Medicare Improvements for Patients and Providers Act of 2008
PL 110-275 (H.R.6331), enacted 07/15/2008

122 STAT. 2494 
PUBLIC LAW 110–275—JULY 15, 2008 
Public Law 110–275 
110th Congress 
An Act 
To amend titles XVIII and XIX of the Social Security Act to extend expiring 
provisions under the Medicare Program, to improve beneficiary access to preventive 
and mental health services, to enhance low-income benefit programs, and to 
maintain access to care in rural areas, including pharmacy access, and for other 
purposes. 
Be it enacted by the Senate and House of Representatives of 
the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the ‘‘Medicare 
Improvements for Patients and Providers Act of 2008’’. 
(b) TABLE OF CONTENTS.—The table of contents of this Act 
is as follows: 
Sec. 1. Short title; table of contents. 
TITLE I—MEDICARE 
Subtitle A—Beneficiary Improvements 
PART I—PREVENTION, MENTAL HEALTH, AND MARKETING 
Sec. 101. Improvements to coverage of preventive services. 
Sec. 102. Elimination of discriminatory copayment rates for Medicare outpatient 
psychiatric services. 
Sec. 103. Prohibitions and limitations on certain sales and marketing activities 
under Medicare Advantage plans and prescription drug plans. 
Sec. 104. Improvements to the Medigap program. 
PART II—LOW-INCOME PROGRAMS 
Sec. 111. Extension of qualifying individual (QI) program. 
Sec. 112. Application of full LIS subsidy assets test under Medicare Savings Pro-
gram. 
Sec. 113. Eliminating barriers to enrollment. 
Sec. 114. Elimination of Medicare part D late enrollment penalties paid by subsidy 
eligible individuals. 
Sec. 115. Eliminating application of estate recovery. 
Sec. 116. Exemptions from income and resources for determination of eligibility for 
low-income subsidy. 
Sec. 117. Judicial review of decisions of the Commissioner of Social Security under 
the Medicare part D low-income subsidy program. 
Sec. 118. Translation of model form. 
Sec. 119. Medicare enrollment assistance. 
Subtitle B—Provisions Relating to Part A 
Sec. 121. Expansion and extension of the Medicare Rural Hospital Flexibility Pro-
gram. 
Sec. 122. Rebasing for sole community hospitals. 
Sec. 123. Demonstration project on community health integration models in certain 
rural counties. 
Sec. 124. Extension of the reclassification of certain hospitals. 
Sec. 125. Revocation of unique deeming authority of the Joint Commission. 
42 USC 1305 
note. 
Medicare 
Improvements 
for Patients and 
Providers Act of 
2008. 
Inter- 
governmental 
relations. 
July 15, 2008 
[H.R. 6331] 
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122 STAT. 2495 
PUBLIC LAW 110–275—JULY 15, 2008 
Subtitle C—Provisions Relating to Part B 
PART I—PHYSICIANS’ SERVICES 
Sec. 131. Physician payment, efficiency, and quality improvements. 
Sec. 132. Incentives for electronic prescribing. 
Sec. 133. Expanding access to primary care services. 
Sec. 134. Extension of floor on Medicare work geographic adjustment under the 
Medicare physician fee schedule. 
Sec. 135. Imaging provisions. 
Sec. 136. Extension of treatment of certain physician pathology services under 
Medicare. 
Sec. 137. Accommodation of physicians ordered to active duty in the Armed Serv-
ices. 
Sec. 138. Adjustment for Medicare mental health services. 
Sec. 139. Improvements for Medicare anesthesia teaching programs. 
PART II—OTHER PAYMENT AND COVERAGE IMPROVEMENTS 
Sec. 141. Extension of exceptions process for Medicare therapy caps. 
Sec. 142. Extension of payment rule for brachytherapy and therapeutic radio-
pharmaceuticals. 
Sec. 143. Speech-language pathology services. 
Sec. 144. Payment and coverage improvements for patients with chronic obstructive 
pulmonary disease and other conditions. 
Sec. 145. Clinical laboratory tests. 
Sec. 146. Improved access to ambulance services. 
Sec. 147. Extension and expansion of the Medicare hold harmless provision under 
the prospective payment system for hospital outpatient department 
(HOPD) services for certain hospitals. 
Sec. 148. Clarification of payment for clinical laboratory tests furnished by critical 
access hospitals. 
Sec. 149. Adding certain entities as originating sites for payment of telehealth serv-
ices. 
Sec. 150. MedPAC study and report on improving chronic care demonstration pro-
grams. 
Sec. 151. Increase of FQHC payment limits. 
Sec. 152. Kidney disease education and awareness provisions. 
Sec. 153. Renal dialysis provisions. 
Sec. 154. Delay in and reform of Medicare DMEPOS competitive acquisition pro-
gram. 
Subtitle D—Provisions Relating to Part C 
Sec. 161. Phase-out of indirect medical education (IME). 
Sec. 162. Revisions to requirements for Medicare Advantage private fee-for-service 
plans. 
Sec. 163. Revisions to quality improvement programs. 
Sec. 164. Revisions relating to specialized Medicare Advantage plans for special 
needs individuals. 
Sec. 165. Limitation on out-of-pocket costs for dual eligibles and qualified medicare 
beneficiaries enrolled in a specialized Medicare Advantage plan for spe-
cial needs individuals. 
Sec. 166. Adjustment to the Medicare Advantage stabilization fund. 
Sec. 167. Access to Medicare reasonable cost contract plans. 
Sec. 168. MedPAC study and report on quality measures. 
Sec. 169. MedPAC study and report on Medicare Advantage payments. 
Subtitle E—Provisions Relating to Part D 
PART I—IMPROVING PHARMACY ACCESS 
Sec. 171. Prompt payment by prescription drug plans and MA–PD plans under part 
D. 
Sec. 172. Submission of claims by pharmacies located in or contracting with long- 
term care facilities. 
Sec. 173. Regular update of prescription drug pricing standard. 
PART II—OTHER PROVISIONS 
Sec. 175. Inclusion of barbiturates and benzodiazepines as covered part D drugs. 
Sec. 176. Formulary requirements with respect to certain categories or classes of 
drugs. 
Subtitle F—Other Provisions 
Sec. 181. Use of part D data. 
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122 STAT. 2496 
PUBLIC LAW 110–275—JULY 15, 2008 
Sec. 182. Revision of definition of medically accepted indication for drugs. 
Sec. 183. Contract with a consensus-based entity regarding performance measure-
ment. 
Sec. 184. Cost-sharing for clinical trials. 
Sec. 185. Addressing health care disparities. 
Sec. 186. Demonstration to improve care to previously uninsured. 
Sec. 187. Office of the Inspector General report on compliance with and enforce-
ment of national standards on culturally and linguistically appropriate 
services (CLAS) in Medicare. 
Sec. 188. Medicare Improvement Funding. 
Sec. 189. Inclusion of Medicare providers and suppliers in Federal Payment Levy 
and Administrative Offset Program. 
TITLE II—MEDICAID 
Sec. 201. Extension of transitional medical assistance (TMA) and abstinence edu-
cation program. 
Sec. 202. Medicaid DSH extension. 
Sec. 203. Pharmacy reimbursement under Medicaid. 
Sec. 204. Review of administrative claim determinations. 
Sec. 205. County medicaid health insuring organizations. 
TITLE III—MISCELLANEOUS 
Sec. 301. Extension of TANF supplemental grants. 
Sec. 302. 70 percent federal matching for foster care and adoption assistance for 
the District of Columbia. 
Sec. 303. Extension of Special Diabetes Grant Programs. 
Sec. 304. IOM reports on best practices for conducting systematic reviews of clinical 
effectiveness research and for developing clinical protocols. 
TITLE I—MEDICARE 
Subtitle A—Beneficiary Improvements 
PART I—PREVENTION, MENTAL HEALTH, AND 
MARKETING 
SEC. 101. IMPROVEMENTS TO COVERAGE OF PREVENTIVE SERVICES. 
(a) COVERAGE OF ADDITIONAL PREVENTIVE SERVICES.— 
(1) COVERAGE.—Section 1861 of the Social Security Act 
(42 U.S.C. 1395x), as amended by section 114 of the Medicare, 
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110– 
173), is amended— 
(A) in subsection (s)(2)— 
(i) in subparagraph (Z), by striking ‘‘and’’ after 
the semicolon at the end; 
(ii) in subparagraph (AA), by adding ‘‘and’’ after 
the semicolon at the end; and 
(iii) by adding at the end the following new 
subparagraph: 
‘‘(BB) additional preventive services (described in sub-
section (ddd)(1));’’; and 
(B) by adding at the end the following new subsection: 
‘‘Additional Preventive Services 
‘‘(ddd)(1) The term ‘additional preventive services’ means serv-
ices not otherwise described in this title that identify medical condi-
tions or risk factors and that the Secretary determines are— 
‘‘(A) reasonable and necessary for the prevention or early 
detection of an illness or disability; 
‘‘(B) recommended with a grade of A or B by the United 
States Preventive Services Task Force; and 
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122 STAT. 2497 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(C) appropriate for individuals entitled to benefits under 
part A or enrolled under part B. 
‘‘(2) In making determinations under paragraph (1) regarding 
the coverage of a new service, the Secretary shall use the process 
for making national coverage determinations (as defined in section 
1869(f)(1)(B)) under this title. As part of the use of such process, 
the Secretary may conduct an assessment of the relation between 
predicted outcomes and the expenditures for such service and may 
take into account the results of such assessment in making such 
determination.’’. 
(2) PAYMENT AND COINSURANCE FOR ADDITIONAL PREVEN-
TIVE SERVICES.—Section 1833(a)(1) of the Social Security Act 
(42 U.S.C. 1395l(a)(1)) is amended— 
(A) by striking ‘‘and’’ before ‘‘(V)’’; and 
(B) by inserting before the semicolon at the end the 
following: ‘‘, and (W) with respect to additional preventive 
services (as defined in section 1861(ddd)(1)), the amount 
paid shall be (i) in the case of such services which are 
clinical diagnostic laboratory tests, the amount determined 
under subparagraph (D), and (ii) in the case of all other 
such services, 80 percent of the lesser of the actual charge 
for the service or the amount determined under a fee 
schedule established by the Secretary for purposes of this 
subparagraph’’. 
(3) CONFORMING AMENDMENT REGARDING COVERAGE.—Sec-
tion 1862(a)(1)(A) of the Social Security Act (42 U.S.C. 
1395y(a)(1)(A)) is amended by inserting ‘‘or additional preven-
tive services (as described in section 1861(ddd)(1))’’ after ‘‘suc-
ceeding subparagraph’’. 
(4) RULE
OF
CONSTRUCTION.—Nothing in the provisions 
of, or amendments made by, this subsection shall be construed 
to provide coverage under title XVIII of the Social Security 
Act of items and services for the treatment of a medical condi-
tion that is not otherwise covered under such title. 
(b) REVISIONS
TO INITIAL PREVENTIVE PHYSICAL EXAMINA-
TION.— 
(1) IN GENERAL.—Section 1861(ww) of the Social Security 
Act (42 U.S.C. 1395x(ww)) is amended— 
(A) in paragraph (1)— 
(i) by inserting ‘‘body mass index,’’ after ‘‘weight’’; 
(ii) by striking ‘‘, and an electrocardiogram’’; and 
(iii) by inserting ‘‘and end-of-life planning (as 
defined in paragraph (3)) upon the agreement with 
the individual’’ after ‘‘paragraph (2)’’; 
(B) in paragraph (2), by adding at the end the following 
new subparagraphs: 
‘‘(M) An electrocardiogram. 
‘‘(N) Additional preventive services (as defined in subsection 
(ddd)(1)).’’; and 
(C) by adding at the end the following new paragraph: 
‘‘(3) For purposes of paragraph (1), the term ‘end-of-life plan-
ning’ means verbal or written information regarding— 
‘‘(A) an individual’s ability to prepare an advance directive 
in the case that an injury or illness causes the individual 
to be unable to make health care decisions; and 
‘‘(B) whether or not the physician is willing to follow the 
individual’s wishes as expressed in an advance directive.’’. 
42 USC 1395l 
note. 
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122 STAT. 2498 
PUBLIC LAW 110–275—JULY 15, 2008 
(2) WAIVER OF APPLICATION OF DEDUCTIBLE.—The first sen-
tence of section 1833(b) of the Social Security Act (42 U.S.C. 
1395l(b)) is amended— 
(A) by striking ‘‘and’’ before ‘‘(8)’’; and 
(B) by inserting ‘‘, and (9) such deductible shall not 
apply with respect to an initial preventive physical exam-
ination (as defined in section 1861(ww))’’ before the period 
at the end. 
(3) EXTENSION OF ELIGIBILITY PERIOD FROM SIX MONTHS 
TO ONE YEAR.—Section 1862(a)(1)(K) of the Social Security Act 
(42 U.S.C. 1395y(a)(1)(K)) is amended by striking ‘‘6 months’’ 
and inserting ‘‘1 year’’. 
(4) TECHNICAL CORRECTION.—Section 1862(a)(1)(K) of the 
Social Security Act (42 U.S.C. 1395y(a)(1)(K)) is amended by 
striking ‘‘not later’’ and inserting ‘‘more’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply to services furnished on or after January 1, 2009. 
SEC. 102. ELIMINATION OF DISCRIMINATORY COPAYMENT RATES FOR 
MEDICARE OUTPATIENT PSYCHIATRIC SERVICES. 
Section 1833(c) of the Social Security Act (42 U.S.C. 1395l(c)) 
is amended to read as follows: 
‘‘(c)(1) Notwithstanding any other provision of this part, with 
respect to expenses incurred in a calendar year in connection with 
the treatment of mental, psychoneurotic, and personality disorders 
of an individual who is not an inpatient of a hospital at the time 
such expenses are incurred, there shall be considered as incurred 
expenses for purposes of subsections (a) and (b)— 
‘‘(A) for expenses incurred in years prior to 2010, only 
621⁄2 percent of such expenses; 
‘‘(B) for expenses incurred in 2010 or 2011, only 683⁄4 
percent of such expenses; 
‘‘(C) for expenses incurred in 2012, only 75 percent of 
such expenses; 
‘‘(D) for expenses incurred in 2013, only 811⁄4 percent of 
such expenses; and 
‘‘(E) for expenses incurred in 2014 or any subsequent cal-
endar year, 100 percent of such expenses. 
‘‘(2) For purposes of subparagraphs (A) through (D) of para-
graph (1), the term ‘treatment’ does not include brief office visits 
(as defined by the Secretary) for the sole purpose of monitoring 
or changing drug prescriptions used in the treatment of such dis-
orders or partial hospitalization services that are not directly pro-
vided by a physician.’’. 
SEC. 103. PROHIBITIONS AND LIMITATIONS ON CERTAIN SALES AND 
MARKETING ACTIVITIES UNDER MEDICARE ADVANTAGE 
PLANS AND PRESCRIPTION DRUG PLANS. 
(a) PROHIBITIONS.— 
(1) MEDICARE ADVANTAGE PROGRAM.— 
(A) IN GENERAL.—Section 1851 of the Social Security 
Act (42 U.S.C. 1395w–21) is amended— 
(i) in subsection (h)(4)— 
(I) in subparagraph (A)— 
(aa) by striking ‘‘cash or other monetary 
rebates’’ and inserting ‘‘, subject to subsection 
(j)(2)(C), cash, gifts, prizes, or other monetary 
rebates’’; and 
42 USC 1395l 
note. 
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122 STAT. 2499 
PUBLIC LAW 110–275—JULY 15, 2008 
(bb) by striking ‘‘, and’’ at the end and 
inserting a semicolon; 
(II) in subparagraph (B), by striking the period 
at the end and inserting a semicolon; and 
(III) by adding at the end the following new 
subparagraph: 
‘‘(C) shall not permit a Medicare Advantage organiza-
tion (or the agents, brokers, and other third parties rep-
resenting such organization) to conduct the prohibited 
activities described in subsection (j)(1); and’’; and 
(ii) by adding at the end the following new sub-
section: 
‘‘(j) PROHIBITED ACTIVITIES DESCRIBED
AND LIMITATIONS
ON 
THE CONDUCT OF CERTAIN OTHER ACTIVITIES.— 
‘‘(1) PROHIBITED
ACTIVITIES
DESCRIBED.—The following 
prohibited activities are described in this paragraph: 
‘‘(A) UNSOLICITED
MEANS
OF
DIRECT
CONTACT.—Any 
unsolicited means of direct contact of prospective enrollees, 
including soliciting door-to-door or any outbound tele-
marketing without the prospective enrollee initiating con-
tact. 
‘‘(B) CROSS-SELLING.—The sale of other non-health 
related products (such as annuities and life insurance) 
during any sales or marketing activity or presentation con-
ducted with respect to a Medicare Advantage plan. 
‘‘(C) MEALS.—The provision of meals of any sort, 
regardless of value, to prospective enrollees at promotional 
and sales activities. 
‘‘(D) SALES AND MARKETING IN HEALTH CARE SETTINGS 
AND AT EDUCATIONAL EVENTS.—Sales and marketing activi-
ties for the enrollment of individuals in Medicare Advan-
tage plans that are conducted— 
‘‘(i) in health care settings in areas where health 
care is delivered to individuals (such as physician 
offices and pharmacies), except in the case where such 
activities are conducted in common areas in health 
care settings; and 
‘‘(ii) at educational events.’’. 
(2) MEDICARE
PRESCRIPTION
DRUG
PROGRAM.—Section 
1860D–4 of the Social Security Act (42 U.S.C. 1395w–104) 
is amended by adding at the end the following new subsection: 
‘‘(l) REQUIREMENTS WITH RESPECT TO SALES AND MARKETING 
ACTIVITIES.—The following provisions shall apply to a PDP sponsor 
(and the agents, brokers, and other third parties representing such 
sponsor) in the same manner as such provisions apply to a Medicare 
Advantage organization (and the agents, brokers, and other third 
parties representing such organization): 
‘‘(1) The prohibition under section 1851(h)(4)(C) on con-
ducting activities described in section 1851(j)(1).’’. 
(3) EFFECTIVE DATE.—The amendments made by this sub-
section shall apply to plan years beginning on or after January 
1, 2009. 
(b) LIMITATIONS.— 
(1) MEDICARE ADVANTAGE PROGRAM.—Section 1851 of the 
Social Security Act (42 U.S.C. 1395w–21), as amended by sub-
section (a)(1), is amended— 
42 USC 
1395w–21 note. 
Applicability. 
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122 STAT. 2500 
PUBLIC LAW 110–275—JULY 15, 2008 
(A) in subsection (h)(4), by adding at the end the fol-
lowing new subparagraph: 
‘‘(D) shall only permit a Medicare Advantage organiza-
tion (and the agents, brokers, and other third parties rep-
resenting such organization) to conduct the activities 
described in subsection (j)(2) in accordance with the limita-
tions established under such subsection.’’; and 
(B) in subsection (j), by adding at the end the following 
new paragraph: 
‘‘(2) LIMITATIONS.—The Secretary shall establish limita-
tions with respect to at least the following: 
‘‘(A) SCOPE OF MARKETING APPOINTMENTS.—The scope 
of any appointment with respect to the marketing of a 
Medicare Advantage plan. Such limitation shall require 
advance agreement with a prospective enrollee on the scope 
of the marketing appointment and documentation of such 
agreement by the Medicare Advantage organization. In 
the case where the marketing appointment is in person, 
such documentation shall be in writing. 
‘‘(B) CO-BRANDING.—The use of the name or logo of 
a co-branded network provider on Medicare Advantage plan 
membership and marketing materials. 
‘‘(C) LIMITATION OF GIFTS TO NOMINAL DOLLAR VALUE.— 
The offering of gifts and other promotional items other 
than those that are of nominal value (as determined by 
the Secretary) to prospective enrollees at promotional 
activities. 
‘‘(D) COMPENSATION.—The use of compensation other 
than as provided under guidelines established by the Sec-
retary. Such guidelines shall ensure that the use of com-
pensation creates incentives for agents and brokers to 
enroll individuals in the Medicare Advantage plan that 
is intended to best meet their health care needs. 
‘‘(E) REQUIRED
TRAINING, ANNUAL
RETRAINING, AND 
TESTING OF AGENTS, BROKERS, AND OTHER THIRD PARTIES.— 
The use by a Medicare Advantage organization of any 
individual as an agent, broker, or other third party rep-
resenting the organization that has not completed an initial 
training and testing program and does not complete an 
annual retraining and testing program.’’. 
(2) MEDICARE
PRESCRIPTION
DRUG
PROGRAM.—Section 
1860D–4(l) of the Social Security Act, as added by subsection 
(a)(2), is amended by adding at the end the following new 
paragraph: 
‘‘(2) The requirement under section 1851(h)(4)(D) to conduct 
activities described in section 1851(j)(2) in accordance with 
the limitations established under such subsection.’’. 
(3) EFFECTIVE DATE.—The amendments made by this sub-
section shall take effect on a date specified by the Secretary 
(but in no case later than November 15, 2008). 
(c) REQUIRED INCLUSION OF PLAN TYPE IN PLAN NAME.— 
(1) MEDICARE
ADVANTAGE
PROGRAM.—Section 1851(h) of 
the Social Security Act (42 U.S.C. 1395w–21(h)) is amended 
by adding at the end following new paragraph: 
‘‘(6) REQUIRED INCLUSION OF PLAN TYPE IN PLAN NAME.— 
For plan years beginning on or after January 1, 2010, a Medi-
care Advantage organization must ensure that the name of 
Effective date. 
Deadline. 
42 USC 
1395w–21 note. 
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122 STAT. 2501 
PUBLIC LAW 110–275—JULY 15, 2008 
each Medicare Advantage plan offered by the Medicare Advan-
tage organization includes the plan type of the plan (using 
standard terminology developed by the Secretary).’’. 
(2) PRESCRIPTION DRUG PLANS.—Section 1860D–4(l) of the 
Social Security Act, as added by subsection (a)(2) and amended 
by subsection (b)(2), is amended by adding at the end the 
following new paragraph: 
‘‘(3) The inclusion of the plan type in the plan name under 
section 1851(h)(6).’’. 
(d) STRENGTHENING
THE
ABILITY
OF
STATES
TO
ACT
IN 
COLLABORATION WITH THE SECRETARY TO ADDRESS FRAUDULENT 
OR INAPPROPRIATE MARKETING PRACTICES.— 
(1) MEDICARE
ADVANTAGE
PROGRAM.—Section 1851(h) of 
the Social Security Act (42 U.S.C. 1395w–21(h), as amended 
by subsection (c)(1), is amended by adding at the end the 
following new paragraph: 
‘‘(7) STRENGTHENING
THE
ABILITY
OF
STATES
TO
ACT
IN 
COLLABORATION WITH THE SECRETARY TO ADDRESS FRAUDULENT 
OR INAPPROPRIATE MARKETING PRACTICES.— 
‘‘(A) APPOINTMENT
OF
AGENTS
AND
BROKERS.—Each 
Medicare Advantage organization shall— 
‘‘(i) only use agents and brokers who have been 
licensed under State law to sell Medicare Advantage 
plans offered by the Medicare Advantage organization; 
‘‘(ii) in the case where a State has a State appoint-
ment law, abide by such law; and 
‘‘(iii) report to the applicable State the termination 
of any such agent or broker, including the reasons 
for such termination (as required under applicable 
State law). 
‘‘(B) 
COMPLIANCE
WITH
STATE
INFORMATION 
REQUESTS.—Each Medicare Advantage organization shall 
comply in a timely manner with any request by a State 
for information regarding the performance of a licensed 
agent, broker, or other third party representing the Medi-
care Advantage organization as part of an investigation 
by the State into the conduct of the agent, broker, or 
other third party.’’. 
(2) PRESCRIPTION DRUG PLANS.—Section 1860D–4(l) of the 
Social Security Act, as amended by subsection (c)(2), is amended 
by adding at the end the following new paragraph: 
‘‘(4) The requirements regarding the appointment of agents 
and brokers and compliance with State information requests 
under subparagraphs (A) and (B), respectively, of section 
1851(h)(7).’’. 
(3) EFFECTIVE DATE.—The amendments made by this sub-
section shall apply to plan years beginning on or after January 
1, 2009. 
SEC. 104. IMPROVEMENTS TO THE MEDIGAP PROGRAM. 
(a) IMPLEMENTATION OF NAIC RECOMMENDATIONS.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services (in this section referred to as the ‘‘Secretary’’) shall 
provide for implementation of the changes in the NAIC model 
law and regulations approved by the National Association of 
Insurance Commissioners in its Model #651 (‘‘Model Regulation 
42 USC 1395ss 
note. 
42 USC 
1395w–21 note. 
Reports. 
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122 STAT. 2502 
PUBLIC LAW 110–275—JULY 15, 2008 
to Implement the NAIC Medicare Supplement Insurance Min-
imum Standards Model Act’’) on March 11, 2007, as modified 
to reflect the changes made under this Act and the Genetic 
Information Nondiscrimination Act of 2008 (Public Law 110– 
233). 
(2) IMPLEMENTATION DATES.— 
(A) IN
GENERAL.—The modifications to Model #651 
required under paragraph (1) shall be completed by the 
National Association of Insurance Commissioners not later 
than October 31, 2008. Except as provided in subparagraph 
(B), each State shall have 1 year from the date the National 
Association of Insurance Commissioners adopts the revised 
NAIC model law and regulations (as changed by Model 
#651, as so modified) to conform the regulatory program 
established by the State to such revised NAIC model law 
and regulations. 
(B) EXTENSION
OF
EFFECTIVE
DATE
FOR
STATE
LAW 
AMENDMENT.—In the case of a State which the Secretary 
determines requires State legislation in order to conform 
the regulatory program established by the State to such 
revised NAIC model law and regulations, the State shall 
not be regarded as failing to comply with the requirements 
of this section solely on the basis of its failure to meet 
such requirements before the first day of the first calendar 
quarter beginning after the close of the first regular session 
of the State legislature that begins after the date of the 
enactment of this Act. For purposes of the previous sen-
tence, in the case of a State that has a 2-year legislative 
session, each year of the session is considered to be a 
separate regular session of the State legislature. 
(C) TRANSITION DATES.—No carrier may issue a new 
or revised medicare supplemental policy or certificate under 
section 1882 of the Social Security Act (42 U.S.C. 1395ss) 
that meets the requirements of such revised NAIC model 
law and regulations for coverage effective prior to June 
1, 2010. A carrier may continue to offer or issue a medicare 
supplemental policy under such section that meets the 
requirements of the NAIC model law and regulations and 
State law (as in effect prior to the adoption of such revised 
NAIC model law and regulations) prior to June 1, 2010. 
Nothing shall preclude carriers from marketing new or 
revised medicare supplemental policies or certificates that 
meet the requirements of such revised NAIC model law 
and regulations on or after the date on which the State 
conforms the regulatory program established by the State 
to such revised NAIC model law and regulations. 
(b) REQUIRED OFFERING
OF
A RANGE
OF POLICIES.—Section 
1882(o) of the Social Security Act (42 U.S.C. 1395s(o)), as amended 
by section 104(b)(3) of the Genetic Information Nondiscrimination 
Act of 2008 (Public Law 110–233), is amended by adding at the 
end the following new paragraph: 
‘‘(5) In addition to the requirement under paragraph (2), 
the issuer of the policy must make available to the individual 
at least Medicare supplemental policies with benefit packages 
classified as ‘C’ or ‘F’.’’. 
(c) CLARIFICATION.—Any health insurance policy that provides 
reimbursement for expenses incurred for items and services for 
42 USC 
1395ss–1. 
42 USC 1395ss. 
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122 STAT. 2503 
PUBLIC LAW 110–275—JULY 15, 2008 
which payment may be made under title XVIII of the Social Security 
Act but which are not reimbursable by reason of the applicability 
of deductibles, coinsurance, copayments or other limitations imposed 
by a Medicare Advantage plan (including a Medicare Advantage 
private fee-for-service plan) under part C of such title shall comply 
with the requirements of section 1882(o) of the such Act (42 U.S.C. 
1395ss(o)). 
PART II—LOW-INCOME PROGRAMS 
SEC. 111. EXTENSION OF QUALIFYING INDIVIDUAL (QI) PROGRAM. 
(a) EXTENSION.—Section 1902(a)(10)(E)(iv) of the Social Security 
Act (42 U.S.C. 1396a(a)(10)(E)(iv)) is amended by striking ‘‘June 
2008’’ and inserting ‘‘December 2009’’. 
(b) EXTENDING TOTAL AMOUNT AVAILABLE FOR ALLOCATION.— 
Section 1933(g) of such Act (42 U.S.C. 1396u–3(g)) is amended— 
(1) in paragraph (2)— 
(A) by striking ‘‘and’’ at the end of subparagraph (H); 
(B) in subparagraph (I)— 
(i) by striking ‘‘June 30’’ and inserting ‘‘September 
30’’; 
(ii) by striking ‘‘$200,000,000’’ and inserting 
‘‘$300,000,000’’; and 
(iii) by striking the period at the end and inserting 
a semicolon; and 
(C) by adding at the end the following new subpara-
graphs: 
‘‘(J) for the period that begins on October 1, 2008, 
and ends on December 31, 2008, the total allocation amount 
is $100,000,000; 
‘‘(K) for the period that begins on January 1, 2009, 
and ends on September 30, 2009, the total allocation 
amount is $350,000,000; and 
‘‘(L) for the period that begins on October 1, 2009, 
and ends on December 31, 2009, the total allocation amount 
is $150,000,000.’’; and 
(2) in paragraph (3), in the matter preceding subparagraph 
(A), by striking ‘‘or (H)’’ and inserting ‘‘(H), (J), or (L)’’. 
SEC. 112. APPLICATION OF FULL LIS SUBSIDY ASSETS TEST UNDER 
MEDICARE SAVINGS PROGRAM. 
Section 1905(p)(1)(C) of such Act (42 U.S.C. 1396d(p)(1)(C)) 
is amended by inserting before the period at the end the following: 
‘‘or, effective beginning with January 1, 2010, whose resources 
(as so determined) do not exceed the maximum resource level 
applied for the year under subparagraph (D) of section 1860D– 
14(a)(3) (determined without regard to the life insurance policy 
exclusion provided under subparagraph (G) of such section) 
applicable to an individual or to the individual and the individual’s 
spouse (as the case may be)’’. 
SEC. 113. ELIMINATING BARRIERS TO ENROLLMENT. 
(a) SSA ASSISTANCE WITH MEDICARE SAVINGS PROGRAM AND 
LOW-INCOME SUBSIDY PROGRAM APPLICATIONS.—Section 1144 of 
such Act (42 U.S.C. 1320b–14) is amended by adding at the end 
the following new subsection: 
‘‘(c) ASSISTANCE WITH MEDICARE SAVINGS PROGRAM AND LOW- 
INCOME SUBSIDY PROGRAM APPLICATIONS.— 
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122 STAT. 2504 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(1) DISTRIBUTION OF APPLICATIONS AND INFORMATION TO 
INDIVIDUALS WHO ARE POTENTIALLY ELIGIBLE FOR LOW-INCOME 
SUBSIDY
PROGRAM.—For each individual who submits an 
application for low-income subsidies under section 1860D–14, 
requests an application for such subsidies, or is otherwise 
identified as an individual who is potentially eligible for such 
subsidies, the Commissioner shall do the following: 
‘‘(A) Provide information describing the low-income 
subsidy program under section 1860D–14 and the Medicare 
Savings Program (as defined in paragraph (7)). 
‘‘(B) Provide an application for enrollment under such 
low-income subsidy program (if not already received by 
the Commissioner). 
‘‘(C) In accordance with paragraph (3), transmit data 
from such an application for purposes of initiating an 
application for benefits under the Medicare Savings Pro-
gram. 
‘‘(D) Provide information on how the individual may 
obtain assistance in completing such application and an 
application under the Medicare Savings Program, including 
information on how the individual may contact the State 
health insurance assistance program (SHIP). 
‘‘(E) Make the application described in subparagraph 
(B) and the information described in subparagraphs (A) 
and (D) available at local offices of the Social Security 
Administration. 
‘‘(2) TRAINING PERSONNEL IN EXPLAINING BENEFIT PROGRAMS 
AND ASSISTING IN COMPLETING LIS APPLICATION.—The Commis-
sioner shall provide training to those employees of the Social 
Security Administration who are involved in receiving applica-
tions for benefits described in paragraph (1)(B) in order that 
they may promote beneficiary understanding of the low-income 
subsidy program and the Medicare Savings Program in order 
to increase participation in these programs. Such employees 
shall provide assistance in completing an application described 
in paragraph (1)(B) upon request. 
‘‘(3) TRANSMITTAL
OF
DATA
TO
STATES.—Beginning on 
January 1, 2010, with the consent of an individual completing 
an application for benefits described in paragraph (1)(B), the 
Commissioner shall electronically transmit to the appropriate 
State Medicaid agency data from such application, as deter-
mined by the Commissioner, which transmittal shall initiate 
an application of the individual for benefits under the Medicare 
Savings Program with the State Medicaid agency. In order 
to ensure that such data transmittal provides effective assist-
ance for purposes of State adjudication of applications for bene-
fits under the Medicare Savings Program, the Commissioner 
shall consult with the Secretary, after the Secretary has con-
sulted with the States, regarding the content, form, frequency, 
and manner in which data (on a uniform basis for all States) 
shall be transmitted under this subparagraph. 
‘‘(4) COORDINATION
WITH
OUTREACH.—The Commissioner 
shall coordinate outreach activities under this subsection in 
connection with the low-income subsidy program and the Medi-
care Savings Program. 
‘‘(5) REIMBURSEMENT OF SOCIAL SECURITY ADMINISTRATION 
ADMINISTRATIVE COSTS.— 
Appropriation 
authorization. 
Effective date. 
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122 STAT. 2505 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(A) INITIAL MEDICARE SAVINGS PROGRAM COSTS; ADDI-
TIONAL LOW-INCOME SUBSIDY COSTS.— 
‘‘(i) INITIAL MEDICARE SAVINGS PROGRAM COSTS.— 
There are hereby appropriated to the Commissioner 
to carry out this subsection, out of any funds in the 
Treasury not otherwise appropriated, $24,100,000. The 
amount appropriated under ths clause shall be avail-
able on October 1, 2008, and shall remain available 
until expended. 
‘‘(ii) ADDITIONAL AMOUNT FOR LOW-INCOME SUBSIDY 
ACTIVITIES.—There are hereby appropriated to the 
Commissioner, out of any funds in the Treasury not 
otherwise appropriated, $24,800,000 for fiscal year 
2009 to carry out low-income subsidy activities under 
section 1860D–14 and the Medicare Savings Program 
(in accordance with this subsection), to remain avail-
able until expended. Such funds shall be in addition 
to the Social Security Administration’s Limitation on 
Administrative Expenditure appropriations for such 
fiscal year. 
‘‘(B) SUBSEQUENT FUNDING UNDER AGREEMENTS.— 
‘‘(i) IN GENERAL.—Effective for fiscal years begin-
ning on or after October 1, 2010, the Commissioner 
and the Secretary shall enter into an agreement which 
shall provide funding (subject to the amount appro-
priated under clause (ii)) to cover the administrative 
costs of the Commissioner’s activities under this sub-
section. Such agreement shall— 
‘‘(I) provide funds to the Commissioner for the 
full cost of the Social Security Administration’s 
work related to the Medicare Savings Program 
required under this section; 
‘‘(II) provide such funding quarterly in advance 
of the applicable quarter based on estimating 
methodology agreed to by the Commissioner and 
the Secretary; and 
‘‘(III) require an annual accounting and rec-
onciliation of the actual costs incurred and funds 
provided under this subsection. 
‘‘(ii) APPROPRIATION.—There are hereby appro-
priated to the Secretary solely for the purpose of pro-
viding payments to the Commissioner pursuant to an 
agreement specified in clause (i) that is in effect, out 
of any funds in the Treasury not otherwise appro-
priated, not more than $3,000,000 for fiscal year 2011 
and each fiscal year thereafter. 
‘‘(C) LIMITATION.—In no case shall funds from the 
Social Security Administration’s Limitation on Administra-
tive Expenses be used to carry out activities related to 
the Medicare Savings Program. For fiscal years beginning 
on or after October 1, 2010, no such activities shall be 
undertaken by the Social Security Administration unless 
the agreement specified in subparagraph (B) is in effect 
and full funding has been provided to the Commissioner 
as specified in such subparagraph. 
‘‘(6) GAO ANALYSIS AND REPORT.— 
Effective date. 
Effective date. 
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122 STAT. 2506 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(A) ANALYSIS.—The Comptroller General of the United 
States shall prepare an analysis of the impact of this 
subsection— 
‘‘(i) in increasing participation in the Medicare 
Savings Program, and 
‘‘(ii) on States and the Social Security Administra-
tion. 
‘‘(B) REPORT.—Not later than January 1, 2012, the 
Comptroller General shall submit to Congress, the Commis-
sioner, and the Secretary a report on the analysis conducted 
under subparagraph (A). 
‘‘(7) MEDICARE SAVINGS PROGRAM DEFINED.—For purposes 
of this subsection, the term ‘Medicare Savings Program’ means 
the program of medical assistance for payment of the cost 
of medicare cost-sharing under the Medicaid program pursuant 
to sections 1902(a)(10)(E) and 1933.’’. 
(b) MEDICAID AGENCY CONSIDERATION OF DATA TRANSMITTAL.— 
(1) IN GENERAL.—Section 1935(a) of such Act (42 U.S.C. 
1396u–5(a)) is amended by adding at the end the following 
new paragraph: 
‘‘(4) CONSIDERATION OF DATA TRANSMITTED BY THE SOCIAL 
SECURITY ADMINISTRATION FOR PURPOSES OF MEDICARE SAVINGS 
PROGRAM.—The State shall accept data transmitted under sec-
tion 1144(c)(3) and act on such data in the same manner 
and in accordance with the same deadlines as if the data 
constituted an initiation of an application for benefits under 
the Medicare Savings Program (as defined for purposes of such 
section) that had been submitted directly by the applicant. 
The date of the individual’s application for the low income 
subsidy program from which the data have been derived shall 
constitute the date of filing of such application for benefits 
under the Medicare Savings Program.’’. 
(2) CONFORMING
AMENDMENTS.—Section 1935(a) of such 
Act (42 U.S.C. 1396u–5(a)) is amended in the subsection 
heading by striking ‘‘AND’’ and by inserting ‘‘, AND MEDICARE 
COST-SHARING’’ after ‘‘ASSISTANCE’’. 
(c) EFFECTIVE DATE.—Except as otherwise provided, the amend-
ments made by this section shall take effect on January 1, 2010. 
SEC. 114. ELIMINATION OF MEDICARE PART D LATE ENROLLMENT 
PENALTIES PAID BY SUBSIDY ELIGIBLE INDIVIDUALS. 
(a) WAIVER OF LATE ENROLLMENT PENALTY.— 
(1) IN GENERAL.—Section 1860D–13(b) of the Social Secu-
rity Act (42 U.S.C. 1395w–113(b)) is amended by adding at 
the end the following new paragraph: 
‘‘(8) WAIVER OF PENALTY FOR SUBSIDY-ELIGIBLE INDIVID-
UALS.—In no case shall a part D eligible individual who is 
determined to be a subsidy eligible individual (as defined in 
section 1860D–14(a)(3)) be subject to an increase in the monthly 
beneficiary premium established under subsection (a).’’. 
(2) CONFORMING AMENDMENT.—Section 1860D–14(a)(1)(A) 
of the Social Security Act (42 U.S.C. 1395w–114(a)(1)(A)) is 
amended by striking ‘‘equal to’’ and all that follows through 
the period and inserting ‘‘equal to 100 percent of the amount 
described in subsection (b)(1), but not to exceed the premium 
amount specified in subsection (b)(2)(B).’’. 
42 USC 
1320b–14 note. 
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122 STAT. 2507 
PUBLIC LAW 110–275—JULY 15, 2008 
(b) EFFECTIVE DATE.—The amendments made by this section 
shall apply to subsidies for months beginning with January 2009. 
SEC. 115. ELIMINATING APPLICATION OF ESTATE RECOVERY. 
(a) IN GENERAL.—Section 1917(b)(1)(B)(ii) of the Social Security 
Act (42 U.S.C. 1396p(b)(1)(B)(ii)) is amended by inserting ‘‘(but 
not including medical assistance for medicare cost-sharing or for 
benefits described in section 1902(a)(10)(E))’’ before the period at 
the end. 
(b) EFFECTIVE DATE.—The amendment made by subsection (a) 
shall take effect as of January 1, 2010. 
SEC. 116. EXEMPTIONS FROM INCOME AND RESOURCES FOR DETER-
MINATION OF ELIGIBILITY FOR LOW-INCOME SUBSIDY. 
(a) IN GENERAL.—Section 1860D–14(a)(3) of the Social Security 
Act (42 U.S.C. 1395w–114(a)(3)) is amended— 
(1) in subparagraph (C)(i), by inserting ‘‘and except that 
support and maintenance furnished in kind shall not be counted 
as income’’ after ‘‘section 1902(r)(2)’’; 
(2) in subparagraph (D), in the matter before clause (i), 
by inserting ‘‘subject to the life insurance policy exclusion pro-
vided under subparagraph (G)’’ before ‘‘)’’; 
(3) in subparagraph (E)(i), in the matter before subclause 
(I), by inserting ‘‘subject to the life insurance policy exclusion 
provided under subparagraph (G)’’ before ‘‘)’’; and 
(4) by adding at the end the following new subparagraph: 
‘‘(G) LIFE
INSURANCE
POLICY
EXCLUSION.—In deter-
mining the resources of an individual (and the eligible 
spouse of the individual, if any) under section 1613 for 
purposes of subparagraphs (D) and (E) no part of the 
value of any life insurance policy shall be taken into 
account.’’. 
(b) EFFECTIVE DATE.—The amendments made by this section 
shall take effect with respect to applications filed on or after 
January 1, 2010. 
SEC. 117. JUDICIAL REVIEW OF DECISIONS OF THE COMMISSIONER 
OF SOCIAL SECURITY UNDER THE MEDICARE PART D LOW- 
INCOME SUBSIDY PROGRAM. 
(a) IN GENERAL.—Section 1860D–14(a)(3)(B)(iv) of the Social 
Security Act (42 U.S.C. 1395w–114(a)(3)(B)(iv)) is amended— 
(1) in subclause (I), by striking ‘‘and’’ at the end; 
(2) in subclause (II), by striking the period at the end 
and inserting ‘‘; and’’; and 
(3) by adding at the end the following new subclause: 
‘‘(III) judicial review of the final decision of 
the Commissioner made after a hearing shall be 
available to the same extent, and with the same 
limitations, as provided in subsections (g) and (h) 
of section 205.’’. 
(b) EFFECTIVE DATE.—The amendments made by subsection 
(a) shall take effect as if included in the enactment of section 
101 of the Medicare Prescription Drug, Improvement, and Mod-
ernization Act of 2003. 
SEC. 118. TRANSLATION OF MODEL FORM. 
(a) IN GENERAL.—Section 1905(p)(5)(A) of the Social Security 
Act (42 U.S.C. 1396d(p)(5)(A)) is amended by adding at the end 
42 USC 
1395w–114 note. 
42 USC 
1395w–114 note. 
42 USC 1396p 
note. 
42 USC 
1395w–113 note. 
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122 STAT. 2508 
PUBLIC LAW 110–275—JULY 15, 2008 
the following: ‘‘The Secretary shall provide for the translation of 
such application form into at least the 10 languages (other than 
English) that are most often used by individuals applying for hos-
pital insurance benefits under section 226 or 226A and shall make 
the translated forms available to the States and to the Commis-
sioner of Social Security.’’. 
(b) EFFECTIVE DATE.—The amendment made by subsection (a) 
shall take effect on January 1, 2010. 
SEC. 119. MEDICARE ENROLLMENT ASSISTANCE. 
(a) ADDITIONAL FUNDING FOR STATE HEALTH INSURANCE ASSIST-
ANCE PROGRAMS.— 
(1) GRANTS.— 
(A) IN GENERAL.—The Secretary of Health and Human 
Services (in this section referred to as the ‘‘Secretary’’) 
shall use amounts made available under subparagraph (B) 
to make grants to States for State health insurance assist-
ance programs receiving assistance under section 4360 of 
the Omnibus Budget Reconciliation Act of 1990. 
(B) FUNDING.—For purposes of making grants under 
this subsection, the Secretary shall provide for the transfer, 
from the Federal Hospital Insurance Trust Fund under 
section 1817 of the Social Security Act (42 U.S.C. 1395i) 
and the Federal Supplementary Medical Insurance Trust 
Fund under section 1841 of such Act (42 U.S.C. 1395t), 
in the same proportion as the Secretary determines under 
section 1853(f) of such Act (42 U.S.C. 1395w–23(f)), of 
$7,500,000 to the Centers for Medicare & Medicaid Services 
Program Management Account for fiscal year 2009, to 
remain available until expended. 
(2) AMOUNT OF GRANTS.—The amount of a grant to a State 
under this subsection from the total amount made available 
under paragraph (1) shall be equal to the sum of the amount 
allocated to the State under paragraph (3)(A) and the amount 
allocated to the State under subparagraph (3)(B). 
(3) ALLOCATION TO STATES.— 
(A) ALLOCATION BASED ON PERCENTAGE OF LOW-INCOME 
BENEFICIARIES.—The amount allocated to a State under 
this subparagraph from 2⁄3 of the total amount made avail-
able under paragraph (1) shall be based on the number 
of individuals who meet the requirement under subsection 
(a)(3)(A)(ii) of section 1860D–14 of the Social Security Act 
(42 U.S.C. 1395w–114) but who have not enrolled to receive 
a subsidy under such section 1860D–14 relative to the 
total number of individuals who meet the requirement 
under such subsection (a)(3)(A)(ii) in each State, as esti-
mated by the Secretary. 
(B) ALLOCATION BASED ON PERCENTAGE OF RURAL BENE-
FICIARIES.—The amount allocated to a State under this 
subparagraph from 1⁄3 of the total amount made available 
under paragraph (1) shall be based on the number of part 
D eligible individuals (as defined in section 1860D– 
1(a)(3)(A) of such Act (42 U.S.C. 1395w–101(a)(3)(A))) 
residing in a rural area relative to the total number of 
such individuals in each State, as estimated by the Sec-
retary. 
42 USC 1395b–3 
note. 
42 USC 1396d 
note. 
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122 STAT. 2509 
PUBLIC LAW 110–275—JULY 15, 2008 
(4) PORTION
OF
GRANT
BASED
ON
PERCENTAGE
OF
LOW- 
INCOME BENEFICIARIES TO BE USED TO PROVIDE OUTREACH TO 
INDIVIDUALS WHO MAY BE SUBSIDY ELIGIBLE INDIVIDUALS OR 
ELIGIBLE FOR THE MEDICARE SAVINGS PROGRAM.—Each grant 
awarded under this subsection with respect to amounts allo-
cated under paragraph (3)(A) shall be used to provide outreach 
to individuals who may be subsidy eligible individuals (as 
defined in section 1860D–14(a)(3)(A) of the Social Security Act 
(42 U.S.C. 1395w–114(a)(3)(A)) or eligible for the Medicare 
Savings Program (as defined in subsection (f)). 
(b) ADDITIONAL FUNDING
FOR AREA AGENCIES
ON AGING.— 
(1) GRANTS.— 
(A) IN GENERAL.—The Secretary, acting through the 
Assistant Secretary for Aging, shall make grants to States 
for area agencies on aging (as defined in section 102 of 
the Older Americans Act of 1965 (42 U.S.C. 3002)) and 
Native American programs carried out under the Older 
Americans Act of 1965 (42 U.S.C. 3001 et seq.). 
(B) FUNDING.—For purposes of making grants under 
this subsection, the Secretary shall provide for the transfer, 
from the Federal Hospital Insurance Trust Fund under 
section 1817 of the Social Security Act (42 U.S.C. 1395i) 
and the Federal Supplementary Medical Insurance Trust 
Fund under section 1841 of such Act (42 U.S.C. 1395t), 
in the same proportion as the Secretary determines under 
section 1853(f) of such Act (42 U.S.C. 1395w–23(f)), of 
$7,500,000 to the Administration on Aging for fiscal year 
2009, to remain available until expended. 
(2) AMOUNT OF GRANT AND ALLOCATION TO STATES BASED 
ON PERCENTAGE OF LOW-INCOME AND RURAL BENEFICIARIES.— 
The amount of a grant to a State under this subsection from 
the total amount made available under paragraph (1) shall 
be determined in the same manner as the amount of a grant 
to a State under subsection (a), from the total amount made 
available under paragraph (1) of such subsection, is determined 
under paragraph (2) and subparagraphs (A) and (B) of para-
graph (3) of such subsection. 
(3) REQUIRED USE OF FUNDS.— 
(A) ALL
FUNDS.—Subject to subparagraph (B), each 
grant awarded under this subsection shall be used to pro-
vide outreach to eligible Medicare beneficiaries regarding 
the benefits available under title XVIII of the Social Secu-
rity Act. 
(B) OUTREACH TO INDIVIDUALS WHO MAY BE SUBSIDY 
ELIGIBLE
INDIVIDUALS
OR
ELIGIBLE
FOR
THE
MEDICARE 
SAVINGS PROGRAM.—Subsection (a)(4) shall apply to each 
grant awarded under this subsection in the same manner 
as it applies to a grant under subsection (a). 
(c) ADDITIONAL FUNDING FOR AGING AND DISABILITY RESOURCE 
CENTERS.— 
(1) GRANTS.— 
(A) IN
GENERAL.—The Secretary shall make grants 
to Aging and Disability Resource Centers under the Aging 
and Disability Resource Center grant program that are 
established centers under such program on the date of 
the enactment of this Act. 
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122 STAT. 2510 
PUBLIC LAW 110–275—JULY 15, 2008 
(B) FUNDING.—For purposes of making grants under 
this subsection, the Secretary shall provide for the transfer, 
from the Federal Hospital Insurance Trust Fund under 
section 1817 of the Social Security Act (42 U.S.C. 1395i) 
and the Federal Supplementary Medical Insurance Trust 
Fund under section 1841 of such Act (42 U.S.C. 1395t), 
in the same proportion as the Secretary determines under 
section 1853(f) of such Act (42 U.S.C. 1395w–23(f)), of 
$5,000,000 to the Administration on Aging for fiscal year 
2009, to remain available until expended. 
(2) REQUIRED USE OF FUNDS.—Each grant awarded under 
this subsection shall be used to provide outreach to individuals 
regarding the benefits available under the Medicare prescrip-
tion drug benefit under part D of title XVIII of the Social 
Security Act and under the Medicare Savings Program. 
(d) COORDINATION OF EFFORTS TO INFORM OLDER AMERICANS 
ABOUT BENEFITS AVAILABLE UNDER FEDERAL
AND STATE PRO-
GRAMS.— 
(1) IN GENERAL.—The Secretary, acting through the Assist-
ant Secretary for Aging, in cooperation with related Federal 
agency partners, shall make a grant to, or enter into a contract 
with, a qualified, experienced entity under which the entity 
shall— 
(A) maintain and update web-based decision support 
tools, and integrated, person-centered systems, designed 
to inform older individuals (as defined in section 102 of 
the Older Americans Act of 1965 (42 U.S.C. 3002)) about 
the full range of benefits for which the individuals may 
be eligible under Federal and State programs; 
(B) utilize cost-effective strategies to find older individ-
uals with the greatest economic need (as defined in such 
section 102) and inform the individuals of the programs; 
(C) develop and maintain an information clearinghouse 
on best practices and the most cost-effective methods for 
finding older individuals with greatest economic need and 
informing the individuals of the programs; and 
(D) provide, in collaboration with related Federal 
agency partners administering the Federal programs, 
training and technical assistance on the most effective out-
reach, screening, and follow-up strategies for the Federal 
and State programs. 
(2) FUNDING.—For purposes of making a grant or entering 
into a contract under paragraph (1), the Secretary shall provide 
for the transfer, from the Federal Hospital Insurance Trust 
Fund under section 1817 of the Social Security Act (42 U.S.C. 
1395i) and the Federal Supplementary Medical Insurance Trust 
Fund under section 1841 of such Act (42 U.S.C. 1395t), in 
the same proportion as the Secretary determines under section 
1853(f) of such Act (42 U.S.C. 1395w–23(f)), of $5,000,000 to 
the Administration on Aging for fiscal year 2009, to remain 
available until expended. 
(e) REPROGRAMMING FUNDS FROM MEDICARE, MEDICAID, AND 
SCHIP EXTENSION ACT OF 2007.—The Secretary shall only use 
the $5,000,000 in funds allocated to make grants to States for 
Area Agencies on Aging and Aging Disability and Resource Centers 
for the period of fiscal years 2008 through 2009 under section 
118 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 
Internet. 
Grants. 
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122 STAT. 2511 
PUBLIC LAW 110–275—JULY 15, 2008 
(Public Law 110–173) for the sole purpose of providing outreach 
to individuals regarding the benefits available under the Medicare 
prescription drug benefit under part D of title XVIII of the Social 
Security Act. The Secretary shall republish the request for proposals 
issued on April 17, 2008, in order to comply with the preceding 
sentence. 
(f) MEDICARE SAVINGS PROGRAM DEFINED.—For purposes of 
this section, the term ‘‘Medicare Savings Program’’ means the pro-
gram of medical assistance for payment of the cost of medicare 
cost-sharing under the Medicaid program pursuant to sections 
1902(a)(10)(E) and 1933 of the Social Security Act (42 U.S.C. 
1396a(a)(10)(E), 1396u–3). 
Subtitle B—Provisions Relating to Part A 
SEC. 121. EXPANSION AND EXTENSION OF THE MEDICARE RURAL HOS-
PITAL FLEXIBILITY PROGRAM. 
(a) IN GENERAL.—Section 1820(g) of the Social Security Act 
(42 U.S.C. 1395i–4(g)) is amended by adding at the end the following 
new paragraph: 
‘‘(6) PROVIDING
MENTAL
HEALTH
SERVICES
AND
OTHER 
HEALTH SERVICES TO VETERANS AND OTHER RESIDENTS OF RURAL 
AREAS.— 
‘‘(A) GRANTS TO STATES.—The Secretary may award 
grants to States that have submitted applications in accord-
ance with subparagraph (B) for increasing the delivery 
of mental health services or other health care services 
deemed necessary to meet the needs of veterans of Oper-
ation Iraqi Freedom and Operation Enduring Freedom 
living in rural areas (as defined for purposes of section 
1886(d) and including areas that are rural census tracks, 
as defined by the Administrator of the Health Resources 
and Services Administration), including for the provision 
of crisis intervention services and the detection of post- 
traumatic stress disorder, traumatic brain injury, and other 
signature injuries of veterans of Operation Iraqi Freedom 
and Operation Enduring Freedom, and for referral of such 
veterans to medical facilities operated by the Department 
of Veterans Affairs, and for the delivery of such services 
to other residents of such rural areas. 
‘‘(B) APPLICATION.— 
‘‘(i) IN GENERAL.—An application is in accordance 
with this subparagraph if the State submits to the 
Secretary at such time and in such form as the Sec-
retary may require an application containing the assur-
ances described in subparagraphs (A)(ii) and (A)(iii) 
of subsection (b)(1). 
‘‘(ii) CONSIDERATION
OF
REGIONAL
APPROACHES, 
NETWORKS, OR TECHNOLOGY.—The Secretary may, as 
appropriate in awarding grants to States under 
subparagraph (A), consider whether the application 
submitted by a State under this subparagraph includes 
1 or more proposals that utilize regional approaches, 
networks, health information technology, telehealth, 
or telemedicine to deliver services described in 
subparagraph (A) to individuals described in that 
Publication. 
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122 STAT. 2512 
PUBLIC LAW 110–275—JULY 15, 2008 
subparagraph. For purposes of this clause, a network 
may, as the Secretary determines appropriate, include 
Federally qualified health centers (as defined in section 
1861(aa)(4)), rural health clinics (as defined in section 
1861(aa)(2)), home health agencies (as defined in sec-
tion 1861(o)), community mental health centers (as 
defined in section 1861(ff)(3)(B)) and other providers 
of mental health services, pharmacists, local govern-
ment, and other providers deemed necessary to meet 
the needs of veterans. 
‘‘(iii) COORDINATION
AT
LOCAL
LEVEL.—The Sec-
retary shall require, as appropriate, a State to dem-
onstrate consultation with the hospital association of 
such State, rural hospitals located in such State, pro-
viders of mental health services, or other appropriate 
stakeholders for the provision of services under a grant 
awarded under this paragraph. 
‘‘(iv) SPECIAL CONSIDERATION OF CERTAIN APPLICA-
TIONS.—In awarding grants to States under subpara-
graph (A), the Secretary shall give special consideration 
to applications submitted by States in which veterans 
make up a high percentage (as determined by the 
Secretary) of the total population of the State. Such 
consideration shall be given without regard to the 
number of veterans of Operation Iraqi Freedom and 
Operation Enduring Freedom living in the areas in 
which mental health services and other health care 
services would be delivered under the application. 
‘‘(C) COORDINATION WITH VA.—The Secretary shall, as 
appropriate, consult with the Director of the Office of Rural 
Health of the Department of Veterans Affairs in awarding 
and administering grants to States under subparagraph 
(A). 
‘‘(D) USE OF FUNDS.—A State awarded a grant under 
this paragraph may, as appropriate, use the funds to 
reimburse providers of services described in subparagraph 
(A) to individuals described in that subparagraph. 
‘‘(E) LIMITATION ON USE OF GRANT FUNDS FOR ADMINIS-
TRATIVE EXPENSES.—A State awarded a grant under this 
paragraph may not expend more than 15 percent of the 
amount of the grant for administrative expenses. 
‘‘(F) INDEPENDENT EVALUATION AND FINAL REPORT.— 
The Secretary shall provide for an independent evaluation 
of the grants awarded under subparagraph (A). Not later 
than 1 year after the date on which the last grant is 
awarded to a State under such subparagraph, the Secretary 
shall submit a report to Congress on such evaluation. Such 
report shall include an assessment of the impact of such 
grants on increasing the delivery of mental health services 
and other health services to veterans of the United States 
Armed Forces living in rural areas (as so defined and 
including such areas that are rural census tracks), with 
particular emphasis on the impact of such grants on the 
delivery of such services to veterans of Operation Enduring 
Freedom and Operation Iraqi Freedom, and to other 
individuals living in such rural areas.’’. 
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122 STAT. 2513 
PUBLIC LAW 110–275—JULY 15, 2008 
(b) USE OF FUNDS FOR FEDERAL ADMINISTRATIVE EXPENSES.— 
Section 1820(g)(5) of the Social Security Act (42 U.S.C. 1395i– 
4(g)(5)) is amended— 
(1) by striking ‘‘beginning with fiscal year 2005’’ and 
inserting ‘‘for each of fiscal years 2005 through 2008’’; and 
(2) by inserting ‘‘and, of the total amount appropriated 
for grants under paragraphs (1), (2), and (6) for a fiscal year 
(beginning with fiscal year 2009)’’ after ‘‘2005)’’. 
(c) EXTENSION OF AUTHORIZATION FOR FLEX GRANTS.—Section 
1820(j) of the Social Security Act (42 U.S.C. 1395i–4(j)) is 
amended— 
(1) by striking ‘‘and for’’ and inserting ‘‘for’’; and 
(2) by inserting ‘‘, for making grants to all States under 
paragraphs (1) and (2) of subsection (g), $55,000,000 in each 
of fiscal years 2009 and 2010, and for making grants to all 
States under paragraph (6) of subsection (g), $50,000,000 in 
each of fiscal years 2009 and 2010, to remain available until 
expended’’ before the period at the end. 
(d) MEDICARE RURAL HOSPITAL FLEXIBILITY PROGRAM.—Section 
1820(g)(1) of the Social Security Act (42 U.S.C. 1395i–4(g)(1)) is 
amended— 
(1) in subparagraph (B), by striking ‘‘and’’ at the end; 
(2) in subparagraph (C), by striking the period at the 
end and inserting ‘‘; and’’; and 
(3) by adding at the end the following new subparagraph: 
‘‘(D) providing support for critical access hospitals for 
quality 
improvement, 
quality 
reporting, 
performance 
improvements, and benchmarking.’’. 
(e) ASSISTANCE
TO
SMALL
CRITICAL
ACCESS
HOSPITALS 
TRANSITIONING
TO SKILLED NURSING FACILITIES
AND ASSISTED 
LIVING FACILITIES.—Section 1820(g) of the Social Security Act (42 
U.S.C. 1395i–4(g)), as amended by subsection (a), is amended by 
adding at the end the following new paragraph: 
‘‘(7) CRITICAL ACCESS HOSPITALS TRANSITIONING TO SKILLED 
NURSING FACILITIES AND ASSISTED LIVING FACILITIES.— 
‘‘(A) GRANTS.—The Secretary may award grants to 
eligible critical access hospitals that have submitted 
applications in accordance with subparagraph (B) for 
assisting such hospitals in the transition to skilled nursing 
facilities and assisted living facilities. 
‘‘(B) APPLICATION.—An applicable critical access hos-
pital seeking a grant under this paragraph shall submit 
an application to the Secretary on or before such date 
and in such form and manner as the Secretary specifies. 
‘‘(C) ADDITIONAL REQUIREMENTS.—The Secretary may 
not award a grant under this paragraph to an eligible 
critical access hospital unless— 
‘‘(i) local organizations or the State in which the 
hospital is located provides matching funds; and 
‘‘(ii) the hospital provides assurances that it will 
surrender critical access hospital status under this title 
within 180 days of receiving the grant. 
‘‘(D) AMOUNT OF GRANT.—A grant to an eligible critical 
access hospital under this paragraph may not exceed 
$1,000,000. 
‘‘(E) FUNDING.—There are appropriated from the Fed-
eral Hospital Insurance Trust Fund under section 1817 
Appropriation 
authorization. 
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122 STAT. 2514 
PUBLIC LAW 110–275—JULY 15, 2008 
for making grants under this paragraph, $5,000,000 for 
fiscal year 2008. 
‘‘(F) ELIGIBLE CRITICAL ACCESS HOSPITAL DEFINED.— 
For purposes of this paragraph, the term ‘eligible critical 
access hospital’ means a critical access hospital that has 
an average daily acute census of less than 0.5 and an 
average daily swing bed census of greater than 10.0.’’. 
SEC. 122. REBASING FOR SOLE COMMUNITY HOSPITALS. 
(a) REBASING PERMITTED.—Section 1886(b)(3) of the Social 
Security Act (42 U.S.C. 1395ww(b)(3)) is amended by adding at 
the end the following new subparagraph: 
‘‘(L)(i) For cost reporting periods beginning on or after January 
1, 2009, in the case of a sole community hospital there shall be 
substituted for the amount otherwise determined under subsection 
(d)(5)(D)(i) of this section, if such substitution results in a greater 
amount of payment under this section for the hospital, the subpara-
graph (L) rebased target amount. 
‘‘(ii) For purposes of this subparagraph, the term ‘subparagraph 
(L) rebased target amount’ has the meaning given the term ‘target 
amount’ in subparagraph (C), except that— 
‘‘(I) there shall be substituted for the base cost reporting 
period the 12-month cost reporting period beginning during 
fiscal year 2006; 
‘‘(II) any reference in subparagraph (C)(i) to the ‘first cost 
reporting period’ described in such subparagraph is deemed 
a reference to the first cost reporting period beginning on 
or after January 1, 2009; and 
‘‘(III) the applicable percentage increase shall only be 
applied under subparagraph (C)(iv) for discharges occurring 
on or after January 1, 2009.’’. 
(b) CONFORMING AMENDMENTS.—Section 1886(b)(3) of the Social 
Security Act (42 U.S.C. 1395ww(b)(3)) is amended— 
(1) in subparagraph (C), in the matter preceding clause 
(i), by striking ‘‘subparagraph (I)’’ and inserting ‘‘subparagraphs 
(I) and (L)’’; and 
(2) in subparagraph (I)(i), in the matter preceding subclause 
(I), by striking ‘‘For’’ and inserting ‘‘Subject to subparagraph 
(L), for’’. 
SEC. 123. DEMONSTRATION PROJECT ON COMMUNITY HEALTH 
INTEGRATION MODELS IN CERTAIN RURAL COUNTIES. 
(a) IN GENERAL.—The Secretary shall establish a demonstration 
project to allow eligible entities to develop and test new models 
for the delivery of health care services in eligible counties for 
the purpose of improving access to, and better integrating the 
delivery of, acute care, extended care, and other essential health 
care services to Medicare beneficiaries. 
(b) PURPOSE.—The purpose of the demonstration project under 
this section is to— 
(1) explore ways to increase access to, and improve the 
adequacy of, payments for acute care, extended care, and other 
essential health care services provided under the Medicare 
and Medicaid programs in eligible counties; and 
(2) evaluate regulatory challenges facing such providers 
and the communities they serve. 
(c) REQUIREMENTS.—The following requirements shall apply 
under the demonstration project: 
42 USC 1395i–4 
note. 
Applicability. 
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122 STAT. 2515 
PUBLIC LAW 110–275—JULY 15, 2008 
(1) Health care providers in eligible counties selected to 
participate in the demonstration project under subsection (d)(3) 
shall (when determined appropriate by the Secretary), instead 
of the payment rates otherwise applicable under the Medicare 
program, be reimbursed at a rate that covers at least the 
reasonable costs of the provider in furnishing acute care, 
extended care, and other essential health care services to Medi-
care beneficiaries. 
(2) Methods to coordinate the survey and certification 
process under the Medicare program and the Medicaid program 
across all health service categories included in the demonstra-
tion project shall be tested with the goal of assuring quality 
and safety while reducing administrative burdens, as appro-
priate, related to completing such survey and certification 
process. 
(3) Health care providers in eligible counties selected to 
participate in the demonstration project under subsection (d)(3) 
and the Secretary shall work with the State to explore ways 
to revise reimbursement policies under the Medicaid program 
to improve access to the range of health care services available 
in such eligible counties. 
(4) The Secretary shall identify regulatory requirements 
that may be revised appropriately to improve access to care 
in eligible counties. 
(5) Other essential health care services necessary to ensure 
access to the range of health care services in eligible counties 
selected to participate in the demonstration project under sub-
section (d)(3) shall be identified. Ways to ensure adequate 
funding for such services shall also be explored. 
(d) APPLICATION PROCESS.— 
(1) ELIGIBILITY.— 
(A) IN GENERAL.—Eligibility to participate in the dem-
onstration project under this section shall be limited to 
eligible entities. 
(B) ELIGIBLE
ENTITY
DEFINED.—In this section, the 
term ‘‘eligible entity’’ means an entity that— 
(i) is a Rural Hospital Flexibility Program grantee 
under section 1820(g) of the Social Security Act (42 
U.S.C. 1395i–4(g)); and 
(ii) is located in a State in which at least 65 
percent of the counties in the State are counties that 
have 6 or less residents per square mile. 
(2) APPLICATION.— 
(A) IN GENERAL.—An eligible entity seeking to partici-
pate in the demonstration project under this section shall 
submit an application to the Secretary at such time, in 
such manner, and containing such information as the Sec-
retary may require. 
(B) LIMITATION.—The Secretary shall select eligible 
entities located in not more than 4 States to participate 
in the demonstration project under this section. 
(3) SELECTION OF ELIGIBLE COUNTIES.—An eligible entity 
selected by the Secretary to participate in the demonstration 
project under this section shall select not more than 6 eligible 
counties in the State in which the entity is located in which 
to conduct the demonstration project. 
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122 STAT. 2516 
PUBLIC LAW 110–275—JULY 15, 2008 
(4) ELIGIBLE COUNTY DEFINED.—In this section, the term 
‘‘eligible county’’ means a county that meets the following 
requirements: 
(A) The county has 6 or less residents per square 
mile. 
(B) As of the date of the enactment of this Act, a 
facility designated as a critical access hospital which meets 
the following requirements was located in the county: 
(i) As of the date of the enactment of this Act, 
the critical access hospital furnished 1 or more of the 
following: 
(I) Home health services. 
(II) Hospice care. 
(III) Rural health clinic services. 
(ii) As of the date of the enactment of this Act, 
the critical access hospital has an average daily 
inpatient census of 5 or less. 
(C) As of the date of the enactment of this Act, skilled 
nursing facility services were available in the county in— 
(i) a critical access hospital using swing beds; or 
(ii) a local nursing home. 
(e) ADMINISTRATION.— 
(1) IN
GENERAL.—The demonstration project under this 
section shall be administered jointly by the Administrator of 
the Office of Rural Health Policy of the Health Resources and 
Services Administration and the Administrator of the Centers 
for Medicare & Medicaid Services, in accordance with para-
graphs (2) and (3). 
(2) HRSA DUTIES.—In administering the demonstration 
project under this section, the Administrator of the Office of 
Rural Health Policy of the Health Resources and Services 
Administration shall— 
(A) award grants to the eligible entities selected to 
participate in the demonstration project; and 
(B) work with such entities to provide technical assist-
ance related to the requirements under the project. 
(3) CMS DUTIES.—In administering the demonstration 
project under this section, the Administrator of the Centers 
for Medicare & Medicaid Services shall determine which provi-
sions of titles XVIII and XIX of the Social Security Act (42 
U.S.C. 1395 et seq.; 1396 et seq.) the Secretary should waive 
under the waiver authority under subsection (i) that are rel-
evant to the development of alternative reimbursement meth-
odologies, which may include, as appropriate, covering at least 
the reasonable costs of the provider in furnishing acute care, 
extended care, and other essential health care services to Medi-
care beneficiaries and coordinating the survey and certification 
process under the Medicare and Medicaid programs, as appro-
priate, across all service categories included in the demonstra-
tion project. 
(f) DURATION.— 
(1) IN
GENERAL.—The demonstration project under this 
section shall be conducted for a 3-year period beginning on 
October 1, 2009. 
(2) BEGINNING
DATE
OF
DEMONSTRATION
PROJECT.—The 
demonstration project under this section shall be considered 
to have begun in a State on the date on which the eligible 
Grants. 
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122 STAT. 2517 
PUBLIC LAW 110–275—JULY 15, 2008 
counties selected to participate in the demonstration project 
under subsection (d)(3) begin operations in accordance with 
the requirements under the demonstration project. 
(g) FUNDING.— 
(1) CMS.— 
(A) IN GENERAL.—The Secretary shall provide for the 
transfer, in appropriate part from the Federal Hospital 
Insurance Trust Fund established under section 1817 of 
the Social Security Act (42 U.S.C. 1395i) and the Federal 
Supplementary Medical Insurance Trust Fund established 
under section 1841 of such Act (42 U.S.C. 1395t), of such 
sums as are necessary for the costs to the Centers for 
Medicare & Medicaid Services of carrying out its duties 
under the demonstration project under this section. 
(B) BUDGET
NEUTRALITY.—In conducting the dem-
onstration project under this section, the Secretary shall 
ensure that the aggregate payments made by the Secretary 
do not exceed the amount which the Secretary estimates 
would have been paid if the demonstration project under 
this section was not implemented. 
(2) HRSA.—There are authorized to be appropriated to 
the Office of Rural Health Policy of the Health Resources and 
Services Administration $800,000 for each of fiscal years 2010, 
2011, and 2012 for the purpose of carrying out the duties 
of such Office under the demonstration project under this sec-
tion, to remain available for the duration of the demonstration 
project. 
(h) REPORT.— 
(1) INTERIM REPORT.—Not later than the date that is 2 
years after the date on which the demonstration project under 
this section is implemented, the Administrator of the Office 
of Rural Health Policy of the Health Resources and Services 
Administration, in coordination with the Administrator of the 
Centers for Medicare & Medicaid Services, shall submit a report 
to Congress on the status of the demonstration project that 
includes initial recommendations on ways to improve access 
to, and the availability of, health care services in eligible coun-
ties based on the findings of the demonstration project. 
(2) FINAL REPORT.—Not later than 1 year after the comple-
tion of the demonstration project, the Administrator of the 
Office of Rural Health Policy of the Health Resources and 
Services Administration, in coordination with the Administrator 
of the Centers for Medicare & Medicaid Services, shall submit 
a report to Congress on such project, together with rec-
ommendations for such legislation and administrative action 
as the Secretary determines appropriate. 
(i) WAIVER AUTHORITY.—The Secretary may waive such require-
ments of titles XVIII and XIX of the Social Security Act (42 U.S.C. 
1395 et seq.; 1396 et seq.) as may be necessary and appropriate 
for the purpose of carrying out the demonstration project under 
this section. 
(j) DEFINITIONS.—In this section: 
(1) EXTENDED CARE SERVICES.—The term ‘‘extended care 
services’’ means the following: 
(A) Home health services. 
(B) Covered skilled nursing facility services. 
(C) Hospice care. 
Appropriation 
authorization. 
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122 STAT. 2518 
PUBLIC LAW 110–275—JULY 15, 2008 
(2) COVERED
SKILLED
NURSING
FACILITY
SERVICES.—The 
term ‘‘covered skilled nursing facility services’’ has the meaning 
given such term in section 1888(e)(2)(A) of the Social Security 
Act (42 U.S.C. 1395yy(e)(2)(A)). 
(3) CRITICAL ACCESS HOSPITAL.—The term ‘‘critical access 
hospital’’ means a facility designated as a critical access hospital 
under section 1820(c) of such Act (42 U.S.C. 1395i–4(c)). 
(4) HOME HEALTH SERVICES.—The term ‘‘home health serv-
ices’’ has the meaning given such term in section 1861(m) 
of such Act (42 U.S.C. 1395x(m)). 
(5) HOSPICE
CARE.—The term ‘‘hospice care’’ has the 
meaning given such term in section 1861(dd) of such Act (42 
U.S.C. 1395x(dd)). 
(6) MEDICAID
PROGRAM.—The term ‘‘Medicaid program’’ 
means the program under title XIX of such Act (42 U.S.C. 
1396 et seq.). 
(7) MEDICARE
PROGRAM.—The term ‘‘Medicare program’’ 
means the program under title XVIII of such Act (42 U.S.C. 
1395 et seq.). 
(8) OTHER ESSENTIAL HEALTH CARE SERVICES.—The term 
‘‘other essential health care services’’ means the following: 
(A) Ambulance services (as described in section 
1861(s)(7) of the Social Security Act (42 U.S.C. 1395x(s)(7))). 
(B) Rural health clinic services. 
(C) Public health services (as defined by the Secretary). 
(D) Other health care services determined appropriate 
by the Secretary. 
(9) RURAL
HEALTH
CLINIC
SERVICES.—The term ‘‘rural 
health clinic services’’ has the meaning given such term in 
section 1861(aa)(1) of such Act (42 U.S.C. 1395x(aa)(1)). 
(10) SECRETARY.—The term ‘‘Secretary’’ means the Sec-
retary of Health and Human Services. 
SEC. 124. EXTENSION OF THE RECLASSIFICATION OF CERTAIN HOS-
PITALS. 
(a) IN GENERAL.—Subsection (a) of section 106 of division B 
of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395 
note), as amended by section 117 of the Medicare, Medicaid, and 
SCHIP Extension Act of 2007 (Public Law 110–173), is amended 
by striking ‘‘September 30, 2008’’ and inserting ‘‘September 30, 
2009’’. 
(b) SPECIAL EXCEPTION RECLASSIFICATIONS.—Section 117(a)(2) 
of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public 
Law 110–173)) is amended by striking ‘‘September 30, 2008’’ and 
inserting ‘‘the last date of the extension of reclassifications under 
section 106(a) of the Medicare Improvement and Extension Act 
of 2006 (division B of Public Law 109–432)’’. 
(c) DISREGARDING SECTION 508 HOSPITAL RECLASSIFICATIONS 
FOR PURPOSES
OF GROUP RECLASSIFICATIONS.—Section 508(g) of 
the Medicare Prescription Drug, Improvement, and Modernization 
Act of 2003 (Public Law 108–173, 42 U.S.C. 1395ww note), as 
added by section 117(b) of the Medicare, Medicaid, and SCHIP 
Extension Act of 2008 (Public Law 110–173)), is amended by 
striking ‘‘during fiscal year 2008’’ and inserting ‘‘beginning on 
October 1, 2007, and ending on the last date of the extension 
42 USC 1395ww 
note. 
42 USC 1395ww 
note. 
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122 STAT. 2519 
PUBLIC LAW 110–275—JULY 15, 2008 
of reclassifications under section 106(a) of the Medicare Improve-
ment and Extension Act of 2006 (division B of Public Law 109– 
432)’’. 
SEC. 125. REVOCATION OF UNIQUE DEEMING AUTHORITY OF THE 
JOINT COMMISSION. 
(a) REVOCATION.—Section 1865 of the Social Security Act (42 
U.S.C. 1395bb) is amended— 
(1) by striking subsection (a); and 
(2) by redesignating subsections (b), (c), (d), and (e) as 
subsections (a), (b), (c), and (d), respectively. 
(b) CONFORMING AMENDMENTS.—(1) Section 1865 of the Social 
Security Act (42 U.S.C. 1395bb) is amended— 
(A) in subsection (a)(1), as redesignated by subsection (a)(2), 
by striking ‘‘In addition, if’’ and inserting ‘‘If’’; 
(B) in subsection (b), as so redesignated— 
(i) by striking ‘‘released to him by the Joint Commission 
on Accreditation of Hospitals,’’ and inserting ‘‘released to 
the Secretary by’’; and 
(ii) by striking the comma after ‘‘Association’’; 
(C) in subsection (c), as so redesignated, by striking ‘‘pursu-
ant to subsection (a) or (b)(1)’’ and inserting ‘‘pursuant to sub-
section (a)(1)’’; and 
(D) in subsection (d), as so redesignated, by striking ‘‘pursu-
ant to subsection (a) or (b)(1)’’ and inserting ‘‘pursuant to sub-
section (a)(1)’’. 
(2) Section 1861(e) of the Social Security Act (42 U.S.C. 
1395x(e)) is amended in the fourth sentence by striking ‘‘and (ii) 
is accredited by the Joint Commission on Accreditation of Hospitals, 
or is accredited by or approved by a program of the country in 
which such institution is located if the Secretary finds the accredita-
tion or comparable approval standards of such program to be essen-
tially equivalent to those of the Joint Commission on Accreditation 
of Hospitals’’ and inserting ‘‘and (ii) is accredited by a national 
accreditation body recognized by the Secretary under section 
1865(a), or is accredited by or approved by a program of the country 
in which such institution is located if the Secretary finds the accredi-
tation or comparable approval standards of such program to be 
essentially equivalent to those of such a national accreditation 
body.’’. 
(3) Section 1864(c) of the Social Security Act (42 U.S.C. 
1395aa(c)) is amended by striking ‘‘pursuant to subsection (a) or 
(b)(1) of section 1865’’ and inserting ‘‘pursuant to section 1865(a)(1)’’. 
(4) Section 1875(b) of the Social Security Act (42 U.S.C. 
1395ll(b)) is amended by striking ‘‘the Joint Commission on Accredi-
tation of Hospitals,’’ and inserting ‘‘national accreditation bodies 
under section 1865(a)’’. 
(5) Section 1834(a)(20)(B) of the Social Security Act (42 U.S.C. 
1395m(a)(20)(B)) is amended by striking ‘‘section 1865(b)’’ and 
inserting ‘‘section 1865(a)’’. 
(6) Section 1852(e)(4)(C) of the Social Security Act (42 U.S.C. 
1395w–22(e)(4)(C)) is amended by striking ‘‘section 1865(b)(2)’’ and 
inserting ‘‘section 1865(a)(2)’’. 
(c) AUTHORITY TO RECOGNIZE
THE JOINT COMMISSION
AS
A 
NATIONAL ACCREDITATION BODY.—The Secretary of Health and 
Human Services may recognize the Joint Commission as a national 
accreditation body under section 1865 of the Social Security Act 
42 USC 1395bb 
note. 
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122 STAT. 2520 
PUBLIC LAW 110–275—JULY 15, 2008 
(42 U.S.C. 1395bb), as amended by this section, upon such terms 
and conditions, and upon submission of such information, as the 
Secretary may require. 
(d) EFFECTIVE DATE; TRANSITION RULE.—(1) Subject to para-
graph (2), the amendments made by this section shall apply with 
respect to accreditations of hospitals granted on or after the date 
that is 24 months after the date of the enactment of this Act. 
(2) For purposes of title XVIII of the Social Security Act (42 
U.S.C. 1395 et seq.), the amendments made by this section shall 
not effect the accreditation of a hospital by the Joint Commission, 
or under accreditation or comparable approval standards found 
to be essentially equivalent to accreditation or approval standards 
of the Joint Commission, for the period of time applicable under 
such accreditation. 
Subtitle C—Provisions Relating to Part B 
PART I—PHYSICIANS’ SERVICES 
SEC. 131. PHYSICIAN PAYMENT, EFFICIENCY, AND QUALITY IMPROVE-
MENTS. 
(a) IN GENERAL.— 
(1) INCREASE IN UPDATE FOR THE SECOND HALF OF 2008 
AND FOR 2009.— 
(A) FOR THE SECOND HALF OF 2008.—Section 1848(d)(8) 
of the Social Security Act (42 U.S.C. 1395w–4(d)(8)), as 
added by section 101 of the Medicare, Medicaid, and SCHIP 
Extension Act of 2007 (Public Law 110–173), is amended— 
(i) in the heading, by striking ‘‘A PORTION OF’’; 
(ii) in subparagraph (A), by striking ‘‘for the period 
beginning on January 1, 2008, and ending on June 
30, 2008,’’; and 
(iii) in subparagraph (B)— 
(I) in the heading, by striking ‘‘THE REMAINING 
PORTION OF 2008 AND’’; and 
(II) by striking ‘‘for the period beginning on 
July 1, 2008, and ending on December 31, 2008, 
and’’. 
(B) FOR 2009.—Section 1848(d) of the Social Security 
Act (42 U.S.C. 1395w–4(d)), as amended by section 101 
of the Medicare, Medicaid, and SCHIP Extension Act of 
2007 (Public Law 110–173), is amended by adding at the 
end the following new paragraph: 
‘‘(9) UPDATE FOR 2009.— 
‘‘(A) IN GENERAL.—Subject to paragraphs (7)(B) and 
(8)(B), in lieu of the update to the single conversion factor 
established in paragraph (1)(C) that would otherwise apply 
for 2009, the update to the single conversion factor shall 
be 1.1 percent. 
‘‘(B) NO
EFFECT
ON
COMPUTATION
OF
CONVERSION 
FACTOR FOR 2010 AND SUBSEQUENT YEARS.—The conversion 
factor under this subsection shall be computed under para-
graph (1)(A) for 2010 and subsequent years as if subpara-
graph (A) had never applied.’’. 
(3) REVISION OF THE PHYSICIAN ASSISTANCE AND QUALITY 
INITIATIVE FUND.— 
Applicability. 
42 USC 1395bb 
note. 
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122 STAT. 2521 
PUBLIC LAW 110–275—JULY 15, 2008 
(A) IN GENERAL.—Subject to subparagraph (B), section 
1848(l)(2) of the Social Security Act (42 U.S.C. 1395w– 
4(l)(2)), as amended by section 101(a)(2) of the Medicare, 
Medicaid, and SCHIP Extension Act of 2007 (Public Law 
110–173), is amended— 
(i) in subparagraph (A)— 
(I) by striking clause (i)(III); and 
(II) by striking clause (ii)(III); and 
(ii) in subparagraph (B)— 
(I) in clause (i), by adding ‘‘and’’ at the end; 
(II) in clause (ii), by striking ‘‘; and’’ and 
inserting a period; and 
(III) by striking clause (iii). 
(B) CONTINGENCY.—If there is enacted, before, on, or 
after the date of the enactment of this Act, a Supplemental 
Appropriations Act, 2008 that includes a provision 
amending section 1848(l) of the Social Security Act, the 
alternative amendment described in subparagraph (C)— 
(i) shall apply instead of the amendments made 
by subparagraph (A); and 
(ii) shall be executed after such provision in such 
Supplemental Appropriations Act. 
(C) ALTERNATIVE AMENDMENT DESCRIBED.—The alter-
native amendment described in this subparagraph is as 
follows: Section 1848(l)(2) of the Social Security Act (42 
U.S.C. 1395w–4(l)(2)), as amended by section 101(a)(2) of 
the Medicare, Medicaid, and SCHIP Extension Act of 2007 
(Public Law 110–173) and by the Supplemental Appropria-
tions Act, 2008, is amended— 
(i) in subparagraph (A)— 
(I) by striking subclauses (III) and (IV) of 
clause (i); and 
(II) by striking subclauses (III) and (IV) of 
clause (ii); and 
(ii) in subparagraph (B)— 
(I) in clause (i), by adding ‘‘and’’ at the end; 
(II) in clause (ii), by striking the semicolon 
at the end and inserting a period; and 
(III) by striking clauses (iii) and (iv). 
(b) EXTENSION AND IMPROVEMENT OF THE QUALITY REPORTING 
SYSTEM.— 
(1) SYSTEM.—Section 1848(k)(2) of the Social Security Act 
(42 U.S.C. 1395w–4(k)(2)), as amended by section 101(b)(1) 
of the Medicare, Medicaid, and SCHIP Extension Act of 2007 
(Public Law 110–173), is amended by adding at the end the 
following new subparagraphs: 
‘‘(C) FOR 2010 AND SUBSEQUENT YEARS.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), for pur-
poses of reporting data on quality measures for covered 
professional services furnished during 2010 and each 
subsequent year, subject to subsection (m)(3)(C), the 
quality measures (including electronic prescribing 
quality measures) specified under this paragraph shall 
be such measures selected by the Secretary from meas-
ures that have been endorsed by the entity with a 
contract with the Secretary under section 1890(a). 
Applicability. 
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122 STAT. 2522 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(ii) EXCEPTION.—In the case of a specified area 
or medical topic determined appropriate by the Sec-
retary for which a feasible and practical measure has 
not been endorsed by the entity with a contract under 
section 1890(a), the Secretary may specify a measure 
that is not so endorsed as long as due consideration 
is given to measures that have been endorsed or 
adopted by a consensus organization identified by the 
Secretary, such as the AQA alliance. 
‘‘(D) OPPORTUNITY
TO
PROVIDE
INPUT
ON
MEASURES 
FOR
2009
AND
SUBSEQUENT
YEARS.—For each quality 
measure (including an electronic prescribing quality 
measure) adopted by the Secretary under subparagraph 
(B) (with respect to 2009) or subparagraph (C), the Sec-
retary shall ensure that eligible professionals have the 
opportunity to provide input during the development, 
endorsement, or selection of measures applicable to services 
they furnish.’’. 
(2) REDESIGNATION OF REPORTING SYSTEM.—Subsection (c) 
of section 101 of division B of the Tax Relief and Health 
Care Act of 2006 (42 U.S.C. 1395w–4 note), as amended by 
section 101(b)(2) of the Medicare, Medicaid, and SCHIP Exten-
sion Act of 2007 (Public Law 110–173), is redesignated as 
subsection (m) of section 1848 of the Social Security Act. 
(3) INCENTIVE PAYMENTS UNDER REPORTING SYSTEM.—Sec-
tion 1848(m) of the Social Security Act, as redesignated by 
paragraph (2), is amended— 
(A) by amending the heading to read as follows: 
‘‘INCENTIVE PAYMENTS FOR QUALITY REPORTING’’; 
(B) by striking paragraph (1) and inserting the fol-
lowing: 
‘‘(1) INCENTIVE PAYMENTS.— 
‘‘(A) IN GENERAL.—For 2007 through 2010, with respect 
to covered professional services furnished during a 
reporting period by an eligible professional, if— 
‘‘(i) there are any quality measures that have been 
established under the physician reporting system that 
are applicable to any such services furnished by such 
professional for such reporting period; and 
‘‘(ii) the eligible professional satisfactorily submits 
(as determined under this subsection) to the Secretary 
data on such quality measures in accordance with such 
reporting system for such reporting period, 
in addition to the amount otherwise paid under this part, 
there also shall be paid to the eligible professional (or 
to an employer or facility in the cases described in clause 
(A) of section 1842(b)(6)) or, in the case of a group practice 
under paragraph (3)(C), to the group practice, from the 
Federal Supplementary Medical Insurance Trust Fund 
established under section 1841 an amount equal to the 
applicable quality percent of the Secretary’s estimate (based 
on claims submitted not later than 2 months after the 
end of the reporting period) of the allowed charges under 
this part for all such covered professional services furnished 
by the eligible professional (or, in the case of a group 
practice under paragraph (3)(C), by the group practice) 
during the reporting period. 
Deadline. 
42 USC 1395w–4. 
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122 STAT. 2523 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(B) APPLICABLE QUALITY PERCENT.—For purposes of 
subparagraph (A), the term ‘applicable quality percent’ 
means— 
‘‘(i) for 2007 and 2008, 1.5 percent; and 
‘‘(ii) for 2009 and 2010, 2.0 percent.’’; 
(C) by striking paragraph (3) and redesignating para-
graph (2) as paragraph (3); 
(D) in paragraph (3), as so redesignated— 
(i) in the matter preceding subparagraph (A), by 
striking ‘‘For purposes’’ and inserting the following: 
‘‘(A) IN GENERAL.—For purposes’’; 
(ii) by redesignating subparagraphs (A) and (B) 
as clauses (i) and (ii), respectively, and moving the 
indentation of such clauses 2 ems to the right; 
(iii) in subparagraph (A), as added by clause (i), 
by adding at the end the following flush sentence: 
‘‘For years after 2008, quality measures for purposes of 
this subparagraph shall not include electronic prescribing 
quality measures.’’; and 
(iv) by adding at the end the following new sub-
paragraphs: 
‘‘(C) SATISFACTORY REPORTING MEASURES FOR GROUP 
PRACTICES.— 
‘‘(i) IN GENERAL.—By January 1, 2010, the Sec-
retary shall establish and have in place a process under 
which eligible professionals in a group practice (as 
defined by the Secretary) shall be treated as satisfac-
torily submitting data on quality measures under 
subparagraph (A) and as meeting the requirement 
described in subparagraph (B)(ii) for covered profes-
sional services for a reporting period (or, for purposes 
of subsection (a)(5), for a reporting period for a year) 
if, in lieu of reporting measures under subsection 
(k)(2)(C), the group practice reports measures deter-
mined appropriate by the Secretary, such as measures 
that target high-cost chronic conditions and preventive 
care, in a form and manner, and at a time, specified 
by the Secretary. 
‘‘(ii) STATISTICAL SAMPLING MODEL.—The process 
under clause (i) shall provide for the use of a statistical 
sampling model to submit data on measures, such as 
the model used under the Physician Group Practice 
demonstration project under section 1866A. 
‘‘(iii) NO DOUBLE PAYMENTS.—Payments to a group 
practice under this subsection by reason of the process 
under clause (i) shall be in lieu of the payments that 
would otherwise be made under this subsection to 
eligible professionals in the group practice for satisfac-
torily submitting data on quality measures. 
‘‘(D) AUTHORITY TO REVISE SATISFACTORILY REPORTING 
DATA.—For years after 2009, the Secretary, in consultation 
with stakeholders and experts, may revise the criteria 
under this subsection for satisfactorily submitting data on 
quality measures under subparagraph (A) and the criteria 
for submitting data on electronic prescribing quality meas-
ures under subparagraph (B)(ii).’’; 
(E) in paragraph (5)— 
Deadline. 
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122 STAT. 2524 
PUBLIC LAW 110–275—JULY 15, 2008 
(i) in subparagraph (C), by inserting ‘‘for 2007, 
2008, and 2009,’’ after ‘‘provision of law,’’; 
(ii) in subparagraph (D)— 
(I) in clause (i)— 
(aa) by inserting ‘‘for 2007 and 2008’’ after 
‘‘under this subsection’’; and 
(bb) by striking ‘‘paragraph (2)’’ and 
inserting ‘‘this subsection’’; 
(II) in clause (ii), by striking ‘‘shall’’ and 
inserting ‘‘may establish procedures to’’; and 
(III) in clause (iii)— 
(aa) by inserting ‘‘(or, in the case of a 
group practice under paragraph (3)(C), the 
group practice)’’ after ‘‘an eligible profes-
sional’’; 
(bb) by striking ‘‘bonus incentive payment’’ 
and inserting ‘‘incentive payment under this 
subsection’’; and 
(cc) by adding at the end the following 
new sentence: ‘‘If such payments for such 
period have already been made, the Secretary 
shall recoup such payments from the eligible 
professional (or the group practice).’’; 
(iii) in subparagraph (E)— 
(I) by striking ‘‘(I) IN GENERAL.—’’; 
(II) by striking clause (ii); 
(III) by redesignating subclauses (I) through 
(IV) as clauses (i) through (iv), respectively, and 
moving the indentation of such clauses 2 ems to 
the left; 
(IV) in clause (ii), as so redesignated, by 
striking ‘‘paragraph (2)’’ and inserting ‘‘this sub-
section’’; and 
(V) in clause (iv), as so redesignated— 
(aa) by striking ‘‘the bonus’’ and inserting 
‘‘any’’; and 
(bb) by inserting ‘‘and the payment adjust-
ment under subsection (a)(5)(A)’’ before the 
period at the end; 
(iv) in subparagraph (F)— 
(I) by striking ‘‘2009, paragraph (3) shall not 
apply, and’’ and inserting ‘‘subsequent years,’’; and 
(II) by striking ‘‘paragraph (2)’’ and inserting 
‘‘this subsection’’; and 
(v) by adding at the end the following new subpara-
graph: 
‘‘(G) POSTING ON WEBSITE.—The Secretary shall post 
on the Internet website of the Centers for Medicare & 
Medicaid Services, in an easily understandable format, a 
list of the names of the following: 
‘‘(i) The eligible professionals (or, in the case of 
reporting under paragraph (3)(C), the group practices) 
who satisfactorily submitted data on quality measures 
under this subsection. 
‘‘(ii) The eligible professionals (or, in the case of 
reporting under paragraph (3)(C), the group practices) 
who are successful electronic prescribers.’’; and 
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122 STAT. 2525 
PUBLIC LAW 110–275—JULY 15, 2008 
(F) in paragraph (6), by striking subparagraph (C) 
and inserting the following: 
‘‘(C) REPORTING PERIOD.— 
‘‘(i) IN GENERAL.—Subject to clauses (ii) and (iii), 
the term ‘reporting period’ means— 
‘‘(I) for 2007, the period beginning on July 
1, 2007, and ending on December 31, 2007; and 
‘‘(II) for 2008, 2009, 2010, and 2011, the entire 
year. 
‘‘(ii) AUTHORITY TO REVISE REPORTING PERIOD.— 
For years after 2009, the Secretary may revise the 
reporting period under clause (i) if the Secretary deter-
mines such revision is appropriate, produces valid 
results on measures reported, and is consistent with 
the goals of maximizing scientific validity and reducing 
administrative burden. If the Secretary revises such 
period pursuant to the preceding sentence, the term 
‘reporting period’ shall mean such revised period. 
‘‘(iii) REFERENCE.—Any reference in this subsection 
to a reporting period with respect to the application 
of subsection (a)(5) shall be deemed a reference to 
the reporting period under subparagraph (D)(iii) of 
such subsection.’’. 
(4) INCLUSION
OF
QUALIFIED
AUDIOLOGISTS
AS
ELIGIBLE 
PROFESSIONALS.— 
(A) IN GENERAL.—Section 1848(k)(3)(B) of the Social 
Security Act (42 U.S.C. 1395w–4(k)(3)(B)), is amended by 
adding at the end the following new clause: 
‘‘(iv) Beginning with 2009, a qualified audiologist 
(as defined in section 1861(ll)(3)(B)).’’. 
(B) NO CHANGE IN BILLING.—Nothing in the amend-
ment made by subparagraph (A) shall be construed to 
change the way in which billing for audiology services 
(as defined in section 1861(ll)(2) of the Social Security 
Act (42 U.S.C. 1395x(ll)(2))) occurs under title XVIII of 
such Act as of July 1, 2008. 
(5) CONFORMING
AMENDMENTS.—Section 1848(m) of the 
Social Security Act, as added and amended by paragraphs 
(2) and (3), is amended— 
(A) in paragraph (5)— 
(i) in subparagraph (A)— 
(I) by striking ‘‘section 1848(k) of the Social 
Security Act, as added by subsection (b),’’ and 
inserting ‘‘subsection (k)’’; and 
(II) by striking ‘‘such section’’ and inserting 
‘‘such subsection’’; 
(ii) in subparagraph (B), by striking ‘‘of the Social 
Security Act (42 U.S.C. 1395l)’’; 
(iii) in subparagraph (E), in the matter preceding 
clause (i), by striking ‘‘1869 or 1878 of the Social Secu-
rity Act or otherwise’’ and inserting ‘‘1869, section 
1878, or otherwise’’; and 
(iv) in subparagraph (F)— 
(I) by striking ‘‘paragraph (2)(B) of section 
1848(k) of the Social Security Act (42 U.S.C. 
1395w–4(k))’’ and inserting ‘‘subsection (k)(2)(B)’’; 
and 
42 USC 1395w–4 
note. 
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122 STAT. 2526 
PUBLIC LAW 110–275—JULY 15, 2008 
(II) by striking ‘‘paragraph (4) of such section’’ 
and inserting ‘‘subsection (k)(4)’’; 
(B) in paragraph (6)— 
(i) in subparagraph (A), by striking ‘‘section 
1848(k)(3) of the Social Security Act, as added by sub-
section (b)’’ and inserting ‘‘subsection (k)(3)’’; and 
(ii) in subparagraph (B), by striking ‘‘section 
1848(k) of the Social Security Act, as added by sub-
section (b)’’ and inserting ‘‘subsection (k)’’; and 
(C) by striking paragraph (6)(D). 
(6) NO AFFECT ON INCENTIVE PAYMENTS FOR 2007 OR 2008.— 
Nothing in the amendments made by this subsection or section 
132 shall affect the operation of the provisions of section 
1848(m) of the Social Security Act, as redesignated and 
amended by such subsection and section, with respect to 2007 
or 2008. 
(c) PHYSICIAN FEEDBACK PROGRAM TO IMPROVE EFFICIENCY 
AND CONTROL COSTS.— 
(1) IN GENERAL.—Section 1848 of the Social Security Act 
(42 U.S.C. 1395w–4), as amended by subsection (b), is amended 
by adding at the end the following new subsection: 
‘‘(n) PHYSICIAN FEEDBACK PROGRAM.— 
‘‘(1) ESTABLISHMENT.— 
‘‘(A) IN
GENERAL.—The Secretary shall establish a 
Physician Feedback Program (in this subsection referred 
to as the ‘Program’) under which the Secretary shall use 
claims data under this title (and may use other data) 
to provide confidential reports to physicians (and, as deter-
mined appropriate by the Secretary, to groups of physi-
cians) that measure the resources involved in furnishing 
care to individuals under this title. If determined appro-
priate by the Secretary, the Secretary may include informa-
tion on the quality of care furnished to individuals under 
this title by the physician (or group of physicians) in such 
reports. 
‘‘(B) RESOURCE
USE.—The resources described in 
subparagraph (A) may be measured— 
‘‘(i) on an episode basis; 
‘‘(ii) on a per capita basis; or 
‘‘(iii) on both an episode and a per capita basis. 
‘‘(2) IMPLEMENTATION.—The Secretary shall implement the 
Program by not later than January 1, 2009. 
‘‘(3) DATA FOR REPORTS.—To the extent practicable, reports 
under the Program shall be based on the most recent data 
available. 
‘‘(4) AUTHORITY TO FOCUS APPLICATION.—The Secretary may 
focus the application of the Program as appropriate, such as 
focusing the Program on— 
‘‘(A) physician specialties that account for a certain 
percentage of all spending for physicians’ services under 
this title; 
‘‘(B) physicians who treat conditions that have a high 
cost or a high volume, or both, under this title; 
‘‘(C) physicians who use a high amount of resources 
compared to other physicians; 
‘‘(D) physicians practicing in certain geographic areas; 
or 
Deadline. 
42 USC 1395w–4 
note. 
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122 STAT. 2527 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(E) physicians who treat a minimum number of 
individuals under this title. 
‘‘(5) AUTHORITY
TO
EXCLUDE
CERTAIN
INFORMATION
IF 
INSUFFICIENT INFORMATION.—The Secretary may exclude cer-
tain information regarding a service from a report under the 
Program with respect to a physician (or group of physicians) 
if the Secretary determines that there is insufficient informa-
tion relating to that service to provide a valid report on that 
service. 
‘‘(6) ADJUSTMENT OF DATA.—To the extent practicable, the 
Secretary shall make appropriate adjustments to the data used 
in preparing reports under the Program, such as adjustments 
to take into account variations in health status and other 
patient characteristics. 
‘‘(7) EDUCATION AND OUTREACH.—The Secretary shall pro-
vide for education and outreach activities to physicians on 
the operation of, and methodologies employed under, the Pro-
gram. 
‘‘(8) DISCLOSURE EXEMPTION.—Reports under the Program 
shall be exempt from disclosure under section 552 of title 
5, United States Code.’’. 
(2) GAO STUDY AND REPORT ON THE PHYSICIAN FEEDBACK 
PROGRAM.— 
(A) STUDY.—The Comptroller General of the United 
States shall conduct a study of the Physician Feedback 
Program conducted under section 1848(n) of the Social 
Security Act, as added by paragraph (1), including the 
implementation of the Program. 
(B) REPORT.—Not later than March 1, 2011, the Comp-
troller General of the United States shall submit a report 
to Congress containing the results of the study conducted 
under subparagraph (A), together with recommendations 
for such legislation and administrative action as the Comp-
troller General determines appropriate. 
(d) PLAN FOR TRANSITION TO VALUE-BASED PURCHASING PRO-
GRAM FOR PHYSICIANS AND OTHER PRACTITIONERS.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services shall develop a plan to transition to a value-based 
purchasing program for payment under the Medicare program 
for covered professional services (as defined in section 
1848(k)(3)(A) of the Social Security Act (42 U.S.C. 1395w– 
4(k)(3)(A))). 
(2) REPORT.—Not later than May 1, 2010, the Secretary 
of Health and Human Services shall submit a report to Con-
gress containing the plan developed under paragraph (1), 
together with recommendations for such legislation and 
administrative action as the Secretary determines appropriate. 
SEC. 132. INCENTIVES FOR ELECTRONIC PRESCRIBING. 
(a) INCENTIVE PAYMENTS.—Section 1848(m) of the Social Secu-
rity Act, as added and amended by section 131(b), is amended— 
(1) by inserting after paragraph (1), the following new 
paragraph: 
‘‘(2) INCENTIVE PAYMENTS FOR ELECTRONIC PRESCRIBING.— 
‘‘(A) IN GENERAL.—For 2009 through 2013, with respect 
to covered professional services furnished during a 
reporting period by an eligible professional, if the eligible 
Deadline. 
42 USC 1395w–4. 
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122 STAT. 2528 
PUBLIC LAW 110–275—JULY 15, 2008 
professional is a successful electronic prescriber for such 
reporting period, in addition to the amount otherwise paid 
under this part, there also shall be paid to the eligible 
professional (or to an employer or facility in the cases 
described in clause (A) of section 1842(b)(6)) or, in the 
case of a group practice under paragraph (3)(C), to the 
group practice, from the Federal Supplementary Medical 
Insurance Trust Fund established under section 1841 an 
amount equal to the applicable electronic prescribing per-
cent of the Secretary’s estimate (based on claims submitted 
not later than 2 months after the end of the reporting 
period) of the allowed charges under this part for all such 
covered professional services furnished by the eligible 
professional (or, in the case of a group practice under 
paragraph (3)(C), by the group practice) during the 
reporting period. 
‘‘(B) LIMITATION WITH RESPECT TO ELECTRONIC PRE-
SCRIBING QUALITY MEASURES.—The provisions of this para-
graph and subsection (a)(5) shall not apply to an eligible 
professional (or, in the case of a group practice under 
paragraph (3)(C), to the group practice) if, for the reporting 
period (or, for purposes of subsection (a)(5), for the 
reporting period for a year)— 
‘‘(i) the allowed charges under this part for all 
covered professional services furnished by the eligible 
professional (or group, as applicable) for the codes to 
which the electronic prescribing quality measure 
applies (as identified by the Secretary and published 
on the Internet website of the Centers for Medicare 
& Medicaid Services as of January 1, 2008, and as 
subsequently modified by the Secretary) are less than 
10 percent of the total of the allowed charges under 
this part for all such covered professional services fur-
nished by the eligible professional (or the group, as 
applicable); or 
‘‘(ii) if determined appropriate by the Secretary, 
the eligible professional does not submit (including 
both electronically and nonelectronically) a sufficient 
number (as determined by the Secretary) of prescrip-
tions under part D. 
If the Secretary makes the determination to apply clause 
(ii) for a period, then clause (i) shall not apply for such 
period. 
‘‘(C) APPLICABLE ELECTRONIC PRESCRIBING PERCENT.— 
For purposes of subparagraph (A), the term ‘applicable 
electronic prescribing percent’ means— 
‘‘(i) for 2009 and 2010, 2.0 percent; 
‘‘(ii) for 2011 and 2012, 1.0 percent; and 
‘‘(iii) for 2013, 0.5 percent.’’; 
(2) in paragraph (3), as redesignated by section 131(b)— 
(A) in the heading, by inserting ‘‘AND SUCCESSFUL ELEC-
TRONIC PRESCRIBER’’ after ‘‘REPORTING’’; and 
(B) by inserting after subparagraph (A) the following 
new subparagraph: 
‘‘(B) SUCCESSFUL ELECTRONIC PRESCRIBER.— 
‘‘(i) IN GENERAL.—For purposes of paragraph (2) 
and subsection (a)(5), an eligible professional shall be 
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122 STAT. 2529 
PUBLIC LAW 110–275—JULY 15, 2008 
treated as a successful electronic prescriber for a 
reporting period (or, for purposes of subsection (a)(5), 
for the reporting period for a year) if the eligible profes-
sional meets the requirement described in clause (ii), 
or, if the Secretary determines appropriate, the 
requirement described in clause (iii). If the Secretary 
makes the determination under the preceding sentence 
to apply the requirement described in clause (iii) for 
a period, then the requirement described in clause 
(ii) shall not apply for such period. 
‘‘(ii) REQUIREMENT FOR SUBMITTING DATA ON ELEC-
TRONIC PRESCRIBING QUALITY MEASURES.—The require-
ment described in this clause is that, with respect 
to covered professional services furnished by an eligible 
professional during a reporting period (or, for purposes 
of subsection (a)(5), for the reporting period for a year), 
if there are any electronic prescribing quality measures 
that have been established under the physician 
reporting system and are applicable to any such serv-
ices furnished by such professional for the period, such 
professional reported each such measure under such 
system in at least 50 percent of the cases in which 
such measure is reportable by such professional under 
such system. 
‘‘(iii) REQUIREMENT
FOR
ELECTRONICALLY
PRE-
SCRIBING UNDER PART D.—The requirement described 
in this clause is that the eligible professional electroni-
cally submitted a sufficient number (as determined 
by the Secretary) of prescriptions under part D during 
the reporting period (or, for purposes of subsection 
(a)(5), for the reporting period for a year). 
‘‘(iv) USE OF PART D DATA.—Notwithstanding sec-
tions 1860D-15(d)(2)(B) and 1860D-15(f)(2), the Sec-
retary may use data regarding drug claims submitted 
for purposes of section 1860D-15 that are necessary 
for purposes of clause (iii), paragraph (2)(B)(ii), and 
paragraph (5)(G). 
‘‘(v) STANDARDS FOR ELECTRONIC PRESCRIBING.— 
To the extent practicable, in determining whether 
eligible professionals meet the requirements under 
clauses (ii) and (iii) for purposes of clause (i), the 
Secretary shall ensure that eligible professionals utilize 
electronic prescribing systems in compliance with 
standards established for such systems pursuant to 
the Part D Electronic Prescribing Program under sec-
tion 1860D–4(e).’’; and 
(3) in paragraph (5)(E), by striking clause (iii) and inserting 
the following new clause: 
‘‘(iii) the determination of a successful electronic 
prescriber under paragraph (3), the limitation under 
paragraph (2)(B), and the exception under subsection 
(a)(5)(B); and’’. 
(b) INCENTIVE PAYMENT ADJUSTMENT.—Section 1848(a) of the 
Social Security Act (42 U.S.C. 1395w–4(a)) is amended by adding 
at the end the following new paragraph: 
‘‘(5) INCENTIVES FOR ELECTRONIC PRESCRIBING.— 
‘‘(A) ADJUSTMENT.— 
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122 STAT. 2530 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(i) IN GENERAL.—Subject to subparagraph (B) and 
subsection (m)(2)(B), with respect to covered profes-
sional services furnished by an eligible professional 
during 2012 or any subsequent year, if the eligible 
professional is not a successful electronic prescriber 
for the reporting period for the year (as determined 
under subsection (m)(3)(B)), the fee schedule amount 
for such services furnished by such professional during 
the year (including the fee schedule amount for pur-
poses of determining a payment based on such amount) 
shall be equal to the applicable percent of the fee 
schedule amount that would otherwise apply to such 
services under this subsection (determined after 
application of paragraph (3) but without regard to this 
paragraph). 
‘‘(ii) APPLICABLE PERCENT.—For purposes of clause 
(i), the term ‘applicable percent’ means— 
‘‘(I) for 2012, 99 percent; 
‘‘(II) for 2013, 98.5 percent; and 
‘‘(III) for 2014 and each subsequent year, 98 
percent. 
‘‘(B) SIGNIFICANT HARDSHIP EXCEPTION.—The Secretary 
may, on a case-by-case basis, exempt an eligible profes-
sional from the application of the payment adjustment 
under subparagraph (A) if the Secretary determines, sub-
ject to annual renewal, that compliance with the require-
ment for being a successful electronic prescriber would 
result in a significant hardship, such as in the case of 
an eligible professional who practices in a rural area with-
out sufficient Internet access. 
‘‘(C) APPLICATION.— 
‘‘(i) PHYSICIAN REPORTING SYSTEM RULES.—Para-
graphs (5), (6), and (8) of subsection (k) shall apply 
for purposes of this paragraph in the same manner 
as they apply for purposes of such subsection. 
‘‘(ii) INCENTIVE
PAYMENT
VALIDATION
RULES.— 
Clauses (ii) and (iii) of subsection (m)(5)(D) shall apply 
for purposes of this paragraph in a similar manner 
as they apply for purposes of such subsection. 
‘‘(D) DEFINITIONS.—For purposes of this paragraph: 
‘‘(i) ELIGIBLE
PROFESSIONAL; COVERED
PROFES-
SIONAL SERVICES.—The terms ‘eligible professional’ and 
‘covered professional services’ have the meanings given 
such terms in subsection (k)(3). 
‘‘(ii) PHYSICIAN
REPORTING
SYSTEM.—The term 
‘physician reporting system’ means the system estab-
lished under subsection (k). 
‘‘(iii) REPORTING
PERIOD.—The term ‘reporting 
period’ means, with respect to a year, a period specified 
by the Secretary.’’. 
(c) GAO REPORT ON ELECTRONIC PRESCRIBING.—Not later than 
September 1, 2012, the Comptroller General of the United States 
shall submit to Congress a report on the implementation of the 
incentives for electronic prescribing established under the provisions 
of, and amendments made by, this section. Such report shall include 
information regarding the following: 
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122 STAT. 2531 
PUBLIC LAW 110–275—JULY 15, 2008 
(1) The percentage of eligible professionals (as defined in 
section 1848(k)(3) of the Social Security Act (42 U.S.C. 1395w– 
4(k)(3)) that are using electronic prescribing systems, including 
a determination of whether less than 50 percent of eligible 
professionals are using electronic prescribing systems. 
(2) If less than 50 percent of eligible professionals are 
using electronic prescribing systems, recommendations for 
increasing the use of electronic prescribing systems by eligible 
professionals, such as changes to the incentive payment adjust-
ments established under section 1848(a)(5) of such Act, as 
added by subsection (b). 
(3) The estimated savings to the Medicare program under 
title XVIII of such Act resulting from the use of electronic 
prescribing systems. 
(4) Reductions in avoidable medical errors resulting from 
the use of electronic prescribing systems. 
(5) The extent to which the privacy and security of the 
personal health information of Medicare beneficiaries is pro-
tected when such beneficiaries’ prescription drug data and 
usage information is used for purposes other than their direct 
clinical care, including— 
(A) whether information identifying the beneficiary is, 
and remains, removed from data regarding the beneficiary’s 
prescription drug utilization; and 
(B) the extent to which current law requires sufficient 
and appropriate oversight and audit capabilities to monitor 
the practice of prescription drug data mining. 
(6) Such other recommendations and administrative action 
as the Comptroller General determines to be appropriate. 
SEC. 133. EXPANDING ACCESS TO PRIMARY CARE SERVICES. 
(a) REVISIONS TO THE MEDICARE MEDICAL HOME DEMONSTRA-
TION PROJECT.— 
(1) AUTHORITY TO EXPAND.—Section 204(b) of division B 
of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 
1395b–1 note) is amended— 
(A) in paragraph (1), by striking ‘‘The project’’ and 
inserting ‘‘Subject to paragraph (3), the project’’; and 
(B) by adding at the end the following new paragraph: 
‘‘(3) EXPANSION.—The Secretary may expand the duration 
and the scope of the project under paragraph (1), to an extent 
determined appropriate by the Secretary, if the Secretary deter-
mines that such expansion will result in any of the following 
conditions being met: 
‘‘(A) The expansion of the project is expected to improve 
the quality of patient care without increasing spending 
under the Medicare program (not taking into account 
amounts available under subsection (g)). 
‘‘(B) The expansion of the project is expected to reduce 
spending under the Medicare program (not taking into 
account amounts available under subsection (g)) without 
reducing the quality of patient care.’’. 
(2) FUNDING
AND
APPLICATION.—Section 204 of division 
B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 
1395b–1 note) is amended by adding at the end the following 
new subsections: 
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122 STAT. 2532 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(g) FUNDING FROM SMI TRUST FUND.—There shall be avail-
able, from the Federal Supplementary Medical Insurance Trust 
Fund (under section 1841 of the Social Security Act (42 U.S.C. 
1395t)), the amount of $100,000,000 to carry out the project. 
‘‘(h) APPLICATION.—Chapter 35 of title 44, United States Code, 
shall not apply to the conduct of the project.’’. 
(b) APPLICATION OF BUDGET-NEUTRALITY ADJUSTOR TO CONVER-
SION FACTOR.—Section 1848(c)(2)(B) of the Social Security Act (42 
U.S.C. 1395w–4(c)(2)(B)) is amended by adding at the end the 
following new clause: 
‘‘(vi) ALTERNATIVE
APPLICATION
OF
BUDGET-NEU-
TRALITY
ADJUSTMENT.—Notwithstanding 
subsection 
(d)(9)(A), effective for fee schedules established begin-
ning with 2009, with respect to the 5-year review of 
work relative value units used in fee schedules for 
2007 and 2008, in lieu of continuing to apply budget- 
neutrality adjustments required under clause (ii) for 
2007 and 2008 to work relative value units, the Sec-
retary shall apply such budget-neutrality adjustments 
to the conversion factor otherwise determined for years 
beginning with 2009.’’. 
SEC. 134. EXTENSION OF FLOOR ON MEDICARE WORK GEOGRAPHIC 
ADJUSTMENT UNDER THE MEDICARE PHYSICIAN FEE 
SCHEDULE. 
(a) IN GENERAL.—Section 1848(e)(1)(E) of the Social Security 
Act (42 U.S.C. 1395w–4(e)(1)(E)), as amended by section 103 of 
the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public 
Law 110–173), is amended by striking ‘‘before July 1, 2008’’ and 
inserting ‘‘before January 1, 2010’’. 
(b) TREATMENT OF PHYSICIANS’ SERVICES FURNISHED IN CER-
TAIN AREAS.—Section 1848(e)(1)(G) of the Social Security Act (42 
U.S.C. 1395w–4(e)(1)(G)) is amended by adding at the end the 
following new sentence: ‘‘For purposes of payment for services fur-
nished in the State described in the preceding sentence on or 
after January 1, 2009, after calculating the work geographic index 
in subparagraph (A)(iii), the Secretary shall increase the work 
geographic index to 1.5 if such index would otherwise be less 
than 1.5’’. 
(c) TECHNICAL CORRECTION.—Section 602(1) of the Medicare 
Prescription Drug, Improvement, and Modernization Act of 2003 
(Public Law 108–173; 117 Stat. 2301) is amended to read as follows: 
‘‘(1) in subparagraph (A), by striking ‘subparagraphs (B), 
(C), and (E)’ and inserting ‘subparagraphs (B), (C), (E), and 
(G)’; and’’. 
SEC. 135. IMAGING PROVISIONS. 
(a) ACCREDITATION REQUIREMENT.— 
(1) ACCREDITATION
REQUIREMENT.—Section 1834 of the 
Social Security Act (42 U.S.C. 1395m) is amended by inserting 
after subsection (d) the following new subsection: 
‘‘(e) ACCREDITATION REQUIREMENT FOR ADVANCED DIAGNOSTIC 
IMAGING SERVICES.— 
‘‘(1) IN GENERAL.— 
‘‘(A) IN GENERAL.—Beginning with January 1, 2012, 
with respect to the technical component of advanced diag-
nostic imaging services for which payment is made under 
the fee schedule established under section 1848(b) and 
Effective date. 
42 USC 1395w–4. 
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122 STAT. 2533 
PUBLIC LAW 110–275—JULY 15, 2008 
that are furnished by a supplier, payment may only be 
made if such supplier is accredited by an accreditation 
organization designated by the Secretary under paragraph 
(2)(B)(i). 
‘‘(B) 
ADVANCED
DIAGNOSTIC
IMAGING
SERVICES 
DEFINED.—In this subsection, the term ‘advanced diagnostic 
imaging services’ includes— 
‘‘(i) diagnostic magnetic resonance imaging, com-
puted tomography, and nuclear medicine (including 
positron emission tomography); and 
‘‘(ii) such other diagnostic imaging services, 
including services described in section 1848(b)(4)(B) 
(excluding X-ray, ultrasound, and fluoroscopy), as 
specified by the Secretary in consultation with physi-
cian specialty organizations and other stakeholders. 
‘‘(C) SUPPLIER DEFINED.—In this subsection, the term 
‘supplier’ has the meaning given such term in section 
1861(d). 
‘‘(2) ACCREDITATION ORGANIZATIONS.— 
‘‘(A) FACTORS
FOR
DESIGNATION
OF
ACCREDITATION 
ORGANIZATIONS.—The Secretary shall consider the following 
factors in designating accreditation organizations under 
subparagraph (B)(i) and in reviewing and modifying the 
list of accreditation organizations designated pursuant to 
subparagraph (C): 
‘‘(i) The ability of the organization to conduct 
timely reviews of accreditation applications. 
‘‘(ii) Whether the organization has established a 
process for the timely integration of new advanced 
diagnostic imaging services into the organization’s 
accreditation program. 
‘‘(iii) Whether the organization uses random site 
visits, site audits, or other strategies for ensuring 
accredited suppliers maintain adherence to the criteria 
described in paragraph (3). 
‘‘(iv) The ability of the organization to take into 
account the capacities of suppliers located in a rural 
area (as defined in section 1886(d)(2)(D)). 
‘‘(v) Whether the organization has established 
reasonable fees to be charged to suppliers applying 
for accreditation. 
‘‘(vi) Such other factors as the Secretary deter-
mines appropriate. 
‘‘(B) DESIGNATION.—Not later than January 1, 2010, 
the Secretary shall designate organizations to accredit sup-
pliers furnishing the technical component of advanced diag-
nostic imaging services. The list of accreditation organiza-
tions so designated may be modified pursuant to subpara-
graph (C). 
‘‘(C) REVIEW AND MODIFICATION OF LIST OF ACCREDITA-
TION ORGANIZATIONS.— 
‘‘(i) IN GENERAL.—The Secretary shall review the 
list of accreditation organizations designated under 
subparagraph (B) taking into account the factors under 
subparagraph (A). Taking into account the results of 
such review, the Secretary may, by regulation, modify 
Deadline. 
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122 STAT. 2534 
PUBLIC LAW 110–275—JULY 15, 2008 
the list of accreditation organizations designated under 
subparagraph (B). 
‘‘(ii) SPECIAL
RULE
FOR
ACCREDITATIONS
DONE 
PRIOR TO REMOVAL FROM LIST OF DESIGNATED ACCREDI-
TATION ORGANIZATIONS.—In the case where the Sec-
retary removes an organization from the list of accredi-
tation organizations designated under subparagraph 
(B), any supplier that is accredited by the organization 
during the period beginning on the date on which 
the organization is designated as an accreditation 
organization under subparagraph (B) and ending on 
the date on which the organization is removed from 
such list shall be considered to have been accredited 
by an organization designated by the Secretary under 
subparagraph (B) for the remaining period such 
accreditation is in effect. 
‘‘(3) CRITERIA
FOR
ACCREDITATION.—The Secretary shall 
establish procedures to ensure that the criteria used by an 
accreditation organization designated under paragraph (2)(B) 
to evaluate a supplier that furnishes the technical component 
of advanced diagnostic imaging services for the purpose of 
accreditation of such supplier is specific to each imaging 
modality. Such criteria shall include— 
‘‘(A) standards for qualifications of medical personnel 
who are not physicians and who furnish the technical 
component of advanced diagnostic imaging services; 
‘‘(B) standards for qualifications and responsibilities 
of medical directors and supervising physicians, including 
standards that recognize the considerations described in 
paragraph (4); 
‘‘(C) procedures to ensure that equipment used in fur-
nishing the technical component of advanced diagnostic 
imaging services meets performance specifications; 
‘‘(D) standards that require the supplier have proce-
dures in place to ensure the safety of persons who furnish 
the technical component of advanced diagnostic imaging 
services and individuals to whom such services are fur-
nished; 
‘‘(E) standards that require the establishment and 
maintenance of a quality assurance and quality control 
program by the supplier that is adequate and appropriate 
to ensure the reliability, clarity, and accuracy of the tech-
nical quality of diagnostic images produced by such sup-
plier; and 
‘‘(F) any other standards or procedures the Secretary 
determines appropriate. 
‘‘(4) RECOGNITION IN STANDARDS FOR THE EVALUATION OF 
MEDICAL DIRECTORS AND SUPERVISING PHYSICIANS.—The stand-
ards described in paragraph (3)(B) shall recognize whether 
a medical director or supervising physician— 
‘‘(A) in a particular specialty receives training in 
advanced diagnostic imaging services in a residency pro-
gram; 
‘‘(B) has attained, through experience, the necessary 
expertise to be a medical director or a supervising physi-
cian; 
Procedures. 
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122 STAT. 2535 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(C) has completed any continuing medical education 
courses relating to such services; or 
‘‘(D) has met such other standards as the Secretary 
determines appropriate. 
‘‘(5) RULE FOR ACCREDITATIONS MADE PRIOR TO DESIGNA-
TION.—In the case of a supplier that is accredited before 
January 1, 2010, by an accreditation organization designated 
by the Secretary under paragraph (2)(B) as of January 1, 2010, 
such supplier shall be considered to have been accredited by 
an organization designated by the Secretary under such para-
graph as of January 1, 2012, for the remaining period such 
accreditation is in effect.’’. 
(2) CONFORMING AMENDMENTS.— 
(A) IN GENERAL.—Section 1862(a) of the Social Security 
Act (42 U.S.C. 1395y(a)) is amended— 
(i) in paragraph (21), by striking ‘‘or’’ at the end; 
(ii) in paragraph (22), by striking the period at 
the end and inserting ‘‘; or’’; and 
(iii) by inserting after paragraph (22) the following 
new paragraph: 
‘‘(23) which are the technical component of advanced diag-
nostic imaging services described in section 1834(e)(1)(B) for 
which payment is made under the fee schedule established 
under section 1848(b) and that are furnished by a supplier 
(as defined in section 1861(d)), if such supplier is not accredited 
by an accreditation organization designated by the Secretary 
under section 1834(e)(2)(B).’’. 
(B) EFFECTIVE DATE.—The amendments made by this 
paragraph shall apply to advanced diagnostic imaging serv-
ices furnished on or after January 1, 2012. 
(b) DEMONSTRATION PROJECT TO ASSESS THE APPROPRIATE USE 
OF IMAGING SERVICES.— 
(1) CONDUCT OF DEMONSTRATION PROJECT.— 
(A) IN GENERAL.—The Secretary of Health and Human 
Services (in this section referred to as the ‘‘Secretary’’) 
shall conduct a demonstration project using the models 
described in paragraph (2)(E) to collect data regarding 
physician compliance with appropriateness criteria selected 
under paragraph (2)(D) in order to determine the appro-
priateness of advanced diagnostic imaging services fur-
nished to Medicare beneficiaries. 
(B) ADVANCED DIAGNOSTIC IMAGING SERVICES.—In this 
subsection, the term ‘‘advanced diagnostic imaging services’’ 
has the meaning given such term in section 1834(e)(1)(B) 
of the Social Security Act, as added by subsection (a). 
(C) AUTHORITY TO FOCUS DEMONSTRATION PROJECT.— 
The Secretary may focus the demonstration project with 
respect to certain advanced diagnostic imaging services, 
such as services that account for a large amount of expendi-
tures under the Medicare program, services that have 
recently experienced a high rate of growth, or services 
for which appropriateness criteria exists. 
(2) IMPLEMENTATION
AND
DESIGN
OF
DEMONSTRATION 
PROJECT.— 
(A) IMPLEMENTATION AND DURATION.— 
42 USC 1395m 
note. 
42 USC 1395y 
note. 
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122 STAT. 2536 
PUBLIC LAW 110–275—JULY 15, 2008 
(i) IMPLEMENTATION.—The Secretary shall imple-
ment the demonstration project under this subsection 
not later than January 1, 2010. 
(ii) DURATION.—The Secretary shall conduct the 
demonstration project under this subsection for a 2- 
year period. 
(B) APPLICATION
AND
SELECTION
OF
PARTICIPATING 
PHYSICIANS.— 
(i) APPLICATION.—Each physician that desires to 
participate in the demonstration project under this 
subsection shall submit an application to the Secretary 
at such time, in such manner, and containing such 
information as the Secretary may require. 
(ii) SELECTION.—The Secretary shall select physi-
cians to participate in the demonstration project under 
this subsection from among physicians submitting 
applications under clause (i). The Secretary shall 
ensure that the physicians selected— 
(I) represent a wide range of geographic areas, 
demographic characteristics (such as urban, rural, 
and suburban), and practice settings (such as pri-
vate and academic practices); and 
(II) have the capability to submit data to the 
Secretary (or an entity under a subcontract with 
the Secretary) in an electronic format in accord-
ance with standards established by the Secretary. 
(C) ADMINISTRATIVE COSTS AND INCENTIVES.—The Sec-
retary shall— 
(i) reimburse physicians for reasonable administra-
tive costs incurred in participating in the demonstra-
tion project under this subsection; and 
(ii) provide reasonable incentives to physicians to 
encourage participation in the demonstration project 
under this subsection. 
(D) USE OF APPROPRIATENESS CRITERIA.— 
(i) IN
GENERAL.—The Secretary, in consultation 
with medical specialty societies and other stakeholders, 
shall select criteria with respect to the clinical appro-
priateness of advanced diagnostic imaging services for 
use in the demonstration project under this subsection. 
(ii) CRITERIA
SELECTED.—Any criteria selected 
under clause (i) shall— 
(I) be developed or endorsed by a medical spe-
cialty society; and 
(II) be developed in adherence to appropriate-
ness principles developed by a consensus organiza-
tion, such as the AQA alliance. 
(E) MODELS FOR COLLECTING DATA REGARDING PHYSI-
CIAN
COMPLIANCE
WITH
SELECTED
CRITERIA.—Subject to 
subparagraph (H), in carrying out the demonstration 
project under this subsection, the Secretary shall use each 
of the following models for collecting data regarding physi-
cian compliance with appropriateness criteria selected 
under subparagraph (D): 
(i) A model described in subparagraph (F). 
(ii) A model described in subparagraph (G). 
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122 STAT. 2537 
PUBLIC LAW 110–275—JULY 15, 2008 
(iii) Any other model that the Secretary determines 
to be useful in evaluating the use of appropriateness 
criteria for advanced diagnostic imaging services. 
(F) POINT
OF
SERVICE
MODEL
DESCRIBED.—A model 
described in this subparagraph is a model that— 
(i) uses an electronic or paper intake form that— 
(I) contains a certification by the physician 
furnishing the imaging service that the data on 
the intake form was confirmed with the Medicare 
beneficiary before the service was furnished; 
(II) contains standardized data elements for 
diagnosis, service ordered, service furnished, and 
such other information determined by the Sec-
retary, in consultation with medical specialty soci-
eties and other stakeholders, to be germane to 
evaluating the effectiveness of the use of appro-
priateness criteria selected under subparagraph 
(D); and 
(III) is accessible to physicians participating 
in the demonstration project under this subsection 
in a format that allows for the electronic submis-
sion of such form; and 
(ii) provides for feedback reports in accordance 
with paragraph (3)(B). 
(G) POINT
OF
ORDER
MODEL
DESCRIBED.—A model 
described in this subparagraph is a model that— 
(i) uses a computerized order-entry system that 
requires 
the 
transmittal 
of 
relevant 
supporting 
information at the time of referral for advanced diag-
nostic imaging services and provides automated deci-
sion-support feedback to the referring physician 
regarding the appropriateness of furnishing such 
imaging services; and 
(ii) provides for feedback reports in accordance 
with paragraph (3)(B). 
(H) LIMITATION.—In no case may the Secretary use 
prior authorization— 
(i) as a model for collecting data regarding physi-
cian compliance with appropriateness criteria selected 
under subparagraph (D) under the demonstration 
project under this subsection; or 
(ii) under any model used for collecting such data 
under the demonstration project. 
(I) REQUIRED
CONTRACTS
AND
PERFORMANCE
STAND-
ARDS FOR CERTAIN ENTITIES.— 
(i) IN GENERAL.—The Secretary shall enter into 
contracts with entities to carry out the model described 
in subparagraph (G). 
(ii) PERFORMANCE
STANDARDS.—The Secretary 
shall establish and enforce performance standards for 
such entities under the contracts entered into under 
clause (i), including performance standards with 
respect to— 
(I) the satisfaction of Medicare beneficiaries 
who are furnished advanced diagnostic imaging 
services by a physician participating in the dem-
onstration project; 
Certification. 
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122 STAT. 2538 
PUBLIC LAW 110–275—JULY 15, 2008 
(II) the satisfaction of physicians participating 
in the demonstration project; 
(III) if applicable, timelines for the provision 
of feedback reports under paragraph (3)(B); and 
(IV) any other areas determined appropriate 
by the Secretary. 
(3) COMPARISON OF UTILIZATION OF ADVANCED DIAGNOSTIC 
IMAGING SERVICES AND FEEDBACK REPORTS.— 
(A) COMPARISON OF UTILIZATION OF ADVANCED DIAG-
NOSTIC
IMAGING
SERVICES.—The Secretary shall consult 
with medical specialty societies and other stakeholders to 
develop mechanisms for comparing the utilization of 
advanced diagnostic imaging services by physicians partici-
pating in the demonstration project under this subsection 
against— 
(i) the appropriateness criteria selected under 
paragraph (2)(D); and 
(ii) to the extent feasible, the utilization of such 
services by physicians not participating in the dem-
onstration project. 
(B) FEEDBACK REPORTS.—The Secretary shall, in con-
sultation with medical specialty societies and other stake-
holders, develop mechanisms to provide feedback reports 
to physicians participating in the demonstration project 
under this subsection. Such feedback reports shall 
include— 
(i) a profile of the rate of compliance by the physi-
cian with appropriateness criteria selected under para-
graph (2)(D), including a comparison of— 
(I) the rate of compliance by the physician 
with such criteria; and 
(II) the rate of compliance by the physician’s 
peers (as defined by the Secretary) with such cri-
teria; and 
(ii) to the extent feasible, a comparison of— 
(I) the rate of utilization of advanced diag-
nostic imaging services by the physician; and 
(II) the rate of utilization of such services by 
the physician’s peers (as defined by the Secretary) 
who are not participating in the demonstration 
project. 
(4) CONDUCT OF DEMONSTRATION PROJECT AND WAIVER.— 
(A) CONDUCT OF DEMONSTRATION PROJECT.—Chapter 
35 of title 44, United States Code, shall not apply to the 
conduct of the demonstration project under this subsection. 
(B) WAIVER.—The Secretary may waive such provisions 
of titles XI and XVIII of the Social Security Act (42 U.S.C. 
1301 et seq.; 1395 et seq.) as may be necessary to carry 
out the demonstration project under this subsection. 
(5) EVALUATION AND REPORT.— 
(A) EVALUATION.—The Secretary shall evaluate the 
demonstration project under this subsection to— 
(i) assess the timeliness and efficacy of the dem-
onstration project; 
(ii) assess the performance of entities under a con-
tract entered into under paragraph (2)(I)(i); 
(iii) analyze data— 
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122 STAT. 2539 
PUBLIC LAW 110–275—JULY 15, 2008 
(I) on the rates of appropriate, uncertain, and 
inappropriate advanced diagnostic imaging serv-
ices furnished by physicians participating in the 
demonstration project; 
(II) on patterns and trends in the appropriate-
ness and inappropriateness of such services fur-
nished by such physicians; 
(III) on patterns and trends in national and 
regional variations of care with respect to the fur-
nishing of such services; and 
(IV) on the correlation between the appro-
priateness of the services furnished and image 
results; and 
(iv) address— 
(I) the thresholds used under the demonstra-
tion project to identify acceptable and outlier levels 
of performance with respect to the appropriateness 
of advanced diagnostic imaging services furnished; 
(II) whether prospective use of appropriateness 
criteria could have an effect on the volume of such 
services furnished; 
(III) whether expansion of the use of appro-
priateness criteria with respect to such services 
to a broader population of Medicare beneficiaries 
would be advisable; 
(IV) whether, under such an expansion, physi-
cians who demonstrate consistent compliance with 
such appropriateness criteria should be exempted 
from certain requirements; 
(V) the use of incident-specific versus practice- 
specific outlier information in formulating future 
recommendations with respect to the use of appro-
priateness criteria for such services under the 
Medicare program; and 
(VI) the potential for using methods (including 
financial incentives), in addition to those used 
under the models under the demonstration project, 
to ensure compliance with such criteria. 
(B) REPORT.—Not later than 1 year after the comple-
tion of the demonstration project under this subsection, 
the Secretary shall submit to Congress a report containing 
the results of the evaluation of the demonstration project 
conducted under subparagraph (A), together with rec-
ommendations for such legislation and administrative 
action as the Secretary determines appropriate. 
(6) FUNDING.—The Secretary shall provide for the transfer 
from the Federal Supplementary Medical Insurance Trust Fund 
established under section 1841 of the Social Security Act (42 
U.S.C. 1395t) of $10,000,000, for carrying out the demonstration 
project under this subsection (including costs associated with 
administering the demonstration project, reimbursing physi-
cians for administrative costs and providing incentives to 
encourage participation under paragraph (2)(C), entering into 
contracts under paragraph (2)(I), and evaluating the demonstra-
tion project under paragraph (5)). 
(c) GAO STUDY AND REPORTS ON ACCREDITATION REQUIREMENT 
FOR ADVANCED DIAGNOSTIC IMAGING SERVICES.— 
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122 STAT. 2540 
PUBLIC LAW 110–275—JULY 15, 2008 
(1) STUDY.— 
(A) IN
GENERAL.—The Comptroller General of the 
United States (in this subsection referred to as the ‘‘Comp-
troller General’’) shall conduct a study, by imaging 
modality, on— 
(i) the effect of the accreditation requirement under 
section 1834(e) of the Social Security Act, as added 
by subsection (a); and 
(ii) any other relevant questions involving access 
to, and the value of, advanced diagnostic imaging serv-
ices for Medicare beneficiaries. 
(B) ISSUES.—The study conducted under subparagraph 
(A) shall examine the following: 
(i) The impact of such accreditation requirement 
on the number, type, and quality of imaging services 
furnished to Medicare beneficiaries. 
(ii) The cost of such accreditation requirement, 
including costs to facilities of compliance with such 
requirement and costs to the Secretary of admin-
istering such requirement. 
(iii) Access to imaging services by Medicare bene-
ficiaries, especially in rural areas, before and after 
implementation of such accreditation requirement. 
(iv) Such other issues as the Secretary determines 
appropriate. 
(2) REPORTS.— 
(A) PRELIMINARY REPORT.—Not later than March 1, 
2013, the Comptroller General shall submit a preliminary 
report to Congress on the study conducted under paragraph 
(1). 
(B) FINAL
REPORT.—Not later than March 1, 2014, 
the Comptroller General shall submit a final report to 
Congress on the study conducted under paragraph (1), 
together with recommendations for such legislation and 
administrative action as the Comptroller General deter-
mines appropriate. 
SEC. 136. EXTENSION OF TREATMENT OF CERTAIN PHYSICIAN 
PATHOLOGY SERVICES UNDER MEDICARE. 
Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits 
Improvement and Protection Act of 2000 (as enacted into law by 
section 1(a)(6) of Public Law 106–554), as amended by section 
732 of the Medicare Prescription Drug, Improvement, and Mod-
ernization Act of 2003 (42 U.S.C. 1395w–4 note), section 104 of 
division B of the Tax Relief and Health Care Act of 2006 (42 
U.S.C. 1395w–4 note), and section 104 of the Medicare, Medicaid, 
and SCHIP Extension Act of 2007 (Public Law 110–173), is amended 
by striking ‘‘2007, and the first 6 months of 2008’’ and inserting 
‘‘2007, 2008, and 2009’’. 
SEC. 137. ACCOMMODATION OF PHYSICIANS ORDERED TO ACTIVE 
DUTY IN THE ARMED SERVICES. 
Section 1842(b)(6)(D)(iii) of the Social Security Act (42 U.S.C. 
1395u(b)(6)(D)(iii)), as amended by section 116 of the Medicare, 
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110– 
173), is amended by striking ‘‘(before July 1, 2008)’’. 
42 USC 1395w–4 
note. 
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122 STAT. 2541 
PUBLIC LAW 110–275—JULY 15, 2008 
SEC. 138. ADJUSTMENT FOR MEDICARE MENTAL HEALTH SERVICES. 
(a) PAYMENT ADJUSTMENT.— 
(1) IN
GENERAL.—For purposes of payment for services 
furnished under the physician fee schedule under section 1848 
of the Social Security Act (42 U.S.C. 1395w–4) during the 
period beginning on July 1, 2008, and ending on December 
31, 2009, the Secretary of Health and Human Services shall 
increase the fee schedule otherwise applicable for specified 
services by 5 percent. 
(2) NONAPPLICATION OF BUDGET-NEUTRALITY.—The budget- 
neutrality provision of section 1848(c)(2)(B)(ii) of the Social 
Security Act (42 U.S.C. 1395w–4(c)(2)(B)(ii)) shall not apply 
to the adjustments described in paragraph (1). 
(b) DEFINITION OF SPECIFIED SERVICES.—In this section, the 
term ‘‘specified services’’ means procedure codes for services in 
the categories of the Health Care Common Procedure Coding 
System, established by the Secretary of Health and Human Services 
under section 1848(c)(5) of the Social Security Act (42 U.S.C. 1395w– 
4(c)(5)), as of July 1, 2007, and as subsequently modified by the 
Secretary, consisting of psychiatric therapeutic procedures furnished 
in office or other outpatient facility settings or in inpatient hospital, 
partial hospital, or residential care facility settings, but only with 
respect to such services in such categories that are in the subcat-
egories of services which are— 
(1) insight oriented, behavior modifying, or supportive 
psychotherapy; or 
(2) interactive psychotherapy. 
(c) IMPLEMENTATION.—Notwithstanding any other provision of 
law, the Secretary may implement this section by program instruc-
tion or otherwise. 
SEC. 139. IMPROVEMENTS FOR MEDICARE ANESTHESIA TEACHING 
PROGRAMS. 
(a) SPECIAL
PAYMENT
RULE
FOR
TEACHING
ANESTHESIOL-
OGISTS.—Section 1848(a) of the Social Security Act (42 U.S.C. 
1395w–4(a)), as amended by section 132(b), is amended— 
(1) in paragraph (4)(A), by inserting ‘‘except as provided 
in paragraph (5),’’ after ‘‘anesthesia cases,’’; and 
(2) by adding at the end the following new paragraph: 
‘‘(6) SPECIAL
RULE
FOR
TEACHING
ANESTHESIOLOGISTS.— 
With respect to physicians’ services furnished on or after 
January 1, 2010, in the case of teaching anesthesiologists 
involved in the training of physician residents in a single anes-
thesia case or two concurrent anesthesia cases, the fee schedule 
amount to be applied shall be 100 percent of the fee schedule 
amount otherwise applicable under this section if the anes-
thesia services were personally performed by the teaching 
anesthesiologist alone and paragraph (4) shall not apply if— 
‘‘(A) the teaching anesthesiologist is present during 
all critical or key portions of the anesthesia service or 
procedure involved; and 
‘‘(B) the teaching anesthesiologist (or another anesthe-
siologist with whom the teaching anesthesiologist has 
entered into an arrangement) is immediately available to 
furnish anesthesia services during the entire procedure.’’. 
(b) TREATMENT
OF
CERTIFIED
REGISTERED
NURSE
ANES-
THETISTS.—With respect to items and services furnished on or after 
Effective date. 
42 USC 1395l. 
Effective date. 
42 USC 1395w–4. 
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122 STAT. 2542 
PUBLIC LAW 110–275—JULY 15, 2008 
January 1, 2010, the Secretary of Health and Human Services 
shall make appropriate adjustments to payments under the Medi-
care program under title XVIII of the Social Security Act for 
teaching certified registered nurse anesthetists to implement a 
policy with respect to teaching certified registered nurse anes-
thetists that— 
(1) is consistent with the adjustments made by the special 
rule for teaching anesthesiologists under section 1848(a)(6) of 
the Social Security Act, as added by subsection (a); and 
(2) maintains the existing payment differences between 
teaching anesthesiologists and teaching certified registered 
nurse anesthetists. 
PART II—OTHER PAYMENT AND COVERAGE 
IMPROVEMENTS 
SEC. 141. EXTENSION OF EXCEPTIONS PROCESS FOR MEDICARE 
THERAPY CAPS. 
Section 1833(g)(5) of the Social Security Act (42 U.S.C. 
1395l(g)(5)), as amended by section 105 of the Medicare, Medicaid, 
and SCHIP Extension Act of 2007 (Public Law 110–173), is amended 
by striking ‘‘June 30, 2008’’ and inserting ‘‘December 31, 2009’’. 
SEC. 142. EXTENSION OF PAYMENT RULE FOR BRACHYTHERAPY AND 
THERAPEUTIC RADIOPHARMACEUTICALS. 
Section 1833(t)(16)(C) of the Social Security Act (42 U.S.C. 
1395l(t)(16)(C)), as amended by section 106 of the Medicare, Med-
icaid, and SCHIP Extension Act of 2007 (Public Law 110–173), 
is amended by striking ‘‘July 1, 2008’’ each place it appears and 
inserting ‘‘January 1, 2010’’. 
SEC. 143. SPEECH-LANGUAGE PATHOLOGY SERVICES. 
(a) IN GENERAL.—Section 1861(ll) of the Social Security Act 
(42 U.S.C. 1395x(ll)) is amended— 
(1) by redesignating paragraphs (2) and (3) as paragraphs 
(3) and (4), respectively; and 
(2) by inserting after paragraph (1) the following new para-
graph: 
‘‘(2) The term ‘outpatient speech-language pathology services’ 
has the meaning given the term ‘outpatient physical therapy serv-
ices’ in subsection (p), except that in applying such subsection— 
‘‘(A) ‘speech-language pathology’ shall be substituted for 
‘physical therapy’ each place it appears; and 
‘‘(B) ‘speech-language pathologist’ shall be substituted for 
‘physical therapist’ each place it appears.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) Section 1832(a)(2)(C) of the Social Security Act (42 
U.S.C. 1395k(a)(2)(C)) is amended— 
(A) by striking ‘‘and outpatient’’ and inserting ‘‘, out-
patient’’; and 
(B) by inserting before the semicolon at the end the 
following: ‘‘, and outpatient speech-language pathology 
services (other than services to which the second sentence 
of section 1861(p) applies through the application of section 
1861(ll)(2))’’. 
(2) Subparagraphs (A) and (B) of section 1833(a)(8) of the 
Social Security Act (42 U.S.C. 1395l(a)(8)) are each amended 
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122 STAT. 2543 
PUBLIC LAW 110–275—JULY 15, 2008 
by striking ‘‘(which includes outpatient speech-language 
pathology services)’’ and inserting ‘‘, outpatient speech-language 
pathology services,’’. 
(3) Section 1833(g)(1) of the Social Security Act (42 U.S.C. 
1395l(g)(1)) is amended— 
(A) by inserting ‘‘and speech-language pathology serv-
ices of the type described in such section through the 
application of section 1861(ll)(2)’’ after ‘‘1861(p)’’; and 
(B) by inserting ‘‘and speech-language pathology serv-
ices’’ after ‘‘and physical therapy services’’. 
(4) The second sentence of section 1835(a) of the Social 
Security Act (42 U.S.C. 1395n(a)) is amended— 
(A) by striking ‘‘section 1861(g)’’ and inserting ‘‘sub-
section (g) or (ll)(2) of section 1861’’ each place it appears; 
and 
(B) by inserting ‘‘or outpatient speech-language 
pathology 
services, 
respectively’’ 
after 
‘‘occupational 
therapy services’’. 
(5) Section 1861(p) of the Social Security Act (42 U.S.C. 
1395x(p)) is amended by striking the fourth sentence. 
(6) Section 1861(s)(2)(D) of the Social Security Act (42 
U.S.C. 1395x(s)(2)(D)) is amended by inserting ‘‘, outpatient 
speech-language pathology services,’’ after ‘‘physical therapy 
services’’. 
(7) Section 1862(a)(20) of the Social Security Act (42 U.S.C. 
1395y(a)(20)) is amended— 
(A) by striking ‘‘outpatient occupational therapy serv-
ices or outpatient physical therapy services’’ and inserting 
‘‘outpatient physical therapy services, outpatient speech- 
language pathology services, or outpatient occupational 
therapy services’’; and 
(B) by striking ‘‘section 1861(g)’’ and inserting ‘‘sub-
section (g) or (ll)(2) of section 1861’’. 
(8) Section 1866(e)(1) of the Social Security Act (42 U.S.C. 
1395cc(e)(1)) is amended— 
(A) by striking ‘‘section 1861(g)’’ and inserting ‘‘sub-
section (g) or (ll)(2) of section 1861’’ the first two places 
it appears; 
(B) by striking ‘‘defined) or’’ and inserting ‘‘defined),’’; 
and 
(C) by inserting before the semicolon at the end the 
following: ‘‘, or (through the operation of section 1861(ll)(2)) 
with respect to the furnishing of outpatient speech-lan-
guage pathology’’. 
(9) Section 1877(h)(6) of the Social Security Act (42 U.S.C. 
1395nn(h)(6)) is amended by adding at the end the following 
new subparagraph: 
‘‘(L) Outpatient speech-language pathology services.’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply to services furnished on or after July 1, 2009. 
(d) CONSTRUCTION.—Nothing in this section shall be construed 
to affect existing regulations and policies of the Centers for Medicare 
& Medicaid Services that require physician oversight of care as 
a condition of payment for speech-language pathology services under 
part B of the Medicare program. 
42 USC 1395k 
note. 
42 USC 1395k 
note. 
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122 STAT. 2544 
PUBLIC LAW 110–275—JULY 15, 2008 
SEC. 144. PAYMENT AND COVERAGE IMPROVEMENTS FOR PATIENTS 
WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND 
OTHER CONDITIONS. 
(a) COVERAGE OF PULMONARY AND CARDIAC REHABILITATION.— 
(1) IN GENERAL.—Section 1861 of the Social Security Act 
(42 U.S.C. 1395x), as amended by section 101(a), is amended— 
(A) in subsection (s)(2)— 
(i) in subparagraph (AA), by striking ‘‘and’’ at the 
end; 
(ii) by adding at the end the following new sub-
paragraphs: 
‘‘(CC) items and services furnished under a cardiac 
rehabilitation program (as defined in subsection (eee)(1)) 
or under a pulmonary rehabilitation program (as defined 
in subsection (fff)(1)); and 
‘‘(DD) items and services furnished under an intensive 
cardiac rehabilitation program (as defined in subsection 
(eee)(4));’’; and 
(B) by adding at the end the following new subsections: 
‘‘Cardiac Rehabilitation Program; Intensive Cardiac Rehabilitation 
Program 
‘‘(eee)(1) The term ‘cardiac rehabilitation program’ means a 
physician-supervised program (as described in paragraph (2)) that 
furnishes the items and services described in paragraph (3). 
‘‘(2) A program described in this paragraph is a program under 
which— 
‘‘(A) items and services under the program are delivered— 
‘‘(i) in a physician’s office; 
‘‘(ii) in a hospital on an outpatient basis; or 
‘‘(iii) in other settings determined appropriate by the 
Secretary. 
‘‘(B) a physician is immediately available and accessible 
for medical consultation and medical emergencies at all times 
items and services are being furnished under the program, 
except that, in the case of items and services furnished under 
such a program in a hospital, such availability shall be pre-
sumed; and 
‘‘(C) individualized treatment is furnished under a written 
plan established, reviewed, and signed by a physician every 
30 days that describes— 
‘‘(i) the individual’s diagnosis; 
‘‘(ii) the type, amount, frequency, and duration of the 
items and services furnished under the plan; and 
‘‘(iii) the goals set for the individual under the plan. 
‘‘(3) The items and services described in this paragraph are— 
‘‘(A) physician-prescribed exercise; 
‘‘(B) cardiac risk factor modification, including education, 
counseling, and behavioral intervention (to the extent such 
education, counseling, and behavioral intervention is closely 
related to the individual’s care and treatment and is tailored 
to the individual’s needs); 
‘‘(C) psychosocial assessment; 
‘‘(D) outcomes assessment; and 
‘‘(E) such other items and services as the Secretary may 
determine, but only if such items and services are— 
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122 STAT. 2545 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(i) reasonable and necessary for the diagnosis or active 
treatment of the individual’s condition; 
‘‘(ii) reasonably expected to improve or maintain the 
individual’s condition and functional level; and 
‘‘(iii) furnished under such guidelines relating to the 
frequency and duration of such items and services as the 
Secretary shall establish, taking into account accepted 
norms of medical practice and the reasonable expectation 
of improvement of the individual. 
‘‘(4)(A) The term ‘intensive cardiac rehabilitation program’ 
means a physician-supervised program (as described in paragraph 
(2)) that furnishes the items and services described in paragraph 
(3) and has shown, in peer-reviewed published research, that it 
accomplished— 
‘‘(i) one or more of the following: 
‘‘(I) positively affected the progression of coronary heart 
disease; or 
‘‘(II) reduced the need for coronary bypass surgery; 
or 
‘‘(III) reduced the need for percutaneous coronary inter-
ventions; and 
‘‘(ii) a statistically significant reduction in 5 or more of 
the following measures from their level before receipt of cardiac 
rehabilitation services to their level after receipt of such serv-
ices: 
‘‘(I) low density lipoprotein; 
‘‘(II) triglycerides; 
‘‘(III) body mass index; 
‘‘(IV) systolic blood pressure; 
‘‘(V) diastolic blood pressure; or 
‘‘(VI) the need for cholesterol, blood pressure, and 
diabetes medications. 
‘‘(B) To be eligible for an intensive cardiac rehabilitation pro-
gram, an individual must have— 
‘‘(i) had an acute myocardial infarction within the preceding 
12 months; 
‘‘(ii) had coronary bypass surgery; 
‘‘(iii) stable angina pectoris; 
‘‘(iv) had heart valve repair or replacement; 
‘‘(v) had percutaneous transluminal coronary angioplasty 
(PTCA) or coronary stenting; or 
‘‘(vi) had a heart or heart-lung transplant. 
‘‘(C) An intensive cardiac rehabilitation program may be pro-
vided in a series of 72 one-hour sessions (as defined in section 
1848(b)(5)), up to 6 sessions per day, over a period of up to 18 
weeks. 
‘‘(5) The Secretary shall establish standards to ensure that 
a physician with expertise in the management of individuals with 
cardiac pathophysiology who is licensed to practice medicine in 
the State in which a cardiac rehabilitation program (or the intensive 
cardiac rehabilitation program, as the case may be) is offered— 
‘‘(A) is responsible for such program; and 
‘‘(B) in consultation with appropriate staff, is involved 
substantially in directing the progress of individual in the 
program. 
Standards. 
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122 STAT. 2546 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘Pulmonary Rehabilitation Program 
‘‘(fff)(1) The term ‘pulmonary rehabilitation program’ means 
a physician-supervised program (as described in subsection (eee)(2) 
with respect to a program under this subsection) that furnishes 
the items and services described in paragraph (2). 
‘‘(2) The items and services described in this paragraph are— 
‘‘(A) physician-prescribed exercise; 
‘‘(B) education or training (to the extent the education 
or training is closely and clearly related to the individual’s 
care and treatment and is tailored to such individual’s needs); 
‘‘(C) psychosocial assessment; 
‘‘(D) outcomes assessment; and 
‘‘(E) such other items and services as the Secretary may 
determine, but only if such items and services are— 
‘‘(i) reasonable and necessary for the diagnosis or active 
treatment of the individual’s condition; 
‘‘(ii) reasonably expected to improve or maintain the 
individual’s condition and functional level; and 
‘‘(iii) furnished under such guidelines relating to the 
frequency and duration of such items and services as the 
Secretary shall establish, taking into account accepted 
norms of medical practice and the reasonable expectation 
of improvement of the individual. 
‘‘(3) The Secretary shall establish standards to ensure that 
a physician with expertise in the management of individuals with 
respiratory pathophysiology who is licensed to practice medicine 
in the State in which a pulmonary rehabilitation program is 
offered— 
‘‘(A) is responsible for such program; and 
‘‘(B) in consultation with appropriate staff, is involved 
substantially in directing the progress of individual in the 
program.’’. 
(2) PAYMENT FOR INTENSIVE CARDIAC REHABILITATION PRO-
GRAMS.— 
(A) INCLUSION IN PHYSICIAN FEE SCHEDULE.—Section 
1848(j)(3) of the Social Security Act (42 U.S.C. 1395w– 
4(j)(3)) is amended by inserting ‘‘(2)(DD),’’ after ‘‘(2)(AA),’’. 
(B) CONFORMING AMENDMENT.—Section 1848(b) of the 
Social Security Act (42 U.S.C. 1395w–4(b)) is amended 
by adding at the end the following new paragraph: 
‘‘(5) TREATMENT
OF
INTENSIVE
CARDIAC
REHABILITATION 
PROGRAM.— 
‘‘(A) IN GENERAL.—In the case of an intensive cardiac 
rehabilitation program described in section 1861(eee)(4), 
the Secretary shall substitute the Medicare OPD fee 
schedule amount established under the prospective pay-
ment system for hospital outpatient department service 
under paragraph (3)(D) of section 1833(t) for cardiac 
rehabilitation (under HCPCS codes 93797 and 93798 for 
calendar year 2007, or any succeeding HCPCS codes for 
cardiac rehabilitation). 
‘‘(B) DEFINITION
OF
SESSION.—Each of the services 
described in subparagraphs (A) through (E) of section 
1861(eee)(3), when furnished for one hour, is a separate 
session of intensive cardiac rehabilitation. 
Standards. 
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122 STAT. 2547 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(C) MULTIPLE SESSIONS PER DAY.—Payment may be 
made for up to 6 sessions per day of the series of 72 
one-hour sessions of intensive cardiac rehabilitation serv-
ices described in section 1861(eee)(4)(B).’’. 
(3) EFFECTIVE DATE.—The amendments made by this sub-
section shall apply to items and services furnished on or after 
January 1, 2010. 
(b) REPEAL OF TRANSFER OF OWNERSHIP OF OXYGEN EQUIP-
MENT.— 
(1) IN GENERAL.—Section 1834(a)(5)(F) of the Social Secu-
rity Act (42 U.S.C. 1395m(a)(5)(F)) is amended— 
(A) in the heading, by striking ‘‘OWNERSHIP OF 
EQUIPMENT’’ and inserting ‘‘RENTAL CAP’’; and 
(B) by striking clause (ii) and inserting the following: 
‘‘(ii) PAYMENTS AND RULES AFTER RENTAL CAP.— 
After the 36th continuous month during which pay-
ment is made for the equipment under this para-
graph— 
‘‘(I) the supplier furnishing such equipment 
under this subsection shall continue to furnish 
the equipment during any period of medical need 
for the remainder of the reasonable useful lifetime 
of the equipment, as determined by the Secretary; 
‘‘(II) payments for oxygen shall continue to 
be made in the amount recognized for oxygen 
under paragraph (9) for the period of medical need; 
and 
‘‘(III) maintenance and servicing payments 
shall, if the Secretary determines such payments 
are reasonable and necessary, be made (for parts 
and labor not covered by the supplier’s or manufac-
turer’s warranty, as determined by the Secretary 
to be appropriate for the equipment), and such 
payments shall be in an amount determined to 
be appropriate by the Secretary.’’. 
(2) EFFECTIVE DATE.—The amendments made by paragraph 
(1) shall take effect on January 1, 2009. 
SEC. 145. CLINICAL LABORATORY TESTS. 
(a) REPEAL OF MEDICARE COMPETITIVE BIDDING DEMONSTRA-
TION PROJECT FOR CLINICAL LABORATORY SERVICES.— 
(1) IN GENERAL.—Section 1847 of the Social Security Act 
(42 U.S.C. 1395w–3) is amended by striking subsection (e). 
(2) CONFORMING
AMENDMENTS.—Section 1833(a)(1)(D) of 
the Social Security Act (42 U.S.C. 1395l(a)(1)(D)) is amended— 
(A) by inserting ‘‘or’’ before ‘‘(ii)’’; and 
(B) by striking ‘‘or (iii) on the basis’’ and all that 
follows before the comma at the end. 
(3) EFFECTIVE DATE.—The amendments made by this sub-
section shall take effect on the date of the enactment of this 
Act. 
(b) CLINICAL LABORATORY TEST FEE SCHEDULE UPDATE ADJUST-
MENT.—Section 1833(h)(2)(A)(i) of the Social Security Act (42 U.S.C. 
1395l(h)(2)(A)(ii)) is amended by inserting ‘‘minus, for each of the 
years 2009 through 2013, 0.5 percentage points’’ after ‘‘city aver-
age)’’. 
42 USC 1395l. 
42 USC 1395m 
note. 
42 USC 1395w–4 
note. 
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122 STAT. 2548 
PUBLIC LAW 110–275—JULY 15, 2008 
SEC. 146. IMPROVED ACCESS TO AMBULANCE SERVICES. 
(a) EXTENSION OF INCREASED MEDICARE PAYMENTS FOR GROUND 
AMBULANCE SERVICES.—Section 1834(l)(13) of the Social Security 
Act (42 U.S.C. 1395m(l)(13)) is amended— 
(1) in subparagraph (A)— 
(A) in the matter preceding clause (i), by inserting 
‘‘and for such services furnished on or after July 1, 2008, 
and before January 1, 2010’’ after ‘‘2007,’’; 
(B) in clause (i), by inserting ‘‘(or 3 percent if such 
service is furnished on or after July 1, 2008, and before 
January 1, 2010)’’ after ‘‘2 percent’’; and 
(C) in clause (ii), by inserting ‘‘(or 2 percent if such 
service is furnished on or after July 1, 2008, and before 
January 1, 2010)’’ after ‘‘1 percent’’; and 
(2) in subparagraph (B)— 
(A) in the heading, by striking ‘‘2006’’ and inserting 
‘‘APPLICABLE PERIOD’’; and 
(B) by inserting ‘‘applicable’’ before ‘‘period’’. 
(b) AIR AMBULANCE PAYMENT IMPROVEMENTS.— 
(1) TREATMENT OF CERTAIN AREAS FOR PAYMENT FOR AIR 
AMBULANCE SERVICES UNDER THE AMBULANCE FEE SCHEDULE.— 
Notwithstanding any other provision of law, for purposes of 
making payments under section 1834(l) of the Social Security 
Act (42 U.S.C. 1395m(l)) for air ambulance services furnished 
during the period beginning on July 1, 2008, and ending on 
December 31, 2009, any area that was designated as a rural 
area for purposes of making payments under such section for 
air ambulance services furnished on December 31, 2006, shall 
be treated as a rural area for purposes of making payments 
under such section for air ambulance services furnished during 
such period. 
(2) CLARIFICATION REGARDING SATISFACTION OF REQUIRE-
MENT OF MEDICALLY NECESSARY.— 
(A) IN GENERAL.—Section 1834(l)(14)(B)(i) of the Social 
Security Act (42 U.S.C. 1395m(l)(14)(B)(i)) is amended by 
striking ‘‘reasonably determines or certifies’’ and inserting 
‘‘certifies or reasonably determines’’. 
(B) EFFECTIVE
DATE.—The amendment made by 
subparagraph (A) shall apply to services furnished on or 
after the date of the enactment of this Act. 
SEC. 147. EXTENSION AND EXPANSION OF THE MEDICARE HOLD HARM-
LESS PROVISION UNDER THE PROSPECTIVE PAYMENT 
SYSTEM 
FOR 
HOSPITAL 
OUTPATIENT 
DEPARTMENT 
(HOPD) SERVICES FOR CERTAIN HOSPITALS. 
Section 1833(t)(7)(D)(i) of the Social Security Act (42 U.S.C. 
1395l(t)(7)(D)(i)) is amended— 
(1) in subclause (II)— 
(A) in the first sentence, by striking ‘‘2009’’ and 
inserting ‘‘2010’’; and 
(B) by striking the second sentence and inserting the 
following new sentence: ‘‘For purposes of the preceding 
sentence, the applicable percentage shall be 95 percent 
with respect to covered OPD services furnished in 2006, 
90 percent with respect to such services furnished in 2007, 
and 85 percent with respect to such services furnished 
in 2008 or 2009.’’; and 
42 USC 1395m 
note. 
Time period. 
42 USC 1395m 
note. 
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122 STAT. 2549 
PUBLIC LAW 110–275—JULY 15, 2008 
(2) by adding at the end the following new subclause: 
‘‘(III) In the case of a sole community hospital 
(as defined in section 1886(d)(5)(D)(iii)) that has not 
more than 100 beds, for covered OPD services fur-
nished on or after January 1, 2009, and before January 
1, 2010, for which the PPS amount is less than the 
pre-BBA amount, the amount of payment under this 
subsection shall be increased by 85 percent of the 
amount of such difference.’’. 
SEC. 148. CLARIFICATION OF PAYMENT FOR CLINICAL LABORATORY 
TESTS FURNISHED BY CRITICAL ACCESS HOSPITALS. 
(a) IN GENERAL.—Section 1834(g)(4) of the Social Security Act 
(42 U.S.C. 1395m(g)(4)) is amended— 
(1) in the heading, by striking ‘‘NO
BENEFICIARY
COST- 
SHARING FOR’’ and inserting ‘‘TREATMENT OF’’; and 
(2) by adding at the end the following new sentence: ‘‘For 
purposes of the preceding sentence and section 1861(mm)(3), 
clinical diagnostic laboratory services furnished by a critical 
access hospital shall be treated as being furnished as part 
of outpatient critical access services without regard to whether 
the individual with respect to whom such services are furnished 
is physically present in the critical access hospital, or in a 
skilled nursing facility or a clinic (including a rural health 
clinic) that is operated by a critical access hospital, at the 
time the specimen is collected.’’. 
(b) EFFECTIVE DATE.—The amendments made by subsection 
(a) shall apply to services furnished on or after July 1, 2009. 
SEC. 149. ADDING CERTAIN ENTITIES AS ORIGINATING SITES FOR PAY-
MENT OF TELEHEALTH SERVICES. 
(a) IN GENERAL.—Section 1834(m)(4)(C)(ii) of the Social Security 
Act (42 U.S.C. 1395m(m)(4)(C)(ii)) is amended by adding at the 
end the following new subclauses: 
‘‘(VI) A hospital-based or critical access hos-
pital-based renal dialysis center (including sat-
ellites). 
‘‘(VII) A skilled nursing facility (as defined 
in section 1819(a)). 
‘‘(VIII) A community mental health center (as 
defined in section 1861(ff)(3)(B)).’’. 
(b) CONFORMING AMENDMENT.—Section 1888(e)(2)(A)(ii) of the 
Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by 
inserting 
‘‘telehealth 
services 
furnished 
under 
section 
1834(m)(4)(C)(ii)(VII),’’ after ‘‘section 1861(s)(2),’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply to services furnished on or after January 1, 2009. 
SEC. 150. MEDPAC STUDY AND REPORT ON IMPROVING CHRONIC CARE 
DEMONSTRATION PROGRAMS. 
(a) STUDY.—The Medicare Payment Advisory Commission (in 
this section referred to as the ‘‘Commission’’) shall conduct a study 
on the feasability and advisability of establishing a Medicare 
Chronic Care Practice Research Network that would serve as a 
standing network of providers testing new models of care coordina-
tion and other care approaches for chronically ill beneficiaries, 
including the initiation, operation, evaluation, and, if appropriate, 
42 USC 1395m 
note. 
42 USC 1395m 
note. 
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122 STAT. 2550 
PUBLIC LAW 110–275—JULY 15, 2008 
expansion of such models to the broader Medicare patient popu-
lation. In conducting such study, the Commission shall take into 
account the structure, implementation, and results of prior and 
existing care coordination and disease management demonstrations 
and pilots, including the Medicare Coordinated Care Demonstration 
Project under section 4016 of the Balanced Budget Act of 1997 
(42 U.S.C. 1395b–1 note) and the chronic care improvement pro-
grams under section 1807 of the Social Security Act (42 U.S.C. 
1395b–8), commonly known to as ‘‘Medicare Health Support’’. 
(b) REPORT.—Not later than June 15, 2009, the Commission 
shall submit to Congress a report containing the results of the 
study conducted under subsection (a). 
SEC. 151. INCREASE OF FQHC PAYMENT LIMITS. 
(a) IN GENERAL.—Section 1833 of the Social Security Act (42 
U.S.C. 1395l) is amended by adding at the end the following new 
subsection: 
‘‘(v) INCREASE OF FQHC PAYMENT LIMITS.—In the case of serv-
ices furnished by Federally qualified health centers (as defined 
in section 1861(aa)(4)), the Secretary shall establish payment limits 
with respect to such services under this part for services furnished— 
‘‘(1) in 2010, at the limits otherwise established under 
this part for such year increased by $5; and 
‘‘(2) in a subsequent year, at the limits established under 
this subsection for the previous year increased by the percent-
age increase in the MEI (as defined in section 1842(i)(3)) for 
such subsequent year.’’. 
(b) STUDY AND REPORT ON THE EFFECTS AND ADEQUACY OF 
THE MEDICARE FEDERALLY QUALIFIED HEALTH CENTER PAYMENT 
STRUCTURE.— 
(1) STUDY.—The Comptroller General of the United States 
shall conduct a study to determine whether the structure for 
payments for services furnished by Federally qualified health 
centers (as defined in section 1861(aa)(4) of the Social Security 
Act (42 U.S.C. 1395x(aa)(4)) under part B of title XVIII of 
the Social Security Act (42 U.S.C. 1395j et seq.) adequately 
reimburses Federally qualified health centers for the care fur-
nished to Medicare beneficiaries. In conducting such study, 
the Comptroller General shall— 
(A) use the most current cost report data available; 
(B) examine the effects of the payment limits estab-
lished with respect to such services under such part B 
on the ability of Federally qualified health centers to fur-
nish care to Medicare beneficiaries; and 
(C) examine the cost of furnishing services covered 
under the Medicare program as of the date of the enactment 
of this Act that were not covered under such program 
as of the date on which the Secretary determined the 
payment rate for Federally qualified health centers in 1991. 
(2) REPORT.—Not later than 15 months after the date of 
the enactment of this Act, the Comptroller General of the 
United States shall submit to Congress a report on the study 
conducted under paragraph (1), together with recommendations 
for such legislation and administrative action the Comptroller 
General determines appropriate, taking into consideration the 
structure and adequacy of the prospective payment methodology 
used to make payments to Federally qualified health centers 
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122 STAT. 2551 
PUBLIC LAW 110–275—JULY 15, 2008 
under the Medicaid program under title XIX of the Social 
Security Act (42 U.S.C. 1396 et seq.). 
SEC. 152. KIDNEY DISEASE EDUCATION AND AWARENESS PROVISIONS. 
(a) CHRONIC KIDNEY DISEASE INITIATIVES.—Part P of title III 
of the Public Health Service Act (42 U.S.C. 280g et seq.) is amended 
by adding at the end the following new section: 
‘‘SEC. 399R. CHRONIC KIDNEY DISEASE INITIATIVES. 
‘‘(a) IN GENERAL.—The Secretary shall establish pilot projects 
to— 
‘‘(1) increase public and medical community awareness 
(particularly of those who treat patients with diabetes and 
hypertension) regarding chronic kidney disease, focusing on 
prevention; 
‘‘(2) increase screening for chronic kidney disease, focusing 
on Medicare beneficiaries at risk of chronic kidney disease; 
and 
‘‘(3) enhance surveillance systems to better assess the 
prevalence and incidence of chronic kidney disease. 
‘‘(b) SCOPE AND DURATION.— 
‘‘(1) SCOPE.—The Secretary shall select at least 3 States 
in which to conduct pilot projects under this section. 
‘‘(2) DURATION.—The pilot projects under this section shall 
be conducted for a period that is not longer than 5 years 
and shall begin on January 1, 2009. 
‘‘(c) EVALUATION
AND REPORT.—The Comptroller General of 
the United States shall conduct an evaluation of the pilot projects 
conducted under this section. Not later than 12 months after the 
date on which the pilot projects are completed, the Comptroller 
General shall submit to Congress a report on the evaluation. 
‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated such sums as may be necessary for the purpose 
of carrying out this section.’’. 
(b) MEDICARE COVERAGE OF KIDNEY DISEASE PATIENT EDU-
CATION SERVICES.— 
(1) COVERAGE OF KIDNEY DISEASE EDUCATION SERVICES.— 
(A) COVERAGE.—Section 1861(s)(2) of the Social Secu-
rity Act (42 U.S.C. 1395x(s)(2)), as amended by section 
144(a), is amended— 
(i) in subparagraph (CC), by striking ‘‘and’’ after 
the semicolon at the end; 
(ii) in subparagraph (DD), by adding ‘‘and’’ after 
the semicolon at the end; and 
(iii) by adding at the end the following new 
subparagraph: 
‘‘(EE) kidney disease education services (as defined in sub-
section (ggg));’’. 
(B) SERVICES DESCRIBED.—Section 1861 of the Social 
Security Act (42 U.S.C. 1395x), as amended by section 
144(a), is amended by adding at the end the following 
new subsection: 
‘‘Kidney Disease Education Services 
‘‘(ggg)(1) The term ‘kidney disease education services’ means 
educational services that are— 
42 USC 280g–6. 
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122 STAT. 2552 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(A) furnished to an individual with stage IV chronic kidney 
disease who, according to accepted clinical guidelines identified 
by the Secretary, will require dialysis or a kidney transplant; 
‘‘(B) furnished, upon the referral of the physician managing 
the individual’s kidney condition, by a qualified person (as 
defined in paragraph (2)); and 
‘‘(C) designed— 
‘‘(i) to provide comprehensive information (consistent 
with the standards set under paragraph (3)) regarding— 
‘‘(I) the management of comorbidities, including 
for purposes of delaying the need for dialysis; 
‘‘(II) the prevention of uremic complications; and 
‘‘(III) each option for renal replacement therapy 
(including hemodialysis and peritoneal dialysis at home 
and in-center as well as vascular access options and 
transplantation); 
‘‘(ii) to ensure that the individual has the opportunity 
to actively participate in the choice of therapy; and 
‘‘(iii) to be tailored to 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 physi-
cian assistant, nurse practitioner, or clinical nurse specialist 
(as defined in section 1861(aa)(5)), who furnishes services for 
which payment may be made under the fee schedule established 
under section 1848; and 
‘‘(ii) a provider of services located in a rural area (as defined 
in section 1886(d)(2)(D)). 
‘‘(B) Such term does not include a provider of services (other 
than a provider of services described in subparagraph (A)(ii)) or 
a renal dialysis facility. 
‘‘(3) The Secretary shall set standards for the content of such 
information to be provided under paragraph (1)(C)(i) after con-
sulting with physicians, other health professionals, health edu-
cators, professional organizations, accrediting organizations, kidney 
patient organizations, dialysis facilities, transplant centers, network 
organizations described in section 1881(c)(2), and other knowledge-
able persons. To the extent possible the Secretary shall consult 
with persons or entities described in the previous sentence, other 
than a dialysis facility, that has not received industry funding 
from a drug or biological manufacturer or dialysis facility. 
‘‘(4) No individual shall be furnished more than 6 sessions 
of kidney disease education services under this title.’’. 
(C) PAYMENT UNDER THE PHYSICIAN FEE SCHEDULE.— 
Section 1848(j)(3) of the Social Security Act (42 U.S.C. 
1395w–4(j)(3)), as amended by section 144(b), is amended 
by inserting ‘‘(2)(EE),’’ after ‘‘(2)(DD),’’. 
(D) LIMITATION
ON
NUMBER
OF
SESSIONS.—Section 
1862(a)(1) of the Social Security Act (42 U.S.C. 1395y(a)(1)) 
is amended— 
(i) in subparagraph (M), by striking ‘‘and’’ at the 
end; 
(ii) in subparagraph (N), by striking the semicolon 
at the end and inserting ‘‘, and’’; and 
(iii) by adding at the end the following new 
subparagraph: 
Standards. 
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122 STAT. 2553 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(O) in the case of kidney disease education services (as 
defined in paragraph (1) of section 1861(ggg)), which are fur-
nished in excess of the number of sessions covered under para-
graph (4) of such section;’’. 
(2) EFFECTIVE DATE.—The amendments made by this sub-
section shall apply to services furnished on or after January 
1, 2010. 
SEC. 153. RENAL DIALYSIS PROVISIONS. 
(a) COMPOSITE RATE.— 
(1) UPDATE.—Section 1881(b)(12)(G) of the Social Security 
Act (42 U.S.C. 1395rr(b)(12)(G)) is amended— 
(A) in clause (i), by striking ‘‘and’’ at the end; 
(B) in clause (ii)— 
(i) by inserting ‘‘and before January 1, 2009,’’ after 
‘‘April 1, 2007,’’; and 
(ii) by striking the period at the end and inserting 
a semicolon; and 
(C) by adding at the end the following new clauses: 
‘‘(iii) furnished on or after January 1, 2009, and before 
January 1, 2010, by 1.0 percent above the amount of such 
composite rate component for such services furnished on 
December 31, 2008; and 
‘‘(iv) furnished on or after January 1, 2010, by 1.0 percent 
above the amount of such composite rate component for such 
services furnished on December 31, 2009.’’. 
(2) SITE NEUTRAL COMPOSITE RATE.—Section 1881(b)(12)(A) 
of the Social Security Act (42 U.S.C. 1395rr(b)(12)(A)) is 
amended by adding at the end the following new sentence: 
‘‘Under such system, the payment rate for dialysis services 
furnished on or after January 1, 2009, by providers of services 
shall be the same as the payment rate (computed without 
regard to this sentence) for such services furnished by renal 
dialysis facilities, and in applying the geographic index under 
subparagraph (D) to providers of services, the labor share shall 
be based on the labor share otherwise applied for renal dialysis 
facilities.’’. 
(b) DEVELOPMENT OF ESRD BUNDLED PAYMENT SYSTEM.— 
(1) IN GENERAL.—Section 1881(b) of the Social Security 
Act (42 U.S.C. 1395rr(b)) is amended by adding at the end 
the following new paragraph: 
‘‘(14)(A)(i) Subject to subparagraph (E), for services furnished 
on or after January 1, 2011, the Secretary shall implement a 
payment system under which a single payment is made under 
this title to a provider of services or a renal dialysis facility for 
renal dialysis services (as defined in subparagraph (B)) in lieu 
of any other payment (including a payment adjustment under para-
graph (12)(B)(ii)) and for such services and items furnished pursu-
ant to paragraph (4). 
‘‘(ii) In implementing the system under this paragraph the 
Secretary shall ensure that the estimated total amount of payments 
under this title for 2011 for renal dialysis services shall equal 
98 percent of the estimated total amount of payments for renal 
dialysis services, including payments under paragraph (12)(B)(ii), 
that would have been made under this title with respect to services 
furnished in 2011 if such system had not been implemented. In 
making the estimation under subclause (I), the Secretary shall 
Effective date. 
Effective date. 
Effective date. 
Time period. 
42 USC 1395w–4 
note. 
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122 STAT. 2554 
PUBLIC LAW 110–275—JULY 15, 2008 
use per patient utilization data from 2007, 2008, or 2009, whichever 
has the lowest per patient utilization. 
‘‘(B) For purposes of this paragraph, the term ‘renal dialysis 
services’ includes— 
‘‘(i) items and services included in the composite rate for 
renal dialysis services as of December 31, 2010; 
‘‘(ii) erythropoiesis stimulating agents and any oral form 
of such agents that are furnished to individuals for the treat-
ment of end stage renal disease; 
‘‘(iii) other drugs and biologicals that are furnished to 
individuals for the treatment of end stage renal disease and 
for which payment was (before the application of this para-
graph) made separately under this title, and any oral equivalent 
form of such drug or biological; and 
‘‘(iv) diagnostic laboratory tests and other items and serv-
ices not described in clause (i) that are furnished to individuals 
for the treatment of end stage renal disease. 
Such term does not include vaccines. 
‘‘(C) The system under this paragraph may provide for payment 
on the basis of services furnished during a week or month or 
such other appropriate unit of payment as the Secretary specifies. 
‘‘(D) Such system— 
‘‘(i) shall include a payment adjustment based on case 
mix that may take into account patient weight, body mass 
index, comorbidities, length of time on dialysis, age, race, eth-
nicity, and other appropriate factors; 
‘‘(ii) shall include a payment adjustment for high cost 
outliers due to unusual variations in the type or amount of 
medically necessary care, including variations in the amount 
of erythropoiesis stimulating agents necessary for anemia 
management; 
‘‘(iii) shall include a payment adjustment that reflects the 
extent to which costs incurred by low-volume facilities (as 
defined by the Secretary) in furnishing renal dialysis services 
exceed the costs incurred by other facilities in furnishing such 
services, and for payment for renal dialysis services furnished 
on or after January 1, 2011, and before January 1, 2014, 
such payment adjustment shall not be less than 10 percent; 
and 
‘‘(iv) may include such other payment adjustments as the 
Secretary determines appropriate, such as a payment adjust-
ment— 
‘‘(I) for pediatric providers of services and renal dialysis 
facilities; 
‘‘(II) by a geographic index, such as the index referred 
to in paragraph (12)(D), as the Secretary determines to 
be appropriate; and 
‘‘(III) for providers of services or renal dialysis facilities 
located in rural areas. 
The Secretary shall take into consideration the unique treatment 
needs of children and young adults in establishing such system. 
‘‘(E)(i) The Secretary shall provide for a four-year phase-in 
(in equal increments) of the payment amount under the payment 
system under this paragraph, with such payment amount being 
fully implemented for renal dialysis services furnished on or after 
January 1, 2014. 
Effective date. 
Time period. 
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122 STAT. 2555 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(ii) A provider of services or renal dialysis facility may make 
a one-time election to be excluded from the phase-in under clause 
(i) and be paid entirely based on the payment amount under the 
payment system under this paragraph. Such an election shall be 
made prior to January 1, 2011, in a form and manner specified 
by the Secretary, and is final and may not be rescinded. 
‘‘(iii) The Secretary shall make an adjustment to the payments 
under this paragraph for years during which the phase-in under 
clause (i) is applicable so that the estimated total amount of pay-
ments under this paragraph, including payments under this 
subparagraph, shall equal the estimated total amount of payments 
that would otherwise occur under this paragraph without such 
phase-in. 
‘‘(F)(i) Subject to clause (ii), beginning in 2012, the Secretary 
shall annually increase payment amounts established under this 
paragraph by an ESRD market basket percentage increase factor 
for a bundled payment system for renal dialysis services that 
reflects changes over time in the prices of an appropriate mix 
of goods and services included in renal dialysis services minus 
1.0 percentage point. 
‘‘(ii) For years during which a phase-in of the payment system 
pursuant to subparagraph (E) is applicable, the following rules 
shall apply to the portion of the payment under the system that 
is based on the payment of the composite rate that would otherwise 
apply if the system under this paragraph had not been enacted: 
‘‘(I) The update under clause (i) shall not apply. 
‘‘(II) The Secretary shall annually increase such composite 
rate by the ESRD market basket percentage increase factor 
described in clause (i) minus 1.0 percentage point. 
‘‘(G) There shall be no administrative or judicial review under 
section 1869, section 1878, or otherwise of the determination of 
payment amounts under subparagraph (A), the establishment of 
an appropriate unit of payment under subparagraph (C), the identi-
fication of renal dialysis services included in the bundled payment, 
the adjustments under subparagraph (D), the application of the 
phase-in under subparagraph (E), and the establishment of the 
market basket percentage increase factors under subparagraph (F). 
‘‘(H) Erythropoiesis stimulating agents and other drugs and 
biologicals shall be treated as prescribed and dispensed or adminis-
tered and available only under part B if they are— 
‘‘(i) furnished to an individual for the treatment of end 
stage renal disease; and 
‘‘(ii) included in subparagraph (B) for purposes of payment 
under this paragraph.’’. 
(2) PROHIBITION OF UNBUNDLING.—Section 1862(a) of the 
Social Security Act (42 U.S.C. 1395y(a)), as amended by section 
135(a)(2), is amended— 
(A) in paragraph (22), by striking ‘‘or’’ at the end; 
(B) in paragraph (23), by striking the period at the 
end and inserting ‘‘; or’’; and 
(C) by inserting after paragraph (23) the following 
new paragraph: 
‘‘(24) where such expenses are for renal dialysis services 
(as defined in subparagraph (B) of section 1881(b)(14)) for which 
payment is made under such section unless such payment 
is made under such section to a provider of services or a 
renal dialysis facility for such services.’’. 
Effective date. 
Deadline. 
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122 STAT. 2556 
PUBLIC LAW 110–275—JULY 15, 2008 
(3) CONFORMING AMENDMENTS.—(A) Section 1881(b) of the 
Social Security Act (42 U.S.C. 1395rr(b)) is amended— 
(i) in paragraph (12)(A), by striking ‘‘In lieu of pay-
ment’’ and inserting ‘‘Subject to paragraph (14), in lieu 
of payment’’; 
(ii) in the second sentence of paragraph (12)(F)— 
(I) by inserting ‘‘or paragraph (14)’’ after ‘‘this para-
graph’’; and 
(II) by inserting ‘‘or under the system under para-
graph (14)’’ after ‘‘subparagraph (B)’’; and 
(iii) in paragraph (13)— 
(I) in subparagraph (A), in the matter preceding 
clause (i), by striking ‘‘The payment amounts’’ and 
inserting ‘‘Subject to paragraph (14), the payment 
amounts’’; and 
(II) in subparagraph (B)— 
(aa) in clause (i), by striking ‘‘(i)’’ after ‘‘(B)’’ 
and by inserting ‘‘, subject to paragraph (14)’’ 
before the period at the end; and 
(bb) by striking clause (ii). 
(B) Section 1861(s)(2)(F) of the Social Security Act (42 
U.S.C. 1395x(s)(2)(F)) is amended by inserting ‘‘, and, for items 
and services furnished on or after January 1, 2011, renal 
dialysis services (as defined in section 1881(b)(14)(B))’’ before 
the semicolon at the end. 
(C) Section 623(e) of the Medicare Prescription Drug, 
Improvement, and Modernization Act of 2003 (42 U.S.C. 1395rr 
note) is repealed. 
(4) RULE OF CONSTRUCTION.—Nothing in this subsection 
or the amendments made by this subsection shall be construed 
as authorizing or requiring the Secretary of Health and Human 
Services to make payments under the payment system imple-
mented under paragraph (14)(A)(i) of section 1881(b) of the 
Social Security Act (42 U.S.C. 1395rr(b)), as added by paragraph 
(1), for any unrecovered amount for any bad debt attributable 
to deductible and coinsurance on items and services not 
included in the basic case-mix adjusted composite rate under 
paragraph (12) of such section as in effect before the date 
of the enactment of this Act. 
(c) QUALITY INCENTIVES
IN
THE END-STAGE RENAL DISEASE 
PROGRAM.—Section 1881 of the Social Security Act (42 U.S.C. 
1395rr) is amended by adding at the end the following new sub-
section: 
‘‘(h) QUALITY INCENTIVES IN THE END-STAGE RENAL DISEASE 
PROGRAM.— 
‘‘(1) QUALITY INCENTIVES.— 
‘‘(A) IN GENERAL.—With respect to renal dialysis serv-
ices (as defined in subsection (b)(14)(B)) furnished on or 
after January 1, 2012, in the case of a provider of services 
or a renal dialysis facility that does not meet the require-
ment described in subparagraph (B) with respect to the 
year, payments otherwise made to such provider or facility 
under the system under subsection (b)(14) for such services 
shall be reduced by up to 2.0 percent, as determined appro-
priate by the Secretary. 
‘‘(B) REQUIREMENT.—The requirement described in this 
subparagraph is that the provider or facility meets (or 
Effective date. 
42 USC 1395rr 
note. 
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122 STAT. 2557 
PUBLIC LAW 110–275—JULY 15, 2008 
exceeds) the total performance score under paragraph (3) 
with respect to performance standards established by the 
Secretary with respect to measures specified in paragraph 
(2). 
‘‘(C) NO EFFECT IN SUBSEQUENT YEARS.—The reduction 
under subparagraph (A) shall apply only with respect to 
the year involved, and the Secretary shall not take into 
account such reduction in computing the single payment 
amount under the system under paragraph (14) in a subse-
quent year. 
‘‘(2) MEASURES.— 
‘‘(A) IN GENERAL.—The measures specified under this 
paragraph with respect to the year involved shall include— 
‘‘(i) measures on anemia management that reflect 
the labeling approved by the Food and Drug Adminis-
tration for such management and measures on dialysis 
adequacy; 
‘‘(ii) to the extent feasible, such measure (or meas-
ures) of patient satisfaction as the Secretary shall 
specify; and 
‘‘(iii) such other measures as the Secretary speci-
fies, including, to the extent feasible, measures on— 
‘‘(I) iron management; 
‘‘(II) bone mineral metabolism; and 
‘‘(III) vascular access, including for maximizing 
the placement of arterial venous fistula. 
‘‘(B) USE OF ENDORSED MEASURES.— 
‘‘(i) IN
GENERAL.—Subject to clause (ii), any 
measure specified by the Secretary under subpara-
graph (A)(iii) must have been endorsed by the entity 
with a contract under section 1890(a). 
‘‘(ii) EXCEPTION.—In the case of a specified area 
or medical topic determined appropriate by the Sec-
retary for which a feasible and practical measure has 
not been endorsed by the entity with a contract under 
section 1890(a), the Secretary may specify a measure 
that is not so endorsed as long as due consideration 
is given to measures that have been endorsed or 
adopted by a consensus organization identified by the 
Secretary. 
‘‘(C) UPDATING MEASURES.—The Secretary shall estab-
lish a process for updating the measures specified under 
subparagraph (A) in consultation with interested parties. 
‘‘(D) CONSIDERATION.—In specifying measures under 
subparagraph (A), the Secretary shall consider the avail-
ability of measures that address the unique treatment 
needs of children and young adults with kidney failure. 
‘‘(3) PERFORMANCE SCORES.— 
‘‘(A) TOTAL PERFORMANCE SCORE.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), the Sec-
retary shall develop a methodology for assessing the 
total performance of each provider of services and renal 
dialysis facility based on performance standards with 
respect to the measures selected under paragraph (2) 
for a performance period established under paragraph 
(4)(D) (in this subsection referred to as the ‘total 
performance score’). 
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122 STAT. 2558 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(ii) APPLICATION.—For providers of services and 
renal dialysis facilities that do not meet (or exceed) 
the total performance score established by the Sec-
retary, the Secretary shall ensure that the application 
of the methodology developed under clause (i) results 
in an appropriate distribution of reductions in payment 
under paragraph (1) among providers and facilities 
achieving different levels of total performance scores, 
with providers and facilities achieving the lowest total 
performance scores receiving the largest reduction in 
payment under paragraph (1)(A). 
‘‘(iii) WEIGHTING OF MEASURES.—In calculating the 
total performance score, the Secretary shall weight 
the scores with respect to individual measures cal-
culated under subparagraph (B) to reflect priorities 
for quality improvement, such as weighting scores to 
ensure that providers of services and renal dialysis 
facilities have strong incentives to meet or exceed 
anemia management and dialysis adequacy perform-
ance standards, as determined appropriate by the Sec-
retary. 
‘‘(B) PERFORMANCE SCORE WITH RESPECT TO INDIVIDUAL 
MEASURES.—The Secretary shall also calculate separate 
performance scores for each measure, including for dialysis 
adequacy and anemia management. 
‘‘(4) PERFORMANCE STANDARDS.— 
‘‘(A) ESTABLISHMENT.—Subject to subparagraph (E), 
the Secretary shall establish performance standards with 
respect to measures selected under paragraph (2) for a 
performance period with respect to a year (as established 
under subparagraph (D)). 
‘‘(B) ACHIEVEMENT AND IMPROVEMENT.—The perform-
ance standards established under subparagraph (A) shall 
include levels of achievement and improvement, as deter-
mined appropriate by the Secretary. 
‘‘(C) TIMING.—The Secretary shall establish the 
performance standards under subparagraph (A) prior to 
the beginning of the performance period for the year 
involved. 
‘‘(D) PERFORMANCE PERIOD.—The Secretary shall estab-
lish the performance period with respect to a year. Such 
performance period shall occur prior to the beginning of 
such year. 
‘‘(E) SPECIAL RULE.—The Secretary shall initially use 
as the performance standard for the measures specified 
under paragraph (2)(A)(i) for a provider of services or a 
renal dialysis facility the lesser of— 
‘‘(i) the performance of such provider or facility 
for such measures in the year selected by the Secretary 
under the second sentence of subsection (b)(14)(A)(ii); 
or 
‘‘(ii) a performance standard based on the national 
performance rates for such measures in a period deter-
mined by the Secretary. 
‘‘(5) LIMITATION ON REVIEW.—There shall be no administra-
tive or judicial review under section 1869, section 1878, or 
otherwise of the following: 
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122 STAT. 2559 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(A) The determination of the amount of the payment 
reduction under paragraph (1). 
‘‘(B) The establishment of the performance standards 
and the performance period under paragraph (4). 
‘‘(C) The specification of measures under paragraph 
(2). 
‘‘(D) The methodology developed under paragraph (3) 
that is used to calculate total performance scores and 
performance scores for individual measures. 
‘‘(6) PUBLIC REPORTING.— 
‘‘(A) IN GENERAL.—The Secretary shall establish proce-
dures for making information regarding performance under 
this subsection available to the public, including— 
‘‘(i) the total performance score achieved by the 
provider of services or renal dialysis facility under 
paragraph (3) and appropriate comparisons of pro-
viders of services and renal dialysis facilities to the 
national average with respect to such scores; and 
‘‘(ii) the performance score achieved by the provider 
or facility with respect to individual measures. 
‘‘(B) OPPORTUNITY TO REVIEW.—The procedures estab-
lished under subparagraph (A) shall ensure that a provider 
of services and a renal dialysis facility has the opportunity 
to review the information that is to be made public with 
respect to the provider or facility prior to such data being 
made public. 
‘‘(C) CERTIFICATES.— 
‘‘(i) IN GENERAL.—The Secretary shall provide cer-
tificates to providers of services and renal dialysis 
facilities who furnish renal dialysis services under this 
section to display in patient areas. The certificate shall 
indicate the total performance score achieved by the 
provider or facility under paragraph (3). 
‘‘(ii) DISPLAY.—Each facility or provider receiving 
a certificate under clause (i) shall prominently display 
the certificate at the provider or facility. 
‘‘(D) WEB-BASED LIST.—The Secretary shall establish 
a list of providers of services and renal dialysis facilities 
who furnish renal dialysis services under this section that 
indicates the total performance score and the performance 
score for individual measures achieved by the provider 
and facility under paragraph (3). Such information shall 
be posted on the Internet website of the Centers for Medi-
care & Medicaid Services in an easily understandable for-
mat.’’. 
(d) GAO REPORT ON ESRD BUNDLING SYSTEM AND QUALITY 
INITIATIVE.—Not later than March 1, 2013, the Comptroller General 
of the United States shall submit to Congress a report on the 
implementation of the payment system under subsection (b)(14) 
of section 1881 of the Social Security Act (as added by subsection 
(b)) for renal dialysis services and related services (defined in 
subparagraph (B) of such subsection (b)(14)) and the quality initia-
tive under subsection (h) of such section 1881 (as added by sub-
section (b)). Such report shall include the following information: 
(1) The changes in utilization rates for erythropoiesis 
stimulating agents. 
Procedures. 
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122 STAT. 2560 
PUBLIC LAW 110–275—JULY 15, 2008 
(2) The mode of administering such agents, including 
information on the proportion of individuals receiving such 
agents intravenously as compared to subcutaneously. 
(3) An analysis of the payment adjustment under subpara-
graph (D)(iii) of such subsection (b)(14), including an examina-
tion of the extent to which costs incurred by rural, low-volume 
providers and facilities (as defined by the Secretary) in fur-
nishing renal dialysis services exceed the costs incurred by 
other providers and facilities in furnishing such services, and 
a recommendation regarding the appropriateness of such 
adjustment. 
(4) The changes, if any, in utilization rates of drugs and 
biologicals that the Secretary identifies under subparagraph 
(B)(iii) of such subsection (b)(14), and any oral equivalent or 
oral substitutable forms of such drugs and biologicals or of 
drugs and biologicals described in clause (ii), that have occurred 
after implementation of the payment system under such sub-
section (b)(14). 
(5) Any other information or recommendations for legisla-
tive and administrative actions determined appropriate by the 
Comptroller General. 
SEC. 154. DELAY IN AND REFORM OF MEDICARE DMEPOS COMPETI-
TIVE ACQUISITION PROGRAM. 
(a) TEMPORARY DELAY AND REFORM.— 
(1) IN GENERAL.—Section 1847(a)(1) of the Social Security 
Act (42 U.S.C. 1395w–3(a)(1)) is amended— 
(A) in paragraph (1)— 
(i) in subparagraph (B)(i), in the matter before 
subclause (I), by inserting ‘‘consistent with subpara-
graph (D)’’ after ‘‘in a manner’’; 
(ii) in subparagraph (B)(i)(II), by striking ‘‘80’’ and 
‘‘in 2009’’ and inserting ‘‘an additional 70’’ and ‘‘in 
2011’’, respectively; 
(iii) in subparagraph (B)(i)(III), by striking ‘‘after 
2009’’ and inserting ‘‘after 2011 (or, in the case of 
national mail order for items and services, after 2010)’’; 
and 
(iv) by adding at the end the following new sub-
paragraphs: 
‘‘(D) CHANGES
IN
COMPETITIVE
ACQUISITION
PRO-
GRAMS.— 
‘‘(i) ROUND
1
OF
COMPETITIVE
ACQUISITION
PRO-
GRAM.—Notwithstanding subparagraph (B)(i)(I) and in 
implementing the first round of the competitive 
acquisition programs under this section— 
‘‘(I) the contracts awarded under this section 
before the date of the enactment of this subpara-
graph are terminated, no payment shall be made 
under this title on or after the date of the enact-
ment of this subparagraph based on such a con-
tract, and, to the extent that any damages may 
be applicable as a result of the termination of 
such contracts, such damages shall be payable 
from the Federal Supplementary Medical Insur-
ance Trust Fund under section 1841; 
Contracts. 
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122 STAT. 2561 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(II) the Secretary shall conduct the competi-
tion for such round in a manner so that it occurs 
in 2009 with respect to the same items and services 
and the same areas, except as provided in sub-
clauses (III) and (IV); 
‘‘(III) the Secretary shall exclude Puerto Rico 
so that such round of competition covers 9, instead 
of 10, of the largest metropolitan statistical areas; 
and 
‘‘(IV) there shall be excluded negative pressure 
wound therapy items and services. 
Nothing in subclause (I) shall be construed to provide 
an independent cause of action or right to administra-
tive or judicial review with regard to the termination 
provided under such subclause. 
‘‘(ii) ROUND 2 OF COMPETITIVE ACQUISITION PRO-
GRAM.—In implementing the second round of the 
competitive acquisition programs under this section 
described in subparagraph (B)(i)(II)— 
‘‘(I) the metropolitan statistical areas to be 
included shall be those metropolitan statistical 
areas selected by the Secretary for such round 
as of June 1, 2008; and 
‘‘(II) the Secretary may subdivide metropolitan 
statistical areas with populations (based upon the 
most recent data from the Census Bureau) of at 
least 8,000,000 into separate areas for competitive 
acquisition purposes. 
‘‘(iii) EXCLUSION OF CERTAIN AREAS IN SUBSEQUENT 
ROUNDS OF COMPETITIVE ACQUISITION PROGRAMS.—In 
implementing subsequent rounds of the competitive 
acquisition programs under this section, including 
under subparagraph (B)(i)(III), for competitions occur-
ring before 2015, the Secretary shall exempt from the 
competitive acquisition program (other than national 
mail order) the following: 
‘‘(I) Rural areas. 
‘‘(II) Metropolitan statistical areas not selected 
under round 1 or round 2 with a population of 
less than 250,000. 
‘‘(III) Areas with a low population density 
within a metropolitan statistical area that is other-
wise selected, as determined for purposes of para-
graph (3)(A). 
‘‘(E) VERIFICATION BY OIG.—The Inspector General of 
the Department of Health and Human Services shall, 
through post-award audit, survey, or otherwise, assess the 
process used by the Centers for Medicare & Medicaid Serv-
ices to conduct competitive bidding and subsequent pricing 
determinations under this section that are the basis for 
pivotal bid amounts and single payment amounts for items 
and services in competitive bidding areas under rounds 
1 and 2 of the competitive acquisition programs under 
this section and may continue to verify such calculations 
for subsequent rounds of such programs. 
‘‘(F) SUPPLIER FEEDBACK ON MISSING FINANCIAL DOCU-
MENTATION.— 
Puerto Rico. 
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122 STAT. 2562 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(i) IN GENERAL.—In the case of a bid where one 
or more covered documents in connection with such 
bid have been submitted not later than the covered 
document review date specified in clause (ii), the Sec-
retary— 
‘‘(I) shall provide, by not later than 45 days 
(in the case of the first round of the competitive 
acquisition programs as described in subparagraph 
(B)(i)(I)) or 90 days (in the case of a subsequent 
round of such programs) after the covered docu-
ment review date, for notice to the bidder of all 
such documents that are missing as of the covered 
document review date; and 
‘‘(II) may not reject the bid on the basis that 
any covered document is missing or has not been 
submitted on a timely basis, if all such missing 
documents identified in the notice provided to the 
bidder under subclause (I) are submitted to the 
Secretary not later than 10 business days after 
the date of such notice. 
‘‘(ii) COVERED DOCUMENT REVIEW DATE.—The cov-
ered document review date specified in this clause 
with respect to a competitive acquisition program is 
the later of— 
‘‘(I) the date that is 30 days before the final 
date specified by the Secretary for submission of 
bids under such program; or 
‘‘(II) the date that is 30 days after the first 
date specified by the Secretary for submission of 
bids under such program. 
‘‘(iii) LIMITATIONS OF PROCESS.—The process pro-
vided under this subparagraph— 
‘‘(I) applies only to the timely submission of 
covered documents; 
‘‘(II) does not apply to any determination as 
to the accuracy or completeness of covered docu-
ments submitted or whether such documents meet 
applicable requirements; 
‘‘(III) shall not prevent the Secretary from 
rejecting a bid based on any basis not described 
in clause (i)(II); and 
‘‘(IV) shall not be construed as permitting a 
bidder to change bidding amounts or to make other 
changes in a bid submission. 
‘‘(iv) 
COVERED
DOCUMENT
DEFINED.—In 
this 
subparagraph, the term ‘covered document’ means a 
financial, tax, or other document required to be sub-
mitted by a bidder as part of an original bid submission 
under a competitive acquisition program in order to 
meet required financial standards. Such term does not 
include other documents, such as the bid itself or 
accreditation documentation.’’; and 
(B) in paragraph (2)(A), by inserting before the period 
at the end the following: ‘‘and excluding certain complex 
rehabilitative power wheelchairs recognized by the Sec-
retary as classified within group 3 or higher (and related 
Deadlines. 
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122 STAT. 2563 
PUBLIC LAW 110–275—JULY 15, 2008 
accessories when furnished in connection with such wheel-
chairs)’’. 
(2) BUDGET NEUTRAL OFFSET.— 
(A) IN GENERAL.—Section 1834(a)(14) of such Act (42 
U.S.C. 1395m(a)(14)) is amended— 
(i) by striking ‘‘and’’ at the end of subparagraphs 
(H) and (I); 
(ii) by redesignating subparagraph (J) as subpara-
graph (M); and 
(iii) by inserting after subparagraph (I) the fol-
lowing new subparagraphs: 
‘‘(J) for 2009— 
‘‘(i) in the case of items and services furnished 
in any geographic area, if such items or services were 
selected for competitive acquisition in any area under 
the competitive acquisition program under section 
1847(a)(1)(B)(i)(I) before July 1, 2008, including related 
accessories but only if furnished with such items and 
services selected for such competition and diabetic sup-
plies but only if furnished through mail order, - 9.5 
percent; or 
‘‘(ii) in the case of other items and services, the 
percentage increase in the consumer price index for 
all urban consumers (U.S. urban average) for the 12- 
month period ending with June 2008; 
‘‘(K) for 2010, 2011, 2012, and 2013, the percentage 
increase in the consumer price index for all urban con-
sumers (U.S. urban average) for the 12-month period 
ending with June of the previous year; 
‘‘(L) for 2014— 
‘‘(i) in the case of items and services described 
in subparagraph (J)(i) for which a payment adjustment 
has not been made under subsection (a)(1)(F)(ii) in 
any previous year, the percentage increase in the con-
sumer price index for all urban consumers (U.S. urban 
average) for the 12-month period ending with June 
2013, plus 2.0 percentage points; or 
‘‘(ii) in the case of other items and services, the 
percentage increase in the consumer price index for 
all urban consumers (U.S. urban average) for the 12- 
month period ending with June 2013; and’’. 
(B) CONFORMING TREATMENT FOR CERTAIN ITEMS AND 
SERVICES.—The second sentence of section 1842(s)(1) of 
such Act (42 U.S.C. 1395u(s)(1)) is amended by striking 
‘‘except that’’ and all that follows and inserting the fol-
lowing: ‘‘except that for items and services described in 
paragraph (2)(D)— 
‘‘(A) for 2009 section 1834(a)(14)(J)(i) shall apply under 
this paragraph instead of the percentage increase otherwise 
applicable; and 
‘‘(B) for 2014, if subparagraph (A) is applied to the items 
and services and there has not been a payment adjustment 
under paragraph (3)(B) for the items and services for any 
previous year, the percentage increase computed under section 
1834(a)(14)(L)(i) shall apply instead of the percentage increase 
otherwise applicable.’’. 
Applicability. 
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122 STAT. 2564 
PUBLIC LAW 110–275—JULY 15, 2008 
(3) 
CONFORMING
DELAY.—Subsections 
(a)(1)(F) 
and 
(h)(1)(H) of section 1834 of the Social Security Act (42 U.S.C. 
1395m) are each amended by striking ‘‘January 1, 2009’’ and 
inserting ‘‘January 1, 2011’’. 
(4) CONSIDERATIONS IN APPLICATION.—Section 1834 of such 
Act (42 U.S.C. 1395m) is amended— 
(A) in subsection (a)(1)— 
(i) in subparagraph (F), by inserting ‘‘subject to 
subparagraph (G),’’ before ‘‘that are included’’; and 
(ii) by adding at the end the following new 
subparagraph: 
‘‘(G) USE OF INFORMATION ON COMPETITIVE BID RATES.— 
The Secretary shall specify by regulation the methodology 
to be used in applying the provisions of subparagraph 
(F)(ii) and subsection (h)(1)(H)(ii). In promulgating such 
regulation, the Secretary shall consider the costs of items 
and services in areas in which such provisions would be 
applied compared to the payment rates for such items 
and services in competitive acquisition areas.’’; and 
(B) in subsection (h)(1)(H), by inserting ‘‘subject to 
subsection (a)(1)(G),’’ before ‘‘that are included’’. 
(b) QUALITY STANDARDS.— 
(1) APPLICATION OF ACCREDITATION REQUIREMENT.— 
(A) IN
GENERAL.—Section 1834(a)(20) of the Social 
Security Act (42 U.S.C. 1395m(a)(20)) is amended— 
(i) in subparagraph (E), by inserting ‘‘including 
subparagraph (F),’’ after ‘‘under this paragraph,’’; and 
(ii) by adding at the end the following new 
subparagraph: 
‘‘(F) APPLICATION OF ACCREDITATION REQUIREMENT.— 
In implementing quality standards under this paragraph— 
‘‘(i) subject to clause (ii), the Secretary shall require 
suppliers furnishing items and services described in 
subparagraph (D) on or after October 1, 2009, directly 
or as a subcontractor for another entity, to have sub-
mitted to the Secretary evidence of accreditation by 
an 
accreditation 
organization 
designated 
under 
subparagraph (B) as meeting applicable quality stand-
ards; and 
‘‘(ii) in applying such standards and the accredita-
tion requirement of clause (i) with respect to eligible 
professionals (as defined in section 1848(k)(3)(B)), and 
including such other persons, such as orthotists and 
prosthetists, as specified by the Secretary, furnishing 
such items and services— 
‘‘(I) such standards and accreditation require-
ment shall not apply to such professionals and 
persons unless the Secretary determines that the 
standards being applied are designed specifically 
to be applied to such professionals and persons; 
and 
‘‘(II) the Secretary may exempt such profes-
sionals and persons from such standards and 
requirement if the Secretary determines that 
licensing, accreditation, or other mandatory quality 
Effective date. 
Regulations. 
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122 STAT. 2565 
PUBLIC LAW 110–275—JULY 15, 2008 
requirements apply to such professionals and per-
sons with respect to the furnishing of such items 
and services.’’. 
(B) CONSTRUCTION.—Section 1834(a)(20)(F)(ii) of the 
Social Security Act, as added by subparagraph (A), shall 
not be construed as preventing the Secretary of Health 
and Human Services from implementing the first round 
of competition under section 1847 of such Act on a timely 
basis. 
(2) DISCLOSURE OF SUBCONTRACTORS UNDER COMPETITIVE 
ACQUISITION
PROGRAM.—Section 1847(b)(3) of such Act (42 
U.S.C. 1395w–3(b)(3)) is amended by adding at the end the 
following new subparagraph: 
‘‘(C) DISCLOSURE OF SUBCONTRACTORS.— 
‘‘(i) INITIAL DISCLOSURE.—Not later than 10 days 
after the date a supplier enters into a contract with 
the Secretary under this section, such supplier shall 
disclose to the Secretary, in a form and manner speci-
fied by the Secretary, the information on— 
‘‘(I) each subcontracting relationship that such 
supplier has in furnishing items and services 
under the contract; and 
‘‘(II) whether each such subcontractor meets 
the requirement of section 1834(a)(20)(F)(i), if 
applicable to such subcontractor. 
‘‘(ii) SUBSEQUENT DISCLOSURE.—Not later than 10 
days after such a supplier subsequently enters into 
a subcontracting relationship described in clause (i)(II), 
such supplier shall disclose to the Secretary, in such 
form and manner, the information described in sub-
clauses (I) and (II) of clause (i).’’. 
(3) COMPETITIVE ACQUISITION OMBUDSMAN.—Such section 
is further amended by adding at the end the following new 
subsection: 
‘‘(f) COMPETITIVE ACQUISITION OMBUDSMAN.—The Secretary 
shall provide for a competitive acquisition ombudsman within the 
Centers for Medicare & Medicaid Services in order to respond 
to complaints and inquiries made by suppliers and individuals 
relating to the application of the competitive acquisition program 
under this section. The ombudsman may be within the office of 
the Medicare Beneficiary Ombudsman appointed under section 
1808(c). The ombudsman shall submit to Congress an annual report 
on the activities under this subsection, which report shall be coordi-
nated with the report provided under section 1808(c)(2)(C).’’. 
(c) CHANGE IN REPORTS AND DEADLINES.— 
(1) GAO 
REPORT.—Section 302(b)(3) of the Medicare 
Prescription Drug, Improvement, and Modernization Act of 
2003 (Public Law 108-173) is amended— 
(A) in subparagraph (A)— 
(i) by inserting ‘‘and as amended by section 2 of 
the 
Medicare 
DMEPOS 
Competitive 
Acquisition 
Reform Act of 2008’’ after ‘‘as amended by paragraph 
(1)’’; and 
(ii) by inserting before the period at the end the 
following: ‘‘and the topics specified in subparagraph 
(C)’’; 
42 USC 1395w–3 
note. 
Reports. 
Establishment. 
Deadline. 
42 USC 1395m 
note. 
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122 STAT. 2566 
PUBLIC LAW 110–275—JULY 15, 2008 
(B) in subparagraph (B), by striking ‘‘Not later than 
January 1, 2009,’’ and inserting ‘‘Not later than 1 year 
after the first date that payments are made under section 
1847 of the Social Security Act,’’; and 
(C) by adding at the end the following new subpara-
graph: 
‘‘(C) TOPICS.—The topics specified in this subpara-
graph, for the study under subparagraph (A) concerning 
the competitive acquisition program, are the following: 
‘‘(i) Beneficiary access to items and services under 
the program, including the impact on such access of 
awarding contracts to bidders that— 
‘‘(I) did not have a physical presence in an 
area where they received a contract; or 
‘‘(II) had no previous experience providing the 
product category they were contracted to provide. 
‘‘(ii) Beneficiary satisfaction with the program and 
cost savings to beneficiaries under the program. 
‘‘(iii) Costs to suppliers of participating in the pro-
gram and recommendations about ways to reduce those 
costs without compromising quality standards or 
savings to the Medicare program. 
‘‘(iv) Impact of the program on small business sup-
pliers. 
‘‘(v) Analysis of the impact on utilization of dif-
ferent items and services paid within the same 
Healthcare 
Common 
Procedure 
Coding 
System 
(HCPCS) code. 
‘‘(vi) Costs to the Centers for Medicare & Medicaid 
Services, including payments made to contractors, for 
administering the program compared with administra-
tion of a fee schedule, in comparison with the relative 
savings of the program. 
‘‘(vii) Impact on access, Medicare spending, and 
beneficiary spending of any difference in treatment 
for diabetic testing supplies depending on how such 
supplies are furnished. 
‘‘(viii) Such other topics as the Comptroller General 
determines to be appropriate.’’. 
(2) DELAY IN OTHER DEADLINES.— 
(A) PROGRAM ADVISORY AND OVERSIGHT COMMITTEE.— 
Section 1847(c)(5) of the Social Security Act (42 U.S.C. 
1395w–3(c)(5)) is amended by striking ‘‘December 31, 2009’’ 
and inserting ‘‘December 31, 2011’’. 
(B) SECRETARIAL REPORT.—Section 1847(d) of such Act 
(42 U.S.C. 1395w–3(d)) is amended by striking ‘‘July 1, 
2009’’ and inserting ‘‘July 1, 2011’’. 
(C) IG 
REPORT.—Section 302(e) of the Medicare 
Prescription Drug, Improvement, and Modernization Act 
of 2003 (Public Law 108-173) is amended by striking ‘‘July 
1, 2009’’ and inserting ‘‘July 1, 2011’’. 
(3) EVALUATION
OF
CERTAIN
CODE.—The Secretary of 
Health and Human Services shall evaluate the existing Health 
Care Common Procedure Coding System (HCPCS) codes for 
negative pressure wound therapy to ensure accurate reporting 
and billing for items and services under such codes. In carrying 
out such evaluation, the Secretary shall use an existing process, 
42 USC 1395m 
note. 
42 USC 1395w–3 
note. 
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122 STAT. 2567 
PUBLIC LAW 110–275—JULY 15, 2008 
administered by the Durable Medical Equipment Medicare 
Administrative Contractors, for the consideration of coding 
changes and consider all relevant studies and information fur-
nished pursuant to such process. 
(d) OTHER PROVISIONS.— 
(1) EXEMPTION FROM COMPETITIVE ACQUISITION FOR CER-
TAIN OFF-THE-SHELF ORTHOTICS.—Section 1847(a) of the Social 
Security Act (42 U.S.C. 1395w–3(a)) is amended by adding 
at the end the following new paragraph: 
‘‘(7) EXEMPTION FROM COMPETITIVE ACQUISITION.—The pro-
grams under this section shall not apply to the following: 
‘‘(A) CERTAIN OFF-THE-SHELF ORTHOTICS.—Items and 
services described in paragraph (2)(C) if furnished— 
‘‘(i) by a physician or other practitioner (as defined 
by the Secretary) to the physician’s or practitioner’s 
own patients as part of the physician’s or practitioner’s 
professional service; or 
‘‘(ii) by a hospital to the hospital’s own patients 
during an admission or on the date of discharge. 
‘‘(B) CERTAIN
DURABLE
MEDICAL
EQUIPMENT.—Those 
items and services described in paragraph (2)(A)— 
‘‘(i) that are furnished by a hospital to the hos-
pital’s own patients during an admission or on the 
date of discharge; and 
‘‘(ii) to which such programs would not apply, as 
specified by the Secretary, if furnished by a physician 
to the physician’s own patients as part of the physi-
cian’s professional service.’’. 
(2) CORRECTION IN FACE-TO-FACE EXAMINATION REQUIRE-
MENT.—Section 1834(a)(1)(E)(ii) of such Act (42 U.S.C. 
1395m(a)(1)(E)(ii)) is amended by striking ‘‘1861(r)(1)’’ and 
inserting ‘‘1861(r)’’. 
(3) SPECIAL RULE IN CASE OF NATIONAL MAIL-ORDER COM-
PETITION FOR DIABETIC TESTING STRIPS.—Section 1847(b) of such 
Act (42 U.S.C. 1395w–3(b)) is amended— 
(A) by redesignating paragraph (10) as paragraph (11); 
and 
(B) by inserting after paragraph (9) the following new 
paragraph: 
‘‘(10) SPECIAL RULE IN CASE OF COMPETITION FOR DIABETIC 
TESTING STRIPS.— 
‘‘(A) IN
GENERAL.—With respect to the competitive 
acquisition program for diabetic testing strips conducted 
after the first round of the competitive acquisition pro-
grams, if an entity does not demonstrate to the Secretary 
that its bid covers types of diabetic testing strip products 
that, in the aggregate and taking into account volume 
for the different products, cover 50 percent (or such higher 
percentage as the Secretary may specify) of all such types 
of products, the Secretary shall reject such bid. The volume 
for such types of products may be determined in accordance 
with such data (which may be market based data) as 
the Secretary recognizes. 
‘‘(B) STUDY OF TYPES OF TESTING STRIP PRODUCTS.— 
Before 2011, the Inspector General of the Department of 
Health and Human Services shall conduct a study to deter-
mine the types of diabetic testing strip products by volume 
Deadline. 
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122 STAT. 2568 
PUBLIC LAW 110–275—JULY 15, 2008 
that could be used to make determinations pursuant to 
subparagraph (A) for the first competition under the 
competitive acquisition program described in such subpara-
graph and submit to the Secretary a report on the results 
of the study. The Inspector General shall also conduct 
such a study and submit such a report before the Secretary 
conducts a subsequent competitive acquistion program 
described in subparagraph (A).’’. 
(4) OTHER CONFORMING AMENDMENTS.—Section 1847(b)(11) 
of such Act, as redesignated by paragraph (3), is amended— 
(A) in subparagraph (C), by inserting ‘‘and the identi-
fication of areas under subsection (a)(1)(D)(iii)’’ after 
‘‘(a)(1)(A)’’; 
(B) in subparagraph (D), by inserting ‘‘and implementa-
tion of subsection (a)(1)(D)’’ after ‘‘(a)(1)(B)’’; 
(C) in subparagraph (E), by striking ‘‘or’’ at the end; 
(D) in subparagraph (F), by striking the period at 
the end and inserting ‘‘; or’’; and 
(E) by adding at the end the following new subpara-
graph: 
‘‘(G) the implementation of the special rule described 
in paragraph (10).’’. 
(5) FUNDING FOR IMPLEMENTATION.—In addition to funds 
otherwise available, for purposes of implementing the provi-
sions of, and amendments made by, this section, other than 
the amendment made by subsection (c)(1) and other than sec-
tion 1847(a)(1)(E) of the Social Security Act, the Secretary 
of Health and Human Services shall provide for the transfer 
from the Federal Supplementary Medical Insurance Trust Fund 
established under section 1841 of the Social Security Act (42 
U.S.C. 1395t) to the Centers for Medicare & Medicaid Services 
Program Management Account of $20,000,000 for fiscal year 
2008, and $25,000,000 for each of fiscal years 2009 through 
2012. Amounts transferred under this paragraph for a fiscal 
year shall be available until expended. 
(e) EFFECTIVE DATE.—The amendments made by this section 
shall take effect as of June 30, 2008. 
Subtitle D—Provisions Relating to Part C 
SEC. 161. PHASE-OUT OF INDIRECT MEDICAL EDUCATION (IME). 
(a) IN GENERAL.—Section 1853(k) of the Social Security Act 
(42 U.S.C. 1395w–23(k)) is amended— 
(1) in paragraph (1), in the matter preceding subparagraph 
(A), by striking ‘‘paragraph (2)’’ and inserting ‘‘paragraphs (2) 
and (4)’’; and 
(2) by adding at the end the following new paragraph: 
‘‘(4) PHASE-OUT OF THE INDIRECT COSTS OF MEDICAL EDU-
CATION FROM CAPITATION RATES.— 
‘‘(A) IN
GENERAL.—After determining the applicable 
amount for an area for a year under paragraph (1) (begin-
ning with 2010), the Secretary shall adjust such applicable 
amount to exclude from such applicable amount the phase- 
in percentage (as defined in subparagraph (B)(i)) for the 
year of the Secretary’s estimate of the standardized costs 
for payments under section 1886(d)(5)(B) in the area for 
42 USC 1395m 
note. 
Reports. 
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122 STAT. 2569 
PUBLIC LAW 110–275—JULY 15, 2008 
the year. Any adjustment under the preceding sentence 
shall be made prior to the application of paragraph (2). 
‘‘(B) PERCENTAGES
DEFINED.—For purposes of this 
paragraph: 
‘‘(i) PHASE-IN
PERCENTAGE.—The term ‘phase-in 
percentage’ means, for an area for a year, the ratio 
(expressed as a percentage, but in no case greater 
than 100 percent) of— 
‘‘(I) the maximum cumulative adjustment 
percentage for the year (as defined in clause (ii)); 
to 
‘‘(II) the standardized IME cost percentage (as 
defined in clause (iii)) for the area and year. 
‘‘(ii) MAXIMUM CUMULATIVE ADJUSTMENT PERCENT-
AGE.—The term ‘maximum cumulative adjustment 
percentage’ means, for— 
‘‘(I) 2010, 0.60 percent; and 
‘‘(II) a subsequent year, the maximum cumu-
lative adjustment percentage for the previous year 
increased by 0.60 percentage points. 
‘‘(iii) STANDARDIZED IME COST PERCENTAGE.—The 
term ‘standardized IME cost percentage’ means, for 
an area for a year, the per capita costs for payments 
under section 1886(d)(5)(B) (expressed as a percentage 
of the fee-for-service amount specified in subparagraph 
(C)) for the area and the year. 
‘‘(C) FEE-FOR-SERVICE
AMOUNT.—The fee-for-service 
amount specified in this subparagraph for an area for 
a year is the amount specified under subsection (c)(1)(D) 
for the area and the year.’’. 
(b) EXCLUDING
ADJUSTMENT
FROM
THE
UPDATE.—Section 
1853(k)(1)(B)(i) of the Social Security Act (42 U.S.C. 1395w– 
23(k)(1)(B)(i)) is amended by striking ‘‘paragraph (2)’’ and inserting 
‘‘paragraphs (2) and (4)’’. 
(c) HOLD HARMLESS FOR PACE PROGRAM PAYMENTS.—Section 
1894(d) of the Social Security Act (42 U.S.C. 1395eee(d)) is amended 
by adding at the end the following new paragraph: 
‘‘(3) CAPITATION RATES DETERMINED WITHOUT REGARD TO 
THE PHASE-OUT OF THE INDIRECT COSTS OF MEDICAL EDUCATION 
FROM THE ANNUAL MEDICARE ADVANTAGE CAPITATION RATE.— 
Capitation amounts under this subsection shall be determined 
without regard to the application of section 1853(k)(4).’’. 
SEC. 162. REVISIONS TO REQUIREMENTS FOR MEDICARE ADVANTAGE 
PRIVATE FEE-FOR-SERVICE PLANS. 
(a) REQUIREMENTS TO ASSURE ACCESS
TO NETWORK COV-
ERAGE.— 
(1) INDIVIDUAL
MARKET.—Section 1852(d) of the Social 
Security Act (42 U.S.C. 1395w–22(d)) is amended— 
(A) in paragraph (4), in the second sentence, by striking 
‘‘The Secretary’’ and inserting ‘‘Subject to paragraph (5), 
the Secretary’’; and 
(B) by adding at the end the following new paragraph: 
‘‘(5) REQUIREMENT
OF
CERTAIN
NONEMPLOYER
MEDICARE 
ADVANTAGE PRIVATE FEE-FOR-SERVICE PLANS TO USE CONTRACTS 
WITH PROVIDERS.— 
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122 STAT. 2570 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(A) IN GENERAL.—For plan year 2011 and subsequent 
plan years, in the case of a Medicare Advantage private 
fee-for-service plan not described in paragraph (1) or (2) 
of section 1857(i) operating in a network area (as defined 
in subparagraph (B)), the plan shall meet the access stand-
ards under paragraph (4) in that area only through 
entering into written contracts as provided for under 
subparagraph (B) of such paragraph and not, in whole 
or in part, through the establishment of payment rates 
meeting the requirements under subparagraph (A) of such 
paragraph. 
‘‘(B) 
NETWORK
AREA
DEFINED.—For 
purposes 
of 
subparagraph (A), the term ‘network area’ means, for a 
plan year, an area which the Secretary identifies (in the 
Secretary’s announcement of the proposed payment rates 
for the previous plan year under section 1853(b)(1)(B)) as 
having at least 2 network-based plans (as defined in 
subparagraph (C)) with enrollment under this part as of 
the first day of the year in which such announcement 
is made. 
‘‘(C) NETWORK-BASED PLAN DEFINED.— 
‘‘(i) IN GENERAL.—For purposes of subparagraph 
(B), the term ‘network-based plan’ means— 
‘‘(I) except as provided in clause (ii), a Medi-
care Advantage plan that is a coordinated care 
plan described in section 1851(a)(2)(A)(i); 
‘‘(II) a network-based MSA plan; and 
‘‘(III) a reasonable cost reimbursement plan 
under section 1876. 
‘‘(ii) 
EXCLUSION
OF
NON-NETWORK
REGIONAL 
PPOS.—The term ‘network-based plan’ shall not include 
an MA regional plan that, with respect to the area, 
meets access adequacy standards under this part 
substantially 
through 
the 
authority 
of 
section 
422.112(a)(1)(ii) of title 42, Code of Federal Regula-
tions, rather than through written contracts.’’. 
(2) EMPLOYER PLANS.—Section 1852(d) of the Social Secu-
rity Act (42 U.S.C. 1395w–22(d)), as amended by paragraph 
(1), is amended— 
(A) in paragraph (4), in the second sentence, by striking 
‘‘paragraph (5)’’ and inserting ‘‘paragraphs (5) and (6)’’; 
and 
(B) by adding at the end the following new paragraph: 
‘‘(6) REQUIREMENT OF ALL EMPLOYER MEDICARE ADVANTAGE 
PRIVATE FEE-FOR-SERVICE PLANS TO USE CONTRACTS WITH PRO-
VIDERS.—For plan year 2011 and subsequent plan years, in 
the case of a Medicare Advantage private fee-for-service plan 
that is described in paragraph (1) or (2) of section 1857(i), 
the plan shall meet the access standards under paragraph 
(4) only through entering into written contracts as provided 
for under subparagraph (B) of such paragraph and not, in 
whole or in part, through the establishment of payment rates 
meeting the requirements under subparagraph (A) of such para-
graph.’’. 
(3) ACCESS REQUIREMENTS.— 
(A) IN GENERAL.—Section 1852(d)(4)(B) of the Social 
Security Act (42 U.S.C. 1395w–22(d)(4)(B)) is amended by 
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122 STAT. 2571 
PUBLIC LAW 110–275—JULY 15, 2008 
striking ‘‘a sufficient number’’ through ‘‘terms of the plan’’ 
and inserting ‘‘a sufficient number and range of providers 
within such category to meet the access standards in sub-
paragraphs (A) through (E) of paragraph (1)’’. 
(B) EFFECTIVE
DATE.—The amendment made by 
subparagraph (A) shall apply to plan year 2010 and subse-
quent plan years. 
(b) CLARIFICATION REGARDING UTILIZATION.—Section 1859(b)(2) 
of the Social Security Act (42 U.S.C. 1395w–28(b)(2)) is amended 
by adding at the end the following flush sentence: 
‘‘Nothing in subparagraph (B) shall be construed to preclude 
a plan from varying rates for such a provider based on the 
specialty of the provider, the location of the provider, or other 
factors related to such provider that are not related to utiliza-
tion, or to preclude a plan from increasing rates for such 
a provider based on increased utilization of specified preventive 
or screening services.’’. 
SEC. 163. REVISIONS TO QUALITY IMPROVEMENT PROGRAMS. 
(a) REQUIREMENT FOR MA PRIVATE FEE-FOR-SERVICE AND MSA 
PLANS
TO
HAVE
A
QUALITY
IMPROVEMENT
PROGRAM.—Section 
1852(e)(1) of the Social Security Act (42 U.S.C. 1395w–22(e)(1)) 
is amended by striking ‘‘(other than an MA private fee-for-service 
plan or an MSA plan)’’. 
(b) DATA COLLECTION REQUIREMENTS FOR MA REGIONAL PLANS, 
MA PRIVATE FEE-FOR-SERVICE PLANS, AND MSA PLANS.—Section 
1852(e)(3)(A) of the Social Security Act (42 U.S.C. 1395w– 
22(e)(3)(A)) is amended— 
(1) in clause (i), by adding at the end the following new 
sentence: ‘‘With respect to MA private fee-for-service plans and 
MSA plans, the requirements under the preceding sentence 
may not exceed the requirements under this subparagraph 
with respect to MA local plans that are preferred provider 
organization plans, except that, for plan year 2010, the limita-
tion under clause (iii) shall not apply and such requirements 
shall apply only with respect to administrative claims data.’’ 
(2) by striking clause (ii); and 
(3) in clause (iii)— 
(A) in the heading— 
(i) by inserting ‘‘LOCAL’’ after ‘‘TO’’; and 
(ii) by inserting ‘‘AND MA REGIONAL PLANS’’ after 
‘‘ORGANIZATIONS’’; and 
(B) by inserting ‘‘and to MA regional plans’’ after 
‘‘organization plans’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply to plan years beginning on or after January 1, 2010. 
SEC. 164. REVISIONS RELATING TO SPECIALIZED MEDICARE ADVAN-
TAGE PLANS FOR SPECIAL NEEDS INDIVIDUALS. 
(a) EXTENSION OF AUTHORITY TO RESTRICT ENROLLMENT.—Sec-
tion 1859(f) of the Social Security Act (42 U.S.C. 1395w–28(f)), 
as amended by section 108(a) of the Medicare, Medicaid, and SCHIP 
Extension Act of 2007 (Public Law 110–173) is amended by striking 
‘‘2010’’ and inserting ‘‘2011’’. 
(b) MORATORIUM ON AUTHORITY TO DESIGNATE OTHER PLANS 
AS
SPECIALIZED
MA PLANS.—During the period beginning on 
January 1, 2010, and ending on December 31, 2010, the Secretary 
of Health and Human Services may not exercise the authority 
Time period. 
42 USC 
1395w–21 note. 
42 USC 
1395w–22 note. 
42 USC 
1395w–22 note. 
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122 STAT. 2572 
PUBLIC LAW 110–275—JULY 15, 2008 
provided under section 231(d) of the Medicare Prescription Drug, 
Improvement, and Modernization Act of 2003 (42 U.S.C. 1395w– 
21 note) to designate other plans as specialized MA plans for 
special needs individuals. 
(c) REQUIREMENTS FOR ENROLLMENT.— 
(1) IN GENERAL.—Section 1859 of the Social Security Act 
(42 U.S.C. 1395w–28) is amended— 
(A) in subsection (b)(6)(A), by inserting ‘‘and that, as 
of January 1, 2010, meets the applicable requirements 
of paragraph (2), (3), or (4) of subsection (f), as the case 
may be’’ before the period at the end; and 
(B) in subsection (f)— 
(i) by amending the heading to read as follows: 
‘‘REQUIREMENTS REGARDING ENROLLMENT IN SPECIAL-
IZED MA PLANS FOR SPECIAL NEEDS INDIVIDUALS’’; 
(ii) by designating the sentence beginning ‘‘In the 
case of’’ as paragraph (1) with the heading ‘‘REQUIRE-
MENTS
FOR
ENROLLMENT.—’’ and with appropriate 
indentation; and 
(iii) by adding at the end the following new para-
graphs: 
‘‘(2) ADDITIONAL REQUIREMENTS FOR INSTITUTIONAL SNPS.— 
In the case of a specialized MA plan for special needs individ-
uals described in subsection (b)(6)(B)(i), the applicable require-
ments described in this paragraph are as follows: 
‘‘(A) Each individual that enrolls in the plan on or 
after January 1, 2010, is a special needs individuals 
described in subsection (b)(6)(B)(i). In the case of an indi-
vidual who is living in the community but requires an 
institutional level of care, such individual shall not be 
considered a special needs individual described in sub-
section (b)(6)(B)(i) unless the determination that the indi-
vidual requires an institutional level of care was made— 
‘‘(i) using a State assessment tool of the State 
in which the individual resides; and 
‘‘(ii) by an entity other than the organization 
offering the plan. 
‘‘(B) The plan meets the requirements described in 
paragraph (5). 
‘‘(3) ADDITIONAL REQUIREMENTS FOR DUAL SNPS.—In the 
case of a specialized MA plan for special needs individuals 
described in subsection (b)(6)(B)(ii), the applicable requirements 
described in this paragraph are as follows: 
‘‘(A) Each individual that enrolls in the plan on or 
after January 1, 2010, is a special needs individuals 
described in subsection (b)(6)(B)(ii). 
‘‘(B) The plan meets the requirements described in 
paragraph (5). 
‘‘(C) The plan provides each prospective enrollee, prior 
to enrollment, with a comprehensive written statement 
(using standardized content and format established by the 
Secretary) that describes— 
‘‘(i) the benefits and cost-sharing protections that 
the individual is entitled to under the State Medicaid 
program under title XIX; and 
‘‘(ii) which of such benefits and cost-sharing protec-
tions are covered under the plan. 
Effective date. 
Effective date. 
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122 STAT. 2573 
PUBLIC LAW 110–275—JULY 15, 2008 
Such statement shall be included with any description of 
benefits offered by the plan. 
‘‘(D) The plan has a contract with the State Medicaid 
agency to provide benefits, or arrange for benefits to be 
provided, for which such individual is entitled to receive 
as medical assistance under title XIX. Such benefits may 
include long-term care services consistent with State policy. 
‘‘(4) ADDITIONAL REQUIREMENTS FOR SEVERE OR DISABLING 
CHRONIC CONDITION SNPS.—In the case of a specialized MA 
plan for special needs individuals described in subsection 
(b)(6)(B)(iii), the applicable requirements described in this para-
graph are as follows: 
‘‘(A) Each individual that enrolls in the plan on or 
after January 1, 2010, is a special needs individual 
described in subsection (b)(6)(B)(iii). 
‘‘(B) The plan meets the requirements described in 
paragraph (5).’’. 
(2) AUTHORITY TO OPERATE BUT NO SERVICE AREA EXPAN-
SION FOR DUAL SNPS THAT DO NOT MEET CERTAIN REQUIRE-
MENTS.—Notwithstanding subsection (f) of section 1859 of the 
Social Security Act (42 U.S.C. 1395w–28), during the period 
beginning on January 1, 2010, and ending on December 31, 
2010, in the case of a specialized Medicare Advantage plan 
for special needs individuals described in subsection (b)(6)(B)(ii) 
of such section, as amended by this section, that does not 
meet the requirement described in subsection (f)(3)(D) of such 
section, the Secretary of Health and Human Services— 
(A) shall permit such plan to be offered under part 
C of title XVIII of such Act; and 
(B) shall not permit an expansion of the service area 
of the plan under such part C. 
(3) RESOURCES FOR STATE MEDICAID AGENCIES.—The Sec-
retary of Health and Human Services shall provide for the 
designation of appropriate staff and resources that can address 
State inquiries with respect to the coordination of State and 
Federal policies for specialized MA plans for special needs 
individuals described in section 1859(b)(6)(B)(ii) of the Social 
Security Act (42 U.S.C. 1395w–28(b)(6)(B)(ii)), as amended by 
this section. 
(4) NO REQUIREMENT FOR CONTRACT.—Nothing in the provi-
sions of, or amendments made by, this subsection shall require 
a State to enter into a contract with a Medicare Advantage 
organization with respect to a specialized MA plan for special 
needs individuals described in section 1859(b)(6)(B)(ii) of the 
Social Security Act (42 U.S.C. 1395w–28(b)(6)(B)(ii)), as 
amended by this section. 
(d) CARE MANAGEMENT REQUIREMENTS FOR ALL SNPS.— 
(1) REQUIREMENTS.—Section 1859(f) of the Social Security 
Act (42 U.S.C. 1395w–28(f)), as amended by subsection (c)(1), 
is amended by adding at the end the following new paragraph: 
‘‘(5) CARE MANAGEMENT REQUIREMENTS FOR ALL SNPS.— 
The requirements described in this paragraph are that the 
organization offering a specialized MA plan for special needs 
individuals described in subsection (b)(6)(B)(i)— 
‘‘(A) have in place an evidenced-based model of care 
with appropriate networks of providers and specialists; and 
Time period. 
42 USC 
1395w–28 note. 
Effective date. 
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122 STAT. 2574 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(B) with respect to each individual enrolled in the 
plan— 
‘‘(i) conduct an initial assessment and an annual 
reassessment of the individual’s physical, psychosocial, 
and functional needs; 
‘‘(ii) develop a plan, in consultation with the indi-
vidual as feasible, that identifies goals and objectives, 
including measurable outcomes as well as specific serv-
ices and benefits to be provided; and 
‘‘(iii) use an interdisciplinary team in the manage-
ment of care.’’. 
(2) REVIEW TO ENSURE COMPLIANCE WITH CARE MANAGE-
MENT REQUIREMENTS.—Section 1857(d) of the Social Security 
Act (42 U.S.C. 1395w–27(d)) is amended by adding at the 
end the following new paragraph: 
‘‘(6) REVIEW TO ENSURE COMPLIANCE WITH CARE MANAGE-
MENT REQUIREMENTS FOR SPECIALIZED MEDICARE ADVANTAGE 
PLANS FOR SPECIAL NEEDS INDIVIDUALS.—In conjunction with 
the periodic audit of a specialized Medicare Advantage plan 
for special needs individuals under paragraph (1), the Secretary 
shall conduct a review to ensure that such organization offering 
the plan meets the requirements described in section 
1859(f)(5).’’. 
(e) CLARIFICATION OF THE DEFINITION OF A SEVERE OR DIS-
ABLING CHRONIC CONDITIONS SPECIALIZED NEEDS INDIVIDUAL.— 
(1) IN
GENERAL.—Section 1859(b)(6)(B)(iii) of the Social 
Security Act (42 U.S.C. 1395w–28(b)(6)(B)(iii)) is amended by 
inserting ‘‘who have one or more comorbid and medically com-
plex chronic conditions that are substantially disabling or life 
threatening, have a high risk of hospitalization or other signifi-
cant adverse health outcomes, and require specialized delivery 
systems across domains of care’’ before the period at the end. 
(2) PANEL.—The Secretary of Health and Human Services 
shall convene a panel of clinical advisors to determine the 
conditions that meet the definition of severe and disabling 
chronic conditions under section 1859(b)(6)(B)(iii) of the Social 
Security Act (42 U.S.C. 1395w–28(b)(6)(B)(iii)), as amended by 
paragraph (1). The panel shall include the Director of the 
Agency for Healthcare Research and Quality (or the Director’s 
designee). 
(f) SPECIAL REQUIREMENTS REGARDING QUALITY REPORTING FOR 
SPECIALIZED MA PLANS FOR SPECIAL NEEDS INDIVIDUALS.— 
(1) IN GENERAL.—Section 1852(e)(3)(A) of the Social Secu-
rity Act (42 U.S.C. 1395w–22(e)(3)(A)), as amended by section 
163, is amended by inserting after clause (i) the following 
new clause: 
‘‘(ii) SPECIAL REQUIREMENTS FOR SPECIALIZED MA 
PLANS FOR SPECIAL NEEDS INDIVIDUALS.—In addition 
to the data required to be collected, analyzed, and 
reported under clause (i) and notwithstanding the 
limitations under subparagraph (B), as part of the 
quality improvement program under paragraph (1), 
each MA organization offering a specialized Medicare 
Advantage plan for special needs individuals shall pro-
vide for the collection, analysis, and reporting of data 
that permits the measurement of health outcomes and 
Establishment. 
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122 STAT. 2575 
PUBLIC LAW 110–275—JULY 15, 2008 
other indices of quality with respect to the require-
ments described in paragraphs (2) through (5) of sub-
section (f). Such data may be based on claims data 
and shall be at the plan level.’’. 
(2) EFFECTIVE DATE.—The amendment made by paragraph 
(1) shall take effect on a date specified by the Secretary of 
Health and Human Services (but in no case later than January 
1, 2010), and shall apply to all specialized Medicare Advantage 
plans for special needs individuals regardless of when the plan 
first entered the Medicare Advantage program under part C 
of title XVIII of the Social Security Act. 
(g) EFFECTIVE DATE AND APPLICATION.—The amendments made 
by subsections (c)(1), (d), and (e)(1) shall apply to plan years begin-
ning on or after January 1, 2010, and shall apply to all specialized 
Medicare Advantage plans for special needs individuals regardless 
of when the plan first entered the Medicare Advantage program 
under part C of title XVIII of the Social Security Act. 
(h) NO AFFECT ON MEDICAID BENEFITS FOR DUALS.—Nothing 
in the provisions of, or amendments made by, this section shall 
affect the benefits available under the Medicaid program under 
title XIX of the Social Security Act for special needs individuals 
described in section 1859(b)(6)(B)(ii) of such Act (42 U.S.C. 1395w– 
28(b)(6)(B)(ii)). 
SEC. 165. LIMITATION ON OUT-OF-POCKET COSTS FOR DUAL ELIGI-
BLES 
AND 
QUALIFIED 
MEDICARE 
BENEFICIARIES 
ENROLLED IN A SPECIALIZED MEDICARE ADVANTAGE 
PLAN FOR SPECIAL NEEDS INDIVIDUALS. 
(a) IN GENERAL.—Section 1852(a) of the Social Security Act 
(42 U.S.C. 1395w–22(a)) is amended by adding at the end the 
following new paragraph: 
‘‘(7) LIMITATION ON COST-SHARING FOR DUAL ELIGIBLES AND 
QUALIFIED MEDICARE BENEFICIARIES.—In the case of an indi-
vidual who is a full-benefit dual eligible individual (as defined 
in section 1935(c)(6)) or a qualified medicare beneficiary (as 
defined in section 1905(p)(1)) and who is enrolled in a special-
ized Medicare Advantage plan for special needs individuals 
described in section 1859(b)(6)(B)(ii), the plan may not impose 
cost-sharing that exceeds the amount of cost-sharing that would 
be permitted with respect to the individual under title XIX 
if the individual were not enrolled in such plan.’’. 
(b) EFFECTIVE DATE.—The amendment made by subsection (a) 
shall apply to plan years beginning on or after January 1, 2010. 
SEC. 166. ADJUSTMENT TO THE MEDICARE ADVANTAGE STABILIZA-
TION FUND. 
Section 1858(e)(2)(A)(i) of the Social Security Act (42 U.S.C. 
1395w–27a(e)(2)(A)(i)), as amended by section 110 of the Medicare, 
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110– 
173), is amended— 
(1) by striking ‘‘2013’’ and inserting ‘‘2014’’; and 
(2) by striking ‘‘$1,790,000,000’’ and inserting ‘‘$1’’. 
SEC. 167. ACCESS TO MEDICARE REASONABLE COST CONTRACT PLANS. 
(a) EXTENSION
OF REASONABLE COST CONTRACTS.—Section 
1876(h)(5)(C)(ii) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395mm(h)(5)(C)(ii)), as amended by section 109 of the Medicare, 
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110– 
42 USC 
1395w–22 note. 
42 USC 
1395w–28 note. 
42 USC 
1395w–27 note. 
42 USC 
1395w–22 note. 
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122 STAT. 2576 
PUBLIC LAW 110–275—JULY 15, 2008 
173), is amended by striking ‘‘January 1, 2009’’ and inserting 
‘‘January 1, 2010’’ in the matter preceding subclause (I). 
(b) REQUIREMENT FOR AT LEAST TWO MEDICARE ADVANTAGE 
ORGANIZATIONS TO BE OFFERING A PLAN IN AN AREA FOR THE 
PROHIBITION TO BE APPLICABLE.—Subclauses (I) and (II) of section 
1876(h)(5)(C)(ii) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395mm(h)(5)(C)(ii)) are each amended by inserting ‘‘, provided 
that all such plans are not offered by the same Medicare Advantage 
organization’’ after ‘‘clause (iii)’’. 
(c) REVISION OF REQUIREMENTS FOR A PLAN THAT ARE USED 
TO DETERMINE IF PROHIBITION IS APPLICABLE.— 
(1) IN GENERAL.—Section 1876(h)(5)(C)(iii)(I) of the Social 
Security Act (42 U.S.C. 1395mm(h)(5)(C)(iii)(I)) is amended by 
inserting ‘‘that are not in another Metropolitan Statistical Area 
with a population of more than 250,000’’ after ‘‘such Metropoli-
tan Statistical Area’’. 
(2) CLARIFICATION.—Section 1876(h)(5)(C)(iii)(I) of the 
Social Security Act (42 U.S.C. 1395mm(h)(5)(C)(iii)(I)) is 
amended by adding at the end the following new sentence: 
‘‘If the service area includes a portion in more than 1 Metropoli-
tan Statistical Area with a population of more than 250,000, 
the minimum enrollment determination under the preceding 
sentence shall be made with respect to each such Metropolitan 
Statistical Area (and such applicable contiguous counties to 
such Metropolitan Statistical Area).’’. 
(d) GAO STUDY AND REPORT.— 
(1) STUDY.—The Comptroller General of the United States 
shall conduct a study of the reasons (if any) why reasonable 
cost contracts under section 1876(h) of the Social Security Act 
(42 U.S.C. 1395mm(h)) are unable to become Medicare Advan-
tage plans under part C of title XVIII of such Act. 
(2) REPORT.—Not later than December 31, 2009, the Comp-
troller General of the United States shall submit to Congress 
a report containing the results of the study conducted under 
paragraph (1), together with recommendations for such legisla-
tion and administrative action as the Comptroller General 
determines appropriate. 
SEC. 168. MEDPAC STUDY AND REPORT ON QUALITY MEASURES. 
(a) STUDY.—The Medicare Payment Advisory Commission shall 
conduct a study on how comparable measures of performance and 
patient experience can be collected and reported by 2011 for the 
Medicare Advantage program under part C of title XVIII of the 
Social Security Act and the original Medicare fee-for-service pro-
gram under parts A and B of such title. Such study shall address 
technical issues, such as data requirements, in addition to issues 
relating to appropriate quality benchmarks that— 
(1) compare the quality of care Medicare beneficiaries 
receive across Medicare Advantage plans; and 
(2) compare the quality of care Medicare beneficiaries 
receive under Medicare Advantage plans and under the original 
Medicare fee-for-service program. 
(b) REPORT.—Not later than March 31, 2010, the Medicare 
Payment Advisory Commission shall submit to Congress a report 
containing the results of the study conducted under subsection 
(a), together with recommendations for such legislation and 
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122 STAT. 2577 
PUBLIC LAW 110–275—JULY 15, 2008 
administrative action as the Medicare Payment Advisory Commis-
sion determines appropriate. 
SEC. 169. MEDPAC STUDY AND REPORT ON MEDICARE ADVANTAGE 
PAYMENTS. 
(a) STUDY.—The Medicare Payment Advisory Commission (in 
this section referred to as the ‘‘Commission’’) shall conduct a study 
of the following: 
(1) The correlation between— 
(A) the costs that Medicare Advantage organizations 
with respect to Medicare Advantage plans incur in pro-
viding coverage under the plan for items and services cov-
ered under the original Medicare fee-for-service program 
under parts A and B of title XVIII of the Social Security 
Act, as reflected in plan bids; and 
(B) county-level spending under such original Medicare 
fee-for-service program on a per capita basis, as calculated 
by the Chief Actuary of the Centers for Medicare & Med-
icaid Services. 
The study with respect to the issue described in the preceding 
sentence shall include differences in correlation statistics by 
plan type and geographic area. 
(2) Based on these results of the study with respect to 
the issue described in paragraph (1), and other data the 
Commission determines appropriate— 
(A) alternate approaches to payment with respect to 
a Medicare beneficiary enrolled in a Medicare Advantage 
plan other than through county-level payment area equiva-
lents. 
(B) the accuracy and completeness of county-level esti-
mates of per capita spending under such original Medicare 
fee-for-service program (including counties in Puerto Rico), 
as used to determine the annual Medicare Advantage capi-
tation rate under section 1853 of the Social Security Act 
(42 U.S.C. 1395w–23), and whether such estimates 
include— 
(i) expenditures with respect to Medicare bene-
ficiaries at facilities of the Department of Veterans 
Affairs; and 
(ii) 
all 
appropriate 
administrative 
expenses, 
including claims processing. 
(3) Ways to improve the accuracy and completeness of 
county-level estimates of per capita spending described in para-
graph (2)(B). 
(b) REPORT.—Not later than March 31, 2010, the Commission 
shall submit to Congress a report containing the results of the 
study conducted under subsection (a), together with recommenda-
tions for such legislation and administrative action as the Commis-
sion determines appropriate. 
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122 STAT. 2578 
PUBLIC LAW 110–275—JULY 15, 2008 
Subtitle E—Provisions Relating to Part D 
PART I—IMPROVING PHARMACY ACCESS 
SEC. 171. PROMPT PAYMENT BY PRESCRIPTION DRUG PLANS AND 
MA–PD PLANS UNDER PART D. 
(a) PROMPT PAYMENT BY PRESCRIPTION DRUG PLANS.—Section 
1860D–12(b) of the Social Security Act (42 U.S.C. 1395w–112(b)) 
is amended by adding at the end the following new paragraph: 
‘‘(4) PROMPT PAYMENT OF CLEAN CLAIMS.— 
‘‘(A) PROMPT PAYMENT.— 
‘‘(i) IN GENERAL.—Each contract entered into with 
a PDP sponsor under this part with respect to a 
prescription drug plan offered by such sponsor shall 
provide that payment shall be issued, mailed, or other-
wise transmitted with respect to all clean claims sub-
mitted by pharmacies (other than pharmacies that dis-
pense drugs by mail order only or are located in, or 
contract with, a long-term care facility) under this 
part within the applicable number of calendar days 
after the date on which the claim is received. 
‘‘(ii) CLEAN
CLAIM
DEFINED.—In this paragraph, 
the term ‘clean claim’ means a claim that has no defect 
or impropriety (including any lack of any required 
substantiating 
documentation) 
or 
particular 
cir-
cumstance requiring special treatment that prevents 
timely payment from being made on the claim under 
this part. 
‘‘(iii) DATE OF RECEIPT OF CLAIM.—In this para-
graph, a claim is considered to have been received— 
‘‘(I) with respect to claims submitted electroni-
cally, on the date on which the claim is transferred; 
and 
‘‘(II) with respect to claims submitted other-
wise, on the 5th day after the postmark date of 
the claim or the date specified in the time stamp 
of the transmission. 
‘‘(B) 
APPLICABLE
NUMBER
OF
CALENDAR
DAYS 
DEFINED.—In this paragraph, the term ‘applicable number 
of calendar days’ means— 
‘‘(i) with respect to claims submitted electronically, 
14 days; and 
‘‘(ii) with respect to claims submitted otherwise, 
30 days. 
‘‘(C) INTEREST PAYMENT.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), if payment 
is not issued, mailed, or otherwise transmitted within 
the applicable number of calendar days (as defined 
in subparagraph (B)) after a clean claim is received, 
the PDP sponsor shall pay interest to the pharmacy 
that submitted the claim at a rate equal to the 
weighted average of interest on 3-month marketable 
Treasury securities determined for such period, 
increased by 0.1 percentage point for the period begin-
ning on the day after the required payment date and 
ending on the date on which payment is made (as 
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122 STAT. 2579 
PUBLIC LAW 110–275—JULY 15, 2008 
determined under subparagraph (D)(iv)). Interest 
amounts paid under this subparagraph shall not be 
counted against the administrative costs of a prescrip-
tion drug plan or treated as allowable risk corridor 
costs under section 1860D–15(e). 
‘‘(ii) AUTHORITY NOT TO CHARGE INTEREST.—The 
Secretary may provide that a PDP sponsor is not 
charged interest under clause (i) in the case where 
there are exigent circumstances, including natural 
disasters and other unique and unexpected events, that 
prevent the timely processing of claims. 
‘‘(D) PROCEDURES INVOLVING CLAIMS.— 
‘‘(i) CLAIM
DEEMED
TO
BE
CLEAN.—A claim is 
deemed to be a clean claim if the PDP sponsor involved 
does not provide notice to the claimant of any deficiency 
in the claim— 
‘‘(I) with respect to claims submitted electroni-
cally, within 10 days after the date on which the 
claim is received; and 
‘‘(II) with respect to claims submitted other-
wise, within 15 days after the date on which the 
claim is received. 
‘‘(ii) CLAIM
DETERMINED
TO
NOT
BE
A
CLEAN 
CLAIM.— 
‘‘(I) IN GENERAL.—If a PDP sponsor determines 
that a submitted claim is not a clean claim, the 
PDP sponsor shall, not later than the end of the 
period described in clause (i), notify the claimant 
of such determination. Such notification shall 
specify all defects or improprieties in the claim 
and shall list all additional information or docu-
ments necessary for the proper processing and pay-
ment of the claim. 
‘‘(II) DETERMINATION
AFTER
SUBMISSION
OF 
ADDITIONAL INFORMATION.—A claim is deemed to 
be a clean claim under this paragraph if the PDP 
sponsor involved does not provide notice to the 
claimant of any defect or impropriety in the claim 
within 10 days of the date on which additional 
information is received under subclause (I). 
‘‘(iii) OBLIGATION TO PAY.—A claim submitted to 
a PDP sponsor that is not paid or contested by the 
sponsor within the applicable number of days (as 
defined in subparagraph (B)) after the date on which 
the claim is received shall be deemed to be a clean 
claim and shall be paid by the PDP sponsor in accord-
ance with subparagraph (A). 
‘‘(iv) DATE
OF
PAYMENT
OF
CLAIM.—Payment of 
a clean claim under such subparagraph is considered 
to have been made on the date on which— 
‘‘(I) with respect to claims paid electronically, 
the payment is transferred; and 
‘‘(II) with respect to claims paid otherwise, 
the payment is submitted to the United States 
Postal Service or common carrier for delivery. 
Notice. 
Deadlines. 
Notice. 
Deadlines. 
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122 STAT. 2580 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(E) ELECTRONIC TRANSFER OF FUNDS.—A PDP sponsor 
shall pay all clean claims submitted electronically by elec-
tronic transfer of funds if the pharmacy so requests or 
has so requested previously. In the case where such pay-
ment is made electronically, remittance may be made by 
the PDP sponsor electronically as well. 
‘‘(F) PROTECTING THE RIGHTS OF CLAIMANTS.— 
‘‘(i) IN GENERAL.—Nothing in this paragraph shall 
be construed to prohibit or limit a claim or action 
not covered by the subject matter of this section that 
any individual or organization has against a provider 
or a PDP sponsor. 
‘‘(ii) 
ANTI-RETALIATION.—Consistent 
with 
applicable Federal or State law, a PDP sponsor shall 
not retaliate against an individual or provider for exer-
cising a right of action under this subparagraph. 
‘‘(G) RULE OF CONSTRUCTION.—A determination under 
this paragraph that a claim submitted by a pharmacy 
is a clean claim shall not be construed as a positive deter-
mination regarding eligibility for payment under this title, 
nor is it an indication of government approval of, or 
acquiescence regarding, the claim submitted. The deter-
mination shall not relieve any party of civil or criminal 
liability with respect to the claim, nor does it offer a defense 
to any administrative, civil, or criminal action with respect 
to the claim.’’. 
(b) PROMPT PAYMENT BY MA–PD PLANS.—Section 1857(f) of 
the Social Security Act (42 U.S.C. 1395w–27) is amended by adding 
at the end the following new paragraph: 
‘‘(3) INCORPORATION OF CERTAIN PRESCRIPTION DRUG PLAN 
CONTRACT REQUIREMENTS.—The following provisions shall apply 
to contracts with a Medicare Advantage organization offering 
an MA–PD plan in the same manner as they apply to contracts 
with a PDP sponsor offering a prescription drug plan under 
part D: 
‘‘(A) PROMPT PAYMENT.—Section 1860D–12(b)(4).’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply to plan years beginning on or after January 1, 2010. 
SEC. 172. SUBMISSION OF CLAIMS BY PHARMACIES LOCATED IN OR 
CONTRACTING WITH LONG-TERM CARE FACILITIES. 
(a) SUBMISSION
OF CLAIMS
BY PHARMACIES LOCATED
IN
OR 
CONTRACTING WITH LONG-TERM CARE FACILITIES.— 
(1) SUBMISSION OF CLAIMS TO PRESCRIPTION DRUG PLANS.— 
Section 1860D–12(b) of the Social Security Act (42 U.S.C. 
1395w–112(b)), as amended by section 171(a), is amended by 
adding at the end the following new paragraph: 
‘‘(5) SUBMISSION OF CLAIMS BY PHARMACIES LOCATED IN 
OR CONTRACTING WITH LONG-TERM CARE FACILITIES.—Each con-
tract entered into with a PDP sponsor under this part with 
respect to a prescription drug plan offered by such sponsor 
shall provide that a pharmacy located in, or having a contract 
with, a long-term care facility shall have not less than 30 
days (but not more than 90 days) to submit claims to the 
sponsor for reimbursement under the plan.’’. 
(2) SUBMISSION
OF
CLAIMS
TO
MA–PD
PLANS.—Section 
1857(f)(3) of the Social Security Act, as added by section 171(b), 
Deadline. 
42 USC 
1395w–27 note. 
Applicability. 
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122 STAT. 2581 
PUBLIC LAW 110–275—JULY 15, 2008 
is amended by adding at the end the following new subpara-
graph: 
‘‘(B) SUBMISSION OF CLAIMS BY PHARMACIES LOCATED 
IN OR CONTRACTING WITH LONG-TERM CARE FACILITIES.— 
Section 1860D–12(b)(5).’’. 
(b) EFFECTIVE DATE.—The amendments made by this section 
shall apply to plan years beginning on or after January 1, 2010. 
SEC. 173. REGULAR UPDATE OF PRESCRIPTION DRUG PRICING 
STANDARD. 
(a) REQUIREMENT
FOR PRESCRIPTION DRUG PLANS.—Section 
1860D–12(b) of the Social Security Act (42 U.S.C. 1395w–112(b)), 
as amended by section 172(a)(1), is amended by adding at the 
end the following new paragraph: 
‘‘(6) REGULAR
UPDATE
OF
PRESCRIPTION
DRUG
PRICING 
STANDARD.—If the PDP sponsor of a prescription drug plan 
uses a standard for reimbursement of pharmacies based on 
the cost of a drug, each contract entered into with such sponsor 
under this part with respect to the plan shall provide that 
the sponsor shall update such standard not less frequently 
than once every 7 days, beginning with an initial update on 
January 1 of each year, to accurately reflect the market price 
of acquiring the drug.’’. 
(b) REQUIREMENT FOR MA–PD PLANS.—Section 1857(f)(3) of 
the Social Security Act, as amended by section 172(a)(2), is amended 
by adding at the end the following new subparagraph: 
‘‘(C) REGULAR UPDATE OF PRESCRIPTION DRUG PRICING 
STANDARD.—Section 1860D–12(b)(6).’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply to plan years beginning on or after January 1, 2009. 
PART II—OTHER PROVISIONS 
SEC. 175. INCLUSION OF BARBITURATES AND BENZODIAZEPINES AS 
COVERED PART D DRUGS. 
(a) IN GENERAL.—Section 1860D–2(e)(2)(A) of the Social Secu-
rity Act (42 U.S.C. 1395w–102(e)(2)(A)) is amended by inserting 
after ‘‘agents),’’ the following ‘‘other than subparagraph (I) of such 
section (relating to barbiturates) if the barbiturate is used in the 
treatment of epilepsy, cancer, or a chronic mental health disorder, 
and other than subparagraph (J) of such section (relating to 
benzodiazepines),’’. 
(b) EFFECTIVE DATE.—The amendments made by subsection 
(a) shall apply to prescriptions dispensed on or after January 1, 
2013. 
SEC. 176. FORMULARY REQUIREMENTS WITH RESPECT TO CERTAIN 
CATEGORIES OR CLASSES OF DRUGS. 
Section 1860D–4(b)(3) of the Social Security Act (42 U.S.C. 
1395w–104(b)(3)) is amended— 
(1) in subparagraph (C)(i), by striking ‘‘The formulary’’ 
and inserting ‘‘Subject to subparagraph (G), the formulary’’; 
and 
(2) by inserting after subparagraph (F) the following new 
subparagraph: 
‘‘(G) REQUIRED INCLUSION OF DRUGS IN CERTAIN CAT-
EGORIES AND CLASSES.— 
42 USC 
1395w–102 note. 
42 USC 
1395w–27 note. 
42 USC 
1395w–27 note. 
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122 STAT. 2582 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(i) IDENTIFICATION
OF
DRUGS
IN
CERTAIN
CAT-
EGORIES
AND
CLASSES.—Beginning with plan year 
2010, the Secretary shall identify, as appropriate, cat-
egories and classes of drugs for which both of the 
following criteria are met: 
‘‘(I) Restricted access to drugs in the category 
or class would have major or life threatening clin-
ical consequences for individuals who have a dis-
ease or disorder treated by the drugs in such cat-
egory or class. 
‘‘(II) There is significant clinical need for such 
individuals to have access to multiple drugs within 
a category or class due to unique chemical actions 
and pharmacological effects of the drugs within 
the category or class, such as drugs used in the 
treatment of cancer. 
‘‘(ii) FORMULARY REQUIREMENTS.—Subject to clause 
(iii), PDP sponsors offering prescription drug plans 
shall be required to include all covered part D drugs 
in the categories and classes identified by the Secretary 
under clause (i). 
‘‘(iii) EXCEPTIONS.—The Secretary may establish 
exceptions that permits a PDP sponsor of a prescription 
drug plan to exclude from its formulary a particular 
covered part D drug in a category or class that is 
otherwise required to be included in the formulary 
under clause (ii) (or to otherwise limit access to such 
a drug, including through prior authorization or utiliza-
tion management). Any exceptions established under 
the preceding sentence shall be provided under a 
process that— 
‘‘(I) ensures that any exception to such require-
ment is based upon scientific evidence and medical 
standards of practice (and, in the case of 
antiretroviral medications, is consistent with the 
Department of Health and Human Services Guide-
lines for the Use of Antiretroviral Agents in HIV- 
1-Infected Adults and Adolescents); and 
‘‘(II) includes a public notice and comment 
period.’’. 
Subtitle F—Other Provisions 
SEC. 181. USE OF PART D DATA. 
Section 1860D–12(b)(3)(D) of the Social Security Act (42 U.S.C. 
1395w–112(b)(3)(D)) is amended by adding at the end the following 
sentence: ‘‘Notwithstanding any other provision of law, information 
provided to the Secretary under the application of section 1857(e)(1) 
to contracts under this section under the preceding sentence— 
‘‘(i) may be used for the purposes of carrying out 
this part, improving public health through research 
on the utilization, safety, effectiveness, quality, and 
efficiency of health care services (as the Secretary 
determines appropriate); and 
‘‘(ii) shall be made available to Congressional sup-
port agencies (in accordance with their obligations to 
Effective date. 
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122 STAT. 2583 
PUBLIC LAW 110–275—JULY 15, 2008 
support Congress as set out in their authorizing stat-
utes) for the purposes of conducting Congressional 
oversight, monitoring, making recommendations, and 
analysis of the program under this title.’’. 
SEC. 182. REVISION OF DEFINITION OF MEDICALLY ACCEPTED INDICA-
TION FOR DRUGS. 
(a) REVISION OF DEFINITION FOR PART D DRUGS.— 
(1) IN GENERAL.—Section 1860D–2(e)(1) of the Social Secu-
rity Act (42 U.S.C. 1395w–102(e)(1)) is amended, in the matter 
following subparagraph (B)— 
(A) by striking ‘‘(as defined in section 1927(k)(6))’’ and 
inserting ‘‘(as defined in paragraph (4))’’; and 
(B) by adding at the end the following new paragraph: 
‘‘(4) MEDICALLY ACCEPTED INDICATION DEFINED.— 
‘‘(A) IN GENERAL.—For purposes of paragraph (1), the 
term ‘medically accepted indication’ has the meaning given 
that term— 
‘‘(i) in the case of a covered part D drug used 
in an anticancer chemotherapeutic regimen, in section 
1861(t)(2)(B), except that in applying such section— 
‘‘(I) ‘prescription drug plan or MA–PD plan’ 
shall be substituted for ‘carrier’ each place it 
appears; and 
‘‘(II) subject to subparagraph (B), the com-
pendia described in section 1927(g)(1)(B)(i)(III) 
shall be included in the list of compendia described 
in clause (ii)(I) section 1861(t)(2)(B); and 
‘‘(ii) in the case of any other covered part D drug, 
in section 1927(k)(6). 
‘‘(B) CONFLICT OF INTEREST.—On and after January 
1, 2010, subparagraph (A)(i)(II) shall not apply unless the 
compendia described in section 1927(g)(1)(B)(i)(III) meets 
the 
requirement 
in 
the 
third 
sentence 
of 
section 
1861(t)(2)(B). 
‘‘(C) UPDATE.—For purposes of applying subparagraph 
(A)(ii), the Secretary shall revise the list of compendia 
described in section 1927(g)(1)(B)(i) as is appropriate for 
identifying medically accepted indications for drugs. Any 
such revision shall be done in a manner consistent with 
the 
process 
for 
revising 
compendia 
under 
section 
1861(t)(2)(B).’’. 
(2) EFFECTIVE DATE.—The amendments made by this sub-
section shall apply to plan years beginning on or after January 
1, 2009. 
(b) CONFLICTS OF INTEREST.—Section 1861(t)(2)(B) of the Social 
Security Act (42 U.S.C. 1395x(t)(2)(B)) is amended by adding at 
the end the following new sentence: ‘‘On and after January 1, 
2010, no compendia may be included on the list of compendia 
under this subparagraph unless the compendia has a publicly trans-
parent process for evaluating therapies and for identifying potential 
conflicts of interests.’’. 
SEC. 183. CONTRACT WITH A CONSENSUS-BASED ENTITY REGARDING 
PERFORMANCE MEASUREMENT. 
(a) CONTRACT.— 
Effective date. 
42 USC 
1395w–102 note. 
Effective date. 
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122 STAT. 2584 
PUBLIC LAW 110–275—JULY 15, 2008 
(1) IN GENERAL.—Part E of title XVIII of the Social Security 
Act (42 U.S.C. 1395x et seq.) is amended by inserting after 
section 1889 the following new section: 
‘‘CONTRACT WITH A CONSENSUS-BASED ENTITY REGARDING 
PERFORMANCE MEASUREMENT 
‘‘SEC. 1890. (a) CONTRACT.— 
‘‘(1) IN
GENERAL.—For purposes of activities conducted 
under this Act, the Secretary shall identify and have in effect 
a contract with a consensus-based entity, such as the National 
Quality Forum, that meets the requirements described in sub-
section (c). Such contract shall provide that the entity will 
perform the duties described in subsection (b). 
‘‘(2) TIMING FOR FIRST CONTRACT.—As soon as practicable 
after the date of the enactment of this subsection, the Secretary 
shall enter into the first contract under paragraph (1). 
‘‘(3) PERIOD OF CONTRACT.—A contract under paragraph 
(1) shall be for a period of 4 years (except as may be renewed 
after a subsequent bidding process). 
‘‘(4) COMPETITIVE
PROCEDURES.—Competitive procedures 
(as defined in section 4(5) of the Office of Federal Procurement 
Policy Act (41 U.S.C. 403(5))) shall be used to enter into a 
contract under paragraph (1). 
‘‘(b) DUTIES.—The duties described in this subsection are the 
following: 
‘‘(1) PRIORITY
SETTING
PROCESS.—The entity shall syn-
thesize evidence and convene key stakeholders to make rec-
ommendations, with respect to activities conducted under this 
Act, on an integrated national strategy and priorities for health 
care performance measurement in all applicable settings. In 
making such recommendations, the entity shall— 
‘‘(A) ensure that priority is given to measures— 
‘‘(i) that address the health care provided to 
patients with prevalent, high-cost chronic diseases; 
‘‘(ii) with the greatest potential for improving the 
quality, efficiency, and patient-centeredness of health 
care; and 
‘‘(iii) that may be implemented rapidly due to 
existing evidence, standards of care, or other reasons; 
and 
‘‘(B) take into account measures that— 
‘‘(i) may assist consumers and patients in making 
informed health care decisions; 
‘‘(ii) address health disparities across groups and 
areas; and 
‘‘(iii) address the continuum of care a patient 
receives, including services furnished by multiple 
health care providers or practitioners and across mul-
tiple settings. 
‘‘(2) ENDORSEMENT OF MEASURES.—The entity shall provide 
for the endorsement of standardized health care performance 
measures. The endorsement process under the preceding sen-
tence shall consider whether a measure— 
‘‘(A) is evidence-based, reliable, valid, verifiable, rel-
evant to enhanced health outcomes, actionable at the care-
giver level, feasible to collect and report, and responsive 
to variations in patient characteristics, such as health 
42 USC 1395aaa. 
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122 STAT. 2585 
PUBLIC LAW 110–275—JULY 15, 2008 
status, language capabilities, race or ethnicity, and income 
level; and 
‘‘(B) is consistent across types of health care providers, 
including hospitals and physicians. 
‘‘(3) MAINTENANCE OF MEASURES.—The entity shall estab-
lish and implement a process to ensure that measures endorsed 
under paragraph (2) are updated (or retired if obsolete) as 
new evidence is developed. 
‘‘(4) PROMOTION
OF
THE
DEVELOPMENT
OF
ELECTRONIC 
HEALTH RECORDS.—The entity shall promote the development 
and use of electronic health records that contain the 
functionality for automated collection, aggregation, and trans-
mission of performance measurement information. 
‘‘(5) ANNUAL REPORT TO CONGRESS AND THE SECRETARY; 
SECRETARIAL PUBLICATION AND COMMENT.— 
‘‘(A) ANNUAL REPORT.—By not later than March 1 of 
each year (beginning with 2009), the entity shall submit 
to Congress and the Secretary a report containing a descrip-
tion of— 
‘‘(i) the implementation of quality measurement 
initiatives under this Act and the coordination of such 
initiatives with quality initiatives implemented by 
other payers; 
‘‘(ii) the recommendations made under paragraph 
(1); and 
‘‘(iii) the performance by the entity of the duties 
required under the contract entered into with the Sec-
retary under subsection (a). 
‘‘(B) SECRETARIAL REVIEW AND PUBLICATION OF ANNUAL 
REPORT.—Not later than 6 months after receiving a report 
under subparagraph (A) for a year, the Secretary shall— 
‘‘(i) review such report; and 
‘‘(ii) publish such report in the Federal Register, 
together with any comments of the Secretary on such 
report. 
‘‘(c) REQUIREMENTS DESCRIBED.—The requirements described 
in this subsection are the following: 
‘‘(1) PRIVATE NONPROFIT.—The entity is a private nonprofit 
entity governed by a board. 
‘‘(2) BOARD MEMBERSHIP.—The members of the board of 
the entity include— 
‘‘(A) representatives of health plans and health care 
providers and practitioners or representatives of groups 
representing such health plans and health care providers 
and practitioners; 
‘‘(B) health care consumers or representatives of groups 
representing health care consumers; and 
‘‘(C) representatives of purchasers and employers or 
representatives of groups representing purchasers or 
employers. 
‘‘(3) ENTITY MEMBERSHIP.—The membership of the entity 
includes persons who have experience with— 
‘‘(A) urban health care issues; 
‘‘(B) safety net health care issues; 
‘‘(C) rural and frontier health care issues; and 
‘‘(D) health care quality and safety issues. 
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122 STAT. 2586 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(4) OPEN
AND
TRANSPARENT.—With respect to matters 
related to the contract with the Secretary under subsection 
(a), the entity conducts its business in an open and transparent 
manner and provides the opportunity for public comment on 
its activities. 
‘‘(5) VOLUNTARY CONSENSUS STANDARDS SETTING ORGANIZA-
TION.—The entity operates as a voluntary consensus standards 
setting organization as defined for purposes of section 12(d) 
of the National Technology Transfer and Advancement Act 
of 1995 (Public Law 104–113) and Office of Management and 
Budget Revised Circular A–119 (published in the Federal Reg-
ister on February 10, 1998). 
‘‘(6) EXPERIENCE.—The entity has at least 4 years of experi-
ence in establishing national consensus standards. 
‘‘(7) MEMBERSHIP FEES.—If the entity requires a member-
ship fee for participation in the functions of the entity, such 
fees shall be reasonable and adjusted based on the capacity 
of the potential member to pay the fee. In no case shall member-
ship fees pose a barrier to the participation of individuals 
or groups with low or nominal resources to participate in the 
functions of the entity. 
‘‘(d) FUNDING.—For purposes of carrying out this section, the 
Secretary shall provide for the transfer, from the Federal Hospital 
Insurance Trust Fund under section 1817 and the Federal Supple-
mentary Medical Insurance Trust Fund under section 1841 (in 
such proportion as the Secretary determines appropriate), of 
$10,000,000 to the Centers for Medicare & Medicaid Services Pro-
gram Management Account for each of fiscal years 2009 through 
2012.’’. 
(2) SENSE OF THE SENATE.—It is the Sense of the Senate 
that the selection by the Secretary of Health and Human Serv-
ices of an entity to contract with under section 1890(a) of 
the Social Security Act, as added by paragraph (1), should 
not be construed as diminishing the significant contributions 
of the Boards of Medicine, the quality alliances, and other 
clinical and technical experts to efforts to measure and improve 
the quality of health care services. 
(b) GAO STUDY AND REPORTS ON THE PERFORMANCE AND COSTS 
OF THE CONSENSUS-BASED ENTITY UNDER THE CONTRACT.— 
(1) IN GENERAL.—The Comptroller General of the United 
States shall conduct a study on— 
(A) the performance of the entity with a contract with 
the Secretary of Health and Human Services under section 
1890(a) of the Social Security Act, as added by subsection 
(a), of its duties under such contract; and 
(B) the costs incurred by such entity in performing 
such duties. 
(2) REPORTS.—Not later than 18 months and 36 months 
after the effective date of the first contract entered into under 
such section 1890(a), the Comptroller General of the United 
States shall submit to Congress a report containing the results 
of the study conducted under paragraph (1), together with 
recommendations for such legislation and administrative action 
as the Comptroller General determines appropriate. 
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122 STAT. 2587 
PUBLIC LAW 110–275—JULY 15, 2008 
SEC. 184. COST-SHARING FOR CLINICAL TRIALS. 
Section 1833 of the Social Security Act (42 U.S.C. 1395l), as 
amended by section 151(a), is amended by adding at the end the 
following new subsection: 
‘‘(w) METHODS OF PAYMENT.—The Secretary may develop alter-
native methods of payment for items and services provided under 
clinical trials and comparative effectiveness studies sponsored or 
supported by an agency of the Department of Health and Human 
Services, as determined by the Secretary, to those that would other-
wise apply under this section, to the extent such alternative 
methods are necessary to preserve the scientific validity of such 
trials or studies, such as in the case where masking the identity 
of interventions from patients and investigators is necessary to 
comply with the particular trial or study design.’’. 
SEC. 185. ADDRESSING HEALTH CARE DISPARITIES. 
Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) 
is amended by inserting after section 1808 the following new section: 
‘‘ADDRESSING HEALTH CARE DISPARITIES 
‘‘SEC. 1809. (a) EVALUATING DATA COLLECTION APPROACHES.— 
The Secretary shall evaluate approaches for the collection of data 
under this title, to be performed in conjunction with existing quality 
reporting requirements and programs under this title, that allow 
for the ongoing, accurate, and timely collection and evaluation 
of data on disparities in health care services and performance 
on the basis of race, ethnicity, and gender. In conducting such 
evaluation, the Secretary shall consider the following objectives: 
‘‘(1) Protecting patient privacy. 
‘‘(2) Minimizing the administrative burdens of data collec-
tion and reporting on providers and health plans participating 
under this title. 
‘‘(3) Improving Medicare program data on race, ethnicity, 
and gender. 
‘‘(b) REPORTS TO CONGRESS.— 
‘‘(1) REPORT ON EVALUATION.—Not later than 18 months 
after the date of the enactment of this section, the Secretary 
shall submit to Congress a report on the evaluation conducted 
under subsection (a). Such report shall, taking into consider-
ation the results of such evaluation— 
‘‘(A) identify approaches (including defining methodolo-
gies) for identifying and collecting and evaluating data 
on health care disparities on the basis of race, ethnicity, 
and gender for the original Medicare fee-for-service pro-
gram under parts A and B, the Medicare Advantage pro-
gram under part C, and the Medicare prescription drug 
program under part D; and 
‘‘(B) include recommendations on the most effective 
strategies and approaches to reporting HEDIS quality 
measures as required under section 1852(e)(3) and other 
nationally recognized quality performance measures, as 
appropriate, on the basis of race, ethnicity, and gender. 
‘‘(2) REPORTS ON DATA ANALYSES.—Not later than 4 years 
after the date of the enactment of this section, and 4 years 
thereafter, the Secretary shall submit to Congress a report 
that includes recommendations for improving the identification 
42 USC 
1395b–10. 
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122 STAT. 2588 
PUBLIC LAW 110–275—JULY 15, 2008 
of health care disparities for Medicare beneficiaries based on 
analyses of the data collected under subsection (c). 
‘‘(c) IMPLEMENTING EFFECTIVE APPROACHES.—Not later than 
24 months after the date of the enactment of this section, the 
Secretary shall implement the approaches identified in the report 
submitted under subsection (b)(1) for the ongoing, accurate, and 
timely collection and evaluation of data on health care disparities 
on the basis of race, ethnicity, and gender.’’. 
SEC. 186. DEMONSTRATION TO IMPROVE CARE TO PREVIOUSLY UNIN-
SURED. 
(a) ESTABLISHMENT.—Within one year after the date of the 
enactment of this Act, the Secretary (in this section referred to 
as the ‘‘Secretary’’) shall establish a demonstration project to deter-
mine the greatest needs and most effective methods of outreach 
to medicare beneficiaries who were previously uninsured. 
(b) SCOPE.—The demonstration shall be in no fewer than 10 
sites, and shall include state health insurance assistance programs, 
community health centers, community-based organizations, commu-
nity health workers, and other service providers under parts A, 
B, and C of title XVIII of the Social Security Act. Grantees that 
are plans operating under part C shall document that enrollees 
who were previously uninsured receive the ‘‘Welcome to Medicare’’ 
physical exam. 
(c) DURATION.—The Secretary shall conduct the demonstration 
project for a period of 2 years. 
(d) REPORT AND EVALUATION.—The Secretary shall conduct an 
evaluation of the demonstration and not later than 1 year after 
the completion of the project shall submit to Congress a report 
including the following: 
(1) An analysis of the effectiveness of outreach activities 
targeting beneficiaries who were previously uninsured, such 
as revising outreach and enrollment materials (including the 
potential for use of video information), providing one-on-one 
counseling, working with community health workers, and 
amending the Medicare and You handbook. 
(2) The effect of such outreach on beneficiary access to 
care, utilization of services, efficiency and cost-effectiveness 
of health care delivery, patient satisfaction, and select health 
outcomes. 
SEC. 187. OFFICE OF THE INSPECTOR GENERAL REPORT ON COMPLI-
ANCE WITH AND ENFORCEMENT OF NATIONAL STAND-
ARDS ON CULTURALLY AND LINGUISTICALLY APPRO-
PRIATE SERVICES (CLAS) IN MEDICARE. 
(a) REPORT.—Not later than two years after the date of the 
enactment of this Act, the Inspector General of the Department 
of Health and Human Services shall prepare and publish a report 
on— 
(1) the extent to which Medicare providers and plans are 
complying with the Office for Civil Rights’ Guidance to Federal 
Financial Assistance Recipients Regarding Title VI Prohibition 
Against National Origin Discrimination Affecting Limited 
English Proficient Persons and the Office of Minority Health’s 
Culturally and Linguistically Appropriate Services Standards 
in health care; and 
(2) a description of the costs associated with or savings 
related to the provision of language services. 
42 USC 1395cc 
note. 
Deadline. 
42 USC 1395b–4 
note. 
Deadline. 
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122 STAT. 2589 
PUBLIC LAW 110–275—JULY 15, 2008 
Such report shall include recommendations on improving compli-
ance with CLAS Standards and recommendations on improving 
enforcement of CLAS Standards. 
(b) IMPLEMENTATION.—Not later than one year after the date 
of publication of the report under subsection (a), the Department 
of Health and Human Services shall implement changes responsive 
to any deficiencies identified in the report. 
SEC. 188. MEDICARE IMPROVEMENT FUNDING. 
(a) MEDICARE IMPROVEMENT FUND.— 
(1) IN GENERAL.—Subject to paragraph (2), title XVIII of 
the Social Security Act (42 U.S.C. 1395 et seq.) is amended 
by adding at the end the following new section: 
‘‘MEDICARE IMPROVEMENT FUND 
‘‘SEC. 1898. (a) ESTABLISHMENT.— 
‘‘The Secretary shall establish under this title a Medicare 
Improvement Fund (in this section referred to as the ‘Fund’) 
which shall be available to the Secretary to make improvements 
under the original fee-for-service program under parts A and 
B for individuals entitled to, or enrolled for, benefits under 
part A or enrolled under part B. 
‘‘(b) FUNDING.— 
‘‘(1) IN GENERAL.—There shall be available to the Fund, 
for expenditures from the Fund for services furnished during 
fiscal years 2014 through 2017, $19,900,000,000. 
‘‘(2) PAYMENT FROM TRUST FUNDS.—The amount specified 
under paragraph (1) shall be available to the Fund, as expendi-
tures are made from the Fund, from the Federal Hospital 
Insurance Trust Fund and the Federal Supplementary Medical 
Insurance Trust Fund in such proportion as the Secretary 
determines appropriate. 
‘‘(3) FUNDING LIMITATION.—Amounts in the Fund shall be 
available in advance of appropriations but only if the total 
amount obligated from the Fund does not exceed the amount 
available to the Fund under paragraph (1). The Secretary may 
obligate funds from the Fund only if the Secretary determines 
(and the Chief Actuary of the Centers for Medicare & Medicaid 
Services and the appropriate budget officer certify) that there 
are available in the Fund sufficient amounts to cover all such 
obligations incurred consistent with the previous sentence.’’. 
(2) CONTINGENCY.— 
(A) IN GENERAL.—If there is enacted, before, on, or 
after the date of the enactment of this Act, a Supplemental 
Appropriations Act, 2008 that includes a provision pro-
viding for a Medicare Improvement Fund under a section 
1898 of the Social Security Act, the alternative amendment 
described in subparagraph (B)— 
(i) shall apply instead of the amendment made 
by paragraph (1); and 
(ii) shall be executed after such provision in such 
Supplemental Appropriations Act. 
(B) ALTERNATIVE AMENDMENT DESCRIBED.—The alter-
native amendment described in this subparagraph is as 
follows: Section 1898(b)(1) of the Social Security Act, as 
added by the Supplemental Appropriations Act, 2008, is 
amended by inserting before the period at the end the 
42 USC 1395iii. 
Applicability. 
Certification. 
Deadline. 
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122 STAT. 2590 
PUBLIC LAW 110–275—JULY 15, 2008 
following: ‘‘ and, in addition for services furnished during 
fiscal years 2014 through 2017, $19,900,000,000’’. 
(b) IMPLEMENTATION.—For purposes of carrying out the provi-
sions of, and amendments made by, this title, in addition to any 
other amounts provided in such provisions and amendments, the 
Secretary of Health and Human Services shall provide for the 
transfer, from the Federal Hospital Insurance Trust Fund under 
section 1817 of the Social Security Act (42 U.S.C. 1395i) and the 
Federal Supplementary Medical Insurance Trust Fund under sec-
tion 1841 of such Act (42 U.S.C. 1395t), in the same proportion 
as the Secretary determines under section 1853(f) of such Act (42 
U.S.C. 1395w–23(f)), of $140,000,000 to the Centers for Medicare 
& Medicaid Services Program Management Account for the period 
of fiscal years 2009 through 2013. 
SEC. 189. INCLUSION OF MEDICARE PROVIDERS AND SUPPLIERS IN 
FEDERAL PAYMENT LEVY AND ADMINISTRATIVE OFFSET 
PROGRAM. 
(a) IN GENERAL.—Section 1874 of the Social Security Act (42 
U.S.C. 1395kk) is amended by adding at the end the following 
new subsection: 
‘‘(d) INCLUSION
OF MEDICARE PROVIDER
AND SUPPLIER PAY-
MENTS IN FEDERAL PAYMENT LEVY PROGRAM.— 
‘‘(1) IN GENERAL.—The Centers for Medicare & Medicaid 
Services shall take all necessary steps to participate in the 
Federal Payment Levy Program under section 6331(h) of the 
Internal Revenue Code of 1986 as soon as possible and shall 
ensure that— 
‘‘(A) at least 50 percent of all payments under parts 
A and B are processed through such program beginning 
within 1 year after the date of the enactment of this section; 
‘‘(B) at least 75 percent of all payments under parts 
A and B are processed through such program beginning 
within 2 years after such date; and 
‘‘(C) all payments under parts A and B are processed 
through such program beginning not later than September 
30, 2011. 
‘‘(2) ASSISTANCE.—The Financial Management Service and 
the Internal Revenue Service shall provide assistance to the 
Centers for Medicare & Medicaid Services to ensure that all 
payments described in paragraph (1) are included in the Federal 
Payment Levy Program by the deadlines specified in that sub-
section.’’. 
(b) APPLICATION
OF ADMINISTRATIVE OFFSET PROVISIONS
TO 
MEDICARE PROVIDER OR SUPPLIER PAYMENTS.—Section 3716 of title 
31, United States Code, is amended— 
(1) by inserting ‘‘the Department of Health and Human 
Services,’’ after ‘‘United States Postal Service,’’ in subsection 
(c)(1)(A); and 
(2) by adding at the end of subsection (c)(3) the following 
new subparagraph: 
‘‘(D) This section shall apply to payments made after 
the date which is 90 days after the enactment of this 
subparagraph (or such earlier date as designated by the 
Secretary of Health and Human Services) with respect 
to claims or debts, and to amounts payable, under title 
XVIII of the Social Security Act.’’. 
Applicability. 
Effective date. 
Deadline. 
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122 STAT. 2591 
PUBLIC LAW 110–275—JULY 15, 2008 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall take effect on the date of the enactment of this Act. 
TITLE II—MEDICAID 
SEC. 201. EXTENSION OF TRANSITIONAL MEDICAL ASSISTANCE (TMA) 
AND ABSTINENCE EDUCATION PROGRAM. 
Section 401 of division B of the Tax Relief and Health Care 
Act of 2006 (Public Law 109–432, 120 Stat. 2994), as amended 
by section 1 of Public Law 110–48 (121 Stat. 244), section 2 of 
the TMA, Abstinence, Education, and QI Programs Extension Act 
of 2007 (Public Law 110–90, 121 Stat. 984), and section 202 of 
the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public 
Law 110–173) is amended— 
(1) by striking ‘‘June 30, 2008’’ and inserting ‘‘June 30, 
2009’’; 
(2) by striking ‘‘the third quarter of fiscal year 2008’’ and 
inserting ‘‘the third quarter of fiscal year 2009’’; and 
(3) by striking ‘‘the third quarter of fiscal year 2007’’ and 
inserting ‘‘the third quarter of fiscal year 2008’’. 
SEC. 202. MEDICAID DSH EXTENSION. 
Section 1923(f)(6) of the Social Security Act (42 U.S.C. 1396r– 
4(f)(6)) is amended— 
(1) in the heading, by striking ‘‘FISCAL YEAR 2007 AND POR-
TIONS OF FISCAL YEAR 2008’’ and inserting ‘‘FISCAL YEARS 2007 
THROUGH 2009 AND THE FIRST CALENDAR QUARTER OF FISCAL 
YEAR 2010’’; and 
(2) in subparagraph (A)— 
(A) in clause (i)— 
(i) in the second sentence— 
(I) by striking ‘‘fiscal year 2008 for the period 
ending on June 30, 2008’’ and inserting ‘‘fiscal 
years 2008 and 2009’’; and 
(II) by striking ‘‘3⁄4 of’’; and 
(ii) by adding at the end the following new sen-
tences: ‘‘Only with respect to fiscal year 2010 for the 
period ending on December 31, 2009, the DSH allot-
ment for Tennessee for such portion of the fiscal year, 
notwithstanding such table or terms, shall be 1⁄4 of 
the amount specified in the first sentence for fiscal 
year 2007.’’; 
(B) in clause (ii), by striking ‘‘or for a period in fiscal 
year 2008’’ and inserting ‘‘, 2008, 2009, or for a period 
in fiscal year 2010’’; 
(C) in clause (iv)— 
(i) in the heading, by striking ‘‘FISCAL YEAR 2007 
AND FISCAL YEAR 2008’’ and inserting ‘‘FISCAL YEARS 
2007 THROUGH 2009 AND THE FIRST CALENDAR QUARTER 
OF FISCAL YEAR 2010’’; 
(ii) in subclause (I), by striking ‘‘or for a period 
in fiscal year 2008’’ and inserting ‘‘, 2008, 2009, or 
for a period in fiscal year 2010’’; and 
(iii) in subclause (II), by striking ‘‘or for a period 
in fiscal year 2008’’ and inserting ‘‘, 2008, 2009, or 
for a period in fiscal year 2010’’; and 
31 USC 3176 
note. 
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122 STAT. 2592 
PUBLIC LAW 110–275—JULY 15, 2008 
(3) in subparagraph (B)(i)— 
(A) in the first sentence, by striking ‘‘fiscal year 2007’’ 
and inserting ‘‘each of fiscal years 2007 through 2009’’; 
and 
(B) by striking the second sentence and inserting the 
following: ‘‘Only with respect to fiscal year 2010 for the 
period ending on December 31, 2009, the DSH allotment 
for Hawaii for such portion of the fiscal year, notwith-
standing the table set forth in paragraph (2), shall be 
$2,500,000.’’. 
SEC. 203. PHARMACY REIMBURSEMENT UNDER MEDICAID. 
(a) DELAY IN APPLICATION OF NEW PAYMENT LIMIT FOR MUL-
TIPLE SOURCE DRUGS UNDER MEDICAID.—Notwithstanding para-
graphs (4) and (5) of subsection (e) of section 1927 of the Social 
Security Act (42 U.S.C. 1396r–8) or part 447 of title 42, Code 
of Federal Regulations, as published on July 17, 2007 (72 Federal 
Register 39142)— 
(1) the specific upper limit under section 447.332 of title 
42, Code of Federal Regulations (as in effect on December 
31, 2006) applicable to payments made by a State for multiple 
source drugs under a State Medicaid plan shall continue to 
apply through September 30, 2009, for purposes of the avail-
ability of Federal financial participation for such payments; 
and 
(2) the Secretary of Health and Human Services shall 
not, prior to October 1, 2009, finalize, implement, enforce, or 
otherwise take any action (through promulgation of regulation, 
issuance of regulatory guidance, use of Federal payment audit 
procedures, or other administrative action, policy, or practice, 
including a Medical Assistance Manual transmittal or letter 
to State Medicaid directors) to impose the specific upper limit 
established under section 447.514(b) of title 42, Code of Federal 
Regulations as published on July 17, 2007 (72 Federal Register 
39142). 
(b) TEMPORARY SUSPENSION OF UPDATED PUBLICLY AVAILABLE 
AMP DATA.—Notwithstanding clause (v) of section 1927(b)(3)(D) 
of the Social Security Act (42 U.S.C. 1396r–8(b)(3)(D)), the Secretary 
of Health and Human Services shall not, prior to October 1, 2009, 
make publicly available any AMP disclosed to the Secretary. 
(c) DEFINITIONS.—In this subsection: 
(1) The term ‘‘multiple source drug’’ has the meaning given 
that term in section 1927(k)(7)(A)(i) of the Social Security Act 
(42 U.S.C. 1396r–8(k)(7)(A)(i)). 
(2) The term ‘‘AMP’’ has the meaning given ‘‘average manu-
facturer price’’ in section 1927(k)(1) of the Social Security Act 
(42 U.S.C. 1396r–8(k)(1)) and ‘‘AMP’’ in section 447.504(a) of 
title 42, Code of Federal Regulations as published on July 
17, 2007 (72 Federal Register 39142). 
SEC. 204. REVIEW OF ADMINISTRATIVE CLAIM DETERMINATIONS. 
(a) IN GENERAL.—Section 1116 of the Social Security Act (42 
U.S.C. 1316) is amended by adding at the end the following new 
subsection: 
‘‘(e)(1) Whenever the Secretary determines that any item or 
class of items on account of which Federal financial participation 
is claimed under title XIX shall be disallowed for such participation, 
the State shall be entitled to and upon request shall receive a 
Time periods. 
42 USC 1396r–8 
note. 
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122 STAT. 2593 
PUBLIC LAW 110–275—JULY 15, 2008 
reconsideration of the disallowance, provided that such request 
is made during the 60-day period that begins on the date the 
State receives notice of the disallowance. 
‘‘(2)(A) A State may appeal a disallowance of a claim for federal 
financial participation under title XIX by the Secretary, or an 
unfavorable reconsideration of a disallowance, during the 60-day 
period that begins on the date the State receives notice of the 
disallowance or of the unfavorable reconsideration, in whole or 
in part, to the Departmental Appeals Board, established in the 
Department of Health and Human Services (in this paragraph 
referred to as the ‘Board’), by filing a notice of appeal with the 
Board. 
‘‘(B) The Board shall consider a State’s appeal of a disallowance 
of such a claim (or of an unfavorable reconsideration of a disallow-
ance) on the basis of such documentation as the State may submit 
and as the Board may require to support the final decision of 
the Board. In deciding whether to uphold a disallowance of such 
a claim or any portion thereof, the Board shall be bound by all 
applicable laws and regulations and shall conduct a thorough review 
of the issues, taking into account all relevant evidence. The Board’s 
decision of an appeal under subparagraph (A) shall be the final 
decision of the Secretary and shall be subject to reconsideration 
by the Board only upon motion of either party filed during the 
60-day period that begins on the date of the Board’s decision or 
to judicial review in accordance with subparagraph (C). 
‘‘(C) A State may obtain judicial review of a decision of the 
Board by filing an action in any United States District Court 
located within the appealing State (or, if several States jointly 
appeal the disallowance of claims for Federal financial participation 
under section 1903, in any United States District Court that is 
located within any State that is a party to the appeal) or the 
United States District Court for the District of Columbia. Such 
an action may only be filed— 
‘‘(i) if no motion for reconsideration was filed within the 
60-day period specified in subparagraph (B), during such 60- 
day period; or 
‘‘(ii) if such a motion was filed within such period, during 
the 60-day period that begins on the date of the Board’s decision 
on such motion.’’. 
(b) CONFORMING AMENDMENT.—Section 1116(d) of such Act (42 
U.S.C. 1316(d)) is amended by striking ‘‘or XIX,’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
take effect on the date of the enactment of this Act and apply 
to any disallowance of a claim for Federal financial participation 
under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) 
made on or after such date or during the 60-day period prior 
to such date. 
SEC. 205. COUNTY MEDICAID HEALTH INSURING ORGANIZATIONS. 
(a) IN GENERAL.—Section 9517(c)(3) of the Consolidated Omni-
bus Budget Reconciliation Act of 1985 (42 U.S.C. 1396b note), 
as added by section 4734 of the Omnibus Budget Reconciliation 
Act of 1990 and as amended by section 704 of the Medicare, Med-
icaid, and SCHIP Benefits Improvement and Protection Act of 2000, 
is amended— 
42 USC 1316 
note. 
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122 STAT. 2594 
PUBLIC LAW 110–275—JULY 15, 2008 
(1) in subparagraph (A), by inserting ‘‘, in the case of 
any health insuring organization described in such subpara-
graph that is operated by a public entity established by Ventura 
County, and in the case of any health insuring organization 
described in such subparagraph that is operated by a public 
entity established by Merced County’’ after ‘‘described in 
subparagraph (B)’’; and 
(2) in subparagraph (C), by striking ‘‘14 percent’’ and 
inserting ‘‘16 percent’’. 
(b) EFFECTIVE DATE.—The amendments made by subsection 
(a) shall take effect on the date of the enactment of this Act. 
TITLE III—MISCELLANEOUS 
SEC. 301. EXTENSION OF TANF SUPPLEMENTAL GRANTS. 
(a) EXTENSION THROUGH FISCAL YEAR 2009.—Section 7101(a) 
of the Deficit Reduction Act of 2005 (Public Law 109–171; 120 
Stat. 135) is amended by striking ‘‘fiscal year 2008’’ and inserting 
‘‘fiscal year 2009’’. 
(b) CONFORMING AMENDMENT.—Section 403(a)(3)(H)(ii) of the 
Social Security Act (42 U.S.C. 603(a)(3)(H)(ii)) is amended to read 
as follows: 
‘‘(ii) subparagraph (G) shall be applied as if ‘fiscal 
year 2009’ were substituted for ‘fiscal year 2001’; and’’. 
SEC. 302. 70 PERCENT FEDERAL MATCHING FOR FOSTER CARE AND 
ADOPTION ASSISTANCE FOR THE DISTRICT OF COLUMBIA. 
(a) IN GENERAL.—Section 474(a) of the Social Security Act 
(42 U.S.C. 674(a)) is amended in each of paragraphs (1) and (2) 
by striking ‘‘(as defined in section 1905(b) of this Act)’’ and inserting 
‘‘(which shall be as defined in section 1905(b), in the case of a 
State other than the District of Columbia, or 70 percent, in the 
case of the District of Columbia)’’. 
(b) EFFECTIVE DATE.—The amendment made by subsection (a) 
shall take effect on October 1, 2008, and shall apply to calendar 
quarters beginning on or after that date. 
SEC. 303. EXTENSION OF SPECIAL DIABETES GRANT PROGRAMS. 
(a) SPECIAL DIABETES PROGRAMS FOR TYPE I DIABETES.—Sec-
tion 330B(b)(2)(C) of the Public Health Service Act (42 U.S.C. 254c– 
2(b)(2)) is amended by striking ‘‘2009’’ and inserting ‘‘2011’’. 
(b) SPECIAL
DIABETES
PROGRAMS
FOR
INDIANS.—Section 
330C(c)(2)(C) of the Public Health Service Act (42 U.S.C. 254c– 
3(c)(2)(C)) is amended by striking ‘‘2009’’ and inserting ‘‘2011’’. 
(c) REPORT ON GRANT PROGRAMS.—Section 4923(b) of the Bal-
anced Budget Act of 1997 (42 U.S.C. 1254c–2 note), as amended 
by section 931(c) of the Medicare, Medicaid, and SCHIP Benefits 
Improvement and Protection Act of 2000, as enacted into law by 
section 1(a)(6) of Public Law 106–554, and section 1(c) of Public 
Law 107–360, is amended— 
(1) in paragraph (1), by striking ‘‘and’’ at the end; 
(2) in paragraph (2)— 
(A) by striking ‘‘a final report’’ and inserting ‘‘a second 
interim report’’; and 
(B) by striking the period at the end and inserting 
‘‘; and’’; and 
(3) by adding at the end the following new paragraph: 
42 USC 254c–2 
note. 
42 USC 674 note. 
42 USC 1396b 
note. 
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122 STAT. 2595 
PUBLIC LAW 110–275—JULY 15, 2008 
‘‘(3) a report on such evaluation not later than January 
1, 2011.’’. 
SEC. 304. IOM REPORTS ON BEST PRACTICES FOR CONDUCTING 
SYSTEMATIC 
REVIEWS 
OF 
CLINICAL 
EFFECTIVENESS 
RESEARCH AND FOR DEVELOPING CLINICAL PROTOCOLS. 
(a) 
SYSTEMATIC
REVIEWS
OF
CLINICAL
EFFECTIVENESS 
RESEARCH.— 
(1) STUDY.—Not later than 60 days after the date of the 
enactment of this Act, the Secretary of Health and Human 
Services shall enter into a contract with the Institute of Medi-
cine of the National Academies (in this section referred to 
as the ‘‘Institute’’) under which the Institute shall conduct 
a study to identify the methodological standards for conducting 
systematic reviews of clinical effectiveness research on health 
and health care in order to ensure that organizations conducting 
such reviews have information on methods that are objective, 
scientifically valid, and consistent. 
(2) REPORT.—Not later than 18 months after the effective 
date of the contract under paragraph (1), the Institute, as 
part of such contract, shall submit to the Secretary of Health 
and Human Services and the appropriate committees of juris-
diction of Congress a report containing the results of the study 
conducted under paragraph (1), together with recommendations 
for such legislation and administrative action as the Institute 
determines appropriate. 
(3) PARTICIPATION.—The contract under paragraph (1) shall 
require that stakeholders with expertise in conducting clinical 
effectiveness research participate on the panel responsible for 
conducting the study under paragraph (1) and preparing the 
report under paragraph (2). 
(b) CLINICAL PROTOCOLS.— 
(1) STUDY.—Not later than 60 days after the date of the 
enactment of this Act, the Secretary of Health and Human 
Services shall enter into a contract with the Institute of Medi-
cine of the National Academies (in this section referred to 
as the ‘‘Institute’’) under which the Institute shall conduct 
a study on the best methods used in developing clinical practice 
guidelines in order to ensure that organizations developing 
such guidelines have information on approaches that are objec-
tive, scientifically valid, and consistent. 
(2) REPORT.—Not later than 18 months after the effective 
date of the contract under paragraph (1), the Institute, as 
part of such contract, shall submit to the Secretary of Health 
and Human Services and the appropriate committees of juris-
diction of Congress a report containing the results of the study 
conducted under paragraph (1), together with recommendations 
for such legislation and administrative action as the Institute 
determines appropriate. 
(3) PARTICIPATION.—The contract under paragraph (1) shall 
require that stakeholders with expertise in making clinical 
recommendations participate on the panel responsible for con-
ducting the study under paragraph (1) and preparing the report 
under paragraph (2). 
Contracts. 
Contracts. 
Deadline. 
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122 STAT. 2596 
PUBLIC LAW 110–275—JULY 15, 2008 
(c) FUNDING.—Out of any funds in the Treasury not otherwise 
appropriated, there are appropriated for the period of fiscal years 
2009 and 2010, $3,000,000 to carry out this section. 
Nancy Pelosi 
Speaker of the House of Representatives. 
Robert C. Byrd 
President of the Senate pro tempore. 
IN THE HOUSE OF REPRESENTATIVES, U.S. 
July 15, 2008. 
The House of Representatives having proceeded to reconsider the bill (H.R. 6331) 
entitled ‘An Act to amend titles XVIII and XIX of the Social Security Act to extend 
expiring provisions under the Medicare Program, to improve beneficiary access to 
preventive and mental health services, to enhance low-income benefit programs, and 
to maintain access to care in rural areas, including pharmacy access, and for other 
purposes’’, returned by the President of the United States with his objections, to the 
House of Representatives, in which it originated, it was 
Resolved, That the said bill pass, two-thirds of the House of Representatives 
agreeing to pass the same. 
Lorraine C. Miller 
Clerk. 
By 
Robert F. Reeves 
Deputy Clerk. 
I certify that this Act originated in the House of Representatives. 
Lorraine C. Miller 
Clerk. 
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122 STAT. 2597 
PUBLIC LAW 110–275—JULY 15, 2008 
LEGISLATIVE HISTORY—H.R. 6331: 
CONGRESSIONAL RECORD, Vol. 154 (2008): 
June 24, considered and passed House. 
July 9, considered and passed Senate. 
WEEKLY COMPILATION OF PRESIDENTIAL DOCUMENTS, Vol. 44 (2008): 
July 15, Presidential veto message. 
CONGRESSIONAL RECORD, Vol. 154 (2008): 
July 15, House and Senate overrode veto. 
IN THE SENATE OF THE UNITED STATES, 
July 15, 2008. 
The Senate having proceeded to reconsider the bill (H.R. 6331) entitled ‘‘An Act 
to amend titles XVIII and XIX of the Social Security Act to extend expiring provi-
sions under the Medicare Program, to improve beneficiary access to preventive and 
mental health services, to enhance low-income benefit programs, and to maintain 
access to care in rural areas, including pharmacy access, and for other purposes’’, 
returned by the President of the United States with his objections, to the House of 
Representatives, in which it originated, and passed by the House of Representatives 
on reconsideration of the same, it was 
Resolved, That the said bill pass, two-thirds of the Senators present having voted 
in the affirmative. 
Nancy Erickson 
Secretary. 
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