113 HR 4015 : SGR Repeal and Medicare Provider Payment Modernization Act of 2014
U.S. House of Representatives
2014-03-24
text/xml
EN
Pursuant to Title 17 Section 105 of the United States Code, this file is not subject to copyright protection and is in the public domain.

		II
		113th CONGRESS
		2d Session
		H. R. 4015
		IN THE SENATE OF THE UNITED STATES
		March 24, 2014ReceivedAN ACT
		To amend title XVIII of the Social Security Act to repeal the Medicare sustainable growth rate and
			 improve Medicare payments for physicians and other professionals, and for
			 other purposes.

		1.Short title; table of contents
			(a)Short titleThis Act may be cited as the SGR Repeal and Medicare Provider Payment Modernization Act of 2014.
			(b)Table of contentsThe table of contents of this Act is as follows:

					Sec. 1. Short title; table of contents.
					Sec. 2. Repealing the sustainable growth rate (SGR) and improving Medicare payment for physicians’
			 services.
					Sec. 3. Priorities and funding for measure development.
					Sec. 4. Encouraging care management for individuals with chronic care needs.
					Sec. 5. Ensuring accurate valuation of services under the physician fee schedule.
					Sec. 6. Promoting evidence-based care.
					Sec. 7. Empowering beneficiary choices through access to information on physicians’ services.
					Sec. 8. Expanding availability of Medicare data.
					Sec. 9. Reducing administrative burden and other provisions.
					Sec. 10. Delay in implementation of penalty for failure to comply with individual health insurance
			 mandate.

			2.Repealing the sustainable growth rate (SGR) and improving Medicare payment for physicians’ services
			(a)Stabilizing fee updates
				(1)Repeal of SGR payment methodologySection 1848 of the Social Security Act (42 U.S.C. 1395w–4) is amended—
					(A)in subsection (d)—
						(i)in paragraph (1)(A), by inserting or a subsequent paragraph after paragraph (4); and
						(ii)in paragraph (4)—
							(I)in the heading, by inserting and ending with 2013 after years beginning with 2001; and
							(II)in subparagraph (A), by inserting and ending with 2013 after a year beginning with 2001; and
							(B)in subsection (f)—
						(i)in paragraph (1)(B), by inserting through 2013 after of each succeeding year; and
						(ii)in paragraph (2), in the matter preceding subparagraph (A), by inserting and ending with 2013 after beginning with 2000.
						(2)Update of rates for April through December of 2014, 2015, and subsequent yearsSubsection (d) of section 1848 of the Social Security Act (42 U.S.C. 1395w–4) is amended by
			 striking paragraph (15) and inserting the following new paragraphs:

						(15)Update for 2014 through 2018The update to the single conversion factor established in paragraph (1)(C) for 2014 and each
			 subsequent year through 2018 shall be 0.5 percent.
						(16)Update for 2019 through 2023The update to the single conversion factor established in paragraph (1)(C) for 2019 and each
			 subsequent year through 2023 shall be zero percent.
						(17)Update for 2024 and subsequent yearsThe update to the single conversion factor established in paragraph (1)(C) for 2024 and each
			 subsequent year shall be—
							(A)for items and services furnished by a qualifying APM participant (as defined in section 1833(z)(2))
			 for such year, 1.0 percent; and
							(B)for other items and services, 0.5 percent..
				(3)MedPAC reports
					(A)Initial reportNot later than July 1, 2016, the Medicare Payment Advisory Commission shall submit to Congress a
			 report on the relationship between—
						(i)physician and other health professional utilization and expenditures (and the rate of increase of
			 such utilization and expenditures) of items and services for which payment
			 is made under section 1848 of the Social Security Act (42 U.S.C. 1395w–4);
			 and
						(ii)total utilization and expenditures (and the rate of increase of such utilization and expenditures)
			 under parts A, B, and D of title XVIII of such Act.Such report shall include a methodology to describe such relationship and the impact of changes in
			 such physician and other health professional practice and service ordering
			 patterns on total utilization and expenditures under parts A, B, and D of
			 such title.(B)Final reportNot later than July 1, 2020, the Medicare Payment Advisory Commission shall submit to Congress a
			 report on the relationship described in subparagraph (A), including the
			 results determined from applying the methodology included in the report
			 submitted under such subparagraph.
					(C)Report on update to physicians’ services under MedicareNot later than July 1, 2018, the Medicare Payment Advisory Commission shall submit to Congress a
			 report on—
						(i)the payment update for professional services applied under the Medicare program under title XVIII
			 of the Social Security Act for the period of years 2014 through 2018;
						(ii)the effect of such update on the efficiency, economy, and quality of care provided under such
			 program;
						(iii)the effect of such update on ensuring a sufficient number of providers to maintain access to care
			 by Medicare beneficiaries; and
						(iv)recommendations for any future payment updates for professional services under such program to
			 ensure adequate access to care is maintained for Medicare beneficiaries.
						(b)Consolidation of certain current law performance programs with new merit-Based Incentive Payment
			 System
				(1)EHR meaningful use incentive program
					(A)Sunsetting separate meaningful use payment adjustmentsSection 1848(a)(7)(A) of the Social Security Act (42 U.S.C. 1395w–4(a)(7)(A)) is amended—
						(i)in clause (i), by striking or any subsequent payment year and inserting or 2017;
						(ii)in clause (ii)—
							(I)in the matter preceding subclause (I), by striking Subject to clause (iii), for and inserting For;
							(II)in subclause (I), by adding at the end and;
							(III)in subclause (II), by striking ; and and inserting a period; and
							(IV)by striking subclause (III); and
							(iii)by striking clause (iii).
						(B)Continuation of meaningful use determinations for MIPSSection 1848(o)(2) of the Social Security Act (42 U.S.C. 1395w–4(o)(2)) is amended—
						(i)in subparagraph (A), in the matter preceding clause (i)—
							(I)by striking For purposes of paragraph (1), an and inserting An; and
							(II)by inserting , or pursuant to subparagraph (D) for purposes of subsection (q), for a performance period under
			 such subsection for a year after under such subsection for a year; and
							(ii)by adding at the end the following new subparagraph:

								(D)Continued application for purposes of MIPSWith respect to 2018 and each subsequent payment year, the Secretary shall, for purposes of
			 subsection (q) and in accordance with paragraph (1)(F) of such subsection,
			 determine whether an eligible professional who is a MIPS eligible
			 professional (as defined in subsection (q)(1)(C)) for such year is a
			 meaningful EHR user under this paragraph for the performance period under
			 subsection (q) for such year..
						(2)Quality reporting
					(A)Sunsetting separate quality reporting incentivesSection 1848(a)(8)(A) of the Social Security Act (42 U.S.C. 1395w–4(a)(8)(A)) is amended—
						(i)in clause (i), by striking or any subsequent year and inserting or 2017; and
						(ii)in clause (ii)(II), by striking and each subsequent year.
						(B)Continuation of quality measures and processes for MIPSSection 1848 of the Social Security Act (42 U.S.C. 1395w–4) is amended—
						(i)in subsection (k), by adding at the end the following new paragraph:

								(9)Continued application for purposes of MIPS and for certain professionals volunteering to reportThe Secretary shall, in accordance with subsection (q)(1)(F), carry out the provisions of this
			 subsection—
									(A)for purposes of subsection (q); and
									(B)for eligible professionals who are not MIPS eligible professionals (as defined in subsection
			 (q)(1)(C)) for the year involved.; and
						(ii)in subsection (m)—
							(I)by redesignating paragraph (7) added by section 10327(a) of Public Law 111–148 as paragraph (8);
			 and
							(II)by adding at the end the following new paragraph:

									(9)Continued application for purposes of MIPS and for certain professionals volunteering to reportThe Secretary shall, in accordance with subsection (q)(1)(F), carry out the processes under this
			 subsection—
										(A)for purposes of subsection (q); and
										(B)for eligible professionals who are not MIPS eligible professionals (as defined in subsection
			 (q)(1)(C)) for the year involved..
							(3)Value-based payments
					(A)Sunsetting separate value-based paymentsClause (iii) of section 1848(p)(4)(B) of the Social Security Act (42 U.S.C. 1395w–4(p)(4)(B)) is
			 amended to read as follows:

							(iii)ApplicationThe Secretary shall apply the payment modifier established under this subsection for items and
			 services furnished on or after January 1, 2015, but before January 1,
			 2018, with respect to specific physicians and groups of physicians the
			 Secretary determines appropriate. Such payment modifier shall not be
			 applied for items and services furnished on or after January 1, 2018..
					(B)Continuation of value-based payment modifier measures for MIPSSection 1848(p) of the Social Security Act (42 U.S.C. 1395w–4(p)) is amended—
						(i)in paragraph (2), by adding at the end the following new subparagraph:

								(C)Continued application for purposes of MIPSThe Secretary shall, in accordance with subsection (q)(1)(F), carry out subparagraph (B) for
			 purposes of subsection (q).; and
						(ii)in paragraph (3), by adding at the end the following: With respect to 2018 and each subsequent year, the Secretary shall, in accordance with subsection
			 (q)(1)(F), carry out this paragraph for purposes of subsection (q)..
						(c)Merit-Based Incentive Payment System
				(1)In generalSection 1848 of the Social Security Act (42 U.S.C. 1395w–4) is amended by adding at the end the
			 following new subsection:

						(q)Merit-Based Incentive Payment System
							(1)Establishment
								(A)In generalSubject to the succeeding provisions of this subsection, the Secretary shall establish an eligible
			 professional Merit-based Incentive Payment System (in this subsection
			 referred to as the MIPS) under which the Secretary shall—
									(i)develop a methodology for assessing the total performance of each MIPS eligible professional
			 according to performance standards under paragraph (3) for a performance
			 period (as established under paragraph (4)) for a year;
									(ii)using such methodology, provide for a composite performance score in accordance with paragraph (5)
			 for each such professional for each performance period; and
									(iii)use such composite performance score of the MIPS eligible professional for a performance period for
			 a year to determine and apply a MIPS adjustment factor (and, as
			 applicable, an additional MIPS adjustment factor) under paragraph (6) to
			 the professional for the year.
									(B)Program implementationThe MIPS shall apply to payments for items and services furnished on or after January 1, 2018.
								(C)MIPS eligible professional defined
									(i)In generalFor purposes of this subsection, subject to clauses (ii) and (iv), the term MIPS eligible professional means—
										(I)for the first and second years for which the MIPS applies to payments (and for the performance
			 period for such first and second year), a physician (as defined in section
			 1861(r)), a physician assistant, nurse practitioner, and clinical nurse
			 specialist (as such terms are defined in section 1861(aa)(5)), and a
			 certified registered nurse anesthetist (as defined in section 1861(bb)(2))
			 and a group that includes such professionals; and
										(II)for the third year for which the MIPS applies to payments (and for the performance period for such
			 third year) and for each succeeding year (and for the performance period
			 for each such year), the professionals described in subclause (I) and such
			 other eligible professionals (as defined in subsection (k)(3)(B)) as
			 specified by the Secretary and a group that includes such professionals.
										(ii)ExclusionsFor purposes of clause (i), the term MIPS eligible professional does not include, with respect to a year, an eligible professional (as defined in subsection
			 (k)(3)(B)) who—
										(I)is a qualifying APM participant (as defined in section 1833(z)(2));
										(II)subject to clause (vii), is a partial qualifying APM participant (as defined in clause (iii)) for
			 the most recent period for which data are available and who, for the
			 performance period with respect to such year, does not report on
			 applicable measures and activities described in paragraph (2)(B) that are
			 required to be reported by such a professional under the MIPS; or
										(III)for the performance period with respect to such year, does not exceed the low-volume threshold
			 measurement selected under clause (iv).
										(iii)Partial qualifying APM participantFor purposes of this subparagraph, the term partial qualifying APM participant means, with respect to a year, an eligible professional for whom the Secretary determines the
			 minimum payment percentage (or percentages), as applicable, described in
			 paragraph (2) of section 1833(z) for such year have not been satisfied,
			 but who would be considered a qualifying APM participant (as defined in
			 such paragraph) for such year if—
										(I)with respect to 2018 and 2019, the reference in subparagraph (A) of such paragraph to 25 percent
			 was instead a reference to 20 percent;
										(II)with respect to 2020 and 2021—
											(aa)the reference in subparagraph (B)(i) of such paragraph to 50 percent was instead a reference to 40
			 percent; and
											(bb)the references in subparagraph (B)(ii) of such paragraph to 50 percent and 25 percent of such
			 paragraph were instead references to 40 percent and 20 percent,
			 respectively; and
											(III)with respect to 2022 and subsequent years—
											(aa)the reference in subparagraph (C)(i) of such paragraph to 75 percent was instead a reference to 50
			 percent; and
											(bb)the references in subparagraph (C)(ii) of such paragraph to 75 percent and 25 percent of such
			 paragraph were instead references to 50 percent and 20 percent,
			 respectively.
											(iv)Selection of low-volume threshold measurementThe Secretary shall select a low-volume threshold to apply for purposes of clause (ii)(III), which
			 may include one or more or a combination of the following:
										(I)The minimum number (as determined by the Secretary) of individuals enrolled under this part who are
			 treated by the eligible professional for the performance period involved.
										(II)The minimum number (as determined by the Secretary) of items and services furnished to individuals
			 enrolled under this part by such professional for such performance period.
										(III)The minimum amount (as determined by the Secretary) of allowed charges billed by such professional
			 under this part for such performance period.
										(v)Treatment of new Medicare enrolled eligible professionalsIn the case of a professional who first becomes a Medicare enrolled eligible professional during
			 the performance period for a year (and had not previously submitted claims
			 under this title such as a person, an entity, or a part of a physician
			 group or under a different billing number or tax identifier), such
			 professional shall not be treated under this subsection as a MIPS eligible
			 professional until the subsequent year and performance period for such
			 subsequent year.
									(vi)ClarificationIn the case of items and services furnished during a year by an individual who is not a MIPS
			 eligible professional (including pursuant to clauses (ii) and (v)) with
			 respect to a year, in no case shall a MIPS adjustment factor (or
			 additional MIPS adjustment factor) under paragraph (6) apply to such
			 individual for such year.
									(vii)Partial qualifying APM participant clarifications
										(I)Treatment as MIPS eligible professionalIn the case of an eligible professional who is a partial qualifying APM participant, with respect
			 to a year, and who for the performance period for such year reports on
			 applicable measures and activities described in paragraph (2)(B) that are
			 required to be reported by such a professional under the MIPS, such
			 eligible professional is considered to be a MIPS eligible professional
			 with respect to such year.
										(II)Not eligible for qualifying APM participant paymentsIn no case shall an eligible professional who is a partial qualifying APM participant, with respect
			 to a year, be considered a qualifying APM participant (as defined in
			 paragraph (2) of section 1833(z)) for such year or be eligible for the
			 additional payment under paragraph (1) of such section for such year.
										(D)Application to group practices
									(i)In generalUnder the MIPS:
										(I)Quality performance categoryThe Secretary shall establish and apply a process that includes features of the provisions of
			 subsection (m)(3)(C) for MIPS eligible professionals in a group practice
			 with respect to assessing performance of such group with respect to the
			 performance category described in clause (i) of paragraph (2)(A).
										(II)Other performance categoriesThe Secretary may establish and apply a process that includes features of the provisions of
			 subsection (m)(3)(C) for MIPS eligible professionals in a group practice
			 with respect to assessing the performance of such group with respect to
			 the performance categories described in clauses (ii) through (iv) of such
			 paragraph.
										(ii)Ensuring comprehensiveness of group practice assessmentThe process established under clause (i) shall to the extent practicable reflect the range of items
			 and services furnished by the MIPS eligible professionals in the group
			 practice involved.
									(iii)ClarificationMIPS eligible professionals electing to be a virtual group under paragraph (5)(I) shall not be
			 considered MIPS eligible professionals in a group practice for purposes of
			 applying this subparagraph.
									(E)Use of registriesUnder the MIPS, the Secretary shall encourage the use of qualified clinical data registries
			 pursuant to subsection (m)(3)(E) in carrying out this subsection.
								(F)Application of certain provisionsIn applying a provision of subsection (k), (m), (o), or (p) for purposes of this subsection, the
			 Secretary shall—
									(i)adjust the application of such provision to ensure the provision is consistent with the provisions
			 of this subsection; and
									(ii)not apply such provision to the extent that the provision is duplicative with a provision of this
			 subsection.
									(G)Accounting for risk factors
									(i)Risk factorsTaking into account the relevant studies conducted and recommendations made in reports under
			 section 2(f)(1) of the SGR Repeal and Medicare Provider Payment
			 Modernization Act of 2014, the Secretary, on an ongoing basis, shall
			 estimate how an individual’s health status and other risk factors affect
			 quality and resource use outcome measures and, as feasible, shall
			 incorporate information from quality and resource use outcome measurement
			 (including care episode and patient condition groups) into the MIPS.
									(ii)Accounting for other factors in payment adjustmentsTaking into account the studies conducted and recommendations made in reports under section 2(f)(1)
			 of the SGR Repeal and Medicare Provider Payment Modernization Act of 2014
			 and other information as appropriate, the Secretary shall account for
			 identified factors with an effect on quality and resource use outcome
			 measures when determining payment adjustments, composite performance
			 scores, scores for performance categories, or scores for measures or
			 activities under the MIPS.
									(2)Measures and activities under performance categories
								(A)Performance categoriesUnder the MIPS, the Secretary shall use the following performance categories (each of which is
			 referred to in this subsection as a performance category) in determining
			 the composite performance score under paragraph (5):
									(i)Quality.
									(ii)Resource use.
									(iii)Clinical practice improvement activities.
									(iv)Meaningful use of certified EHR technology.
									(B)Measures and activities specified for each categoryFor purposes of paragraph (3)(A) and subject to subparagraph (C), measures and activities specified
			 for a performance period (as established under paragraph (4)) for a year
			 are as follows:
									(i)QualityFor the performance category described in subparagraph (A)(i), the quality measures included in the
			 final measures list published under subparagraph (D)(i) for such year and
			 the list of quality measures described in subparagraph (D)(vi) used by
			 qualified clinical data registries under subsection (m)(3)(E).
									(ii)Resource useFor the performance category described in subparagraph (A)(ii), the measurement of resource use for
			 such period under subsection (p)(3), using the methodology under
			 subsection (r) as appropriate, and, as feasible and applicable, accounting
			 for the cost of drugs under part D.
									(iii)Clinical practice improvement activitiesFor the performance category described in subparagraph (A)(iii), clinical practice improvement
			 activities (as defined in subparagraph (C)(v)(III)) under subcategories
			 specified by the Secretary for such period, which shall include at least
			 the following:
										(I)The subcategory of expanded practice access, which shall include activities such as same day
			 appointments for urgent needs and after hours access to clinician advice.
										(II)The subcategory of population management, which shall include activities such as monitoring health
			 conditions of individuals to provide timely health care interventions or
			 participation in a qualified clinical data registry.
										(III)The subcategory of care coordination, which shall include activities such as timely communication
			 of test results, timely exchange of clinical information to patients and
			 other providers, and use of remote monitoring or telehealth.
										(IV)The subcategory of beneficiary engagement, which shall include activities such as the establishment
			 of care plans for individuals with complex care needs, beneficiary
			 self-management assessment and training, and using shared decision-making
			 mechanisms.
										(V)The subcategory of patient safety and practice assessment, such as through use of clinical or
			 surgical checklists and practice assessments related to maintaining
			 certification.
										(VI)The subcategory of participation in an alternative payment model (as defined in section
			 1833(z)(3)(C)).In establishing activities under this clause, the Secretary shall give consideration to the
			 circumstances of small practices (consisting of 15 or fewer professionals)
			 and practices located in rural areas and in health professional shortage
			 areas (as designated under section 332(a)(1)(A) of the Public Health
			 Service Act).(iv)Meaningful EHR useFor the performance category described in subparagraph (A)(iv), the requirements established for
			 such period under subsection (o)(2) for determining whether an eligible
			 professional is a meaningful EHR user.
									(C)Additional provisions
									(i)Emphasizing outcome measures under the quality performance categoryIn applying subparagraph (B)(i), the Secretary shall, as feasible, emphasize the application of
			 outcome measures.
									(ii)Application of additional system measuresThe Secretary may use measures used for a payment system other than for physicians, such as
			 measures for inpatient hospitals, for purposes of the performance
			 categories described in clauses (i) and (ii) of subparagraph (A). For
			 purposes of the previous sentence, the Secretary may not use measures for
			 hospital outpatient departments, except in the case of emergency
			 physicians.
									(iii)Global and population-based measuresThe Secretary may use global measures, such as global outcome measures, and population-based
			 measures for purposes of the performance category described in
			 subparagraph (A)(i).
									(iv)Application of measures and activities to non-patient-facing professionalsIn carrying out this paragraph, with respect to measures and activities specified in subparagraph
			 (B) for performance categories described in subparagraph (A), the
			 Secretary—
										(I)shall give consideration to the circumstances of professional types (or subcategories of those
			 types determined by practice characteristics) who typically furnish
			 services that do not involve face-to-face interaction with a patient; and
										(II)may, to the extent feasible and appropriate, take into account such circumstances and apply under
			 this subsection with respect to MIPS eligible professionals of such
			 professional types or subcategories, alternative measures or activities
			 that fulfill the goals of the applicable performance category.In carrying out the previous sentence, the Secretary shall consult with professionals of such
			 professional types or subcategories.(v)Clinical practice improvement activities
										(I)Request for informationIn initially applying subparagraph (B)(iii), the Secretary shall use a request for information to
			 solicit recommendations from stakeholders to identify activities described
			 in such subparagraph and specifying criteria for such activities.
										(II)Contract authority for clinical practice improvement activities performance categoryIn applying subparagraph (B)(iii), the Secretary may contract with entities to assist the Secretary
			 in—
											(aa)identifying activities described in subparagraph (B)(iii);
											(bb)specifying criteria for such activities; and
											(cc)determining whether a MIPS eligible professional meets such criteria.
											(III)Clinical practice improvement activities definedFor purposes of this subsection, the term clinical practice improvement activity means an activity that relevant eligible professional organizations and other relevant
			 stakeholders identify as improving clinical practice or care delivery and
			 that the Secretary determines, when effectively executed, is likely to
			 result in improved outcomes.
										(D)Annual list of quality measures available for MIPS assessment
									(i)In generalUnder the MIPS, the Secretary, through notice and comment rulemaking and subject to the succeeding
			 clauses of this subparagraph, shall, with respect to the performance
			 period for a year, establish an annual final list of quality measures from
			 which MIPS eligible professionals may choose for purposes of assessment
			 under this subsection for such performance period. Pursuant to the
			 previous sentence, the Secretary shall—
										(I)not later than November 1 of the year prior to the first day of the first performance period under
			 the MIPS, establish and publish in the Federal Register a final list of
			 quality measures; and
										(II)not later than November 1 of the year prior to the first day of each subsequent performance period,
			 update the final list of quality measures from the previous year (and
			 publish such updated final list in the Federal Register), by—
											(aa)removing from such list, as appropriate, quality measures, which may include the removal of
			 measures that are no longer meaningful (such as measures that are topped
			 out);
											(bb)adding to such list, as appropriate, new quality measures; and
											(cc)determining whether or not quality measures on such list that have undergone substantive changes
			 should be included in the updated list.
											(ii)Call for quality measures
										(I)In generalEligible professional organizations and other relevant stakeholders shall be requested to identify
			 and submit quality measures to be considered for selection under this
			 subparagraph in the annual list of quality measures published under clause
			 (i) and to identify and submit updates to the measures on such list. For
			 purposes of the previous sentence, measures may be submitted regardless of
			 whether such measures were previously published in a proposed rule or
			 endorsed by an entity with a contract under section 1890(a).
										(II)Eligible professional organization definedIn this subparagraph, the term eligible professional organization means a professional organization as defined by nationally recognized multispecialty boards of
			 certification or equivalent certification boards.
										(iii)RequirementsIn selecting quality measures for inclusion in the annual final list under clause (i), the
			 Secretary shall—
										(I)provide that, to the extent practicable, all quality domains (as defined in subsection (s)(1)(B))
			 are addressed by such measures; and
										(II)ensure that such selection is consistent with the process for selection of measures under
			 subsections (k), (m), and (p)(2).
										(iv)Peer reviewBefore including a new measure or a measure described in clause (i)(II)(cc) in the final list of
			 measures published under clause (i) for a year, the Secretary shall submit
			 for publication in applicable specialty-appropriate peer-reviewed journals
			 such measure and the method for developing and selecting such measure,
			 including clinical and other data supporting such measure.
									(v)Measures for inclusionThe final list of quality measures published under clause (i) shall include, as applicable,
			 measures under subsections (k), (m), and (p)(2), including quality
			 measures from among—
										(I)measures endorsed by a consensus-based entity;
										(II)measures developed under subsection (s); and
										(III)measures submitted under clause (ii)(I).Any measure selected for inclusion in such list that is not endorsed by a consensus-based entity
			 shall have a focus that is evidence-based.(vi)Exception for qualified clinical data registry measuresMeasures used by a qualified clinical data registry under subsection (m)(3)(E) shall not be subject
			 to the requirements under clauses (i), (iv), and (v). The Secretary shall
			 publish the list of measures used by such qualified clinical data
			 registries on the Internet website of the Centers for Medicare & Medicaid Services.
									(vii)Exception for existing quality measuresAny quality measure specified by the Secretary under subsection (k) or (m), including under
			 subsection (m)(3)(E), and any measure of quality of care established under
			 subsection (p)(2) for the reporting period under the respective subsection
			 beginning before the first performance period under the MIPS—
										(I)shall not be subject to the requirements under clause (i) (except under items (aa) and (cc) of
			 subclause (II) of such clause) or to the requirement under clause (iv);
			 and
										(II)shall be included in the final list of quality measures published under clause (i) unless removed
			 under clause (i)(II)(aa).
										(viii)Consultation with relevant eligible professional organizations and other relevant stakeholdersRelevant eligible professional organizations and other relevant stakeholders, including State and
			 national medical societies, shall be consulted in carrying out this
			 subparagraph.
									(ix)Optional applicationThe process under section 1890A is not required to apply to the selection of measures under this
			 subparagraph.
									(3)Performance standards
								(A)EstablishmentUnder the MIPS, the Secretary shall establish performance standards with respect to measures and
			 activities specified under paragraph (2)(B) for a performance period (as
			 established under paragraph (4)) for a year.
								(B)Considerations in establishing standardsIn establishing such performance standards with respect to measures and activities specified under
			 paragraph (2)(B), the Secretary shall consider the following:
									(i)Historical performance standards.
									(ii)Improvement.
									(iii)The opportunity for continued improvement.
									(4)Performance periodThe Secretary shall establish a performance period (or periods) for a year (beginning with the year
			 described in paragraph (1)(B)). Such performance period (or periods) shall
			 begin and end prior to the beginning of such year and be as close as
			 possible to such year. In this subsection, such performance period (or
			 periods) for a year shall be referred to as the performance period for the
			 year.
							(5)Composite performance score
								(A)In generalSubject to the succeeding provisions of this paragraph and taking into account, as available and
			 applicable, paragraph (1)(G), the Secretary shall develop a methodology
			 for assessing the total performance of each MIPS eligible professional
			 according to performance standards under paragraph (3) with respect to
			 applicable measures and activities specified in paragraph (2)(B) with
			 respect to each performance category applicable to such professional for a
			 performance period (as established under paragraph (4)) for a year. Using
			 such methodology, the Secretary shall provide for a composite assessment
			 (using a scoring scale of 0 to 100) for each such professional for the
			 performance period for such year. In this subsection such a composite
			 assessment for such a professional with respect to a performance period
			 shall be referred to as the composite performance score for such professional for such performance period.
								(B)Incentive to report; encouraging use of certified EHR technology for reporting quality measures
									(i)Incentive to reportUnder the methodology established under subparagraph (A), the Secretary shall provide that in the
			 case of a MIPS eligible professional who fails to report on an applicable
			 measure or activity that is required to be reported by the professional,
			 the professional shall be treated as achieving the lowest potential score
			 applicable to such measure or activity.
									(ii)Encouraging use of certified EHR technology and qualified clinical data registries for reporting
			 quality measuresUnder the methodology established under subparagraph (A), the Secretary shall—
										(I)encourage MIPS eligible professionals to report on applicable measures with respect to the
			 performance category described in paragraph (2)(A)(i) through the use of
			 certified EHR technology and qualified clinical data registries; and
										(II)with respect to a performance period, with respect to a year, for which a MIPS eligible
			 professional reports such measures through the use of such EHR technology,
			 treat such professional as satisfying the clinical quality measures
			 reporting requirement described in subsection (o)(2)(A)(iii) for such
			 year.
										(C)Clinical practice improvement activities performance score
									(i)Rule for accreditationA MIPS eligible professional who is in a practice that is certified as a patient-centered medical
			 home or comparable specialty practice pursuant to subsection (b)(8)(B)(i)
			 with respect to a performance period shall be given the highest potential
			 score for the performance category described in paragraph (2)(A)(iii) for
			 such period.
									(ii)APM participationParticipation by a MIPS eligible professional in an alternative payment model (as defined in
			 section 1833(z)(3)(C)) with respect to a performance period shall earn
			 such eligible professional a minimum score of one-half of the highest
			 potential score for the performance category described in paragraph
			 (2)(A)(iii) for such performance period.
									(iii)SubcategoriesA MIPS eligible professional shall not be required to perform activities in each subcategory under
			 paragraph (2)(B)(iii) or participate in an alternative payment model in
			 order to achieve the highest potential score for the performance category
			 described in paragraph (2)(A)(iii).
									(D)Achievement and improvement
									(i)Taking into account improvementBeginning with the second year to which the MIPS applies, in addition to the achievement of a MIPS
			 eligible professional, if data sufficient to measure improvement is
			 available, the methodology developed under subparagraph (A)—
										(I)in the case of the performance score for the performance category described in clauses (i) and (ii)
			 of paragraph (2)(A), shall take into account the improvement of the
			 professional; and
										(II)in the case of performance scores for other performance categories, may take into account the
			 improvement of the professional.
										(ii)Assigning higher weight for achievementBeginning with the fourth year to which the MIPS applies, under the methodology developed under
			 subparagraph (A), the Secretary may assign a higher scoring weight under
			 subparagraph (F) with respect to the achievement of a MIPS eligible
			 professional than with respect to any improvement of such professional
			 applied under clause (i) with respect to a measure, activity, or category
			 described in paragraph (2).
									(E)Weights for the performance categories
									(i)In generalUnder the methodology developed under subparagraph (A), subject to subparagraph (F)(i) and clauses
			 (ii) and (iii), the composite performance score shall be determined as
			 follows:
										(I)Quality
											(aa)In generalSubject to item (bb), thirty percent of such score shall be based on performance with respect to
			 the category described in clause (i) of paragraph (2)(A). In applying the
			 previous sentence, the Secretary shall, as feasible, encourage the
			 application of outcome measures within such category.
											(bb)First 2 yearsFor the first and second years for which the MIPS applies to payments, the percentage applicable
			 under item (aa) shall be increased in a manner such that the total
			 percentage points of the increase under this item for the respective year
			 equals the total number of percentage points by which the percentage
			 applied under subclause (II)(bb) for the respective year is less than 30
			 percent.
											(II)Resource use
											(aa)In generalSubject to item (bb), thirty percent of such score shall be based on performance with respect to
			 the category described in clause (ii) of paragraph (2)(A).
											(bb)First 2 yearsFor the first year for which the MIPS applies to payments, not more than 10 percent of such score
			 shall be based on performance with respect to the category described in
			 clause (ii) of paragraph (2)(A). For the second year for which the MIPS
			 applies to payments, not more than 15 percent of such score shall be based
			 on performance with respect to the category described in clause (ii) of
			 paragraph (2)(A).
											(III)Clinical practice improvement activitiesFifteen percent of such score shall be based on performance with respect to the category described
			 in clause (iii) of paragraph (2)(A).
										(IV)Meaningful use of certified EHR technologyTwenty-five percent of such score shall be based on performance with respect to the category
			 described in clause (iv) of paragraph (2)(A).
										(ii)Authority to adjust percentages in case of high EHR meaningful use adoptionIn any year in which the Secretary estimates that the proportion of eligible professionals (as
			 defined in subsection (o)(5)) who are meaningful EHR users (as determined
			 under subsection (o)(2)) is 75 percent or greater, the Secretary may
			 reduce the percent applicable under clause (i)(IV), but not below 15
			 percent. If the Secretary makes such reduction for a year, subject to
			 subclauses (I)(bb) and (II)(bb) of clause (i), the percentages applicable
			 under one or more of subclauses (I), (II), and (III) of clause (i) for
			 such year shall be increased in a manner such that the total percentage
			 points of the increase under this clause for such year equals the total
			 number of percentage points reduced under the preceding sentence for such
			 year.
									(F)Certain flexibility for weighting performance categories, measures, and activitiesUnder the methodology under subparagraph (A), if there are not sufficient measures and clinical
			 practice improvement activities applicable and available to each type of
			 eligible professional involved, the Secretary shall assign different
			 scoring weights (including a weight of 0)—
									(i)which may vary from the scoring weights specified in subparagraph (E), for each performance
			 category based on the extent to which the category is applicable to the
			 type of eligible professional involved; and
									(ii)for each measure and activity specified under paragraph (2)(B) with respect to each such category
			 based on the extent to which the measure or activity is applicable and
			 available to the type of eligible professional involved.
									(G)Resource useAnalysis of the performance category described in paragraph (2)(A)(ii) shall include results from
			 the methodology described in subsection (r)(5), as appropriate.
								(H)Inclusion of quality measure data from other payersIn applying subsections (k), (m), and (p) with respect to measures described in paragraph
			 (2)(B)(i), analysis of the performance category described in paragraph
			 (2)(A)(i) may include data submitted by MIPS eligible professionals with
			 respect to items and services furnished to individuals who are not
			 individuals entitled to benefits under part A or enrolled under part B.
								(I)Use of voluntary virtual groups for certain assessment purposes
									(i)In generalIn the case of MIPS eligible professionals electing to be a virtual group under clause (ii) with
			 respect to a performance period for a year, for purposes of applying the
			 methodology under subparagraph (A)—
										(I)the assessment of performance provided under such methodology with respect to the performance
			 categories described in clauses (i) and (ii) of paragraph (2)(A) that is
			 to be applied to each such professional in such group for such performance
			 period shall be with respect to the combined performance of all such
			 professionals in such group for such period; and
										(II)the composite score provided under this paragraph for such performance period with respect to each
			 such performance category for each such MIPS eligible professional in such
			 virtual group shall be based on the assessment of the combined performance
			 under subclause (I) for the performance category and performance period.
										(ii)Election of practices to be a virtual groupThe Secretary shall, in accordance with clause (iii), establish and have in place a process to
			 allow an individual MIPS eligible professional or a group practice
			 consisting of not more than 10 MIPS eligible professionals to elect, with
			 respect to a performance period for a year, for such individual MIPS
			 eligible professional or all such MIPS eligible professionals in such
			 group practice, respectively, to be a virtual group under this
			 subparagraph with at least one other such individual MIPS eligible
			 professional or group practice making such an election. Such a virtual
			 group may be based on geographic areas or on provider specialties defined
			 by nationally recognized multispecialty boards of certification or
			 equivalent certification boards and such other eligible professional
			 groupings in order to capture classifications of providers across eligible
			 professional organizations and other practice areas or categories.
									(iii)RequirementsThe process under clause (ii)—
										(I)shall provide that an election under such clause, with respect to a performance period, shall be
			 made before or during the beginning of such performance period and may not
			 be changed during such performance period;
										(II)shall provide that a practice described in such clause, and each MIPS eligible professional in such
			 practice, may elect to be in no more than one virtual group for a
			 performance period; and
										(III)may provide that a virtual group may be combined at the tax identification number level.
										(6)MIPS payments
								(A)MIPS adjustment factorTaking into account paragraph (1)(G), the Secretary shall specify a MIPS adjustment factor for each
			 MIPS eligible professional for a year. Such MIPS adjustment factor for a
			 MIPS eligible professional for a year shall be in the form of a percent
			 and shall be determined—
									(i)by comparing the composite performance score of the eligible professional for such year to the
			 performance threshold established under subparagraph (D)(i) for such year;
									(ii)in a manner such that the adjustment factors specified under this subparagraph for a year result in
			 differential payments under this paragraph reflecting that—
										(I)MIPS eligible professionals with composite performance scores for such year at or above such
			 performance threshold for such year receive zero or positive incentive
			 payment adjustment factors for such year in accordance with clause (iii),
			 with such professionals having higher composite performance scores
			 receiving higher adjustment factors; and
										(II)MIPS eligible professionals with composite performance scores for such year below such performance
			 threshold for such year receive negative payment adjustment factors for
			 such year in accordance with clause (iv), with such professionals having
			 lower composite performance scores receiving lower adjustment factors;
										(iii)in a manner such that MIPS eligible professionals with composite scores described in clause (ii)(I)
			 for such year, subject to clauses (i) and (ii) of subparagraph (F),
			 receive a zero or positive adjustment factor on a linear sliding scale
			 such that an adjustment factor of 0 percent is assigned for a score at the
			 performance threshold and an adjustment factor of the applicable percent
			 specified in subparagraph (B) is assigned for a score of 100; and
									(iv)in a manner such that—
										(I)subject to subclause (II), MIPS eligible professionals with composite performance scores described
			 in clause (ii)(II) for such year receive a negative payment adjustment
			 factor on a linear sliding scale such that an adjustment factor of 0
			 percent is assigned for a score at the performance threshold and an
			 adjustment factor of the negative of the applicable percent specified in
			 subparagraph (B) is assigned for a score of 0; and
										(II)MIPS eligible professionals with composite performance scores that are equal to or greater than 0,
			 but not greater than 1/4 of the performance threshold specified under subparagraph (D)(i) for such year, receive a negative
			 payment adjustment factor that is equal to the negative of the applicable
			 percent specified in subparagraph (B) for such year.
										(B)Applicable percent definedFor purposes of this paragraph, the term applicable percent means—
									(i)for 2018, 4 percent;
									(ii)for 2019, 5 percent;
									(iii)for 2020, 7 percent; and
									(iv)for 2021 and subsequent years, 9 percent.
									(C)Additional MIPS adjustment factors for exceptional performance
									(i)In generalIn the case of a MIPS eligible professional with a composite performance score for a year at or
			 above the additional performance threshold under subparagraph (D)(ii) for
			 such year, in addition to the MIPS adjustment factor under subparagraph
			 (A) for the eligible professional for such year, subject to the
			 availability of funds under clause (ii), the Secretary shall specify an
			 additional positive MIPS adjustment factor for such professional and year.
			 Such additional MIPS adjustment factors shall be determined by the
			 Secretary in a manner such that professionals having higher composite
			 performance scores above the additional performance threshold receive
			 higher additional MIPS adjustment factors.
									(ii)Additional funding poolFor 2018 and each subsequent year through 2023, there is appropriated from the Federal
			 Supplementary Medical Insurance Trust Fund $500,000,000 for MIPS payments
			 under this paragraph resulting from the application of the additional MIPS
			 adjustment factors under clause (i).
									(D)Establishment of performance thresholds
									(i)Performance thresholdFor each year of the MIPS, the Secretary shall compute a performance threshold with respect to
			 which the composite performance score of MIPS eligible professionals shall
			 be compared for purposes of determining adjustment factors under
			 subparagraph (A) that are positive, negative, and zero. Such performance
			 threshold for a year shall be the mean or median (as selected by the
			 Secretary) of the composite performance scores for all MIPS eligible
			 professionals with respect to a prior period specified by the Secretary.
			 The Secretary may reassess the selection under the previous sentence every
			 3 years.
									(ii)Additional performance threshold for exceptional performanceIn addition to the performance threshold under clause (i), for each year of the MIPS, the Secretary
			 shall compute an additional performance threshold for purposes of
			 determining the additional MIPS adjustment factors under subparagraph
			 (C)(i). For each such year, the Secretary shall apply either of the
			 following methods for computing such additional performance threshold for
			 such a year:
										(I)The threshold shall be the score that is equal to the 25th percentile of the range of possible
			 composite performance scores above the performance threshold with respect
			 to the prior period described in clause (i).
										(II)The threshold shall be the score that is equal to the 25th percentile of the actual composite
			 performance scores for MIPS eligible professionals with composite
			 performance scores at or above the performance threshold with respect to
			 the prior period described in clause (i).
										(iii)Special rule for initial 2 yearsWith respect to each of the first two years to which the MIPS applies, the Secretary shall, prior
			 to the performance period for such years, establish a performance
			 threshold for purposes of determining MIPS adjustment factors under
			 subparagraph (A) and a threshold for purposes of determining additional
			 MIPS adjustment factors under subparagraph (C)(i). Each such performance
			 threshold shall—
										(I)be based on a period prior to such performance periods; and
										(II)take into account—
											(aa)data available with respect to performance on measures and activities that may be used under the
			 performance categories under subparagraph (2)(B); and
											(bb)other factors determined appropriate by the Secretary.
											(E)Application of MIPS adjustment factorsIn the case of items and services furnished by a MIPS eligible professional during a year
			 (beginning with 2018), the amount otherwise paid under this part with
			 respect to such items and services and MIPS eligible professional for such
			 year, shall be multiplied by—
									(i)1, plus
									(ii)the sum of—
										(I)the MIPS adjustment factor determined under subparagraph (A) divided by 100, and
										(II)as applicable, the additional MIPS adjustment factor determined under subparagraph (C)(i) divided
			 by 100.
										(F)Aggregate application of MIPS adjustment factors
									(i)Application of scaling factor
										(I)In generalWith respect to positive MIPS adjustment factors under subparagraph (A)(ii)(I) for eligible
			 professionals whose composite performance score is above the performance
			 threshold under subparagraph (D)(i) for such year, subject to subclause
			 (II), the Secretary shall increase or decrease such adjustment factors by
			 a scaling factor in order to ensure that the budget neutrality requirement
			 of clause (ii) is met.
										(II)Scaling factor limitIn no case may be the scaling factor applied under this clause exceed 3.0.
										(ii)Budget neutrality requirement
										(I)In generalSubject to clause (iii), the Secretary shall ensure that the estimated amount described in
			 subclause (II) for a year is equal to the estimated amount described in
			 subclause (III) for such year.
										(II)Aggregate increasesThe amount described in this subclause is the estimated increase in the aggregate allowed charges
			 resulting from the application of positive MIPS adjustment factors under
			 subparagraph (A) (after application of the scaling factor described in
			 clause (i)) to MIPS eligible professionals whose composite performance
			 score for a year is above the performance threshold under subparagraph
			 (D)(i) for such year.
										(III)Aggregate decreasesThe amount described in this subclause is the estimated decrease in the aggregate allowed charges
			 resulting from the application of negative MIPS adjustment factors under
			 subparagraph (A) to MIPS eligible professionals whose composite
			 performance score for a year is below the performance threshold under
			 subparagraph (D)(i) for such year.
										(iii)Exceptions
										(I)In the case that all MIPS eligible professionals receive composite performance scores for a year
			 that are below the performance threshold under subparagraph (D)(i) for
			 such year, the negative MIPS adjustment factors under subparagraph (A)
			 shall apply with respect to such MIPS eligible professionals and the
			 budget neutrality requirement of clause (ii) shall not apply for such
			 year.
										(II)In the case that, with respect to a year, the application of clause (i) results in a scaling factor
			 equal to the maximum scaling factor specified in clause (i)(II), such
			 scaling factor shall apply and the budget neutrality requirement of clause
			 (ii) shall not apply for such year.
										(iv)Additional incentive payment adjustmentsIn specifying the MIPS additional adjustment factors under subparagraph (C)(i) for each applicable
			 MIPS eligible professional for a year, the Secretary shall ensure that the
			 estimated increase in payments under this part resulting from the
			 application of such additional adjustment factors for MIPS eligible
			 professionals in a year shall be equal (as estimated by the Secretary) to
			 the additional funding pool amount for such year under subparagraph
			 (C)(ii).
									(7)Announcement of result of adjustmentsUnder the MIPS, the Secretary shall, not later than 30 days prior to January 1 of the year
			 involved, make available to MIPS eligible professionals the MIPS
			 adjustment factor (and, as applicable, the additional MIPS adjustment
			 factor) under paragraph (6) applicable to the eligible professional for
			 items and services furnished by the professional for such year. The
			 Secretary may include such information in the confidential feedback under
			 paragraph (12).
							(8)No effect in subsequent yearsThe MIPS adjustment factors and additional MIPS adjustment factors under paragraph (6) shall apply
			 only with respect to the year involved, and the Secretary shall not take
			 into account such adjustment factors in making payments to a MIPS eligible
			 professional under this part in a subsequent year.
							(9)Public reporting
								(A)In generalThe Secretary shall, in an easily understandable format, make available on the Physician Compare
			 Internet website of the Centers for Medicare & Medicaid Services the following:
									(i)Information regarding the performance of MIPS eligible professionals under the MIPS, which—
										(I)shall include the composite score for each such MIPS eligible professional and the performance of
			 each such MIPS eligible professional with respect to each performance
			 category; and
										(II)may include the performance of each such MIPS eligible professional with respect to each measure or
			 activity specified in paragraph (2)(B).
										(ii)The names of eligible professionals in eligible alternative payment models (as defined in section
			 1833(z)(3)(D)) and, to the extent feasible, the names of such eligible
			 alternative payment models and performance of such models.
									(B)DisclosureThe information made available under this paragraph shall indicate, where appropriate, that
			 publicized information may not be representative of the eligible
			 professional’s entire patient population, the variety of services
			 furnished by the eligible professional, or the health conditions of
			 individuals treated.
								(C)Opportunity to review and submit correctionsThe Secretary shall provide for an opportunity for a professional described in subparagraph (A) to
			 review, and submit corrections for, the information to be made public with
			 respect to the professional under such subparagraph prior to such
			 information being made public.
								(D)Aggregate informationThe Secretary shall periodically post on the Physician Compare Internet website aggregate
			 information on the MIPS, including the range of composite scores for all
			 MIPS eligible professionals and the range of the performance of all MIPS
			 eligible professionals with respect to each performance category.
								(10)ConsultationThe Secretary shall consult with stakeholders in carrying out the MIPS, including for the
			 identification of measures and activities under paragraph (2)(B) and the
			 methodologies developed under paragraphs (5)(A) and (6) and regarding the
			 use of qualified clinical data registries. Such consultation shall include
			 the use of a request for information or other mechanisms determined
			 appropriate.
							(11)Technical assistance to small practices and practices in health professional shortage areas
								(A)In generalThe Secretary shall enter into contracts or agreements with appropriate entities (such as quality
			 improvement organizations, regional extension centers (as described in
			 section 3012(c) of the Public Health Service Act), or regional health
			 collaboratives) to offer guidance and assistance to MIPS eligible
			 professionals in practices of 15 or fewer professionals (with priority
			 given to such practices located in rural areas, health professional
			 shortage areas (as designated under in section 332(a)(1)(A) of such Act),
			 and medically underserved areas, and practices with low composite scores)
			 with respect to—
									(i)the performance categories described in clauses (i) through (iv) of paragraph (2)(A); or
									(ii)how to transition to the implementation of and participation in an alternative payment model as
			 described in section 1833(z)(3)(C).
									(B)Funding for implementation
									(i)In generalFor purposes of implementing subparagraph (A), the Secretary shall provide for the transfer from
			 the Federal Supplementary Medical Insurance Trust Fund established under
			 section 1841 to the Centers for Medicare & Medicaid Services Program Management Account of $40,000,000 for each of fiscal years 2015 through
			 2019. Amounts transferred under this subparagraph for a fiscal year shall
			 be available until expended.
									(ii)Technical assistanceOf the amounts transferred pursuant to clause (i) for each of fiscal years 2015 through 2019, not
			 less than $10,000,000 shall be made available for each such year for
			 technical assistance to small practices in health professional shortage
			 areas (as so designated) and medically underserved areas.
									(12)Feedback and information to improve performance
								(A)Performance feedback
									(i)In generalBeginning July 1, 2016, the Secretary—
										(I)shall make available timely (such as quarterly) confidential feedback to MIPS eligible
			 professionals on the performance of such professionals with respect to the
			 performance categories under clauses (i) and (ii) of paragraph (2)(A); and
										(II)may make available confidential feedback to each such professional on the performance of such
			 professional with respect to the performance categories under clauses
			 (iii) and (iv) of such paragraph.
										(ii)MechanismsThe Secretary may use one or more mechanisms to make feedback available under clause (i), which may
			 include use of a web-based portal or other mechanisms determined
			 appropriate by the Secretary. With respect to the performance category
			 described in paragraph (2)(A)(i), feedback under this subparagraph shall,
			 to the extent an eligible professional chooses to participate in a data
			 registry for purposes of this subsection (including registries under
			 subsections (k) and (m)), be provided based on performance on quality
			 measures reported through the use of such registries. With respect to any
			 other performance category described in paragraph (2)(A), the Secretary
			 shall encourage provision of feedback through qualified clinical data
			 registries as described in subsection (m)(3)(E)).
									(iii)Use of dataFor purposes of clause (i), the Secretary may use data, with respect to a MIPS eligible
			 professional, from periods prior to the current performance period and may
			 use rolling periods in order to make illustrative calculations about the
			 performance of such professional.
									(iv)Disclosure exemptionFeedback made available under this subparagraph shall be exempt from disclosure under section 552
			 of title 5, United States Code.
									(v)Receipt of informationThe Secretary may use the mechanisms established under clause (ii) to receive information from
			 professionals, such as information with respect to this subsection.
									(B)Additional information
									(i)In generalBeginning July 1, 2017, the Secretary shall make available to each MIPS eligible professional
			 information, with respect to individuals who are patients of such MIPS
			 eligible professional, about items and services for which payment is made
			 under this title that are furnished to such individuals by other suppliers
			 and providers of services, which may include information described in
			 clause (ii). Such information may be made available under the previous
			 sentence to such MIPS eligible professionals by mechanisms determined
			 appropriate by the Secretary, which may include use of a web-based portal.
			 Such information may be made available in accordance with the same or
			 similar terms as data are made available to accountable care organizations
			 participating in the shared savings program under section 1899, including
			 a beneficiary opt-out.
									(ii)Type of informationFor purposes of clause (i), the information described in this clause, is the following:
										(I)With respect to selected items and services (as determined appropriate by the Secretary) for which
			 payment is made under this title and that are furnished to individuals,
			 who are patients of a MIPS eligible professional, by another supplier or
			 provider of services during the most recent period for which data are
			 available (such as the most recent three-month period), such as the name
			 of such providers furnishing such items and services to such patients
			 during such period, the types of such items and services so furnished, and
			 the dates such items and services were so furnished.
										(II)Historical data, such as averages and other measures of the distribution if appropriate, of the
			 total, and components of, allowed charges (and other figures as determined
			 appropriate by the Secretary).
										(13)Review
								(A)Targeted reviewThe Secretary shall establish a process under which a MIPS eligible professional may seek an
			 informal review of the calculation of the MIPS adjustment factor
			 applicable to such eligible professional under this subsection for a year.
			 The results of a review conducted pursuant to the previous sentence shall
			 not be taken into account for purposes of paragraph (6) with respect to a
			 year (other than with respect to the calculation of such eligible
			 professional’s MIPS adjustment factor for such year or additional MIPS
			 adjustment factor for such year) after the factors determined in
			 subparagraph (A) and subparagraph (C) of such paragraph have been
			 determined for such year.
								(B)LimitationExcept as provided for in subparagraph (A), there shall be no administrative or judicial review
			 under section 1869, section 1878, or otherwise of the following:
									(i)The methodology used to determine the amount of the MIPS adjustment factor under paragraph (6)(A)
			 and the amount of the additional MIPS adjustment factor under paragraph
			 (6)(C)(i) and the determination of such amounts.
									(ii)The establishment of the performance standards under paragraph (3) and the performance period under
			 paragraph (4).
									(iii)The identification of measures and activities specified under paragraph (2)(B) and information made
			 public or posted on the Physician Compare Internet website of the Centers
			 for Medicare & Medicaid Services under paragraph (9).
									(iv)The methodology developed under paragraph (5) that is used to calculate performance scores and the
			 calculation of such scores, including the weighting of measures and
			 activities under such methodology..
				(2)GAO reports
					(A)Evaluation of eligible professional MIPSNot later than October 1, 2019, and October 1, 2022, the Comptroller General of the United States
			 shall submit to Congress a report evaluating the eligible professional
			 Merit-based Incentive Payment System under subsection (q) of section 1848
			 of the Social Security Act (42 U.S.C. 1395w–4), as added by paragraph (1).
			 Such report shall—
						(i)examine the distribution of the composite performance scores and MIPS adjustment factors (and
			 additional MIPS adjustment factors) for MIPS eligible professionals (as
			 defined in subsection (q)(1)(c) of such section) under such program, and
			 patterns relating to such scores and adjustment factors, including based
			 on type of provider, practice size, geographic location, and patient mix;
						(ii)provide recommendations for improving such program;
						(iii)evaluate the impact of technical assistance funding under section 1848(q)(11) of the Social
			 Security Act, as added by paragraph (1), on the ability of professionals
			 to improve within such program or successfully transition to an
			 alternative payment model (as defined in section 1833(z)(3) of the Social
			 Security Act, as added by subsection (e)), with priority for such
			 evaluation given to practices located in rural areas, health professional
			 shortage areas (as designated in section 332(a)(1)(a) of the Public Health
			 Service Act), and medically underserved areas; and
						(iv)provide recommendations for optimizing the use of such technical assistance funds.
						(B)Study to examine alignment of quality measures used in public and private programs
						(i)In generalNot later than 18 months after the date of the enactment of this Act, the Comptroller General of
			 the United States shall submit to Congress a report that—
							(I)compares the similarities and differences in the use of quality measures under the original
			 Medicare fee-for-service program under parts A and B of title XVIII of the
			 Social Security Act, the Medicare Advantage program under part C of such
			 title, selected State Medicaid programs under title XIX of such Act, and
			 private payer arrangements; and
							(II)makes recommendations on how to reduce the administrative burden involved in applying such quality
			 measures.
							(ii)RequirementsThe report under clause (i) shall—
							(I)consider those measures applicable to individuals entitled to, or enrolled for, benefits under such
			 part A, or enrolled under such part B and individuals under the age of 65;
			 and
							(II)focus on those measures that comprise the most significant component of the quality performance
			 category of the eligible professional MIPS incentive program under
			 subsection (q) of section 1848 of the Social Security Act (42 U.S.C.
			 1395w–4), as added by paragraph (1).
							(C)Study on role of independent risk managersNot later than January 1, 2016, the Comptroller General of the United States shall submit to
			 Congress a report examining whether entities that pool financial risk for
			 physician practices, such as independent risk managers, can play a role in
			 supporting physician practices, particularly small physician practices, in
			 assuming financial risk for the treatment of patients. Such report shall
			 examine barriers that small physician practices currently face in assuming
			 financial risk for treating patients, the types of risk management
			 entities that could assist physician practices in participating in
			 two-sided risk payment models, and how such entities could assist with
			 risk management and with quality improvement activities. Such report shall
			 also include an analysis of any existing legal barriers to such
			 arrangements.
					(D)Study to examine rural and health professional shortage area alternative payment modelsNot later than October 1, 2020, and October 1, 2022, the Comptroller General of the United States
			 shall submit to Congress a report that examines the transition of
			 professionals in rural areas, health professional shortage areas (as
			 designated in section 332(a)(1)(A) of the Public Health Service Act), or
			 medically underserved areas to an alternative payment model (as defined in
			 section 1833(z)(3) of the Social Security Act, as added by subsection
			 (e)). Such report shall make recommendations for removing administrative
			 barriers to practices, including small practices consisting of 15 or fewer
			 professionals, in rural areas, health professional shortage areas, and
			 medically underserved areas to participation in such models.
					(3)Funding for implementationFor purposes of implementing the provisions of and the amendments made by this section, the
			 Secretary of Health and Human Services shall provide for the transfer of
			 $80,000,000 from the Supplementary Medical Insurance Trust Fund
			 established under section 1841 of the Social Security Act (42 U.S.C.
			 1395t) to the Centers for Medicare & Medicaid Program Management Account for each of the fiscal years 2014 through 2018. Amounts
			 transferred under this paragraph shall be available until expended.
				(d)Improving quality reporting for composite scores
				(1)Changes for group reporting option
					(A)In generalSection 1848(m)(3)(C)(ii)) of the Social Security Act (42 U.S.C. 1395w–4(m)(3)(C)(ii)) is amended
			 by inserting and, for 2015 and subsequent years, may provide after shall provide.
					(B)Clarification of qualified clinical data registry reporting to group practicesSection 1848(m)(3)(D) of the Social Security Act (42 U.S.C. 1395w–4(m)(3)(D)) is amended by
			 inserting and, for 2015 and subsequent years, subparagraph (A) or (C) after subparagraph (A).
					(2)Changes for multiple reporting periods and alternative criteria for satisfactory reportingSection 1848(m)(5)(F) of the Social Security Act (42 U.S.C. 1395w–4(m)(5)(F)) is amended—
					(A)by striking and subsequent years and inserting through reporting periods occurring in 2014; and
					(B)by inserting and, for reporting periods occurring in 2015 and subsequent years, the Secretary may establish following shall establish.
					(3)Physician feedback program reports succeeded by reports under MIPSSection 1848(n) of the Social Security Act (42 U.S.C. 1395w–4(n)) is amended by adding at the end
			 the following new paragraph:

						(11)Reports ending with 2016Reports under the Program shall not be provided after December 31, 2016. See subsection (q)(12) for
			 reports under the eligible professionals Merit-based Incentive Payment
			 System..
				(4)Coordination with satisfying meaningful EHR use clinical quality measure reporting requirementSection 1848(o)(2)(A)(iii) of the Social Security Act (42 U.S.C. 1395w–4(o)(2)(A)(iii)) is amended
			 by inserting and subsection (q)(5)(B)(ii)(II) after Subject to subparagraph (B)(ii).
				(e)Promoting alternative payment models
				(1)Increasing transparency of physician focused payment modelsSection 1868 of the Social Security Act (42 U.S.C. 1395ee) is amended by adding at the end the
			 following new subsection:

						(c)Physician focused payment models
							(1)Technical advisory committee
								(A)EstablishmentThere is established an ad hoc committee to be known as the Payment Model Technical Advisory Committee (referred to in this subsection as the Committee).
								(B)Membership
									(i)Number and appointmentThe Committee shall be composed of 11 members appointed by the Comptroller General of the United
			 States.
									(ii)QualificationsThe membership of the Committee shall include individuals with national recognition for their
			 expertise in payment models and related delivery of care. No more than 5
			 members of the Committee shall be providers of services or suppliers, or
			 representatives of providers of services or suppliers.
									(iii)Prohibition on federal employmentA member of the Committee shall not be an employee of the Federal Government.
									(iv)Ethics disclosureThe Comptroller General shall establish a system for public disclosure by members of the Committee
			 of financial and other potential conflicts of interest relating to such
			 members. Members of the Committee shall be treated as employees of
			 Congress for purposes of applying title I of the Ethics in Government Act
			 of 1978 (Public Law 95–521).
									(v)Date of initial appointmentsThe initial appointments of members of the Committee shall be made by not later than 180 days after
			 the date of enactment of this subsection.
									(C)Term; vacancies
									(i)TermThe terms of members of the Committee shall be for 3 years except that the Comptroller General
			 shall designate staggered terms for the members first appointed.
									(ii)VacanciesAny member appointed to fill a vacancy occurring before the expiration of the term for which the
			 member’s predecessor was appointed shall be appointed only for the
			 remainder of that term. A member may serve after the expiration of that
			 member’s term until a successor has taken office. A vacancy in the
			 Committee shall be filled in the manner in which the original appointment
			 was made.
									(D)DutiesThe Committee shall meet, as needed, to provide comments and recommendations to the Secretary, as
			 described in paragraph (2)(C), on physician-focused payment models.
								(E)Compensation of members
									(i)In generalExcept as provided in clause (ii), a member of the Committee shall serve without compensation.
									(ii)Travel expensesA member of the Committee shall be allowed travel expenses, including per diem in lieu of
			 subsistence, at rates authorized for an employee of an agency under
			 subchapter I of chapter 57 of title 5, United States Code, while away from
			 the home or regular place of business of the member in the performance of
			 the duties of the Committee.
									(F)Operational and technical support
									(i)In generalThe Assistant Secretary for Planning and Evaluation shall provide technical and operational support
			 for the Committee, which may be by use of a contractor. The Office of the
			 Actuary of the Centers for Medicare & Medicaid Services shall provide to the Committee actuarial assistance as needed.
									(ii)FundingThe Secretary shall provide for the transfer, from the Federal Supplementary Medical Insurance
			 Trust Fund under section 1841, such amounts as are necessary to carry out
			 clause (i) (not to exceed $5,000,000) for fiscal year 2014 and each
			 subsequent fiscal year. Any amounts transferred under the preceding
			 sentence for a fiscal year shall remain available until expended.
									(G)ApplicationSection 14 of the Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to the Committee.
								(2)Criteria and process for submission and review of physician-focused payment models
								(A)Criteria for assessing physician-focused payment models
									(i)RulemakingNot later than November 1, 2015, the Secretary shall, through notice and comment rulemaking,
			 following a request for information, establish criteria for
			 physician-focused payment models, including models for specialist
			 physicians, that could be used by the Committee for making comments and
			 recommendations pursuant to paragraph (1)(D).
									(ii)MedPAC submission of commentsDuring the comment period for the proposed rule described in clause (i), the Medicare Payment
			 Advisory Commission may submit comments to the Secretary on the proposed
			 criteria under such clause.
									(iii)UpdatingThe Secretary may update the criteria established under this subparagraph through rulemaking.
									(B)Stakeholder submission of physician focused payment modelsOn an ongoing basis, individuals and stakeholder entities may submit to the Committee proposals for
			 physician-focused payment models that such individuals and entities
			 believe meet the criteria described in subparagraph (A).
								(C)TAC review of models submittedThe Committee shall, on a periodic basis, review models submitted under subparagraph (B), prepare
			 comments and recommendations regarding whether such models meet the
			 criteria described in subparagraph (A), and submit such comments and
			 recommendations to the Secretary.
								(D)Secretary review and responseThe Secretary shall review the comments and recommendations submitted by the Committee under
			 subparagraph (C) and post a detailed response to such comments and
			 recommendations on the Internet Website of the Centers for Medicare & Medicaid Services.
								(3)Rule of constructionNothing in this subsection shall be construed to impact the development or testing of models under
			 this title or titles XI, XIX, or XXI..
				(2)Incentive payments for participation in eligible alternative payment modelsSection 1833 of the Social Security Act (42 U.S.C. 1395l) is amended by adding at the end the
			 following new subsection:

						(z)Incentive payments for participation in eligible alternative payment models
							(1)Payment incentive
								(A)In generalIn the case of covered professional services furnished by an eligible professional during a year
			 that is in the period beginning with 2018 and ending with 2023 and for
			 which the professional is a qualifying APM participant, in addition to the
			 amount of payment that would otherwise be made for such covered
			 professional services under this part for such year, there also shall be
			 paid to such professional an amount equal to 5 percent of the payment
			 amount for the covered professional services under this part for the
			 preceding year. For purposes of the previous sentence, the payment amount
			 for the preceding year may be an estimation for the full preceding year
			 based on a period of such preceding year that is less than the full year.
			 The Secretary shall establish policies to implement this subparagraph in
			 cases where payment for covered professional services furnished by a
			 qualifying APM participant in an alternative payment model is made to an
			 entity participating in the alternative payment model rather than directly
			 to the qualifying APM participant.
								(B)Form of paymentPayments under this subsection shall be made in a lump sum, on an annual basis, as soon as
			 practicable.
								(C)Treatment of payment incentivePayments under this subsection shall not be taken into account for purposes of determining actual
			 expenditures under an alternative payment model and for purposes of
			 determining or rebasing any benchmarks used under the alternative payment
			 model.
								(D)CoordinationThe amount of the additional payment for an item or service under this subsection or subsection (m)
			 shall be determined without regard to any additional payment for the item
			 or service under subsection (m) and this subsection, respectively. The
			 amount of the additional payment for an item or service under this
			 subsection or subsection (x) shall be determined without regard to any
			 additional payment for the item or service under subsection (x) and this
			 subsection, respectively. The amount of the additional payment for an item
			 or service under this subsection or subsection (y) shall be determined
			 without regard to any additional payment for the item or service under
			 subsection (y) and this subsection, respectively.
								(2)Qualifying APM participantFor purposes of this subsection, the term qualifying APM participant means the following:
								(A)2018 and 2019With respect to 2018 and 2019, an eligible professional for whom the Secretary determines that at
			 least 25 percent of payments under this part for covered professional
			 services furnished by such professional during the most recent period for
			 which data are available (which may be less than a year) were attributable
			 to such services furnished under this part through an entity that
			 participates in an eligible alternative payment model with respect to such
			 services.
								(B)2020 and 2021With respect to 2020 and 2021, an eligible professional described in either of the following
			 clauses:
									(i)Medicare revenue threshold optionAn eligible professional for whom the Secretary determines that at least 50 percent of payments
			 under this part for covered professional services furnished by such
			 professional during the most recent period for which data are available
			 (which may be less than a year) were attributable to such services
			 furnished under this part through an entity that participates in an
			 eligible alternative payment model with respect to such services.
									(ii)Combination all-payer and Medicare revenue threshold optionAn eligible professional—
										(I)for whom the Secretary determines, with respect to items and services furnished by such
			 professional during the most recent period for which data are available
			 (which may be less than a year), that at least 50 percent of the sum of—
											(aa)payments described in clause (i); and
											(bb)all other payments, regardless of payer (other than payments made by the Secretary of Defense or
			 the Secretary of Veterans Affairs under chapter 55 of title 10, United
			 States Code, or title 38, United States Code, or any other provision of
			 law, and other than payments made under title XIX in a State in which no
			 medical home or alternative payment model is available under the State
			 program under that title),meet the requirement described in clause (iii)(I) with respect to payments described in item (aa)
			 and meet the requirement described in clause (iii)(II) with respect to
			 payments described in item (bb);(II)for whom the Secretary determines at least 25 percent of payments under this part for covered
			 professional services furnished by such professional during the most
			 recent period for which data are available (which may be less than a year)
			 were attributable to such services furnished under this part through an
			 entity that participates in an eligible alternative payment model with
			 respect to such services; and
										(III)who provides to the Secretary such information as is necessary for the Secretary to make a
			 determination under subclause (I), with respect to such professional.
										(iii)RequirementFor purposes of clause (ii)(I)—
										(I)the requirement described in this subclause, with respect to payments described in item (aa) of
			 such clause, is that such payments are made under an eligible alternative
			 payment model; and
										(II)the requirement described in this subclause, with respect to payments described in item (bb) of
			 such clause, is that such payments are made under an arrangement in which—
											(aa)quality measures comparable to measures under the performance category described in section
			 1848(q)(2)(B)(i) apply;
											(bb)certified EHR technology is used; and
											(cc)the eligible professional (AA) bears more than nominal financial risk if actual aggregate
			 expenditures exceeds expected aggregate expenditures; or (BB) is a medical
			 home (with respect to beneficiaries under title XIX) that meets criteria
			 comparable to medical homes expanded under section 1115A(c).
											(C)Beginning in 2022With respect to 2022 and each subsequent year, an eligible professional described in either of the
			 following clauses:
									(i)Medicare revenue threshold optionAn eligible professional for whom the Secretary determines that at least 75 percent of payments
			 under this part for covered professional services furnished by such
			 professional during the most recent period for which data are available
			 (which may be less than a year) were attributable to such services
			 furnished under this part through an entity that participates in an
			 eligible alternative payment model with respect to such services.
									(ii)Combination all-payer and Medicare revenue threshold optionAn eligible professional—
										(I)for whom the Secretary determines, with respect to items and services furnished by such
			 professional during the most recent period for which data are available
			 (which may be less than a year), that at least 75 percent of the sum of—
											(aa)payments described in clause (i); and
											(bb)all other payments, regardless of payer (other than payments made by the Secretary of Defense or
			 the Secretary of Veterans Affairs under chapter 55 of title 10, United
			 States Code, or title 38, United States Code, or any other provision of
			 law, and other than payments made under title XIX in a State in which no
			 medical home or alternative payment model is available under the State
			 program under that title),meet the requirement described in clause (iii)(I) with respect to payments described in item (aa)
			 and meet the requirement described in clause (iii)(II) with respect to
			 payments described in item (bb);(II)for whom the Secretary determines at least 25 percent of payments under this part for covered
			 professional services furnished by such professional during the most
			 recent period for which data are available (which may be less than a year)
			 were attributable to such services furnished under this part through an
			 entity that participates in an eligible alternative payment model with
			 respect to such services; and
										(III)who provides to the Secretary such information as is necessary for the Secretary to make a
			 determination under subclause (I), with respect to such professional.
										(iii)RequirementFor purposes of clause (ii)(I)—
										(I)the requirement described in this subclause, with respect to payments described in item (aa) of
			 such clause, is that such payments are made under an eligible alternative
			 payment model; and
										(II)the requirement described in this subclause, with respect to payments described in item (bb) of
			 such clause, is that such payments are made under an arrangement in which—
											(aa)quality measures comparable to measures under the performance category described in section
			 1848(q)(2)(B)(i) apply;
											(bb)certified EHR technology is used; and
											(cc)the eligible professional (AA) bears more than nominal financial risk if actual aggregate
			 expenditures exceeds expected aggregate expenditures; or (BB) is a medical
			 home (with respect to beneficiaries under title XIX) that meets criteria
			 comparable to medical homes expanded under section 1115A(c).
											(3)Additional definitionsIn this subsection:
								(A)Covered professional servicesThe term covered professional services has the meaning given that term in section 1848(k)(3)(A).
								(B)Eligible professionalThe term eligible professional has the meaning given that term in section 1848(k)(3)(B).
								(C)Alternative payment model (APM)The term alternative payment model means any of the following:
									(i)A model under section 1115A (other than a health care innovation award).
									(ii)The shared savings program under section 1899.
									(iii)A demonstration under section 1866C.
									(iv)A demonstration required by Federal law.
									(D)Eligible alternative payment model (APM)
									(i)In generalThe term eligible alternative payment model means, with respect to a year, an alternative payment model—
										(I)that requires use of certified EHR technology (as defined in subsection (o)(4));
										(II)that provides for payment for covered professional services based on quality measures comparable to
			 measures under the performance category described in section
			 1848(q)(2)(B)(i); and
										(III)that satisfies the requirement described in clause (ii).
										(ii)Additional requirementFor purposes of clause (i)(III), the requirement described in this clause, with respect to a year
			 and an alternative payment model, is that the alternative payment model—
										(I)is one in which one or more entities bear financial risk for monetary losses under such model that
			 are in excess of a nominal amount; or
										(II)is a medical home expanded under section 1115A(c).
										(4)LimitationThere shall be no administrative or judicial review under section 1869, 1878, or otherwise, of the
			 following:
								(A)The determination that an eligible professional is a qualifying APM participant under paragraph (2)
			 and the determination that an alternative payment model is an eligible
			 alternative payment model under paragraph (3)(D).
								(B)The determination of the amount of the 5 percent payment incentive under paragraph (1)(A),
			 including any estimation as part of such determination..
				(3)Coordination conforming amendmentsSection 1833 of the Social Security Act (42 U.S.C. 1395l) is further amended—
					(A)in subsection (x)(3), by adding at the end the following new sentence: The amount of the additional payment for a service under this subsection and subsection (z) shall
			 be determined without regard to any additional payment for the service
			 under subsection (z) and this subsection, respectively.; and
					(B)in subsection (y)(3), by adding at the end the following new sentence: The amount of the additional payment for a service under this subsection and subsection (z) shall
			 be determined without regard to any additional payment for the service
			 under subsection (z) and this subsection, respectively..
					(4)Encouraging development and testing of certain modelsSection 1115A(b)(2) of the Social Security Act (42 U.S.C. 1315a(b)(2)) is amended—
					(A)in subparagraph (B), by adding at the end the following new clauses:

							(xxi)Focusing primarily on physicians’ services (as defined in section 1848(j)(3)) furnished by
			 physicians who are not primary care practitioners.
							(xxii)Focusing on practices of 15 or fewer professionals.
							(xxiii)Focusing on risk-based models for small physician practices which may involve two-sided risk and
			 prospective patient assignment, and which examine risk-adjusted decreases
			 in mortality rates, hospital readmissions rates, and other relevant and
			 appropriate clinical measures.
							(xxiv)Focusing primarily on title XIX, working in conjunction with the Center for Medicaid and CHIP
			 Services.; and
					(B)in subparagraph (C)(viii), by striking other public sector or private sector payers and inserting other public sector payers, private sector payers, or Statewide payment models.
					(5)Construction regarding telehealth servicesNothing in the provisions of, or amendments made by, this Act shall be construed as precluding an
			 alternative payment model or a qualifying APM participant (as those terms
			 are defined in section 1833(z) of the Social Security Act, as added by
			 paragraph (1)) from furnishing a telehealth service for which payment is
			 not made under section 1834(m) of the Social Security Act (42 U.S.C.
			 1395m(m)).
				(6)Integrating Medicare Advantage alternative payment modelsNot later than July 1, 2015, the Secretary of Health and Human Services shall submit to Congress a
			 study that examines the feasibility of integrating alternative payment
			 models in the Medicare Advantage payment system. The study shall include
			 the feasibility of including a value-based modifier and whether such
			 modifier should be budget neutral.
				(7)Study and report on fraud related to alternative payment models under the Medicare program
					(A)StudyThe Secretary of Health and Human Services, in consultation with the Inspector General of the
			 Department of Health and Human Services, shall conduct a study that—
						(i)examines the applicability of the Federal fraud prevention laws to items and services furnished
			 under title XVIII of the Social Security Act for which payment is made
			 under an alternative payment model (as defined in section 1833(z)(3)(C) of
			 such Act (42 U.S.C. 1395l(z)(3)(C)));
						(ii)identifies aspects of such alternative payment models that are vulnerable to fraudulent activity;
			 and
						(iii)examines the implications of waivers to such laws granted in support of such alternative payment
			 models, including under any potential expansion of such models.
						(B)ReportNot later than 2 years after the date of the enactment of this Act, the Secretary shall submit to
			 Congress a report containing the results of the study conducted under
			 subparagraph (A). Such report shall include recommendations for actions to
			 be taken to reduce the vulnerability of such alternative payment models to
			 fraudulent activity. Such report also shall include, as appropriate,
			 recommendations of the Inspector General for changes in Federal fraud
			 prevention laws to reduce such vulnerability.
					(f)Improving payment accuracy
				(1)Studies and reports of effect of certain information on quality and resource use
					(A)Study using existing Medicare data
						(i)StudyThe Secretary of Health and Human Services (in this subsection referred to as the Secretary) shall conduct a study that examines the effect of individuals’ socioeconomic status on quality
			 and resource use outcome measures for individuals under the Medicare
			 program (such as to recognize that less healthy individuals may require
			 more intensive interventions). The study shall use information collected
			 on such individuals in carrying out such program, such as urban and rural
			 location, eligibility for Medicaid (recognizing and accounting for varying
			 Medicaid eligibility across States), and eligibility for benefits under
			 the supplemental security income (SSI) program. The Secretary shall carry
			 out this paragraph acting through the Assistant Secretary for Planning and
			 Evaluation.
						(ii)ReportNot later than 2 years after the date of the enactment of this Act, the Secretary shall submit to
			 Congress a report on the study conducted under clause (i).
						(B)Study using other data
						(i)StudyThe Secretary shall conduct a study that examines the impact of risk factors, such as those
			 described in section 1848(p)(3) of the Social Security Act (42 U.S.C.
			 1395w–4(p)(3)), race, health literacy, limited English proficiency (LEP),
			 and patient activation, on quality and resource use outcome measures under
			 the Medicare program (such as to recognize that less healthy individuals
			 may require more intensive interventions). In conducting such study the
			 Secretary may use existing Federal data and collect such additional data
			 as may be necessary to complete the study.
						(ii)ReportNot later than 5 years after the date of the enactment of this Act, the Secretary shall submit to
			 Congress a report on the study conducted under clause (i).
						(C)Examination of data in conducting studiesIn conducting the studies under subparagraphs (A) and (B), the Secretary shall examine what
			 non-Medicare data sets, such as data from the American Community Survey
			 (ACS), can be useful in conducting the types of studies under such
			 paragraphs and how such data sets that are identified as useful can be
			 coordinated with Medicare administrative data in order to improve the
			 overall data set available to do such studies and for the administration
			 of the Medicare program.
					(D)Recommendations to account for information in payment adjustment mechanismsIf the studies conducted under subparagraphs (A) and (B) find a relationship between the factors
			 examined in the studies and quality and resource use outcome measures,
			 then the Secretary shall also provide recommendations for how the Centers
			 for Medicare & Medicaid Services should—
						(i)obtain access to the necessary data (if such data is not already being collected) on such factors,
			 including recommendations on how to address barriers to the Centers in
			 accessing such data; and
						(ii)account for such factors in determining payment adjustments based on quality and resource use
			 outcome measures under the eligible professional Merit-based Incentive
			 Payment System under section 1848(q) of the Social Security Act (42 U.S.C.
			 1395w–4(q)) and, as the Secretary determines appropriate, other similar
			 provisions of title XVIII of such Act.
						(E)FundingThere are hereby appropriated from the Federal Supplementary Medical Insurance Trust Fund under
			 section 1841 of the Social Security Act to the Secretary to carry out this
			 paragraph $6,000,000, to remain available until expended.
					(2)CMS activities
					(A)Hierarchal Condition Category (HCC) improvementTaking into account the relevant studies conducted and recommendations made in reports under
			 paragraph (1), the Secretary, on an ongoing basis, shall, as the Secretary
			 determines appropriate, estimate how an individual’s health status and
			 other risk factors affect quality and resource use outcome measures and,
			 as feasible, shall incorporate information from quality and resource use
			 outcome measurement (including care episode and patient condition groups)
			 into provisions of title XVIII of the Social Security Act that are similar
			 to the eligible professional Merit-based Incentive Payment System under
			 section 1848(q) of such Act.
					(B)Accounting for other factors in payment adjustment mechanisms
						(i)In generalTaking into account the studies conducted and recommendations made in reports under paragraph (1)
			 and other information as appropriate, the Secretary shall, as the
			 Secretary determines appropriate, account for identified factors with an
			 effect on quality and resource use outcome measures when determining
			 payment adjustment mechanisms under provisions of title XVIII of the
			 Social Security Act that are similar to the eligible professional
			 Merit-based Incentive Payment System under section 1848(q) of such Act.
						(ii)Accessing dataThe Secretary shall collect or otherwise obtain access to the data necessary to carry out this
			 paragraph through existing and new data sources.
						(iii)Periodic analysesThe Secretary shall carry out periodic analyses, at least every 3 years, based on the factors
			 referred to in clause (i) so as to monitor changes in possible
			 relationships.
						(C)FundingThere are hereby appropriated from the Federal Supplementary Medical Insurance Trust Fund under
			 section 1841 of the Social Security Act to the Secretary to carry out this
			 paragraph and the application of this paragraph to the Merit-based
			 Incentive Payment System under section 1848(q) of such Act $10,000,000, to
			 remain available until expended.
					(3)Strategic plan for accessing race and ethnicity dataNot later than 18 months after the date of the enactment of this Act, the Secretary shall develop
			 and report to Congress on a strategic plan for collecting or otherwise
			 accessing data on race and ethnicity for purposes of carrying out the
			 eligible professional Merit-based Incentive Payment System under section
			 1848(q) of the Social Security Act and, as the Secretary determines
			 appropriate, other similar provisions of title XVIII of such Act.
				(g)Collaborating with the physician, practitioner, and other stakeholder communities To improve
			 resource use measurementSection 1848 of the Social Security Act (42 U.S.C. 1395w–4), as amended by subsection (c), is
			 further amended by adding at the end the following new subsection:

					(r)Collaborating with the physician, practitioner, and other stakeholder communities To improve
			 resource use measurement
						(1)In generalIn order to involve the physician, practitioner, and other stakeholder communities in enhancing the
			 infrastructure for resource use measurement, including for purposes of the
			 value-based performance incentive program under subsection (q) and
			 alternative payment models under section 1833(z), the Secretary shall
			 undertake the steps described in the succeeding provisions of this
			 subsection.
						(2)Development of care episode and patient condition groups and classification codes
							(A)In generalIn order to classify similar patients into care episode groups and patient condition groups, the
			 Secretary shall undertake the steps described in the succeeding provisions
			 of this paragraph.
							(B)Public availability of existing efforts to design an episode grouperNot later than 120 days after the date of the enactment of this subsection, the Secretary shall
			 post on the Internet website of the Centers for Medicare & Medicaid Services a list of the episode groups developed pursuant to subsection (n)(9)(A) and
			 related descriptive information.
							(C)Stakeholder inputThe Secretary shall accept, through the date that is 60 days after the day the Secretary posts the
			 list pursuant to subparagraph (B), suggestions from physician specialty
			 societies, applicable practitioner organizations, and other stakeholders
			 for episode groups in addition to those posted pursuant to such
			 subparagraph, and specific clinical criteria and patient characteristics
			 to classify patients into—
								(i)care episode groups; and
								(ii)patient condition groups.
								(D)Development of proposed classification codes
								(i)In generalTaking into account the information described in subparagraph (B) and the information received
			 under subparagraph (C), the Secretary shall—
									(I)establish care episode groups and patient condition groups, which account for a target of an
			 estimated 2/3 of expenditures under parts A and B; and
									(II)assign codes to such groups.
									(ii)Care episode groupsIn establishing the care episode groups under clause (i), the Secretary shall take into account—
									(I)the patient’s clinical problems at the time items and services are furnished during an episode of
			 care, such as the clinical conditions or diagnoses, whether or not
			 inpatient hospitalization is anticipated or occurs, and the principal
			 procedures or services planned or furnished; and
									(II)other factors determined appropriate by the Secretary.
									(iii)Patient condition groupsIn establishing the patient condition groups under clause (i), the Secretary shall take into
			 account—
									(I)the patient’s clinical history at the time of each medical visit, such as the patient’s combination
			 of chronic conditions, current health status, and recent significant
			 history (such as hospitalization and major surgery during a previous
			 period, such as 3 months); and
									(II)other factors determined appropriate by the Secretary, such as eligibility status under this title
			 (including eligibility under section 226(a), 226(b), or 226A, and dual
			 eligibility under this title and title XIX).
									(E)Draft care episode and patient condition groups and classification codesNot later than 180 days after the end of the comment period described in subparagraph (C), the
			 Secretary shall post on the Internet website of the Centers for Medicare & Medicaid Services a draft list of the care episode and patient condition codes established under
			 subparagraph (D) (and the criteria and characteristics assigned to such
			 code).
							(F)Solicitation of inputThe Secretary shall seek, through the date that is 60 days after the Secretary posts the list
			 pursuant to subparagraph (E), comments from physician specialty societies,
			 applicable practitioner organizations, and other stakeholders, including
			 representatives of individuals entitled to benefits under part A or
			 enrolled under this part, regarding the care episode and patient condition
			 groups (and codes) posted under subparagraph (E). In seeking such
			 comments, the Secretary shall use one or more mechanisms (other than
			 notice and comment rulemaking) that may include use of open door forums,
			 town hall meetings, or other appropriate mechanisms.
							(G)Operational list of care episode and patient condition groups and codesNot later than 180 days after the end of the comment period described in subparagraph (F), taking
			 into account the comments received under such subparagraph, the Secretary
			 shall post on the Internet website of the Centers for Medicare & Medicaid Services an operational list of care episode and patient condition codes (and the
			 criteria and characteristics assigned to such code).
							(H)Subsequent revisionsNot later than November 1 of each year (beginning with 2017), the Secretary shall, through
			 rulemaking, make revisions to the operational lists of care episode and
			 patient condition codes as the Secretary determines may be appropriate.
			 Such revisions may be based on experience, new information developed
			 pursuant to subsection (n)(9)(A), and input from the physician specialty
			 societies, applicable practitioner organizations, and other stakeholders,
			 including representatives of individuals entitled to benefits under part A
			 or enrolled under this part.
							(3)Attribution of patients to physicians or practitioners
							(A)In generalIn order to facilitate the attribution of patients and episodes (in whole or in part) to one or
			 more physicians or applicable practitioners furnishing items and services,
			 the Secretary shall undertake the steps described in the succeeding
			 provisions of this paragraph.
							(B)Development of patient relationship categories and codesThe Secretary shall develop patient relationship categories and codes that define and distinguish
			 the relationship and responsibility of a physician or applicable
			 practitioner with a patient at the time of furnishing an item or service.
			 Such patient relationship categories shall include different relationships
			 of the physician or applicable practitioner to the patient (and the codes
			 may reflect combinations of such categories), such as a physician or
			 applicable practitioner who—
								(i)considers themself to have the primary responsibility for the general and ongoing care for the
			 patient over extended periods of time;
								(ii)considers themself to be the lead physician or practitioner and who furnishes items and services
			 and coordinates care furnished by other physicians or practitioners for
			 the patient during an acute episode;
								(iii)furnishes items and services to the patient on a continuing basis during an acute episode of care,
			 but in a supportive rather than a lead role;
								(iv)furnishes items and services to the patient on an occasional basis, usually at the request of
			 another physician or practitioner; or
								(v)furnishes items and services only as ordered by another physician or practitioner.
								(C)Draft list of patient relationship categories and codesNot later than 270 days after the date of the enactment of this subsection, the Secretary shall
			 post on the Internet website of the Centers for Medicare & Medicaid Services a draft list of the patient relationship categories and codes developed under
			 subparagraph (B).
							(D)Stakeholder InputThe Secretary shall seek, through the date that is 60 days after the Secretary posts the list
			 pursuant to subparagraph (C), comments from physician specialty societies,
			 applicable practitioner organizations, and other stakeholders, including
			 representatives of individuals entitled to benefits under part A or
			 enrolled under this part, regarding the patient relationship categories
			 and codes posted under subparagraph (C). In seeking such comments, the
			 Secretary shall use one or more mechanisms (other than notice and comment
			 rulemaking) that may include open door forums, town hall meetings, or
			 other appropriate mechanisms.
							(E)Operational list of patient relationship categories and codesNot later than 180 days after the end of the comment period described in subparagraph (D), taking
			 into account the comments received under such subparagraph, the Secretary
			 shall post on the Internet website of the Centers for Medicare & Medicaid Services an operational list of patient relationship categories and codes.
							(F)Subsequent revisionsNot later than November 1 of each year (beginning with 2017), the Secretary shall, through
			 rulemaking, make revisions to the operational list of patient relationship
			 categories and codes as the Secretary determines appropriate. Such
			 revisions may be based on experience, new information developed pursuant
			 to subsection (n)(9)(A), and input from the physician specialty societies,
			 applicable practitioner organizations, and other stakeholders, including
			 representatives of individuals entitled to benefits under part A or
			 enrolled under this part.
							(4)Reporting of information for resource use measurementClaims submitted for items and services furnished by a physician or applicable practitioner on or
			 after January 1, 2017, shall, as determined appropriate by the Secretary,
			 include—
							(A)applicable codes established under paragraphs (2) and (3); and
							(B)the national provider identifier of the ordering physician or applicable practitioner (if different
			 from the billing physician or applicable practitioner).
							(5)Methodology for resource use analysis
							(A)In generalIn order to evaluate the resources used to treat patients (with respect to care episode and patient
			 condition groups), the Secretary shall—
								(i)use the patient relationship codes reported on claims pursuant to paragraph (4) to attribute
			 patients (in whole or in part) to one or more physicians and applicable
			 practitioners;
								(ii)use the care episode and patient condition codes reported on claims pursuant to paragraph (4) as a
			 basis to compare similar patients and care episodes and patient condition
			 groups; and
								(iii)conduct an analysis of resource use (with respect to care episodes and patient condition groups of
			 such patients), as the Secretary determines appropriate.
								(B)Analysis of patients of physicians and practitionersIn conducting the analysis described in subparagraph (A)(iii) with respect to patients attributed
			 to physicians and applicable practitioners, the Secretary shall, as
			 feasible—
								(i)use the claims data experience of such patients by patient condition codes during a common period,
			 such as 12 months; and
								(ii)use the claims data experience of such patients by care episode codes—
									(I)in the case of episodes without a hospitalization, during periods of time (such as the number of
			 days) determined appropriate by the Secretary; and
									(II)in the case of episodes with a hospitalization, during periods of time (such as the number of days)
			 before, during, and after the hospitalization.
									(C)Measurement of resource useIn measuring such resource use, the Secretary—
								(i)shall use per patient total allowed charges for all services under part A and this part (and, if
			 the Secretary determines appropriate, part D) for the analysis of patient
			 resource use, by care episode codes and by patient condition codes; and
								(ii)may, as determined appropriate, use other measures of allowed charges (such as subtotals for
			 categories of items and services) and measures of utilization of items and
			 services (such as frequency of specific items and services and the ratio
			 of specific items and services among attributed patients or episodes).
								(D)Stakeholder InputThe Secretary shall seek comments from the physician specialty societies, applicable practitioner
			 organizations, and other stakeholders, including representatives of
			 individuals entitled to benefits under part A or enrolled under this part,
			 regarding the resource use methodology established pursuant to this
			 paragraph. In seeking comments the Secretary shall use one or more
			 mechanisms (other than notice and comment rulemaking) that may include
			 open door forums, town hall meetings, or other appropriate mechanisms.
							(6)ImplementationTo the extent that the Secretary contracts with an entity to carry out any part of the provisions
			 of this subsection, the Secretary may not contract with an entity or an
			 entity with a subcontract if the entity or subcontracting entity currently
			 makes recommendations to the Secretary on relative values for services
			 under the fee schedule for physicians’ services under this section.
						(7)LimitationThere shall be no administrative or judicial review under section 1869, section 1878, or otherwise
			 of—
							(A)care episode and patient condition groups and codes established under paragraph (2);
							(B)patient relationship categories and codes established under paragraph (3); and
							(C)measurement of, and analyses of resource use with respect to, care episode and patient condition
			 codes and patient relationship codes pursuant to paragraph (5).
							(8)AdministrationChapter 35 of title 44, United States Code, shall not apply to this section.
						(9)DefinitionsIn this section:
							(A)PhysicianThe term physician has the meaning given such term in section 1861(r)(1).
							(B)Applicable practitionerThe term applicable practitioner means—
								(i)a physician assistant, nurse practitioner, and clinical nurse specialist (as such terms are defined
			 in section 1861(aa)(5)), and a certified registered nurse anesthetist (as
			 defined in section 1861(bb)(2)); and
								(ii)beginning January 1, 2018, such other eligible professionals (as defined in subsection (k)(3)(B))
			 as specified by the Secretary.
								(10)ClarificationThe provisions of sections 1890(b)(7) and 1890A shall not apply to this subsection..
			3.Priorities and funding for measure developmentSection 1848 of the Social Security Act (42 U.S.C. 1395w–4), as amended by subsections (c) and (g)
			 of section 2, is further amended by inserting at the end the following new
			 subsection:

				(s)Priorities and funding for measure development
					(1)Plan identifying measure development priorities and timelines
						(A)Draft measure development planNot later than January 1, 2015, the Secretary shall develop, and post on the Internet website of
			 the Centers for Medicare & Medicaid Services, a draft plan for the development of quality measures for application under the
			 applicable provisions (as defined in paragraph (5)). Under such plan the
			 Secretary shall—
							(i)address how measures used by private payers and integrated delivery systems could be incorporated
			 under title XVIII;
							(ii)describe how coordination, to the extent possible, will occur across organizations developing such
			 measures; and
							(iii)take into account how clinical best practices and clinical practice guidelines should be used in
			 the development of quality measures.
							(B)Quality domainsFor purposes of this subsection, the term quality domains means at least the following domains:
							(i)Clinical care.
							(ii)Safety.
							(iii)Care coordination.
							(iv)Patient and caregiver experience.
							(v)Population health and prevention.
							(C)ConsiderationIn developing the draft plan under this paragraph, the Secretary shall consider—
							(i)gap analyses conducted by the entity with a contract under section 1890(a) or other contractors or
			 entities;
							(ii)whether measures are applicable across health care settings;
							(iii)clinical practice improvement activities submitted under subsection (q)(2)(C)(iv) for identifying
			 possible areas for future measure development and identifying existing
			 gaps with respect to such measures; and
							(iv)the quality domains applied under this subsection.
							(D)PrioritiesIn developing the draft plan under this paragraph, the Secretary shall give priority to the
			 following types of measures:
							(i)Outcome measures, including patient reported outcome and functional status measures.
							(ii)Patient experience measures.
							(iii)Care coordination measures.
							(iv)Measures of appropriate use of services, including measures of over use.
							(E)Stakeholder inputThe Secretary shall accept through March 1, 2015, comments on the draft plan posted under paragraph
			 (1)(A) from the public, including health care providers, payers,
			 consumers, and other stakeholders.
						(F)Final measure development planNot later than May 1, 2015, taking into account the comments received under this subparagraph, the
			 Secretary shall finalize the plan and post on the Internet website of the
			 Centers for Medicare & Medicaid Services an operational plan for the development of quality measures for use under the
			 applicable provisions. Such plan shall be updated as appropriate.
						(2)Contracts and other arrangements for quality measure development
						(A)In generalThe Secretary shall enter into contracts or other arrangements with entities for the purpose of
			 developing, improving, updating, or expanding in accordance with the plan
			 under paragraph (1) quality measures for application under the applicable
			 provisions. Such entities shall include organizations with quality measure
			 development expertise.
						(B)Prioritization
							(i)In generalIn entering into contracts or other arrangements under subparagraph (A), the Secretary shall give
			 priority to the development of the types of measures described in
			 paragraph (1)(D).
							(ii)ConsiderationIn selecting measures for development under this subsection, the Secretary shall consider—
								(I)whether such measures would be electronically specified; and
								(II)clinical practice guidelines to the extent that such guidelines exist.
								(3)Annual report by the Secretary
						(A)In generalNot later than May 1, 2016, and annually thereafter, the Secretary shall post on the Internet
			 website of the Centers for Medicare & Medicaid Services a report on the progress made in developing quality measures for application
			 under the applicable provisions.
						(B)RequirementsEach report submitted pursuant to subparagraph (A) shall include the following:
							(i)A description of the Secretary’s efforts to implement this paragraph.
							(ii)With respect to the measures developed during the previous year—
								(I)a description of the total number of quality measures developed and the types of such measures,
			 such as an outcome or patient experience measure;
								(II)the name of each measure developed;
								(III)the name of the developer and steward of each measure;
								(IV)with respect to each type of measure, an estimate of the total amount expended under this title to
			 develop all measures of such type; and
								(V)whether the measure would be electronically specified.
								(iii)With respect to measures in development at the time of the report—
								(I)the information described in clause (ii), if available; and
								(II)a timeline for completion of the development of such measures.
								(iv)A description of any updates to the plan under paragraph (1) (including newly identified gaps and
			 the status of previously identified gaps) and the inventory of measures
			 applicable under the applicable provisions.
							(v)Other information the Secretary determines to be appropriate.
							(4)Stakeholder inputWith respect to paragraph (1), the Secretary shall seek stakeholder input with respect to—
						(A)the identification of gaps where no quality measures exist, particularly with respect to the types
			 of measures described in paragraph (1)(D);
						(B)prioritizing quality measure development to address such gaps; and
						(C)other areas related to quality measure development determined appropriate by the Secretary.
						(5)Definition of applicable provisionsIn this subsection, the term applicable provisions means the following provisions:
						(A)Subsection (q)(2)(B)(i).
						(B)Section 1833(z)(2)(C).
						(6)FundingFor purposes of carrying out this subsection, the Secretary shall provide for the transfer, from
			 the Federal Supplementary Medical Insurance Trust Fund under section 1841,
			 of $15,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for each of fiscal years 2014 through 2018. Amounts
			 transferred under this paragraph shall remain available through the end of
			 fiscal year 2021..
		4.Encouraging care management for individuals with chronic care needs
			(a)In generalSection 1848(b) of the Social Security Act (42 U.S.C. 1395w–4(b)) is amended by adding at the end
			 the following new paragraph:

					(8)Encouraging care management for individuals with chronic care needs
						(A)In generalIn order to encourage the management of care by an applicable provider (as defined in subparagraph
			 (B)) for individuals with chronic care needs the Secretary shall—
							(i)establish one or more HCPCS codes for chronic care management services for such individuals; and
							(ii)subject to subparagraph (D), make payment (as the Secretary determines to be appropriate) under
			 this section for such management services furnished on or after January 1,
			 2015, by an applicable provider.
							(B)Applicable provider definedFor purposes of this paragraph, the term applicable provider means a physician (as defined in section 1861(r)(1)), physician assistant or nurse practitioner
			 (as defined in section 1861(aa)(5)(A)), or clinical nurse specialist (as
			 defined in section 1861(aa)(5)(B)) who furnishes services as part of a
			 patient-centered medical home or a comparable specialty practice that—
							(i)is recognized as such a medical home or comparable specialty practice by an organization that is
			 recognized by the Secretary for purposes of such recognition as such a
			 medical home or practice; or
							(ii)meets such other comparable qualifications as the Secretary determines to be appropriate.
							(C)Budget neutralityThe budget neutrality provision under subsection (c)(2)(B)(ii)(II) shall apply in establishing the
			 payment under subparagraph (A)(ii).
						(D)Policies relating to paymentIn carrying out this paragraph, with respect to chronic care management services, the Secretary
			 shall—
							(i)make payment to only one applicable provider for such services furnished to an individual during a
			 period;
							(ii)not make payment under subparagraph (A) if such payment would be duplicative of payment that is
			 otherwise made under this title for such services (such as in the case of
			 hospice care or home health services); and
							(iii)not require that an annual wellness visit (as defined in section 1861(hhh)) or an initial
			 preventive physical examination (as defined in section 1861(ww)) be
			 furnished as a condition of payment for such management services..
			(b)Education and outreach
				(1)Campaign
					(A)In generalThe Secretary of Health and Human Services (in this subsection referred to as the Secretary) shall conduct an education and outreach campaign to inform professionals who furnish items and
			 services under part B of title XVIII of the Social Security Act and
			 individuals enrolled under such part of the benefits of chronic care
			 management services described in section 1848(b)(8) of the Social Security
			 Act, as added by subsection (a), and encourage such individuals with
			 chronic care needs to receive such services.
					(B)RequirementsSuch campaign shall—
						(i)be directed by the Office of Rural Health Policy of the Department of Health and Human Services and
			 the Office of Minority Health of the Centers for Medicare & Medicaid Services; and
						(ii)focus on encouraging participation by underserved rural populations and racial and ethnic minority
			 populations.
						(2)Report
					(A)In generalNot later than December 31, 2017, the Secretary shall submit to Congress a report on the use of
			 chronic care management services described in such section 1848(b)(8) by
			 individuals living in rural areas and by racial and ethnic minority
			 populations. Such report shall—
						(i)identify barriers to receiving chronic care management services; and
						(ii)make recommendations for increasing the appropriate use of chronic care management services.
						5.Ensuring accurate valuation of services under the physician fee schedule
			(a)Authority To collect and use information on physicians’ services in the determination of relative
			 values
				(1)In generalSection 1848(c)(2) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)) is amended by adding at the
			 end the following new subparagraph:

						(M)Authority to collect and use information on physicians’ services in the determination of relative
			 values
							(i)Collection of informationNotwithstanding any other provision of law, the Secretary may collect or obtain information on the
			 resources directly or indirectly related to furnishing services for which
			 payment is made under the fee schedule established under subsection (b).
			 Such information may be collected or obtained from any eligible
			 professional or any other source.
							(ii)Use of informationNotwithstanding any other provision of law, subject to clause (v), the Secretary may (as the
			 Secretary determines appropriate) use information collected or obtained
			 pursuant to clause (i) in the determination of relative values for
			 services under this section.
							(iii)Types of informationThe types of information described in clauses (i) and (ii) may, at the Secretary’s discretion,
			 include any or all of the following:
								(I)Time involved in furnishing services.
								(II)Amounts and types of practice expense inputs involved with furnishing services.
								(III)Prices (net of any discounts) for practice expense inputs, which may include paid invoice prices or
			 other documentation or records.
								(IV)Overhead and accounting information for practices of physicians and other suppliers.
								(V)Any other element that would improve the valuation of services under this section.
								(iv)Information collection mechanismsInformation may be collected or obtained pursuant to this subparagraph from any or all of the
			 following:
								(I)Surveys of physicians, other suppliers, providers of services, manufacturers, and vendors.
								(II)Surgical logs, billing systems, or other practice or facility records.
								(III)Electronic health records.
								(IV)Any other mechanism determined appropriate by the Secretary.
								(v)Transparency of use of information
								(I)In generalSubject to subclauses (II) and (III), if the Secretary uses information collected or obtained under
			 this subparagraph in the determination of relative values under this
			 subsection, the Secretary shall disclose the information source and
			 discuss the use of such information in such determination of relative
			 values through notice and comment rulemaking.
								(II)Thresholds for useThe Secretary may establish thresholds in order to use such information, including the exclusion of
			 information collected or obtained from eligible professionals who use very
			 high resources (as determined by the Secretary) in furnishing a service.
								(III)Disclosure of informationThe Secretary shall make aggregate information available under this subparagraph but shall not
			 disclose information in a form or manner that identifies an eligible
			 professional or a group practice, or information collected or obtained
			 pursuant to a nondisclosure agreement.
								(vi)Incentive to participateThe Secretary may provide for such payments under this part to an eligible professional that
			 submits such solicited information under this subparagraph as the
			 Secretary determines appropriate in order to compensate such eligible
			 professional for such submission. Such payments shall be provided in a
			 form and manner specified by the Secretary.
							(vii)AdministrationChapter 35 of title 44, United States Code, shall not apply to information collected or obtained
			 under this subparagraph.
							(viii)Definition of eligible professionalIn this subparagraph, the term eligible professional has the meaning given such term in subsection (k)(3)(B).
							(ix)FundingFor purposes of carrying out this subparagraph, in addition to funds otherwise appropriated, the
			 Secretary shall provide for the transfer, from the Federal Supplementary
			 Medical Insurance Trust Fund under section 1841, of $2,000,000 to the
			 Centers for Medicare & Medicaid Services Program Management Account for each fiscal year beginning with fiscal year 2014.
			 Amounts transferred under the preceding sentence for a fiscal year shall
			 be available until expended..
				(2)Limitation on reviewSection 1848(i)(1) of the Social Security Act (42 U.S.C. 1395w–4(i)(1)) is amended—
					(A)in subparagraph (D), by striking and at the end;
					(B)in subparagraph (E), by striking the period at the end and inserting , and; and
					(C)by adding at the end the following new subparagraph:

							(F)the collection and use of information in the determination of relative values under subsection
			 (c)(2)(M)..
					(b)Authority for alternative approaches To establishing practice expense relative valuesSection 1848(c)(2) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)), as amended by subsection
			 (a), is amended by adding at the end the following new subparagraph:

					(N)Authority for alternative approaches to establishing practice expense relative valuesThe Secretary may establish or adjust practice expense relative values under this subsection using
			 cost, charge, or other data from suppliers or providers of services,
			 including information collected or obtained under subparagraph (M)..
			(c)Revised and expanded identification of potentially misvalued codesSection 1848(c)(2)(K)(ii) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)(K)(ii)) is amended to
			 read as follows:

					(ii)Identification of potentially misvalued codesFor purposes of identifying potentially misvalued codes pursuant to clause (i)(I), the Secretary
			 shall examine codes (and families of codes as appropriate) based on any or
			 all of the following criteria:
						(I)Codes that have experienced the fastest growth.
						(II)Codes that have experienced substantial changes in practice expenses.
						(III)Codes that describe new technologies or services within an appropriate time period (such as 3
			 years) after the relative values are initially established for such codes.
						(IV)Codes which are multiple codes that are frequently billed in conjunction with furnishing a single
			 service.
						(V)Codes with low relative values, particularly those that are often billed multiple times for a
			 single treatment.
						(VI)Codes that have not been subject to review since implementation of the fee schedule.
						(VII)Codes that account for the majority of spending under the physician fee schedule.
						(VIII)Codes for services that have experienced a substantial change in the hospital length of stay or
			 procedure time.
						(IX)Codes for which there may be a change in the typical site of service since the code was last
			 valued.
						(X)Codes for which there is a significant difference in payment for the same service between different
			 sites of service.
						(XI)Codes for which there may be anomalies in relative values within a family of codes.
						(XII)Codes for services where there may be efficiencies when a service is furnished at the same time as
			 other services.
						(XIII)Codes with high intra-service work per unit of time.
						(XIV)Codes with high practice expense relative value units.
						(XV)Codes with high cost supplies.
						(XVI)Codes as determined appropriate by the Secretary..
			(d)Target for relative value adjustments for misvalued services
				(1)In generalSection 1848(c)(2) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)), as amended by subsections
			 (a) and (b), is amended by adding at the end the following new
			 subparagraph:

						(O)Target for relative value adjustments for misvalued servicesWith respect to fee schedules established for each of 2015 through 2018, the following shall apply:
							(i)Determination of net reduction in expendituresFor each year, the Secretary shall determine the estimated net reduction in expenditures under the
			 fee schedule under this section with respect to the year as a result of
			 adjustments to the relative values established under this paragraph for
			 misvalued codes.
							(ii)Budget neutral redistribution of funds if target met and counting overages towards the target for
			 the succeeding yearIf the estimated net reduction in expenditures determined under clause (i) for the year is equal to
			 or greater than the target for the year—
								(I)reduced expenditures attributable to such adjustments shall be redistributed for the year in a
			 budget neutral manner in accordance with subparagraph (B)(ii)(II); and
								(II)the amount by which such reduced expenditures exceeds the target for the year shall be treated as a
			 reduction in expenditures described in clause (i) for the succeeding year,
			 for purposes of determining whether the target has or has not been met
			 under this subparagraph with respect to that year.
								(iii)Exemption from budget neutrality if target not metIf the estimated net reduction in expenditures determined under clause (i) for the year is less
			 than the target for the year, reduced expenditures in an amount equal to
			 the target recapture amount shall not be taken into account in applying
			 subparagraph (B)(ii)(II) with respect to fee schedules beginning with
			 2015.
							(iv)Target recapture amountFor purposes of clause (iii), the target recapture amount is, with respect to a year, an amount
			 equal to the difference between—
								(I)the target for the year; and
								(II)the estimated net reduction in expenditures determined under clause (i) for the year.
								(v)TargetFor purposes of this subparagraph, with respect to a year, the target is calculated as 0.5 percent
			 of the estimated amount of expenditures under the fee schedule under this
			 section for the year..
				(2)Conforming amendmentSection 1848(c)(2)(B)(v) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)(B)(v)) is amended by
			 adding at the end the following new subclause:

						(VIII)Reductions for misvalued services if target not metEffective for fee schedules beginning with 2015, reduced expenditures attributable to the
			 application of the target recapture amount described in subparagraph
			 (O)(iii)..
				(e)Phase-In of significant relative value unit (RVU) reductions
				(1)In generalSection 1848(c) of the Social Security Act (42 U.S.C. 1395w–4(c)) is amended by adding at the end
			 the following new paragraph:

						(7)Phase-in of significant relative value unit (RVU) reductionsEffective for fee schedules established beginning with 2015, if the total relative value units for
			 a service for a year would otherwise be decreased by an estimated amount
			 equal to or greater than 20 percent as compared to the total relative
			 value units for the previous year, the applicable adjustments in work,
			 practice expense, and malpractice relative value units shall be phased-in
			 over a 2-year period..
				(2)Conforming amendmentsSection 1848(c)(2) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)) is amended—
					(A)in subparagraph (B)(ii)(I), by striking subclause (II) and inserting subclause (II) and paragraph (7); and
					(B)in subparagraph (K)(iii)(VI)—
						(i)by striking provisions of subparagraph (B)(ii)(II) and inserting provisions of subparagraph (B)(ii)(II) and paragraph (7); and
						(ii)by striking under subparagraph (B)(ii)(II) and inserting under subparagraph (B)(ii)(I).
						(f)Authority To smooth relative values within groups of servicesSection 1848(c)(2)(C) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)(C)) is amended—
				(1)in each of clauses (i) and (iii), by striking the service and inserting the service or group of services each place it appears; and
				(2)in the first sentence of clause (ii), by inserting or group of services before the period.
				(g)GAO study and report on Relative Value Scale Update Committee
				(1)StudyThe Comptroller General of the United States (in this subsection referred to as the Comptroller General) shall conduct a study of the processes used by the Relative Value Scale Update Committee (RUC) to
			 provide recommendations to the Secretary of Health and Human Services
			 regarding relative values for specific services under the Medicare
			 physician fee schedule under section 1848 of the Social Security Act (42
			 U.S.C. 1395w–4).
				(2)ReportNot later than 1 year after the date of the enactment of this Act, the Comptroller General shall
			 submit to Congress a report containing the results of the study conducted
			 under paragraph (1).
				(h)Adjustment to Medicare payment localities
				(1)In generalSection 1848(e) of the Social Security Act (42 U.S.C. 1395w–4(e)) is amended by adding at the end
			 the following new paragraph:

						(6)Use of MSAs as fee schedule areas in California
							(A)In generalSubject to the succeeding provisions of this paragraph and notwithstanding the previous provisions
			 of this subsection, for services furnished on or after January 1, 2017,
			 the fee schedule areas used for payment under this section applicable to
			 California shall be the following:
								(i)Each Metropolitan Statistical Area (each in this paragraph referred to as an MSA), as defined by the Director of the Office of Management and Budget as of December 31 of the
			 previous year, shall be a fee schedule area.
								(ii)All areas not included in an MSA shall be treated as a single rest-of-State fee schedule area.
								(B)Transition for MSAs previously in rest-of-State payment locality or in locality 3
								(i)In generalFor services furnished in California during a year beginning with 2017 and ending with 2021 in an
			 MSA in a transition area (as defined in subparagraph (D)), subject to
			 subparagraph (C), the geographic index values to be applied under this
			 subsection for such year shall be equal to the sum of the following:
									(I)Current law componentThe old weighting factor (described in clause (ii)) for such year multiplied by the geographic
			 index values under this subsection for the fee schedule area that included
			 such MSA that would have applied in such area (as estimated by the
			 Secretary) if this paragraph did not apply.
									(II)MSA-based componentThe MSA-based weighting factor (described in clause (iii)) for such year multiplied by the
			 geographic index values computed for the fee schedule area under
			 subparagraph (A) for the year (determined without regard to this
			 subparagraph).
									(ii)Old weighting factorThe old weighting factor described in this clause—
									(I)for 2017, is 5/6; and
									(II)for each succeeding year, is the old weighting factor described in this clause for the previous
			 year minus 1/6.
									(iii)MSA-based weighting factorThe MSA-based weighting factor described in this clause for a year is 1 minus the old weighting
			 factor under clause (ii) for that year.
								(C)Hold harmlessFor services furnished in a transition area in California during a year beginning with 2017, the
			 geographic index values to be applied under this subsection for such year
			 shall not be less than the corresponding geographic index values that
			 would have applied in such transition area (as estimated by the Secretary)
			 if this paragraph did not apply.
							(D)Transition area definedIn this paragraph, the term transition area means each of the following fee schedule areas for 2013:
								(i)The rest-of-State payment locality.
								(ii)Payment locality 3.
								(E)References to fee schedule areasEffective for services furnished on or after January 1, 2017, for California, any reference in this
			 section to a fee schedule area shall be deemed a reference to a fee
			 schedule area established in accordance with this paragraph..
				(2)Conforming amendment to definition of fee schedule areaSection 1848(j)(2) of the Social Security Act (42 U.S.C. 1395w–4(j)(2)) is amended by striking The term and inserting Except as provided in subsection (e)(6)(D), the term.
				(i)Disclosure of data used To establish multiple procedure payment reduction policyThe Secretary of Health and Human Services shall make publicly available the information used to
			 establish the multiple procedure payment reduction policy to the
			 professional component of imaging services in the final rule published in
			 the Federal Register, v. 77, n. 222, November 16, 2012, pages 68891–69380
			 under the physician fee schedule under section 1848 of the Social Security
			 Act (42 U.S.C. 1395w–4).
			6.Promoting evidence-based care
			(a)In generalSection 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by adding at the end the
			 following new subsection:

					(p)Recognizing appropriate use criteria for certain imaging services
						(1)Program established
							(A)In generalThe Secretary shall establish a program to promote the use of appropriate use criteria (as defined
			 in subparagraph (B)) for applicable imaging services (as defined in
			 subparagraph (C)) furnished in an applicable setting (as defined in
			 subparagraph (D)) by ordering professionals and furnishing professionals
			 (as defined in subparagraphs (E) and (F), respectively).
							(B)Appropriate use criteria definedIn this subsection, the term appropriate use criteria means criteria, only developed or endorsed by national professional medical specialty societies or
			 other provider-led entities, to assist ordering professionals and
			 furnishing professionals in making the most appropriate treatment decision
			 for a specific clinical condition. To the extent feasible, such criteria
			 shall be evidence-based.
							(C)Applicable imaging service definedIn this subsection, the term applicable imaging service means an advanced diagnostic imaging service (as defined in subsection (e)(1)(B)) for which the
			 Secretary determines—
								(i)one or more applicable appropriate use criteria specified under paragraph (2) apply;
								(ii)there are one or more qualified clinical decision support mechanisms listed under paragraph (3)(C);
			 and
								(iii)one or more of such mechanisms is available free of charge.
								(D)Applicable setting definedIn this subsection, the term applicable setting means a physician’s office, a hospital outpatient department (including an emergency department),
			 an ambulatory surgical center, and any other provider-led outpatient
			 setting determined appropriate by the Secretary.
							(E)Ordering professional definedIn this subsection, the term ordering professional means a physician (as defined in section 1861(r)) or a practitioner described in section
			 1842(b)(18)(C) who orders an applicable imaging service for an individual.
							(F)Furnishing professional definedIn this subsection, the term furnishing professional means a physician (as defined in section 1861(r)) or a practitioner described in section
			 1842(b)(18)(C) who furnishes an applicable imaging service for an
			 individual.
							(2)Establishment of applicable appropriate use criteria
							(A)In generalNot later than November 15, 2015, the Secretary shall through rulemaking, and in consultation with
			 physicians, practitioners, and other stakeholders, specify applicable
			 appropriate use criteria for applicable imaging services only from among
			 appropriate use criteria developed or endorsed by national professional
			 medical specialty societies or other provider-led entities.
							(B)ConsiderationsIn specifying applicable appropriate use criteria under subparagraph (A), the Secretary shall take
			 into account whether the criteria—
								(i)have stakeholder consensus;
								(ii)are scientifically valid and evidence based; and
								(iii)are based on studies that are published and reviewable by stakeholders.
								(C)RevisionsThe Secretary shall review, on an annual basis, the specified applicable appropriate use criteria
			 to determine if there is a need to update or revise (as appropriate) such
			 specification of applicable appropriate use criteria and make such updates
			 or revisions through rulemaking.
							(D)Treatment of multiple applicable appropriate use criteriaIn the case where the Secretary determines that more than one appropriate use criteria applies with
			 respect to an applicable imaging service, the Secretary shall permit one
			 or more applicable appropriate use criteria under this paragraph for the
			 service.
							(3)Mechanisms for consultation with applicable appropriate use criteria
							(A)Identification of mechanisms to consult with applicable appropriate use criteria
								(i)In generalThe Secretary shall specify qualified clinical decision support mechanisms that could be used by
			 ordering professionals to consult with applicable appropriate use criteria
			 for applicable imaging services.
								(ii)ConsultationThe Secretary shall consult with physicians, practitioners, health care technology experts, and
			 other stakeholders in specifying mechanisms under this paragraph.
								(iii)Inclusion of certain mechanismsMechanisms specified under this paragraph may include any or all of the following that meet the
			 requirements described in subparagraph (B)(ii):
									(I)Use of clinical decision support modules in certified EHR technology (as defined in section
			 1848(o)(4)).
									(II)Use of private sector clinical decision support mechanisms that are independent from certified EHR
			 technology, which may include use of clinical decision support mechanisms
			 available from medical specialty organizations.
									(III)Use of a clinical decision support mechanism established by the Secretary.
									(B)Qualified clinical decision support mechanisms
								(i)In generalFor purposes of this subsection, a qualified clinical decision support mechanism is a mechanism
			 that the Secretary determines meets the requirements described in clause
			 (ii).
								(ii)RequirementsThe requirements described in this clause are the following:
									(I)The mechanism makes available to the ordering professional applicable appropriate use criteria
			 specified under paragraph (2) and the supporting documentation for the
			 applicable imaging service ordered.
									(II)In the case where there are more than one applicable appropriate use criteria specified under such
			 paragraph for an applicable imaging service, the mechanism indicates the
			 criteria that it uses for the service.
									(III)The mechanism determines the extent to which an applicable imaging service ordered is consistent
			 with the applicable appropriate use criteria so specified.
									(IV)The mechanism generates and provides to the ordering professional a certification or documentation
			 that documents that the qualified clinical decision support mechanism was
			 consulted by the ordering professional.
									(V)The mechanism is updated on a timely basis to reflect revisions to the specification of applicable
			 appropriate use criteria under such paragraph.
									(VI)The mechanism meets privacy and security standards under applicable provisions of law.
									(VII)The mechanism performs such other functions as specified by the Secretary, which may include a
			 requirement to provide aggregate feedback to the ordering professional.
									(C)List of mechanisms for consultation with applicable appropriate use criteria
								(i)Initial listNot later than April 1, 2016, the Secretary shall publish a list of mechanisms specified under this
			 paragraph.
								(ii)Periodic updating of listThe Secretary shall identify on an annual basis the list of qualified clinical decision support
			 mechanisms specified under this paragraph.
								(4)Consultation with applicable appropriate use criteria
							(A)Consultation by ordering professionalBeginning with January 1, 2017, subject to subparagraph (C), with respect to an applicable imaging
			 service ordered by an ordering professional that would be furnished in an
			 applicable setting and paid for under an applicable payment system (as
			 defined in subparagraph (D)), an ordering professional shall—
								(i)consult with a qualified decision support mechanism listed under paragraph (3)(C); and
								(ii)provide to the furnishing professional the information described in clauses (i) through (iii) of
			 subparagraph (B).
								(B)Reporting by furnishing professionalBeginning with January 1, 2017, subject to subparagraph (C), with respect to an applicable imaging
			 service furnished in an applicable setting and paid for under an
			 applicable payment system (as defined in subparagraph (D)), payment for
			 such service may only be made if the claim for the service includes the
			 following:
								(i)Information about which qualified clinical decision support mechanism was consulted by the ordering
			 professional for the service.
								(ii)Information regarding—
									(I)whether the service ordered would adhere to the applicable appropriate use criteria specified under
			 paragraph (2);
									(II)whether the service ordered would not adhere to such criteria; or
									(III)whether such criteria was not applicable to the service ordered.
									(iii)The national provider identifier of the ordering professional (if different from the furnishing
			 professional).
								(C)ExceptionsThe provisions of subparagraphs (A) and (B) and paragraph (6)(A) shall not apply to the following:
								(i)Emergency servicesAn applicable imaging service ordered for an individual with an emergency medical condition (as
			 defined in section 1867(e)(1)).
								(ii)Inpatient servicesAn applicable imaging service ordered for an inpatient and for which payment is made under part A.
								(iii)Alternative payment modelsAn applicable imaging service ordered by an ordering professional with respect to an individual
			 attributed to an alternative payment model (as defined in section
			 1833(z)(3)(C)).
								(iv)Significant hardshipAn applicable imaging service ordered by an ordering professional who the Secretary may, on a
			 case-by-case basis, exempt from the application of such provisions if the
			 Secretary determines, subject to annual renewal, that consultation with
			 applicable appropriate use criteria would result in a significant
			 hardship, such as in the case of a professional who practices in a rural
			 area without sufficient Internet access.
								(D)Applicable payment system definedIn this subsection, the term applicable payment system means the following:
								(i)The physician fee schedule established under section 1848(b).
								(ii)The prospective payment system for hospital outpatient department services under section 1833(t).
								(iii)The ambulatory surgical center payment systems under section 1833(i).
								(5)Identification of outlier ordering professionals
							(A)In generalWith respect to applicable imaging services furnished beginning with 2017, the Secretary shall
			 determine, on an annual basis, no more than five percent of the total
			 number of ordering professionals who are outlier ordering professionals.
							(B)Outlier ordering professionalsThe determination of an outlier ordering professional shall—
								(i)be based on low adherence to applicable appropriate use criteria specified under paragraph (2),
			 which may be based on comparison to other ordering professionals; and
								(ii)include data for ordering professionals for whom prior authorization under paragraph (6)(A)
			 applies.
								(C)Use of two years of dataThe Secretary shall use two years of data to identify outlier ordering professionals under this
			 paragraph.
							(D)ProcessThe Secretary shall establish a process for determining when an outlier ordering professional is no
			 longer an outlier ordering professional.
							(E)Consultation with stakeholdersThe Secretary shall consult with physicians, practitioners and other stakeholders in developing
			 methods to identify outlier ordering professionals under this paragraph.
							(6)Prior authorization for ordering professionals who are outliers
							(A)In generalBeginning January 1, 2020, subject to paragraph (4)(C), with respect to services furnished during a
			 year, the Secretary shall, for a period determined appropriate by the
			 Secretary, apply prior authorization for applicable imaging services that
			 are ordered by an outlier ordering professional identified under paragraph
			 (5).
							(B)Appropriate use criteria in prior authorizationIn applying prior authorization under subparagraph (A), the Secretary shall utilize only the
			 applicable appropriate use criteria specified under this subsection.
							(C)FundingFor purposes of carrying out this paragraph, the Secretary shall provide for the transfer, from the
			 Federal Supplementary Medical Insurance Trust Fund under section 1841, of
			 $5,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for each of fiscal years 2019 through 2021. Amounts
			 transferred under the preceding sentence shall remain available until
			 expended.
							(7)ConstructionNothing in this subsection shall be construed as granting the Secretary the authority to develop or
			 initiate the development of clinical practice guidelines or appropriate
			 use criteria..
			(b)Conforming amendmentSection 1833(t)(16) of the Social Security Act (42 U.S.C. 1395l(t)(16)) is amended by adding at the
			 end the following new subparagraph:

					(E)Application of appropriate use criteria for certain imaging servicesFor provisions relating to the application of appropriate use criteria for certain imaging
			 services, see section 1834(p)..
			(c)Report on experience of imaging appropriate use criteria programNot later than 18 months after the date of the enactment of this Act, the Comptroller General of
			 the United States shall submit to Congress a report that includes a
			 description of the extent to which appropriate use criteria could be used
			 for other services under part B of title XVIII of the Social Security Act
			 (42 U.S.C. 1395j et seq.), such as radiation therapy and clinical
			 diagnostic laboratory services.
			7.Empowering beneficiary choices through access to information on physicians’ services
			(a)In generalThe Secretary shall make publicly available on Physician Compare the information described in
			 subsection (b) with respect to eligible professionals.
			(b)Information describedThe following information, with respect to an eligible professional, is described in this
			 subsection:
				(1)Information on the number of services furnished by the eligible professional under part B of title
			 XVIII of the Social Security Act (42 U.S.C. 1395j et seq.), which may
			 include information on the most frequent services furnished or groupings
			 of services.
				(2)Information on submitted charges and payments for services under such part.
				(3)A unique identifier for the eligible professional that is available to the public, such as a
			 national provider identifier.
				(c)SearchabilityThe information made available under this section shall be searchable by at least the following:
				(1)The specialty or type of the eligible professional.
				(2)Characteristics of the services furnished, such as volume or groupings of services.
				(3)The location of the eligible professional.
				(d)DisclosureThe information made available under this section shall indicate, where appropriate, that
			 publicized information may not be representative of the eligible
			 professional’s entire patient population, the variety of services
			 furnished by the eligible professional, or the health conditions of
			 individuals treated.
			(e)Implementation
				(1)Initial implementationPhysician Compare shall include the information described in subsection (b)—
					(A)with respect to physicians, by not later than July 1, 2015; and
					(B)with respect to other eligible professionals, by not later than July 1, 2016.
					(2)Annual updatingThe information made available under this section shall be updated on Physician Compare not less
			 frequently than on an annual basis.
				(f)Opportunity To review and submit correctionsThe Secretary shall provide for an opportunity for an eligible professional to review, and submit
			 corrections for, the information to be made public with respect to the
			 eligible professional under this section prior to such information being
			 made public.
			(g)DefinitionsIn this section:
				(1)Eligible professional; physician; secretaryThe terms eligible professional, physician, and Secretary have the meaning given such terms in section 10331(i) of Public Law 111–148.
				(2)Physician CompareThe term Physician Compare means the Physician Compare Internet website of the Centers for Medicare & Medicaid Services (or a successor website).
				8.Expanding availability of Medicare data
			(a)Expanding uses of Medicare data by qualified entities
				(1)Additional analyses
					(A)In generalSubject to subparagraph (B), to the extent consistent with applicable information, privacy,
			 security, and disclosure laws (including paragraph (3)), notwithstanding
			 paragraph (4)(B) of section 1874(e) of the Social Security Act (42 U.S.C.
			 1395kk(e)) and the second sentence of paragraph (4)(D) of such section,
			 beginning July 1, 2015, a qualified entity may use the combined data
			 described in paragraph (4)(B)(iii) of such section received by such entity
			 under such section, and information derived from the evaluation described
			 in such paragraph (4)(D), to conduct additional non-public analyses (as
			 determined appropriate by the Secretary) and provide or sell such analyses
			 to authorized users for non-public use (including for the purposes of
			 assisting providers of services and suppliers to develop and participate
			 in quality and patient care improvement activities, including developing
			 new models of care).
					(B)Limitations with respect to analyses
						(i)EmployersAny analyses provided or sold under subparagraph (A) to an employer described in paragraph
			 (9)(A)(iii) may only be used by such employer for purposes of providing
			 health insurance to employees and retirees of the employer.
						(ii)Health insurance issuersA qualified entity may not provide or sell an analysis to a health insurance issuer described in
			 paragraph (9)(A)(iv) unless the issuer is providing the qualified entity
			 with data under section 1874(e)(4)(B)(iii) of the Social Security Act (42
			 U.S.C. 1395kk(e)(4)(B)(iii)).
						(2)Access to certain data
					(A)AccessTo the extent consistent with applicable information, privacy, security, and disclosure laws
			 (including paragraph (3)), notwithstanding paragraph (4)(B) of section
			 1874(e) of the Social Security Act (42 U.S.C. 1395kk(e)) and the second
			 sentence of paragraph (4)(D) of such section, beginning July 1, 2015, a
			 qualified entity may—
						(i)provide or sell the combined data described in paragraph (4)(B)(iii) of such section to authorized
			 users described in clauses (i), (ii), and (v) of paragraph (9)(A) for
			 non-public use, including for the purposes described in subparagraph (B);
			 or
						(ii)subject to subparagraph (C), provide Medicare claims data to authorized users described in clauses
			 (i), (ii), and (v), of paragraph (9)(A) for non-public use, including for
			 the purposes described in subparagraph (B).
						(B)Purposes describedThe purposes described in this subparagraph are assisting providers of services and suppliers in
			 developing and participating in quality and patient care improvement
			 activities, including developing new models of care.
					(C)Medicare claims data must be provided at no costA qualified entity may not charge a fee for providing the data under subparagraph (A)(ii).
					(3)Protection of information
					(A)In generalExcept as provided in subparagraph (B), an analysis or data that is provided or sold under
			 paragraph (1) or (2) shall not contain information that individually
			 identifies a patient.
					(B)Information on patients of the provider of services or supplierTo the extent consistent with applicable information, privacy, security, and disclosure laws, an
			 analysis or data that is provided or sold to a provider of services or
			 supplier under paragraph (1) or (2) may contain information that
			 individually identifies a patient of such provider or supplier, including
			 with respect to items and services furnished to the patient by other
			 providers of services or suppliers.
					(C)Prohibition on using analyses or data for marketing purposesAn authorized user shall not use an analysis or data provided or sold under paragraph (1) or (2)
			 for marketing purposes.
					(4)Data use agreementA qualified entity and an authorized user described in clauses (i), (ii), and (v) of paragraph
			 (9)(A) shall enter into an agreement regarding the use of any data that
			 the qualified entity is providing or selling to the authorized user under
			 paragraph (2). Such agreement shall describe the requirements for privacy
			 and security of the data and, as determined appropriate by the Secretary,
			 any prohibitions on using such data to link to other individually
			 identifiable sources of information. If the authorized user is not a
			 covered entity under the rules promulgated pursuant to the Health
			 Insurance Portability and Accountability Act of 1996, the agreement shall
			 identify the relevant regulations, as determined by the Secretary, that
			 the user shall comply with as if it were acting in the capacity of such a
			 covered entity.
				(5)No redisclosure of analyses or data
					(A)In generalExcept as provided in subparagraph (B), an authorized user that is provided or sold an analysis or
			 data under paragraph (1) or (2) shall not redisclose or make public such
			 analysis or data or any analysis using such data.
					(B)Permitted redisclosureA provider of services or supplier that is provided or sold an analysis or data under paragraph (1)
			 or (2) may, as determined by the Secretary, redisclose such analysis or
			 data for the purposes of performance improvement and care coordination
			 activities but shall not make public such analysis or data or any analysis
			 using such data.
					(6)Opportunity for providers of services and suppliers to reviewPrior to a qualified entity providing or selling an analysis to an authorized user under paragraph
			 (1), to the extent that such analysis would individually identify a
			 provider of services or supplier who is not being provided or sold such
			 analysis, such qualified entity shall provide such provider or supplier
			 with the opportunity to appeal and correct errors in the manner described
			 in section 1874(e)(4)(C)(ii) of the Social Security Act (42 U.S.C.
			 1395kk(e)(4)(C)(ii)).
				(7)Assessment for a breach
					(A)In generalIn the case of a breach of a data use agreement under this section or section 1874(e) of the Social
			 Security Act (42 U.S.C. 1395kk(e)), the Secretary shall impose an
			 assessment on the qualified entity both in the case of—
						(i)an agreement between the Secretary and a qualified entity; and
						(ii)an agreement between a qualified entity and an authorized user.
						(B)AssessmentThe assessment under subparagraph (A) shall be an amount up to $100 for each individual entitled
			 to, or enrolled for, benefits under part A of title XVIII of the Social
			 Security Act or enrolled for benefits under part B of such title—
						(i)in the case of an agreement described in subparagraph (A)(i), for whom the Secretary provided data
			 on to the qualified entity under paragraph (2); and
						(ii)in the case of an agreement described in subparagraph (A)(ii), for whom the qualified entity
			 provided data on to the authorized user under paragraph (2).
						(C)Deposit of amounts collectedAny amounts collected pursuant to this paragraph shall be deposited in Federal Supplementary
			 Medical Insurance Trust Fund under section 1841 of the Social Security Act
			 (42 U.S.C. 1395t).
					(8)Annual reportsAny qualified entity that provides or sells an analysis or data under paragraph (1) or (2) shall
			 annually submit to the Secretary a report that includes—
					(A)a summary of the analyses provided or sold, including the number of such analyses, the number of
			 purchasers of such analyses, and the total amount of fees received for
			 such analyses;
					(B)a description of the topics and purposes of such analyses;
					(C)information on the entities who received the data under paragraph (2), the uses of the data, and
			 the total amount of fees received for providing, selling, or sharing the
			 data; and
					(D)other information determined appropriate by the Secretary.
					(9)DefinitionsIn this subsection and subsection (b):
					(A)Authorized userThe term authorized user means the following:
						(i)A provider of services.
						(ii)A supplier.
						(iii)An employer (as defined in section 3(5) of the Employee Retirement Insurance Security Act of 1974).
						(iv)A health insurance issuer (as defined in section 2791 of the Public Health Service Act).
						(v)A medical society or hospital association.
						(vi)Any entity not described in clauses (i) through (v) that is approved by the Secretary (other than
			 an employer or health insurance issuer not described in clauses (iii) and
			 (iv), respectively, as determined by the Secretary).
						(B)Provider of servicesThe term provider of services has the meaning given such term in section 1861(u) of the Social Security Act (42 U.S.C.
			 1395x(u)).
					(C)Qualified entityThe term qualified entity has the meaning given such term in section 1874(e)(2) of the Social Security Act (42 U.S.C.
			 1395kk(e)).
					(D)SecretaryThe term Secretary means the Secretary of Health and Human Services.
					(E)SupplierThe term supplier has the meaning given such term in section 1861(d) of the Social Security Act (42 U.S.C.
			 1395x(d)).
					(b)Access to Medicare data by qualified clinical data registries To facilitate quality improvement
				(1)Access
					(A)In generalTo the extent consistent with applicable information, privacy, security, and disclosure laws,
			 beginning July 1, 2015, the Secretary shall, at the request of a qualified
			 clinical data registry under section 1848(m)(3)(E) of the Social Security
			 Act (42 U.S.C. 1395w–4(m)(3)(E)), provide the data described in
			 subparagraph (B) (in a form and manner determined to be appropriate) to
			 such qualified clinical data registry for purposes of linking such data
			 with clinical outcomes data and performing risk-adjusted, scientifically
			 valid analyses and research to support quality improvement or patient
			 safety, provided that any public reporting of such analyses or research
			 that identifies a provider of services or supplier shall only be conducted
			 with the opportunity of such provider or supplier to appeal and correct
			 errors in the manner described in subsection (a)(6).
					(B)Data describedThe data described in this subparagraph is—
						(i)claims data under the Medicare program under title XVIII of the Social Security Act; and
						(ii)if the Secretary determines appropriate, claims data under the Medicaid program under title XIX of
			 such Act and the State Children's Health Insurance Program under title XXI
			 of such Act.
						(2)FeeData described in paragraph (1)(B) shall be provided to a qualified clinical data registry under
			 paragraph (1) at a fee equal to the cost of providing such data. Any fee
			 collected pursuant to the preceding sentence shall be deposited in the
			 Centers for Medicare & Medicaid Services Program Management Account.
				(c)Expansion of data available to qualified entitiesSection 1874(e) of the Social Security Act (42 U.S.C. 1395kk(e)) is amended—
				(1)in the subsection heading, by striking Medicare; and
				(2)in paragraph (3)—
					(A)by inserting after the first sentence the following new sentence: Beginning July 1, 2015, if the Secretary determines appropriate, the data described in this
			 paragraph may also include standardized extracts (as determined by the
			 Secretary) of claims data under titles XIX and XXI for assistance provided
			 under such titles for one or more specified geographic areas and time
			 periods requested by a qualified entity.; and
					(B)in the last sentence, by inserting or under titles XIX or XXI before the period at the end.
					(d)Revision of placement of feesSection 1874(e)(4)(A) of the Social Security Act (42 U.S.C. 1395kk(e)(4)(A)) is amended, in the
			 second sentence—
				(1)by inserting , for periods prior to July 1, 2015, after deposited; and
				(2)by inserting the following before the period at the end: , and, beginning July 1, 2015, into the Centers for Medicare & Medicaid Services Program Management Account.
				9.Reducing administrative burden and other provisions
			(a)Medicare physician and practitioner opt-Out to private contract
				(1)Indefinite, continuing automatic extension of opt out election
					(A)In generalSection 1802(b)(3) of the Social Security Act (42 U.S.C. 1395a(b)(3)) is amended—
						(i)in subparagraph (B)(ii), by striking during the 2-year period beginning on the date the affidavit is signed and inserting during the applicable 2-year period (as defined in subparagraph (D));
						(ii)in subparagraph (C), by striking during the 2-year period described in subparagraph (B)(ii) and inserting during the applicable 2-year period; and
						(iii)by adding at the end the following new subparagraph:

								(D)Applicable 2-year periods for effectiveness of affidavitsIn this subsection, the term applicable 2-year period means, with respect to an affidavit of a physician or practitioner under subparagraph (B), the
			 2-year period beginning on the date the affidavit is signed and includes
			 each subsequent 2-year period unless the physician or practitioner
			 involved provides notice to the Secretary (in a form and manner specified
			 by the Secretary), not later than 30 days before the end of the previous
			 2-year period, that the physician or practitioner does not want to extend
			 the application of the affidavit for such subsequent 2-year period..
						(B)Effective dateThe amendments made by subparagraph (A) shall apply to affidavits entered into on or after the date
			 that is 60 days after the date of the enactment of this Act.
					(2)Public availability of information on opt-out physicians and practitionersSection 1802(b) of the Social Security Act (42 U.S.C. 1395a(b)) is amended—
					(A)in paragraph (5), by adding at the end the following new subparagraph:

							(D)Opt-out physician or practitionerThe term opt-out physician or practitioner means a physician or practitioner who has in effect an affidavit under paragraph (3)(B).;
					(B)by redesignating paragraph (5) as paragraph (6); and
					(C)by inserting after paragraph (4) the following new paragraph:

							(5)Posting of information on opt-out physicians and practitioners
								(A)In generalBeginning not later than February 1, 2015, the Secretary shall make publicly available through an
			 appropriate publicly accessible website of the Department of Health and
			 Human Services information on the number and characteristics of opt-out
			 physicians and practitioners and shall update such information on such
			 website not less often than annually.
								(B)Information to be includedThe information to be made available under subparagraph (A) shall include at least the following
			 with respect to opt-out physicians and practitioners:
									(i)Their number.
									(ii)Their physician or professional specialty or other designation.
									(iii)Their geographic distribution.
									(iv)The timing of their becoming opt-out physicians and practitioners, relative to when they first
			 entered practice and with respect to applicable 2-year periods.
									(v)The proportion of such physicians and practitioners who billed for emergency or urgent care
			 services..
					(b)Gainsharing study and reportNot later than 6 months after the date of the enactment of this Act, the Secretary of Health and
			 Human Services, in consultation with the Inspector General of the
			 Department of Health and Human Services, shall submit to Congress a report
			 with legislative recommendations to amend existing fraud and abuse laws,
			 through exceptions, safe harbors, or other narrowly targeted provisions,
			 to permit gainsharing or similar arrangements between physicians and
			 hospitals that improve care while reducing waste and increasing
			 efficiency. The report shall—
				(1)consider whether such provisions should apply to ownership interests, compensation arrangements, or
			 other relationships;
				(2)describe how the recommendations address accountability, transparency, and quality, including how
			 best to limit inducements to stint on care, discharge patients
			 prematurely, or otherwise reduce or limit medically necessary care; and
				(3)consider whether a portion of any savings generated by such arrangements should accrue to the
			 Medicare program under title XVIII of the Social Security Act.
				(c)Promoting interoperability of electronic health record systems
				(1)Recommendations for achieving widespread EHR interoperability
					(A)ObjectiveAs a consequence of a significant Federal investment in the implementation of health information
			 technology through the Medicare and Medicaid EHR incentive programs,
			 Congress declares it a national objective to achieve widespread exchange
			 of health information through interoperable certified EHR technology
			 nationwide by December 31, 2017.
					(B)DefinitionsIn this paragraph:
						(i)Widespread interoperabilityThe term widespread interoperability means interoperability between certified EHR technology systems employed by meaningful EHR users
			 under the Medicare and Medicaid EHR incentive programs and other
			 clinicians and health care providers on a nationwide basis.
						(ii)InteroperabilityThe term interoperability means the ability of two or more health information systems or components to exchange clinical and
			 other information and to use the information that has been exchanged using
			 common standards as to provide access to longitudinal information for
			 health care providers in order to facilitate coordinated care and improved
			 patient outcomes.
						(C)Establishment of metricsNot later than July 1, 2015, and in consultation with stakeholders, the Secretary shall establish
			 metrics to be used to determine if and to the extent that the objective
			 described in subparagraph (A) has been achieved.
					(D)Recommendations if objective not achievedIf the Secretary of Health and Human Services determines that the objective described in
			 subparagraph (A) has not been achieved by December 31, 2017, then the
			 Secretary shall submit to Congress a report, by not later than December
			 31, 2018, that identifies barriers to such objective and recommends
			 actions that the Federal Government can take to achieve such objective.
			 Such recommended actions may include recommendations—
						(i)to adjust payments for not being meaningful EHR users under the Medicare EHR incentive programs;
			 and
						(ii)for criteria for decertifying certified EHR technology products.
						(2)Preventing blocking the sharing of information
					(A)For meaningful EHR professionalsSection 1848(o)(2)(A)(ii) of the Social Security Act (42 U.S.C. 1395w–4(o)(2)(A)(ii)) is amended by
			 inserting before the period at the end the following: , and the professional demonstrates (through a process specified by the Secretary, such as the use
			 of an attestation) that the professional has not knowingly and willfully
			 taken any action to limit or restrict the compatibility or
			 interoperability of the certified EHR technology.
					(B)For meaningful EHR hospitalsSection 1886(n)(3)(A)(ii) of the Social Security Act (42 U.S.C. 1395ww(n)(3)(A)(ii)) is amended by
			 inserting before the period at the end the following: , and the hospital demonstrates (through a process specified by the Secretary, such as the use of
			 an attestation) that the hospital has not knowingly and willfully taken
			 any action to limit or restrict the compatibility or interoperability of
			 the certified EHR technology.
					(C)Effective dateThe amendments made by this subsection shall apply to meaningful EHR users as of the date that is
			 one year after the date of the enactment of this Act.
					(3)Study and report on the feasibility of establishing a website to compare certified EHR technology
			 products
					(A)StudyThe Secretary shall conduct a study to examine the feasibility of establishing mechanisms that
			 includes aggregated results of surveys of meaningful EHR users on the
			 functionality of certified EHR technology products to enable such users to
			 directly compare the functionality and other features of such products.
			 Such information may be made available through contracts with physician,
			 hospital, or other organizations that maintain such comparative
			 information.
					(B)ReportNot later than 1 year after the date of the enactment of this Act, the Secretary shall submit to
			 Congress a report on the website. The report shall include information on
			 the benefits of, and resources needed to develop and maintain, such a
			 website.
					(4)DefinitionsIn this subsection:
					(A)The term certified EHR technology has the meaning given such term in section 1848(o)(4) of the Social Security Act (42 U.S.C.
			 1395w–4(o)(4)).
					(B)The term meaningful EHR user has the meaning given such term under the Medicare EHR incentive programs.
					(C)The term Medicare and Medicaid EHR incentive programs means—
						(i)in the case of the Medicare program under title XVIII of the Social Security Act, the incentive
			 programs under section 1814(l)(3), section 1848(o), subsections (l) and
			 (m) of section 1853, and section 1886(n) of the Social Security Act (42
			 U.S.C. 1395f(l)(3), 1395w–4(o), 1395w–23, 1395ww(n)); and
						(ii)in the case of the Medicaid program under title XIX of such Act, the incentive program under
			 subsections (a)(3)(F) and (t) of section 1903 of such Act (42 U.S.C.
			 1396b).
						(D)The term Secretary means the Secretary of Health and Human Services.
					(d)GAO studies and reports on the use of telehealth under Federal programs and on remote patient
			 monitoring services
				(1)Study on telehealth servicesThe Comptroller General of the United States shall conduct a study on the following:
					(A)How the definition of telehealth across various Federal programs and Federal efforts can inform the
			 use of telehealth in the Medicare program under title XVIII of the Social
			 Security Act (42 U.S.C. 1395 et seq.).
					(B)Issues that can facilitate or inhibit the use of telehealth under the Medicare program under such
			 title, including oversight and professional licensure, changing
			 technology, privacy and security, infrastructure requirements, and varying
			 needs across urban and rural areas.
					(C)Potential implications of greater use of telehealth with respect to payment and delivery system
			 transformations under the Medicare program under such title XVIII and the
			 Medicaid program under title XIX of such Act (42 U.S.C. 1396 et seq.).
					(D)How the Centers for Medicare & Medicaid Services conducts oversight of payments made under the Medicare program under such title
			 XVIII to providers for telehealth services.
					(2)Study on remote patient monitoring services
					(A)In generalThe Comptroller General of the United States shall conduct a study—
						(i)of the dissemination of remote patient monitoring technology in the private health insurance
			 market;
						(ii)of the financial incentives in the private health insurance market relating to adoption of such
			 technology;
						(iii)of the barriers to adoption of such services under the Medicare program under title XVIII of the
			 Social Security Act;
						(iv)that evaluates the patients, conditions, and clinical circumstances that could most benefit from
			 remote patient monitoring services; and
						(v)that evaluates the challenges related to establishing appropriate valuation for remote patient
			 monitoring services under the Medicare physician fee schedule under
			 section 1848 of the Social Security Act (42 U.S.C. 1395w–4) in order to
			 accurately reflect the resources involved in furnishing such services.
						(B)DefinitionsFor purposes of this paragraph:
						(i)Remote patient monitoring servicesThe term remote patient monitoring services means services furnished through remote patient monitoring technology.
						(ii)Remote patient monitoring technologyThe term remote patient monitoring technology means a coordinated system that uses one or more home-based or mobile monitoring devices that
			 automatically transmit vital sign data or information on activities of
			 daily living and may include responses to assessment questions collected
			 on the devices wirelessly or through a telecommunications connection to a
			 server that complies with the Federal regulations (concerning the privacy
			 of individually identifiable health information) promulgated under section
			 264(c) of the Health Insurance Portability and Accountability Act of 1996,
			 as part of an established plan of care for that patient that includes the
			 review and interpretation of that data by a health care professional.
						(3)ReportsNot later than 24 months after the date of the enactment of this Act, the Comptroller General shall
			 submit to Congress—
					(A)a report containing the results of the study conducted under paragraph (1); and
					(B)a report containing the results of the study conducted under paragraph (2).A report required under this paragraph shall be submitted together with recommendations for such
			 legislation and administrative action as the Comptroller General
			 determines appropriate. The Comptroller General may submit one report
			 containing the results described in subparagraphs (A) and (B) and the
			 recommendations described in the previous sentence.(e)Rule of construction regarding healthcare provider standards of care
				(1)Maintenance of state standardsThe development, recognition, or implementation of any guideline or other standard under any
			 Federal health care provision shall not be construed—
					(A)to establish the standard of care or duty of care owed by a health care provider to a patient in
			 any medical malpractice or medical product liability action or claim; or
					(B)to preempt any standard of care or duty of care, owed by a health care provider to a patient, duly
			 established under State or common law.
					(2)DefinitionsFor purposes of this subsection:
					(A)Federal health care provisionThe term Federal health care provision means any provision of the Patient Protection and Affordable Care Act (Public Law 111–148), title
			 I or subtitle B of title II of the Health Care and Education
			 Reconciliation Act of 2010 (Public Law 111–152), or title XVIII or XIX of
			 the Social Security Act.
					(B)Health care providerThe term health care provider means any individual or entity—
						(i)licensed, registered, or certified under Federal or State laws or regulations to provide health
			 care services; or
						(ii)required to be so licensed, registered, or certified but that is exempted by other statute or
			 regulation.
						(C)Medical malpractice or medical product liability action or claimThe term medical malpractice or medical product liability action or claim means a medical malpractice action or claim (as defined in section 431(7) of the Health Care
			 Quality Improvement Act of 1986 (42 U.S.C. 11151(7))) and includes a
			 liability action or claim relating to a health care provider’s
			 prescription or provision of a drug, device, or biological product (as
			 such terms are defined in section 201 of the Federal Food, Drug, and
			 Cosmetic Act or section 351 of the Public Health Service Act).
					(D)StateThe term State includes the District of Columbia, Puerto Rico, and any other commonwealth, possession, or
			 territory of the United States.
					(3)Preservation of State lawNo provision of the Patient Protection and Affordable Care Act (Public Law 111–148), title I or
			 subtitle B of title II of the Health Care and Education Reconciliation Act
			 of 2010 (Public Law 111–152), or title XVIII or XIX of the Social Security
			 Act shall be construed to preempt any State or common law governing
			 medical professional or medical product liability actions or claims.
				10.Delay in implementation of penalty for failure to comply with individual health insurance mandate
			(a)In generalSection 5000A(c) of the Internal Revenue Code of 1986 is amended by adding at the end the following
			 new paragraph:

					(5)Delay in implementation of penaltyNotwithstanding any other provision of this subsection, the monthly penalty amount with respect to
			 any taxpayer for any month beginning before January 1, 2019, shall be
			 zero..
			(b)Delay of certain phase ins and indexing
				(1)Phase in of percentage of income limitationSection 5000A(c)(2)(B) of such Code is amended—
					(A)by striking 2014 in clause (i) and inserting 2019, and
					(B)by striking 2015 in clauses (ii) and (iii) and inserting 2020.
					(2)Phase in of applicable dollar amountSection 5000A(c)(3)(B) of such Code is amended—
					(A)by striking 2014 and inserting 2019, and
					(B)by striking 2015 (before amendment by subparagraph (A)) and inserting 2020.
					(3)Indexing of applicable dollar amountSection 5000A(c)(3)(D) of such Code is amended—
					(A)by striking 2016 in the matter preceding clause (i) and inserting 2021, and
					(B)by striking 2015 in clause (ii) and inserting 2020.
					(4)Indexing of exemption based on household incomeSection 5000A(e)(1)(D) of such Code is amended—
					(A)by striking 2014 (before amendment by subparagraph (B)) and inserting 2019, and
					(B)by striking 2013 and inserting 2018.
					(c)Effective dateThe amendments made by this section shall apply to months beginning after December 31, 2013.

	Passed the House of Representatives March 14, 2014.Karen L. Haas,Clerk