applicablepayment systems under subparagraph (C).(ii)The determinationof whether a department of a provider meets the term described insubparagraph (B).(iii)Any informationthat hospitals are required to report pursuant to subparagraph (D).(iv)The determinationof an audit under subparagraph (B)(vii).[135]
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(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.
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(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)
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(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;
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(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)
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(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)
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(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)
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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)Application.The provisions of paragraph (2) and (4) of subsection (m) shallapply to the determination of additional payments under this subsectionin the same manner as such provisions apply to the determination ofadditional payments under subsection (m).(z)IncentivePayments for Participation in Eligible Alternative Payment Models.[140](1)Paymentincentive.(A)In general.In the case of coveredprofessional services furnished by an eligible professional duringa year that is in the period beginning with 2019 and ending with 2024and for which the professional is a qualifying APM participant withrespect to such year, in addition to the amount of payment that wouldotherwise be made for such covered professional services under thispart for such year, there also shall be paid to such professionalan amount equal to 5 percent of the estimated aggregate payment amountsfor such covered professional services under this part for the precedingyear. For purposes of the previous sentence, the payment amount forthe preceding year may be an estimation for the full preceding yearbased on a period of such preceding year that is less than the fullyear. The Secretary shall establish policies to implement this subparagraphin cases in which payment for covered professional services furnishedby a qualifying APM participant in an alternative payment model(i)is made to aneligible alternative payment entity rather than directly to the qualifyingAPM participant; or(ii)is made on abasis other than a fee- for-service basis (such as payment on a capitatedbasis).(B)Form of payment.Payments under thissubsection shall be made in a lump sum, on an annual basis, as soonas practicable.(C)