		II
		Calendar No. 772
		110th CONGRESS
		2d Session
		S. 3101
		IN THE SENATE OF THE UNITED STATES

			June 6, 2008
			Mr. Baucus (for himself,
			 Ms. Snowe, Mr.
			 Rockefeller, and Mr. Smith)
			 ordered introduced the following bill; which was read the first
			 time

			June 9, 2008
			Read the second time and placed on the
			 calendar

		A BILL
		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.

		1.Short
			 title; table of contents
			(a)Short
			 titleThis Act may be cited
			 as the Medicare Improvements for
			 Patients and Providers Act of 2008.
			(b)Table of
			 contentsThe 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 Program.
					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 Program.
					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.
					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 Services.
					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 radiopharmaceuticals.
					Sec. 143. Speech-language pathology services.
					Sec. 144. Payment and coverage improvements for patients with
				chronic obstructive pulmonary disease and other conditions.
					Sec. 145. Revision of payment for power-driven
				wheelchairs.
					Sec. 146. Clinical laboratory tests.
					Sec. 147. Improved access to ambulance services.
					Sec. 148. Extension and expansion of the Medicare hold harmless
				provision under the prospective payment system for hospital outpatient
				department (HOPD) services for certain hospitals.
					Sec. 149. Clarification of payment for clinical laboratory
				tests furnished by critical access hospitals.
					Sec. 150. Adding certain entities as originating sites for
				payment of telehealth services.
					Sec. 151. MedPAC study and report on improving chronic care
				demonstration programs.
					Sec. 152. Increase of FQHC payment limits.
					Sec. 153. Kidney disease education and awareness
				provisions.
					Sec. 154. Renal dialysis provisions.
					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 special 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.
					Sec. 182. Revision of definition of medically accepted
				indication for drugs.
					Sec. 183. Contract with a consensus-based entity regarding
				performance measurement.
					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 enforcement of national standards on culturally and linguistically
				appropriate services (CLAS) in Medicare.
					Sec. 188. Medicare Improvement Funding.
					TITLE II—Medicaid
					Sec. 201. Extension of transitional medical assistance (TMA)
				and abstinence education program.
					Sec. 202. Medicaid
				DSH extension.
					Sec. 203. Pharmacy reimbursement under Medicaid.
					Sec. 204. Review of administrative claim
				determinations.
					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.

			IMedicare
			ABeneficiary
			 improvements
				IPrevention,
			 mental health, and marketing
					101.Improvements to
			 coverage of preventive services
						(a)Coverage of
			 additional preventive services
							(1)CoverageSection
			 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 subsection (ddd)(1));
											;
				and
									(B)by adding at the
			 end the following new subsection:

										(ddd)Additional preventive services(1)The term
				additional preventive services means services not otherwise
				described in this title that identify medical conditions 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
												(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 preventive servicesSection 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 coverageSection 1862(a)(1)(A) of the Social
			 Security Act (42 U.S.C. 1395y(a)(1)(A)) is amended by inserting or
			 additional preventive services (as described in section 1861(ddd)(1))
			 after succeeding subparagraph.
							(4)Rule of
			 constructionNothing 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
			 condition that is not otherwise covered under such title.
							(b)Revisions to
			 initial preventive physical examination
							(1)In
			 generalSection 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 planning 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.
											.
								(2)Waiver of
			 application of deductibleThe first sentence 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 examination (as defined in section 1861(ww)) before
			 the period at the end.
								(3)Extension of
			 eligibility period from six months to one yearSection 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
			 correctionSection 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
			 dateThe amendments made by this section shall apply to services
			 furnished on or after January 1, 2009.
						102.Elimination of
			 discriminatory copayment rates for Medicare outpatient psychiatric
			 servicesSection 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 calendar year, 100 percent of such expenses.
									(2)For purposes of subparagraphs (A) through
				(D) of paragraph (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 disorders or
				partial hospitalization services that are not directly provided by a
				physician.
								.
					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
			 generalSection 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
											(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 organization (or the agents, brokers, and other third
				parties representing such organization) to conduct the prohibited activities
				described in subsection (j)(1); and
												;
				and
										(ii)by
			 adding at the end the following new subsection:

											(j)Prohibited
				activities described and limitations on the conduct of certain other
				activities
												(1)Prohibited
				activities describedThe following prohibited activities are
				described in this paragraph:
													(A)Unsolicited
				means of direct contactAny unsolicited means of direct contact
				of prospective enrollees, including soliciting door-to-door or any outbound
				telemarketing without the prospective enrollee initiating contact.
													(B)Cross-sellingThe
				sale of other non-health related products (such as annuities and life
				insurance) during any sales or marketing activity or presentation conducted
				with respect to a Medicare Advantage plan.
													(C)MealsThe
				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 eventsSales
				and marketing activities for the enrollment of individuals in Medicare
				Advantage 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 programSection 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 activitiesThe 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 conducting activities described in section
				1851(j)(1).
										.
							(3)Effective
			 dateThe amendments made by this subsection shall apply to plan
			 years beginning on or after January 1, 2009.
							(b)Limitations
							(1)Medicare
			 advantage programSection 1851 of the Social Security Act (42
			 U.S.C. 1395w–21), as amended by subsection (a)(1), is amended—
								(A)in subsection
			 (h)(4), by adding at the end the following new subparagraph:

										(D)shall only permit a Medicare Advantage
				organization (and the agents, brokers, and other third parties representing
				such organization) to conduct the activities described in subsection (j)(2) in
				accordance with the limitations established under such
				subsection.
										;
				and
								(B)in subsection
			 (j), by adding at the end the following new paragraph:

										(2)LimitationsThe
				Secretary shall establish limitations with respect to at least the
				following:
											(A)Scope of
				marketing appointmentsThe 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-brandingThe
				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 valueThe 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)CompensationThe
				use of compensation other than as provided under guidelines established by the
				Secretary. Such guidelines shall ensure that the use of compensation 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
				partiesThe use by a Medicare Advantage organization of any
				individual as an agent, broker, or other third party representing 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 programSection 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
			 dateThe amendments made by this subsection 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 programSection 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 nameFor plan years beginning on
				or after January 1, 2010, a Medicare Advantage organization must ensure that
				the name of each Medicare Advantage plan offered by the Medicare Advantage
				organization includes the plan type of the plan (using standard terminology
				developed by the
				Secretary).
									.
							(2)Prescription
			 drug plansSection 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 programSection 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 brokersEach 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 appointment 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 requestsEach 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 Medicare Advantage organization as part of an investigation by
				the State into the conduct of the agent, broker, or other third
				party.
										.
							(2)Prescription
			 drug plansSection 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
			 dateThe amendments made by this subsection shall apply to plan
			 years beginning on or after January 1, 2009.
							104.Improvements
			 to the Medigap program
						(a)Implementation
			 of NAIC recommendations
							(1)In
			 generalThe 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 to Implement the NAIC Medicare Supplement Insurance
			 Minimum 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
			 generalThe 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 amendmentIn 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
			 sentence, 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
			 datesNo 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 policiesSection 1882(o) of the Social
			 Security Act (42 U.S.C. 1395s(o)) is amended by adding at the end the following
			 new paragraph:

								(4)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.
								.
						IILow-income
			 programs
					111.Extension of
			 qualifying individual (QI) program
						(a)ExtensionSection
			 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 AllocationSection 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 subparagraphs:

										(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).
							112.Application of
			 full LIS subsidy assets test under Medicare Savings ProgramSection 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).
					113.Eliminating
			 barriers to enrollment
						(a)SSA assistance
			 with medicare savings program and low-income subsidy program
			 applicationsSection 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
									(1)Distribution of
				applications and information to individuals who are potentially eligible for
				low-income subsidy programFor 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
				Program.
										(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
				applicationThe Commissioner
				shall provide training to those employees of the Social Security Administration
				who are involved in receiving applications 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 StatesBeginning 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 determined by the Commissioner,
				which transmittal shall initiate an application of the individual for benefits
				under the Medicare Savings Program. In order to ensure that such data
				transmittal provides effective assistance for purposes of State adjudication of
				applications for benefits under the Medicare Savings Program, the Commissioner
				shall consult with the Secretary, after the Secretary has consulted 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 outreachThe
				Commissioner shall coordinate outreach activities under this subsection with
				outreach activities conducted by States in connection with the low-income
				subsidy program and the Medicare Savings Program.
									(5)Reimbursement of
				social security administration administrative costs
										(A)Initial medicare
				savings program costs; additional low-income subsidy costs
											(i)Initial
				medicare savings program costsThere are hereby appropriated to the
				Commissioner to carry out this subsection, out of any funds in the Treasury not
				otherwise appropriated, $21,100,000. The amount appropriated under ths clause
				shall be available on October 1, 2008, and shall remain available until
				expended.
											(ii)Additional
				amount for low-income subsidy activitiesThere 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 this Act, to remain available 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
				generalEffective for fiscal years beginning on or after October
				1, 2010, the Commissioner and the Secretary shall enter into an agreement which
				shall provide funding to cover the administrative costs of the Commissioner's
				activities under this subsection. 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 reconciliation of the actual costs incurred and funds
				provided under this subsection.
												(ii)AppropriationThere
				are hereby appropriated to the Secretary solely for the purpose of providing
				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 appropriated,
				not more than $3,000,000 for fiscal year 2011 and each fiscal year
				thereafter.
											(C)LimitationIn no case shall funds from the Social
				Security Administration’s Limitation on Administrative Expenses be used to
				carry out activities under this subsection. 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
										(A)AnalysisThe
				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 Administration.
											(B)ReportNot later than January 1, 2012, the
				Comptroller General shall submit to Congress, the Commissioner, and the
				Secretary a report on the analysis conducted under subparagraph (A).
										(7)Medicare Savings
				Program definedFor 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 transmittalSection 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 ProgramThe State shall accept data transmitted under
				section 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.
								.
						(c)Effective
			 dateExcept as otherwise
			 provided, the amendments made by this section shall take effect on January 1,
			 2010.
						114.Elimination of
			 Medicare part D late enrollment penalties paid by subsidy eligible
			 individuals
						(a)Waiver of late
			 enrollment penalty
							(1)In
			 generalSection 1860D–13(b) of the Social Security 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 individualsIn 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
			 amendmentSection 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)..
							(b)Effective
			 dateThe amendments made by this section shall apply to subsidies
			 for months beginning with January 2009.
						115.Eliminating
			 application of estate recovery
						(a)In
			 generalSection 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
			 dateThe amendment made by subsection (a) shall take effect as of
			 January 1, 2010.
						116.Exemptions from
			 income and resources for determination of eligibility for low-income
			 subsidy
						(a)In
			 generalSection 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 provided 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 exclusionIn determining 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
			 dateThe amendments made by this section shall take effect on
			 January 1, 2010, and shall apply to determinations of eligibility for months
			 beginning with January 2010.
						117.Judicial
			 review of decisions of the Commissioner of Social Security under the Medicare
			 part D low-income subsidy program
						(a)In
			 generalSection 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
			 dateThe amendments made by subsection (a) shall take effect as
			 if included in the enactment of section 101 of the Medicare Prescription Drug,
			 Improvement, and Modernization Act of 2003.
						118.Translation of
			 model form
						(a)In
			 generalSection 1905(p)(5)(A)
			 of the Social Security Act (42 U.S.C. 1396d(p)(5)(A)) is amended by adding at
			 the end 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 hospital insurance
			 benefits under section 226 or 226A and shall make the translated forms
			 available to the States and to the Commissioner of Social
			 Security..
						(b)Effective
			 dateThe amendment made by subsection (a) shall take effect on
			 January 1, 2010.
						119.Medicare
			 enrollment assistance
						(a)Additional
			 Funding for State Health Insurance Assistance Programs
							(1)Grants
								(A)In
			 generalThe 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 assistance programs receiving assistance under section 4360 of the
			 Omnibus Budget Reconciliation Act of 1990.
								(B)FundingFor 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
			 grantsThe 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 beneficiariesThe amount
			 allocated to a State under this subparagraph from 2/3 of
			 the total amount made available 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
			 estimated by the Secretary.
								(B)Allocation
			 based on percentage of rural beneficiariesThe 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 Secretary.
								(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 ProgramEach grant awarded under this
			 subsection with respect to amounts allocated 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 (e)).
							(b)Additional
			 Funding for Area Agencies on Aging
							(1)Grants
								(A)In
			 generalThe 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)).
								(B)FundingFor 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
			 beneficiariesThe 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 paragraph (3) of such subsection.
							(3)Required use of
			 funds
								(A)All
			 fundsSubject to subparagraph (B), each grant awarded under this
			 subsection shall be used to provide outreach to eligible Medicare beneficiaries
			 regarding the benefits available under title XVIII of the
			 Social Security Act.
								(B)Outreach to
			 individuals who may be subsidy eligible individuals or eligible for the
			 Medicare Savings ProgramSubsection (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
			 generalThe 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.
								(B)FundingFor 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
			 fundsEach grant awarded under this subsection shall be used to
			 provide outreach to individuals regarding the benefits available under the
			 Medicare prescription 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 programs
							(1)In
			 generalThe Secretary, acting through the Assistant 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 individuals 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 outreach,
			 screening, and follow-up strategies for the Federal and State programs.
								(2)FundingFor 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)Medicare Savings Program
			 definedFor purposes of this
			 section, 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 of the Social
			 Security Act (42 U.S.C. 1396a(a)(10)(E), 1396u–3).
						BProvisions
			 relating to part A
				121.Expansion and
			 extension of the Medicare Rural Hospital Flexibility Program
					(a)In
			 generalSection 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
				statesThe Secretary may award grants to States that have
				submitted applications in accordance 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 Operation 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
				generalAn application is in accordance with this subparagraph if
				the State submits to the Secretary at such time and in such form as the
				Secretary may require an application containing the assurances described in
				subparagraphs (A)(ii) and (A)(iii) of subsection (b)(1).
									(ii)Consideration
				of regional approaches, networks, or technologyThe 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 subparagraph.
				For purposes of this clause, a network may, as the Secretary determines
				appropriate, include federally qualified health centers, rural health clinics,
				home health agencies, community mental health clinics and other providers of
				mental health services, pharmacists, local government, and other providers
				deemed necessary to meet the needs of veterans.
									(iii)Coordination
				at local levelThe Secretary shall require, as appropriate, a
				State to demonstrate consultation with the hospital association of such State,
				rural hospitals located in such State, providers 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 applicationsIn awarding grants to
				States under subparagraph (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 VAThe 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
				fundsA 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 administrative expensesA 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 reportThe 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.
								.
					(b)Use of funds
			 for federal administrative expensesSection 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 grantsSection 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 programSection 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 facilitiesSection 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)GrantsThe
				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)ApplicationAn
				applicable critical access hospital 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
				requirementsThe 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
				grantA grant to an eligible critical access hospital under this
				paragraph may not exceed $1,000,000.
								(E)FundingThere
				are appropriated from the Federal Hospital Insurance Trust Fund under section
				1817 for making grants under this paragraph, $5,000,000 for fiscal year
				2008.
								(F)Eligible
				critical access hospital definedFor 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.
								.
					122.Rebasing for
			 sole community hospitals
					(a)Rebasing
			 permittedSection 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 subparagraph (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
			 amendmentsSection 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.
						123.Demonstration
			 project on community health integration models in certain rural
			 counties
					(a)In
			 generalThe 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)PurposeThe
			 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)RequirementsThe
			 following requirements shall apply under the demonstration project:
						(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 Medicare 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
			 demonstration project shall be tested with the goal of assuring quality and
			 safety while reducing administrative burdens, as appropriate, 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 subsection (d)(3) shall be identified. Ways to ensure adequate
			 funding for such services shall also be explored.
						(d)Application
			 process
						(1)Eligibility
							(A)In
			 generalEligibility to participate in the demonstration project
			 under this section shall be limited to eligible entities.
							(B)Eligible entity
			 definedIn 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
			 generalAn eligible entity seeking to participate 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
			 Secretary may require.
							(B)LimitationThe
			 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 countiesAn 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.
						(4)Eligible county
			 definedIn 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
			 generalThe 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 paragraphs
			 (2) and (3).
						(2)HRSA
			 dutiesIn 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 assistance related to the requirements under the
			 project.
							(3)CMS
			 dutiesIn administering the demonstration project under this
			 section, the Administrator of the Centers for Medicare & Medicaid Services
			 shall determine which provisions 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 relevant to the development of
			 alternative reimbursement methodologies, 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 Medicare
			 beneficiaries and coordinating the survey and certification process under the
			 Medicare and Medicaid programs, as appropriate, across all service categories
			 included in the demonstration project.
						(f)Duration
						(1)In
			 generalThe demonstration project under this section shall be
			 conducted for a 3-year period beginning on October 1, 2009.
						(2)Beginning date
			 of demonstration projectThe demonstration project under this
			 section shall be considered to have begun in a State on the date on which the
			 eligible 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
			 generalThe 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
			 neutralityIn conducting the demonstration 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)HRSAThere
			 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 section, to remain available for the
			 duration of the demonstration project.
						(h)Report
						(1)Interim
			 reportNot 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 counties based on the findings of the demonstration project.
						(2)Final
			 reportNot later than 1 year after the completion 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 recommendations for such
			 legislation and administrative action as the Secretary determines
			 appropriate.
						(i)Waiver
			 authorityThe Secretary may waive such requirements 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)DefinitionsIn
			 this section:
						(1)Extended care
			 servicesThe term extended care services means the
			 following:
							(A)Home health
			 services.
							(B)Covered skilled
			 nursing facility services.
							(C)Hospice
			 care.
							(2)Covered skilled
			 nursing facility servicesThe 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
			 hospitalThe 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
			 servicesThe term home health services has the
			 meaning given such term in section 1861(m) of such Act (42 U.S.C.
			 1395x(m)).
						(5)Hospice
			 careThe term hospice care has the meaning given
			 such term in section 1861(dd) of such Act (42 U.S.C. 1395x(dd)).
						(6)Medicaid
			 programThe term Medicaid program means the program
			 under title XIX of such Act (42 U.S.C. 1396 et seq.).
						(7)Medicare
			 programThe term Medicare program means the program
			 under title XVIII of such Act (42 U.S.C. 1395 et seq.).
						(8)Other essential
			 health care servicesThe 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 servicesThe 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)SecretaryThe
			 term Secretary means the Secretary of Health and Human
			 Services.
						124.Extension of
			 the reclassification of certain hospitals
					(a)In
			 generalSubsection (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 reclassificationsSection 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 September 30,
			 2009.
					125.Revocation of
			 unique deeming authority of the Joint Commission
					(a)RevocationSection
			 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 pursuant to subsection (a) or (b)(1) and inserting
			 pursuant to subsection (a)(1); and
							(D)in subsection (d), as so redesignated,
			 by striking pursuant to subsection (a) or (b)(1) and inserting
			 pursuant to subsection (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 accreditation or
			 comparable approval standards of such program to be essentially 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 accreditation 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 Accreditation 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
			 BodyThe 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 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 paragraph
			 (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.
						CProvisions
			 relating to part B
				IPhysicians'
			 services
					131.Physician
			 payment, efficiency, and quality improvements
						(a)In
			 general
							(1)Increase in
			 update for the second half of 2008 and for 2009
								(A)For the second
			 half of 2008Section 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
			 2009Section 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
				generalSubject 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
				yearsThe conversion factor under this subsection shall be
				computed under paragraph (1)(A) for 2010 and subsequent years as if
				subparagraph (A) had never
				applied.
											.
								(2)Beneficiary
			 premium protectionSection
			 1839(g) of the Social Security Act (42 U.S.C. 1395r(g)) is amended—
								(A)by redesignating
			 paragraphs (1) and (2) as subparagraphs (A) and (B), respectively, and moving
			 such subparagraphs 2 ems to the right;
								(B)in the matter
			 preceding paragraph (1), by striking shall exclude an estimate
			 and inserting “shall exclude—

										(1)an
				estimate
										;
				and
								(C)by adding at the
			 end the following new paragraph:

										(2)with respect to
				the monthly premium rate under subsection (a)(3) for 2009,
				$_________ of benefits and administrative
				costs.
										.
								(3)Revision of the
			 Physician Assistance and Quality Initiative FundSection
			 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—
								(A)in subparagraph
			 (A)—
									(i)by striking
			 clause (i)(III); and
									(ii)by striking
			 clause (ii)(III); and
									(B)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)Extension and
			 improvement of the quality reporting system
							(1)SystemSection
			 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
				generalSubject to clause (ii), for purposes 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 measures that
				have been endorsed by the entity with a contract with the Secretary under
				section 1890(a).
										(ii)ExceptionIn the case of a specified area or medical
				topic determined appropriate by the Secretary 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 yearsFor each quality measure (including an
				electronic prescribing quality measure) adopted by the Secretary under
				subparagraph (B) (with respect to 2009) or subparagraph (C), the Secretary
				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 systemSubsection (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 Extension 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 systemSection 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 following:

										(1)Incentive
				payments
											(A)In
				generalFor 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.(B)Applicable
				quality percentFor 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 paragraph (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
				generalFor
				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 subparagraphs:

											(C)Satisfactory
				reporting measures for group practices
												(i)In
				generalBy January 1, 2010, the Secretary 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 satisfactorily submitting
				data on quality measures under subparagraph (A) and as meeting the requirement
				described in subparagraph (B)(ii) for covered professional 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 determined 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 modelThe 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
				paymentsPayments 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 satisfactorily submitting data on quality measures.
												(D)Authority to
				revise satisfactorily reporting dataFor 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 measures under subparagraph
				(B)(ii).
											;
									(E)in paragraph
			 (5)—
									(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
			 professional;
											(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 subsection; and
										(V)in clause (iv),
			 as so redesignated—
											(aa)by
			 striking the bonus and inserting any; and
											(bb)by
			 inserting and the payment adjustment 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 subparagraph:

											(G)Posting on
				websiteThe 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
									(F)in paragraph (6),
			 by striking subparagraph (C) and inserting the following:

										(C)Reporting
				period
											(i)In
				generalSubject 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 periodFor years after 2009, the Secretary may
				revise the reporting period under clause (i) if the Secretary determines 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)ReferenceAny
				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
			 generalSection 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
			 billingNothing in the amendment 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
			 amendmentsSection 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 Security 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
										(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 subsection (b) and inserting subsection
			 (k)(3); and
									(ii)in
			 subparagraph (B), by striking section 1848(k) of the Social Security
			 Act, as added by subsection (b) and inserting subsection
			 (k); and
									(C)by striking
			 paragraph (6)(D).
								(6)No affect on
			 incentive payments for 2007 or 2008Nothing 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
			 generalSection 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
				generalThe 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 determined
				appropriate by the Secretary, to groups of physicians) that measure the
				resources involved in furnishing care to individuals under this title. If
				determined appropriate by the Secretary, the Secretary may include information
				on the quality of care furnished to individuals under this title by the
				physician (or group of physicians) in such reports.
											(B)Resource
				useThe 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)ImplementationThe
				Secretary shall implement the Program by not later than January 1, 2009.
										(3)Data for
				reportsTo the extent practicable, reports under the Program
				shall be based on the most recent data available.
										(4)Authority to
				focus applicationThe 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
											(E)physicians who
				treat a minimum number of individuals under this title.
											(5)Authority to
				Exclude certain information if insufficient informationThe
				Secretary may exclude certain 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 information relating to that
				service to provide a valid report on that service.
										(6)Adjustment of
				dataTo 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
				outreachThe Secretary shall provide for education and outreach
				activities to physicians on the operation of, and methodologies employed under,
				the Program.
										(8)Disclosure
				exemptionReports 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)StudyThe
			 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)ReportNot
			 later than March 1, 2011, the Comptroller 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 Comptroller General determines appropriate.
								(d)Plan for
			 transition to value-based purchasing program for physicians and other
			 practitioners
							(1)In
			 generalThe 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)ReportNot
			 later than May 1, 2010, the Secretary of Health and Human Services shall submit
			 a report to Congress containing the plan developed under paragraph (1),
			 together with recommendations for such legislation and administrative action as
			 the Secretary determines appropriate.
							132.Incentives for
			 electronic prescribing
						(a)Incentive
			 paymentsSection 1848(m) of
			 the Social Security 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
				generalFor 2009 through 2013, with respect to covered
				professional services furnished during a reporting period by an eligible
				professional, if the eligible 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 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.
										(B)Limitation with respect to electronic
				prescribing quality measuresThe provisions of this paragraph 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 furnished 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 prescriptions 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 percentFor 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 electronic prescriber after
			 reporting; and
								(B)by inserting
			 after subparagraph (A) the following new subparagraph:

										(B)Successful
				electronic prescriber
											(i)In
				generalFor purposes of paragraph (2) and subsection (a)(5), an
				eligible professional shall be 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 professional 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 electronic prescribing quality
				measuresThe requirement 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 services 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 prescribing under part DThe requirement
				described in this clause is that the eligible professional electronically
				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
				dataNotwithstanding sections 1860D–15(d)(2)(B) and
				1860D–15(f)(2), the Secretary 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 prescribingTo 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 section
				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 adjustmentSection 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
										(i)In
				generalSubject to subparagraph (B) and subsection (m)(2)(B),
				with respect to covered professional 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 purposes 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
				percentFor purposes of clause (i), the term applicable
				percent means—
											(I)for 2012, 99
				percent;
											(II)for 2012, 98.5
				percent; and
											(III)for 2014 and
				each subsequent year, 98 percent.
											(B)Significant
				hardship exceptionThe Secretary may, on a case-by-case basis,
				exempt an eligible professional from the application of the payment adjustment
				under subparagraph (A) if the Secretary determines, subject to annual renewal,
				that compliance with the requirement 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 without sufficient Internet
				access.
									(C)Application
										(i)Physician
				reporting system rulesParagraphs (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 rulesClauses (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)DefinitionsFor
				purposes of this paragraph:
										(i)Eligible
				professional; covered professional servicesThe terms
				eligible professional and covered professional
				services have the meanings given such terms in subsection (k)(3).
										(ii)Physician
				reporting systemThe term physician reporting system
				means the system established under subsection (k).
										(iii)Reporting
				periodThe term reporting period means, with
				respect to a year, a period specified by the
				Secretary.
										.
						(c)GAO report on
			 electronic prescribingNot 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:
							(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 adjustments
			 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 protected 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.
							133.Expanding
			 access to primary care services
						(a)Incentive
			 payment program for primary care services furnished in physician scarcity
			 areas
							(1)In
			 generalSection 1833 of the Social Security Act (42 U.S.C. 1395l)
			 is amended by adding at the end the following new subsection:

									(v)Incentive payments for primary care
				services furnished in physician scarcity areas
										(1)In
				generalIn the case of primary care services furnished on or
				after January 1, 2011, by a primary care physician in a primary care scarcity
				county, in addition to the amount of payment that would otherwise be made for
				such services under this part, there also shall be paid (on a monthly or
				quarterly basis) an amount equal to 5 percent of the payment amount for the
				service under this part.
										(2)DefinitionsIn
				this subsection:
											(A)Primary care
				physicianThe term primary care physician means a
				physician (as described in section 1861(r)(1)) for whom primary care services
				accounted for at least a specified percent (as determined by the Secretary) of
				the allowed charges under this part for such physician in a prior period as
				determined appropriate by the Secretary.
											(B)Primary care
				scarcity countyThe term primary care scarcity
				county means the primary care scarcity counties that the Secretary was
				using under subsection (u) with respect to physicians' services furnished on
				December 31, 2007.
											(C)Primary care
				servicesThe term primary care services means
				procedure codes for services in the category of the Healthcare Common Procedure
				Coding System, as established by the Secretary under section 1848(c)(5) (as of
				December 31, 2008 and as subsequently modified by the Secretary) consisting of
				evaluation and management services, but limited to such procedure codes in the
				category of office or other outpatient services, and consisting of
				subcategories of such procedure codes for services for both new and established
				patients.
											(3)Judicial
				reviewThere shall be no administrative or judicial review under
				section 1869, 1878, or otherwise, respecting the identification of primary care
				physicians, primary care specialty areas, or primary care services under this
				subsection.
										.
							(2)Conforming
			 amendmentSection 1834(g)(2)(B) of the Social Security Act (42
			 U.S.C. 1395m(g)(2)(B)) is amended by adding at the end the following sentence:
			 Section 1833(v) shall not be taken into account in determining the
			 amounts that would otherwise be paid pursuant to the preceding
			 sentence..
							(b)Revisions to
			 the Medicare medical home demonstration project
							(1)Authority to
			 expandSection 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)ExpansionThe
				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
				determines 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
			 applicationSection 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:

									(g)Funding from SMI
				trust fundThere shall be available, 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)ApplicationChapter
				35 of title 44, United States Code, shall not apply to the conduct of the
				project.
									.
							(c)Application of
			 budget-neutrality adjustor to conversion factorSection
			 1848(c)(2)(B) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)(B)) is
			 amended by inserting at the end the following new clause:

								(iv)Alternative
				application of budget-neutrality adjustmentNotwithstanding
				subsection (d)(9)(A), effective for fee schedules established beginning 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 Secretary shall apply such budget-neutrality
				adjustments to the conversion factor otherwise determined for years beginning
				with
				2009.
								.
						134.Extension of
			 floor on Medicare work geographic adjustment under the Medicare physician fee
			 schedule
						(a)In
			 generalSection 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 certain areasSection
			 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 furnished 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
			 correctionSection 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
								.
						135.Imaging
			 provisions
						(a)Accreditation
			 requirement
							(1)Accreditation
			 requirementSection 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
				generalBeginning with January 1, 2012, with respect to the
				technical component of advanced diagnostic imaging services for which payment
				is made under the fee schedule established under section 1848(b) and 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 definedIn this subsection, the term
				advanced diagnostic imaging services includes—
												(i)diagnostic
				magnetic resonance imaging, computed 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 physician specialty organizations and other
				stakeholders.
												(C)Supplier
				definedIn this subsection, the term supplier has
				the meaning given such term in section 1861(d).
											(2)Accreditation
				organizations
											(A)Factors for
				designation of accreditation organizationsThe 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 determines appropriate.
												(B)DesignationNot later than January 1, 2010, the
				Secretary shall designate organizations to accredit suppliers furnishing the
				technical component of advanced diagnostic imaging services. The list of
				accreditation organizations so designated may be modified pursuant to
				subparagraph (C).
											(C)Review and
				modification of list of accreditation organizations
												(i)In
				generalThe 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 the list of accreditation organizations
				designated under subparagraph (B).
												(ii)Special rule
				for accreditations done prior to removal from list of designated accreditation
				organizationsIn the case where the Secretary removes an
				organization from the list of accreditation 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
				accreditationThe 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 furnishing the technical component of advanced
				diagnostic imaging services meets performance specifications;
											(D)standards that
				require the supplier have procedures 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 furnished;
											(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 technical quality of diagnostic
				images produced by such supplier; and
											(F)any other
				standards or procedures the Secretary determines appropriate.
											(4)Recognition in
				standards for the evaluation of medical directors and supervising
				physiciansThe standards 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 program;
											(B)has attained,
				through experience, the necessary expertise to be a medical director or a
				supervising physician;
											(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 designationIn 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 paragraph as of January 1,
				2012, for the remaining period such accreditation is in
				effect.
										.
							(2)Conforming
			 amendments
								(A)In
			 generalSection 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 diagnostic 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
			 dateThe amendments made by this paragraph shall apply to
			 advanced diagnostic imaging services 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
			 generalThe 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 appropriateness of advanced
			 diagnostic imaging services furnished to Medicare beneficiaries.
								(B)Advanced
			 diagnostic imaging servicesIn 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 projectThe Secretary may focus the
			 demonstration project with respect to certain advanced diagnostic imaging
			 services, such as services that account for a large amount of expenditures
			 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
									(i)ImplementationThe
			 Secretary shall implement the demonstration project under this subsection not
			 later than January 1, 2010.
									(ii)DurationThe
			 Secretary shall conduct the demonstration project under this subsection for a
			 2-year period.
									(B)Application and
			 selection of participating physicians
									(i)ApplicationEach
			 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)SelectionThe
			 Secretary shall select physicians 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 private 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 accordance with standards established by
			 the Secretary.
										(C)Administrative
			 costs and incentivesThe Secretary shall—
									(i)reimburse
			 physicians for reasonable administrative costs incurred in participating in the
			 demonstration 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
			 generalThe Secretary, in consultation with medical specialty
			 societies and other stakeholders, shall select criteria with respect to the
			 clinical appropriateness of advanced diagnostic imaging services for use in the
			 demonstration project under this subsection.
									(ii)Criteria
			 selectedAny criteria selected under clause (i) shall—
										(I)be developed or
			 endorsed by a medical specialty society; and
										(II)be developed in
			 adherence to appropriateness principles developed by a consensus organization,
			 such as the AQA alliance.
										(E)Models for
			 collecting data regarding physician compliance with selected
			 criteriaSubject 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 physician compliance with
			 appropriateness criteria selected under subparagraph (D):
									(i)A
			 model described in subparagraph (F).
									(ii)A
			 model described in subparagraph (G).
									(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 describedA 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 Secretary, in consultation with
			 medical specialty societies and other stakeholders, to be germane to evaluating
			 the effectiveness of the use of appropriateness 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 submission of such form; and
										(ii)provides for
			 feedback reports in accordance with paragraph (3)(B).
									(G)Point of order
			 model describedA 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 diagnostic imaging
			 services and provides automated decision-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)LimitationIn
			 no case may the Secretary use prior authorization—
									(i)as a
			 model for collecting data regarding physician 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 standards for certain entities
									(i)In
			 generalThe Secretary shall enter into contracts with entities to
			 carry out the model described in subparagraph (G).
									(ii)Performance
			 standardsThe 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 demonstration project;
										(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 diagnostic imaging servicesThe Secretary
			 shall consult with medical specialty societies and other stakeholders to
			 develop mechanisms for comparing the utilization of advanced diagnostic imaging
			 services by physicians participating 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 demonstration project.
									(B)Feedback
			 reportsThe Secretary shall, in consultation with medical
			 specialty societies and other stakeholders, 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 physician with appropriateness
			 criteria selected under paragraph (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
			 criteria; and
										(ii)to
			 the extent feasible, a comparison of—
										(I)the rate of
			 utilization of advanced diagnostic 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 projectChapter 35 of title 44, United States Code,
			 shall not apply to the conduct of the demonstration project under this
			 subsection.
								(B)WaiverThe
			 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)EvaluationThe
			 Secretary shall evaluate the demonstration project under this subsection
			 to—
									(i)assess the
			 timeliness and efficacy of the demonstration project;
									(ii)assess the
			 performance of entities under a contract entered into under paragraph
			 (2)(I)(i);
									(iii)analyze
			 data—
										(I)on the rates of
			 appropriate, uncertain, and inappropriate advanced diagnostic imaging services
			 furnished by physicians participating in the demonstration project;
										(II)on patterns and
			 trends in the appropriateness and inappropriateness of such services furnished
			 by such physicians;
										(III)on patterns and
			 trends in national and regional variations of care with respect to the
			 furnishing of such services; and
										(IV)on the
			 correlation between the appropriateness of the services furnished and image
			 results; and
										(iv)address—
										(I)the thresholds
			 used under the demonstration 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 appropriateness criteria with respect to such services
			 to a broader population of Medicare beneficiaries would be advisable;
										(IV)whether, under
			 such an expansion, physicians 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 appropriateness 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)ReportNot
			 later than 1 year after the completion 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 recommendations for such legislation and
			 administrative action as the Secretary determines appropriate.
								(6)FundingThe
			 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 physicians for administrative costs and
			 providing incentives to encourage participation under paragraph (2)(C),
			 entering into contracts under paragraph (2)(I), and evaluating the
			 demonstration project under paragraph (5)).
							(c)GAO studies and
			 reports
							(1)Study on
			 accreditation requirement for advanced diagnostic imaging services
								(A)Study
									(i)In
			 generalThe Comptroller General of the United States (in this
			 subsection referred to as the Comptroller 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 services for Medicare beneficiaries.
										(ii)IssuesThe
			 study conducted under clause (i) 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 administering such
			 requirement.
										(III)Access to
			 imaging services by Medicare beneficiaries, especially in rural areas, before
			 and after implementation of such accreditation requirement.
										(IV)Such other issues
			 as the Secretary determines appropriate.
										(B)Reports
									(i)Preliminary
			 reportNot later than March 1, 2013, the Comptroller General
			 shall submit a preliminary report to Congress on the study conducted under
			 subparagraph (A).
									(ii)Final
			 reportNot later than March 1, 2014, the Comptroller General
			 shall submit a final report to Congress on the study conducted under
			 subparagraph (A), together with recommendations for such legislation and
			 administrative action as the Comptroller General determines appropriate.
									(2)Study on
			 interest rate and equipment utilization assumptions used in determining
			 practice expense
								(A)Study
									(i)In
			 generalThe Comptroller General shall conduct a study on the
			 assumptions used for interest rate and equipment utilization in the methodology
			 for determination of practice expense relative value units under section
			 1848(c)(2)(C)(ii) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)(C)(ii))
			 with respect to imaging services.
									(ii)Collection of
			 dataIn conducting the study under clause (i), the Comptroller
			 General shall collect data on imaging equipment utilization for different
			 modalities of imaging equipment used in—
										(I)different types of
			 practices; and
										(II)different
			 geographic areas.
										(B)ReportNot
			 later than June 1, 2010, the Comptroller General shall submit to Congress a
			 report containing the results of the study conducted under subparagraph (A),
			 including the data collected under clause (ii) of such subparagraph, together
			 with recommendations for such legislation and administrative action as the
			 Comptroller General determines appropriate.
								136.Extension of
			 treatment of certain physician pathology services under MedicareSection 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 Modernization 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.
					137.Accommodation of
			 physicians ordered to active duty in the Armed ServicesSection 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).
					138.Adjustment for
			 Medicare mental health services
						(a)Payment
			 adjustment
							(1)In
			 generalFor 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-neutralityThe 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 servicesIn 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 subcategories of services which
			 are—
							(1)insight oriented,
			 behavior modifying, or supportive psychotherapy; or
							(2)interactive
			 psychotherapy.
							(c)ImplementationNotwithstanding
			 any other provision of law, the Secretary may implement this section by program
			 instruction or otherwise.
						139.Improvements
			 for Medicare anesthesia teaching programs
						(a)Special payment
			 rule for teaching anesthesiologistsSection 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 anesthesiologistsWith 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
				anesthesia 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 anesthesia 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 anesthesiologist 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 anesthetistsWith respect to items and
			 services furnished on or after January 1, 2010, the Secretary of Health and
			 Human Services shall make appropriate adjustments to payments under the
			 Medicare 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 anesthetists 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.
							IIOther payment
			 and coverage improvements
					141.Extension of
			 exceptions process for Medicare therapy capsSection 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.
					142.Extension of
			 payment rule for brachytherapy and therapeutic
			 radiopharmaceuticalsSection
			 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, Medicaid, 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.
					143.Speech-language
			 pathology services
						(a)In
			 generalSection 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 paragraph:

									(2)The term outpatient
				speech-language pathology services has the meaning given the term
				outpatient physical therapy services 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 , outpatient;
			 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
			 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 services 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 services 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 subsection (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 services 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 subsection (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 subsection (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-language 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
			 dateThe amendments made by this section shall apply to services
			 furnished on or after July 1, 2009.
						(d)ConstructionNothing 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.
						144.Payment and
			 coverage improvements for patients with chronic obstructive pulmonary disease
			 and other conditions
						(a)Coverage of
			 pulmonary and cardiac rehabilitation
							(1)In
			 generalSection 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)in
			 subparagraph (BB), by adding and after the semicolon at the end;
			 and
									(iii)by adding at
			 the end the following new subparagraph:

											(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
									(B)by adding at the end the following new
			 subsections:

										(eee)Cardiac rehabilitation program(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 presumed; 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—
													(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)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.
												(fff)Pulmonary rehabilitation
		  program(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)Effective
			 dateThe amendments made by
			 this subsection shall apply to items and services furnished on or after January
			 1, 2010.
							(b)Repeal of
			 transfer of ownership of oxygen equipment
							(1)In
			 generalSection 1834(a)(5)(F) of the Social Security 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 capAfter the 36th continuous month during
				which payment is made for the equipment under this paragraph—
											(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 manufacturer’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
			 dateThe amendments made by paragraph (1) shall take effect on
			 January 1, 2009.
							(c)Revision of
			 payment for oxygen and oxygen equipment, portable oxygen equipment, and oxygen
			 for stationary equipment
							(1)Separate payment
			 for oxygen equipment and oxygen for stationary equipmentSection 1834(a) of the Social Security Act
			 (42 U.S.C. 1395m(a)) is amended by adding at the end the following new
			 paragraph:

									(22)Additional
				special payment rule beginning in 2009
										(A)In
				generalNotwithstanding the preceding provisions of this
				subsection, for oxygen equipment (other than portable oxygen and oxygen
				equipment) furnished during 2009, the payment amount otherwise determined under
				this subsection for such equipment shall be equal to—
											(i)the amount of the
				monthly payment amount otherwise established by the Secretary under this
				subsection for oxygen and oxygen equipment (other than portable oxygen
				equipment) furnished in 2009; minus
											(ii)71 percent of the
				amount of the monthly payment amount established by the Secretary under this
				subsection for oxygen for stationary equipment furnished in such year.
											(B)Application of update to special payment
				amountThe covered item
				update under paragraph (14) for oxygen equipment for 2010 and each subsequent
				year shall be applied to the payment amount under subparagraph (A) unless
				payment is made for such items and supplies under section
				1847.
										.
							(2)Add-on payment
			 for oxygen for stationary oxygen equipmentSection 1834(a)(5) of
			 the Social Security Act (42 U.S.C. 1395m(a)(5)) is amended by adding at the end
			 the following new subparagraph:

									(G)Add-on for
				oxygen for stationary oxygen equipmentIn the case of oxygen
				furnished on or after January 1, 2009, when oxygen is used with stationary
				oxygen equipment, the payment amount recognized under subparagraph (A) shall be
				increased by the amount established by the Secretary for such oxygen (or 71
				percent of such amount during the rental period for such
				equipment).
									.
							(3)Equalizing
			 add-on payment for oxygen for portable oxygen and oxygen equipment during
			 monthly rental period and payment for such oxygen and oxygen equipment after
			 such rental periodSection 1834(a)(9) of the Social Security Act
			 (42 U.S.C. 1395m(a)(9)) is amended by adding at the end the following new
			 subparagraph:

									(E)Special rule for
				add-on payment for portable oxygen and oxygen equipmentIn the
				case of oxygen and oxygen equipment furnished on or after January 1, 2009, for
				purposes of paragraph (5)(B), the monthly amount recognized under this
				paragraph for portable oxygen and oxygen equipment in a year shall be equal to
				the monthly payment amount for portable oxygen and oxygen equipment applicable
				for the year under this subsection after the end of the 36-month period under
				paragraph
				(5)(F).
									.
							(4)Special rule for
			 add-on payments for oxygen generating portable equipmentSection
			 1834(a)(9) of the Social Security Act (42 U.S.C. 1395m(a)(9)), as amended by
			 paragraph (3), is amended by adding at the end the following new
			 subparagraph:

									(F)Special rule for
				add-on payment for oxygen generating portable equipmentIn the
				case of oxygen generating portable equipment, as defined by the Secretary,
				furnished on or after January 1, 2009, the Secretary shall make the following
				monthly add-on payments during the 36-month rental period under paragraph
				(5)(F):
										(i)An
				amount equal to the monthly payment amount specified in subparagraph (E) for
				the month.
										(ii)An amount equal
				to the monthly payment amount otherwise established by the Secretary under this
				subsection for such equipment for the month that recognizes that such equipment
				substitutes for the delivery of portable oxygen and oxygen contents during the
				remaining useful life of the equipment that occurs after the end of such
				36-month rental
				period.
										.
							(5)Cap on total
			 monthly payment for liquid or gaseous stationary and portable
			 systemsSection 1834(a)(5) of the Social Security Act (42 U.S.C.
			 1395m(a)(5)), as amended by paragraph (2), is amended by adding at the end the
			 following new subparagraph:

									(H)Cap on total
				payments for liquid or gaseous stationary and portable systemsIn
				the case of a liquid or gaseous stationary and portable system furnished on or
				after January 1, 2009, the total monthly amount recognized under this part for
				such system for a month (including any add-on payments under this subsection)
				may not exceed the total monthly amount that would have otherwise been
				recognized under this part for such system for the month (including any add-on
				payments under this subsection) if the amendments made by section 144(c) of the
				Medicare Improvements for Patients and
				Providers Act of 2008 had not been
				enacted.
									.
							(6)Conforming
			 amendments(A)Section 1834(a)(5)(A) of
			 the Social Security Act (42 U.S.C. 1395m(a)(5)(A)) is amended—
									(i)by inserting and, in the
			 case of items and services furnished on or after January 1, 2009, other than
			 oxygen for stationary equipment after portable oxygen
			 equipment; and
									(ii)by striking subparagraphs
			 (B), (C), (E), and (F) and inserting the succeeding provisions
			 of this paragraph.
									(B)Section 1834(a)(9) of the Social Security
			 Act (42 U.S.C. 1395m(a)(9)) is amended—
									(i)in the first sentence of the matter
			 preceding subparagraph (A), by striking For purposes and
			 inserting Subject to paragraphs (21) and (22), for purposes;
			 and
									(ii)in the second sentence of the matter
			 preceding subparagraph (A)—
										(I)by
			 inserting and, in the case of items and services furnished on or after
			 January 1, 2009, other than oxygen for stationary equipment after
			 portable oxygen equipment;
										(II)by striking and before
			 (ii) and inserting a comma; and
										(III)by inserting , and (iii) in the
			 case of items and services furnished on or after January 1, 2009, for oxygen
			 for stationary equipment before (each such group.
										(d)Application to
			 competitive biddingThe amendments made by subsections (b) and
			 (c) shall not apply to contracts entered into under section 1847 of the Social
			 Security Act (42 U.S.C. 1395w–3) prior to September 1, 2008, pursuant to the
			 implementation of subsection (a)(1)(B)(i)(I) of such section 1847.
						(e)Institute of
			 Medicine study and report on payments for different classes of oxygen
			 equipment
							(1)StudyNot
			 later than 3 months 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
			 Medicine of the National Academies (in this section referred to as the
			 Institute) under which the Institute shall conduct a study on
			 the furnishing of, and payments for, oxygen and oxygen equipment under the
			 Medicare program. Such study shall include an analysis of the following:
								(A)The costs and
			 activities associated with furnishing different modalities of oxygen equipment
			 (covering gaseous and liquid portable equipment and oxygen generating portable
			 equipment), including—
									(i)the acquisition
			 cost of the oxygen equipment;
									(ii)the delivery and
			 refilling of oxygen contents for stationary and portable systems, including the
			 frequency of delivery;
									(iii)the delivery of
			 the equipment and the provision of supplies and accessories;
									(iv)training and
			 education, intake of patient information and related documentation, and
			 responding to beneficiary inquiries;
									(v)servicing of
			 different types of oxygen and oxygen equipment, including—
										(I)the type and
			 frequency of routine and nonroutine servicing furnished, and variation across
			 suppliers in furnishing such servicing; and
										(II)the extent to
			 which emergency or after hours servicing is needed and furnished; and
										(vi)other items or
			 activities involved with furnishing oxygen and oxygen equipment not described
			 in clauses (i) though (v).
									(B)Whether the
			 various items and activities described in subparagraph (A) are medically
			 necessary and affect patient outcomes.
								(C)(i)The adequacy of Medicare
			 payment rates for oxygen equipment and necessary servicing and items and
			 activities furnished in connection with the provision of oxygen and oxygen
			 equipment; and
									(ii)how such payment rates compare to
			 competitively bid rates.
									(D)Whether payment
			 rates for oxygen and oxygen equipment under the Medicare program should vary
			 depending on the modality of oxygen equipment used or should be the same for
			 all modalities.
								(E)The adequacy of
			 add-on payments under the Medicare program for—
									(i)contents for
			 stationary equipment;
									(ii)contents for
			 portable equipment; and
									(iii)oxygen-generating
			 portable equipment.
									(F)(i)Whether, during the
			 rental period for oxygen equipment under the Medicare program, payment for such
			 equipment and servicing should be bundled together or whether separate payments
			 are appropriate; and
									(ii)if separate payments are
			 appropriate, how the payment should be allocated between equipment and
			 servicing.
									(G)Options that could
			 be considered for suppliers to document or report under the Medicare program
			 detailed information on activities related to furnishing oxygen and oxygen
			 equipment to Medicare beneficiaries.
								(2)SurveyIn
			 conducting the study under paragraph (1), the Institute shall conduct a survey
			 of suppliers of oxygen and oxygen equipment to obtain data on items described
			 in paragraph (1)(A).
							(3)ReportNot
			 later than 18 months after the date of the enactment of this Act, the Institute
			 shall submit to the Secretary of Health and Human Services a report containing
			 the results of the study conducted under paragraph (1), together with such
			 recommendations as the Institute determines appropriate.
							(4)FundingFor
			 the purpose of carrying out this section, 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), of $5,000,000 to the Centers for Medicare & Medicaid
			 Services Program Management Account.
							145.Revision of payment
			 for power-driven wheelchairs
						(a)In
			 generalSection 1834(a)(7)(A) of the Social Security Act (42
			 U.S.C. 1395m(a)(7)(A)) is amended—
							(1)in clause
			 (i)—
								(A)in subclause (II),
			 by inserting subclause (III) and after Subject
			 to; and
								(B)by adding at the
			 end the following new subclause:

										(III)Special rule
				for power-driven wheelchairsFor purposes of payment for
				power-driven wheelchairs, subclause (II) shall be applied by substituting
				15 percent and 6 percent for 10
				percent and 7.5 percent,
				respectively.
										;
				and
								(2)in clause
			 (iii)—
								(A)in the heading, by
			 inserting complex,
			 rehabilitative before power-driven; and
								(B)by inserting
			 complex, rehabilitative before
			 power-driven.
								(b)Technical
			 amendmentSection 1834(a)(7)(C)(ii)(II) of the Social Security
			 Act (42 U.S.C. 1395m(a)(7)(C)(ii)(II)) is amended by striking (A)(ii)
			 or.
						(c)Effective
			 date
							(1)In
			 generalSubject to paragraph (2), the amendments made by
			 subsection (a) shall take effect on January 1, 2009, and shall apply to
			 power-driven wheelchairs furnished on or after such date.
							(2)Application to
			 competitive biddingThe amendments made by subsection (a) shall
			 not apply to contracts entered into under section 1847 of the Social Security
			 Act (42 U.S.C. 1395w–3) prior to January 1, 2009, pursuant to the
			 implementation of subsection (a)(1)(B)(i)(I) of such section 1847.
							146.Clinical laboratory
			 tests
						(a)Repeal of
			 Medicare competitive bidding demonstration project for clinical laboratory
			 services
							(1)In
			 generalSection 1847 of the Social Security Act (42 U.S.C.
			 1395w–3) is amended by striking subsection (e).
							(2)Conforming
			 amendmentsSection 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
			 dateThe amendments made by this subsection shall take effect on
			 the date of the enactment of this Act.
							(b)Clinical
			 laboratory test fee schedule update adjustmentSection
			 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 average).
						147.Improved
			 access to ambulance services
						(a)Extension of
			 increased Medicare payments for ground ambulance servicesSection 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
			 scheduleNotwithstanding 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 requirement of medically necessary
								(A)In
			 generalSection 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
			 dateThe amendment made by subparagraph (A) shall apply to
			 services furnished on or after the date of the enactment of this Act.
								148.Extension and
			 expansion of the Medicare hold harmless provision under the prospective payment
			 system for hospital outpatient department (HOPD) services for certain
			 hospitalsSection
			 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
							(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 furnished 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.
								.
						149.Clarification
			 of payment for clinical laboratory tests furnished by critical access
			 hospitals
						(a)In
			 generalSection 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
			 dateThe amendments made by subsection (a) shall apply to
			 services furnished on or after July 1, 2009.
						150.Adding certain
			 entities as originating sites for payment of telehealth services
						(a)In
			 generalSection 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 hospital-based renal dialysis center (including
				satellites).
								(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
			 amendmentSection 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
			 DateThe amendments made by
			 this section shall apply to services furnished on or after January 1,
			 2009.
						151.MedPAC study
			 and report on improving chronic care demonstration programs
						(a)StudyThe
			 Medicare Payment Advisory 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 coordination and other care approaches for chronically ill
			 beneficiaries, including the initiation, operation, evaluation, and, if
			 appropriate, expansion of such models to the broader Medicare patient
			 population.
						(b)ReportNot
			 later than June 15, 2009, the Medicare Payment Advisory Commission shall submit
			 to Congress a report containing the results of the study conducted under
			 subsection (a).
						152.Increase of
			 FQHC payment limits
						(a)In
			 generalSection 1833 of the Social Security Act (42 U.S.C.
			 1395l), as amended by section 133(a), is amended by adding at the end the
			 following new subsection:

								(w)Increase of
				FQHC payment limitsIn the case of services 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 percentage 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)StudyThe
			 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 furnished 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 established with respect to such services under
			 such part B on the ability of federally qualified health centers to furnish
			 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)ReportNot
			 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 under the Medicaid program under title XIX of the Social
			 Security Act (42 U.S.C. 1396 et seq.).
							153.Kidney disease
			 education and awareness provisions
						(a)Chronic kidney
			 disease initiativesPart 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:

								399R.Chronic
				kidney disease initiatives
									(a)In
				generalThe 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)ScopeThe
				Secretary shall select at least 3 States in which to conduct pilot projects
				under this section.
										(2)DurationThe
				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
				reportThe 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 appropriationsThere 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 education services
							(1)Coverage of
			 kidney disease education services
								(A)CoverageSection
			 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)), as amended by
			 section 144(a), is amended—
									(i)in
			 subparagraph (BB), by striking and after the semicolon at the
			 end;
									(ii)in
			 subparagraph (CC), by adding and after the semicolon at the end;
			 and
									(iii)by
			 adding at the end the following new subparagraph:

											(DD)kidney disease education services (as
				defined in subsection
				(ggg));
											.
									(B)Services
			 describedSection 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:

										(ggg)Kidney disease education services(1)The term kidney
				disease education services means educational services that are—
												(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 physician 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
				consulting with physicians, other health professionals, health educators,
				professional organizations, accrediting organizations, kidney patient
				organizations, dialysis facilities, transplant centers, network organizations
				described in section 1881(c)(2), and other knowledgeable 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 scheduleSection 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),.
								(D)Limitation on
			 number of sessionsSection 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:

											(O)in the case of kidney disease
				education services (as defined in paragraph (1) of section 1861(ggg)), which
				are furnished in excess of the number of sessions covered under paragraph (4)
				of such
				section;
											.
									(2)Effective
			 dateThe amendments made by this subsection shall apply to
			 services furnished on or after January 1, 2010.
							154.Renal dialysis
			 provisions
						(a)Composite
			 rate
							(1)UpdateSection
			 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 rateSection 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
			 generalSection 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 paragraph (12)(B)(ii)) and for such services and items
				furnished pursuant 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 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 treatment 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 paragraph) made separately
				under this title, and any oral equivalent form of such drug or biological;
				and
											(iv)diagnostic laboratory tests and other items
				and services 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, ethnicity, 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
				adjustment—
												(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.
											(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
				payments 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 identification 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
				administered 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
			 unbundlingSection 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.
										.
								(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 payment 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 paragraph; and
										(II)by inserting or under the system
			 under paragraph (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
			 constructionNothing 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 implemented 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 programSection 1881 of
			 the Social Security Act (42 U.S.C. 1395rr) is amended by adding at the end the
			 following new subsection:

								(h)Quality
				incentives in the end-stage renal disease program
									(1)Quality
				incentives
										(A)In
				generalWith respect to renal dialysis services (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
				requirement 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
				appropriate by the Secretary.
										(B)RequirementThe
				requirement described in this subparagraph is that the provider or facility
				meets (or 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 yearsThe 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 subsequent year.
										(2)Measures
										(A)In
				generalThe 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
				Administration for such management and measures on dialysis adequacy;
											(ii)to the extent feasible, such measure (or
				measures) of patient satisfaction as the Secretary shall specify; and
											(iii)such other
				measures as the Secretary specifies, 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
				generalSubject to clause (ii), any measure specified by the
				Secretary under subparagraph (A)(iii) must have been endorsed by the entity
				with a contract under section 1890(a).
											(ii)ExceptionIn
				the case of a specified area or medical topic determined appropriate by the
				Secretary 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
				measuresThe Secretary shall establish a process for updating the
				measures specified under subparagraph (A) in consultation with interested
				parties.
										(D)ConsiderationIn specifying measures under subparagraph
				(A), the Secretary shall consider the availability 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
				generalSubject to clause (ii), the Secretary 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).
											(ii)ApplicationFor
				providers of services and renal dialysis facilities that do not meet (or
				exceed) the total performance score established by the Secretary, 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
				measuresIn calculating the total performance score, the
				Secretary shall weight the scores with respect to individual measures
				calculated 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 performance standards, as determined
				appropriate by the Secretary.
											(B)Performance
				score with respect to individual measuresThe Secretary shall
				also calculate separate performance scores for each measure, including for
				dialysis adequacy and anemia management.
										(4)Performance
				standards
										(A)EstablishmentSubject
				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
				improvementThe performance standards established under
				subparagraph (A) shall include levels of achievement and improvement, as
				determined appropriate by the Secretary.
										(C)TimingThe
				Secretary shall establish the performance standards under subparagraph (A)
				prior to the beginning of the performance period for the year involved.
										(D)Performance
				periodThe Secretary shall establish the performance period with
				respect to a year. Such performance period shall occur prior to the beginning
				of such year.
										(E)Special
				ruleThe 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
				determined by the Secretary.
											(5)Limitation on
				reviewThere shall be no
				administrative or judicial review under section 1869, section 1878, or
				otherwise of the following:
										(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
				generalThe Secretary shall establish procedures 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 providers 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
				reviewThe procedures established 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
				generalThe Secretary shall provide certificates 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)DisplayEach
				facility or provider receiving a certificate under clause (i) shall prominently
				display the certificate at the provider or facility.
											(D)Web-based
				listThe 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 Medicare & Medicaid Services in an easily understandable
				format.
										.
						(d)GAO report on
			 ESRD bundling system and quality initiativeNot 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 initiative under subsection (h) of
			 such section 1881 (as added by subsection (b)). Such report shall include the
			 following information:
							(1)The changes in utilization rates for
			 erythropoiesis stimulating agents.
							(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 subparagraph (D)(iii) of such subsection (b)(14),
			 including an examination of the extent to which costs incurred by rural,
			 low-volume providers and facilities (as defined by the Secretary) in furnishing
			 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 subsection (b)(14).
							(5)Any other
			 information or recommendations for legislative and administrative actions
			 determined appropriate by the Comptroller General.
							DProvisions
			 relating to part C
				161.Phase-out of
			 indirect medical education (IME)
					(a)In
			 generalSection 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 education from capitation rates
									(A)In
				generalAfter determining the
				applicable amount for an area for a year under paragraph (1) (beginning 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 the year. Any adjustment under the
				preceding sentence shall be made prior to the application of paragraph
				(2).
									(B)Percentages
				definedFor purposes of this
				paragraph:
										(i)Phase-in
				percentageThe 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 percentageThe term maximum cumulative
				adjustment percentage means, for—
											(I)2010,
				0.65 percent; and
											(II)a subsequent
				year, the maximum cumulative adjustment percentage for the previous year
				increased by 0.65 percentage points.
											(iii)Standardized
				IME cost percentageThe 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
				amountThe 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 updateSection 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 paymentsSection 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
				rateCapitation amounts under this subsection shall be determined
				without regard to the application of section
				1853(k)(4).
							.
					162.Revisions to
			 requirements for Medicare Advantage private fee-for-service plans
					(a)Requirements To
			 assure access to network coverage
						(1)Individual
			 marketSection 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
										(A)In
				generalFor 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 standards 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
				definedFor 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
				generalFor purposes of subparagraph (B), the term
				network-based plan means—
												(I)except as provided
				in clause (ii), a Medicare 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 PPOsThe 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
				Regulations, rather than through written
				contracts.
											.
							(2)Employer
			 plansSection 1852(d) of the Social Security 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 providersFor 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
				paragraph.
									.
							(3)Access
			 requirements
							(A)In
			 generalSection 1852(d)(4)(B) of the Social Security Act (42
			 U.S.C. 1395w–22(d)(4)(B)) is amended by 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 subparagraphs (A) through (E) of paragraph
			 (1).
							(B)Effective
			 dateThe amendment made by subparagraph (A) shall apply to plan
			 year 2010 and subsequent plan years.
							(b)Clarification
			 regarding utilizationSection 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 utilization, or to preclude a
				plan from increasing rates for such a provider based on increased utilization
				of specified preventive or screening
				services..
					163.Revisions to
			 quality improvement programs
					(a)Requirement for
			 MA private fee-for-service and MSA plans To have a quality improvement
			 program
						(1)In
			 generalSection 1852(e)(1) of
			 the Social Security Act (42 U.S.C. 1395w–112(e)(1)) is amended by striking
			 (other than an MA private fee-for-service plan or an MSA
			 plan).
						(2)Effective
			 dateThe amendment made by paragraph (1) shall apply to plan
			 years beginning on or after January 1, 2010.
						(b)Data collection
			 requirements for MA regional plans, MA private fee-for-service plans, and MSA
			 plans
						(1)In
			 generalSection 1852(e)(3)(A) of the Social Security Act (42
			 U.S.C. 1395w–22(e)(3)(A)) is amended—
							(A)in clause (i), by
			 adding at the end the following new sentence: With respect to MA private
			 fee-for-service plans and MSA plans, such requirements may not exceed the
			 requirements under this subparagraph with respect to MA local plans that are
			 preferred provider organization plans, except that the limitation under clause
			 (iii) shall not apply and such requirements shall apply regardless of whether
			 or not the services are furnished by providers of services, physicians, or
			 other health care practitioners and suppliers that have contracts with the
			 organization offering the MA private fee-for-service plan or the MSA
			 plan.
							(B)by striking clause
			 (ii)—
							(C)in clause
			 (iii)—
								(i)in the
			 heading—
									(I)by inserting
			 local after to; and
									(II)by inserting
			 and MA regional
			 plans after organizations; and
									(ii)by inserting
			 and to MA regional plans after organization
			 plans.
								(2)Effective
			 dateThe amendments made by paragraph (1) shall apply to plan
			 years beginning on or after January 1, 2010.
						164.Revisions
			 relating to specialized Medicare Advantage plans for special needs
			 individuals
					(a)Extension of
			 authority To restrict enrollmentSection 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 plansDuring
			 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 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
			 generalSection 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 specialized
			 MA plans for special needs individuals;
								(ii)by
			 designating the sentence beginning In the case of as paragraph
			 (1) with the heading Requirements for enrollment.— and with
			 appropriate indentation; and
								(iii)by adding at
			 the end the following new paragraphs:

										(2)Additional
				requirements for institutional SNPsIn the case of a specialized
				MA plan for special needs individuals described in subsection (b)(6)(B)(i), 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)(i). In the case of an individual
				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
				subsection (b)(6)(B)(i) unless the determination that the individual 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 SNPsIn
				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 protections are covered under the plan.
												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 SNPsIn the case of a specialized MA plan for
				special needs individuals described in subsection (b)(6)(B)(iii), 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 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 expansion for dual SNPs that do not meet certain
			 requirementsNotwithstanding 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 agenciesThe Secretary 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 contractNothing in the provisions 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)RequirementsSection
			 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 SNPsThe 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
									(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 individual as feasible, that identifies goals and
				objectives, including measurable outcomes as well as specific services and
				benefits to be provided; and
										(iii)use an
				interdisciplinary team in the management of
				care.
										.
						(2)Review to
			 ensure compliance with care management requirementsSection
			 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 management requirements for specialized Medicare
				Advantage plans for special needs individualsIn 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 disabling chronic conditions specialized needs
			 individual
						(1)In
			 generalSection 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 complex chronic conditions that are substantially
			 disabling or life threatening, have a high risk of hospitalization or other
			 significant adverse health outcomes, and require specialized delivery systems
			 across domains of care before the period at the end.
						(2)PanelThe
			 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
			 generalSection 1852(e)(3)(A) of the Social Security 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
				individualsIn 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 provide for the collection, analysis,
				and reporting of data that permits the measurement of health outcomes and other
				indices of quality with respect to the requirements described in paragraphs (2)
				through (5) of subsection (f). Such data may be based on claims data and shall
				be at the plan
				level.
								.
						(2)Effective
			 dateThe 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 applicationThe amendments made by subsections (c)(1), (d),
			 and (e)(1) shall apply to plan years beginning 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 dualsNothing 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)).
					165.Limitation on
			 out-of-pocket costs for dual eligibles and qualified medicare beneficiaries
			 enrolled in a specialized Medicare Advantage plan for special needs
			 individuals
					(a)In
			 generalSection 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
				beneficiariesIn the case of
				an individual 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 specialized 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
			 dateThe amendment made by subsection (a) shall apply to plan
			 years beginning on or after January 1, 2010.
					166.Adjustment to
			 the Medicare Advantage stabilization fundSection 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.
					167.Access to
			 Medicare reasonable cost contract plans
					(a)Extension of
			 reasonable cost contractsSection 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 110–173), 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 applicableSubclauses (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
			 generalSection 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 Metropolitan Statistical Area.
						(2)ClarificationSection
			 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
			 Metropolitan 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)StudyThe
			 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 Advantage
			 plans under part C of title XVIII of such Act.
						(2)ReportNot
			 later than December 31, 2009, 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.
						168.MedPAC study
			 and report on quality measures
					(a)StudyThe
			 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 program 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)ReportNot
			 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
			 administrative action as the Medicare Payment Advisory Commission determines
			 appropriate.
					169.MedPAC study
			 and report on Medicare Advantage payments
					(a)StudyThe
			 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 providing coverage under the plan for items and services covered 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 &
			 Medicaid 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
			 equivalents.
							(B)the accuracy and
			 completeness of county-level estimates 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 capitation 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 beneficiaries 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 paragraph (2)(B).
						(b)ReportNot
			 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 recommendations for such legislation and administrative action as the
			 Commission determines appropriate.
					EProvisions
			 relating to part D
				IImproving
			 pharmacy access
					171.Prompt payment by prescription drug plans
			 and MA–PD plans under part D
						(a)Prompt payment by prescription drug
			 plansSection 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 generalEach 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 otherwise
				transmitted with respect to all clean claims submitted by pharmacies (other
				than pharmacies that dispense 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 definedIn 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 circumstance
				requiring special treatment that prevents timely payment from being made on the
				claim under this part.
										(iii)Date of
				receipt of claimIn this paragraph, a claim is considered to have
				been received—
											(I)with respect to claims submitted
				electronically, on the date on which the claim is transferred; and
											(II)with respect to claims submitted otherwise,
				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
				definedIn 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
				generalSubject 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 beginning on the day after the required
				payment date and ending on the date on which payment is made (as determined
				under subparagraph (D)(iv)). Interest amounts paid under this subparagraph
				shall not be counted against the administrative costs of a prescription drug
				plan or treated as allowable risk corridor costs under section
				1860D–15(e).
										(ii)Authority not
				to charge interestThe 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 cleanA 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
				electronically, within 10 days after the date on which the claim is received;
				and
											(II)with respect to
				claims submitted otherwise, within 15 days after the date on which the claim is
				received.
											(ii)Claim determined to not be a clean
				claim
											(I)In generalIf 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 documents necessary for
				the proper processing and payment of the claim.
											(II)Determination after submission of
				additional informationA
				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 payA 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
				accordance with subparagraph (A).
										(iv)Date of Payment of ClaimPayment 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.
											(E)Electronic transfer of fundsA PDP sponsor shall pay all clean claims
				submitted electronically by electronic transfer of funds if the pharmacy so
				requests or has so requested previously. In the case where such payment is made
				electronically, remittance may be made by the PDP sponsor electronically as
				well.
									(F)Protecting the rights of claimants
										(i)In generalNothing 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-RetaliationConsistent with applicable Federal or State
				law, a PDP sponsor shall not retaliate against an individual or provider for
				exercising a right of action under this subparagraph.
										(G)Rule of constructionA determination under this paragraph that a
				claim submitted by a pharmacy is a clean claim shall not be construed as a
				positive determination regarding eligibility for payment under this title, nor
				is it an indication of government approval of, or acquiescence regarding, the
				claim submitted. The determination 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 plansSection 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 requirementsThe 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
				paymentSection
				1860D–12(b)(4).
									.
						(c)Effective
			 dateThe amendments made by
			 this section shall apply to plan years beginning on or after January 1,
			 2010.
						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
			 plansSection 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 facilitiesEach contract 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
			 plansSection 1857(f)(3) of
			 the Social Security Act, as added by section 171(b), is amended by adding at
			 the end the following new subparagraph:

									(B)Submission of claims by pharmacies located
				in or contracting with long-term care facilitiesSection
				1860D–12(b)(5).
									.
							(b)Effective
			 dateThe amendments made by
			 this section shall apply to plan years beginning on or after January 1,
			 2010.
						173.Regular update of prescription drug pricing
			 standard
						(a)Requirement for prescription drug
			 plansSection 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
				standardIf 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 plansSection 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
				StandardSection
				1860D–12(b)(6).
								.
						(c)Effective
			 dateThe amendments made by
			 this section shall apply to plan years beginning on or after January 1,
			 2009.
						IIOther
			 provisions
					175.Inclusion of
			 barbiturates and benzodiazepines as covered part
			 D drugs
						(a)In
			 generalSection
			 1860D–2(e)(2)(A) of the Social Security
			 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
			 dateThe amendments made by
			 subsection (a) shall apply to prescriptions dispensed on or after January 1,
			 2012.
						176.Formulary
			 requirements with respect to certain categories or classes of
			 drugsSection 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 categories and classes
									(i)Identification
				of drugs in certain categories and classesBeginning with plan
				year 2010, the Secretary shall identify, as appropriate, categories 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 clinical
				consequences for individuals who have a disease or disorder treated by the
				drugs in such category 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
				requirementsSubject 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)ExceptionsThe
				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). Any exceptions
				established under the preceding sentence shall be provided under a process
				that—
										(I)ensures that any
				exception to such requirement is based upon scientific evidence and medical
				standards of practice; and
										(II)includes a
				public notice and comment
				period.
										.
						FOther
			 provisions
				181.Use of part D
			 dataSection 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 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 conducting Congressional oversight, monitoring, and analysis of the program
			 under this title..
				182.Revision of
			 definition of medically accepted indication for drugs
					(a)Revision of
			 definition for part D drugs
						(1)In
			 generalSection 1860D–2(e)(1) of the Social Security 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
				generalFor 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 compendia 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
				interestOn 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)UpdateFor
				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
			 dateThe amendments made by this subsection shall apply to plan
			 years beginning on or after January 1, 2009.
						(b)Conflicts of
			 interestSection 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 transparent process for evaluating therapies and for identifying
			 potential conflicts of interests..
					183.Contract with a
			 consensus-based entity regarding performance measurement
					(a)Contract
						(1)In
			 generalPart 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:

								1890.Contract with a consensus-based entity regarding performance
		  measurement(a)Contract
										(1)In
				generalFor 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 subsection (c). Such contract shall provide that the entity will
				perform the duties described in subsection (b).
										(2)Timing for
				first contractAs 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 contractA contract
				under paragraph (1) shall be for a period of 4 years (except as may be renewed
				after a subsequent bidding process).
										(4)Competitive proceduresCompetitive 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)DutiesThe
				duties described in this subsection are the following:
										(1)Priority
				setting processThe entity shall synthesize evidence and convene
				key stakeholders to make recommendations, 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 multiple settings.
												(2)Endorsement of
				measuresThe entity shall provide for the endorsement of
				standardized health care performance measures. The endorsement process under
				the preceding sentence shall consider whether a measure—
											(A)is
				evidence-based, reliable, valid, verifiable, relevant to enhanced health
				outcomes, actionable at the caregiver level, feasible to collect and report,
				and responsive to variations in patient characteristics, such as health 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
				measuresThe entity shall establish 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 recordsThe entity shall
				promote the development and use of electronic health records that contain the
				functionality for automated collection, aggregation, and transmission of
				performance measurement information.
										(5)Annual report
				to Congress and the Secretary; Secretarial publication and comment
											(A)Annual
				reportBy not later than March 1 of each year (beginning with
				2009), the entity shall submit to Congress and the Secretary a report
				containing a description 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
				Secretary under subsection (a).
												(B)Secretarial
				review and publication of annual reportNot 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
				describedThe requirements described in this subsection are the
				following:
										(1)Private
				nonprofitThe entity is a private nonprofit entity governed by a
				board.
										(2)Board
				membershipThe 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
				membershipThe 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.
											(4)Open and
				transparentWith 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 organizationThe 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 Register on February 10, 1998).
										(6)ExperienceThe
				entity has at least 4 years of experience in establishing national consensus
				standards.
										(7)Membership
				feesIf the entity requires a membership 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
				membership 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)FundingFor
				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 Supplementary 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 Program Management Account for
				each of fiscal years 2009 through
				2012.
									.
						(2)Sense of the
			 SenateIt is the Sense of the Senate that the selection by the
			 Secretary of Health and Human Services 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
			 generalThe 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)ReportsNot
			 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.
						184.Cost-sharing
			 for clinical trialsSection
			 1833 of the Social Security Act (42 U.S.C. 1395l), as amended by section
			 152(a), is amended by adding at the end the following new subsection:

						(x)Methods of
				paymentThe Secretary may develop alternative 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
				otherwise 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.
						.
				185.Addressing
			 health care disparitiesTitle
			 XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is amended by
			 inserting after section 1808 the following new section:

						1809.Addressing health care disparities(a)Evaluating data
				collection approachesThe 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 collection 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
				evaluationNot 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
				consideration the results of such evaluation—
									(A)identify
				approaches (including defining methodologies) 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 program under parts A and
				B, the Medicare Advantage program 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
				analysesNot 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 of
				health care disparities for Medicare beneficiaries based on analyses of the
				data collected under subsection (c).
								(c)Implementing
				effective approachesNot 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.
							.
				186.Demonstration
			 to improve care to previously uninsured
					(a)EstablishmentWithin
			 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 determine the greatest needs and most effective
			 methods of outreach to medicare beneficiaries who were previously
			 uninsured.
					(b)ScopeThe demonstration shall be in no fewer than
			 10 sites, and shall include state health insurance assistance programs,
			 community health centers, community-based organizations, community 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)DurationThe
			 Secretary shall conduct the demonstration project for a period of 2
			 years.
					(d)Report and
			 evaluationThe 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.
						187.Office of the
			 Inspector General report on compliance with and enforcement of national
			 standards on culturally and linguistically appropriate services (CLAS) in
			 Medicare
					(a)ReportNot
			 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.
						Such report
			 shall include recommendations on improving compliance with CLAS Standards and
			 recommendations on improving enforcement of CLAS Standards.(b)ImplementationNot
			 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.
					188.Medicare
			 Improvement Funding
					(a)Medicare
			 Improvement FundTitle XVIII
			 of the Social Security Act (42 U.S.C. 1395 et seq.) is amended by adding at the
			 end the following new section:

							1898.Medicare improvement fund(a)EstablishmentThe 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
				generalThere shall be
				available to the Fund, for expenditures from the Fund for services furnished
				during fiscal year 2014,
				$______.
									(2)Payment from trust fundsThe amount specified under paragraph (1)
				shall be available to the Fund, as expenditures 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 limitationAmounts 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.
									.
					(b)ImplementationFor purposes of carrying out the provisions
			 of, and amendments made by, this Act, 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 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 $140,000,000 to the Centers for
			 Medicare & Medicaid Services Program Management Account for the period of
			 fiscal years 2009 through 2013.
					IIMedicaid
			201.Extension of
			 transitional medical assistance (TMA) and abstinence education
			 programSection 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 December 31, 2009;
				(2)by striking
			 the third quarter of fiscal year 2008 and inserting the
			 first quarter of fiscal year 2010; and
				(3)by striking the third quarter of
			 fiscal year 2007 and inserting the first quarter of fiscal year
			 2008.
				202.Medicaid DSH extensionSection 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
			 portions 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
			 ¾ of; and
							(ii)by adding at the
			 end the following new sentences: Only with respect to fiscal year 2010
			 for the period ending on December 31, 2009, the DSH allotment for Tennessee for
			 such portion of the fiscal year, notwithstanding such table or terms, shall be
			 ¼ 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
						(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, notwithstanding the table set forth
			 in paragraph (2), shall be $2,500,000..
					203.Pharmacy
			 reimbursement under Medicaid
				(a)Delay in new
			 payment limits for multiple source drugs under
			 MedicaidNotwithstanding paragraphs (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 in effect on the date of the
			 enactment of this Act), the Secretary of Health and Human Services shall not
			 require a State to establish prior to September 30, 2009, payment limits for
			 multiple source drugs under a State Medicaid plan that do not exceed the
			 specific upper limit established under section 447.514(b) of title 42, Code of
			 Federal Regulations (as so in effect) and shall permit any State to continue to
			 receive Federal financial participation for payments for such drugs that do not
			 exceed the specific upper limit that would have applied to such payments under
			 section 447.332 of title 42, Code of Federal Regulations (as in effect on
			 December 31, 2006).
				(b)Temporary
			 suspension of updated publicly available AMP dataNotwithstanding
			 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 September 30, 2009, make publicly available any AMP disclosed to the
			 Secretary.
				(c)DefinitionsIn
			 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));
			 and
					(2)The term
			 AMP has the meaning given average manufacturer 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 in effect on the date of the enactment of this Act).
					204.Review of
			 administrative claim determinations
				(a)In
			 generalSection 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
				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 disallowance) 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
			 amendmentSection 1116(d) of such Act (42 U.S.C. 1316(d)) is
			 amended by striking or XIX,.
				(c)Effective
			 dateThe 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.
				IIIMiscellaneous
			301.Extension of
			 TANF supplemental grants
				(a)Extension
			 through fiscal year 2009Section 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
			 amendmentSection 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
						.
				302.70 percent
			 federal matching for foster care and adoption assistance for the District of
			 Columbia
				(a)In
			 generalSection 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
			 dateThe amendment made by subsection (a) shall take effect on
			 October 1, 2008, and shall apply to calendar quarters beginning on or after
			 that date.
				303.Extension of
			 Special Diabetes Grant Programs
				(a)Special
			 Diabetes Programs for Type I DiabetesSection 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 IndiansSection 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
			 ProgramsSection 4923(b) of the Balanced 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:

							(3)a report on such
				evaluation not later than January 1,
				2011.
							.
					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)StudyNot
			 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
			 Medicine 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)ReportNot
			 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 jurisdiction 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)ParticipationThe
			 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)StudyNot
			 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
			 Medicine 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 objective, scientifically valid, and consistent.
					(2)ReportNot
			 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 jurisdiction 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)ParticipationThe
			 contract under paragraph (1) shall require that stakeholders with expertise in
			 making clinical recommendations participate on the panel responsible for
			 conducting the study under paragraph (1) and preparing the report under
			 paragraph (2).
					(c)FundingOut
			 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.

		June 9, 2008
		Read the second time and placed on the
		  calendar