Several policies that would have reduced spending and increased revenues were poised to take effect at the end of 2012; collectively, these were referred to by some as the "fiscal cliff." Had these policies taken effect, CBO projected that the ensuing fiscal contraction would have resulted in a recession in 2013. On January 2, 2013, the President signed H.R. 8 , the American Taxpayer Relief Act of 2012 (ATRA, P.L. 112-240 ), which prevented many—but not all—of the fiscal cliff policies from going into effect. This Act was passed by the Senate on January 1, 2013 by a vote of 89-8, and by the House later that day, 257-167. Title VI of the Act extends several expiring provisions in the Medicare and Medicaid programs and makes other changes in federally funded health programs. Many of the sections in Title VI of the ATRA extend current law provisions, resulting in higher Medicare provider payments or extending authorization and/or funding for expiring programs. Specifically, provisions in Title VI of ATRA that will result in higher physician fee schedule payments include the override of the sustainable growth rate (SGR) update mechanism of the Medicare physician fee schedule that would have reduced payments had it taken effect, and the extensions of the physician work geographic adjustment. Other provisions preserved some Medicare hospital payments by extending adjustments for low-volume hospitals and the Medicare-dependent hospital program. Sections that addressed Medicare managed care include the extension of the Medicare Advantage special needs plans and reasonable cost contracts. Medicare beneficiaries will continue to have access to the exceptions process for outpatient therapy limits and outreach and assistance programs for low-income beneficiaries. Other health programs extended by the ATRA include the qualifying individual (QI) program, the transitional medical assistance (TMA) program, the Medicaid and the State Children's Health Insurance Program (CHIP) express lane option, family-to-family health information centers, and special diabetes programs for Type I diabetes and for American Indians and Alaska Natives. Some sections make changes to federal health programs that result in savings to the federal budget. Provisions addressing hospital care include modifications to documentation and coding for inpatient hospital services, changes in payment for certain radiology services furnished under the Medicare hospital outpatient department prospective payment system, and the rebasing of state disproportionate share allotments. Savings achieved from changes in payments for Medicare physician services include changes in the payment policies for multiple therapy service treatments and adjustments to the equipment utilization rate in the calculation of payments for advanced imaging services. Medicare managed care plans will see an adjustment for coding intensity that will be reflected in their capitation payments. Other Medicare provider payments will be affected by revisions to the end-stage renal disease (ESRD) bundled payment system, the payment of competitive prices for diabetic supplies, an adjustment for non-emergency ambulance transports for ESRD beneficiaries, and the extension of the period, from three to five years, during which overpayments to providers can be identified. Finally other ATRA sections that address other federal health care programs have minimal impact on direct spending, including the provisions in Title VI that repeal the Community Living Assistance Services and Supports program and establish a Commission on Long-Term Care. The Congressional Budget Office (CBO) estimates that the health provisions in H.R. 8 will result in a net increase in direct spending of $800 million over the ten-year period from FY2013 through FY2022. The physician payment override or "doc fix" ($25.2 billion in direct spending over 10 years) and the various health-related extensions ($4.1 billion) cumulatively add $29.3 billion to direct spending. CBO estimates that the other health provisions cumulatively result in offsets of all but $800 million as a result of the direct effects of the provisions and the interactions between provisions. This report provides short descriptions of the health-related provisions contained in Title VI of the ATRA. Below is a text box providing the common acronyms for public laws referred to in this report. The Sustainable Growth Rate (SGR) is the statutory method for determining the annual updates to the Medicare physician fee schedule. The SGR system was established because of the concern that the Medicare fee schedule itself would not adequately constrain overall increases in spending for physicians' services. Generally, under the SGR formula, if expenditures over a period are less than the cumulative spending target for the period, the annual update is increased. However, if spending exceeds the cumulative spending target over a certain period, future updates are reduced to bring spending back in line with the target. In the first few years of the SGR system, the actual expenditures did not exceed the targets and the updates to the physician fee schedule were close to the Medicare economic index (MEI, a price index of inputs required to produce physician services). Beginning in 2002, the actual expenditures exceeded allowed targets, and the discrepancy has grown with each year. However, with the exception of 2002, when a 4.8% decrease was applied, Congress has enacted a series of laws to override the reductions. The SGR-determined update for Medicare physician payment required a reduction in the Medicare physician fee schedule (MPFS) payment rates of 26.5% beginning on January 1, 2013. This ATRA provision averts the reduction and maintains the Medicare physician fee schedule (MPFS) payments at their current rates through December 31, 2013. The conversion factor for 2014 and afterwards will be computed as if the modification to the conversion factor in this section had never applied. The Physician Quality Reporting System (PQRS) was established by the Centers for Medicare & Medicaid Services (CMS) to reward eligible professionals for reporting specified quality data to the agency. This provision requires the Secretary of Health and Human Services (the "Secretary") to deem those eligible professionals who satisfactorily participate in a qualified clinical data registry as having met the quality reporting requirements for PQRS for 2014 and subsequent years. The provision also requires the Secretary to establish requirements for a qualified clinical data registry and in so doing to consider, among other things, whether an entity has mechanisms in place to ensure transparency and to support quality improvement initiatives for participants. Measures used in the qualified clinical data registries may be endorsed by the National Quality Forum (NQF). These measures are not subject to the process for measure selection being carried out by multi-stakeholder groups. In defining the requirements for the qualified clinical data registries, the Secretary must consult with interested parties and establish a process to determine whether the requirements have been met. The Government Accountability Office (GAO) is also required to conduct a study on the potential of clinical data registries to improve the quality and efficiency of care in the Medicare program, including through payment incentives. GAO must submit to Congress a report on this study by November 15, 2013, along with recommendations for legislative and administrative action. The CBO score for the override of the Medicare physician payment update is $21 .1 bi llion for FY2013-FY2017 and $25.2 billion for FY2013-FY2022 , while the score for the advancement of the qualified clinical data registries is $100 million for both the five- and ten-year period . The Medicare physician fee schedule is adjusted geographically for three factors to reflect differences in the cost of resources needed to produce physician services: physician work, practice expense, and medical malpractice insurance. The geographic adjustments are indices—known as Geographic Practice Cost Indices (GPCIs)—that reflect how each area compares to the national average in a "market basket" of goods. A value of 1.00 represents the average across all areas. These indices are used in the calculation of the payment rate under the Medicare physician fee schedule. A series of bills set a temporary floor value of 1.00 on the physician work index beginning January 2004 and continuing through December 31, 2012. This ATRA provision extends the 1.00 floor for the physician work geographic index through December 31, 2013. The CBO score is $500 m illion for both FY2013-FY2017 and for FY2013-FY2022. BBA97 established two annual per beneficiary payment limits for all Medicare-covered outpatient therapy services provided by non-hospital providers, to be applied separately (1) for physical therapy services and speech-language pathology services, and (2) for occupational therapy services. Initially set at $1,500 by BBA97 to apply beginning in 1999, these limits were suspended from 2000-2005. The DRA re-implemented the limits beginning in 2006 and required the Secretary to implement an exceptions process throughout 2006 for services meeting specified criteria for medically necessary services. A series of legislative acts have extended the exceptions process and increased the limits each year since then. The 2012 annual cap was $1,880 for each of the two categories of therapy services. MCTRJCA set the annual threshold at $3,700 to be applied separately for the two categories of therapy services effective October 1, 2012. However, this increased amount applied to therapy service received both in physicians' offices and hospital outpatient departments for the first time. The condition was to expire coincident with the expiration of the exceptions process. This ATRA provision extends the exceptions process through December 31, 2013, extends the application of the cap and threshold to therapy services furnished in a hospital outpatient department (OPD) and counts outpatient therapy services furnished in a Critical Access Hospital (CAH) towards the cap and threshold. This change will not affect the payment method for outpatient therapy services provided by CAHs. ATRA also extends the mandate that Medicare perform manual medical review of therapy services furnished January 1, 2013 through December 31, 2013, for which an exception is requested when the beneficiary has reached a dollar aggregate threshold amount of $3,700 for therapy services.