evekhm/cms_iom_500 huggingface dataset:
(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;
(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)
(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)
(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)
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)
(B)Form of payment.Payments under thissubsection shall be made in a lump sum, on an annual basis, as soonas practicable.(C)Treatment of payment incentive.Paymentsunder this subsection shall not be taken into account for purposesof determining actual expenditures under an alternative payment modeland for purposes of determining or rebasing any benchmarks used underthe alternative payment model.(D)Coordination.The amount of the additionalpayment under this subsection or subsection (m) shall be determinedwithout regard to any additional payment under subsection (m) andthis subsection, respectively. The amount of the additional paymentunder this subsection or subsection (x) shall be determined withoutregard to any additional payment under subsection (x) and this subsection,respectively. The amount of the additional payment under this subsectionor subsection (y) shall be determined without regard to any additionalpayment under subsection (y) and this subsection, respectively.(2)Qualifyingapm participant.For purposes of thissubsection, the term qualifying APM participant meansthe following:(A)2019 and 2020.With respect to 2019and 2020, an eligible professional for whom the Secretary determinesthat at least 25 percent of payments under this part for covered professionalservices furnished by such professional during the most recent periodfor which data are available (which may be less than a year) wereattributable to such services furnished under this part through aneligible alternative payment entity.(B)2021 and 2022.With respect to 2021and 2022, an eligible professional described in either of the followingclauses:(i)Medicarepayment threshold option.An eligibleprofessional for whom the Secretary determines that at least 50 percentof payments under this part for covered professional services furnishedby such professional during the most recent period for which dataare available (which may be less than a year) were attributable tosuch services furnished under this part through an eligible alternativepayment entity.(ii)Combinationall-payer and medicare payment threshold option.An eligible professional(I)for whomthe Secretary determines, with respect to items and services furnishedby such professional during the most recent period for which dataare available (which may be less than a year), that at least 50 percentof the sum of(aa)paymentsdescribed in clause (i); and
(aa)paymentsdescribed in clause (i); and(bb)all otherpayments, regardless of payer (other than payments made by the Secretaryof Defense or the Secretary of Veterans Affairs and other than paymentsmade under title XIX in a State in which no medical home or alternativepayment model is available under the State program under that title),meet the requirement described in clause (iii)(I) with respect topayments described in item (aa) and meet the requirement describedin clause (iii)(II) with respect to payments described in item (bb);(II)for whomthe Secretary determines at least 25 percent of payments under thispart for covered professional services furnished by such professionalduring the most recent period for which data are available (whichmay be less than a year) were attributable to such services furnishedunder this part through an eligible alternative payment entity; and(III)whoprovides to the Secretary such information as is necessary for theSecretary to make a determination under subclause (I), with respectto such professional.(iii)Requirement.For purposes of clause(ii)(I)(I)the requirementdescribed in this subclause, with respect to payments described initem (aa) of such clause, is that such payments are made to an eligiblealternative payment entity; and(II)the requirementdescribed in this subclause, with respect to payments described initem (bb) of such clause, is that such payments are made under arrangementsin which(aa)qualitymeasures comparable to measures under the performance category describedin section 1848(q)(2)(B)(i) apply;(bb)certifiedEHR technology is used; and(cc)the eligibleprofessional participates in an entity that(AA)bearsmore than nominal financial risk if actual aggregate expendituresexceeds expected aggregate expenditures; or(BB)withrespect to beneficiaries under title XIX, is a medical home that meetscriteria comparable to medical homes expanded under section 1115A(c).(C)Beginning in 2023.With respect to2023 and each subsequent year, an eligible professional describedin either of the following clauses:(i)
(C)Beginning in 2023.With respect to2023 and each subsequent year, an eligible professional describedin either of the following clauses:(i)Medicarepayment threshold option.An eligibleprofessional for whom the Secretary determines that at least 75 percentof payments under this part for covered professional services furnishedby such professional during the most recent period for which dataare available (which may be less than a year) were attributable tosuch services furnished under this part through an eligible alternativepayment entity.(ii)Combinationall-payer and medicare payment threshold option.An eligible professional(I)for whomthe Secretary determines, with respect to items and services furnishedby such professional during the most recent period for which dataare available (which may be less than a year), that at least 75 percentof the sum of(aa)paymentsdescribed in clause (i); and(bb)all otherpayments, regardless of payer (other than payments made by the Secretaryof Defense or the Secretary of Veterans Affairs and other than paymentsmade under title XIX in a State in which no medical home or alternativepayment model is available under the State program under that title),meet the requirement described in clause (iii)(I) with respect topayments described in item (aa) and meet the requirement describedin clause (iii)(II) with respect to payments described in item (bb);(II)for whomthe Secretary determines at least 25 percent of payments under thispart for covered professional services furnished by such professionalduring the most recent period for which data are available (whichmay be less than a year) were attributable to such services furnishedunder this part through an eligible alternative payment entity; and(III)whoprovides to the Secretary such information as is necessary for theSecretary to make a determination under subclause (I), with respectto such professional.(iii)Requirement.For purposes of clause(ii)(I)(I)the requirementdescribed in this subclause, with respect to payments described initem (aa) of such clause, is that such payments are made to an eligiblealternative payment entity; and(II)the requirementdescribed in this subclause, with respect to payments described initem (bb) of such clause, is that such payments are made under arrangementsin which
(II)the requirementdescribed in this subclause, with respect to payments described initem (bb) of such clause, is that such payments are made under arrangementsin which(aa)qualitymeasures comparable to measures under the performance category describedin section 1848(q)(2)(B)(i) apply;(bb)certifiedEHR technology is used; and(cc)the eligibleprofessional participates in an entity that(AA)bearsmore than nominal financial risk if actual aggregate expendituresexceeds expected aggregate expenditures; or(BB)withrespect to beneficiaries under title XIX, is a medical home that meetscriteria comparable to medical homes expanded under section 1115A(c).(D)Use of patient approach.The Secretarymay base the determination of whether an eligible professional isa qualifying APM participant under this subsection and the determinationof whether an eligible professional is a partial qualifying APM participantunder section 1848(q)(1)(C)(iii) by using counts of patients in lieuof using payments and using the same or similar percentage criteria(as specified in this subsection and such section, respectively),as the Secretary determines appropriate.(3)Additionaldefinitions.In this subsection:(A)Covered professional services.Theterm covered professional services has the meaninggiven that term in section 1848(k)(3)(A).(B)Eligible professional.The term eligible professional has the meaning given that term insection 1848(k)(3)(B) and includes a group that includes such professionals.(C)Alternative payment model (apm).Theterm alternative payment model means, other than forpurposes of subparagraphs (B)(ii)(I)(bb) and (C)(ii)(I)(bb) of paragraph(2), any of the following:(i)A model undersection 1115A (other than a health care innovation award).(ii)The shared savingsprogram under section 1899.(iii)A demonstrationunder section 1866C.(iv)A demonstrationrequired by Federal law.(D)Eligible alternative payment entity.The term eligible alternative payment entity means,with respect to a year, an entity that(i)participates inan alternative payment model that
(iv)A demonstrationrequired by Federal law.(D)Eligible alternative payment entity.The term eligible alternative payment entity means,with respect to a year, an entity that(i)participates inan alternative payment model that(I)requiresparticipants in such model to use certified EHR technology (as definedin subsection (o)(4)); and(II)providesfor payment for covered professional services based on quality measurescomparable to measures under the performance category described insection 1848(q)(2)(B)(i); and(ii)(I)bears financialrisk for monetary losses under such alternative payment model thatare in excess of a nominal amount; or(II)is a medicalhome expanded under section 1115A(c).(4)Limitation.There shall be no administrative or judicial review under section1869, 1878, or otherwise, of the following:(A)The determinationthat an eligible professional is a qualifying APM participant underparagraph (2) and the determination that an entity is an eligiblealternative payment entity under paragraph (3)(D).(B)The determinationof the amount of the 5 percent payment incentive under paragraph (1)(A),including any estimation as part of such determination.[141](z)MedicalReview of Spinal Subluxation Services.[142](1)In general.The Secretary shall implement a process for the medical review(as described in paragraph (2)) of treatment by a chiropractor describedin section 1861(r)(5) by meansof manual manipulation of the spine to correct a subluxation (as describedin such section) of an individual who is enrolled under this partand apply such process to such services furnished on or after January1, 2017, focusing on services such as(A)servicesfurnished by a such a chiropractor whose pattern of billing is aberrantcompared to peers; and(B)servicesfurnished by such a chiropractor who, in a prior period, has a servicesdenial percentage in the 85th percentile or greater, taking into considerationthe extent that service denials are overturned on appeal.(2)Medicalreview.(A)Prior authorization medical review.(i)
(2)Medicalreview.(A)Prior authorization medical review.(i)Ingeneral.Subject to clause (ii), theSecretary shall use prior authorization medical review for servicesdescribed in paragraph (1) that are furnished to an individual bya chiropractor described in section 1861(r)(5) that are part of an episode of treatment that includesmore than 12 services. For purposes of the preceding sentence, anepisode of treatment shall be determined by the underlying cause thatjustifies the need for services, such as a diagnosis code.(ii)Endingapplication of prior authorization medical review.The Secretary shall end the application of prior authorizationmedical review under clause (i) to services described in paragraph(1) by such a chiropractor if the Secretary determines that the chiropractorhas a low denial rate under such prior authorization medical review.The Secretary may subsequently reapply prior authorization medicalreview to such chiropractor if the Secretary determines it to be appropriateand the chiropractor has, in the time period subsequent to the determinationby the Secretary of a low denial rate with respect to the chiropractor,furnished such services described in paragraph (1).(iii)Early request for prior authorization review permitted.Nothing in this subsection shall be construed to prevent sucha chiropractor from requesting prior authorization for services describedin paragraph (1) that are to be furnished to an individual beforethe chiropractor furnishes the twelfth such service to such individualfor an episode of treatment.(B)Type of review.The Secretary may usepre- payment review or post-payment review of services described insection 1861(r)(5) that arenot subject to prior authorization medical review under subparagraph(A).(C)Relationship to law enforcement activities.The Secretary may determine that medical review under this subsectiondoes not apply in the case where potential fraud may be involved.(3)No paymentwithout prior authorization.With respectto a service described in paragraph (1) for which prior authorizationmedical review under this subsection applies, the following shallapply:(A)Prior authorization determination.The Secretary shall make a determination, prior to the service beingfurnished, of whether the service would or would not meet the applicablerequirements of section 1862(a)(1)(A).(B)