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116th Congress } { Rept. 116-332
HOUSE OF REPRESENTATIVES
1st Session } { Part 1
_______________________________________________________________________
REAUTHORIZING AND EXTENDING AMERICA'S COMMUNITY HEALTH ACT
----------
R E P O R T
of the
COMMITTEE ON ENERGY AND COMMERCE
December 9, 2019.--Ordered to be printed
REAUTHORIZING AND EXTENDING AMERICA'S COMMUNITY HEALTH ACT
116th Congress } { Rept. 116-332
HOUSE OF REPRESENTATIVES
1st Session } { Part 1
_______________________________________________________________________
REAUTHORIZING AND EXTENDING AMERICA'S COMMUNITY HEALTH ACT
__________
R E P O R T
of the
COMMITTEE ON ENERGY AND COMMERCE
December 9, 2019.--Ordered to be printed
______
U.S. GOVERNMENT PUBLISHING OFFICE
38-564 WASHINGTON : 2019
CONTENTS
Page
I. Purpose and Summary.............................................28
II. Background and Need for the Legislation.........................28
III. Committee Hearings..............................................35
IV. Committee Consideration.........................................36
V. Committee Votes.................................................37
VI. Oversight Findings..............................................37
VII. New Budget Authority, Entitlement Authority, and Tax Expenditure37
VIII.Federal Mandates Statement......................................37
IX. Statement of General Performance Goals and Objectives...........38
X. Duplication of Federal Programs.................................38
XI. Committee Cost Estimate.........................................38
XII. Earmarks, Limited Tax Benefits, and Limited Tariff Benefits.....38
XIII.Advisory Committee Statement....................................38
XIV. Applicability to Legislative Branch.............................38
XV. Section-by-Section Analysis of the Legislation..................38
XVI. Changes in Existing Law Made by the Bill, as Reported...........45
116th Congress } { Rept. 116-332
HOUSE OF REPRESENTATIVES
1st Session } { Part 1
======================================================================
REAUTHORIZING AND EXTENDING AMERICA'S COMMUNITY HEALTH ACT
_______
December 9, 2019.--Ordered to be printed
_______
Mr. Pallone, from the Committee on Energy and Commerce, submitted the
following
R E P O R T
[To accompany H.R. 2328]
The Committee on Energy and Commerce, to whom was referred
the bill (H.R. 2328) to reauthorize and extend funding for
community health centers and the National Health Service Corps,
having considered the same, report favorably thereon with
amendments and recommend that the bill as amended do pass.
The amendments are as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Reauthorizing and
Extending America's Community Health Act'' or the ``REACH Act''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--PUBLIC HEALTH EXTENDERS
Sec. 101. Extension for community health centers, the National Health
Service Corps, and teaching health centers that operate GME programs.
Sec. 102. Extension for special diabetes programs.
Sec. 103. Extension of Personal Responsibility Education Program.
Sec. 104. Extension of sexual risk avoidance education program.
TITLE II--MEDICARE EXTENDERS
Sec. 201. Extension of the work geographic index floor under the
Medicare program.
Sec. 202. Extension of funding outreach and assistance for low-income
programs.
Sec. 203. Extension of funding for quality measure endorsement, input,
and selection under the Medicare program.
Sec. 204. Extension of the Independence at Home Medical Practice
Demonstration Program under the Medicare program.
Sec. 205. Extension of appropriations and transfers to the Patient-
Centered Outcomes Research Trust Fund; extension of certain health
insurance fees.
Sec. 206. Transitional coverage and retroactive Medicare part D
coverage for certain low-income beneficiaries.
Sec. 207. Health Equity and Access for Returning Troops and
Servicemembers Act of 2019.
Sec. 208. Exclusion of complex rehabilitative manual wheelchairs from
Medicare competitive acquisition program; Non-application of Medicare
fee-schedule adjustments for certain wheelchair accessories and
cushions.
TITLE III--MEDICAID PROVISIONS
Sec. 301. Modification of reductions in Medicaid DSH allotments.
Sec. 302. Public availability of hospital upper payment limit
demonstrations.
Sec. 303. Report by Comptroller General.
Sec. 304. Sense of Congress regarding the need to develop a more
permanent legislative solution to provide the territories with a
reliable and consistent source of Federal funding under the Medicaid
program.
TITLE IV--NO SURPRISES ACT
Sec. 401. Short title.
Sec. 402. Preventing surprise medical bills.
Sec. 403. Government Accountability Office study on profit- and
revenue-sharing in health care.
Sec. 404. State All Payer Claims Databases.
Sec. 405. Air ambulance cost data reporting program.
Sec. 406. Report by Secretary of Labor.
Sec. 407. Billing statute of limitations.
Sec. 408. GAO report on impact of surprise billing provisions.
Sec. 409. Report by the Secretary of Health and Human Services.
TITLE V--TERRITORIES HEALTH CARE IMPROVEMENT ACT
Sec. 501. Short title.
Sec. 502. Medicaid payments for Puerto Rico and the other territories
for certain fiscal years.
Sec. 503. Application of certain requirements under Medicaid program to
certain territories.
Sec. 504. Additional program integrity requirements.
TITLE I--PUBLIC HEALTH EXTENDERS
SEC. 101. EXTENSION FOR COMMUNITY HEALTH CENTERS, THE NATIONAL HEALTH
SERVICE CORPS, AND TEACHING HEALTH CENTERS THAT
OPERATE GME PROGRAMS.
(a) Community Health Centers.--Section 10503(b)(1)(F) of the Patient
Protection and Affordable Care Act (42 U.S.C. 254b-2(b)(1)(F)) is
amended by striking ``fiscal year 2019'' and inserting ``each of fiscal
years 2019 through 2023''.
(b) National Health Service Corps.--Section 10503(b)(2)(F) of the
Patient Protection and Affordable Care Act (42 U.S.C. 254b-2(b)(2)(F))
is amended by striking ``2018 and 2019'' and inserting ``2019 through
2023''.
(c) Teaching Health Centers That Operate Graduate Medical Education
Programs.--Section 340H(g)(1) of the Public Health Service Act (42
U.S.C. 256h(g)(1)) is amended by striking ``2018 and 2019'' and
inserting ``2019 through 2023''.
(d) Application.--Amounts appropriated for a program pursuant to the
amendments made by subsection (a), (b), or (c) for fiscal years 2020
through 2023 are subject to the requirements and limitations of the
most recently enacted regular or full-year continuing appropriations
Act or resolution (as of the date of obligation of current funds)
applicable to the respective program.
SEC. 102. EXTENSION FOR SPECIAL DIABETES PROGRAMS.
(a) Reauthorization of Special Diabetes Programs for Type I
Diabetes.--Section 330B(b)(2)(D) of the Public Health Service Act (42
U.S.C. 254c-2(b)(2)(D)) is amended by striking ``each of fiscal years
2018 and 2019'' and inserting ``fiscal years 2019 through 2023''.
(b) Reauthorization of Special Diabetes Programs for Indians for
Diabetes Services.--Section 330C(c)(2)(D) of the Public Health Service
Act (42 U.S.C. 254c-3(c)(2)(D)) is amended by striking ``fiscal years
2018 and 2019'' and inserting ``fiscal years 2019 through 2023''.
SEC. 103. EXTENSION OF PERSONAL RESPONSIBILITY EDUCATION PROGRAM.
Section 513 of the Social Security Act (42 U.S.C. 713) is amended--
(1) in paragraphs (1)(A) and (4)(A) of subsection (a), by
striking ``2019'' and inserting ``2023'' each place it appears;
(2) in subsection (a)(4)(B)(i), by striking ``2019'' and
inserting ``2023''; and
(3) in subsection (f), by striking ``2019'' and inserting
``2023''.
SEC. 104. EXTENSION OF SEXUAL RISK AVOIDANCE EDUCATION PROGRAM.
Section 510 of the Social Security Act (42 U.S.C. 710) is amended by
striking ``fiscal years 2018 and 2019'' each place it appears in
subsections (a)(1), (a)(2)(A), (f)(1) and (f)(2) and inserting ``fiscal
years 2019 through 2023''.
TITLE II--MEDICARE EXTENDERS
SEC. 201. EXTENSION OF THE WORK GEOGRAPHIC INDEX FLOOR UNDER THE
MEDICARE PROGRAM.
Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)(E)) is amended by striking ``2020'' and inserting ``2023''.
SEC. 202. EXTENSION OF FUNDING OUTREACH AND ASSISTANCE FOR LOW-INCOME
PROGRAMS.
(a) Additional Funding for State Health Insurance Programs.--
Subsection (a)(1)(B) of section 119 of the Medicare Improvements for
Patients and Providers Act of 2008 (42 U.S.C. 1395b-3 note), as amended
by section 3306 of the Patient Protection and Affordable Care Act
(Public Law 111-148), section 610 of the American Taxpayer Relief Act
of 2012 (Public Law 112-240), section 1110 of the Pathway for SGR
Reform Act of 2013 (Public Law 113-67), section 110 of the Protecting
Access to Medicare Act of 2014 (Public Law 113-93), section 208 of the
Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 114-
10), and section 50207 of the Bipartisan Budget Act of 2018 (Public Law
115-123), is amended--
(1) in clause (vii), by striking ``and'' at the end;
(2) in clause (viii), by striking ``and'' at the end;
(3) in clause (ix), by striking the period at the end and
inserting ``; and''; and
(4) by inserting after clause (ix) the following new clause:
``(x) for each of fiscal years 2020 through
2022, of $15,000,000.''.
(b) Additional Funding for Area Agencies on Aging.--Subsection
(b)(1)(B) of such section 119, as so amended, is amended--
(1) in clause (vii), by striking ``and'' at the end;
(2) in clause (viii), by striking ``and'' at the end;
(3) in clause (ix), by striking the period at the end and
inserting ``; and''; and
(4) by inserting after clause (ix) the following new clause:
``(x) for each of fiscal years 2020 through
2022, of $15,000,000.''.
(c) Additional Funding for Aging and Disability Resource Centers.--
Subsection (c)(1)(B) of such section 119, as so amended, is amended--
(1) in clause (vii), by striking ``and'' at the end;
(2) in clause (viii), by striking ``and'' at the end;
(3) in clause (ix), by striking the period at the end and
inserting ``; and''; and
(4) by inserting after clause (ix) the following new clause:
``(x) for each of fiscal years 2020 through
2022, of $5,000,000.''.
(d) Additional Funding for Contract With the National Center for
Benefits and Outreach Enrollment.--Subsection (d)(2) of such section
119, as so amended, is amended--
(1) in clause (vii), by striking ``and'' at the end;
(2) in clause (viii), by striking ``and'' at the end;
(3) in clause (ix), by striking the period at the end and
inserting ``; and''; and
(4) by inserting after clause (ix) the following new clause:
``(x) for each of fiscal years 2020 through
2022, of $15,000,000.''.
SEC. 203. EXTENSION OF FUNDING FOR QUALITY MEASURE ENDORSEMENT, INPUT,
AND SELECTION UNDER THE MEDICARE PROGRAM.
(a) In General.--Section 1890(d)(2) of the Social Security Act (42
U.S.C. 1395aaa(d)(2)) is amended--
(1) by striking ``and $7,500,000'' and inserting
``$7,500,000''; and
(2) by striking ``and 2019.'' and inserting ``and 2019, and
$30,000,000 for each of fiscal years 2020 through 2022.''.
(b) Input for Removal of Measures.--Section 1890(b) of the Social
Security Act (42 U.S.C. 1395aaa(b)) is amended by inserting after
paragraph (3) the following:
``(4) Removal of measures.--The entity may, through the
multistakeholder groups convened under paragraph (7)(A),
provide input to the Secretary on quality and efficiency
measures described in paragraph (7)(B) that could be considered
for removal.''.
(c) Prioritization of Measure Endorsement.--Section 1890(b) of the
Social Security Act (42 U.S.C. 1395aaa(b)), as amended by subsection
(b), is further amended by adding at the end the following:
``(9) Prioritization of measure endorsement.--The entity--
``(A) during the period beginning on the date of the
enactment of this paragraph and ending on December 31,
2023, shall prioritize the endorsement of measures
relating to maternal morbidity and mortality by the
entity with a contract under subsection (a) in
connection with endorsement of measures described in
paragraph (2); and
``(B) on and after January 1, 2024, may prioritize
the endorsement of such measures by such entity.''.
SEC. 204. EXTENSION OF THE INDEPENDENCE AT HOME MEDICAL PRACTICE
DEMONSTRATION PROGRAM UNDER THE MEDICARE PROGRAM.
(a) In General.--Section 1866E(e)(1) of the Social Security Act (42
U.S.C. 1395cc-5(e)(1)) is amended by striking ``7-year'' and inserting
``10-year''.
(b) Effective Date.--The amendment made by subsection (a) shall take
effect as if included in the enactment of Public Law 111-148.
SEC. 205. EXTENSION OF APPROPRIATIONS AND TRANSFERS TO THE PATIENT-
CENTERED OUTCOMES RESEARCH TRUST FUND; EXTENSION OF
CERTAIN HEALTH INSURANCE FEES.
(a) In General.--
(1) Internal revenue code.--Section 9511 of the Internal
Revenue Code of 1986 is amended--
(A) in subsection (b)(1)(E), by striking ``2014'' and
all that follows through ``2019'' and inserting ``2014
through 2022'';
(B) in subsection (d)(2)(A), by striking ``2019'' and
inserting ``2022''; and
(C) in subsection (f), by striking ``2019'' and
inserting ``2022''.
(2) Title xi.--Section 1183(a)(2) of the Social Security Act
(42 U.S.C. 1320e-2(a)(2)) is amended by striking ``2014'' and
all that follows through ``2019'' and inserting ``2014 through
2022''.
(b) Extension of Certain Health Insurance Fees.--
(1) Health insurance policies.--Section 4375(e) of the
Internal Revenue Code of 1986 is amended by striking ``2019''
and inserting ``2022''.
(2) Self-insured health plans.--Section 4376(e) of the
Internal Revenue Code of 1986 is amended by striking ``2019''
and inserting ``2022''.
SEC. 206. TRANSITIONAL COVERAGE AND RETROACTIVE MEDICARE PART D
COVERAGE FOR CERTAIN LOW-INCOME BENEFICIARIES.
Section 1860D-14 of the Social Security Act (42 U.S.C. 1395w-114) is
amended--
(1) by redesignating subsection (e) as subsection (f); and
(2) by adding after subsection (d) the following new
subsection:
``(e) Limited Income Newly Eligible Transition Program.--
``(1) In general.--Beginning not later than January 1, 2021,
the Secretary shall carry out a program to provide transitional
coverage for covered part D drugs for LI NET eligible
individuals in accordance with this subsection.
``(2) LI net eligible individual defined.--For purposes of
this subsection, the term `LI NET eligible individual' means a
part D eligible individual who--
``(A) meets the requirements of clauses (ii) and
(iii) of subsection (a)(3)(A); and
``(B) has not yet enrolled in a prescription drug
plan or an MA-PD plan, or, who has so enrolled, but
with respect to whom coverage under such plan has not
yet taken effect.
``(3) Transitional coverage.--For purposes of this
subsection, the term `transitional coverage' means, with
respect to an LI NET eligible individual--
``(A) immediate access to covered part D drugs at the
point of sale during the period that begins on the
first day of the month such individual is determined to
meet the requirements of clauses (ii) and (iii) of
subsection (a)(3)(A) and ends on the date that coverage
under a prescription drug plan or MA-PD plan takes
effect with respect to such individual; and
``(B) in the case of an LI NET eligible individual
who is a full-benefit dual eligible individual (as
defined in section 1935(c)(6)) or a recipient of
supplemental security income benefits under title XVI,
retroactive coverage (in the form of reimbursement of
the amounts that would have been paid under this part
had such individual been enrolled in a prescription
drug plan or MA-PD plan) of covered part D drugs
purchased by such individual during the period that
begins on the date that is the later of--
``(i) the date that such individual was first
eligible for a low-income subsidy under this
part; or
``(ii) the date that is 36 months prior to
the date such individual enrolls in a
prescription drug plan or MA-PD plan,
and ends on the date that coverage under such plan
takes effect.
``(4) Program administration.--
``(A) Single point of contact.--The Secretary shall,
to the extent feasible, administer the program under
this subsection through a contract with a single
program administrator.
``(B) Benefit design.--The Secretary shall ensure
that the transitional coverage provided to LI NET
eligible individuals under this subsection--
``(i) provides access to all covered part D
drugs under an open formulary;
``(ii) permits all pharmacies determined by
the Secretary to be in good standing to process
claims under the program;
``(iii) is consistent with such requirements
as the Secretary considers necessary to improve
patient safety and ensure appropriate
dispensing of medication; and
``(iv) meets such other requirements as the
Secretary may establish.
``(5) Relationship to other provisions of this title; waiver
authority.--
``(A) In general.--The following provisions shall not
apply with respect to the program under this
subsection:
``(i) Paragraphs (1) and (3)(B) of section
1860D-4(a) (relating to dissemination of
general information; availability of
information on changes in formulary through the
internet).
``(ii) Subparagraphs (A) and (B) of section
1860D-4(b)(3) (relating to requirements on
development and application of formularies;
formulary development).
``(iii) Paragraphs (1)(C) and (2) of section
1860D-4(c) (relating to medication therapy
management program).
``(B) Waiver authority.--The Secretary may waive such
other requirements of titles XI and this title as may
be necessary to carry out the purposes of the program
established under this subsection.''.
SEC. 207. HEALTH EQUITY AND ACCESS FOR RETURNING TROOPS AND
SERVICEMEMBERS ACT OF 2019.
(a) Modification of Requirement for Certain Former Members of the
Armed Forces to Enroll in Medicare Part B to Be Eligible for TRICARE
for Life.--
(1) TRICARE eligibility.--
(A) In general.--Subsection (d) of section 1086 of
title 10, United States Code, is amended by adding at
the end the following new paragraph:
``(6)(A) The requirement in paragraph (2)(A) to enroll in the
supplementary medical insurance program under part B of title XVIII of
the Social Security Act (42 U.S.C. 1395j et seq.) shall not apply to a
person described in subparagraph (B) during any month in which such
person is not entitled to a benefit described in subparagraph (A) of
section 226(b)(2) of the Social Security Act (42 U.S.C. 426(b)(2)) if
such person has received the counseling and information under
subparagraph (C).
``(B) A person described in this subparagraph is a person--
``(i) who is under 65 years of age;
``(ii) who is entitled to hospital insurance benefits under
part A of title XVIII of the Social Security Act pursuant to
subparagraph (A) or (C) of section 226(b)(2) of such Act (42
U.S.C. 426(b)(2));
``(iii) whose entitlement to a benefit described in
subparagraph (A) of such section has terminated due to
performance of substantial gainful activity; and
``(iv) who is retired under chapter 61 of this title.
``(C) The Secretary of Defense shall coordinate with the Secretary of
Health and Human Services and the Commissioner of Social Security to
notify persons described in subparagraph (B) of, and provide
information and counseling regarding, the effects of not enrolling in
the supplementary medical insurance program under part B of title XVIII
of the Social Security Act (42 U.S.C. 1395j et seq.), as described in
subparagraph (A).''.
(B) Conforming amendment.--Paragraph (2)(A) of such
subsection is amended by striking ``is enrolled'' and
inserting ``except as provided by paragraph (6), is
enrolled''.
(C) Identification of persons.--Section 1110a of such
title is amended by adding at the end the following new
subsection:
``(c) Certain Individuals Not Required To Enroll in Medicare Part
B.--In carrying out subsection (a), the Secretary of Defense shall
coordinate with the Secretary of Health and Human Services and the
Commissioner of Social Security to--
``(1) identify persons described in subparagraph (B) of
section 1086(d)(6) of this title; and
``(2) provide information and counseling pursuant to
subparagraph (C) of such section.''.
(2) Non-application of medicare part b late enrollment
penalty.--Section 1839(b) of the Social Security Act (42 U.S.C.
1395r(b)) is amended, in the second sentence, by inserting ``or
months for which the individual can demonstrate that the
individual is an individual described in paragraph (6)(B) of
section 1086(d) of title 10, United States Code, who is
enrolled in the TRICARE program pursuant to such section''
after ``an individual described in section 1837(k)(3)''.
(3) Report.--Not later than October 1, 2024, the Secretary of
Defense, the Secretary of Health and Human Services, and the
Commissioner of Social Security shall jointly submit to the
Committees on Armed Services of the House of Representatives
and the Senate, the Committee on Ways and Means and the
Committee on Energy and Commerce of the House of
Representatives, and the Committee on Finance of the Senate a
report on the implementation of section 1086(d)(6) of title 10,
United States Code, as added by paragraph (1). Such report
shall include, with respect to the period covered by the
report--
(A) the number of individuals enrolled in TRICARE for
Life who are not enrolled in the supplementary medical
insurance program under part B of title XVIII of the
Social Security Act (42 U.S.C. 1395j et seq.) by reason
of such section 1086(d)(6); and
(B) the number of individuals who--
(i) are retired from the Armed Forces under
chapter 61 of title 10, United States Code;
(ii) are entitled to hospital insurance
benefits under part A of title XVIII of the
Social Security Act pursuant to receiving
benefits for 24 months as described in
subparagraph (A) or (C) of section 226(b)(2) of
such Act (42 U.S.C. 426(b)(2)); and
(iii) because of such entitlement, are no
longer enrolled in TRICARE Standard, TRICARE
Prime, TRICARE Extra, or TRICARE Select under
chapter 55 of title 10, United States Code.
(4) Deposit of savings into medicare improvement fund.--
Section 1898(b)(1) of the Social Security Act (42 U.S.C.
1395iii(b)(1)) is amended by striking ``during and after fiscal
year 2021, $0'' and inserting ``during and after fiscal year
2024, $5,000,000''.
(5) Application.--The amendments made by paragraphs (1) and
(2) shall apply with respect to a person who, on or after
October 1, 2023, is a person described in section 1086(d)(6)(B)
of title 10, United States Code, as added by paragraph (1).
(b) Coverage of Certain DNA Specimen Provenance Assay Tests Under
Medicare.--
(1) Benefit.--
(A) Coverage.--Section 1861 of the Social Security
Act (42 U.S.C. 1395x) is amended--
(i) in subsection (s)(2)--
(I) in subparagraph (GG), by striking
``and'' at the end;
(II) in subparagraph (HH), by
striking the period and inserting ``;
and''; and
(III) by adding at the end the
following new subparagraph:
``(II) a prostate cancer DNA Specimen Provenance Assay test
(DSPA test) (as defined in subsection (kkk));''; and
(ii) by adding at the end the following new
subsection:
``(kkk) Prostate Cancer DNA Specimen Provenance Assay Test.--The term
`prostate cancer DNA Specimen Provenance Assay Test' (DSPA test) means
a test that, after a determination of cancer in one or more prostate
biopsy specimens obtained from an individual, assesses the identity of
the DNA in such specimens by comparing such DNA with the DNA that was
separately taken from such individual at the time of the biopsy.''.
(B) Exclusion from coverage.--Section 1862(a)(1) of
the Social Security Act (42 U.S.C. 1395y(a)(1)) is
amended--
(i) in subparagraph (O), by striking ``and''
at the end;
(ii) in subparagraph (P), by striking the
semicolon at the end and inserting ``, and'';
and
(iii) by adding at the end the following new
subparagraph:
``(Q) in the case of a prostate cancer DNA Specimen
Provenance Assay test (DSPA test) (as defined in section
1861(kkk)), unless such test is furnished on or after January
1, 2021, and before January 1, 2026, and such test is ordered
by the physician who furnished the prostate cancer biopsy that
obtained the specimen tested;''.
(2) Payment amount and related requirements.--Section 1834 of
the Social Security Act (42 U.S.C. 1395m) is amended by adding
at the end the following new subsection:
``(x) Prostate Cancer DNA Specimen Provenance Assay Tests.--
``(1) Payment for covered tests.--
``(A) In general.--Subject to subparagraph (B), the
payment amount for a prostate cancer DNA Specimen
Provenance Assay test (DSPA test) (as defined in
section 1861(kkk)) shall be $200. Such payment shall be
payment for all of the specimens obtained from the
biopsy furnished to an individual that are tested.
``(B) Limitation.--Payment for a DSPA test under
subparagraph (A) may only be made on an assignment-
related basis.
``(C) Prohibition on separate payment.--No separate
payment shall be made for obtaining DNA that was
separately taken from an individual at the time of a
biopsy described in subparagraph (A).
``(2) HCPCS code and modifier assignment.--
``(A) In general.--The Secretary shall assign one or
more HCPCS codes to a prostate cancer DNA Specimen
Provenance Assay test and may use a modifier to
facilitate making payment under this section for such
test.
``(B) Identification of dna match on claim.--The
Secretary shall require an indication on a claim for a
prostate cancer DNA Specimen Provenance Assay test of
whether the DNA of the prostate biopsy specimens match
the DNA of the individual diagnosed with prostate
cancer. Such indication may be made through use of a
HCPCS code, a modifier, or other means, as determined
appropriate by the Secretary.
``(3) DNA match review.--
``(A) In general.--The Secretary shall review at
least three years of claims under part B for prostate
cancer DNA Specimen Provenance Assay tests to identify
whether the DNA of the prostate biopsy specimens match
the DNA of the individuals diagnosed with prostate
cancer.
``(B) Posting on internet website.--Not later than
July 1, 2023, the Secretary shall post on the internet
website of the Centers for Medicare & Medicaid Services
the findings of the review conducted under subparagraph
(A).''.
(3) Cost-sharing.--Section 1833(a)(1) of the Social Security
Act (42 U.S.C. 1395l(a)(1)) is amended--
(A) by striking ``and (CC)'' and inserting ``(CC)'';
and
(B) by inserting before the semicolon at the end the
following: ``, and (DD) with respect to a prostate
cancer DNA Specimen Provenance Assay test (DSPA test)
(as defined in section 1861(kkk)), the amount paid
shall be an amount equal to 80 percent of the lesser of
the actual charge for the test or the amount specified
under section 1834(x)''.
SEC. 208. EXCLUSION OF COMPLEX REHABILITATIVE MANUAL WHEELCHAIRS FROM
MEDICARE COMPETITIVE ACQUISITION PROGRAM; NON-
APPLICATION OF MEDICARE FEE-SCHEDULE ADJUSTMENTS
FOR CERTAIN WHEELCHAIR ACCESSORIES AND CUSHIONS.
(a) Exclusion of Complex Rehabilitative Manual Wheelchairs From
Competitive Acquisition Program.--Section 1847(a)(2)(A) of the Social
Security Act (42 U.S.C. 1395w-3(a)(2)(A)) is amended--
(1) by inserting ``, complex rehabilitative manual
wheelchairs (as determined by the Secretary), and certain
manual wheelchairs (identified, as of October 1, 2018, by HCPCS
codes E1235, E1236, E1237, E1238, and K0008 or any successor to
such codes)'' after ``group 3 or higher''; and
(2) by striking ``such wheelchairs'' and inserting ``such
complex rehabilitative power wheelchairs, complex
rehabilitative manual wheelchairs, and certain manual
wheelchairs''.
(b) Non-Application of Medicare Fee Schedule Adjustments for
Wheelchair Accessories and Seat and Back Cushions When Furnished in
Connection With Complex Rehabilitative Manual Wheelchairs.--
(1) In general.--Notwithstanding any other provision of law,
the Secretary of Health and Human Services shall not, during
the period beginning on January 1, 2020, and ending on December
31, 2020, use information on the payment determined under the
competitive acquisition programs under section 1847 of the
Social Security Act (42 U.S.C. 1395w-3) to adjust the payment
amount that would otherwise be recognized under section
1834(a)(1)(B)(ii) of such Act (42 U.S.C. 1395m(a)(1)(B)(ii))
for wheelchair accessories (including seating systems) and seat
and back cushions when furnished in connection with complex
rehabilitative manual wheelchairs (as determined by the
Secretary), and certain manual wheelchairs (identified, as of
October 1, 2018, by HCPCS codes E1235, E1236, E1237, E1238, and
K0008 or any successor to such codes).
(2) Implementation.--Notwithstanding any other provision of
law, the Secretary may implement this subsection by program
instruction or otherwise.
TITLE III--MEDICAID PROVISIONS
SEC. 301. MODIFICATION OF REDUCTIONS IN MEDICAID DSH ALLOTMENTS.
Section 1923(f)(7)(A) of the Social Security Act (42 U.S.C. 1396r-
4(f)(7)(A)) is amended--
(1) in clause (i), in the matter preceding subclause (I), by
striking ``2020'' and inserting ``2022''; and
(2) in clause (ii)--
(A) in subclause (I), by striking ``2020'' and
inserting ``2022''; and
(B) in subclause (II), by striking ``for each of
fiscal years 2021 through 2025'' and inserting ``for
each of fiscal years 2023 through 2025''.
SEC. 302. PUBLIC AVAILABILITY OF HOSPITAL UPPER PAYMENT LIMIT
DEMONSTRATIONS.
Section 1903 of the Social Security Act (42 U.S.C. 1396b) is amended
by adding at the end the following new subsection:
``(bb) Public Availability of Hospital Upper Payment Limit
Demonstrations.--The Secretary shall make publicly available upper
payment limit demonstrations for hospital services that a State submits
with respect to a fiscal year of the State (beginning with State fiscal
year 2022) to the Administrator of the Centers for Medicare & Medicaid
Services.''.
SEC. 303. REPORT BY COMPTROLLER GENERAL.
Not later than the date that is 21 months after the date of the
enactment of this Act, the Comptroller General of the United States
shall identify and report to Congress policy considerations for
legislative action with respect to establishing an equitable formula
for determining disproportionate share hospital allotments for States
under section 1923 of the Social Security Act (42 U.S.C. 1396r-4) that
takes into account the following factors:
(1) The level of uncompensated care costs of hospitals in a
State.
(2) Expenditures of a State with respect to hospitals,
including payment adjustments made under such section 1923 to
disproportionate share hospitals (as defined under the State
plan under title XIX of such Act (42 U.S.C. 1396 et seq.)
pursuant to subsection (a)(1)(A) of such section 1923), upper
payment limit supplemental payments, and other related payments
that hospitals may receive from the State.
(3) State policy decisions that may affect the level of
uncompensated care costs of hospitals in a State.
SEC. 304. SENSE OF CONGRESS REGARDING THE NEED TO DEVELOP A MORE
PERMANENT LEGISLATIVE SOLUTION TO PROVIDE THE
TERRITORIES WITH A RELIABLE AND CONSISTENT SOURCE
OF FEDERAL FUNDING UNDER THE MEDICAID PROGRAM.
It is the sense of Congress that--
(1) the territories of American Samoa, the Commonwealth of
the Northern Mariana Islands, Guam, Puerto Rico, and the United
States Virgin Islands are currently subject to Federal funding
caps for their Medicaid programs;
(2) as a result of these Federal funding caps, which have not
been adjusted over time, the territories continue to struggle
in managing their Medicaid programs, including planning for
their respective financial obligations and managing health care
services for low-income adults, children, pregnant women,
elderly adults, and persons with disabilities;
(3) to address this disparate funding treatment and to
provide the territories with some measure of relief, Congress
has had to enact legislation six times in the last 15 years,
including multiple temporary increases in the Federal funding
caps, higher Federal medical assistance percentage rates, and
billions of dollars in supplemental block grants;
(4) the supplemental funding provided to the territories
under title V with respect to their Medicaid programs continues
Congress' commitment to ensuring the sustainability of these
critically important programs and the people these programs
serve; and
(5) a more permanent legislative solution must be developed
in order to provide the territories with a reliable and
consistent source of Federal funding under their Medicaid
programs so that the territories can continue to meet the
health care needs of vulnerable populations.
TITLE IV--NO SURPRISES ACT
SEC. 401. SHORT TITLE.
This title may be cited as the ``No Surprises Act''.
SEC. 402. PREVENTING SURPRISE MEDICAL BILLS.
(a) Coverage of Emergency Services.--Section 2719A(b) of the Public
Health Service Act (42 U.S.C. 300gg-19a(b)) is amended--
(1) in paragraph (1)--
(A) in the matter preceding subparagraph (A)--
(i) by striking ``a group health plan, or a
health insurance issuer offering group or
individual health insurance issuer,'' and
inserting ``a health plan (as defined in
subsection (e)(2)(A))'';
(ii) by inserting ``or, for plan year 2021 or
a subsequent plan year, with respect to
emergency services in an independent
freestanding emergency department (as defined
in paragraph (3)(D))'' after ``emergency
department of a hospital'';
(iii) by striking ``the plan or issuer'' and
inserting ``the plan''; and
(iv) by striking ``paragraph (2)(B)'' and
inserting ``paragraph (3)(C)'';
(B) in subparagraph (B), by inserting ``or a
participating emergency facility, as applicable,''
after ``participating provider''; and
(C) in subparagraph (C)--
(i) in the matter preceding clause (i), by
inserting ``by a nonparticipating provider or a
nonparticipating emergency facility'' after
``enrollee'';
(ii) by striking clause (i);
(iii) by striking ``(ii)(I) such services''
and inserting ``(i) such services'';
(iv) by striking ``where the provider of
services does not have a contractual
relationship with the plan for the providing of
services'';
(v) by striking ``emergency department
services received from providers who do have
such a contractual relationship with the plan;
and'' and inserting ``emergency services
received from participating providers and
participating emergency facilities with respect
to such plan;'';
(vi) by striking ``(II) if such services''
and all that follows through ``were provided
in-network;'' and inserting the following:
``(ii) the cost-sharing requirement
(expressed as a copayment amount or coinsurance
rate) is not greater than the requirement that
would apply if such services were provided by a
participating provider or a participating
emergency facility;''; and
(vii) by adding at the end the following new
clauses:
``(iii) such requirement is calculated as if
the total amount that would have been charged
for such services by such participating
provider or participating emergency facility
were equal to--
``(I) in the case of such services
furnished in a State described in
paragraph (3)(H)(ii), the median
contracted rate (as defined in
paragraph (3)(E)(i)) for such services;
and
``(II) in the case of such services
furnished in a State described in
paragraph (3)(H)(i), the lesser of--
``(aa) the amount determined
by such State for such services
in accordance with the method
described in such paragraph;
and
``(bb) the median contracted
rate (as so defined) for such
services;
``(iv) the health plan pays to such provider
or facility, respectively, the amount by which
the recognized amount (as defined in paragraph
(3)(H)) for such services exceeds the cost-
sharing amount for such services (as determined
in accordance with clauses (ii) and (iii)); and
``(v) any cost-sharing payments made by the
participant, beneficiary, or enrollee with
respect to such emergency services so furnished
shall be counted toward any in-network
deductible or out-of-pocket maximums applied
under the plan (and such in-network deductible
shall be applied) in the same manner as if such
cost-sharing payments were with respect to
emergency services furnished by a participating
provider and a participating emergency
facility; and'';
(2) by redesignating paragraph (2) as paragraph (3);
(3) by inserting after paragraph (1) the following new
paragraph:
``(2) Audit process for median contracted rates.--
``(A) In general.--Not later than July 1, 2020, the
Secretary, in consultation with appropriate State
agencies, shall establish through rulemaking a process,
in accordance with subparagraph (B), under which health
plans are audited by such Secretaries to ensure that--
``(i) such plans are in compliance with the
requirement of applying a median contracted
rate under this section; and
``(ii) that such median contracted rate so
applied satisfies the definition under
paragraph (3)(E) with respect to the year
involved, including with respect to a health
plan described in clause (ii) of such
paragraph.
``(B) Audit samples.--Under the process established
pursuant to subparagraph (A), the Secretary--
``(i) shall conduct audits described in such
subparagraph, with respect to a year (beginning
with 2021), of a sample with respect to such
year of claims data from not more than 25
health plans; and
``(ii) may audit any health plan if the
Secretary has received any complaint about such
plan that involves the compliance of the plan
with either of the requirements described in
clauses (i) and (ii) of such subparagraph.'';
and
(4) in paragraph (3), as redesignated by paragraph (2) of
this subsection--
(A) in the matter preceding subparagraph (A), by
inserting ``and subsection (e)'' after ``this
subsection'';
(B) by redesignating subparagraphs (A) through (C) as
subparagraphs (B) through (D), respectively;
(C) by inserting before subparagraph (B), as
redesignated by subparagraph (B) of this paragraph, the
following new subparagraph:
``(A) Emergency department of a hospital.--The term
`emergency department of a hospital' includes a
hospital outpatient department that provides emergency
services.'';
(D) by amending subparagraph (C), as redesignated by
subparagraph (B) of this paragraph, to read as follows:
``(C) Emergency services.--
``(i) In general.--The term `emergency
services', with respect to an emergency medical
condition, means--
``(I) a medical screening examination
(as required under section 1867 of the
Social Security Act, or as would be
required under such section if such
section applied to an independent
freestanding emergency department) that
is within the capability of the
emergency department of a hospital or
of an independent freestanding
emergency department, as applicable,
including ancillary services routinely
available to the emergency department
to evaluate such emergency medical
condition; and
``(II) within the capabilities of the
staff and facilities available at the
hospital or the independent
freestanding emergency department, as
applicable, such further medical
examination and treatment as are
required under section 1867 of such
Act, or as would be required under such
section if such section applied to an
independent freestanding emergency
department, to stabilize the patient.
``(ii) Inclusion of poststabilization
services.--For purposes of this subsection and
section 2799, in the case of an individual
enrolled in a health plan who is furnished
services described in clause (i) by a provider
or facility to stabilize such individual with
respect to an emergency medical condition, the
term `emergency services' shall include such
items and services in addition to those
described in clause (i) that such a provider or
facility determines are needed to be furnished
(after such stabilization but during such visit
in which such individual is so stabilized) to
such individual, unless each of the following
conditions are met:
``(I) Such a provider or facility
determines such individual is able to
travel using nonmedical transportation
or nonemergency medical transportation.
``(II) Such provider furnishing such
additional items and services is in
compliance with section 2799A(d) with
respect to such items and services.'';
(E) by redesignating subparagraph (D), as
redesignated by subparagraph (B) of this paragraph, as
subparagraph (I); and
(F) by inserting after subparagraph (C), as
redesignated by subparagraph (B) of this paragraph, the
following new subparagraphs:
``(D) Independent freestanding emergency
department.--The term `independent freestanding
emergency department' means a facility that--
``(i) is geographically separate and distinct
and licensed separately from a hospital under
applicable State law; and
``(ii) provides emergency services.
``(E) Median contracted rate.--
``(i) In general.--The term `median
contracted rate' means, with respect to an item
or service and a health plan (as defined in
subsection (e)(2)(A))--
``(I) for 2021, the median of the
negotiated rates recognized by the
sponsor or issuer of such plan
(determined with respect to all such
plans of such sponsor or such issuer
that are within the same line of
business) as the total maximum payment
(including the cost-sharing amount
imposed for such services (as
determined in accordance with clauses
(ii) and (iii) of paragraph (1)(C) or
subparagraphs (A) and (B) of subsection
(e)(1), as applicable) and the amount
to be paid by the plan or issuer) under
such plans in 2019 for the same or a
similar item or service that is
provided by a provider in the same or
similar specialty and provided in the
geographic region in which the item or
service is furnished, consistent with
the methodology established by the
Secretary under section 402(e) of the
No Surprises Act, increased by the
percentage increase in the consumer
price index for all urban consumers
(United States city average) over 2019
and 2020; and
``(II) for 2022 and each subsequent
year, the median contracted rate
determined under this clause for the
previous year, increased by the
percentage increase in the consumer
price index for all urban consumers
(United States city average) over such
previous year.
``(ii) Special rule.--The Secretary shall
provide pursuant to rulemaking described in
section 402(e) of the No Surprises Act that--
``(I) if the sponsor or issuer of a
health plan does not have sufficient
information to calculate a median
contracted rate for an item or service
or provider type, or amount of, claims
for items or services (as determined by
the Secretary) provided in a particular
geographic area (other than in a case
described in item (bb)), such sponsor
or issuer shall demonstrate that such
sponsor or issuer will use any database
free of conflicts of interest that has
sufficient information reflecting
allowed amounts paid to a health care
provider for relevant services provided
in the applicable geographic region
(such as State All Payer Claims
Databases (as defined in section 404(d)
of such Act)), and that such sponsor or
issuer will use any such database to
determine a median contracted rate and
cover the cost of accessing any such
database; and
``(II) in the case of a sponsor or
issuer offering a health plan in a
geographic region that did not offer
any health plan in such region during
2019, such sponsor or issuer shall use
a methodology established by the
Secretary for determining the median
contracted rate for items and services
covered by such plan for the first year
in which such plan is offered in such
region, and that, for each succeeding
year, the median contracted rate for
such items and services under such plan
shall be the median contracted rate for
such items and services under such plan
for the previous year, increased by the
percentage increase in the consumer
price index for all urban consumers
(United States city average) over such
previous year.
``(F) Nonparticipating emergency facility;
participating emergency facility.--
``(i) Nonparticipating emergency facility.--
The term `nonparticipating emergency facility'
means, with respect to an item or service and a
health plan, an emergency department of a
hospital, or an independent freestanding
emergency department, that does not have a
contractual relationship with the plan (or, if
applicable, issuer offering the plan) for
furnishing such item or service under the plan.
``(ii) Participating emergency facility.--The
term `participating emergency facility' means,
with respect to an item or service and a health
plan, an emergency department of a hospital, or
an independent freestanding emergency
department, that has a contractual relationship
with the plan (or, if applicable, issuer
offering the plan) for furnishing such item or
service under the plan.
``(G) Nonparticipating providers; participating
providers.--
``(i) Nonparticipating provider.--The term
`nonparticipating provider' means, with respect
to an item or service and a health plan, a
physician or other health care provider who is
acting within the scope of practice of that
provider's license or certification under
applicable State law and who does not have a
contractual relationship with the plan (or, if
applicable, issuer offering the plan) for
furnishing such item or service under the plan.
``(ii) Participating provider.--The term
`participating provider' means, with respect to
an item or service and a health plan, a
physician or other health care provider who is
acting within the scope of practice of that
provider's license or certification under
applicable State law and who has a contractual
relationship with the plan (or, if applicable,
issuer offering the plan) for furnishing such
item or service under the plan.
``(H) Recognized amount.--The term `recognized
amount' means, with respect to an item or service--
``(i) in the case of such item or service
furnished in a State that has in effect a State
law that provides for a method for determining
the amount of payment that is required to be
covered by a health plan regulated by such
State in the case of a participant,
beneficiary, or enrollee covered under such
plan and receiving such item or service from a
nonparticipating provider or facility, not more
than the amount determined in accordance with
such law plus the cost-sharing amount imposed
under the plan for such item or service (as
determined in accordance with clauses (ii) and
(iii) of paragraph (1)(C) or subparagraphs (A)
and (B) of subsection (e)(1), as applicable);
or
``(ii) in the case of such item or service
furnished in a State that does not have in
effect such a law, an amount that is at least
the median contracted rate (as defined in
subparagraph (E)(i) and determined in
accordance with rulemaking described in section
402(e) of the No Surprises Act) for such item
or service.''.
(b) Coverage of Non-emergency Services Performed by Nonparticipating
Providers at Certain Participating Facilities; Independent Dispute
Resolution Process.--Section 2719A of the Public Health Service Act (42
U.S.C. 300gg-19a) is amended by adding at the end the following new
subsections:
``(e) Coverage of Non-emergency Services Performed by
Nonparticipating Providers at Certain Participating Facilities.--
``(1) In general.--Subject to paragraph (3), in the case of
items or services (other than emergency services to which
subsection (b) applies) furnished to a participant,
beneficiary, or enrollee of a health plan (as defined in
paragraph (2)(A)) by a nonparticipating provider (as defined in
subsection (b)(3)(G)(i)) during a visit (as defined by the
Secretary in accordance with paragraph (2)(C)) at a
participating health care facility (as defined in paragraph
(2)(B)), with respect to such plan, the plan--
``(A) shall not impose on such participant,
beneficiary, or enrollee a cost-sharing amount
(expressed as a copayment amount or coinsurance rate)
for such items and services so furnished that is
greater than the cost-sharing amount that would apply
under such plan had such items or services been
furnished by a participating provider (as defined in
subsection (b)(3)(G)(ii));
``(B) shall calculate such cost-sharing amount as if
the amount that would have been charged for such items
and services by such participating provider were equal
to--
``(i) in the case of such items and services
furnished in a State described in subsection
(b)(3)(H)(ii), the median contracted rate (as
defined in subsection (b)(3)(E)(i)) for such
items and services; and
``(ii) in the case of such items and services
furnished in a State described in subsection
(b)(3)(H)(i), the lesser of--
``(I) the amount determined by such
State for such items and services in
accordance with the method described in
such subsection; and
``(II) the median contracted rate (as
so defined) for such items and
services;
``(C) shall pay to such provider furnishing such
items and services to such participant, beneficiary, or
enrollee the amount by which the recognized amount (as
defined in subsection (b)(3)(H)) for such items and
services exceeds the cost-sharing amount imposed under
the plan for such items and services (as determined in
accordance with subparagraphs (A) and (B)); and
``(D) shall count toward any in-network deductible or
out-of-pocket maximums applied under the plan any cost-
sharing payments made by the participant, beneficiary,
or enrollee (and such in-network deductible shall be
applied) with respect to such items and services so
furnished in the same manner as if such cost-sharing
payments were with respect to items and services
furnished by a participating provider.
``(2) Definitions.--In this subsection and subsection (b):
``(A) Health plan.--The term `health plan' means a
group health plan and health insurance coverage offered
by a heath insurance issuer in the group or individual
market and includes a grandfathered health plan (as
defined in section 1251(e) of the Patient Protection
and Affordable Care Act).
``(B) Participating health care facility.--
``(i) In general.--The term `participating
health care facility' means, with respect to an
item or service and a health plan, a health
care facility described in clause (ii) that has
a contractual relationship with the plan (or,
if applicable, issuer offering the plan) for
furnishing such item or service.
``(ii) Health care facility described.--A
health care facility described in this clause
is each of the following:
``(I) A hospital (as defined in
1861(e) of the Social Security Act).
``(II) A critical access hospital (as
defined in section 1861(mm) of such
Act).
``(III) An ambulatory surgical center
(as defined in section 1833(i)(1)(A) of
such Act).
``(IV) A laboratory.
``(V) A radiology facility or imaging
center.
``(C) During a visit.--The term `during a visit'
shall, with respect to items and services furnished to
an individual at a participating health care facility,
include equipment and devices, telemedicine services,
imaging services, laboratory services, and such other
items and services as the Secretary may specify,
regardless of whether or not the provider furnishing
such items or services is at the facility.
``(3) Exception.--Paragraph (1) shall not apply to a health
plan in the case of items or services (other than emergency
services to which subsection (b) applies) furnished to a
participant, beneficiary, or enrollee of a health plan (as
defined in paragraph (2)(A)) by a nonparticipating provider (as
defined in subsection (b)(3)(G)(i)) during a visit (as defined
by the Secretary in accordance with paragraph (2)(C)) at a
participating health care facility (as defined in paragraph
(2)(B)) if such provider is in compliance with section 2799A(d)
with respect to such items and services.
``(f) Independent Dispute Resolution Process.--
``(1) Establishment.--
``(A) In general.--Not later than 1 year after the
date of the enactment of this subsection, the
Secretary, in consultation with the Secretary of Labor,
shall establish by regulation an independent dispute
resolution process (referred to in this subsection as
the `IDR process') under which--
``(i) a nonparticipating provider (as defined
in subparagraph (G) of subsection (b)(3)),
nonparticipating emergency facility (as defined
in subparagraph (F) of such subsection), or
health plan (as defined in subsection
(e)(2)(A)) may submit a request for resolution
by an entity certified under paragraph (2) (in
this subsection referred to as a `certified IDR
entity') of a specified claim; and
``(ii) in the case a settlement described in
subparagraph (B) of paragraph (4) is not
reached with respect to such claim, such entity
so resolves such claim in accordance with such
paragraph.
``(B) Definitions.--In this subsection:
``(i) Specified claim.--
``(I) In general.--Subject to
subclause (II), the term `specified
claim' means a claim by a
nonparticipating provider, a
nonparticipating emergency facility, or
a health plan with respect to
qualifying items and services (as
defined in clause (ii)) furnished by
such provider or facility in a State
described in subparagraph (H)(ii) of
subsection (b)(3) for which a health
plan is required to make payment
pursuant to subsection (b)(1) or
subsection (e)(1)--
``(aa) that such payment
should be increased or
decreased; and
``(bb) that is made not later
than--
``(AA) in the case of
such a claim filed by
such a provider or
facility, the date on
which the appeal with
respect to such items
and services described
in clause
(ii)(I)(aa)(AA) has
been resolved (or the
date that is 30 days
after such appeal is
filed, whichever is
earlier); or
``(BB) in the case of
such a claim filed by
such plan, the date on
which the period
described in clause
(ii)(I)(bb)(BB) with
respect to such items
and services elapses.
``(II) Limitation on packaging of
items and services in a specified
claim.--The term `specified claim'
shall not include, in the case such
claim is made by such provider,
facility, or plan with respect to
multiple items and services, any claim
with respect to items and services
furnished by such provider or facility
if--
``(aa) such items and
services were not furnished by
the same provider or facility;
``(bb) payment for such items
and services made pursuant to
subsection (b)(1) or subsection
(e)(1) was made by multiple
health plans;
``(cc) such items and
services are not related to the
treatment of the same
condition; or
``(dd) such items and
services were not furnished
within 30 days of the date of
the earliest item or service
furnished that is included in
such claim.
``(ii) Qualifying items and services.--
``(I) In general.--Subject to
subclause (II), the term `qualifying
items and services' means--
``(aa) with respect to a
specified claim made by a
nonparticipating provider or
nonparticipating emergency
facility, items and services
furnished by such provider or
facility for which a health
plan is required to make
payment pursuant to subsection
(b)(1) or subsection (e)(1),
but only if--
``(AA) such items and
services are included
in an appeal filed
under such plan's
internal appeals
process not later than
30 days after such
payment is received;
and
``(BB) such appeal
under such plan's
internal appeals
process has been
resolved, or a 30-day
period has elapsed
since such appeal was
so filed; and
``(bb) with respect to a
specified claim made by a
health plan, items and services
furnished by such a provider or
facility for which such health
plan is required to make
payment pursuant to subsection
(b)(1) or subsection (e)(1),
but only if--
``(AA) such plan
submits a notice to
such provider or
facility not later than
30 days after such
provider or facility
receives such payment
that such plan disputes
the amount of such
payment with respect to
such items and
services; and
``(BB) a 30-day
period has elapsed
since the submission of
such notice.
``(II) Limitation.--The term
`qualifying items and services' shall
not include an item or service
furnished in a geographic area during a
year by such provider or facility for
which a health plan is required to make
payment pursuant to subsection (b)(1)
or subsection (e)(1) if the median
contracted rate (as defined in
subsection (b)(3)(E)) under such plan
for such year with respect to such item
or service furnished by such a provider
or such a facility in such area does
not exceed--
``(aa) with respect to an
item or service furnished
during 2021, $1,250; and
``(bb) with respect to an
item or service furnished
during a subsequent year, the
amount specified under this
subclause for the previous
year, increased by the
percentage increase in the
consumer price index for all
urban consumers (United States
city average) over such
previous year.
``(2) Certification of entities.--
``(A) Process of certification.--The process
described in paragraph (1) shall include a
certification process under which eligible entities may
be certified to carry out the IDR process.
``(B) Eligibility.--
``(i) In general.--For purposes of
subparagraph (A), an eligible entity is an
entity that is a nongovernmental entity that
agrees to comply with the fee limitations
described in clause (ii).
``(ii) Fee limitation.--For purposes of
clause (i), the fee limitations described in
this clause are limitations established by the
Secretary on the amount a certified IDR entity
may charge a nonparticipating provider,
nonparticipating emergency facility, or health
plan for services furnished by such entity with
respect to the resolution of a specified claim
of such provider, facility, or plan under the
process described in paragraph (1).
``(3) Selection of certified idr entity for a specified
claim.--With respect to the resolution of a specified claim
under the IDR process, the health plan and the nonparticipating
provider or the nonparticipating emergency facility (as
applicable) involved shall agree on a certified IDR entity to
resolve such claim. In the case that such plan and such
provider or facility (as applicable) cannot so agree, such an
entity shall be selected by the Secretary at random.
``(4) Payment determination.--
``(A) Timing.--A certified IDR entity selected under
paragraph (3) by a health plan and a nonparticipating
provider or a nonparticipating emergency facility (as
applicable) with respect to a specified claim shall,
subject to subparagraph (B), not later than 30 days
after being so selected, determine the total
reimbursement that should have been made for items and
services included in such claim in accordance with
subparagraph (C).
``(B) Settlement.--
``(i) In general.--If such entity determines
that a settlement between the health plan and
the provider or facility is likely with respect
to a specified claim, the entity may direct the
parties to attempt, for a period not to exceed
10 days, a good faith negotiation for a
settlement of such claim.
``(ii) Timing.--The period for a settlement
described in clause (i) shall accrue towards
the 30-day period described in subparagraph
(A).
``(C) Determination of amount.--
``(i) In general.--The health plan and the
nonparticipating provider or nonparticipating
emergency facility (as applicable) shall, with
respect to a specified claim, each submit to
the certified IDR entity a final offer of
payment or reimbursement (as applicable) with
respect to items and services which are the
subject of the specified claim. Such entity
shall determine which such offer is the most
reasonable in accordance with clause (ii).
``(ii) Considerations in determination.--
``(I) In general.--In determining
which final offer is the most
reasonable under clause (i), the
certified IDR entity shall consider--
``(aa) the median contracted
rates (as defined in subsection
(b)(3)(E)) for items or
services that are comparable to
the items and services included
in the specified claim and that
are furnished in the same
geographic area (as defined by
the Secretary for purposes of
such subsection) as such items
and services (not including any
facility fees with respect to
such rates); and
``(bb) the circumstances
described in subclause (II), if
any information with respect to
such circumstances is submitted
by either party.
``(II) Additional circumstances.--For
purposes of subclause (I)(bb), the
circumstances described in this
subclause are, with respect to items
and services included in the specified
claim of a nonparticipating provider,
nonparticipating emergency facility, or
health plan, the following:
``(aa) The level of training,
education, experience, and
quality and outcomes
measurements of the provider or
facility that furnished such
items and services.
``(bb) Any other extenuating
circumstances with respect to
the furnishing of such items
and services that relate to the
acuity of the individual
receiving such items and
services or the complexity of
furnishing such items and
services to such individual.
``(III) Prohibition on consideration
of billed charges.--In determining
which final offer is the most
reasonable under clause (i) with
respect to items and services furnished
by a provider or facility and included
in a specified claim, the certified IDR
entity may not consider the amount that
would have been billed by such provider
or facility with respect to such items
and services had the provisions of
section 2799 or 2799A (as applicable)
not applied.
``(iii) Effect of determination.--A
determination of a certified IDR entity under
clause (i)--
``(I) shall be binding; and
``(II) shall not be subject to
judicial review, except in a case
described in any of paragraphs (1)
through (4) of section 10(a) of title
9, United States Code.
``(iv) Costs of independent dispute
resolution process.--In the case of a specified
claim made by a nonparticipating provider,
nonparticipating emergency facility, or health
plan and submitted to a certified IDR entity--
``(I) if such entity makes a
determination with respect to such
claim under clause (i), the party whose
offer is not chosen under such clause
shall be responsible for paying all
fees charged by such entity; and
``(II) if the parties reach a
settlement with respect to such claim
prior to such a determination, such
fees shall be divided equally between
the parties, unless the parties
otherwise agree.
``(v) Payment.--Not later than 30 days after
a determination described in clause (i) is made
with respect to a specified claim of a
nonparticipating provider, nonparticipating
emergency facility, or health plan--
``(I) in the case that such
determination finds that the amount
paid with respect to such specified
claim by the health plan should have
been greater than the amount so paid,
such plan shall pay directly to the
provider or facility (as applicable)
the difference between the amount so
paid and the amount so determined; and
``(II) in the case that such
determination finds that the amount
paid with respect to such specified
claim by the health plan should have
been less than the amount so paid, the
provider or facility (as applicable)
shall pay directly to the plan the
difference between the amount so paid
and the amount so determined.
``(5) Publication of information relating to disputes.--
``(A) In general.--For 2021 and each subsequent year,
the Secretary and the Secretary of Labor shall publish
on the public website of the Department of Health and
Human Services and the Department of Labor,
respectively--
``(i) the number of specified claims filed
during such year;
``(ii) the number of such claims with respect
to which a final determination was made under
paragraph (4)(C)(i); and
``(iii) the information described in
subparagraph (B) with respect to each specified
claim with respect to which such a decision was
so made.
``(B) Information with respect to specified claims.--
For purposes of subparagraph (A), the information
described in this subparagraph is, with respect to a
specified claim of a nonparticiapting provider,
nonparticipating emergency facility, or health plan--
``(i) a description of each item and service
included in such claim;
``(ii) the amount of the offer submitted
under paragraph (4)(C)(i) by the health plan
and by the nonparticipating provider or
nonparticipating emergency facility (as
applicable);
``(iii) whether the offer selected by the
certified IDR entity under such paragraph was
the offer submitted by such plan or by such
provider or facility (as applicable) and the
amount of such offer so selected; and
``(iv) the category and practice specialty of
each such provider or facility involved in
furnishing such items and services.
``(C) Confidentiality of parties.--None of the
information published under this paragraph may specify
the identity of a health plan, provider, facility, or
individual with respect to a specified claim.''.
(c) Provider Directory Requirements; Disclosure on Patient
Protections.--Section 2719A of the Public Health Service Act, as
amended by subsection (b), is further amended by adding at the end the
following new subsections:
``(g) Provider Directory Information Requirements.--
``(1) In general.--Not later than 1 year after the date of
the enactment of this subsection, each group health plan and
health insurance issuer offering group or individual health
insurance coverage shall--
``(A) establish the verification process described in
paragraph (2);
``(B) establish the response protocol described in
paragraph (3);
``(C) establish the database described in paragraph
(4); and
``(D) include in any print directory containing
provider directory information with respect to such
plan or such coverage the information described in
paragraph (5).
``(2) Verification process.--The verification process
described in this paragraph is, with respect to a group health
plan or a health insurance issuer offering group or individual
health insurance coverage, a process--
``(A) under which not less frequently than once every
90 days, such plan or such issuer (as applicable)
verifies and updates the provider directory information
included on the database described in paragraph (4) of
such plan or issuer of each health care provider and
health care facility included in such database; and
``(B) that establishes a procedure for the removal of
such a provider or facility with respect to which such
plan or issuer has been unable to verify such
information during a period specified by the plan or
issuer.
``(3) Response protocol.--The response protocol described in
this paragraph is, in the case of an individual enrolled under
a group health plan or group or individual health insurance
coverage offered by a health insurance issuer who requests
information on whether a health care provider or health care
facility has a contractual relationship to furnish items and
services under such plan or such coverage, a protocol under
which such plan or such issuer (as applicable), in the case
such request is made through a telephone call--
``(A) responds to such individual as soon as
practicable and in no case later than 1 business day
after such call is received through a written
electronic communication; and
``(B) retains such communication in such individual's
file for at least 2 years following such response.
``(4) Database.--The database described in this paragraph is,
with respect to a group health plan or health insurance issuer
offering group or individual health insurance coverage, a
database on the public website of such plan or issuer that
contains--
``(A) a list of each health care provider and health
care facility with which such plan or such issuer has a
contractual relationship for furnishing items and
services under such plan or such coverage; and
``(B) provider directory information with respect to
each such provider and facility.
``(5) Information.--The information described in this
paragraph is, with respect to a print directory containing
provider directory information with respect to a group health
plan or individual or group health insurance coverage offered
by a health insurance issuer, a notification that such
information contained in such directory was accurate as of the
date of publication of such directory and that an individual
enrolled under such plan or such coverage should consult the
database described in paragraph (4) with respect to such plan
or such coverage or contact such plan or the issuer of such
coverage to obtain the most current provider directory
information with respect to such plan or such coverage.
``(6) Definition.--For purposes of this subsection, the term
`provider directory information' includes, with respect to a
group health plan and a health insurance issuer offering group
or individual health insurance coverage, the name, address,
specialty, and telephone number of each health care provider or
health care facility with which such plan or such issuer has a
contractual relationship for furnishing items and services
under such plan or such coverage.
``(h) Disclosure on Patient Protections.--Each group health plan and
health insurance issuer offering group or individual health insurance
coverage shall make publicly available, and (if applicable) post on a
public website of such plan or issuer--
``(1) information in plain language on--
``(A) the requirements and prohibitions applied under
sections 2799 and 2799A (relating to prohibitions on
balance billing in certain
``(B) if provided for under applicable State law, any
other requirements on providers and facilities
regarding the amounts such providers and facilities
may, with respect to an item or service, charge a
participant, beneficiary, or enrollee of such plan or
coverage with respect to which such a provider or
facility does not have a contractual relationship for
furnishing such item or service under the plan or
coverage after receiving payment from the plan or
coverage for such item or service and any applicable
cost-sharing payment from such participant,
beneficiary, or enrollee; and
``(C) the requirements applied under subsections (b)
and (e); and
``(2) information on contacting appropriate State and Federal
agencies in the case that an individual believes that such a
provider or facility has violated any requirement described in
paragraph (1) with respect to such individual.''.
(d) Preventing Certain Cases of Balance Billing.--Title XXVII of the
Public Health Service Act is amended by adding at the end the following
new part:
``PART D--PREVENTING CERTAIN CASES OF BALANCE BILLING
``SEC. 2799. BALANCE BILLING IN CASES OF EMERGENCY SERVICES.
``(a) In General.--In the case of a participant, beneficiary, or
enrollee with benefits under a health plan who is furnished on or after
January 1, 2021, emergency services with respect to an emergency
medical condition during a visit at an emergency department of a
hospital or an independent freestanding emergency department--
``(1) the emergency department of a hospital or independent
freestanding emergency department shall not hold the
participant, beneficiary, or enrollee liable for a payment
amount for such emergency services so furnished that is more
than the cost-sharing amount for such services (as determined
in accordance with clauses (ii) and (iii) of section
2719A(b)(1)(C)); and
``(2) a health care provider shall not hold such participant,
beneficiary, or enrollee liable for a payment amount for an
emergency service furnished to such individual by such provider
with respect to such emergency medical condition and visit for
which the individual receives emergency services at the
hospital or emergency department that is more than the cost-
sharing amount for such services furnished by the provider (as
determined in accordance with clauses (ii) and (iii) of section
2719A(b)(1)(C)).
``(b) Definitions.--In this section:
``(1) The terms `emergency department of a hospital',
`emergency medical condition', `emergency services', and
`independent freestanding emergency department' have the
meanings given such terms, respectively, in section
2719A(b)(3).
``(2) The term `health plan' has the meaning given such term
in section 2719A(e).
``(3) The term `during a visit' shall have such meaning as
applied to such term for purposes of section 2719A(e).
``SEC. 2799A. BALANCE BILLING IN CASES OF NON-EMERGENCY SERVICES
PERFORMED BY NONPARTICIPATING PROVIDERS AT CERTAIN
PARTICIPATING FACILITIES.
``(a) In General.--Subject to subsection (b), in the case of a
participant, beneficiary, or enrollee with benefits under a health plan
(as defined in section 2799(b)) who is furnished on or after January 1,
2021, items or services (other than emergency services to which section
2799 applies) at a participating health care facility by a
nonparticipating provider, such provider shall not hold such
participant, beneficiary, or enrollee liable for a payment amount for
such an item or service furnished by such provider during a visit at
such facility that is more than the cost-sharing amount for such item
or service (as determined in accordance with subparagraphs (A) and (B)
of section 2719A(e)(1)).
``(b) Exception.--
``(1) In general.--Subsection (a) shall not apply to a
nonparticipating provider (other than a specified provider at a
participating health care facility), with respect to items or
services furnished by the provider to a participant,
beneficiary, or enrollee of a health plan, if the provider is
in compliance with the notice and consent requirements of
subsection (d).
``(2) Specified provider defined.--For purposes of paragraph
(1), the term `specified provider', with respect to a
participating health care facility--
``(A) means a facility-based provider, including
emergency medicine providers, anesthesiologists,
pathologists, radiologists, neonatologists, assistant
surgeons, hospitalists, intensivists, or other
providers as determined by the Secretary; and
``(B) includes, with respect to an item or service, a
nonparticipating provider if there is no participating
provider at such facility who can furnish such item or
service.
``(c) Clarification.--In the case of a nonparticipating provider
(other than a specified provider at a participating health care
facility) that complies with the notice and consent requirements of
subsection (d) with respect to an item or service (referred to in this
subsection as a `covered item or service'), such notice and consent
requirements may not be construed as applying with respect to any item
or service that is furnished as a result of unforeseen medical needs
that arise at the time such covered item or service is furnished.
``(d) Compliance With Notice and Consent Requirements.--
``(1) In general.--A nonparticipating provider or
nonparticipating facility is in compliance with this
subsection, with respect to items or services furnished by the
provider or facility to a participant, beneficiary, or enrollee
of a health plan, if the provider (or, if applicable, the
participating health care facility on behalf of such provider)
or nonparticipating facility--
``(A) provides to the participant, beneficiary, or
enrollee (or to an authorized representative of the
participant, beneficiary, or enrollee) on the date on
which the individual is furnished such items or
services and, in the case that the participant,
beneficiary, or enrollee makes an appointment to be
furnished such items or services, on such date the
appointment is made--
``(i) an oral explanation of the written
notice described in clause (ii); and
``(ii) a written notice specified by the
Secretary, not later than July 1, 2020, through
guidance (which shall be updated as determined
necessary by the Secretary) that--
``(I) contains the information
required under paragraph (2); and
``(II) is signed and dated by the
participant, beneficiary, or enrollee
(or by an authorized representative of
the participant, beneficiary, or
enrollee) and, with respect to items or
services to be furnished by such a
provider that are not poststabilization
services described in section
2719A(b)(3)(C)(ii), is so signed and
dated not less than 72 hours prior to
the participant, beneficiary, or
enrollee being furnished such items or
services by such provider; and
``(B) obtains from the participant, beneficiary, or
enrollee (or from such an authorized representative)
the consent described in paragraph (3).
``(2) Information required under written notice.--For
purposes of paragraph (1)(A)(ii)(I), the information described
in this paragraph, with respect to a nonparticipating provider
or nonparticipating facility and a participant, beneficiary, or
enrollee of a health plan, is each of the following:
``(A) Notification, as applicable, that the health
care provider is a nonparticipating provider with
respect to the health plan or the health care facility
is a nonparticipating facility with respect to the
health plan.
``(B) Notification of the estimated amount that such
provider or facility may charge the participant,
beneficiary, or enrollee for such items and services
involved.
``(C) In the case of a nonparticipating facility, a
list of any participating providers at the facility who
are able to furnish such items and services involved
and notification that the participant, beneficiary, or
enrollee may be referred, at their option, to such a
participating provider.
``(3) Consent described.--For purposes of paragraph (1)(B),
the consent described in this paragraph, with respect to a
participant, beneficiary, or enrollee of a health plan who is
to be furnished items or services by a nonparticipating
provider or nonparticipating facility, is a document specified
by the Secretary through rulemaking that--
``(A) is signed by the participant, beneficiary, or
enrollee (or by an authorized representative of the
participant, beneficiary, or enrollee) and, with
respect to items or services to be furnished by such a
provider or facility that are not poststabilization
services described in section 2719A(b)(3)(C)(ii), is so
signed not less than 72 hours prior to the participant,
beneficiary, or enrollee being furnished such items or
services by such provider or facility;
``(B) acknowledges that the participant, beneficiary,
or enrollee has been--
``(i) provided with a written estimate and an
oral explanation of the charge that the
participant, beneficiary, or enrollee will be
assessed for the items or services anticipated
to be furnished to the participant,
beneficiary, or enrollee by such provider or
facility; and
``(ii) informed that the payment of such
charge by the participant, beneficiary, or
enrollee may not accrue toward meeting any
limitation that the health plan places on cost-
sharing; and
``(C) documents the consent of the participant,
beneficiary, or enrollee to--
``(i) be furnished with such items or
services by such provider or facility; and
``(ii) in the case that the individual is so
furnished such items or services, be charged an
amount that may be greater than the amount that
would otherwise be charged the individual if
furnished by a participating provider or
participating facility with respect to such
items or services and plan.
``(e) Retention of Certain Documents.--A nonparticipating provider
(or, in the case of a nonparticipating provider at a participating
health care facility, such facility) or nonparticipating facility that
obtains from a participant, beneficiary, or enrollee of a health plan
(or an authorized representative of such participant, beneficiary, or
enrollee) a written notice in accordance with subsection (c)(1)(ii),
with respect to furnishing an item or service to such participant,
beneficiary, or enrollee, shall retain such notice for at least a 2-
year period after the date on which such item or service is so
furnished.
``(f) Definitions.--In this section:
``(1) The terms `nonparticipating provider' and
`participating provider' have the meanings given such terms,
respectively, in subsection (b)(3) of section 2719A.
``(2) The terms `participating health care facility' and
`health plan' have the meanings given such terms, respectively,
in subsection (e)(2) of section 2719A.
``(3) The term `nonparticipating facility' means--
``(A) with respect to emergency services (as defined
in section 2719A(b)(3)(C)(i)) and a health plan, an
emergency department of a hospital, or an independent
freestanding emergency department, that does not have a
contractual relationship with the plan (or, if
applicable, issuer offering the plan) for furnishing
such services under the plan; and
``(B) with respect to poststabilization services
described in section 2719A(b)(3)(C)(ii) and a health
plan, an emergency department of a hospital (or other
department of such hospital), or an independent
freestanding emergency department, that does not have a
contractual relationship with the plan (or, if
applicable, issuer offering the plan) for furnishing
such services under the plan.
``(4) The term `participating facility' means--
``(A) with respect to emergency services (as defined
in section 2719A(b)(3)(C)(i)) and a health plan, an
emergency department of a hospital, or an independent
freestanding emergency department, that has a
contractual relationship with the plan (or, if
applicable, issuer offering the plan) for furnishing
such services under the plan; and
``(B) with respect to poststabilization services
described in section 2719A(b)(3)(C)(ii) and a health
plan, an emergency department of a hospital (or other
department of such hospital), or an independent
freestanding emergency department, that has a
contractual relationship with the plan (or, if
applicable, issuer offering the plan) for furnishing
such services under the plan.
``SEC. 2799B. PROVIDER REQUIREMENTS WITH RESPECT TO PROVIDER DIRECTORY
INFORMATION.
``Not later than 1 year after the date of the enactment of this
section, each health care provider and health care facility shall
establish a process under which such provider or facility transmits, to
each health insurance issuer offering group or individual health
insurance coverage and group health plan with which such provider or
facility has in effect a contractual relationship for furnishing items
and services under such coverage or such plan, provider directory
information (as defined in section 2719A(g)(6)) with respect to such
provider or facility, as applicable. Such provider or facility shall so
transmit such information to such issuer offering such coverage or such
group health plan--
``(1) when the provider or facility enters into such a
relationship with respect to such coverage offered by such
issuer or with respect to such plan;
``(2) when the provider or facility terminates such
relationship with respect to such coverage offered by such
issuer or with respect to such plan;
``(3) when there are any other material changes to such
provider directory information of the provider or facility with
respect to such coverage offered by such issuer or with respect
to such plan; and
``(4) at any other time (including upon the request of such
issuer or plan) determined appropriate by the provider,
facility, or the Secretary.
``SEC. 2799C. PROVIDER REQUIREMENT WITH RESPECT TO PUBLIC PROVISION OF
INFORMATION.
``Each health care provider and health care facility shall make
publicly available, and (if applicable) post on a public website of
such provider or facility--
``(1) information in plain language on--
``(A) the requirements and prohibitions of such
provider or facility under sections 2799 and 2799A
(relating to prohibitions on balance billing in certain
circumstances); and
``(B) if provided for under applicable State law, any
other requirements on such provider or facility
regarding the amounts such provider or facility may,
with respect to an item or service, charge a
participant, beneficiary, or enrollee of a health plan
(as defined in section 2719A(e)(2)) with respect to
which such provider or facility does not have a
contractual relationship for furnishing such item or
service under the plan after receiving payment from the
plan for such item or service and any applicable cost-
sharing payment from such participant, beneficiary, or
enrollee; and
``(2) information on contacting appropriate State and Federal
agencies in the case that an individual believes that such
provider or facility has violated any requirement described in
paragraph (1) with respect to such individual.
``SEC. 2799D. ENFORCEMENT.
``(a) State Enforcement.--
``(1) State authority.--Each State may require a provider or
health care facility subject to the requirements of sections
2719A(f), 2799, 2799A, 2799B, or 2799C to satisfy such
requirements applicable to the provider or facility.
``(2) Failure to implement requirements.--In the case of a
determination by the Secretary that a State has failed to
substantially enforce the requirements specified in paragraph
(1) with respect to applicable providers and facilities in the
State, the Secretary shall enforce such requirements under
subsection (b) insofar as they relate to violations of such
requirements occurring in such State.
``(b) Secretarial Enforcement Authority.--
``(1) In general.--If a provider or facility is found to be
in violation specified in subsection (a)(1) by the Secretary,
the Secretary may apply a civil monetary penalty with respect
to such provider or facility in an amount not to exceed $10,000
per violation. The provisions of subsections (c), (d), (e),
(g), (h), (k), and (l) of section 1128A of the Social Security
Act shall apply to a civil monetary penalty or assessment under
this subsection in the same manner as such provisions apply to
a penalty, assessment, or proceeding under subsection (a) of
such section.
``(2) Limitation.--The provisions of paragraph (1) shall
apply to enforcement of a provision (or provisions) specified
in subsection (a)(1) only as provided under subsection (a)(2).
``(3) Complaint process.--The Secretary shall, through
rulemaking, establish a process to receive consumer complaints
of violations of such provisions and resolve such complaints
within 60 days of receipt of such complaints.
``(4) Exception.--The Secretary shall waive the penalties
described under paragraph (1) with respect to a facility or
provider who does not knowingly violate, and should not have
reasonably known it violated, section 2799 or 2799A with
respect to a participant, beneficiary, or enrollee, if such
facility or practitioner, within 30 days of the violation,
withdraws the bill that was in violation of such provision and
reimburses the health plan or enrollee, as applicable, in an
amount equal to the difference between the amount billed and
the amount allowed to be billed under the provision, plus
interest, at an interest rate determined by the Secretary.
``(5) Hardship exemption.--The Secretary may establish a
hardship exemption to the penalties under this subsection.
``(c) Continued Applicability of State Law.--The sections specified
in subsection (a)(1) shall not be construed to supersede any provision
of State law which establishes, implements, or continues in effect any
requirement or prohibition except to the extent that such requirement
or prohibition prevents the application of a requirement or prohibition
of such a section.''.
(e) Rulemaking for Median Contracted Rates.--Not later than July 1,
2020, the Secretary of Health and Human Services, jointly with the
Secretary of Labor, shall establish through rulemaking--
(1) the methodology the sponsor or issuer of a health plan
(as defined in subsection (e) of section 2719A of the Public
Health Service Act (42 U.S.C. 300gg-19a), as added by
subsection (b) of this section) shall use to determine the
median contracted rate (as defined in section 2719A(b) of such
Act, as amended by subsection (a) of this section),
differentiating by business line;
(2) the information such sponsor or issuer shall share with
the nonparticipating provider (as defined in such section)
involved when making such a determination; and
(3) the geographic regions applied for purposes of
subparagraph (E) of section 2719A(b)(3), as amended by
subsection (a) of this section, taking into account the needs
of rural and underserved areas, including health professional
shortage areas.
Such rulemaking shall take into account payments that are made by such
sponsor or issuer that are not on a fee-for-service basis. Such
methodology may account for relevant payment adjustments that take into
account facility type (including higher acuity settings and the case-
mix of various facility types) that are otherwise taken into account
for purposes of determining payment amounts with respect to
participating facilities.
(f) Effective Date.--The amendments made by subsections (a) and (b)
shall apply with respect to plan years beginning on or after January 1,
2021.
SEC. 403. GOVERNMENT ACCOUNTABILITY OFFICE STUDY ON PROFIT- AND
REVENUE-SHARING IN HEALTH CARE.
(a) Study.--The Comptroller General of the United States shall
conduct a study to--
(1) describe what is known about profit- and revenue-sharing
relationships in the commercial health care markets, including
those relationships that--
(A) involve one or more--
(i) physician groups that practice within a
hospital included in the profit- or revenue-
sharing relationship, or refer patients to such
hospital;
(ii) laboratory, radiology, or pharmacy
services that are delivered to privately
insured patients of such hospital;
(iii) surgical services;
(iv) hospitals or group purchasing
organizations; or
(v) rehabilitation or physical therapy
facilities or services; and
(B) include revenue- or profit-sharing whether
through a joint venture, management or professional
services agreement, or other form of gain-sharing
contract;
(2) describe Federal oversight of such relationships,
including authorities of the Department of Health and Human
Services and the Federal Trade Commission to review such
relationships and their potential to increase costs for
patients, and identify limitations in such oversight; and
(3) as appropriate, make recommendations to improve Federal
oversight of such relationships.
(b) Report.--Not later than 2 years after the date of the enactment
of this Act, the Comptroller General of the United States shall prepare
and submit a report on the study conducted under subsection (a) to the
Committee on Health, Education, Labor, and Pensions of the Senate and
the Committee on Education and Labor and Committee on Energy and
Commerce of the House of Representatives.
SEC. 404. STATE ALL PAYER CLAIMS DATABASES.
(a) In General.--The Secretary of Health and Human Services shall
make one-time grants to eligible States for the purposes described in
subsection (b).
(b) Uses.--A State may use a grant received under subsection (a) for
one of the following purposes:
(1) To establish an All Payer Claims Database for the State.
(2) To maintain an existing All Payer Claims Databases for
the State.
(c) Eligibility.--To be eligible to receive a grant under subsection
(a), a State shall submit to the Secretary an application at such time,
in such manner, and containing such information as the Secretary
specifies. Such information shall include, with respect to an All Payer
Claims Database for the State, at least specifics on how the State will
ensure uniform data collection through the database and the security of
such data submitted to and maintained in the database.
(d) All Payer Claims Database.--For purposes of this section, the
term ``All Payer Claims Database'' means, with respect to a State, a
State database that may include medical claims, pharmacy claims, dental
claims, and eligibility and provider files, which are collected from
private and public payers.
(e) Authorization of Appropriations.--To carry out this section,
there are authorized to be appropriated $50,000,000, to remain
available until expended.
SEC. 405. AIR AMBULANCE COST DATA REPORTING PROGRAM.
(a) Cost Data Reporting Program.--
(1) In general.--Not later than 6 months after the date of
the promulgation of the rule under subsection (c), and annually
thereafter, a provider of emergency air medical services shall
submit to the Secretary of Health and Human Services the
information specified in subsection (b) with respect to the
preceding 180-day period (in the case of the initial period)
and the preceding 1-year period (in each subsequent period).
(2) Publication.--Not later than 180 days after the date the
Secretary of Health and Human Services receives from a provider
described in paragraph (1) the information specified in
subsection (b), the Secretary shall make publicly available
such information.
(b) Specified Information.--Information described in subsection (a)
is--
(1) information, with respect to a claim for an item or
service--
(A) identified as paid by health insurance coverage
offered in the group or individual market or a group
health plan (including a self-insured plan);
(B) identified as paid for non-emergent transport
requiring prior authorization and emergent transport;
(C) identified as paid for hospital-affiliated
providers and independent providers;
(D) identified as paid for rural transport and urban
transport;
(E) identified as provided using rotor transport and
fixed wing transport; and
(F) identified as furnished by a provider of
emergency air medical services that has a contractual
relationship with the plan or coverage of an individual
for which such item or service is provided and such a
provider that does not have a contractual relationship
with the plan or coverage or such an individual; and
(2) cost data for an air ambulance service furnished by such
a provider of emergency air medical services that the Secretary
of Health and Human Services, in consultation with suppliers
and providers of such services, determines appropriate,
separated by the cost of air travel and the cost of emergency
medical services and supplies.
(c) Rulemaking.--Not later than 1 year after the date of the
enactment of this Act, the Secretary of Health and Human Services shall
determine the form and manner for submitting the information described
in subsection (b) through notice and comment rulemaking.
(d) Civil Monetary Penalties.--
(1) In general.--A provider of emergency air medical services
who violates the requirements of subsection (a)(1) shall be
subject to a civil monetary penalty of not more than $10,000
for each act constituting such violation.
(2) Procedure.--The provisions of section 1128A of the Social
Security Act (42 U.S.C. 1320a-7a), other than subsections (a)
and (b) and the first sentence of subsection (c)(1) of such
subsection, shall apply to civil monetary penalties under this
subsection in the same manner as such provisions apply to a
penalty or proceeding under such section.
(e) Reporting.--
(1) Secretary of health and human services.--Not later than
July 1, 2023, the Secretary of Health and Human Services shall
submit to Congress a report summarizing the information and
data specified in subsection (b).
(2) Comptroller general.--Not later than July 1, 2023, the
Comptroller General of the United States shall submit to
Congress a report that includes--
(A) an analysis of the cost variation of providers of
emergency air ambulance services by geography and
status; and
(B) any other recommendations the Comptroller General
determines appropriate, which may include a
recommendation of an adequate amount of reimbursement
for such services that reflects operational costs of
such providers in order to preserve access to emergency
air ambulance services.
(f) Limitation.--The information publicly disclosed under subsection
(a) and the reports under subsection (f) may not contain any
proprietary information.
SEC. 406. REPORT BY SECRETARY OF LABOR.
Not later than one year after the date of the enactment of this Act,
and annually thereafter for each of the following 5 years, the
Secretary of Labor shall--
(1) conduct a study of--
(A) the effects of the provisions of, including
amendments made by, this Act on premiums and out-of-
pocket costs in group health plans, including out-of-
pocket costs that are permitted by reason of compliance
with section 2799A(d) of the Public Health Service Act,
as added by section 2(d);
(B) the adequacy of provider networks in group health
plans; and
(C) such other effects of such provisions, and
amendments, as the Secretary deems relevant; and
(2) submit a report on such study to the Committee on Health,
Education, Labor, and Pensions of the Senate and the Committee
on Education and Labor and the Committee on Energy and Commerce
of the House of Representatives.
SEC. 407. BILLING STATUTE OF LIMITATIONS.
Notwithstanding any other provision of law, a health care provider or
health care facility (or health insurance issuer offering health
insurance coverage or group health plan) may not initiate a process to
seek reimbursement from an individual for a service furnished by such
provider or facility to such individual more than a year after such
date of service. Any provider, facility, issuer, or plan that bills an
individual in violation of the previous sentence shall be subject to a
civil monetary penalty in such amount as specified by the Secretary of
Health and Human Services.
SEC. 408. GAO REPORT ON IMPACT OF SURPRISE BILLING PROVISIONS.
Not later than 3 years after the date of the enactment of this Act,
the Comptroller General of the United States shall submit to Congress a
report containing the following:
(1) What is known about the impacts of the provisions of this
Act, including the amendments made by this Act, on the
incidence and prevalence of the furnishing of items and
services to individuals enrolled under a group health plan or
health insurance coverage by health care providers and health
care facilities that do not have a contractual relationship
with such plan or such coverage (as applicable) for furnishing
such items and services to such an individual.
(2) What is known about such impacts on provider shortages
and accessibility to such providers, focusing on rural and
medically underserved communities.
(3) The number of grants that have been awarded under section
404 (relating to State All Payer Claims Databases) and for what
purposes States have used funds made available under such
grants.
(4) An analysis of how data made available through State All
Payer Claims Databases receiving funding under such grants has
been used.
SEC. 409. REPORT BY THE SECRETARY OF HEALTH AND HUMAN SERVICES.
Not later than one year after the date of the enactment of this Act,
and annually thereafter for each of the following 5 years, the
Secretary of Health and Human Services shall--
(1) conduct a study of--
(A) the effects of the provisions of, including
amendments made by, this Act on premiums and out-of-
pocket costs with respect to individual health
insurance coverage and small group health plans;
(B) the adequacy of provider networks with respect to
individual health insurance coverage and small group
health plans, taking into consideration maximum travel
time and distance; and
(C) such other effects of such provisions, and
amendments, as the Secretary deems relevant; and
(2) submit a report on such study to the Committee on Health,
Education, Labor, and Pensions of the Senate and the Committee
on Education and Labor and the Committee on Energy and Commerce
of the House of Representatives.
TITLE V--TERRITORIES HEALTH CARE IMPROVEMENT ACT
SEC. 501. SHORT TITLE.
This title may be cited as the ``Territories Health Care Improvement
Act''.
SEC. 502. MEDICAID PAYMENTS FOR PUERTO RICO AND THE OTHER TERRITORIES
FOR CERTAIN FISCAL YEARS.
(a) Treatment of Cap.--Section 1108(g) of the Social Security Act (42
U.S.C. 1308(g)) is amended--
(1) in paragraph (2)--
(A) in the matter preceding subparagraph (A), by
striking ``subject to and section 1323(a)(2) of the
Patient Protection and Affordable Care Act paragraphs
(3) and (5)'' and inserting ``subject to section
1323(a)(2) of the Patient Protection and Affordable
Care Act and paragraphs (3) and (5)'';
(B) in subparagraph (A)--
(i) by striking ``Puerto Rico shall not
exceed the sum of'' and inserting ``Puerto Rico
shall not exceed--
``(i) except as provided in clause (ii), the
sum of'';
(ii) by striking ``$100,000;'' and inserting
``$100,000; and''; and
(iii) by adding at the end the following new
clause:
``(ii) for each of fiscal years 2020 through
2023, the amount specified in paragraph (6) for
each such fiscal year;'';
(C) in subparagraph (B)--
(i) by striking ``the Virgin Islands shall
not exceed the sum of'' and inserting ``the
Virgin Islands shall not exceed--
``(i) except as provided in clause (ii), the
sum of'';
(ii) by striking ``$10,000;'' and inserting
``$10,000; and''; and
(iii) by adding at the end the following new
clause:
``(ii) for each of fiscal years 2020 through
2025, $126,000,000;'';
(D) in subparagraph (C)--
(i) by striking ``Guam shall not exceed the
sum of'' and inserting ``Guam shall not
exceed--
``(i) except as provided in clause (ii), the
sum of'';
(ii) by striking ``$10,000;'' and inserting
``$10,000; and''; and
(iii) by adding at the end the following new
clause:
``(ii) for each of fiscal years 2020 through
2025, $127,000,000;'';
(E) in subparagraph (D)--
(i) by striking ``the Northern Mariana
Islands shall not exceed the sum of'' and
inserting ``the Northern Mariana Islands shall
not exceed--
``(i) except as provided in clause (ii), the
sum of''; and
(ii) by adding at the end the following new
clause:
``(ii) for each of fiscal years 2020 through
2025, $60,000,000; and''; and
(F) in subparagraph (E)--
(i) by striking ``American Samoa shall not
exceed the sum of'' and inserting ``American
Samoa shall not exceed--
``(i) except as provided in clause (ii), the
sum of'';
(ii) by striking ``$10,000.'' and inserting
``$10,000; and''; and
(iii) by adding at the end the following new
clause:
``(ii) for each of fiscal years 2020 through
2025, $84,000,000.''; and
(2) by adding at the end the following new paragraph:
``(6) Application to puerto rico for fiscal years 2020
through 2023.--For purposes of paragraph (2)(A)(ii), the amount
specified in this paragraph is--
``(A) for fiscal year 2020, $2,823,188,000;
``(B) for fiscal year 2021, $2,919,072,000;
``(C) for fiscal year 2022, $3,012,610,000; and
``(D) for fiscal year 2023, $3,114,331,000.''.
(b) Treatment of Funding Under Enhanced Allotment Program.--Section
1935(e) of the Social Security Act (42 U.S.C. 1396u-5(e)) is amended--
(1) in paragraph (1)(B), by striking ``if the State'' and
inserting ``subject to paragraph (4), if the State'';
(2) by redesignating paragraph (4) as paragraph (5); and
(3) by inserting after paragraph (3) the following new
paragraph:
``(4) Treatment of funding for certain fiscal years.--
``(A) Puerto rico.--Notwithstanding paragraph (1)(B),
in the case that Puerto Rico establishes and submits to
the Secretary a plan described in paragraph (2) with
respect to any of fiscal years 2020 through 2023, the
amount specified in paragraph (3) for Puerto Rico for
such a year shall be taken into account in applying
subparagraph (A)(ii) of section 1108(g)(2) for such
year.
``(B) Other territories.--Notwithstanding paragraph
(1)(B), in the case that the Virgin Islands, Guam, the
Northern Mariana Islands, or American Samoa establishes
and submits to the Secretary a plan described in
paragraph (2) with respect to any of fiscal years 2020
through 2025, the amount specified in paragraph (3) for
the Virgin Islands, Guam, the Northern Mariana Islands,
or American Samoa, as the case may be, shall be taken
into account in applying, as applicable, subparagraph
(B)(ii), (C)(ii), (D)(ii), or (E)(ii) of section
1108(g)(2) for such year.''.
(c) Increased FMAP.--Section 1905 of the Social Security Act (42
U.S.C. 1396d(b)) is amended--
(1) in subsection (b), by striking ``and (aa)'' and inserting
``(aa), and (ff)''; and
(2) by adding at the end the following new subsection:
``(ff) Temporary Increase in FMAP for Territories for Certain Fiscal
Years.--
``(1) Puerto rico.--Notwithstanding subsection (b) and
subject to subsection (z)(2), the Federal medical assistance
percentage for Puerto Rico shall be equal to--
``(A) 83 percent for fiscal years 2020 and 2021; and
``(B) 76 percent for fiscal years 2022 and 2023.
``(2) Virgin islands.--Notwithstanding subsection (b) and
subject to subsection (z)(2), the Federal medical assistance
percentage for the Virgin Islands shall be equal to--
``(A) 100 percent for fiscal year 2020;
``(B) 83 percent for fiscal years 2021 through 2024;
and
``(C) 76 percent for fiscal year 2025.
``(3) Other territories.--Notwithstanding subsection (b) and
subject to subsection (z)(2), the Federal medical assistance
percentage for Guam, the Northern Mariana Islands, and American
Samoa shall be equal to--
``(A) 100 percent for fiscal years 2020 and 2021;
``(B) 83 percent for fiscal years 2022 through 2024;
and
``(C) 76 percent for fiscal year 2025.''.
(d) Annual Report.--Section 1108(g) of the Social Security Act (42
U.S.C. 1308(g)), as amended by subsection (a), is further amended by
adding at the end the following new paragraph:
``(7) Annual report.--
``(A) In general.--Not later than the date that is
180 days after the end of each fiscal year (beginning
with fiscal year 2020 and ending with fiscal year
2025), in the case that a specified territory receives
a Medicaid cap increase, or an increase in the Federal
medical assistance percentage for such territory under
section 1905(ff), for such fiscal year, such territory
shall submit to the Chair and Ranking Member of the
Committee on Energy and Commerce of the House of
Representatives and the Chair and Ranking Member of the
Committee on Finance of the Senate a report that
describes how such territory has used such Medicaid cap
increase, or such increase in the Federal medical
assistance percentage, as applicable, to increase
access to health care under the State Medicaid plan of
such territory under title XIX (or a waiver of such
plan). Such report may include--
``(i) the extent to which such territory has,
with respect to such plan (or waiver)--
``(I) increased payments to health
care providers;
``(II) increased covered benefits;
``(III) expanded health care provider
networks; or
``(IV) improved in any other manner
the carrying out of such plan (or
waiver); and
``(ii) any other information as determined
necessary by such territory.
``(B) Definitions.--In this paragraph:
``(i) Medicaid cap increase.--The term
`Medicaid cap increase' means, with respect to
a specified territory and fiscal year, any
increase in the amounts otherwise determined
under this subsection for such territory for
such fiscal year by reason of the amendments
made by section 502(a) of the Territories
Health Care Improvement Act.
``(ii) Specified territory.--The term
`specified territory' means Puerto Rico, the
Virgin Islands, Guam, the Northern Mariana
Islands, and American Samoa.''.
SEC. 503. APPLICATION OF CERTAIN REQUIREMENTS UNDER MEDICAID PROGRAM TO
CERTAIN TERRITORIES.
(a) Application of Payment Error Rate Measurement Requirements to
Puerto Rico.--Section 1903(u)(4) of the Social Security Act (42 U.S.C.
1396b(u)(4)) is amended--
(1) by striking ``to Puerto Rico, Guam'' and inserting ``to
Guam''; and
(2) by striking ``or American Samoa.'' and inserting ``or
American Samoa, or, for fiscal years before fiscal year 2023,
to Puerto Rico.''.
(b) Application of Asset Verification Program Requirements to Puerto
Rico and Virgin Islands.--Section 1940(a) of the Social Security Act
(42 U.S.C. 1396w(a)) is amended--
(1) in paragraph (3)(A), by adding at the end the following
new clause:
``(iii) Implementation in puerto rico and
virgin islands.--The Secretary shall require
Puerto Rico to implement an asset verification
program under this subsection by the end of
fiscal year 2022 and the Virgin Islands to
implement such a program by the end of fiscal
year 2023.''; and
(2) in paragraph (4)--
(A) in the paragraph heading, by striking ``Exemption
of territories'' and inserting ``Exemption of certain
territories''; and
(B) by striking ``and the District of Columbia'' and
inserting ``, the District of Columbia, Puerto Rico,
and the Virgin Islands''.
(c) Application of Certain Data Reporting and Program Integrity
Requirements to Northern Mariana Islands, American Samoa, and Guam.--
(1) In general.--Section 1902 of the Social Security Act (42
U.S.C. 1396a) is amended by adding at the end the following new
subsection:
``(qq) Application of Certain Data Reporting and Program Integrity
Requirements to Northern Mariana Islands, American Samoa, and Guam.--
Not later than October 1, 2023, the Northern Mariana Islands, American
Samoa, and Guam shall--
``(1) implement methods, satisfactory to the Secretary, for
the collection and reporting of reliable data to the
Transformed Medicaid Statistical Information System (T-MSIS)
(or a successor system); and
``(2) demonstrate progress in establishing a State medicaid
fraud control unit described in section 1903(q).''.
(2) Conforming amendment.--Section 1902(j) of the Social
Security Act (42 U.S.C. 1396a(j)) is amended--
(A) by striking ``or the requirement'' and inserting
``, the requirement''; and
(B) by inserting before the period at the end the
following: ``, or the requirement under subsection
(qq)(1) (relating to data reporting)''.
SEC. 504. ADDITIONAL PROGRAM INTEGRITY REQUIREMENTS.
(a) Audit Relating to Fraud, Waste, and Abuse.--Not sooner than the
date that is one year after the date of the enactment of this Act, the
Inspector General of the Department of Health and Human Services
(referred to in this section as the ``Inspector General'') shall
conduct an audit of Puerto Rico with respect to any part of the
administration of Puerto Rico's State plan under title XIX of the
Social Security Act (42 U.S.C. 1396 et seq.) (or a waiver of such
plan), such as contracting protocols, denials of care, and financial
management, that the Inspector General determines to be at high risk
for waste, fraud, or abuse.
(b) Plan for Audits and Investigations of Contracting Practices.--Not
later than the date that is one year after the date of the enactment of
this Act, the Inspector General shall develop and submit to Congress a
plan for auditing and investigating contracting practices relating to
Puerto Rico's State plan under title XIX of the Social Security Act (42
U.S.C. 1396 et seq.) (or a waiver of such plan).
(c) Report on Contracting Oversight and Approval.--Not later than the
date that is two years after the date of the enactment of this Act, the
Comptroller General of the United States shall issue, and submit to the
Chair and Ranking Member of the Committee on Energy and Commerce of the
House of Representatives and the Chair and Ranking Member of the
Committee on Finance of the Senate, a report on contracting oversight
and approval with respect to Puerto Rico's State plan under title XIX
of the Social Security Act (42 U.S.C. 1396 et seq.) (or a waiver of
such plan). Such report shall--
(1) examine--
(A) the process used by Puerto Rico to evaluate bids
and award contracts under such plan (or waiver);
(B) which contracts are not subject to competitive
bidding or requests for proposals under such plan (or
waiver); and
(C) oversight by the Centers for Medicare & Medicaid
Services of contracts awarded under such plan (or
waiver); and
(2) include any recommendations for Congress, the Secretary
of Health and Human Services, or Puerto Rico relating to
changes that the Inspector General determines necessary to
improve the program integrity of such plan (or waiver).
(d) Reevaluation of Waivers of Medicaid Fraud Control Unit
Requirement.--Not later than the date that is one year after the date
of the enactment of this Act, the Secretary of Health and Human
Services shall--
(1) reevaluate any waiver approved (and in effect as of the
date of the enactment of this Act) for Guam, the Northern
Mariana Islands, or American Samoa under subsection (a)(61) or
subsection (j) of section 1902 of the Social Security Act (42
U.S.C. 1396a) with respect to the requirement to establish a
State medicaid fraud control unit (as described in section
1903(q) of such Act (42 U.S.C. 1396b(q)); and
(2) determine whether any such waiver should continue to be
approved with respect to Guam, the Northern Mariana Islands, or
American Samoa, respectively, after October 1, 2023.
(e) System for Tracking Federal Funding Provided to Puerto Rico.--
Section 1902 of the Social Security Act (42 U.S.C. 1396a), as amended
by section 503(c), is further amended by adding at the end the
following new subsection:
``(rr) Program Integrity Requirements for Puerto Rico.--
``(1) System for tracking federal funding provided to puerto
rico.--
``(A) In general.--Puerto Rico shall establish and
maintain a system for tracking any amounts paid by the
Federal Government to Puerto Rico with respect to the
State plan of Puerto Rico (or a waiver of such plan).
Under such system, Puerto Rico shall ensure that
information is available, with respect to each quarter
in a fiscal year (beginning with the first quarter
beginning on or after the date that is one year after
the date of the enactment of this subsection), on the
following:
``(i) In the case of a quarter other than the
first quarter of such fiscal year--
``(I) the total amount expended by
Puerto Rico during any previous quarter
of such fiscal year under the State
plan of Puerto Rico (or a waiver of
such plan); and
``(II) a description of how such
amount was so expended.
``(ii) The total amount that Puerto Rico
expects to expend during the quarter under the
State plan of Puerto Rico (or a waiver of such
plan), and a description of how Puerto Rico
expects to expend such amount.
``(B) Report to cms.--For each quarter with respect
to which Puerto Rico is required under subparagraph (A)
to ensure that information described in such
subparagraph is available, Puerto Rico shall submit to
the Administrator of the Centers for Medicare &
Medicaid Services a report on such information for such
quarter.
``(2) Submission of documentation on contracts upon
request.--Puerto Rico shall, upon request, submit to the
Administrator of the Centers for Medicare & Medicaid Services
all documentation requested with respect to contracts awarded
under the State plan of Puerto Rico (or a waiver of such
plan).''.
Amend the title so as to read:
A bill to reauthorize and extend funding for critical
public health programs that improve access to health care and
strengthen the health care workforce, to extend provisions of
the Medicare program, to strengthen the Medicaid program in the
territories, to protect health care consumers from surprise
billing practices, and for other purposes.
I. Purpose and Summary
H.R. 2328, the ``Reauthorizing and Extending America's
Community Health Act'' or the ``REACH Act'', was introduced on
April 15, 2019, by Reps. Tom O'Halleran (D-AZ) and Elise
Stefanik (R-NY), originally with the short title of the
``Community Health Investment, Modernization, and Excellence
Act of 2019''. The bill was referred to the Committee on Energy
and Commerce. H.R. 2328 would extend funding for vital public
health programs, including the Community Health Centers Fund
(CHCF), the National Health Service Corps (NHSC), the Teaching
Health Center Graduate Medical Education (THCGME) Program,
special diabetes programs, the State Personal Responsibility
Education Program (PREP), and the Title V State Sexual Risk
Avoidance Education (SRAE) Grant Program. The legislation also
would enhance Medicaid funding for the U.S. territories, while
strengthening program integrity and oversight of these
programs. H.R. 2328 would also adjust the Medicaid
disproportionate share hospital (DSH) allotment reductions and
require greater transparency and disclosure of hospital upper
payment limit (UPL) data. The bill would lower healthcare costs
for Americans by establishing new and comprehensive protections
to protect consumers from surprise medical bills. Finally, the
bill also would fund critical programs to improve quality and
access for Medicare beneficiaries.
II. Background and Need for Legislation
TITLE I--PUBLIC HEALTH EXTENDERS
Title I of H.R. 2328 provides direct health services,
research, and education funding and bolsters the health care
workforce, especially in urban, rural, and tribal community-
based settings. Funding for these programs was last extended in
the Bipartisan Budget Act of 2018 and expires at the end of FY
2019.\1\
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\1\Pub. L. No. 115-123
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The Health Center Program provides grant funding to health
centers that serve medically underserved populations. These
grants provided 18 percent of total revenue for health centers
in 2017, the most recent year for which data is available.\2\
Health centers also rely on other Federal funding sources
including Medicaid and Medicare, which provided 45 percent and
7 percent of health center revenue respectively in 2017.\3\
Funding for health centers was augmented with the creation of
the CHCF as part of the Affordable Care Act (ACA) in 2010. The
increased funding provided to the CHCF has increased the number
of health center locations in the Health Center Program from
8,156 locations in FY 2010 to nearly 12,000 locations today.\4\
The CHCF also increased the number of patients served by health
centers. In FY 2017, health centers served 27.2 million
patients and provided approximately 110 million patient
visits.\5\
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\2\Sara Rosenbaum et al., Community Health Center Financing: The
Role of Medicaid and Section 330 Grant Funding, Kaiser Family
Foundation (March 26, 2019) (www.kff.org/report-section/community-
health-center-financing-the-role-of-medicaid-and-section-330-grant-
funding-explained-issue-brief-9291/).
\3\Id.
\4\Congressional Research Service, Federal Health Centers: An
Overview (May 2017) (R43937).
\5\Department of Health and Human Services, Fiscal Year 2020 Health
Resources and Services Administration Justification of Estimates for
Appropriations Committees, 62.
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The NHSC Program strengthens the health care workforce
throughout the country by providing financial support to health
professional students and primary care providers who commit to
serve in medically underserved communities in urban, rural, and
tribal areas, in the form of scholarships and loan repayment
assistance. As of September 2018, NHSC field strength included
10,939 care providers, with physicians, nurse practitioners,
and mental and behavioral health professionals among the
highest represented disciplines.\6\
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\6\Department of Health and Human Services, Fiscal Year 2020 Health
Resources and Services Administration Justification of Estimates for
Appropriations Committees, 63.
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Section 101 also extends for four years (through FY 2023)
the THCGME program. The THCGME program was established to
increase training of primary care medical and dental residents
in community-based settings, such as Federally Qualified Health
Centers (FQHCs) or Rural Health Clinics (RHCs). THCGME is
administered by the Health Resources and Services
Administration (HRSA), and currently supports approximately 728
residents at 56 teaching health centers across the country.\7\
Physicians trained under teaching health center programs are
more likely to practice in underserved communities compared to
traditional GME residents. In academic year 2017-2018, 82
percent of THCGME residents trained in a medically underserved
and/or rural community compared to 23 percent of traditional
GME residents.\8\ Since 2011 the program has supported the
training of more than 880 new primary care physicians and
dentists.\9\
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\7\Health Resources and Services Administration, Teaching Health
Center Graduate Medical Education Program (accessed: May 23, 2019)
(bhw.hrsa.gov/grants/medicine/thcgme).
\8\American Association of Teaching Health Centers (accessed: May
23, 2019) (aathc.org/know-the-facts/).
\9\Supra note 7.
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The Special Diabetes Program (SDP) supports research on the
prevention and cure for type 1 diabetes. The program is
administered by the National Institute of Diabetes and
Digestive and Kidney Diseases at the National Institutes of
Health (NIH), along with other NIH institutes and the Centers
for Disease Control and Prevention. The Special Diabetes
Program for Indians (SDP-I) is a separate program to address
the diabetes epidemic among American Indians and Alaska
Natives. Coordinated by the Indian Health Service (IHS)
Division of Diabetes, with guidance from the Tribal Leaders
Diabetes Committee, SDP-I provides funds for diabetes treatment
and prevention to IHS, Tribal, and Urban Indian Health
programs.
The State Personal Responsibility Education Program (PREP)
provides grants to states, organizations, tribal organizations,
and communities to fund evidence-based education programs that
inform adolescents about the prevention of teen pregnancy and
sexually-transmitted infections, as well as adulthood
preparation topics such as healthy relationships and financial
literacy. Additionally, the Title V State Sexual Risk Avoidance
Education (SRAE) Grant Program provides grants to implement
programs that educate adolescents on healthy relationships,
goal setting, avoiding risky behaviors such as underage
drinking and illicit drug use, resisting sexual coercion, and
voluntarily refraining from non-marital sexual activity.
TITLE II--MEDICARE EXTENDERS
Title II of H.R. 2328 extends critical Medicare programs
that were last extended in the Bipartisan Budget Act (BBA) of
2018, including the physician work geographic practice cost
index (GPCI) floor, outreach and education programs for low-
income seniors, funding for quality measure development, and
the Independence at Home Medical Practice Demonstration. Title
II also reauthorizes the Patient-Centered Outcomes Research
Trust Fund (PCORTF) and permanently authorizes the Limited
Income Newly Eligible Transition (LI NET) program. Finally, it
exempts manual complex rehabilitative technology (CRT)
wheelchair accessories from competitive bidding for one year
and improves the interaction between TRICARE and Medicare
benefits for certain severely disabled servicemembers.
Section 201 extends for three years (through December 31,
2023) a provision that raises the physician work GPCI to 1.000
for all localities that have a physician work GPCI of less than
1.000 (i.e. below the national average for physician payment).
Payments under the Medicare physician fee schedule are adjusted
geographically by three factors to reflect differences in the
cost of physician services: (1) physician work; (2) practice
expense; and (3) medical malpractice insurance. The ``physician
work'' geographic practice cost index (GPCI) is intended to
reflect the cost of physician labor in different geographic
areas. This provision was originally enacted in the Medicare
Modernization Act (MMA) and last extended through December 31,
2019 in the BBA of 2018. The extension of the physician work
GPCI floor increases payment to physicians in low cost of
living areas and, as a result, reduces disparities in physician
payment between high cost of living and low cost of living
areas.
Section 202 extends funding for three years (through FY
2022) for State Health Insurance Assistance Programs (at $15
million per year), Area Agencies on Aging (at $15 million per
year), Aging and Disability Resource Centers (at $5 million per
year), and the contract with the National Center for Benefits
and Outreach and Enrollment (at $15 million per year); an
increase of $12.5 million from current funding for these
programs. This provision was originally enacted under Section
119 of the Medicare Improvements for Patients and Providers Act
of 2008 (MIPPA) to improve outreach, enrollment, and education
activities for low-income Medicare beneficiaries. Funding for
this provision was last extended under the BBA of 2018 at $37.5
million per year through FY 2019.
Section 203 extends funding for three years (through FY
2022) for the contract with a consensus-based entity, such as
the National Quality Forum (NQF), at $30 million per year.
Section 183 of MIPPA directed the Secretary of Health and Human
Services (HHS) to ``contract with a consensus-based entity,
such as the National Quality Forum'' to support activities
related to quality measurement and performance improvement.\10\
NQF currently reviews and endorses healthcare quality measures
for use in private and public reporting and incentive payment
programs, including annual guidance on measures that should be
included in, or excluded from the Medicare and Medicaid
programs.\11\ The BBA of 2018 authorized $7.5 million in
funding through FY 2019 to support the contract between the
Centers for Medicare & Medicaid Services (CMS) and NQF. This
funding, supplemented by unobligated funds from previous years,
allowed for approximately $30 million per year to support the
contract (consistent with the $30 million in funding authorized
for FY 2015 through 2017 under the Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA)).
---------------------------------------------------------------------------
\10\42 U.S.C. 1395aaa.
\11\Douglas Henley et al., Making Measurement Count: The Importance
of NQF, Health Affairs (September 20, 2017) (www.healthaffairs.org/do/
10.1377/hblog20170920.062052/full/).
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Section 204 extends for three years (through December 31,
2023) the Independence at Home Medical Practice Demonstration
Program. The program allows seniors with multiple, advanced and
often expensive chronic conditions to receive home based
primary care from a team of providers. Home based treatment
increases access to care for seniors and allows for seniors to
be treated in a setting where they are most comfortable. The
program rewards providers that deliver quality care while also
reducing costs. Analysis of the demonstration also found that
participants had fewer hospital readmissions, better medication
management and care planning, and improved follow up. The
demonstration's first cohort began in June 2012.
Section 205 extends for three years (through FY 2022)
annual appropriations and transfers to PCORTF. PCORTF funds the
Patient-Centered Outcomes Research Institute (PCORI), a
private, non-profit funder of comparative clinical
effectiveness research, which compares at least two alternative
health care options. The program is intended to assist
patients, clinicians, purchasers, and policy-makers in making
informed health decisions by advancing the quality and
relevance of clinical evidence. PCORTF receives an annual
appropriation and additionally receives a per-covered-life
assessment from the Medicare trust fund, commercial insurance
plans, and self-insured plans.
Section 206 permanently authorizes the Limited Income Newly
Eligible Transition (LI NET) program, which provides
transitional coverage to certain low-income Medicare Part D
beneficiaries not already enrolled in a Medicare drug program.
In 2010, CMS began the Limited Income Newly Eligible Transition
(LI NET) program as a demonstration to provide temporary Part D
prescription drug coverage to low-income Medicare beneficiaries
who are not already enrolled in a Medicare drug plan as well as
uncovered low-income subsidy (LIS) eligible beneficiaries at
the pharmacy counter. The low-income Medicare beneficiaries
include full benefit dual eligible and supplemental security
income (SSI)-only beneficiaries on a retroactive basis.
Enrollment in the LI NET program is temporary until CMS enrolls
these individuals into a Part D plan, but ensures the
beneficiary has drug coverage in the interim.
Section 207 allows military disability retirees under the
age of 65 to decline to enroll in Medicare Part B in situations
where their Social Security Disability Insurance Payments have
been terminated because they regained employment, as well as
allow them to continue to access their TRICARE benefits
eliminating a current disincentive for severely wounded
servicemembers to rejoin the workforce. Currently, injured
servicemembers eligible for TRICARE but who return to the
workforce must pay Medicare premiums in order to retain their
TRICARE coverage. Enrolling in Medicare would lead to these
servicemembers paying higher rates than they would with their
traditional TRICARE plan. It also provides for Medicare
coverage of a DNA Specimen Provenance Assay clinical diagnostic
laboratory test following a positive prostate cancer biopsy.
Section 208 exempts manual complex rehabilitative
technology (CRT) wheelchair accessories from the Medicare
durable medical equipment (DME) competitive bidding program for
one year (through December 31, 2020). CRT wheelchairs are used
primarily by Medicare beneficiaries with significant
disabilities such as ALS, multiple sclerosis, muscular
dystrophy, spinal cord injury, and traumatic brain injury. CRT
wheelchairs are customizable with different accessories that
may be necessary for individuals with disabilities. These
accessories are paid for separately under the Medicare program.
In 2017, CMS announced its decision to exempt power CRT
wheelchair accessories from competitive bidding. However, the
issue of manual CRT wheelchairs accessories remains outstanding
and requires congressional action to exempt from competitive
bidding.
TITLE III--MEDICAID PROVISIONS
Title III of H.R. 2328 adjusts the magnitude of the
reductions to Medicaid DSH allotments for FY 2020, FY 2021, and
FY 2022. Federal law requires states to provide Medicaid DSH
payments to hospitals to help offset uncompensated care costs
attributable to patients who are uninsured or enrolled in
Medicaid. Hospitals often do not receive payment for services
rendered to uninsured patients, and Medicaid provider payment
rates are generally lower than the rates paid by Medicare and
private insurance. In FY 2017, Medicaid DSH payments totaled
$18.1 billion, which includes $10.4 billion in Federal funds
and $7.7 billion in state funds.\12\
---------------------------------------------------------------------------
\12\Medicaid and CHIP Payment and Access Commission,
Disproportionate share hospital payments (www.macpac.gov/subtopic/
disproportionate-share-hospital-payments/).
---------------------------------------------------------------------------
The ACA directed the Secretary of HHS to reduce Federal
Medicaid DSH allotments beginning FY 2014. The ACA included
these reductions expecting that the law's mandatory Medicaid
expansion and expansion of private insurance coverage would
lead to a decrease in hospital uncompensated care costs.
However, only 33 states and the District of Columbia have
expanded Medicaid; and even in Medicaid expansion states,
uncompensated care costs remain a challenge for many hospitals
serving low-income individuals. Congress delayed the Medicaid
DSH reductions four times from 2013 to 2018. The reductions are
currently scheduled to begin in FY 2020. Under current law, DSH
allotments will be reduced by $4 billion in FY 2020 and $8
billion in FYs 2021-2025. H.R. 2328 eliminates the Medicaid DSH
allotments for FY 2020 and FY 2021 and reduces the Medicaid DSH
allotments for FY 2022 to $4 billion.
TITLE IV--NO SURPRISES ACT
Title IV of H.R. 2328 protects consumers from receiving
surprise medical bills. Surprise billing, also referred to as
balance billing, is when a patient receives a bill from a
provider (other than the cost-sharing required under their
insurance) for any difference between the amount the provider
charged and the payment from the patient's insurance plan for
that service. This occurs because the provider and the
insurance plan have not contracted for a rate which the
provider will accept as payment in full for the contracted
services (i.e. the in-network rate). When a patient is treated
by a provider outside of their plan's network, the plan may
only be required under the terms of the plan to pay for a
portion of the service or may not be required to pay for any
out-of-network services. Under current law, providers are
permitted to bill privately-insured patients for the balance
not paid by the insurance plan.
Surprise bills occur primarily in two scenarios; when an
individual receives emergency services and therefore has no
ability to ensure they are treated by in-network providers, or
when an individual goes to an in-network hospital but certain
providers at that same hospital, that the patient may not have
been aware would be involved in their care, are out-of-network.
For example, patients usually have little ability to choose
certain ``facility-based'' providers such as anesthesiologists,
pathologists, radiologists and emergency providers. As
described by the National Association of Insurance
Commissioners (NAIC), services by these providers are typically
arranged by the facility as part of the facility's general
business operations and the insurance plan or patient generally
``does not specifically select or have a choice of providers
from which to receive such services within the facility.''\13\
Surprise billing occurs across all insurance plan types, even
those with larger, more generous networks.\14\ Research has
found that around one in five emergency department visits and
about nine percent of elective inpatient care at in-network
facilities results in a surprise bill.\15\
---------------------------------------------------------------------------
\13\National Association of Insurance Commissioners, Health Benefit
Plan Network Access and Adequacy Model Act (www.naic.org/store/free/
MDL-74.pdf).
\14\The Commonwealth Fund, Americans' Experiences with ACA
Marketplace Coverage: Affordability and Provider Network Satisfaction,
Exhibit 8 (July 2016) www.commonwealthfund.org/sites/default/files/
documents/
___media_files_publications_issue_brief_2016_jul_1883_gunja_amer-
icans_experience_aca_marketplace_affordability_v2.pdf).
\15\Christopher Garmon and Benjamin Chartock, One In Five Inpatient
Emergency Department Cases May Lead To Surprise Bills (Jan. 2017)
(www.healthaffairs.org/doi/abs/10.1377/hlthaff.2016.0970).
---------------------------------------------------------------------------
Individuals covered by Federal healthcare programs are
largely protected from surprise medical bills. Federal law,
however, does not prohibit balance billing in the private
insurance market.\16\ For example, in the Medicare program,
non-participating providers (only about four percent of
providers in the program) are permitted to balance bill, but
the bill cannot exceed 15 percent of Medicare's established
payment for that service.\17\
---------------------------------------------------------------------------
\16\Loren Adler et.al., Stopping Surprise Medical Bills: Federal
Action Is Needed, Health Affairs (Feb. 1, 2017) (www.healthaffairs.org/
do/10.1377/hblog20170201.058570/full/).
\17\AARP, Medicare's Financial Protections for Consumers: Limits on
Balance Billing and Private Contracting by Physicians (Jan. 2017)
(www.aarp.org/content/dam/aarp/ppi/2017-01/medicare-limits-on-balance-
billing-and-private-contracting-ppi.pdf).
---------------------------------------------------------------------------
About half of states have some form of protections from
surprise medical bills for patients in state regulated plans
(i.e. fully insured plans).\18\ However, the ability of states
to regulate surprise medical bills is constrained by the
Employee Retirement Income Security Act of 1974 (ERISA). ERISA
precludes states from regulating self-funded employer plans
(which currently cover about 100 million Americans). Therefore,
millions remain unprotected absent a Federal solution even
though a growing number of states have enacted surprise billing
laws.
---------------------------------------------------------------------------
\18\The Commonwealth Fund, State Efforts to Protect Consumers from
Balance Billing (Jan. 18, 2019) (www.commonwealthfund.org/blog/2019/
state-efforts-protect-consumers-balance-billing).
---------------------------------------------------------------------------
Title IV ensures that consumers with all types of private
insurance are protected from surprise medical bills in the
following situations:
When a patient receives out-of-network
emergency services;
When a patient receives additional out-of-
network services after they are stabilized but before
they can travel to an in-network provider without
medical transport (i.e. post-stabilization services);
When a patient receives services from a
facility-based provider (such as anesthesiologists,
radiologists, pathologists, neonatologists, assistant
surgeons, or hospitalists);
For scheduled, non-emergency care--when a
patient does not receive written and oral notice of the
provider's network status and charges at the time they
schedule the care and specifically consent to receiving
out-of-network services at least 72 hours in advance of
those services being provided (including laboratory
services or imaging services sent off-site). This
consent requirement would not apply to any unforeseen
medical needs that may arise during the course of
treatment;
When an in-network provider is unavailable
at the facility.
Consumers in these situations could not be balance billed
and would only be required to pay what they would have paid if
the service were provided in-network. The health plan would be
required to pay the out-of-network provider the median
contracted (in-network) rate for the service in the geographic
area the service was delivered. The median contracted rate
would be based on the insurer's rates in 2019 and indexed to
the Consumer Price Index for All Urban Consumers (CPI-U).
Providers would have the option of entering an independent
dispute resolution process for claims where the median
contracted rate paid for the service is greater than $1,250.
TITLE V--TERRITORIES HEALTH CARE IMPROVEMENT ACT
Title V of H.R. 2328 provides additional funding to the
U.S. territories Medicaid programs and makes changes to improve
oversight and program integrity. Each of the five U.S.
territories--Puerto Rico, the U.S. Virgin Islands (USVI), Guam,
American Samoa, and the Commonwealth of the Northern Mariana
Islands (CNMI)--operates a Medicaid program and a Children's
Health Insurance Program (CHIP). Medicaid programs in the
territories differ from Medicaid programs in the 50 states and
the District of Columbia in several aspects. The most notable
differences are the funding structure and the Federal medical
assistance percentage (the matching rate, or FMAP). Territorial
Medicaid programs receive capped funding from the Federal
Government, as opposed to the open-ended funding structure of
state Medicaid programs. Under this structure, the Federal
Government provides matching funds to each territory for
Medicaid expenditures up to a cap. Once a territory reaches its
cap, however, no additional Federal funds are available, and
the territory must fund their programs using only territorial
funds.\19\
---------------------------------------------------------------------------
\19\Government Accountability Office, Medicaid and CHIP: Increased
Funding in U.S. Territories Merits Improved Program Integrity Efforts,
(Apr. 8, 2016) (www.gao.gov/products/GAO-16-324).
---------------------------------------------------------------------------
Congress has provided increased Federal Medicaid funding
and FMAP for the territories several times over the last
decade. The ACA provided additional funds to the territories.
The Consolidated Appropriations Act of 2017 provided Puerto
Rico with nearly $300 million in additional Medicaid funds, and
the Bipartisan Budget Act of 2018 (BBA) provided Puerto Rico
and USVI with increased funds and an FMAP of 100 percent.\20\
The Additional Supplemental Appropriations for Disaster Relief
Act of 2019 (the Disaster Supplemental) provided CNMI with
additional funds for the remainder of FY 2019.\21\ It further
allowed American Samoa and Guam to draw down their Section 1323
funds at an FMAP of 100 percent for expenditures after January
1, 2019.
---------------------------------------------------------------------------
\20\Kaiser Family Foundation, Medicaid Financing Cliff:
Implications for the Health Care Systems in Puerto Rico and USVI (May
2019) (www.kff.org/report-section/medicaid-financingcliff-implications-
for-the-health-care-systems-in-puerto-rico-and-usvi-issue-brief/).
\21\Pub. L. No. 116-20.
---------------------------------------------------------------------------
When the additional funds for the territories expire,
Federal Medicaid funding levels will revert to the historical
Section 1108 allotments. This will be a significant downward
departure in Federal funding for the territories. The
expiration of the additional Federal Medicaid funds is expected
to create significant funding shortfalls in the territories. It
is unclear how territories will adjust to these funding
shortfalls.
III. Committee Hearings
For the purposes of section 103(i) of H. Res. 6 of the
116th Congress--the following hearings were used to develop or
consider H.R. 2328, as amended:
The Subcommittee on Health held a legislative hearing on
June 4, 2019, entitled, ``Investing in America's Health Care''
to consider H.R. 2328, the ``Community Health Investment,
Modernization, and Excellence Act of 2019'' and 11 other bills.
The Subcommittee received testimony from the following
witnesses:
Dean Germano, Chief Executive Officer,
Shasta Community Health Center;
Diana Autin, Executive Co-Director, SPAN
Parent Advocacy Network;
Aaron Kowalski, President and Chief
Executive Officer, JDRF;
Lisa Cooper, Professor of Medicine, Johns
Hopkins University School of Medicine;
Thomas Barker, Partner and Co-Chair of
Healthcare Practice, Foley Hoag;
Mary-Catherine Bohan, Vice President of
Outpatient Services, Rutgers University Behavioral
Health Care;
Michael Waldrum, Chief Executive Officer,
Vidant Health; and,
Fred Riccardi, President, Medicare Rights
Center.
The Subcommittee on Health held a hearing on June 12, 2019,
entitled, ``No More Surprises: Protecting Patients from
Surprise Medical Bills'' to consider the ``No Surprises Act.''
The Subcommittee received testimony from the following
witnesses:
Sonji Wilkes, Patient Advocate;
Sherif Zaafran, M.D., FASA, Chair,
Physicians for Fair Coverage;
Rick Sherlock, President and Chief Executive
Officer, Association of Air Medical Services;
James Gelfand, Senior Vice President, Health
Policy, The ERISA Industry Committee;
Thomas Nickels, Executive Vice President,
American Hospital Association;
Jeanette Thornton, Senior Vice President of
Product, Employer, and Commercial Policy, America's
Health Insurance Plans;
Claire McAndrew, Director of Campaigns and
Partnerships, Families USA; and
Vidor E. Friedman, M.D., FACEP, President,
American College of Emergency Physicians.
The Subcommittee on Health also held a related hearing on
June 20, 2019, entitled, ``Strengthening Health Care in the
U.S. Territories for Today and Into the Future.'' The
Subcommittee received testimony from the following witnesses:
Anne Schwartz, Executive Director, Medicaid
and CHIP Payment and Access Commission;
Angela Avila, Executive Director,
Administracion de Seguros de Salud de Puerto Rico,
Puerto Rico Health Insurance Administration;
Sandra King Young, Medicaid Director,
American Samoa State Agency;
Maria Theresa Arcangel, Chief Administrator,
Guam Division of Public Welfare;
Michal Rymer-Browne, Assistant Commissioner,
Department of Human Services, U.S. Virgin Islands; and
Helen C. Sablan, Medicaid Director,
Commonwealth of the Northern Mariana Islands State
Medicaid Agency.
IV. Committee Consideration
H.R. 2328, the ``Reauthorizing and Extending America's
Community Health Act'' or the ``REACH Act'', was introduced on
April 15, 2019, by Reps. Tom O'Halleran (D-AZ) and Elise
Stefanik (R-NY), originally introduced with the short title of
the ``Community Health Investment, Modernization, and
Excellence Act of 2019''. The bill was referred to the
Committee on Energy and Commerce. Subsequently, H.R. 2328 was
referred to the Subcommittee on Health on April 16, 2019.
Following several hearings, the Subcommittee on Health met in
open markup session, pursuant to notice, on Thursday, July 11,
2019, to consider H.R. 2328. During consideration and markup of
the bill, an amendment in the nature of a substitute (AINS) was
offered by Mr. Butterfield. Mr. Kennedy offered an amendment to
the Butterfield AINS, which was agreed to by a voice vote. The
Subcommittee agreed to the Butterfield AINS, amended, by a
voice vote. A motion made by Ms. Eshoo, chairwoman of the
subcommittee, to favorably forward H.R. 2328 to the full
Committee, amended, was agreed to by a voice vote, a quorum
being present.
The Committee on Energy and Commerce met in open markup
session, pursuant to notice, on Wednesday, July 17, 2019, to
consider a committee print of H.R. 2328 that reflecting the
changes approved by the Subcommittee on Health. An amendment in
the nature of a substitute was first offered by Mr. Pallone,
Chairman of the full Committee, to H.R. 2328, as amended.
During consideration and markup of the Pallone AINS, 11
amendments were offered to the Pallone AINS. Amendments offered
by Reps. Walden, Pallone, Gianforte, Matsui, Kuster, Blunt
Rochester, Lujan, Ruiz, Schrader, and Ruiz were all agreed to
by a voice vote. An amendment offered to the AINS by Ms.
Schakowsky was withdrawn. The Pallone Amendment in the Nature
of a Substitute, amended, to H.R. 2328 was then agreed to by a
voice vote. A motion by Mr. Pallone to order H.R. 2328, the
``REACH Act'' reported favorably to the House, amended, was
agreed to by a voice vote, a quorum being present.
V. Committee Votes
Clause 3(b) of rule XIII of the Rules of the House of
Representatives requires the Committee to list each record vote
on the motion to report legislation and amendments thereto. The
Committee advises that there were no record votes taken on H.R.
2328, including the motion by Mr. Pallone ordering H.R. 2328
favorably reported to the House, amended.
VI. Oversight Findings
Pursuant to clause 3(c)(1) of rule XIII and clause 2(b)(1)
of rule X of the Rules of the House of Representatives, the
Committee's oversight findings and recommendations are
reflected in the descriptive portion of the report.
VII. New Budget Authority, Entitlement Authority, and Tax Expenditures
Pursuant to 3(c)(2) of rule XIII of the Rules of the House
of Representatives, the Committee adopts as its own the
estimate of new budget authority, entitlement authority, or tax
expenditures or revenues contained in the cost estimate
prepared by the Director of the Congressional Budget Office
pursuant to section 402 of the Congressional Budget Act of
1974.
The Committee has requested by not received from the
Director of the Congressional Budget Office a statement as to
whether this bill contains any new budget authority, credit
authority, or an increase or decrease in revenues or tax
expenditures.
VIII. Federal Mandates Statement
The Committee adopts as its own the estimate of Federal
mandates prepared by the Director of the Congressional Budget
Office pursuant to section 423 of the Unfunded Mandates Reform
Act.
IX. Statement of General Performance Goals and Objectives
Pursuant to clause 3(c)(4) of rule XIII, the general
performance goal or objective of this legislation is to
reauthorize and extend funding for critical public health
programs that improve access to health care and strengthen the
health care workforce, to extend provisions of the Medicare
program, to strengthen the Medicaid program in the territories,
to protect health care consumers from surprise billing
practices, and to improve health outcomes and affordability.
X. Duplication of Federal Programs
Pursuant to clause 3(c)(5) of rule XIII, no provision of
H.R. 2328 is known to be duplicative of another Federal
program, including any program that was included in a report to
Congress pursuant to section 21 of Public Law 111-139 or the
most recent Catalog of Federal Domestic Assistance.
XI. Committee Cost Estimate
Pursuant to clause 3(d)(1) of rule XIII, the Committee
adopts as its own the cost estimate prepared by the Director of
the Congressional Budget Office pursuant to section 402 of the
Congressional Budget Act of 1974.
XII. Earmarks, Limited Tax Benefits, and Limited Tariff Benefits
Pursuant to clause 9(e), 9(f), and 9(g) of rule XXI, the
Committee finds that H.R. 2328 contains no earmarks, limited
tax benefits, or limited tariff benefits.
XIII. Advisory Committee Statement
No advisory committee within the meaning of section 5(b) of
the Federal Advisory Committee Act was created by this
legislation.
XIV. Applicability to Legislative Branch
The Committee finds that the legislation does not relate to
the terms and conditions of employment or access to public
services or accommodations within the meaning of section
102(b)(3) of the Congressional Accountability Act.
XV. Section-by-Section Analysis of the Legislation
Section 1. Short title
Section 1 designates that the short title may be cited as
the ``Reauthorizing and Extending America's Community Health
Act'' or the ``REACH Act''.
TITLE I--PUBLIC HEALTH EXTENDERS
Sec. 101. Extension for community health centers, the National Health
Service Corps, and teaching health centers that operate GME
programs
Section 101 extends funding through FY 2023 for the
Community Health Center Fund (at $4 billion per year), the
National Health Service Corps (at $310 million per year), and
the Teaching Health Center Graduate Medical Education Program
(at $126.5 million per year).
Sec. 102. Extension for special diabetes programs
Section 102 extends funding through FY 2023 for the Special
Diabetes Program and the Special Diabetes Program for Indians,
each at $150 million per year.
Sec. 103. Extension of Personal Responsibility Education Program
Section 103 extends funding through FY 2023 for the
Personal Responsibility Education Program at $75 million per
year.
Sec. 104. Extension of sexual risk avoidance education program
Section 104 extends funding through FY 2023 for the Sexual
Risk Avoidance Education Program at $75 million per year.
TITLE II--MEDICARE EXTENDERS
Sec. 201. Extension of the work geographic index floor under the
Medicare program
Section 201 extends for three years (through December 31,
2023) a provision that raises the physician work GPCI to 1.000
for all localities that have a physician work GPCI of less than
1.000 (i.e. below the national average for physician payment).
Sec. 202. Extension of funding outreach and assistance for low-income
programs
Section 202 extends funding for three years (through FY
2022) for State Health Insurance Assistance Programs (at $15
million per year), Area Agencies on Aging (at $15 million per
year), Aging and Disability Resource Centers (at $5 million per
year), and the contract with the National Center for Benefits
and Outreach and Enrollment (at $15 million per year); an
increase of $12.5 million from current funding for these
programs.
Sec. 203. Extension of funding for quality measure endorsement, input,
and selection under the Medicare program
Section 203 extends funding for three years (through FY
2022) for the contract with a consensus-based entity, such as
the NQF, at $30 million per year.
Sec. 204. Extension of the Independence at Home Medical Practice
Demonstration Program under the Medicare program
Section 204 extends for three years (through December 31,
2023) the Independence at Home Medical Practice Demonstration
Program.
Sec. 205. Extension of appropriations and transfers to the Patient-
Centered Outcomes Research Trust Fund; extension of certain
health insurance fees
Section 205 extends the annual appropriation and transfers
from the per-covered life assessments on the Medicare trust
fund, private insurance plans, and self-funded insurance plans
for three years, through FY 2022.
Sec. 206. Transitional coverage and retroactive Medicare Part D
coverage for certain low-income beneficiaries
Section 206 permanently authorizes the Limited Income Newly
Eligible Transition (LI NET) program, which provides
transitional coverage to certain low-income Medicare Part D
beneficiaries not already enrolled in a Medicare drug program.
Sec. 207. Health Equity and Access for Returning Troops and
Servicemembers Act of 2019
Section 207 allows military disability retirees under the
age of 65 to decline to enroll in Medicare Part B in situations
where their Social Security Disability Insurance Payments have
been terminated because they are gainfully employed, as well as
allow them to continue to access their TRICARE benefits. It
also provides for Medicare coverage of a DNA Specimen
Provenance Assay clinical diagnostic laboratory test following
a positive prostate cancer biopsy.
Sec. 208. Exclusion of complex rehabilitative manual wheelchairs from
Medicare competitive acquisition program; Non-application of
Medicare fee-schedule adjustments for certain wheelchair
accessories and cushions.
Section 208 exempts manual CRT wheelchair accessories from
the Medicare durable DME competitive bidding program for one
year (through December 31, 2020).
TITLE III--MEDICAID PROVISIONS
Section 301. Modification in reductions in Medicaid DSH allotments
Section 301 eliminates the Medicaid DSH allotment
reductions for FY 2020 and FY 2021. It reduces the Medicaid DSH
allotment reductions in FY 2022 from $8 billion to $4 billion.
Section 302. Public availability of hospital upper payment limit
demonstrations
Section 302 directs the Secretary of HHS to make publicly
available the upper payment limit demonstrations that a state
submits to the Administrator for CMS, beginning in state fiscal
year 2022.
Section 303. Report by Comptroller General
Section 303 requires no later than 21 months after the date
of enactment, a report by the Comptroller General to Congress
on policy considerations for establishing an equitable formula
for determining Medicaid disproportionate share hospital
allotments to states.
Section 304. Sense of Congress regarding the need to develop a more
permanent legislative solution to provide the territories with
a reliable and consistent source of Federal funding under the
Medicaid program
Section 304 indicates it is the sense of Congress that the
Federal funding caps to the Medicaid programs of the
territories have not been adjusted over time and, accordingly,
have impaired the ability of the territories to manage their
Medicaid programs, including their ability to provide services
to beneficiaries. Furthermore, that the temporary increases to
the caps and the Federal medical assistance percentage
indicates not only the commitment of Congress to ensuring the
sustainability of these programs, but also that a more
permanent legislative solution must be developed to provide the
territories with a consistent source of Federal funding for
their Medicaid programs.
TITLE IV--NO SURPRISES ACT
Sec. 401. Short title
Section 401 designates that the short title may be cited as
the ``No Surprises Act''.
Sec. 402. Preventing surprise medical bills
The ``No Surprises Act'' would ensure that consumers with
all types of private insurance are protected by prohibiting
surprise billing and limiting the patient's cost-sharing to
what it would have been if the services were received in-
network. These protections apply in the following situations:
When a patient receives out-of-network
emergency services;
When a patient receives additional out-of-
network services after they are stabilized but before
they can travel to an in-network provider without
medical transport (i.e. post-stabilization services);
When a patient receives services from a
facility-based provider (such as anesthesiologists,
radiologists, pathologists, neonatologists, assistant
surgeons, or hospitalists);
For scheduled, non-emergency care--when a
patient does not receive written and oral notice of the
provider's network status and charges at the time they
schedule the care and specifically consent to receiving
out-of-network services at least 72 hours in advance of
those services being provided (including laboratory
services or imaging services sent off-site). This
consent requirement would not apply to any unforeseen
medical needs that may arise during the course of
treatment; or
When an in-network provider is unavailable
at the facility.
In addition to requiring facilities and providers to give
patients clear written notices that include information on
network status and cost prior to scheduled care, section 402
requires insurers and providers to better maintain accurate
consumer-facing provider directories. It also requires
providers and insurers to publicly post information regarding
the patient protections that would exist under this legislation
and/or state legislation.
The legislation establishes a minimum payment benchmark set
at the median contracted (in-network) rate for the service in
the geographic area the service was delivered. That rate may
also account for differences in sites of care. It also
preserves a state's ability to determine their own payment
standards for plans regulated by the state. The median
contracted rate would be based on the insurer's rates in 2019
and increased by CPI-U each year. The Secretary of HHS would
conduct audits of the median contracted rate to ensure its
accuracy.
Finally, this section establishes an independent resolution
process. Providers and hospitals would receive the median in-
network payment and have 30 days within which to file an appeal
with the health plan. The plan would then have up to 30 days to
adjudicate the appeal through their plan's usual internal
process, after which the provider could initiate a 30-day
independent dispute resolution process with a neutral arbiter.
In order for a claim to qualify for independent dispute
resolution, the benchmark payment made by the plan (i.e. the
median contracted rate or the rate determined by state law)
must be greater than $1,250--so that only complex cases would
qualify for dispute resolution. The $1,250 threshold would be
indexed to CPI-U. The dispute resolution process would be
``baseball-style,'' meaning that each party will submit a best
and final offer and the arbiter will choose the most reasonable
of the two offers based on certain considerations. The arbiter
would be permitted to consider the following set of objective
facts and circumstances in resolving the dispute: the median
contracted rate; provider's level of training, education,
experience, and quality and outcomes measurements of the
provider or facility; and, any other extenuating circumstances
with respect to the complexity of services or acuity of the
patient.
Sec. 403. Government Accountability Office study on profit- and
revenue-sharing in health care
Section 403 requires the Government Accountability Office
(GAO) to study profit sharing relationships between hospitals,
contract management groups, and providers.
Sec. 404. State All Payer Claims Databases
Section 404 provides $50 million in grants for states
looking to develop or maintain an all-payer claims database.
Sec. 405. Air ambulance cost data reporting program
Section 405 requires air ambulance providers to report to
the Secretary of HHS their costs, broken out by the cost of air
travel and the cost of emergency medical services delivered.
Sec. 406. Report by Secretary of Labor
Section 406 requires the Secretary of Labor to conduct a
report one year after the date of the enactment and annually
thereafter for each of the following five years on the effects
of Title IV on premiums and out-of-pocket costs in group health
plans, the adequacy of provider networks in group health plans,
and other relevant effects.
Sec. 407. Billing statute of limitations
Section 407 states that a health care provider or health
care facility (or health insurance issuer offering health
insurance coverage or group health plan) may not initiate a
process to seek reimbursement from an individual for a service
furnished by such provider or facility to such individual more
than a year after such date of service.
Sec. 408. GAO report on impact of surprise billing provisions
Section 408 requires the Government Accountability Office
to report not later than three years after enactment on: (1)
the incidence and prevalence of the furnishing of items and
services to individuals enrolled under a group health plan or
health insurance coverage by health care providers and health
care facilities that do not have a contractual relationship
with such plan or such coverage (as applicable) for furnishing
such items and services to such an individual; (2) the impacts
on provider shortages and accessibility to such providers,
focusing on rural and medically underserved communities; (3)
the number of grants that have been awarded under section 404
(relating to State All Payer Claims Databases) and for what
purposes states have used funds made available under such
grants; and (4) an analysis of how data made available through
State All Payer Claims Databases receiving funding under such
grants has been used.
Sec. 409. Report by the Secretary of Health and Human Services
Section 409 requires the Secretary of HHS to conduct a
report not later than one year after the date of the enactment
and annually thereafter for each of the following five years on
the impact of this Act on: premiums and out-of-pocket costs
with respect to individual health insurance coverage and small
group health plans; the adequacy of provider networks with
respect to individual health insurance coverage and small group
health plans, taking into consideration maximum travel time and
distance; and other relevant effects.
TITLE V--TERRITORIES HEALTH CARE IMPROVEMENT ACT
Section 501. Short title
Section 501 designates that the short title may be cited as
the ``Territories Health Care Improvement Act''.
Section 502. Medicaid payments for Puerto Rico and the other
territories for certain fiscal years
Section 502 increases the annual Federal Medicaid
allotments to Puerto Rico for FY 2020 through FY 2023 to the
following amounts:
FY 2020: $2,823,188,000
FY 2021: $2,919,072,000
FY 2022: $3,012,610,000
FY 2023: $3,114,331,000.
This section also increases the Federal Medicaid allotments
to the U.S. Virgin Islands to $126,000,000 for each fiscal year
for FY 2020 through FY 2025. It increases the Federal Medicaid
allotments to Guam to $127,000,000 for each fiscal year for FY
2020 through FY 2025. It increases the Federal Medicaid
allotments to the Northern Mariana Islands to $60,000,000 for
each fiscal year for FY 2020 through FY 2025. It increases the
Federal Medicaid allotments to American Samoa to $84,000,000
for each fiscal year for FY 2020 through FY 2025.
Subsection (c) increases the Federal medical assistance
percentage (FMAP) for the territories in the following manner:
For Puerto Rico, for FY 2020 and FY 2021, the FMAP shall be
83 percent; for FY 2022 and FY 2023, the FMAP shall be 76
percent. For the U.S. Virgin Islands, for FY 2020, the FMAP
shall be 100 percent; for FY 2021 through FY 2024, the FMAP
shall be 83 percent; for FY 2025, the FMAP shall be 76 percent.
For Guam, the Northern Mariana Islands, and American Samoa, for
FY 2020 and FY 2021, the FMAP shall be 100 percent; for FY 2022
through FY 2024, the FMAP shall be 83 percent; for FY 2025, the
FMAP shall be 76 percent.
Subsection (d) requires each territory to submit an annual
report, no later than 180 days after the end of each fiscal
year, to the Chair and Ranking Member of the Committee on
Energy and Commerce of the House of Representatives and the
Chair and Ranking Member of the Committee on Finance of the
Senate, that describes how the territory has used the increase
to its FMAP to increase provider payments, increase covered
benefits, expand provider networks, or any other improvements
to its Medicaid program.
Section 503. Application of certain requirements under Medicaid program
to certain territories
Section 503 requires the territories to comply with
different provisions of the Medicaid statute from which they
are currently excluded. Subsection (a) applies the payment
error rate measurement requirements to Puerto Rico, effective
FY 2023. Subsection (b) requires Puerto Rico to implement an
asset verification program by the end of FY 2022 and requires
the U.S. Virgin Islands to implement an asset verification
program by the end of FY 2023. Subsection (c) requires, no
later than FY 2024, the Northern Mariana Islands, American
Samoa, and Guam to implement methods satisfactory to the
Secretary of Health and Human Services for collecting and
reporting data to the Transformed Medicaid Statistical
Information System (T-MSIS), and to demonstrate progress in
establishing a Medicaid fraud control unit.
Section 504. Additional program integrity requirements
Subsection (a) of Section 504 requires no sooner than one
year after the date of enactment, that the Inspector General of
the Department of Health and Human Services conduct an audit of
areas of Puerto Rico's Medicaid program that it determines to
be at high risk for waste, fraud, or abuse; including
contracting protocols, denials of care, and financial
management.
Subsection (b) requires no later than one year after the
date of enactment that the Inspector General develop and submit
to Congress, a plan for auditing and investigating contracting
practices related to Puerto Rico's Medicaid program.
Subsection (c) requires no later than two years after the
date of enactment, that the Comptroller General issue, to the
Chair and Ranking Member of the Committee on Energy and
Commerce of the House of Representatives and the Chair and
Ranking Member of the Committee on Finance of the Senate, a
report that examines the contracting practices of Puerto Rico's
Medicaid program.
Subsection (d) requires no later than one year after the
date of enactment, that the Secretary reevaluate any waivers
granted to Guam, the Northern Mariana Islands, or American
Samoa for establishing a Medicaid fraud control unit, and
determine whether such waivers should continue to be approved.
Subsection (e) requires Puerto Rico to establish a system
for tracking all Federal Medicaid funds in Puerto Rico. It
requires Puerto Rico to track and report CMS the total amount
expended by Puerto Rico during the previous quarter and the
amount Puerto Rico expects to spend on the next quarter. It
further requires, upon request, that Puerto Rico submit to CMS
all documents related to contracts awarded under the Puerto
Rico Medicaid program.
XVI. Changes in Existing Law Made by the Bill, as Reported
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, and existing law in which no
change is proposed is shown in roman):
PATIENT PROTECTION AND AFFORDABLE CARE ACT
* * * * * * *
TITLE X--STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL
AMERICANS
* * * * * * *
Subtitle E--Provisions Relating to Title V
* * * * * * *
SEC. 10503. COMMUNITY HEALTH CENTERS AND THE NATIONAL HEALTH SERVICE
CORPS FUND.
(a) Purpose.--It is the purpose of this section to establish
a Community Health Center Fund (referred to in this section as
the ``CHC Fund''), to be administered through the Office of the
Secretary of the Department of Health and Human Services to
provide for expanded and sustained national investment in
community health centers under section 330 of the Public Health
Service Act and the National Health Service Corps.
(b) Funding.--There is authorized to be appropriated, and
there is appropriated, out of any monies in the Treasury not
otherwise appropriated, to the CHC Fund--
(1) to be transferred to the Secretary of Health and
Human Services to provide enhanced funding for the
community health center program under section 330 of
the Public Health Service Act--
(A) $1,000,000,000 for fiscal year 2011;
(B) $1,200,000,000 for fiscal year 2012;
(C) $1,500,000,000 for fiscal year 2013;
(D) $2,200,000,000 for fiscal year 2014;
(E) $3,600,000,000 for each of fiscal years
2015 through 2017; and
(F) $3,800,000,000 for fiscal year 2018 and
$4,000,000,000 for [fiscal year 2019] each of
fiscal years 2019 through 2023.
(2) to be transferred to the Secretary of Health and
Human Services to provide enhanced funding for the
National Health Service Corps--
(A) $290,000,000 for fiscal year 2011;
(B) $295,000,000 for fiscal year 2012;
(C) $300,000,000 for fiscal year 2013;
(D) $305,000,000 for fiscal year 2014;
(E) $310,000,000 for each of fiscal years
2015 through 2017; and
(F) $310,000,000 for each of fiscal years
[2018 and 2019] 2019 through 2023.
(c) Construction.--There is authorized to be appropriated,
and there is appropriated, out of any monies in the Treasury
not otherwise appropriated, $1,500,000,000 to be available for
fiscal years 2011 through 2015 to be used by the Secretary of
Health and Human Services for the construction and renovation
of community health centers.
(d) Use of Fund.--The Secretary of Health and Human Services
shall transfer amounts in the CHC Fund to accounts within the
Department of Health and Human Services to increase funding,
over the fiscal year 2008 level, for community health centers
and the National Health Service Corps.
(e) Availability.--Amounts appropriated under subsections (b)
and (c) shall remain available until expended.
* * * * * * *
----------
PUBLIC HEALTH SERVICE ACT
* * * * * * *
TITLE III--GENERAL POWERS AND DUTIES OF PUBLIC HEALTH SERVICE
* * * * * * *
Part D--Primary Health Care
Subpart I--Health Centers
* * * * * * *
SEC. 330B. SPECIAL DIABETES PROGRAMS FOR TYPE I DIABETES.
(a) In General.--The Secretary, directly or through grants,
shall provide for research into the prevention and cure of Type
I diabetes.
(b) Funding.--
(1) Transferred funds.--Notwithstanding section
2104(a) of the Social Security Act, from the amounts
appropriated in such section for each of fiscal years
1998 through 2002, $30,000,000 is hereby transferred
and made available in such fiscal year for grants under
this section.
(2) Appropriations.--For the purpose of making grants
under this section, there is appropriated, out of any
funds in the Treasury not otherwise appropriated--
(A) $70,000,000 for each of fiscal years 2001
and 2002 (which shall be combined with amounts
transferred under paragraph (1) for each such
fiscal years);
(B) $100,000,000 for fiscal year 2003;
(C) $150,000,000 for each of fiscal years
2004 through 2017; and
(D) $150,000,000 for [each of fiscal years
2018 and 2019] fiscal years 2019 through 2023,
to remain available until expended.
SEC. 330C. SPECIAL DIABETES PROGRAMS FOR INDIANS.
(a) In General.--The Secretary shall make grants for
providing services for the prevention and treatment of diabetes
in accordance with subsection (b).
(b) Services Through Indian Health Facilities.--For purposes
of subsection (a), services under such subsection are provided
in accordance with this subsection if the services are provided
through any of the following entities:
(1) The Indian Health Service.
(2) An Indian health program operated by an Indian
tribe or tribal organization pursuant to a contract,
grant, cooperative agreement, or compact with the
Indian Health Service pursuant to the Indian Self-
Determination Act.
(3) An urban Indian health program operated by an
urban Indian organization pursuant to a grant or
contract with the Indian Health Service pursuant to
title V of the Indian Health Care Improvement Act.
(c) Funding.--
(1) Transferred funds.--Notwithstanding section
2104(a) of the Social Security Act, from the amounts
appropriated in such section for each of fiscal years
1998 through 2002, $30,000,000, to remain available
until expended, is hereby transferred and made
available in such fiscal year for grants under this
section.
(2) Appropriations.--For the purpose of making grants
under this section, there is appropriated, out of any
money in the Treasury not otherwise appropriated--
(A) $70,000,000 for each of fiscal years 2001
and 2002 (which shall be combined with amounts
transferred under paragraph (1) for each such
fiscal years);
(B) $100,000,000 for fiscal year 2003;
(C) $150,000,000 for each of fiscal years
2004 through 2017; and
(D) $150,000,000 for each of [fiscal years
2018 and 2019] fiscal years 2019 through 2023,
to remain available until expended.
* * * * * * *
Subpart XI --Support of Graduate Medical Education in Qualified
Teaching Health Centers
SEC. 340H. PROGRAM OF PAYMENTS TO TEACHING HEALTH CENTERS THAT OPERATE
GRADUATE MEDICAL EDUCATION PROGRAMS.
(a) Payments.--
(1) In general.--Subject to subsection (h)(2), the
Secretary shall make payments under this section for
direct expenses and indirect expenses to qualified
teaching health centers that are listed as sponsoring
institutions by the relevant accrediting body for, as
appropriate--
(A) maintenance of filled positions at
existing approved graduate medical residency
training programs;
(B) expansion of existing approved graduate
medical residency training programs; and
(C) establishment of new approved graduate
medical residency training programs.
(2) Per resident amount.--In making payments under
paragraph (1), the Secretary shall consider the cost of
training residents at teaching health centers and the
implications of the per resident amount on approved
graduate medical residency training programs at
teaching health centers.
(3) Priority.--In making payments under paragraph
(1)(C), the Secretary shall give priority to qualified
teaching health centers that--
(A) serve a health professional shortage area
with a designation in effect under section 332
or a medically underserved community (as
defined in section 799B); or
(B) are located in a rural area (as defined
in section 1886(d)(2)(D) of the Social Security
Act).
(b) Amount of Payments.--
(1) In general.--Subject to paragraph (2), the
amounts payable under this section to qualified
teaching health centers for an approved graduate
medical residency training program for a fiscal year
are each of the following amounts:
(A) Direct expense amount.--The amount
determined under subsection (c) for direct
expenses associated with sponsoring approved
graduate medical residency training programs.
(B) Indirect expense amount.--The amount
determined under subsection (d) for indirect
expenses associated with the additional costs
relating to teaching residents in such
programs.
(2) Capped amount.--
(A) In general.--The total of the payments
made to qualified teaching health centers under
paragraph (1)(A) or paragraph (1)(B) in a
fiscal year shall not exceed the amount of
funds appropriated under subsection (g) for
such payments for that fiscal year.
(B) Limitation.--The Secretary shall limit
the funding of full-time equivalent residents
in order to ensure the direct and indirect
payments as determined under subsection (c) and
(d) do not exceed the total amount of funds
appropriated in a fiscal year under subsection
(g).
(c) Amount of Payment for Direct Graduate Medical
Education.--
(1) In general.--The amount determined under this
subsection for payments to qualified teaching health
centers for direct graduate expenses relating to
approved graduate medical residency training programs
for a fiscal year is equal to the product of--
(A) the updated national per resident amount
for direct graduate medical education, as
determined under paragraph (2); and
(B) the average number of full-time
equivalent residents in the teaching health
center's graduate approved medical residency
training programs as determined under section
1886(h)(4) of the Social Security Act (without
regard to the limitation under subparagraph (F)
of such section) during the fiscal year.
(2) Updated national per resident amount for direct
graduate medical education.--The updated per resident
amount for direct graduate medical education for a
qualified teaching health center for a fiscal year is
an amount determined as follows:
(A) Determination of qualified teaching
health center per resident amount.--The
Secretary shall compute for each individual
qualified teaching health center a per resident
amount--
(i) by dividing the national average
per resident amount computed under
section 340E(c)(2)(D) into a wage-
related portion and a non-wage related
portion by applying the proportion
determined under subparagraph (B);
(ii) by multiplying the wage-related
portion by the factor applied under
section 1886(d)(3)(E) of the Social
Security Act (but without application
of section 4410 of the Balanced Budget
Act of 1997 (42 U.S.C. 1395ww note))
during the preceding fiscal year for
the teaching health center's area; and
(iii) by adding the non-wage-related
portion to the amount computed under
clause (ii).
(B) Updating rate.--The Secretary shall
update such per resident amount for each such
qualified teaching health center as determined
appropriate by the Secretary.
(d) Amount of Payment for Indirect Medical Education.--
(1) In general.--The amount determined under this
subsection for payments to qualified teaching health
centers for indirect expenses associated with the
additional costs of teaching residents for a fiscal
year is equal to an amount determined appropriate by
the Secretary.
(2) Factors.--In determining the amount under
paragraph (1), the Secretary shall--
(A) evaluate indirect training costs relative
to supporting a primary care residency program
in qualified teaching health centers; and
(B) based on this evaluation, assure that the
aggregate of the payments for indirect expenses
under this section and the payments for direct
graduate medical education as determined under
subsection (c) in a fiscal year do not exceed
the amount appropriated for such expenses as
determined in subsection (g).
(3) Interim payment.--Before the Secretary makes a
payment under this subsection pursuant to a
determination of indirect expenses under paragraph (1),
the Secretary may provide to qualified teaching health
centers a payment, in addition to any payment made
under subsection (c), for expected indirect expenses
associated with the additional costs of teaching
residents for a fiscal year, based on an estimate by
the Secretary.
(e) Clarification Regarding Relationship to Other Payments
for Graduate Medical Education.--Payments under this section--
(1) shall be in addition to any payments--
(A) for the indirect costs of medical
education under section 1886(d)(5)(B) of the
Social Security Act;
(B) for direct graduate medical education
costs under section 1886(h) of such Act; and
(C) for direct costs of medical education
under section 1886(k) of such Act;
(2) shall not be taken into account in applying the
limitation on the number of total full-time equivalent
residents under subparagraphs (F) and (G) of section
1886(h)(4) of such Act and clauses (v), (vi)(I), and
(vi)(II) of section 1886(d)(5)(B) of such Act for the
portion of time that a resident rotates to a hospital;
and
(3) shall not include the time in which a resident is
counted toward full-time equivalency by a hospital
under paragraph (2) or under section 1886(d)(5)(B)(iv)
of the Social Security Act, section 1886(h)(4)(E) of
such Act, or section 340E of this Act.
(f) Reconciliation.--The Secretary shall determine any
changes to the number of residents reported by a teaching
health center in the application of the teaching health center
for the current fiscal year to determine the final amount
payable to the teaching health center for the current fiscal
year for both direct expense and indirect expense amounts.
Based on such determination, the Secretary shall recoup any
overpayments made to pay any balance due to the extent
possible. The final amount so determined shall be considered a
final intermediary determination for the purposes of section
1878 of the Social Security Act and shall be subject to
administrative and judicial review under that section in the
same manner as the amount of payment under section 1186(d) of
such Act is subject to review under such section.
(g) Funding.--
(1) In general.--To carry out this section, there are
appropriated such sums as may be necessary, not to
exceed $230,000,000, for the period of fiscal years
2011 through 2015, $60,000,000 for each of fiscal years
2016 and 2017, and $126,500,000 for each of fiscal
years [2018 and 2019] 2019 through 2023, to remain
available until expended.
(2) Administrative expenses.--Of the amount made
available to carry out this section for any fiscal
year, the Secretary may not use more than 5 percent of
such amount for the expenses of administering this
section.
(h) Annual Reporting Required.--
(1) Annual report.--The report required under this
paragraph for a qualified teaching health center for a
fiscal year is a report that includes (in a form and
manner specified by the Secretary) the following
information for the residency academic year completed
immediately prior to such fiscal year:
(A) The types of primary care resident
approved training programs that the qualified
teaching health center provided for residents.
(B) The number of approved training positions
for residents described in paragraph (4).
(C) The number of residents described in
paragraph (4) who completed their residency
training at the end of such residency academic
year and care for vulnerable populations living
in underserved areas.
(D) The number of patients treated by
residents described in paragraph (4).
(E) The number of visits by patients treated
by residents described in paragraph (4).
(F) Of the number of residents described in
paragraph (4) who completed their residency
training at the end of such residency academic
year, the number and percentage of such
residents entering primary care practice
(meaning any of the areas of practice listed in
the definition of a primary care residency
program in section 749A).
(G) Of the number of residents described in
paragraph (4) who completed their residency
training at the end of such residency academic
year, the number and percentage of such
residents who entered practice at a health care
facility--
(i) primarily serving a health
professional shortage area with a
designation in effect under section 332
or a medically underserved community
(as defined in section 799B); or
(ii) located in a rural area (as
defined in section 1886(d)(2)(D) of the
Social Security Act).
(H) Other information as deemed appropriate
by the Secretary.
(2) Audit authority; limitation on payment.--
(A) Audit authority.--The Secretary may audit
a qualified teaching health center to ensure
the accuracy and completeness of the
information submitted in a report under
paragraph (1).
(B) Limitation on payment.--A teaching health
center may only receive payment in a cost
reporting period for a number of such resident
positions that is greater than the base level
of primary care resident positions, as
determined by the Secretary. For purposes of
this subparagraph, the ``base level of primary
care residents'' for a teaching health center
is the level of such residents as of a base
period.
(3) Reduction in payment for failure to report.--
(A) In general.--The amount payable under
this section to a qualified teaching health
center for a fiscal year shall be reduced by at
least 25 percent if the Secretary determines
that--
(i) the qualified teaching health
center has failed to provide the
Secretary, as an addendum to the
qualified teaching health center's
application under this section for such
fiscal year, the report required under
paragraph (1) for the previous fiscal
year; or
(ii) such report fails to provide
complete and accurate information
required under any subparagraph of such
paragraph.
(B) Notice and opportunity to provide
accurate and missing information.--Before
imposing a reduction under subparagraph (A) on
the basis of a qualified teaching health
center's failure to provide complete and
accurate information described in subparagraph
(A)(ii), the Secretary shall provide notice to
the teaching health center of such failure and
the Secretary's intention to impose such
reduction and shall provide the teaching health
center with the opportunity to provide the
required information within the period of 30
days beginning on the date of such notice. If
the teaching health center provides such
information within such period, no reduction
shall be made under subparagraph (A) on the
basis of the previous failure to provide such
information.
(4) Residents.--The residents described in this
paragraph are those who are in part-time or full-time
equivalent resident training positions at a qualified
teaching health center in any approved graduate medical
residency training program.
(i) Regulations.--The Secretary shall promulgate regulations
to carry out this section.
(j) Definitions.--In this section:
(1) Approved graduate medical residency training
program.--The term ``approved graduate medical
residency training program'' means a residency or other
postgraduate medical training program--
(A) participation in which may be counted
toward certification in a specialty or
subspecialty and includes formal postgraduate
training programs in geriatric medicine
approved by the Secretary; and
(B) that meets criteria for accreditation (as
established by the Accreditation Council for
Graduate Medical Education, the American
Osteopathic Association, or the American Dental
Association).
(2) New approved graduate medical residency training
program.--The term ``new approved graduate medical
residency training program'' means an approved graduate
medical residency training program for which the
sponsoring qualified teaching health center has not
received a payment under this section for a previous
fiscal year (other than pursuant to subsection
(a)(1)(C)).
(3) Primary care residency program.--The term
``primary care residency program'' has the meaning
given that term in section 749A.
(4) Qualified teaching health center.--The term
``qualified teaching health center'' has the meaning
given the term ``teaching health center'' in section
749A.
* * * * * * *
TITLE XXVII--REQUIREMENTS RELATING TO HEALTH INSURANCE COVERAGE
PART A--INDIVIDUAL AND GROUP MARKET REFORMS
* * * * * * *
Subpart II--Improving Coverage
* * * * * * *
SEC. 2719A. PATIENT PROTECTIONS.
(a) Choice of Health Care Professional.--If a group health
plan, or a health insurance issuer offering group or individual
health insurance coverage, requires or provides for designation
by a participant, beneficiary, or enrollee of a participating
primary care provider, then the plan or issuer shall permit
each participant, beneficiary, and enrollee to designate any
participating primary care provider who is available to accept
such individual.
(b) Coverage of Emergency Services.--
(1) In general.--If [a group health plan, or a health
insurance issuer offering group or individual health
insurance issuer,] a health plan (as defined in
subsection (e)(2)(A)) provides or covers any benefits
with respect to services in an emergency department of
a hospital or, for plan year 2021 or a subsequent plan
year, with respect to emergency services in an
independent freestanding emergency department (as
defined in paragraph (3)(D)), [the plan or issuer] the
plan shall cover emergency services (as defined in
[paragraph (2)(B)] paragraph (3)(C))--
(A) without the need for any prior
authorization determination;
(B) whether the health care provider
furnishing such services is a participating
provider or a participating emergency facility,
as applicable, with respect to such services;
(C) in a manner so that, if such services are
provided to a participant, beneficiary, or
enrollee by a nonparticipating provider or a
nonparticipating emergency facility--
[(i) by a nonparticipating health
care provider with or without prior
authorization; or]
[(ii)(I) such services] (i) such
services will be provided without
imposing any requirement under the plan
for prior authorization of services or
any limitation on coverage [where the
provider of services does not have a
contractual relationship with the plan
for the providing of services] that is
more restrictive than the requirements
or limitations that apply to [emergency
department services received from
providers who do have such a
contractual relationship with the plan;
and] emergency services received from
participating providers and
participating emergency facilities with
respect to such plan;
[(II) if such services are provided
out-of-network, the cost-sharing
requirement (expressed as a copayment
amount or coinsurance rate) is the same
requirement that would apply if such
services were provided in-network;]
(ii) the cost-sharing requirement
(expressed as a copayment amount or
coinsurance rate) is not greater than
the requirement that would apply if
such services were provided by a
participating provider or a
participating emergency facility;
(iii) such requirement is calculated
as if the total amount that would have
been charged for such services by such
participating provider or participating
emergency facility were equal to--
(I) in the case of such
services furnished in a State
described in paragraph
(3)(H)(ii), the median
contracted rate (as defined in
paragraph (3)(E)(i)) for such
services; and
(II) in the case of such
services furnished in a State
described in paragraph
(3)(H)(i), the lesser of--
(aa) the amount
determined by such
State for such services
in accordance with the
method described in
such paragraph; and
(bb) the median
contracted rate (as so
defined) for such
services;
(iv) the health plan pays to such
provider or facility, respectively, the
amount by which the recognized amount
(as defined in paragraph (3)(H)) for
such services exceeds the cost-sharing
amount for such services (as determined
in accordance with clauses (ii) and
(iii)); and
(v) any cost-sharing payments made by
the participant, beneficiary, or
enrollee with respect to such emergency
services so furnished shall be counted
toward any in-network deductible or
out-of-pocket maximums applied under
the plan (and such in-network
deductible shall be applied) in the
same manner as if such cost-sharing
payments were with respect to emergency
services furnished by a participating
provider and a participating emergency
facility; and
(D) without regard to any other term or
condition of such coverage (other than
exclusion or coordination of benefits, or an
affiliation or waiting period, permitted under
section 2701 of this Act, section 701 of the
Employee Retirement Income Security Act of
1974, or section 9801 of the Internal Revenue
Code of 1986, and other than applicable cost-
sharing).
(2) Audit process for median contracted rates.--
(A) In general.--Not later than July 1, 2020,
the Secretary, in consultation with appropriate
State agencies, shall establish through
rulemaking a process, in accordance with
subparagraph (B), under which health plans are
audited by such Secretaries to ensure that--
(i) such plans are in compliance with
the requirement of applying a median
contracted rate under this section; and
(ii) that such median contracted rate
so applied satisfies the definition
under paragraph (3)(E) with respect to
the year involved, including with
respect to a health plan described in
clause (ii) of such paragraph.
(B) Audit samples.--Under the process
established pursuant to subparagraph (A), the
Secretary--
(i) shall conduct audits described in
such subparagraph, with respect to a
year (beginning with 2021), of a sample
with respect to such year of claims
data from not more than 25 health
plans; and
(ii) may audit any health plan if the
Secretary has received any complaint
about such plan that involves the
compliance of the plan with either of
the requirements described in clauses
(i) and (ii) of such subparagraph.
[(2)] (3) Definitions.--In this subsection and
subsection (e):
(A) Emergency department of a hospital.--The
term ``emergency department of a hospital''
includes a hospital outpatient department that
provides emergency services.
[(A)] (B) Emergency medical condition.--The
term ``emergency medical condition'' means a
medical condition manifesting itself by acute
symptoms of sufficient severity (including
severe pain) such that a prudent layperson, who
possesses an average knowledge of health and
medicine, could reasonably expect the absence
of immediate medical attention to result in a
condition described in clause (i), (ii), or
(iii) of section 1867(e)(1)(A) of the Social
Security Act.
[(B) Emergency services.--The term
``emergency services'' means, with respect to
an emergency medical condition--
[(i) a medical screening examination
(as required under section 1867 of the
Social Security Act) that is within the
capability of the emergency department
of a hospital, including ancillary
services routinely available to the
emergency department to evaluate such
emergency medical condition, and
[(ii) within the capabilities of the
staff and facilities available at the
hospital, such further medical
examination and treatment as are
required under section 1867 of such Act
to stabilize the patient.]
(C) Emergency services.--
(i) In general.--The term ``emergency
services'', with respect to an
emergency medical condition, means--
(I) a medical screening
examination (as required under
section 1867 of the Social
Security Act, or as would be
required under such section if
such section applied to an
independent freestanding
emergency department) that is
within the capability of the
emergency department of a
hospital or of an independent
freestanding emergency
department, as applicable,
including ancillary services
routinely available to the
emergency department to
evaluate such emergency medical
condition; and
(II) within the capabilities
of the staff and facilities
available at the hospital or
the independent freestanding
emergency department, as
applicable, such further
medical examination and
treatment as are required under
section 1867 of such Act, or as
would be required under such
section if such section applied
to an independent freestanding
emergency department, to
stabilize the patient.
(ii) Inclusion of poststabilization
services.--For purposes of this
subsection and section 2799, in the
case of an individual enrolled in a
health plan who is furnished services
described in clause (i) by a provider
or facility to stabilize such
individual with respect to an emergency
medical condition, the term ``emergency
services'' shall include such items and
services in addition to those described
in clause (i) that such a provider or
facility determines are needed to be
furnished (after such stabilization but
during such visit in which such
individual is so stabilized) to such
individual, unless each of the
following conditions are met:
(I) Such a provider or
facility determines such
individual is able to travel
using nonmedical transportation
or nonemergency medical
transportation.
(II) Such provider furnishing
such additional items and
services is in compliance with
section 2799A(d) with respect
to such items and services.
(D) Independent freestanding emergency
department.--The term ``independent
freestanding emergency department'' means a
facility that--
(i) is geographically separate and
distinct and licensed separately from a
hospital under applicable State law;
and
(ii) provides emergency services.
(E) Median contracted rate.--
(i) In general.--The term ``median
contracted rate'' means, with respect
to an item or service and a health plan
(as defined in subsection (e)(2)(A))--
(I) for 2021, the median of
the negotiated rates recognized
by the sponsor or issuer of
such plan (determined with
respect to all such plans of
such sponsor or such issuer
that are within the same line
of business) as the total
maximum payment (including the
cost-sharing amount imposed for
such services (as determined in
accordance with clauses (ii)
and (iii) of paragraph (1)(C)
or subparagraphs (A) and (B) of
subsection (e)(1), as
applicable) and the amount to
be paid by the plan or issuer)
under such plans in 2019 for
the same or a similar item or
service that is provided by a
provider in the same or similar
specialty and provided in the
geographic region in which the
item or service is furnished,
consistent with the methodology
established by the Secretary
under section 402(e) of the No
Surprises Act, increased by the
percentage increase in the
consumer price index for all
urban consumers (United States
city average) over 2019 and
2020; and
(II) for 2022 and each
subsequent year, the median
contracted rate determined
under this clause for the
previous year, increased by the
percentage increase in the
consumer price index for all
urban consumers (United States
city average) over such
previous year.
(ii) Special rule.--The Secretary
shall provide pursuant to rulemaking
described in section 402(e) of the No
Surprises Act that--
(I) if the sponsor or issuer
of a health plan does not have
sufficient information to
calculate a median contracted
rate for an item or service or
provider type, or amount of,
claims for items or services
(as determined by the
Secretary) provided in a
particular geographic area
(other than in a case described
in item (bb)), such sponsor or
issuer shall demonstrate that
such sponsor or issuer will use
any database free of conflicts
of interest that has sufficient
information reflecting allowed
amounts paid to a health care
provider for relevant services
provided in the applicable
geographic region (such as
State All Payer Claims
Databases (as defined in
section 404(d) of such Act)),
and that such sponsor or issuer
will use any such database to
determine a median contracted
rate and cover the cost of
accessing any such database;
and
(II) in the case of a sponsor
or issuer offering a health
plan in a geographic region
that did not offer any health
plan in such region during
2019, such sponsor or issuer
shall use a methodology
established by the Secretary
for determining the median
contracted rate for items and
services covered by such plan
for the first year in which
such plan is offered in such
region, and that, for each
succeeding year, the median
contracted rate for such items
and services under such plan
shall be the median contracted
rate for such items and
services under such plan for
the previous year, increased by
the percentage increase in the
consumer price index for all
urban consumers (United States
city average) over such
previous year.
(F) Nonparticipating emergency facility;
participating emergency facility.--
(i) Nonparticipating emergency
facility.--The term ``nonparticipating
emergency facility'' means, with
respect to an item or service and a
health plan, an emergency department of
a hospital, or an independent
freestanding emergency department, that
does not have a contractual
relationship with the plan (or, if
applicable, issuer offering the plan)
for furnishing such item or service
under the plan.
(ii) Participating emergency
facility.--The term ``participating
emergency facility'' means, with
respect to an item or service and a
health plan, an emergency department of
a hospital, or an independent
freestanding emergency department, that
has a contractual relationship with the
plan (or, if applicable, issuer
offering the plan) for furnishing such
item or service under the plan.
(G) Nonparticipating providers; participating
providers.--
(i) Nonparticipating provider.--The
term ``nonparticipating provider''
means, with respect to an item or
service and a health plan, a physician
or other health care provider who is
acting within the scope of practice of
that provider's license or
certification under applicable State
law and who does not have a contractual
relationship with the plan (or, if
applicable, issuer offering the plan)
for furnishing such item or service
under the plan.
(ii) Participating provider.--The
term ``participating provider'' means,
with respect to an item or service and
a health plan, a physician or other
health care provider who is acting
within the scope of practice of that
provider's license or certification
under applicable State law and who has
a contractual relationship with the
plan (or, if applicable, issuer
offering the plan) for furnishing such
item or service under the plan.
(H) Recognized amount.--The term ``recognized
amount'' means, with respect to an item or
service--
(i) in the case of such item or
service furnished in a State that has
in effect a State law that provides for
a method for determining the amount of
payment that is required to be covered
by a health plan regulated by such
State in the case of a participant,
beneficiary, or enrollee covered under
such plan and receiving such item or
service from a nonparticipating
provider or facility, not more than the
amount determined in accordance with
such law plus the cost-sharing amount
imposed under the plan for such item or
service (as determined in accordance
with clauses (ii) and (iii) of
paragraph (1)(C) or subparagraphs (A)
and (B) of subsection (e)(1), as
applicable); or
(ii) in the case of such item or
service furnished in a State that does
not have in effect such a law, an
amount that is at least the median
contracted rate (as defined in
subparagraph (E)(i) and determined in
accordance with rulemaking described in
section 402(e) of the No Surprises Act)
for such item or service.
[(C)] (I) Stabilize.--The term ``to
stabilize'', with respect to an emergency
medical condition (as defined in subparagraph
(A)), has the meaning give in section
1867(e)(3) of the Social Security Act (42
U.S.C. 1395dd(e)(3)).
(c) Access to Pediatric Care.--
(1) Pediatric care.--In the case of a person who has
a child who is a participant, beneficiary, or enrollee
under a group health plan, or health insurance coverage
offered by a health insurance issuer in the group or
individual market, if the plan or issuer requires or
provides for the designation of a participating primary
care provider for the child, the plan or issuer shall
permit such person to designate a physician (allopathic
or osteopathic) who specializes in pediatrics as the
child's primary care provider if such provider
participates in the network of the plan or issuer.
(2) Construction.--Nothing in paragraph (1) shall be
construed to waive any exclusions of coverage under the
terms and conditions of the plan or health insurance
coverage with respect to coverage of pediatric care.
(d) Patient Access to Obstetrical and Gynecological Care.--
(1) General rights.--
(A) Direct access.--A group health plan, or
health insurance issuer offering group or
individual health insurance coverage, described
in paragraph (2) may not require authorization
or referral by the plan, issuer, or any person
(including a primary care provider described in
paragraph (2)(B)) in the case of a female
participant, beneficiary, or enrollee who seeks
coverage for obstetrical or gynecological care
provided by a participating health care
professional who specializes in obstetrics or
gynecology. Such professional shall agree to
otherwise adhere to such plan's or issuer's
policies and procedures, including procedures
regarding referrals and obtaining prior
authorization and providing services pursuant
to a treatment plan (if any) approved by the
plan or issuer.
(B) Obstetrical and gynecological care.--A
group health plan or health insurance issuer
described in paragraph (2) shall treat the
provision of obstetrical and gynecological
care, and the ordering of related obstetrical
and gynecological items and services, pursuant
to the direct access described under
subparagraph (A), by a participating health
care professional who specializes in obstetrics
or gynecology as the authorization of the
primary care provider.
(2) Application of paragraph.--A group health plan,
or health insurance issuer offering group or individual
health insurance coverage, described in this paragraph
is a group health plan or coverage that--
(A) provides coverage for obstetric or
gynecologic care; and
(B) requires the designation by a
participant, beneficiary, or enrollee of a
participating primary care provider.
(3) Construction.--Nothing in paragraph (1) shall be
construed to--
(A) waive any exclusions of coverage under
the terms and conditions of the plan or health
insurance coverage with respect to coverage of
obstetrical or gynecological care; or
(B) preclude the group health plan or health
insurance issuer involved from requiring that
the obstetrical or gynecological provider
notify the primary care health care
professional or the plan or issuer of treatment
decisions.
(e) Coverage of Non-emergency Services Performed by
Nonparticipating Providers at Certain Participating
Facilities.--
(1) In general.--Subject to paragraph (3), in the
case of items or services (other than emergency
services to which subsection (b) applies) furnished to
a participant, beneficiary, or enrollee of a health
plan (as defined in paragraph (2)(A)) by a
nonparticipating provider (as defined in subsection
(b)(3)(G)(i)) during a visit (as defined by the
Secretary in accordance with paragraph (2)(C)) at a
participating health care facility (as defined in
paragraph (2)(B)), with respect to such plan, the
plan--
(A) shall not impose on such participant,
beneficiary, or enrollee a cost-sharing amount
(expressed as a copayment amount or coinsurance
rate) for such items and services so furnished
that is greater than the cost-sharing amount
that would apply under such plan had such items
or services been furnished by a participating
provider (as defined in subsection
(b)(3)(G)(ii));
(B) shall calculate such cost-sharing amount
as if the amount that would have been charged
for such items and services by such
participating provider were equal to--
(i) in the case of such items and
services furnished in a State described
in subsection (b)(3)(H)(ii), the median
contracted rate (as defined in
subsection (b)(3)(E)(i)) for such items
and services; and
(ii) in the case of such items and
services furnished in a State described
in subsection (b)(3)(H)(i), the lesser
of--
(I) the amount determined by
such State for such items and
services in accordance with the
method described in such
subsection; and
(II) the median contracted
rate (as so defined) for such
items and services;
(C) shall pay to such provider furnishing
such items and services to such participant,
beneficiary, or enrollee the amount by which
the recognized amount (as defined in subsection
(b)(3)(H)) for such items and services exceeds
the cost-sharing amount imposed under the plan
for such items and services (as determined in
accordance with subparagraphs (A) and (B)); and
(D) shall count toward any in-network
deductible or out-of-pocket maximums applied
under the plan any cost-sharing payments made
by the participant, beneficiary, or enrollee
(and such in-network deductible shall be
applied) with respect to such items and
services so furnished in the same manner as if
such cost-sharing payments were with respect to
items and services furnished by a participating
provider.
(2) Definitions.--In this subsection and subsection
(b):
(A) Health plan.--The term ``health plan''
means a group health plan and health insurance
coverage offered by a heath insurance issuer in
the group or individual market and includes a
grandfathered health plan (as defined in
section 1251(e) of the Patient Protection and
Affordable Care Act).
(B) Participating health care facility.--
(i) In general.--The term
``participating health care facility''
means, with respect to an item or
service and a health plan, a health
care facility described in clause (ii)
that has a contractual relationship
with the plan (or, if applicable,
issuer offering the plan) for
furnishing such item or service.
(ii) Health care facility
described.--A health care facility
described in this clause is each of the
following:
(I) A hospital (as defined in
1861(e) of the Social Security
Act).
(II) A critical access
hospital (as defined in section
1861(mm) of such Act).
(III) An ambulatory surgical
center (as defined in section
1833(i)(1)(A) of such Act).
(IV) A laboratory.
(V) A radiology facility or
imaging center.
(C) During a visit.--The term ``during a
visit'' shall, with respect to items and
services furnished to an individual at a
participating health care facility, include
equipment and devices, telemedicine services,
imaging services, laboratory services, and such
other items and services as the Secretary may
specify, regardless of whether or not the
provider furnishing such items or services is
at the facility.
(3) Exception.--Paragraph (1) shall not apply to a
health plan in the case of items or services (other
than emergency services to which subsection (b)
applies) furnished to a participant, beneficiary, or
enrollee of a health plan (as defined in paragraph
(2)(A)) by a nonparticipating provider (as defined in
subsection (b)(3)(G)(i)) during a visit (as defined by
the Secretary in accordance with paragraph (2)(C)) at a
participating health care facility (as defined in
paragraph (2)(B)) if such provider is in compliance
with section 2799A(d) with respect to such items and
services.
(f) Independent Dispute Resolution Process.--
(1) Establishment.--
(A) In general.--Not later than 1 year after
the date of the enactment of this subsection,
the Secretary, in consultation with the
Secretary of Labor, shall establish by
regulation an independent dispute resolution
process (referred to in this subsection as the
``IDR process'') under which--
(i) a nonparticipating provider (as
defined in subparagraph (G) of
subsection (b)(3)), nonparticipating
emergency facility (as defined in
subparagraph (F) of such subsection),
or health plan (as defined in
subsection (e)(2)(A)) may submit a
request for resolution by an entity
certified under paragraph (2) (in this
subsection referred to as a ``certified
IDR entity'') of a specified claim; and
(ii) in the case a settlement
described in subparagraph (B) of
paragraph (4) is not reached with
respect to such claim, such entity so
resolves such claim in accordance with
such paragraph.
(B) Definitions.--In this subsection:
(i) Specified claim.--
(I) In general.--Subject to
subclause (II), the term
``specified claim'' means a
claim by a nonparticipating
provider, a nonparticipating
emergency facility, or a health
plan with respect to qualifying
items and services (as defined
in clause (ii)) furnished by
such provider or facility in a
State described in subparagraph
(H)(ii) of subsection (b)(3)
for which a health plan is
required to make payment
pursuant to subsection (b)(1)
or subsection (e)(1)--
(aa) that such
payment should be
increased or decreased;
and
(bb) that is made not
later than--
(AA) in the
case of such a
claim filed by
such a provider
or facility,
the date on
which the
appeal with
respect to such
items and
services
described in
clause
(ii)(I)(aa)(AA)
has been
resolved (or
the date that
is 30 days
after such
appeal is
filed,
whichever is
earlier); or
(BB) in the
case of such a
claim filed by
such plan, the
date on which
the period
described in
clause
(ii)(I)(bb)(BB)
with respect to
such items and
services
elapses.
(II) Limitation on packaging
of items and services in a
specified claim.--The term
``specified claim'' shall not
include, in the case such claim
is made by such provider,
facility, or plan with respect
to multiple items and services,
any claim with respect to items
and services furnished by such
provider or facility if--
(aa) such items and
services were not
furnished by the same
provider or facility;
(bb) payment for such
items and services made
pursuant to subsection
(b)(1) or subsection
(e)(1) was made by
multiple health plans;
(cc) such items and
services are not
related to the
treatment of the same
condition; or
(dd) such items and
services were not
furnished within 30
days of the date of the
earliest item or
service furnished that
is included in such
claim.
(ii) Qualifying items and services.--
(I) In general.--Subject to
subclause (II), the term
``qualifying items and
services'' means--
(aa) with respect to
a specified claim made
by a nonparticipating
provider or
nonparticipating
emergency facility,
items and services
furnished by such
provider or facility
for which a health plan
is required to make
payment pursuant to
subsection (b)(1) or
subsection (e)(1), but
only if--
(AA) such
items and
services are
included in an
appeal filed
under such
plan's internal
appeals process
not later than
30 days after
such payment is
received; and
(BB) such
appeal under
such plan's
internal
appeals process
has been
resolved, or a
30-day period
has elapsed
since such
appeal was so
filed; and
(bb) with respect to
a specified claim made
by a health plan, items
and services furnished
by such a provider or
facility for which such
health plan is required
to make payment
pursuant to subsection
(b)(1) or subsection
(e)(1), but only if--
(AA) such
plan submits a
notice to such
provider or
facility not
later than 30
days after such
provider or
facility
receives such
payment that
such plan
disputes the
amount of such
payment with
respect to such
items and
services; and
(BB) a 30-day
period has
elapsed since
the submission
of such notice.
(II) Limitation.--The term
``qualifying items and
services'' shall not include an
item or service furnished in a
geographic area during a year
by such provider or facility
for which a health plan is
required to make payment
pursuant to subsection (b)(1)
or subsection (e)(1) if the
median contracted rate (as
defined in subsection
(b)(3)(E)) under such plan for
such year with respect to such
item or service furnished by
such a provider or such a
facility in such area does not
exceed--
(aa) with respect to
an item or service
furnished during 2021,
$1,250; and
(bb) with respect to
an item or service
furnished during a
subsequent year, the
amount specified under
this subclause for the
previous year,
increased by the
percentage increase in
the consumer price
index for all urban
consumers (United
States city average)
over such previous
year.
(2) Certification of entities.--
(A) Process of certification.--The process
described in paragraph (1) shall include a
certification process under which eligible
entities may be certified to carry out the IDR
process.
(B) Eligibility.--
(i) In general.--For purposes of
subparagraph (A), an eligible entity is
an entity that is a nongovernmental
entity that agrees to comply with the
fee limitations described in clause
(ii).
(ii) Fee limitation.--For purposes of
clause (i), the fee limitations
described in this clause are
limitations established by the
Secretary on the amount a certified IDR
entity may charge a nonparticipating
provider, nonparticipating emergency
facility, or health plan for services
furnished by such entity with respect
to the resolution of a specified claim
of such provider, facility, or plan
under the process described in
paragraph (1).
(3) Selection of certified idr entity for a specified
claim.--With respect to the resolution of a specified
claim under the IDR process, the health plan and the
nonparticipating provider or the nonparticipating
emergency facility (as applicable) involved shall agree
on a certified IDR entity to resolve such claim. In the
case that such plan and such provider or facility (as
applicable) cannot so agree, such an entity shall be
selected by the Secretary at random.
(4) Payment determination.--
(A) Timing.--A certified IDR entity selected
under paragraph (3) by a health plan and a
nonparticipating provider or a nonparticipating
emergency facility (as applicable) with respect
to a specified claim shall, subject to
subparagraph (B), not later than 30 days after
being so selected, determine the total
reimbursement that should have been made for
items and services included in such claim in
accordance with subparagraph (C).
(B) Settlement.--
(i) In general.--If such entity
determines that a settlement between
the health plan and the provider or
facility is likely with respect to a
specified claim, the entity may direct
the parties to attempt, for a period
not to exceed 10 days, a good faith
negotiation for a settlement of such
claim.
(ii) Timing.--The period for a
settlement described in clause (i)
shall accrue towards the 30-day period
described in subparagraph (A).
(C) Determination of amount.--
(i) In general.--The health plan and
the nonparticipating provider or
nonparticipating emergency facility (as
applicable) shall, with respect to a
specified claim, each submit to the
certified IDR entity a final offer of
payment or reimbursement (as
applicable) with respect to items and
services which are the subject of the
specified claim. Such entity shall
determine which such offer is the most
reasonable in accordance with clause
(ii).
(ii) Considerations in
determination.--
(I) In general.--In
determining which final offer
is the most reasonable under
clause (i), the certified IDR
entity shall consider--
(aa) the median
contracted rates (as
defined in subsection
(b)(3)(E)) for items or
services that are
comparable to the items
and services included
in the specified claim
and that are furnished
in the same geographic
area (as defined by the
Secretary for purposes
of such subsection) as
such items and services
(not including any
facility fees with
respect to such rates);
and
(bb) the
circumstances described
in subclause (II), if
any information with
respect to such
circumstances is
submitted by either
party.
(II) Additional
circumstances.--For purposes of
subclause (I)(bb), the
circumstances described in this
subclause are, with respect to
items and services included in
the specified claim of a
nonparticipating provider,
nonparticipating emergency
facility, or health plan, the
following:
(aa) The level of
training, education,
experience, and quality
and outcomes
measurements of the
provider or facility
that furnished such
items and services.
(bb) Any other
extenuating
circumstances with
respect to the
furnishing of such
items and services that
relate to the acuity of
the individual
receiving such items
and services or the
complexity of
furnishing such items
and services to such
individual.
(III) Prohibition on
consideration of billed
charges.--In determining which
final offer is the most
reasonable under clause (i)
with respect to items and
services furnished by a
provider or facility and
included in a specified claim,
the certified IDR entity may
not consider the amount that
would have been billed by such
provider or facility with
respect to such items and
services had the provisions of
section 2799 or 2799A (as
applicable) not applied.
(iii) Effect of determination.--A
determination of a certified IDR entity
under clause (i)--
(I) shall be binding; and
(II) shall not be subject to
judicial review, except in a
case described in any of
paragraphs (1) through (4) of
section 10(a) of title 9,
United States Code.
(iv) Costs of independent dispute
resolution process.--In the case of a
specified claim made by a
nonparticipating provider,
nonparticipating emergency facility, or
health plan and submitted to a
certified IDR entity--
(I) if such entity makes a
determination with respect to
such claim under clause (i),
the party whose offer is not
chosen under such clause shall
be responsible for paying all
fees charged by such entity;
and
(II) if the parties reach a
settlement with respect to such
claim prior to such a
determination, such fees shall
be divided equally between the
parties, unless the parties
otherwise agree.
(v) Payment.--Not later than 30 days
after a determination described in
clause (i) is made with respect to a
specified claim of a nonparticipating
provider, nonparticipating emergency
facility, or health plan--
(I) in the case that such
determination finds that the
amount paid with respect to
such specified claim by the
health plan should have been
greater than the amount so
paid, such plan shall pay
directly to the provider or
facility (as applicable) the
difference between the amount
so paid and the amount so
determined; and
(II) in the case that such
determination finds that the
amount paid with respect to
such specified claim by the
health plan should have been
less than the amount so paid,
the provider or facility (as
applicable) shall pay directly
to the plan the difference
between the amount so paid and
the amount so determined.
(5) Publication of information relating to
disputes.--
(A) In general.--For 2021 and each subsequent
year, the Secretary and the Secretary of Labor
shall publish on the public website of the
Department of Health and Human Services and the
Department of Labor, respectively--
(i) the number of specified claims
filed during such year;
(ii) the number of such claims with
respect to which a final determination
was made under paragraph (4)(C)(i); and
(iii) the information described in
subparagraph (B) with respect to each
specified claim with respect to which
such a decision was so made.
(B) Information with respect to specified
claims.--For purposes of subparagraph (A), the
information described in this subparagraph is,
with respect to a specified claim of a
nonparticiapting provider, nonparticipating
emergency facility, or health plan--
(i) a description of each item and
service included in such claim;
(ii) the amount of the offer
submitted under paragraph (4)(C)(i) by
the health plan and by the
nonparticipating provider or
nonparticipating emergency facility (as
applicable);
(iii) whether the offer selected by
the certified IDR entity under such
paragraph was the offer submitted by
such plan or by such provider or
facility (as applicable) and the amount
of such offer so selected; and
(iv) the category and practice
specialty of each such provider or
facility involved in furnishing such
items and services.
(C) Confidentiality of parties.--None of the
information published under this paragraph may
specify the identity of a health plan,
provider, facility, or individual with respect
to a specified claim.
(g) Provider Directory Information Requirements.--
(1) In general.--Not later than 1 year after the date
of the enactment of this subsection, each group health
plan and health insurance issuer offering group or
individual health insurance coverage shall--
(A) establish the verification process
described in paragraph (2);
(B) establish the response protocol described
in paragraph (3);
(C) establish the database described in
paragraph (4); and
(D) include in any print directory containing
provider directory information with respect to
such plan or such coverage the information
described in paragraph (5).
(2) Verification process.--The verification process
described in this paragraph is, with respect to a group
health plan or a health insurance issuer offering group
or individual health insurance coverage, a process--
(A) under which not less frequently than once
every 90 days, such plan or such issuer (as
applicable) verifies and updates the provider
directory information included on the database
described in paragraph (4) of such plan or
issuer of each health care provider and health
care facility included in such database; and
(B) that establishes a procedure for the
removal of such a provider or facility with
respect to which such plan or issuer has been
unable to verify such information during a
period specified by the plan or issuer.
(3) Response protocol.--The response protocol
described in this paragraph is, in the case of an
individual enrolled under a group health plan or group
or individual health insurance coverage offered by a
health insurance issuer who requests information on
whether a health care provider or health care facility
has a contractual relationship to furnish items and
services under such plan or such coverage, a protocol
under which such plan or such issuer (as applicable),
in the case such request is made through a telephone
call--
(A) responds to such individual as soon as
practicable and in no case later than 1
business day after such call is received
through a written electronic communication; and
(B) retains such communication in such
individual's file for at least 2 years
following such response.
(4) Database.--The database described in this
paragraph is, with respect to a group health plan or
health insurance issuer offering group or individual
health insurance coverage, a database on the public
website of such plan or issuer that contains--
(A) a list of each health care provider and
health care facility with which such plan or
such issuer has a contractual relationship for
furnishing items and services under such plan
or such coverage; and
(B) provider directory information with
respect to each such provider and facility.
(5) Information.--The information described in this
paragraph is, with respect to a print directory
containing provider directory information with respect
to a group health plan or individual or group health
insurance coverage offered by a health insurance
issuer, a notification that such information contained
in such directory was accurate as of the date of
publication of such directory and that an individual
enrolled under such plan or such coverage should
consult the database described in paragraph (4) with
respect to such plan or such coverage or contact such
plan or the issuer of such coverage to obtain the most
current provider directory information with respect to
such plan or such coverage.
(6) Definition.--For purposes of this subsection, the
term ``provider directory information'' includes, with
respect to a group health plan and a health insurance
issuer offering group or individual health insurance
coverage, the name, address, specialty, and telephone
number of each health care provider or health care
facility with which such plan or such issuer has a
contractual relationship for furnishing items and
services under such plan or such coverage.
(h) Disclosure on Patient Protections.--Each group health
plan and health insurance issuer offering group or individual
health insurance coverage shall make publicly available, and
(if applicable) post on a public website of such plan or
issuer--
(1) information in plain language on--
(A) the requirements and prohibitions applied
under sections 2799 and 2799A (relating to
prohibitions on balance billing in certain
circumstances);
(B) if provided for under applicable State
law, any other requirements on providers and
facilities regarding the amounts such providers
and facilities may, with respect to an item or
service, charge a participant, beneficiary, or
enrollee of such plan or coverage with respect
to which such a provider or facility does not
have a contractual relationship for furnishing
such item or service under the plan or coverage
after receiving payment from the plan or
coverage for such item or service and any
applicable cost-sharing payment from such
participant, beneficiary, or enrollee; and
(C) the requirements applied under
subsections (b) and (e); and
(2) information on contacting appropriate State and
Federal agencies in the case that an individual
believes that such a provider or facility has violated
any requirement described in paragraph (1) with respect
to such individual.
* * * * * * *
PART D--PREVENTING CERTAIN CASES OF BALANCE BILLING
SEC. 2799. BALANCE BILLING IN CASES OF EMERGENCY SERVICES.
(a) In General.--In the case of a participant, beneficiary,
or enrollee with benefits under a health plan who is furnished
on or after January 1, 2021, emergency services with respect to
an emergency medical condition during a visit at an emergency
department of a hospital or an independent freestanding
emergency department--
(1) the emergency department of a hospital or
independent freestanding emergency department shall not
hold the participant, beneficiary, or enrollee liable
for a payment amount for such emergency services so
furnished that is more than the cost-sharing amount for
such services (as determined in accordance with clauses
(ii) and (iii) of section 2719A(b)(1)(C)); and
(2) a health care provider shall not hold such
participant, beneficiary, or enrollee liable for a
payment amount for an emergency service furnished to
such individual by such provider with respect to such
emergency medical condition and visit for which the
individual receives emergency services at the hospital
or emergency department that is more than the cost-
sharing amount for such services furnished by the
provider (as determined in accordance with clauses (ii)
and (iii) of section 2719A(b)(1)(C)).
(b) Definitions.--In this section:
(1) The terms ``emergency department of a hospital'',
``emergency medical condition'', ``emergency
services'', and ``independent freestanding emergency
department'' have the meanings given such terms,
respectively, in section 2719A(b)(3).
(2) The term ``health plan'' has the meaning given
such term in section 2719A(e).
(3) The term ``during a visit'' shall have such
meaning as applied to such term for purposes of section
2719A(e).
SEC. 2799A. BALANCE BILLING IN CASES OF NON-EMERGENCY SERVICES
PERFORMED BY NONPARTICIPATING PROVIDERS AT CERTAIN
PARTICIPATING FACILITIES.
(a) In General.--Subject to subsection (b), in the case of a
participant, beneficiary, or enrollee with benefits under a
health plan (as defined in section 2799(b)) who is furnished on
or after January 1, 2021, items or services (other than
emergency services to which section 2799 applies) at a
participating health care facility by a nonparticipating
provider, such provider shall not hold such participant,
beneficiary, or enrollee liable for a payment amount for such
an item or service furnished by such provider during a visit at
such facility that is more than the cost-sharing amount for
such item or service (as determined in accordance with
subparagraphs (A) and (B) of section 2719A(e)(1)).
(b) Exception.--
(1) In general.--Subsection (a) shall not apply to a
nonparticipating provider (other than a specified
provider at a participating health care facility), with
respect to items or services furnished by the provider
to a participant, beneficiary, or enrollee of a health
plan, if the provider is in compliance with the notice
and consent requirements of subsection (d).
(2) Specified provider defined.--For purposes of
paragraph (1), the term ``specified provider'', with
respect to a participating health care facility--
(A) means a facility-based provider,
including emergency medicine providers,
anesthesiologists, pathologists, radiologists,
neonatologists, assistant surgeons,
hospitalists, intensivists, or other providers
as determined by the Secretary; and
(B) includes, with respect to an item or
service, a nonparticipating provider if there
is no participating provider at such facility
who can furnish such item or service.
(c) Clarification.--In the case of a nonparticipating
provider (other than a specified provider at a participating
health care facility) that complies with the notice and consent
requirements of subsection (d) with respect to an item or
service (referred to in this subsection as a ``covered item or
service''), such notice and consent requirements may not be
construed as applying with respect to any item or service that
is furnished as a result of unforeseen medical needs that arise
at the time such covered item or service is furnished.
(d) Compliance With Notice and Consent Requirements.--
(1) In general.--A nonparticipating provider or
nonparticipating facility is in compliance with this
subsection, with respect to items or services furnished
by the provider or facility to a participant,
beneficiary, or enrollee of a health plan, if the
provider (or, if applicable, the participating health
care facility on behalf of such provider) or
nonparticipating facility--
(A) provides to the participant, beneficiary,
or enrollee (or to an authorized representative
of the participant, beneficiary, or enrollee)
on the date on which the individual is
furnished such items or services and, in the
case that the participant, beneficiary, or
enrollee makes an appointment to be furnished
such items or services, on such date the
appointment is made--
(i) an oral explanation of the
written notice described in clause
(ii); and
(ii) a written notice specified by
the Secretary, not later than July 1,
2020, through guidance (which shall be
updated as determined necessary by the
Secretary) that--
(I) contains the information
required under paragraph (2);
and
(II) is signed and dated by
the participant, beneficiary,
or enrollee (or by an
authorized representative of
the participant, beneficiary,
or enrollee) and, with respect
to items or services to be
furnished by such a provider
that are not poststabilization
services described in section
2719A(b)(3)(C)(ii), is so
signed and dated not less than
72 hours prior to the
participant, beneficiary, or
enrollee being furnished such
items or services by such
provider; and
(B) obtains from the participant,
beneficiary, or enrollee (or from such an
authorized representative) the consent
described in paragraph (3).
(2) Information required under written notice.--For
purposes of paragraph (1)(A)(ii)(I), the information
described in this paragraph, with respect to a
nonparticipating provider or nonparticipating facility
and a participant, beneficiary, or enrollee of a health
plan, is each of the following:
(A) Notification, as applicable, that the
health care provider is a nonparticipating
provider with respect to the health plan or the
health care facility is a nonparticipating
facility with respect to the health plan.
(B) Notification of the estimated amount that
such provider or facility may charge the
participant, beneficiary, or enrollee for such
items and services involved.
(C) In the case of a nonparticipating
facility, a list of any participating providers
at the facility who are able to furnish such
items and services involved and notification
that the participant, beneficiary, or enrollee
may be referred, at their option, to such a
participating provider.
(3) Consent described.--For purposes of paragraph
(1)(B), the consent described in this paragraph, with
respect to a participant, beneficiary, or enrollee of a
health plan who is to be furnished items or services by
a nonparticipating provider or nonparticipating
facility, is a document specified by the Secretary
through rulemaking that--
(A) is signed by the participant,
beneficiary, or enrollee (or by an authorized
representative of the participant, beneficiary,
or enrollee) and, with respect to items or
services to be furnished by such a provider or
facility that are not poststabilization
services described in section
2719A(b)(3)(C)(ii), is so signed not less than
72 hours prior to the participant, beneficiary,
or enrollee being furnished such items or
services by such provider or facility;
(B) acknowledges that the participant,
beneficiary, or enrollee has been--
(i) provided with a written estimate
and an oral explanation of the charge
that the participant, beneficiary, or
enrollee will be assessed for the items
or services anticipated to be furnished
to the participant, beneficiary, or
enrollee by such provider or facility;
and
(ii) informed that the payment of
such charge by the participant,
beneficiary, or enrollee may not accrue
toward meeting any limitation that the
health plan places on cost-sharing; and
(C) documents the consent of the participant,
beneficiary, or enrollee to--
(i) be furnished with such items or
services by such provider or facility;
and
(ii) in the case that the individual
is so furnished such items or services,
be charged an amount that may be
greater than the amount that would
otherwise be charged the individual if
furnished by a participating provider
or participating facility with respect
to such items or services and plan.
(e) Retention of Certain Documents.--A nonparticipating
provider (or, in the case of a nonparticipating provider at a
participating health care facility, such facility) or
nonparticipating facility that obtains from a participant,
beneficiary, or enrollee of a health plan (or an authorized
representative of such participant, beneficiary, or enrollee) a
written notice in accordance with subsection (c)(1)(ii), with
respect to furnishing an item or service to such participant,
beneficiary, or enrollee, shall retain such notice for at least
a 2-year period after the date on which such item or service is
so furnished.
(f) Definitions.--In this section:
(1) The terms ``nonparticipating provider'' and
``participating provider'' have the meanings given such
terms, respectively, in subsection (b)(3) of section
2719A.
(2) The terms ``participating health care facility''
and ``health plan'' have the meanings given such terms,
respectively, in subsection (e)(2) of section 2719A.
(3) The term ``nonparticipating facility'' means--
(A) with respect to emergency services (as
defined in section 2719A(b)(3)(C)(i)) and a
health plan, an emergency department of a
hospital, or an independent freestanding
emergency department, that does not have a
contractual relationship with the plan (or, if
applicable, issuer offering the plan) for
furnishing such services under the plan; and
(B) with respect to poststabilization
services described in section
2719A(b)(3)(C)(ii) and a health plan, an
emergency department of a hospital (or other
department of such hospital), or an independent
freestanding emergency department, that does
not have a contractual relationship with the
plan (or, if applicable, issuer offering the
plan) for furnishing such services under the
plan.
(4) The term ``participating facility'' means--
(A) with respect to emergency services (as
defined in section 2719A(b)(3)(C)(i)) and a
health plan, an emergency department of a
hospital, or an independent freestanding
emergency department, that has a contractual
relationship with the plan (or, if applicable,
issuer offering the plan) for furnishing such
services under the plan; and
(B) with respect to poststabilization
services described in section
2719A(b)(3)(C)(ii) and a health plan, an
emergency department of a hospital (or other
department of such hospital), or an independent
freestanding emergency department, that has a
contractual relationship with the plan (or, if
applicable, issuer offering the plan) for
furnishing such services under the plan.
SEC. 2799B. PROVIDER REQUIREMENTS WITH RESPECT TO PROVIDER DIRECTORY
INFORMATION.
Not later than 1 year after the date of the enactment of this
section, each health care provider and health care facility
shall establish a process under which such provider or facility
transmits, to each health insurance issuer offering group or
individual health insurance coverage and group health plan with
which such provider or facility has in effect a contractual
relationship for furnishing items and services under such
coverage or such plan, provider directory information (as
defined in section 2719A(g)(6)) with respect to such provider
or facility, as applicable. Such provider or facility shall so
transmit such information to such issuer offering such coverage
or such group health plan--
(1) when the provider or facility enters into such a
relationship with respect to such coverage offered by
such issuer or with respect to such plan;
(2) when the provider or facility terminates such
relationship with respect to such coverage offered by
such issuer or with respect to such plan;
(3) when there are any other material changes to such
provider directory information of the provider or
facility with respect to such coverage offered by such
issuer or with respect to such plan; and
(4) at any other time (including upon the request of
such issuer or plan) determined appropriate by the
provider, facility, or the Secretary.
SEC. 2799C. PROVIDER REQUIREMENT WITH RESPECT TO PUBLIC PROVISION OF
INFORMATION.
Each health care provider and health care facility shall make
publicly available, and (if applicable) post on a public
website of such provider or facility--
(1) information in plain language on--
(A) the requirements and prohibitions of such
provider or facility under sections 2799 and
2799A (relating to prohibitions on balance
billing in certain circumstances); and
(B) if provided for under applicable State
law, any other requirements on such provider or
facility regarding the amounts such provider or
facility may, with respect to an item or
service, charge a participant, beneficiary, or
enrollee of a health plan (as defined in
section 2719A(e)(2)) with respect to which such
provider or facility does not have a
contractual relationship for furnishing such
item or service under the plan after receiving
payment from the plan for such item or service
and any applicable cost-sharing payment from
such participant, beneficiary, or enrollee; and
(2) information on contacting appropriate State and
Federal agencies in the case that an individual
believes that such provider or facility has violated
any requirement described in paragraph (1) with respect
to such individual.
SEC. 2799D. ENFORCEMENT.
(a) State Enforcement.--
(1) State authority.--Each State may require a
provider or health care facility subject to the
requirements of sections 2719A(f), 2799, 2799A, 2799B,
or 2799C to satisfy such requirements applicable to the
provider or facility.
(2) Failure to implement requirements.--In the case
of a determination by the Secretary that a State has
failed to substantially enforce the requirements
specified in paragraph (1) with respect to applicable
providers and facilities in the State, the Secretary
shall enforce such requirements under subsection (b)
insofar as they relate to violations of such
requirements occurring in such State.
(b) Secretarial Enforcement Authority.--
(1) In general.--If a provider or facility is found
to be in violation specified in subsection (a)(1) by
the Secretary, the Secretary may apply a civil monetary
penalty with respect to such provider or facility in an
amount not to exceed $10,000 per violation. The
provisions of subsections (c), (d), (e), (g), (h), (k),
and (l) of section 1128A of the Social Security Act
shall apply to a civil monetary penalty or assessment
under this subsection in the same manner as such
provisions apply to a penalty, assessment, or
proceeding under subsection (a) of such section.
(2) Limitation.--The provisions of paragraph (1)
shall apply to enforcement of a provision (or
provisions) specified in subsection (a)(1) only as
provided under subsection (a)(2).
(3) Complaint process.--The Secretary shall, through
rulemaking, establish a process to receive consumer
complaints of violations of such provisions and resolve
such complaints within 60 days of receipt of such
complaints.
(4) Exception.--The Secretary shall waive the
penalties described under paragraph (1) with respect to
a facility or provider who does not knowingly violate,
and should not have reasonably known it violated,
section 2799 or 2799A with respect to a participant,
beneficiary, or enrollee, if such facility or
practitioner, within 30 days of the violation,
withdraws the bill that was in violation of such
provision and reimburses the health plan or enrollee,
as applicable, in an amount equal to the difference
between the amount billed and the amount allowed to be
billed under the provision, plus interest, at an
interest rate determined by the Secretary.
(5) Hardship exemption.--The Secretary may establish
a hardship exemption to the penalties under this
subsection.
(c) Continued Applicability of State Law.--The sections
specified in subsection (a)(1) shall not be construed to
supersede any provision of State law which establishes,
implements, or continues in effect any requirement or
prohibition except to the extent that such requirement or
prohibition prevents the application of a requirement or
prohibition of such a section.
* * * * * * *
----------
SOCIAL SECURITY ACT
* * * * * * *
TITLE V--MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT
* * * * * * *
SEC. 510. SEXUAL RISK AVOIDANCE EDUCATION.
(a) In General.--
(1) Allotments to states.--For the purpose described
in subsection (b), the Secretary shall, for each of
[fiscal years 2018 and 2019] fiscal years 2019 through
2023, allot to each State which has transmitted an
application for the fiscal year under section 505(a) an
amount equal to the product of--
(A) the amount appropriated pursuant to
subsection (f)(1) for the fiscal year, minus
the amount reserved under subsection (f)(2) for
the fiscal year; and
(B) the proportion that the number of low-
income children in the State bears to the total
of such numbers of children for all the States.
(2) Other allotments.--
(A) Other entities.--For the purpose
described in subsection (b), the Secretary
shall, for each of [fiscal years 2018 and 2019]
fiscal years 2019 through 2023, for any State
which has not transmitted an application for
the fiscal year under section 505(a), allot to
one or more entities in the State the amount
that would have been allotted to the State
under paragraph (1) if the State had submitted
such an application.
(B) Process.--The Secretary shall select the
recipients of allotments under subparagraph (A)
by means of a competitive grant process under
which--
(i) not later than 30 days after the
deadline for the State involved to
submit an application for the fiscal
year under section 505(a), the
Secretary publishes a notice soliciting
grant applications; and
(ii) not later than 120 days after
such deadline, all such applications
must be submitted.
(b) Purpose.--
(1) In general.--Except for research under paragraph
(5) and information collection and reporting under
paragraph (6), the purpose of an allotment under
subsection (a) to a State (or to another entity in the
State pursuant to subsection (a)(2)) is to enable the
State or other entity to implement education
exclusively on sexual risk avoidance (meaning
voluntarily refraining from sexual activity).
(2) Required components.--Education on sexual risk
avoidance pursuant to an allotment under this section
shall--
(A) ensure that the unambiguous and primary
emphasis and context for each topic described
in paragraph (3) is a message to youth that
normalizes the optimal health behavior of
avoiding nonmarital sexual activity;
(B) be medically accurate and complete;
(C) be age-appropriate;
(D) be based on adolescent learning and
developmental theories for the age group
receiving the education; and
(E) be culturally appropriate, recognizing
the experiences of youth from diverse
communities, backgrounds, and experiences.
(3) Topics.--Education on sexual risk avoidance
pursuant to an allotment under this section shall
address each of the following topics:
(A) The holistic individual and societal
benefits associated with personal
responsibility, self-regulation, goal setting,
healthy decisionmaking, and a focus on the
future.
(B) The advantage of refraining from
nonmarital sexual activity in order to improve
the future prospects and physical and emotional
health of youth.
(C) The increased likelihood of avoiding
poverty when youth attain self-sufficiency and
emotional maturity before engaging in sexual
activity.
(D) The foundational components of healthy
relationships and their impact on the formation
of healthy marriages and safe and stable
families.
(E) How other youth risk behaviors, such as
drug and alcohol usage, increase the risk for
teen sex.
(F) How to resist and avoid, and receive help
regarding, sexual coercion and dating violence,
recognizing that even with consent teen sex
remains a youth risk behavior.
(4) Contraception.--Education on sexual risk
avoidance pursuant to an allotment under this section
shall ensure that--
(A) any information provided on contraception
is medically accurate and complete and ensures
that students understand that contraception
offers physical risk reduction, but not risk
elimination; and
(B) the education does not include
demonstrations, simulations, or distribution of
contraceptive devices.
(5) Research.--
(A) In general.--A State or other entity
receiving an allotment pursuant to subsection
(a) may use up to 20 percent of such allotment
to build the evidence base for sexual risk
avoidance education by conducting or supporting
research.
(B) Requirements.--Any research conducted or
supported pursuant to subparagraph (A) shall
be--
(i) rigorous;
(ii) evidence-based; and
(iii) designed and conducted by
independent researchers who have
experience in conducting and publishing
research in peer-reviewed outlets.
(6) Information collection and reporting.--A State or
other entity receiving an allotment pursuant to
subsection (a) shall, as specified by the Secretary--
(A) collect information on the programs and
activities funded through the allotment; and
(B) submit reports to the Secretary on the
data from such programs and activities.
(c) National Evaluation.--
(1) In general.--The Secretary shall--
(A) in consultation with appropriate State
and local agencies, conduct one or more
rigorous evaluations of the education funded
through this section and associated data; and
(B) submit a report to the Congress on the
results of such evaluations, together with a
summary of the information collected pursuant
to subsection (b)(6).
(2) Consultation.--In conducting the evaluations
required by paragraph (1), including the establishment
of rigorous evaluation methodologies, the Secretary
shall consult with relevant stakeholders and evaluation
experts.
(d) Applicability of Certain Provisions.--
(1) Sections 503, 507, and 508 apply to allotments
under subsection (a) to the same extent and in the same
manner as such sections apply to allotments under
section 502(c), except that section 503(a) shall be
applied by substituting ``the total of the sums'' for
``four-sevenths of the total of the sums''.
(2) Sections 505 and 506 apply to allotments under
subsection (a) to the extent determined by the
Secretary to be appropriate.
(e) Definitions.--In this section:
(1) The term ``age-appropriate'' means suitable (in
terms of topics, messages, and teaching methods) to the
developmental and social maturity of the particular age
or age group of children or adolescents, based on
developing cognitive, emotional, and behavioral
capacity typical for the age or age group.
(2) The term ``medically accurate and complete''
means verified or supported by the weight of research
conducted in compliance with accepted scientific
methods and--
(A) published in peer-reviewed journals,
where applicable; or
(B) comprising information that leading
professional organizations and agencies with
relevant expertise in the field recognize as
accurate, objective, and complete.
(3) The term ``rigorous'', with respect to research
or evaluation, means using--
(A) established scientific methods for
measuring the impact of an intervention or
program model in changing behavior
(specifically sexual activity or other sexual
risk behaviors), or reducing pregnancy, among
youth; or
(B) other evidence-based methodologies
established by the Secretary for purposes of
this section.
(4) The term ``youth'' refers to one or more
individuals who have attained age 10 but not age 20.
(f) Funding.--
(1) In general.--To carry out this section, there is
appropriated, out of any money in the Treasury not
otherwise appropriated, $75,000,000 for each of [fiscal
years 2018 and 2019] fiscal years 2019 through 2023.
(2) Reservation.--The Secretary shall reserve, for
each of [fiscal years 2018 and 2019] fiscal years 2019
through 2023, not more than 20 percent of the amount
appropriated pursuant to paragraph (1) for
administering the program under this section, including
the conducting of national evaluations and the
provision of technical assistance to the recipients of
allotments.
* * * * * * *
SEC. 513. PERSONAL RESPONSIBILITY EDUCATION.
(a) Allotments to States.--
(1) Amount.--
(A) In general.--For the purpose described in
subsection (b), subject to the succeeding
provisions of this section, for each of fiscal
years 2010 through [2019] 2023, the Secretary
shall allot to each State an amount equal to
the product of--
(i) the amount appropriated under
subsection (f) for the fiscal year and
available for allotments to States
after the application of subsection
(c); and
(ii) the State youth population
percentage determined under paragraph
(2).
(B) Minimum allotment.--
(i) In general.--Each State allotment
under this paragraph for a fiscal year
shall be at least $250,000.
(ii) Pro rata adjustments.--The
Secretary shall adjust on a pro rata
basis the amount of the State
allotments determined under this
paragraph for a fiscal year to the
extent necessary to comply with clause
(i).
(C) Application required to access
allotments.--
(i) In general.--A State shall not be
paid from its allotment for a fiscal
year unless the State submits an
application to the Secretary for the
fiscal year and the Secretary approves
the application (or requires changes to
the application that the State
satisfies) and meets such additional
requirements as the Secretary may
specify.
(ii) Requirements.--The State
application shall contain an assurance
that the State has complied with the
requirements of this section in
preparing and submitting the
application and shall include the
following as well as such additional
information as the Secretary may
require:
(I) Based on data from the
Centers for Disease Control and
Prevention National Center for
Health Statistics, the most
recent pregnancy rates for the
State for youth ages 10 to 14
and youth ages 15 to 19 for
which data are available, the
most recent birth rates for
such youth populations in the
State for which data are
available, and trends in those
rates for the most recently
preceding 5-year period for
which such data are available.
(II) State-established goals
for reducing the pregnancy
rates and birth rates for such
youth populations.
(III) A description of the
State's plan for using the
State allotments provided under
this section to achieve such
goals, especially among youth
populations that are the most
high-risk or vulnerable for
pregnancies or otherwise have
special circumstances,
including youth in foster care,
homeless youth, youth with HIV/
AIDS, pregnant youth who are
under 21 years of age, mothers
who are under 21 years of age,
and youth residing in areas
with high birth rates for
youth.
(2) State youth population percentage.--
(A) In general.--For purposes of paragraph
(1)(A)(ii), the State youth population
percentage is, with respect to a State, the
proportion (expressed as a percentage) of--
(i) the number of individuals who
have attained age 10 but not attained
age 20 in the State; to
(ii) the number of such individuals
in all States.
(B) Determination of number of youth.--The
number of individuals described in clauses (i)
and (ii) of subparagraph (A) in a State shall
be determined on the basis of the most recent
Bureau of the Census data.
(3) Availability of state allotments.--Subject to
paragraph (4)(A), amounts allotted to a State pursuant
to this subsection for a fiscal year shall remain
available for expenditure by the State through the end
of the second succeeding fiscal year.
(4) Authority to award grants from state allotments
to local organizations and entities in nonparticipating
states.--
(A) Grants from unexpended allotments.--If a
State does not submit an application under this
section for fiscal year 2010 or 2011, the State
shall no longer be eligible to submit an
application to receive funds from the amounts
allotted for the State for each of fiscal years
2010 through [2019] 2023 and such amounts shall
be used by the Secretary to award grants under
this paragraph for each of fiscal years 2012
through [2019] 2023. The Secretary also shall
use any amounts from the allotments of States
that submit applications under this section for
a fiscal year that remain unexpended as of the
end of the period in which the allotments are
available for expenditure under paragraph (3)
for awarding grants under this paragraph.
(B) Competitive prep grants.--
(i) In general.--The Secretary shall
continue through fiscal year [2019]
2023 grants awarded for any of fiscal
years 2015 through 2017 to local
organizations and entities to conduct,
consistent with subsection (b),
programs and activities in States that
do not submit an application for an
allotment under this section for fiscal
year 2010 or 2011.
(ii) Faith-based organizations or
consortia.--The Secretary may solicit
and award grants under this paragraph
to faith-based organizations or
consortia.
(C) Evaluation.--An organization or entity
awarded a grant under this paragraph shall
agree to participate in a rigorous Federal
evaluation.
(5) Maintenance of effort.--No payment shall be made
to a State from the allotment determined for the State
under this subsection or to a local organization or
entity awarded a grant under paragraph (4), if the
expenditure of non-federal funds by the State,
organization, or entity for activities, programs, or
initiatives for which amounts from allotments and
grants under this subsection may be expended is less
than the amount expended by the State, organization, or
entity for such programs or initiatives for fiscal year
2009.
(6) Data collection and reporting.--A State or local
organization or entity receiving funds under this
section shall cooperate with such requirements relating
to the collection of data and information and reporting
on outcomes regarding the programs and activities
carried out with such funds, as the Secretary shall
specify.
(b) Purpose.--
(1) In general.--The purpose of an allotment under
subsection (a)(1) to a State is to enable the State
(or, in the case of grants made under subsection
(a)(4)(B), to enable a local organization or entity) to
carry out personal responsibility education programs
consistent with this subsection.
(2) Personal responsibility education programs.--
(A) In general.--In this section, the term
``personal responsibility education program''
means a program that is designed to educate
adolescents on--
(i) both abstinence and contraception
for the prevention of pregnancy and
sexually transmitted infections,
including HIV/AIDS, consistent with the
requirements of subparagraph (B); and
(ii) at least 3 of the adulthood
preparation subjects described in
subparagraph (C).
(B) Requirements.--The requirements of this
subparagraph are the following:
(i) The program replicates evidence-
based effective programs or
substantially incorporates elements of
effective programs that have been
proven on the basis of rigorous
scientific research to change behavior,
which means delaying sexual activity,
increasing condom or contraceptive use
for sexually active youth, or reducing
pregnancy among youth.
(ii) The program is medically-
accurate and complete.
(iii) The program includes activities
to educate youth who are sexually
active regarding responsible sexual
behavior with respect to both
abstinence and the use of
contraception.
(iv) The program places substantial
emphasis on both abstinence and
contraception for the prevention of
pregnancy among youth and sexually
transmitted infections.
(v) The program provides age-
appropriate information and activities.
(vi) The information and activities
carried out under the program are
provided in the cultural context that
is most appropriate for individuals in
the particular population group to
which they are directed.
(C) Adulthood preparation subjects.--The
adulthood preparation subjects described in
this subparagraph are the following:
(i) Healthy relationships, including
marriage and family interactions.
(ii) Adolescent development, such as
the development of healthy attitudes
and values about adolescent growth and
development, body image, racial and
ethnic diversity, and other related
subjects.
(iii) Financial literacy.
(iv) Parent-child communication.
(v) Educational and career success,
such as developing skills for
employment preparation, job seeking,
independent living, financial self-
sufficiency, and workplace
productivity.
(vi) Healthy life skills, such as
goal-setting, decision making,
negotiation, communication and
interpersonal skills, and stress
management.
(c) Reservations of Funds.--
(1) Grants to implement innovative strategies.--From
the amount appropriated under subsection (f) for the
fiscal year, the Secretary shall reserve $10,000,000 of
such amount for purposes of awarding grants to entities
to implement innovative youth pregnancy prevention
strategies and target services to high-risk,
vulnerable, and culturally under-represented youth
populations, including youth in foster care, homeless
youth, youth with HIV/AIDS, victims of human
trafficking, pregnant women who are under 21 years of
age and their partners, mothers who are under 21 years
of age and their partners, and youth residing in areas
with high birth rates for youth. An entity awarded a
grant under this paragraph shall agree to participate
in a rigorous Federal evaluation of the activities
carried out with grant funds.
(2) Other reservations.--From the amount appropriated
under subsection (f) for the fiscal year that remains
after the application of paragraph (1), the Secretary
shall reserve the following amounts:
(A) Grants for indian tribes or tribal
organizations.--The Secretary shall reserve 5
percent of such remainder for purposes of
awarding grants to Indian tribes and tribal
organizations in such manner, and subject to
such requirements, as the Secretary, in
consultation with Indian tribes and tribal
organizations, determines appropriate.
(B) Secretarial responsibilities.--
(i) Reservation of funds.--The
Secretary shall reserve 10 percent of
such remainder for expenditures by the
Secretary for the activities described
in clauses (ii) and (iii).
(ii) Program support.--The Secretary
shall provide, directly or through a
competitive grant process, research,
training and technical assistance,
including dissemination of research and
information regarding effective and
promising practices, providing
consultation and resources on a broad
array of teen pregnancy prevention
strategies, including abstinence and
contraception, and developing resources
and materials to support the activities
of recipients of grants and other
State, tribal, and community
organizations working to reduce teen
pregnancy. In carrying out such
functions, the Secretary shall
collaborate with a variety of entities
that have expertise in the prevention
of teen pregnancy, HIV and sexually
transmitted infections, healthy
relationships, financial literacy, and
other topics addressed through the
personal responsibility education
programs.
(iii) Evaluation.--The Secretary
shall evaluate the programs and
activities carried out with funds made
available through allotments or grants
under this section.
(d) Administration.--
(1) In general.--The Secretary shall administer this
section through the Assistant Secretary for the
Administration for Children and Families within the
Department of Health and Human Services.
(2) Application of other provisions of title.--
(A) In general.--Except as provided in
subparagraph (B), the other provisions of this
title shall not apply to allotments or grants
made under this section.
(B) Exceptions.--The following provisions of
this title shall apply to allotments and grants
made under this section to the same extent and
in the same manner as such provisions apply to
allotments made under section 502(c):
(i) Section 504(b)(6) (relating to
prohibition on payments to excluded
individuals and entities).
(ii) Section 504(c) (relating to the
use of funds for the purchase of
technical assistance).
(iii) Section 504(d) (relating to a
limitation on administrative
expenditures).
(iv) Section 506 (relating to reports
and audits), but only to the extent
determined by the Secretary to be
appropriate for grants made under this
section.
(v) Section 507 (relating to
penalties for false statements).
(vi) Section 508 (relating to
nondiscrimination).
(e) Definitions.--In this section:
(1) Age-appropriate.--The term ``age-appropriate'',
with respect to the information in pregnancy
prevention, means topics, messages, and teaching
methods suitable to particular ages or age groups of
children and adolescents, based on developing
cognitive, emotional, and behavioral capacity typical
for the age or age group.
(2) Medically accurate and complete.--The term
``medically accurate and complete'' means verified or
supported by the weight of research conducted in
compliance with accepted scientific methods and--
(A) published in peer-reviewed journals,
where applicable; or
(B) comprising information that leading
professional organizations and agencies with
relevant expertise in the field recognize as
accurate, objective, and complete.
(3) Indian tribes; tribal organizations.--The terms
``Indian tribe'' and ``Tribal organization'' have the
meanings given such terms in section 4 of the Indian
Health Care Improvement Act (25 U.S.C. 1603)).
(4) Youth.--The term ``youth'' means an individual
who has attained age 10 but has not attained age 20.
(f) Appropriation.--For the purpose of carrying out this
section, there is appropriated, out of any money in the
Treasury not otherwise appropriated, $75,000,000 for each of
fiscal years 2010 through [2019] 2023. Amounts appropriated
under this subsection shall remain available until expended.
* * * * * * *
TITLE XI--GENERAL PROVISIONS, PEER REVIEW, AND ADMINISTRATIVE
SIMPLIFICATION
* * * * * * *
Part A--General Provisions
* * * * * * *
SEC. 1108. ADDITIONAL GRANTS TO PUERTO RICO, THE VIRGIN ISLANDS, GUAM,
AND AMERICAN SAMOA; LIMITATION ON TOTAL PAYMENTS.
(a) Limitation on Total Payments to Each Territory.--
(1) In general.--Notwithstanding any other provision
of this Act (except for paragraph (2) of this
subsection), the total amount certified by the
Secretary of Health and Human Services under titles I,
X, XIV, and XVI, under parts A and E of title IV, and
under subsection (b) of this section, for payment to
any territory for a fiscal year shall not exceed the
ceiling amount for the territory for the fiscal year.
(2) Certain payments disregarded.--Paragraph (1) of
this subsection shall be applied without regard to any
payment made under section 403(a)(2), 403(a)(4),
403(a)(5), 406, or 413(f).
(b) Entitlement to Matching Grant.--
(1) In general.--Each territory shall be entitled to
receive from the Secretary for each fiscal year a grant
in an amount equal to 75 percent of the amount (if any)
by which--
(A) the total expenditures of the territory
during the fiscal year under the territory
programs funded under parts A and E of title
IV, including any amount paid to the State
under part A of title IV that is transferred in
accordance with section 404(d) and expended
under the program to which transferred; exceeds
(B) the sum of--
(i) the amount of the family
assistance grant payable to the
territory without regard to section
409; and
(ii) the total amount expended by the
territory during fiscal year 1995
pursuant to parts A and F of title IV
(as so in effect), other than for child
care.
(2) Appropriation.--Out of any money in the Treasury
of the United States not otherwise appropriated, there
are appropriated for each of fiscal years 2017 and
2018, such sums as are necessary for grants under this
paragraph.
(c) Definitions.--As used in this section:
(1) Territory.--The term ``territory'' means Puerto
Rico, the Virgin Islands, Guam, and American Samoa.
(2) Ceiling amount.--The term ``ceiling amount''
means, with respect to a territory and a fiscal year,
the mandatory ceiling amount with respect to the
territory, reduced for the fiscal year in accordance
with subsection (e), and reduced by the amount of any
penalty imposed on the territory under any provision of
law specified in subsection (a) during the fiscal year.
(3) Family assistance grant.--The term ``family
assistance grant'' has the meaning given such term by
section 403(a)(1)(B).
(4) Mandatory ceiling amount.--The term ``mandatory
ceiling amount'' means--
(A) $107,255,000 with respect to Puerto Rico;
(B) $4,686,000 with respect to Guam;
(C) $3,554,000 with respect to the Virgin
Islands; and
(D) $1,000,000 with respect to American
Samoa.
(5) Total amount expended by the territory.--The term
``total amount expended by the territory''--
(A) does not include expenditures during the
fiscal year from amounts made available by the
Federal Government; and
(B) when used with respect to fiscal year
1995, also does not include--
(i) expenditures during fiscal year
1995 under subsection (g) or (i) of
section 402 (as in effect on September
30, 1995); or
(ii) any expenditures during fiscal
year 1995 for which the territory (but
for section 1108, as in effect on
September 30, 1995) would have received
reimbursement from the Federal
Government.
(d) Authority To Transfer Funds to Certain Programs.--A
territory to which an amount is paid under subsection (b) of
this section may use the amount in accordance with section
404(d).
(f) Subject to subsection (g) and section 1935(e)(1)(B), the
total amount certified by the Secretary under title XIX with
respect to a fiscal year for payment to--
(1) Puerto Rico shall not exceed (A) $116,500,000 for
fiscal year 1994 and (B) for each succeeding fiscal
year the amount provided in this paragraph for the
preceding fiscal year increased by the percentage
increase in the medical care component of the consumer
price index for all urban consumers (as published by
the Bureau of Labor Statistics) for the twelve-month
period ending in March preceding the beginning of the
fiscal year, rounded to the nearest $100,000;
(2) the Virgin Islands shall not exceed (A)
$3,837,500 for fiscal year 1994, and (B) for each
succeeding fiscal year the amount provided in this
paragraph for the preceding fiscal year increased by
the percentage increase referred to in paragraph
(1)(B), rounded to the nearest $10,000;
(3) Guam shall not exceed (A) $3,685,000 for fiscal
year 1994, and (B) for each succeeding fiscal year the
amount provided in this paragraph for the preceding
fiscal year increased by the percentage increase
referred to in paragraph (1)(B), rounded to the nearest
$10,000;
(4) Northern Mariana Islands shall not exceed (A)
$1,110,000 for fiscal year 1994, and (B) for each
succeeding fiscal year the amount provided in this
paragraph for the preceding fiscal year increased by
the percentage increase referred to in paragraph
(1)(B), rounded to the nearest $10,000; and
(5) American Samoa shall not exceed (A) $2,140,000
for fiscal year 1994, and (B) for each succeeding
fiscal year the amount provided in this paragraph for
the preceding fiscal year increased by the percentage
increase referred to in paragraph (1)(B), rounded to
the nearest $10,000.
(g) Medicaid Payments to Territories for Fiscal Year 1998 and
Thereafter.--
(1) Fiscal year 1998.--With respect to fiscal year
1998, the amounts otherwise determined for Puerto Rico,
the Virgin Islands, Guam, the Northern Mariana Islands,
and American Samoa under subsection (f) for such fiscal
year shall be increased by the following amounts:
(A) For Puerto Rico, $30,000,000.
(B) For the Virgin Islands, $750,000.
(C) For Guam, $750,000.
(D) For the Northern Mariana Islands,
$500,000.
(E) For American Samoa, $500,000.
(2) Fiscal year 1999 and thereafter.--Notwithstanding
subsection (f) and [subject to and section 1323(a)(2)
of the Patient Protection and Affordable Care Act
paragraphs (3) and (5)] subject to section 1323(a)(2)
of the Patient Protection and Affordable Care Act and
paragraphs (3) and (5), with respect to fiscal year
1999 and any fiscal year thereafter, the total amount
certified by the Secretary under title XIX for payment
to--
(A) [Puerto Rico shall not exceed the sum of]
Puerto Rico shall not exceed--
(i) except as provided in clause
(ii), the sum of the amount provided
in this subsection for the preceding
fiscal year increased by the percentage
increase in the medical care component
of the Consumer Price Index for all
urban consumers (as published by the
Bureau of Labor Statistics) for the 12-
month period ending in March preceding
the beginning of the fiscal year,
rounded to the nearest [$100,000;]
$100,000; and
(ii) for each of fiscal years 2020
through 2023, the amount specified in
paragraph (6) for each such fiscal
year;
(B) [the Virgin Islands shall not exceed the
sum of] the Virgin Islands shall not exceed--
(i) except as provided in clause
(ii), the sum of the amount provided
in this subsection for the preceding
fiscal year increased by the percentage
increase referred to in subparagraph
(A), rounded to the nearest [$10,000;]
$10,000; and
(ii) for each of fiscal years 2020
through 2025, $126,000,000;
(C) [Guam shall not exceed the sum of] Guam
shall not exceed--
(i) except as provided in clause
(ii), the sum of the amount provided
in this subsection for the preceding
fiscal year increased by the percentage
increase referred to in subparagraph
(A), rounded to the nearest [$10,000;]
$10,000; and
(ii) for each of fiscal years 2020
through 2025, $127,000,000;
(D) [the Northern Mariana Islands shall not
exceed the sum of] the Northern Mariana Islands
shall not exceed--
(i) except as provided in clause
(ii), the sum of the amount provided
in this subsection for the preceding
fiscal year increased by the percentage
increase referred to in subparagraph
(A), rounded to the nearest $10,000;
and
(ii) for each of fiscal years 2020
through 2025, $60,000,000; and
(E) [American Samoa shall not exceed the sum
of] American Samoa shall not exceed--
(i) except as provided in clause
(ii), the sum of the amount provided
in this subsection for the preceding
fiscal year increased by the percentage
increase referred to in subparagraph
(A), rounded to the nearest [$10,000.]
$10,000; and
(ii) for each of fiscal years 2020
through 2025, $84,000,000.
(3) Fiscal years 2006 and 2007 for certain insular
areas.--The amounts otherwise determined under this
subsection for Puerto Rico, the Virgin Islands, Guam,
the Northern Mariana Islands, and American Samoa for
fiscal year 2006 and fiscal year 2007 shall be
increased by the following amounts:
(A) For Puerto Rico, $12,000,000 for fiscal
year 2006 and $12,000,000 for fiscal year 2007.
(B) For the Virgin Islands, $2,500,000 for
fiscal year 2006 and $5,000,000 for fiscal year
2007.
(C) For Guam, $2,500,000 for fiscal year 2006
and $5,000,000 for fiscal year 2007.
(D) For the Northern Mariana Islands,
$1,000,000 for fiscal year 2006 and $2,000,000
for fiscal year 2007.
(E) For American Samoa, $2,000,000 for fiscal
year 2006 and $4,000,000 for fiscal year 2007.
Such amounts shall not be taken into account in
applying paragraph (2) for fiscal year 2007 but shall
be taken into account in applying such paragraph for
fiscal year 2008 and subsequent fiscal years.
(4) Exclusion of certain expenditures from payment
limits.--With respect to fiscal years beginning with
fiscal year 2009, if Puerto Rico, the Virgin Islands,
Guam, the Northern Mariana Islands, or American Samoa
qualify for a payment under subparagraph (A)(i), (B),
or (F) of section 1903(a)(3) for a calendar quarter of
such fiscal year, and with respect to fiscal years
beginning with fiscal year 2017, if Puerto Rico
qualifies for a payment under section 1903(a)(6) for a
calendar quarter (beginning on or after July 1, 2017)
of such fiscal year, and with respect to fiscal years
beginning with fiscal year 2018, if the Virgin Islands
qualifies for a payment under section 1903(a)(6) for a
calendar quarter (beginning on or after January 1,
2018) of such fiscal year, the payment shall not be
taken into account in applying subsection (f) (as
increased in accordance with paragraphs (1), (2), (3),
and (4) of this subsection) to such commonwealth or
territory for such fiscal year.
(5) Additional increase.--(A) Subject to
subparagraphs (B), (C), (D), (E), and (F), the
Secretary shall increase the amounts otherwise
determined under this subsection for Puerto Rico, the
Virgin Islands, Guam, the Northern Mariana Islands, and
American Samoa (after the application of subsection (f)
and the preceding paragraphs of this subsection) for
the period beginning July 1, 2011, and ending on
September 30, 2019, by such amounts that the total
additional payments under title XIX to such territories
equals $6,300,000,000 for such period. The Secretary
shall increase such amounts in proportion to the
amounts applicable to such territories under this
subsection and subsection (f) on the date of enactment
of this paragraph.
(B) The amount of the increase otherwise provided
under subparagraph (A) for Puerto Rico shall be further
increased by $295,900,000.
(C) Subject to subparagraphs (D) and (F), for the
period beginning January 1, 2018, and ending September
30, 2019--
(i) the amount of the increase otherwise
provided under subparagraphs (A) and (B) for
Puerto Rico shall be further increased by
$3,600,000,000; and
(ii) the amount of the increase otherwise
provided under subparagraph (A) for the Virgin
Islands shall be further increased by
$106,931,000.
(D) For the period described in subparagraph (C), the
amount of the increase otherwise provided under
subparagraph (A)--
(i) for Puerto Rico shall be further
increased by $1,200,000,000 if the Secretary
certifies that Puerto Rico has taken reasonable
and appropriate steps during such period, in
accordance with a timeline established by the
Secretary, to--
(I) implement methods, satisfactory
to the Secretary, for the collection
and reporting of reliable data to the
Transformed Medicaid Statistical
Information System (T-MSIS) (or a
successor system); and
(II) demonstrate progress in
establishing a State medicaid fraud
control unit described in section
1903(q); and
(ii) for the Virgin Islands shall be further
increased by $35,644,000 if the Secretary
certifies that the Virgin Islands has taken
reasonable and appropriate steps during such
period, in accordance with a timeline
established by the Secretary, to meet the
conditions for certification specified in
subclauses (I) and (II) of clause (i).
(E) Subject to subparagraph (F), for the
period beginning January 1, 2019, and ending
September 30, 2019, the amount of the increase
otherwise provided under subparagraph (A) for
the Northern Mariana Islands shall be further
increased by $36,000,000.
(F) Notwithstanding any other provision of title
XIX--
(i) during the period in which the additional
funds provided under subparagraphs (C), (D),
and (E) are available for Puerto Rico, the
Virgin Islands, and the Northern Mariana
Islands, respectively, with respect to payments
from such additional funds for amounts expended
by Puerto Rico, the Virgin Islands, and the
Northern Mariana Islands under such title, the
Secretary shall increase the Federal medical
assistance percentage or other rate that would
otherwise apply to such payments to 100
percent; and
(ii) for the period beginning January 1,
2019, and ending September 30, 2019, with
respect to payments to Guam and American Samoa
from the additional funds provided under
subparagraph (A), the Secretary shall increase
the Federal medical assistance percentage or
other rate that would otherwise apply to such
payments to 100 percent.
(G) Not later than September 30, 2019, Guam
and American Samoa shall each submit a plan to
the Secretary outlining the steps each such
territory shall take to collect and report
reliable data to the Transformed Medicaid
Statistical Information System (T-MSIS) (or a
successor system).
(6) Application to puerto rico for fiscal years 2020
through 2023.--For purposes of paragraph (2)(A)(ii),
the amount specified in this paragraph is--
(A) for fiscal year 2020, $2,823,188,000;
(B) for fiscal year 2021, $2,919,072,000;
(C) for fiscal year 2022, $3,012,610,000; and
(D) for fiscal year 2023, $3,114,331,000.
(7) Annual report.--
(A) In general.--Not later than the date that
is 180 days after the end of each fiscal year
(beginning with fiscal year 2020 and ending
with fiscal year 2025), in the case that a
specified territory receives a Medicaid cap
increase, or an increase in the Federal medical
assistance percentage for such territory under
section 1905(ff), for such fiscal year, such
territory shall submit to the Chair and Ranking
Member of the Committee on Energy and Commerce
of the House of Representatives and the Chair
and Ranking Member of the Committee on Finance
of the Senate a report that describes how such
territory has used such Medicaid cap increase,
or such increase in the Federal medical
assistance percentage, as applicable, to
increase access to health care under the State
Medicaid plan of such territory under title XIX
(or a waiver of such plan). Such report may
include--
(i) the extent to which such
territory has, with respect to such
plan (or waiver)--
(I) increased payments to
health care providers;
(II) increased covered
benefits;
(III) expanded health care
provider networks; or
(IV) improved in any other
manner the carrying out of such
plan (or waiver); and
(ii) any other information as
determined necessary by such territory.
(B) Definitions.--In this paragraph:
(i) Medicaid cap increase.--The term
``Medicaid cap increase'' means, with
respect to a specified territory and
fiscal year, any increase in the
amounts otherwise determined under this
subsection for such territory for such
fiscal year by reason of the amendments
made by section 502(a) of the
Territories Health Care Improvement
Act.
(ii) Specified territory.--The term
``specified territory'' means Puerto
Rico, the Virgin Islands, Guam, the
Northern Mariana Islands, and American
Samoa.
* * * * * * *
Part D--Comparative Clinical Effectiveness Research
* * * * * * *
trust fund transfers to patient-centered outcomes research trust fund
Sec. 1183. (a) In General.--The Secretary shall provide for
the transfer, from the Federal Hospital Insurance Trust Fund
under section 1817 and the Federal Supplementary Medical
Insurance Trust Fund under section 1841, in proportion (as
estimated by the Secretary) to the total expenditures during
such fiscal year that are made under title XVIII from the
respective trust fund, to the Patient-Centered Outcomes
Research Trust Fund (referred to in this section as the
``PCORTF'') under section 9511 of the Internal Revenue Code of
1986, of the following:
(1) For fiscal year 2013, an amount equal to $1
multiplied by the average number of individuals
entitled to benefits under part A, or enrolled under
part B, of title XVIII during such fiscal year.
(2) For each of fiscal years [2014, 2015, 2016, 2017,
2018, and 2019] 2014 through 2022, an amount equal to
$2 multiplied by the average number of individuals
entitled to benefits under part A, or enrolled under
part B, of title XVIII during such fiscal year.
(b) Adjustments for Increases in Health Care Spending.--In
the case of any fiscal year beginning after September 30, 2014,
the dollar amount in effect under subsection (a)(2) for such
fiscal year shall be equal to the sum of such dollar amount for
the previous fiscal year (determined after the application of
this subsection), plus an amount equal to the product of--
(1) such dollar amount for the previous fiscal year,
multiplied by
(2) the percentage increase in the projected per
capita amount of National Health Expenditures, as most
recently published by the Secretary before the
beginning of the fiscal year.
* * * * * * *
TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED
* * * * * * *
Part B--Supplementary Medical Insurance Benefits for the Aged and
Disabled
* * * * * * *
PAYMENT OF BENEFITS
Sec. 1833. (a) Except as provided in section 1876, and
subject to the succeeding provisions of this section, there
shall be paid from the Federal Supplementary Medical Insurance
Trust Fund, in the case of each individual who is covered under
the insurance program established by this part and incurs
expenses for services with respect to which benefits are
payable under this part, amounts equal to--(1) in the case of
services described in section 1832(a)(1)--80 percent of the
reasonable charges for the services; except that (A) an
organization which provides medical and other health services
(or arranges for their availability) on a prepayment basis (and
either is sponsored by a union or employer, or does not
provide, or arrange for the provision of, any inpatient
hospital services) may elect to be paid 80 percent of the
reasonable cost of services for which payment may be made under
this part on behalf of individuals enrolled in such
organization in lieu of 80 percent of the reasonable charges
for such services if the organization undertakes to charge such
individuals no more than 20 percent of such reasonable cost
plus any amounts payable by them as a result of subsection (b),
(B) with respect to items and services described in section
1861(s)(10)(A), the amounts paid shall be 100 percent of the
reasonable charges for such items and services, (C) with
respect to expenses incurred for those physicians' services for
which payment may be made under this part that are described in
section 1862(a)(4), the amounts paid shall be subject to such
limitations as may be prescribed by regulations, (D) with
respect to clinical diagnostic laboratory tests for which
payment is made under this part (i)(I) on the basis of a fee
schedule under subsection (h)(1) (for tests furnished before
January 1, 2017) or section 1834(d)(1), the amount paid shall
be equal to 80 percent (or 100 percent, in the case of such
tests for which payment is made on an assignment-related basis)
of the lesser of the amount determined under such fee schedule,
the limitation amount for that test determined under subsection
(h)(4)(B), or the amount of the charges billed for the tests,
or (II) undersection 1834A (for tests furnished on or after
January1, 2017), the amount paid shall be equal to 80
percent(or 100 percent, in the case of such tests for
whichpayment is made on an assignment-related basis) ofthe
lesser of the amount determined under such sectionor the amount
of the charges billed for the tests, or (ii) for tests
furnished before January 1, 2017,on the basis of a negotiated
rate established under subsection (h)(6), the amount paid shall
be equal to 100 percent of such negotiated rate,,(E) with
respect to services furnished to individuals who have been
determined to have end stage renal disease, the amounts paid
shall be determined subject to the provisions of section
1881,(F) with respect to clinical social worker services under
section 1861(s)(2)(N), the amounts paid shall be 80 percent of
the lesser of (i) the actual charge for the services or (ii) 75
percent of the amount determined for payment of a psychologist
under clause (L),
(G) with respect to facility services
furnished in connection with a surgical
procedure specified pursuant to subsection
(i)(1)(A) and furnished to an individual in an
ambulatory surgical center described in such
subsection, for services furnished beginning
with the implementation date of a revised
payment system for such services in such
facilities specified in subsection (i)(2)(D),
the amounts paid shall be 80 percent of the
lesser of the actual charge for the services or
the amount determined by the Secretary under
such revised payment system,
(H) with respect to services of a certified
registered nurse anesthetist under section 1861(s)(11),
the amounts paid shall be 80 percent of the least of
the actual charge, the prevailing charge that would be
recognized (or, for services furnished on or after
January 1, 1992, the fee schedule amount provided under
section 1848) if the services had been performed by an
anesthesiologist, or the fee schedule for such services
established by the Secretary in accordance with
subsection (l), (I) with respect to covered items
(described in section 1834(a)(13)), the amounts paid
shall be the amounts described in section 1834(a)(1),
and(J) with respect to expenses incurred for
radiologist services (as defined in section
1834(b)(6)), subject to section 1848, the amounts paid
shall be 80 percent of the lesser of the actual charge
for the services or the amount provided under the fee
schedule established under section 1834(b), (K) with
respect to certified nurse-midwife services under
section 1861(s)(2)(L), the amounts paid shall be 80
percent of the lesser of the actual charge for the
services or the amount determined by a fee schedule
established by the Secretary for the purposes of this
subparagraph (but in no event shall such fee schedule
exceed 65 percent of the prevailing charge that would
be allowed for the same service performed by a
physician, or, for services furnished on or after
January 1, 1992, 65 percent (or 100 percent for
services furnished on or after January 1, 2011) of the
fee schedule amount provided under section 1848 for the
same service performed by a physician), (L) with
respect to qualified psychologist services under
section 1861(s)(2)(M), the amounts paid shall be 80
percent of the lesser of the actual charge for the
services or the amount determined by a fee schedule
established by the Secretary for the purposes of this
subparagraph, (M) with respect to prosthetic devices
and orthotics and prosthetics (as defined in section
1834(h)(4)), the amounts paid shall be the amounts
described in section 1834(h)(1), (N) with respect to
expenses incurred for physicians' services (as defined
in section 1848(j)(3)) other than personalized
prevention plan services (as defined in section
1861(hhh)(1)), the amounts paid shall be 80 percent of
the payment basis determined under section 1848(a)(1),
(O) with respect to services described in section
1861(s)(2)(K) (relating to services furnished by
physician assistants, nurse practitioners, or clinic
nurse specialists), the amounts paid shall be equal to
80 percent of (i) the lesser of the actual charge or 85
percent of the fee schedule amount provided under
section 1848, or (ii) in the case of services as an
assistant at surgery, the lesser of the actual charge
or 85 percent of the amount that would otherwise be
recognized if performed by a physician who is serving
as an assistant at surgery, (P) with respect to
surgical dressings, the amounts paid shall be the
amounts determined under section 1834(i), (Q) with
respect to items or services for which fee schedules
are established pursuant to section 1842(s), the
amounts paid shall be 80 percent of the lesser of the
actual charge or the fee schedule established in such
section, (R) with respect to ambulance services, (i)
the amounts paid shall be 80 percent of the lesser of
the actual charge for the services or the amount
determined by a fee schedule established by the
Secretary under section 1834(l) and (ii) with respect
to ambulance services described in section 1834(l)(8),
the amounts paid shall be the amounts determined under
section 1834(g) for outpatient critical access hospital
services, (S) with respect to drugs and biologicals
(including intravenous immune globulin (as defined in
section 1861(zz))) not paid on a cost or prospective
payment basis as otherwise provided in this part (other
than items and services described in subparagraph (B)),
the amounts paid shall be 80 percent of the lesser of
the actual charge or the payment amount established in
section 1842(o) (or, if applicable, under section 1847,
1847A, or 1847B), (T) with respect to medical nutrition
therapy services (as defined in section 1861(vv)), the
amount paid shall be 80 percent (or 100 percent if such
services are recommended with a grade of A or B by the
United States Preventive Services Task Force for any
indication or population and are appropriate for the
individual) of the lesser of the actual charge for the
services or 85 percent of the amount determined under
the fee schedule established under section 1848(b) for
the same services if furnished by a physician, (U) with
respect to facility fees described in section
1834(m)(2)(B), the amounts paid shall be 80 percent of
the lesser of the actual charge or the amounts
specified in such section, (V) notwithstanding
subparagraphs (I) (relating to durable medical
equipment), (M) (relating to prosthetic devices and
orthotics and prosthetics), and (Q) (relating to
1842(s) items), with respect to competitively priced
items and services (described in section 1847(a)(2))
that are furnished in a competitive area, the amounts
paid shall be the amounts described in section
1847(b)(5), (W) with respect to additional preventive
services (as defined in section 1861(ddd)(1)), the
amount paid shall be (i) in the case of such services
which are clinical diagnostic laboratory tests, the
amount determined under subparagraph (D) (if such
subparagraph were applied, by substituting ``100
percent'' for ``80 percent''), and (ii) in the case of
all other such services, 100 percent of the lesser of
the actual charge for the service or the amount
determined under a fee schedule established by the
Secretary for purposes of this subparagraph, (X) with
respect to personalized prevention plan services (as
defined in section 1861(hhh)(1)), the amount paid shall
be 100 percent of the lesser of the actual charge for
the services or the amount determined under the payment
basis determined under section 1848, (Y) with respect
to preventive services described in subparagraphs (A)
and (B) of section 1861(ddd)(3) that are appropriate
for the individual and, in the case of such services
described in subparagraph (A), are recommended with a
grade of A or B by the United States Preventive
Services Task Force for any indication or population,
the amount paid shall be 100 percent of (i) except as
provided in clause (ii), the lesser of the actual
charge for the services or the amount determined under
the fee schedule that applies to such services under
this part, and (ii) in the case of such services that
are covered OPD services (as defined in subsection
(t)(1)(B)), the amount determined under subsection (t),
(Z) with respect to Federally qualified health center
services for which payment is made under section
1834(o), the amounts paid shall be 80 percent of the
lesser of the actual charge or the amount determined
under such section, (AA) with respect to an applicable
disposable device (as defined in paragraph (2) of
section 1834(s)) furnished to an individual pursuant to
paragraph (1) of such section, the amount paid shall be
equal to 80 percent of the lesser of the actual charge
or the amount determined under paragraph (3) of such
section, (BB) with respect to home infusion therapy,
the amount paid shall be an amount equal to 80 percent
of the lesser of the actual charge for the services or
the amount determined under section 1834(u), [and (CC)]
(CC) with respect to opioid use disorder treatment
services furnished during an episode of care, the
amount paid shall be equal to the amount payable under
section 1834(w) less any copayment required as
specified by the Secretary, and (DD) with respect to a
prostate cancer DNA Specimen Provenance Assay test
(DSPA test) (as defined in section 1861(kkk)), the
amount paid shall be an amount equal to 80 percent of
the lesser of the actual charge for the test or the
amount specified under section 1834(x);
(2) in the case of services described in section
1832(a)(2) (except those services described in
subparagraphs (C), (D), (E), (F), (G), (H), and (I) of
such section and unless otherwise specified in section
1881)--
(A) with respect to home health services
(other than a covered osteoporosis drug) (as
defined in section 1861(kk)), the amount
determined under the prospective payment system
under section 1895;
(B) with respect to other items and services
(except those described in subparagraph (C),
(D), or (E) of this paragraph and except as may
be provided in section 1886 or section
1888(e)(9))--
(i) furnished before January 1, 1999,
the lesser of--
(I) the reasonable cost of
such services, as determined
under section 1861(v), or
(II) the customary charges
with respect to such
services,--less the amount a
provider may charge as
described in clause (ii) of
section 1866(a)(2)(A), but in
no case may the payment for
such other services exceed 80
percent of such reasonable
cost, or
(ii) if such services are furnished
before January 1, 1999, by a public
provider of services, or by another
provider which demonstrates to the
satisfaction of the Secretary that a
significant portion of its patients are
low-income (and requests that payment
be made under this clause), free of
charge or at nominal charges to the
public, 80 percent of the amount
determined in accordance with section
1814(b)(2), or
(iii) if such services are furnished
on or after January 1, 1999, the amount
determined under subsection (t), or
(iv) if (and for so long as) the
conditions described in section
1814(b)(3) are met, the amounts
determined under the reimbursement
system described in such section;
(C) with respect to services described in the
second sentence of section 1861(p), 80 percent
of the reasonable charges for such services;
(D) with respect to clinical diagnostic
laboratory tests for which payment is made
under this part (i)(I)on the basis of a fee
schedule determined under subsection(h)(1) (for
tests furnished before January 1, 2017) or
section 1834(d)(1), the amount paid shall be
equal to 80 percent (or 100 percent, in the
case of such tests for which payment is made on
an assignment-related basis or to a provider
having an agreement under section 1866) of the
lesser of the amount determined under such fee
schedule, the limitation amount for that test
determined under subsection (h)(4)(B), or the
amount of the charges billed for the tests, or
(II) under section 1834A (for tests furnished
on or after January 1, 2017), the amount paid
shall be equal to 80 percent (or 100 percent,
in the case of such tests for which payment is
made on an assignment-related basis or to a
provider having an agreement under section
1866) of the lesser of the amount determined
under such section or the amount of the charges
billed for the tests, or (ii) for tests
furnished before January 1, 2017, on the basis
of a negotiated rate established under
subsection (h)(6), the amount paid shall be
equal to 100 percent of such negotiated rate
for such tests;
(E) with respect to--
(i) outpatient hospital radiology
services (including diagnostic and
therapeutic radiology, nuclear medicine
and CAT scan procedures, magnetic
resonance imaging, and ultrasound and
other imaging services, but excluding
screening mammography and, for services
furnished on or after January 1, 2005,
diagnostic mammography), and
(ii) effective for procedures
performed on or after October 1, 1989,
diagnostic procedures (as defined by
the Secretary) described in section
1861(s)(3) (other than diagnostic x-ray
tests and diagnostic laboratory tests),
the amount determined under subsection (n) or,
for services or procedures performed on or
after January 1, 1999, subsection (t);
(F) with respect to a covered osteoporosis
drug (as defined in section 1861(kk)) furnished
by a home health agency, 80 percent of the
reasonable cost of such service, as determined
under section 1861(v);
(G) with respect to items and services
described in section 1861(s)(10)(A), the lesser
of--
(i) the reasonable cost of such
services, as determined under section
1861(v), or
(ii) the customary charges with
respect to such services; and
(H) with respect to personalized prevention
plan services (as defined in section
1861(hhh)(1)) furnished by an outpatient
department of a hospital, the amount determined
under paragraph (1)(X),
or, if such services are furnished by a public
provider of services, or by another provider
which demonstrates to the satisfaction of the
Secretary that a significant portion of its
patients are low-income (and requests that
payment be made under this provision), free of
charge or at nominal charges to the public, the
amount determined in accordance with section
1814(b)(2);
(3) in the case of services described in section
1832(a)(2)(D)--
(A) except as provided in subparagraph (B),
the costs which are reasonable and related to
the cost of furnishing such services or which
are based on such other tests of reasonableness
as the Secretary may prescribe in regulations,
including those authorized under section
1861(v)(1)(A), less the amount a provider may
charge as described in clause (ii) of section
1866(a)(2)(A), but in no case may the payment
for such services (other than for items and
services described in section 1861(s)(10)(A))
exceed 80 percent of such costs; or
(B) with respect to the services described in
clause (ii) of section 1832(a)(2)(D) that are
furnished to an individual enrolled with a MA
plan under part C pursuant to a written
agreement described in section 1853(a)(4), the
amount (if any) by which--
(i) the amount of payment that would
have otherwise been provided (I) under
subparagraph (A) (calculated as if
``100 percent'' were substituted for
``80 percent'' in such subparagraph)
for such services if the individual had
not been so enrolled, or (II) in the
case of such services furnished on or
after the implementation date of the
prospective payment system under
section 1834(o), under such section
(calculated as if ``100 percent'' were
substituted for ``80 percent'' in such
section) for such services if the
individual had not been so enrolled;
exceeds
(ii) the amount of the payments
received under such written agreement
for such services (not including any
financial incentives provided for in
such agreement such as risk pool
payments, bonuses, or withholds),
less the amount the federally qualified health
center may charge as described in section
1857(e)(3)(B);
(4) in the case of facility services described in
section 1832(a)(2)(F), and outpatient hospital facility
services furnished in connection with surgical
procedures specified by the Secretary pursuant to
section 1833(i)(1)(A), the applicable amount as
determined under paragraph (2) or (3) of subsection (i)
or subsection (t);
(5) in the case of covered items (described in
section 1834(a)(13)) the amounts described in section
1834(a)(1);
(6) in the case of outpatient critical access
hospital services, the amounts described in section
1834(g);
(7) in the case of prosthetic devices and orthotics
and prosthetics (as described in section 1834(h)(4)),
the amounts described in section 1834(h);
(8) in the case of--
(A) outpatient physical therapy services,
outpatient speech-language pathology services,
and outpatient occupational therapy services
furnished--
(i) by a rehabilitation agency,
public health agency, clinic,
comprehensive outpatient rehabilitation
facility, or skilled nursing facility,
(ii) by a home health agency to an
individual who is not homebound, or
(iii) by another entity under an
arrangement with an entity described in
clause (i) or (ii); and
(B) outpatient physical therapy services,
outpatient speech-language pathology services,
and outpatient occupational therapy services
furnished--
(i) by a hospital to an outpatient or
to a hospital inpatient who is entitled
to benefits under part A but has
exhausted benefits for inpatient
hospital services during a spell of
illness or is not so entitled to
benefits under part A, or
(ii) by another entity under an
arrangement with a hospital described
in clause (i),
the amounts described in section 1834(k); and
(9) in the case of services described in section
1832(a)(2)(E) that are not described in paragraph (8),
the amounts described in section 1834(k).
Paragraph (3)(A) shall not apply to Federally
qualified health center services furnished on or after
the implementation date of the prospective payment
system under section 1834(0).
(b) Before applying subsection (a) with respect to expenses
incurred by an individual during any calendar year, the total
amount of the expenses incurred by such individual during such
year (which would, except for this subsection, constitute
incurred expenses from which benefits payable under subsection
(a) are determinable) shall be reduced by a deductible of $75
for calendar years before 1991, $100 for 1991 through 2004,
$110 for 2005, and for a subsequent year the amount of such
deductible for the previous year increased by the annual
percentage increase in the monthly actuarial rate under section
1839(a)(1) ending with such subsequent year (rounded to the
nearest $1); except that (1) such total amount shall not
include expenses incurred for preventive services described in
subparagraph (A) of section 1861(ddd)(3) that are recommended
with a grade of A or B by the United States Preventive Services
Task Force for any indication or population and are appropriate
for the individual., (2) such deductible shall not apply with
respect to home health services (other than a covered
osteoporosis drug (as defined in section 1861(kk))), (3) such
deductible shall not apply with respect to clinical diagnostic
laboratory tests for which payment is made under this part (A)
under subsection (a)(1)(D)(i) or (a)(2)(D)(i) on an assignment-
related basis, or to a provider having an agreement under
section 1866, or (B) for tests furnished before January 1,
2017,on the basis of a negotiated rate determined under
subsection (h)(6), (4) such deductible shall not apply to
Federally qualified health center services, (5) such deductible
shall not apply with respect to screening mammography (as
described in section 1861(jj)), (6) such deductible shall not
apply with respect to screening pap smear and screening pelvic
exam (as described in section 1861(nn)), (7) such deductible
shall not apply with respect to ultrasound screening for
abdominal aortic aneurysm (as defined in section 1861(bbb)),
(8) such deductible shall not apply with respect to colorectal
cancer screening tests (as described in section 1861(pp)(1)),
(9) such deductible shall not apply with respect to an initial
preventive physical examination (as defined in section
1861(ww)), and (10) such deductible shall not apply with
respect to personalized prevention plan services (as defined in
section 1861(hhh)(1)). The total amount of the expenses
incurred by an individual as determined under the preceding
sentence shall, after the reduction specified in such sentence,
be further reduced by an amount equal to the expenses incurred
for the first three pints of whole blood (or equivalent
quantities of packed red blood cells, as defined under
regulations) furnished to the individual during the calendar
year, except that such deductible for such blood shall in
accordance with regulations be appropriately reduced to the
extent that there has been a replacement of such blood (or
equivalent quantities of packed red blood cells, as so
defined); and for such purposes blood (or equivalent quantities
of packed red blood cells, as so defined) furnished such
individual shall be deemed replaced when the institution or
other person furnishing such blood (or such equivalent
quantities of packed red blood cells, as so defined) is given
one pint of blood for each pint of blood (or equivalent
quantities of packed red blood cells, as so defined) furnished
such individual with respect to which a deduction is made under
this sentence. The deductible under the previous sentence for
blood or blood cells furnished an individual in a year shall be
reduced to the extent that a deductible has been imposed under
section 1813(a)(2) to blood or blood cells furnished the
individual in the year. Paragraph (1) of the first sentence of
this subsection shall apply with respect to a colorectal cancer
screening test regardless of the code that is billed for the
establishment of a diagnosis as a result of the test, or for
the removal of tissue or other matter or other procedure that
is furnished in connection with, as a result of, and in the
same clinical encounter as the screening test.
(c)(1) Notwithstanding any other provision of this part, with
respect to expenses incurred in a calendar year in connection
with the treatment of mental, psychoneurotic, and personality
disorders of an individual who is not an inpatient of a
hospital at the time such expenses are incurred, there shall be
considered as incurred expenses for purposes of subsections (a)
and (b)--
(A) for expenses incurred in years prior to 2010,
only 62\1/2\ percent of such expenses;
(B) for expenses incurred in 2010 or 2011, only 68\3/
4\ percent of such expenses;
(C) for expenses incurred in 2012, only 75 percent of
such expenses;
(D) for expenses incurred in 2013, only 81\1/4\
percent of such expenses; and
(E) for expenses incurred in 2014 or any subsequent
calendar year, 100 percent of such expenses.
(2) For purposes of subparagraphs (A) through (D) of
paragraph (1), the term ``treatment'' does not include brief
office visits (as defined by the Secretary) for the sole
purpose of monitoring or changing drug prescriptions used in
the treatment of such disorders or partial hospitalization
services that are not directly provided by a physician
(d) No payment may be made under this part with respect to
any services furnished an individual to the extent that such
individual is entitled (or would be entitled except for section
1813) to have payment made with respect to such services under
part A.
(e) No payment shall be made to any provider of services or
other person under this part unless there has been furnished
such information as may be necessary in order to determine the
amounts due such provider or other person under this part for
the period with respect to which the amounts are being paid or
for any prior period.
(f) In establishing limits under subsection (a) on payment
for rural health clinic services provided by rural health
clinics (other than such clinics in hospitals with less than 50
beds), the Secretary shall establish such limit, for services
provided--
(1) in 1988, after March 31, at $46 per visit, and
(2) in a subsequent year, at the limit established
under this subsection for the previous year increased
by the percentage increase in the MEI (as defined in
section 1842(i)(3)) applicable to primary care services
(as defined in section 1842(i)(4)) furnished as of the
first day of that year.
(g)(1)(A) Subject to paragraphs (4) and (5), in the case of
physical therapy services of the type described in section
1861(p) and speech-language pathology services of the type
described in such section through the application of section
1861(ll)(2), but (except as provided in paragraph (6)) not
described in subsection (a)(8)(B), and physical therapy
services and speech-language pathology services of such type
which are furnished by a physician or as incident to
physicians' services, with respect to expenses incurred in any
calendar year, no more than the amount specified in paragraph
(2) for the year shall be considered as incurred expenses for
purposes of subsections (a) and (b). The preceding sentence
shall not apply to expenses incurred with respect to services
furnished after December 31, 2017.
(B) With respect to services furnished during 2018 or a
subsequent year, in the case of physical therapy services of
the type described in section 1861(p), speech-language
pathology services of the type described in such section
through the application of section 1861(ll)(2), and physical
therapy services and speech-language pathology services of such
type which are furnished by a physician or as incident to
physicians' services, with respect to expenses incurred in any
calendar year, any amount that is more than the amount
specified in paragraph (2) for the year shall not be considered
as incurred expenses for purposes of subsections (a) and (b)
unless the applicable requirements of paragraph (7) are met.
(2) The amount specified in this paragraph--
(A) for 1999, 2000, and 2001, is $1,500, and
(B) for a subsequent year is the amount specified in
this paragraph for the preceding year increased by the
percentage increase in the MEI (as defined in section
1842(i)(3)) for such subsequent year;
except that if an increase under subparagraph (B) for a year is
not a multiple of $10, it shall be rounded to the nearest
multiple of $10.
(3)(A) Subject to paragraphs (4) and (5), in the case of
occupational therapy services (of the type that are described
in section 1861(p) (but (except as provided in paragraph (6))
not described in subsection (a)(8)(B)) through the operation of
section 1861(g) and of such type which are furnished by a
physician or as incident to physicians' services), with respect
to expenses incurred in any calendar year, no more than the
amount specified in paragraph (2) for the year shall be
considered as incurred expenses for purposes of subsections (a)
and (b). The preceding sentence shall not apply to expenses
incurred with respect to services furnished after December 31,
2017.
(B) With respect to services furnished during 2018 or a
subsequent year, in the case of occupational therapy services
(of the type that are described in section 1861(p) through the
operation of section 1861(g) and of such type which are
furnished by a physician or as incident to physicians'
services), with respect to expenses incurred in any calendar
year, any amount that is more than the amount specified in
paragraph (2) for the year shall not be considered as incurred
expenses for purposes of subsections (a) and (b) unless the
applicable requirements of paragraph (7) are met.
(4) This subsection shall not apply to expenses incurred with
respect to services furnished during 2000, 2001, 2002, 2004,
and 2005.
(5)(A) With respect to expenses incurred during the period
beginning on January 1, 2006, and ending on December 31, 2017,
for services, the Secretary shall implement a process under
which an individual enrolled under this part may, upon request
of the individual or a person on behalf of the individual,
obtain an exception from the uniform dollar limitation
specified in paragraph (2), for services described in
paragraphs (1) and (3) if the provision of such services is
determined to be medically necessary and if the requirement of
subparagraph (B) is met. Under such process, if the Secretary
does not make a decision on such a request for an exception
within 10 business days of the date of the Secretary's receipt
of the request made in accordance with such requirement, the
Secretary shall be deemed to have found the services to be
medically necessary.
(B) In the case of outpatient therapy services for which an
exception is requested under the first sentence of subparagraph
(A), the claim for such services shall contain an appropriate
modifier (such as the KX modifier used as of the date of the
enactment of this subparagraph) indicating that such services
are medically necessary as justified by appropriate
documentation in the medical record involved.
(C)(i) In applying this paragraph with respect to a request
for an exception with respect to expenses that would be
incurred for outpatient therapy services (including services
described in subsection (a)(8)(B)) that would exceed the
threshold described in clause (ii) for a year, the request for
such an exception, for services furnished on or after October
1, 2012, shall be subject to a manual medical review process
that, subject to subparagraph (E), is similar to the manual
medical review process used for certain exceptions under this
paragraph in 2006.
(ii) The threshold under this clause for a year is $3,700.
Such threshold shall be applied separately--
(I) for physical therapy services and speech-language
pathology services; and
(II) for occupational therapy services.
(E)(i) In place of the manual medical review process under
subparagraph (C)(i), the Secretary shall implement a process
for medical review under this subparagraph under which the
Secretary shall identify and conduct medical review for
services described in subparagraph (C)(i) furnished by a
provider of services or supplier (in this subparagraph referred
to as a ``therapy provider'') using such factors as the
Secretary determines to be appropriate.
(ii) Such factors may include the following:
(I) The therapy provider has had a high claims denial
percentage for therapy services under this part or is
less compliant with applicable requirements under this
title.
(II) The therapy provider has a pattern of billing
for therapy services under this part that is aberrant
compared to peers or otherwise has questionable billing
practices for such services, such as billing medically
unlikely units of services in a day.
(III) The therapy provider is newly enrolled under
this title or has not previously furnished therapy
services under this part.
(IV) The services are furnished to treat a type of
medical condition.
(V) The therapy provider is part of group that
includes another therapy provider identified using the
factors determined under this subparagraph.
(iii) For purposes of carrying out this subparagraph, 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 fiscal years 2015 and 2016, to
remain available until expended. Such funds may not be used by
a contractor under section 1893(h) for medical reviews under
this subparagraph.
(iv) The targeted review process under this subparagraph
shall not apply to services for which expenses are incurred
beyond the period for which the exceptions process under
subparagraph (A) is implemented, except as such process is
applied under paragraph (7)(B).
(6)(A) In applying paragraphs (1) and (3) to services
furnished during the period beginning not later than October 1,
2012, and ending on December 31, 2017, the exclusion of
services described in subsection (a)(8)(B) from the uniform
dollar limitation specified in paragraph (2) shall not apply to
such services furnished during 2012 through 2017.
(B)(i) With respect to outpatient therapy services furnished
beginning on or after January 1, 2013, and before January 1,
2014, for which payment is made under section 1834(g), the
Secretary shall count toward the uniform dollar limitations
described in paragraphs (1) and (3) and the threshold described
in paragraph (5)(C) the amount that would be payable under this
part if such services were paid under section 1834(k)(1)(B)
instead of being paid under section 1834(g).
(ii) Nothing in clause (i) shall be construed as changing the
method of payment for outpatient therapy services under section
1834(g).
(7) For purposes of paragraphs (1)(B) and (3)(B), with
respect to services described in such paragraphs, the
requirements described in this paragraph are as follows:
(A) Inclusion of appropriate modifier.--The claim for
such services contains an appropriate modifier (such as
the KX modifier described in paragraph (5)(B))
indicating that such services are medically necessary
as justified by appropriate documentation in the
medical record involved.
(B) Targeted medical review for certain services
above threshold.--
(i) In general.--In the case where expenses
that would be incurred for such services would
exceed the threshold described in clause (ii)
for the year, such services shall be subject to
the process for medical review implemented
under paragraph (5)(E).
(ii) Threshold.--The threshold under this
clause for--
(I) a year before 2028, is $3,000;
(II) 2028, is the amount specified in
subclause (I) increased by the
percentage increase in the MEI (as
defined in section 1842(i)(3)) for
2028; and
(III) a subsequent year, is the
amount specified in this clause for the
preceding year increased by the
percentage increase in the MEI (as
defined in section 1842(i)(3)) for such
subsequent year;
except that if an increase under subclause (II)
or (III) for a year is not a multiple of $10,
it shall be rounded to the nearest multiple of
$10.
(iii) Application.--The threshold under
clause (ii) shall be applied separately--
(I) for physical therapy services and
speech-language pathology services; and
(II) for occupational therapy
services.
(iv) Funding.--For purposes of carrying out
this subparagraph, the Secretary shall provide
for the transfer, from the Federal
Supplementary Medical Insurance Trust Fund
under section 1841 to the Centers for Medicare
& Medicaid Services Program Management Account,
of $5,000,000 for each fiscal year beginning
with fiscal year 2018, to remain available
until expended. Such funds may not be used by a
contractor under section 1893(h) for medical
reviews under this subparagraph.
(8) With respect to services furnished on or after January 1,
2013, where payment may not be made as a result of application
of paragraphs (1) and (3), section 1879 shall apply in the same
manner as such section applies to a denial that is made by
reason of section 1862(a)(1).
(h)(1)(A) Subject to section 1834(d)(1), the Secretary shall
establish fee schedules for clinical diagnostic laboratory
tests (including prostate cancer screening tests under section
1861(oo) consisting of prostate-specific antigen blood tests)
for which payment is made under this part, other than such
tests performed by a provider of services for an inpatient of
such provider.
(B) In the case of clinical diagnostic laboratory tests
performed by a physician or by a laboratory (other than tests
performed by a qualified hospital laboratory (as defined in
subparagraph (D)) for outpatients of such hospital), the fee
schedules established under subparagraph (A) shall be
established on a regional, statewide, or carrier service area
basis (as the Secretary may determine to be appropriate) for
tests furnished on or after July 1, 1984.
(C) In the case of clinical diagnostic laboratory tests
performed by a qualified hospital laboratory (as defined in
subparagraph (D)) for outpatients of such hospital, the fee
schedules established under subparagraph (A) shall be
established on a regional, statewide, or carrier service area
basis (as the Secretary may determine to be appropriate) for
tests furnished on or after July 1, 1984.
(D) In this subsection, the term ``qualified hospital
laboratory'' means a hospital laboratory, in a sole community
hospital (as defined in section 1886(d)(5)(D)(iii)), which
provides some clinical diagnostic laboratory tests 24 hours a
day in order to serve a hospital emergency room which is
available to provide services 24 hours a day and 7 days a week.
(2)(A)(i) Except as provided in clause (v), subparagraph (B),
and paragraph (4), the Secretary shall set the fee schedules at
60 percent (or, in the case of a test performed by a qualified
hospital laboratory (as defined in paragraph (1)(D)) for
outpatients of such hospital, 62 percent) of the prevailing
charge level determined pursuant to the third and fourth
sentences of section 1842(b)(3) for similar clinical diagnostic
laboratory tests for the applicable region, State, or area for
the 12-month period beginning July 1, 1984, adjusted annually
(to become effective on January 1 of each year) by, subject to
clause (iv), a percentage increase or decrease equal to the
percentage increase or decrease in the Consumer Price Index for
All Urban Consumers (United States city average) minus, for
each of the years 2009 and 2010, 0.5 percentage points, and,
for tests furnished before the dateof enactment of section
1834A, subject to such other adjustments as the Secretary
determines are justified by technological changes.
(ii) Notwithstanding clause (i)--
(I) any change in the fee schedules which would have
become effective under this subsection for tests
furnished on or after January 1, 1988, shall not be
effective for tests furnished during the 3-month period
beginning on January 1, 1988,
(II) the Secretary shall not adjust the fee schedules
under clause (i) to take into account any increase in
the consumer price index for 1988,
(III) the annual adjustment in the fee schedules
determined under clause (i) for each of the years 1991,
1992, and 1993 shall be 2 percent, and
(IV) the annual adjustment in the fee schedules
determined under clause (i) for each of the years 1994
and 1995, 1998 through 2002, and 2004 through 2008
shall be 0 percent.
(iii) In establishing fee schedules under clause (i) with
respect to automated tests and tests (other than cytopathology
tests) which before July 1, 1984, the Secretary made subject to
a limit based on lowest charge levels under the sixth sentence
of section 1842(b)(3) performed after March 31, 1988, the
Secretary shall reduce by 8.3 percent the fee schedules
otherwise established for 1988, and such reduced fee schedules
shall serve as the base for 1989 and subsequent years.
(iv) After determining the adjustment to the fee schedules
under clause (i), the Secretary shall reduce such adjustment--
(I) for 2011 and each subsequent year, by the
productivity adjustment described in section
1886(b)(3)(B)(xi)(II); and
(II) for each of 2011 through 2015, by 1.75
percentage points.
Subclause (I) shall not apply in a year where the adjustment to
the fee schedules determined under clause (i) is 0.0 or a
percentage decrease for a year. The application of the
productivity adjustment under subclause (I) shall not result in
an adjustment to the fee schedules under clause (i) being less
than 0.0 for a year. The application of subclause (II) may
result in an adjustment to the fee schedules under clause (i)
being less than 0.0 for a year, and may result in payment rates
for a year being less than such payment rates for the preceding
year.
(v) The Secretary shall reduce by 2 percent the fee schedules
otherwise determined under clause (i) for 2013, and such
reduced fee schedules shall serve as the base for 2014 and
subsequent years.
(B) The Secretary may make further adjustments or exceptions
to the fee schedules to assure adequate reimbursement of (i)
emergency laboratory tests needed for the provision of bona
fide emergency services, and (ii) certain low volume high-cost
tests where highly sophisticated equipment or extremely skilled
personnel are necessary to assure quality.
(3) In addition to the amounts provided under the fee
schedules (for tests furnished before January 1, 2017)or under
section 1834A (for tests furnished on or afterJanuary 1, 2017),
subject to subsection (b)(5) of such section, the Secretary
shall provide for and establish (A) a nominal fee to cover the
appropriate costs in collecting the sample on which a clinical
diagnostic laboratory test was performed and for which payment
is made under this part, except that not more than one such fee
may be provided under this paragraph with respect to samples
collected in the same encounter, and (B) a fee to cover the
transportation and personnel expenses for trained personnel to
travel to the location of an individual to collect the sample,
except that such a fee may be provided only with respect to an
individual who is homebound or an inpatient in an inpatient
facility (other than a hospital). In establishing a fee to
cover the transportation and personnel expenses for trained
personnel to travel to the location of an individual to collect
a sample, the Secretary shall provide a method for computing
the fee based on the number of miles traveled and the personnel
costs associated with the collection of each individual sample,
but the Secretary shall only be required to apply such method
in the case of tests furnished during the period beginning on
April 1, 1989, and ending on December 31, 1990, by a laboratory
that establishes to the satisfaction of the Secretary (based on
data for the 12-month period ending June 30, 1988) that (i) the
laboratory is dependent upon payments under this title for at
least 80 percent of its collected revenues for clinical
diagnostic laboratory tests, (ii) at least 85 percent of its
gross revenues for such tests are attributable to tests
performed with respect to individuals who are homebound or who
are residents in a nursing facility, and (iii) the laboratory
provided such tests for residents in nursing facilities
representing at least 20 percent of the number of such
facilities in the State in which the laboratory is located.
(4)(A) In establishing any fee schedule under this
subsection, the Secretary may provide for an adjustment to take
into account, with respect to the portion of the expenses of
clinical diagnostic laboratory tests attributable to wages, the
relative difference between a region's or local area's wage
rates and the wage rate presumed in the data on which the
schedule is based.
(B) For purposes of subsections (a)(1)(D)(i) and
(a)(2)(D)(i), the limitation amount for a clinical diagnostic
laboratory test performed--
(i) on or after July 1, 1986, and before April 1,
1988, is equal to 115 percent of the median of all the
fee schedules established for that test for that
laboratory setting under paragraph (1),
(ii) after March 31, 1988, and before January 1,
1990, is equal to the median of all the fee schedules
established for that test for that laboratory setting
under paragraph (1),
(iii) after December 31, 1989, and before January 1,
1991, is equal to 93 percent of the median of all the
fee schedules established for that test for that
laboratory setting under paragraph (1),
(iv) after December 31, 1990, and before January 1,
1994, is equal to 88 percent of such median,
(v) after December 31, 1993, and before January 1,
1995, is equal to 84 percent of such median,
(vi) after December 31, 1994, and before January 1,
1996, is equal to 80 percent of such median,
(vii) after December 31, 1995, and before January 1,
1998, is equal to 76 percent of such median, and
(viii) after December 31, 1997, is equal to 74
percent of such median (or 100 percent of such median
in the case of a clinical diagnostic laboratory test
performed on or after January 1, 2001, that the
Secretary determines is a new test for which no
limitation amount has previously been established under
this subparagraph).
(5)(A) In the case of a bill or request for payment for a
clinical diagnostic laboratory test for which payment may
otherwise be made under this part on an assignment-related
basis or under a provider agreement under section 1866, payment
may be made only to the person or entity which performed or
supervised the performance of such test; except that--
(i) if a physician performed or supervised the
performance of such test, payment may be made to
another physician with whom he shares his practice,
(ii) in the case of a test performed at the request
of a laboratory by another laboratory, payment may be
made to the referring laboratory but only if--
(I) the referring laboratory is located in,
or is part of, a rural hospital,
(II) the referring laboratory is wholly owned
by the entity performing such test, the
referring laboratory wholly owns the entity
performing such test, or both the referring
laboratory and the entity performing such test
are wholly-owned by a third entity, or
(III) not more than 30 percent of the
clinical diagnostic laboratory tests for which
such referring laboratory (but not including a
laboratory described in subclause (II)),
receives requests for testing during the year
in which the test is performed are performed by
another laboratory, and
(iii) in the case of a clinical diagnostic laboratory
test provided under an arrangement (as defined in
section 1861(w)(1)) made by a hospital, critical access
hospital, or skilled nursing facility, payment shall be
made to the hospital or skilled nursing facility.
(B) In the case of such a bill or request for payment for a
clinical diagnostic laboratory test for which payment may
otherwise be made under this part, and which is not described
in subparagraph (A), payment may be made to the beneficiary
only on the basis of the itemized bill of the person or entity
which performed or supervised the performance of the test.
(C) Payment for a clinical diagnostic laboratory test,
including a test performed in a physician's office but
excluding a test performed by a rural health clinic may only be
made on an assignment-related basis or to a provider of
services with an agreement in effect under section 1866.
(D) A person may not bill for a clinical diagnostic
laboratory test, including a test performed in a physician's
office but excluding a test performed by a rural health clinic,
other than on an assignment-related basis. If a person
knowingly and willfully and on a repeated basis bills for a
clinical diagnostic laboratory test in violation of the
previous sentence, the Secretary may apply sanctions against
the person in the same manner as the Secretary may apply
sanctions against a physician in accordance with paragraph (2)
of section 1842(j) in the same manner such paragraphs apply
with respect to a physician. Paragraph (4) of such section
shall apply in this subparagraph in the same manner as such
paragraph applies to such section.
(6) For tests furnished before January 1, 2017, inthe case of
any diagnostic laboratory test payment for which is not made on
the basis of a fee schedule under paragraph (1), the Secretary
may establish a payment rate which is acceptable to the person
or entity performing the test and which would be considered the
full charge for such tests. Such negotiated rate shall be
limited to an amount not in excess of the total payment that
would have been made for the services in the absence of such
rate.
(7) Notwithstanding paragraphs (1) and (4)and section 1834A,
the Secretary shall establish a national minimum payment amount
under this part for a diagnostic or screening pap smear
laboratory test (including all cervical cancer screening
technologies that have been approved by the Food and Drug
Administration as a primary screening method for detection of
cervical cancer) equal to $14.60 for tests furnished in 2000.
For such tests furnished in subsequent years, such national
minimum payment amount shall be adjusted annually as provided
in paragraph (2).
(8)(A) The Secretary shall establish by regulation procedures
for determining the basis for, and amount of, payment under
this subsection for any clinical diagnostic laboratory test
with respect to which a new or substantially revised HCPCS code
is assigned on or after January 1, 2005 (in this paragraph
referred to as ``new tests'').
(B) Determinations under subparagraph (A) shall be made only
after the Secretary--
(i) makes available to the public (through an
Internet website and other appropriate mechanisms) a
list that includes any such test for which
establishment of a payment amount under this subsection
is being considered for a year;
(ii) on the same day such list is made available,
causes to have published in the Federal Register notice
of a meeting to receive comments and recommendations
(and data on which recommendations are based) from the
public on the appropriate basis under this subsection
for establishing payment amounts for the tests on such
list;
(iii) not less than 30 days after publication of such
notice convenes a meeting, that includes
representatives of officials of the Centers for
Medicare & Medicaid Services involved in determining
payment amounts, to receive such comments and
recommendations (and data on which the recommendations
are based);
(iv) taking into account the comments and
recommendations (and accompanying data) received at
such meeting, develops and makes available to the
public (through an Internet website and other
appropriate mechanisms) a list of proposed
determinations with respect to the appropriate basis
for establishing a payment amount under this subsection
for each such code, together with an explanation of the
reasons for each such determination, the data on which
the determinations are based, and a request for public
written comments on the proposed determination; and
(v) taking into account the comments received during
the public comment period, develops and makes available
to the public (through an Internet website and other
appropriate mechanisms) a list of final determinations
of the payment amounts for such tests under this
subsection, together with the rationale for each such
determination, the data on which the determinations are
based, and responses to comments and suggestions
received from the public.
(C) Under the procedures established pursuant to subparagraph
(A), the Secretary shall--
(i) set forth the criteria for making determinations
under subparagraph (A); and
(ii) make available to the public the data (other
than proprietary data) considered in making such
determinations.
(D) The Secretary may convene such further public meetings to
receive public comments on payment amounts for new tests under
this subsection as the Secretary deems appropriate.
(E) For purposes of this paragraph:
(i) The term ``HCPCS'' refers to the Health Care
Procedure Coding System.
(ii) A code shall be considered to be ``substantially
revised'' if there is a substantive change to the
definition of the test or procedure to which the code
applies (such as a new analyte or a new methodology for
measuring an existing analyte-specific test).
(9) Notwithstanding any other provision in this part, in the
case of any diagnostic laboratory test for HbA1c that is
labeled by the Food and Drug Administration for home use and is
furnished on or after April 1, 2008, the payment rate for such
test shall be the payment rate established under this part for
a glycated hemoglobin test (identified as of October 1, 2007,
by HCPCS code 83036 (and any succeeding codes)).
(i)(1) The Secretary shall, in consultation with appropriate
medical organizations--
(A) specify those surgical procedures which are
appropriately (when considered in terms of the proper
utilization of hospital inpatient facilities) performed
on an inpatient basis in a hospital but which also can
be performed safely on an ambulatory basis in an
ambulatory surgical center (meeting the standards
specified under section 1832(a)(2)(F)(i)), critical
access hospital, or hospital outpatient department, and
(B) specify those surgical procedures which are
appropriately (when considered in terms of the proper
utilization of hospital inpatient facilities) performed
on an inpatient basis in a hospital but which also can
be performed safely on an ambulatory basis in a
physician's office.
The lists of procedures established under subparagraphs (A) and
(B) shall be reviewed and updated not less often than every 2
years, in consultation with appropriate trade and professional
organizations.
(2)(A) For services furnished prior to the implementation of
the system described in subparagraph (D), subject to
subparagraph (E), the amount of payment to be made for facility
services furnished in connection with a surgical procedure
specified pursuant to paragraph (1)(A) and furnished to an
individual in an ambulatory surgical center described in such
paragraph shall be equal to 80 percent of a standard overhead
amount established by the Secretary (with respect to each such
procedure) on the basis of the Secretary's estimate of a fair
fee which--
(i) takes into account the costs incurred by such
centers, or classes of centers, generally in providing
services furnished in connection with the performance
of such procedure, as determined in accordance with a
survey (based upon a representative sample of
procedures and facilities) of the actual audited costs
incurred by such centers in providing such services,
(ii) takes such costs into account in such a manner
as will assure that the performance of the procedure in
such a center will result in substantially less amounts
paid under this title than would have been paid if the
procedure had been performed on an inpatient basis in a
hospital, and
(iii) in the case of insertion of an intraocular lens
during or subsequent to cataract surgery includes
payment which is reasonable and related to the cost of
acquiring the class of lens involved.
Each amount so established shall be reviewed and updated not
later than July 1, 1987, and annually thereafter to take
account of varying conditions in different areas.
(B) The amount of payment to be made under this part for
facility services furnished, in connection with a surgical
procedure specified pursuant to paragraph (1)(B), in a
physician's office shall be equal to 80 percent of a standard
overhead amount established by the Secretary (with respect to
each such procedure) on the basis of the Secretary's estimate
of a fair fee which--
(i) takes into account additional costs, not usually
included in the professional fee, incurred by
physicians in securing, maintaining, and staffing the
facilities and ancillary services appropriate for the
performance of such procedure in the physician's
office, and
(ii) takes such items into account in such a manner
which will assure that the performance of such
procedure in the physician's office will result in
substantially less amounts paid under this title than
would have been paid if the services had been furnished
on an inpatient basis in a hospital.
Each amount so established shall be reviewed and updated not
later than July 1, 1987, and annually thereafter to take
account of varying conditions in different areas.
(C)(i) Notwithstanding the second sentence of each of
subparagraphs (A) and (B), except as otherwise specified in
clauses (ii), (iii), and (iv), if the Secretary has not updated
amounts established under such subparagraphs or under
subparagraph (D), with respect to facility services furnished
during a fiscal year (beginning with fiscal year 1986 or a
calendar year (beginning with 2006)), such amounts shall be
increased by the percentage increase in the Consumer Price
Index for all urban consumers (U.S. city average) as estimated
by the Secretary for the 12-month period ending with the
midpoint of the year involved.
(ii) In each of the fiscal years 1998 through 2002, the
increase under this subparagraph shall be reduced (but not
below zero) by 2.0 percentage points.
(iii) In fiscal year 2004, beginning with April 1, 2004, the
increase under this subparagraph shall be the Consumer Price
Index for all urban consumers (U.S. city average) as estimated
by the Secretary for the 12-month period ending with March 31,
2003, minus 3.0 percentage points.
(iv) In fiscal year 2005, the last quarter of calendar year
2005, and each of calendar years 2006 through 2009, the
increase under this subparagraph shall be 0 percent.
(D)(i) Taking into account the recommendations in the report
under section 626(d) of Medicare Prescription Drug,
Improvement, and Modernization Act of 2003, the Secretary shall
implement a revised payment system for payment of surgical
services furnished in ambulatory surgical centers.
(ii) In the year the system described in clause (i) is
implemented, such system shall be designed to result in the
same aggregate amount of expenditures for such services as
would be made if this subparagraph did not apply, as estimated
by the Secretary and taking into account reduced expenditures
that would apply if subparagraph (E) were to continue to apply,
as estimated by the Secretary.
(iii) The Secretary shall implement the system described in
clause (i) for periods in a manner so that it is first
effective beginning on or after January 1, 2006, and not later
than January 1, 2008.
(iv) The Secretary may implement such system in a manner so
as to provide for a reduction in any annual update for failure
to report on quality measures in accordance with paragraph (7).
(v) In implementing the system described in clause
(i) for 2011 and each subsequent year, any annual
update under such system for the year, after
application of clause (iv), shall be reduced by the
productivity adjustment described in section
1886(b)(3)(B)(xi)(II). The application of the preceding
sentence may result in such update being less than 0.0
for a year, and may result in payment rates under the
system described in clause (i) for a year being less
than such payment rates for the preceding year.
(vi) There shall be no administrative or judicial review
under section 1869, 1878, or otherwise, of the classification
system, the relative weights, payment amounts, and the
geographic adjustment factor, if any, under this subparagraph.
(E) With respect to surgical procedures furnished on or after
January 1, 2007, and before the effective date of the
implementation of a revised payment system under subparagraph
(D), if--
(i) the standard overhead amount under subparagraph
(A) for a facility service for such procedure, without
the application of any geographic adjustment, exceeds
(ii) the Medicare OPD fee schedule amount established
under the prospective payment system for hospital
outpatient department services under paragraph (3)(D)
of section 1833(t) for such service for such year,
determined without regard to geographic adjustment
under paragraph (2)(D) of such section,
the Secretary shall substitute under subparagraph (A) the
amount described in clause (ii) for the standard overhead
amount for such service referred to in clause (i).
(3)(A) The aggregate amount of the payments to be made under
this part for outpatient hospital facility services or critical
access hospital services furnished before January 1, 1999, in
connection with surgical procedures specified under paragraph
(1)(A) shall be equal to the lesser of--
(i) the amount determined with respect to such
services under subsection (a)(2)(B); or
(ii) the blend amount (described in subparagraph
(B)).
(B)(i) The blend amount for a cost reporting period is the
sum of--
(I) the cost proportion (as defined in clause
(ii)(I)) of the amount described in subparagraph
(A)(i), and
(II) the ASC proportion (as defined in clause
(ii)(II)) of the standard overhead amount payable with
respect to the same surgical procedure as if it were
provided in an ambulatory surgical center in the same
area, as determined under paragraph (2)(A), less the
amount a provider may charge as described in clause
(ii) of section 1866(a)(2)(A).
(ii) Subject to paragraph (4), in this paragraph:
(I) The term ``cost proportion'' means 75 percent for
cost reporting periods beginning in fiscal year 1988,
50 percent for portions of cost reporting periods
beginning on or after October 1, 1988, and ending on or
before December 31, 1990, and 42 percent for portions
of cost reporting periods beginning on or after January
1, 1991.
(II) The term ``ASC proportion'' means 25 percent for
cost reporting periods beginning in fiscal year 1988,
50 percent for portions of cost reporting periods
beginning on or after October 1, 1988, and ending on or
before December 31, 1990, and 58 percent for portions
of cost reporting periods beginning on or after January
1, 1991.
(4)(A) In the case of a hospital that--
(i) makes application to the Secretary and
demonstrates that it specializes in eye services or eye
and ear services (as determined by the Secretary),
(ii) receives more than 30 percent of its total
revenues from outpatient services, and
(iii) on October 1, 1987--
(I) was an eye specialty hospital or an eye
and ear specialty hospital, or
(II) was operated as an eye or eye and ear
unit (as defined in subparagraph (B)) of a
general acute care hospital which, on the date
of the application described in clause (i),
operates less than 20 percent of the beds that
the hospital operated on October 1, 1987, and
has sold or otherwise disposed of a substantial
portion of the hospital's other acute care
operations,
the cost proportion and ASC proportion in effect under
subclauses (I) and (II) of paragraph (3)(B)(ii) for cost
reporting periods beginning in fiscal year 1988 shall remain in
effect for cost reporting periods beginning on or after October
1, 1988, and before January 1, 1995.
(B) For purposes of this subparagraph (A)(iii)(II), the term
``eye or eye and ear unit'' means a physically separate or
distinct unit containing separate surgical suites devoted
solely to eye or eye and ear services.
(5)(A) The Secretary is authorized to provide by regulations
that in the case of a surgical procedure, specified by the
Secretary pursuant to paragraph (1)(A), performed in an
ambulatory surgical center described in such paragraph, there
shall be paid (in lieu of any amounts otherwise payable under
this part) with respect to the facility services furnished by
such center and with respect to all related services (including
physicians' services, laboratory, X-ray, and diagnostic
services) a single all-inclusive fee established pursuant to
subparagraph (B), if all parties furnishing all such services
agree to accept such fee (to be divided among the parties
involved in such manner as they shall have previously agreed
upon) as full payment for the services furnished.
(B) In implementing this paragraph, the Secretary shall
establish with respect to each surgical procedure specified
pursuant to paragraph (1)(A) the amount of the all-inclusive
fee for such procedure, taking into account such factors as may
be appropriate. The amount so established with respect to any
surgical procedure shall be reviewed periodically and may be
adjusted by the Secretary, when appropriate, to take account of
varying conditions in different areas.
(6) Any person, including a facility having an agreement
under section 1832(a)(2)(F)(i), who knowingly and willfully
presents, or causes to be presented, a bill or request for
payment, for an intraocular lens inserted during or subsequent
to cataract surgery for which payment may be made under
paragraph (2)(A)(iii), is subject to a civil money penalty of
not to exceed $2,000. The provisions of section 1128A (other
than subsections (a) and (b)) shall apply to a civil money
penalty under the previous sentence in the same manner as such
provisions apply to a penalty or proceeding under section
1128A(a).
(7)(A) For purposes of paragraph (2)(D)(iv), the Secretary
may provide, in the case of an ambulatory surgical center that
does not submit, to the Secretary in accordance with this
paragraph, data required to be submitted on measures selected
under this paragraph with respect to a year, any annual
increase provided under the system established under paragraph
(2)(D) for such year shall be reduced by 2.0 percentage points.
A reduction under this subparagraph shall apply only with
respect to the year involved and the Secretary shall not take
into account such reduction in computing any annual increase
factor for a subsequent year.
(B) Except as the Secretary may otherwise provide, the
provisions of subparagraphs (B), (C), (D), and (E) of paragraph
(17) of section 1833(t) shall apply with respect to services of
ambulatory surgical centers under this paragraph in a similar
manner to the manner in which they apply under such paragraph
and, for purposes of this subparagraph, any reference to a
hospital, outpatient setting, or outpatient hospital services
is deemed a reference to an ambulatory surgical center, the
setting of such a center, or services of such a center,
respectively.
(8) The Secretary shall conduct a similar type of review as
required under paragraph (22) of section 1833(t)), including
the second sentence of subparagraph (C) of such paragraph, to
payment for services under this subsection, and make such
revisions under this paragraph, in an appropriate manner (as
determined by the Secretary).
(j) Whenever a final determination is made that the amount of
payment made under this part either to a provider of services
or to another person pursuant to an assignment under section
1842(b)(3)(B)(ii) was in excess of or less than the amount of
payment that is due, and payment of such excess or deficit is
not made (or effected by offset) within 30 days of the date of
the determination, interest shall accrue on the balance of such
excess or deficit not paid or offset (to the extent that the
balance is owed by or owing to the provider) at a rate
determined in accordance with the regulations of the Secretary
of the Treasury applicable to charges for late payments.
(k) With respect to services described in section
1861(s)(10)(B), the Secretary may provide, instead of the
amount of payment otherwise provided under this part, for
payment of such an amount or amounts as reasonably reflects the
general cost of efficiently providing such services.
(l)(1)(A) The Secretary shall establish a fee schedule for
services of certified registered nurse anesthetists under
section 1861(s)(11).
(B) In establishing the fee schedule under this paragraph the
Secretary may utilize a system of time units, a system of base
and time units, or any appropriate methodology.
(C) The provisions of this subsection shall not apply to
certain services furnished in certain hospitals in rural areas
under the provisions of section 9320(k) of the Omnibus Budget
Reconciliation Act of 1986, as amended by section 6132 of the
Omnibus Budget Reconciliation Act of 1989.
(2) Except as provided in paragraph (3), the fee schedule
established under paragraph (1) shall be initially based on
audited data from cost reporting periods ending in fiscal year
1985 and such other data as the Secretary determines necessary.
(3)(A) In establishing the initial fee schedule for those
services, the Secretary shall adjust the fee schedule to the
extent necessary to ensure that the estimated total amount
which will be paid under this title for those services plus
applicable coinsurance in 1989 will equal the estimated total
amount which would be paid under this title for those services
in 1989 if the services were included as inpatient hospital
services and payment for such services was made under part A in
the same manner as payment was made in fiscal year 1987,
adjusted to take into account changes in prices and technology
relating to the administration of anesthesia.
(B) The Secretary shall also reduce the prevailing charge of
physicians for medical direction of a certified registered
nurse anesthetist, or the fee schedule for services of
certified registered nurse anesthetists, or both, to the extent
necessary to ensure that the estimated total amount which will
be paid under this title plus applicable coinsurance for such
medical direction and such services in 1989 and 1990 will not
exceed the estimated total amount which would have been paid
plus applicable coinsurance but for the enactment of the
amendments made by section 9320 of the Omnibus Budget
Reconciliation Act of 1986. A reduced prevailing charge under
this subparagraph shall become the prevailing charge but for
subsequent years for purposes of applying the economic index
under the fourth sentence of section 1842(b)(3).
(4)(A) Except as provided in subparagraphs (C) and (D), in
determining the amount paid under the fee schedule under this
subsection for services furnished on or after January 1, 1991,
by a certified registered nurse anesthetist who is not
medically directed--
(i) the conversion factor shall be--
(I) for services furnished in 1991, $15.50,
(II) for services furnished in 1992, $15.75,
(III) for services furnished in 1993, $16.00,
(IV) for services furnished in 1994, $16.25,
(V) for services furnished in 1995, $16.50,
(VI) for services furnished in 1996, $16.75,
and
(VII) for services furnished in calendar
years after 1996, the previous year's
conversion factor increased by the update
determined under section 1848(d) for physician
anesthesia services for that year;
(ii) the payment areas to be used shall be the fee
schedule areas used under section 1848 (or, in the case
of services furnished during 1991, the localities used
under section 1842(b)) for purposes of computing
payments for physicians' services that are anesthesia
services;
(iii) the geographic adjustment factors to be applied
to the conversion factor under clause (i) for services
in a fee schedule area or locality is--
(I) in the case of services furnished in
1991, the geographic work index value and the
geographic practice cost index value specified
in section 1842(q)(1)(B) for physicians'
services that are anesthesia services furnished
in the area or locality, and
(II) in the case of services furnished after
1991, the geographic work index value, the
geographic practice cost index value, and the
geographic malpractice index value used for
determining payments for physicians' services
that are anesthesia services under section
1848,
with 70 percent of the conversion factor treated as
attributable to work and 30 percent as attributable to
overhead for services furnished in 1991 (and the
portions attributable to work, practice expenses, and
malpractice expenses in 1992 and thereafter being the
same as is applied under section 1848).
(B)(i) Except as provided in clause (ii) and subparagraph
(D), in determining the amount paid under the fee schedule
under this subsection for services furnished on or after
January 1, 1991, and before January 1, 1994, by a certified
registered nurse anesthetist who is medically directed, the
Secretary shall apply the same methodology specified in
subparagraph (A).
(ii) The conversion factor used under clause (i) shall be--
(I) for services furnished in 1991, $10.50,
(II) for services furnished in 1992, $10.75, and
(III) for services furnished in 1993, $11.00.
(iii) In the case of services of a certified registered nurse
anesthetist who is medically directed or medically supervised
by a physician which are furnished on or after January 1, 1994,
the fee schedule amount shall be one-half of the amount
described in section 1848(a)(5)(B) with respect to the
physician.
(C) Notwithstanding subclauses (I) through (V) of
subparagraph (A)(i)--
(i) in the case of a 1990 conversion factor that is
greater than $16.50, the conversion factor for a
calendar year after 1990 and before 1996 shall be the
1990 conversion factor reduced by the product of the
last digit of the calendar year and one-fifth of the
amount by which the 1990 conversion factor exceeds
$16.50; and
(ii) in the case of a 1990 conversion factor that is
greater than $15.49 but less than $16.51, the
conversion factor for a calendar year after 1990 and
before 1996 shall be the greater of--
(I) the 1990 conversion factor, or
(II) the conversion factor specified in
subparagraph (A)(i) for the year involved.
(D) Notwithstanding subparagraph (C), in no case may the
conversion factor used to determine payment for services in a
fee schedule area or locality under this subsection, as
adjusted by the adjustment factors specified in subparagraphs
(A)(iii), exceed the conversion factor used to determine the
amount paid for physicians' services that are anesthesia
services in the area or locality.
(5)(A) Payment for the services of a certified registered
nurse anesthetist (for which payment may otherwise be made
under this part) may be made on the basis of a claim or request
for payment presented by the certified registered nurse
anesthetist furnishing such services, or by a hospital,
critical access hospital, physician, group practice, or
ambulatory surgical center with which the certified registered
nurse anesthetist furnishing such services has an employment or
contractual relationship that provides for payment to be made
under this part for such services to such hospital, critical
access hospital, physician, group practice, or ambulatory
surgical center.
(B) No hospital or critical access hospital that presents a
claim or request for payment for services of a certified nurse
anesthetist under this part may treat any uncollected
coinsurance amount imposed under this part with respect to such
services as a bad debt of such hospital or critical access
hospital for purposes of this title.
(6) If an adjustment under paragraph (3)(B) results in a
reduction in the reasonable charge for a physicians' service
and a nonparticipating physician furnishes the service to an
individual entitled to benefits under this part after the
effective date of the reduction, the physician's actual charge
is subject to a limit under section 1842(j)(1)(D).
(m)(1) In the case of physicians' services furnished in a
year to an individual, who is covered under the insurance
program established by this part and who incurs expenses for
such services, in an area that is designated (under section
332(a)(1)(A) of the Public Health Service Act) as a health
professional shortage area as identified by the Secretary prior
to the beginning of such year, in addition to the amount
otherwise paid under this part, there also shall be paid to the
physician (or to an employer or facility in the cases described
in clause (A) of section 1842(b)(6)) (on a monthly or quarterly
basis) from the Federal Supplementary Medical Insurance Trust
Fund an amount equal to 10 percent of the payment amount for
the service under this part.
(2) For each health professional shortage area identified in
paragraph (1) that consists of an entire county, the Secretary
shall provide for the additional payment under paragraph (1)
without any requirement on the physician to identify the health
professional shortage area involved. The Secretary may
implement the previous sentence using the method specified in
subsection (u)(4)(C).
(3) The Secretary shall post on the Internet website of the
Centers for Medicare & Medicaid Services a list of the health
professional shortage areas identified in paragraph (1) that
consist of a partial county to facilitate the additional
payment under paragraph (1) in such areas.
(4) There shall be no administrative or judicial review under
section 1869, section 1878, or otherwise, respecting--
(A) the identification of a county or area;
(B) the assignment of a specialty of any physician
under this paragraph;
(C) the assignment of a physician to a county under
this subsection; or
(D) the assignment of a postal ZIP Code to a county
or other area under this subsection.
(n)(1)(A) The aggregate amount of the payments to be made for
all or part of a cost reporting period for services described
in subsection (a)(2)(E)(i) furnished under this part on or
after October 1, 1988, and before January 1, 1999, and for
services described in subsection (a)(2)(E)(ii) furnished under
this part on or after October 1, 1989, and before January 1,
1999, shall be equal to the lesser of--
(i) the amount determined with respect to such
services under subsection (a)(2)(B), or
(ii) the blend amount for radiology services and
diagnostic procedures determined in accordance with
subparagraph (B).
(B)(i) The blend amount for radiology services and diagnostic
procedures for a cost reporting period is the sum of--
(I) the cost proportion (as defined in clause (ii))
of the amount described in subparagraph (A)(i); and
(II) the charge proportion (as defined in clause
(ii)(II)) of 62 percent (for services described in
subsection (a)(2)(E)(i)), or (for procedures described
in subsection (a)(2)(E)(ii)), 42 percent or such other
percent established by the Secretary (or carriers
acting pursuant to guidelines issued by the Secretary)
based on prevailing charges established with actual
charge data, of the prevailing charge or (for services
described in subsection (a)(2)(E)(i) furnished on or
after January 1, 1989) the fee schedule amount
established for participating physicians for the same
services as if they were furnished in a physician's
office in the same locality as determined under section
1842(b), less the amount a provider may charge as
described in clause (ii) of section 1866(a)(2)(A).
(ii) In this subparagraph:
(I) The term ``cost proportion'' means 50 percent,
except that such term means 65 percent in the case of
outpatient radiology services for portions of cost
reporting periods which occur in fiscal year 1989 and
in the case of diagnostic procedures described in
subsection (a)(2)(E)(ii) for portions of cost reporting
periods which occur in fiscal year 1990, and such term
means 42 percent in the case of outpatient radiology
services for portions of cost reporting periods
beginning on or after January 1, 1991.
(II) The term ``charge proportion'' means 100 percent
minus the cost proportion.
(o)(1) In the case of shoes described in section
1861(s)(12)--
(A) no payment may be made under this part, with
respect to any individual for any year, for the
furnishing of--
(i) more than one pair of custom molded shoes
(including inserts provided with such shoes)
and 2 additional pairs of inserts for such
shoes, or
(ii) more than one pair of extra-depth shoes
(not including inserts provided with such
shoes) and 3 pairs of inserts for such shoes,
and
(B) with respect to expenses incurred in any calendar
year, no more than the amount of payment applicable
under paragraph (2) shall be considered as incurred
expenses for purposes of subsections (a) and (b).
Payment for shoes (or inserts) under this part shall be
considered to include payment for any expenses for the fitting
of such shoes (or inserts).
(2)(A) Except as provided by the Secretary under
subparagraphs (B) and (C), the amount of payment under this
paragraph for custom molded shoes, extra-depth shoes, and
inserts shall be the amount determined for such items by the
Secretary under section 1834(h).
(B) The Secretary may establish payment amounts for shoes and
inserts that are lower than the amount established under
section 1834(h) if the Secretary finds that shoes and inserts
of an appropriate quality are readily available at or below the
amount established under such section.
(C) In accordance with procedures established by the
Secretary, an individual entitled to benefits with respect to
shoes described in section 1861(s)(12) may substitute
modification of such shoes instead of obtaining one (or more,
as specified by the Secretary) pair of inserts (other than the
original pair of inserts with respect to such shoes). In such
case, the Secretary shall substitute, for the payment amount
established under section 1834(h), a payment amount that the
Secretary estimates will assure that there is no net increase
in expenditures under this subsection as a result of this
subparagraph.
(3) In this title, the term ``shoes'' includes, except for
purposes of subparagraphs (A)(ii) and (B) of paragraph (2),
inserts for extra-depth shoes.
(q)(1) Each request for payment, or bill submitted, for an
item or service furnished by an entity for which payment may be
made under this part and for which the entity knows or has
reason to believe there has been a referral by a referring
physician (within the meaning of section 1877) shall include
the name and unique physician identification number for the
referring physician.
(2)(A) In the case of a request for payment for an item or
service furnished by an entity under this part on an
assignment-related basis and for which information is required
to be provided under paragraph (1) but not included, payment
may be denied under this part.
(B) In the case of a request for payment for an item or
service furnished by an entity under this part not submitted on
an assignment-related basis and for which information is
required to be provided under paragraph (1) but not included--
(i) if the entity knowingly and willfully fails to
provide such information promptly upon request of the
Secretary or a carrier, the entity may be subject to a
civil money penalty in an amount not to exceed $2,000,
and
(ii) if the entity knowingly, willfully, and in
repeated cases fails, after being notified by the
Secretary of the obligations and requirements of this
subsection to provide the information required under
paragraph (1), the entity may be subject to exclusion
from participation in the programs under this Act for a
period not to exceed 5 years, in accordance with the
procedures of subsections (c), (f), and (g) of section
1128.
The provisions of section 1128A (other than subsections (a) and
(b)) shall apply to civil money penalties under clause (i) in
the same manner as they apply to a penalty or proceeding under
section 1128A(a).
(r)(1) With respect to services described in section
1861(s)(2)(K)(ii) (relating to nurse practitioner or clinical
nurse specialist services), payment may be made on the basis of
a claim or request for payment presented by the nurse
practitioner or clinical nurse specialist furnishing such
services, or by a hospital, critical access hospital, skilled
nursing facility or nursing facility (as defined in section
1919(a)), physician, group practice, or ambulatory surgical
center with which the nurse practitioner or clinical nurse
specialist has an employment or contractual relationship that
provides for payment to be made under this part for such
services to such hospital, physician, group practice, or
ambulatory surgical center.
(2) No hospital or critical access hospital that presents a
claim or request for payment under this part for services
described in section 1861(s)(2)(K)(ii) may treat any
uncollected coinsurance amount imposed under this part with
respect to such services as a bad debt of such hospital for
purposes of this title.
(s) The Secretary may not provide for payment under
subsection (a)(1)(A) with respect to an organization unless the
organization provides assurances satisfactory to the Secretary
that the organization meets the requirement of section 1866(f)
(relating to maintaining written policies and procedures
respecting advance directives).
(t) Prospective Payment System for Hospital Outpatient
Department Services.--
(1) Amount of payment.--
(A) In general.--With respect to covered OPD
services (as defined in subparagraph (B))
furnished during a year beginning with 1999,
the amount of payment under this part shall be
determined under a prospective payment system
established by the Secretary in accordance with
this subsection.
(B) Definition of covered opd services.--For
purposes of this subsection, the term ``covered
OPD services''--
(i) means hospital outpatient
services designated by the Secretary;
(ii) subject to clause (iv), includes
inpatient hospital services designated
by the Secretary that are covered under
this part and furnished to a hospital
inpatient who (I) is entitled to
benefits under part A but has exhausted
benefits for inpatient hospital
services during a spell of illness, or
(II) is not so entitled;
(iii) includes implantable items
described in paragraph (3), (6), or (8)
of section 1861(s);
(iv) does not include any therapy
services described in subsection (a)(8)
or ambulance services, for which
payment is made under a fee schedule
described in section 1834(k) or section
1834(l) and does not include screening
mammography (as defined in section
1861(jj)), diagnostic mammography, or
personalized prevention plan services
(as defined in section 1861(hhh)(1));
and
(v) does not include applicable items
and services (as defined in
subparagraph (A) of paragraph (21))
that are furnished on or after January
1, 2017, by an off-campus outpatient
department of a provider (as defined in
subparagraph (B) of such paragraph).
(2) System requirements.--Under the payment system--
(A) the Secretary shall develop a
classification system for covered OPD services;
(B) the Secretary may establish groups of
covered OPD services, within the classification
system described in subparagraph (A), so that
services classified within each group are
comparable clinically and with respect to the
use of resources and so that an implantable
item is classified to the group that includes
the service to which the item relates;
(C) the Secretary shall, using data on claims
from 1996 and using data from the most recent
available cost reports, establish relative
payment weights for covered OPD services (and
any groups of such services described in
subparagraph (B)) based on median (or, at the
election of the Secretary, mean) hospital costs
and shall determine projections of the
frequency of utilization of each such service
(or group of services) in 1999;
(D) subject to paragraph (19), the Secretary
shall determine a wage adjustment factor to
adjust the portion of payment and coinsurance
attributable to labor-related costs for
relative differences in labor and labor-related
costs across geographic regions in a budget
neutral manner;
(E) the Secretary shall establish, in a
budget neutral manner, outlier adjustments
under paragraph (5) and transitional pass-
through payments under paragraph (6) and other
adjustments as determined to be necessary to
ensure equitable payments, such as adjustments
for certain classes of hospitals;
(F) the Secretary shall develop a method for
controlling unnecessary increases in the volume
of covered OPD services;
(G) the Secretary shall create additional
groups of covered OPD services that classify
separately those procedures that utilize
contrast agents from those that do not; and
(H) with respect to devices of brachytherapy
consisting of a seed or seeds (or radioactive
source), the Secretary shall create additional
groups of covered OPD services that classify
such devices separately from the other services
(or group of services) paid for under this
subsection in a manner reflecting the number,
isotope, and radioactive intensity of such
devices furnished, including separate groups
for palladium-103 and iodine-125 devices and
for stranded and non-stranded devices furnished
on or after July 1, 2007.
For purposes of subparagraph (B), items and services
within a group shall not be treated as ``comparable
with respect to the use of resources'' if the highest
median cost (or mean cost, if elected by the Secretary
under subparagraph (C)) for an item or service within
the group is more than 2 times greater than the lowest
median cost (or mean cost, if so elected) for an item
or service within the group; except that the Secretary
may make exceptions in unusual cases, such as low
volume items and services, but may not make such an
exception in the case of a drug or biological that has
been designated as an orphan drug under section 526 of
the Federal Food, Drug and Cosmetic Act.
(3) Calculation of base amounts.--
(A) Aggregate amounts that would be payable
if deductibles were disregarded.--The Secretary
shall estimate the sum of--
(i) the total amounts that would be
payable from the Trust Fund under this
part for covered OPD services in 1999,
determined without regard to this
subsection, as though the deductible
under section 1833(b) did not apply,
and
(ii) the total amounts of copayments
estimated to be paid under this
subsection by beneficiaries to
hospitals for covered OPD services in
1999, as though the deductible under
section 1833(b) did not apply.
(B) Unadjusted copayment amount.--
(i) In general.--For purposes of this
subsection, subject to clause (ii), the
``unadjusted copayment amount''
applicable to a covered OPD service (or
group of such services) is 20 percent
of the national median of the charges
for the service (or services within the
group) furnished during 1996, updated
to 1999 using the Secretary's estimate
of charge growth during the period.
(ii) Adjusted to be 20 percent when
fully phased in.--If the pre-deductible
payment percentage for a covered OPD
service (or group of such services)
furnished in a year would be equal to
or exceed 80 percent, then the
unadjusted copayment amount shall be 20
percent of amount determined under
subparagraph (D).
(iii) Rules for new services.--The
Secretary shall establish rules for
establishment of an unadjusted
copayment amount for a covered OPD
service not furnished during 1996,
based upon its classification within a
group of such services.
(C) Calculation of conversion factors.--
(i) For 1999.--
(I) In general.--The
Secretary shall establish a
1999 conversion factor for
determining the medicare OPD
fee schedule amounts for each
covered OPD service (or group
of such services) furnished in
1999. Such conversion factor
shall be established on the
basis of the weights and
frequencies described in
paragraph (2)(C) and in such a
manner that the sum for all
services and groups of the
products (described in
subclause (II) for each such
service or group) equals the
total projected amount
described in subparagraph (A).
(II) Product described.--The
Secretary shall determine for
each service or group the
product of the medicare OPD fee
schedule amounts (taking into
account appropriate adjustments
described in paragraphs (2)(D)
and (2)(E)) and the estimated
frequencies for such service or
group.
(ii) Subsequent years.--Subject to
paragraph (8)(B), the Secretary shall
establish a conversion factor for
covered OPD services furnished in
subsequent years in an amount equal to
the conversion factor established under
this subparagraph and applicable to
such services furnished in the previous
year increased by the OPD fee schedule
increase factor specified under clause
(iv) for the year involved.
(iii) Adjustment for service mix
changes.--Insofar as the Secretary
determines that the adjustments for
service mix under paragraph (2) for a
previous year (or estimates that such
adjustments for a future year) did (or
are likely to) result in a change in
aggregate payments under this
subsection during the year that are a
result of changes in the coding or
classification of covered OPD services
that do not reflect real changes in
service mix, the Secretary may adjust
the conversion factor computed under
this subparagraph for subsequent years
so as to eliminate the effect of such
coding or classification changes.
(iv) OPD fee schedule increase
factor.--For purposes of this
subparagraph, subject to paragraph (17)
and subparagraph (F) of this paragraph,
the ``OPD fee schedule increase
factor'' for services furnished in a
year is equal to the market basket
percentage increase applicable under
section 1886(b)(3)(B)(iii) to hospital
discharges occurring during the fiscal
year ending in such year, reduced by 1
percentage point for such factor for
services furnished in each of 2000 and
2002. In applying the previous sentence
for years beginning with 2000, the
Secretary may substitute for the market
basket percentage increase an annual
percentage increase that is computed
and applied with respect to covered OPD
services furnished in a year in the
same manner as the market basket
percentage increase is determined and
applied to inpatient hospital services
for discharges occurring in a fiscal
year.
(D) Calculation of medicare opd fee schedule
amounts.--The Secretary shall compute a
medicare OPD fee schedule amount for each
covered OPD service (or group of such services)
furnished in a year, in an amount equal to the
product of--
(i) the conversion factor computed
under subparagraph (C) for the year,
and
(ii) the relative payment weight
(determined under paragraph (2)(C)) for
the service or group.
(E) Pre-deductible payment percentage.--The
pre-deductible payment percentage for a covered
OPD service (or group of such services)
furnished in a year is equal to the ratio of--
(i) the medicare OPD fee schedule
amount established under subparagraph
(D) for the year, minus the unadjusted
copayment amount determined under
subparagraph (B) for the service or
group, to
(ii) the medicare OPD fee schedule
amount determined under subparagraph
(D) for the year for such service or
group.
(F) Productivity and other adjustment.--After
determining the OPD fee schedule increase
factor under subparagraph (C)(iv), the
Secretary shall reduce such increase factor--
(i) for 2012 and subsequent years, by
the productivity adjustment described
in section 1886(b)(3)(B)(xi)(II); and
(ii) for each of 2010 through 2019,
by the adjustment described in
subparagraph (G).
The application of this subparagraph may result
in the increase factor under subparagraph
(C)(iv) being less than 0.0 for a year, and may
result in payment rates under the payment
system under this subsection for a year being
less than such payment rates for the preceding
year.
(G) Other adjustment.--For purposes of
subparagraph (F)(ii), the adjustment described
in this subparagraph is--
(i) for each of 2010 and 2011, 0.25
percentage point;
(ii) for each of 2012 and 2013, 0.1
percentage point;
(iii) for 2014, 0.3 percentage point;
(iv) for each of 2015 and 2016, 0.2
percentage point; and
(v) for each of 2017, 2018, and 2019,
0.75 percentage point.
(4) Medicare payment amount.--The amount of payment
made from the Trust Fund under this part for a covered
OPD service (and such services classified within a
group) furnished in a year is determined, subject to
paragraph (7), as follows:
(A) Fee schedule adjustments.--The medicare
OPD fee schedule amount (computed under
paragraph (3)(D)) for the service or group and
year is adjusted for relative differences in
the cost of labor and other factors determined
by the Secretary, as computed under paragraphs
(2)(D) and (2)(E).
(B) Subtract applicable deductible.--Reduce
the adjusted amount determined under
subparagraph (A) by the amount of the
deductible under section 1833(b), to the extent
applicable.
(C) Apply payment proportion to remainder.--
The amount of payment is the amount so
determined under subparagraph (B) multiplied by
the pre-deductible payment percentage (as
determined under paragraph (3)(E)) for the
service or group and year involved, plus the
amount of any reduction in the copayment amount
attributable to paragraph (8)(C).
(5) Outlier adjustment.--
(A) In general.--Subject to subparagraph (D),
the Secretary shall provide for an additional
payment for each covered OPD service (or group
of services) for which a hospital's charges,
adjusted to cost, exceed--
(i) a fixed multiple of the sum of--
(I) the applicable medicare
OPD fee schedule amount
determined under paragraph
(3)(D), as adjusted under
paragraph (4)(A) (other than
for adjustments under this
paragraph or paragraph (6));
and
(II) any transitional pass-
through payment under paragraph
(6); and
(ii) at the option of the Secretary,
such fixed dollar amount as the
Secretary may establish.
(B) Amount of adjustment.--The amount of the
additional payment under subparagraph (A) shall
be determined by the Secretary and shall
approximate the marginal cost of care beyond
the applicable cutoff point under such
subparagraph.
(C) Limit on aggregate outlier adjustments.--
(i) In general.--The total of the
additional payments made under this
paragraph for covered OPD services
furnished in a year (as estimated by
the Secretary before the beginning of
the year) may not exceed the applicable
percentage (specified in clause (ii))
of the total program payments estimated
to be made under this subsection for
all covered OPD services furnished in
that year. If this paragraph is first
applied to less than a full year, the
previous sentence shall apply only to
the portion of such year.
(ii) Applicable percentage.--For
purposes of clause (i), the term
``applicable percentage'' means a
percentage specified by the Secretary
up to (but not to exceed)--
(I) for a year (or portion of
a year) before 2004, 2.5
percent; and
(II) for 2004 and thereafter,
3.0 percent.
(D) Transitional authority.--In applying
subparagraph (A) for covered OPD services
furnished before January 1, 2002, the Secretary
may--
(i) apply such subparagraph to a bill
for such services related to an
outpatient encounter (rather than for a
specific service or group of services)
using OPD fee schedule amounts and
transitional pass-through payments
covered under the bill; and
(ii) use an appropriate cost-to-
charge ratio for the hospital involved
(as determined by the Secretary),
rather than for specific departments
within the hospital.
(E) Exclusion of separate drug and biological
apcs from outlier payments.--No additional
payment shall be made under subparagraph (A) in
the case of ambulatory payment classification
groups established separately for drugs or
biologicals.
(6) Transitional pass-through for additional costs of
innovative medical devices, drugs, and biologicals.--
(A) In general.--The Secretary shall provide
for an additional payment under this paragraph
for any of the following that are provided as
part of a covered OPD service (or group of
services):
(i) Current orphan drugs.--A drug or
biological that is used for a rare
disease or condition with respect to
which the drug or biological has been
designated as an orphan drug under
section 526 of the Federal Food, Drug
and Cosmetic Act if payment for the
drug or biological as an outpatient
hospital service under this part was
being made on the first date that the
system under this subsection is
implemented.
(ii) Current cancer therapy drugs and
biologicals and brachytherapy.--A drug
or biological that is used in cancer
therapy, including (but not limited to)
a chemotherapeutic agent, an
antiemetic, a hematopoietic growth
factor, a colony stimulating factor, a
biological response modifier, a
bisphosphonate, and a device of
brachytherapy or temperature monitored
cryoablation, if payment for such drug,
biological, or device as an outpatient
hospital service under this part was
being made on such first date.
(iii) Current radiopharmaceutical
drugs and biological products.--A
radiopharmaceutical drug or biological
product used in diagnostic, monitoring,
and therapeutic nuclear medicine
procedures if payment for the drug or
biological as an outpatient hospital
service under this part was being made
on such first date.
(iv) New medical devices, drugs, and
biologicals.--A medical device, drug,
or biological not described in clause
(i), (ii), or (iii) if--
(I) payment for the device,
drug, or biological as an
outpatient hospital service
under this part was not being
made as of December 31, 1996;
and
(II) the cost of the drug or
biological or the average cost
of the category of devices is
not insignificant in relation
to the OPD fee schedule amount
(as calculated under paragraph
(3)(D)) payable for the service
(or group of services)
involved.
(B) Use of categories in determining
eligibility of a device for pass-through
payments.--The following provisions apply for
purposes of determining whether a medical
device qualifies for additional payments under
clause (ii) or (iv) of subparagraph (A):
(i) Establishment of initial
categories.--
(I) In general.--The
Secretary shall initially
establish under this clause
categories of medical devices
based on type of device by
April 1, 2001. Such categories
shall be established in a
manner such that each medical
device that meets the
requirements of clause (ii) or
(iv) of subparagraph (A) as of
January 1, 2001, is included in
such a category and no such
device is included in more than
one category. For purposes of
the preceding sentence, whether
a medical device meets such
requirements as of such date
shall be determined on the
basis of the program memoranda
issued before such date.
(II) Authorization of
implementation other than
through regulations.--The
categories may be established
under this clause by program
memorandum or otherwise, after
consultation with groups
representing hospitals,
manufacturers of medical
devices, and other affected
parties.
(ii) Establishing criteria for
additional categories.--
(I) In general.--The
Secretary shall establish
criteria that will be used for
creation of additional
categories (other than those
established under clause (i))
through rulemaking (which may
include use of an interim final
rule with comment period).
(II) Standard.--Such
categories shall be established
under this clause in a manner
such that no medical device is
described by more than one
category. Such criteria shall
include a test of whether the
average cost of devices that
would be included in a category
and are in use at the time the
category is established is not
insignificant, as described in
subparagraph (A)(iv)(II).
(III) Deadline.--Criteria
shall first be established
under this clause by July 1,
2001. The Secretary may
establish in compelling
circumstances categories under
this clause before the date
such criteria are established.
(IV) Adding categories.--The
Secretary shall promptly
establish a new category of
medical devices under this
clause for any medical device
that meets the requirements of
subparagraph (A)(iv) and for
which none of the categories in
effect (or that were previously
in effect) is appropriate.
(iii) Period for which category is in
effect.--A category of medical devices
established under clause (i) or (ii)
shall be in effect for a period of at
least 2 years, but not more than 3
years, that begins--
(I) in the case of a category
established under clause (i),
on the first date on which
payment was made under this
paragraph for any device
described by such category
(including payments made during
the period before April 1,
2001); and
(II) in the case of any other
category, on the first date on
which payment is made under
this paragraph for any medical
device that is described by
such category.
(iv) Requirements treated as met.--A
medical device shall be treated as
meeting the requirements of
subparagraph (A)(iv), regardless of
whether the device meets the
requirement of subclause (I) of such
subparagraph, if--
(I) the device is described
by a category established and
in effect under clause (i); or
(II) the device is described
by a category established and
in effect under clause (ii) and
an application under section
515 of the Federal Food, Drug,
and Cosmetic Act has been
approved with respect to the
device, or the device has been
cleared for market under
section 510(k) of such Act, or
the device is exempt from the
requirements of section 510(k)
of such Act pursuant to
subsection (l) or (m) of
section 510 of such Act or
section 520(g) of such Act.
Nothing in this clause shall be
construed as requiring an application
or prior approval (other than that
described in subclause (II)) in order
for a covered device described by a
category to qualify for payment under
this paragraph.
(C) Limited period of payment.--
(i) Drugs and biologicals.--Subject
to subparagraph (G), the payment under
this paragraph with respect to a drug
or biological shall only apply during a
period of at least 2 years, but not
more than 3 years, that begins--
(I) on the first date this
subsection is implemented in
the case of a drug or
biological described in clause
(i), (ii), or (iii) of
subparagraph (A) and in the
case of a drug or biological
described in subparagraph
(A)(iv) and for which payment
under this part is made as an
outpatient hospital service
before such first date; or
(II) in the case of a drug or
biological described in
subparagraph (A)(iv) not
described in subclause (I), on
the first date on which payment
is made under this part for the
drug or biological as an
outpatient hospital service.
(ii) Medical devices.--Payment shall
be made under this paragraph with
respect to a medical device only if
such device--
(I) is described by a
category of medical devices
established and in effect under
subparagraph (B); and
(II) is provided as part of a
service (or group of services)
paid for under this subsection
and provided during the period
for which such category is in
effect under such subparagraph.
(D) Amount of additional payment.--Subject to
subparagraph (E)(iii), the amount of the
payment under this paragraph with respect to a
device, drug, or biological provided as part of
a covered OPD service is--
(i) subject to subparagraph (H), in
the case of a drug or biological, the
amount by which the amount determined
under section 1842(o) (or if the drug
or biological is covered under a
competitive acquisition contract under
section 1847B, an amount determined by
the Secretary equal to the average
price for the drug or biological for
all competitive acquisition areas and
year established under such section as
calculated and adjusted by the
Secretary for purposes of this
paragraph) for the drug or biological
exceeds the portion of the otherwise
applicable medicare OPD fee schedule
that the Secretary determines is
associated with the drug or biological;
or
(ii) in the case of a medical device,
the amount by which the hospital's
charges for the device, adjusted to
cost, exceeds the portion of the
otherwise applicable medicare OPD fee
schedule that the Secretary determines
is associated with the device.
(E) Limit on aggregate annual adjustment.--
(i) In general.--The total of the
additional payments made under this
paragraph for covered OPD services
furnished in a year (as estimated by
the Secretary before the beginning of
the year) may not exceed the applicable
percentage (specified in clause (ii))
of the total program payments estimated
to be made under this subsection for
all covered OPD services furnished in
that year. If this paragraph is first
applied to less than a full year, the
previous sentence shall apply only to
the portion of such year. This clause
shall not apply for 2018.
(ii) Applicable percentage.--For
purposes of clause (i), the term
``applicable percentage'' means--
(I) for a year (or portion of
a year) before 2004, 2.5
percent; and
(II) for 2004 and thereafter,
a percentage specified by the
Secretary up to (but not to
exceed) 2.0 percent.
(iii) Uniform prospective reduction
if aggregate limit projected to be
exceeded.--If the Secretary estimates
before the beginning of a year that the
amount of the additional payments under
this paragraph for the year (or portion
thereof) as determined under clause (i)
without regard to this clause will
exceed the limit established under such
clause, the Secretary shall reduce pro
rata the amount of each of the
additional payments under this
paragraph for that year (or portion
thereof) in order to ensure that the
aggregate additional payments under
this paragraph (as so estimated) do not
exceed such limit.
(F) Limitation of application of functional
equivalence standard.--
(i) In general.--The Secretary may
not publish regulations that apply a
functional equivalence standard to a
drug or biological under this
paragraph.
(ii) Application.--Clause (i) shall
apply to the application of a
functional equivalence standard to a
drug or biological on or after the date
of enactment of the Medicare
Prescription Drug, Improvement, and
Modernization Act of 2003 unless--
(I) such application was
being made to such drug or
biological prior to such date
of enactment; and
(II) the Secretary applies
such standard to such drug or
biological only for the purpose
of determining eligibility of
such drug or biological for
additional payments under this
paragraph and not for the
purpose of any other payments
under this title.
(iii) Rule of construction.--Nothing
in this subparagraph shall be construed
to effect the Secretary's authority to
deem a particular drug to be identical
to another drug if the 2 products are
pharmaceutically equivalent and
bioequivalent, as determined by the
Commissioner of Food and Drugs.
(G) Pass-through extension for certain drugs
and biologicals.--In the case of a drug or
biological whose period of pass-through status
under this paragraph ended on December 31,
2017, and for which payment under this
subsection was packaged into a payment for a
covered OPD service (or group of services)
furnished beginning January 1, 2018, such pass-
through status shall be extended for a 2-year
period beginning on October 1, 2018.
(H) Temporary payment rule for certain drugs
and biologicals.--In the case of a drug or
biological whose period of pass-through status
under this paragraph ended on December 31,
2017, and for which payment under this
subsection was packaged into a payment for a
covered OPD service (or group of services)
furnished beginning January 1, 2018, the
payment amount for such drug or biological
under this subsection that is furnished during
the period beginning on October 1, 2018, and
ending on March 31, 2019, shall be the greater
of--
(i) the payment amount that would
otherwise apply under subparagraph
(D)(i) for such drug or biological
during such period; or
(ii) the payment amount that applied
under such subparagraph (D)(i) for such
drug or biological on December 31,
2017.
(I) Special payment adjustment rules for last
quarter of 2018.--In the case of a drug or
biological whose period of pass-through status
under this paragraph ended on December 31,
2017, and for which payment under this
subsection was packaged into a payment amount
for a covered OPD service (or group of
services) beginning January 1, 2018, the
following rules shall apply with respect to
payment amounts under this subsection for
covered a OPD service (or group of services)
furnished during the period beginning on
October 1, 2018, and ending on December 31,
2018:
(i) The Secretary shall remove the
packaged costs of such drug or
biological (as determined by the
Secretary) from the payment amount
under this subsection for the covered
OPD service (or group of services) with
which it is packaged.
(ii) The Secretary shall not make any
adjustments to payment amounts under
this subsection for a covered OPD
service (or group of services) for
which no costs were removed under
clause (i).
(7) Transitional adjustment to limit decline in
payment.--
(A) Before 2002.--Subject to subparagraph
(D), for covered OPD services furnished before
January 1, 2002, for which the PPS amount (as
defined in subparagraph (E)) is--
(i) at least 90 percent, but less
than 100 percent, of the pre-BBA amount
(as defined in subparagraph (F)), the
amount of payment under this subsection
shall be increased by 80 percent of the
amount of such difference;
(ii) at least 80 percent, but less
than 90 percent, of the pre-BBA amount,
the amount of payment under this
subsection shall be increased by the
amount by which (I) the product of 0.71
and the pre-BBA amount, exceeds (II)
the product of 0.70 and the PPS amount;
(iii) at least 70 percent, but less
than 80 percent, of the pre-BBA amount,
the amount of payment under this
subsection shall be increased by the
amount by which (I) the product of 0.63
and the pre-BBA amount, exceeds (II)
the product of 0.60 and the PPS amount;
or
(iv) less than 70 percent of the pre-
BBA amount, the amount of payment under
this subsection shall be increased by
21 percent of the pre-BBA amount.
(B) 2002.--Subject to subparagraph (D), for
covered OPD services furnished during 2002, for
which the PPS amount is--
(i) at least 90 percent, but less
than 100 percent, of the pre-BBA
amount, the amount of payment under
this subsection shall be increased by
70 percent of the amount of such
difference;
(ii) at least 80 percent, but less
than 90 percent, of the pre-BBA amount,
the amount of payment under this
subsection shall be increased by the
amount by which (I) the product of 0.61
and the pre-BBA amount, exceeds (II)
the product of 0.60 and the PPS amount;
or
(iii) less than 80 percent of the
pre-BBA amount, the amount of payment
under this subsection shall be
increased by 13 percent of the pre-BBA
amount.
(C) 2003.--Subject to subparagraph (D), for
covered OPD services furnished during 2003, for
which the PPS amount is--
(i) at least 90 percent, but less
than 100 percent, of the pre-BBA
amount, the amount of payment under
this subsection shall be increased by
60 percent of the amount of such
difference; or
(ii) less than 90 percent of the pre-
BBA amount, the amount of payment under
this subsection shall be increased by 6
percent of the pre-BBA amount.
(D) Hold harmless provisions.--
(i) Temporary treatment for certain
rural hospitals.--(I) In the case of a
hospital located in a rural area and
that has not more than 100 beds or a
sole community hospital (as defined in
section 1886(d)(5)(D)(iii)) located in
a rural area, for covered OPD services
furnished before January 1, 2006, for
which the PPS amount is less than the
pre-BBA amount, the amount of payment
under this subsection shall be
increased by the amount of such
difference.
(II) In the case of a hospital
located in a rural area and that has
not more than 100 beds and that is not
a sole community hospital (as defined
in section 1886(d)(5)(D)(iii)), for
covered OPD services furnished on or
after January 1, 2006, and before
January 1, 2013, for which the PPS
amount is less than the pre-BBA amount,
the amount of payment under this
subsection shall be increased by the
applicable percentage of the amount of
such difference. For purposes of the
preceding sentence, the applicable
percentage shall be 95 percent with
respect to covered OPD services
furnished in 2006, 90 percent with
respect to such services furnished in
2007, and 85 percent with respect to
such services furnished in 2008, 2009,
2010, 2011, or 2012.
(III) In the case of a sole community
hospital (as defined in section
1886(d)(5)(D)(iii)) that has not more
than 100 beds, for covered OPD services
furnished on or after January 1, 2009,
and before January 1, 2013, for which
the PPS amount is less than the pre-BBA
amount, the amount of payment under
this subsection shall be increased by
85 percent of the amount of such
difference. In the case of covered OPD
services furnished on or after January
1, 2010, and before March 1, 2012, the
preceding sentence shall be applied
without regard to the 100-bed
limitation.
(ii) Permanent treatment for cancer
hospitals and children's hospitals.--In
the case of a hospital described in
clause (iii) or (v) of section
1886(d)(1)(B), for covered OPD services
for which the PPS amount is less than
the pre-BBA amount, the amount of
payment under this subsection shall be
increased by the amount of such
difference.
(E) PPS amount defined.--In this paragraph,
the term ``PPS amount'' means, with respect to
covered OPD services, the amount payable under
this title for such services (determined
without regard to this paragraph), including
amounts payable as copayment under paragraph
(8), coinsurance under section
1866(a)(2)(A)(ii), and the deductible under
section 1833(b).
(F) Pre-BBA amount defined.--
(i) In general.--In this paragraph,
the ``pre-BBA amount'' means, with
respect to covered OPD services
furnished by a hospital in a year, an
amount equal to the product of the
reasonable cost of the hospital for
such services for the portions of the
hospital's cost reporting period (or
periods) occurring in the year and the
base OPD payment-to-cost ratio for the
hospital (as defined in clause (ii)).
(ii) Base payment-to-cost-ratio
defined.--For purposes of this
subparagraph, the ``base payment-to-
cost ratio'' for a hospital means the
ratio of--
(I) the hospital's
reimbursement under this part
for covered OPD services
furnished during the cost
reporting period ending in 1996
(or in the case of a hospital
that did not submit a cost
report for such period, during
the first subsequent cost
reporting period ending before
2001 for which the hospital
submitted a cost report),
including any reimbursement for
such services through cost-
sharing described in
subparagraph (E), to
(II) the reasonable cost of
such services for such period.
The Secretary shall determine such
ratios as if the amendments made by
section 4521 of the Balanced Budget Act
of 1997 were in effect in 1996.
(G) Interim payments.--The Secretary shall
make payments under this paragraph to hospitals
on an interim basis, subject to retrospective
adjustments based on settled cost reports.
(H) No effect on copayments.--Nothing in this
paragraph shall be construed to affect the
unadjusted copayment amount described in
paragraph (3)(B) or the copayment amount under
paragraph (8).
(I) Application without regard to budget
neutrality.--The additional payments made under
this paragraph--
(i) shall not be considered an
adjustment under paragraph (2)(E); and
(ii) shall not be implemented in a
budget neutral manner.
(8) Copayment amount.--
(A) In general.--Except as provided in
subparagraphs (B) and (C), the copayment amount
under this subsection is the amount by which
the amount described in paragraph (4)(B)
exceeds the amount of payment determined under
paragraph (4)(C).
(B) Election to offer reduced copayment
amount.--The Secretary shall establish a
procedure under which a hospital, before the
beginning of a year (beginning with 1999), may
elect to reduce the copayment amount otherwise
established under subparagraph (A) for some or
all covered OPD services to an amount that is
not less than 20 percent of the medicare OPD
fee schedule amount (computed under paragraph
(3)(D)) for the service involved. Under such
procedures, such reduced copayment amount may
not be further reduced or increased during the
year involved and the hospital may disseminate
information on the reduction of copayment
amount effected under this subparagraph.
(C) Limitation on copayment amount.--
(i) To inpatient hospital deductible
amount.--In no case shall the copayment
amount for a procedure performed in a
year exceed the amount of the inpatient
hospital deductible established under
section 1813(b) for that year.
(ii) To specified percentage.--The
Secretary shall reduce the national
unadjusted copayment amount for a
covered OPD service (or group of such
services) furnished in a year in a
manner so that the effective copayment
rate (determined on a national
unadjusted basis) for that service in
the year does not exceed the following
percentage:
(I) For procedures performed
in 2001, on or after April 1,
2001, 57 percent.
(II) For procedures performed
in 2002 or 2003, 55 percent.
(III) For procedures
performed in 2004, 50 percent.
(IV) For procedures performed
in 2005, 45 percent.
(V) For procedures performed
in 2006 and thereafter, 40
percent.
(D) No impact on deductibles.--Nothing in
this paragraph shall be construed as affecting
a hospital's authority to waive the charging of
a deductible under section 1833(b).
(E) Computation ignoring outlier and pass-
through adjustments.--The copayment amount
shall be computed under subparagraph (A) as if
the adjustments under paragraphs (5) and (6)
(and any adjustment made under paragraph (2)(E)
in relation to such adjustments) had not
occurred.
(9) Periodic review and adjustments components of
prospective payment system.--
(A) Periodic review.--The Secretary shall
review not less often than annually and revise
the groups, the relative payment weights, and
the wage and other adjustments described in
paragraph (2) to take into account changes in
medical practice, changes in technology, the
addition of new services, new cost data, and
other relevant information and factors. The
Secretary shall consult with an expert outside
advisory panel composed of an appropriate
selection of representatives of providers to
review (and advise the Secretary concerning)
the clinical integrity of the groups and
weights. Such panel may use data collected or
developed by entities and organizations (other
than the Department of Health and Human
Services) in conducting such review.
(B) Budget neutrality adjustment.--If the
Secretary makes adjustments under subparagraph
(A), then the adjustments for a year may not
cause the estimated amount of expenditures
under this part for the year to increase or
decrease from the estimated amount of
expenditures under this part that would have
been made if the adjustments had not been made.
In determining adjustments under the preceding
sentence for 2004 and 2005, the Secretary shall
not take into account under this subparagraph
or paragraph (2)(E) any expenditures that would
not have been made but for the application of
paragraph (14).
(C) Update factor.--If the Secretary
determines under methodologies described in
paragraph (2)(F) that the volume of services
paid for under this subsection increased beyond
amounts established through those
methodologies, the Secretary may appropriately
adjust the update to the conversion factor
otherwise applicable in a subsequent year.
(10) Special rule for ambulance services.--The
Secretary shall pay for hospital outpatient services
that are ambulance services on the basis described in
section 1861(v)(1)(U), or, if applicable, the fee
schedule established under section 1834(l).
(11) Special rules for certain hospitals.--In the
case of hospitals described in clause (iii) or (v) of
section 1886(d)(1)(B)--
(A) the system under this subsection shall
not apply to covered OPD services furnished
before January 1, 2000; and
(B) the Secretary may establish a separate
conversion factor for such services in a manner
that specifically takes into account the unique
costs incurred by such hospitals by virtue of
their patient population and service intensity.
(12) Limitation on review.--There shall be no
administrative or judicial review under section 1869,
1878, or otherwise of--
(A) the development of the classification
system under paragraph (2), including the
establishment of groups and relative payment
weights for covered OPD services, of wage
adjustment factors, other adjustments, and
methods described in paragraph (2)(F);
(B) the calculation of base amounts under
paragraph (3);
(C) periodic adjustments made under paragraph
(6);
(D) the establishment of a separate
conversion factor under paragraph (8)(B); and
(E) the determination of the fixed multiple,
or a fixed dollar cutoff amount, the marginal
cost of care, or applicable percentage under
paragraph (5) or the determination of
insignificance of cost, the duration of the
additional payments, the determination and
deletion of initial and new categories
(consistent with subparagraphs (B) and (C) of
paragraph (6)), the portion of the medicare OPD
fee schedule amount associated with particular
devices, drugs, or biologicals, and the
application of any pro rata reduction under
paragraph (6).
(13) Authorization of adjustment for rural
hospitals.--
(A) Study.--The Secretary shall conduct a
study to determine if, under the system under
this subsection, costs incurred by hospitals
located in rural areas by ambulatory payment
classification groups (APCs) exceed those costs
incurred by hospitals located in urban areas.
(B) Authorization of adjustment.--Insofar as
the Secretary determines under subparagraph (A)
that costs incurred by hospitals located in
rural areas exceed those costs incurred by
hospitals located in urban areas, the Secretary
shall provide for an appropriate adjustment
under paragraph (2)(E) to reflect those higher
costs by January 1, 2006.
(14) Drug apc payment rates.--
(A) In general.--The amount of payment under
this subsection for a specified covered
outpatient drug (defined in subparagraph (B))
that is furnished as part of a covered OPD
service (or group of services)--
(i) in 2004, in the case of--
(I) a sole source drug shall
in no case be less than 88
percent, or exceed 95 percent,
of the reference average
wholesale price for the drug;
(II) an innovator multiple
source drug shall in no case
exceed 68 percent of the
reference average wholesale
price for the drug; or
(III) a noninnovator multiple
source drug shall in no case
exceed 46 percent of the
reference average wholesale
price for the drug;
(ii) in 2005, in the case of--
(I) a sole source drug shall
in no case be less than 83
percent, or exceed 95 percent,
of the reference average
wholesale price for the drug;
(II) an innovator multiple
source drug shall in no case
exceed 68 percent of the
reference average wholesale
price for the drug; or
(III) a noninnovator multiple
source drug shall in no case
exceed 46 percent of the
reference average wholesale
price for the drug; or
(iii) in a subsequent year, shall be
equal, subject to subparagraph (E)--
(I) to the average
acquisition cost for the drug
for that year (which, at the
option of the Secretary, may
vary by hospital group (as
defined by the Secretary based
on volume of covered OPD
services or other relevant
characteristics)), as
determined by the Secretary
taking into account the
hospital acquisition cost
survey data under subparagraph
(D); or
(II) if hospital acquisition
cost data are not available,
the average price for the drug
in the year established under
section 1842(o), section 1847A,
or section 1847B, as the case
may be, as calculated and
adjusted by the Secretary as
necessary for purposes of this
paragraph.
(B) Specified covered outpatient drug
defined.--
(i) In general.--In this paragraph,
the term ``specified covered outpatient
drug'' means, subject to clause (ii), a
covered outpatient drug (as defined in
section 1927(k)(2)) for which a
separate ambulatory payment
classification group (APC) has been
established and that is--
(I) a radiopharmaceutical; or
(II) a drug or biological for
which payment was made under
paragraph (6) (relating to
pass-through payments) on or
before December 31, 2002.
(ii) Exception.--Such term does not
include--
(I) a drug or biological for
which payment is first made on
or after January 1, 2003, under
paragraph (6);
(II) a drug or biological for
which a temporary HCPCS code
has not been assigned; or
(III) during 2004 and 2005,
an orphan drug (as designated
by the Secretary).
(C) Payment for designated orphan drugs
during 2004 and 2005.--The amount of payment
under this subsection for an orphan drug
designated by the Secretary under subparagraph
(B)(ii)(III) that is furnished as part of a
covered OPD service (or group of services)
during 2004 and 2005 shall equal such amount as
the Secretary may specify.
(D) Acquisition cost survey for hospital
outpatient drugs.--
(i) Annual gao surveys in 2004 and
2005.--
(I) In general.--The
Comptroller General of the
United States shall conduct a
survey in each of 2004 and 2005
to determine the hospital
acquisition cost for each
specified covered outpatient
drug. Not later than April 1,
2005, the Comptroller General
shall furnish data from such
surveys to the Secretary for
use in setting the payment
rates under subparagraph (A)
for 2006.
(II) Recommendations.--Upon
the completion of such surveys,
the Comptroller General shall
recommend to the Secretary the
frequency and methodology of
subsequent surveys to be
conducted by the Secretary
under clause (ii).
(ii) Subsequent secretarial
surveys.--The Secretary, taking into
account such recommendations, shall
conduct periodic subsequent surveys to
determine the hospital acquisition cost
for each specified covered outpatient
drug for use in setting the payment
rates under subparagraph (A).
(iii) Survey requirements.--The
surveys conducted under clauses (i) and
(ii) shall have a large sample of
hospitals that is sufficient to
generate a statistically significant
estimate of the average hospital
acquisition cost for each specified
covered outpatient drug. With respect
to the surveys conducted under clause
(i), the Comptroller General shall
report to Congress on the justification
for the size of the sample used in
order to assure the validity of such
estimates.
(iv) Differentiation in cost.--In
conducting surveys under clause (i),
the Comptroller General shall determine
and report to Congress if there is (and
the extent of any) variation in
hospital acquisition costs for drugs
among hospitals based on the volume of
covered OPD services performed by such
hospitals or other relevant
characteristics of such hospitals (as
defined by the Comptroller General).
(v) Comment on proposed rates.--Not
later than 30 days after the date the
Secretary promulgated proposed rules
setting forth the payment rates under
subparagraph (A) for 2006, the
Comptroller General shall evaluate such
proposed rates and submit to Congress a
report regarding the appropriateness of
such rates based on the surveys the
Comptroller General has conducted under
clause (i).
(E) Adjustment in payment rates for overhead
costs.--
(i) Medpac report on drug apc
design.--The Medicare Payment Advisory
Commission shall submit to the
Secretary, not later than July 1, 2005,
a report on adjustment of payment for
ambulatory payment classifications for
specified covered outpatient drugs to
take into account overhead and related
expenses, such as pharmacy services and
handling costs. Such report shall
include--
(I) a description and
analysis of the data available
with regard to such expenses;
(II) a recommendation as to
whether such a payment
adjustment should be made; and
(III) if such adjustment
should be made, a
recommendation regarding the
methodology for making such an
adjustment.
(ii) Adjustment authorized.--The
Secretary may adjust the weights for
ambulatory payment classifications for
specified covered outpatient drugs to
take into account the recommendations
contained in the report submitted under
clause (i).
(F) Classes of drugs.--For purposes of this
paragraph:
(i) Sole source drugs.--The term
``sole source drug'' means--
(I) a biological product (as
defined under section
1861(t)(1)); or
(II) a single source drug (as
defined in section
1927(k)(7)(A)(iv)).
(ii) Innovator multiple source
drugs.--The term ``innovator multiple
source drug'' has the meaning given
such term in section 1927(k)(7)(A)(ii).
(iii) Noninnovator multiple source
drugs.--The term ``noninnovator
multiple source drug'' has the meaning
given such term in section
1927(k)(7)(A)(iii).
(G) Reference average wholesale price.--The
term ``reference average wholesale price''
means, with respect to a specified covered
outpatient drug, the average wholesale price
for the drug as determined under section
1842(o) as of May 1, 2003.
(H) Inapplicability of expenditures in
determining conversion, weighting, and other
adjustment factors.--Additional expenditures
resulting from this paragraph shall not be
taken into account in establishing the
conversion, weighting, and other adjustment
factors for 2004 and 2005 under paragraph (9),
but shall be taken into account for subsequent
years.
(15) Payment for new drugs and biologicals until
hcpcs code assigned.--With respect to payment under
this part for an outpatient drug or biological that is
covered under this part and is furnished as part of
covered OPD services for which a HCPCS code has not
been assigned, the amount provided for payment for such
drug or biological under this part shall be equal to 95
percent of the average wholesale price for the drug or
biological.
(16) Miscellaneous provisions.--
(A) Application of reclassification of
certain hospitals.--If a hospital is being
treated as being located in a rural area under
section 1886(d)(8)(E), that hospital shall be
treated under this subsection as being located
in that rural area.
(B) Threshold for establishment of separate
apcs for drugs.--The Secretary shall reduce the
threshold for the establishment of separate
ambulatory payment classification groups (APCs)
with respect to drugs or biologicals to $50 per
administration for drugs and biologicals
furnished in 2005 and 2006.
(C) Payment for devices of brachytherapy and
therapeutic radiopharmaceuticals at charges
adjusted to cost.--Notwithstanding the
preceding provisions of this subsection, for a
device of brachytherapy consisting of a seed or
seeds (or radioactive source) furnished on or
after January 1, 2004, and before January 1,
2010, and for therapeutic radiopharmaceuticals
furnished on or after January 1, 2008, and
before January 1, 2010, the payment basis for
the device or therapeutic radiopharmaceutical
under this subsection shall be equal to the
hospital's charges for each device or
therapeutic radiopharmaceutical furnished,
adjusted to cost. Charges for such devices or
therapeutic radiopharmaceuticals shall not be
included in determining any outlier payment
under this subsection.
(D) Special payment rule.--
(i) In general.--In the case of
covered OPD services furnished on or
after April 1, 2013, in a hospital
described in clause (ii), if--
(I) the payment rate that
would otherwise apply under
this subsection for
stereotactic radiosurgery,
complete course of treatment of
cranial lesion(s) consisting of
1 session that is multi-source
Cobalt 60 based (identified as
of January 1, 2013, by HCPCS
code 77371 (and any succeeding
code) and reimbursed as of such
date under APC 0127 (and any
succeeding classification
group)); exceeds
(II) the payment rate that
would otherwise apply under
this subsection for linear
accelerator based stereotactic
radiosurgery, complete course
of therapy in one session
(identified as of January 1,
2013, by HCPCS code G0173 (and
any succeeding code) and
reimbursed as of such date
under APC 0067 (and any
succeeding classification
group)),
the payment rate for the service
described in subclause (I) shall be
reduced to an amount equal to the
payment rate for the service described
in subclause (II).
(ii) Hospital described.--A hospital
described in this clause is a hospital
that is not--
(I) located in a rural area
(as defined in section
1886(d)(2)(D));
(II) classified as a rural
referral center under section
1886(d)(5)(C); or
(III) a sole community
hospital (as defined in section
1886(d)(5)(D)(iii)).
(iii) Not budget neutral.--In making
any budget neutrality adjustments under
this subsection for 2013 (with respect
to covered OPD services furnished on or
after April 1, 2013, and before January
1, 2014) or a subsequent year, the
Secretary shall not take into account
the reduced expenditures that result
from the application of this
subparagraph.
(E) Application of appropriate use criteria
for certain imaging services.--For provisions
relating to the application of appropriate use
criteria for certain imaging services, see
section 1834(q).
(F) Payment incentive for the transition from
traditional x-ray imaging to digital
radiography.--Notwithstanding the previous
provisions of this subsection:
(i) Limitation on payment for film x-
ray imaging services.--In the case of
an imaging service that is an X-ray
taken using film and that is furnished
during 2017 or a subsequent year, the
payment amount for such service
(including the X-ray component of a
packaged service) that would otherwise
be determined under this section
(without application of this paragraph
and before application of any other
adjustment under this subsection) for
such year shall be reduced by 20
percent.
(ii) Phased-in limitation on payment
for computed radiography imaging
services.--In the case of an imaging
service that is an X-ray taken using
computed radiography technology (as
defined in section 1848(b)(9)(C))--
(I) in the case of such a
service furnished during 2018,
2019, 2020, 2021, or 2022, the
payment amount for such service
(including the X-ray component
of a packaged service) that
would otherwise be determined
under this section (without
application of this paragraph
and before application of any
other adjustment under this
subsection) for such year shall
be reduced by 7 percent; and
(II) in the case of such a
service furnished during 2023
or a subsequent year, the
payment amount for such service
(including the X-ray component
of a packaged service) that
would otherwise be determined
under this section (without
application of this paragraph
and before application of any
other adjustment under this
subsection) for such year shall
be reduced by 10 percent.
(iii) Application without regard to
budget neutrality.--The reductions made
under this subparagraph--
(I) shall not be considered
an adjustment under paragraph
(2)(E); and
(II) shall not be implemented
in a budget neutral manner.
(iv) Implementation.--In order to
implement this subparagraph, the
Secretary shall adopt appropriate
mechanisms which may include use of
modifiers.
(17) Quality reporting.--
(A) Reduction in update for failure to
report.--
(i) In general.--For purposes of
paragraph (3)(C)(iv) for 2009 and each
subsequent year, in the case of a
subsection (d) hospital (as defined in
section 1886(d)(1)(B)) that does not
submit, to the Secretary in accordance
with this paragraph, data required to
be submitted on measures selected under
this paragraph with respect to such a
year, the OPD fee schedule increase
factor under paragraph (3)(C)(iv) for
such year shall be reduced by 2.0
percentage points.
(ii) Non-cumulative application.--A
reduction under this subparagraph shall
apply only with respect to the year
involved and the Secretary shall not
take into account such reduction in
computing the OPD fee schedule increase
factor for a subsequent year.
(B) Form and manner of submission.--Each
subsection (d) hospital shall submit data on
measures selected under this paragraph to the
Secretary in a form and manner, and at a time,
specified by the Secretary for purposes of this
paragraph.
(C) Development of outpatient measures.--
(i) In general.--The Secretary shall
develop measures that the Secretary
determines to be appropriate for the
measurement of the quality of care
(including medication errors) furnished
by hospitals in outpatient settings and
that reflect consensus among affected
parties and, to the extent feasible and
practicable, shall include measures set
forth by one or more national consensus
building entities.
(ii) Construction.--Nothing in this
paragraph shall be construed as
preventing the Secretary from selecting
measures that are the same as (or a
subset of) the measures for which data
are required to be submitted under
section 1886(b)(3)(B)(viii).
(D) Replacement of measures.--For purposes of
this paragraph, the Secretary may replace any
measures or indicators in appropriate cases,
such as where all hospitals are effectively in
compliance or the measures or indicators have
been subsequently shown not to represent the
best clinical practice.
(E) Availability of data.--The Secretary
shall establish procedures for making data
submitted under this paragraph available to the
public. Such procedures shall ensure that a
hospital has the opportunity to review the data
that are to be made public with respect to the
hospital prior to such data being made public.
The Secretary shall report quality measures of
process, structure, outcome, patients'
perspectives on care, efficiency, and costs of
care that relate to services furnished in
outpatient settings in hospitals on the
Internet website of the Centers for Medicare &
Medicaid Services.
(18) Authorization of adjustment for cancer
hospitals.--
(A) Study.--The Secretary shall conduct a
study to determine if, under the system under
this subsection, costs incurred by hospitals
described in section 1886(d)(1)(B)(v) with
respect to ambulatory payment classification
groups exceed those costs incurred by other
hospitals furnishing services under this
subsection (as determined appropriate by the
Secretary). In conducting the study under this
subparagraph, the Secretary shall take into
consideration the cost of drugs and biologicals
incurred by such hospitals.
(B) Authorization of adjustment.--Insofar as
the Secretary determines under subparagraph (A)
that costs incurred by hospitals described in
section 1886(d)(1)(B)(v) exceed those costs
incurred by other hospitals furnishing services
under this subsection, the Secretary shall,
subject to subparagraph (C), provide for an
appropriate adjustment under paragraph (2)(E)
to reflect those higher costs effective for
services furnished on or after January 1, 2011.
(C) Target pcr adjustment.--In applying
section 419.43(i) of title 42 of the Code of
Federal Regulations to implement the
appropriate adjustment under this paragraph for
services furnished on or after January 1, 2018,
the Secretary shall use a target PCR that is
1.0 percentage points less than the target PCR
that would otherwise apply. In addition to the
percentage point reduction under the previous
sentence, the Secretary may consider making an
additional percentage point reduction to such
target PCR that takes into account payment
rates for applicable items and services
described in paragraph (21)(C) other than for
services furnished by hospitals described in
section 1886(d)(1)(B)(v). In making any budget
neutrality adjustments under this subsection
for 2018 or a subsequent year, the Secretary
shall not take into account the reduced
expenditures that result from the application
of this subparagraph.
(19) Floor on area wage adjustment factor for
hospital outpatient department services in frontier
states.--
(A) In general.--Subject to subparagraph (B),
with respect to covered OPD services furnished
on or after January 1, 2011, the area wage
adjustment factor applicable under the payment
system established under this subsection to any
hospital outpatient department which is located
in a frontier State (as defined in section
1886(d)(3)(E)(iii)(II)) may not be less than
1.00. The preceding sentence shall not be
applied in a budget neutral manner.
(B) Limitation.--This paragraph shall not
apply to any hospital outpatient department
located in a State that receives a non-labor
related share adjustment under section
1886(d)(5)(H).
(20) Not budget neutral application of reduced
expenditures resulting from quality incentives for
computed tomography.--The Secretary shall not take into
account the reduced expenditures that result from the
application of section 1834(p) in making any budget
neutrality adjustments this subsection.
(21) Services furnished by an off-campus outpatient
department of a provider.--
(A) Applicable items and services.--For
purposes of paragraph (1)(B)(v) and this
paragraph, the term ``applicable items and
services'' means items and services other than
items and services furnished by a dedicated
emergency department (as defined in section
489.24(b) of title 42 of the Code of Federal
Regulations).
(B) Off-campus outpatient department of a
provider.--
(i) In general.--For purposes of
paragraph (1)(B)(v) and this paragraph,
subject to the subsequent provisions of
this subparagraph, the term ``off-
campus outpatient department of a
provider'' means a department of a
provider (as defined in section
413.65(a)(2) of title 42 of the Code of
Federal Regulations, as in effect as of
the date of the enactment of this
paragraph) that is not located--
(I) on the campus (as defined
in such section 413.65(a)(2))
of such provider; or
(II) within the distance
(described in such definition
of campus) from a remote
location of a hospital facility
(as defined in such section
413.65(a)(2)).
(ii) Exception.--For purposes of
paragraph (1)(B)(v) and this paragraph,
the term ``off-campus outpatient
department of a provider'' shall not
include a department of a provider (as
so defined) that was billing under this
subsection with respect to covered OPD
services furnished prior to the date of
the enactment of this paragraph.
(iii) Deemed treatment for 2017.--For
purposes of applying clause (ii) with
respect to applicable items and
services furnished during 2017, a
department of a provider (as so
defined) not described in such clause
is deemed to be billing under this
subsection with respect to covered OPD
services furnished prior to November 2,
2015, if the Secretary received from
the provider prior to December 2, 2015,
an attestation (pursuant to section
413.65(b)(3) of title 42 of the Code of
Federal Regulations) that such
department was a department of a
provider (as so defined).
(iv) Alternative exception beginning
with 2018.--For purposes of paragraph
(1)(B)(v) and this paragraph with
respect to applicable items and
services furnished during 2018 or a
subsequent year, the term ``off-campus
outpatient department of a provider''
also shall not include a department of
a provider (as so defined) that is not
described in clause (ii) if--
(I) the Secretary receives
from the provider an
attestation (pursuant to such
section 413.65(b)(3)) not later
than December 31, 2016 (or, if
later, 60 days after the date
of the enactment of this
clause), that such department
met the requirements of a
department of a provider
specified in section 413.65 of
title 42 of the Code of Federal
Regulations;
(II) the provider includes
such department as part of the
provider on its enrollment form
in accordance with the
enrollment process under
section 1866(j); and
(III) the department met the
mid-build requirement of clause
(v) and the Secretary receives,
not later than 60 days after
the date of the enactment of
this clause, from the chief
executive officer or chief
operating officer of the
provider a written
certification that the
department met such
requirement.
(v) Mid-build requirement
described.--The mid-build requirement
of this clause is, with respect to a
department of a provider, that before
November 2, 2015, the provider had a
binding written agreement with an
outside unrelated party for the actual
construction of such department.
(vi) Exclusion for certain cancer
hospitals.--For purposes of paragraph
(1)(B)(v) and this paragraph with
respect to applicable items and
services furnished during 2017 or a
subsequent year, the term ``off-campus
outpatient department of a provider''
also shall not include a department of
a provider (as so defined) that is not
described in clause (ii) if the
provider is a hospital described in
section 1886(d)(1)(B)(v) and--
(I) in the case of a
department that met the
requirements of section 413.65
of title 42 of the Code of
Federal Regulations after
November 1, 2015, and before
the date of the enactment of
this clause, the Secretary
receives from the provider an
attestation that such
department met such
requirements not later than 60
days after such date of
enactment; or
(II) in the case of a
department that meets such
requirements after such date of
enactment, the Secretary
receives from the provider an
attestation that such
department meets such
requirements not later than 60
days after the date such
requirements are first met with
respect to such department.
(vii) Audit.--Not later than December
31, 2018, the Secretary shall audit the
compliance with requirements of clause
(iv) with respect to each department of
a provider to which such clause
applies. Not later than 2 years after
the date the Secretary receives an
attestation under clause (vi) relating
to compliance of a department of a
provider with requirements referred to
in such clause, the Secretary shall
audit the compliance with such
requirements with respect to the
department. If the Secretary finds as a
result of an audit under this clause
that the applicable requirements were
not met with respect to such
department, the department shall not be
excluded from the term ``off-campus
outpatient department of a provider''
under such clause.
(viii) Implementation.--For purposes
of implementing clauses (iii) through
(vii):
(I) Notwithstanding any other
provision of law, the Secretary
may implement such clauses by
program instruction or
otherwise.
(II) Subchapter I of chapter
35 of title 44, United States
Code, shall not apply.
(III) For purposes of
carrying out this subparagraph
with respect to clauses (iii)
and (iv) (and clause (vii)
insofar as it relates to clause
(iv)), $10,000,000 shall be
available from the Federal
Supplementary Medical Insurance
Trust Fund under section 1841,
to remain available until
December 31, 2018. For purposes
of carrying out this
subparagraph with respect to
clause (vi) (and clause (vii)
insofar as it relates to such
clause), $2,000,000 shall be
available from the Federal
Supplementary Medical Insurance
Trust Fund under section 1841,
to remain available until
expended.
(C) Availability of payment under other
payment systems.--Payments for applicable items
and services furnished by an off-campus
outpatient department of a provider that are
described in paragraph (1)(B)(v) shall be made
under the applicable payment system under this
part (other than under this subsection) if the
requirements for such payment are otherwise
met.
(D) Information needed for implementation.--
Each hospital shall provide to the Secretary
such information as the Secretary determines
appropriate to implement this paragraph and
paragraph (1)(B)(v) (which may include
reporting of information on a hospital claim
using a code or modifier and reporting
information about off-campus outpatient
departments of a provider on the enrollment
form described in section 1866(j)).
(E) Limitations.--There shall be no
administrative or judicial review under section
1869, section 1878, or otherwise of the
following:
(i) The determination of the
applicable items and services under
subparagraph (A) and applicable payment
systems under subparagraph (C).
(ii) The determination of whether a
department of a provider meets the term
described in subparagraph (B).
(iii) Any information that hospitals
are required to report pursuant to
subparagraph (D).
(iv) The determination of an audit
under subparagraph (B)(vii).
(22) Review and revisions of payments for non-opioid
alternative treatments.--
(A) In general.--With respect to payments
made under this subsection for covered OPD
services (or groups of services), including
covered OPD services assigned to a
comprehensive ambulatory payment
classification, the Secretary--
(i) shall, as soon as practicable,
conduct a review (part of which may
include a request for information) of
payments for opioids and evidence-based
non-opioid alternatives for pain
management (including drugs and
devices, nerve blocks, surgical
injections, and neuromodulation) with a
goal of ensuring that there are not
financial incentives to use opioids
instead of non-opioid alternatives;
(ii) may, as the Secretary determines
appropriate, conduct subsequent reviews
of such payments; and
(iii) shall consider the extent to
which revisions under this subsection
to such payments (such as the creation
of additional groups of covered OPD
services to classify separately those
procedures that utilize opioids and
non-opioid alternatives for pain
management) would reduce payment
incentives to use opioids instead of
non-opioid alternatives for pain
management.
(B) Priority.--In conducting the review under
clause (i) of subparagraph (A) and considering
revisions under clause (iii) of such
subparagraph, the Secretary shall focus on
covered OPD services (or groups of services)
assigned to a comprehensive ambulatory payment
classification, ambulatory payment
classifications that primarily include surgical
services, and other services determined by the
Secretary which generally involve treatment for
pain management.
(C) Revisions.--If the Secretary identifies
revisions to payments pursuant to subparagraph
(A)(iii), the Secretary shall, as determined
appropriate, begin making such revisions for
services furnished on or after January 1, 2020.
Revisions under the previous sentence shall be
treated as adjustments for purposes of
application of paragraph (9)(B).
(D) Rules of construction.--Nothing in this
paragraph shall be construed to preclude the
Secretary--
(i) from conducting a demonstration
before making the revisions described
in subparagraph (C); or
(ii) prior to implementation of this
paragraph, from changing payments under
this subsection for covered OPD
services (or groups of services) which
include opioids or non-opioid
alternatives for pain management.
(u) Incentive Payments for Physician Scarcity Areas.--
(1) In general.--In the case of physicians' services
furnished on or after January 1, 2005, and before July
1, 2008--
(A) by a primary care physician in a primary
care scarcity county (identified under
paragraph (4)); or
(B) by a physician who is not a primary care
physician in a specialist care scarcity county
(as so identified),
in addition to the amount of payment that would
otherwise be made for such services under this part,
there also shall be paid an amount equal to 5 percent
of the payment amount for the service under this part.
(2) Determination of ratios of physicians to medicare
beneficiaries in area.--Based upon available data, the
Secretary shall establish for each county or equivalent
area in the United States, the following:
(A) Number of physicians practicing in the
area.--The number of physicians who furnish
physicians' services in the active practice of
medicine or osteopathy in that county or area,
other than physicians whose practice is
exclusively for the Federal Government,
physicians who are retired, or physicians who
only provide administrative services. Of such
number, the number of such physicians who are--
(i) primary care physicians; or
(ii) physicians who are not primary
care physicians.
(B) Number of medicare beneficiaries residing
in the area.--The number of individuals who are
residing in the county and are entitled to
benefits under part A or enrolled under this
part, or both (in this subsection referred to
as ``individuals'').
(C) Determination of ratios.--
(i) Primary care ratio.--The ratio
(in this paragraph referred to as the
``primary care ratio'') of the number
of primary care physicians (determined
under subparagraph (A)(i)), to the
number of individuals determined under
subparagraph (B).
(ii) Specialist care ratio.--The
ratio (in this paragraph referred to as
the ``specialist care ratio'') of the
number of other physicians (determined
under subparagraph (A)(ii)), to the
number of individuals determined under
subparagraph (B).
(3) Ranking of counties.--The Secretary shall rank
each such county or area based separately on its
primary care ratio and its specialist care ratio.
(4) Identification of counties.--
(A) In general.--The Secretary shall
identify--
(i) those counties and areas (in this
paragraph referred to as ``primary care
scarcity counties'') with the lowest
primary care ratios that represent, if
each such county or area were weighted
by the number of individuals determined
under paragraph (2)(B), an aggregate
total of 20 percent of the total of the
individuals determined under such
paragraph; and
(ii) those counties and areas (in
this subsection referred to as
``specialist care scarcity counties'')
with the lowest specialist care ratios
that represent, if each such county or
area were weighted by the number of
individuals determined under paragraph
(2)(B), an aggregate total of 20
percent of the total of the individuals
determined under such paragraph.
(B) Periodic revisions.--The Secretary shall
periodically revise the counties or areas
identified in subparagraph (A) (but not less
often than once every three years) unless the
Secretary determines that there is no new data
available on the number of physicians
practicing in the county or area or the number
of individuals residing in the county or area,
as identified in paragraph (2).
(C) Identification of counties where service
is furnished.--For purposes of paying the
additional amount specified in paragraph (1),
if the Secretary uses the 5-digit postal ZIP
Code where the service is furnished, the
dominant county of the postal ZIP Code (as
determined by the United States Postal Service,
or otherwise) shall be used to determine
whether the postal ZIP Code is in a scarcity
county identified in subparagraph (A) or
revised in subparagraph (B).
(D) Special rule.--With respect to
physicians' services furnished on or after
January 1, 2008, and before July 1, 2008, for
purposes of this subsection, the Secretary
shall use the primary care scarcity counties
and the specialty care scarcity counties (as
identified under the preceding provisions of
this paragraph) that the Secretary was using
under this subsection with respect to
physicians' services furnished on December 31,
2007.
(E) Judicial review.--There shall be no
administrative or judicial review under section
1869, 1878, or otherwise, respecting--
116.(i) the identification of a
county or area;
(ii) the assignment of a specialty of
any physician under this paragraph;
(iii) the assignment of a physician
to a county under paragraph (2); or
(iv) the assignment of a postal ZIP
Code to a county or other area under
this subsection.
(5) Rural census tracts.--To the extent feasible, the
Secretary shall treat a rural census tract of a
metropolitan statistical area (as determined under the
most recent modification of the Goldsmith Modification,
originally published in the Federal Register on
February 27, 1992 (57 Fed. Reg. 6725)), as an
equivalent area for purposes of qualifying as a primary
care scarcity county or specialist care scarcity county
under this subsection.
(6) Physician Defined.--For purposes of this
paragraph, the term ``physician'' means a physician
described in section 1861(r)(1) and the term ``primary
care physician'' means a physician who is identified in
the available data as a general practitioner, family
practice practitioner, general internist, or
obstetrician or gynecologist.
(7) Publication of list of counties; posting on
website.--With respect to a year for which a county or
area is identified or revised under paragraph (4), the
Secretary shall identify such counties or areas as part
of the proposed and final rule to implement the
physician fee schedule under section 1848 for the
applicable year. The Secretary shall post the list of
counties identified or revised under paragraph (4) on
the Internet website of the Centers for Medicare &
Medicaid Services.
(v) Increase of FQHC Payment Limits.--In the case of services
furnished by Federally qualified health centers (as defined in
section 1861(aa)(4)), the Secretary shall establish payment
limits with respect to such services under this part for
services furnished--
(1) in 2010, at the limits otherwise established
under this part for such year increased by $5; and
(2) in a subsequent year, at the limits established
under this subsection for the previous year increased
by the percentage increase in the MEI (as defined in
section 1842(i)(3)) for such subsequent year.
(w) Methods of Payment.--The Secretary may develop
alternative methods of payment for items and services provided
under clinical trials and comparative effectiveness studies
sponsored or supported by an agency of the Department of Health
and Human Services, as determined by the Secretary, to those
that would otherwise apply under this section, to the extent
such alternative methods are necessary to preserve the
scientific validity of such trials or studies, such as in the
case where masking the identity of interventions from patients
and investigators is necessary to comply with the particular
trial or study design.
(x) Incentive Payments for Primary Care Services.--
(1) In general.--In the case of primary care services
furnished on or after January 1, 2011, and before
January 1, 2016, by a primary care practitioner, in
addition to the amount of payment that would otherwise
be made for such services under this part, there also
shall be paid (on a monthly or quarterly basis) an
amount equal to 10 percent of the payment amount for
the service under this part.
(2) Definitions.--In this subsection:
(A) Primary care practitioner.--The term
``primary care practitioner'' means an
individual--
(i) who--
(I) is a physician (as
described in section
1861(r)(1)) who has a primary
specialty designation of family
medicine, internal medicine,
geriatric medicine, or
pediatric medicine; or
(II) is a nurse practitioner,
clinical nurse specialist, or
physician assistant (as those
terms are defined in section
1861(aa)(5)); and
(ii) for whom primary care services
accounted for at least 60 percent of
the allowed charges under this part for
such physician or practitioner in a
prior period as determined appropriate
by the Secretary.
(B) Primary care services.--The term
``primary care services'' means services
identified, as of January 1, 2009, by the
following HCPCS codes (and as subsequently
modified by the Secretary):
(i) 99201 through 99215.
(ii) 99304 through 99340.
(iii) 99341 through 99350.
(3) Coordination with other payments.--The amount of
the additional payment for a service under this
subsection and subsection (m) shall be determined
without regard to any additional payment for the
service under subsection (m) and this subsection,
respectively. 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) Limitation on review.--There shall be no
administrative or judicial review under section 1869,
1878, or otherwise, respecting the identification of
primary care practitioners under this subsection.
(y) Incentive Payments for Major Surgical Procedures
Furnished in Health Professional Shortage Areas.--
(1) In general.--In the case of major surgical
procedures furnished on or after January 1, 2011, and
before January 1, 2016, by a general surgeon in an area
that is designated (under section 332(a)(1)(A) of the
Public Health Service Act) as a health professional
shortage area as identified by the Secretary prior to
the beginning of the year involved, in addition to the
amount of payment that would otherwise be made for such
services under this part, there also shall be paid (on
a monthly or quarterly basis) an amount equal to 10
percent of the payment amount for the service under
this part.
(2) Definitions.--In this subsection:
(A) General surgeon.--In this subsection, the
term ``general surgeon'' means a physician (as
described in section 1861(r)(1)) who has
designated CMS specialty code 02-General
Surgery as their primary specialty code in the
physician's enrollment under section 1866(j).
(B) Major surgical procedures.--The term
``major surgical procedures'' means physicians'
services which are surgical procedures for
which a 10-day or 90-day global period is used
for payment under the fee schedule under
section 1848(b).
(3) Coordination with other payments.--The amount of
the additional payment for a service under this
subsection and subsection (m) shall be determined
without regard to any additional payment for the
service under subsection (m) and this subsection,
respectively. 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) Application.--The provisions of paragraph (2) and
(4) of subsection (m) shall apply to the determination
of additional payments under this subsection in the
same manner as such provisions apply to the
determination of additional payments under subsection
(m).
(z) Incentive Payments for Participation in Eligible
Alternative Payment Models.--
(1) Payment incentive.--
(A) In general.--In the case of covered
professional services furnished by an eligible
professional during a year that is in the
period beginning with 2019 and ending with 2024
and for which the professional is a qualifying
APM participant with respect to such year, 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 estimated
aggregate payment amounts for such 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 in which
payment for covered professional services
furnished by a qualifying APM participant in an
alternative payment model--
(i) is made to an eligible
alternative payment entity rather than
directly to the qualifying APM
participant; or
(ii) is made on a basis other than a
fee-for-service basis (such as payment
on a capitated basis).
(B) Form of payment.--Payments under this
subsection shall be made in a lump sum, on an
annual basis, as soon as practicable.
(C) Treatment of payment incentive.--Payments
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) Coordination.--The amount of the
additional payment under this subsection or
subsection (m) shall be determined without
regard to any additional payment under
subsection (m) and this subsection,
respectively. The amount of the additional
payment under this subsection or subsection (x)
shall be determined without regard to any
additional payment under subsection (x) and
this subsection, respectively. The amount of
the additional payment under this subsection or
subsection (y) shall be determined without
regard to any additional payment under
subsection (y) and this subsection,
respectively.
(2) Qualifying apm participant.--For purposes of this
subsection, the term ``qualifying APM participant''
means the following:
(A) 2019 and 2020.--With respect to 2019 and
2020, 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 eligible
alternative payment entity.
(B) 2021 and 2022.--With respect to 2021 and
2022, an eligible professional described in
either of the following clauses:
(i) Medicare payment threshold
option.--An 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 eligible alternative payment
entity.
(ii) Combination all-payer and
medicare payment threshold option.--An
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 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 eligible
alternative payment entity; 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) Requirement.--For 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 to an
eligible alternative payment
entity; 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 arrangements 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
participates in an
entity that--
(AA) bears
more than
nominal
financial risk
if actual
aggregate
expenditures
exceeds
expected
aggregate
expenditures;
or
(BB) with
respect to
beneficiaries
under title
XIX, is a
medical home
that meets
criteria
comparable to
medical homes
expanded under
section
1115A(c).
(C) Beginning in 2023.--With respect to 2023
and each subsequent year, an eligible
professional described in either of the
following clauses:
(i) Medicare payment threshold
option.--An 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 eligible alternative payment
entity.
(ii) Combination all-payer and
medicare payment threshold option.--An
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 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 eligible
alternative payment entity; 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) Requirement.--For 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 to an
eligible alternative payment
entity; 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 arrangements 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
participates in an
entity that--
(AA) bears
more than
nominal
financial risk
if actual
aggregate
expenditures
exceeds
expected
aggregate
expenditures;
or
(BB) with
respect to
beneficiaries
under title
XIX, is a
medical home
that meets
criteria
comparable to
medical homes
expanded under
section
1115A(c).
(D) Use of patient approach.--The Secretary
may base the determination of whether an
eligible professional is a qualifying APM
participant under this subsection and the
determination of whether an eligible
professional is a partial qualifying APM
participant under section 1848(q)(1)(C)(iii) by
using counts of patients in lieu of using
payments and using the same or similar
percentage criteria (as specified in this
subsection and such section, respectively), as
the Secretary determines appropriate.
(3) Additional definitions.--In this subsection:
(A) Covered professional services.--The term
``covered professional services'' has the
meaning given that term in section
1848(k)(3)(A).
(B) Eligible professional.--The term
``eligible professional'' has the meaning given
that term in section 1848(k)(3)(B) and includes
a group that includes such professionals.
(C) Alternative payment model (apm).--The
term ``alternative payment model'' means, other
than for purposes of subparagraphs
(B)(ii)(I)(bb) and (C)(ii)(I)(bb) of paragraph
(2), 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 entity.--The
term ``eligible alternative payment entity''
means, with respect to a year, an entity that--
(i) participates in an alternative
payment model that--
(I) requires participants in
such model to use certified EHR
technology (as defined in
subsection (o)(4)); and
(II) 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
(ii)(I) bears financial risk for
monetary losses under such alternative
payment model that are in excess of a
nominal amount; or
(II) is a medical home expanded under
section 1115A(c).
(4) Limitation.--There 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 entity is an eligible alternative payment
entity 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.
(aa) Medical Review of Spinal Subluxation Services.--
(1) In general.--The Secretary shall implement a
process for the medical review (as described in
paragraph (2)) of treatment by a chiropractor described
in section 1861(r)(5) by means of manual manipulation
of the spine to correct a subluxation (as described in
such section) of an individual who is enrolled under
this part and apply such process to such services
furnished on or after January 1, 2017, focusing on
services such as--
(A) services furnished by a such a
chiropractor whose pattern of billing is
aberrant compared to peers; and
(B) services furnished by such a chiropractor
who, in a prior period, has a services denial
percentage in the 85th percentile or greater,
taking into consideration the extent that
service denials are overturned on appeal.
(2) Medical review.--
(A) Prior authorization medical review.--
(i) In general.--Subject to clause
(ii), the Secretary shall use prior
authorization medical review for
services described in paragraph (1)
that are furnished to an individual by
a chiropractor described in section
1861(r)(5) that are part of an episode
of treatment that includes more than 12
services. For purposes of the preceding
sentence, an episode of treatment shall
be determined by the underlying cause
that justifies the need for services,
such as a diagnosis code.
(ii) Ending application of prior
authorization medical review.--The
Secretary shall end the application of
prior authorization medical review
under clause (i) to services described
in paragraph (1) by such a chiropractor
if the Secretary determines that the
chiropractor has a low denial rate
under such prior authorization medical
review. The Secretary may subsequently
reapply prior authorization medical
review to such chiropractor if the
Secretary determines it to be
appropriate and the chiropractor has,
in the time period subsequent to the
determination by the Secretary of a low
denial rate with respect to the
chiropractor, furnished such services
described in paragraph (1).
(iii) Early request for prior
authorization review permitted.--
Nothing in this subsection shall be
construed to prevent such a
chiropractor from requesting prior
authorization for services described in
paragraph (1) that are to be furnished
to an individual before the
chiropractor furnishes the twelfth such
service to such individual for an
episode of treatment.
(B) Type of review.--The Secretary may use
pre-payment review or post-payment review of
services described in section 1861(r)(5) that
are not subject to prior authorization medical
review under subparagraph (A).
(C) Relationship to law enforcement
activities.--The Secretary may determine that
medical review under this subsection does not
apply in the case where potential fraud may be
involved.
(3) No payment without prior authorization.--With
respect to a service described in paragraph (1) for
which prior authorization medical review under this
subsection applies, the following shall apply:
(A) Prior authorization determination.--The
Secretary shall make a determination, prior to
the service being furnished, of whether the
service would or would not meet the applicable
requirements of section 1862(a)(1)(A).
(B) Denial of payment.--Subject to paragraph
(5), no payment may be made under this part for
the service unless the Secretary determines
pursuant to subparagraph (A) that the service
would meet the applicable requirements of such
section 1862(a)(1)(A).
(4) Submission of information.--A chiropractor
described in section 1861(r)(5) may submit the
information necessary for medical review by fax, by
mail, or by electronic means. The Secretary shall make
available the electronic means described in the
preceding sentence as soon as practicable.
(5) Timeliness.--If the Secretary does not make a
prior authorization determination under paragraph
(3)(A) within 14 business days of the date of the
receipt of medical documentation needed to make such
determination, paragraph (3)(B) shall not apply.
(6) Application of limitation on beneficiary
liability.--Where payment may not be made as a result
of the application of paragraph (2)(B), section 1879
shall apply in the same manner as such section applies
to a denial that is made by reason of section
1862(a)(1).
(7) Review by contractors.--The medical review
described in paragraph (2) may be conducted by medicare
administrative contractors pursuant to section
1874A(a)(4)(G) or by any other contractor determined
appropriate by the Secretary that is not a recovery
audit contractor.
(8) Multiple services.--The Secretary shall, where
practicable, apply the medical review under this
subsection in a manner so as to allow an individual
described in paragraph (1) to obtain, at a single time
rather than on a service-by-service basis, an
authorization in accordance with paragraph (3)(A) for
multiple services.
(9) Construction.--With respect to a service
described in paragraph (1) that has been affirmed by
medical review under this subsection, nothing in this
subsection shall be construed to preclude the
subsequent denial of a claim for such service that does
not meet other applicable requirements under this Act.
(10) Implementation.--
(A) Authority.--The Secretary may implement
the provisions of this subsection by interim
final rule with comment period.
(B) Administration.--Chapter 35 of title 44,
United States Code, shall not apply to medical
review under this subsection.
(bb) Additional Payments for Certain Rural Health Clinics
With Physicians or Practitioners Receiving DATA 2000 Waivers.--
(1) In general.--In the case of a rural health clinic
with respect to which, beginning on or after January 1,
2019, rural health clinic services (as defined in
section 1861(aa)(1)) are furnished for the treatment of
opioid use disorder by a physician or practitioner who
meets the requirements described in paragraph (3), the
Secretary shall, subject to availability of funds under
paragraph (4), make a payment (at such time and in such
manner as specified by the Secretary) to such rural
health clinic after receiving and approving an
application described in paragraph (2). Such payment
shall be in an amount determined by the Secretary,
based on an estimate of the average costs of training
for purposes of receiving a waiver described in
paragraph (3)(B). Such payment may be made only one
time with respect to each such physician or
practitioner.
(2) Application.--In order to receive a payment
described in paragraph (1), a rural health clinic shall
submit to the Secretary an application for such a
payment at such time, in such manner, and containing
such information as specified by the Secretary. A rural
health clinic may apply for such a payment for each
physician or practitioner described in paragraph (1)
furnishing services described in such paragraph at such
clinic.
(3) Requirements.--For purposes of paragraph (1), the
requirements described in this paragraph, with respect
to a physician or practitioner, are the following:
(A) The physician or practitioner is employed
by or working under contract with a rural
health clinic described in paragraph (1) that
submits an application under paragraph (2).
(B) The physician or practitioner first
receives a waiver under section 303(g) of the
Controlled Substances Act on or after January
1, 2019.
(4) Funding.--For purposes of making payments under
this subsection, there are appropriated, out of amounts
in the Treasury not otherwise appropriated, $2,000,000,
which shall remain available until expended.
SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
Sec. 1834. (a) Payment for Durable Medical Equipment.--
(1) General rule for payment.--
(A) In general.--With respect to a covered
item (as defined in paragraph (13)) for which
payment is determined under this subsection,
payment shall be made in the frequency
specified in paragraphs (2) through (7) and in
an amount equal to 80 percent of the payment
basis described in subparagraph (B).
(B) Payment basis.--Subject to subparagraph
(F)(i), the payment basis described in this
subparagraph is the lesser of--
(i) the actual charge for the item,
or
(ii) the payment amount recognized
under paragraphs (2) through (7) of
this subsection for the item;
except that clause (i) shall not apply if the
covered item is furnished by a public home
health agency (or by another home health agency
which demonstrates to the satisfaction of the
Secretary that a significant portion of its
patients are low income) free of charge or at
nominal charges to the public.
(C) Exclusive payment rule.--Subject to
subparagraph (F)(ii), this subsection shall
constitute the exclusive provision of this
title for payment for covered items under this
part or under part A to a home health agency.
(D) Reduction in fee schedules for certain
items.--With respect to a seat-lift chair or
transcutaneous electrical nerve stimulator
furnished on or after April 1, 1990, the
Secretary shall reduce the payment amount
applied under subparagraph (B)(ii) for such an
item by 15 percent, and, in the case of a
transcutaneous electrical nerve stimulator
furnished on or after January 1, 1991, the
Secretary shall further reduce such payment
amount (as previously reduced) by 45 percent.
(E) Clinical conditions for coverage.--
(i) In general.--The Secretary shall
establish standards for clinical
conditions for payment for covered
items under this subsection.
(ii) Requirements.--The standards
established under clause (i) shall
include the specification of types or
classes of covered items that require,
as a condition of payment under this
subsection, a face-to-face examination
of the individual by a physician (as
defined in section 1861(r)), a
physician assistant, nurse
practitioner, or a clinical nurse
specialist (as those terms are defined
in section 1861(aa)(5)) and a
prescription for the item.
(iii) Priority of establishment of
standards.--In establishing the
standards under this subparagraph, the
Secretary shall first establish
standards for those covered items for
which the Secretary determines there
has been a proliferation of use,
consistent findings of charges for
covered items that are not delivered,
or consistent findings of falsification
of documentation to provide for payment
of such covered items under this part.
(iv) Standards for power
wheelchairs.--Effective on the date of
the enactment of this subparagraph, in
the case of a covered item consisting
of a motorized or power wheelchair for
an individual, payment may not be made
for such covered item unless a
physician (as defined in section
1861(r)(1)), a physician assistant,
nurse practitioner, or a clinical nurse
specialist (as those terms are defined
in section 1861(aa)(5)) has conducted a
face-to-face examination of the
individual and written a prescription
for the item.
(v) Limitation on payment for covered
items.--Payment may not be made for a
covered item under this subsection
unless the item meets any standards
established under this subparagraph for
clinical condition of coverage.
(F) Application of competitive acquisition;
limitation of inherent reasonableness
authority.--In the case of covered items
furnished on or after January 1, 2011, subject
to subparagraphs (G) and (H), that are included
in a competitive acquisition program in a
competitive acquisition area under section
1847(a)--
(i) the payment basis under this
subsection for such items and services
furnished in such area shall be the
payment basis determined under such
competitive acquisition program;
(ii) the Secretary may (and, in the
case of covered items furnished on or
after January 1, 2016, subject to
clause (iii), shall) use information on
the payment determined under such
competitive acquisition programs to
adjust the payment amount otherwise
recognized under subparagraph (B)(ii)
for an area that is not a competitive
acquisition area under section 1847 and
in the case of such adjustment,
paragraph (10)(B) shall not be applied;
and
(iii) in the case of covered items
furnished on or after January 1, 2016,
the Secretary shall continue to make
such adjustments described in clause
(ii) as, under such competitive
acquisition programs, additional
covered items are phased in or
information is updated as contracts
under section 1847 are recompeted in
accordance with section 1847(b)(3)(B).
(G) Use of information on competitive bid
rates.--The Secretary shall specify by
regulation the methodology to be used in
applying the provisions of subparagraph (F)(ii)
and subsection (h)(1)(H)(ii). In promulgating
such regulation, the Secretary shall consider
the costs of items and services in areas in
which such provisions would be applied compared
to the payment rates for such items and
services in competitive acquisition areas.In
the case of items and services furnished on or
after January 1, 2019, in making any
adjustments under clause (ii) or (iii) of
subparagraph (F), under subsection
(h)(1)(H)(ii), or under section 1842(s)(3)(B),
the Secretary shall--
(i) solicit and take into account
stakeholder input; and
(ii) take into account the highest
amount bid by a winning supplier in a
competitive acquisition area and a
comparison of each of the following
with respect to non-competitive
acquisition areas and competitive
acquisition areas:
(I) The average travel
distance and cost associated
with furnishing items and
services in the area.
(II) The average volume of
items and services furnished by
suppliers in the area.
(III) The number of suppliers
in the area.
(H) Diabetic supplies.--
(i) In general.--On or after the date
described in clause (ii), the payment
amount under this part for diabetic
supplies, including testing strips,
that are non-mail order items (as
defined by the Secretary) shall be
equal to the single payment amounts
established under the national mail
order competition for diabetic supplies
under section 1847.
(ii) Date described.--The date
described in this clause is the date of
the implementation of the single
payment amounts under the national mail
order competition for diabetic supplies
under section 1847.
(I) Treatment of vacuum erection systems.--
Effective for items and services furnished on
and after July 1, 2015, vacuum erection systems
described as prosthetic devices described in
section 1861(s)(8) shall be treated in the same
manner as erectile dysfunction drugs are
treated for purposes of section 1860D-
2(e)(2)(A).
(2) Payment for inexpensive and other routinely
purchased durable medical equipment.--
(A) In general.--Payment for an item of
durable medical equipment (as defined in
paragraph (13))--
(i) the purchase price of which does
not exceed $150,
(ii) which the Secretary determines
is acquired at least 75 percent of the
time by purchase,
(iii) which is an accessory used in
conjunction with a nebulizer,
aspirator, or a ventilator excluded
under paragraph (3)(A), or
(iv) in the case of devices furnished
on or after October 1, 2015, which
serves as a speech generating device or
which is an accessory that is needed
for the individual to effectively
utilize such a device,
shall be made on a rental basis or in a lump-
sum amount for the purchase of the item. The
payment amount recognized for purchase or
rental of such equipment is the amount
specified in subparagraph (B) for purchase or
rental, except that the total amount of
payments with respect to an item may not exceed
the payment amount specified in subparagraph
(B) with respect to the purchase of the item.
(B) Payment amount.--For purposes of
subparagraph (A), the amount specified in this
subparagraph, with respect to the purchase or
rental of an item furnished in a carrier
service area--
(i) in 1989 and in 1990 is the
average reasonable charge in the area
for the purchase or rental,
respectively, of the item for the 12-
month period ending on June 30, 1987,
increased by the percentage increase in
the consumer price index for all urban
consumers (U.S. city average) for the
6-month period ending with December
1987;
(ii) in 1991 is the sum of (I) 67
percent of the local payment amount for
the item or device computed under
subparagraph (C)(i)(I) for 1991, and
(II) 33 percent of the national limited
payment amount for the item or device
computed under subparagraph (C)(ii) for
1991;
(iii) in 1992 is the sum of (I) 33
percent of the local payment amount for
the item or device computed under
subparagraph (C)(i)(II) for 1992, and
(II) 67 percent of the national limited
payment amount for the item or device
computed under subparagraph (C)(ii) for
1992; and
(iv) in 1993 and each subsequent year
is the national limited payment amount
for the item or device computed under
subparagraph (C)(ii) for that year
(reduced by 10 percent, in the case of
a blood glucose testing strip furnished
after 1997 for an individual with
diabetes).
(C) Computation of local payment amount and
national limited payment amount.--For purposes
of subparagraph (B)--
(i) the local payment amount for an
item or device for a year is equal to--
(I) for 1991, the amount
specified in subparagraph
(B)(i) for 1990 increased by
the covered item update for
1991, and
(II) for 1992, 1993, and 1994
the amount determined under
this clause for the preceding
year increased by the covered
item update for the year; and
(ii) the national limited payment
amount for an item or device for a year
is equal to--
(I) for 1991, the local
payment amount determined under
clause (i) for such item or
device for that year, except
that the national limited
payment amount may not exceed
100 percent of the weighted
average of all local payment
amounts determined under such
clause for such item for that
year and may not be less than
85 percent of the weighted
average of all local payment
amounts determined under such
clause for such item,
(II) for 1992 and 1993, the
amount determined under this
clause for the preceding year
increased by the covered item
update for such subsequent
year,
(III) for 1994, the local
payment amount determined under
clause (i) for such item or
device for that year, except
that the national limited
payment amount may not exceed
100 percent of the median of
all local payment amounts
determined under such clause
for such item for that year and
may not be less than 85 percent
of the median of all local
payment amounts determined
under such clause for such item
or device for that year, and
(IV) for each subsequent
year, the amount determined
under this clause for the
preceding year increased by the
covered item update for such
subsequent year.
(3) Payment for items requiring frequent and
substantial servicing.--
(A) In general.--Payment for a covered item
(such as IPPB machines and ventilators,
excluding ventilators that are either
continuous airway pressure devices or
intermittent assist devices with continuous
airway pressure devices) for which there must
be frequent and substantial servicing in order
to avoid risk to the patient's health shall be
made on a monthly basis for the rental of the
item and the amount recognized is the amount
specified in subparagraph (B).
(B) Payment amount.--For purposes of
subparagraph (A), the amount specified in this
subparagraph, with respect to an item or device
furnished in a carrier service area--
(i) in 1989 and in 1990 is the
average reasonable charge in the area
for the rental of the item or device
for the 12-month period ending with
June 1987, increased by the percentage
increase in the consumer price index
for all urban consumers (U.S. city
average) for the 6-month period ending
with December 1987;
(ii) in 1991 is the sum of (I) 67
percent of the local payment amount for
the item or device computed under
subparagraph (C)(i)(I) for 1991, and
(II) 33 percent of the national limited
payment amount for the item or device
computed under subparagraph (C)(ii) for
1991;
(iii) in 1992 is the sum of (I) 33
percent of the local payment amount for
the item or device computed under
subparagraph (C)(i)(II) for 1992, and
(II) 67 percent of the national limited
payment amount for the item or device
computed under subparagraph (C)(ii) for
1992; and
(iv) in 1993 and each subsequent year
is the national limited payment amount
for the item or device computed under
subparagraph (C)(ii) for that year.
(C) Computation of local payment amount and
national limited payment amount.--For purposes
of subparagraph (B)--
(i) the local payment amount for an
item or device for a year is equal to--
(I) for 1991, the amount
specified in subparagraph
(B)(i) for 1990 increased by
the covered item update for
1991, and
(II) for 1992, 1993, and 1994
the amount determined under
this clause for the preceding
year increased by the covered
item update for the year; and
(ii) the national limited payment
amount for an item or device for a year
is equal to--
(I) for 1991, the local
payment amount determined under
clause (i) for such item or
device for that year, except
that the national limited
payment amount may not exceed
100 percent of the weighted
average of all local payment
amounts determined under such
clause for such item for that
year and may not be less than
85 percent of the weighted
average of all local payment
amounts determined under such
clause for such item,
(II) for 1992 and 1993, the
amount determined under this
clause for the preceding year
increased by the covered item
update for such subsequent
year,
(III) for 1994, the local
payment amount determined under
clause (i) for such item or
device for that year, except
that the national limited
payment amount may not exceed
100 percent of the median of
all local payment amounts
determined under such clause
for such item for that year and
may not be less than 85 percent
of the median of all local
payment amounts determined
under such clause for such item
or device for that year, and
(IV) for each subsequent
year, the amount determined
under this clause for the
preceding year increased by the
covered item update for such
subsequent year.
(4) Payment for certain customized items.--Payment
with respect to a covered item that is uniquely
constructed or substantially modified to meet the
specific needs of an individual patient, and for that
reason cannot be grouped with similar items for
purposes of payment under this title, shall be made in
a lump-sum amount (A) for the purchase of the item in a
payment amount based upon the carrier's individual
consideration for that item, and (B) for the reasonable
and necessary maintenance and servicing for parts and
labor not covered by the supplier's or manufacturer's
warranty, when necessary during the period of medical
need, and the amount recognized for such maintenance
and servicing shall be paid on a lump-sum, as needed
basis based upon the carrier's individual consideration
for that item. In the case of a wheelchair furnished on
or after January 1, 1992, the wheelchair shall be
treated as a customized item for purposes of this
paragraph if the wheelchair has been measured, fitted,
or adapted in consideration of the patient's body size,
disability, period of need, or intended use, and has
been assembled by a supplier or ordered from a
manufacturer who makes available customized features,
modifications, or components for wheelchairs that are
intended for an individual patient's use in accordance
with instructions from the patient's physician.
(5) Payment for oxygen and oxygen equipment.--
(A) In general.--Payment for oxygen and
oxygen equipment shall be made on a monthly
basis in the monthly payment amount recognized
under paragraph (9) for oxygen and oxygen
equipment (other than portable oxygen
equipment), subject to subparagraphs (B), (C),
(E), and (F).
(B) Add-on for portable oxygen equipment.--
When portable oxygen equipment is used, but
subject to subparagraph (D), the payment amount
recognized under subparagraph (A) shall be
increased by the monthly payment amount
recognized under paragraph (9) for portable
oxygen equipment.
(C) Volume adjustment.--When the attending
physician prescribes an oxygen flow rate--
(i) exceeding 4 liters per minute,
the payment amount recognized under
subparagraph (A), subject to
subparagraph (D), shall be increased by
50 percent, or
(ii) of less than 1 liter per minute,
the payment amount recognized under
subparagraph (A) shall be decreased by
50 percent.
(D) Limit on adjustment.--When portable
oxygen equipment is used and the attending
physician prescribes an oxygen flow rate
exceeding 4 liters per minute, there shall only
be an increase under either subparagraph (B) or
(C), whichever increase is larger, and not
under both such subparagraphs.
(E) Recertification for patients receiving
home oxygen therapy.--In the case of a patient
receiving home oxygen therapy services who, at
the time such services are initiated, has an
initial arterial blood gas value at or above a
partial pressure of 56 or an arterial oxygen
saturation at or above 89 percent (or such
other values, pressures, or criteria as the
Secretary may specify) no payment may be made
under this part for such services after the
expiration of the 90-day period that begins on
the date the patient first receives such
services unless the patient's attending
physician certifies that, on the basis of a
follow-up test of the patient's arterial blood
gas value or arterial oxygen saturation
conducted during the final 30 days of such 90-
day period, there is a medical need for the
patient to continue to receive such services.
(F) Rental Cap.--
(i) In general.--Payment for oxygen
equipment (including portable oxygen
equipment) under this paragraph may not
extend over a period of continuous use
(as determined by the Secretary) of
longer than 36 months.
(ii) Payments and rules after rental
cap.--After the 36th continuous month
during which payment is made for the
equipment under this paragraph--
(I) the supplier furnishing
such equipment under this
subsection shall continue to
furnish the equipment during
any period of medical need for
the remainder of the reasonable
useful lifetime of the
equipment, as determined by the
Secretary;
(II) payments for oxygen
shall continue to be made in
the amount recognized for
oxygen under paragraph (9) for
the period of medical need; and
(III) maintenance and
servicing payments shall, if
the Secretary determines such
payments are reasonable and
necessary, be made (for parts
and labor not covered by the
supplier's or manufacturer's
warranty, as determined by the
Secretary to be appropriate for
the equipment), and such
payments shall be in an amount
determined to be appropriate by
the Secretary.
(6) Payment for other covered items (other than
durable medical equipment).--Payment for other covered
items (other than durable medical equipment and other
covered items described in paragraph (3), (4), or (5))
shall be made in a lump-sum amount for the purchase of
the item in the amount of the purchase price recognized
under paragraph (8).
(7) Payment for other items of durable medical
equipment.--
(A) Payment.--In the case of an item of
durable medical equipment not described in
paragraphs (2) through (6), the following rules
shall apply:
(i) Rental.--
(I) In general.--Except as
provided in clause (iii),
payment for the item shall be
made on a monthly basis for the
rental of the item during the
period of medical need (but
payments under this clause may
not extend over a period of
continuous use (as determined
by the Secretary) of longer
than 13 months).
(II) Payment amount.--Subject
to subclause (III) and
subparagraph (B), the amount
recognized for the item, for
each of the first 3 months of
such period, is 10 percent of
the purchase price recognized
under paragraph (8) with
respect to the item, and, for
each of the remaining months of
such period, is 7.5 percent of
such purchase price.
(III) Special rule for power-
driven wheelchairs.--For
purposes of payment for power-
driven wheelchairs, subclause
(II) shall be applied by
substituting ``15 percent'' and
``6 percent'' for ``10
percent'' and ``7.5 percent'',
respectively.
(ii) Ownership after rental.--On the
first day that begins after the 13th
continuous month during which payment
is made for the rental of an item under
clause (i), the supplier of the item
shall transfer title to the item to the
individual.
(iii) Purchase agreement option for
complex, rehabilitative power-driven
wheelchairs.--In the case of a complex,
rehabilitative power-driven wheelchair,
at the time the supplier furnishes the
item, the supplier shall offer the
individual the option to purchase the
item, and payment for such item shall
be made on a lump-sum basis if the
individual exercises such option.
(iv) Maintenance and servicing.--
After the supplier transfers title to
the item under clause (ii) or in the
case of a power-driven wheelchair for
which a purchase agreement has been
entered into under clause (iii),
maintenance and servicing payments
shall, if the Secretary determines such
payments are reasonable and necessary,
be made (for parts and labor not
covered by the supplier's or
manufacturer's warranty, as determined
by the Secretary to be appropriate for
the particular type of durable medical
equipment), and such payments shall be
in an amount determined to be
appropriate by the Secretary.
(B) Range for rental amounts.--
(i) For 1989.--For items furnished
during 1989, the payment amount
recognized under subparagraph (A)(i)
shall not be more than 115 percent, and
shall not be less than 85 percent, of
the prevailing charge established for
rental of the item in January 1987,
increased by the percentage increase in
the consumer price index for all urban
consumers (U.S. city average) for the
6-month period ending with December
1987.
(ii) For 1990.--For items furnished
during 1990, clause (i) shall apply in
the same manner as it applies to items
furnished during 1989.
(C) Replacement of items.--
(i) Establishment of reasonable
useful lifetime.--In accordance with
clause (iii), the Secretary shall
determine and establish a reasonable
useful lifetime for items of durable
medical equipment for which payment may
be made under this paragraph.
(ii) Payment for replacement items.--
If the reasonable lifetime of such an
item, as so established, has been
reached during a continuous period of
medical need, or the carrier determines
that the item is lost or irreparably
damaged, the patient may elect to have
payment for an item serving as a
replacement for such item made--
(I) on a monthly basis for
the rental of the replacement
item in accordance with
subparagraph (A); or
(II) in the case of an item
for which a purchase agreement
has been entered into under
subparagraph (A)(iii), in a
lump-sum amount for the
purchase of the item.
(iii) Length of reasonable useful
lifetime.--The reasonable useful
lifetime of an item of durable medical
equipment under this subparagraph shall
be equal to 5 years, except that, if
the Secretary determines that, on the
basis of prior experience in making
payments for such an item under this
title, a reasonable useful lifetime of
5 years is not appropriate with respect
to a particular item, the Secretary
shall establish an alternative
reasonable lifetime for such item.
(8) Purchase price recognized for miscellaneous
devices and items.--For purposes of paragraphs (6) and
(7), the amount that is recognized under this paragraph
as the purchase price for a covered item is the amount
described in subparagraph (C) of this paragraph,
determined as follows:
(A) Computation of local purchase price.--
Each carrier under section 1842 shall compute a
base local purchase price for the item as
follows:
(i) The carrier shall compute a base
local purchase price, for each item
described--
(I) in paragraph (6) equal to
the average reasonable charge
in the locality for the
purchase of the item for the
12-month period ending with
June 1987, or
(II) in paragraph (7) equal
to the average of the purchase
prices on the claims submitted
on an assignment-related basis
for the unused item supplied
during the 6-month period
ending with December 1986.
(ii) The carrier shall compute a
local purchase price, with respect to
the furnishing of each particular
item--
(I) in 1989 and 1990, equal
to the base local purchase
price computed under clause (i)
increased by the percentage
increase in the consumer price
index for all urban consumers
(U.S. city average) for the 6-
month period ending with
December 1987,
(II) in 1991, equal to the
local purchase price computed
under this clause for the
previous year, increased by the
covered item update for 1991,
and decreased by the percentage
by which the average of the
reasonable charges for claims
paid for all items described in
paragraph (7) is lower than the
average of the purchase prices
submitted for such items during
the final 9 months of 1988; or
(III) in 1992, 1993, and 1994
equal to the local purchase
price computed under this
clause for the previous year
increased by the covered item
update for the year.
(B) Computation of national limited purchase
price.--With respect to the furnishing of a
particular item in a year, the Secretary shall
compute a national limited purchase price--
(i) for 1991, equal to the local
purchase price computed under
subparagraph (A)(ii) for the item for
the year, except that such national
limited purchase price may not exceed
100 percent of the weighted average of
all local purchase prices for the item
computed under such subparagraph for
the year, and may not be less than 85
percent of the weighted average of all
local purchase prices for the item
computed under such subparagraph for
the year;
(ii) for 1992 and 1993, the amount
determined under this subparagraph for
the preceding year increased by the
covered item update for such subsequent
year;
(iii) for 1994, the local purchase
price computed under subparagraph
(A)(ii) for the item for the year,
except that such national limited
purchase price may not exceed 100
percent of the median of all local
purchase prices computed for the item
under such subparagraph for the year
and may not be less than 85 percent of
the median of all local purchase prices
computed under such subparagraph for
the item for the year; and
(iv) for each subsequent year, equal
to the amount determined under this
subparagraph for the preceding year
increased by the covered item update
for such subsequent year.
(C) Purchase price recognized.--For purposes
of paragraphs (6) and (7), the amount that is
recognized under this paragraph as the purchase
price for each item furnished--
(i) in 1989 or 1990, is 100 percent
of the local purchase price computed
under subparagraph (A)(ii)(I);
(ii) in 1991, is the sum of (I) 67
percent of the local purchase price
computed under subparagraph (A)(ii)(II)
for 1991, and (II) 33 percent of the
national limited purchase price
computed under subparagraph (B) for
1991;
(iii) in 1992, is the sum of (I) 33
percent of the local purchase price
computed under subparagraph
(A)(ii)(III) for 1992, and (II) 67
percent of the national limited
purchase price computed under
subparagraph (B) for 1992; and
(iv) in 1993 or a subsequent year, is
the national limited purchase price
computed under subparagraph (B) for
that year.
(9) Monthly payment amount recognized with respect to
oxygen and oxygen equipment.--For purposes of paragraph
(5), the amount that is recognized under this paragraph
for payment for oxygen and oxygen equipment is the
monthly payment amount described in subparagraph (C) of
this paragraph. Such amount shall be computed
separately (i) for all items of oxygen and oxygen
equipment (other than portable oxygen equipment) and
(ii) for portable oxygen equipment (each such group
referred to in this paragraph as an ``item'').
(A) Computation of local monthly payment
rate.--Each carrier under this section shall
compute a base local payment rate for each item
as follows:
(i) The carrier shall compute a base
local average monthly payment rate per
beneficiary as an amount equal to (I)
the total reasonable charges for the
item during the 12-month period ending
with December 1986, divided by (II) the
total number of months for all
beneficiaries receiving the item in the
area during the 12-month period for
which the carrier made payment for the
item under this title.
(ii) The carrier shall compute a
local average monthly payment rate for
the item applicable--
(I) to 1989 and 1990, equal
to 95 percent of the base local
average monthly payment rate
computed under clause (i) for
the item increased by the
percentage increase in the
consumer price index for all
urban consumers (U.S. city
average) for the 6-month period
ending with December 1987, or
(II) to 1991, 1992, 1993, and
1994 equal to the local average
monthly payment rate computed
under this clause for the item
for the previous year increased
by the covered item increase
for the year.
(B) Computation of national limited monthly
payment rate.--With respect to the furnishing
of an item in a year, the Secretary shall
compute a national limited monthly payment rate
equal to--
(i) for 1991, the local monthly
payment rate computed under
subparagraph (A)(ii)(II) for the item
for the year, except that such national
limited monthly payment rate may not
exceed 100 percent of the weighted
average of all local monthly payment
rates computed for the item under such
subparagraph for the year, and may not
be less than 85 percent of the weighted
average of all local monthly payment
rates computed for the item under such
subparagraph for the year;
(ii) for 1992 and 1993, the amount
determined under this subparagraph for
the preceding year increased by the
covered item update for such subsequent
year;
(iii) for 1994, the local monthly
payment rate computed under
subparagraph (A)(ii) for the item for
the year, except that such national
limited monthly payment rate may not
exceed 100 percent of the median of all
local monthly payment rates computed
for the item under such subparagraph
for the year and may not be less than
85 percent of the median of all local
monthly payment rates computed for the
item under such subparagraph for the
year;
(iv) for 1995, 1996, and 1997, equal
to the amount determined under this
subparagraph for the preceding year
increased by the covered item update
for such subsequent year;
(v) for 1998, 75 percent of the
amount determined under this
subparagraph for 1997; and
(vi) for 1999 and each subsequent
year, 70 percent of the amount
determined under this subparagraph for
1997.
(C) Monthly payment amount recognized.--For
purposes of paragraph (5), the amount that is
recognized under this paragraph as the base
monthly payment amount for each item
furnished--
(i) in 1989 and in 1990, is 100
percent of the local average monthly
payment rate computed under
subparagraph (A)(ii) for the item;
(ii) in 1991, is the sum of (I) 67
percent of the local average monthly
payment rate computed under
subparagraph (A)(ii)(II) for the item
for 1991, and (II) 33 percent of the
national limited monthly payment rate
computed under subparagraph (B)(i) for
the item for 1991;
(iii) in 1992, is the sum of (I) 33
percent of the local average monthly
payment rate computed under
subparagraph (A)(ii)(II) for the item
for 1992, and (II) 67 percent of the
national limited monthly payment rate
computed under subparagraph (B)(ii) for
the item for 1992; and
(iv) in a subsequent year, is the
national limited monthly payment rate
computed under subparagraph (B) for the
item for that year.
(10) Exceptions and adjustments.--
(A) Areas outside continental united
states.--Exceptions to the amounts recognized
under the previous provisions of this
subsection shall be made to take into account
the unique circumstances of covered items
furnished in Alaska, Hawaii, or Puerto Rico.
(B) Adjustment for inherent reasonableness.--
The Secretary is authorized to apply the
provisions of paragraphs (8) and (9) of section
1842(b) to covered items and suppliers of such
items and payments under this subsection in an
area and with respect to covered items and
services for which the Secretary does not make
a payment amount adjustment under paragraph
(1)(F).
(C) Transcutaneous electrical nerve
stimulator (tens).--In order to permit an
attending physician time to determine whether
the purchase of a transcutaneous electrical
nerve stimulator is medically appropriate for a
particular patient, the Secretary may determine
an appropriate payment amount for the initial
rental of such item for a period of not more
than 2 months. If such item is subsequently
purchased, the payment amount with respect to
such purchase is the payment amount determined
under paragraph (2).
(11) Improper billing and requirement of physician
order.--
(A) Improper billing for certain rental
items.--Notwithstanding any other provision of
this title, a supplier of a covered item for
which payment is made under this subsection and
which is furnished on a rental basis shall
continue to supply the item without charge
(other than a charge provided under this
subsection for the maintenance and servicing of
the item) after rental payments may no longer
be made under this subsection. If a supplier
knowingly and willfully violates the previous
sentence, the Secretary may apply sanctions
against the supplier under section 1842(j)(2)
in the same manner such sanctions may apply
with respect to a physician.
(B) Requirement of physician order.--
(i) In general.--The Secretary is
authorized to require, for specified
covered items, that payment may be made
under this subsection with respect to
the item only if a physician enrolled
under section 1866(j) or an eligible
professional under section
1848(k)(3)(B) that is enrolled under
section 1866(j) has communicated to the
supplier, before delivery of the item,
a written order for the item.
(ii) Requirement for face to face
encounter.--The Secretary shall require
that such an order be written pursuant
to a physician, a physician assistant,
a nurse practitioner, or a clinical
nurse specialist (as those terms are
defined in section 1861(aa)(5))
documenting such physician, physician
assistant, practitioner, or specialist
has had a face-to-face encounter
(including through use of telehealth
under subsection (m) and other than
with respect to encounters that are
incident to services involved) with the
individual involved during the 6-month
period preceding such written order, or
other reasonable timeframe as
determined by the Secretary.
(12) Regional carriers.--The Secretary may designate,
by regulation under section 1842, one carrier for one
or more entire regions to process all claims within the
region for covered items under this section.
(13) Covered item.--In this subsection, the term
``covered item'' means durable medical equipment (as
defined in section 1861(n)), including such equipment
described in section 1861(m)(5), but not including
implantable items for which payment may be made under
section 1833(t).
(14) Covered item update.--In this subsection, the
term ``covered item update'' means, with respect to a
year--
(A) for 1991 and 1992, the percentage
increase in the consumer price index for all
urban consumers (U.S. city average) for the 12-
month period ending with June of the previous
year reduced by 1 percentage point;
(B) for 1993, 1994, 1995, 1996, and 1997, the
percentage increase in the consumer price index
for all urban consumers (U.S. city average) for
the 12-month period ending with June of the
previous year;
(C) for each of the years 1998 through 2000,
0 percentage points;
(D) for 2001, the percentage increase in the
consumer price index for all urban consumers
(U.S. city average) for the 12-month period
ending with June 2000;
(E) for 2002, 0 percentage points;
(F) for 2003, the percentage increase in the
consumer price index for all urban consumers
(U.S. urban average) for the 12-month period
ending with June of 2002;
(G) for 2004 through 2006--
(i) subject to clause (ii), in the
case of class III medical devices
described in section 513(a)(1)(C) of
the Federal Food, Drug, and Cosmetic
Act (21 U.S.C. 360(c)(1)(C)), the
percentage increase described in
subparagraph (B) for the year involved;
and
(ii) in the case of covered items not
described in clause (i), 0 percentage
points;
(H) for 2007--
(i) subject to clause (ii), in the
case of class III medical devices
described in section 513(a)(1)(C) of
the Federal Food, Drug, and Cosmetic
Act (21 U.S.C. 360(c)(1)(C)), the
percentage change determined by the
Secretary to be appropriate taking into
account recommendations contained in
the report of the Comptroller General
of the United States under section
302(c)(1)(B) of the Medicare
Prescription Drug, Improvement, and
Modernization Act of 2003; and
(ii) in the case of covered items not
described in clause (i), 0 percentage
points;
(I) for 2008--
(i) subject to clause (ii), in the
case of class III medical devices
described in section 513(a)(1)(C) of
the Federal Food, Drug, and Cosmetic
Act (21 U.S.C. 360(c)(1)(C)), the
percentage increase described in
subparagraph (B) (as applied to the
payment amount for 2007 determined
after the application of the percentage
change under subparagraph (H)(i)); and
(ii) in the case of covered items not
described in clause (i), 0 percentage
points;
(J) for 2009--
(i) in the case of items and services
furnished in any geographic area, if
such items or services were selected
for competitive acquisition in any area
under the competitive acquisition
program under section
1847(a)(1)(B)(i)(I) before July 1,
2008, including related accessories but
only if furnished with such items and
services selected for such competition
and diabetic supplies but only if
furnished through mail order, - 9.5
percent; or
(ii) in the case of other items and
services, the percentage increase in
the consumer price index for all urban
consumers (U.S. urban average) for the
12-month period ending with June 2008;
(K) for 2010, the percentage increase in the
consumer price index for all urban consumers
(U.S. urban average) for the 12-month period
ending with June of the previous year; and
(L) for 2011 and each subsequent year--
(i) the percentage increase in the
consumer price index for all urban
consumers (United States city average)
for the 12-month period ending with
June of the previous year, reduced by--
(ii) the productivity adjustment
described in section
1886(b)(3)(B)(xi)(II).
The application of subparagraph (L)(ii) may result in
the covered item update under this paragraph being less
than 0.0 for a year, and may result in payment rates
under this subsection for a year being less than such
payment rates for the preceding year.
(15) Advance determinations of coverage for certain
items.--
(A) Development of lists of items by
secretary.--The Secretary may develop and
periodically update a list of items for which
payment may be made under this subsection that
the Secretary determines, on the basis of prior
payment experience, are frequently subject to
unnecessary utilization throughout a carrier's
entire service area or a portion of such area.
(B) Development of lists of suppliers by
secretary.--The Secretary may develop and
periodically update a list of suppliers of
items for which payment may be made under this
subsection with respect to whom--
(i) the Secretary has found that a
substantial number of claims for
payment under this part for items
furnished by the supplier have been
denied on the basis of the application
of section 1862(a)(1); or
(ii) the Secretary has identified a
pattern of overutilization resulting
from the business practice of the
supplier.
(C) Determinations of coverage in advance.--A
carrier shall determine in advance of delivery
of an item whether payment for the item may not
be made because the item is not covered or
because of the application of section
1862(a)(1) if--
(i) the item is included on the list
developed by the Secretary under
subparagraph (A);
(ii) the item is furnished by a
supplier included on the list developed
by the Secretary under subparagraph
(B); or
(iii) the item is a customized item
(other than inexpensive items specified
by the Secretary) and the patient to
whom the item is to be furnished or the
supplier requests that such advance
determination be made.
(16) Disclosure of information and surety bond.--The
Secretary shall not provide for the issuance (or
renewal) of a provider number for a supplier of durable
medical equipment, for purposes of payment under this
part for durable medical equipment furnished by the
supplier, unless the supplier provides the Secretary on
a continuing basis--
(A) with--
(i) full and complete information as
to the identity of each person with an
ownership or control interest (as
defined in section 1124(a)(3)) in the
supplier or in any subcontractor (as
defined by the Secretary in
regulations) in which the supplier
directly or indirectly has a 5 percent
or more ownership interest; and
(ii) to the extent determined to be
feasible under regulations of the
Secretary, the name of any disclosing
entity (as defined in section
1124(a)(2)) with respect to which a
person with such an ownership or
control interest in the supplier is a
person with such an ownership or
control interest in the disclosing
entity; and
(B) with a surety bond in a form specified by
the Secretary and in an amount that is not less
than $50,000 that the Secretary determines is
commensurate with the volume of the billing of
the supplier.
The Secretary may waive the requirement of a bond under
subparagraph (B) in the case of a supplier that
provides a comparable surety bond under State law. The
Secretary, at the Secretary's discretion, may impose
the requirements of the first sentence with respect to
some or all providers of items or services under part A
or some or all suppliers or other persons (other than
physicians or other practitioners, as defined in
section 1842(b)(18)(C)) who furnish items or services
under this part.
(17) Prohibition against unsolicited telephone
contacts by suppliers.--
(A) In general.--A supplier of a covered item
under this subsection may not contact an
individual enrolled under this part by
telephone regarding the furnishing of a covered
item to the individual unless 1 of the
following applies:
(i) The individual has given written
permission to the supplier to make
contact by telephone regarding the
furnishing of a covered item.
(ii) The supplier has furnished a
covered item to the individual and the
supplier is contacting the individual
only regarding the furnishing of such
covered item.
(iii) If the contact is regarding the
furnishing of a covered item other than
a covered item already furnished to the
individual, the supplier has furnished
at least 1 covered item to the
individual during the 15-month period
preceding the date on which the
supplier makes such contact.
(B) Prohibiting payment for items furnished
subsequent to unsolicited contacts.--If a
supplier knowingly contacts an individual in
violation of subparagraph (A), no payment may
be made under this part for any item
subsequently furnished to the individual by the
supplier.
(C) Exclusion from program for suppliers
engaging in pattern of unsolicited contacts.--
If a supplier knowingly contacts individuals in
violation of subparagraph (A) to such an extent
that the supplier's conduct establishes a
pattern of contacts in violation of such
subparagraph, the Secretary shall exclude the
supplier from participation in the programs
under this Act, in accordance with the
procedures set forth in subsections (c), (f),
and (g) of section 1128.
(18) Refund of amounts collected for certain
disallowed items.--
(A) In general.--If a nonparticipating
supplier furnishes to an individual enrolled
under this part a covered item for which no
payment may be made under this part by reason
of paragraph (17)(B), the supplier shall refund
on a timely basis to the patient (and shall be
liable to the patient for) any amounts
collected from the patient for the item,
unless--
(i) the supplier establishes that the
supplier did not know and could not
reasonably have been expected to know
that payment may not be made for the
item by reason of paragraph (17)(B), or
(ii) before the item was furnished,
the patient was informed that payment
under this part may not be made for
that item and the patient has agreed to
pay for that item.
(B) Sanctions.--If a supplier knowingly and
willfully fails to make refunds in violation of
subparagraph (A), the Secretary may apply
sanctions against the supplier in accordance
with section 1842(j)(2).
(C) Notice.--Each carrier with a contract in
effect under this part with respect to
suppliers of covered items shall send any
notice of denial of payment for covered items
by reason of paragraph (17)(B) and for which
payment is not requested on an assignment-
related basis to the supplier and the patient
involved.
(D) Timely basis defined.--A refund under
subparagraph (A) is considered to be on a
timely basis only if--
(i) in the case of a supplier who
does not request reconsideration or
seek appeal on a timely basis, the
refund is made within 30 days after the
date the supplier receives a denial
notice under subparagraph (C), or
(ii) in the case in which such a
reconsideration or appeal is taken, the
refund is made within 15 days after the
date the supplier receives notice of an
adverse determination on
reconsideration or appeal.
(19) Certain upgraded items.--
(A) Individual's right to choose upgraded
item.--Notwithstanding any other provision of
this title, the Secretary may issue regulations
under which an individual may purchase or rent
from a supplier an item of upgraded durable
medical equipment for which payment would be
made under this subsection if the item were a
standard item.
(B) Payments to supplier.--In the case of the
purchase or rental of an upgraded item under
subparagraph (A)--
(i) the supplier shall receive
payment under this subsection with
respect to such item as if such item
were a standard item; and
(ii) the individual purchasing or
renting the item shall pay the supplier
an amount equal to the difference
between the supplier's charge and the
amount under clause (i).
In no event may the supplier's charge for an
upgraded item exceed the applicable fee
schedule amount (if any) for such item.
(C) Consumer protection safeguards.--Any
regulations under subparagraph (A) shall
provide for consumer protection standards with
respect to the furnishing of upgraded equipment
under subparagraph (A). Such regulations shall
provide for--
(i) determination of fair market
prices with respect to an upgraded
item;
(ii) full disclosure of the
availability and price of standard
items and proof of receipt of such
disclosure information by the
beneficiary before the furnishing of
the upgraded item;
(iii) conditions of participation for
suppliers in the billing arrangement;
(iv) sanctions of suppliers who are
determined to engage in coercive or
abusive practices, including exclusion;
and
(v) such other safeguards as the
Secretary determines are necessary.
(20) Identification of quality standards.--
(A) In general.--Subject to subparagraph (C),
the Secretary shall establish and implement
quality standards for suppliers of items and
services described in subparagraph (D) to be
applied by recognized independent accreditation
organizations (as designated under subparagraph
(B)) and with which such suppliers shall be
required to comply in order to--
(i) furnish any such item or service
for which payment is made under this
part; and
(ii) receive or retain a provider or
supplier number used to submit claims
for reimbursement for any such item or
service for which payment may be made
under this title.
(B) Designation of independent accreditation
organizations.--Not later than the date that is
1 year after the date on which the Secretary
implements the quality standards under
subparagraph (A), notwithstanding section
1865(a), the Secretary shall designate and
approve one or more independent accreditation
organizations for purposes of such
subparagraph.
(C) Quality standards.--The quality standards
described in subparagraph (A) may not be less
stringent than the quality standards that would
otherwise apply if this paragraph did not apply
and shall include consumer services standards.
(D) Items and services described.--The items
and services described in this subparagraph are
the following items and services, as the
Secretary determines appropriate:
(i) Covered items (as defined in
paragraph (13)) for which payment may
otherwise be made under this
subsection.
(ii) Prosthetic devices and orthotics
and prosthetics described in section
1834(h)(4).
(iii) Items and services described in
section 1842(s)(2).
(E) Implementation.--The Secretary may
establish by program instruction or otherwise
the quality standards under this paragraph,
including subparagraph (F), after consultation
with representatives of relevant parties. Such
standards shall be applied prospectively and
shall be published on the Internet website of
the Centers for Medicare & Medicaid Services.
(F) Application of accreditation
requirement.--In implementing quality standards
under this paragraph--
(i) subject to clause (ii) and
subparagraph (G), the Secretary shall
require suppliers furnishing items and
services described in subparagraph (D)
on or after October 1, 2009, directly
or as a subcontractor for another
entity, to have submitted to the
Secretary evidence of accreditation by
an accreditation organization
designated under subparagraph (B) as
meeting applicable quality standards,
except that the Secretary shall not
require under this clause pharmacies to
obtain such accreditation before
January 1, 2010, except that the
Secretary shall not require a pharmacy
to have submitted to the Secretary such
evidence of accreditation prior to
January 1, 2011; and
(ii) in applying such standards and
the accreditation requirement of clause
(i) with respect to eligible
professionals (as defined in section
1848(k)(3)(B)), and including such
other persons, such as orthotists and
prosthetists, as specified by the
Secretary, furnishing such items and
services--
(I) such standards and
accreditation requirement shall
not apply to such professionals
and persons unless the
Secretary determines that the
standards being applied are
designed specifically to be
applied to such professionals
and persons; and
(II) the Secretary may exempt
such professionals and persons
from such standards and
requirement if the Secretary
determines that licensing,
accreditation, or other
mandatory quality requirements
apply to such professionals and
persons with respect to the
furnishing of such items and
services.
(G) Application of accreditation requirement
to certain pharmacies.--
(i) In general.--With respect to
items and services furnished on or
after January 1, 2011, in implementing
quality standards under this
paragraph--
(I) subject to subclause
(II), in applying such
standards and the accreditation
requirement of subparagraph
(F)(i) with respect to
pharmacies described in clause
(ii) furnishing such items and
services, such standards and
accreditation requirement shall
not apply to such pharmacies;
and
(II) the Secretary may apply
to such pharmacies an
alternative accreditation
requirement established by the
Secretary if the Secretary
determines such alternative
accreditation requirement is
more appropriate for such
pharmacies.
(ii) Pharmacies described.--A
pharmacy described in this clause is a
pharmacy that meets each of the
following criteria:
(I) The total billings by the
pharmacy for such items and
services under this title are
less than 5 percent of total
pharmacy sales, as determined
based on the average total
pharmacy sales for the previous
3 calendar years, 3 fiscal
years, or other yearly period
specified by the Secretary.
(II) The pharmacy has been
enrolled under section 1866(j)
as a supplier of durable
medical equipment, prosthetics,
orthotics, and supplies, has
been issued (which may include
the renewal of) a provider
number for at least 5 years,
and for which a final adverse
action (as defined in section
424.57(a) of title 42, Code of
Federal Regulations) has not
been imposed in the past 5
years.
(III) The pharmacy submits to
the Secretary an attestation,
in a form and manner, and at a
time, specified by the
Secretary, that the pharmacy
meets the criteria described in
subclauses (I) and (II). Such
attestation shall be subject to
section 1001 of title 18,
United States Code.
(IV) The pharmacy agrees to
submit materials as requested
by the Secretary, or during the
course of an audit conducted on
a random sample of pharmacies
selected annually, to verify
that the pharmacy meets the
criteria described in
subclauses (I) and (II).
Materials submitted under the
preceding sentence shall
include a certification by an
accountant on behalf of the
pharmacy or the submission of
tax returns filed by the
pharmacy during the relevant
periods, as requested by the
Secretary.
(21) Special payment rule for specified items and
supplies.--
(A) In general.--Notwithstanding the
preceding provisions of this subsection, for
specified items and supplies (described in
subparagraph (B)) furnished during 2005, the
payment amount otherwise determined under this
subsection for such specified items and
supplies shall be reduced by the percentage
difference between--
(i) the amount of payment otherwise
determined for the specified item or
supply under this subsection for 2002,
and
(ii) the amount of payment for the
specified item or supply under chapter
89 of title 5, United States Code, as
identified in the column entitled
``Median FEHP Price'' in the table
entitled ``SUMMARY OF MEDICARE PRICES
COMPARED TO VA, MEDICAID, RETAIL, AND
FEHP PRICES FOR 16 ITEMS'' included in
the Testimony of the Inspector General
before the Senate Committee on
Appropriations, June 12, 2002, or any
subsequent report by the Inspector
General.
(B) Specified item or supply described.--For
purposes of subparagraph (A), a specified item
or supply means oxygen and oxygen equipment,
standard wheelchairs (including standard power
wheelchairs), nebulizers, diabetic supplies
consisting of lancets and testing strips,
hospital beds, and air mattresses, but only if
the HCPCS code for the item or supply is
identified in a table referred to in
subparagraph (A)(ii).
(C) Application of update to special payment
amount.--The covered item update under
paragraph (14) for specified items and supplies
for 2006 and each subsequent year shall be
applied to the payment amount under
subparagraph (A) unless payment is made for
such items and supplies under section 1847.
(22) Special payment rule for diabetic supplies.--
Notwithstanding the preceding provisions of this
subsection, for purposes of determining the payment
amount under this subsection for diabetic supplies
furnished on or after the first day of the calendar
quarter during 2013 that is at least 30 days after the
date of the enactment of this paragraph and before the
date described in paragraph (1)(H)(ii), the Secretary
shall recalculate and apply the covered item update
under paragraph (14) as if subparagraph (J)(i) of such
paragraph was amended by striking ``but only if
furnished through mail order''.
(b) Fee Schedules for Radiologist Services.--
(1) Development.--The Secretary shall develop--
(A) a relative value scale to serve as the
basis for the payment for radiologist services
under this part, and
(B) using such scale and appropriate
conversion factors and subject to subsection
(c)(1)(A), fee schedules (on a regional,
statewide, locality, or carrier service area
basis) for payment for radiologist services
under this part, to be implemented for such
services furnished during 1989.
(2) Consultation.--In carrying out paragraph (1), the
Secretary shall regularly consult closely with the
Physician Payment Review Commission, the American
College of Radiology, and other organizations
representing physicians or suppliers who furnish
radiologist services and shall share with them the data
and data analysis being used to make the determinations
under paragraph (1), including data on variations in
current medicare payments by geographic area, and by
service and physician specialty.
(3) Considerations.--In developing the relative value
scale and fee schedules under paragraph (1), the
Secretary--
(A) shall take into consideration variations
in the cost of furnishing such services among
geographic areas and among different sites
where services are furnished, and
(B) may also take into consideration such
other factors respecting the manner in which
physicians in different specialties furnish
such services as may be appropriate to assure
that payment amounts are equitable and designed
to promote effective and efficient provision of
radiologist services by physicians in the
different specialties.
(4) Savings.--
(A) Budget neutral fee schedules.--The
Secretary shall develop preliminary fee
schedules for 1989, which are designed to
result in the same amount of aggregate payments
(net of any coinsurance and deductibles under
sections 1833(a)(1)(J) and 1833(b)) for
radiologist services furnished in 1989 as would
have been made if this subsection had not been
enacted.
(B) Initial savings.--The fee schedules
established for payment purposes under this
subsection for services furnished in 1989 shall
be 97 percent of the amounts permitted under
these preliminary fee schedules developed under
subparagraph (A).
(C) 1990 fee schedules.--For radiologist
services (other than portable X-ray services)
furnished under this part during 1990, after
March 31 of such year, the conversion factors
used under this subsection shall be 96 percent
of the conversion factors that applied under
this subsection as of December 31, 1989.
(D) 1991 fee schedules.--For radiologist
services (other than portable X-ray services)
furnished under this part during 1991, the
conversion factors used in a locality under
this subsection shall, subject to clause (vii),
be reduced to the adjusted conversion factor
for the locality determined as follows:
(i) National weighted average
conversion factor.--The Secretary shall
estimate the national weighted average
of the conversion factors used under
this subsection for services furnished
during 1990 beginning on April 1, using
the best available data.
(ii) Reduced national weighted
average.--The national weighted average
estimated under clause (i) shall be
reduced by 13 percent.
(iii) Computation of 1990 locality
index relative to national average.--
The Secretary shall establish an index
which reflects, for each locality, the
ratio of the conversion factor used in
the locality under this subsection to
the national weighted average estimated
under clause (i).
(iv) Adjusted conversion factor.--The
adjusted conversion factor for the
professional or technical component of
a service in a locality is the sum of
\1/2\ of the locally-adjusted amount
determined under clause (v) and \1/2\
of the GPCI-adjusted amount determined
under clause (vi).
(v) Locally-adjusted amount.--For
purposes of clause (iv), the locally
adjusted amount determined under this
clause is the product of (I) the
national weighted average conversion
factor computed under clause (ii), and
(II) the index value established under
clause (iii) for the locality.
(vi) GPCI-adjusted amount.--For
purposes of clause (iv), the GPCI-
adjusted amount determined under this
clause is the sum of--
(I) the product of (a) the
portion of the reduced national
weighted average conversion
factor computed under clause
(ii) which is attributable to
physician work and (b) the
geographic work index value for
the locality (specified in
Addendum C to the Model Fee
Schedule for Physician Services
(published on September 4,
1990, 55 Federal Register pp.
36238-36243)); and
(II) the product of (a) the
remaining portion of the
reduced national weighted
average conversion factor
computed under clause (ii), and
(b) the geographic practice
cost index value specified in
section 1842(b)(14)(C)(iv) for
the locality.
In applying this clause with respect to
the professional component of a
service, 80 percent of the conversion
factor shall be considered to be
attributable to physician work and with
respect to the technical component of
the service, 0 percent shall be
considered to be attributable to
physician work.
(vii) Limits on conversion factor.--
The conversion factor to be applied to
a locality to the professional or
technical component of a service shall
not be reduced under this subparagraph
by more than 9.5 percent below the
conversion factor applied in the
locality under subparagraph (C) to such
component, but in no case shall the
conversion factor be less than 60
percent of the national weighted
average of the conversion factors
(computed under clause (i)).
(E) Rule for certain scanning services.--In
the case of the technical components of
magnetic resonance imaging (MRI) services and
computer assisted tomography (CAT) services
furnished after December 31, 1990, the amount
otherwise payable shall be reduced by 10
percent.
(F) Subsequent updating.--For radiologist
services furnished in subsequent years, the fee
schedules shall be the schedules for the
previous year updated by the percentage
increase in the MEI (as defined in section
1842(i)(3)) for the year.
(G) Nonparticipating physicians and
suppliers.--Each fee schedule so established
shall provide that the payment rate recognized
for nonparticipating physicians and suppliers
is equal to the appropriate percent (as defined
in section 1842(b)(4)(A)(iv)) of the payment
rate recognized for participating physicians
and suppliers.
(5) Limiting charges of nonparticipating physicians
and suppliers.--
(A) In general.--In the case of radiologist
services furnished after January 1, 1989, for
which payment is made under a fee schedule
under this subsection, if a nonparticipating
physician or supplier furnishes the service to
an individual entitled to benefits under this
part, the physician or supplier may not charge
the individual more than the limiting charge
(as defined in subparagraph (B)).
(B) Limiting charge defined.--In subparagraph
(A), the term ``limiting charge'' means, with
respect to a service furnished--
(i) in 1989, 125 percent of the
amount specified for the service in the
appropriate fee schedule established
under paragraph (1),
(ii) in 1990, 120 percent of the
amount specified for the service in the
appropriate fee schedule established
under paragraph (1), and
(iii) after 1990, 115 percent of the
amount specified for the service in the
appropriate fee schedule established
under paragraph (1).
(C) Enforcement.--If a physician or supplier
knowingly and willfully bills in violation of
subparagraph (A), the Secretary may apply
sanctions against such physician or supplier in
accordance with section 1842(j)(2) in the same
manner as such sanctions may apply to a
physician.
(6) Radiologist services defined.--For the purposes
of this subsection and section 1833(a)(1)(J), the term
``radiologist services'' only includes radiology
services performed by, or under the direction or
supervision of, a physician--
(A) who is certified, or eligible to be
certified, by the American Board of Radiology,
or
(B) for whom radiology services account for
at least 50 percent of the total amount of
charges made under this part.
(c) Payment and Standards for Screening Mammography.--
(1) In general.--With respect to expenses incurred
for screening mammography (as defined in section
1861(jj)), payment may be made only--
(A) for screening mammography conducted
consistent with the frequency permitted under
paragraph (2); and
(B) if the screening mammography is conducted
by a facility that has a certificate (or
provisional certificate) issued under section
354 of the Public Health Service Act.
(2) Frequency covered.--
(A) In general.--Subject to revision by the
Secretary under subparagraph (B)--
(i) no payment may be made under this
part for screening mammography
performed on a woman under 35 years of
age;
(ii) payment may be made under this
part for only one screening mammography
performed on a woman over 34 years of
age, but under 40 years of age; and
(iii) in the case of a woman over 39
years of age, payment may not be made
under this part for screening
mammography performed within 11 months
following the month in which a previous
screening mammography was performed.
(B) Revision of frequency.--
(i) Review.--The Secretary, in
consultation with the Director of the
National Cancer Institute, shall review
periodically the appropriate frequency
for performing screening mammography,
based on age and such other factors as
the Secretary believes to be pertinent.
(ii) Revision of frequency.--The
Secretary, taking into consideration
the review made under clause (i), may
revise from time to time the frequency
with which screening mammography may be
paid for under this subsection.
(d) Frequency Limits and Payment for Colorectal Cancer
Screening Tests.--
(1) Screening fecal-occult blood tests.--
(A) Payment amount.--The payment amount for
colorectal cancer screening tests consisting of
screening fecal-occult blood tests is equal to
the payment amount established for diagnostic
fecal-occult blood tests under section 1833(h).
(B) Frequency limit.--No payment may be made
under this part for a colorectal cancer
screening test consisting of a screening fecal-
occult blood test--
(i) if the individual is under 50
years of age; or
(ii) if the test is performed within
the 11 months after a previous
screening fecal-occult blood test.
(2) Screening flexible sigmoidoscopies.--
(A) Fee schedule.--With respect to colorectal
cancer screening tests consisting of screening
flexible sigmoidoscopies, payment under section
1848 shall be consistent with payment under
such section for similar or related services.
(B) Payment limit.--In the case of screening
flexible sigmoidoscopy services, payment under
this part shall not exceed such amount as the
Secretary specifies, based upon the rates
recognized for diagnostic flexible
sigmoidoscopy services.
(C) Facility payment limit.--
(i) In general.--Notwithstanding
subsections (i)(2)(A) and (t) of
section 1833, in the case of screening
flexible sigmoidoscopy services
furnished on or after January 1, 1999,
that--
(I) in accordance with
regulations, may be performed
in an ambulatory surgical
center and for which the
Secretary permits ambulatory
surgical center payments under
this part, and
(II) are performed in an
ambulatory surgical center or
hospital outpatient department,
payment under this part shall be based
on the lesser of the amount under the
fee schedule that would apply to such
services if they were performed in a
hospital outpatient department in an
area or the amount under the fee
schedule that would apply to such
services if they were performed in an
ambulatory surgical center in the same
area.
(ii) Limitation on coinsurance.--
Notwithstanding any other provision of
this title, in the case of a
beneficiary who receives the services
described in clause (i)--
(I) in computing the amount
of any applicable copayment,
the computation of such
coinsurance shall be based upon
the fee schedule under which
payment is made for the
services, and
(II) the amount of such
coinsurance is equal to 25
percent of the payment amount
under the fee schedule
described in subclause (I).
(D) Special rule for detected lesions.--If
during the course of such screening flexible
sigmoidoscopy, a lesion or growth is detected
which results in a biopsy or removal of the
lesion or growth, payment under this part shall
not be made for the screening flexible
sigmoidoscopy but shall be made for the
procedure classified as a flexible
sigmoidoscopy with such biopsy or removal.
(E) Frequency limit.--No payment may be made
under this part for a colorectal cancer
screening test consisting of a screening
flexible sigmoidoscopy--
(i) if the individual is under 50
years of age; or
(ii) if the procedure is performed
within the 47 months after a previous
screening flexible sigmoidoscopy or, in
the case of an individual who is not at
high risk for colorectal cancer, if the
procedure is performed within the 119
months after a previous screening
colonoscopy.
(3) Screening colonoscopy.--
(A) Fee schedule.--With respect to colorectal
cancer screening test consisting of a screening
colonoscopy, payment under section 1848 shall
be consistent with payment amounts under such
section for similar or related services.
(B) Payment limit.--In the case of screening
colonoscopy services, payment under this part
shall not exceed such amount as the Secretary
specifies, based upon the rates recognized for
diagnostic colonoscopy services.
(C) Facility payment limit.--
(i) In general.--Notwithstanding
subsections (i)(2)(A) and (t) of
section 1833, in the case of screening
colonoscopy services furnished on or
after January 1, 1999, that are
performed in an ambulatory surgical
center or a hospital outpatient
department, payment under this part
shall be based on the lesser of the
amount under the fee schedule that
would apply to such services if they
were performed in a hospital outpatient
department in an area or the amount
under the fee schedule that would apply
to such services if they were performed
in an ambulatory surgical center in the
same area.
(ii) Limitation on coinsurance.--
Notwithstanding any other provision of
this title, in the case of a
beneficiary who receives the services
described in clause (i)--
(I) in computing the amount
of any applicable coinsurance,
the computation of such
coinsurance shall be based upon
the fee schedule under which
payment is made for the
services, and
(II) the amount of such
coinsurance is equal to 25
percent of the payment amount
under the fee schedule
described in subclause (I).
(D) Special rule for detected lesions.--If
during the course of such screening
colonoscopy, a lesion or growth is detected
which results in a biopsy or removal of the
lesion or growth, payment under this part shall
not be made for the screening colonoscopy but
shall be made for the procedure classified as a
colonoscopy with such biopsy or removal.
(E) Frequency limit.--No payment may be made
under this part for a colorectal cancer
screening test consisting of a screening
colonoscopy for individuals at high risk for
colorectal cancer if the procedure is performed
within the 23 months after a previous screening
colonoscopy or for other individuals if the
procedure is performed within the 119 months
after a previous screening colonoscopy or
within 47 months after a previous screening
flexible sigmoidoscopy.
(e) Accreditation Requirement for Advanced Diagnostic Imaging
Services.--
(1) In general.--
(A) In general.--Beginning with January 1,
2012, with respect to the technical component
of advanced diagnostic imaging services for
which payment is made under the fee schedule
established under section 1848(b) and that are
furnished by a supplier, payment may only be
made if such supplier is accredited by an
accreditation organization designated by the
Secretary under paragraph (2)(B)(i).
(B) Advanced diagnostic imaging services
defined.--In this subsection, the term
``advanced diagnostic imaging services''
includes--
(i) diagnostic magnetic resonance
imaging, computed tomography, and
nuclear medicine (including positron
emission tomography); and
(ii) such other diagnostic imaging
services, including services described
in section 1848(b)(4)(B) (excluding X-
ray, ultrasound, and fluoroscopy), as
specified by the Secretary in
consultation with physician specialty
organizations and other stakeholders.
(C) Supplier defined.--In this subsection,
the term ``supplier'' has the meaning given
such term in section 1861(d).
(2) Accreditation organizations.--
(A) Factors for designation of accreditation
organizations.--The Secretary shall consider
the following factors in designating
accreditation organizations under subparagraph
(B)(i) and in reviewing and modifying the list
of accreditation organizations designated
pursuant to subparagraph (C):
(i) The ability of the organization
to conduct timely reviews of
accreditation applications.
(ii) Whether the organization has
established a process for the timely
integration of new advanced diagnostic
imaging services into the
organization's accreditation program.
(iii) Whether the organization uses
random site visits, site audits, or
other strategies for ensuring
accredited suppliers maintain adherence
to the criteria described in paragraph
(3).
(iv) The ability of the organization
to take into account the capacities of
suppliers located in a rural area (as
defined in section 1886(d)(2)(D)).
(v) Whether the organization has
established reasonable fees to be
charged to suppliers applying for
accreditation.
(vi) Such other factors as the
Secretary determines appropriate.
(B) Designation.--Not later than January 1,
2010, the Secretary shall designate
organizations to accredit suppliers furnishing
the technical component of advanced diagnostic
imaging services. The list of accreditation
organizations so designated may be modified
pursuant to subparagraph (C).
(C) Review and modification of list of
accreditation organizations.--
(i) In general.--The Secretary shall
review the list of accreditation
organizations designated under
subparagraph (B) taking into account
the factors under subparagraph (A).
Taking into account the results of such
review, the Secretary may, by
regulation, modify the list of
accreditation organizations designated
under subparagraph (B).
(ii) Special rule for accreditations
done prior to removal from list of
designated accreditation
organizations.--In the case where the
Secretary removes an organization from
the list of accreditation organizations
designated under subparagraph (B), any
supplier that is accredited by the
organization during the period
beginning on the date on which the
organization is designated as an
accreditation organization under
subparagraph (B) and ending on the date
on which the organization is removed
from such list shall be considered to
have been accredited by an organization
designated by the Secretary under
subparagraph (B) for the remaining
period such accreditation is in effect.
(3) Criteria for accreditation.--The Secretary shall
establish procedures to ensure that the criteria used
by an accreditation organization designated under
paragraph (2)(B) to evaluate a supplier that furnishes
the technical component of advanced diagnostic imaging
services for the purpose of accreditation of such
supplier is specific to each imaging modality. Such
criteria shall include--
(A) standards for qualifications of medical
personnel who are not physicians and who
furnish the technical component of advanced
diagnostic imaging services;
(B) standards for qualifications and
responsibilities of medical directors and
supervising physicians, including standards
that recognize the considerations described in
paragraph (4);
(C) procedures to ensure that equipment used
in furnishing the technical component of
advanced diagnostic imaging services meets
performance specifications;
(D) standards that require the supplier have
procedures in place to ensure the safety of
persons who furnish the technical component of
advanced diagnostic imaging services and
individuals to whom such services are
furnished;
(E) standards that require the establishment
and maintenance of a quality assurance and
quality control program by the supplier that is
adequate and appropriate to ensure the
reliability, clarity, and accuracy of the
technical quality of diagnostic images produced
by such supplier; and
(F) any other standards or procedures the
Secretary determines appropriate.
(4) Recognition in standards for the evaluation of
medical directors and supervising physicians.--The
standards described in paragraph (3)(B) shall recognize
whether a medical director or supervising physician--
(A) in a particular specialty receives
training in advanced diagnostic imaging
services in a residency program;
(B) has attained, through experience, the
necessary expertise to be a medical director or
a supervising physician;
(C) has completed any continuing medical
education courses relating to such services; or
(D) has met such other standards as the
Secretary determines appropriate.
(5) Rule for accreditations made prior to
designation.--In the case of a supplier that is
accredited before January 1, 2010, by an accreditation
organization designated by the Secretary under
paragraph (2)(B) as of January 1, 2010, such supplier
shall be considered to have been accredited by an
organization designated by the Secretary under such
paragraph as of January 1, 2012, for the remaining
period such accreditation is in effect.
(f) Reduction in Payments for Physician Pathology Services
During 1991.--
(1) In general.--For physician pathology services
furnished under this part during 1991, the prevailing
charges used in a locality under this part shall be 7
percent below the prevailing charges used in the
locality under this part in 1990 after March 31.
(2) Limitation.--The prevailing charge for the
technical and professional components of an physician
pathology service furnished by a physician through an
independent laboratory shall not be reduced pursuant to
paragraph (1) to the extent that such reduction would
reduce such prevailing charge below 115 percent of the
prevailing charge for the professional component of
such service when furnished by a hospital-based
physician in the same locality. For purposes of the
preceding sentence, an independent laboratory is a
laboratory that is independent of a hospital and
separate from the attending or consulting physicians'
office.
(g) Payment for Outpatient Critical Access Hospital
Services.--
(1) In general.--The amount of payment for outpatient
critical access hospital services of a critical access
hospital is equal to 101 percent of the reasonable
costs of the hospital in providing such services,
unless the hospital makes the election under paragraph
(2).
(2) Election of cost-based hospital outpatient
service payment plus fee schedule for professional
services.--A critical access hospital may elect to be
paid for outpatient critical access hospital services
amounts equal to the sum of the following, less the
amount that such hospital may charge as described in
section 1866(a)(2)(A):
(A) Facility fee.--With respect to facility
services, not including any services for which
payment may be made under subparagraph (B), 101
percent of the reasonable costs of the critical
access hospital in providing such services.
(B) Fee schedule for professional services.--
With respect to professional services otherwise
included within outpatient critical access
hospital services, 115 percent of such amounts
as would otherwise be paid under this part if
such services were not included in outpatient
critical access hospital services. Subsections
(x) and (y) of section 1833 shall not be taken
into account in determining the amounts that
would otherwise be paid pursuant to the
preceding sentence.
The Secretary may not require, as a condition for
applying subparagraph (B) with respect to a critical
access hospital, that each physician or other
practitioner providing professional services in the
hospital must assign billing rights with respect to
such services, except that such subparagraph shall not
apply to those physicians and practitioners who have
not assigned such billing rights.
(3) Disregarding charges.--The payment amounts under
this subsection shall be determined without regard to
the amount of the customary or other charge.
(4) Treatment of clinical diagnostic laboratory
services.--No coinsurance, deductible, copayment, or
other cost-sharing otherwise applicable under this part
shall apply with respect to clinical diagnostic
laboratory services furnished as an outpatient critical
access hospital service. Nothing in this title shall be
construed as providing for payment for clinical
diagnostic laboratory services furnished as part of
outpatient critical access hospital services, other
than on the basis described in this subsection. For
purposes of the preceding sentence and section
1861(mm)(3), clinical diagnostic laboratory services
furnished by a critical access hospital shall be
treated as being furnished as part of outpatient
critical access services without regard to whether the
individual with respect to whom such services are
furnished is physically present in the critical access
hospital, or in a skilled nursing facility or a clinic
(including a rural health clinic) that is operated by a
critical access hospital, at the time the specimen is
collected.
(5) Coverage of costs for certain emergency room on-
call providers.--In determining the reasonable costs of
outpatient critical access hospital services under
paragraphs (1) and (2)(A), the Secretary shall
recognize as allowable costs, amounts (as defined by
the Secretary) for reasonable compensation and related
costs for physicians, physician assistants, nurse
practitioners, and clinical nurse specialists who are
on-call (as defined by the Secretary) to provide
emergency services but who are not present on the
premises of the critical access hospital involved, and
are not otherwise furnishing services covered under
this title and are not on-call at any other provider or
facility.
(h) Payment for Prosthetic Devices and Orthotics and
Prosthetics.--
(1) General rule for payment.--
(A) In general.--Payment under this
subsection for prosthetic devices and orthotics
and prosthetics shall be made in a lump-sum
amount for the purchase of the item in an
amount equal to 80 percent of the payment basis
described in subparagraph (B).
(B) Payment basis.--Except as provided in
subparagraphs (C), (E), and (H)(i), the payment
basis described in this subparagraph is the
lesser of--
(i) the actual charge for the item;
or
(ii) the amount recognized under
paragraph (2) as the purchase price for
the item.
(C) Exception for certain public home health
agencies.--Subparagraph (B)(i) shall not apply
to an item furnished by a public home health
agency (or by another home health agency which
demonstrates to the satisfaction of the
Secretary that a significant portion of its
patients are low income) free of charge or at
nominal charges to the public.
(D) Exclusive payment rule.--Subject to
subparagraph (H)(ii), this subsection shall
constitute the exclusive provision of this
title for payment for prosthetic devices,
orthotics, and prosthetics under this part or
under part A to a home health agency.
(E) Exception for certain items.--Payment for
ostomy supplies, tracheostomy supplies, and
urologicals shall be made in accordance with
subparagraphs (B) and (C) of section
1834(a)(2).
(F) Special payment rules for certain
prosthetics and custom-fabricated orthotics.--
(i) In general.--No payment shall be
made under this subsection for an item
of custom-fabricated orthotics
described in clause (ii) or for an item
of prosthetics unless such item is--
(I) furnished by a qualified
practitioner; and
(II) fabricated by a
qualified practitioner or a
qualified supplier at a
facility that meets such
criteria as the Secretary
determines appropriate.
(ii) Description of custom-fabricated
item.--
(I) In general.--An item
described in this clause is an
item of custom-fabricated
orthotics that requires
education, training, and
experience to custom-fabricate
and that is included in a list
established by the Secretary in
subclause (II). Such an item
does not include shoes and shoe
inserts.
(II) List of items.--The
Secretary, in consultation with
appropriate experts in
orthotics (including national
organizations representing
manufacturers of orthotics),
shall establish and update as
appropriate a list of items to
which this subparagraph
applies. No item may be
included in such list unless
the item is individually
fabricated for the patient over
a positive model of the
patient.
(iii) Qualified practitioner
defined.--In this subparagraph, the
term ``qualified practitioner'' means a
physician or other individual who--
(I) is a qualified physical
therapist or a qualified
occupational therapist;
(II) in the case of a State
that provides for the licensing
of orthotics and prosthetics,
is licensed in orthotics or
prosthetics by the State in
which the item is supplied; or
(III) in the case of a State
that does not provide for the
licensing of orthotics and
prosthetics, is specifically
trained and educated to provide
or manage the provision of
prosthetics and custom-designed
or -fabricated orthotics, and
is certified by the American
Board for Certification in
Orthotics and Prosthetics, Inc.
or by the Board for Orthotist/
Prosthetist Certification, or
is credentialed and approved by
a program that the Secretary
determines, in consultation
with appropriate experts in
orthotics and prosthetics, has
training and education
standards that are necessary to
provide such prosthetics and
orthotics.
(iv) Qualified supplier defined.--In
this subparagraph, the term ``qualified
supplier'' means any entity that is
accredited by the American Board for
Certification in Orthotics and
Prosthetics, Inc. or by the Board for
Orthotist/Prosthetist Certification, or
accredited and approved by a program
that the Secretary determines has
accreditation and approval standards
that are essentially equivalent to
those of such Board.
(G) Replacement of prosthetic devices and
parts.--
(i) In general.--Payment shall be
made for the replacement of prosthetic
devices which are artificial limbs, or
for the replacement of any part of such
devices, without regard to continuous
use or useful lifetime restrictions if
an ordering physician determines that
the provision of a replacement device,
or a replacement part of such a device,
is necessary because of any of the
following:
(I) A change in the
physiological condition of the
patient.
(II) An irreparable change in
the condition of the device, or
in a part of the device.
(III) The condition of the
device, or the part of the
device, requires repairs and
the cost of such repairs would
be more than 60 percent of the
cost of a replacement device,
or, as the case may be, of the
part being replaced.
(ii) Confirmation may be required if
device or part being replaced is less
than 3 years old.--If a physician
determines that a replacement device,
or a replacement part, is necessary
pursuant to clause (i)--
(I) such determination shall
be controlling; and
(II) such replacement device
or part shall be deemed to be
reasonable and necessary for
purposes of section
1862(a)(1)(A);
except that if the device, or part,
being replaced is less than 3 years old
(calculated from the date on which the
beneficiary began to use the device or
part), the Secretary may also require
confirmation of necessity of the
replacement device or replacement part,
as the case may be.
(H) Application of competitive acquisition to
orthotics; limitation of inherent
reasonableness authority.--In the case of
orthotics described in paragraph (2)(C) of
section 1847(a) furnished on or after January
1, 2009, subject to subsection (a)(1)(G), that
are included in a competitive acquisition
program in a competitive acquisition area under
such section--
(i) the payment basis under this
subsection for such orthotics furnished
in such area shall be the payment basis
determined under such competitive
acquisition program; and
(ii) subject to subsection (a)(1)(G),
the Secretary may use information on
the payment determined under such
competitive acquisition programs to
adjust the payment amount otherwise
recognized under subparagraph (B)(ii)
for an area that is not a competitive
acquisition area under section 1847,
and in the case of such adjustment,
paragraphs (8) and (9) of section
1842(b) shall not be applied.
(2) Purchase price recognized.--For purposes of
paragraph (1), the amount that is recognized under this
paragraph as the purchase price for prosthetic devices,
orthotics, and prosthetics is the amount described in
subparagraph (C) of this paragraph, determined as
follows:
(A) Computation of local purchase price.--
Each carrier under section 1842 shall compute a
base local purchase price for the item as
follows:
(i) The carrier shall compute a base
local purchase price for each item
equal to the average reasonable charge
in the locality for the purchase of the
item for the 12-month period ending
with June 1987.
(ii) The carrier shall compute a
local purchase price, with respect to
the furnishing of each particular
item--
(I) in 1989 and 1990, equal
to the base local purchase
price computed under clause (i)
increased by the percentage
increase in the consumer price
index for all urban consumers
(United States city average)
for the 6-month period ending
with December 1987, or
(II) in 1991, 1992 or 1993,
equal to the local purchase
price computed under this
clause for the previous year
increased by the applicable
percentage increase for the
year.
(B) Computation of regional purchase price.--
With respect to the furnishing of a particular
item in each region (as defined by the
Secretary), the Secretary shall compute a
regional purchase price--
(i) for 1992, equal to the average
(weighted by relative volume of all
claims among carriers) of the local
purchase prices for the carriers in the
region computed under subparagraph
(A)(ii)(II) for the year, and
(ii) for each subsequent year, equal
to the regional purchase price computed
under this subparagraph for the
previous year increased by the
applicable percentage increase for the
year.
(C) Purchase price recognized.--For purposes
of paragraph (1) and subject to subparagraph
(D), the amount that is recognized under this
paragraph as the purchase price for each item
furnished--
(i) in 1989, 1990, or 1991, is 100
percent of the local purchase price
computed under subparagraph (A)(ii);
(ii) in 1992, is the sum of (I) 75
percent of the local purchase price
computed under subparagraph (A)(ii)(II)
for 1992, and (II) 25 percent of the
regional purchase price computed under
subparagraph (B) for 1992;
(iii) in 1993, is the sum of (I) 50
percent of the local purchase price
computed under subparagraph (A)(ii)(II)
for 1993, and (II) 50 percent of the
regional purchase price computed under
subparagraph (B) for 1993; and
(iv) in 1994 or a subsequent year, is
the regional purchase price computed
under subparagraph (B) for that year.
(D) Range on amount recognized.--The amount
that is recognized under subparagraph (C) as
the purchase price for an item furnished--
(i) in 1992, may not exceed 125
percent, and may not be lower than 85
percent, of the average of the purchase
prices recognized under such
subparagraph for all the carrier
service areas in the United States in
that year; and
(ii) in a subsequent year, may not
exceed 120 percent, and may not be
lower than 90 percent, of the average
of the purchase prices recognized under
such subparagraph for all the carrier
service areas in the United States in
that year.
(3) Applicability of certain provisions relating to
durable medical equipment.--Paragraphs (12) and (17)
and subparagraphs (A) and (B) of paragraph (10) and
paragraph (11) of subsection (a) shall apply to
prosthetic devices, orthotics, and prosthetics in the
same manner as such provisions apply to covered items
under such subsection.
(4) Definitions.--In this subsection--
(A) the term ``applicable percentage
increase'' means--
(i) for 1991, 0 percent;
(ii) for 1992 and 1993, the
percentage increase in the consumer
price index for all urban consumers
(United States city average) for the
12-month period ending with June of the
previous year;
(iii) for 1994 and 1995, 0 percent;
(iv) for 1996 and 1997, the
percentage increase in the consumer
price index for all urban consumers
(United States city average) for the
12-month period ending with June of the
previous year;
(v) for each of the years 1998
through 2000, 1 percent;
(vi) for 2001, the percentage
increase in the consumer price index
for all urban consumers (U.S. city
average) for the 12-month period ending
with June 2000;
(vii) for 2002, 1 percent;
(viii) for 2003, the percentage
increase in the consumer price index
for all urban consumers (United States
city average) for the 12-month period
ending with June of the previous year;
(ix) for 2004, 2005, and 2006, 0
percent;
(x) for for each of 2007 through
2010, the percentage increase in the
consumer price index for all urban
consumers (United States city average)
for the 12-month period ending with
June of the previous year; and
(xi) for 2011 and each subsequent
year--
(I) the percentage increase
in the consumer price index for
all urban consumers (United
States city average) for the
12-month period ending with
June of the previous year,
reduced by--
(II) the productivity
adjustment described in section
1886(b)(3)(B)(xi)(II).
(B) the term ``prosthetic devices'' has the
meaning given such term in section 1861(s)(8),
except that such term does not include
parenteral and enteral nutrition nutrients,
supplies, and equipment and does not include an
implantable item for which payment may be made
under section 1833(t); and
(C) the term ``orthotics and prosthetics''
has the meaning given such term in section
1861(s)(9) (and includes shoes described in
section 1861(s)(12)), but does not include
intraocular lenses or medical supplies
(including catheters, catheter supplies, ostomy
bags, and supplies related to ostomy care)
furnished by a home health agency under section
1861(m)(5).
The application of subparagraph (A)(xi)(II) may result
in the applicable percentage increase under
subparagraph (A) being less than 0.0 for a year, and
may result in payment rates under this subsection for a
year being less than such payment rates for the
preceding year.
(5) Documentation created by orthotists and
prosthetists.--For purposes of determining the
reasonableness and medical necessity of orthotics and
prosthetics, documentation created by an orthotist or
prosthetist shall be considered part of the
individual's medical record to support documentation
created by eligible professionals described in section
1848(k)(3)(B).
(i) Payment for Surgical Dressings.--
(1) In general.--Payment under this subsection for
surgical dressings (described in section 1861(s)(5))
shall be made in a lump sum amount for the purchase of
the item in an amount equal to 80 percent of the lesser
of--
(A) the actual charge for the item; or
(B) a payment amount determined in accordance
with the methodology described in subparagraphs
(B) and (C) of subsection (a)(2) (except that
in applying such methodology, the national
limited payment amount referred to in such
subparagraphs shall be initially computed based
on local payment amounts using average
reasonable charges for the 12-month period
ending December 31, 1992, increased by the
covered item updates described in such
subsection for 1993 and 1994).
(2) Exceptions.--Paragraph (1) shall not apply to
surgical dressings that are--
(A) furnished as an incident to a physician's
professional service; or
(B) furnished by a home health agency.
(j) Requirements for Suppliers of Medical Equipment and
Supplies.--
(1) Issuance and renewal of supplier number.--
(A) Payment.--Except as provided in
subparagraph (C), no payment may be made under
this part after the date of the enactment of
the Social Security Act Amendments of 1994 for
items furnished by a supplier of medical
equipment and supplies unless such supplier
obtains (and renews at such intervals as the
Secretary may require) a supplier number.
(B) Standards for possessing a supplier
number.--A supplier may not obtain a supplier
number unless--
(i) for medical equipment and
supplies furnished on or after the date
of the enactment of the Social Security
Act Amendments of 1994 and before
January 1, 1996, the supplier meets
standards prescribed by the Secretary
in regulations issued on June 18, 1992;
and
(ii) for medical equipment and
supplies furnished on or after January
1, 1996, the supplier meets revised
standards prescribed by the Secretary
(in consultation with representatives
of suppliers of medical equipment and
supplies, carriers, and consumers) that
shall include requirements that the
supplier--
(I) comply with all
applicable State and Federal
licensure and regulatory
requirements;
(II) maintain a physical
facility on an appropriate
site;
(III) have proof of
appropriate liability
insurance; and
(IV) meet such other
requirements as the Secretary
may specify.
(C) Exception for items furnished as incident
to a physician's service.--Subparagraph (A)
shall not apply with respect to medical
equipment and supplies furnished incident to a
physician's service.
(D) Prohibition against multiple supplier
numbers.--The Secretary may not issue more than
one supplier number to any supplier of medical
equipment and supplies unless the issuance of
more than one number is appropriate to identify
subsidiary or regional entities under the
supplier's ownership or control.
(E) Prohibition against delegation of
supplier determinations.--The Secretary may not
delegate (other than by contract under section
1842) the responsibility to determine whether
suppliers meet the standards necessary to
obtain a supplier number.
(2) Certificates of medical necessity.--
(A) Limitation on information provided by
suppliers on certificates of medical
necessity.--
(i) In general.--Effective 60 days
after the date of the enactment of the
Social Security Act Amendments of 1994,
a supplier of medical equipment and
supplies may distribute to physicians,
or to individuals entitled to benefits
under this part, a certificate of
medical necessity for commercial
purposes which contains no more than
the following information completed by
the supplier:
(I) An identification of the
supplier and the beneficiary to
whom such medical equipment and
supplies are furnished.
(II) A description of such
medical equipment and supplies.
(III) Any product code
identifying such medical
equipment and supplies.
(IV) Any other administrative
information (other than
information relating to the
beneficiary's medical
condition) identified by the
Secretary.
(ii) Information on payment amount
and charges.--If a supplier distributes
a certificate of medical necessity
containing any of the information
permitted to be supplied under clause
(i), the supplier shall also list on
the certificate of medical necessity
the fee schedule amount and the
supplier's charge for the medical
equipment or supplies being furnished
prior to distribution of such
certificate to the physician.
(iii) Penalty.--Any supplier of
medical equipment and supplies who
knowingly and willfully distributes a
certificate of medical necessity in
violation of clause (i) or fails to
provide the information required under
clause (ii) is subject to a civil money
penalty in an amount not to exceed
$1,000 for each such certificate of
medical necessity so distributed. The
provisions of section 1128A (other than
subsections (a) and (b)) shall apply to
civil money penalties under this
subparagraph in the same manner as they
apply to a penalty or proceeding under
section 1128A(a).
(B) Definition.--For purposes of this
paragraph, the term ``certificate of medical
necessity'' means a form or other document
containing information required by the carrier
to be submitted to show that an item is
reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve
the functioning of a malformed body member.
(3) Coverage and review criteria.--The Secretary
shall annually review the coverage and utilization of
items of medical equipment and supplies to determine
whether such items should be made subject to coverage
and utilization review criteria, and if appropriate,
shall develop and apply such criteria to such items.
(4) Limitation on patient liability.--If a supplier
of medical equipment and supplies (as defined in
paragraph (5))--
(A) furnishes an item or service to a
beneficiary for which no payment may be made by
reason of paragraph (1);
(B) furnishes an item or service to a
beneficiary for which payment is denied in
advance under subsection (a)(15); or
(C) furnishes an item or service to a
beneficiary for which payment is denied under
section 1862(a)(1);
any expenses incurred for items and services furnished
to an individual by such a supplier not on an assigned
basis shall be the responsibility of such supplier. The
individual shall have no financial responsibility for
such expenses and the supplier shall refund on a timely
basis to the individual (and shall be liable to the
individual for) any amounts collected from the
individual for such items or services. The provisions
of subsection (a)(18) shall apply to refunds required
under the previous sentence in the same manner as such
provisions apply to refunds under such subsection.
(5) Definition.--The term ``medical equipment and
supplies'' means--
(A) durable medical equipment (as defined in
section 1861(n));
(B) prosthetic devices (as described in
section 1861(s)(8));
(C) orthotics and prosthetics (as described
in section 1861(s)(9));
(D) surgical dressings (as described in
section 1861(s)(5));
(E) such other items as the Secretary may
determine; and
(F) for purposes of paragraphs (1) and (3)--
(i) home dialysis supplies and
equipment (as described in section
1861(s)(2)(F)),
(ii) immunosuppressive drugs (as
described in section 1861(s)(2)(J)),
(iii) therapeutic shoes for diabetics
(as described in section 1861(s)(12)),
(iv) oral drugs prescribed for use as
an anticancer therapeutic agent (as
described in section 1861(s)(2)(Q)),
and
(v) self-administered erythropoetin
(as described in section
1861(s)(2)(P)).
(k) Payment for Outpatient Therapy Services and Comprehensive
Outpatient Rehabilitation Services.--
(1) In general.--With respect to services described
in section 1833(a)(8) or 1833(a)(9) for which payment
is determined under this subsection, the payment basis
shall be--
(A) for services furnished during 1998, the
amount determined under paragraph (2); or
(B) for services furnished during a
subsequent year, 80 percent of the lesser of--
(i) the actual charge for the
services, or
(ii) the applicable fee schedule
amount (as defined in paragraph (3))
for the services.
(2) Payment in 1998 based upon adjusted reasonable
costs.--The amount under this paragraph for services is
the lesser of--
(A) the charges imposed for the services, or
(B) the adjusted reasonable costs (as defined
in paragraph (4)) for the services,
less 20 percent of the amount of the charges imposed
for such services.
(3) Applicable fee schedule amount.--In this
subsection, the term ``applicable fee schedule amount''
means, with respect to services furnished in a year,
the amount determined under the fee schedule
established under section 1848 for such services
furnished during the year or, if there is no such fee
schedule established for such services, the amount
determined under the fee schedule established for such
comparable services as the Secretary specifies.
(4) Adjusted reasonable costs.--In paragraph (2), the
term ``adjusted reasonable costs'' means, with respect
to any services, reasonable costs determined for such
services, reduced by 10 percent. The 10-percent
reduction shall not apply to services described in
section 1833(a)(8)(B) (relating to services provided by
hospitals).
(5) Uniform coding.--For claims for services
submitted on or after April 1, 1998, for which the
amount of payment is determined under this subsection,
the claim shall include a code (or codes) under a
uniform coding system specified by the Secretary that
identifies the services furnished.
(6) Restraint on billing.--The provisions of
subparagraphs (A) and (B) of section 1842(b)(18) shall
apply to therapy services for which payment is made
under this subsection in the same manner as they apply
to services provided by a practitioner described in
section 1842(b)(18)(C).
(7) Adjustment in discount for certain multiple
therapy services.--In the case of therapy services
furnished on or after April 1, 2013, and for which
payment is made under this subsection pursuant to the
applicable fee schedule amount (as defined in paragraph
(3)), instead of the 25 percent multiple procedure
payment reduction specified in the final rule published
by the Secretary in the Federal Register on November
29, 2010, the reduction percentage shall be 50 percent.
(l) Establishment of Fee Schedule for Ambulance Services.--
(1) In general.--The Secretary shall establish a fee
schedule for payment for ambulance services whether
provided directly by a supplier or provider or under
arrangement with a provider under this part through a
negotiated rulemaking process described in title 5,
United States Code, and in accordance with the
requirements of this subsection.
(2) Considerations.--In establishing such fee
schedule, the Secretary shall--
(A) establish mechanisms to control increases
in expenditures for ambulance services under
this part;
(B) establish definitions for ambulance
services which link payments to the type of
services provided;
(C) consider appropriate regional and
operational differences;
(D) consider adjustments to payment rates to
account for inflation and other relevant
factors; and
(E) phase in the application of the payment
rates under the fee schedule in an efficient
and fair manner consistent with paragraph (11),
except that such phase-in shall provide for
full payment of any national mileage rate for
ambulance services provided by suppliers that
are paid by carriers in any of the 50 States
where payment by a carrier for such services
for all such suppliers in such State did not,
prior to the implementation of the fee
schedule, include a separate amount for all
mileage within the county from which the
beneficiary is transported.
(3) Savings.--In establishing such fee schedule, the
Secretary shall--
(A) ensure that the aggregate amount of
payments made for ambulance services under this
part during 2000 does not exceed the aggregate
amount of payments which would have been made
for such services under this part during such
year if the amendments made by section 4531(a)
of the Balanced Budget Act of 1997 continued in
effect, except that in making such
determination the Secretary shall assume an
update in such payments for 2002 equal to
percentage increase in the consumer price index
for all urban consumers (U.S. city average) for
the 12-month period ending with June of the
previous year reduced in the case of 2002 by
1.0 percentage points;
(B) set the payment amounts provided under
the fee schedule for services furnished in 2001
and each subsequent year at amounts equal to
the payment amounts under the fee schedule for
services furnished during the previous year,
increased, subject to subparagraph (C) and the
succeeding sentence of this paragraph, by the
percentage increase in the consumer price index
for all urban consumers (U.S. city average) for
the 12-month period ending with June of the
previous year reduced in the case of 2002 by
1.0 percentage points; and
(C) for 2011 and each subsequent year, after
determining the percentage increase under
subparagraph (B) for the year, reduce such
percentage increase by the productivity
adjustment described in section
1886(b)(3)(B)(xi)(II).
The application of subparagraph (C) may result in the
percentage increase under subparagraph (B) being less
than 0.0 for a year, and may result in payment rates
under the fee schedule under this subsection for a year
being less than such payment rates for the preceding
year.
(4) Consultation.--In establishing the fee schedule
for ambulance services under this subsection, the
Secretary shall consult with various national
organizations representing individuals and entities who
furnish and regulate ambulance services and share with
such organizations relevant data in establishing such
schedule.
(5) Limitation on review.--There shall be no
administrative or judicial review under section 1869 or
otherwise of the amounts established under the fee
schedule for ambulance services under this subsection,
including matters described in paragraph (2).
(6) Restraint on billing.--The provisions of
subparagraphs (A) and (B) of section 1842(b)(18) shall
apply to ambulance services for which payment is made
under this subsection in the same manner as they apply
to services provided by a practitioner described in
section 1842(b)(18)(C).
(7) Coding system.--The Secretary may require the
claim for any services for which the amount of payment
is determined under this subsection to include a code
(or codes) under a uniform coding system specified by
the Secretary that identifies the services furnished.
(8) Services furnished by critical access
hospitals.--Notwithstanding any other provision of this
subsection, the Secretary shall pay 101 percent of the
reasonable costs incurred in furnishing ambulance
services if such services are furnished--
(A) by a critical access hospital (as defined
in section 1861(mm)(1)), or
(B) by an entity that is owned and operated
by a critical access hospital,
but only if the critical access hospital or entity is
the only provider or supplier of ambulance services
that is located within a 35-mile drive of such critical
access hospital.
(9) Transitional assistance for rural providers.--In
the case of ground ambulance services furnished on or
after July 1, 2001, and before January 1, 2004, for
which the transportation originates in a rural area (as
defined in section 1886(d)(2)(D)) or in a rural census
tract of a metropolitan statistical area (as determined
under the most recent modification of the Goldsmith
Modification, originally published in the Federal
Register on February 27, 1992 (57 Fed. Reg. 6725)), the
fee schedule established under this subsection shall
provide that, with respect to the payment rate for
mileage for a trip above 17 miles, and up to 50 miles,
the rate otherwise established shall be increased by
not less than \1/2\ of the additional payment per mile
established for the first 17 miles of such a trip
originating in a rural area.
(10) Phase-in providing floor using blend of fee
schedule and regional fee schedules.--In carrying out
the phase-in under paragraph (2)(E) for each level of
ground service furnished in a year, the portion of the
payment amount that is based on the fee schedule shall
be the greater of the amount determined under such fee
schedule (without regard to this paragraph) or the
following blended rate of the fee schedule under
paragraph (1) and of a regional fee schedule for the
region involved:
(A) For 2004 (for services furnished on or
after July 1, 2004), the blended rate shall be
based 20 percent on the fee schedule under
paragraph (1) and 80 percent on the regional
fee schedule.
(B) For 2005, the blended rate shall be based
40 percent on the fee schedule under paragraph
(1) and 60 percent on the regional fee
schedule.
(C) For 2006, the blended rate shall be based
60 percent on the fee schedule under paragraph
(1) and 40 percent on the regional fee
schedule.
(D) For 2007, 2008, and 2009, the blended
rate shall be based 80 percent on the fee
schedule under paragraph (1) and 20 percent on
the regional fee schedule.
(E) For 2010 and each succeeding year, the
blended rate shall be based 100 percent on the
fee schedule under paragraph (1).
For purposes of this paragraph, the Secretary shall
establish a regional fee schedule for each of the nine
census divisions (referred to in section 1886(d)(2))
using the methodology (used in establishing the fee
schedule under paragraph (1)) to calculate a regional
conversion factor and a regional mileage payment rate
and using the same payment adjustments and the same
relative value units as used in the fee schedule under
such paragraph.
(11) Adjustment in payment for certain long trips.--
In the case of ground ambulance services furnished on
or after July 1, 2004, and before January 1, 2009,
regardless of where the transportation originates, the
fee schedule established under this subsection shall
provide that, with respect to the payment rate for
mileage for a trip above 50 miles the per mile rate
otherwise established shall be increased by \1/4\ of
the payment per mile otherwise applicable to miles in
excess of 50 miles in such trip.
(12) Assistance for rural providers furnishing
services in low population density areas.--
(A) In general.--In the case of ground
ambulance services furnished on or after July
1, 2004, and before January 1, 2023, for which
the transportation originates in a qualified
rural area (identified under subparagraph
(B)(iii)), the Secretary shall provide for a
percent increase in the base rate of the fee
schedule for a trip established under this
subsection. In establishing such percent
increase, the Secretary shall estimate the
average cost per trip for such services (not
taking into account mileage) in the lowest
quartile as compared to the average cost per
trip for such services (not taking into account
mileage) in the highest quartile of all rural
county populations.
(B) Identification of qualified rural
areas.--
(i) Determination of population
density in area.--Based upon data from
the United States decennial census for
the year 2000, the Secretary shall
determine, for each rural area, the
population density for that area.
(ii) Ranking of areas.--The Secretary
shall rank each such area based on such
population density.
(iii) Identification of qualified
rural areas.--The Secretary shall
identify those areas (in subparagraph
(A) referred to as ``qualified rural
areas'') with the lowest population
densities that represent, if each such
area were weighted by the population of
such area (as used in computing such
population densities), an aggregate
total of 25 percent of the total of the
population of all such areas.
(iv) Rural area.--For purposes of
this paragraph, the term ``rural area''
has the meaning given such term in
section 1886(d)(2)(D). If feasible, the
Secretary shall treat a rural census
tract of a metropolitan statistical
area (as determined under the most
recent modification of the Goldsmith
Modification, originally published in
the Federal Register on February 27,
1992 (57 Fed. Reg. 6725) as a rural
area for purposes of this paragraph.
(v) Judicial review.--There shall be
no administrative or judicial review
under section 1869, 1878, or otherwise,
respecting the identification of an
area under this subparagraph.
(13) Temporary increase for ground ambulance
services.--
(A) In general.--After computing the rates
with respect to ground ambulance services under
the other applicable provisions of this
subsection, in the case of such services
furnished on or after July 1, 2004, and before
January 1, 2007, and for such services
furnished on or after July 1, 2008, and before
January 1, 2023, for which the transportation
originates in--
(i) a rural area described in
paragraph (9) or in a rural census
tract described in such paragraph, the
fee schedule established under this
section shall provide that the rate for
the service otherwise established,
after the application of any increase
under paragraphs (11) and (12), shall
be increased by 2 percent (or 3 percent
if such service is furnished on or
after July 1, 2008, and before January
1, 2023); and
(ii) an area not described in clause
(i), the fee schedule established under
this subsection shall provide that the
rate for the service otherwise
established, after the application of
any increase under paragraph (11),
shall be increased by 1 percent (or 2
percent if such service is furnished on
or after July 1, 2008, and before
January 1, 2023).
(B) Application of increased payments after
applicable period.--The increased payments
under subparagraph (A) shall not be taken into
account in calculating payments for services
furnished after the applicable period specified
in such subparagraph.
(14) Providing appropriate coverage of rural air
ambulance services.--
(A) In general.--The regulations described in
section 1861(s)(7) shall provide, to the extent
that any ambulance services (whether ground or
air) may be covered under such section, that a
rural air ambulance service (as defined in
subparagraph (C)) is reimbursed under this
subsection at the air ambulance rate if the air
ambulance service--
(i) is reasonable and necessary based
on the health condition of the
individual being transported at or
immediately prior to the time of the
transport; and
(ii) complies with equipment and crew
requirements established by the
Secretary.
(B) Satisfaction of requirement of medically
necessary.--The requirement of subparagraph
(A)(i) is deemed to be met for a rural air
ambulance service if--
(i) subject to subparagraph (D), such
service is requested by a physician or
other qualified medical personnel (as
specified by the Secretary) who
certifies or reasonably determines that
the individual's condition is such that
the time needed to transport the
individual by land or the instability
of transportation by land poses a
threat to the individual's survival or
seriously endangers the individual's
health; or
(ii) such service is furnished
pursuant to a protocol that is
established by a State or regional
emergency medical service (EMS) agency
and recognized or approved by the
Secretary under which the use of an air
ambulance is recommended, if such
agency does not have an ownership
interest in the entity furnishing such
service.
(C) Rural air ambulance service defined.--For
purposes of this paragraph, the term ``rural
air ambulance service'' means fixed wing and
rotary wing air ambulance service in which the
point of pick up of the individual occurs in a
rural area (as defined in section
1886(d)(2)(D)) or in a rural census tract of a
metropolitan statistical area (as determined
under the most recent modification of the
Goldsmith Modification, originally published in
the Federal Register on February 27, 1992 (57
Fed. Reg. 6725)).
(D) Limitation.--
(i) In general.--Subparagraph (B)(i)
shall not apply if there is a financial
or employment relationship between the
person requesting the rural air
ambulance service and the entity
furnishing the ambulance service, or an
entity under common ownership with the
entity furnishing the air ambulance
service, or a financial relationship
between an immediate family member of
such requester and such an entity.
(ii) Exception.--Where a hospital and
the entity furnishing rural air
ambulance services are under common
ownership, clause (i) shall not apply
to remuneration (through employment or
other relationship) by the hospital of
the requester or immediate family
member if the remuneration is for
provider-based physician services
furnished in a hospital (as described
in section 1887) which are reimbursed
under part A and the amount of the
remuneration is unrelated directly or
indirectly to the provision of rural
air ambulance services.
(15) Payment adjustment for non-emergency ambulance
transports for esrd beneficiaries.--The fee schedule
amount otherwise applicable under the preceding
provisions of this subsection shall be reduced by 10
percent for ambulance services furnished during the
period beginning on October 1, 2013, and ending on
September 30, 2018, and by 23 percent for such services
furnished on or after October 1, 2018, consisting of
non-emergency basic life support services involving
transport of an individual with end-stage renal disease
for renal dialysis services (as described in section
1881(b)(14)(B)) furnished other than on an emergency
basis by a provider of services or a renal dialysis
facility.
(16) Prior authorization for repetitive scheduled
non-emergent ambulance transports.--
(A) In general.--Beginning January 1, 2017,
if the expansion to all States of the model of
prior authorization described in paragraph (2)
of section 515(a) of the Medicare Access and
CHIP Reauthorization Act of 2015 meets the
requirements described in paragraphs (1)
through (3) of section 1115A(c), then the
Secretary shall expand such model to all
States.
(B) Funding.--The Secretary shall use funds
made available under section 1893(h)(10) to
carry out this paragraph.
(C) Clarification regarding budget
neutrality.--Nothing in this paragraph may be
construed to limit or modify the application of
section 1115A(b)(3)(B) to models described in
such section, including with respect to the
model described in subparagraph (A) and
expanded beginning on January 1, 2017, under
such subparagraph.
(17) Submission of cost and other information.--
(A) Development of data collection system.--
The Secretary shall develop a data collection
system (which may include use of a cost survey)
to collect cost, revenue, utilization, and
other information determined appropriate by the
Secretary with respect to providers of services
(in this paragraph referred to as
``providers'') and suppliers of ground
ambulance services. Such system shall be
designed to collect information--
(i) needed to evaluate the extent to
which reported costs relate to payment
rates under this subsection;
(ii) on the utilization of capital
equipment and ambulance capacity,
including information consistent with
the type of information described in
section 1121(a); and
(iii) on different types of ground
ambulance services furnished in
different geographic locations,
including rural areas and low
population density areas described in
paragraph (12).
(B) Specification of data collection
system.--
(i) In general.--The Secretary
shall--
(I) not later than December
31, 2019, specify the data
collection system under
subparagraph (A); and
(II) identify the providers
and suppliers of ground
ambulance services that would
be required to submit
information under such data
collection system, including
the representative sample
described in clause (ii).
(ii) Determination of representative
sample.--
(I) In general.--Not later
than December 31, 2019, with
respect to the data collection
for the first year under such
system, and for each subsequent
year through 2024, the
Secretary shall determine a
representative sample to submit
information under the data
collection system.
(II) Requirements.--The
sample under subclause (I)
shall be representative of the
different types of providers
and suppliers of ground
ambulance services (such as
those providers and suppliers
that are part of an emergency
service or part of a government
organization) and the
geographic locations in which
ground ambulance services are
furnished (such as urban,
rural, and low population
density areas).
(III) Limitation.--The
Secretary shall not include an
individual provider or supplier
of ground ambulance services in
the sample under subclause (I)
in 2 consecutive years, to the
extent practicable.
(C) Reporting of cost information.--For each
year, a provider or supplier of ground
ambulance services identified by the Secretary
under subparagraph (B)(i)(II) as being required
to submit information under the data collection
system with respect to a period for the year
shall submit to the Secretary information
specified under the system. Such information
shall be submitted in a form and manner, and at
a time, specified by the Secretary for purposes
of this subparagraph.
(D) Payment reduction for failure to
report.--
(i) In general.--Beginning January 1,
2022, subject to clause (ii), a 10
percent reduction to payments under
this subsection shall be made for the
applicable period (as defined in clause
(ii)) to a provider or supplier of
ground ambulance services that--
(I) is required to submit
information under the data
collection system with respect
to a period under subparagraph
(C); and
(II) does not sufficiently
submit such information, as
determined by the Secretary.
(ii) Applicable period defined.--For
purposes of clause (i), the term
``applicable period'' means, with
respect to a provider or supplier of
ground ambulance services, a year
specified by the Secretary not more
than 2 years after the end of the
period with respect to which the
Secretary has made a determination
under clause (i)(II) that the provider
or supplier of ground ambulance
services failed to sufficiently submit
information under the data collection
system.
(iii) Hardship exemption.--The
Secretary may exempt a provider or
supplier from the payment reduction
under clause (i) with respect to an
applicable period in the event of
significant hardship, such as a natural
disaster, bankruptcy, or other similar
situation that the Secretary determines
interfered with the ability of the
provider or supplier of ground
ambulance services to submit such
information in a timely manner for the
specified period.
(iv) Informal review.--The Secretary
shall establish a process under which a
provider or supplier of ground
ambulance services may seek an informal
review of a determination that the
provider or supplier is subject to the
payment reduction under clause (i).
(E) Ongoing data collection.--
(i) Revision of data collection
system.--The Secretary may, as the
Secretary determines appropriate and,
if available, taking into consideration
the report (or reports) under
subparagraph (F), revise the data
collection system under subparagraph
(A).
(ii) Subsequent data collection.--In
order to continue to evaluate the
extent to which reported costs relate
to payment rates under this subsection
and for other purposes the Secretary
deems appropriate, the Secretary shall
require providers and suppliers of
ground ambulance services to submit
information for years after 2024 as the
Secretary determines appropriate, but
in no case less often than once every 3
years.
(F) Ground ambulance data collection system
study.--
(i) In general.--Not later than March
15, 2023, and as determined necessary
by the Medicare Payment Advisory
Commission thereafter, such Commission
shall assess, and submit to Congress a
report on, information submitted by
providers and suppliers of ground
ambulance services through the data
collection system under subparagraph
(A), the adequacy of payments for
ground ambulance services under this
subsection, and geographic variations
in the cost of furnishing such
services.
(ii) Contents.--A report under clause
(i) shall contain the following:
(I) An analysis of
information submitted through
the data collection system.
(II) An analysis of any
burden on providers and
suppliers of ground ambulance
services associated with the
data collection system.
(III) A recommendation as to
whether information should
continue to be submitted
through such data collection
system or if such system should
be revised under subparagraph
(E)(i).
(IV) Other information
determined appropriate by the
Commission.
(G) Public availability.--The Secretary shall
post information on the results of the data
collection under this paragraph on the Internet
website of the Centers for Medicare & Medicaid
Services, as determined appropriate by the
Secretary.
(H) Implementation.--The Secretary shall
implement this paragraph through notice and
comment rulemaking.
(I) Administration.--Chapter 35 of title 44,
United States Code, shall not apply to the
collection of information required under this
subsection.
(J) Limitations on review.--There shall be no
administrative or judicial review under section
1869, section 1878, or otherwise of the data
collection system or identification of
respondents under this paragraph.
(K) Funding for implementation.--For purposes
of carrying out subparagraph (A), 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 fiscal year
2018. Amounts transferred under this
subparagraph shall remain available until
expended.
(m) Payment for Telehealth Services.--
(1) In general.--The Secretary shall pay for
telehealth services that are furnished via a
telecommunications system by a physician (as defined in
section 1861(r)) or a practitioner (described in
section 1842(b)(18)(C)) to an eligible telehealth
individual enrolled under this part notwithstanding
that the individual physician or practitioner providing
the telehealth service is not at the same location as
the beneficiary. For purposes of the preceding
sentence, in the case of any Federal telemedicine
demonstration program conducted in Alaska or Hawaii,
the term ``telecommunications system'' includes store-
and-forward technologies that provide for the
asynchronous transmission of health care information in
single or multimedia formats.
(2) Payment amount.--
(A) Distant site.--The Secretary shall pay to
a physician or practitioner located at a
distant site that furnishes a telehealth
service to an eligible telehealth individual an
amount equal to the amount that such physician
or practitioner would have been paid under this
title had such service been furnished without
the use of a telecommunications system.
(B) Facility fee for originating site.--
(i) In general.--Subject to clause
(ii) and paragraph (6)(C), with respect
to a telehealth service, subject to
section 1833(a)(1)(U), there shall be
paid to the originating site a facility
fee equal to--
(I) for the period beginning
on October 1, 2001, and ending
on December 31, 2001, and for
2002, $20; and
(II) for a subsequent year,
the facility fee specified in
subclause (I) or this subclause
for the preceding year
increased by the percentage
increase in the MEI (as defined
in section 1842(i)(3)) for such
subsequent year.
(ii) No facility fee if originating
site is the home.--No facility fee
shall be paid under this subparagraph
to an originating site described in
paragraph (4)(C)(ii)(X).
(C) Telepresenter not required.--Nothing in
this subsection shall be construed as requiring
an eligible telehealth individual to be
presented by a physician or practitioner at the
originating site for the furnishing of a
service via a telecommunications system, unless
it is medically necessary (as determined by the
physician or practitioner at the distant site).
(3) Limitation on beneficiary charges.--
(A) Physician and practitioner.--The
provisions of section 1848(g) and subparagraphs
(A) and (B) of section 1842(b)(18) shall apply
to a physician or practitioner receiving
payment under this subsection in the same
manner as they apply to physicians or
practitioners under such sections.
(B) Originating site.--The provisions of
section 1842(b)(18) shall apply to originating
sites receiving a facility fee in the same
manner as they apply to practitioners under
such section.
(4) Definitions.--For purposes of this subsection:
(A) Distant site.--The term ``distant site''
means the site at which the physician or
practitioner is located at the time the service
is provided via a telecommunications system.
(B) Eligible telehealth individual.--The term
``eligible telehealth individual'' means an
individual enrolled under this part who
receives a telehealth service furnished at an
originating site.
(C) Originating site.--
(i) In general.--Except as provided
in paragraphs (5), (6), and (7), the
term``originating site'' means only
those sites described in clause (ii) at
which the eligible telehealth
individual is located at the time the
service is furnished via a
telecommunications system and only if
such site is located--
(I) in an area that is
designated as a rural health
professional shortage area
under section 332(a)(1)(A) of
the Public Health Service Act
(42 U.S.C. 254e(a)(1)(A));
(II) in a county that is not
included in a Metropolitan
Statistical Area; or
(III) from an entity that
participates in a Federal
telemedicine demonstration
project that has been approved
by (or receives funding from)
the Secretary of Health and
Human Services as of December
31, 2000.
(ii) Sites described.--The sites
referred to in clause (i) are the
following sites:
(I) The office of a physician
or practitioner.
(II) A critical access
hospital (as defined in section
1861(mm)(1)).
(III) A rural health clinic
(as defined in section
1861(aa)(2)).
(IV) A Federally qualified
health center (as defined in
section 1861(aa)(4)).
(V) A hospital (as defined in
section 1861(e)).
(VI) A hospital-based or
critical access hospital-based
renal dialysis center
(including satellites).
(VII) A skilled nursing
facility (as defined in section
1819(a)).
(VIII) A community mental
health center (as defined in
section 1861(ff)(3)(B)).
(IX) A renal dialysis
facility, but only for purposes
of section 1881(b)(3)(B).
(X) The home of an
individual, but only for
purposes of section
1881(b)(3)(B) or telehealth
services described in paragraph
(7).
(D) Physician.--The term ``physician'' has
the meaning given that term in section 1861(r).
(E) Practitioner.--The term ``practitioner''
has the meaning given that term in section
1842(b)(18)(C).
(F) Telehealth service.--
(i) In general.--The term
``telehealth service'' means
professional consultations, office
visits, and office psychiatry services
(identified as of July 1, 2000, by
HCPCS codes 99241-99275, 99201-99215,
90804-90809, and 90862 (and as
subsequently modified by the
Secretary)), and any additional service
specified by the Secretary.
(ii) Yearly update.--The Secretary
shall establish a process that
provides, on an annual basis, for the
addition or deletion of services (and
HCPCS codes), as appropriate, to those
specified in clause (i) for authorized
payment under paragraph (1).
(5) Treatment of home dialysis monthly esrd-related
visit.--The geographic requirements described in
paragraph (4)(C)(i) shall not apply with respect to
telehealth services furnished on or after January 1,
2019, for purposes of section 1881(b)(3)(B), at an
originating site described in subclause (VI), (IX), or
(X) of paragraph (4)(C)(ii).
(6) Treatment of stroke telehealth services.--
(A) Non-application of originating site
requirements.--The requirements described in
paragraph (4)(C) shall not apply with respect
to telehealth services furnished on or after
January 1, 2019, for purposes of diagnosis,
evaluation, or treatment of symptoms of an
acute stroke, as determined by the Secretary.
(B) Inclusion of certain sites.--With respect
to telehealth services described in
subparagraph (A), the term ``originating site''
shall include any hospital (as defined in
section 1861(e)) or critical access hospital
(as defined in section 1861(mm)(1)), any mobile
stroke unit (as defined by the Secretary), or
any other site determined appropriate by the
Secretary, at which the eligible telehealth
individual is located at the time the service
is furnished via a telecommunications system.
(C) No originating site facility fee for new
sites.--No facility fee shall be paid under
paragraph (2)(B) to an originating site with
respect to a telehealth service described in
subparagraph (A) if the originating site does
not otherwise meet the requirements for an
originating site under paragraph (4)(C).
(7) Treatment of substance use disorder services
furnished through telehealth.--The geographic
requirements described in paragraph (4)(C)(i) shall not
apply with respect to telehealth services furnished on
or after July 1, 2019, to an eligible telehealth
individual with a substance use disorder diagnosis for
purposes of treatment of such disorder or co-occurring
mental health disorder, as determined by the Secretary,
at an originating site described in paragraph
(4)(C)(ii) (other than an originating site described in
subclause (IX) of such paragraph).
(n) Authority To Modify or Eliminate Coverage of Certain
Preventive Services.--Notwithstanding any other provision of
this title, effective beginning on January 1, 2010, if the
Secretary determines appropriate, the Secretary may--
(1) modify--
(A) the coverage of any preventive service
described in subparagraph (A) of section
1861(ddd)(3) to the extent that such
modification is consistent with the
recommendations of the United States Preventive
Services Task Force; and
(B) the services included in the initial
preventive physical examination described in
subparagraph (B) of such section; and
(2) provide that no payment shall be made under this
title for a preventive service described in
subparagraph (A) of such section that has not received
a grade of A, B, C, or I by such Task Force.
(o) Development and Implementation of Prospective Payment
System.--
(1) Development.--
(A) In general.--The Secretary shall develop
a prospective payment system for payment for
Federally qualified health center services
furnished by Federally qualified health centers
under this title. Such system shall include a
process for appropriately describing the
services furnished by Federally qualified
health centers and shall establish payment
rates for specific payment codes based on such
appropriate descriptions of services. Such
system shall be established to take into
account the type, intensity, and duration of
services furnished by Federally qualified
health centers. Such system may include
adjustments, including geographic adjustments,
determined appropriate by the Secretary.
(B) Collection of data and evaluation.--By
not later than January 1, 2011, the Secretary
shall require Federally qualified health
centers to submit to the Secretary such
information as the Secretary may require in
order to develop and implement the prospective
payment system under this subsection, including
the reporting of services using HCPCS codes.
(2) Implementation.--
(A) In general.--Notwithstanding section
1833(a)(3)(A), the Secretary shall provide, for
cost reporting periods beginning on or after
October 1, 2014, for payments of prospective
payment rates for Federally qualified health
center services furnished by Federally
qualified health centers under this title in
accordance with the prospective payment system
developed by the Secretary under paragraph (1).
(B) Payments.--
(i) Initial payments.--The Secretary
shall implement such prospective
payment system so that the estimated
aggregate amount of prospective payment
rates (determined prior to the
application of section 1833(a)(1)(Z))
under this title for Federally
qualified health center services in the
first year that such system is
implemented is equal to 100 percent of
the estimated amount of reasonable
costs (determined without the
application of a per visit payment
limit or productivity screen and prior
to the application of section
1866(a)(2)(A)(ii)) that would have
occurred for such services under this
title in such year if the system had
not been implemented.
(ii) Payments in subsequent years.--
Payment rates in years after the year
of implementation of such system shall
be the payment rates in the previous
year increased--
(I) in the first year after
implementation of such system,
by the percentage increase in
the MEI (as defined in section
1842(i)(3)) for the year
involved; and
(II) in subsequent years, by
the percentage increase in a
market basket of Federally
qualified health center goods
and services as promulgated
through regulations, or if such
an index is not available, by
the percentage increase in the
MEI (as defined in section
1842(i)(3)) for the year
involved.
(C) Preparation for pps implementation.--
Notwithstanding any other provision of law, the
Secretary may establish and implement by
program instruction or otherwise the payment
codes to be used under the prospective payment
system under this section.
(3) Additional payments for certain fqhcs with
physicians or other practitioners receiving data 2000
waivers.--
(A) In general.--In the case of a Federally
qualified health center with respect to which,
beginning on or after January 1, 2019,
Federally qualified health center services (as
defined in section 1861(aa)(3)) are furnished
for the treatment of opioid use disorder by a
physician or practitioner who meets the
requirements described in subparagraph (C), the
Secretary shall, subject to availability of
funds under subparagraph (D), make a payment
(at such time and in such manner as specified
by the Secretary) to such Federally qualified
health center after receiving and approving an
application submitted by such Federally
qualified health center under subparagraph (B).
Such a payment shall be in an amount determined
by the Secretary, based on an estimate of the
average costs of training for purposes of
receiving a waiver described in subparagraph
(C)(ii). Such a payment may be made only one
time with respect to each such physician or
practitioner.
(B) Application.--In order to receive a
payment described in subparagraph (A), a
Federally qualified health center shall submit
to the Secretary an application for such a
payment at such time, in such manner, and
containing such information as specified by the
Secretary. A Federally qualified health center
may apply for such a payment for each physician
or practitioner described in subparagraph (A)
furnishing services described in such
subparagraph at such center.
(C) Requirements.--For purposes of
subparagraph (A), the requirements described in
this subparagraph, with respect to a physician
or practitioner, are the following:
(i) The physician or practitioner is
employed by or working under contract
with a Federally qualified health
center described in subparagraph (A)
that submits an application under
subparagraph (B).
(ii) The physician or practitioner
first receives a waiver under section
303(g) of the Controlled Substances Act
on or after January 1, 2019.
(D) Funding.--For purposes of making payments
under this paragraph, there are appropriated,
out of amounts in the Treasury not otherwise
appropriated, $6,000,000, which shall remain
available until expended.
(p) Quality Incentives To Promote Patient Safety and Public
Health in Computed Tomography.--
(1) Quality incentives.--In the case of an applicable
computed tomography service (as defined in paragraph
(2)) for which payment is made under an applicable
payment system (as defined in paragraph (3)) and that
is furnished on or after January 1, 2016, using
equipment that is not consistent with the CT equipment
standard (described in paragraph (4)), the payment
amount for such service shall be reduced by the
applicable percentage (as defined in paragraph (5)).
(2) Applicable computed tomography services
defined.--In this subsection, the term ``applicable
computed tomography service'' means a service billed
using diagnostic radiological imaging codes for
computed tomography (identified as of January 1, 2014,
by HCPCS codes 70450-70498, 71250-71275, 72125-72133,
72191-72194, 73200-73206, 73700-73706, 74150-74178,
74261-74263, and 75571-75574 (and any succeeding
codes).
(3) Applicable payment system defined.--In this
subsection, the term ``applicable payment system''
means the following:
(A) The technical component and the technical
component of the global fee under the fee
schedule established under section 1848(b).
(B) The prospective payment system for
hospital outpatient department services under
section 1833(t).
(4) Consistency with ct equipment standard.--In this
subsection, the term ``not consistent with the CT
equipment standard'' means, with respect to an
applicable computed tomography service, that the
service was furnished using equipment that does not
meet each of the attributes of the National Electrical
Manufacturers Association (NEMA) Standard XR-29-2013,
entitled ``Standard Attributes on CT Equipment Related
to Dose Optimization and Management''. Through
rulemaking, the Secretary may apply successor
standards.
(5) Applicable percentage defined.--In this
subsection, the term ``applicable percentage'' means--
(A) for 2016, 5 percent; and
(B) for 2017 and subsequent years, 15
percent.
(6) Implementation.--
(A) Information.--The Secretary shall require
that information be provided and attested to by
a supplier and a hospital outpatient department
that indicates whether an applicable computed
tomography service was furnished that was not
consistent with the CT equipment standard
(described in paragraph (4)). Such information
may be included on a claim and may be a
modifier. Such information shall be verified,
as appropriate, as part of the periodic
accreditation of suppliers under section
1834(e) and hospitals under section 1865(a).
(B) Administration.--Chapter 35 of title 44,
United States Code, shall not apply to
information described in subparagraph (A).
(q) Recognizing Appropriate Use Criteria for Certain Imaging
Services.--
(1) Program established.--
(A) In general.--The 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 defined.--In
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 for an individual. To the
extent feasible, such criteria shall be
evidence-based.
(C) Applicable imaging service defined.--In
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 defined.--In 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 defined.--In 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.
(F) Furnishing professional defined.--In 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.
(2) Establishment of applicable appropriate use
criteria.--
(A) In general.--Not 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) Considerations.--In 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) Revisions.--The 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 criteria.--In the case where
the Secretary determines that more than one
appropriate use criterion applies with respect
to an applicable imaging service, the Secretary
shall apply 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 general.--The 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) Consultation.--The Secretary
shall consult with physicians,
practitioners, health care technology
experts, and other stakeholders in
specifying mechanisms under this
paragraph.
(iii) Inclusion of certain
mechanisms.--Mechanisms 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 general.--For 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) Requirements.--The 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
is more than one applicable
appropriate use criterion
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 list.--Not later than
April 1, 2016, the Secretary shall
publish a list of mechanisms specified
under this paragraph.
(ii) Periodic updating of list.--The
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 professional.--
Beginning 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 professional.--
Beginning 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) Exceptions.--The provisions of
subparagraphs (A) and (B) and paragraph (6)(A)
shall not apply to the following:
(i) Emergency services.--An
applicable imaging service ordered for
an individual with an emergency medical
condition (as defined in section
1867(e)(1)).
(ii) Inpatient services.--An
applicable imaging service ordered for
an inpatient and for which payment is
made under part A.
(iii) Significant hardship.--An
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 defined.--In
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 general.--With 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 professionals.--The
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 data.--The Secretary
shall use two years of data to identify outlier
ordering professionals under this paragraph.
(D) Process.--The Secretary shall establish a
process for determining when an outlier
ordering professional is no longer an outlier
ordering professional.
(E) Consultation with stakeholders.--The
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 general.--Beginning 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
authorization.--In applying prior authorization
under subparagraph (A), the Secretary shall
utilize only the applicable appropriate use
criteria specified under this subsection.
(C) Funding.--For 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) Construction.--Nothing 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.
(r) Payment for Renal Dialysis Services for Individuals With
Acute Kidney Injury.--
(1) Payment rate.--In the case of renal dialysis
services (as defined in subparagraph (B) of section
1881(b)(14)) furnished under this part by a renal
dialysis facility or provider of services paid under
such section during a year (beginning with 2017) to an
individual with acute kidney injury (as defined in
paragraph (2)), the amount of payment under this part
for such services shall be the base rate for renal
dialysis services determined for such year under such
section, as adjusted by any applicable geographic
adjustment factor applied under subparagraph
(D)(iv)(II) of such section and may be adjusted by the
Secretary (on a budget neutral basis for payments under
this paragraph) by any other adjustment factor under
subparagraph (D) of such section.
(2) Individual with acute kidney injury defined.--In
this subsection, the term ``individual with acute
kidney injury'' means an individual who has acute loss
of renal function and does not receive renal dialysis
services for which payment is made under section
1881(b)(14).
(s) Payment for Applicable Disposable Devices.--
(1) Separate payment.--The Secretary shall make a
payment (separate from the payments otherwise made
under section 1895) in the amount established under
paragraph (3) to a home health agency for an applicable
disposable device (as defined in paragraph (2)) when
furnished on or after January 1, 2017, to an individual
who receives home health services for which payment is
made under section 1895(b).
(2) Applicable disposable device.--In this
subsection, the term applicable disposable device means
a disposable device that, as determined by the
Secretary, is--
(A) a disposable negative pressure wound
therapy device that is an integrated system
comprised of a non-manual vacuum pump, a
receptacle for collecting exudate, and
dressings for the purposes of wound therapy;
and
(B) a substitute for, and used in lieu of, a
negative pressure wound therapy durable medical
equipment item that is an integrated system of
a negative pressure vacuum pump, a separate
exudate collection canister, and dressings that
would otherwise be covered for individuals for
such wound therapy.
(3) Payment amount.--The separate payment amount
established under this paragraph for an applicable
disposable device for a year shall be equal to the
amount of the payment that would be made under section
1833(t) (relating to payment for covered OPD services)
for the year for the Level I Healthcare Common
Procedure Coding System (HCPCS) code for which the
description for a professional service includes the
furnishing of such device.
(t) Site-of-Service Price Transparency.--
(1) In general.--In order to facilitate price
transparency with respect to items and services for
which payment may be made either to a hospital
outpatient department or to an ambulatory surgical
center under this title, the Secretary shall, for 2018
and each year thereafter, make available to the public
via a searchable Internet website, with respect to an
appropriate number of such items and services--
(A) the estimated payment amount for the item
or service under the outpatient department fee
schedule under subsection (t) of section 1833
and the ambulatory surgical center payment
system under subsection (i) of such section;
and
(B) the estimated amount of beneficiary
liability applicable to the item or service.
(2) Calculation of estimated beneficiary liability.--
For purposes of paragraph (1)(B), the estimated amount
of beneficiary liability, with respect to an item or
service, is the amount for such item or service for
which an individual who does not have coverage under a
Medicare supplemental policy certified under section
1882 or any other supplemental insurance coverage is
responsible.
(3) Implementation.--In carrying out this subsection,
the Secretary--
(A) shall include in the notice described in
section 1804(a) a notification of the
availability of the estimated amounts made
available under paragraph (1); and
(B) may utilize mechanisms in existence on
the date of enactment of this subsection, such
as the portion of the Internet website of the
Centers for Medicare & Medicaid Services on
which information comparing physician
performance is posted (commonly referred to as
the Physician Compare Internet website), to
make available such estimated amounts under
such paragraph.
(4) Funding.--For purposes of implementing this
subsection, the Secretary shall provide for the
transfer, from the Federal Supplementary Medical
Insurance Trust Fund under section 1841 to the Centers
for Medicare & Medicaid Services Program Management
Account, of $6,000,000 for fiscal year 2017, to remain
available until expended.
(u) Payment and Related Requirements for Home Infusion
Therapy.--
(1) Payment.--
(A) Single payment.--
(i) In general.--Subject to clause
(iii) and subparagraphs (B) and (C),
the Secretary shall implement a payment
system under which a single payment is
made under this title to a qualified
home infusion therapy supplier for
items and services described in
subparagraphs (A) and (B) of section
1861(iii)(2)) furnished by a qualified
home infusion therapy supplier (as
defined in section 1861(iii)(3)(D)) in
coordination with the furnishing of
home infusion drugs (as defined in
section 1861(iii)(3)(C)) under this
part.
(ii) Unit of single payment.--A unit
of single payment under the payment
system implemented under this
subparagraph is for each infusion drug
administration calendar day in the
individual's home. The Secretary shall,
as appropriate, establish single
payment amounts for types of infusion
therapy, including to take into account
variation in utilization of nursing
services by therapy type.
(iii) Limitation.--The single payment
amount determined under this
subparagraph after application of
subparagraph (B) and paragraph (3)
shall not exceed the amount determined
under the fee schedule under section
1848 for infusion therapy services
furnished in a calendar day if
furnished in a physician office
setting, except such single payment
shall not reflect more than 5 hours of
infusion for a particular therapy in a
calendar day.
(B) Required adjustments.--The Secretary
shall adjust the single payment amount
determined under subparagraph (A) for home
infusion therapy services under section
1861(iii)(1) to reflect other factors such as--
(i) a geographic wage index and other
costs that may vary by region; and
(ii) patient acuity and complexity of
drug administration.
(C) Discretionary adjustments.--
(i) In general.--Subject to clause
(ii), the Secretary may adjust the
single payment amount determined under
subparagraph (A) (after application of
subparagraph (B)) to reflect outlier
situations and other factors as the
Secretary determines appropriate.
(ii) Requirement of budget
neutrality.--Any adjustment under this
subparagraph shall be made in a budget
neutral manner.
(2) Considerations.--In developing the payment system
under this subsection, the Secretary may consider the
costs of furnishing infusion therapy in the home,
consult with home infusion therapy suppliers, consider
payment amounts for similar items and services under
this part and part A, and consider payment amounts
established by Medicare Advantage plans under part C
and in the private insurance market for home infusion
therapy (including average per treatment day payment
amounts by type of home infusion therapy).
(3) Annual updates.--
(A) In general.--Subject to subparagraph (B),
the Secretary shall update the single payment
amount under this subsection from year to year
beginning in 2022 by increasing the single
payment amount from the prior year by the
percentage increase in the Consumer Price Index
for all urban consumers (United States city
average) for the 12-month period ending with
June of the preceding year.
(B) Adjustment.--For each year, the Secretary
shall reduce the percentage increase described
in subparagraph (A) by the productivity
adjustment described in section
1886(b)(3)(B)(xi)(II). The application of the
preceding sentence may result in a percentage
being less than 0.0 for a year, and may result
in payment being less than such payment rates
for the preceding year.
(4) Authority to apply prior authorization.--The
Secretary may, as determined appropriate by the
Secretary, apply prior authorization for home infusion
therapy services under section 1861(iii)(1).
(5) Accreditation of qualified home infusion therapy
suppliers.--
(A) Factors for designation of accreditation
organizations.--The Secretary shall consider
the following factors in designating
accreditation organizations under subparagraph
(B) and in reviewing and modifying the list of
accreditation organizations designated pursuant
to subparagraph (C):
(i) The ability of the organization
to conduct timely reviews of
accreditation applications.
(ii) The ability of the organization
to take into account the capacities of
suppliers located in a rural area (as
defined in section 1886(d)(2)(D)).
(iii) Whether the organization has
established reasonable fees to be
charged to suppliers applying for
accreditation.
(iv) Such other factors as the
Secretary determines appropriate.
(B) Designation.--Not later than January 1,
2021, the Secretary shall designate
organizations to accredit suppliers furnishing
home infusion therapy. The list of
accreditation organizations so designated may
be modified pursuant to subparagraph (C).
(C) Review and modification of list of
accreditation organizations.--
(i) In general.--The Secretary shall
review the list of accreditation
organizations designated under
subparagraph (B) taking into account
the factors under subparagraph (A).
Taking into account the results of such
review, the Secretary may, by
regulation, modify the list of
accreditation organizations designated
under subparagraph (B).
(ii) Special rule for accreditations
done prior to removal from list of
designated accreditation
organizations.--In the case where the
Secretary removes an organization from
the list of accreditation organizations
designated under subparagraph (B), any
supplier that is accredited by the
organization during the period
beginning on the date on which the
organization is designated as an
accreditation organization under
subparagraph (B) and ending on the date
on which the organization is removed
from such list shall be considered to
have been accredited by an organization
designated by the Secretary under
subparagraph (B) for the remaining
period such accreditation is in effect.
(D) Rule for accreditations made prior to
designation.--In the case of a supplier that is
accredited before January 1, 2021, by an
accreditation organization designated by the
Secretary under subparagraph (B) as of January
1, 2019, such supplier shall be considered to
have been accredited by an organization
designated by the Secretary under such
paragraph as of January 1, 2023, for the
remaining period such accreditation is in
effect.
(6) Notification of infusion therapy options
available prior to furnishing home infusion therapy.--
Prior to the furnishing of home infusion therapy to an
individual, the physician who establishes the plan
described in section 1861(iii)(1) for the individual
shall provide notification (in a form, manner, and
frequency determined appropriate by the Secretary) of
the options available (such as home, physician's
office, hospital outpatient department) for the
furnishing of infusion therapy under this part.
(7) Home infusion therapy services temporary
transitional payment.--
(A) Temporary transitional payment.--
(i) In general.--The Secretary shall,
in accordance with the payment
methodology described in subparagraph
(B) and subject to the provisions of
this paragraph, provide a home infusion
therapy services temporary transitional
payment under this part to an eligible
home infusion supplier (as defined in
subparagraph (F)) for items and
services described in subparagraphs (A)
and (B) of section 1861(iii)(2))
furnished during the period specified
in clause (ii) by such supplier in
coordination with the furnishing of
transitional home infusion drugs (as
defined in clause (iii)).
(ii) Period specified.--For purposes
of clause (i), the period specified in
this clause is the period beginning on
January 1, 2019, and ending on the day
before the date of the implementation
of the payment system under paragraph
(1)(A).
(iii) Transitional home infusion drug
defined.--For purposes of this
paragraph, the term ``transitional home
infusion drug'' has the meaning given
to the term ``home infusion drug''
under section 1861(iii)(3)(C)), except
that clause (ii) of such section shall
not apply if a drug described in such
clause is identified in clauses (i),
(ii), (iii) or (iv) of subparagraph (C)
as of the date of the enactment of this
paragraph.
(B) Payment methodology.--For purposes of
this paragraph, the Secretary shall establish a
payment methodology, with respect to items and
services described in subparagraph (A)(i).
Under such payment methodology the Secretary
shall--
(i) create the three payment
categories described in clauses (i),
(ii), and (iii) of subparagraph (C);
(ii) assign drugs to such categories,
in accordance with such clauses;
(iii) assign appropriate Healthcare
Common Procedure Coding System (HCPCS)
codes to each payment category; and
(iv) establish a single payment
amount for each such payment category,
in accordance with subparagraph (D),
for each infusion drug administration
calendar day in the individual's home
for drugs assigned to such category.
(C) Payment categories.--
(i) Payment category 1.--The
Secretary shall create a payment
category 1 and assign to such category
drugs which are covered under the Local
Coverage Determination on External
Infusion Pumps (LCD number L33794) and
billed with the following HCPCS codes
(as identified as of January 1, 2018,
and as subsequently modified by the
Secretary): J0133, J0285, J0287, J0288,
J0289, J0895, J1170, J1250, J1265,
J1325, J1455, J1457, J1570, J2175,
J2260, J2270, J2274, J2278, J3010, or
J3285.
(ii) Payment category 2.--The
Secretary shall create a payment
category 2 and assign to such category
drugs which are covered under such
local coverage determination and billed
with the following HCPCS codes (as
identified as of January 1, 2018, and
as subsequently modified by the
Secretary): J1555 JB, J1559 JB, J1561
JB, J1562 JB, J1569 JB, or J1575 JB.
(iii) Payment category 3.--The
Secretary shall create a payment
category 3 and assign to such category
drugs which are covered under such
local coverage determination and billed
with the following HCPCS codes (as
identified as of January 1, 2018, and
as subsequently modified by the
Secretary): J9000, J9039, J9040, J9065,
J9100, J9190, J9200, J9360, or J9370.
(iv) Infusion drugs not otherwise
included.--With respect to drugs that
are not included in payment category 1,
2, or 3 under clause (i), (ii), or
(iii), respectively, the Secretary
shall assign to the most appropriate of
such categories, as determined by the
Secretary, drugs which are--
(I) covered under such local
coverage determination and
billed under HCPCS codes J7799
or J7999 (as identified as of
July 1, 2017, and as
subsequently modified by the
Secretary); or
(II) billed under any code
that is implemented after the
date of the enactment of this
paragraph and included in such
local coverage determination or
included in subregulatory
guidance as a home infusion
drug described in subparagraph
(A)(i).
(D) Payment amounts.--
(i) In general.--Under the payment
methodology, the Secretary shall pay
eligible home infusion suppliers, with
respect to items and services described
in subparagraph (A)(i) furnished during
the period described in subparagraph
(A)(ii) by such supplier to an
individual, at amounts equal to the
amounts determined under the physician
fee schedule established under section
1848 for services furnished during the
year for codes and units of such codes
described in clauses (ii), (iii), and
(iv) with respect to drugs included in
the payment category under subparagraph
(C) specified in the respective clause,
determined without application of the
geographic adjustment under subsection
(e) of such section.
(ii) Payment amount for category 1.--
For purposes of clause (i), the codes
and units described in this clause,
with respect to drugs included in
payment category 1 described in
subparagraph (C)(i), are one unit of
HCPCS code 96365 plus three units of
HCPCS code 96366 (as identified as of
January 1, 2018, and as subsequently
modified by the Secretary).
(iii) Payment amount for category
2.--For purposes of clause (i), the
codes and units described in this
clause, with respect to drugs included
in payment category 2 described in
subparagraph (C)(i), are one unit of
HCPCS code 96369 plus three units of
HCPCS code 96370 (as identified as of
January 1, 2018, and as subsequently
modified by the Secretary).
(iv) Payment amount for category 3.--
For purposes of clause (i), the codes
and units described in this clause,
with respect to drugs included in
payment category 3 described in
subparagraph (C)(i), are one unit of
HCPCS code 96413 plus three units of
HCPCS code 96415 (as identified as of
January 1, 2018, and as subsequently
modified by the Secretary).
(E) Clarifications.--
(i) Infusion drug administration
day.--For purposes of this subsection,
with respect to the furnishing of
transitional home infusion drugs or
home infusion drugs to an individual by
an eligible home infusion supplier or a
qualified home infusion therapy
supplier, a reference to payment to
such supplier for an infusion drug
administration calendar day in the
individual's home shall refer to
payment only for the date on which
professional services (as described in
section 1861(iii)(2)(A)) were furnished
to administer such drugs to such
individual. For purposes of the
previous sentence, an infusion drug
administration calendar day shall
include all such drugs administered to
such individual on such day.
(ii) Treatment of multiple drugs
administered on same infusion drug
administration day.--In the case that
an eligible home infusion supplier,
with respect to an infusion drug
administration calendar day in an
individual's home, furnishes to such
individual transitional home infusion
drugs which are not all assigned to the
same payment category under
subparagraph (C), payment to such
supplier for such infusion drug
administration calendar day in the
individual's home shall be a single
payment equal to the amount of payment
under this paragraph for the drug,
among all such drugs so furnished to
such individual during such calendar
day, for which the highest payment
would be made under this paragraph.
(F) Eligible home infusion suppliers.--In
this paragraph, the term ``eligible home
infusion supplier'' means a supplier that is
enrolled under this part as a pharmacy that
provides external infusion pumps and external
infusion pump supplies and that maintains all
pharmacy licensure requirements in the State in
which the applicable infusion drugs are
administered.
(G) Implementation.--Notwithstanding any
other provision of law, the Secretary may
implement this paragraph by program instruction
or otherwise.
(v) Payment for Outpatient Physical Therapy Services and
Outpatient Occupational Therapy Services Furnished by a Therapy
Assistant.--
(1) In general.--In the case of an outpatient
physical therapy service or outpatient occupational
therapy service furnished on or after January 1, 2022,
for which payment is made under section 1848 or
subsection (k), that is furnished in whole or in part
by a therapy assistant (as defined by the Secretary),
the amount of payment for such service shall be an
amount equal to 85 percent of the amount of payment
otherwise applicable for the service under this part.
Nothing in the preceding sentence shall be construed to
change applicable requirements with respect to such
services.
(2) Use of modifier.--
(A) Establishment.--Not later than January 1,
2019, the Secretary shall establish a modifier
to indicate (in a form and manner specified by
the Secretary), in the case of an outpatient
physical therapy service or outpatient
occupational therapy service furnished in whole
or in part by a therapy assistant (as so
defined), that the service was furnished by a
therapy assistant.
(B) Required use.--Each request for payment,
or bill submitted, for an outpatient physical
therapy service or outpatient occupational
therapy service furnished in whole or in part
by a therapy assistant (as so defined) on or
after January 1, 2020, shall include the
modifier established under subparagraph (A) for
each such service.
(3) Implementation.--The Secretary shall implement
this subsection through notice and comment rulemaking.
(w) Opioid Use Disorder Treatment Services.--
(1) In general.--The Secretary shall pay to an opioid
treatment program (as defined in paragraph (2) of
section 1861(jjj)) an amount that is equal to 100
percent of a bundled payment under this part for opioid
use disorder treatment services (as defined in
paragraph (1) of such section) that are furnished by
such program to an individual during an episode of care
(as defined by the Secretary) beginning on or after
January 1, 2020. The Secretary shall ensure, as
determined appropriate by the Secretary, that no
duplicative payments are made under this part or part D
for items and services furnished by an opioid treatment
program.
(2) Considerations.--The Secretary may implement this
subsection through one or more bundles based on the
type of medication provided (such as buprenorphine,
methadone, naltrexone, or a new innovative drug), the
frequency of services, the scope of services furnished,
characteristics of the individuals furnished such
services, or other factors as the Secretary determine
appropriate. In developing such bundles, the Secretary
may consider payment rates paid to opioid treatment
programs for comparable services under State plans
under title XIX or under the TRICARE program under
chapter 55 of title 10 of the United States Code.
(3) Annual updates.--The Secretary shall provide an
update each year to the bundled payment amounts under
this subsection.
(x) Prostate Cancer DNA Specimen Provenance Assay Tests.--
(1) Payment for covered tests.--
(A) In general.--Subject to subparagraph (B),
the payment amount for a prostate cancer DNA
Specimen Provenance Assay test (DSPA test) (as
defined in section 1861(kkk)) shall be $200.
Such payment shall be payment for all of the
specimens obtained from the biopsy furnished to
an individual that are tested.
(B) Limitation.--Payment for a DSPA test
under subparagraph (A) may only be made on an
assignment-related basis.
(C) Prohibition on separate payment.--No
separate payment shall be made for obtaining
DNA that was separately taken from an
individual at the time of a biopsy described in
subparagraph (A).
(2) HCPCS code and modifier assignment.--
(A) In general.--The Secretary shall assign
one or more HCPCS codes to a prostate cancer
DNA Specimen Provenance Assay test and may use
a modifier to facilitate making payment under
this section for such test.
(B) Identification of dna match on claim.--
The Secretary shall require an indication on a
claim for a prostate cancer DNA Specimen
Provenance Assay test of whether the DNA of the
prostate biopsy specimens match the DNA of the
individual diagnosed with prostate cancer. Such
indication may be made through use of a HCPCS
code, a modifier, or other means, as determined
appropriate by the Secretary.
(3) DNA match review.--
(A) In general.--The Secretary shall review
at least three years of claims under part B for
prostate cancer DNA Specimen Provenance Assay
tests to identify whether the DNA of the
prostate biopsy specimens match the DNA of the
individuals diagnosed with prostate cancer.
(B) Posting on internet website.--Not later
than July 1, 2023, the Secretary shall post on
the internet website of the Centers for
Medicare & Medicaid Services the findings of
the review conducted under subparagraph (A).
* * * * * * *
amounts of premiums
Sec. 1839. (a)(1) The Secretary shall, during September of
1983 and of each year thereafter, determine the monthly
actuarial rate for enrollees age 65 and over which shall be
applicable for the succeeding calendar year. Subject to
paragraphs (5) and (6), such actuarial rate shall be the amount
the Secretary estimates to be necessary so that the aggregate
amount for such calendar year with respect to those enrollees
age 65 and older will equal one-half of the total of the
benefits and administrative costs which he estimates will be
payable from the Federal Supplementary Medical Insurance Trust
Fund for services performed and related administrative costs
incurred in such calendar year with respect to such enrollees.
In calculating the monthly actuarial rate, the Secretary shall
include an appropriate amount for a contingency margin. In
applying this paragraph there shall not be taken into account
additional payments under section 1848(o) and section
1853(l)(3) and the Government contribution under section
1844(a)(3).
(2) The monthly premium of each individual enrolled under
this part for each month after December 1983 shall be the
amount determined under paragraph (3), adjusted as required in
accordance with subsections (b), (c), (f), and (i), and to
reflect any credit provided under section
1854(b)(1)(C)(ii)(III).
(3) The Secretary, during September of each year, shall
determine and promulgate a monthly premium rate for the
succeeding calendar year that (except as provided in subsection
(g)) is equal to 50 percent of the monthly actuarial rate for
enrollees age 65 and over, determined according to paragraph
(1), for that succeeding calendar year. Whenever the Secretary
promulgates the dollar amount which shall be applicable as the
monthly premium rate for any period, he shall, at the time such
promulgation is announced, issue a public statement setting
forth the actuarial assumptions and bases employed by him in
arriving at the amount of an adequate actuarial rate for
enrollees age 65 and older as provided in paragraph (1).
(4) The Secretary shall also, during September of 1983 and of
each year thereafter, determine the monthly actuarial rate for
disabled enrollees under age 65 which shall be applicable for
the succeeding calendar year. Such actuarial rate shall be the
amount the Secretary estimates to be necessary so that the
aggregate amount for such calendar year with respect to
disabled enrollees under age 65 will equal one-half of the
total of the benefits and administrative costs which he
estimates will be payable from the Federal Supplementary
Medical Insurance Trust Fund for services performed and related
administrative costs incurred in such calendar year with
respect to such enrollees. In calculating the monthly actuarial
rate under this paragraph, the Secretary shall include an
appropriate amount for a contingency margin.
(5)(A) In applying this part (including subsection (i) and
section 1833(b)), the monthly actuarial rate for enrollees age
65 and over for 2016 shall be determined as if subsection (f)
did not apply.
(B) Subsection (f) shall continue to be applied to paragraph
(6)(A) (during a repayment month, as described in paragraph
(6)(B)) and without regard to the application of subparagraph
(A).
(6)(A) With respect to a repayment month (as described in
subparagraph (B)), the monthly premium otherwise established
under paragraph (3) shall be increased by, subject to
subparagraph (D), $3.
(B) For purposes of this paragraph, a repayment month is a
month during a year, beginning with 2016, for which a balance
due amount is computed under subparagraph (C) as greater than
zero.
(C) For purposes of this paragraph, the balance due amount
computed under this subparagraph, with respect to a month, is
the amount estimated by the Chief Actuary of the Centers for
Medicare & Medicaid Services to be equal to--
(i) the amount transferred under section 1844(d)(1);
plus
(ii) the amount that is equal to the aggregate
reduction, for all individuals enrolled under this
part, in the income related monthly adjustment amount
as a result of the application of paragraph (5); minus
(iii) the amounts payable under this part as a result
of the application of this paragraph for preceding
months.
(D) If the balance due amount computed under subparagraph
(C), without regard to this subparagraph, for December of a
year would be less than zero, the Chief Actuary of the Centers
for Medicare & Medicaid Services shall estimate, and the
Secretary shall apply, a reduction to the dollar amount
increase applied under subparagraph (A) for each month during
such year in a manner such that the balance due amount for
January of the subsequent year is equal to zero.
(b) In the case of an individual whose coverage period began
pursuant to an enrollment after his initial enrollment period
(determined pursuant to subsection (c) or (d) of section 1837)
and not pursuant to a special enrollment period under
subsection (i)(4) or (l) of section 1837, the monthly premium
determined under subsection (a) (without regard to any
adjustment under subsection (i)) shall be increased by 10
percent of the monthly premium so determined for each full 12
months (in the same continuous period of eligibility) in which
he could have been but was not enrolled. For purposes of the
preceding sentence, there shall be taken into account (1) the
months which elapsed between the close of his initial
enrollment period and the close of the enrollment period in
which he enrolled, plus (in the case of an individual who
reenrolls) (2) the months which elapsed between the date of
termination of a previous coverage period and the close of the
enrollment period in which he reenrolled, but there shall not
be taken into account months for which the individual can
demonstrate that the individual was enrolled in a group health
plan described in section 1862(b)(1)(A)(v) by reason of the
individual's (or the individual's spouse's) current employment
or months during which the individual has not attained the age
of 65 and for which the individual can demonstrate that the
individual was enrolled in a large group health plan as an
active individual (as those terms are defined in section
1862(b)(1)(B)(iii)) or months for which the individual can
demonstrate that the individual was an individual described in
section 1837(k)(3) or months for which the individual can
demonstrate that the individual is an individual described in
paragraph (6)(B) of section 1086(d) of title 10, United States
Code, who is enrolled in the TRICARE program pursuant to such
section. Any increase in an individual's monthly premium under
the first sentence of this subsection with respect to a
particular continuous period of eligibility shall not be
applicable with respect to any other continuous period of
eligibility which such individual may have. No increase in the
premium shall be effected for a month in the case of an
individual who enrolls under this part during 2001, 2002, 2003,
or 2004 and who demonstrates to the Secretary before December
31, 2004, that the individual is a covered beneficiary (as
defined in section 1072(5) of title 10, United States Code).
The Secretary of Health and Human Services shall consult with
the Secretary of Defense in identifying individuals described
in the previous sentence.
(c) If any monthly premium determined under the foregoing
provisions of this section is not a multiple of 10 cents, such
premium shall be rounded to the nearest multiple of 10 cents.
(d) For purposes of subsection (b) (and section 1837(g)(1)),
an individual's ``continuous period of eligibility'' is the
period beginning with the first day on which he is eligible to
enroll under section 1836 and ending with his death; except
that any period during all of which an individual satisfied
paragraph (1) of section 1836 and which terminated in or before
the month preceding the month in which he attained age 65 shall
be a separate ``continuous period of eligibility'' with respect
to such individual (and each such period which terminates shall
be deemed not to have existed for purposes of subsequently
applying this section).
(e)(1) Upon the request of a State (or any appropriate State
or local governmental entity specified by the Secretary), the
Secretary may enter into an agreement with the State (or such
entity) under which the State (or such entity) agrees to pay on
a quarterly or other periodic basis to the Secretary (to be
deposited in the Treasury to the credit of the Federal
Supplementary Medical Insurance Trust Fund) an amount equal to
the amount of the part B late enrollment premium increases with
respect to the premiums for eligible individuals (as defined in
paragraph (3)(A)).
(2) No part B late enrollment premium increase shall apply to
an eligible individual for premiums for months for which the
amount of such an increase is payable under an agreement under
paragraph (1).
(3) In this subsection:
(A) The term ``eligible individual'' means an
individual who is enrolled under this part B and who is
within a class of individuals specified in the
agreement under paragraph (1).
(B) The term ``part B late enrollment premium
increase'' means any increase in a premium as a result
of the application of subsection (b).
(f) For any calendar year after 1988, if an individual is
entitled to monthly benefits under section 202 or 223 or to a
monthly annuity under section 3(a), 4(a), or 4(f) of the
Railroad Retirement Act of 1974 for November and December of
the preceding year, if the monthly premium of the individual
under this section for December and for January is deducted
from those benefits under section 1840(a)(1) or section
1840(b)(1), and if the amount of the individual's premium is
not adjusted for such January under subsection (i), the monthly
premium otherwise determined under this section for an
individual for that year shall not be increased, pursuant to
this subsection, to the extent that such increase would reduce
the amount of benefits payable to that individual for that
December below the amount of benefits payable to that
individual for that November (after the deduction of the
premium under this section). For purposes of this subsection,
retroactive adjustments or payments and deductions on account
of work shall not be taken into account in determining the
monthly benefits to which an individual is entitled under
section 202 or 223 or under the Railroad Retirement Act of
1974.
(g) In estimating the benefits and administrative costs which
will be payable from the Federal Supplementary Medical
Insurance Trust Fund for a year for purposes of determining the
monthly premium rate under subsection (a)(3), the Secretary
shall exclude an estimate of any benefits and administrative
costs attributable to--
(1) the application of section 1861(v)(1)(L)(viii) or
to the establishment under section 1861(v)(1)(L)(i)(V)
of a per visit limit at 106 percent of the median
(instead of 105 percent of the median), but only to the
extent payment for home health services under this
title is not being made under section 1895 (relating to
prospective payment for home health services); and
(2) the medicare prescription drug discount card and
transitional assistance program under section 1860D-31.
(h) Potential Application of Comparative Cost Adjustment in
CCA Areas.--
(1) In general.--Certain individuals who are residing
in a CCA area under section 1860C-1 who are not
enrolled in an MA plan under part C may be subject to a
premium adjustment under subsection (f) of such section
for months in which the CCA program under such section
is in effect in such area.
(2) No effect on late enrollment penalty or income-
related adjustment in subsidies.--Nothing in this
subsection or section 1860C-1(f) shall be construed as
affecting the amount of any premium adjustment under
subsection (b) or (i). Subsection (f) shall be applied
without regard to any premium adjustment referred to in
paragraph (1).
(3) Implementation.--In order to carry out a premium
adjustment under this subsection and section 1860C-1(f)
(insofar as it is effected through the manner of
collection of premiums under section 1840(a)), the
Secretary shall transmit to the Commissioner of Social
Security--
(A) at the beginning of each year, the name,
social security account number, and the amount
of the premium adjustment (if any) for each
individual enrolled under this part for each
month during the year; and
(B) periodically throughout the year,
information to update the information
previously transmitted under this paragraph for
the year.
(i) Reduction in Premium Subsidy Based on Income.--
(1) In general.--In the case of an individual whose
modified adjusted gross income exceeds the threshold
amount under paragraph (2), the monthly amount of the
premium subsidy applicable to the premium under this
section for a month after December 2006 shall be
reduced (and the monthly premium shall be increased) by
the monthly adjustment amount specified in paragraph
(3).
(2) Threshold amount.--For purposes of this
subsection, subject to paragraph (6), the threshold
amount is--
(A) except as provided in subparagraph (B),
$80,000 (or, beginning with 2018, $85,000), and
(B) in the case of a joint return, twice the
amount applicable under subparagraph (A) for
the calendar year.
(3) Monthly adjustment amount.--
(A) In general.--Subject to subparagraph (B),
the monthly adjustment amount specified in this
paragraph for an individual for a month in a
year is equal to the product of the following:
(i) Sliding scale percentage.--
Subject to paragraph (6), the
applicable percentage specified in the
applicable table in subparagraph (C)
for the individual minus 25 percentage
points.
(ii) Unsubsidized part b premium
amount.--
(I) 200 percent of the monthly
actuarial rate for enrollees age 65 and
over (as determined under subsection
(a)(1) for the year); plus
(II) 4 times the amount of
the increase in the monthly
premium under subsection (a)(6)
for a month in the year.
(B) 3-year phase in.--The monthly adjustment
amount specified in this paragraph for an
individual for a month in a year before 2009 is
equal to the following percentage of the
monthly adjustment amount specified in
subparagraph (A):
(i) For 2007, 33 percent.
(ii) For 2008, 67 percent.
(C) Applicable percentage.--
(i) In general.--
(I) Subject to paragraphs (5)
and (6), for years before 2018:
If the modified adjusted gross income is: The applicable
percentage is:
More than $80,000 but not more than $100,000.............35 percent
More than $100,000 but not more than $150,000............50 percent
More than $150,000 but not more than $200,000............65 percent
More than $200,000.......................................80 percent.
(II) Subject to paragraph
(5), for 2018:
If the modified adjusted gross income is: The applicable
percentage is:
More than $85,000 but not more than $107,000..... 35 percent
More than $107,000 but not more than $133,500.... 50 percent
More than $133,500 but not more than $160,000.... 65 percent
More than $160,000............................... 80 percent.
(III) Subject to paragraph
(5), for years beginning with
2019:
If the modified adjusted gross income is:......... The applicable
percentage is:
More than $85,000 but not more than $107,000...... 35 percent
More than $107,000 but not more than $133,500..... 50 percent
More than $133,500 but not more than $160,000..... 65 percent
More than $160,000 but less than $500,000......... 80 percent
At least $500,000................................. 85 percent.
(ii) Joint returns.--In the case of a
joint return, clause (i) shall be
applied by substituting dollar amounts
which are twice the dollar amounts
otherwise applicable under clause (i)
for the calendar year except, with
respect to the dollar amounts applied
in the last row of the table under
subclause (III) of such clause (and the
second dollar amount specified in the
second to last row of such table),
clause (i) shall be applied by
substituting dollar amounts which are
150 percent of such dollar amounts for
the calendar year.
(iii) Married individuals filing
separate returns.--In the case of an
individual who--
(I) is married as of the
close of the taxable year
(within the meaning of section
7703 of the Internal Revenue
Code of 1986) but does not file
a joint return for such year,
and
(II) does not live apart from
such individual's spouse at all
times during the taxable year,
clause (i) shall be applied by reducing
each of the dollar amounts otherwise
applicable under such clause for the
calendar year by the threshold amount
for such year applicable to an
unmarried individual.
(4) Modified adjusted gross income.--
(A) In general.--For purposes of this
subsection, the term ``modified adjusted gross
income'' means adjusted gross income (as
defined in section 62 of the Internal Revenue
Code of 1986)--
(i) determined without regard to
sections 135, 911, 931, and 933 of such
Code; and
(ii) increased by the amount of
interest received or accrued during the
taxable year which is exempt from tax
under such Code.
In the case of an individual filing a joint
return, any reference in this subsection to the
modified adjusted gross income of such
individual shall be to such return's modified
adjusted gross income.
(B) Taxable year to be used in determining
modified adjusted gross income.--
(i) In general.--In applying this
subsection for an individual's premiums
in a month in a year, subject to clause
(ii) and subparagraph (C), the
individual's modified adjusted gross
income shall be such income determined
for the individual's last taxable year
beginning in the second calendar year
preceding the year involved.
(ii) Temporary use of other data.--
If, as of October 15 before a calendar
year, the Secretary of the Treasury
does not have adequate data for an
individual in appropriate electronic
form for the taxable year referred to
in clause (i), the individual's
modified adjusted gross income shall be
determined using the data in such form
from the previous taxable year. Except
as provided in regulations prescribed
by the Commissioner of Social Security
in consultation with the Secretary, the
preceding sentence shall cease to apply
when adequate data in appropriate
electronic form are available for the
individual for the taxable year
referred to in clause (i), and proper
adjustments shall be made to the extent
that the premium adjustments determined
under the preceding sentence were
inconsistent with those determined
using such taxable year.
(iii) Non-filers.--In the case of
individuals with respect to whom the
Secretary of the Treasury does not have
adequate data in appropriate electronic
form for either taxable year referred
to in clause (i) or clause (ii), the
Commissioner of Social Security, in
consultation with the Secretary, shall
prescribe regulations which provide for
the treatment of the premium adjustment
with respect to such individual under
this subsection, including regulations
which provide for--
(I) the application of the
highest applicable percentage
under paragraph (3)(C) to such
individual if the Commissioner
has information which indicates
that such individual's modified
adjusted gross income might
exceed the threshold amount for
the taxable year referred to in
clause (i), and
(II) proper adjustments in
the case of the application of
an applicable percentage under
subclause (I) to such
individual which is
inconsistent with such
individual's modified adjusted
gross income for such taxable
year.
(C) Use of more recent taxable year.--
(i) In general.--The Commissioner of
Social Security in consultation with
the Secretary of the Treasury shall
establish a procedures under which an
individual's modified adjusted gross
income shall, at the request of such
individual, be determined under this
subsection--
(I) for a more recent taxable
year than the taxable year
otherwise used under
subparagraph (B), or
(II) by such methodology as
the Commissioner, in
consultation with such
Secretary, determines to be
appropriate, which may include
a methodology for aggregating
or disaggregating information
from tax returns in the case of
marriage or divorce.
(ii) Standard for granting
requests.--A request under clause
(i)(I) to use a more recent taxable
year may be granted only if--
(I) the individual furnishes
to such Commissioner with
respect to such year such
documentation, such as a copy
of a filed Federal income tax
return or an equivalent
document, as the Commissioner
specifies for purposes of
determining the premium
adjustment (if any) under this
subsection; and
(II) the individual's
modified adjusted gross income
for such year is significantly
less than such income for the
taxable year determined under
subparagraph (B) by reason of
the death of such individual's
spouse, the marriage or divorce
of such individual, or other
major life changing events
specified in regulations
prescribed by the Commissioner
in consultation with the
Secretary.
(5) Inflation adjustment.--
(A) In general.--Subject to subparagraph (C),
in the case of any calendar year beginning
after 2007 (other than 2018 and 2019), each
dollar amount in paragraph (2) or (3) shall be
increased by an amount equal to--
(i) such dollar amount, multiplied by
(ii) the percentage (if any) by which
the average of the Consumer Price Index
for all urban consumers (United States
city average) for the 12-month period
ending with August of the preceding
calendar year exceeds such average for
the 12-month period ending with August
2006 (or, in the case of a calendar
year beginning with 2020, August 2018).
(B) Rounding.--If any dollar amount after
being increased under subparagraph (A) or (C)
is not a multiple of $1,000, such dollar amount
shall be rounded to the nearest multiple of
$1,000.
(C) Treatment of adjustments for certain
higher income individuals.--
(i) In general.--Subparagraph (A)
shall not apply with respect to each
dollar amount in paragraph (3) of
$500,000.
(ii) Adjustment beginning 2028.--In
the case of any calendar year beginning
after 2027, each dollar amount in
paragraph (3) of $500,000 shall be
increased by an amount equal to--
(I) such dollar amount,
multiplied by
(II) the percentage (if any)
by which the average of the
Consumer Price Index for all
urban consumers (United States
city average) for the 12-month
period ending with August of
the preceding calendar year
exceeds such average for the
12-month period ending with
August 2026.
(6) Temporary adjustment to income thresholds.--
Notwithstanding any other provision of this subsection,
during the period beginning on January 1, 2011, and
ending on December 31, 2017--
(A) the threshold amount otherwise applicable
under paragraph (2) shall be equal to such
amount for 2010; and
(B) the dollar amounts otherwise applicable
under paragraph (3)(C)(i) shall be equal to
such dollar amounts for 2010.
(7) Joint return defined.--For purposes of this
subsection, the term ``joint return'' has the meaning
given to such term by section 7701(a)(38) of the
Internal Revenue Code of 1986.
* * * * * * *
competitive acquisition of certain items and services
Sec. 1847. (a) Establishment of Competitive Acquisition
Programs.--
(1) Implementation of programs.--
(A) In general.--The Secretary shall
establish and implement programs under which
competitive acquisition areas are established
throughout the United States for contract award
purposes for the furnishing under this part of
competitively priced items and services
(described in paragraph (2)) for which payment
is made under this part. Such areas may differ
for different items and services.
(B) Phased-in implementation.--The programs--
(i) shall be phased in among
competitive acquisition areas in a
manner consistent with subparagraph (D)
so that the competition under the
programs occurs in--
(I) 10 of the largest
metropolitan statistical areas
in 2007;
(II) an additional 91 of the
largest metropolitan
statistical areas in 2011; and
(III) additional areas after
2011 (or, in the case of
national mail order for items
and services, after 2010); and
(ii) may be phased in first among the
highest cost and highest volume items
and services or those items and
services that the Secretary determines
have the largest savings potential.
(C) Waiver of certain provisions.--In
carrying out the programs, the Secretary may
waive such provisions of the Federal
Acquisition Regulation as are necessary for the
efficient implementation of this section, other
than provisions relating to confidentiality of
information and such other provisions as the
Secretary determines appropriate.
(D) Changes in competitive acquisition programs.--
(i) Round 1 of competitive acquisition
program.--Notwithstanding subparagraph
(B)(i)(I) and in implementing the first round
of the competitive acquisition programs under
this section--
(I) the contracts awarded under this
section before the date of the
enactment of this subparagraph are
terminated, no payment shall be made
under this title on or after the date
of the enactment of this subparagraph
based on such a contract, and, to the
extent that any damages may be
applicable as a result of the
termination of such contracts, such
damages shall be payable from the
Federal Supplementary Medical Insurance
Trust Fund under section 1841;
(II) the Secretary shall conduct the
competition for such round in a manner
so that it occurs in 2009 with respect
to the same items and services and the
same areas, except as provided in
subclauses (III) and (IV);
(III) the Secretary shall exclude
Puerto Rico so that such round of
competition covers 9, instead of 10, of
the largest metropolitan statistical
areas; and
(IV) there shall be excluded negative
pressure wound therapy items and
services.
Nothing in subclause (I) shall be construed to
provide an independent cause of action or right
to administrative or judicial review with
regard to the termination provided under such
subclause.
(ii) Round 2 of competitive acquisition
program.--In implementing the second round of
the competitive acquisition programs under this
section described in subparagraph (B)(i)(II)--
(I) the metropolitan statistical
areas to be included shall be those
metropolitan statistical areas selected
by the Secretary for such round as of
June 1, 2008;
(II) the Secretary shall include the
next 21 largest metropolitan
statistical areas by total population
(after those selected under subclause
(I)) for such round; and
(III) the Secretary may subdivide
metropolitan statistical areas with
populations (based upon the most recent
data from the Census Bureau) of at
least 8,000,000 into separate areas for
competitive acquisition purposes.
(iii) Exclusion of certain areas in
subsequent rounds of competitive acquisition
programs.--In implementing subsequent rounds of
the competitive acquisition programs under this
section, including under subparagraph
(B)(i)(III), for competitions occurring before
2015, the Secretary shall exempt from the
competitive acquisition program (other than
national mail order) the following:
(I) Rural areas.
(II) Metropolitan statistical areas
not selected under round 1 or round 2
with a population of less than 250,000.
(III) Areas with a low population
density within a metropolitan
statistical area that is otherwise
selected, as determined for purposes of
paragraph (3)(A).
(E) Verification by oig.--The Inspector General of the
Department of Health and Human Services shall, through post-
award audit, survey, or otherwise, assess the process used by
the Centers for Medicare & Medicaid Services to conduct
competitive bidding and subsequent pricing determinations under
this section that are the basis for pivotal bid amounts and
single payment amounts for items and services in competitive
bidding areas under rounds 1 and 2 of the competitive
acquisition programs under this section and may continue to
verify such calculations for subsequent rounds of such
programs.
(F) Supplier feedback on missing financial documentation.--
(i) In general.--In the case of a bid where one or
more covered documents in connection with such bid have
been submitted not later than the covered document
review date specified in clause (ii), the Secretary--
(I) shall provide, by not later than 45 days
(in the case of the first round of the
competitive acquisition programs as described
in subparagraph (B)(i)(I)) or 90 days (in the
case of a subsequent round of such programs)
after the covered document review date, for
notice to the bidder of all such documents that
are missing as of the covered document review
date; and
(II) may not reject the bid on the basis that
any covered document is missing or has not been
submitted on a timely basis, if all such
missing documents identified in the notice
provided to the bidder under subclause (I) are
submitted to the Secretary not later than 10
business days after the date of such notice.
(ii) Covered document review date.--The covered
document review date specified in this clause with
respect to a competitive acquisition program is the
later of--
(I) the date that is 30 days before the final
date specified by the Secretary for submission
of bids under such program; or
(II) the date that is 30 days after the first
date specified by the Secretary for submission
of bids under such program.
(iii) Limitations of process.--The process provided
under this subparagraph--
(I) applies only to the timely submission of
covered documents;
(II) does not apply to any determination as
to the accuracy or completeness of covered
documents submitted or whether such documents
meet applicable requirements;
(III) shall not prevent the Secretary from
rejecting a bid based on any basis not
described in clause (i)(II); and
(IV) shall not be construed as permitting a
bidder to change bidding amounts or to make
other changes in a bid submission.
(iv) Covered document defined.--In this subparagraph,
the term ``covered document'' means a financial, tax,
or other document required to be submitted by a bidder
as part of an original bid submission under a
competitive acquisition program in order to meet
required financial standards. Such term does not
include other documents, such as the bid itself or
accreditation documentation.
(G) Requiring bid bonds for bidding
entities.--With respect to rounds of
competitions beginning under this subsection
for contracts beginning not earlier than
January 1, 2017, and not later than January 1,
2019, an entity may not submit a bid for a
competitive acquisition area unless, as of the
deadline for bid submission, the entity has
obtained (and provided the Secretary with proof
of having obtained) a bid surety bond (in this
paragraph referred to as a ``bid bond'') in a
form specified by the Secretary consistent with
subparagraph (H) and in an amount that is not
less than $50,000 and not more than $100,000
for each competitive acquisition area in which
the entity submits the bid.
(H) Treatment of bid bonds submitted.--
(i) For bidders that submit bids at
or below the median and are offered but
do not accept the contract.--In the
case of a bidding entity that is
offered a contract for any product
category for a competitive acquisition
area, if--
(I) the entity's composite
bid for such product category
and area was at or below the
median composite bid rate for
all bidding entities included
in the calculation of the
single payment amounts for such
product category and area; and
(II) the entity does not
accept the contract offered for
such product category and area,
the bid bond submitted by such entity
for such area shall be forfeited by the
entity and the Secretary shall collect
on it.
(ii) Treatment of other bidders.--In
the case of a bidding entity for any
product category for a competitive
acquisition area, if the entity does
not meet the bid forfeiture conditions
in subclauses (I) and (II) of clause
(i) for any product category for such
area, the bid bond submitted by such
entity for such area shall be returned
within 90 days of the public
announcement of the contract suppliers
for such area.
(2) Items and services described.--The items and
services referred to in paragraph (1) are the
following:
(A) Durable medical equipment and medical
supplies.--Covered items (as defined in section
1834(a)(13)) for which payment would otherwise
be made under section 1834(a), including items
used in infusion and drugs (other than
inhalation drugs) and supplies used in
conjunction with durable medical equipment, but
excluding class III devices under the Federal
Food, Drug, and Cosmetic Act, excluding certain
complex rehabilitative power wheelchairs
recognized by the Secretary as classified
within group 3 or higher, complex
rehabilitative manual wheelchairs (as
determined by the Secretary), and certain
manual wheelchairs (identified, as of October
1, 2018, by HCPCS codes E1235, E1236, E1237,
E1238, and K0008 or any successor to such
codes) (and related accessories when furnished
in connection with [such wheelchairs] such
complex rehabilitative power wheelchairs,
complex rehabilitative manual wheelchairs, and
certain manual wheelchairs), and excluding
drugs and biologicals described in section
1842(o)(1)(D).
(B) Other equipment and supplies.--Items and
services described in section 1842(s)(2)(D),
other than parenteral nutrients, equipment, and
supplies.
(C) Off-the-shelf orthotics.--Orthotics
described in section 1861(s)(9) for which
payment would otherwise be made under section
1834(h) which require minimal self-adjustment
for appropriate use and do not require
expertise in trimming, bending, molding,
assembling, or customizing to fit to the
individual.
(3) Exception authority.--In carrying out the
programs under this section, the Secretary may exempt--
(A) rural areas and areas with low population
density within urban areas that are not
competitive, unless there is a significant
national market through mail order for a
particular item or service; and
(B) items and services for which the
application of competitive acquisition is not
likely to result in significant savings.
(4) Special rule for certain rented items of durable
medical equipment and oxygen.--In the case of a covered
item for which payment is made on a rental basis under
section 1834(a) and in the case of payment for oxygen
under section 1834(a)(5), the Secretary shall establish
a process by which rental agreements for the covered
items and supply arrangements with oxygen suppliers
entered into before the application of the competitive
acquisition program under this section for the item may
be continued notwithstanding this section. In the case
of any such continuation, the supplier involved shall
provide for appropriate servicing and replacement, as
required under section 1834(a).
(5) Physician authorization.--
(A) In general.--With respect to items or
services included within a particular HCPCS
code, the Secretary may establish a process for
certain items and services under which a
physician may prescribe a particular brand or
mode of delivery of an item or service within
such code if the physician determines that use
of the particular item or service would avoid
an adverse medical outcome on the individual,
as determined by the Secretary.
(B) No effect on payment amount.--A
prescription under subparagraph (A) shall not
affect the amount of payment otherwise
applicable for the item or service under the
code involved.
(6) Application.--For each competitive acquisition
area in which the program is implemented under this
subsection with respect to items and services, the
payment basis determined under the competition
conducted under subsection (b) shall be substituted for
the payment basis otherwise applied under section
1834(a), section 1834(h), or section 1842(s), as
appropriate.
(7) Exemption from competitive acquisition.--The
programs under this section shall not apply to the
following:
(A) Certain off-the-shelf orthotics.--Items
and services described in paragraph (2)(C) if
furnished--
(i) by a physician or other
practitioner (as defined by the
Secretary) to the physician's or
practitioner's own patients as part of
the physician's or practitioner's
professional service; or
(ii) by a hospital to the hospital's
own patients during an admission or on
the date of discharge.
(B) Certain durable medical equipment.--Those
items and services described in paragraph
(2)(A)--
(i) that are furnished by a hospital
to the hospital's own patients during
an admission or on the date of
discharge; and
(ii) to which such programs would not
apply, as specified by the Secretary,
if furnished by a physician to the
physician's own patients as part of the
physician's professional service.
(b) Program Requirements.--
(1) In general.--The Secretary shall conduct a
competition among entities supplying items and services
described in subsection (a)(2) for each competitive
acquisition area in which the program is implemented
under subsection (a) with respect to such items and
services.
(2) Conditions for awarding contract.--
(A) In general.--The Secretary may not award
a contract to any entity under the competition
conducted in an competitive acquisition area
pursuant to paragraph (1) to furnish such items
or services unless the Secretary finds all of
the following:
(i) The entity meets applicable
quality standards specified by the
Secretary under section 1834(a)(20).
(ii) The entity meets applicable
financial standards specified by the
Secretary, taking into account the
needs of small providers.
(iii) The total amounts to be paid to
contractors in a competitive
acquisition area are expected to be
less than the total amounts that would
otherwise be paid.
(iv) Access of individuals to a
choice of multiple suppliers in the
area is maintained.
(v) The entity meets applicable State
licensure requirements.
(B) Timely implementation of program.--Any
delay in the implementation of quality
standards under section 1834(a)(20) or delay in
the receipt of advice from the program
oversight committee established under
subsection (c) shall not delay the
implementation of the competitive acquisition
program under this section.
(3) Contents of contract.--
(A) In general.--A contract entered into with
an entity under the competition conducted
pursuant to paragraph (1) is subject to terms
and conditions that the Secretary may specify.
(B) Term of contracts.--The Secretary shall
recompete contracts under this section not less
often than once every 3 years.
(C) Disclosure of subcontractors.--
(i) Initial disclosure.--Not later
than 10 days after the date a supplier
enters into a contract with the
Secretary under this section, such
supplier shall disclose to the
Secretary, in a form and manner
specified by the Secretary, the
information on--
(I) each subcontracting
relationship that such supplier
has in furnishing items and
services under the contract;
and
(II) whether each such
subcontractor meets the
requirement of section
1834(a)(20)(F)(i), if
applicable to such
subcontractor.
(ii) Subsequent disclosure.--Not
later than 10 days after such a
supplier subsequently enters into a
subcontracting relationship described
in clause (i)(II), such supplier shall
disclose to the Secretary, in such form
and manner, the information described
in subclauses (I) and (II) of clause
(i).
(4) Limit on number of contractors.--
(A) In general.--The Secretary may limit the
number of contractors in a competitive
acquisition area to the number needed to meet
projected demand for items and services covered
under the contracts. In awarding contracts, the
Secretary shall take into account the ability
of bidding entities to furnish items or
services in sufficient quantities to meet the
anticipated needs of individuals for such items
or services in the geographic area covered
under the contract on a timely basis.
(B) Multiple winners.--The Secretary shall
award contracts to multiple entities submitting
bids in each area for an item or service.
(5) Payment.--
(A) In general.--Payment under this part for
competitively priced items and services
described in subsection (a)(2) shall be based
on bids submitted and accepted under this
section for such items and services. Based on
such bids the Secretary shall determine a
single payment amount for each item or service
in each competitive acquisition area.
(B) Reduced beneficiary cost-sharing.--
(i) Application of coinsurance.--
Payment under this section for items
and services shall be in an amount
equal to 80 percent of the payment
basis described in subparagraph (A).
(ii) Application of deductible.--
Before applying clause (i), the
individual shall be required to meet
the deductible described in section
1833(b).
(C) Payment on assignment-related basis.--
Payment for any item or service furnished by
the entity may only be made under this section
on an assignment-related basis.
(D) Construction.--Nothing in this section
shall be construed as precluding the use of an
advanced beneficiary notice with respect to a
competitively priced item and service.
(6) Participating contractors.--
(A) In general.--Except as provided in
subsection (a)(4), payment shall not be made
for items and services described in subsection
(a)(2) furnished by a contractor and for which
competition is conducted under this section
unless--
(i) the contractor has submitted a
bid for such items and services under
this section; and
(ii) the Secretary has awarded a
contract to the contractor for such
items and services under this section.
(B) Bid defined.--In this section, the term
``bid'' means an offer to furnish an item or
service for a particular price and time period
that includes, where appropriate, any services
that are attendant to the furnishing of the
item or service.
(C) Rules for mergers and acquisitions.--In
applying subparagraph (A) to a contractor, the
contractor shall include a successor entity in
the case of a merger or acquisition, if the
successor entity assumes such contract along
with any liabilities that may have occurred
thereunder.
(D) Protection of small suppliers.--In
developing procedures relating to bids and the
awarding of contracts under this section, the
Secretary shall take appropriate steps to
ensure that small suppliers of items and
services have an opportunity to be considered
for participation in the program under this
section.
(7) Consideration in determining categories for
bids.--The Secretary may consider the clinical
efficiency and value of specific items within codes,
including whether some items have a greater therapeutic
advantage to individuals.
(8) Authority to contract for education, monitoring,
outreach, and complaint services.--The Secretary may
enter into contracts with appropriate entities to
address complaints from individuals who receive items
and services from an entity with a contract under this
section and to conduct appropriate education of and
outreach to such individuals and monitoring quality of
services with respect to the program.
(9) Authority to contract for implementation.--The
Secretary may contract with appropriate entities to
implement the competitive bidding program under this
section.
(10) Special rule in case of competition for diabetic
testing strips.--
(A) In general.--With respect to the
competitive acquisition program for diabetic
testing strips conducted after the first round
of the competitive acquisition programs, if an
entity does not demonstrate to the Secretary
that its bid covers types of diabetic testing
strip products that, in the aggregate and
taking into account volume for the different
products, cover 50 percent (or such higher
percentage as the Secretary may specify) of all
such types of products, the Secretary shall
reject such bid. With respect to bids to
furnish such types of products on or after
January 1, 2019, the volume for such types of
products shall be determined by the Secretary
through the use of multiple sources of data
(from mail order and non-mail order Medicare
markets), including market-based data measuring
sales of diabetic testing strip products that
are not exclusively sold by a single retailer
from such markets.
(B) Study of types of testing strip
products.--Before 2011, the Inspector General
of the Department of Health and Human Services
shall conduct a study to determine the types of
diabetic testing strip products by volume that
could be used to make determinations pursuant
to subparagraph (A) for the first competition
under the competitive acquisition program
described in such subparagraph and submit to
the Secretary a report on the results of the
study. The Inspector General shall also conduct
such a study and submit such a report before
the Secretary conducts a subsequent competitive
acquistion program described in subparagraph
(A).
(C) Demonstration of ability to furnish types
of diabetic testing strip products.--With
respect to bids to furnish diabetic testing
strip products on or after January 1, 2019, an
entity shall attest to the Secretary that the
entity has the ability to obtain an inventory
of the types and quantities of diabetic testing
strip products that will allow the entity to
furnish such products in a manner consistent
with its bid and--
(i) demonstrate to the Secretary,
through letters of intent with
manufacturers, wholesalers, or other
suppliers, or other evidence as the
Secretary may specify, such ability; or
(ii) demonstrate to the Secretary
that it made a good faith attempt to
obtain such a letter of intent or such
other evidence.
(D) Use of unlisted types in calculation of
percentage.--With respect to bids to furnish
diabetic testing strip products on or after
January 1, 2019, in determining under
subparagraph (A) whether a bid submitted by an
entity under such subparagraph covers 50
percent (or such higher percentage as the
Secretary may specify) of all types of diabetic
testing strip products, the Secretary may not
attribute a percentage to types of diabetic
testing strip products that the Secretary does
not identify by brand, model, and market share
volume.
(E) Adherence to demonstration.--
(i) In general.--In the case of an
entity that is furnishing diabetic
testing strip products on or after
January 1, 2019, under a contract
entered into under the competition
conducted pursuant to paragraph (1),
the Secretary shall establish a process
to monitor, on an ongoing basis, the
extent to which such entity continues
to cover the product types included in
the entity's bid.
(ii) Termination.--If the Secretary
determines that an entity described in
clause (i) fails to maintain in
inventory, or otherwise maintain ready
access to (through requirements,
contracts, or otherwise) a type of
product included in the entity's bid,
the Secretary may terminate such
contract unless the Secretary finds
that the failure of the entity to
maintain inventory of, or ready access
to, the product is the result of the
discontinuation of the product by the
product manufacturer, a market-wide
shortage of the product, or the
introduction of a newer model or
version of the product in the market
involved.
(11) Additional special rules in case of competition
for diabetic testing strips.--
(A) In general.--With respect to an entity
that is furnishing diabetic testing strip
products to individuals under a contract
entered into under the competitive acquisition
program established under this section, the
entity shall furnish to each individual a brand
of such products that is compatible with the
home blood glucose monitor selected by the
individual.
(B) Prohibition on influencing and
incentivizing.--An entity described in
subparagraph (A) may not attempt to influence
or incentivize an individual to switch the
brand of glucose monitor or diabetic testing
strip product selected by the individual,
including by--
(i) persuading, pressuring, or
advising the individual to switch; or
(ii) furnishing information about
alternative brands to the individual
where the individual has not requested
such information.
(C) Provision of information.--
(i) Standardized information.--Not
later than January 1, 2019, the
Secretary shall develop and make
available to entities described in
subparagraph (A) standardized
information that describes the rights
of an individual with respect to such
an entity. The information described in
the preceding sentence shall include
information regarding--
(I) the requirements
established under subparagraphs
(A) and (B);
(II) the right of the
individual to purchase diabetic
testing strip products from
another mail order supplier of
such products or a retail
pharmacy if the entity is not
able to furnish the brand of
such product that is compatible
with the home blood glucose
monitor selected by the
individual; and
(III) the right of the
individual to return diabetic
testing strip products
furnished to the individual by
the entity.
(ii) Requirement.--With respect to
diabetic testing strip products
furnished on or after the date on which
the Secretary develops the standardized
information under clause (i), an entity
described in subparagraph (A) may not
communicate directly to an individual
until the entity has verbally provided
the individual with such standardized
information.
(D) Order refills.--With respect to diabetic
testing strip products furnished on or after
January 1, 2019, the Secretary shall require an
entity furnishing diabetic testing strip
products to an individual to contact and
receive a request from the individual for such
products not more than 14 days prior to
dispensing a refill of such products to the
individual.
(12) No administrative or judicial review.--There
shall be no administrative or judicial review under
section 1869, section 1878, or otherwise, of--
(A) the establishment of payment amounts
under paragraph (5);
(B) the awarding of contracts under this
section;
(C) the designation of competitive
acquisition areas under subsection (a)(1)(A)
and the identification of areas under
subsection (a)(1)(D)(iii);
(D) the phased-in implementation under
subsection (a)(1)(B) and implementation of
subsection (a)(1)(D);
(E) the selection of items and services for
competitive acquisition under subsection
(a)(2);
(F) the bidding structure and number of
contractors selected under this section; or
(G) the implementation of the special rule
described in paragraph (10).
(c) Program Advisory and Oversight Committee.--
(1) Establishment.--The Secretary shall establish a
Program Advisory and Oversight Committee (hereinafter
in this section referred to as the ``Committee'').
(2) Membership; terms.--The Committee shall consist
of such members as the Secretary may appoint who shall
serve for such term as the Secretary may specify.
(3) Duties.--
(A) Advice.--The Committee shall provide
advice to the Secretary with respect to the
following functions:
(i) The implementation of the program
under this section.
(ii) The establishment of financial
standards for purposes of subsection
(b)(2)(A)(ii).
(iii) The establishment of
requirements for collection of data for
the efficient management of the
program.
(iv) The development of proposals for
efficient interaction among
manufacturers, providers of services,
suppliers (as defined in section
1861(d)), and individuals.
(v) The establishment of quality
standards under section 1834(a)(20).
(B) Additional duties.--The Committee shall
perform such additional functions to assist the
Secretary in carrying out this section as the
Secretary may specify.
(4) Inapplicability of faca.--The provisions of the
Federal Advisory Committee Act (5 U.S.C. App.) shall
not apply.
(5) Termination.--The Committee shall terminate on
December 31, 2011.
(d) Report.--Not later than July 1, 2011, the Secretary shall
submit to Congress a report on the programs under this section.
The report shall include information on savings, reductions in
cost-sharing, access to and quality of items and services, and
satisfaction of individuals.
(f) Competitive Acquisition Ombudsman.--The Secretary shall
provide for a competitive acquisition ombudsman within the
Centers for Medicare & Medicaid Services in order to respond to
complaints and inquiries made by suppliers and individuals
relating to the application of the competitive acquisition
program under this section. The ombudsman may be within the
office of the Medicare Beneficiary Ombudsman appointed under
section 1808(c). The ombudsman shall submit to Congress an
annual report on the activities under this subsection, which
report shall be coordinated with the report provided under
section 1808(c)(2)(C).
* * * * * * *
payment for physicians' services
Sec. 1848. (a) Payment Based on Fee Schedule.--
(1) In general.--Effective for all physicians'
services (as defined in subsection (j)(3)) furnished
under this part during a year (beginning with 1992) for
which payment is otherwise made on the basis of a
reasonable charge or on the basis of a fee schedule
under section 1834(b), payment under this part shall
instead be based on the lesser of--
(A) the actual charge for the service, or
(B) subject to the succeeding provisions of
this subsection, the amount determined under
the fee schedule established under subsection
(b) for services furnished during that year (in
this subsection referred to as the ``fee
schedule amount'').
(2) Transition to full fee schedule.--
(A) Limiting reductions and increases to 15
percent in 1992.--
(i) Limit on increase.--In the case
of a service in a fee schedule area (as
defined in subsection (j)(2)) for which
the adjusted historical payment basis
(as defined in subparagraph (D)) is
less than 85 percent of the fee
schedule amount for services furnished
in 1992, there shall be substituted for
the fee schedule amount an amount equal
to the adjusted historical payment
basis plus 15 percent of the fee
schedule amount otherwise established
(without regard to this paragraph).
(ii) Limit in reduction.--In the case
of a service in a fee schedule area for
which the adjusted historical payment
basis exceeds 115 percent of the fee
schedule amount for services furnished
in 1992, there shall be substituted for
the fee schedule amount an amount equal
to the adjusted historical payment
basis minus 15 percent of the fee
schedule amount otherwise established
(without regard to this paragraph).
(B) Special rule for 1993, 1994, and 1995.--
If a physicians' service in a fee schedule area
is subject to the provisions of subparagraph
(A) in 1992, for physicians' services furnished
in the area--
(i) during 1993, there shall be
substituted for the fee schedule amount
an amount equal to the sum of--
(I) 75 percent of the fee
schedule amount determined
under subparagraph (A),
adjusted by the update
established under subsection
(d)(3) for 1993, and
(II) 25 percent of the fee
schedule amount determined
under paragraph (1) for 1993
without regard to this
paragraph;
(ii) during 1994, there shall be
substituted for the fee schedule amount
an amount equal to the sum of--
(I) 67 percent of the fee
schedule amount determined
under clause (i), adjusted by
the update established under
subsection (d)(3) for 1994 and
as adjusted under subsection
(c)(2)(F)(ii) and under section
13515(b) of the Omnibus Budget
Reconciliation Act of 1993, and
(II) 33 percent of the fee
schedule amount determined
under paragraph (1) for 1994
without regard to this
paragraph; and
(iii) during 1995, there shall be
substituted for the fee schedule amount
an amount equal to the sum of--
(I) 50 percent of the fee
schedule amount determined
under clause (ii) adjusted by
the update established under
subsection (d)(3) for 1995, and
(II) 50 percent of the fee
schedule amount determined
under paragraph (1) for 1995
without regard to this
paragraph.
(C) Special rule for anesthesia and radiology
services.--With respect to physicians' services
which are anesthesia services, the Secretary
shall provide for a transition in the same
manner as a transition is provided for other
services under subparagraph (B). With respect
to radiology services, ``109 percent'' and ``9
percent'' shall be substituted for ``115
percent'' and ``15 percent'', respectively, in
subparagraph (A)(ii).
(D) Adjusted historical payment basis
defined.--
(i) In general.--In this paragraph,
the term ``adjusted historical payment
basis'' means, with respect to a
physicians' service furnished in a fee
schedule area, the weighted average
prevailing charge applied in the area
for the service in 1991 (as determined
by the Secretary without regard to
physician specialty and as adjusted to
reflect payments for services with
customary charges below the prevailing
charge or other payment limitations
imposed by law or regulation) adjusted
by the update established under
subsection (d)(3) for 1992.
(ii) Application to radiology
services.--In applying clause (i) in
the case of physicians' services which
are radiology services (including
radiologist services, as defined in
section 1834(b)(6)), but excluding
nuclear medicine services that are
subject to section 6105(b) of the
Omnibus Budget Reconciliation Act of
1989, there shall be substituted for
the weighted average prevailing charge
the amount provided under the fee
schedule established for the service
for the fee schedule area under section
1834(b).
(iii) Nuclear medicine services.--In
applying clause (i) in the case of
physicians' services which are nuclear
medicine services, there shall be
substituted for the weighted average
prevailing charge the amount provided
under section 6105(b) of the Omnibus
Budget Reconciliation Act of 1989.
(3) Incentives for participating physicians and
suppliers.--In applying paragraph (1)(B) in the case of
a nonparticipating physician or a nonparticipating
supplier or other person, the fee schedule amount shall
be 95 percent of such amount otherwise applied under
this subsection (without regard to this paragraph). In
the case of physicians' services (including services
which the Secretary excludes pursuant to subsection
(j)(3)) of a nonparticipating physician, supplier, or
other person for which payment is made under this part
on a basis other than the fee schedule amount, the
payment shall be based on 95 percent of the payment
basis for such services furnished by a participating
physician, supplier, or other person.
(4) Special rule for medical direction.--
(A) In general.--With respect to physicians'
services furnished on or after January 1, 1994,
and consisting of medical direction of two,
three, or four concurrent anesthesia cases,
except as provided in paragraph (5), the fee
schedule amount to be applied shall be equal to
one-half of the amount described in
subparagraph (B).
(B) Amount.--The amount described in this
subparagraph, for a physician's medical
direction of the performance of anesthesia
services, is the following percentage of the
fee schedule amount otherwise applicable under
this section if the anesthesia services were
personally performed by the physician alone:
(i) For services furnished during
1994, 120 percent.
(ii) For services furnished during
1995, 115 percent.
(iii) For services furnished during
1996, 110 percent.
(iv) For services furnished during
1997, 105 percent.
(v) For services furnished after
1997, 100 percent.
(5) Incentives for electronic prescribing.--
(A) Adjustment.--
(i) In general.--Subject to
subparagraph (B) and subsection
(m)(2)(B), with respect to covered
professional services furnished by an
eligible professional during 2012, 2013
or 2014, if the eligible professional
is not a successful electronic
prescriber for the reporting period for
the year (as determined under
subsection (m)(3)(B)), the fee schedule
amount for such services furnished by
such professional during the year
(including the fee schedule amount for
purposes of determining a payment based
on such amount) shall be equal to the
applicable percent of the fee schedule
amount that would otherwise apply to
such services under this subsection
(determined after application of
paragraph (3) but without regard to
this paragraph).
(ii) Applicable percent.--For
purposes of clause (i), the term
``applicable percent'' means--
(I) for 2012, 99 percent;
(II) for 2013, 98.5 percent;
and
(III) for 2014, 98 percent.
(B) Significant hardship exception.--The
Secretary may, on a case-by-case basis, exempt
an eligible professional from the application
of the payment adjustment under subparagraph
(A) if the Secretary determines, subject to
annual renewal, that compliance with the
requirement for being a successful electronic
prescriber would result in a significant
hardship, such as in the case of an eligible
professional who practices in a rural area
without sufficient Internet access.
(C) Application.--
(i) Physician reporting system
rules.--Paragraphs (5), (6), and (8) of
subsection (k) shall apply for purposes
of this paragraph in the same manner as
they apply for purposes of such
subsection.
(ii) Incentive payment validation
rules.--Clauses (ii) and (iii) of
subsection (m)(5)(D) shall apply for
purposes of this paragraph in a similar
manner as they apply for purposes of
such subsection.
(D) Definitions.--For purposes of this
paragraph:
(i) Eligible professional; covered
professional services.--The terms
``eligible professional'' and ``covered
professional services'' have the
meanings given such terms in subsection
(k)(3).
(ii) Physician reporting system.--The
term ``physician reporting system''
means the system established under
subsection (k).
(iii) Reporting period.--The term
``reporting period'' means, with
respect to a year, a period specified
by the Secretary.
(6) Special rule for teaching anesthesiologists.--
With respect to physicians' services furnished on or
after January 1, 2010, in the case of teaching
anesthesiologists involved in the training of physician
residents in a single anesthesia case or two concurrent
anesthesia cases, the fee schedule amount to be applied
shall be 100 percent of the fee schedule amount
otherwise applicable under this section if the
anesthesia services were personally performed by the
teaching anesthesiologist alone and paragraph (4) shall
not apply if--
(A) the teaching anesthesiologist is present
during all critical or key portions of the
anesthesia service or procedure involved; and
(B) the teaching anesthesiologist (or another
anesthesiologist with whom the teaching
anesthesiologist has entered into an
arrangement) is immediately available to
furnish anesthesia services during the entire
procedure.
(7) Incentives for meaningful use of certified ehr
technology.--
(A) Adjustment.--
(i) In general.--Subject to
subparagraphs (B) and (D), with respect
to covered professional services
furnished by an eligible professional
during each of 2015 through 2018, if
the eligible professional is not a
meaningful EHR user (as determined
under subsection (o)(2)) for an EHR
reporting period for the year, the fee
schedule amount for such services
furnished by such professional during
the year (including the fee schedule
amount for purposes of determining a
payment based on such amount) shall be
equal to the applicable percent of the
fee schedule amount that would
otherwise apply to such services under
this subsection (determined after
application of paragraph (3) but
without regard to this paragraph).
(ii) Applicable percent.--Subject to
clause (iii), for purposes of clause
(i), the term ``applicable percent''
means--
(I) for 2015, 99 percent (or,
in the case of an eligible
professional who was subject to
the application of the payment
adjustment under section
1848(a)(5) for 2014, 98
percent);
(II) for 2016, 98 percent;
and
(III) for 2017 and 2018, 97
percent.
(iii) Authority to decrease
applicable percentage for 2018.--For
2018, if the Secretary finds that the
proportion of eligible professionals
who are meaningful EHR users (as
determined under subsection (o)(2)) is
less than 75 percent, the applicable
percent shall be decreased by 1
percentage point from the applicable
percent in the preceding year.
(B) Significant hardship exception.--The
Secretary may, on a case-by-case basis (and,
with respect to the payment adjustment under
subparagraph (A) for 2017, for categories of
eligible professionals, as established by the
Secretary and posted on the Internet website of
the Centers for Medicare & Medicaid Services
prior to December 15, 2015, an application for
which must be submitted to the Secretary by not
later than March 15, 2016), exempt an eligible
professional from the application of the
payment adjustment under subparagraph (A) if
the Secretary determines, subject to annual
renewal, that compliance with the requirement
for being a meaningful EHR user would result in
a significant hardship, such as in the case of
an eligible professional who practices in a
rural area without sufficient Internet access.
The Secretary shall exempt an eligible
professional from the application of the
payment adjustment under subparagraph (A) with
respect to a year, subject to annual renewal,
if the Secretary determines that compliance
with the requirement for being a meaningful EHR
user is not possible because the certified EHR
technology used by such professional has been
decertified under a program kept or recognized
pursuant to section 3001(c)(5) of the Public
Health Service Act. In no case may an eligible
professional be granted an exemption under this
subparagraph for more than 5 years.
(C) Application of physician reporting system
rules.--Paragraphs (5), (6), and (8) of
subsection (k) shall apply for purposes of this
paragraph in the same manner as they apply for
purposes of such subsection.
(D) Non-application to hospital-based and
ambulatory surgical center-based eligible
professionals.--
(i) Hospital-based.--No payment
adjustment may be made under
subparagraph (A) in the case of
hospital-based eligible professionals
(as defined in subsection
(o)(1)(C)(ii)).
(ii) Ambulatory surgical center-
based.--Subject to clause (iv), no
payment adjustment may be made under
subparagraph (A) for 2017 and 2018 in
the case of an eligible professional
with respect to whom substantially all
of the covered professional services
furnished by such professional are
furnished in an ambulatory surgical
center.
(iii) Determination.--The
determination of whether an eligible
professional is an eligible
professional described in clause (ii)
may be made on the basis of--
(I) the site of service (as
defined by the Secretary); or
(II) an attestation submitted
by the eligible professional.
Determinations made under subclauses
(I) and (II) shall be made without
regard to any employment or billing
arrangement between the eligible
professional and any other supplier or
provider of services.
(iv) Sunset.--Clause (ii) shall no
longer apply as of the first year that
begins more than 3 years after the date
on which the Secretary determines,
through notice and comment rulemaking,
that certified EHR technology
applicable to the ambulatory surgical
center setting is available.
(E) Definitions.--For purposes of this
paragraph:
(i) Covered professional services.--
The term ``covered professional
services'' has the meaning given such
term in subsection (k)(3).
(ii) EHR reporting period.--The term
``EHR reporting period'' means, with
respect to a year, a period (or
periods) specified by the Secretary.
(iii) Eligible professional.--The
term ``eligible professional'' means a
physician, as defined in section
1861(r).
(8) Incentives for quality reporting.--
(A) Adjustment.--
(i) In general.--With respect to
covered professional services furnished
by an eligible professional during each
of 2015 through 2018, if the eligible
professional does not satisfactorily
submit data on quality measures for
covered professional services for the
quality reporting period for the year
(as determined under subsection
(m)(3)(A)), the fee schedule amount for
such services furnished by such
professional during the year (including
the fee schedule amount for purposes of
determining a payment based on such
amount) shall be equal to the
applicable percent of the fee schedule
amount that would otherwise apply to
such services under this subsection
(determined after application of
paragraphs (3), (5), and (7), but
without regard to this paragraph).
(ii) Applicable percent.--For
purposes of clause (i), the term
``applicable percent'' means--
(I) for 2015, 98.5 percent;
and
(II) for 2016, 2017, and
2018, 98 percent.
(B) Application.--
(i) Physician reporting system
rules.--Paragraphs (5), (6), and (8) of
subsection (k) shall apply for purposes
of this paragraph in the same manner as
they apply for purposes of such
subsection.
(ii) Incentive payment validation
rules.--Clauses (ii) and (iii) of
subsection (m)(5)(D) shall apply for
purposes of this paragraph in a similar
manner as they apply for purposes of
such subsection.
(C) Definitions.--For purposes of this
paragraph:
(i) Eligible professional; covered
professional services.--The terms
``eligible professional'' and ``covered
professional services'' have the
meanings given such terms in subsection
(k)(3).
(ii) Physician reporting system.--The
term ``physician reporting system''
means the system established under
subsection (k).
(iii) Quality reporting period.--The
term ``quality reporting period''
means, with respect to a year, a period
specified by the Secretary.
(9) Information reporting on services included in
global surgical packages.--With respect to services for
which a physician is required to report information in
accordance with subsection (c)(8)(B)(i), the Secretary
may through rulemaking delay payment of 5 percent of
the amount that would otherwise be payable under the
physician fee schedule under this section for such
services until the information so required is reported.
(b) Establishment of Fee Schedules.--
(1) In general.--Before November 1 of the preceding
year, for each year beginning with 1998, subject to
subsection (p), the Secretary shall establish, by
regulation, fee schedules that establish payment
amounts for all physicians' services furnished in all
fee schedule areas (as defined in subsection (j)(2))
for the year. Except as provided in paragraph (2), each
such payment amount for a service shall be equal to the
product of--
(A) the relative value for the service (as
determined in subsection (c)(2)),
(B) the conversion factor (established under
subsection (d)) for the year, and
(C) the geographic adjustment factor
(established under subsection (e)(2)) for the
service for the fee schedule area.
(2) Treatment of radiology services and anesthesia
services.--
(A) Radiology services.--With respect to
radiology services (including radiologist
services, as defined in section 1834(b)(6)),
the Secretary shall base the relative values on
the relative value scale developed under
section 1834(b)(1)(A), with appropriate
modifications of the relative values to assure
that the relative values established for
radiology services which are similar or related
to other physicians' services are consistent
with the relative values established for those
similar or related services.
(B) Anesthesia services.--In establishing the
fee schedule for anesthesia services for which
a relative value guide has been established
under section 4048(b) of the Omnibus Budget
Reconciliation Act of 1987, the Secretary shall
use, to the extent practicable, such relative
value guide, with appropriate adjustment of the
conversion factor, in a manner to assure that
the fee schedule amounts for anesthesia
services are consistent with the fee schedule
amounts for other services determined by the
Secretary to be of comparable value. In
applying the previous sentence, the Secretary
shall adjust the conversion factor by
geographic adjustment factors in the same
manner as such adjustment is made under
paragraph (1)(C).
(C) Consultation.--The Secretary shall
consult with the Physician Payment Review
Commission and organizations representing
physicians or suppliers who furnish radiology
services and anesthesia services in applying
subparagraphs (A) and (B).
(3) Treatment of interpretation of
electrocardiograms.--The Secretary--
(A) shall make separate payment under this
section for the interpretation of
electrocardiograms performed or ordered to be
performed as part of or in conjunction with a
visit to or a consultation with a physician,
and
(B) shall adjust the relative values
established for visits and consultations under
subsection (c) so as not to include relative
value units for interpretations of
electrocardiograms in the relative value for
visits and consultations.
(4) Special rule for imaging services.--
(A) In general.--In the case of imaging
services described in subparagraph (B)
furnished on or after January 1, 2007, if--
(i) the technical component
(including the technical component
portion of a global fee) of the service
established for a year under the fee
schedule described in paragraph (1)
without application of the geographic
adjustment factor described in
paragraph (1)(C), exceeds
(ii) the Medicare OPD fee schedule
amount established under the
prospective payment system for hospital
outpatient department services under
paragraph (3)(D) of section 1833(t) for
such service for such year, determined
without regard to geographic adjustment
under paragraph (2)(D) of such section,
the Secretary shall substitute the amount
described in clause (ii), adjusted by the
geographic adjustment factor described in
paragraph (1)(C), for the fee schedule amount
for such technical component for such year.
(B) Imaging services described.--For purposes
of this paragraph, imaging services described
in this subparagraph are imaging and computer-
assisted imaging services, including X-ray,
ultrasound (including echocardiography),
nuclear medicine (including positron emission
tomography), magnetic resonance imaging,
computed tomography, and fluoroscopy, but
excluding diagnostic and screening mammography,
and for 2010, 2011, and the first 2 months of
2012, dual-energy x-ray absorptiometry services
(as described in paragraph (6)).
(C) Adjustment in imaging utilization rate.--
With respect to fee schedules established for
2011, 2012, and 2013, in the methodology for
determining practice expense relative value
units for expensive diagnostic imaging
equipment under the final rule published by the
Secretary in the Federal Register on November
25, 2009 (42 CFR 410 et al.), the Secretary
shall use a 75 percent assumption instead of
the utilization rates otherwise established in
such final rule. With respect to fee schedules
established for 2014 and subsequent years, in
such methodology, the Secretary shall use a 90
percent utilization rate.
(D) Adjustment in technical component
discount on single-session imaging involving
consecutive body parts.--For services furnished
on or after July 1, 2010, the Secretary shall
increase the reduction in payments attributable
to the multiple procedure payment reduction
applicable to the technical component for
imaging under the final rule published by the
Secretary in the Federal Register on November
21, 2005 (part 405 of title 42, Code of Federal
Regulations) from 25 percent to 50 percent.
(5) Treatment of intensive cardiac rehabilitation
program.--
(A) In general.--In the case of an intensive
cardiac rehabilitation program described in
section 1861(eee)(4), the Secretary shall
substitute the Medicare OPD fee schedule amount
established under the prospective payment
system for hospital outpatient department
service under paragraph (3)(D) of section
1833(t) for cardiac rehabilitation (under HCPCS
codes 93797 and 93798 for calendar year 2007,
or any succeeding HCPCS codes for cardiac
rehabilitation).
(B) Definition of session.--Each of the
services described in subparagraphs (A) through
(E) of section 1861(eee)(3), when furnished for
one hour, is a separate session of intensive
cardiac rehabilitation.
(C) Multiple sessions per day.--Payment may
be made for up to 6 sessions per day of the
series of 72 one-hour sessions of intensive
cardiac rehabilitation services described in
section 1861(eee)(4)(B).
(6) Treatment of bone mass scans.--For dual-energy x-
ray absorptiometry services (identified in 2006 by
HCPCS codes 76075 and 76077 (and any succeeding codes))
furnished during 2010, 2011, and the first 2 months of
2012, instead of the payment amount that would
otherwise be determined under this section for such
years, the payment amount shall be equal to 70 percent
of the product of--
(A) the relative value for the service (as
determined in subsection (c)(2)) for 2006;
(B) the conversion factor (established under
subsection (d)) for 2006; and
(C) the geographic adjustment factor
(established under subsection (e)(2)) for the
service for the fee schedule area for 2010,
2011, and the first 2 months of 2012,
respectively.
(7) Adjustment in discount for certain multiple
therapy services.--In the case of therapy services
furnished on or after January 1, 2011, and before April
1, 2013, and for which payment is made under fee
schedules established under this section, instead of
the 25 percent multiple procedure payment reduction
specified in the final rule published by the Secretary
in the Federal Register on November 29, 2010, the
reduction percentage shall be 20 percent. In the case
of such services furnished on or after April 1, 2013,
and for which payment is made under such fee schedules,
instead of the 25 percent multiple procedure payment
reduction specified in such final rule, the reduction
percentage shall be 50 percent.
(8) Encouraging care management for individuals with
chronic care needs.--
(A) In general.--In order to encourage the
management of care for individuals with chronic
care needs the Secretary shall, subject to
subparagraph (B), make payment (as the
Secretary determines to be appropriate) under
this section for chronic care management
services furnished on or after January 1, 2015,
by a physician (as defined in section
1861(r)(1)), physician assistant or nurse
practitioner (as defined in section
1861(aa)(5)(A)), clinical nurse specialist (as
defined in section 1861(aa)(5)(B)), or
certified nurse midwife (as defined in section
1861(gg)(2)).
(B) Policies relating to payment.--In
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; 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.
(9) Special rule to incentivize transition from
traditional x-ray imaging to digital radiography.--
(A) Limitation on payment for film x-ray
imaging services.--In the case of an imaging
service (including the imaging portion of a
service) that is an X-ray taken using film and
that is furnished during 2017 or a subsequent
year, the payment amount for the technical
component (including the technical component
portion of a global service) of such service
that would otherwise be determined under this
section (without application of this paragraph
and before application of any other adjustment
under this section) for such year shall be
reduced by 20 percent.
(B) Phased-in limitation on payment for
computed radiography imaging services.--In the
case of an imaging service (including the
imaging portion of a service) that is an X-ray
taken using computed radiography technology--
(i) in the case of such a service
furnished during 2018, 2019, 2020,
2021, or 2022, the payment amount for
the technical component (including the
technical component portion of a global
service) of such service that would
otherwise be determined under this
section (without application of this
paragraph and before application of any
other adjustment under this section)
for such year shall be reduced by 7
percent; and
(ii) in the case of such a service
furnished during 2023 or a subsequent
year, the payment amount for the
technical component (including the
technical component portion of a global
service) of such service that would
otherwise be determined under this
section (without application of this
paragraph and before application of any
other adjustment under this section)
for such year shall be reduced by 10
percent.
(C) Computed radiography technology
defined.--For purposes of this paragraph, the
term ``computed radiography technology'' means
cassette-based imaging which utilizes an
imaging plate to create the image involved.
(D) Implementation.--In order to implement
this paragraph, the Secretary shall adopt
appropriate mechanisms which may include use of
modifiers.
(10) Reduction of discount in payment for
professional component of multiple imaging services.--
In the case of the professional component of imaging
services furnished on or after January 1, 2017, instead
of the 25 percent reduction for multiple procedures
specified in the final rule published by the Secretary
in the Federal Register on November 28, 2011, as
amended in the final rule published by the Secretary in
the Federal Register on November 16, 2012, the
reduction percentage shall be 5 percent.
(11) Special rule for certain radiation therapy
services.--The code definitions, the work relative
value units under subsection (c)(2)(C)(i), and the
direct inputs for the practice expense relative value
units under subsection (c)(2)(C)(ii) for radiation
treatment delivery and related imaging services
(identified in 2016 by HCPCS G-codes G6001 through
G6015) for the fee schedule established under this
subsection for services furnished in 2017, 2018, and
2019 shall be the same as such definitions, units, and
inputs for such services for the fee schedule
established for services furnished in 2016.
(c) Determination of Relative Values for Physicians'
Services.--
(1) Division of physicians' services into
components.--In this section, with respect to a
physicians' service:
(A) Work component defined.--The term ``work
component'' means the portion of the resources
used in furnishing the service that reflects
physician time and intensity in furnishing the
service. Such portion shall--
(i) include activities before and
after direct patient contact, and
(ii) be defined, with respect to
surgical procedures, to reflect a
global definition including pre-
operative and post-operative
physicians' services.
(B) Practice expense component defined.--The
term ``practice expense component'' means the
portion of the resources used in furnishing the
service that reflects the general categories of
expenses (such as office rent and wages of
personnel, but excluding malpractice expenses)
comprising practice expenses.
(C) Malpractice component defined.--The term
``malpractice component'' means the portion of
the resources used in furnishing the service
that reflects malpractice expenses in
furnishing the service.
(2) Determination of relative values.--
(A) In general.--
(i) Combination of units for
components.--The Secretary shall
develop a methodology for combining the
work, practice expense, and malpractice
relative value units, determined under
subparagraph (C), for each service in a
manner to produce a single relative
value for that service. Such relative
values are subject to adjustment under
subparagraph (F)(i) and section
13515(b) of the Omnibus Budget
Reconciliation Act of 1993.
(ii) Extrapolation.--The Secretary
may use extrapolation and other
techniques to determine the number of
relative value units for physicians'
services for which specific data are
not available and shall take into
account recommendations of the
Physician Payment Review Commission and
the results of consultations with
organizations representing physicians
who provide such services.
(B) Periodic review and adjustments in
relative values.--
(i) Periodic review.--The Secretary,
not less often than every 5 years,
shall review the relative values
established under this paragraph for
all physicians' services.
(ii) Adjustments.--
(I) In general.--The
Secretary shall, to the extent
the Secretary determines to be
necessary and subject to
subclause (II) and paragraph
(7), adjust the number of such
units to take into account
changes in medical practice,
coding changes, new data on
relative value components, or
the addition of new procedures.
The Secretary shall publish an
explanation of the basis for
such adjustments.
(II) Limitation on annual
adjustments.--Subject to
clauses (iv) and (v), the
adjustments under subclause (I)
for a year may not cause the
amount of expenditures under
this part for the year to
differ by more than $20,000,000
from the amount of expenditures
under this part that would have
been made if such adjustments
had not been made.
(iii) Consultation.--The Secretary,
in making adjustments under clause
(ii), shall consult with the Medicare
Payment Advisory Commission and
organizations representing physicians.
(iv) Exemption of certain additional
expenditures from budget neutrality.--
The additional expenditures
attributable to--
(I) subparagraph (H) shall
not be taken into account in
applying clause (ii)(II) for
2004;
(II) subparagraph (I) insofar
as it relates to a physician
fee schedule for 2005 or 2006
shall not be taken into account
in applying clause (ii)(II) for
drug administration services
under the fee schedule for such
year for a specialty described
in subparagraph (I)(ii)(II);
(III) subparagraph (J)
insofar as it relates to a
physician fee schedule for 2005
or 2006 shall not be taken into
account in applying clause
(ii)(II) for drug
administration services under
the fee schedule for such year;
and
(IV) subsection (b)(6) shall
not be taken into account in
applying clause (ii)(II) for
2010, 2011, or the first 2
months of 2012.
(v) Exemption of certain reduced
expenditures from budget-neutrality
calculation.--The following reduced
expenditures, as estimated by the
Secretary, shall not be taken into
account in applying clause (ii)(II):
(I) Reduced payment for
multiple imaging procedures.--
Effective for fee schedules
established beginning with
2007, reduced expenditures
attributable to the multiple
procedure payment reduction for
imaging under the final rule
published by the Secretary in
the Federal Register on
November 21, 2005 (42 CFR 405,
et al.) insofar as it relates
to the physician fee schedules
for 2006 and 2007.
(II) OPD payment cap for
imaging services.--Effective
for fee schedules established
beginning with 2007, reduced
expenditures attributable to
subsection (b)(4).
(III) Change in utilization
rate for certain imaging
services.--Effective for fee
schedules established beginning
with 2011, reduced expenditures
attributable to the changes in
the utilization rate applicable
to 2011 and 2014, as described
in the first and second
sentence, respectively, of
subsection (b)(4)(C).
(VI) Additional reduced
payment for multiple imaging
procedures.--Effective for fee
schedules established beginning
with 2010 (but not applied for
services furnished prior to
July 1, 2010), reduced
expenditures attributable to
the increase in the multiple
procedure payment reduction
from 25 to 50 percent (as
described in subsection
(b)(4)(D)).
(VII) Reduced expenditures
for multiple therapy
services.--Effective for fee
schedules established beginning
with 2011, reduced expenditures
attributable to the multiple
procedure payment reduction for
therapy services (as described
in subsection (b)(7)).
(VIII) Reduced expenditures
attributable to application of
quality incentives for computed
tomography.--Effective for fee
schedules established beginning
with 2016, reduced expenditures
attributable to the application
of the quality incentives for
computed tomography under
section 1834(p)
(IX) Reductions for misvalued
services if target not met.--
Effective for fee schedules
beginning with 2016, reduced
expenditures attributable to
the application of the target
recapture amount described in
subparagraph (O)(iii).
(X) Reduced expenditures
attributable to incentives to
transition to digital
radiography.--Effective for fee
schedules established beginning
with 2017, reduced expenditures
attributable to subparagraph
(A) of subsection (b)(9) and
effective for fee schedules
established beginning with
2018, reduced expenditures
attributable to subparagraph
(B) of such subsection.
(XI) Discount in payment for
professional component of
imaging services.--Effective
for fee schedules established
beginning with 2017, reduced
expenditures attributable to
subsection (b)(10).
(vi) Alternative application of
budget-neutrality adjustment.--
Notwithstanding subsection (d)(9)(A),
effective for fee schedules established
beginning with 2009, with respect to
the 5-year review of work relative
value units used in fee schedules for
2007 and 2008, in lieu of continuing to
apply budget-neutrality adjustments
required under clause (ii) for 2007 and
2008 to work relative value units, the
Secretary shall apply such budget-
neutrality adjustments to the
conversion factor otherwise determined
for years beginning with 2009.
(C) Computation of relative value units for
components.--For purposes of this section for
each physicians' service--
(i) Work relative value units.--The
Secretary shall determine a number of
work relative value units for the
service or group of services based on
the relative resources incorporating
physician time and intensity required
in furnishing the service or group of
services.
(ii) Practice expense relative value
units.--The Secretary shall determine a
number of practice expense relative
value units for the service for years
before 1999 equal to the product of--
(I) the base allowed charges
(as defined in subparagraph
(D)) for the service, and
(II) the practice expense
percentage for the service (as
determined under paragraph
(3)(C)(ii)),
and for years beginning with 1999 based
on the relative practice expense
resources involved in furnishing the
service or group of services. For 1999,
such number of units shall be
determined based 75 percent on such
product and based 25 percent on the
relative practice expense resources
involved in furnishing the service. For
2000, such number of units shall be
determined based 50 percent on such
product and based 50 percent on such
relative practice expense resources.
For 2001, such number of units shall be
determined based 25 percent on such
product and based 75 percent on such
relative practice expense resources.
For a subsequent year, such number of
units shall be determined based
entirely on such relative practice
expense resources.
(iii) Malpractice relative value
units.--The Secretary shall determine a
number of malpractice relative value
units for the service or group of
services for years before 2000 equal to
the product of--
(I) the base allowed charges
(as defined in subparagraph
(D)) for the service or group
of services, and
(II) the malpractice
percentage for the service or
group of services (as
determined under paragraph
(3)(C)(iii)),
and for years beginning with 2000 based
on the malpractice expense resources
involved in furnishing the service or
group of services.
(D) Base allowed charges defined.--In this
paragraph, the term ``base allowed charges''
means, with respect to a physician's service,
the national average allowed charges for the
service under this part for services furnished
during 1991, as estimated by the Secretary
using the most recent data available.
(E) Reduction in practice expense relative
value units for certain services.--
(i) In general.--Subject to clause
(ii), the Secretary shall reduce the
practice expense relative value units
applied to services described in clause
(iii) furnished in--
(I) 1994, by 25 percent of
the number by which the number
of practice expense relative
value units (determined for
1994 without regard to this
subparagraph) exceeds the
number of work relative value
units determined for 1994,
(II) 1995, by an additional
25 percent of such excess, and
(III) 1996, by an additional
25 percent of such excess.
(ii) Floor on reductions.--The
practice expense relative value units
for a physician's service shall not be
reduced under this subparagraph to a
number less than 128 percent of the
number of work relative value units.
(iii) Services covered.--For purposes
of clause (i), the services described
in this clause are physicians' services
that are not described in clause (iv)
and for which--
(I) there are work relative
value units, and
(II) the number of practice
expense relative value units
(determined for 1994) exceeds
128 percent of the number of
work relative value units
(determined for such year).
(iv) Excluded services.--For purposes
of clause (iii), the services described
in this clause are services which the
Secretary determines at least 75
percent of which are provided under
this title in an office setting.
(F) Budget neutrality adjustments.--The
Secretary--
(i) shall reduce the relative values
for all services (other than anesthesia
services) established under this
paragraph (and in the case of
anesthesia services, the conversion
factor established by the Secretary for
such services) by such percentage as
the Secretary determines to be
necessary so that, beginning in 1996,
the amendment made by section 13514(a)
of the Omnibus Budget Reconciliation
Act of 1993 would not result in
expenditures under this section that
exceed the amount of such expenditures
that would have been made if such
amendment had not been made, and
(ii) shall reduce the amounts
determined under subsection
(a)(2)(B)(ii)(I) by such percentage as
the Secretary determines to be required
to assure that, taking into account the
reductions made under clause (i), the
amendment made by section 13514(a) of
the Omnibus Budget Reconciliation Act
of 1993 would not result in
expenditures under this section in 1994
that exceed the amount of such
expenditures that would have been made
if such amendment had not been made.
(G) Adjustments in relative value units for
1998.--
(i) In general.--The Secretary
shall--
(I) subject to clauses (iv)
and (v), reduce the practice
expense relative value units
applied to any services
described in clause (ii)
furnished in 1998 to a number
equal to 110 percent of the
number of work relative value
units, and
(II) increase the practice
expense relative value units
for office visit procedure
codes during 1998 by a uniform
percentage which the Secretary
estimates will result in an
aggregate increase in payments
for such services equal to the
aggregate decrease in payments
by reason of subclause (I).
(ii) Services covered.--For purposes
of clause (i), the services described
in this clause are physicians' services
that are not described in clause (iii)
and for which--
(I) there are work relative
value units, and
(II) the number of practice
expense relative value units
(determined for 1998) exceeds
110 percent of the number of
work relative value units
(determined for such year).
(iii) Excluded services.--For
purposes of clause (ii), the services
described in this clause are services
which the Secretary determines at least
75 percent of which are provided under
this title in an office setting.
(iv) Limitation on aggregate
reallocation.--If the application of
clause (i)(I) would result in an
aggregate amount of reductions under
such clause in excess of $390,000,000,
such clause shall be applied by
substituting for 110 percent such
greater percentage as the Secretary
estimates will result in the aggregate
amount of such reductions equaling
$390,000,000.
(v) No reduction for certain
services.--Practice expense relative
value units for a procedure performed
in an office or in a setting out of an
office shall not be reduced under
clause (i) if the in-office or out-of-
office practice expense relative value,
respectively, for the procedure would
increase under the proposed rule on
resource-based practice expenses issued
by the Secretary on June 18, 1997 (62
Federal Register 33158 et seq.).
(H) Adjustments in practice expense relative
value units for certain drug administration
services beginning in 2004.--
(i) Use of survey data.--In
establishing the physician fee schedule
under subsection (b) with respect to
payments for services furnished on or
after January 1, 2004, the Secretary
shall, in determining practice expense
relative value units under this
subsection, utilize a survey submitted
to the Secretary as of January 1, 2003,
by a physician specialty organization
pursuant to section 212 of the
Medicare, Medicaid, and SCHIP Balanced
Budget Refinement Act of 1999 if the
survey--
(I) covers practice expenses
for oncology drug
administration services; and
(II) meets criteria
established by the Secretary
for acceptance of such surveys.
(ii) Pricing of clinical oncology
nurses in practice expense
methodology.--If the survey described
in clause (i) includes data on wages,
salaries, and compensation of clinical
oncology nurses, the Secretary shall
utilize such data in the methodology
for determining practice expense
relative value units under subsection
(c).
(iii) Work relative value units for
certain drug administration services.--
In establishing the relative value
units under this paragraph for drug
administration services described in
clause (iv) furnished on or after
January 1, 2004, the Secretary shall
establish work relative value units
equal to the work relative value units
for a level 1 office medical visit for
an established patient.
(iv) Drug administration services
described.--The drug administration
services described in this clause are
physicians' services--
(I) which are classified as
of October 1, 2003, within any
of the following groups of
procedures: therapeutic or
diagnostic infusions (excluding
chemotherapy); chemotherapy
administration services; and
therapeutic, prophylactic, or
diagnostic injections;
(II) for which there are no
work relative value units
assigned under this subsection
as of such date; and
(III) for which national
relative value units have been
assigned under this subsection
as of such date.
(I) Adjustments in practice expense relative
value units for certain drug administration
services beginning with 2005.--
(i) In general.--In establishing the
physician fee schedule under subsection
(b) with respect to payments for
services furnished on or after January
1, 2005 or 2006, the Secretary shall
adjust the practice expense relative
value units for such year consistent
with clause (ii).
(ii) Use of supplemental survey
data.--
(I) In general.--Subject to
subclause (II), if a specialty
submits to the Secretary by not
later than March 1, 2004, for
2005, or March 1, 2005, for
2006, data that includes
expenses for the administration
of drugs and biologicals for
which the payment amount is
determined pursuant to section
1842(o), the Secretary shall
use such supplemental survey
data in carrying out this
subparagraph for the years
involved insofar as they are
collected and provided by
entities and organizations
consistent with the criteria
established by the Secretary
pursuant to section 212(a) of
the Medicare, Medicaid, and
SCHIP Balanced Budget
Refinement Act of 1999.
(II) Limitation on
specialty.--Subclause (I) shall
apply to a specialty only
insofar as not less than 40
percent of payments for the
specialty under this title in
2002 are attributable to the
administration of drugs and
biologicals, as determined by
the Secretary.
(III) Application.--This
clause shall not apply with
respect to a survey to which
subparagraph (H)(i) applies.
(J) Provisions for appropriate reporting and
billing for physicians' services associated
with the administration of covered outpatient
drugs and biologicals.--
(i) Evaluation of codes.--The
Secretary shall promptly evaluate
existing drug administration codes for
physicians' services to ensure accurate
reporting and billing for such
services, taking into account levels of
complexity of the administration and
resource consumption.
(ii) Use of existing processes.--In
carrying out clause (i), the Secretary
shall use existing processes for the
consideration of coding changes and, to
the extent coding changes are made,
shall use such processes in
establishing relative values for such
services.
(iii) Implementation.--In carrying
out clause (i), the Secretary shall
consult with representatives of
physician specialties affected by the
implementation of section 1847A or
section 1847B, and shall take such
steps within the Secretary's authority
to expedite such considerations under
clause (ii).
(iv) Subsequent, budget neutral
adjustments permitted.--Nothing in
subparagraph (H) or (I) or this
subparagraph shall be construed as
preventing the Secretary from providing
for adjustments in practice expense
relative value units under (and
consistent with) subparagraph (B) for
years after 2004, 2005, or 2006,
respectively.
(K) Potentially misvalued codes.--
(i) In general.--The Secretary
shall--
(I) periodically identify
services as being potentially
misvalued using criteria
specified in clause (ii); and
(II) review and make
appropriate adjustments to the
relative values established
under this paragraph for
services identified as being
potentially misvalued under
subclause (I).
(ii) Identification of potentially
misvalued codes.--For 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.
(iii) Review and adjustments.--
(I) The Secretary may use
existing processes to receive
recommendations on the review
and appropriate adjustment of
potentially misvalued services
described in clause (i)(II).
(II) The Secretary may
conduct surveys, other data
collection activities, studies,
or other analyses as the
Secretary determines to be
appropriate to facilitate the
review and appropriate
adjustment described in clause
(i)(II).
(III) The Secretary may use
analytic contractors to
identify and analyze services
identified under clause (i)(I),
conduct surveys or collect
data, and make recommendations
on the review and appropriate
adjustment of services
described in clause (i)(II).
(IV) The Secretary may
coordinate the review and
appropriate adjustment
described in clause (i)(II)
with the periodic review
described in subparagraph (B).
(V) As part of the review and
adjustment described in clause
(i)(II), including with respect
to codes with low relative
values described in clause
(ii), the Secretary may make
appropriate coding revisions
(including using existing
processes for consideration of
coding changes) which may
include consolidation of
individual services into
bundled codes for payment under
the fee schedule under
subsection (b).
(VI) The provisions of
subparagraph (B)(ii)(II) and
paragraph (7) shall apply to
adjustments to relative value
units made pursuant to this
subparagraph in the same manner
as such provisions apply to
adjustments under subparagraph
(B)(ii)(I).
(iv) Treatment of certain radiation
therapy services.--Radiation treatment
delivery and related imaging services
identified under subsection (b)(11)
shall not be considered as potentially
misvalued services for purposes of this
subparagraph and subparagraph (O) for
2017, 2018, and 2019.
(L) Validating relative value units.--
(i) In general.--The Secretary shall
establish a process to validate
relative value units under the fee
schedule under subsection (b).
(ii) Components and elements of
work.--The process described in clause
(i) may include validation of work
elements (such as time, mental effort
and professional judgment, technical
skill and physical effort, and stress
due to risk) involved with furnishing a
service and may include validation of
the pre-, post-, and intra-service
components of work.
(iii) Scope of codes.--The validation
of work relative value units shall
include a sampling of codes for
services that is the same as the codes
listed under subparagraph (K)(ii).
(iv) Methods.--The Secretary may
conduct the validation under this
subparagraph using methods described in
subclauses (I) through (V) of
subparagraph (K)(iii) as the Secretary
determines to be appropriate.
(v) Adjustments.--The Secretary shall
make appropriate adjustments to the
work relative value units under the fee
schedule under subsection (b). The
provisions of subparagraph (B)(ii)(II)
shall apply to adjustments to relative
value units made pursuant to this
subparagraph in the same manner as such
provisions apply to adjustments under
subparagraph (B)(ii)(II).
(M) Authority to collect and use information
on physicians' services in the determination of
relative values.--
(i) Collection of information.--
Notwithstanding 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 information.--
Notwithstanding 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 information.--The
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
mechanisms.--Information 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 general.--Subject 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 use.--The
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
information.--The 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 participate.--The
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) Administration.--Chapter 35 of
title 44, United States Code, shall not
apply to information collected or
obtained under this subparagraph.
(viii) Definition of eligible
professional.--In this subparagraph,
the term ``eligible professional'' has
the meaning given such term in
subsection (k)(3)(B).
(ix) Funding.--For 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.
(N) Authority for alternative approaches to
establishing practice expense relative
values.--The 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).
(O) Target for relative value adjustments for
misvalued services.--With respect to fee
schedules established for each of 2016 through
2018, the following shall apply:
(i) Determination of net reduction in
expenditures.--For 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 year.--If 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 met.--If 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
2016.
(iv) Target recapture amount.--For
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) Target.--For purposes of this
subparagraph, with respect to a year,
the target is calculated as 0.5 percent
(or, for 2016, 1.0 percent) of the
estimated amount of expenditures under
the fee schedule under this section for
the year.
(3) Component percentages.--For purposes of paragraph
(2), the Secretary shall determine a work percentage, a
practice expense percentage, and a malpractice
percentage for each physician's service as follows:
(A) Division of services by specialty.--For
each physician's service or class of
physicians' services, the Secretary shall
determine the average percentage of each such
service or class of services that is performed,
nationwide, under this part by physicians in
each of the different physician specialties (as
identified by the Secretary).
(B) Division of specialty by component.--The
Secretary shall determine the average
percentage division of resources, among the
work component, the practice expense component,
and the malpractice component, used by
physicians in each of such specialties in
furnishing physicians' services. Such
percentages shall be based on national data
that describe the elements of physician
practice costs and revenues, by physician
specialty. The Secretary may use extrapolation
and other techniques to determine practice
costs and revenues for specialties for which
adequate data are not available.
(C) Determination of component percentages.--
(i) Work percentage.--The work
percentage for a service (or class of
services) is equal to the sum (for all
physician specialties) of--
(I) the average percentage
division for the work component
for each physician specialty
(determined under subparagraph
(B)), multiplied by
(II) the proportion
(determined under subparagraph
(A)) of such service (or
services) performed by
physicians in that specialty.
(ii) Practice expense percentage.--
For years before 2002, the practice
expense percentage for a service (or
class of services) is equal to the sum
(for all physician specialties) of--
(I) the average percentage
division for the practice
expense component for each
physician specialty (determined
under subparagraph (B)),
multiplied by
(II) the proportion
(determined under subparagraph
(A)) of such service (or
services) performed by
physicians in that specialty.
(iii) Malpractice percentage.--For
years before 1999, the malpractice
percentage for a service (or class of
services) is equal to the sum (for all
physician specialties) of--
(I) the average percentage
division for the malpractice
component for each physician
specialty (determined under
subparagraph (B)), multiplied
by
(II) the proportion
(determined under subparagraph
(A)) of such service (or
services) performed by
physicians in that specialty.
(D) Periodic recomputation.--The Secretary
may, from time to time, provide for the
recomputation of work percentages, practice
expense percentages, and malpractice
percentages determined under this paragraph.
(4) Ancillary policies.--The Secretary may establish
ancillary policies (with respect to the use of
modifiers, local codes, and other matters) as may be
necessary to implement this section.
(5) Coding.--The Secretary shall establish a uniform
procedure coding system for the coding of all
physicians' services. The Secretary shall provide for
an appropriate coding structure for visits and
consultations. The Secretary may incorporate the use of
time in the coding for visits and consultations. The
Secretary, in establishing such coding system, shall
consult with the Physician Payment Review Commission
and other organizations representing physicians.
(6) No variation for specialists.--The Secretary may
not vary the conversion factor or the number of
relative value units for a physicians' service based on
whether the physician furnishing the service is a
specialist or based on the type of specialty of the
physician.
(7) Phase-in of significant relative value unit (rvu)
reductions.--Effective for fee schedules established
beginning with 2016, for services that are not new or
revised codes, 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.
(8) Global surgical packages.--
(A) Prohibition of implementation of rule
regarding global surgical packages.--
(i) In general.--The Secretary shall
not implement the policy established in
the final rule published on November
13, 2014 (79 Fed. Reg. 67548 et seq.),
that requires the transition of all 10-
day and 90-day global surgery packages
to 0-day global periods.
(ii) Construction.--Nothing in clause
(i) shall be construed to prevent the
Secretary from revaluing misvalued
codes for specific surgical services or
assigning values to new or revised
codes for surgical services.
(B) Collection of data on services included
in global surgical packages.--
(i) In general.--Subject to clause
(ii), the Secretary shall through
rulemaking develop and implement a
process to gather, from a
representative sample of physicians,
beginning not later than January 1,
2017, information needed to value
surgical services. Such information
shall include the number and level of
medical visits furnished during the
global period and other items and
services related to the surgery and
furnished during the global period, as
appropriate. Such information shall be
reported on claims at the end of the
global period or in another manner
specified by the Secretary. For
purposes of carrying out this paragraph
(other than clause (iii)), the
Secretary shall transfer from the
Federal Supplemental Medical Insurance
Trust Fund under section 1841
$2,000,000 to the Center for Medicare &
Medicaid Services Program Management
Account for fiscal year 2015. Amounts
transferred under the previous sentence
shall remain available until expended.
(ii) Reassessment and potential
sunset.--Every 4 years, the Secretary
shall reassess the value of the
information collected pursuant to
clause (i). Based on such a
reassessment and by regulation, the
Secretary may discontinue the
requirement for collection of
information under such clause if the
Secretary determines that the Secretary
has adequate information from other
sources, such as qualified clinical
data registries, surgical logs, billing
systems or other practice or facility
records, and electronic health records,
in order to accurately value global
surgical services under this section.
(iii) Inspector general audit.--The
Inspector General of the Department of
Health and Human Services shall audit a
sample of the information reported
under clause (i) to verify the accuracy
of the information so reported.
(C) Improving accuracy of pricing for
surgical services.--For years beginning with
2019, the Secretary shall use the information
reported under subparagraph (B)(i) as
appropriate and other available data for the
purpose of improving the accuracy of valuation
of surgical services under the physician fee
schedule under this section.
(d) Conversion Factors.--
(1) Establishment.--
(A) In general.--The conversion factor for
each year shall be the conversion factor
established under this subsection for the
previous year (or, in the case of 1992,
specified in subparagraph (B)) adjusted by the
update (established under paragraph (3)) for
the year involved (for years before 2001) and,
for years beginning with 2001 and ending with
2025, multiplied by the update (established
under paragraph (4) or a subsequent paragraph)
for the year involved. There shall be two
separate conversion factors for each year
beginning with 2026, one for items and services
furnished by a qualifying APM participant (as
defined in section 1833(z)(2)) (referred to in
this subsection as the ``qualifying APM
conversion factor'') and the other for other
items and services (referred to in this
subsection as the ``nonqualifying APM
conversion factor''), equal to the respective
conversion factor for the previous year (or, in
the case of 2026, equal to the single
conversion factor for 2025) multiplied by the
update established under paragraph (20) for
such respective conversion factor for such
year.
(B) Special provision for 1992.--For purposes
of subparagraph (A), the conversion factor
specified in this subparagraph is a conversion
factor (determined by the Secretary) which, if
this section were to apply during 1991 using
such conversion factor, would result in the
same aggregate amount of payments under this
part for physicians' services as the estimated
aggregate amount of the payments under this
part for such services in 1991.
(C) Special rules for 1998.--Except as
provided in subparagraph (D), the single
conversion factor for 1998 under this
subsection shall be the conversion factor for
primary care services for 1997, increased by
the Secretary's estimate of the weighted
average of the three separate updates that
would otherwise occur were it not for the
enactment of chapter 1 of subtitle F of title
IV of the Balanced Budget Act of 1997.
(D) Special rules for anesthesia services.--
The separate conversion factor for anesthesia
services for a year shall be equal to 46
percent of the single conversion factor (or,
beginning with 2026, applicable conversion
factor) established for other physicians'
services, except as adjusted for changes in
work, practice expense, or malpractice relative
value units.
(E) Publication and dissemination of
information.--The Secretary shall--
(i) cause to have published in the
Federal Register not later than
November 1 of each year (beginning with
2000) the conversion factor which will
apply to physicians' services for the
succeeding year, the update determined
under paragraph (4) for such succeeding
year, and the allowed expenditures
under such paragraph for such
succeeding year; and
(ii) make available to the Medicare
Payment Advisory Commission and the
public by March 1 of each year
(beginning with 2000) an estimate of
the sustainable growth rate and of the
conversion factor which will apply to
physicians' services for the succeeding
year and data used in making such
estimate.
(3) Update for 1999 and 2000.--
(A) In general.--Unless otherwise provided by
law, subject to subparagraph (D) and the
budget-neutrality factor determined by the
Secretary under subsection (c)(2)(B)(ii), the
update to the single conversion factor
established in paragraph (1)(C) for 1999 and
2000 is equal to the product of--
(i) 1 plus the Secretary's estimate
of the percentage increase in the MEI
(as defined in section 1842(i)(3)) for
the year (divided by 100), and
(ii) 1 plus the Secretary's estimate
of the update adjustment factor for the
year (divided by 100),
minus 1 and multiplied by 100.
(B) Update adjustment factor.--For purposes
of subparagraph (A)(ii), the ``update
adjustment factor'' for a year is equal (as
estimated by the Secretary) to--
(i) the difference between (I) the
sum of the allowed expenditures for
physicians' services (as determined
under subparagraph (C)) for the period
beginning April 1, 1997, and ending on
March 31 of the year involved, and (II)
the amount of actual expenditures for
physicians' services furnished during
the period beginning April 1, 1997, and
ending on March 31 of the preceding
year; divided by
(ii) the actual expenditures for
physicians' services for the 12-month
period ending on March 31 of the
preceding year, increased by the
sustainable growth rate under
subsection (f) for the fiscal year
which begins during such 12-month
period.
(C) Determination of allowed expenditures.--
For purposes of this paragraph and paragraph
(4), the allowed expenditures for physicians'
services for the 12-month period ending with
March 31 of--
(i) 1997 is equal to the actual
expenditures for physicians' services
furnished during such 12-month period,
as estimated by the Secretary; or
(ii) a subsequent year is equal to
the allowed expenditures for
physicians' services for the previous
year, increased by the sustainable
growth rate under subsection (f) for
the fiscal year which begins during
such 12-month period.
(D) Restriction on variation from medicare
economic index.--Notwithstanding the amount of
the update adjustment factor determined under
subparagraph (B) for a year, the update in the
conversion factor under this paragraph for the
year may not be--
(i) greater than 100 times the
following amount: (1.03 + (MEI
percentage/100)) -1; or
(ii) less than 100 times the
following amount: (0.93 + (MEI
percentage/100)) -1,
where ``MEI percentage'' means the Secretary's
estimate of the percentage increase in the MEI
(as defined in section 1842(i)(3)) for the year
involved.
(4) Update for years beginning with 2001 and ending
with 2014.--
(A) In general.--Unless otherwise provided by
law, subject to the budget-neutrality factor
determined by the Secretary under subsection
(c)(2)(B)(ii) and subject to adjustment under
subparagraph (F), the update to the single
conversion factor established in paragraph
(1)(C) for a year beginning with 2001 and
ending with 2014 is equal to the product of--
(i) 1 plus the Secretary's estimate
of the percentage increase in the MEI
(as defined in section 1842(i)(3)) for
the year (divided by 100); and
(ii) 1 plus the Secretary's estimate
of the update adjustment factor under
subparagraph (B) for the year.
(B) Update adjustment factor.--For purposes
of subparagraph (A)(ii), subject to
subparagraph (D) and the succeeding paragraphs
of this subsection, the ``update adjustment
factor'' for a year is equal (as estimated by
the Secretary) to the sum of the following:
(i) Prior year adjustment
component.--An amount determined by--
(I) computing the difference
(which may be positive or
negative) between the amount of
the allowed expenditures for
physicians' services for the
prior year (as determined under
subparagraph (C)) and the
amount of the actual
expenditures for such services
for that year;
(II) dividing that difference
by the amount of the actual
expenditures for such services
for that year; and
(III) multiplying that
quotient by 0.75.
(ii) Cumulative adjustment
component.--An amount determined by--
(I) computing the difference
(which may be positive or
negative) between the amount of
the allowed expenditures for
physicians' services (as
determined under subparagraph
(C)) from April 1, 1996,
through the end of the prior
year and the amount of the
actual expenditures for such
services during that period;
(II) dividing that difference
by actual expenditures for such
services for the prior year as
increased by the sustainable
growth rate under subsection
(f) for the year for which the
update adjustment factor is to
be determined; and
(III) multiplying that
quotient by 0.33.
(C) Determination of allowed expenditures.--
For purposes of this paragraph:
(i) Period up to april 1, 1999.--The
allowed expenditures for physicians'
services for a period before April 1,
1999, shall be the amount of the
allowed expenditures for such period as
determined under paragraph (3)(C).
(ii) Transition to calendar year
allowed expenditures.--Subject to
subparagraph (E), the allowed
expenditures for--
(I) the 9-month period
beginning April 1, 1999, shall
be the Secretary's estimate of
the amount of the allowed
expenditures that would be
permitted under paragraph
(3)(C) for such period; and
(II) the year of 1999, shall
be the Secretary's estimate of
the amount of the allowed
expenditures that would be
permitted under paragraph
(3)(C) for such year.
(iii) Years beginning with 2000.--The
allowed expenditures for a year
(beginning with 2000) is equal to the
allowed expenditures for physicians'
services for the previous year,
increased by the sustainable growth
rate under subsection (f) for the year
involved.
(D) Restriction on update adjustment
factor.--The update adjustment factor
determined under subparagraph (B) for a year
may not be less than -0.07 or greater than
0.03.
(E) Recalculation of allowed expenditures for
updates beginning with 2001.--For purposes of
determining the update adjustment factor for a
year beginning with 2001, the Secretary shall
recompute the allowed expenditures for previous
periods beginning on or after April 1, 1999,
consistent with subsection (f)(3).
(F) Transitional adjustment designed to
provide for budget neutrality.--Under this
subparagraph the Secretary shall provide for an
adjustment to the update under subparagraph
(A)--
(i) for each of 2001, 2002, 2003, and
2004, of -0.2 percent; and
(ii) for 2005 of +0.8 percent.
(5) Update for 2004 and 2005.--The update to the
single conversion factor established in paragraph
(1)(C) for each of 2004 and 2005 shall be not less than
1.5 percent.
(6) Update for 2006.--The update to the single
conversion factor established in paragraph (1)(C) for
2006 shall be 0 percent.
(7) Conversion factor for 2007.--
(A) In general.--The conversion factor that
would otherwise be applicable under this
subsection for 2007 shall be the amount of such
conversion factor divided by the product of--
(i) 1 plus the Secretary's estimate
of the percentage increase in the MEI
(as defined in section 1842(i)(3)) for
2007 (divided by 100); and
(ii) 1 plus the Secretary's estimate
of the update adjustment factor under
paragraph (4)(B) for 2007.
(B) No effect on computation of conversion
factor for 2008.--The conversion factor under
this subsection shall be computed under
paragraph (1)(A) for 2008 as if subparagraph
(A) had never applied.
(8) Update for 2008.--
(A) In general.--Subject to paragraph (7)(B),
in lieu of the update to the single conversion
factor established in paragraph (1)(C) that
would otherwise apply for 2008, the update to
the single conversion factor shall be 0.5
percent.
(B) No effect on computation of conversion
factor for 2009.--The conversion factor under
this subsection shall be computed under
paragraph (1)(A) for 2009 and subsequent years
as if subparagraph (A) had never applied.
(9) Update for 2009.--
(A) In general.--Subject to paragraphs (7)(B)
and (8)(B), in lieu of the update to the single
conversion factor established in paragraph
(1)(C) that would otherwise apply for 2009, the
update to the single conversion factor shall be
1.1 percent.
(B) No effect on computation of conversion
factor for 2010 and subsequent years.--The
conversion factor under this subsection shall
be computed under paragraph (1)(A) for 2010 and
subsequent years as if subparagraph (A) had
never applied.
(10) Update for January through may of 2010.--
(A) In general.--Subject to paragraphs
(7)(B), (8)(B), and (9)(B), in lieu of the
update to the single conversion factor
established in paragraph (1)(C) that would
otherwise apply for 2010 for the period
beginning on January 1, 2010, and ending on May
31, 2010, the update to the single conversion
factor shall be 0 percent for 2010.
(B) No effect on computation of conversion
factor for remaining portion of 2010 and
subsequent years.--The conversion factor under
this subsection shall be computed under
paragraph (1)(A) for the period beginning on
June 1, 2010, and ending on December 31, 2010,
and for 2011 and subsequent years as if
subparagraph (A) had never applied.
(11) Update for june through december of 2010.--
(A) In general.--Subject to paragraphs
(7)(B), (8)(B), (9)(B), and (10)(B), in lieu of
the update to the single conversion factor
established in paragraph (1)(C) that would
otherwise apply for 2010 for the period
beginning on June 1, 2010, and ending on
December 31, 2010, the update to the single
conversion factor shall be 2.2 percent.
(B) No effect on computation of conversion
factor for 2011 and subsequent years.--The
conversion factor under this subsection shall
be computed under paragraph (1)(A) for 2011 and
subsequent years as if subparagraph (A) had
never applied.
(12) Update for 2011.--
(A) In general.--Subject to paragraphs
(7)(B), (8)(B), (9)(B), (10)(B), and (11)(B),
in lieu of the update to the single conversion
factor established in paragraph (1)(C) that
would otherwise apply for 2011, the update to
the single conversion factor shall be 0
percent.
(B) No effect on computation of conversion
factor for 2012 and subsequent years.--The
conversion factor under this subsection shall
be computed under paragraph (1)(A) for 2012 and
subsequent years as if subparagraph (A) had
never applied.
(13) Update for 2012.--
(A) In general.--Subject to paragraphs
(7)(B), (8)(B), (9)(B), (10)(B), (11)(B), and
(12)(B), in lieu of the update to the single
conversion factor established in paragraph
(1)(C) that would otherwise apply for 2012, the
update to the single conversion factor shall be
zero percent.
(B) No effect on computation of conversion
factor for 2013 and subsequent years.--The
conversion factor under this subsection shall
be computed under paragraph (1)(A) for 2013 and
subsequent years as if subparagraph (A) had
never applied.
(14) Update for 2013.--
(A) In general.--Subject to paragraphs
(7)(B), (8)(B), (9)(B), (10)(B), (11)(B),
(12)(B), and (13)(B), in lieu of the update to
the single conversion factor established in
paragraph (1)(C) that would otherwise apply for
2013, the update to the single conversion
factor for such year shall be zero percent.
(B) No effect on computation of conversion
factor for 2014 and subsequent years.--The
conversion factor under this subsection shall
be computed under paragraph (1)(A) for 2014 and
subsequent years as if subparagraph (A) had
never applied.
(15) Update for 2014.--
(A) In general.--Subject to paragraphs
(7)(B), (8)(B), (9)(B), (10)(B), (11)(B),
(12)(B), (13)(B), and (14)(B), in lieu of the
update to the single conversion factor
established in paragraph (1)(C) that would
otherwise apply for 2014, the update to the
single conversion factor shall be 0.5 percent.
(B) No effect on computation of conversion
factor for subsequent years.--The conversion
factor under this subsection shall be computed
under paragraph (1)(A) for 2015 and subsequent
years as if subparagraph (A) had never applied.
(16) Update for january through june of 2015.--
Subject to paragraphs (7)(B), (8)(B), (9)(B), (10)(B),
(11)(B), (12)(B), (13)(B), (14)(B), and (15)(B), in
lieu of the update to the single conversion factor
established in paragraph (1)(C) that would otherwise
apply for 2015 for the period beginning on January 1,
2015, and ending on June 30, 2015, the update to the
single conversion factor shall be 0.0 percent.
(17) Update for july through december of 2015.--The
update to the single conversion factor established in
paragraph (1)(C) for the period beginning on July 1,
2015, and ending on December 31, 2015, shall be 0.5
percent.
(18) Update for 2016 through 2019.--The update to the
single conversion factor established in paragraph
(1)(C)--
(A) for 2016 and each subsequent year through
2018 shall be 0.5 percent; and
(B) for 2019 shall be 0.25 percent.
(19) Update for 2020 through 2025.--The update to the
single conversion factor established in paragraph
(1)(C) for 2020 and each subsequent year through 2025
shall be 0.0 percent.
(20) Update for 2026 and subsequent years.--For 2026
and each subsequent year, the update to the qualifying
APM conversion factor established under paragraph
(1)(A) is 0.75 percent, and the update to the
nonqualifying APM conversion factor established under
such paragraph is 0.25 percent.
(e) Geographic Adjustment Factors.--
(1) Establishment of geographic indices.--
(A) In general.--Subject to subparagraphs
(B), (C), (E), (G), (H), and (I), the Secretary
shall establish--
(i) an index which reflects the
relative costs of the mix of goods and
services comprising practice expenses
(other than malpractice expenses) in
the different fee schedule areas
compared to the national average of
such costs,
(ii) an index which reflects the
relative costs of malpractice expenses
in the different fee schedule areas
compared to the national average of
such costs, and
(iii) an index which reflects \1/4\
of the difference between the relative
value of physicians' work effort in
each of the different fee schedule
areas and the national average of such
work effort.
(B) Class-specific geographic cost-of-
practice indices.--The Secretary may establish
more than one index under subparagraph (A)(i)
in the case of classes of physicians' services,
if, because of differences in the mix of goods
and services comprising practice expenses for
the different classes of services, the
application of a single index under such clause
to different classes of such services would be
substantially inequitable.
(C) Peridic review and adjustments in
geographic adjustment factors.--The Secretary,
not less often than every 3 years, shall, in
consultation with appropriate representatives
of physicians, review the indices established
under subparagraph (A) and the geographic index
values applied under this subsection for all
fee schedule areas. Based on such review, the
Secretary may revise such index and adjust such
index values, except that, if more than 1 year
has elapsed since the date of the last previous
adjustment, the adjustment to be applied in the
first year of the next adjustment shall be \1/
2\ of the adjustment that otherwise would be
made.
(D) Use of recent data.--In establishing
indices and index values under this paragraph,
the Secretary shall use the most recent data
available relating to practice expenses,
malpractice expenses, and physician work effort
in different fee schedule areas.
(E) Floor at 1.0 on work geographic index.--
After calculating the work geographic index in
subparagraph (A)(iii), for purposes of payment
for services furnished on or after January 1,
2004, and before January 1, [2020] 2023, the
Secretary shall increase the work geographic
index to 1.00 for any locality for which such
work geographic index is less than 1.00.
(G) Floor for practice expense, malpractice,
and work geographic indices for services
furnished in alaska.--For purposes of payment
for services furnished in Alaska on or after
January 1, 2004, and before January 1, 2006,
after calculating the practice expense,
malpractice, and work geographic indices in
clauses (i), (ii), and (iii) of subparagraph
(A) and in subparagraph (B), the Secretary
shall increase any such index to 1.67 if such
index would otherwise be less than 1.67. For
purposes of payment for services furnished in
the State described in the preceding sentence
on or after January 1, 2009, after calculating
the work geographic index in subparagraph
(A)(iii), the Secretary shall increase the work
geographic index to 1.5 if such index would
otherwise be less than 1.5
(H) Practice expense geographic adjustment
for 2010 and subsequent years.--
(i) For 2010.--Subject to clause
(iii), for services furnished during
2010, the employee wage and rent
portions of the practice expense
geographic index described in
subparagraph (A)(i) shall reflect \1/2\
of the difference between the relative
costs of employee wages and rents in
each of the different fee schedule
areas and the national average of such
employee wages and rents.
(ii) For 2011.--Subject to clause
(iii), for services furnished during
2011, the employee wage and rent
portions of the practice expense
geographic index described in
subparagraph (A)(i) shall reflect \1/2\
of the difference between the relative
costs of employee wages and rents in
each of the different fee schedule
areas and the national average of such
employee wages and rents.
(iii) Hold harmless.--The practice
expense portion of the geographic
adjustment factor applied in a fee
schedule area for services furnished in
2010 or 2011 shall not, as a result of
the application of clause (i) or (ii),
be reduced below the practice expense
portion of the geographic adjustment
factor under subparagraph (A)(i) (as
calculated prior to the application of
such clause (i) or (ii), respectively)
for such area for such year.
(iv) Analysis.--The Secretary shall
analyze current methods of establishing
practice expense geographic adjustments
under subparagraph (A)(i) and evaluate
data that fairly and reliably
establishes distinctions in the costs
of operating a medical practice in the
different fee schedule areas. Such
analysis shall include an evaluation of
the following:
(I) The feasibility of using
actual data or reliable survey
data developed by medical
organizations on the costs of
operating a medical practice,
including office rents and non-
physician staff wages, in
different fee schedule areas.
(II) The office expense
portion of the practice expense
geographic adjustment described
in subparagraph (A)(i),
including the extent to which
types of office expenses are
determined in local markets
instead of national markets.
(III) The weights assigned to
each of the categories within
the practice expense geographic
adjustment described in
subparagraph (A)(i).
(v) Revision for 2012 and subsequent
years.--As a result of the analysis
described in clause (iv), the Secretary
shall, not later than January 1, 2012,
make appropriate adjustments to the
practice expense geographic adjustment
described in subparagraph (A)(i) to
ensure accurate geographic adjustments
across fee schedule areas, including--
(I) basing the office rents
component and its weight on
office expenses that vary among
fee schedule areas; and
(II) considering a
representative range of
professional and non-
professional personnel employed
in a medical office based on
the use of the American
Community Survey data or other
reliable data for wage
adjustments.
Such adjustments shall be made without
regard to adjustments made pursuant to
clauses (i) and (ii) and shall be made
in a budget neutral manner.
(I) Floor for practice expense index for
services furnished in frontier states.--
(i) In general.--Subject to clause
(ii), for purposes of payment for
services furnished in a frontier State
(as defined in section
1886(d)(3)(E)(iii)(II)) on or after
January 1, 2011, after calculating the
practice expense index in subparagraph
(A)(i), the Secretary shall increase
any such index to 1.00 if such index
would otherwise be less that 1.00. The
preceding sentence shall not be applied
in a budget neutral manner.
(ii) Limitation.--This subparagraph
shall not apply to services furnished
in a State that receives a non-labor
related share adjustment under section
1886(d)(5)(H).
(2) Computation of geographic adjustment factor.--For
purposes of subsection (b)(1)(C), for all physicians'
services for each fee schedule area the Secretary shall
establish a geographic adjustment factor equal to the
sum of the geographic cost-of-practice adjustment
factor (specified in paragraph (3)), the geographic
malpractice adjustment factor (specified in paragraph
(4)), and the geographic physician work adjustment
factor (specified in paragraph (5)) for the service and
the area.
(3) Geographic cost-of-practice adjustment factor.--
For purposes of paragraph (2), the ``geographic cost-
of-practice adjustment factor'', for a service for a
fee schedule area, is the product of--
(A) the proportion of the total relative
value for the service that reflects the
relative value units for the practice expense
component, and
(B) the geographic cost-of-practice index
value for the area for the service, based on
the index established under paragraph (1)(A)(i)
or (1)(B) (as the case may be).
(4) Geographic malpractice adjustment factor.--For
purposes of paragraph (2), the ``geographic malpractice
adjustment factor'', for a service for a fee schedule
area, is the product of--
(A) the proportion of the total relative
value for the service that reflects the
relative value units for the malpractice
component, and
(B) the geographic malpractice index value
for the area, based on the index established
under paragraph (1)(A)(ii).
(5) Geographic physician work adjustment factor.--For
purposes of paragraph (2), the ``geographic physician
work adjustment factor'', for a service for a fee
schedule area, is the product of--
(A) the proportion of the total relative
value for the service that reflects the
relative value units for the work component,
and
(B) the geographic physician work index value
for the area, based on the index established
under paragraph (1)(A)(iii).
(6) Use of msas as fee schedule areas in
california.--
(A) In general.--Subject 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 general.--For 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 component.--
The 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 component.--
The 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 factor.--The 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 factor.--
The 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 harmless.--For 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 defined.--In 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 areas.--
Effective 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.
(f) Sustainable Growth Rate.--
(1) Publication.--The Secretary shall cause to have
published in the Federal Register not later than--
(A) November 1, 2000, the sustainable growth
rate for 2000 and 2001; and
(B) November 1 of each succeeding year
through 2014 the sustainable growth rate for
such succeeding year and each of the preceding
2 years.
(2) Specification of growth rate.--The sustainable
growth rate for all physicians' services for a fiscal
year (beginning with fiscal year 1998 and ending with
fiscal year 2000) and a year beginning with 2000 and
ending with 2014 shall be equal to the product of--
(A) 1 plus the Secretary's estimate of the
weighted average percentage increase (divided
by 100) in the fees for all physicians'
services in the applicable period involved,
(B) 1 plus the Secretary's estimate of the
percentage change (divided by 100) in the
average number of individuals enrolled under
this part (other than Medicare+Choice plan
enrollees) from the previous applicable period
to the applicable period involved,
(C) 1 plus the Secretary's estimate of the
annual average percentage growth in real gross
domestic product per capita (divided by 100)
during the 10-year period ending with the
applicable period involved, and
(D) 1 plus the Secretary's estimate of the
percentage change (divided by 100) in
expenditures for all physicians' services in
the applicable period (compared with the
previous applicable period) which will result
from changes in law and regulations, determined
without taking into account estimated changes
in expenditures resulting from the update
adjustment factor determined under subsection
(d)(3)(B) or (d)(4)(B), as the case may be,
minus 1 and multiplied by 100.
(3) Data to be used.--For purposes of determining the
update adjustment factor under subsection (d)(4)(B) for
a year beginning with 2001, the sustainable growth
rates taken into consideration in the determination
under paragraph (2) shall be determined as follows:
(A) For 2001.--For purposes of such
calculations for 2001, the sustainable growth
rates for fiscal year 2000 and the years 2000
and 2001 shall be determined on the basis of
the best data available to the Secretary as of
September 1, 2000.
(B) For 2002.--For purposes of such
calculations for 2002, the sustainable growth
rates for fiscal year 2000 and for years 2000,
2001, and 2002 shall be determined on the basis
of the best data available to the Secretary as
of September 1, 2001.
(C) For 2003 and succeeding years.--For
purposes of such calculations for a year after
2002--
(i) the sustainable growth rates for
that year and the preceding 2 years
shall be determined on the basis of the
best data available to the Secretary as
of September 1 of the year preceding
the year for which the calculation is
made; and
(ii) the sustainable growth rate for
any year before a year described in
clause (i) shall be the rate as most
recently determined for that year under
this subsection.
Nothing in this paragraph shall be construed as
affecting the sustainable growth rates established for
fiscal year 1998 or fiscal year 1999.
(4) Definitions.--In this subsection:
(A) Services included in physicians'
services.--The term ``physicians' services''
includes other items and services (such as
clinical diagnostic laboratory tests and
radiology services), specified by the
Secretary, that are commonly performed or
furnished by a physician or in a physician's
office, but does not include services furnished
to a Medicare+Choice plan enrollee.
(B) Medicare+choice plan enrollee.--The term
``Medicare+Choice plan enrollee'' means, with
respect to a fiscal year, an individual
enrolled under this part who has elected to
receive benefits under this title for the
fiscal year through a Medicare+Choice plan
offered under part C, and also includes an
individual who is receiving benefits under this
part through enrollment with an eligible
organization with a risk-sharing contract under
section 1876.
(C) Applicable period.--The term ``applicable
period'' means--
(i) a fiscal year, in the case of
fiscal year 1998, fiscal year 1999, and
fiscal year 2000; or
(ii) a calendar year with respect to
a year beginning with 2000;
as the case may be.
(g) Limitation on Beneficiary Liability.--
(1) Limitation on actual charges.--
(A) In general.--In the case of a
nonparticipating physician or nonparticipating
supplier or other person (as defined in section
1842(i)(2)) who does not accept payment on an
assignment-related basis for a physician's
service furnished with respect to an individual
enrolled under this part, the following rules
apply:
(i) Application of limiting charge.--
No person may bill or collect an actual
charge for the service in excess of the
limiting charge described in paragraph
(2) for such service.
(ii) No liability for excess
charges.--No person is liable for
payment of any amounts billed for the
service in excess of such limiting
charge.
(iii) Correction of excess charges.--
If such a physician, supplier, or other
person bills, but does not collect, an
actual charge for a service in
violation of clause (i), the physician,
supplier, or other person shall reduce
on a timely basis the actual charge
billed for the service to an amount not
to exceed the limiting charge for the
service.
(iv) Refund of excess collections.--
If such a physician, supplier, or other
person collects an actual charge for a
service in violation of clause (i), the
physician, supplier, or other person
shall provide on a timely basis a
refund to the individual charged in the
amount by which the amount collected
exceeded the limiting charge for the
service. The amount of such a refund
shall be reduced to the extent the
individual has an outstanding balance
owed by the individual to the
physician.
(B) Sanctions.--If a physician, supplier, or
other person--
(i) knowingly and willfully bills or
collects for services in violation of
subparagraph (A)(i) on a repeated
basis, or
(ii) fails to comply with clause
(iii) or (iv) of subparagraph (A) on a
timely basis,
the Secretary may apply sanctions against the
physician, supplier, or other person in
accordance with paragraph (2) of section
1842(j). In applying this subparagraph,
paragraph (4) of such section applies in the
same manner as such paragraph applies to such
section and any reference in such section to a
physician is deemed also to include a reference
to a supplier or other person under this
subparagraph.
(C) Timely basis.--For purposes of this
paragraph, a correction of a bill for an excess
charge or refund of an amount with respect to a
violation of subparagraph (A)(i) in the case of
a service is considered to be provided ``on a
timely basis'', if the reduction or refund is
made not later than 30 days after the date the
physician, supplier, or other person is
notified by the carrier under this part of such
violation and of the requirements of
subparagraph (A).
(2) Limiting charge defined.--
(A) For 1991.--For physicians' services of a
physician furnished during 1991, other than
radiologist services subject to section
1834(b), the ``limiting charge'' shall be the
same percentage (or, if less, 25 percent) above
the recognized payment amount under this part
with respect to the physician (as a
nonparticipating physician) as the percentage
by which--
(i) the maximum allowable actual
charge (as determined under section
1842(j)(1)(C) as of December 31, 1990,
or, if less, the maximum actual charge
otherwise permitted for the service
under this part as of such date) for
the service of the physician, exceeds
(ii) the recognized payment amount
for the service of the physician (as a
nonparticipating physician) as of such
date.
In the case of evaluation and management services (as specified
in section 1842(b)(16)(B)(ii)), the preceding sentence shall be
applied by substituting ``40 percent'' for ``25 percent''.
(B) For 1992.--For physicians' services
furnished during 1992, other than radiologist
services subject to section 1834(b), the
``limiting charge'' shall be the same
percentage (or, if less, 20 percent) above the
recognized payment amount under this part for
nonparticipating physicians as the percentage
by which--
(i) the limiting charge (as
determined under subparagraph (A) as of
December 31, 1991) for the service,
exceeds
(ii) the recognized payment amount
for the service for nonparticipating
physicians as of such date.
(C) After 1992.--For physicians' services
furnished in a year after 1992, the ``limiting
charge'' shall be 115 percent of the recognized
payment amount under this part for
nonparticipating physicians or for
nonparticipating suppliers or other persons.
(D) Recognized payment amount.--In this
section, the term ``recognized payment amount''
means, for services furnished on or after
January 1, 1992, the fee schedule amount
determined under subsection (a) (or, if payment
under this part is made on a basis other than
the fee schedule under this section, 95 percent
of the other payment basis), and, for services
furnished during 1991, the applicable
percentage (as defined in section
1842(b)(4)(A)(iv)) of the prevailing charge (or
fee schedule amount) for nonparticipating
physicians for that year.
(3) Limitation on charges for medicare beneficiaries
eligible for medicaid benefits.--
(A) In general.--Payment for physicians'
services furnished on or after April 1, 1990,
to an individual who is enrolled under this
part and eligible for any medical assistance
(including as a qualified medicare beneficiary,
as defined in section 1905(p)(1)) with respect
to such services under a State plan approved
under title XIX may only be made on an
assignment-related basis and the provisions of
section 1902(n)(3)(A) apply to further limit
permissible charges under this section.
(B) Penalty.--A person may not bill for
physicians' services subject to subparagraph
(A) other than on an assignment-related basis.
No person is liable for payment of any amounts
billed for such a service in violation of the
previous sentence. If a person knowingly and
willfully bills for physicians' services in
violation of the first sentence, the Secretary
may apply sanctions against the person in
accordance with section 1842(j)(2).
(4) Physician submission of claims.--
(A) In general.--For services furnished on or
after September 1, 1990, within 1 year after
the date of providing a service for which
payment is made under this part on a reasonable
charge or fee schedule basis, a physician,
supplier, or other person (or an employer or
facility in the cases described in section
1842(b)(6)(A))--
(i) shall complete and submit a claim
for such service on a standard claim
form specified by the Secretary to the
carrier on behalf of a beneficiary, and
(ii) may not impose any charge
relating to completing and submitting
such a form.
(B) Penalty.--(i) With respect to an assigned
claim wherever a physician, provider, supplier
or other person (or an employer or facility in
the cases described in section 1842(b)(6)(A))
fails to submit such a claim as required in
subparagraph (A), the Secretary shall reduce by
10 percent the amount that would otherwise be
paid for such claim under this part.
(ii) If a physician, supplier, or other
person (or an employer or facility in the cases
described in section 1842(b)(6)(A)) fails to
submit a claim required to be submitted under
subparagraph (A) or imposes a charge in
violation of such subparagraph, the Secretary
shall apply the sanction with respect to such a
violation in the same manner as a sanction may
be imposed under section 1842(p)(3) for a
violation of section 1842(p)(1).
(5) Electronic billing; direct deposit.--The
Secretary shall encourage and develop a system
providing for expedited payment for claims submitted
electronically. The Secretary shall also encourage and
provide incentives allowing for direct deposit as
payments for services furnished by participating
physicians. The Secretary shall provide physicians with
such technical information as necessary to enable such
physicians to submit claims electronically. The
Secretary shall submit a plan to Congress on this
paragraph by May 1, 1990.
(6) Monitoring of charges.--
(A) In general.--The Secretary shall
monitor--
(i) the actual charges of
nonparticipating physicians for
physicians' services furnished on or
after January 1, 1991, to individuals
enrolled under this part, and
(ii) changes (by specialty, type of
service, and geographic area) in (I)
the proportion of expenditures for
physicians' services provided under
this part by participating physicians,
(II) the proportion of expenditures for
such services for which payment is made
under this part on an assignment-
related basis, and (III) the amounts
charged above the recognized payment
amounts under this part.
(B) Report.--The Secretary shall, by not
later than April 15 of each year (beginning in
1992), report to the Congress information on
the extent to which actual charges exceed
limiting charges, the number and types of
services involved, and the average amount of
excess charges and information regarding the
changes described in subparagraph (A)(ii).
(C) Plan.--If the Secretary finds that there
has been a significant decrease in the
proportions described in subclauses (I) and
(II) of subparagraph (A)(ii) or an increase in
the amounts described in subclause (III) of
that subparagraph, the Secretary shall develop
a plan to address such a problem and transmit
to Congress recommendations regarding the plan.
The Medicare Payment Advisory Commission shall
review the Secretary's plan and recommendations
and transmit to Congress its comments regarding
such plan and recommendations.
(7) Monitoring of utilization and access.--
(A) In general.--The Secretary shall
monitor--
(i) changes in the utilization of and
access to services furnished under this
part within geographic, population, and
service related categories,
(ii) possible sources of
inappropriate utilization of services
furnished under this part which
contribute to the overall level of
expenditures under this part, and
(iii) factors underlying these
changes and their interrelationships.
(B) Report.--The Secretary shall by not later
than April 15, of each year (beginning with
1991) report to the Congress on the changes
described in subparagraph (A)(i) and shall
include in the report an examination of the
factors (including factors relating to
different services and specific categories and
groups of services and geographic and
demographic variations in utilization) which
may contribute to such changes.
(C) Recommendations.--The Secretary shall
include in each annual report under
subparagraph (B) recommendations--
(i) addressing any identified
patterns of inappropriate utilization,
(ii) on utilization review,
(iii) on physician education or
patient education,
(iv) addressing any problems of
beneficiary access to care made evident
by the monitoring process, and
(v) on such other matters as the
Secretary deems appropriate.
The Medicare Payment Advisory Commission shall
comment on the Secretary's recommendations and
in developing its comments, the Commission
shall convene and consult a panel of physician
experts to evaluate the implications of medical
utilization patterns for the quality of and
access to patient care.
(h) Sending Information to Physicians.--Before the beginning
of each year (beginning with 1992), the Secretary shall send to
each physician or nonparticipating supplier or other person
furnishing physicians' services (as defined in section
1848(j)(3)) furnishing physicians' services under this part,
for services commonly performed by the physician, supplier, or
other person, information on fee schedule amounts that apply
for the year in the fee schedule area for participating and
non-participating physicians, and the maximum amount that may
be charged consistent with subsection (g)(2). Such information
shall be transmitted in conjunction with notices to physicians,
suppliers, and other persons under section 1842(h) (relating to
the participating physician program) for a year.
(i) Miscellaneous Provisions.--
(1) Restriction on administrative and judicial
review.--There shall be no administrative or judicial
review under section 1869 or otherwise of--
(A) the determination of the adjusted
historical payment basis (as defined in
subsection (a)(2)(D)(i)),
(B) the determination of relative values and
relative value units under subsection (c),
including adjustments under subsections
(c)(2)(F), (c)(2)(H), and (c)(2)(I) and section
13515(b) of the Omnibus Budget Reconciliation
Act of 1993,
(C) the determination of conversion factors
under subsection (d), including without
limitation a prospective redetermination of the
sustainable growth rates for any or all
previous fiscal years,
(D) the establishment of geographic
adjustment factors under subsection (e),
(E) the establishment of the system for the
coding of physicians' services under this
section, and
(F) the collection and use of information in
the determination of relative values under
subsection (c)(2)(M).
(2) Assistants-at-surgery.--
(A) In general.--Subject to subparagraph (B),
in the case of a surgical service furnished by
a physician, if payment is made separately
under this part for the services of a physician
serving as an assistant-at-surgery, the fee
schedule amount shall not exceed 16 percent of
the fee schedule amount otherwise determined
under this section for the global surgical
service involved.
(B) Denial of payment in certain cases.--If
the Secretary determines, based on the most
recent data available, that for a surgical
procedure (or class of surgical procedures) the
national average percentage of such procedure
performed under this part which involve the use
of a physician as an assistant at surgery is
less than 5 percent, no payment may be made
under this part for services of an assistant at
surgery involved in the procedure.
(3) No comparability adjustment.--For physicians'
services for which payment under this part is
determined under this section--
(A) a carrier may not make any adjustment in
the payment amount under section 1842(b)(3)(B)
on the basis that the payment amount is higher
than the charge applicable, for comparable
services and under comparable circumstances, to
the policyholders and subscribers of the
carrier,
(B) no payment adjustment may be made under
section 1842(b)(8), and
(C) section 1842(b)(9) shall not apply.
(j) Definitions.--In this section:
(1) Category.--For services furnished before January
1, 1998, the term ``category'' means, with respect to
physicians' services, surgical services (as defined by
the Secretary and including anesthesia services),
primary care services (as defined in section
1842(i)(4)), and all other physicians' services. The
Secretary shall define surgical services and publish
such definitions in the Federal Register no later than
May 1, 1990, after consultation with organizations
representing physicians.
(2) Fee schedule area.--Except as provided in
subsection (e)(6)(D), the term ``fee schedule area''
means a locality used under section 1842(b) for
purposes of computing payment amounts for physicians'
services.
(3) Physicians' services.--The term ``physicians'
services'' includes items and services described in
paragraphs (1), (2)(A), (2)(D), (2)(G), (2)(P) (with
respect to services described in subparagraphs (A) and
(C) of section 1861(oo)(2)), (2)(R) (with respect to
services described in suparagraphs (B), (C), and (D) of
section 1861(pp)(1)), (2)(S), (2)(W), (2)(AA), (2)(DD),
(2)(EE), (2)(FF) (including administration of the
health risk assessment), (3), (4), (13), (14) (with
respect to services described in section 1861(nn)(2)),
and (15) of section 1861(s) (other than clinical
diagnostic laboratory tests and, except for purposes of
subsection (a)(3), (g), and (h) such other items and
services as the Secretary may specify).
(4) Practice expenses.--The term ``practice
expenses'' includes all expenses for furnishing
physicians' services, excluding malpractice expenses,
physician compensation, and other physician fringe
benefits.
(k) Quality Reporting System.--
(1) In general.--The Secretary shall implement a
system for the reporting by eligible professionals of
data on quality measures specified under paragraph (2).
Such data shall be submitted in a form and manner
specified by the Secretary (by program instruction or
otherwise), which may include submission of such data
on claims under this part.
(2) Use of consensus-based quality measures.--
(A) For 2007.--
(i) In general.--For purposes of
applying this subsection for the
reporting of data on quality measures
for covered professional services
furnished during the period beginning
July 1, 2007, and ending December 31,
2007, the quality measures specified
under this paragraph are the measures
identified as 2007 physician quality
measures under the Physician Voluntary
Reporting Program as published on the
public website of the Centers for
Medicare & Medicaid Services as of the
date of the enactment of this
subsection, except as may be changed by
the Secretary based on the results of a
consensus-based process in January of
2007, if such change is published on
such website by not later than April 1,
2007.
(ii) Subsequent refinements in
application permitted.--The Secretary
may, from time to time (but not later
than July 1, 2007), publish on such
website (without notice or opportunity
for public comment) modifications or
refinements (such as code additions,
corrections, or revisions) for the
application of quality measures
previously published under clause (i),
but may not, under this clause, change
the quality measures under the
reporting system.
(iii) Implementation.--
Notwithstanding any other provision of
law, the Secretary may implement by
program instruction or otherwise this
subsection for 2007.
(B) For 2008 and 2009.--
(i) In general.--For purposes of
reporting data on quality measures for
covered professional services furnished
during 2008 and 2009, the quality
measures specified under this paragraph
for covered professional services shall
be measures that have been adopted or
endorsed by a consensus organization
(such as the National Quality Forum or
AQA), that include measures that have
been submitted by a physician
specialty, and that the Secretary
identifies as having used a consensus-
based process for developing such
measures. Such measures shall include
structural measures, such as the use of
electronic health records and
electronic prescribing technology.
(ii) Proposed set of measures.--Not
later than August 15 of each of 2007
and 2008, the Secretary shall publish
in the Federal Register a proposed set
of quality measures that the Secretary
determines are described in clause (i)
and would be appropriate for eligible
professionals to use to submit data to
the Secretary in 2008 or 2009, as
applicable. The Secretary shall provide
for a period of public comment on such
set of measures.
(iii) Final set of measures.--Not
later than November 15 of each of 2007
and 2008, the Secretary shall publish
in the Federal Register a final set of
quality measures that the Secretary
determines are described in clause (i)
and would be appropriate for eligible
professionals to use to submit data to
the Secretary in 2008 or 2009, as
applicable.
(C) For 2010 and subsequent years.--
(i) In general.--Subject to clause
(ii), for purposes of reporting data on
quality measures for covered
professional services furnished during
2010 and each subsequent year, subject
to subsection (m)(3)(C), the quality
measures (including electronic
prescribing quality measures) specified
under this paragraph shall be such
measures selected by the Secretary from
measures that have been endorsed by the
entity with a contract with the
Secretary under section 1890(a).
(ii) Exception.--In the case of a
specified area or medical topic
determined appropriate by the Secretary
for which a feasible and practical
measure has not been endorsed by the
entity with a contract under section
1890(a), the Secretary may specify a
measure that is not so endorsed as long
as due consideration is given to
measures that have been endorsed or
adopted by a consensus organization
identified by the Secretary, such as
the AQA alliance.
(D) Opportunity to provide input on measures
for 2009 and subsequent years.--For each
quality measure (including an electronic
prescribing quality measure) adopted by the
Secretary under subparagraph (B) (with respect
to 2009) or subparagraph (C), the Secretary
shall ensure that eligible professionals have
the opportunity to provide input during the
development, endorsement, or selection of
measures applicable to services they furnish.
(3) Covered professional services and eligible
professionals defined.--For purposes of this
subsection:
(A) Covered professional services.--The term
``covered professional services'' means
services for which payment is made under, or is
based on, the fee schedule established under
this section and which are furnished by an
eligible professional.
(B) Eligible professional.--The term
``eligible professional'' means any of the
following:
(i) A physician.
(ii) A practitioner described in
section 1842(b)(18)(C).
(iii) A physical or occupational
therapist or a qualified speech-
language pathologist.
(iv) Beginning with 2009, a qualified
audiologist (as defined in section
1861(ll)(3)(B)).
(4) Use of registry-based reporting.--As part of the
publication of proposed and final quality measures for
2008 under clauses (ii) and (iii) of paragraph (2)(B),
the Secretary shall address a mechanism whereby an
eligible professional may provide data on quality
measures through an appropriate medical registry (such
as the Society of Thoracic Surgeons National Database)
or through a Maintenance of Certification program
operated by a specialty body of the American Board of
Medical Specialties that meets the criteria for such a
registry, as identified by the Secretary.
(5) Identification units.--For purposes of applying
this subsection, the Secretary may identify eligible
professionals through billing units, which may include
the use of the Provider Identification Number, the
unique physician identification number (described in
section 1833(q)(1)), the taxpayer identification
number, or the National Provider Identifier. For
purposes of applying this subsection for 2007, the
Secretary shall use the taxpayer identification number
as the billing unit.
(6) Education and outreach.--The Secretary shall
provide for education and outreach to eligible
professionals on the operation of this subsection.
(7) Limitations on review.--There shall be no
administrative or judicial review under section 1869,
section 1878, or otherwise, of the development and
implementation of the reporting system under paragraph
(1), including identification of quality measures under
paragraph (2) and the application of paragraphs (4) and
(5).
(8) Implementation.--The Secretary shall carry out
this subsection acting through the Administrator of the
Centers for Medicare & Medicaid Services.
(9) Continued application for purposes of mips and
for certain professionals volunteering to report.--The
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.
(l) Physician Assistance and Quality Initiative Fund.--
(1) Establishment.--The Secretary shall establish
under this subsection a Physician Assistance and
Quality Initiative Fund (in this subsection referred to
as the ``Fund'') which shall be available to the
Secretary for physician payment and quality improvement
initiatives, which may include application of an
adjustment to the update of the conversion factor under
subsection (d).
(2) Funding.--
(A) Amount available.--
(i) In general.--Subject to clause
(ii), there shall be available to the
Fund the following amounts:
(I) For expenditures during
2008, an amount equal to
$150,500,000.
(II) For expenditures during
2009, an amount equal to
$24,500,000.
(ii) Limitations on expenditures.--
(I) 2008.--The amount
available for expenditures
during 2008 shall be reduced as
provided by subparagraph (A) of
section 225(c)(1) and section
524 of the Departments of
Labor, Health and Human
Services, and Education, and
Related Agencies Appropriations
Act, 2008 (division G of the
Consolidated Appropriations
Act, 2008).
(II) 2009.--The amount
available for expenditures
during 2009 shall be reduced as
provided by subparagraph (B) of
such section 225(c)(1).
(B) Timely obligation of all available funds
for services.--The Secretary shall provide for
expenditures from the Fund in a manner designed
to provide (to the maximum extent feasible) for
the obligation of the entire amount available
for expenditures, after application of
subparagraph (A)(ii), during--
(i) 2008 for payment with respect to
physicians' services furnished during
2008; and
(ii) 2009 for payment with respect to
physicians' services furnished during
2009.
(C) Payment from trust fund.--The amount
specified in subparagraph (A) shall be
available to the Fund, as expenditures are made
from the Fund, from the Federal Supplementary
Medical Insurance Trust Fund under section
1841.
(D) Funding limitation.--Amounts in the Fund
shall be available in advance of appropriations
in accordance with subparagraph (B) but only if
the total amount obligated from the Fund does
not exceed the amount available to the Fund
under subparagraph (A). The Secretary may
obligate funds from the Fund only if the
Secretary determines (and the Chief Actuary of
the Centers for Medicare & Medicaid Services
and the appropriate budget officer certify)
that there are available in the Fund sufficient
amounts to cover all such obligations incurred
consistent with the previous sentence.
(E) Construction.--In the case that
expenditures from the Fund are applied to, or
otherwise affect, a conversion factor under
subsection (d) for a year, the conversion
factor under such subsection shall be computed
for a subsequent year as if such application or
effect had never occurred.
(m) Incentive Payments for Quality Reporting.--
(1) Incentive payments.--
(A) In general.--For 2007 through 2014, with
respect to covered professional services
furnished during a reporting period by an
eligible professional, if--
(i) there are any quality measures
that have been established under the
physician reporting system that are
applicable to any such services
furnished by such professional for such
reporting period;
(ii) the eligible professional
satisfactorily submits (as determined
under this subsection) to the Secretary
data on such quality measures in
accordance with such reporting system
for such reporting period,
in addition to the amount otherwise paid under
this part, there also shall be paid to the
eligible professional (or to an employer or
facility in the cases described in clause (A)
of section 1842(b)(6)) or, in the case of a
group practice under paragraph (3)(C), to the
group practice, from the Federal Supplementary
Medical Insurance Trust Fund established under
section 1841 an amount equal to the applicable
quality percent of the Secretary's estimate
(based on claims submitted not later than 2
months after the end of the reporting period)
of the allowed charges under this part for all
such covered professional services furnished by
the eligible professional (or, in the case of a
group practice under paragraph (3)(C), by the
group practice) during the reporting period.
(B) Applicable quality percent.--For purposes
of subparagraph (A), the term ``applicable
quality percent'' means--
(i) for 2007 and 2008, 1.5 percent;
and
(ii) for 2009 and 2010, 2.0 percent;
(iii) for 2011, 1.0 percent; and
(iv) for 2012, 2013, and 2014, 0.5
percent.
(2) Incentive payments for electronic prescribing.--
(A) In general.--Subject to subparagraph (D),
for 2009 through 2013, with respect to covered
professional services furnished during a
reporting period by an eligible professional,
if the eligible professional is a successful
electronic prescriber for such reporting
period, in addition to the amount otherwise
paid under this part, there also shall be paid
to the eligible professional (or to an employer
or facility in the cases described in clause
(A) of section 1842(b)(6)) or, in the case of a
group practice under paragraph (3)(C), to the
group practice, from the Federal Supplementary
Medical Insurance Trust Fund established under
section 1841 an amount equal to the applicable
electronic prescribing percent of the
Secretary's estimate (based on claims submitted
not later than 2 months after the end of the
reporting period) of the allowed charges under
this part for all such covered professional
services furnished by the eligible professional
(or, in the case of a group practice under
paragraph (3)(C), by the group practice) during
the reporting period.
(B) Limitation with respect to electronic
prescribing quality measures.--The provisions
of this paragraph and subsection (a)(5) shall
not apply to an eligible professional (or, in
the case of a group practice under paragraph
(3)(C), to the group practice) if, for the
reporting period (or, for purposes of
subsection (a)(5), for the reporting period for
a year)--
(i) the allowed charges under this
part for all covered professional
services furnished by the eligible
professional (or group, as applicable)
for the codes to which the electronic
prescribing quality measure applies (as
identified by the Secretary and
published on the Internet website of
the Centers for Medicare & Medicaid
Services as of January 1, 2008, and as
subsequently modified by the Secretary)
are less than 10 percent of the total
of the allowed charges under this part
for all such covered professional
services furnished by the eligible
professional (or the group, as
applicable); or
(ii) if determined appropriate by the
Secretary, the eligible professional
does not submit (including both
electronically and nonelectronically) a
sufficient number (as determined by the
Secretary) of prescriptions under part
D.
If the Secretary makes the determination to
apply clause (ii) for a period, then clause (i)
shall not apply for such period.
(C) Applicable electronic prescribing
percent.--For purposes of subparagraph (A), the
term ``applicable electronic prescribing
percent'' means--
(i) for 2009 and 2010, 2.0 percent;
(ii) for 2011 and 2012, 1.0 percent;
and
(iii) for 2013, 0.5 percent.
(D) Limitation with respect to ehr incentive
payments.--The provisions of this paragraph
shall not apply to an eligible professional
(or, in the case of a group practice under
paragraph (3)(C), to the group practice) if,
for the EHR reporting period the eligible
professional (or group practice) receives an
incentive payment under subsection (o)(1)(A)
with respect to a certified EHR technology (as
defined in subsection (o)(4)) that has the
capability of electronic prescribing.
(3) Satisfactory reporting and successful electronic
prescriber and described.--
(A) In general.--For purposes of paragraph
(1), an eligible professional shall be treated
as satisfactorily submitting data on quality
measures for covered professional services for
a reporting period (or, for purposes of
subsection (a)(8), for the quality reporting
period for the year) if quality measures have
been reported as follows:
(i) Three or fewer quality measures
applicable.--If there are no more than
3 quality measures that are provided
under the physician reporting system
and that are applicable to such
services of such professional furnished
during the period, each such quality
measure has been reported under such
system in at least 80 percent of the
cases in which such measure is
reportable under the system.
(ii) Four or more quality measures
applicable.--If there are 4 or more
quality measures that are provided
under the physician reporting system
and that are applicable to such
services of such professional
furnishedduring the period, at least 3
such quality measures have been
reported under such system in at least
80 percent of the cases in which the
respective measure is reportable under
the system.
For years after 2008, quality measures for
purposes of this subparagraph shall not include
electronic prescribing quality measures.
(B) Successful electronic prescriber.--
(i) In general.--For purposes of
paragraph (2) and subsection (a)(5), an
eligible professional shall be treated
as a successful electronic prescriber
for a reporting period (or, for
purposes of subsection (a)(5), for the
reporting period for a year) if the
eligible professional meets the
requirement described in clause (ii),
or, if the Secretary determines
appropriate, the requirement described
in clause (iii). If the Secretary makes
the determination under the preceding
sentence to apply the requirement
described in clause (iii) for a period,
then the requirement described in
clause (ii) shall not apply for such
period.
(ii) Requirement for submitting data
on electronic prescribing quality
measures.--The requirement described in
this clause is that, with respect to
covered professional services furnished
by an eligible professional during a
reporting period (or, for purposes of
subsection (a)(5), for the reporting
period for a year), if there are any
electronic prescribing quality measures
that have been established under the
physician reporting system and are
applicable to any such services
furnished by such professional for the
period, such professional reported each
such measure under such system in at
least 50 percent of the cases in which
such measure is reportable by such
professional under such system.
(iii) Requirement for electronically
prescribing under part d.--The
requirement described in this clause is
that the eligible professional
electronically submitted a sufficient
number (as determined by the Secretary)
of prescriptions under part D during
the reporting period (or, for purposes
of subsection (a)(5), for the reporting
period for a year).
(iv) Use of part d data.--
Notwithstanding sections 1860D-
15(d)(2)(B) and 1860D-15(f)(2), the
Secretary may use data regarding drug
claims submitted for purposes of
section 1860D-15 that are necessary for
purposes of clause (iii), paragraph
(2)(B)(ii), and paragraph (5)(G).
(v) Standards for electronic
prescribing.--To the extent
practicable, in determining whether
eligible professionals meet the
requirements under clauses (ii) and
(iii) for purposes of clause (i), the
Secretary shall ensure that eligible
professionals utilize electronic
prescribing systems in compliance with
standards established for such systems
pursuant to the Part D Electronic
Prescribing Program under section
1860D-4(e).
(C) Satisfactory reporting measures for group
practices.--
(i) In general.--By January 1, 2010,
the Secretary shall establish and have
in place a process under which eligible
professionals in a group practice (as
defined by the Secretary) shall be
treated as satisfactorily submitting
data on quality measures under
subparagraph (A) and as meeting the
requirement described in subparagraph
(B)(ii) for covered professional
services for a reporting period (or,
for purposes of subsection (a)(5), for
a reporting period for a year, or, for
purposes of subsection (a)(8), for a
quality reporting period for the year)
if, in lieu of reporting measures under
subsection (k)(2)(C), the group
practice reports measures determined
appropriate by the Secretary, such as
measures that target high-cost chronic
conditions and preventive care, in a
form and manner, and at a time,
specified by the Secretary.
(ii) Statistical sampling model.--The
process under clause (i) shall provide
and, for 2016 and subsequent years, may
provide for the use of a statistical
sampling model to submit data on
measures, such as the model used under
the Physician Group Practice
demonstration project under section
1866A.
(iii) No double payments.--Payments
to a group practice under this
subsection by reason of the process
under clause (i) shall be in lieu of
the payments that would otherwise be
made under this subsection to eligible
professionals in the group practice for
satisfactorily submitting data on
quality measures.
(D) Satisfactory reporting measures through
participation in a qualified clinical data
registry.--For 2014 and subsequent years, the
Secretary shall treat an eligible professional
as satisfactorily submitting data on quality
measures under subparagraph (A) and, for 2016
and subsequent years, subparagraph (A) or (C)
if, in lieu of reporting measures under
subsection (k)(2)(C), the eligible professional
is satisfactorily participating, as determined
by the Secretary, in a qualified clinical data
registry (as described in subparagraph (E)) for
the year.
(E) Qualified clinical data registry.--
(i) In general.--The Secretary shall
establish requirements for an entity to
be considered a qualified clinical data
registry. Such requirements shall
include a requirement that the entity
provide the Secretary with such
information, at such times, and in such
manner, as the Secretary determines
necessary to carry out this subsection.
(ii) Considerations.--In establishing
the requirements under clause (i), the
Secretary shall consider whether an
entity--
(I) has in place mechanisms
for the transparency of data
elements and specifications,
risk models, and measures;
(II) requires the submission
of data from participants with
respect to multiple payers;
(III) provides timely
performance reports to
participants at the individual
participant level; and
(IV) supports quality
improvement initiatives for
participants.
(iii) Measures.--With respect to
measures used by a qualified clinical
data registry--
(I) sections 1890(b)(7) and
1890A(a) shall not apply; and
(II) measures endorsed by the
entity with a contract with the
Secretary under section 1890(a)
may be used.
(iv) Consultation.--In carrying out
this subparagraph, the Secretary shall
consult with interested parties.
(v) Determination.--The Secretary
shall establish a process to determine
whether or not an entity meets the
requirements established under clause
(i). Such process may involve one or
both of the following:
(I) A determination by the
Secretary.
(II) A designation by the
Secretary of one or more
independent organizations to
make such determination.
(F) Authority to revise satisfactorily
reporting data.--For years after 2009, the
Secretary, in consultation with stakeholders
and experts, may revise the criteria under this
subsection for satisfactorily submitting data
on quality measures under subparagraph (A) and
the criteria for submitting data on electronic
prescribing quality measures under subparagraph
(B)(ii).
(4) Form of payment.--The payment under this
subsection shall be in the form of a single
consolidated payment.
(5) Application.--
(A) Physician reporting system rules.--
Paragraphs (5), (6),and (8) of subsection (k)
shall apply for purposes of this subsection in
the same manner as they apply for purposes of
such subsection.
(B) Coordination with other bonus payments.--
The provisions of this subsection shall not be
taken into account in applying subsections (m)
and (u) of section 1833 and any payment under
such subsections shall not be taken into
account in computing allowable charges under
this subsection.
(C) Implementation.--Notwithstanding any
other provision of law, for 2007, 2008, and
2009, the Secretary may implement by program
instruction or otherwise this subsection.
(D) Validation.--
(i) In general.--Subject to the
succeeding provisions of this
subparagraph, for purposes of
determining whether a measure is
applicable to the covered professional
services of an eligible professional
under this subsection for 2007 and 288,
the Secretary shall presume that if an
eligible professional submits data for
a measure, such measure is applicable
to such professional.
(ii) Method.--The Secretary may
establish procedures to validate (by
sampling or other means as the
Secretary determines to be appropriate)
whether measures applicable to covered
professional services of an eligible
professional have been reported.
(iii) Denial of payment authority.--
If the Secretary determines that an
eligible professional (or, in the case
of a group practice under paragraph
(3)(C), the group practice) has not
reported measures applicable to covered
professional services of such
professional, the Secretary shall not
pay the incentive payment under this
subsection. If such payments for such
period have already been made, the
Secretary shall recoup such payments
from the eligible professional (or the
group practice).
(E) Limitations on review.--
Except as provided in subparagraph
(I), there shall be no administrative
or judicial review under 1869, section
1878, or otherwise of
(i) the determination of measures
applicable to services furnished by
eligible professionals under this
subsection;
(ii) the determination of
satisfactory reporting under this
subsection;
(iii) the determination of a
successful electronic prescriber under
paragraph (3), the limitation under
paragraph (2)(B), and the exception
under subsection (a)(5)(B); and
(iv) the determination of any
incentive payment under this subsection
and the payment adjustment under
paragraphs (5)(A) and (8)(A) of
subsection (a).
(F) Extension.--For 2008 through reporting
periods occurring in 2015, the Secretary shall
establish and, for reporting periods occurring
in 2016 and subsequent years, the Secretary may
establish alternative criteria for
satisfactorily reporting under this subsection
and alternative reporting periods under
paragraph (6)(C) for reporting groups of
measures under subsection (k)(2)(B) and for
reporting using the method specified in
subsection (k)(4).
(G) Posting on website.--The Secretary shall
post on the Internet website of the Centers for
Medicare & Medicaid Services, in an easily
understandable format, a list of the names of
the following:
(i) The eligible professionals (or,
in the case of reporting under
paragraph (3)(C), the group practices)
who satisfactorily submitted data on
quality measures under this subsection.
(ii) The eligible professionals (or,
in the case of reporting under
paragraph (3)(C), the group practices)
who are successful electronic
prescribers.
(H) Feedback.--The Secretary shall provide
timely feedback to eligible professionals on
the performance of the eligible professional
with respect to satisfactorily submitting data
on quality measures under this subsection.
(I) Informal appeals process.--The Secretary
shall, by not later than January 1, 2011,
establish and have in place an informal process
for eligible professionals to seek a review of
the determination that an eligible professional
did not satisfactorily submit data on quality
measures under this subsection.
(6) Definitions.--For purposes of this subsection:
(A) Eligible professional; covered
professional services.--The terms ``eligible
professional'' and ``covered professional
services'' have the meanings given such termsin
subsection (k)(3).
(B) Physician reporting system.--The term
``physician reporting system'' means the system
established under subsection (k).
(C) Reporting period.--
(i) In general.--Subject to clauses
(ii) and (iii), the term ``reporting
period'' means--
(I) for 2007, the period
beginning on July 1, 2007, and
ending on December 31, 2007;
and
(II) for 2008 and subsequent
years, the entire year.
(ii) Authority to revise reporting
period.--For years after 2009, the
Secretary may revise the reporting
period under clause (i) if the
Secretary determines such revision is
appropriate, produces valid results on
measures reported, and is consistent
with the goals of maximizing scientific
validity and reducing administrative
burden. If the Secretary revises such
period pursuant to the preceding
sentence, the term ``reporting period''
shall mean such revised period.
(iii) Reference.--Any reference in
this subsection to a reporting period
with respect to the application of
subsection (a)(5) (a)(8) shall be
deemed a reference to the reporting
period under subsection (a)(5)(D)(iii)
or the quality reporting period under
subsection (a)(8)(D)(iii),
respectively.
(7) Integration of physician quality reporting and
ehr reporting.--Not later than January 1, 2012, the
Secretary shall develop a plan to integrate reporting
on quality measures under this subsection with
reporting requirements under subsection (o) relating to
the meaningful use of electronic health records. Such
integration shall consist of the following:
(A) The selection of measures, the reporting
of which would both demonstrate--
(i) meaningful use of an electronic
health record for purposes of
subsection (o); and
(ii) quality of care furnished to an
individual.
(B) Such other activities as specified by the
Secretary.
(8) Additional incentive payment.--
(A) In general.--For 2011 through 2014, if an
eligible professional meets the requirements
described in subparagraph (B), the applicable
quality percent for such year, as described in
clauses (iii) and (iv) of paragraph (1)(B),
shall be increased by 0.5 percentage points.
(B) Requirements described.--In order to
qualify for the additional incentive payment
described in subparagraph (A), an eligible
professional shall meet the following
requirements:
(i) The eligible professional shall--
(I) satisfactorily submit
data on quality measures for
purposes of paragraph (1) for a
year; and
(II) have such data submitted
on their behalf through a
Maintenance of Certification
Program (as defined in
subparagraph (C)(i)) that
meets--
(aa) the criteria for
a registry (as
described in subsection
(k)(4)); or
(bb) an alternative
form and manner
determined appropriate
by the Secretary.
(ii) The eligible professional, more
frequently than is required to qualify
for or maintain board certification
status--
(I) participates in such a
Maintenance of Certification
program for a year; and
(II) successfully completes a
qualified Maintenance of
Certification Program practice
assessment (as defined in
subparagraph (C)(ii)) for such
year.
(iii) A Maintenance of Certification
program submits to the Secretary, on
behalf of the eligible professional,
information--
(I) in a form and manner
specified by the Secretary,
that the eligible professional
has successfully met the
requirements of clause (ii)
(which may be in the form of a
structural measure);
(II) if requested by the
Secretary, on the survey of
patient experience with care
(as described in subparagraph
(C)(ii)(II)); and
(III) as the Secretary may
require, on the methods,
measures, and data used under
the Maintenance of
Certification Program and the
qualified Maintenance of
Certification Program practice
assessment.
(C) Definitions.--For purposes of this
paragraph:
(i) The term ``Maintenance of
Certification Program'' means a
continuous assessment program, such as
qualified American Board of Medical
Specialties Maintenance of
Certification program or an equivalent
program (as determined by the
Secretary), that advances quality and
the lifelong learning and self-
assessment of board certified specialty
physicians by focusing on the
competencies of patient care, medical
knowledge, practice-based learning,
interpersonal and communication skills
and professionalism. Such a program
shall include the following:
(I) The program requires the
physician to maintain a valid,
unrestricted medical license in
the United States.
(II) The program requires a
physician to participate in
educational and self-assessment
programs that require an
assessment of what was learned.
(III) The program requires a
physician to demonstrate,
through a formalized, secure
examination, that the physician
has the fundamental diagnostic
skills, medical knowledge, and
clinical judgment to provide
quality care in their
respective specialty.
(IV) The program requires
successful completion of a
qualified Maintenance of
Certification Program practice
assessment as described in
clause (ii).
(ii) The term ``qualified Maintenance
of Certification Program practice
assessment'' means an assessment of a
physician's practice that--
(I) includes an initial
assessment of an eligible
professional's practice that is
designed to demonstrate the
physician's use of evidence-
based medicine;
(II) includes a survey of
patient experience with care;
and
(III) requires a physician to
implement a quality improvement
intervention to address a
practice weakness identified in
the initial assessment under
subclause (I) and then to
remeasure to assess performance
improvement after such
intervention.
(9) Continued application for purposes of mips and
for certain professionals volunteering to report.--The
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.
(n) Physician Feedback Program.--
(1) Establishment.--
(A) In general.--
(i) Establishment.--The Secretary
shall establish a Physician Feedback
Program (in this subsection referred to
as the ``Program'').
(ii) Reports on resources.--The
Secretary shall use claims data under
this title (and may use other data) to
provide confidential reports to
physicians (and, as determined
appropriate by the Secretary, to groups
of physicians) that measure the
resources involved in furnishing care
to individuals under this title.
(iii) Inclusion of certain
information.--If determined appropriate
by the Secretary, the Secretary may
include information on the quality of
care furnished to individuals under
this title by the physician (or group
of physicians) in such reports.
(B) Resource use.--The resources described in
subparagraph (A)(ii) may be measured--
(i) on an episode basis;
(ii) on a per capita basis; or
(iii) on both an episode and a per
capita basis.
(2) Implementation.--The Secretary shall implement
the Program by not later than January 1, 2009.
(3) Data for reports.--To the extent practicable,
reports under the Program shall be based on the most
recent data available.
(4) Authority to focus initial application.--The
Secretary may focus the initial application of the
Program as appropriate, such as focusing the Program
on--
(A) physician specialties that account for a
certain percentage of all spending for
physicians' services under this title;
(B) physicians who treat conditions that have
a high cost or a high volume, or both, under
this title;
(C) physicians who use a high amount of
resources compared to other physicians;
(D) physicians practicing in certain
geographic areas; or
(E) physicians who treat a minimum number of
individuals under this title.
(5) Authority to exclude certain information if
insufficient information.--The Secretary may exclude
certain information regarding a service from a report
under the Program with respect to a physician (or group
of physicians) if the Secretary determines that there
is insufficient information relating to that service to
provide a valid report on that service.
(6) Adjustment of data.--To the extent practicable,
the Secretary shall make appropriate adjustments to the
data used in preparing reports under the Program, such
as adjustments to take into account variations in
health status and other patient characteristics. For
adjustments for reports on utilization under paragraph
(9), see subparagraph (D) of such paragraph.
(7) Education and outreach.--The Secretary shall
provide for education and outreach activities to
physicians on the operation of, and methodologies
employed under, the Program.
(8) Disclosure exemption.--Reports under the Program
shall be exempt from disclosure under section 552 of
title 5, United States Code.
(9) Reports on utilization.--
(A) Development of episode grouper.--
(i) In general.--The Secretary shall
develop an episode grouper that
combines separate but clinically
related items and services into an
episode of care for an individual, as
appropriate.
(ii) Timeline for development.--The
episode grouper described in
subparagraph (A) shall be developed by
not later than January 1, 2012.
(iii) Public availability.--The
Secretary shall make the details of the
episode grouper described in
subparagraph (A) available to the
public.
(iv) Endorsement.--The Secretary
shall seek endorsement of the episode
grouper described in subparagraph (A)
by the entity with a contract under
section 1890(a).
(B) Reports on utilization.--Effective
beginning with 2012, the Secretary shall
provide reports to physicians that compare, as
determined appropriate by the Secretary,
patterns of resource use of the individual
physician to such patterns of other physicians.
(C) Analysis of data.--The Secretary shall,
for purposes of preparing reports under this
paragraph, establish methodologies as
appropriate, such as to--
(i) attribute episodes of care, in
whole or in part, to physicians;
(ii) identify appropriate physicians
for purposes of comparison under
subparagraph (B); and
(iii) aggregate episodes of care
attributed to a physician under clause
(i) into a composite measure per
individual.
(D) Data adjustment.--In preparing reports
under this paragraph, the Secretary shall make
appropriate adjustments, including
adjustments--
(i) to account for differences in
socioeconomic and demographic
characteristics, ethnicity, and health
status of individuals (such as to
recognize that less healthy individuals
may require more intensive
interventions); and
(ii) to eliminate the effect of
geographic adjustments in payment rates
(as described in subsection (e)).
(E) Public availability of methodology.--The
Secretary shall make available to the public--
(i) the methodologies established
under subparagraph (C);
(ii) information regarding any
adjustments made to data under
subparagraph (D); and
(iii) aggregate reports with respect
to physicians.
(F) Definition of physician.--In this
paragraph:
(i) In general.--The term
``physician'' has the meaning given
that term in section 1861(r)(1).
(ii) Treatment of groups.--Such term
includes, as the Secretary determines
appropriate, a group of physicians.
(G) Limitations on review.--There shall be no
administrative or judicial review under section
1869, section 1878, or otherwise of the
establishment of the methodology under
subparagraph (C), including the determination
of an episode of care under such methodology.
(10) Coordination with other value-based purchasing
reforms.--The Secretary shall coordinate the Program
with the value-based payment modifier established under
subsection (p) and, as the Secretary determines
appropriate, other similar provisions of this title.
(11) Reports ending with 2017.--Reports under the
Program shall not be provided after December 31, 2017.
See subsection (q)(12) for reports under the eligible
professionals Merit-based Incentive Payment System.
(o) Incentives for Adoption and Meaningful Use of Certified
EHR Technology.--
(1) Incentive payments.--
(A) In general.--
(i) In general.--Subject to the
succeeding subparagraphs of this
paragraph, with respect to covered
professional services furnished by an
eligible professional during a payment
year (as defined in subparagraph (E)),
if the eligible professional is a
meaningful EHR user (as determined
under paragraph (2)) for the EHR
reporting period with respect to such
year, in addition to the amount
otherwise paid under this part, there
also shall be paid to the eligible
professional (or to an employer or
facility in the cases described in
clause (A) of section 1842(b)(6)), from
the Federal Supplementary Medical
Insurance Trust Fund established under
section 1841 an amount equal to 75
percent of the Secretary's estimate
(based on claims submitted not later
than 2 months after the end of the
payment year) of the allowed charges
under this part for all such covered
professional services furnished by the
eligible professional during such year.
(ii) No incentive payments with
respect to years after 2016.--No
incentive payments may be made under
this subsection with respect to a year
after 2016.
(B) Limitations on amounts of incentive
payments.--
(i) In general.--In no case shall the
amount of the incentive payment
provided under this paragraph for an
eligible professional for a payment
year exceed the applicable amount
specified under this subparagraph with
respect to such eligible professional
and such year.
(ii) Amount.--Subject to clauses
(iii) through (v), the applicable
amount specified in this subparagraph
for an eligible professional is as
follows:
(I) For the first payment
year for such professional,
$15,000 (or, if the first
payment year for such eligible
professional is 2011 or 2012,
$18,000).
(II) For the second payment
year for such professional,
$12,000.
(III) For the third payment
year for such professional,
$8,000.
(IV) For the fourth payment
year for such professional,
$4,000.
(V) For the fifth payment
year for such professional,
$2,000.
(VI) For any succeeding
payment year for such
professional, $0.
(iii) Phase down for eligible
professionals first adopting ehr after
2013.--If the first payment year for an
eligible professional is after 2013,
then the amount specified in this
subparagraph for a payment year for
such professional is the same as the
amount specified in clause (ii) for
such payment year for an eligible
professional whose first payment year
is 2013.
(iv) Increase for certain eligible
professionals.--In the case of an
eligible professional who predominantly
furnishes services under this part in
an area that is designated by the
Secretary (under section 332(a)(1)(A)
of the Public Health Service Act) as a
health professional shortage area, the
amount that would otherwise apply for a
payment year for such professional
under subclauses (I) through (V) of
clause (ii) shall be increased by 10
percent. In implementing the preceding
sentence, the Secretary may, as
determined appropriate, apply
provisions of subsections (m) and (u)
of section 1833 in a similar manner as
such provisions apply under such
subsection.
(v) No incentive payment if first
adopting after 2014.--If the first
payment year for an eligible
professional is after 2014 then the
applicable amount specified in this
subparagraph for such professional for
such year and any subsequent year shall
be $0.
(C) Non-application to hospital-based
eligible professionals.--
(i) In general.--No incentive payment
may be made under this paragraph in the
case of a hospital-based eligible
professional.
(ii) Hospital-based eligible
professional.--For purposes of clause
(i), the term ``hospital-based eligible
professional'' means, with respect to
covered professional services furnished
by an eligible professional during the
EHR reporting period for a payment
year, an eligible professional, such as
a pathologist, anesthesiologist, or
emergency physician, who furnishes
substantially all of such services in a
hospital inpatient or emergency room
setting and through the use of the
facilities and equipment, including
qualified electronic health records, of
the hospital. The determination of
whether an eligible professional is a
hospital-based eligible professional
shall be made on the basis of the site
of service (as defined by the
Secretary) and without regard to any
employment or billing arrangement
between the eligible professional and
any other provider.
(D) Payment.--
(i) Form of payment.--The payment
under this paragraph may be in the form
of a single consolidated payment or in
the form of such periodic installments
as the Secretary may specify.
(ii) Coordination of application of
limitation for professionals in
different practices.--In the case of an
eligible professional furnishing
covered professional services in more
than one practice (as specified by the
Secretary), the Secretary shall
establish rules to coordinate the
incentive payments, including the
application of the limitation on
amounts of such incentive payments
under this paragraph, among such
practices.
(iii) Coordination with medicaid.--
The Secretary shall seek, to the
maximum extent practicable, to avoid
duplicative requirements from Federal
and State governments to demonstrate
meaningful use of certified EHR
technology under this title and title
XIX. The Secretary may also adjust the
reporting periods under such title and
such subsections in order to carry out
this clause.
(E) Payment year defined.--
(i) In general.--For purposes of this
subsection, the term ``payment year''
means a year beginning with 2011.
(ii) First, second, etc. payment
year.--The term ``first payment year''
means, with respect to covered
professional services furnished by an
eligible professional, the first year
for which an incentive payment is made
for such services under this
subsection. The terms ``second payment
year'', ``third payment year'',
``fourth payment year'', and ``fifth
payment year'' mean, with respect to
covered professional services furnished
by such eligible professional, each
successive year immediately following
the first payment year for such
professional.
(2) Meaningful ehr user.--
(A) In general.--An eligible professional
shall be treated as a meaningful EHR user for
an EHR reporting period for a payment year (or,
for purposes of subsection (a)(7), for an EHR
reporting period under such subsection for a
year, or pursuant to subparagraph (D) for
purposes of subsection (q), for a performance
period under such subsection for a year) if
each of the following requirements is met:
(i) Meaningful use of certified ehr
technology.--The eligible professional
demonstrates to the satisfaction of the
Secretary, in accordance with
subparagraph (C)(i), that during such
period the professional is using
certified EHR technology in a
meaningful manner, which shall include
the use of electronic prescribing as
determined to be appropriate by the
Secretary.
(ii) Information exchange.--The
eligible professional demonstrates to
the satisfaction of the Secretary, in
accordance with subparagraph (C)(i),
that during such period such certified
EHR technology is connected in a manner
that provides, in accordance with law
and standards applicable to the
exchange of information, for the
electronic exchange of health
information to improve the quality of
health care, such as promoting care
coordination, 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 action (such as to
disable functionality) to limit or
restrict the compatibility or
interoperability of the certified EHR
technology.
(iii) Reporting on measures using
ehr.--Subject to subparagraph (B)(ii)
and subsection (q)(5)(B)(ii)(II) and
using such certified EHR technology,
the eligible professional submits
information for such period, in a form
and manner specified by the Secretary,
on such clinical quality measures and
such other measures as selected by the
Secretary under subparagraph (B)(i).
The Secretary may provide for the use of
alternative means for meeting the requirements
of clauses (i), (ii), and (iii) in the case of
an eligible professional furnishing covered
professional services in a group practice (as
defined by the Secretary). The Secretary shall
seek to improve the use of electronic health
records and health care quality over time.
(B) Reporting on measures.--
(i) Selection.--The Secretary shall
select measures for purposes of
subparagraph (A)(iii) but only
consistent with the following:
(I) The Secretary shall
provide preference to clinical
quality measures that have been
endorsed by the entity with a
contract with the Secretary
under section 1890(a).
(II) Prior to any measure
being selected under this
subparagraph, the Secretary
shall publish in the Federal
Register such measure and
provide for a period of public
comment on such measure.
(ii) Limitation.--The Secretary may
not require the electronic reporting of
information on clinical quality
measures under subparagraph (A)(iii)
unless the Secretary has the capacity
to accept the information
electronically, which may be on a pilot
basis.
(iii) Coordination of reporting of
information.--In selecting such
measures, and in establishing the form
and manner for reporting measures under
subparagraph (A)(iii), the Secretary
shall seek to avoid redundant or
duplicative reporting otherwise
required, including reporting under
subsection (k)(2)(C).
(C) Demonstration of meaningful use of
certified ehr technology and information
exchange.--
(i) In general.--A professional may
satisfy the demonstration requirement
of clauses (i) and (ii) of subparagraph
(A) through means specified by the
Secretary, which may include--
(I) an attestation;
(II) the submission of claims
with appropriate coding (such
as a code indicating that a
patient encounter was
documented using certified EHR
technology);
(III) a survey response;
(IV) reporting under
subparagraph (A)(iii); and
(V) other means specified by
the Secretary.
(ii) Use of part d data.--
Notwithstanding sections 1860D-
15(d)(2)(B) and 1860D-15(f)(2), the
Secretary may use data regarding drug
claims submitted for purposes of
section 1860D-15 that are necessary for
purposes of subparagraph (A).
(D) Continued application for purposes of
mips.--With respect to 2019 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. The
provisions of subparagraphs (B) and (D) of
subsection (a)(7), shall apply to assessments
of MIPS eligible professionals under subsection
(q) with respect to the performance category
described in subsection (q)(2)(A)(iv) in an
appropriate manner which may be similar to the
manner in which such provisions apply with
respect to payment adjustments made under
subsection (a)(7)(A).
(3) Application.--
(A) Physician reporting system rules.--
Paragraphs (5), (6), and (8) of subsection (k)
shall apply for purposes of this subsection in
the same manner as they apply for purposes of
such subsection.
(B) Coordination with other payments.--The
provisions of this subsection shall not be
taken into account in applying the provisions
of subsection (m) of this section and of
section 1833(m) and any payment under such
provisions shall not be taken into account in
computing allowable charges under this
subsection.
(C) Limitations on review.--There shall be no
administrative or judicial review under section
1869, section 1878, or otherwise, of--
(i) the methodology and standards for
determining payment amounts under this
subsection and payment adjustments
under subsection (a)(7)(A), including
the limitation under paragraph (1)(B)
and coordination under clauses (ii) and
(iii) of paragraph (1)(D);
(ii) the methodology and standards
for determining a meaningful EHR user
under paragraph (2), including
selection of measures under paragraph
(2)(B), specification of the means of
demonstrating meaningful EHR use under
paragraph (2)(C), and the hardship
exception under subsection (a)(7)(B);
(iii) the methodology and standards
for determining a hospital-based
eligible professional under paragraph
(1)(C); and
(iv) the specification of reporting
periods under paragraph (5) and the
selection of the form of payment under
paragraph (1)(D)(i).
(D) Posting on website.--The Secretary shall
post on the Internet website of the Centers for
Medicare & Medicaid Services, in an easily
understandable format, a list of the names,
business addresses, and business phone numbers
of the eligible professionals who are
meaningful EHR users and, as determined
appropriate by the Secretary, of group
practices receiving incentive payments under
paragraph (1).
(4) Certified ehr technology defined.--For purposes
of this section, the term ``certified EHR technology''
means a qualified electronic health record (as defined
in section 3000(13) of the Public Health Service Act)
that is certified pursuant to section 3001(c)(5) of
such Act as meeting standards adopted under section
3004 of such Act that are applicable to the type of
record involved (as determined by the Secretary, such
as an ambulatory electronic health record for office-
based physicians or an inpatient hospital electronic
health record for hospitals).
(5) Definitions.--For purposes of this subsection:
(A) Covered professional services.--The term
``covered professional services'' has the
meaning given such term in subsection (k)(3).
(B) EHR reporting period.--The term ``EHR
reporting period'' means, with respect to a
payment year, any period (or periods) as
specified by the Secretary.
(C) Eligible professional.--The term
``eligible professional'' means a physician, as
defined in section 1861(r).
(p) Establishment of Value-based Payment Modifier.--
(1) In general.--The Secretary shall establish a
payment modifier that provides for differential payment
to a physician or a group of physicians under the fee
schedule established under subsection (b) based upon
the quality of care furnished compared to cost (as
determined under paragraphs (2) and (3), respectively)
during a performance period. Such payment modifier
shall be separate from the geographic adjustment
factors established under subsection (e).
(2) Quality.--
(A) In general.--For purposes of paragraph
(1), quality of care shall be evaluated, to the
extent practicable, based on a composite of
measures of the quality of care furnished (as
established by the Secretary under subparagraph
(B)).
(B) Measures.--
(i) The Secretary shall establish
appropriate measures of the quality of
care furnished by a physician or group
of physicians to individuals enrolled
under this part, such as measures that
reflect health outcomes. Such measures
shall be risk adjusted as determined
appropriate by the Secretary.
(ii) The Secretary shall seek
endorsement of the measures established
under this subparagraph by the entity
with a contract under section 1890(a).
(C) Continued application for purposes of
mips.--The Secretary shall, in accordance with
subsection (q)(1)(F), carry out subparagraph
(B) for purposes of subsection (q).
(3) Costs.--For purposes of paragraph (1), costs
shall be evaluated, to the extent practicable, based on
a composite of appropriate measures of costs
established by the Secretary (such as the composite
measure under the methodology established under
subsection (n)(9)(C)(iii)) that eliminate the effect of
geographic adjustments in payment rates (as described
in subsection (e)), and take into account risk factors
(such as socioeconomic and demographic characteristics,
ethnicity, and health status of individuals (such as to
recognize that less healthy individuals may require
more intensive interventions) and other factors
determined appropriate by the Secretary. With respect
to 2019 and each subsequent year, the Secretary shall,
in accordance with subsection (q)(1)(F), carry out this
paragraph for purposes of subsection (q).
(4) Implementation.--
(A) Publication of measures, dates of
implementation, performance period.--Not later
than January 1, 2012, the Secretary shall
publish the following:
(i) The measures of quality of care
and costs established under paragraphs
(2) and (3), respectively.
(ii) The dates for implementation of
the payment modifier (as determined
under subparagraph (B)).
(iii) The initial performance period
(as specified under subparagraph
(B)(ii)).
(B) Deadlines for implementation.--
(i) Initial implementation.--Subject
to the preceding provisions of this
subparagraph, the Secretary shall begin
implementing the payment modifier
established under this subsection
through the rulemaking process during
2013 for the physician fee schedule
established under subsection (b).
(ii) Initial performance period.--
(I) In general.--The
Secretary shall specify an
initial performance period for
application of the payment
modifier established under this
subsection with respect to
2015.
(II) Provision of information
during initial performance
period.--During the initial
performance period, the
Secretary shall, to the extent
practicable, provide
information to physicians and
groups of physicians about the
quality of care furnished by
the physician or group of
physicians to individuals
enrolled under this part
compared to cost (as determined
under paragraphs (2) and (3),
respectively) with respect to
the performance period.
(iii) Application.--The Secretary
shall apply the payment modifier
established under this subsection for
items and services furnished on or
after January 1, 2015, with respect to
specific physicians and groups of
physicians the Secretary determines
appropriate, and for services furnished
on or after January 1, 2017, with
respect to all physicians and groups of
physicians. Such payment modifier shall
not be applied for items and services
furnished on or after January 1, 2019.
(C) Budget neutrality.--The payment modifier
established under this subsection shall be
implemented in a budget neutral manner.
(5) Systems-based care.--The Secretary shall, as
appropriate, apply the payment modifier established
under this subsection in a manner that promotes
systems-based care.
(6) Consideration of special circumstances of certain
providers.--In applying the payment modifier under this
subsection, the Secretary shall, as appropriate, take
into account the special circumstances of physicians or
groups of physicians in rural areas and other
underserved communities.
(7) Application.--For purposes of the initial
application of the payment modifier established under
this subsection during the period beginning on January
1, 2015, and ending on December 31, 2016, the term
``physician'' has the meaning given such term in
section 1861(r). On or after January 1, 2017, the
Secretary may apply this subsection to eligible
professionals (as defined in subsection (k)(3)(B)) as
the Secretary determines appropriate.
(8) Definitions.--For purposes of this subsection:
(A) Costs.--The term ``costs'' means
expenditures per individual as determined
appropriate by the Secretary. In making the
determination under the preceding sentence, the
Secretary may take into account the amount of
growth in expenditures per individual for a
physician compared to the amount of such growth
for other physicians.
(B) Performance period.--The term
``performance period'' means a period specified
by the Secretary.
(9) Coordination with other value-based purchasing
reforms.--The Secretary shall coordinate the value-
based payment modifier established under this
subsection with the Physician Feedback Program under
subsection (n) and, as the Secretary determines
appropriate, other similar provisions of this title.
(10) Limitations on review.--There shall be no
administrative or judicial review under section 1869,
section 1878, or otherwise of--
(A) the establishment of the value-based
payment modifier under this subsection;
(B) the evaluation of quality of care under
paragraph (2), including the establishment of
appropriate measures of the quality of care
under paragraph (2)(B);
(C) the evaluation of costs under paragraph
(3), including the establishment of appropriate
measures of costs under such paragraph;
(D) the dates for implementation of the
value-based payment modifier;
(E) the specification of the initial
performance period and any other performance
period under paragraphs (4)(B)(ii) and (8)(B),
respectively;
(F) the application of the value-based
payment modifier under paragraph (7); and
(G) the determination of costs under
paragraph (8)(A).
(q) Merit-Based Incentive Payment System.--
(1) Establishment.--
(A) In general.--Subject 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.
Notwithstanding subparagraph (C)(ii), under the
MIPS, the Secretary shall permit any eligible
professional (as defined in subsection
(k)(3)(B)) to report on applicable measures and
activities described in paragraph (2)(B).
(B) Program implementation.--The MIPS shall
apply to payments for covered professional
services (as defined in subsection (k)(3)(A))
furnished on or after January 1, 2019.
(C) MIPS eligible professional defined.--
(i) In general.--For 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)), 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),
such other eligible
professionals (as defined in
subsection (k)(3)(B)) as
specified by the Secretary, and
a group that includes such
professionals.
(ii) Exclusions.--For 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
participant.--For 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 2019 and
2020, the reference in
subparagraph (A) of such
paragraph to 25 percent was
instead a reference to 20
percent;
(II) with respect to 2021 and
2022--
(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 2023
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 measurement.--The 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--
(aa) for performance
periods beginning
before January 1, 2018,
individuals enrolled
under this part who are
treated by the eligible
professional for the
performance period
involved; and
(bb) for performance
periods beginning on or
after January 1, 2018,
individuals enrolled
under this part who are
furnished covered
professional services
(as defined in
subsection (k)(3)(A))
by the eligible
professional for the
performance period
involved.
(II) The minimum number (as
determined by the Secretary) of
covered professional services
(as defined in subsection
(k)(3)(A)) furnished to
individuals enrolled under this
part by such professional for
such performance period.
(III) The minimum amount (as
determined by the Secretary)
of--
(aa) for performance
periods beginning
before January 1, 2018,
allowed charges billed
by such professional
under this part for
such performance
period; and
(bb) for performance
periods beginning on or
after January 1, 2018,
allowed charges for
covered professional
services (as defined in
subsection (k)(3)(A))
billed by such
professional for such
performance period.
(v) Treatment of new medicare
enrolled eligible professionals.--In
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) Clarification.--In 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 professional.--In 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
payments.--In 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 general.--Under the MIPS:
(I) Quality performance
category.--The 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
categories.--The 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 assessment.--The 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.
(E) Use of registries.--Under 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 provisions.--In
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 factors.--Taking into
account the relevant studies conducted
and recommendations made in reports
under section 2(d) of the Improving
Medicare Post-Acute Care Transformation
Act of 2014, and, as appropriate, other
information, including information
collected before completion of such
studies and recommendations, the
Secretary, on an ongoing basis, shall,
as the Secretary determines appropriate
and based on an individual's health
status and other risk factors--
(I) assess appropriate
adjustments to quality
measures, resource use
measures, and other measures
used under the MIPS; and
(II) assess and implement
appropriate adjustments to
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 categories.--Under 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 category.--For 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) Quality.--For 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 use.--For 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
activities.--For 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, such
as same day appointments for
urgent needs and after hours
access to clinician advice.
(II) The subcategory of
population management, 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, 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, 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 use.--For 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
category.--In applying subparagraph
(B)(i), the Secretary shall, as
feasible, emphasize the application of
outcome measures.
(ii) Application of additional system
measures.--The 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 items and services furnished by
emergency physicians, radiologists, and
anesthesiologists.
(iii) Global and population-based
measures.--The 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
professionals.--In 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
information.--In 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
category.--In 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
defined.--For 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 general.--Under 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 general.--Eligible
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 defined.--In this
subparagraph, the term
``eligible professional
organization'' means a
professional organization as
defined by nationally
recognized specialty boards of
certification or equivalent
certification boards.
(iii) Requirements.--In 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 review.--Before including a
new measure 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 inclusion.--The
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 measures.--Measures 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
measures.--Any 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 or performance 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 stakeholders.--Relevant
eligible professional organizations and
other relevant stakeholders, including
State and national medical societies,
shall be consulted in carrying out this
subparagraph.
(ix) Optional application.--The
process under section 1890A is not
required to apply to the selection of
measures under this subparagraph.
(3) Performance standards.--
(A) Establishment.--Under 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
standards.--In 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 period.--The Secretary shall
establish a performance period (or periods) for a year
(beginning with 2019). 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 general.--Subject 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 report.--Under 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
measures.--Under 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 certification.--A MIPS
eligible professional who is in a
practice that is certified as a
patient-centered medical home or
comparable specialty practice, as
determined by the Secretary, 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 participation.--
Participation 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) Subcategories.--A 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
improvement.--Beginning 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), subject to
clause (iii), 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
achievement.--Subject to clause (i),
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).
(iii) Transition years.--For each of
the second, third, fourth, and fifth
years for which the MIPS applies to
payments, the performance score for the
performance category described in
paragraph (2)(A)(ii) shall not take
into account the improvement of the
professional involved.
(E) Weights for the performance categories.--
(i) In general.--Under the
methodology developed under
subparagraph (A), subject to
subparagraph (F)(i) and clause (ii),
the composite performance score shall
be determined as follows:
(I) Quality.--
(aa) In general.--
Subject 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 5 years.--
For each of the first
through fifth 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 general.--
Subject 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 5 years.--
For 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 each of the
second, third, fourth,
and fifth years for
which the MIPS applies
to payments, not less
than 10 percent and not
more than 30 percent of
such score shall be
based on performance
with respect to the
category described in
clause (ii) of
paragraph (2)(A).
Nothing in the previous
sentence shall be
construed, with respect
to a performance period
for a year described in
the previous sentence,
as preventing the
Secretary from basing
30 percent of such
score for such year
with respect to the
category described in
such clause (ii), if
the Secretary
determines, based on
information posted
under subsection
(r)(2)(I) that
sufficient resource use
measures are ready for
adoption for use under
the performance
category under
paragraph (2)(A)(ii)
for such performance
period.
(III) Clinical practice
improvement activities.--
Fifteen 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 technology.--
Twenty-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
adoption.--In 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
activities.--Under the methodology under
subparagraph (A), if there are not sufficient
measures and activities (described in paragraph
(2)(B)) 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 use.--Analysis 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 payers.--In 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 general.--In 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) with
respect to the performance categories
described in clauses (i) and (ii) of
paragraph (2)(A)--
(I) the assessment of
performance provided under such
methodology with respect to
such performance categories
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) with respect to the
composite performance score
provided under this paragraph
for such performance period for
each such MIPS eligible
professional in such virtual
group, the components of the
composite performance score
that assess performance with
respect to such performance
categories shall be based on
the assessment of the combined
performance under subclause (I)
for such performance categories
and performance period.
(ii) Election of practices to be a
virtual group.--The Secretary shall, in
accordance with the requirements under
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 to be a virtual group under
this subparagraph with at least one
other such individual MIPS eligible
professional or group practice. Such a
virtual group may be based on
appropriate classifications of
providers, such as by geographic areas
or by provider specialties defined by
nationally recognized specialty boards
of certification or equivalent
certification boards.
(iii) Requirements.--The requirements
for the process under clause (ii)
shall--
(I) provide that an election
under such clause, with respect
to a performance period, shall
be made before the beginning of
such performance period and may
not be changed during such
performance period;
(II) provide that an
individual MIPS eligible
professional and a group
practice described in clause
(ii) may elect to be in no more
than one virtual group for a
performance period and that, in
the case of such a group
practice that elects to be in
such virtual group for such
performance period, such
election applies to all MIPS
eligible professionals in such
group practice;
(III) provide that a virtual
group be a combination of tax
identification numbers;
(IV) provide for formal
written agreements among MIPS
eligible professionals electing
to be a virtual group under
this subparagraph; and
(V) include such other
requirements as the Secretary
determines appropriate.
(6) MIPS payments.--
(A) MIPS adjustment factor.--Taking 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
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 defined.--For purposes
of this paragraph, the term ``applicable
percent'' means--
(i) for 2019, 4 percent;
(ii) for 2020, 5 percent;
(iii) for 2021, 7 percent; and
(iv) for 2022 and subsequent years, 9
percent.
(C) Additional mips adjustment factors for
exceptional performance.--For 2019 and each
subsequent year through 2024, in 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 subparagraph (F)(iv),
the Secretary shall specify an additional
positive MIPS adjustment factor for such
professional and year. Such additional MIPS
adjustment factors shall be in the form of a
percent and 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.
(D) Establishment of performance
thresholds.--
(i) Performance threshold.--For 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. Subject
to clauses (iii) and (iv), 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 of the mean or median
under the previous sentence every 3
years.
(ii) Additional performance threshold
for exceptional performance.--In
addition to the performance threshold
under clause (i), for each year of the
MIPS (beginning with 2019 and ending
with 2024), the Secretary shall compute
an additional performance threshold for
purposes of determining the additional
MIPS adjustment factors under
subparagraph (C). For each such year,
subject to clause (iii), 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 determined under
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 5
years.--With respect to each of the
first five 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). 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.
(iv) Additional special rule for
third, fourth and fifth years of
mips.--For purposes of determining MIPS
adjustment factors under subparagraph
(A), in addition to the requirements
specified in clause (iii), the
Secretary shall increase the
performance threshold with respect to
each of the third, fourth, and fifth
years to which the MIPS applies to
ensure a gradual and incremental
transition to the performance threshold
described in clause (i) (as estimated
by the Secretary) with respect to the
sixth year to which the MIPS applies.
(E) Application of mips adjustment factors.--
In the case of covered professional services
(as defined in subsection (k)(3)(A)) furnished
by a MIPS eligible professional during a year
(beginning with 2019), the amount otherwise
paid under this part with respect to such
covered professional 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) divided by
100.
(F) Aggregate application of mips adjustment
factors.--
(i) Application of scaling factor.--
(I) In general.--With 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 limit.--
In no case may the scaling
factor applied under this
clause exceed 3.0.
(ii) Budget neutrality requirement.--
(I) In general.--Subject 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 increases.--
The 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 decreases.--
The 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) and the
additional adjustment factors
under clause (iv) 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
adjustments.--
(I) In general.--Subject to
subclause (II), in specifying
the MIPS additional adjustment
factors under subparagraph (C)
for each applicable MIPS
eligible professional for a
year, the Secretary shall
ensure that the estimated
aggregate 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
$500,000,000 for each year
beginning with 2019 and ending
with 2024.
(II) Limitation on additional
incentive payment
adjustments.--The MIPS
additional adjustment factor
under subparagraph (C) for a
year for an applicable MIPS
eligible professional whose
composite performance score is
above the additional
performance threshold under
subparagraph (D)(ii) for such
year shall not exceed 10
percent. The application of the
previous sentence may result in
an aggregate amount of
additional incentive payments
that are less than the amount
specified in subclause (I).
(7) Announcement of result of adjustments.--Under 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 covered professional services (as
defined in subsection (k)(3)(A)) 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 years.--The 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 general.--The 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) Disclosure.--The 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
corrections.--The 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 information.--The 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) Consultation.--The 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 general.--The 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 technical assistance.--For
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 $20,000,000 for
each of fiscal years 2016 through 2020. Amounts
transferred under this subparagraph for a
fiscal year shall be available until expended.
(12) Feedback and information to improve
performance.--
(A) Performance feedback.--
(i) In general.--Beginning July 1,
2017, 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 such
professionals on the
performance of such
professionals with respect to
the performance categories
under clauses (iii) and (iv) of
such paragraph.
(ii) Mechanisms.--The 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 data.--For 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 exemption.--Feedback
made available under this subparagraph
shall be exempt from disclosure under
section 552 of title 5, United States
Code.
(v) Receipt of information.--The
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 general.--Beginning July 1,
2018, the Secretary shall make
available to MIPS eligible
professionals information, with respect
to individuals who are patients of such
MIPS eligible professionals, 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.
(ii) Type of information.--For
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 review.--The Secretary shall
establish a process under which a MIPS eligible
professional may seek an informal review of the
calculation of the MIPS adjustment factor (or
factors) 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) Limitation.--Except 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) 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.
(r) Collaborating With the Physician, Practitioner, and Other
Stakeholder Communities To Improve Resource Use Measurement.--
(1) In general.--In order to involve the physician,
practitioner, and other stakeholder communities in
enhancing the infrastructure for resource use
measurement, including for purposes of the Merit-based
Incentive Payment System 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 general.--In 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 grouper.--Not later than
180 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 input.--The Secretary shall
accept, through the date that is 120 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 general.--Taking 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 \1/2\ of
expenditures under parts A and
B (with such target increasing
over time as appropriate); and
(II) assign codes to such
groups.
(ii) Care episode groups.--In
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
occurs, and the principal
procedures or services
furnished; and
(II) other factors determined
appropriate by the Secretary.
(iii) Patient condition groups.--In
establishing the patient condition
groups under clause (i), the Secretary
shall take into account--
(I) the patient's clinical
history at the time of a
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 codes.--Not later
than 270 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 input.--The Secretary
shall seek, through the date that is 120 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 codes.--Not later
than 270 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 revisions.--Not later than
November 1 of each year (beginning with 2018),
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.
(I) Information.--The Secretary shall, not
later than December 31st of each year
(beginning with 2018), post on the Internet
website of the Centers for Medicare & Medicaid
Services information on resource use measures
in use under subsection (q), resource use
measures under development and the time-frame
for such development, potential future resource
use measure topics, a description of
stakeholder engagement, and the percent of
expenditures under part A and this part that
are covered by resource use measures.
(3) Attribution of patients to physicians or
practitioners.--
(A) In general.--In 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 codes.--The 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 codes.--Not later than one year
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 input.--The Secretary shall
seek, through the date that is 120 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, web-based forums, or other
appropriate mechanisms.
(E) Operational list of patient relationship
categories and codes.--Not later than 240 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 revisions.--Not later than
November 1 of each year (beginning with 2018),
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
measurement.--Claims submitted for items and services
furnished by a physician or applicable practitioner on
or after January 1, 2018, 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 general.--In order to evaluate the
resources used to treat patients (with respect
to care episode and patient condition groups),
the Secretary shall, as the Secretary
determines appropriate--
(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).
(B) Analysis of patients of physicians and
practitioners.--In 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 use.--In
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 input.--The 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, web-based
forums, or other appropriate mechanisms.
(6) Implementation.--To 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) Limitation.--There 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) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to this section.
(9) Definitions.--In this subsection:
(A) Physician.--The term ``physician'' has
the meaning given such term in section
1861(r)(1).
(B) Applicable practitioner.--The 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, 2019, such
other eligible professionals (as
defined in subsection (k)(3)(B)) as
specified by the Secretary.
(10) Clarification.--The provisions of sections
1890(b)(7) and 1890A shall not apply to this
subsection.
(s) Priorities and Funding for Measure Development.--
(1) Plan identifying measure development priorities
and timelines.--
(A) Draft measure development plan.--Not
later than January 1, 2016, 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 domains.--For 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) Consideration.--In 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) Priorities.--In 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 input.--The Secretary shall
accept through March 1, 2016, 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 plan.--Not
later than May 1, 2016, 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 general.--The 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 general.--In 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) Consideration.--In 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 general.--Not later than May 1, 2017,
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) Requirements.--Each 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 input.--With 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 provisions.--In this
subsection, the term ``applicable provisions'' means
the following provisions:
(A) Subsection (q)(2)(B)(i).
(B) Section 1833(z)(3)(D).
(6) Funding.--For 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 2015
through 2019. Amounts transferred under this paragraph
shall remain available through the end of fiscal year
2022.
(7) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to the collection of
information for the development of quality measures.
* * * * * * *
Part D--Voluntary Prescription Drug Benefit Program
* * * * * * *
Subpart 2--Prescription Drug Plans; PDP Sponsors; Financing
* * * * * * *
premium and cost-sharing subsidies for low-income individuals
Sec. 1860D-14. (a) Income-Related Subsidies for Individuals
With Income Up to 150 Percent of Poverty Line.--
(1) Individuals with income below 135 percent of
poverty line.--In the case of a subsidy eligible
individual (as defined in paragraph (3)) who is
determined to have income that is below 135 percent of
the poverty line applicable to a family of the size
involved and who meets the resources requirement
described in paragraph (3)(D) or who is covered under
this paragraph under paragraph (3)(B)(i), the
individual is entitled under this section to the
following:
(A) Full premium subsidy.--An income-related
premium subsidy equal to 100 percent of the
amount described in subsection (b)(1), but not
to exceed the premium amount specified in
subsection (b)(2)(B).
(B) Elimination of deductible.--A reduction
in the annual deductible applicable under
section 1860D-2(b)(1) to $0.
(C) Continuation of coverage above the
initial coverage limit.--The continuation of
coverage from the initial coverage limit (under
paragraph (3) of section 1860D-2(b)) for
expenditures incurred through the total amount
of expenditures at which benefits are available
under paragraph (4) of such section, subject to
the reduced cost-sharing described in
subparagraph (D).
(D) Reduction in cost-sharing below out-of-
pocket threshold.--
(i) Institutionalized individuals.--
In the case of an individual who is a
full-benefit dual eligible individual
and who is an institutionalized
individual or couple (as defined in
section 1902(q)(1)(B)) or, effective on
a date specified by the Secretary (but
in no case earlier than January 1,
2012), who would be such an
institutionalized individual or couple,
if the full-benefit dual eligible
individual were not receiving services
under a home and community-based waiver
authorized for a State under section
1115 or subsection (c) or (d) of
section 1915 or under a State plan
amendment under subsection (i) of such
section or services provided through
enrollment in a medicaid managed care
organization with a contract under
section 1903(m) or under section 1932,
the elimination of any beneficiary
coinsurance described in section 1860D-
2(b)(2) (for all amounts through the
total amount of expenditures at which
benefits are available under section
1860D-2(b)(4)).
(ii) Lowest income dual eligible
individuals.--In the case of an
individual not described in clause (i)
who is a full-benefit dual eligible
individual and whose income does not
exceed 100 percent of the poverty line
applicable to a family of the size
involved, the substitution for the
beneficiary coinsurance described in
section 1860D-2(b)(2) (for all amounts
through the total amount of
expenditures at which benefits are
available under section 1860D-2(b)(4))
of a copayment amount that does not
exceed $1 for a generic drug or a
preferred drug that is a multiple
source drug (as defined in section
1927(k)(7)(A)(i)) and $3 for any other
drug, or, if less, the copayment amount
applicable to an individual under
clause (iii).
(iii) Other individuals.--In the case
of an individual not described in
clause (i) or (ii), the substitution
for the beneficiary coinsurance
described in section 1860D-2(b)(2) (for
all amounts through the total amount of
expenditures at which benefits are
available under section 1860D-2(b)(4))
of a copayment amount that does not
exceed the copayment amount specified
under section 1860D-2(b)(4)(A)(i)(I)
for the drug and year involved.
(E) Elimination of cost-sharing above annual
out-of-pocket threshold.--The elimination of
any cost-sharing imposed under section 1860D-
2(b)(4)(A).
(2) Other individuals with income below 150 percent
of poverty line.--In the case of a subsidy eligible
individual who is not described in paragraph (1), the
individual is entitled under this section to the
following:
(A) Sliding scale premium subsidy.--An
income-related premium subsidy determined on a
linear sliding scale ranging from 100 percent
of the amount described in paragraph (1)(A) for
individuals with incomes at or below 135
percent of such level to 0 percent of such
amount for individuals with incomes at 150
percent of such level.
(B) Reduction of deductible.--A reduction in
the annual deductible applicable under section
1860D-2(b)(1) to $50.
(C) Continuation of coverage above the
initial coverage limit.--The continuation of
coverage from the initial coverage limit (under
paragraph (3) of section 1860D-2(b)) for
expenditures incurred through the total amount
of expenditures at which benefits are available
under paragraph (4) of such section, subject to
the reduced coinsurance described in
subparagraph (D).
(D) Reduction in cost-sharing below out-of-
pocket threshold.--The substitution for the
beneficiary coinsurance described in section
1860D-2(b)(2) (for all amounts above the
deductible under subparagraph (B) through the
total amount of expenditures at which benefits
are available under section 1860D-2(b)(4)) of
coinsurance of ``15 percent'' instead of
coinsurance of ``25 percent'' in section 1860D-
2(b)(2).
(E) Reduction of cost-sharing above annual
out-of-pocket threshold.--Subject to subsection
(c), the substitution for the cost-sharing
imposed under section 1860D-2(b)(4)(A) of a
copayment or coinsurance not to exceed the
copayment or coinsurance amount specified under
section 1860D-2(b)(4)(A)(i)(I) for the drug and
year involved.
(3) Determination of eligibility.--
(A) Subsidy eligible individual defined.--For
purposes of this part, subject to subparagraph
(F), the term ``subsidy eligible individual''
means a part D eligible individual who--
(i) is enrolled in a prescription
drug plan or MA-PD plan;
(ii) has income below 150 percent of
the poverty line applicable to a family
of the size involved; and
(iii) meets the resources requirement
described in subparagraph (D) or (E).
(B) Determinations.--
(i) In general.--The determination of
whether a part D eligible individual
residing in a State is a subsidy
eligible individual and whether the
individual is described in paragraph
(1) shall be determined under the State
plan under title XIX for the State
under section 1935(a) or by the
Commissioner of Social Security. There
are authorized to be appropriated to
the Social Security Administration such
sums as may be necessary for the
determination of eligibility under this
subparagraph.
(ii) Effective period.--
Determinations under this subparagraph
shall be effective beginning with the
month in which the individual applies
for a determination that the individual
is a subsidy eligible individual and
shall remain in effect for a period
specified by the Secretary, but not to
exceed 1 year.
(iii) Redeterminations and appeals
through medicaid.--Redeterminations and
appeals, with respect to eligibility
determinations under clause (i) made
under a State plan under title XIX,
shall be made in accordance with the
frequency of, and manner in which,
redeterminations and appeals of
eligibility are made under such plan
for purposes of medical assistance
under such title.
(iv) Redeterminations and appeals
through commissioner.--With respect to
eligibility determinations under clause
(i) made by the Commissioner of Social
Security--
(I) redeterminations shall be
made at such time or times as
may be provided by the
Commissioner;
(II) the Commissioner shall
establish procedures for
appeals of such determinations
that are similar to the
procedures described in the
third sentence of section
1631(c)(1)(A); and
(III) judicial review of the
final decision of the
Commissioner made after a
hearing shall be available to
the same extent, and with the
same limitations, as provided
in subsections (g) and (h) of
section 205.
(v) Treatment of medicaid
beneficiaries.--Subject to subparagraph
(F), the Secretary--
(I) shall provide that part D
eligible individuals who are
full-benefit dual eligible
individuals (as defined in
section 1935(c)(6)) or who are
recipients of supplemental
security income benefits under
title XVI shall be treated as
subsidy eligible individuals
described in paragraph (1); and
(II) may provide that part D
eligible individuals not
described in subclause (I) who
are determined for purposes of
the State plan under title XIX
to be eligible for medical
assistance under clause (i),
(iii), or (iv) of section
1902(a)(10)(E) are treated as
being determined to be subsidy
eligible individuals described
in paragraph (1).
Insofar as the Secretary determines
that the eligibility requirements under
the State plan for medical assistance
referred to in subclause (II) are
substantially the same as the
requirements for being treated as a
subsidy eligible individual described
in paragraph (1), the Secretary shall
provide for the treatment described in
such subclause.
(vi) Special rule for widows and
widowers.--Notwithstanding the
preceding provisions of this
subparagraph, in the case of an
individual whose spouse dies during the
effective period for a determination or
redetermination that has been made
under this subparagraph, such effective
period shall be extended through the
date that is 1 year after the date on
which the determination or
redetermination would (but for the
application of this clause) otherwise
cease to be effective.
(C) Income determinations.--For purposes of
applying this section--
(i) in the case of a part D eligible
individual who is not treated as a
subsidy eligible individual under
subparagraph (B)(v), income shall be
determined in the manner described in
section 1905(p)(1)(B), without regard
to the application of section
1902(r)(2) and except that support and
maintenance furnished in kind shall not
be counted as income; and
(ii) the term ``poverty line'' has
the meaning given such term in section
673(2) of the Community Services Block
Grant Act (42 U.S.C. 9902(2)),
including any revision required by such
section.
Nothing in clause (i) shall be construed to
affect the application of section 1902(r)(2)
for the determination of eligibility for
medical assistance under title XIX.
(D) Resource standard applied to full low-
income subsidy to be based on three times ssi
resource standard.--The resources requirement
of this subparagraph is that an individual's
resources (as determined under section 1613 for
purposes of the supplemental security income
program subject to the life insurance policy
exclusion provided under subparagraph (G)) do
not exceed--
(i) for 2006 three times the maximum
amount of resources that an individual
may have and obtain benefits under that
program; and
(ii) for a subsequent year the
resource limitation established under
this clause for the previous year
increased by the annual percentage
increase in the consumer price index
(all items; U.S. city average) as of
September of such previous year.
Any resource limitation established under
clause (ii) that is not a multiple of $10 shall
be rounded to the nearest multiple of $10.
(E) Alternative resource standard.--
(i) In general.--The resources
requirement of this subparagraph is
that an individual's resources (as
determined under section 1613 for
purposes of the supplemental security
income program subject to the life
insurance policy exclusion provided
under subparagraph (G)) do not exceed--
(I) for 2006, $10,000 (or
$20,000 in the case of the
combined value of the
individual's assets or
resources and the assets or
resources of the individual's
spouse); and
(II) for a subsequent year
the dollar amounts specified in
this subclause (or subclause
(I)) for the previous year
increased by the annual
percentage increase in the
consumer price index (all
items; U.S. city average) as of
September of such previous
year.
Any dollar amount established under
subclause (II) that is not a multiple
of $10 shall be rounded to the nearest
multiple of $10.
(ii) Use of simplified application
form and process.--The Secretary,
jointly with the Commissioner of Social
Security, shall--
(I) develop a model,
simplified application form and
process consistent with clause
(iii) for the determination and
verification of a part D
eligible individual's assets or
resources under this
subparagraph; and
(II) provide such form to
States.
(iii) Documentation and safeguards.--
Under such process--
(I) the application form
shall consist of an attestation
under penalty of perjury
regarding the level of assets
or resources (or combined
assets and resources in the
case of a married part D
eligible individual) and
valuations of general classes
of assets or resources;
(II) such form shall be
accompanied by copies of recent
statements (if any) from
financial institutions in
support of the application; and
(III) matters attested to in
the application shall be
subject to appropriate methods
of verification.
(iv) Methodology flexibility.--The
Secretary may permit a State in making
eligibility determinations for premium
and cost-sharing subsidies under this
section to use the same asset or
resource methodologies that are used
with respect to eligibility for medical
assistance for medicare cost-sharing
described in section 1905(p) so long as
the Secretary determines that the use
of such methodologies will not result
in any significant differences in the
number of individuals determined to be
subsidy eligible individuals.
(F) Treatment of territorial residents.--In
the case of a part D eligible individual who is
not a resident of the 50 States or the District
of Columbia, the individual is not eligible to
be a subsidy eligible individual under this
section but may be eligible for financial
assistance with prescription drug expenses
under section 1935(e).
(G) Life insurance policy exclusion.--In
determining the resources of an individual (and
the eligible spouse of the individual, if any)
under section 1613 for purposes of
subparagraphs (D) and (E) no part of the value
of any life insurance policy shall be taken
into account.
(4) Indexing dollar amounts.--
(A) Copayment for lowest income dual eligible
individuals.--The dollar amounts applied under
paragraph (1)(D)(ii)--
(i) for 2007 shall be the dollar
amounts specified in such paragraph
increased by the annual percentage
increase in the consumer price index
(all items; U.S. city average) as of
September of such previous year; or
(ii) for a subsequent year shall be
the dollar amounts specified in this
clause (or clause (i)) for the previous
year increased by the annual percentage
increase in the consumer price index
(all items; U.S. city average) as of
September of such previous year.
Any amount established under clause (i) or
(ii), that is based on an increase of $1 or $3,
that is not a multiple of 5 cents or 10 cents,
respectively, shall be rounded to the nearest
multiple of 5 cents or 10 cents, respectively.
(B) Reduced deductible.--The dollar amount
applied under paragraph (2)(B)--
(i) for 2007 shall be the dollar
amount specified in such paragraph
increased by the annual percentage
increase described in section 1860D-
2(b)(6) for 2007; or
(ii) for a subsequent year shall be
the dollar amount specified in this
clause (or clause (i)) for the previous
year increased by the annual percentage
increase described in section 1860D-
2(b)(6) for the year involved.
Any amount established under clause (i) or (ii)
that is not a multiple of $1 shall be rounded
to the nearest multiple of $1.
(5) Waiver of de minimis premiums.--The Secretary
shall, under procedures established by the Secretary,
permit a prescription drug plan or an MA-PD plan to
waive the monthly beneficiary premium for a subsidy
eligible individual if the amount of such premium is de
minimis. If such premium is waived under the plan, the
Secretary shall not reassign subsidy eligible
individuals enrolled in the plan to other plans based
on the fact that the monthly beneficiary premium under
the plan was greater than the low-income benchmark
premium amount.
(b) Premium Subsidy Amount.--
(1) In general.--The premium subsidy amount described
in this subsection for a subsidy eligible individual
residing in a PDP region and enrolled in a prescription
drug plan or MA-PD plan is the low-income benchmark
premium amount (as defined in paragraph (2)) for the
PDP region in which the individual resides or, if
greater, the amount specified in paragraph (3).
(2) Low-income benchmark premium amount defined.--
(A) In general.--For purposes of this
subsection, the term ``low-income benchmark
premium amount'' means, with respect to a PDP
region in which--
(i) all prescription drug plans are
offered by the same PDP sponsor, the
weighted average of the amounts
described in subparagraph (B)(i) for
such plans; or
(ii) there are prescription drug
plans offered by more than one PDP
sponsor, the weighted average of
amounts described in subparagraph (B)
for prescription drug plans and MA-PD
plans described in section
1851(a)(2)(A)(i) offered in such
region.
(B) Premium amounts described.--The premium
amounts described in this subparagraph are, in
the case of--
(i) a prescription drug plan that is
a basic prescription drug plan, the
monthly beneficiary premium for such
plan;
(ii) a prescription drug plan that
provides alternative prescription drug
coverage the actuarial value of which
is greater than that of standard
prescription drug coverage, the portion
of the monthly beneficiary premium that
is attributable to basic prescription
drug coverage; and
(iii) an MA-PD plan, the portion of
the MA monthly prescription drug
beneficiary premium that is
attributable to basic prescription drug
benefits (described in section
1852(a)(6)(B)(ii)) and determined
before the application of the monthly
rebate computed under section
1854(b)(1)(C)(i) for that plan and year
involved and, in the case of a
qualifying plan, before the application
of the increase under section 1853(o)
for that plan and year involved.
The premium amounts described in this
subparagraph do not include any amounts
attributable to late enrollment penalties under
section 1860D-13(b).
(3) Access to 0 premium plan.--In no case shall the
premium subsidy amount under this subsection for a PDP
region be less than the lowest monthly beneficiary
premium for a prescription drug plan that offers basic
prescription drug coverage in the region.
(c) Administration of Subsidy Program.--
(1) In general.--The Secretary shall provide a
process whereby, in the case of a part D eligible
individual who is determined to be a subsidy eligible
individual and who is enrolled in a prescription drug
plan or is enrolled in an MA-PD plan--
(A) the Secretary provides for a notification
of the PDP sponsor or the MA organization
offering the plan involved that the individual
is eligible for a subsidy and the amount of the
subsidy under subsection (a);
(B) the sponsor or organization involved
reduces the premiums or cost-sharing otherwise
imposed by the amount of the applicable subsidy
and submits to the Secretary information on the
amount of such reduction;
(C) the Secretary periodically and on a
timely basis reimburses the sponsor or
organization for the amount of such reductions;
and
(D) the Secretary ensures the confidentiality
of individually identifiable information.
In applying subparagraph (C), the Secretary shall
compute reductions based upon imposition under
subsections (a)(1)(D) and (a)(2)(E) of unreduced
copayment amounts applied under such subsections.
(2) Use of capitated form of payment.--The
reimbursement under this section with respect to cost-
sharing subsidies may be computed on a capitated basis,
taking into account the actuarial value of the
subsidies and with appropriate adjustments to reflect
differences in the risks actually involved.
(d) Facilitation of Reassignments.--Beginning not later than
January 1, 2011, the Secretary shall, in the case of a subsidy
eligible individual who is enrolled in one prescription drug
plan and is subsequently reassigned by the Secretary to a new
prescription drug plan, provide the individual, within 30 days
of such reassignment, with--
(1) information on formulary differences between the
individual's former plan and the plan to which the
individual is reassigned with respect to the
individual's drug regimens; and
(2) a description of the individual's right to
request a coverage determination, exception, or
reconsideration under section 1860D-4(g), bring an
appeal under section 1860D-4(h), or resolve a grievance
under section 1860D-4(f).
(e) Limited Income Newly Eligible Transition Program.--
(1) In general.--Beginning not later than January 1,
2021, the Secretary shall carry out a program to
provide transitional coverage for covered part D drugs
for LI NET eligible individuals in accordance with this
subsection.
(2) LI net eligible individual defined.--For purposes
of this subsection, the term ``LI NET eligible
individual'' means a part D eligible individual who--
(A) meets the requirements of clauses (ii)
and (iii) of subsection (a)(3)(A); and
(B) has not yet enrolled in a prescription
drug plan or an MA-PD plan, or, who has so
enrolled, but with respect to whom coverage
under such plan has not yet taken effect.
(3) Transitional coverage.--For purposes of this
subsection, the term ``transitional coverage'' means,
with respect to an LI NET eligible individual--
(A) immediate access to covered part D drugs
at the point of sale during the period that
begins on the first day of the month such
individual is determined to meet the
requirements of clauses (ii) and (iii) of
subsection (a)(3)(A) and ends on the date that
coverage under a prescription drug plan or MA-
PD plan takes effect with respect to such
individual; and
(B) in the case of an LI NET eligible
individual who is a full-benefit dual eligible
individual (as defined in section 1935(c)(6))
or a recipient of supplemental security income
benefits under title XVI, retroactive coverage
(in the form of reimbursement of the amounts
that would have been paid under this part had
such individual been enrolled in a prescription
drug plan or MA-PD plan) of covered part D
drugs purchased by such individual during the
period that begins on the date that is the
later of--
(i) the date that such individual was
first eligible for a low-income subsidy
under this part; or
(ii) the date that is 36 months prior
to the date such individual enrolls in
a prescription drug plan or MA-PD plan,
and ends on the date that coverage under such
plan takes effect.
(4) Program administration.--
(A) Single point of contact.--The Secretary
shall, to the extent feasible, administer the
program under this subsection through a
contract with a single program administrator.
(B) Benefit design.--The Secretary shall
ensure that the transitional coverage provided
to LI NET eligible individuals under this
subsection--
(i) provides access to all covered
part D drugs under an open formulary;
(ii) permits all pharmacies
determined by the Secretary to be in
good standing to process claims under
the program;
(iii) is consistent with such
requirements as the Secretary considers
necessary to improve patient safety and
ensure appropriate dispensing of
medication; and
(iv) meets such other requirements as
the Secretary may establish.
(5) Relationship to other provisions of this title;
waiver authority.--
(A) In general.--The following provisions
shall not apply with respect to the program
under this subsection:
(i) Paragraphs (1) and (3)(B) of
section 1860D-4(a) (relating to
dissemination of general information;
availability of information on changes
in formulary through the internet).
(ii) Subparagraphs (A) and (B) of
section 1860D-4(b)(3) (relating to
requirements on development and
application of formularies; formulary
development).
(iii) Paragraphs (1)(C) and (2) of
section 1860D-4(c) (relating to
medication therapy management program).
(B) Waiver authority.--The Secretary may
waive such other requirements of titles XI and
this title as may be necessary to carry out the
purposes of the program established under this
subsection.
[(e)] (f) Relation to Medicaid Program.--For special
provisions under the medicaid program relating to medicare
prescription drug benefits, see section 1935.
* * * * * * *
Part E--Miscellaneous Provisions
definitions of services, institutions, etc.
Sec. 1861. For purposes of this title--
Spell of Illness
(a) The term ``spell of illness'' with respect to any
individual means a period of consecutive days--
(1) beginning with the first day (not included in a
previous spell of illness) (A) on which such individual
is furnished inpatient hospital services, inpatient
critical access hospital services or extended care
services, and (B) which occurs in a month for which he
is entitled to benefits under part A, and
(2) ending with the close of the first period of 60
consecutive days thereafter on each of which he is
neither an inpatient of a hospital or critical access
hospital nor an inpatient of a facility described in
section 1819(a)(1) or subsection (y)(1).
Inpatient Hospital Services
(b) The term ``inpatient hospital services'' means the
following items and services furnished to an inpatient of a
hospital and (except as provided in paragraph (3)) by the
hospital--
(1) bed and board;
(2) such nursing services and other related services,
such use of hospital facilities, and such medical
social services as are ordinarily furnished by the
hospital for the care and treatment of inpatients, and
such drugs, biologicals, supplies, appliances, and
equipment, for use in the hospital, as are ordinarily
furnished by such hospital for the care and treatment
of inpatients; and
(3) such other diagnostic or therapeutic items or
services, furnished by the hospital or by others under
arrangements with them made by the hospital, as are
ordinarily furnished to inpatients either by such
hospital or by others under such arrangements;
excluding, however--
(4) medical or surgical services provided by a
physician, resident, or intern, services described by
subsection (s)(2)(K), certified nurse-midwife services,
qualified psychologist services, and services of a
certified registered nurse anesthetist; and
(5) the services of a private-duty nurse or other
private-duty attendant.
Paragraph (4) shall not apply to services provided in a
hospital by--
(6) an intern or a resident-in-training under a
teaching program approved by the Council on Medical
Education of the American Medical Association or, in
the case of an osteopathic hospital, approved by the
Committee on Hospitals of the Bureau of Professional
Education of the American Osteopathic Association, or,
in the case of services in a hospital or osteopathic
hospital by an intern or resident-in-training in the
field of dentistry, approved by the Council on Dental
Education of the American Dental Association, or in the
case of services in a hospital or osteopathic hospital
by an intern or resident-in-training in the field of
podiatry, approved by the Council on Podiatric Medical
Education of the American Podiatric Medical
Association; or
(7) a physician where the hospital has a teaching
program approved as specified in paragraph (6), if (A)
the hospital elects to receive any payment due under
this title for reasonable costs of such services, and
(B) all physicians in such hospital agree not to bill
charges for professional services rendered in such
hospital to individuals covered under the insurance
program established by this title.
Inpatient Psychiatric Hospital Services
(c) The term ``inpatient psychiatric hospital services''
means inpatient hospital services furnished to an inpatient of
a psychiatric hospital.
Supplier
(d) The term ``supplier'' means, unless the context otherwise
requires, a physician or other practitioner, a facility, or
other entity (other than a provider of services) that furnishes
items or services under this title.
Hospital
(e) The term ``hospital'' (except for purposes of sections
1814(d), 1814(f), and 1835(b), subsection (a)(2) of this
section, paragraph (7) of this subsection, and subsection (i)
of this section) means an institution which--
(1) is primarily engaged in providing, by or under
the supervision of physicians, to inpatients (A)
diagnostic services and therapeutic services for
medical diagnosis, treatment, and care of injured,
disabled, or sick persons, or (B) rehabilitation
services for the rehabilitation of injured, disabled,
or sick persons;
(2) maintains clinical records on all patients;
(3) has bylaws in effect with respect to its staff of
physicians;
(4) has a requirement that every patient with respect
to whom payment may be made under this title must be
under the care of a physician, except that a patient
receiving qualified psychologist services (as defined
in subsection (ii)) may be under the care of a clinical
psychologist with respect to such services to the
extent permitted under State law;
(5) provides 24-hour nursing service rendered or
supervised by a registered professional nurse, and has
a licensed practical nurse or registered professional
nurse on duty at all times; except that until January
1, 1979, the Secretary is authorized to waive the
requirement of this paragraph for any one-year period
with respect to any institution, insofar as such
requirement relates to the provision of twenty-four-
hour nursing service rendered or supervised by a
registered professional nurse (except that in any event
a registered professional nurse must be present on the
premises to render or supervise the nursing service
provided, during at least the regular daytime shift),
where immediately preceding such one-year period he
finds that--
(A) such institution is located in a rural
area and the supply of hospital services in
such area is not sufficient to meet the needs
of individuals residing therein,
(B) the failure of such institution to
qualify as a hospital would seriously reduce
the availability of such services to such
individuals, and
(C) such institution has made and continues
to make a good faith effort to comply with this
paragraph, but such compliance is impeded by
the lack of qualified nursing personnel in such
area;
(6)(A) has in effect a hospital utilization review
plan which meets the requirements of subsection (k) and
(B) has in place a discharge planning process that
meets the requirements of subsection (ee);
(7) in the case of an institution in any State in
which State or applicable local law provides for the
licensing of hospitals, (A) is licensed pursuant to
such law or (B) is approved, by the agency of such
State or locality responsible for licensing hospitals,
as meeting the standards established for such
licensing;
(8) has in effect an overall plan and budget that
meets the requirements of subsection (z); and
(9) meets such other requirements as the Secretary
finds necessary in the interest of the health and
safety of individuals who are furnished services in the
institution.
For purposes of subsection (a)(2), such term includes any
institution which meets the requirements of paragraph (1) of
this subsection. For purposes of sections 1814(d) and 1835(b)
(including determination of whether an individual received
inpatient hospital services or diagnostic services for purposes
of such sections), section 1814(f)(2), and subsection (i) of
this section, such term includes any institution which (i)
meets the requirements of paragraphs (5) and (7) of this
subsection, (ii) is not primarily engaged in providing the
services described in section 1861(j)(1)(A) and (iii) is
primarily engaged in providing, by or under the supervision of
individuals referred to in paragraph (1) of section 1861(r), to
inpatients diagnostic services and therapeutic services for
medical diagnosis, treatment, and care of injured, disabled, or
sick persons, or rehabilitation services for the rehabilitation
of injured, disabled, or sick persons. For purposes of section
1814(f)(1), such term includes an institution which (i) is a
hospital for purposes of sections 1814(d), 1814(f)(2), and
1835(b) and (ii) is accredited by a national accreditation body
recognized by the Secretary under section 1865(a), or is
accredited by or approved by a program of the country in which
such institution is located if the Secretary finds the
accreditation or comparable approval standards of such program
to be essentially equivalent to those of such a national
accreditation body.. Notwithstanding the preceding provisions
of this subsection, such term shall not, except for purposes of
subsection (a)(2), include any institution which is primarily
for the care and treatment of mental diseases unless it is a
psychiatric hospital (as defined in subsection (f)). The term
``hospital'' also includes a religious nonmedical health care
institution (as defined in subsection (ss)(1)), but only with
respect to items and services ordinarily furnished by such
institution to inpatients, and payment may be made with respect
to services provided by or in such an institution only to such
extent and under such conditions, limitations, and requirements
(in addition to or in lieu of the conditions, limitations, and
requirements otherwise applicable) as may be provided in
regulations consistent with section 1821. For provisions
deeming certain requirements of this subsection to be met in
the case of accredited institutions, see section 1865. The term
``hospital'' also includes a facility of fifty beds or less
which is located in an area determined by the Secretary to meet
the definition relating to a rural area described in
subparagraph (A) of paragraph (5) of this subsection and which
meets the other requirements of this subsection, except that--
(A) with respect to the requirements for nursing
services applicable after December 31, 1978, such
requirements shall provide for temporary waiver of the
requirements, for such period as the Secretary deems
appropriate, where (i) the facility's failure to fully
comply with the requirements is attributable to a
temporary shortage of qualified nursing personnel in
the area in which the facility is located, (ii) a
registered professional nurse is present on the
premises to render or supervise the nursing service
provided during at least the regular daytime shift, and
(iii) the Secretary determines that the employment of
such nursing personnel as are available to the facility
during such temporary period will not adversely affect
the health and safety of patients;
(B) with respect to the health and safety
requirements promulgated under paragraph (9), such
requirements shall be applied by the Secretary to a
facility herein defined in such manner as to assure
that personnel requirements take into account the
availability of technical personnel and the educational
opportunities for technical personnel in the area in
which such facility is located, and the scope of
services rendered by such facility; and the Secretary,
by regulations, shall provide for the continued
participation of such a facility where such personnel
requirements are not fully met, for such period as the
Secretary determines that (i) the facility is making
good faith efforts to fully comply with the personnel
requirements, (ii) the employment by the facility of
such personnel as are available to the facility will
not adversely affect the health and safety of patients,
and (iii) if the Secretary has determined that because
of the facility's waiver under this subparagraph the
facility should limit its scope of services in order
not to adversely affect the health and safety of the
facility's patients, the facility is so limiting the
scope of services it provides; and
(C) with respect to the fire and safety requirements
promulgated under paragraph (9), the Secretary (i) may
waive, for such period as he deems appropriate,
specific provisions of such requirements which if
rigidly applied would result in unreasonable hardship
for such a facility and which, if not applied, would
not jeopardize the health and safety of patients, and
(ii) may accept a facility's compliance with all
applicable State codes relating to fire and safety in
lieu of compliance with the fire and safety
requirements promulgated under paragraph (9), if he
determines that such State has in effect fire and
safety codes, imposed by State law, which adequately
protect patients.
The term ``hospital'' does not include, unless the context
otherwise requires, a critical access hospital (as defined in
section 1861(mm)(1)).
Psychiatric Hospital
(f) The term ``psychiatric hospital'' means an institution
which--
(1) is primarily engaged in providing, by or under
the supervision of a physician, psychiatric services
for the diagnosis and treatment of mentally ill
persons;
(2) satisfies the requirements of paragraphs (3)
through (9) of subsection (e);
(3) maintains clinical records on all patients and
maintains such records as the Secretary finds to be
necessary to determine the degree and intensity of the
treatment provided to individuals entitled to hospital
insurance benefits under part A; and
(4) meets such staffing requirements as the Secretary
finds necessary for the institution to carry out an
active program of treatment for individuals who are
furnished services in the institution.
In the case of an institution which satisfies paragraphs (1)
and (2) of the preceding sentence and which contains a distinct
part which also satisfies paragraphs (3) and (4) of such
sentence, such distinct part shall be considered to be a
``psychiatric hospital''.
Outpatient Occupational Therapy Services
(g) The term ``outpatient occupational therapy services'' has
the meaning given the term ``outpatient physical therapy
services'' in subsection (p), except that ``occupational''
shall be substituted for ``physical'' each place it appears
therein.
Extended Care Services
(h) The term ``extended care services'' means the following
items and services furnished to an inpatient of a skilled
nursing facility and (except as provided in paragraphs (3), (6)
and (7)) by such skilled nursing facility--
(1) nursing care provided by or under the supervision
of a registered professional nurse;
(2) bed and board in connection with the furnishing
of such nursing care;
(3) physical or occupational therapy or speech-
language pathology services furnished by the skilled
nursing facility or by others under arrangements with
them made by the facility;
(4) medical social services;
(5) such drugs, biologicals, supplies, appliances,
and equipment, furnished for use in the skilled nursing
facility, as are ordinarily furnished by such facility
for the care and treatment of inpatients;
(6) medical services provided by an intern or
resident-in- training of a hospital with which the
facility has in effect a transfer agreement (meeting
the requirements of subsection (l)), under a teaching
program of such hospital approved as provided in the
last sentence of subsection (b), and other diagnostic
or therapeutic services provided by a hospital with
which the facility has such an agreement in effect; and
(7) such other services necessary to the health of
the patients as are generally provided by skilled
nursing facilities, or by others under arrangements
with them made by the facility;
excluding, however, any item or service if it would not be
included under subsection (b) if furnished to an inpatient of a
hospital.
Post-Hospital Extended Care Services
(i) The term ``post-hospital extended care services'' means
extended care services furnished an individual after transfer
from a hospital in which he was an inpatient for not less than
3 consecutive days before his discharge from the hospital in
connection with such transfer. For purposes of the preceding
sentence, items and services shall be deemed to have been
furnished to an individual after transfer from a hospital, and
he shall be deemed to have been an inpatient in the hospital
immediately before transfer therefrom, if he is admitted to the
skilled nursing facility (A) within 30 days after discharge
from such hospital, or (B) within such time as it would be
medically appropriate to begin an active course of treatment,
in the case of an individual whose condition is such that
skilled nursing facility care would not be medically
appropriate within 30 days after discharge from a hospital; and
an individual shall be deemed not to have been discharged from
a skilled nursing facility if, within 30 days after discharge
therefrom, he is admitted to such facility or any other skilled
nursing facility.
Skilled Nursing Facility
(j) The term ``skilled nursing facility'' has the meaning
given such term in section 1819(a).
Utilization Review
(k) A utilization review plan of a hospital or skilled
nursing facility shall be considered sufficient if it is
applicable to services furnished by the institution to
individuals entitled to insurance benefits under this title and
if it provides--
(1) for the review, on a sample or other basis, of
admissions to the institution, the duration of stays
therein, and the professional services (including drugs
and biologicals) furnished, (A) with respect to the
medical necessity of the services, and (B) for the
purpose of promoting the most efficient use of
available health facilities and services;
(2) for such review to be made by either (A) a staff
committee of the institution composed of two or more
physicians (of which at least two must be physicians
described in subsection (r)(1) of this section), with
or without participation of other professional
personnel, or (B) a group outside the institution which
is similarly composed and (i) which is established by
the local medical society and some or all of the
hospitals and skilled nursing facilities in the
locality, or (ii) if (and for as long as) there has not
been established such a group which serves such
institution, which is established in such other manner
as may be approved by the Secretary;
(3) for such review, in each case of inpatient
hospital services or extended care services furnished
to such an individual during a continuous period of
extended duration, as of such days of such period
(which may differ for different classes of cases) as
may be specified in regulations, with such review to be
made as promptly as possible, after each day so
specified, and in no event later than one week
following such day; and
(4) for prompt notification to the institution, the
individual, and his attending physician of any finding
(made after opportunity for consultation to such
attending physician) by the physician members of such
committee or group that any further stay in the
institution is not medically necessary.
The review committee must be composed as provided in clause (B)
of paragraph (2) rather than as provided in clause (A) of such
paragraph in the case of any hospital or skilled nursing
facility where, because of the small size of the institution,
or (in the case of a skilled nursing facility) because of lack
of an organized medical staff, or for such other reason or
reasons as may be included in regulations, it is impracticable
for the institution to have a properly functioning staff
committee for the purposes of this subsection. If the Secretary
determines that the utilization review procedures established
pursuant to title XIX are superior in their effectiveness to
the procedures required under this section, he may, to the
extent that he deems it appropriate, require for purposes of
this title that the procedures established pursuant to title
XIX be utilized instead of the procedures required by this
section.
Agreements for Transfer Between Skilled Nursing Facilities and
Hospitals
(l) A hospital and a skilled nursing facility shall be
considered to have a transfer agreement in effect if, by reason
of a written agreement between them or (in case the two
institutions are under common control) by reason of a written
undertaking by the person or body which controls them, there is
reasonable assurance that--
(1) transfer of patients will be effected between the
hospital and the skilled nursing facility whenever such
transfer is medically appropriate as determined by the
attending physician; and
(2) there will be interchange of medical and other
information necessary or useful in the care and
treatment of individuals transferred between the
institutions, or in determining whether such
individuals can be adequately cared for otherwise than
in either of such institutions.
Any skilled nursing facility which does not have such an
agreement in effect, but which is found by a State agency (of
the State in which such facility is situated) with which an
agreement under section 1864 is in effect (or, in the case of a
State in which no such agency has an agreement under section
1864, by the Secretary) to have attempted in good faith to
enter into such an agreement with a hospital sufficiently close
to the facility to make feasible the transfer between them of
patients and the information referred to in paragraph (2),
shall be considered to have such an agreement in effect if and
for so long as such agency (or the Secretary, as the case may
be) finds that to do so is in the public interest and essential
to assuring extended care services for persons in the community
who are eligible for payments with respect to such services
under this title.
Home Health Services
(m) The term ``home health services'' means the following
items and services furnished to an individual, who is under the
care of a physician, by a home health agency or by others under
arrangements with them made by such agency, under a plan (for
furnishing such items and services to such individual)
established and periodically reviewed by a physician, which
items and services are, except as provided in paragraph (7),
provided on a visiting basis in a place of residence used as
such individual's home--
(1) part-time or intermittent nursing care provided
by or under the supervision of a registered
professional nurse;
(2) physical or occupational therapy or speech-
language pathology services;
(3) medical social services under the direction of a
physician;
(4) to the extent permitted in regulations, part-time
or intermittent services of a home health aide who has
successfully completed a training program approved by
the Secretary;
(5) medical supplies (including catheters, catheter
supplies, ostomy bags, and supplies related to ostomy
care, and a covered osteoporosis drug (as defined in
subsection (kk)), but excluding other drugs and
biologicals) and durable medical equipment and
applicable disposable devices (as defined in section
1834(s)(2)) while under such a plan;
(6) in the case of a home health agency which is
affiliated or under common control with a hospital,
medical services provided by an intern or resident-in-
training of such hospital, under a teaching program of
such hospital approved as provided in the last sentence
of subsection (b); and
(7) any of the foregoing items and services which are
provided on an outpatient basis, under arrangements
made by the home health agency, at a hospital or
skilled nursing facility, or at a rehabilitation center
which meets such standards as may be prescribed in
regulations, and--
(A) the furnishing of which involves the use
of equipment of such a nature that the items
and services cannot readily be made available
to the individual in such place of residence,
or
(B) which are furnished at such facility
while he is there to receive any such item or
service described in clause (A),
but not including transportation of the individual in
connection with any such item or service;
excluding, however, any item or service if it would not be
included under subsection (b) if furnished to an inpatient of a
hospital and home infusion therapy (as defined in subsection
(iii)(i)). For purposes of paragraphs (1) and (4), the term
``part-time or intermittent services'' means skilled nursing
and home health aide services furnished any number of days per
week as long as they are furnished (combined) less than 8 hours
each day and 28 or fewer hours each week (or, subject to review
on a case-by-case basis as to the need for care, less than 8
hours each day and 35 or fewer hours per week). For purposes of
sections 1814(a)(2)(C) and 1835(a)(2)(A), ``intermittent''
means skilled nursing care that is either provided or needed on
fewer than 7 days each week, or less than 8 hours of each day
for periods of 21 days or less (with extensions in exceptional
circumstances when the need for additional care is finite and
predictable).
Durable Medical Equipment
(n) The term ``durable medical equipment'' includes iron
lungs, oxygen tents, hospital beds, and wheelchairs (which may
include a power-operated vehicle that may be appropriately used
as a wheelchair, but only where the use of such a vehicle is
determined to be necessary on the basis of the individual's
medical and physical condition and the vehicle meets such
safety requirements as the Secretary may prescribe) used in the
patient's home (including an institution used as his home other
than an institution that meets the requirements of subsection
(e)(1) of this section or section 1819(a)(1)), whether
furnished on a rental basis or purchased, and includes blood-
testing strips and blood glucose monitors for individuals with
diabetes without regard to whether the individual has Type I or
Type II diabetes or to the individual's use of insulin (as
determined under standards established by the Secretary in
consultation with the appropriate organizations) and eye
tracking and gaze interaction accessories for speech generating
devices furnished to individuals with a demonstrated medical
need for such accessories; except that such term does not
include such equipment furnished by a supplier who has used,
for the demonstration and use of specific equipment, an
individual who has not met such minimum training standards as
the Secretary may establish with respect to the demonstration
and use of such specific equipment. With respect to a seat-lift
chair, such term includes only the seat-lift mechanism and does
not include the chair.
Home Health Agency
(o) The term ``home health agency'' means a public agency or
private organization, or a subdivision of such an agency or
organization, which--
(1) is primarily engaged in providing skilled nursing
services and other therapeutic services;
(2) has policies, established by a group of
professional personnel (associated with the agency or
organization), including one or more physicians and one
or more registered professional nurses, to govern the
services (referred to in paragraph (1)) which it
provides, and provides for supervision of such services
by a physician or registered professional nurse;
(3) maintains clinical records on all patients;
(4) in the case of an agency or organization in any
State in which State or applicable local law provides
for the licensing of agencies or organizations of this
nature, (A) is licensed pursuant to such law, or (B) is
approved, by the agency of such State or locality
responsible for licensing agencies or organizations of
this nature, as meeting the standards established for
such licensing;
(5) has in effect an overall plan and budget that
meets the requirements of subsection (z);
(6) meets the conditions of participation specified
in section 1891(a) and such other conditions of
participation as the Secretary may find necessary in
the interest of the health and safety of individuals
who are furnished services by such agency or
organization;
(7) provides the Secretary with a surety bond--
(A) in a form specified by the Secretary and
in an amount that is not less than the minimum
of $50,000; and
(B) that the Secretary determines is
commensurate with the volume of payments to the
home health agency; and
(8) meets such additional requirements (including
conditions relating to bonding or establishing of
escrow accounts as the Secretary finds necessary for
the financial security of the program) as the Secretary
finds necessary for the effective and efficient
operation of the program;
except that for purposes of part A such term shall not include
any agency or organization which is primarily for the care and
treatment of mental diseases. The Secretary may waive the
requirement of a surety bond under paragraph (7) in the case of
an agency or organization that provides a comparable surety
bond under State law.
Outpatient Physical Therapy Services
(p) The term ``outpatient physical therapy services'' means
physical therapy services furnished by a provider of services,
a clinic, rehabilitation agency, or a public health agency, or
by others under an arrangement with, and under the supervision
of, such provider, clinic, rehabilitation agency, or public
health agency to an individual as an outpatient--
(1) who is under the care of a physician (as defined
in paragraph (1), (3), or (4) of section 1861(r)), and
(2) with respect to whom a plan prescribing the type,
amount, and duration of physical therapy services that
are to be furnished such individual has been
established by a physician (as so defined) or by a
qualified physical therapist and is periodically
reviewed by a physician (as so defined);
excluding, however--
(3) any item or service if it would not be included
under subsection (b) if furnished to an inpatient of a
hospital; and
(4) any such service--
(A) if furnished by a clinic or
rehabilitation agency, or by others under
arrangements with such clinic or agency, unless
such clinic or rehabilitation agency--
(i) provides an adequate program of
physical therapy services for
outpatients and has the facilities and
personnel required for such program or
required for the supervision of such a
program, in accordance with such
requirements as the Secretary may
specify,
(ii) has policies, established by a
group of professional personnel,
including one or more physicians
(associated with the clinic or
rehabilitation agency) and one or more
qualified physical therapists, to
govern the services (referred to in
clause (i)) it provides,
(iii) maintains clinical records on
all patients,
(iv) if such clinic or agency is
situated in a State in which State or
applicable local law provides for the
licensing of institutions of this
nature, (I) is licensed pursuant to
such law, or (II) is approved by the
agency of such State or locality
responsible for licensing institutions
of this nature, as meeting the
standards established for such
licensing; and
(v) meets such other conditions
relating to the health and safety of
individuals who are furnished services
by such clinic or agency on an
outpatient basis, as the Secretary may
find necessary, and provides the
Secretary on a continuing basis with a
surety bond in a form specified by the
Secretary and in an amount that is not
less than $50,000, or
(B) if furnished by a public health agency,
unless such agency meets such other conditions
relating to health and safety of individuals
who are furnished services by such agency on an
outpatient basis, as the Secretary may find
necessary.
The term ``outpatient physical therapy services'' also includes
physical therapy services furnished an individual by a physical
therapist (in his office or in such individual's home) who
meets licensing and other standards prescribed by the Secretary
in regulations, otherwise than under an arrangement with and
under the supervision of a provider of services, clinic,
rehabilitation agency, or public health agency, if the
furnishing of such services meets such conditions relating to
health and safety as the Secretary may find necessary. In
addition, such term includes physical therapy services which
meet the requirements of the first sentence of this subsection
except that they are furnished to an individual as an inpatient
of a hospital or extended care facility. Nothing in this
subsection shall be construed as requiring, with respect to
outpatients who are not entitled to benefits under this title,
a physical therapist to provide outpatient physical therapy
services only to outpatients who are under the care of a
physician or pursuant to a plan of care established by a
physician. The Secretary may waive the requirement of a surety
bond under paragraph (4)(A)(v) in the case of a clinic or
agency that provides a comparable surety bond under State law.
Physicians' Services
(q) The term ``physicians' services'' means professional
services performed by physicians, including surgery,
consultation, and home, office, and institutional calls (but
not including services described in subsection (b)(6)).
Physician
(r) The term ``physician'', when used in connection with the
performance of any function or action, means (1) a doctor of
medicine or osteopathy legally authorized to practice medicine
and surgery by the State in which he performs such function or
action (including a physician within the meaning of section
1101(a)(7)), (2) a doctor of dental surgery or of dental
medicine who is legally authorized to practice dentistry by the
State in which he performs such function and who is acting
within the scope of his license when he performs such
functions, (3) a doctor of podiatric medicine for the purposes
of subsections (k), (m), (p)(1), and (s) of this section and
sections 1814(a), 1832(a)(2)(F)(ii), and 1835 but only with
respect to functions which he is legally authorized to perform
as such by the State in which he performs them, (4) a doctor of
optometry, but only for purposes of subsection (p)(1) and with
respect to the provision of items or services described in
subsection (s) which he is legally authorized to perform as a
doctor of optometry by the State in which he performs them, or
(5) a chiropractor who is licensed as such by the State (or in
a State which does not license chiropractors as such, is
legally authorized to perform the services of a chiropractor in
the jurisdiction in which he performs such services), and who
meets uniform minimum standards promulgated by the Secretary,
but only for the purpose of sections 1861(s)(1) and
1861(s)(2)(A) and only with respect to treatment by means of
manual manipulation of the spine (to correct a subluxation)
which he is legally authorized to perform by the State or
jurisdiction in which such treatment is provided. For the
purposes of section 1862(a)(4) and subject to the limitations
and conditions provided in the previous sentence, such term
includes a doctor of one of the arts, specified in such
previous sentence, legally authorized to practice such art in
the country in which the inpatient hospital services (referred
to in such section 1862(a)(4)) are furnished.
Medical and Other Health Services
(s) The term ``medical and other health services'' means any
of the following items or services:
(1) physicians' services;
(2)(A) services and supplies (including drugs and
biologicals which are not usually self-administered by
the patient) furnished as an incident to a physician's
professional service, of kinds which are commonly
furnished in physicians' offices and are commonly
either rendered without charge or included in the
physicians' bills (or would have been so included but
for the application of section 1847B);
(B) hospital services (including drugs and
biologicals which are not usually self-administered by
the patient) incident to physicians' services rendered
to outpatients and partial hospitalization services
incident to such services;
(C) diagnostic services which are--
(i) furnished to an individual as an
outpatient by a hospital or by others under
arrangements with them made by a hospital, and
(ii) ordinarily furnished by such hospital
(or by others under such arrangements) to its
outpatients for the purpose of diagnostic
study;
(D) outpatient physical therapy services, outpatient
speech-language pathology services, and outpatient
occupational therapy services;
(E) rural health clinic services and Federally
qualified health center services;
(F) home dialysis supplies and equipment, self-care
home dialysis support services, and institutional
dialysis services and supplies, and, for items and
services furnished on or after January 1, 2011, renal
dialysis services (as defined in section
1881(b)(14)(B)), including such renal dialysis services
furnished on or after January 1, 2017, by a renal
dialysis facility or provider of services paid under
section 1881(b)(14) to an individual with acute kidney
injury (as defined in section 1834(r)(2));
(G) antigens (subject to quantity limitations
prescribed in regulations by the Secretary) prepared by
a physician, as defined in section 1861(r)(1), for a
particular patient, including antigens so prepared
which are forwarded to another qualified person
(including a rural health clinic) for administration to
such patient, from time to time, by or under the
supervision of another such physician;
(H)(i) services furnished pursuant to a contract
under section 1876 to a member of an eligible
organization by a physician assistant or by a nurse
practitioner (as defined in subsection (aa)(5)) and
such services and supplies furnished as an incident to
his service to such a member as would otherwise be
covered under this part if furnished by a physician or
as an incident to a physician's service; and
(ii) services furnished pursuant to a risk-sharing
contract under section 1876(g) to a member of an
eligible organization by a clinical psychologist (as
defined by the Secretary) or by a clinical social
worker (as defined in subsection (hh)(2)), and such
services and supplies furnished as an incident to such
clinical psychologist's services or clinical social
worker's services to such a member as would otherwise
be covered under this part if furnished by a physician
or as an incident to a physician's service;
(I) blood clotting factors, for hemophilia patients
competent to use such factors to control bleeding
without medical or other supervision, and items related
to the administration of such factors, subject to
utilization controls deemed necessary by the Secretary
for the efficient use of such factors;
(J) prescription drugs used in immunosuppressive
therapy furnished, to an individual who receives an
organ transplant for which payment is made under this
title;
(K)(i) services which would be physicians' services
and services described in subsections (ww)(1) and (hhh)
if furnished by a physician (as defined in subsection
(r)(1)) and which are performed by a physician
assistant (as defined in subsection (aa)(5)) under the
supervision of a physician (as so defined) and which
the physician assistant is legally authorized to
perform by the State in which the services are
performed, and such services and supplies furnished as
incident to such services as would be covered under
subparagraph (A) if furnished incident to a physician's
professional service, but only if no facility or other
provider charges or is paid any amounts with respect to
the furnishing of such services,
(ii) services which would be physicians' services and
services described in subsections (ww)(1) and (hhh) if
furnished by a physician (as defined in subsection
(r)(1)) and which are performed by a nurse practitioner
or clinical nurse specialist (as defined in subsection
(aa)(5)) working in collaboration (as defined in
subsection (aa)(6)) with a physician (as defined in
subsection (r)(1)) which the nurse practitioner or
clinical nurse specialist is legally authorized to
perform by the State in which the services are
performed, and such services and supplies furnished as
an incident to such services as would be covered under
subparagraph (A) if furnished incident to a physician's
professional service, but only if no facility or other
provider charges or is paid any amounts with respect to
the furnishing of such services;
(L) certified nurse-midwife services;
(M) qualified psychologist services;
(N) clinical social worker services (as defined in
subsection (hh)(2));
(O) erythropoietin for dialysis patients competent to
use such drug without medical or other supervision with
respect to the administration of such drug, subject to
methods and standards established by the Secretary by
regulation for the safe and effective use of such drug,
and items related to the administration of such drug;
(P) prostate cancer screening tests (as defined in
subsection (oo));
(Q) an oral drug (which is approved by the Federal
Food and Drug Administration) prescribed for use as an
anticancer chemotherapeutic agent for a given
indication, and containing an active ingredient (or
ingredients), which is the same indication and active
ingredient (or ingredients) as a drug which the carrier
determines would be covered pursuant to subparagraph
(A) or (B) if the drug could not be self-administered;
(R) colorectal cancer screening tests (as defined in
subsection (pp));
(S) diabetes outpatient self-management training
services (as defined in subsection (qq));
(T) an oral drug (which is approved by the Federal
Food and Drug Administration) prescribed for use as an
acute anti-emetic used as part of an anticancer
chemotherapeutic regimen if the drug is administered by
a physician (or as prescribed by a physician)--
(i) for use immediately before, at, or within
48 hours after the time of the administration
of the anticancer chemotherapeutic agent; and
(ii) as a full replacement for the anti-
emetic therapy which would otherwise be
administered intravenously;
(U) screening for glaucoma (as defined in subsection
(uu)) for individuals determined to be at high risk for
glaucoma, individuals with a family history of glaucoma
and individuals with diabetes;
(V) medical nutrition therapy services (as defined in
subsection (vv)(1)) in the case of a beneficiary with
diabetes or a renal disease who--
(i) has not received diabetes outpatient
self-management training services within a time
period determined by the Secretary;
(ii) is not receiving maintenance dialysis
for which payment is made under section 1881;
and
(iii) meets such other criteria determined by
the Secretary after consideration of protocols
established by dietitian or nutrition
professional organizations;
(W) an initial preventive physical examination (as
defined in subsection (ww));
(X) cardiovascular screening blood tests (as defined
in subsection (xx)(1));
(Y) diabetes screening tests (as defined in
subsection (yy));
(Z) intravenous immune globulin for the treatment of
primary immune deficiency diseases in the home (as
defined in subsection (zz));
(AA) ultrasound screening for abdominal aortic
aneurysm (as defined in subsection (bbb)) for an
individual--
(i) who receives a referral for such an
ultrasound screening as a result of an initial
preventive physical examination (as defined in
section 1861(ww)(1));
(ii) who has not been previously furnished
such an ultrasound screening under this title;
and
(iii) who--
(I) has a family history of abdominal
aortic aneurysm; or
(II) manifests risk factors included
in a beneficiary category recommended
for screening by the United States
Preventive Services Task Force
regarding abdominal aortic aneurysms;
(BB) additional preventive services (described in
subsection (ddd)(1));
(CC) items and services furnished under a
cardiac rehabilitation program (as defined in
subsection (eee)(1)) or under a pulmonary
rehabilitation program (as defined in
subsection (fff)(1));
(DD) items and services furnished under an
intensive cardiac rehabilitation program (as
defined in subsection (eee)(4));
(EE) kidney disease education services (as defined in
subsection (ggg));
(FF) personalized prevention plan services (as
defined in subsection (hhh));
(GG) home infusion therapy (as defined in subsection
(iii)(1)); [and]
(HH) opioid use disorder treatment services (as
defined in subsection (jjj))[.]; and
(II) a prostate cancer DNA Specimen Provenance Assay
test (DSPA test) (as defined in subsection (kkk));
(3) diagnostic X-ray tests (including tests under the
supervision of a physician, furnished in a place of
residence used as the patient's home, if the
performance of such tests meets such conditions
relating to health and safety as the Secretary may find
necessary and including diagnostic mammography if
conducted by a facility that has a certificate (or
provisional certificate) issued under section 354 of
the Public Health Service Act), diagnostic laboratory
tests, and other diagnostic tests;
(4) X-ray, radium, and radioactive isotope therapy,
including materials and services of technicians;
(5) surgical dressings, and splints, casts, and other
devices used for reduction of fractures and
dislocations;
(6) durable medical equipment;
(7) ambulance service where the use of other methods
of transportation is contraindicated by the
individual's condition, but, subject to section
1834(l)(14), only to the extent provided in
regulations;
(8) prosthetic devices (other than dental) which
replace all or part of an internal body organ
(including colostomy bags and supplies directly related
to colostomy care), including replacement of such
devices, and including one pair of conventional
eyeglasses or contact lenses furnished subsequent to
each cataract surgery with insertion of an intraocular
lens;
(9) leg, arm, back, and neck braces, and artificial
legs, arms, and eyes, including replacements if
required because of a change in the patient's physical
condition;
(10)(A) pneumococcal vaccine and its administration
and, subject to section 4071(b) of the Omnibus Budget
Reconciliation Act of 1987, influenza vaccine and its
administration; and
(B) hepatitis B vaccine and its administration,
furnished to an individual who is at high or
intermediate risk of contracting hepatitis B (as
determined by the Secretary under regulations);
(11) services of a certified registered nurse
anesthetist (as defined in subsection (bb));
(12) subject to section 4072(e) of the Omnibus Budget
Reconciliation Act of 1987, extra-depth shoes with
inserts or custom molded shoes with inserts for an
individual with diabetes, if--
(A) the physician who is managing the
individual's diabetic condition (i) documents
that the individual has peripheral neuropathy
with evidence of callus formation, a history of
pre-ulcerative calluses, a history of previous
ulceration, foot deformity, or previous
amputation, or poor circulation, and (ii)
certifies that the individual needs such shoes
under a comprehensive plan of care related to
the individual's diabetic condition;
(B) the particular type of shoes are
prescribed by a podiatrist or other qualified
physician (as established by the Secretary);
and
(C) the shoes are fitted and furnished by a
podiatrist or other qualified individual (such
as a pedorthist or orthotist, as established by
the Secretary) who is not the physician
described in subparagraph (A) (unless the
Secretary finds that the physician is the only
such qualified individual in the area);
(13) screening mammography (as defined in subsection
(jj));
(14) screening pap smear and screening pelvic exam;
and
(15) bone mass measurement (as defined in subsection
(rr)).
No diagnostic tests performed in any laboratory, including a
laboratory that is part of a rural health clinic, or a hospital
(which, for purposes of this sentence, means an institution
considered a hospital for purposes of section 1814(d)) shall be
included within paragraph (3) unless such laboratory--
(16) if situated in any State in which State or
applicable local law provides for licensing of
establishments of this nature, (A) is licensed pursuant
to such law, or (B) is approved, by the agency of such
State or locality responsible for licensing
establishments of this nature, as meeting the standards
established for such licensing; and
(17)(A) meets the certification requirements under
section 353 of the Public Health Service Act; and
(B) meets such other conditions relating to the
health and safety of individuals with respect to whom
such tests are performed as the Secretary may find
necessary.
There shall be excluded from the diagnostic services specified
in paragraph (2)(C) any item or service (except services
referred to in paragraph (1)) which would not be included under
subsection (b) if it were furnished to an inpatient of a
hospital. None of the items and services referred to in the
preceding paragraphs (other than paragraphs (1) and (2)(A)) of
this subsection which are furnished to a patient of an
institution which meets the definition of a hospital for
purposes of section 1814(d) shall be included unless such other
conditions are met as the Secretary may find necessary relating
to health and safety of individuals with respect to whom such
items and services are furnished.
Drugs and Biologicals
(t)(1) The term ``drugs'' and the term ``biologicals'',
except for purposes of subsection (m)(5) and paragraph (2),
include only such drugs (including contrast agents) and
biologicals, respectively, as are included (or approved for
inclusion) in the United States Pharmacopoeia, the National
Formulary, or the United States Homeopathic Pharmacopoeia, or
in New Drugs or Accepted Dental Remedies (except for any drugs
and biologicals unfavorably evaluated therein), or as are
approved by the pharmacy and drug therapeutics committee (or
equivalent committee) of the medical staff of the hospital
furnishing such drugs and biologicals for use in such hospital.
(2)(A) For purposes of paragraph (1), the term ``drugs'' also
includes any drugs or biologicals used in an anticancer
chemotherapeutic regimen for a medically accepted indication
(as described in subparagraph (B)).
(B) In subparagraph (A), the term ``medically accepted
indication'', with respect to the use of a drug, includes any
use which has been approved by the Food and Drug Administration
for the drug, and includes another use of the drug if--
(i) the drug has been approved by the Food and Drug
Administration; and
(ii)(I) such use is supported by one or more
citations which are included (or approved for
inclusion) in one or more of the following compendia:
the American Hospital Formulary Service-Drug
Information, the American Medical Association Drug
Evaluations, the United States Pharmacopoeia-Drug
Information (or its successor publications), and other
authoritative compendia as identified by the Secretary,
unless the Secretary has determined that the use is not
medically appropriate or the use is identified as not
indicated in one or more such compendia, or
(II) the carrier involved determines, based upon
guidance provided by the Secretary to carriers for
determining accepted uses of drugs, that such use is
medically accepted based on supportive clinical
evidence in peer reviewed medical literature appearing
in publications which have been identified for purposes
of this subclause by the Secretary.
The Secretary may revise the list of compendia in clause
(ii)(I) as is appropriate for identifying medically accepted
indications for drugs. On and after January 1, 2010, no
compendia may be included on the list of compendia under this
subparagraph unless the compendia has a publicly transparent
process for evaluating therapies and for identifying potential
conflicts of interests.
Provider of Services
(u) The term ``provider of services'' means a hospital,
critical access hospital, skilled nursing facility,
comprehensive outpatient rehabilitation facility, home health
agency, hospice program, or, for purposes of section 1814(g)
and section 1835(e), a fund.
Reasonable Cost
(v)(1)(A) The reasonable cost of any services shall be the
cost actually incurred, excluding therefrom any part of
incurred cost found to be unnecessary in the efficient delivery
of needed health services, and shall be determined in
accordance with regulations establishing the method or methods
to be used, and the items to be included, in determining such
costs for various types or classes of institutions, agencies,
and services; except that in any case to which paragraph (2) or
(3) applies, the amount of the payment determined under such
paragraph with respect to the services involved shall be
considered the reasonable cost of such services. In prescribing
the regulations referred to in the preceding sentence, the
Secretary shall consider, among other things, the principles
generally applied by national organizations or established
prepayment organizations (which have developed such principles)
in computing the amount of payment, to be made by persons other
than the recipients of services, to providers of services on
account of services furnished to such recipients by such
providers. Such regulations may provide for determination of
the costs of services on a per diem, per unit, per capita, or
other basis, may provide for using different methods in
different circumstances, may provide for the use of estimates
of costs of particular items or services, may provide for the
establishment of limits on the direct or indirect overall
incurred costs or incurred costs of specific items or services
or groups of items or services to be recognized as reasonable
based on estimates of the costs necessary in the efficient
delivery of needed health services to individuals covered by
the insurance programs established under this title, and may
provide for the use of charges or a percentage of charges where
this method reasonably reflects the costs. Such regulations
shall (i) take into account both direct and indirect costs of
providers of services (excluding therefrom any such costs,
including standby costs, which are determined in accordance
with regulations to be unnecessary in the efficient delivery of
services covered by the insurance programs established under
this title) in order that, under the methods of determining
costs, the necessary costs of efficiently delivering covered
services to individuals covered by the insurance programs
established by this title will not be borne by individuals not
so covered, and the costs with respect to individuals not so
covered will not be borne by such insurance programs, and (ii)
provide for the making of suitable retroactive corrective
adjustments where, for a provider of services for any fiscal
period, the aggregate reimbursement produced by the methods of
determining costs proves to be either inadequate or excessive.
(B) In the case of extended care services, the regulations
under subparagraph (A) shall not include provision for specific
recognition of a return on equity capital.
(C) Where a hospital has an arrangement with a medical school
under which the faculty of such school provides services at
such hospital, an amount not in excess of the reasonable cost
of such services to the medical school shall be included in
determining the reasonable cost to the hospital of furnishing
services--
(i) for which payment may be made under part A, but
only if--
(I) payment for such services as furnished
under such arrangement would be made under part
A to the hospital had such services been
furnished by the hospital, and
(II) such hospital pays to the medical school
at least the reasonable cost of such services
to the medical school, or
(ii) for which payment may be made under part B, but
only if such hospital pays to the medical school at
least the reasonable cost of such services to the
medical school.
(D) Where (i) physicians furnish services which are either
inpatient hospital services (including services in conjunction
with the teaching programs of such hospital) by reason of
paragraph (7) of subsection (b) or for which entitlement exists
by reason of clause (II) of section 1832(a)(2)(B)(i), and (ii)
such hospital (or medical school under arrangement with such
hospital) incurs no actual cost in the furnishing of such
services, the reasonable cost of such services shall (under
regulations of the Secretary) be deemed to be the cost such
hospital or medical school would have incurred had it paid a
salary to such physicians rendering such services approximately
equivalent to the average salary paid to all physicians
employed by such hospital (or if such employment does not
exist, or is minimal in such hospital, by similar hospitals in
a geographic area of sufficient size to assure reasonable
inclusion of sufficient physicians in development of such
average salary).
(E) Such regulations may, in the case of skilled nursing
facilities in any State, provide for the use of rates,
developed by the State in which such facilities are located,
for the payment of the cost of skilled nursing facility
services furnished under the State's plan approved under title
XIX (and such rates may be increased by the Secretary on a
class or size of institution or on a geographical basis by a
percentage factor not in excess of 10 percent to take into
account determinable items or services or other requirements
under this title not otherwise included in the computation of
such State rates), if the Secretary finds that such rates are
reasonably related to (but not necessarily limited to) analyses
undertaken by such State of costs of care in comparable
facilities in such State. Notwithstanding the previous
sentence, such regulations with respect to skilled nursing
facilities shall take into account (in a manner consistent with
subparagraph (A) and based on patient-days of services
furnished) the costs (including the costs of services required
to attain or maintain the highest practicable physical, mental,
and psychosocial well-being of each resident eligible for
benefits under this title) of such facilities complying with
the requirements of subsections (b), (c), and (d) of section
1819 (including the costs of conducting nurse aide training and
competency evaluation programs and competency evaluation
programs).
(F) Such regulations shall require each provider of services
(other than a fund) to make reports to the Secretary of
information described in section 1121(a) in accordance with the
uniform reporting system (established under such section) for
that type of provider.
(G)(i) In any case in which a hospital provides inpatient
services to an individual that would constitute post-hospital
extended care services if provided by a skilled nursing
facility and a quality improvement organization (or, in the
absence of such a qualified organization, the Secretary or such
agent as the Secretary may designate) determines that inpatient
hospital services for the individual are not medically
necessary but post-hospital extended care services for the
individual are medically necessary and such extended care
services are not otherwise available to the individual (as
determined in accordance with criteria established by the
Secretary) at the time of such determination, payment for such
services provided to the individual shall continue to be made
under this title at the payment rate described in clause (ii)
during the period in which--
(I) such post-hospital extended care services for the
individual are medically necessary and not otherwise
available to the individual (as so determined),
(II) inpatient hospital services for the individual
are not medically necessary, and
(III) the individual is entitled to have payment made
for post-hospital extended care services under this
title,
except that if the Secretary determines that there is not an
excess of hospital beds in such hospital and (subject to clause
(iv)) there is not an excess of hospital beds in the area of
such hospital, such payment shall be made (during such period)
on the basis of the amount otherwise payable under part A with
respect to inpatient hospital services.
(ii)(I) Except as provided in subclause (II), the payment
rate referred to in clause (i) is a rate equal to the estimated
adjusted State-wide average rate per patient-day paid for
services provided in skilled nursing facilities under the State
plan approved under title XIX for the State in which such
hospital is located, or, if the State in which the hospital is
located does not have a State plan approved under title XIX,
the estimated adjusted State-wide average allowable costs per
patient-day for extended care services under this title in that
State.
(II) If a hospital has a unit which is a skilled nursing
facility, the payment rate referred to in clause (i) for the
hospital is a rate equal to the lesser of the rate described in
subclause (I) or the allowable costs in effect under this title
for extended care services provided to patients of such unit.
(iii) Any day on which an individual receives inpatient
services for which payment is made under this subparagraph
shall, for purposes of this Act (other than this subparagraph),
be deemed to be a day on which the individual received
inpatient hospital services.
(iv) In determining under clause (i), in the case of a public
hospital, whether or not there is an excess of hospital beds in
the area of such hospital, such determination shall be made on
the basis of only the public hospitals (including the hospital)
which are in the area of the hospital and which are under
common ownership with that hospital.
(H) In determining such reasonable cost with respect to home
health agencies, the Secretary may not include--
(i) any costs incurred in connection with bonding or
establishing an escrow account by any such agency as a
result of the surety bond requirement described in
subsection (o)(7) and the financial security
requirement described in subsection (o)(8);
(ii) in the case of home health agencies to which the
surety bond requirement described in subsection (o)(7)
and the financial security requirement described in
subsection (o)(8) apply, any costs attributed to
interest charged such an agency in connection with
amounts borrowed by the agency to repay overpayments
made under this title to the agency, except that such
costs may be included in reasonable cost if the
Secretary determines that the agency was acting in good
faith in borrowing the amounts;
(iii) in the case of contracts entered into by a home
health agency after the date of the enactment of this
subparagraph for the purpose of having services
furnished for or on behalf of such agency, any cost
incurred by such agency pursuant to any such contract
which is entered into for a period exceeding five
years; and
(iv) in the case of contracts entered into by a home
health agency before the date of the enactment of this
subparagraph for the purpose of having services
furnished for or on behalf of such agency, any cost
incurred by such agency pursuant to any such contract,
which determines the amount payable by the home health
agency on the basis of a percentage of the agency's
reimbursement or claim for reimbursement for services
furnished by the agency, to the extent that such cost
exceeds the reasonable value of the services furnished
on behalf of such agency.
(I) In determining such reasonable cost, the Secretary may
not include any costs incurred by a provider with respect to
any services furnished in connection with matters for which
payment may be made under this title and furnished pursuant to
a contract between the provider and any of its subcontractors
which is entered into after the date of the enactment of this
subparagraph and the value or cost of which is $10,000 or more
over a twelve-month period unless the contract contains a
clause to the effect that--
(i) until the expiration of four years after the
furnishing of such services pursuant to such contract,
the subcontractor shall make available, upon written
request by the Secretary, or upon request by the
Comptroller General, or any of their duly authorized
representatives, the contract, and books, documents and
records of such subcontractor that are necessary to
certify the nature and extent of such costs, and
(ii) if the subcontractor carries out any of the
duties of the contract through a subcontract, with a
value or cost of $10,000 or more over a twelve-month
period, with a related organization, such subcontract
shall contain a clause to the effect that until the
expiration of four years after the furnishing of such
services pursuant to such subcontract, the related
organization shall make available, upon written request
by the Secretary, or upon request by the Comptroller
General, or any of their duly authorized
representatives, the subcontract, and books, documents
and records of such organization that are necessary to
verify the nature and extent of such costs.
The Secretary shall prescribe in regulation criteria and
procedures which the Secretary shall use in obtaining access to
books, documents, and records under clauses required in
contracts and subcontracts under this subparagraph.
(J) Such regulations may not provide for any inpatient
routine salary cost differential as a reimbursable cost for
hospitals and skilled nursing facilities.
(K)(i) The Secretary shall issue regulations that provide, to
the extent feasible, for the establishment of limitations on
the amount of any costs or charges that shall be considered
reasonable with respect to services provided on an outpatient
basis by hospitals (other than bona fide emergency services as
defined in clause (ii)) or clinics (other than rural health
clinics), which are reimbursed on a cost basis or on the basis
of cost related charges, and by physicians utilizing such
outpatient facilities. Such limitations shall be reasonably
related to the charges in the same area for similar services
provided in physicians' offices. Such regulations shall provide
for exceptions to such limitations in cases where similar
services are not generally available in physicians' offices in
the area to individuals entitled to benefits under this title.
(ii) For purposes of clause (i), the term ``bona fide
emergency services'' means services provided in a hospital
emergency room after the sudden onset of a medical condition
manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that the absence of immediate
medical attention could reasonably be expected to result in--
(I) placing the patient's health in serious jeopardy;
(II) serious impairment to bodily functions; or
(III) serious dysfunction of any bodily organ or
part.
(L)(i) The Secretary, in determining the amount of the
payments that may be made under this title with respect to
services furnished by home health agencies, may not recognize
as reasonable (in the efficient delivery of such services)
costs for the provision of such services by an agency to the
extent these costs exceed (on the aggregate for the agency) for
cost reporting periods beginning on or after--
(I) July 1, 1985, and before July 1, 1986, 120
percent of the mean of the labor-related and nonlabor
per visit costs for freestanding home health agencies,
(II) July 1, 1986, and before July 1, 1987, 115
percent of such mean,
(III) July 1, 1987, and before October 1, 1997, 112
percent of such mean,
(IV) October 1, 1997, and before October 1, 1998, 105
percent of the median of the labor-related and nonlabor
per visit costs for freestanding home health agencies,
or
(V) October 1, 1998, 106 percent of such median.
(ii) Effective for cost reporting periods beginning on or
after July 1, 1986, such limitations shall be applied on an
aggregate basis for the agency, rather than on a discipline
specific basis. The Secretary may provide for such exemptions
and exceptions to such limitation as he deems appropriate.
(iii) Not later than July 1, 1991, and annually thereafter
(but not for cost reporting periods beginning on or after July
1, 1994, and before July 1, 1996, or on or after July 1, 1997,
and before October 1, 1997), the Secretary shall establish
limits under this subparagraph for cost reporting periods
beginning on or after such date by utilizing the area wage
index applicable under section 1886(d)(3)(E) and determined
using the survey of the most recent available wages and wage-
related costs of hospitals located in the geographic area in
which the home health service is furnished (determined without
regard to whether such hospitals have been reclassified to a
new geographic area pursuant to section 1886(d)(8)(B), a
decision of the Medicare Geographic Classification Review Board
under section 1886(d)(10), or a decision of the Secretary).
(iv) In establishing limits under this subparagraph for cost
reporting periods beginning after September 30, 1997, the
Secretary shall not take into account any changes in the home
health market basket, as determined by the Secretary, with
respect to cost reporting periods which began on or after July
1, 1994, and before July 1, 1996.
(v) For services furnished by home health agencies for cost
reporting periods beginning on or after October 1, 1997,
subject to clause (viii)(I), the Secretary shall provide for an
interim system of limits. Payment shall not exceed the costs
determined under the preceding provisions of this subparagraph
or, if lower, the product of--
(I) an agency-specific per beneficiary annual
limitation calculated based 75 percent on 98 percent of
the reasonable costs (including nonroutine medical
supplies) for the agency's 12-month cost reporting
period ending during fiscal year 1994, and based 25
percent on 98 percent of the standardized regional
average of such costs for the agency's census division,
as applied to such agency, for cost reporting periods
ending during fiscal year 1994, such costs updated by
the home health market basket index; and
(II) the agency's unduplicated census count of
patients (entitled to benefits under this title) for
the cost reporting period subject to the limitation.
(vi) For services furnished by home health agencies for cost
reporting periods beginning on or after October 1, 1997, the
following rules apply:
(I) For new providers and those providers without a
12-month cost reporting period ending in fiscal year
1994 subject to clauses (viii)(II) and (viii)(III), the
per beneficiary limitation shall be equal to the median
of these limits (or the Secretary's best estimates
thereof) applied to other home health agencies as
determined by the Secretary. A home health agency that
has altered its corporate structure or name shall not
be considered a new provider for this purpose.
(II) For beneficiaries who use services furnished by
more than one home health agency, the per beneficiary
limitations shall be prorated among the agencies.
(vii)(I) Not later than January 1, 1998, the Secretary shall
establish per visit limits applicable for fiscal year 1998, and
not later than April 1, 1998, the Secretary shall establish per
beneficiary limits under clause (v)(I) for fiscal year 1998.
(II) Not later than August 1 of each year (beginning in 1998)
the Secretary shall establish the limits applicable under this
subparagraph for services furnished during the fiscal year
beginning October 1 of the year.
(viii)(I) In the case of a provider with a 12-month cost
reporting period ending in fiscal year 1994, if the limit
imposed under clause (v) (determined without regard to this
subclause) for a cost reporting period beginning during or
after fiscal year 1999 is less than the median described in
clause (vi)(I) (but determined as if any reference in clause
(v) to ``98 percent'' were a reference to ``100 percent''), the
limit otherwise imposed under clause (v) for such provider and
period shall be increased by \1/3\ of such difference.
(II) Subject to subclause (IV), for new providers and those
providers without a 12-month cost reporting period ending in
fiscal year 1994, but for which the first cost reporting period
begins before fiscal year 1999, for cost reporting periods
beginning during or after fiscal year 1999, the per beneficiary
limitation described in clause (vi)(I) shall be equal to the
median described in such clause (determined as if any reference
in clause (v) to ``98 percent'' were a reference to ``100
percent'').
(III) Subject to subclause (IV), in the case of a new
provider for which the first cost reporting period begins
during or after fiscal year 1999, the limitation applied under
clause (vi)(I) (but only with respect to such provider) shall
be equal to 75 percent of the median described in clause
(vi)(I).
(IV) In the case of a new provider or a provider without a
12-month cost reporting period ending in fiscal year 1994,
subclause (II) shall apply, instead of subclause (III), to a
home health agency which filed an application for home health
agency provider status under this title before September 15,
1998, or which was approved as a branch of its parent agency
before such date and becomes a subunit of the parent agency or
a separate agency on or after such date.
(V) Each of the amounts specified in subclauses (I) through
(III) are such amounts as adjusted under clause (iii) to
reflect variations in wages among different areas.
(ix) Notwithstanding the per beneficiary limit under clause
(viii), if the limit imposed under clause (v) (determined
without regard to this clause) for a cost reporting period
beginning during or after fiscal year 2000 is less than the
median described in clause (vi)(I) (but determined as if any
reference in clause (v) to ``98 percent'' were a reference to
``100 percent''), the limit otherwise imposed under clause (v)
for such provider and period shall be increased by 2 percent.
(x) Notwithstanding any other provision of this subparagraph,
in updating any limit under this subparagraph by a home health
market basket index for cost reporting periods beginning during
each of fiscal years 2000, 2002, and 2003, the update otherwise
provided shall be reduced by 1.1 percentage points. With
respect to cost reporting periods beginning during fiscal year
2001, the update to any limit under this subparagraph shall be
the home health market basket index.
(M) Such regulations shall provide that costs respecting care
provided by a provider of services, pursuant to an assurance
under title VI or XVI of the Public Health Service Act that the
provider will make available a reasonable volume of services to
persons unable to pay therefor, shall not be allowable as
reasonable costs.
(N) In determining such reasonable costs, costs incurred for
activities directly related to influencing employees respecting
unionization may not be included.
(O)(i) In establishing an appropriate allowance for
depreciation and for interest on capital indebtedness with
respect to an asset of a provider of services which has
undergone a change of ownership, such regulations shall
provide, except as provided in clause (iii), that the valuation
of the asset after such change of ownership shall be the
historical cost of the asset, as recognized under this title,
less depreciation allowed, to the owner of record as of the
date of enactment of the Balanced Budget Act of 1997 (or, in
the case of an asset not in existence as of that date, the
first owner of record of the asset after that date).
(ii) Such regulations shall not recognize, as reasonable in
the provision of health care services, costs (including legal
fees, accounting and administrative costs, travel costs, and
the costs of feasibility studies) attributable to the
negotiation or settlement of the sale or purchase of any
capital asset (by acquisition or merger) for which any payment
has previously been made under this title.
(iii) In the case of the transfer of a hospital from
ownership by a State to ownership by a nonprofit corporation
without monetary consideration, the basis for capital
allowances to the new owner shall be the book value of the
hospital to the State at the time of the transfer.
(P) If such regulations provide for the payment for a return
on equity capital (other than with respect to costs of
inpatient hospital services), the rate of return to be
recognized, for determining the reasonable cost of services
furnished in a cost reporting period, shall be equal to the
average of the rates of interest, for each of the months any
part of which is included in the period, on obligations issued
for purchase by the Federal Hospital Insurance Trust Fund.
(Q) Except as otherwise explicitly authorized, the Secretary
is not authorized to limit the rate of increase on allowable
costs of approved medical educational activities.
(R) In determining such reasonable cost, costs incurred by a
provider of services representing a beneficiary in an
unsuccessful appeal of a determination described in section
1869(b) shall not be allowable as reasonable costs.
(S)(i) Such regulations shall not include provision for
specific recognition of any return on equity capital with
respect to hospital outpatient departments.
(ii)(I) Such regulations shall provide that, in determining
the amount of the payments that may be made under this title
with respect to all the capital-related costs of outpatient
hospital services, the Secretary shall reduce the amounts of
such payments otherwise established under this title by 15
percent for payments attributable to portions of cost reporting
periods occurring during fiscal year 1990, by 15 percent for
payments attributable to portions of cost reporting periods
occurring during fiscal year 1991, and by 10 percent for
payments attributable to portions of cost reporting periods
occurring during fiscal years 1992 through 1999 and until the
first date that the prospective payment system under section
1833(t) is implemented.
(II) The Secretary shall reduce the reasonable cost of
outpatient hospital services (other than the capital-related
costs of such services) otherwise determined pursuant to
section 1833(a)(2)(B)(i)(I) by 5.8 percent for payments
attributable to portions of cost reporting periods occurring
during fiscal years 1991 through 1999 and until the first date
that the prospective payment system under section 1833(t) is
implemented.
(III) Subclauses (I) and (II) shall not apply to payments
with respect to the costs of hospital outpatient services
provided by any hospital that is a sole community hospital (as
defined in section 1886(d)(5)(D)(iii)) or a critical access
hospital (as defined in section 1861(mm)(1)).
(IV) In applying subclauses (I) and (II) to services for
which payment is made on the basis of a blend amount under
section 1833(i)(3)(A)(ii) or 1833(n)(1)(A)(ii), the costs
reflected in the amounts described in sections
1833(i)(3)(B)(i)(I) and 1833(n)(1)(B)(i)(I), respectively,
shall be reduced in accordance with such subclause.
(T) In determining such reasonable costs for hospitals, no
reduction in copayments under section 1833(t)(8)(B) shall be
treated as a bad debt and the amount of bad debts otherwise
treated as allowable costs which are attributable to the
deductibles and coinsurance amounts under this title shall be
reduced--
(i) for cost reporting periods beginning during
fiscal year 1998, by 25 percent of such amount
otherwise allowable,
(ii) for cost reporting periods beginning during
fiscal year 1999, by 40 percent of such amount
otherwise allowable,
(iii) for cost reporting periods beginning during
fiscal year 2000, by 45 percent of such amount
otherwise allowable,
(iv) for cost reporting periods beginning during
fiscal years 2001 through 2012, by 30 percent of such
amount otherwise allowable, and
(v) for cost reporting periods beginning during
fiscal year 2013 or a subsequent fiscal year, by 35
percent of such amount otherwise allowable.
(U) In determining the reasonable cost of ambulance services
(as described in subsection (s)(7)) provided during fiscal year
1998, during fiscal year 1999, and during so much of fiscal
year 2000 as precedes January 1, 2000, the Secretary shall not
recognize the costs per trip in excess of costs recognized as
reasonable for ambulance services provided on a per trip basis
during the previous fiscal year (after application of this
subparagraph), increased by the percentage increase in the
consumer price index for all urban consumers (U.S. city
average) as estimated by the Secretary for the 12-month period
ending with the midpoint of the fiscal year involved reduced by
1.0 percentage point. For ambulance services provided after
June 30, 1998, the Secretary may provide that claims for such
services must include a code (or codes) under a uniform coding
system specified by the Secretary that identifies the services
furnished.
(V) In determining such reasonable costs for skilled nursing
facilities and (beginning with respect to cost reporting
periods beginning during fiscal year 2013) for covered skilled
nursing services described in section 1888(e)(2)(A) furnished
by hospital providers of extended care services (as described
in section 1883), the amount of bad debts otherwise treated as
allowed costs which are attributable to the coinsurance amounts
under this title for individuals who are entitled to benefits
under part A and--
(i) are not described in section 1935(c)(6)(A)(ii)
shall be reduced by--
(I) for cost reporting periods beginning on or after
October 1, 2005, but before fiscal year 2013, 30
percent of such amount otherwise allowable; and
(II) for cost reporting periods beginning during
fiscal year 2013 or a subsequent fiscal year, by 35
percent of such amount otherwise allowable.
(ii) are described in such section--
(I) for cost reporting periods beginning on or after
October 1, 2005, but before fiscal year 2013, shall not
be reduced;
(II) for cost reporting periods beginning during
fiscal year 2013, shall be reduced by 12 percent of
such amount otherwise allowable;
(III) for cost reporting periods beginning during
fiscal year 2014, shall be reduced by 24 percent of
such amount otherwise allowable; and
(IV) for cost reporting periods beginning during a
subsequent fiscal year, shall be reduced by 35 percent
of such amount otherwise allowable.
(W)(i) In determining such reasonable costs for providers
described in clause (ii), the amount of bad debts otherwise
treated as allowable costs which are attributable to
deductibles and coinsurance amounts under this title shall be
reduced--
(I) for cost reporting periods beginning during
fiscal year 2013, by 12 percent of such amount
otherwise allowable;
(II) for cost reporting periods beginning during
fiscal year 2014, by 24 percent of such amount
otherwise allowable; and
(III) for cost reporting periods beginning during a
subsequent fiscal year, by 35 percent of such amount
otherwise allowable.
(ii) A provider described in this clause is a provider of
services not described in subparagraph (T) or (V), a supplier,
or any other type of entity that receives payment for bad debts
under the authority under subparagraph (A).
(2)(A) If the bed and board furnished as part of inpatient
hospital services (including inpatient tuberculosis hospital
services and inpatient psychiatric hospital services) or post-
hospital extended care services is in accommodations more
expensive than semi-private accommodations, the amount taken
into account for purposes of payment under this title with
respect to such services may not exceed the amount that would
be taken into account with respect to such services if
furnished in such semi-private accommodations unless the more
expensive accommodations were required for medical reasons.
(B) Where a provider of services which has an agreement in
effect under this title furnishes to an individual items or
services which are in excess of or more expensive than the
items or services with respect to which payment may be made
under part A or part B, as the case may be, the Secretary shall
take into account for purposes of payment to such provider of
services only the items or services with respect to which such
payment may be made.
(3) If the bed and board furnished as part of inpatient
hospital services (including inpatient tuberculosis hospital
services and inpatient psychiatric hospital services) or post-
hospital extended care services is in accommodations other
than, but not more expensive than, semi-private accommodations
and the use of such other accommodations rather than semi-
private accommodations was neither at the request of the
patient nor for a reason which the Secretary determines is
consistent with the purposes of this title, the amount of the
payment with respect to such bed and board under part A shall
be the amount otherwise payable under this title for such bed
and board furnished in semi-private accommodations minus the
difference between the charge customarily made by the hospital
or skilled nursing facility for bed and board in semi-private
accommodations and the charge customarily made by it for bed
and board in the accommodations furnished.
(4) If a provider of services furnishes items or services to
an individual which are in excess of or more expensive than the
items or services determined to be necessary in the efficient
delivery of needed health services and charges are imposed for
such more expensive items or services under the authority
granted in section 1866(a)(2)(B)(ii), the amount of payment
with respect to such items or services otherwise due such
provider in any fiscal period shall be reduced to the extent
that such payment plus such charges exceed the cost actually
incurred for such items or services in the fiscal period in
which such charges are imposed.
(5)(A) Where physical therapy services, occupational therapy
services, speech therapy services, or other therapy services or
services of other health-related personnel (other than
physicians) are furnished under an arrangement with a provider
of services or other organization, specified in the first
sentence of subsection (p) (including through the operation of
subsection (g)) the amount included in any payment to such
provider or other organization under this title as the
reasonable cost of such services (as furnished under such
arrangements) shall not exceed an amount equal to the salary
which would reasonably have been paid for such services
(together with any additional costs that would have been
incurred by the provider or other organization) to the person
performing them if they had been performed in an employment
relationship with such provider or other organization (rather
than under such arrangement) plus the cost of such other
expenses (including a reasonable allowance for traveltime and
other reasonable types of expense related to any differences in
acceptable methods of organization for the provision of such
therapy) incurred by such person, as the Secretary may in
regulations determine to be appropriate.
(B) Notwithstanding the provisions of subparagraph (A), if a
provider of services or other organization specified in the
first sentence of section 1861(p) requires the services of a
therapist on a limited part-time basis, or only to perform
intermittent services, the Secretary may make payment on the
basis of a reasonable rate per unit of service, even though
such rate is greater per unit of time than salary related
amounts, where he finds that such greater payment is, in the
aggregate, less than the amount that would have been paid if
such organization had employed a therapist on a full- or part-
time salary basis.
(6) For purposes of this subsection, the term ``semi-private
accommodations'' means two-bed, three-bed, or four-bed
accommodations.
(7)(A) For limitation on Federal participation for capital
expenditures which are out of conformity with a comprehensive
plan of a State or areawide planning agency, see section 1122.
(B) For further limitations on reasonable cost and
determination of payment amounts for operating costs of
inpatient hospital services and waivers for certain States, see
section 1886.
(C) For provisions restricting payment for provider-based
physicians' services and for payments under certain percentage
arrangements, see section 1887.
(D) For further limitations on reasonable cost and
determination of payment amounts for routine service costs of
skilled nursing facilities, see subsections (a) through (c) of
section 1888.
(8) Items unrelated to patient care.--Reasonable costs do not
include costs for the following--
(i) entertainment, including tickets to sporting and
other entertainment events;
(ii) gifts or donations;
(iii) personal use of motor vehicles;
(iv) costs for fines and penalties resulting from
violations of Federal, State, or local laws; and
(v) education expenses for spouses or other
dependents of providers of services, their employees or
contractors.
Arrangements for Certain Services
(w)(1) The term ``arrangements'' is limited to arrangements
under which receipt of payment by the hospital, critical access
hospital, skilled nursing facility, home health agency, or
hospice program (whether in its own right or as agent), with
respect to services for which an individual is entitled to have
payment made under this title, discharges the liability of such
individual or any other person to pay for the services.
(2) Utilization review activities conducted, in accordance
with the requirements of the program established under part B
of title XI of the Social Security Act with respect to services
furnished by a hospital or critical access hospital to patients
insured under part A of this title or entitled to have payment
made for such services under part B of this title or under a
State plan approved under title XIX, by a quality improvement
organization designated for the area in which such hospital or
critical access hospital is located shall be deemed to have
been conducted pursuant to arrangements between such hospital
or critical access hospital and such organization under which
such hospital or critical access hospital is obligated to pay
to such organization, as a condition of receiving payment for
hospital or critical access hospital services so furnished
under this part or under such a State plan, such amount as is
reasonably incurred and requested (as determined under
regulations of the Secretary) by such organization in
conducting such review activities with respect to services
furnished by such hospital or critical access hospital to such
patients.
State and United States
(x) The terms ``State'' and ``United States'' have the
meaning given to them by subsections (h) and (i), respectively,
of section 210.
Extended Care in Religious Nonmedical Health Care Institutions
(y)(1) The term ``skilled nursing facility'' also includes a
religious nonmedical health care institution (as defined in
subsection (ss)(1)), but only (except for purposes of
subsection (a)(2)) with respect to items and services
ordinarily furnished by such an institution to inpatients, and
payment may be made with respect to services provided by or in
such an institution only to such extent and under such
conditions, limitations, and requirements (in addition to or in
lieu of the conditions, limitations, and requirements otherwise
applicable) as may be provided in regulations consistent with
section 1821.
(2) Notwithstanding any other provision of this title,
payment under part A may not be made for services furnished an
individual in a skilled nursing facility to which paragraph (1)
applies unless such individual elects, in accordance with
regulations, for a spell of illness to have such services
treated as post-hospital extended care services for purposes of
such part; and payment under part A may not be made for post-
hospital extended care services--
(A) furnished an individual during such spell of
illness in a skilled nursing facility to which
paragraph (1) applies after--
(i) such services have been furnished to him
in such a facility for 30 days during such
spell, or
(ii) such services have been furnished to him
during such spell in a skilled nursing facility
to which such paragraph does not apply; or
(B) furnished an individual during such spell of
illness in a skilled nursing facility to which
paragraph (1) does not apply after such services have
been furnished to him during such spell in a skilled
nursing facility to which such paragraph applies.
(3) The amount payable under part A for post-hospital
extended care services furnished an individual during any spell
of illness in a skilled nursing facility to which paragraph (1)
applies shall be reduced by a coinsurance amount equal to one-
eighth of the inpatient hospital deductible for each day before
the 31st day on which he is furnished such services in such a
facility during such spell (and the reduction under this
paragraph shall be in lieu of any reduction under section
1813(a)(3)).
(4) For purposes of subsection (i), the determination of
whether services furnished by or in an institution described in
paragraph (1) constitute post-hospital extended care services
shall be made in accordance with and subject to such
conditions, limitations, and requirements as may be provided in
regulations.
Institutional Planning
(z) An overall plan and budget of a hospital, skilled nursing
facility, comprehensive outpatient rehabilitation facility, or
home health agency shall be considered sufficient if it--
(1) provides for an annual operating budget which
includes all anticipated income and expenses related to
items which would, under generally accepted accounting
principles, be considered income and expense items
(except that nothing in this paragraph shall require
that there be prepared, in connection with any budget,
an item-by-item identification of the components of
each type of anticipated expenditure or income);
(2)(A) provides for a capital expenditures plan for
at least a 3-year period (including the year to which
the operating budget described in paragraph (1) is
applicable) which includes and identifies in detail the
anticipated sources of financing for, and the
objectives of, each anticipated expenditure in excess
of $600,000 (or such lesser amount as may be
established by the State under section 1122(g)(1) in
which the hospital is located) related to the
acquisition of land, the improvement of land,
buildings, and equipment, and the replacement,
modernization, and expansion of the buildings and
equipment which would, under generally accepted
accounting principles, be considered capital items;
(B) provides that such plan is submitted to the
agency designated under section 1122(b), or if no such
agency is designated, to the appropriate health
planning agency in the State (but this subparagraph
shall not apply in the case of a facility exempt from
review under section 1122 by reason of section
1122(j));
(3) provides for review and updating at least
annually; and
(4) is prepared, under the direction of the governing
body of the institution or agency, by a committee
consisting of representatives of the governing body,
the administrative staff, and the medical staff (if
any) of the institution or agency.
Rural Health Clinic Services and Federally Qualified Health Center
Services
(aa)(1) The term ``rural health clinic services'' means --
(A) physicians' services and such services and
supplies as are covered under section 1861(s)(2)(A) if
furnished as an incident to a physician's professional
service and items and services described in section
1861(s)(10),
(B) such services furnished by a physician assistant
or a nurse practitioner (as defined in paragraph (5)),
by a clinical psychologist (as defined by the
Secretary) or by a clinical social worker (as defined
in subsection (hh)(1)), and such services and supplies
furnished as an incident to his service as would
otherwise be covered if furnished by a physician or as
an incident to a physician's service, and
(C) in the case of a rural health clinic located in
an area in which there exists a shortage of home health
agencies, part-time or intermittent nursing care and
related medical supplies (other than drugs and
biologicals) furnished by a registered professional
nurse or licensed practical nurse to a homebound
individual under a written plan of treatment (i)
established and periodically reviewed by a physician
described in paragraph (2)(B), or (ii) established by a
nurse practitioner or physician assistant and
periodically reviewed and approved by a physician
described in paragraph (2)(B),
when furnished to an individual as an outpatient of a rural
health clinic.
(2) The term ``rural health clinic'' means a facility which
--
(A) is primarily engaged in furnishing to outpatients
services described in subparagraphs (A) and (B) of
paragraph (1);
(B) in the case of a facility which is not a
physician-directed clinic, has an arrangement
(consistent with the provisions of State and local law
relative to the practice, performance, and delivery of
health services) with one or more physicians (as
defined in subsection (r)(1)) under which provision is
made for the periodic review by such physicians of
covered services furnished by physician assistants and
nurse practitioners, the supervision and guidance by
such physicians of physician assistants and nurse
practitioners, the preparation by such physicians of
such medical orders for care and treatment of clinic
patients as may be necessary, and the availability of
such physicians for such referral of and consultation
for patients as is necessary and for advice and
assistance in the management of medical emergencies;
and, in the case of a physician-directed clinic, has
one or more of its staff physicians perform the
activities accomplished through such an arrangement;
(C) maintains clinical records on all patients;
(D) has arrangements with one or more hospitals,
having agreements in effect under section 1866, for the
referral and admission of patients requiring inpatient
services or such diagnostic or other specialized
services as are not available at the clinic;
(E) has written policies, which are developed with
the advice of (and with provision for review of such
policies from time to time by) a group of professional
personnel, including one or more physicians and one or
more physician assistants or nurse practitioners, to
govern those services described in paragraph (1) which
it furnishes;
(F) has a physician, physician assistant, or nurse
practitioner responsible for the execution of policies
described in subparagraph (E) and relating to the
provision of the clinic's services;
(G) directly provides routine diagnostic services,
including clinical laboratory services, as prescribed
in regulations by the Secretary, and has prompt access
to additional diagnostic services from facilities
meeting requirements under this title;
(H) in compliance with State and Federal law, has
available for administering to patients of the clinic
at least such drugs and biologicals as are determined
by the Secretary to be necessary for the treatment of
emergency cases (as defined in regulations) and has
appropriate procedures or arrangements for storing,
administering, and dispensing any drugs and
biologicals;
(I) has a quality assessment and performance
improvement program, and appropriate procedures for
review of utilization of clinic services, as the
Secretary may specify;
(J) has a nurse practitioner, a physician assistant,
or a certified nurse-midwife (as defined in subsection
(gg)) available to furnish patient care services not
less than 50 percent of the time the clinic operates;
and
(K) meets such other requirements as the Secretary
may find necessary in the interest of the health and
safety of the individuals who are furnished services by
the clinic.
For the purposes of this title, such term includes only a
facility which (i) is located in an area that is not an
urbanized area (as defined by the Bureau of the Census) and in
which there are insufficient numbers of needed health care
practitioners (as determined by the Secretary), and that,
within the previous 4-year period, has been designated by the
chief executive officer of the State and certified by the
Secretary as an area with a shortage of personal health
services or designated by the Secretary either (I) as an area
with a shortage of personal health services under section
330(b)(3) or 1302(7) of the Public Health Service Act, (II) as
a health professional shortage area described in section
332(a)(1)(A) of that Act because of its shortage of primary
medical care manpower, (III) as a high impact area described in
section 329(a)(5) of that Act, of (IV) as an area which
includes a population group which the Secretary determines has
a health manpower shortage under section 332(a)(1)(B) of that
Act, (ii) has filed an agreement with the Secretary by which it
agrees not to charge any individual or other person for items
or services for which such individual is entitled to have
payment made under this title, except for the amount of any
deductible or coinsurance amount imposed with respect to such
items or services (not in excess of the amount customarily
charged for such items and services by such clinic), pursuant
to subsections (a) and (b) of section 1833, (iii) employs a
physician assistant or nurse practitioner, and (iv) is not a
rehabilitation agency or a facility which is primarily for the
care and treatment of mental diseases. A facility that is in
operation and qualifies as a rural health clinic under this
title or title XIX and that subsequently fails to satisfy the
requirement of clause (i) shall be considered, for purposes of
this title and title XIX, as still satisfying the requirement
of such clause if it is determined, in accordance with criteria
established by the Secretary in regulations, to be essential to
the delivery of primary care services that would otherwise be
unavailable in the geographic area served by the clinic. If a
State agency has determined under section 1864(a) that a
facility is a rural health clinic and the facility has applied
to the Secretary for approval as such a clinic, the Secretary
shall notify the facility of the Secretary's approval or
disapproval not later than 60 days after the date of the State
agency determination or the application (whichever is later).
(3) The term ``Federally qualified health center services''
means--
(A) services of the type described in subparagraphs
(A) through (C) of paragraph (1) and preventive
services (as defined in section 1861(ddd)(3)); and
(B) preventive primary health services that a center
is required to provide under section 330 of the Public
Health Service Act,
when furnished to an individual as an outpatient of a Federally
qualified health center by the center or by a health care
professional under contract with the center and, for this
purpose, any reference to a rural health clinic or a physician
described in paragraph (2)(B) is deemed a reference to a
Federally qualified health center or a physician at the center,
respectively.
(4) The term ``Federally qualified health center'' means an
entity which--
(A)(i) is receiving a grant under section 330 of the
Public Health Service Act, or
(ii)(I) is receiving funding from such a grant under
a contract with the recipient of such a grant, and (II)
meets the requirements to receive a grant under section
330 of such Act;
(B) based on the recommendation of the Health
Resources and Services Administration within the Public
Health Service, is determined by the Secretary to meet
the requirements for receiving such a grant;
(C) was treated by the Secretary, for purposes of
part B, as a comprehensive Federally funded health
center as of January 1, 1990; or
(D) is an outpatient health program or facility
operated by a tribe or tribal organization under the
Indian Self-Determination Act or by an urban Indian
organization receiving funds under title V of the
Indian Health Care Improvement Act.
(5)(A) The term ``physician assistant'' and the term ``nurse
practitioner'' mean, for purposes of this title, a physician
assistant or nurse practitioner who performs such services as
such individual is legally authorized to perform (in the State
in which the individual performs such services) in accordance
with State law (or the State regulatory mechanism provided by
State law), and who meets such training, education, and
experience requirements (or any combination thereof) as the
Secretary may prescribe in regulations.
(B) The term ``clinical nurse specialist'' means, for
purposes of this title, an individual who--
(i) is a registered nurse and is licensed to practice
nursing in the State in which the clinical nurse
specialist services are performed; and
(ii) holds a master's degree in a defined clinical
area of nursing from an accredited educational
institution.
(6) The term ``collaboration'' means a process in which a
nurse practitioner works with a physician to deliver health
care services within the scope of the practitioner's
professional expertise, with medical direction and appropriate
supervision as provided for in jointly developed guidelines or
other mechanisms as defined by the law of the State in which
the services are performed.
(7)(A) The Secretary shall waive for a 1-year period the
requirements of paragraph (2) that a rural health clinic employ
a physician assistant, nurse practitioner or certified nurse
midwife or that such clinic require such providers to furnish
services at least 50 percent of the time that the clinic
operates for any facility that requests such waiver if the
facility demonstrates that the facility has been unable,
despite reasonable efforts, to hire a physician assistant,
nurse practitioner, or certified nurse-midwife in the previous
90-day period.
(B) The Secretary may not grant such a waiver under
subparagraph (A) to a facility if the request for the waiver is
made less than 6 months after the date of the expiration of any
previous such waiver for the facility, or if the facility has
not yet been determined to meet the requirements (including
subparagraph (J) of the first sentence of paragraph (2)) of a
rural health clinic.
(C) A waiver which is requested under this paragraph shall be
deemed granted unless such request is denied by the Secretary
within 60 days after the date such request is received.
Services of a Certified Registered Nurse Anesthetist
(bb)(1) The term ``services of a certified registered nurse
anesthetist'' means anesthesia services and related care
furnished by a certified registered nurse anesthetist (as
defined in paragraph (2)) which the nurse anesthetist is
legally authorized to perform as such by the State in which the
services are furnished.
(2) The term ``certified registered nurse anesthetist'' means
a certified registered nurse anesthetist licensed by the State
who meets such education, training, and other requirements
relating to anesthesia services and related care as the
Secretary may prescribe. In prescribing such requirements the
Secretary may use the same requirements as those established by
a national organization for the certification of nurse
anesthetists. Such term also includes, as prescribed by the
Secretary, an anesthesiologist assistant.
Comprehensive Outpatient Rehabilitation Facility Services
(cc)(1) The term ``comprehensive outpatient rehabilitation
facility services'' means the following items and services
furnished by a physician or other qualified professional
personnel (as defined in regulations by the Secretary) to an
individual who is an outpatient of a comprehensive outpatient
rehabilitation facility under a plan (for furnishing such items
and services to such individual) established and periodically
reviewed by a physician--
(A) physicians' services;
(B) physical therapy, occupational therapy, speech-
language pathology services, and respiratory therapy;
(C) prosthetic and orthotic devices, including
testing, fitting, or training in the use of prosthetic
and orthotic devices;
(D) social and psychological services;
(E) nursing care provided by or under the supervision
of a registered professional nurse;
(F) drugs and biologicals which cannot, as determined
in accordance with regulations, be self-administered;
(G) supplies and durable medical equipment; and
(H) such other items and services as are medically
necessary for the rehabilitation of the patient and are
ordinarily furnished by comprehensive outpatient
rehabilitation facilities,
excluding, however, any item or service if it would not be
included under subsection (b) if furnished to an inpatient of a
hospital. In the case of physical therapy, occupational
therapy, and speech pathology services, there shall be no
requirement that the item or service be furnished at any single
fixed location if the item or service is furnished pursuant to
such plan and payments are not otherwise made for the item or
service under this title.
(2) The term ``comprehensive outpatient rehabilitation
facility'' means a facility which--
(A) is primarily engaged in providing (by or under
the supervision of physicians) diagnostic, therapeutic,
and restorative services to outpatients for the
rehabilitation of injured, disabled, or sick persons;
(B) provides at least the following comprehensive
outpatient rehabilitation services: (i) physicians'
services (rendered by physicians, as defined in section
1861(r)(1), who are available at the facility on a
full- or part-time basis); (ii) physical therapy; and
(iii) social or psychological services;
(C) maintains clinical records on all patients;
(D) has policies established by a group of
professional personnel (associated with the facility),
including one or more physicians defined in subsection
(r)(1) to govern the comprehensive outpatient
rehabilitation services it furnishes, and provides for
the carrying out of such policies by a full- or part-
time physician referred to in subparagraph (B)(i);
(E) has a requirement that every patient must be
under the care of a physician;
(F) in the case of a facility in any State in which
State or applicable local law provides for the
licensing of facilities of this nature (i) is licensed
pursuant to such law, or (ii) is approved by the agency
of such State or locality, responsible for licensing
facilities of this nature, as meeting the standards
established for such licensing;
(G) has in effect a utilization review plan in
accordance with regulations prescribed by the
Secretary;
(H) has in effect an overall plan and budget that
meets the requirements of subsection (z);
(I) provides the Secretary on a continuing basis with
a surety bond in a form specified by the Secretary and
in an amount that is not less than $50,000; and
(J) meets such other conditions of participation as
the Secretary may find necessary in the interest of the
health and safety of individuals who are furnished
services by such facility, including conditions
concerning qualifications of personnel in these
facilities.
The Secretary may waive the requirement of a surety bond under
subparagraph (I) in the case of a facility that provides a
comparable surety bond under State law.
Hospice Care; Hospice Program
(dd)(1) The term ``hospice care'' means the following items
and services provided to a terminally ill individual by, or by
others under arrangements made by, a hospice program under a
written plan (for providing such care to such individual)
established and periodically reviewed by the individual's
attending physician and by the medical director (and by the
interdisciplinary group described in paragraph (2)(B)) of the
program--
(A) nursing care provided by or under the supervision
of a registered professional nurse,
(B) physical or occupational therapy, or speech-
language pathology services,
(C) medical social services under the direction of a
physician,
(D)(i) services of a home health aide who has
successfully completed a training program approved by
the Secretary and (ii) homemaker services,
(E) medical supplies (including drugs and
biologicals) and the use of medical appliances, while
under such a plan,
(F) physicians' services,
(G) short-term inpatient care (including both respite
care and procedures necessary for pain control and
acute and chronic symptom management) in an inpatient
facility meeting such conditions as the Secretary
determines to be appropriate to provide such care, but
such respite care may be provided only on an
intermittent, nonroutine, and occasional basis and may
not be provided consecutively over longer than five
days,
(H) counseling (including dietary counseling) with
respect to care of the terminally ill individual and
adjustment to his death, and
(I) any other item or service which is specified in
the plan and for which payment may otherwise be made
under this title.
The care and services described in subparagraphs (A) and (D)
may be provided on a 24-hour, continuous basis only during
periods of crisis (meeting criteria established by the
Secretary) and only as necessary to maintain the terminally ill
individual at home.
(2) The term ``hospice program'' means a public agency or
private organization (or a subdivision thereof) which--
(A)(i) is primarily engaged in providing the care and
services described in paragraph (1) and makes such
services available (as needed) on a 24-hour basis and
which also provides bereavement counseling for the
immediate family of terminally ill individuals and
services described in section 1812(a)(5),
(ii) provides for such care and services in
individuals' homes, on an outpatient basis, and on a
short-term inpatient basis, directly or under
arrangements made by the agency or organization, except
that--
(I) the agency or organization must routinely
provide directly substantially all of each of
the services described in subparagraphs (A),
(C), and (H) of paragraph (1), except as
otherwise provided in paragraph (5), and
(II) in the case of other services described
in paragraph (1) which are not provided
directly by the agency or organization, the
agency or organization must maintain
professional management responsibility for all
such services furnished to an individual,
regardless of the location or facility in which
such services are furnished; and
(iii) provides assurances satisfactory to the
Secretary that the aggregate number of days of
inpatient care described in paragraph (1)(G) provided
in any 12-month period to individuals who have an
election in effect under section 1812(d) with respect
to that agency or organization does not exceed 20
percent of the aggregate number of days during that
period on which such elections for such individuals are
in effect;
(B) has an interdisciplinary group of personnel
which--
(i) includes at least--
(I) one physician (as defined in
subsection (r)(1)),
(II) one registered professional
nurse, and
(III) one social worker,
employed by or, in the case of a physician described in
subclause (I), under contract with the agency or
organization, and also includes at least one pastoral
or other counselor,
(ii) provides (or supervises the provision
of) the care and services described in
paragraph (1), and
(iii) establishes the policies governing the
provision of such care and services;
(C) maintains central clinical records on all
patients;
(D) does not discontinue the hospice care it provides
with respect to a patient because of the inability of
the patient to pay for such care;
(E)(i) utilizes volunteers in its provision of care
and services in accordance with standards set by the
Secretary, which standards shall ensure a continuing
level of effort to utilize such volunteers, and (ii)
maintains records on the use of these volunteers and
the cost savings and expansion of care and services
achieved through the use of these volunteers;
(F) in the case of an agency or organization in any
State in which State or applicable local law provides
for the licensing of agencies or organizations of this
nature, is licensed pursuant to such law; and
(G) meets such other requirements as the Secretary
may find necessary in the interest of the health and
safety of the individuals who are provided care and
services by such agency or organization.
(3)(A) An individual is considered to be ``terminally ill''
if the individual has a medical prognosis that the individual's
life expectancy is 6 months or less.
(B) The term ``attending physician'' means, with respect to
an individual, the physician (as defined in subsection (r)(1)),
the nurse practitioner (as defined in subsection (aa)(5)), or
the physician assistant (as defined in such subsection), who
may be employed by a hospice program, whom the individual
identifies as having the most significant role in the
determination and delivery of medical care to the individual at
the time the individual makes an election to receive hospice
care.
(4)(A) An entity which is certified as a provider of services
other than a hospice program shall be considered, for purposes
of certification as a hospice program, to have met any
requirements under paragraph (2) which are also the same
requirements for certification as such other type of provider.
The Secretary shall coordinate surveys for determining
certification under this title so as to provide, to the extent
feasible, for simultaneous surveys of an entity which seeks to
be certified as a hospice program and as a provider of services
of another type.
(B) Any entity which is certified as a hospice program and as
a provider of another type shall have separate provider
agreements under section 1866 and shall file separate cost
reports with respect to costs incurred in providing hospice
care and in providing other services and items under this
title.
(C) Any entity that is certified as a hospice program shall
be subject to a standard survey by an appropriate State or
local survey agency, or an approved accreditation agency, as
determined by the Secretary, not less frequently than once
every 36 months beginning 6 months after the date of the
enactment of this subparagraph and ending September 30, 2025.
(5)(A) The Secretary may waive the requirements of paragraph
(2)(A)(ii)(I) for an agency or organization with respect to all
or part of the nursing care described in paragraph (1)(A) if
such agency or organization--
(i) is located in an area which is not an urbanized
area (as defined by the Bureau of the Census);
(ii) was in operation on or before January 1, 1983;
and
(iii) has demonstrated a good faith effort (as
determined by the Secretary) to hire a sufficient
number of nurses to provide such nursing care directly.
(B) Any waiver, which is in such form and containing such
information as the Secretary may require and which is requested
by an agency or organization under subparagraph (A) or (C),
shall be deemed to be granted unless such request is denied by
the Secretary within 60 days after the date such request is
received by the Secretary. The granting of a waiver under
subparagraph (A) or (C) shall not preclude the granting of any
subsequent waiver request should such a waiver again become
necessary.
(C) The Secretary may waive the requirements of paragraph
(2)(A)(i) and (2)(A)(ii) for an agency or organization with
respect to the services described in paragraph (1)(B) and, with
respect to dietary counseling, paragraph (1)(H), if such agency
or organization--
(i) is located in an area which is not an urbanized
area (as defined by the Bureau of Census), and
(ii) demonstrates to the satisfaction of the
Secretary that the agency or organization has been
unable, despite diligent efforts, to recruit
appropriate personnel.
(D) In extraordinary, exigent, or other non-routine
circumstances, such as unanticipated periods of high patient
loads, staffing shortages due to illness or other events, or
temporary travel of a patient outside a hospice program's
service area, a hospice program may enter into arrangements
with another hospice program for the provision by that other
program of services described in paragraph (2)(A)(ii)(I). The
provisions of paragraph (2)(A)(ii)(II) shall apply with respect
to the services provided under such arrangements.
(E) A hospice program may provide services described in
paragraph (1)(A) other than directly by the program if the
services are highly specialized services of a registered
professional nurse and are provided non-routinely and so
infrequently so that the provision of such services directly
would be impracticable and prohibitively expensive.
Discharge Planning Process
(ee)(1) A discharge planning process of a hospital shall be
considered sufficient if it is applicable to services furnished
by the hospital to individuals entitled to benefits under this
title and if it meets the guidelines and standards established
by the Secretary under paragraph (2).
(2) The Secretary shall develop guidelines and standards for
the discharge planning process in order to ensure a timely and
smooth transition to the most appropriate type of and setting
for post-hospital or rehabilitative care. The guidelines and
standards shall include the following:
(A) The hospital must identify, at an early stage of
hospitalization, those patients who are likely to
suffer adverse health consequences upon discharge in
the absence of adequate discharge planning.
(B) Hospitals must provide a discharge planning
evaluation for patients identified under subparagraph
(A) and for other patients upon the request of the
patient, patient's representative, or patient's
physician.
(C) Any discharge planning evaluation must be made on
a timely basis to ensure that appropriate arrangements
for post-hospital care will be made before discharge
and to avoid unnecessary delays in discharge.
(D) A discharge planning evaluation must include an
evaluation of a patient's likely need for appropriate
post-hospital services, including hospice care and
post-hospital extended care services, and the
availability of those services, including the
availability of home health services through
individuals and entities that participate in the
program under this title and that serve the area in
which the patient resides and that request to be listed
by the hospital as available and, in the case of
individuals who are likely to need post-hospital
extended care services, the availability of such
services through facilities that participate in the
program under this title and that serve the area in
which the patient resides.
(E) The discharge planning evaluation must be
included in the patient's medical record for use in
establishing an appropriate discharge plan and the
results of the evaluation must be discussed with the
patient (or the patient's representative).
(F) Upon the request of a patient's physician, the
hospital must arrange for the development and initial
implementation of a discharge plan for the patient.
(G) Any discharge planning evaluation or discharge
plan required under this paragraph must be developed
by, or under the supervision of, a registered
professional nurse, social worker, or other
appropriately qualified personnel.
(H) Consistent with section 1802, the discharge plan
shall--
(i) not specify or otherwise limit the
qualified provider which may provide post-
hospital home health services, and
(ii) identify (in a form and manner specified
by the Secretary) any entity to whom the
individual is referred in which the hospital
has a disclosable financial interest (as
specified by the Secretary consistent with
section 1866(a)(1)(S)) or which has such an
interest in the hospital.
(3) With respect to a discharge plan for an individual who is
enrolled with a Medicare+Choice organization under a
Medicare+Choice plan and is furnished inpatient hospital
services by a hospital under a contract with the organization--
(A) the discharge planning evaluation under paragraph
(2)(D) is not required to include information on the
availability of home health services through
individuals and entities which do not have a contract
with the organization; and
(B) notwithstanding subparagraph (H)(i), the plan may
specify or limit the provider (or providers) of post-
hospital home health services or other post-hospital
services under the plan.
Partial Hospitalization Services
(ff)(1) The term ``partial hospitalization services'' means
the items and services described in paragraph (2) prescribed by
a physician and provided under a program described in paragraph
(3) under the supervision of a physician pursuant to an
individualized, written plan of treatment established and
periodically reviewed by a physician (in consultation with
appropriate staff participating in such program), which plan
sets forth the physician's diagnosis, the type, amount,
frequency, and duration of the items and services provided
under the plan, and the goals for treatment under the plan.
(2) The items and services described in this paragraph are--
(A) individual and group therapy with physicians or
psychologists (or other mental health professionals to
the extent authorized under State law),
(B) occupational therapy requiring the skills of a
qualified occupational therapist,
(C) services of social workers, trained psychiatric
nurses, and other staff trained to work with
psychiatric patients,
(D) drugs and biologicals furnished for therapeutic
purposes (which cannot, as determined in accordance
with regulations, be self-administered),
(E) individualized activity therapies that are not
primarily recreational or diversionary,
(F) family counseling (the primary purpose of which
is treatment of the individual's condition),
(G) patient training and education (to the extent
that training and educational activities are closely
and clearly related to individual's care and
treatment),
(H) diagnostic services, and
(I) such other items and services as the Secretary
may provide (but in no event to include meals and
transportation);
that are reasonable and necessary for the diagnosis or active
treatment of the individual's condition, reasonably expected to
improve or maintain the individual's condition and functional
level and to prevent relapse or hospitalization, and furnished
pursuant to such guidelines relating to frequency and duration
of services as the Secretary shall by regulation establish
(taking into account accepted norms of medical practice and the
reasonable expectation of patient improvement).
(3)(A) A program described in this paragraph is a program
which is furnished by a hospital to its outpatients or by a
community mental health center (as defined in subparagraph
(B)), and which is a distinct and organized intensive
ambulatory treatment service offering less than 24-hour-daily
care other than in an individual's home or in an inpatient or
residential setting.
(B) For purposes of subparagraph (A), the term ``community
mental health center'' means an entity that--
(i)(I) provides the mental health services described
in section 1913(c)(1) of the Public Health Service Act;
or
(II) in the case of an entity operating in a State
that by law precludes the entity from providing itself
the service described in subparagraph (E) of such
section, provides for such service by contract with an
approved organization or entity (as determined by the
Secretary);
(ii) meets applicable licensing or certification
requirements for community mental health centers in the
State in which it is located;
(iii) provides at least 40 percent of its services to
individuals who are not eligible for benefits under
this title; and
(iv) meets such additional conditions as the
Secretary shall specify to ensure (I) the health and
safety of individuals being furnished such services,
(II) the effective and efficient furnishing of such
services, and (III) the compliance of such entity with
the criteria described in section 1931(c)(1) of the
Public Health Service Act.
Certified Nurse-Midwife Services
(gg)(1) The term ``certified nurse-midwife services'' means
such services furnished by a certified nurse-midwife (as
defined in paragraph (2)) and such services and supplies
furnished as an incident to the nurse-midwife's service which
the certified nurse-midwife is legally authorized to perform
under State law (or the State regulatory mechanism provided by
State law) as would otherwise be covered if furnished by a
physician or as an incident to a physicians' service.
(2) The term ``certified nurse-midwife'' means a registered
nurse who has successfully completed a program of study and
clinical experience meeting guidelines prescribed by the
Secretary, or has been certified by an organization recognized
by the Secretary.
Clinical Social Worker; Clinical Social Worker Services
(hh)(1) The term ``clinical social worker'' means an
individual who--
(A) possesses a master's or doctor's degree in social
work;
(B) after obtaining such degree has performed at
least 2 years of supervised clinical social work; and
(C)(i) is licensed or certified as a clinical social
worker by the State in which the services are
performed, or
(ii) in the case of an individual in a State which
does not provide for licensure or certification--
(I) has completed at least 2 years or 3,000
hours of post-master's degree supervised
clinical social work practice under the
supervision of a master's level social worker
in an appropriate setting (as determined by the
Secretary), and
(II) meets such other criteria as the
Secretary establishes.
(2) The term ``clinical social worker services'' means
services performed by a clinical social worker (as defined in
paragraph (1)) for the diagnosis and treatment of mental
illnesses (other than services furnished to an inpatient of a
hospital and other than services furnished to an inpatient of a
skilled nursing facility which the facility is required to
provide as a requirement for participation) which the clinical
social worker is legally authorized to perform under State law
(or the State regulatory mechanism provided by State law) of
the State in which such services are performed as would
otherwise be covered if furnished by a physician or as an
incident to a physician's professional service.
Qualified Psychologist Services
(ii) The term ``qualified psychologist services'' means such
services and such services and supplies furnished as an
incident to his service furnished by a clinical psychologist
(as defined by the Secretary) which the psychologist is legally
authorized to perform under State law (or the State regulatory
mechanism provided by State law) as would otherwise be covered
if furnished by a physician or as an incident to a physician's
service.
Screening Mammography
(jj) The term ``screening mammography'' means a radiologic
procedure provided to a woman for the purpose of early
detection of breast cancer and includes a physician's
interpretation of the results of the procedure.
Covered Osteoporosis Drug
(kk) The term ``covered osteoporosis drug'' means an
injectable drug approved for the treatment of post-menopausal
osteoporosis provided to an individual by a home health agency
if, in accordance with regulations promulgated by the
Secretary--
(1) the individual's attending physician certifies
that the individual has suffered a bone fracture
related to post-menopausal osteoporosis and that the
individual is unable to learn the skills needed to
self-administer such drug or is otherwise physically or
mentally incapable of self-administering such drug; and
(2) the individual is confined to the individual's
home (except when receiving items and services referred
to in subsection (m)(7)).
Speech-Language Pathology Services; Audiology Services
(ll)(1) The term ``speech-language pathology services'' means
such speech, language, and related function assessment and
rehabilitation services furnished by a qualified speech-
language pathologist as the speech-language pathologist is
legally authorized to perform under State law (or the State
regulatory mechanism provided by State law) as would otherwise
be covered if furnished by a physician.
(2) The term ``outpatient speech-language pathology
services'' has the meaning given the term ``outpatient physical
therapy services'' in subsection (p), except that in applying
such subsection--
(A) ``speech-language pathology'' shall be
substituted for ``physical therapy'' each place it
appears; and
(B) ``speech-language pathologist'' shall be
substituted for ``physical therapist'' each place it
appears.
(3) The term ``audiology services'' means such hearing and
balance assessment services furnished by a qualified
audiologist as the audiologist is legally authorized to perform
under State law (or the State regulatory mechanism provided by
State law), as would otherwise be covered if furnished by a
physician.
(4) In this subsection:
(A) The term ``qualified speech-language
pathologist'' means an individual with a master's or
doctoral degree in speech-language pathology who--
(i) is licensed as a speech-language
pathologist by the State in which the
individual furnishes such services, or
(ii) in the case of an individual who
furnishes services in a State which does not
license speech-language pathologists, has
successfully completed 350 clock hours of
supervised clinical practicum (or is in the
process of accumulating such supervised
clinical experience), performed not less than 9
months of supervised full-time speech-language
pathology services after obtaining a master's
or doctoral degree in speech-language pathology
or a related field, and successfully completed
a national examination in speech-language
pathology approved by the Secretary.
(B) The term ``qualified audiologist'' means an
individual with a master's or doctoral degree in
audiology who--
(i) is licensed as an audiologist by the
State in which the individual furnishes such
services, or
(ii) in the case of an individual who
furnishes services in a State which does not
license audiologists, has successfully
completed 350 clock hours of supervised
clinical practicum (or is in the process of
accumulating such supervised clinical
experience), performed not less than 9 months
of supervised full-time audiology services
after obtaining a master's or doctoral degree
in audiology or a related field, and
successfully completed a national examination
in audiology approved by the Secretary.
Critical Access Hospital; Critical Access Hospital Services
(mm)(1) The term ``critical access hospital'' means a
facility certified by the Secretary as a critical access
hospital under section 1820(e).
(2) The term ``inpatient critical access hospital services''
means items and services, furnished to an inpatient of a
critical access hospital by such facility, that would be
inpatient hospital services if furnished to an inpatient of a
hospital by a hospital.
(3) The term ``outpatient critical access hospital services''
means medical and other health services furnished by a critical
access hospital on an outpatient basis.
Screening Pap Smear; Screening Pelvic Exam
(nn)(1) The term ``screening pap smear'' means a diagnostic
laboratory test consisting of a routine exfoliative cytology
test (Papanicolaou test) provided to a woman for the purpose of
early detection of cervical or vaginal cancer and includes a
physician's interpretation of the results of the test, if the
individual involved has not had such a test during the
preceding 2 years, or during the preceding year in the case of
a woman described in paragraph (3).
(2) The term ``screening pelvic exam'' means a pelvic
examination provided to a woman if the woman involved has not
had such an examination during the preceding 2 years, or during
the preceding year in the case of a woman described in
paragraph (3), and includes a clinical breast examination.
(3) A woman described in this paragraph is a woman who--
(A) is of childbearing age and has had a test
described in this subsection during any of the
preceding 3 years that indicated the presence of
cervical or vaginal cancer or other abnormality; or
(B) is at high risk of developing cervical or vaginal
cancer (as determined pursuant to factors identified by
the Secretary).
Prostate Cancer Screening Tests
(oo)(1) The term ``prostate cancer screening test'' means a
test that consists of any (or all) of the procedures described
in paragraph (2) provided for the purpose of early detection of
prostate cancer to a man over 50 years of age who has not had
such a test during the preceding year.
(2) The procedures described in this paragraph are as
follows:
(A) A digital rectal examination.
(B) A prostate-specific antigen blood test.
(C) For years beginning after 2002, such other
procedures as the Secretary finds appropriate for the
purpose of early detection of prostate cancer, taking
into account changes in technology and standards of
medical practice, availability, effectiveness, costs,
and such other factors as the Secretary considers
appropriate.
Colorectal Cancer Screening Tests
(pp)(1) The term ``colorectal cancer screening test'' means
any of the following procedures furnished to an individual for
the purpose of early detection of colorectal cancer:
(A) Screening fecal-occult blood test.
(B) Screening flexible sigmoidoscopy.
(C) Screening colonoscopy.
(D) Such other tests or procedures, and modifications
to tests and procedures under this subsection, with
such frequency and payment limits, as the Secretary
determines appropriate, in consultation with
appropriate organizations.
(2) An ``individual at high risk for colorectal cancer'' is
an individual who, because of family history, prior experience
of cancer or precursor neoplastic polyps, a history of chronic
digestive disease condition (including inflammatory bowel
disease, Crohn's Disease, or ulcerative colitis), the presence
of any appropriate recognized gene markers for colorectal
cancer, or other predisposing factors, faces a high risk for
colorectal cancer.
Diabetes Outpatient Self-Management Training Services
(qq)(1) The term ``diabetes outpatient self-management
training services'' means educational and training services
furnished (at such times as the Secretary determines
appropriate) to an individual with diabetes by a certified
provider (as described in paragraph (2)(A)) in an outpatient
setting by an individual or entity who meets the quality
standards described in paragraph (2)(B), but only if the
physician who is managing the individual's diabetic condition
certifies that such services are needed under a comprehensive
plan of care related to the individual's diabetic condition to
ensure therapy compliance or to provide the individual with
necessary skills and knowledge (including skills related to the
self-administration of injectable drugs) to participate in the
management of the individual's condition.
(2) In paragraph (1)--
(A) a ``certified provider'' is a physician, or other
individual or entity designated by the Secretary, that,
in addition to providing diabetes outpatient self-
management training services, provides other items or
services for which payment may be made under this
title; and
(B) a physician, or such other individual or entity,
meets the quality standards described in this paragraph
if the physician, or individual or entity, meets
quality standards established by the Secretary, except
that the physician or other individual or entity shall
be deemed to have met such standards if the physician
or other individual or entity meets applicable
standards originally established by the National
Diabetes Advisory Board and subsequently revised by
organizations who participated in the establishment of
standards by such Board, or is recognized by an
organization that represents individuals (including
individuals under this title) with diabetes as meeting
standards for furnishing the services.
Bone Mass Measurement
(rr)(1) The term ``bone mass measurement'' means a radiologic
or radioisotopic procedure or other procedure approved by the
Food and Drug Administration performed on a qualified
individual (as defined in paragraph (2)) for the purpose of
identifying bone mass or detecting bone loss or determining
bone quality, and includes a physician's interpretation of the
results of the procedure.
(2) For purposes of this subsection, the term ``qualified
individual'' means an individual who is (in accordance with
regulations prescribed by the Secretary)--
(A) an estrogen-deficient woman at clinical risk for
osteoporosis;
(B) an individual with vertebral abnormalities;
(C) an individual receiving long-term glucocorticoid
steroid therapy;
(D) an individual with primary hyperparathyroidism;
or
(E) an individual being monitored to assess the
response to or efficacy of an approved osteoporosis
drug therapy.
(3) The Secretary shall establish such standards regarding
the frequency with which a qualified individual shall be
eligible to be provided benefits for bone mass measurement
under this title.
Religious Nonmedical Health Care Institution
(ss)(1) The term ``religious nonmedical health care
institution'' means an institution that--
(A) is described in subsection (c)(3) of
section 501 of the Internal Revenue Code of
1986 and is exempt from taxes under subsection
(a) of such section;
(B) is lawfully operated under all applicable
Federal, State, and local laws and regulations;
(C) provides only nonmedical nursing items
and services exclusively to patients who choose
to rely solely upon a religious method of
healing and for whom the acceptance of medical
health services would be inconsistent with
their religious beliefs;
(D) provides such nonmedical items and
services exclusively through nonmedical nursing
personnel who are experienced in caring for the
physical needs of such patients;
(E) provides such nonmedical items and
services to inpatients on a 24-hour basis;
(F) on the basis of its religious beliefs,
does not provide through its personnel or
otherwise medical items and services (including
any medical screening, examination, diagnosis,
prognosis, treatment, or the administration of
drugs) for its patients;
(G)(i) is not owned by, under common
ownership with, or has an ownership interest
in, a provider of medical treatment or
services;
(ii) is not affiliated with--
(I) a provider of medical treatment
or services, or
(II) an individual who has an
ownership interest in a provider of
medical treatment or services;
(H) has in effect a utilization review plan
which--
(i) provides for the review of
admissions to the institution, of the
duration of stays therein, of cases of
continuous extended duration, and of
the items and services furnished by the
institution,
(ii) requires that such reviews be
made by an appropriate committee of the
institution that includes the
individuals responsible for overall
administration and for supervision of
nursing personnel at the institution,
(iii) provides that records be
maintained of the meetings, decisions,
and actions of such committee, and
(iv) meets such other requirements as
the Secretary finds necessary to
establish an effective utilization
review plan;
(I) provides the Secretary with such
information as the Secretary may require to
implement section 1821, including information
relating to quality of care and coverage
determinations; and
(J) meets such other requirements as the
Secretary finds necessary in the interest of
the health and safety of individuals who are
furnished services in the institution.
(2) To the extent that the Secretary finds that the
accreditation of an institution by a State, regional, or
national agency or association provides reasonable assurances
that any or all of the requirements of paragraph (1) are met or
exceeded, the Secretary may treat such institution as meeting
the condition or conditions with respect to which the Secretary
made such finding.
(3)(A)(i) In administering this subsection and section 1821,
the Secretary shall not require any patient of a religious
nonmedical health care institution to undergo medical
screening, examination, diagnosis, prognosis, or treatment or
to accept any other medical health care service, if such
patient (or legal representative of the patient) objects
thereto on religious grounds.
(ii) Clause (i) shall not be construed as preventing the
Secretary from requiring under section 1821(a)(2) the provision
of sufficient information regarding an individual's condition
as a condition for receipt of benefits under part A for
services provided in such an institution.
(B)(i) In administering this subsection and section 1821, the
Secretary shall not subject a religious nonmedical health care
institution or its personnel to any medical supervision,
regulation, or control, insofar as such supervision,
regulation, or control would be contrary to the religious
beliefs observed by the institution or such personnel.
(ii) Clause (i) shall not be construed as preventing the
Secretary from reviewing items and services billed by the
institution to the extent the Secretary determines such review
to be necessary to determine whether such items and services
were not covered under part A, are excessive, or are
fraudulent.
(4)(A) For purposes of paragraph (1)(G)(i), an ownership
interest of less than 5 percent shall not be taken into
account.
(B) For purposes of paragraph (1)(G)(ii), none of the
following shall be considered to create an affiliation:
(i) An individual serving as an uncompensated
director, trustee, officer, or other member of the
governing body of a religious nonmedical health care
institution.
(ii) An individual who is a director, trustee,
officer, employee, or staff member of a religious
nonmedical health care institution having a family
relationship with an individual who is affiliated with
(or has an ownership interest in) a provider of medical
treatment or services.
(iii) An individual or entity furnishing goods or
services as a vendor to both providers of medical
treatment or services and religious nonmedical health
care institutions.
Post-Institutional Home Health Services; Home Health Spell of Illness
(tt)(1) The term ``post-institutional home health services''
means home health services furnished to an individual--
(A) after discharge from a hospital or critical
access hospital in which the individual was an
inpatient for not less than 3 consecutive days before
such discharge if such home health services were
initiated within 14 days after the date of such
discharge; or
(B) after discharge from a skilled nursing facility
in which the individual was provided post-hospital
extended care services if such home health services
were initiated within 14 days after the date of such
discharge.
(2) The term ``home health spell of illness'' with respect to
any individual means a period of consecutive days--
(A) beginning with the first day (not included in a
previous home health spell of illness) (i) on which
such individual is furnished post-institutional home
health services, and (ii) which occurs in a month for
which the individual is entitled to benefits under part
A, and
(B) ending with the close of the first period of 60
consecutive days thereafter on each of which the
individual is neither an inpatient of a hospital or
critical access hospital nor an inpatient of a facility
described in section 1819(a)(1) or subsection (y)(1)
nor provided home health services.
Screening for Glaucoma
(uu) The term ``screening for glaucoma'' means a dilated eye
examination with an intraocular pressure measurement, and a
direct ophthalmoscopy or a slit-lamp biomicroscopic examination
for the early detection of glaucoma which is furnished by or
under the direct supervision of an optometrist or
ophthalmologist who is legally authorized to furnish such
services under State law (or the State regulatory mechanism
provided by State law) of the State in which the services are
furnished, as would otherwise be covered if furnished by a
physician or as an incident to a physician's professional
service, if the individual involved has not had such an
examination in the preceding year.
Medical Nutrition Therapy Services; Registered Dietitian or Nutrition
Professional
(vv)(1) The term ``medical nutrition therapy services'' means
nutritional diagnostic, therapy, and counseling services for
the purpose of disease management which are furnished by a
registered dietitian or nutrition professional (as defined in
paragraph (2)) pursuant to a referral by a physician (as
defined in subsection (r)(1)).
(2) Subject to paragraph (3), the term ``registered dietitian
or nutrition professional'' means an individual who--
(A) holds a baccalaureate or higher degree granted by
a regionally accredited college or university in the
United States (or an equivalent foreign degree) with
completion of the academic requirements of a program in
nutrition or dietetics, as accredited by an appropriate
national accreditation organization recognized by the
Secretary for this purpose;
(B) has completed at least 900 hours of supervised
dietetics practice under the supervision of a
registered dietitian or nutrition professional; and
(C)(i) is licensed or certified as a dietitian or
nutrition professional by the State in which the
services are performed; or
(ii) in the case of an individual in a State that
does not provide for such licensure or certification,
meets such other criteria as the Secretary establishes.
(3) Subparagraphs (A) and (B) of paragraph (2) shall not
apply in the case of an individual who, as of the date of the
enactment of this subsection, is licensed or certified as a
dietitian or nutrition professional by the State in which
medical nutrition therapy services are performed.
Initial Preventive Physical Examination
(ww)(1) The term ``initial preventive physical examination''
means physicians' services consisting of a physical examination
(including measurement of height, weight body mass index,, and
blood pressure) with the goal of health promotion and disease
detection and includes education, counseling, and referral with
respect to screening and other preventive services described in
paragraph (2), end-of-life planning (as defined in paragraph
(3)) upon the agreement with the individual, and the furnishing
of a review of any current opioid prescriptions (as defined in
paragraph (4)), but does not include clinical laboratory tests.
(2) The screening and other preventive services described in
this paragraph include the following:
(A) Pneumococcal, influenza, and hepatitis B vaccine
and administration under subsection (s)(10).
(B) Screening mammography as defined in subsection
(jj).
(C) Screening pap smear and screening pelvic exam as
defined in subsection (nn).
(D) Prostate cancer screening tests as defined in
subsection (oo).
(E) Colorectal cancer screening tests as defined in
subsection (pp).
(F) Diabetes outpatient self-management training
services as defined in subsection (qq)(1).
(G) Bone mass measurement as defined in subsection
(rr).
(H) Screening for glaucoma as defined in subsection
(uu).
(I) Medical nutrition therapy services as defined in
subsection (vv).
(J) Cardiovascular screening blood tests as defined
in subsection (xx)(1).
(K) Diabetes screening tests as defined in subsection
(yy).
(L) Ultrasound screening for abdominal aortic
aneurysm as defined in section 1861(bbb).
(M) An electrocardiogram.
(N) Screening for potential substance use disorders.
(O) Additional preventive services (as defined in
subsection (ddd)(1)).
(3) For purposes of paragraph (1), the term ``end-of-life
planning'' means verbal or written information regarding--
(A) an individual's ability to prepare an advance
directive in the case that an injury or illness causes
the individual to be unable to make health care
decisions; and
(B) whether or not the physician is willing to follow
the individual's wishes as expressed in an advance
directive.
(4) For purposes of paragraph (1), the term ``a review of any
current opioid prescriptions'' means, with respect to an
individual determined to have a current prescription for
opioids--
(A) a review of the potential risk factors to the
individual for opioid use disorder;
(B) an evaluation of the individual's severity of
pain and current treatment plan;
(C) the provision of information on non-opioid
treatment options; and
(D) a referral to a specialist, as appropriate.
Cardiovascular Screening Blood Test
(xx)(1) The term ``cardiovascular screening blood test''
means a blood test for the early detection of cardiovascular
disease (or abnormalities associated with an elevated risk of
cardiovascular disease) that tests for the following:
(A) Cholesterol levels and other lipid or
triglyceride levels.
(B) Such other indications associated with the
presence of, or an elevated risk for, cardiovascular
disease as the Secretary may approve for all
individuals (or for some individuals determined by the
Secretary to be at risk for cardiovascular disease),
including indications measured by noninvasive testing.
The Secretary may not approve an indication under subparagraph
(B) for any individual unless a blood test for such is
recommended by the United States Preventive Services Task
Force.
(2) The Secretary shall establish standards, in consultation
with appropriate organizations, regarding the frequency for
each type of cardiovascular screening blood tests, except that
such frequency may not be more often than once every 2 years.
Diabetes Screening Tests
(yy)(1) The term ``diabetes screening tests'' means testing
furnished to an individual at risk for diabetes (as defined in
paragraph (2)) for the purpose of early detection of diabetes,
including--
(A) a fasting plasma glucose test; and
(B) such other tests, and modifications to tests, as
the Secretary determines appropriate, in consultation
with appropriate organizations.
(2) For purposes of paragraph (1), the term ``individual at
risk for diabetes'' means an individual who has any of the
following risk factors for diabetes:
(A) Hypertension.
(B) Dyslipidemia.
(C) Obesity, defined as a body mass index greater
than or equal to 30 kg/m2.
(D) Previous identification of an elevated impaired
fasting glucose.
(E) Previous identification of impaired glucose
tolerance.
(F) A risk factor consisting of at least 2 of the
following characteristics:
(i) Overweight, defined as a body mass index
greater than 25, but less than 30, kg/
m2.
(ii) A family history of diabetes.
(iii) A history of gestational diabetes
mellitus or delivery of a baby weighing greater
than 9 pounds.
(iv) 65 years of age or older.
(3) The Secretary shall establish standards, in consultation
with appropriate organizations, regarding the frequency of
diabetes screening tests, except that such frequency may not be
more often than twice within the 12-month period following the
date of the most recent diabetes screening test of that
individual.
Intravenous Immune Globulin
(zz) The term ``intravenous immune globulin'' means an
approved pooled plasma derivative for the treatment in the
patient's home of a patient with a diagnosed primary immune
deficiency disease, but not including items or services related
to the administration of the derivative, if a physician
determines administration of the derivative in the patient's
home is medically appropriate.
Extended Care in Religious Nonmedical Health Care Institutions
(aaa)(1) The term ``home health agency'' also includes a
religious nonmedical health care institution (as defined in
subsection (ss)(1)), but only with respect to items and
services ordinarily furnished by such an institution to
individuals in their homes, and that are comparable to items
and services furnished to individuals by a home health agency
that is not religious nonmedical health care institution.
(2)(A) Subject to subparagraphs (B), payment may be made with
respect to services provided by such an institution only to
such extent and under such conditions, limitations, and
requirements (in addition to or in lieu of the conditions,
limitations, and requirements otherwise applicable) as may be
provided in regulations consistent with section 1821.
(B) Notwithstanding any other provision of this title,
payment may not be made under subparagraph (A)--
(i) in a year insofar as such payments exceed
$700,000; and
(ii) after December 31, 2006.
Ultrasound Screening for Abdominal Aortic Aneurysm
(bbb) The term ``ultrasound screening for abdominal aortic
aneurysm'' means--
(1) a procedure using sound waves (or such other
procedures using alternative technologies, of
commensurate accuracy and cost, that the Secretary may
specify) provided for the early detection of abdominal
aortic aneurysm; and
(2) includes a physician's interpretation of the
results of the procedure.
Long-Term Care Hospital
(ccc) The term ``long-term care hospital'' means a hospital
which--
(1) is primarily engaged in providing inpatient
services, by or under the supervision of a physician,
to Medicare beneficiaries whose medically complex
conditions require a long hospital stay and programs of
care provided by a long-term care hospital;
(2) has an average inpatient length of stay (as
determined by the Secretary) of greater than 25 days,
or meets the requirements of clause (II) of section
1886(d)(1)(B)(iv);
(3) satisfies the requirements of subsection (e); and
(4) meets the following facility criteria:
(A) the institution has a patient review
process, documented in the patient medical
record, that screens patients prior to
admission for appropriateness of admission to a
long-term care hospital, validates within 48
hours of admission that patients meet admission
criteria for long-term care hospitals,
regularly evaluates patients throughout their
stay for continuation of care in a long-term
care hospital, and assesses the available
discharge options when patients no longer meet
such continued stay criteria;
(B) the institution has active physician
involvement with patients during their
treatment through an organized medical staff,
physician-directed treatment with physician on-
site availability on a daily basis to review
patient progress, and consulting physicians on
call and capable of being at the patient's side
within a moderate period of time, as determined
by the Secretary; and
(C) the institution has interdisciplinary
team treatment for patients, requiring
interdisciplinary teams of health care
professionals, including physicians, to prepare
and carry out an individualized treatment plan
for each patient.
Additional Preventive Services; Preventive Services
(ddd)(1) The term ``additional preventive services'' means
services not described in subparagraph (A) or (C) of paragraph
(3) that identify medical conditions or risk factors and that
the Secretary determines are--
(A) reasonable and necessary for the prevention or
early detection of an illness or disability;
(B) recommended with a grade of A or B by the United
States Preventive Services Task Force; and
(C) appropriate for individuals entitled to benefits
under part A or enrolled under part B.
(2) In making determinations under paragraph (1) regarding
the coverage of a new service, the Secretary shall use the
process for making national coverage determinations (as defined
in section 1869(f)(1)(B)) under this title. As part of the use
of such process, the Secretary may conduct an assessment of the
relation between predicted outcomes and the expenditures for
such service and may take into account the results of such
assessment in making such determination.
(3) The term ``preventive services'' means the following:
(A) The screening and preventive services described
in subsection (ww)(2) (other than the service described
in subparagraph (M) of such subsection).
(B) An initial preventive physical examination (as
defined in subsection (ww)).
(C) Personalized prevention plan services (as defined
in subsection (hhh)(1)).
Cardiac Rehabilitation Program; Intensive Cardiac Rehabilitation
Program
(eee)(1) The term ``cardiac rehabilitation program'' means a
program (as described in paragraph (2)) that furnishes the
items and services described in paragraph (3) under the
supervision of a physician (as defined in subsection (r)(1)) or
a physician assistant, nurse practitioner, or clinical nurse
specialist (as those terms are defined in subsection (aa)(5)).
(2) A program described in this paragraph is a program under
which--
(A) items and services under the program are
delivered--
(i) in a physician's office;
(ii) in a hospital on an outpatient basis; or
(iii) in other settings determined
appropriate by the Secretary;
(B) a physician (as defined in subsection (r)(1)) or
a physician assistant, nurse practitioner, or clinical
nurse specialist (as those terms are defined in
subsection (aa)(5)) is immediately available and
accessible for medical consultation and medical
emergencies at all times items and services are being
furnished under the program, except that, in the case
of items and services furnished under such a program in
a hospital, such availability shall be presumed; and
(C) individualized treatment is furnished under a
written plan established, reviewed, and signed by a
physician every 30 days that describes--
(i) the individual's diagnosis;
(ii) the type, amount, frequency, and
duration of the items and services furnished
under the plan; and
(iii) the goals set for the individual under
the plan.
(3) The items and services described in this paragraph are--
(A) physician-prescribed exercise;
(B) cardiac risk factor modification, including
education, counseling, and behavioral intervention (to
the extent such education, counseling, and behavioral
intervention is closely related to the individual's
care and treatment and is tailored to the individual's
needs);
(C) psychosocial assessment;
(D) outcomes assessment; and
(E) such other items and services as the Secretary
may determine, but only if such items and services
are--
(i) reasonable and necessary for the
diagnosis or active treatment of the
individual's condition;
(ii) reasonably expected to improve or
maintain the individual's condition and
functional level; and
(iii) furnished under such guidelines
relating to the frequency and duration of such
items and services as the Secretary shall
establish, taking into account accepted norms
of medical practice and the reasonable
expectation of improvement of the individual.
(4)(A) The term ``intensive cardiac rehabilitation program''
means a program (as described in paragraph (2)) that furnishes
the items and services described in paragraph (3) under the
supervision of a physician (as defined in subsection (r)(1)) or
a physician assistant, nurse practitioner, or clinical nurse
specialist (as those terms are defined in subsection (aa)(5))
and has shown, in peer-reviewed published research, that it
accomplished--
(i) one or more of the following:
(I) positively affected the progression of
coronary heart disease; or
(II) reduced the need for coronary bypass
surgery; or
(III) reduced the need for percutaneous
coronary interventions; and
(ii) a statistically significant reduction in 5 or
more of the following measures from their level before
receipt of cardiac rehabilitation services to their
level after receipt of such services:
(I) low density lipoprotein;
(II) triglycerides;
(III) body mass index;
(IV) systolic blood pressure;
(V) diastolic blood pressure; or
(VI) the need for cholesterol, blood
pressure, and diabetes medications.
(B) To be eligible for an intensive cardiac rehabilitation
program, an individual must have--
(i) had an acute myocardial infarction within the
preceding 12 months;
(ii) had coronary bypass surgery;
(iii) stable angina pectoris;
(iv) had heart valve repair or replacement;
(v) had percutaneous transluminal coronary
angioplasty (PTCA) or coronary stenting;
(vi) had a heart or heart-lung transplant;
(vii) stable, chronic heart failure (defined
as patients with left ventricular ejection
fraction of 35 percent or less and New York
Heart Association (NYHA) class II to IV
symptoms despite being on optimal heart failure
therapy for at least 6 weeks); or
(viii) any additional condition for which the
Secretary has determined that a cardiac
rehabilitation program shall be covered, unless
the Secretary determines, using the same
process used to determine that the condition is
covered for a cardiac rehabilitation program,
that such coverage is not supported by the
clinical evidence.
(C) An intensive cardiac rehabilitation program may be
provided in a series of 72 one-hour sessions (as defined in
section 1848(b)(5)), up to 6 sessions per day, over a period of
up to 18 weeks.
(5) The Secretary shall establish standards to ensure that a
physician with expertise in the management of individuals with
cardiac pathophysiology who is licensed to practice medicine in
the State in which a cardiac rehabilitation program (or the
intensive cardiac rehabilitation program, as the case may be)
is offered--
(A) is responsible for such program; and
(B) in consultation with appropriate staff, is
involved substantially in directing the progress of
individual in the program.
Pulmonary Rehabilitation Program
(fff)(1) The term ``pulmonary rehabilitation program'' means
a program (as described in subsection (eee)(2) with respect to
a program under this subsection) that furnishes the items and
services described in paragraph (2) under the supervision of a
physician (as defined in subsection (r)(1)) or a physician
assistant, nurse practitioner, or clinical nurse specialist (as
those terms are defined in subsection (aa)(5)).
(2) The items and services described in this paragraph are--
(A) physician-prescribed exercise;
(B) education or training (to the extent the
education or training is closely and clearly related to
the individual's care and treatment and is tailored to
such individual's needs);
(C) psychosocial assessment;
(D) outcomes assessment; and
(E) such other items and services as the Secretary
may determine, but only if such items and services
are--
(i) reasonable and necessary for the
diagnosis or active treatment of the
individual's condition;
(ii) reasonably expected to improve or
maintain the individual's condition and
functional level; and
(iii) furnished under such guidelines
relating to the frequency and duration of such
items and services as the Secretary shall
establish, taking into account accepted norms
of medical practice and the reasonable
expectation of improvement of the individual.
(3) The Secretary shall establish standards to ensure that a
physician with expertise in the management of individuals with
respiratory pathophysiology who is licensed to practice
medicine in the State in which a pulmonary rehabilitation
program is offered--
(A) is responsible for such program; and
(B) in consultation with appropriate staff, is
involved substantially in directing the progress of
individual in the program.
Kidney Disease Education Services
(ggg)(1) The term ``kidney disease education services'' means
educational services that are--
(A) furnished to an individual with stage IV chronic
kidney disease who, according to accepted clinical
guidelines identified by the Secretary, will require
dialysis or a kidney transplant;
(B) furnished, upon the referral of the physician
managing the individual's kidney condition, by a
qualified person (as defined in paragraph (2)); and
(C) designed--
(i) to provide comprehensive information
(consistent with the standards set under
paragraph (3)) regarding--
(I) the management of comorbidities,
including for purposes of delaying the
need for dialysis;
(II) the prevention of uremic
complications; and
(III) each option for renal
replacement therapy (including
hemodialysis and peritoneal dialysis at
home and in-center as well as vascular
access options and transplantation);
(ii) to ensure that the individual has the
opportunity to actively participate in the
choice of therapy; and
(iii) to be tailored to meet the needs of the
individual involved.
(2)(A) The term ``qualified person'' means--
(i) a physician (as defined in section 1861(r)(1)) or
a physician assistant, nurse practitioner, or clinical
nurse specialist (as defined in section 1861(aa)(5)),
who furnishes services for which payment may be made
under the fee schedule established under section 1848;
and
(ii) a provider of services located in a rural area
(as defined in section 1886(d)(2)(D)).
(B) Such term does not include a provider of services (other
than a provider of services described in subparagraph (A)(ii))
or a renal dialysis facility.
(3) The Secretary shall set standards for the content of such
information to be provided under paragraph (1)(C)(i) after
consulting with physicians, other health professionals, health
educators, professional organizations, accrediting
organizations, kidney patient organizations, dialysis
facilities, transplant centers, network organizations described
in section 1881(c)(2), and other knowledgeable persons. To the
extent possible the Secretary shall consult with persons or
entities described in the previous sentence, other than a
dialysis facility, that has not received industry funding from
a drug or biological manufacturer or dialysis facility.
(4) No individual shall be furnished more than 6 sessions of
kidney disease education services under this title.
Annual Wellness Visit
(hhh)(1) The term ``personalized prevention plan services''
means the creation of a plan for an individual--
(A) that includes a health risk assessment (that
meets the guidelines established by the Secretary under
paragraph (4)(A)) of the individual that is completed
prior to or as part of the same visit with a health
professional described in paragraph (3); and
(B) that--
(i) takes into account the results of the
health risk assessment; and
(ii) may contain the elements described in
paragraph (2).
(2) Subject to paragraph (4)(H), the elements described in
this paragraph are the following:
(A) The establishment of, or an update to, the
individual's medical and family history.
(B) A list of current providers and suppliers that
are regularly involved in providing medical care to the
individual (including a list of all prescribed
medications).
(C) A measurement of height, weight, body mass index
(or waist circumference, if appropriate), blood
pressure, and other routine measurements.
(D) Detection of any cognitive impairment.
(E) The establishment of, or an update to, the
following:
(i) A screening schedule for the next 5 to 10
years, as appropriate, based on recommendations
of the United States Preventive Services Task
Force and the Advisory Committee on
Immunization Practices, and the individual's
health status, screening history, and age-
appropriate preventive services covered under
this title.
(ii) A list of risk factors and conditions
for which primary, secondary, or tertiary
prevention interventions are recommended or are
underway, including any mental health
conditions or any such risk factors or
conditions that have been identified through an
initial preventive physical examination (as
described under subsection (ww)(1)), and a list
of treatment options and their associated risks
and benefits.
(F) The furnishing of personalized health advice and
a referral, as appropriate, to health education or
preventive counseling services or programs aimed at
reducing identified risk factors and improving self-
management, or community-based lifestyle interventions
to reduce health risks and promote self-management and
wellness, including weight loss, physical activity,
smoking cessation, fall prevention, and nutrition.
(G) Screening for potential substance use disorders
and referral for treatment as appropriate.
(H) The furnishing of a review of any current opioid
prescriptions (as defined in subsection (ww)(4)).
(I) Any other element determined appropriate by the
Secretary.
(3) A health professional described in this paragraph is--
(A) a physician;
(B) a practitioner described in clause (i) of section
1842(b)(18)(C); or
(C) a medical professional (including a health
educator, registered dietitian, or nutrition
professional) or a team of medical professionals, as
determined appropriate by the Secretary, under the
supervision of a physician.
(4)(A) For purposes of paragraph (1)(A), the Secretary, not
later than 1 year after the date of enactment of this
subsection, shall establish publicly available guidelines for
health risk assessments. Such guidelines shall be developed in
consultation with relevant groups and entities and shall
provide that a health risk assessment--
(i) identify chronic diseases, injury risks,
modifiable risk factors, and urgent health needs of the
individual; and
(ii) may be furnished--
(I) through an interactive telephonic or web-
based program that meets the standards
established under subparagraph (B);
(II) during an encounter with a health care
professional;
(III) through community-based prevention
programs; or
(IV) through any other means the Secretary
determines appropriate to maximize
accessibility and ease of use by beneficiaries,
while ensuring the privacy of such
beneficiaries.
(B) Not later than 1 year after the date of enactment of this
subsection, the Secretary shall establish standards for
interactive telephonic or web-based programs used to furnish
health risk assessments under subparagraph (A)(ii)(I). The
Secretary may utilize any health risk assessment developed
under section 4004(f) of the Patient Protection and Affordable
Care Act as part of the requirement to develop a personalized
prevention plan to comply with this subparagraph.
(C)(i) Not later than 18 months after the date of enactment
of this subsection, the Secretary shall develop and make
available to the public a health risk assessment model. Such
model shall meet the guidelines under subparagraph (A) and may
be used to meet the requirement under paragraph (1)(A).
(ii) Any health risk assessment that meets the guidelines
under subparagraph (A) and is approved by the Secretary may be
used to meet the requirement under paragraph (1)(A).
(D) The Secretary may coordinate with community-based
entities (including State Health Insurance Programs, Area
Agencies on Aging, Aging and Disability Resource Centers, and
the Administration on Aging) to--
(i) ensure that health risk assessments are
accessible to beneficiaries; and
(ii) provide appropriate support for the completion
of health risk assessments by beneficiaries.
(E) The Secretary shall establish procedures to make
beneficiaries and providers aware of the requirement that a
beneficiary complete a health risk assessment prior to or at
the same time as receiving personalized prevention plan
services.
(F) To the extent practicable, the Secretary shall encourage
the use of, integration with, and coordination of health
information technology (including use of technology that is
compatible with electronic medical records and personal health
records) and may experiment with the use of personalized
technology to aid in the development of self-management skills
and management of and adherence to provider recommendations in
order to improve the health status of beneficiaries.
(G) A beneficiary shall be eligible to receive only an
initial preventive physical examination (as defined under
subsection (ww)(1)) during the 12-month period after the date
that the beneficiary's coverage begins under part B and shall
be eligible to receive personalized prevention plan services
under this subsection each year thereafter provided that the
beneficiary has not received either an initial preventive
physical examination or personalized prevention plan services
within the preceding 12-month period.
(H) The Secretary shall issue guidance that--
(i) identifies elements under paragraph (2) that are
required to be provided to a beneficiary as part of
their first visit for personalized prevention plan
services; and
(ii) establishes a yearly schedule for appropriate
provision of such elements thereafter.
(iii) Home Infusion Therapy.--(1) The term ``home infusion
therapy'' means the items and services described in paragraph
(2) furnished by a qualified home infusion therapy supplier (as
defined in paragraph (3)(D)) which are furnished in the
individual's home (as defined in paragraph (3)(B)) to an
individual--
(A) who is under the care of an applicable provider
(as defined in paragraph (3)(A)); and
(B) with respect to whom a plan prescribing the type,
amount, and duration of infusion therapy services that
are to be furnished such individual has been
established by a physician (as defined in subsection
(r)(1)) and is periodically reviewed by a physician (as
so defined) in coordination with the furnishing of home
infusion drugs (as defined in paragraph (3)(C)) under
part B.
(2) The items and services described in this paragraph are
the following:
(A) Professional services, including nursing
services, furnished in accordance with the plan.
(B) Training and education (not otherwise paid for as
durable medical equipment (as defined in subsection
(n)), remote monitoring, and monitoring services for
the provision of home infusion therapy and home
infusion drugs furnished by a qualified home infusion
therapy supplier.
(3) For purposes of this subsection:
(A) The term ``applicable provider'' means--
(i) a physician;
(ii) a nurse practitioner; and
(iii) a physician assistant.
(B) The term ``home'' means a place of residence used
as the home of an individual (as defined for purposes
of subsection (n)).
(C) The term ``home infusion drug'' means a
parenteral drug or biological administered
intravenously, or subcutaneously for an administration
period of 15 minutes or more, in the home of an
individual through a pump that is an item of durable
medical equipment (as defined in subsection (n)). Such
term does not include the following:
(i) Insulin pump systems.
(ii) A self-administered drug or biological
on a self-administered drug exclusion list.
(D)(i) The term ``qualified home infusion therapy
supplier'' means a pharmacy, physician, or other
provider of services or supplier licensed by the State
in which the pharmacy, physician, or provider or
services or supplier furnishes items or services and
that--
(I) furnishes infusion therapy to individuals
with acute or chronic conditions requiring
administration of home infusion drugs;
(II) ensures the safe and effective provision
and administration of home infusion therapy on
a 7-day-a-week, 24-hour-a-day basis;
(III) is accredited by an organization
designated by the Secretary pursuant to section
1834(u)(5); and
(IV) meets such other requirements as the
Secretary determines appropriate, taking into
account the standards of care for home infusion
therapy established by Medicare Advantage plans
under part C and in the private sector.
(ii) A qualified home infusion therapy supplier may
subcontract with a pharmacy, physician, provider of
services, or supplier to meet the requirements of this
subparagraph.
(jjj) Opioid Use Disorder Treatment Services; Opioid
Treatment Program.--
(1) Opioid use disorder treatment services.--The term
``opioid use disorder treatment services'' means items
and services that are furnished by an opioid treatment
program for the treatment of opioid use disorder,
including--
(A) opioid agonist and antagonist treatment
medications (including oral, injected, or
implanted versions) that are approved by the
Food and Drug Administration under section 505
of the Federal Food, Drug, and Cosmetic Act for
use in the treatment of opioid use disorder;
(B) dispensing and administration of such
medications, if applicable;
(C) substance use counseling by a
professional to the extent authorized under
State law to furnish such services;
(D) individual and group therapy with a
physician or psychologist (or other mental
health professional to the extent authorized
under State law);
(E) toxicology testing, and
(F) other items and services that the
Secretary determines are appropriate (but in no
event to include meals or transportation).
(2) Opioid treatment program.--The term ``opioid
treatment program'' means an entity that is an opioid
treatment program (as defined in section 8.2 of title
42 of the Code of Federal Regulations, or any successor
regulation) that--
(A) is enrolled under section 1866(j);
(B) has in effect a certification by the
Substance Abuse and Mental Health Services
Administration for such a program;
(C) is accredited by an accrediting body
approved by the Substance Abuse and Mental
Health Services Administration; and
(D) meets such additional conditions as the
Secretary may find necessary to ensure--
(i) the health and safety of
individuals being furnished services
under such program; and
(ii) the effective and efficient
furnishing of such services.
(kkk) Prostate Cancer DNA Specimen Provenance Assay Test.--
The term ``prostate cancer DNA Specimen Provenance Assay Test''
(DSPA test) means a test that, after a determination of cancer
in one or more prostate biopsy specimens obtained from an
individual, assesses the identity of the DNA in such specimens
by comparing such DNA with the DNA that was separately taken
from such individual at the time of the biopsy.
exclusions from coverage and medicare as secondary payer
Sec. 1862. (a) Notwithstanding any other provision of this
title, no payment may be made under part A or part B for any
expenses incurred for items or services--
(1)(A) which, except for items and services described
in a succeeding subparagraph or additional preventive
services (as described in section 1861(ddd)(1)), are
not reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the
functioning of a malformed body member,
(B) in the case of items and services described in
section 1861(s)(10), which are not reasonable and
necessary for the prevention of illness,
(C) in the case of hospice care, which are not
reasonable and necessary for the palliation or
management of terminal illness,
(D) in the case of clinical care items and services
provided with the concurrence of the Secretary and with
respect to research and experimentation conducted by,
or under contract with, the Medicare Payment Advisory
Commission or the Secretary, which are not reasonable
and necessary to carry out the purposes of section
1886(e)(6),
(E) in the case of research conducted pursuant to
section 1142, which is not reasonable and necessary to
carry out the purposes of that section,
(F) in the case of screening mammography, which is
performed more frequently than is covered under section
1834(c)(2) or which is not conducted by a facility
described in section 1834(c)(1)(B), in the case of
screening pap smear and screening pelvic exam, which is
performed more frequently than is provided under
section 1861(nn), and, in the case of screening for
glaucoma, which is performed more frequently than is
provided under section 1861(uu),
(G) in the case of prostate cancer screening tests
(as defined in section 1861(oo)), which are performed
more frequently than is covered under such section,
(H) in the case of colorectal cancer screening tests,
which are performed more frequently than is covered
under section 1834(d),
(I) the frequency and duration of home health
services which are in excess of normative guidelines
that the Secretary shall establish by regulation,
(J) in the case of a drug or biological specified in
section 1847A(c)(6)(C) for which payment is made under
part B that is furnished in a competitive area under
section 1847B, that is not furnished by an entity under
a contract under such section,
(K) in the case of an initial preventive physical
examination, which is performed more than 1 year after
the date the individual's first coverage period begins
under part B,
(L) in the case of cardiovascular screening blood
tests (as defined in section 1861(xx)(1)), which are
performed more frequently than is covered under section
1861(xx)(2),
(M) in the case of a diabetes screening test (as
defined in section 1861(yy)(1)), which is performed
more frequently than is covered under section
1861(yy)(3),
(N) in the case of ultrasound screening for abdominal
aortic aneurysm which is performed more frequently than
is provided for under section 1861(s)(2)(AA),
(O) in the case of kidney disease education services
(as defined in paragraph (1) of section 1861(ggg)),
which are furnished in excess of the number of sessions
covered under paragraph (4) of such section, [and]
(P) in the case of personalized prevention plan
services (as defined in section 1861(hhh)(1)), which
are performed more frequently than is covered under
such section[;], and
(Q) in the case of a prostate cancer DNA Specimen
Provenance Assay test (DSPA test) (as defined in
section 1861(kkk)), unless such test is furnished on or
after January 1, 2021, and before January 1, 2026, and
such test is ordered by the physician who furnished the
prostate cancer biopsy that obtained the specimen
tested;
(2) for which the individual furnished such items or
services has no legal obligation to pay, and which no
other person (by reason of such individual's membership
in a prepayment plan or otherwise) has a legal
obligation to provide or pay for, except in the case of
Federally qualified health center services;
(3) which are paid for directly or indirectly by a
governmental entity (other than under this Act and
other than under a health benefits or insurance plan
established for employees of such an entity), except in
the case of rural health clinic services, as defined in
section 1861(aa)(1), in the case of Federally qualified
health center services, as defined in section
1861(aa)(3), in the case of services for which payment
may be made under section 1880(e), and in such other
cases as the Secretary may specify;
(4) which are not provided within the United States
(except for inpatient hospital services furnished
outside the United States under the conditions
described in section 1814(f) and, subject to such
conditions, limitations, and requirements as are
provided under or pursuant to this title, physicians'
services and ambulance services furnished an individual
in conjunction with such inpatient hospital services
but only for the period during which such inpatient
hospital services were furnished);
(5) which are required as a result of war, or of an
act of war, occurring after the effective date of such
individual's current coverage under such part;
(6) which constitute personal comfort items (except,
in the case of hospice care, as is otherwise permitted
under paragraph (1)(C));
(7) where such expenses are for routine physical
checkups, eyeglasses (other than eyewear described in
section 1861(s)(8)) or eye examinations for the purpose
of prescribing, fitting, or changing eyeglasses,
procedures performed (during the course of any eye
examination) to determine the refractive state of the
eyes, hearing aids or examinations therefor, or
immunizations (except as otherwise allowed under
section 1861(s)(10) and subparagraph (B), (F), (G),
(H), (K), or (P) of paragraph (1));
(8) where such expenses are for orthopedic shoes or
other supportive devices for the feet, other than shoes
furnished pursuant to section 1861(s)(12);
(9) where such expenses are for custodial care
(except, in the case of hospice care, as is otherwise
permitted under paragraph (1)(C));
(10) where such expenses are for cosmetic surgery or
are incurred in connection therewith, except as
required for the prompt repair of accidental injury or
for improvement of the functioning of a malformed body
member;
(11) where such expenses constitute charges imposed
by immediate relatives of such individual or members of
his household;
(12) where such expenses are for services in
connection with the care, treatment, filling, removal,
or replacement of teeth or structures directly
supporting teeth, except that payment may be made under
part A in the case of inpatient hospital services in
connection with the provision of such dental services
if the individual, because of his underlying medical
condition and clinical status or because of the
severity of the dental procedure, requires
hospitalization in connection with the provision of
such services;
(13) where such expenses are for--
(A) the treatment of flat foot conditions and
the prescription of supportive devices
therefor,
(B) the treatment of subluxations of the
foot, or
(C) routine foot care (including the cutting
or removal of corns or calluses, the trimming
of nails, and other routine hygienic care);
(14) which are other than physicians' services (as
defined in regulations promulgated specifically for
purposes of this paragraph), services described by
section 1861(s)(2)(K), certified nurse-midwife
services, qualified psychologist services, and services
of a certified registered nurse anesthetist, and which
are furnished to an individual who is a patient of a
hospital or critical access hospital by an entity other
than the hospital or critical access hospital, unless
the services are furnished under arrangements (as
defined in section 1861(w)(1)) with the entity made by
the hospital or critical access hospital;
(15)(A) which are for services of an assistant at
surgery in a cataract operation (including subsequent
insertion of an intraocular lens) unless, before the
surgery is performed, the appropriate quality
improvement organization (under part B of title XI) or
a carrier under section 1842 has approved of the use of
such an assistant in the surgical procedure based on
the existence of a complicating medical condition, or
(B) which are for services of an assistant at surgery
to which section 1848(i)(2)(B) applies;
(16) in the case in which funds may not be used for
such items and services under the Assisted Suicide
Funding Restriction Act of 1997;
(17) where the expenses are for an item or service
furnished in a competitive acquisition area (as
established by the Secretary under section 1847(a)) by
an entity other than an entity with which the Secretary
has entered into a contract under section 1847(b) for
the furnishing of such an item or service in that area,
unless the Secretary finds that the expenses were
incurred in a case of urgent need, or in other
circumstances specified by the Secretary;
(18) which are covered skilled nursing facility
services described in section 1888(e)(2)(A)(i) and
which are furnished to an individual who is a resident
of a skilled nursing facility during a period in which
the resident is provided covered post-hospital extended
care services (or, for services described in section
1861(s)(2)(D), which are furnished to such an
individual without regard to such period), by an entity
other than the skilled nursing facility, unless the
services are furnished under arrangements (as defined
in section 1861(w)(1)) with the entity made by the
skilled nursing facility;
(19) which are for items or services which are
furnished pursuant to a private contract described in
section 1802(b);
(20) in the case of outpatient physical therapy
services, outpatient speech-language pathology
services, or outpatient occupational therapy services
furnished as an incident to a physician's professional
services (as described in section 1861(s)(2)(A)), that
do not meet the standards and conditions (other than
any licensing requirement specified by the Secretary)
under the second sentence of section 1861(p) (or under
such sentence through the operation of subsection (g)
or (ll)(2) of section 1861) as such standards and
conditions would apply to such therapy services if
furnished by a therapist;
(21) where such expenses are for home health services
(including medical supplies described in section
1861(m)(5), but excluding durable medical equipment to
the extent provided for in such section) furnished to
an individual who is under a plan of care of the home
health agency if the claim for payment for such
services is not submitted by the agency;
(22) subject to subsection (h), for which a claim is
submitted other than in an electronic form specified by
the Secretary;
(23) which are the technical component of advanced
diagnostic imaging services described in section
1834(e)(1)(B) for which payment is made under the fee
schedule established under section 1848(b) and that are
furnished by a supplier (as defined in section
1861(d)), if such supplier is not accredited by an
accreditation organization designated by the Secretary
under section 1834(e)(2)(B);
(24) where such expenses are for renal dialysis
services (as defined in subparagraph (B) of section
1881(b)(14)) for which payment is made under such
section unless such payment is made under such section
to a provider of services or a renal dialysis facility
for such services; or
(25) not later than January 1, 2014, for which the
payment is other than by electronic funds transfer
(EFT) or an electronic remittance in a form as
specified in ASC X12 835 Health Care Payment and
Remittance Advice or subsequent standard.
Paragraph (7) shall not apply to Federally qualified health
center services described in section 1861(aa)(3)(B). In making
a national coverage determination (as defined in paragraph
(1)(B) of section 1869(f)) the Secretary shall ensure
consistent with subsection (l) that the public is afforded
notice and opportunity to comment prior to implementation by
the Secretary of the determination; meetings of advisory
committees with respect to the determination are made on the
record; in making the determination, the Secretary has
considered applicable information (including clinical
experience and medical, technical, and scientific evidence)
with respect to the subject matter of the determination; and in
the determination, provide a clear statement of the basis for
the determination (including responses to comments received
from the public), the assumptions underlying that basis, and
make available to the public the data (other than proprietary
data) considered in making the determination.
(b) Medicare as Secondary Payer.--
(1) Requirements of group health plans.--
(A) Working aged under group health plans.--
(i) In general.--A group health
plan--
(I) may not take into account
that an individual (or the
individual's spouse) who is
covered under the plan by
virtue of the individual's
current employment status with
an employer is entitled to
benefits under this title under
section 226(a), and
(II) shall provide that any
individual age 65 or older (and
the spouse age 65 or older of
any individual) who has current
employment status with an
employer shall be entitled to
the same benefits under the
plan under the same conditions
as any such individual (or
spouse) under age 65.
(ii) Exclusion of group health plan
of a small employer.--Clause (i) shall
not apply to a group health plan unless
the plan is a plan of, or contributed
to by, an employer that has 20 or more
employees for each working day in each
of 20 or more calendar weeks in the
current calendar year or the preceding
calendar year.
(iii) Exception for small employers
in multiemployer or multiple employer
group health plans.--Clause (i) also
shall not apply with respect to
individuals enrolled in a multiemployer
or multiple employer group health plan
if the coverage of the individuals
under the plan is by virtue of current
employment status with an employer that
does not have 20 or more individuals in
current employment status for each
working day in each of 20 or more
calendar weeks in the current calendar
year and the preceding calendar year;
except that the exception provided in
this clause shall only apply if the
plan elects treatment under this
clause.
(iv) Exception for individuals with
end stage renal disease.--Subparagraph
(C) shall apply instead of clause (i)
to an item or service furnished in a
month to an individual if for the month
the individual is, or (without regard
to entitlement under section 226) would
upon application be, entitled to
benefits under section 226A.
(v) Group health plan defined.--In
this subparagraph, and subparagraph
(C), the term ``group health plan'' has
the meaning given such term in section
5000(b)(1) of the Internal Revenue Code
of 1986, without regard to section
5000(d) of such Code
(B) Disabled individuals in large group
health plans.--
(i) In general.--A large group health
plan (as defined in clause (iii)) may
not take into account that an
individual (or a member of the
individual's family) who is covered
under the plan by virtue of the
individual's current employment status
with an employer is entitled to
benefits under this title under section
226(b).
(ii) Exception for individuals with
end stage renal disease.--Subparagraph
(C) shall apply instead of clause (i)
to an item or service furnished in a
month to an individual if for the month
the individual is, or (without regard
to entitlement under section 226) would
upon application be, entitled to
benefits under section 226A.
(iii) Large Group Health Plan
Defined.--In this subparagraph, the
term ``large group health plan'' has
the meaning given such term in section
5000(b)(2) of the Internal Revenue Code
of 1986, without regard to section
5000(d) of such Code.
(C) Individuals with end stage renal
disease.--A group health plan (as defined in
subparagraph (A)(v))--
(i) may not take into account that an
individual is entitled to or eligible
for benefits under this title under
section 226A during the 12-month period
which begins with the first month in
which the individual becomes entitled
to benefits under part A under the
provisions of section 226A, or, if
earlier, the first month in which the
individual would have been entitled to
benefits under such part under the
provisions of section 226A if the
individual had filed an application for
such benefits; and
(ii) may not differentiate in the
benefits it provides between
individuals having end stage renal
disease and other individuals covered
by such plan on the basis of the
existence of end stage renal disease,
the need for renal dialysis, or in any
other manner;
except that clause (ii) shall not prohibit a
plan from paying benefits secondary to this
title when an individual is entitled to or
eligible for benefits under this title under
section 226A after the end of the 12-month
period described in clause (i). Effective for
items and services furnished on or after
February 1, 1991, and before the date of
enactment of the Balanced Budget Act of 1997
(with respect to periods beginning on or after
February 1, 1990), this subparagraph shall be
applied by substituting ``18- month'' for ``12-
month'' each place it appears. Effective for
items and services furnished on or after the
date of enactment of the Balanced Budget Act of
1997, (with respect to periods beginning on or
after the date that is 18 months prior to such
date), clauses (i) and (ii) shall be applied by
substituting ``30-month'' for ``12-month'' each
place it appears.
(D) Treatment of certain members of religious
orders.--In this subsection, an individual
shall not be considered to be employed, or an
employee, with respect to the performance of
services as a member of a religious order which
are considered employment only by virtue of an
election made by the religious order under
section 3121(r) of the Internal Revenue Code of
1986.
(E) General Provisions.--For purposes of this
subsection:
(i) Aggregation Rules.--
(I) All employers treated as
a single employer under
subsection (a) or (b) of
section 52 of the Internal
Revenue Code of 1986 shall be
treated as a single employer.
(II) All employees of the
members of an affiliated
service group (as defined in
section 414(m) of such Code)
shall be treated as employed by
a single employer.
(III) Leased employees (as
defined in section 414(n)(2) of
such Code) shall be treated as
employees of the person for
whom they perform services to
the extent they are so treated
under section 414(n) of such
Code.
In applying sections of the Internal
Revenue Code of 1986 under this clause,
the Secretary shall rely upon
regulations and decisions of the
Secretary of the Treasury respecting
such sections.
(ii) Current employment status
defined.--An individual has ``current
employment status'' with an employer if
the individual is an employee, is the
employer, or is associated with the
employer in a business relationship.
(iii) Treatment of self-employed
persons as employers.--The term
``employer'' includes a self-employed
person.
(F) Limitation on beneficiary liability.--An
individual who is entitled to benefits under
this title and is furnished an item or service
for which such benefits are incorrectly paid is
not liable for repayment of such benefits under
this paragraph unless payment of such benefits
was made to the individual.
(2) Medicare secondary payer.--
(A) In general.--Payment under this title may
not be made, except as provided in subparagraph
(B), with respect to any item or service to the
extent that--
(i) payment has been made, or can
reasonably be expected to be made, with
respect to the item or service as
required under paragraph (1), or
(ii) payment has been made or can
reasonably be expected to be made under
a workmen's compensation law or plan of
the United States or a State or under
an automobile or liability insurance
policy or plan (including a self-
insured plan) or under no fault
insurance.
In the subsection, the term ``primary plan''
means a group health plan or large group health
plan, to the extent that clause (i) applies,
and a workmen's compensation law or plan, an
automobile or liability insurance policy or
plan (including a self-insured plan) or no
fault insurance, to the extent that clause (ii)
applies. An entity that engages in a business,
trade, or profession shall be deemed to have a
self-insured plan if it carries its own risk
(whether by a failure to obtain insurance, or
otherwise) in whole or in part.
(B) Conditional payment.--
(i) Authority to make conditional
payment.--The Secretary may make
payment under this title with respect
to an item or service if a primary plan
described in subparagraph (A)(ii) has
not made or cannot reasonably be
expected to make payment with respect
to such item or service promptly (as
determined in accordance with
regulations). Any such payment by the
Secretary shall be conditioned on
reimbursement to the appropriate Trust
Fund in accordance with the succeeding
provisions of this subsection.
(ii) Repayment required.--Subject to
paragraph (9), a primary plan, and an
entity that receives payment from a
primary plan, shall reimburse the
appropriate Trust Fund for any payment
made by the Secretary under this title
with respect to an item or service if
it is demonstrated that such primary
plan has or had a responsibility to
make payment with respect to such item
or service. A primary plan's
responsibility for such payment may be
demonstrated by a judgment, a payment
conditioned upon the recipient's
compromise, waiver, or release (whether
or not there is a determination or
admission of liability) of payment for
items or services included in a claim
against the primary plan or the primary
plan's insured, or by other means. If
reimbursement is not made to the
appropriate Trust Fund before the
expiration of the 60-day period that
begins on the date notice of, or
information related to, a primary
plan's responsibility for such payment
or other information is received, the
Secretary may charge interest
(beginning with the date on which the
notice or other information is
received) on the amount of the
reimbursement until reimbursement is
made (at a rate determined by the
Secretary in accordance with
regulations of the Secretary of the
Treasury applicable to charges for late
payments).
(iii) Action by united states.--In
order to recover payment made under
this title for an item or service, the
United States may bring an action
against any or all entities that are or
were required or responsible (directly,
as an insurer or self-insurer, as a
third-party administrator, as an
employer that sponsors or contributes
to a group health plan, or large group
health plan, or otherwise) to make
payment with respect to the same item
or service (or any portion thereof)
under a primary plan. The United States
may, in accordance with paragraph
(3)(A) collect double damages against
any such entity. In addition, the
United States may recover under this
clause from any entity that has
received payment from a primary plan or
from the proceeds of a primary plan's
payment to any entity. The United
States may not recover from a third-
party administrator under this clause
in cases where the third-party
administrator would not be able to
recover the amount at issue from the
employer or group health plan and is
not employed by or under contract with
the employer or group health plan at
the time the action for recovery is
initiated by the United States or for
whom it provides administrative
services due to the insolvency or
bankruptcy of the employer or plan. An
action may not be brought by the United
States under this clause with respect
to payment owed unless the complaint is
filed not later than 3 years after the
date of the receipt of notice of a
settlement, judgment, award, or other
payment made pursuant to paragraph (8)
relating to such payment owed.
(iv) Subrogation rights.--The United
States shall be subrogated (to the
extent of payment made under this title
for such an item or service) to any
right under this subsection of an
individual or any other entity to
payment with respect to such item or
service under a primary plan.
(v) Waiver of rights.--The Secretary
may waive (in whole or in part) the
provisions of this subparagraph in the
case of an individual claim if the
Secretary determines that the waiver is
in the best interests of the program
established under this title.
(vi) Claims-filing period.--
Notwithstanding any other time limits
that may exist for filing a claim under
an employer group health plan, the
United States may seek to recover
conditional payments in accordance with
this subparagraph where the request for
payment is submitted to the entity
required or responsible under this
subsection to pay with respect to the
item or service (or any portion
thereof) under a primary plan within
the 3-year period beginning on the date
on which the item or service was
furnished.
(vii) Use of website to determine
final conditional reimbursement
amount.--
(I) Notice to secretary of
expected date of a settlement,
judgment, etc.--In the case of
a payment made by the Secretary
pursuant to clause (i) for
items and services provided to
the claimant, the claimant or
applicable plan (as defined in
paragraph (8)(F)) may at any
time beginning 120 days before
the reasonably expected date of
a settlement, judgment, award,
or other payment, notify the
Secretary that a payment is
reasonably expected and the
expected date of such payment.
(II) Secretarial providing
access to claims information
through a website.--The
Secretary shall maintain and
make available to individuals
to whom items and services are
furnished under this title (and
to authorized family or other
representatives recognized
under regulations and to an
applicable plan which has
obtained the consent of the
individual) access to
information on the claims for
such items and services
(including payment amounts for
such claims), including those
claims that relate to a
potential settlement, judgment,
award, or other payment. Such
access shall be provided to an
individual, representative, or
plan through a website that
requires a password to gain
access to the information. The
Secretary shall update the
information on claims and
payments on such website in as
timely a manner as possible but
not later than 15 days after
the date that payment is made.
Information related to claims
and payments subject to the
notice under subclause (I)
shall be maintained and made
available consistent with the
following:
(aa) The information
shall be as complete as
possible and shall
include provider or
supplier name,
diagnosis codes (if
any), dates of service,
and conditional payment
amounts.
(bb) The information
accurately identifies
those claims and
payments that are
related to a potential
settlement, judgment,
award, or other payment
to which the provisions
of this subsection
apply.
(cc) The website
provides a method for
the receipt of secure
electronic
communications with the
individual,
representative, or plan
involved.
(dd) The website
provides that
information is
transmitted from the
website in a form that
includes an official
time and date that the
information is
transmitted.
(ee) The website
shall permit the
individual,
representative, or plan
to download a statement
of reimbursement
amounts (in this clause
referred to as a
``statement of
reimbursement amount'')
on payments for claims
under this title
relating to a potential
settlement, judgment,
award, or other
payment.
(III) Use of timely web
download as basis for final
conditional amount.--If an
individual (or other claimant
or applicable plan with the
consent of the individual)
obtains a statement of
reimbursement amount from the
website during the protected
period as defined in subclause
(V) and the related settlement,
judgment, award or other
payment is made during such
period, then the last statement
of reimbursement amount that is
downloaded during such period
and within 3 business days
before the date of the
settlement, judgment, award, or
other payment shall constitute
the final conditional amount
subject to recovery under
clause (ii) related to such
settlement, judgment, award, or
other payment.
(IV) Resolution of
discrepancies.--If the
individual (or authorized
representative) believes there
is a discrepancy with the
statement of reimbursement
amount, the Secretary shall
provide a timely process to
resolve the discrepancy. Under
such process the individual (or
representative) must provide
documentation explaining the
discrepancy and a proposal to
resolve such discrepancy.
Within 11 business days after
the date of receipt of such
documentation, the Secretary
shall determine whether there
is a reasonable basis to
include or remove claims on the
statement of reimbursement. If
the Secretary does not make
such determination within the
11 business-day period, then
the proposal to resolve the
discrepancy shall be accepted.
If the Secretary determines
within such period that there
is not a reasonable basis to
include or remove claims on the
statement of reimbursement, the
proposal shall be rejected. If
the Secretary determines within
such period that there is a
reasonable basis to conclude
there is a discrepancy, the
Secretary must respond in a
timely manner by agreeing to
the proposal to resolve the
discrepancy or by providing
documentation showing with good
cause why the Secretary is not
agreeing to such proposal and
establishing an alternate
discrepancy resolution. In no
case shall the process under
this subclause be treated as an
appeals process or as
establishing a right of appeal
for a statement of
reimbursement amount and there
shall be no administrative or
judicial review of the
Secretary's determinations
under this subclause.
(V) Protected period.--In
subclause (III), the term
``protected period'' means,
with respect to a settlement,
judgment, award or other
payment relating to an injury
or incident, the portion (if
any) of the period beginning on
the date of notice under
subclause (I) with respect to
such settlement, judgment,
award, or other payment that is
after the end of a Secretarial
response period beginning on
the date of such notice to the
Secretary. Such Secretarial
response period shall be a
period of 65 days, except that
such period may be extended by
the Secretary for a period of
an additional 30 days if the
Secretary determines that
additional time is required to
address claims for which
payment has been made. Such
Secretarial response period
shall be extended and shall not
include any days for any part
of which the Secretary
determines (in accordance with
regulations) that there was a
failure in the claims and
payment posting system and the
failure was justified due to
exceptional circumstances (as
defined in such regulations).
Such regulations shall define
exceptional circumstances in a
manner so that not more than 1
percent of the repayment
obligations under this
subclause would qualify as
exceptional circumstances.
(VI) Effective date.--The
Secretary shall promulgate
final regulations to carry out
this clause not later than 9
months after the date of the
enactment of this clause.
(VII) Website including
successor technology.--In this
clause, the term ``website''
includes any successor
technology.
(viii) Right of appeal for secondary
payer determinations relating to
liability insurance (including self-
insurance), no fault insurance, and
workers' compensation laws and plans.--
The Secretary shall promulgate
regulations establishing a right of
appeal and appeals process, with
respect to any determination under this
subsection for a payment made under
this title for an item or service for
which the Secretary is seeking to
recover conditional payments from an
applicable plan (as defined in
paragraph (8)(F)) that is a primary
plan under subsection (A)(ii), under
which the applicable plan involved, or
an attorney, agent, or third party
administrator on behalf of such plan,
may appeal such determination. The
individual furnished such an item or
service shall be notified of the plan's
intent to appeal such determination
(C) Treatment of questionnaires.--The
Secretary may not fail to make payment under
subparagraph (A) solely on the ground that an
individual failed to complete a questionnaire
concerning the existence of a primary plan.
(3) Enforcement.--
(A) Private cause of action.--There is
established a private cause of action for
damages (which shall be in an amount double the
amount otherwise provided) in the case of a
primary plan which fails to provide for primary
payment (or appropriate reimbursement) in
accordance with paragraphs (1) and (2)(A).
(B) Reference to excise tax with respect to
nonconforming group health plans.--For
provision imposing an excise tax with respect
to nonconforming group health plans, see
section 5000 of the Internal Revenue Code of
1986.
(C) Prohibition of financial incentives not
to enroll in a group health plan or a large
group health plan.--It is unlawful for an
employer or other entity to offer any financial
or other incentive for an individual entitled
to benefits under this title not to enroll (or
to terminate enrollment) under a group health
plan or a large group health plan which would
(in the case of such enrollment) be a primary
plan (as defined in paragraph (2)(A)). Any
entity that violates the previous sentence is
subject to a civil money penalty of not to
exceed $5,000 for each such violation. The
provisions of section 1128A (other than
subsections (a) and (b)) shall apply to a civil
money penalty under the previous sentence in
the same manner as such provisions apply to a
penalty or proceeding under section 1128A(a).
(4) Coordination of benefits.--Where payment for an
item or service by a primary plan is less than the
amount of the charge for such item or service and is
not payment in full, payment may be made under this
title (without regard to deductibles and coinsurance
under this title) for the remainder of such charge,
but--
(A) payment under this title may not exceed
an amount which would be payable under this
title for such item or service if paragraph
(2)(A) did not apply; and
(B) payment under this title, when combined
with the amount payable under the primary plan,
may not exceed--
(i) in the case of an item or service
payment for which is determined under
this title on the basis of reasonable
cost (or other cost-related basis) or
under section 1886, the amount which
would be payable under this title on
such basis, and
(ii) in the case of an item or
service for which payment is authorized
under this title on another basis--
(I) the amount which would be
payable under the primary plan
(without regard to deductibles
and coinsurance under such
plan), or
(II) the reasonable charge or
other amount which would be
payable under this title
(without regard to deductibles
and coinsurance under this
title),
whichever is greater.
(5) Identification of secondary payer situations.--
(A) Requesting matching information.--
(i) Commissioner of social
security.--The Commissioner of Social
Security shall, not less often that
annually, transmit to the Secretary of
the Treasury a list of the names and
TINs of medicare beneficiaries (as
defined in section 6103(l)(12) of the
Internal Revenue Code of 1986) and
request that the Secretary disclose to
the Commissioner the information
described in subparagraph (A) of such
section.
(ii) Administrator.--The
Administrator of the Centers for
Medicare & Medicaid Services shall
request, not less often than annually,
the Commissioner of the Social Security
Administration to disclose to the
Administrator the information described
in subparagraph (B) of section
6103(l)(12) of the Internal Revenue
Code of 1986.
(B) Disclosure to fiscal intermediaries and
carriers.--In addition to any other information
provided under this title to fiscal
intermediaries and carriers, the Administrator
shall disclose to such intermediaries and
carriers (or to such a single intermediary or
carrier as the Secretary may designate) the
information received under subparagraph (A) for
purposes of carrying out this subsection.
(C) Contacting employers.--
(i) In general.--With respect to each
individual (in this subparagraph
referred to as an ``employee'') who was
furnished a written statement under
section 6051 of the Internal Revenue
Code of 1986 by a qualified employer
(as defined in section
6103(l)(12)(E)(iii) of such Code), as
disclosed under subparagraph (B), the
appropriate fiscal intermediary or
carrier shall contact the employer in
order to determine during what period
the employee or employee's spouse may
be (or have been) covered under a group
health plan of the employer and the
nature of the coverage that is or was
provided under the plan (including the
name, address, and identifying number
of the plan).
(ii) Employer response.--Within 30
days of the date of receipt of the
inquiry, the employer shall notify the
intermediary or carrier making the
inquiry as to the determinations
described in clause (i). An employer
(other than a Federal or other
governmental entity) who willfully or
repeatedly fails to provide timely and
accurate notice in accordance with the
previous sentence shall be subject to a
civil money penalty of not to exceed
$1,000 for each individual with respect
to which such an inquiry is made. The
provision of section 1128A (other than
subsections (a) and (b)) shall apply to
a civil money penalty under the
previous sentence in the same manner as
such provisions apply to a penalty or
proceeding under section 1128A(a).
(D) Obtaining information from
beneficiaries.--Before an individual applies
for benefits under part A or enrolls under part
B, the Administrator shall mail the individual
a questionnaire to obtain information on
whether the individual is covered under a
primary plan and the nature of the coverage
provided under the plan, including the name,
address, and identifying number of the plan.
(E) End date.--The provisions of this
paragraph shall not apply to information
required to be provided on or after July 1,
2016.
(6) Screening requirements for providers and
suppliers.--
(A) In general.--Notwithstanding any other
provision of this title, no payment may be made
for any item or service furnished under part B
unless the entity furnishing such item or
service completes (to the best of its knowledge
and on the basis of information obtained from
the individual to whom the item or service is
furnished) the portion of the claim form
relating to the availability of other health
benefit plans.
(B) Penalties.--An entity that knowingly,
willfully, and repeatedly fails to complete a
claim form in accordance with subparagraph (A)
or provides inaccurate information relating to
the availability of other health benefit plans
on a claim form under such subparagraph shall
be subject to a civil money penalty of not to
exceed $2,000 for each such incident. The
provisions of section 1128A (other than
subsections (a) and (b)) shall apply to a civil
money penalty under the previous sentence in
the same manner as such provisions apply to a
penalty or proceeding under section 1128A(a).
(7) Required submission of information by group
health plans.--
(A) Requirement.--On and after the first day
of the first calendar quarter beginning after
the date that is 1 year after the date of the
enactment of this paragraph, an entity serving
as an insurer or third party administrator for
a group health plan, as defined in paragraph
(1)(A)(v), and, in the case of a group health
plan that is self-insured and self-
administered, a plan administrator or
fiduciary, shall--
(i) secure from the plan sponsor and
plan participants such information as
the Secretary shall specify for the
purpose of identifying situations where
the group health plan is or has been--
(I) a primary plan to the
program under this title; or
(II) for calendar quarters
beginning on or after January
1, 2020, a primary payer with
respect to benefits relating to
prescription drug coverage
under part D; and
(ii) submit such information to the
Secretary in a form and manner
(including frequency) specified by the
Secretary.
(B) Enforcement.--
(i) In general.--An entity, a plan
administrator, or a fiduciary described
in subparagraph (A) that fails to
comply with the requirements under such
subparagraph shall be subject to a
civil money penalty of $1,000 for each
day of noncompliance for each
individual for which the information
under such subparagraph should have
been submitted. The provisions of
subsections (e) and (k) of section
1128A shall apply to a civil money
penalty under the previous sentence in
the same manner as such provisions
apply to a penalty or proceeding under
section 1128A(a). A civil money penalty
under this clause shall be in addition
to any other penalties prescribed by
law and in addition to any Medicare
secondary payer claim under this title
with respect to an individual.
(ii) Deposit of amounts collected.--
Any amounts collected pursuant to
clause (i) shall be deposited in the
Federal Hospital Insurance Trust Fund
under section 1817.
(C) Sharing of information.--Notwithstanding
any other provision of law, under terms and
conditions established by the Secretary, the
Secretary--
(i) shall share information on
entitlement under Part A and enrollment
under Part B under this title with
entities, plan administrators, and
fiduciaries described in subparagraph
(A);
(ii) may share the entitlement and
enrollment information described in
clause (i) with entities and persons
not described in such clause; and
(iii) may share information collected
under this paragraph as necessary for
purposes of the proper coordination of
benefits.
(D) Implementation.--Notwithstanding any
other provision of law, the Secretary may
implement this paragraph by program instruction
or otherwise.
(8) Required submission of information by or on
behalf of liability insurance (including self-
insurance), no fault insurance, and workers'
compensation laws and plans.--
(A) Requirement.--On and after the first day
of the first calendar quarter beginning after
the date that is 18 months after the date of
the enactment of this paragraph, an applicable
plan shall--
(i) determine whether a claimant
(including an individual whose claim is
unresolved) is entitled to benefits
under the program under this title on
any basis; and
(ii) if the claimant is determined to
be so entitled, submit the information
described in subparagraph (B) with
respect to the claimant to the
Secretary in a form and manner
(including frequency) specified by the
Secretary.
(B) Required information.--The information
described in this subparagraph is--
(i) the identity of the claimant for
which the determination under
subparagraph (A) was made; and
(ii) such other information as the
Secretary shall specify in order to
enable the Secretary to make an
appropriate determination concerning
coordination of benefits, including any
applicable recovery claim.
Not later than 18 months after the date of
enactment of this sentence, the Secretary shall
modify the reporting requirements under this
paragraph so that an applicable plan in
complying with such requirements is permitted
but not required to access or report to the
Secretary beneficiary social security account
numbers or health identification claim numbers,
except that the deadline for such modification
shall be extended by one or more periods
(specified by the Secretary) of up to 1 year
each if the Secretary notifies the committees
of jurisdiction of the House of Representatives
and of the Senate that the prior deadline for
such modification, without such extension,
threatens patient privacy or the integrity of
the secondary payer program under this
subsection. Any such deadline extension notice
shall include information on the progress being
made in implementing such modification and the
anticipated implementation date for such
modification.
(C) Timing.--Information shall be submitted
under subparagraph (A)(ii) within a time
specified by the Secretary after the claim is
resolved through a settlement, judgment, award,
or other payment (regardless of whether or not
there is a determination or admission of
liability).
(D) Claimant.--For purposes of subparagraph
(A), the term ``claimant'' includes--
(i) an individual filing a claim
directly against the applicable plan;
and
(ii) an individual filing a claim
against an individual or entity insured
or covered by the applicable plan.
(E) Enforcement.--
(i) In general.--An applicable plan
that fails to comply with the
requirements under subparagraph (A)
with respect to any claimant may be
subject to a civil money penalty of up
to $1,000 for each day of noncompliance
with respect to each claimant. The
provisions of subsections (e) and (k)
of section 1128A shall apply to a civil
money penalty under the previous
sentence in the same manner as such
provisions apply to a penalty or
proceeding under section 1128A(a). A
civil money penalty under this clause
shall be in addition to any other
penalties prescribed by law and in
addition to any Medicare secondary
payer claim under this title with
respect to an individual.
(ii) Deposit of amounts collected.--
Any amounts collected pursuant to
clause (i) shall be deposited in the
Federal Hospital Insurance Trust Fund.
(F) Applicable plan.--In this paragraph, the
term ``applicable plan'' means the following
laws, plans, or other arrangements, including
the fiduciary or administrator for such law,
plan, or arrangement:
(i) Liability insurance (including
self-insurance).
(ii) No fault insurance.
(iii) Workers' compensation laws or
plans.
(G) Sharing of information.--The Secretary
may share information collected under this
paragraph as necessary for purposes of the
proper coordination of benefits.
(H) Implementation.--Notwithstanding any
other provision of law, the Secretary may
implement this paragraph by program instruction
or otherwise.
(I) Regulations.--Not later than 60 days
after the date of the enactment of this
subparagraph, the Secretary shall publish a
notice in the Federal Register soliciting
proposals, which will be accepted during a 60-
day period, for the specification of practices
for which sanctions will and will not be
imposed under subparagraph (E), including not
imposing sanctions for good faith efforts to
identify a beneficiary pursuant to this
paragraph under an applicable entity
responsible for reporting information. After
considering the proposals so submitted, the
Secretary, in consultation with the Attorney
General, shall publish in the Federal Register,
including a 60-day period for comment, proposed
specified practices for which such sanctions
will and will not be imposed. After considering
any public comments received during such
period, the Secretary shall issue final rules
specifying such practices.
(9) Exception.--
(A) In general.--Clause (ii) of paragraph
(2)(B) and any reporting required by paragraph
(8) shall not apply with respect to any
settlement, judgment, award, or other payment
by an applicable plan arising from liability
insurance (including self-insurance) and from
alleged physical trauma-based incidents
(excluding alleged ingestion, implantation, or
exposure cases) constituting a total payment
obligation to a claimant of not more than the
single threshold amount calculated by the
Secretary under subparagraph (B) for the year
involved.
(B) Annual computation of threshold.--
(i) In general.--Not later than
November 15 before each year, the
Secretary shall calculate and publish a
single threshold amount for
settlements, judgments, awards, or
other payments for obligations arising
from liability insurance (including
self-insurance) and for alleged
physical trauma-based incidents
(excluding alleged ingestion,
implantation, or exposure cases)
subject to this section for that year.
The annual single threshold amount for
a year shall be set such that the
estimated average amount to be credited
to the Medicare trust funds of
collections of conditional payments
from such settlements, judgments,
awards, or other payments arising from
liability insurance (including self-
insurance) and for such alleged
incidents subject to this section shall
equal the estimated cost of collection
incurred by the United States
(including payments made to
contractors) for a conditional payment
arising from liability insurance
(including self-insurance) and for such
alleged incidents subject to this
section for the year. At the time of
calculating, but before publishing, the
single threshold amount for 2014, the
Secretary shall inform, and seek review
of, the Comptroller General of the
United States with regard to such
amount.
(ii) Publication.--The Secretary
shall include, as part of such
publication for a year--
(I) the estimated cost of
collection incurred by the
United States (including
payments made to contractors)
for a conditional payment
arising from liability
insurance (including self-
insurance) and for such alleged
incidents; and
(II) a summary of the
methodology and data used by
the Secretary in computing such
threshold amount and such cost
of collection.
(C) Exclusion of ongoing expenses.--For
purposes of this paragraph and with respect to
a settlement, judgment, award, or other payment
not otherwise addressed in clause (ii) of
paragraph (2)(B) that includes ongoing
responsibility for medical payments (excluding
settlements, judgments, awards, or other
payments made by a workers' compensation law or
plan or no fault insurance), the amount
utilized for calculation of the threshold
described in subparagraph (A) shall include
only the cumulative value of the medical
payments made under this title.
(D) Report to congress.--Not later than
November 15 before each year, the Secretary
shall submit to the Congress a report on the
single threshold amount for settlements,
judgments, awards, or other payments for
conditional payment obligations arising from
liability insurance (including self-insurance)
and alleged incidents described in subparagraph
(A) for that year and on the establishment and
application of similar thresholds for such
payments for conditional payment obligations
arising from worker compensation cases and from
no fault insurance cases subject to this
section for the year. For each such report, the
Secretary shall--
(i) calculate the threshold amount by
using the methodology applicable to
certain liability claims described in
subparagraph (B); and
(ii) include a summary of the
methodology and data used in
calculating each threshold amount and
the amount of estimated savings under
this title achieved by the Secretary
implementing each such threshold.
(c) No payment may be made under part B for any expenses
incurred for--
(1) a drug product--
(A) which is described in section 107(c)(3)
of the Drug Amendments of 1962,
(B) which may be dispensed only upon
prescription,
(C) for which the Secretary has issued a
notice of an opportunity for a hearing under
subsection (e) of section 505 of the Federal
Food, Drug, and Cosmetic Act on a proposed
order of the Secretary to withdraw approval of
an application for such drug product under such
section because the Secretary has determined
that the drug is less than effective for all
conditions of use prescribed, recommended, or
suggested in its labeling, and
(D) for which the Secretary has not
determined there is a compelling justification
for its medical need; and
(2) any other drug product--
(A) which is identical, related, or similar
(as determined in accordance with section 310.6
of title 21 of the Code of Federal Regulations)
to a drug product described in paragraph (1),
and
(B) for which the Secretary has not
determined there is a compelling justification
for its medical need,
until such time as the Secretary withdraws such proposed order.
(d) For purposes of subsection (a)(1)(A), in the case of any
item or service that is required to be provided pursuant to
section 1867 to an individual who is entitled to benefits under
this title, determinations as to whether the item or service is
reasonable and necessary shall be made on the basis of the
information available to the treating physician or practitioner
(including the patient's presenting symptoms or complaint) at
the time the item or service was ordered or furnished by the
physician or practitioner (and not on the patient's principal
diagnosis). When making such determinations with respect to
such an item or service, the Secretary shall not consider the
frequency with which the item or service was provided to the
patient before or after the time of the admission or visit.
(e)(1) No payment may be made under this title with respect
to any item or service (other than an emergency item or
service, not including items or services furnished in an
emergency room of a hospital) furnished--
(A) by an individual or entity during the period when
such individual or entity is excluded pursuant to
section 1128, 1128A, 1156 or 1842(j)(2) from
participation in the program under this title; or
(B) at the medical direction or on the prescription
of a physician during the period when he is excluded
pursuant to section 1128, 1128A, 1156 or 1842(j)(2)
from participation in the program under this title and
when the person furnishing such item or service knew or
had reason to know of the exclusion (after a reasonable
time period after reasonable notice has been furnished
to the person).
(2) Where an individual eligible for benefits under this
title submits a claim for payment for items or services
furnished by an individual or entity excluded from
participation in the programs under this title, pursuant to
section 1128, 1128A, 1156, 1160 (as in effect on September 2,
1982), 1842(j)(2), 1862(d) (as in effect on the date of the
enactment of the Medicare and Medicaid Patient and Program
Protection Act of 1987), or l866, and such beneficiary did not
know or have reason to know that such individual or entity was
so excluded, then, to the extent permitted by this title, and
notwithstanding such exclusion, payment shall be made for such
items or services. In each such case the Secretary shall notify
the beneficiary of the exclusion of the individual or entity
furnishing the items or services. Payment shall not be made for
items or services furnished by an excluded individual or entity
to a beneficiary after a reasonable time (as determined by the
Secretary in regulations) after the Secretary has notified the
beneficiary of the exclusion of that individual or entity.
(f) The Secretary shall establish utilization guidelines for
the determination of whether or not payment may be made,
consistent with paragraph (1)(A) of subsection (a), under part
A or part B for expenses incurred with respect to the provision
of home health services, and shall provide for the
implementation of such guidelines through a process of
selective postpayment coverage review by intermediaries or
otherwise.
(g) The Secretary shall, in making the determinations under
paragraphs (1) and (9) of subsection (a), and for the purposes
of promoting the effective, efficient, and economical delivery
of health care services, and of promoting the quality of
services of the type for which payment may be made under this
title, enter into contracts with quality improvement
organizations pursuant to part B of title XI of this Act.
(h)(1) The Secretary--
(A) shall waive the application of subsection (a)(22)
in cases in which--
(i) there is no method available for the
submission of claims in an electronic form; or
(ii) the entity submitting the claim is a
small provider of services or supplier; and
(B) may waive the application of such subsection in
such unusual cases as the Secretary finds appropriate.
(2) For purposes of this subsection, the term ``small
provider of services or supplier'' means--
(A) a provider of services with fewer than 25 full-
time equivalent employees; or
(B) a physician, practitioner, facility, or supplier
(other than provider of services) with fewer than 10
full-time equivalent employees.
(i) In order to supplement the activities of the Medicare
Payment Advisory Commission under section 1886(e) in assessing
the safety, efficacy, and cost-effectiveness of new and
existing medical procedures, the Secretary may carry out, or
award grants or contracts for, original research and
experimentation of the type described in clause (ii) of section
1886(e)(6)(E) with respect to such a procedure if the Secretary
finds that--
(1) such procedure is not of sufficient commercial
value to justify research and experimentation by a
commercial organization;
(2) research and experimentation with respect to such
procedure is not of a type that may appropriately be
carried out by an institute, division, or bureau of the
National Institutes of Health; and
(3) such procedure has the potential to be more cost-
effective in the treatment of a condition than
procedures currently in use with respect to such
condition.
(j)(1) Any advisory committee appointed to advise the
Secretary on matters relating to the interpretation,
application, or implementation of subsection (a)(1) shall
assure the full participation of a nonvoting member in the
deliberations of the advisory committee, and shall provide such
nonvoting member access to all information and data made
available to voting members of the advisory committee, other
than information that--
(A) is exempt from disclosure pursuant to subsection
(a) of section 552 of title 5, United States Code, by
reason of subsection (b)(4) of such section (relating
to trade secrets); or
(B) the Secretary determines would present a conflict
of interest relating to such nonvoting member.
(2) If an advisory committee described in paragraph (1)
organizes into panels of experts according to types of items or
services considered by the advisory committee, any such panel
of experts may report any recommendation with respect to such
items or services directly to the Secretary without the prior
approval of the advisory committee or an executive committee
thereof.
(k)(1) Subject to paragraph (2), a group health plan (as
defined in subsection (a)(1)(A)(v)) providing supplemental or
secondary coverage to individuals also entitled to services
under this title shall not require a medicare claims
determination under this title for dental benefits specifically
excluded under subsection (a)(12) as a condition of making a
claims determination for such benefits under the group health
plan.
(2) A group health plan may require a claims determination
under this title in cases involving or appearing to involve
inpatient dental hospital services or dental services expressly
covered under this title pursuant to actions taken by the
Secretary.
(l) National and Local Coverage Determination Process.--
(1) Factors and evidence used in making national
coverage determinations.--The Secretary shall make
available to the public the factors considered in
making national coverage determinations of whether an
item or service is reasonable and necessary. The
Secretary shall develop guidance documents to carry out
this paragraph in a manner similar to the development
of guidance documents under section 701(h) of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C.
371(h)).
(2) Timeframe for decisions on requests for national
coverage determinations.--In the case of a request for
a national coverage determination that--
(A) does not require a technology assessment
from an outside entity or deliberation from the
Medicare Coverage Advisory Committee, the
decision on the request shall be made not later
than 6 months after the date of the request; or
(B) requires such an assessment or
deliberation and in which a clinical trial is
not requested, the decision on the request
shall be made not later than 9 months after the
date of the request.
(3) Process for public comment in national coverage
determinations.--
(A) Period for proposed decision.--Not later
than the end of the 6-month period (or 9-month
period for requests described in paragraph
(2)(B)) that begins on the date a request for a
national coverage determination is made, the
Secretary shall make a draft of proposed
decision on the request available to the public
through the Internet website of the Centers for
Medicare & Medicaid Services or other
appropriate means.
(B) 30-day period for public comment.--
Beginning on the date the Secretary makes a
draft of the proposed decision available under
subparagraph (A), the Secretary shall provide a
30-day period for public comment on such draft.
(C) 60-day period for final decision.--Not
later than 60 days after the conclusion of the
30-day period referred to under subparagraph
(B), the Secretary shall--
(i) make a final decision on the
request;
(ii) include in such final decision
summaries of the public comments
received and responses to such
comments;
(iii) make available to the public
the clinical evidence and other data
used in making such a decision when the
decision differs from the
recommendations of the Medicare
Coverage Advisory Committee; and
(iv) in the case of a final decision
under clause (i) to grant the request
for the national coverage
determination, the Secretary shall
assign a temporary or permanent code
(whether existing or unclassified) and
implement the coding change.
(4) Consultation with outside experts in certain
national coverage determinations.--With respect to a
request for a national coverage determination for which
there is not a review by the Medicare Coverage Advisory
Committee, the Secretary shall consult with appropriate
outside clinical experts.
(5) Local coverage determination process.--
(A) Plan to promote consistency of coverage
determinations.--The Secretary shall develop a
plan to evaluate new local coverage
determinations to determine which
determinations should be adopted nationally and
to what extent greater consistency can be
achieved among local coverage determinations.
(B) Consultation.--The Secretary shall
require the fiscal intermediaries or carriers
providing services within the same area to
consult on all new local coverage
determinations within the area.
(C) Dissemination of information.--The
Secretary should serve as a center to
disseminate information on local coverage
determinations among fiscal intermediaries and
carriers to reduce duplication of effort.
(D) Local coverage determinations.--The
Secretary shall require each Medicare
administrative contractor that develops a local
coverage determination to make available on the
Internet website of such contractor and on the
Medicare Internet website, at least 45 days
before the effective date of such
determination, the following information:
(i) Such determination in its
entirety.
(ii) Where and when the proposed
determination was first made public.
(iii) Hyperlinks to the proposed
determination and a response to
comments submitted to the contractor
with respect to such proposed
determination.
(iv) A summary of evidence that was
considered by the contractor during the
development of such determination and a
list of the sources of such evidence.
(v) An explanation of the rationale
that supports such determination.
(6) National and local coverage determination
defined.--For purposes of this subsection--
(A) National coverage determination.--The
term ``national coverage determination'' means
a determination by the Secretary with respect
to whether or not a particular item or service
is covered nationally under this title.
(B) Local coverage determination.--The term
``local coverage determination'' has the
meaning given that in section 1869(f)(2)(B).
(m) Coverage of Routine Costs Associated With Certain
Clinical Trials of Category A Devices.--
(1) In general.--In the case of an individual
entitled to benefits under part A, or enrolled under
part B, or both who participates in a category A
clinical trial, the Secretary shall not exclude under
subsection (a)(1) payment for coverage of routine costs
of care (as defined by the Secretary) furnished to such
individual in the trial.
(2) Category a clinical trial.--For purposes of
paragraph (1), a ``category A clinical trial'' means a
trial of a medical device if--
(A) the trial is of an experimental/
investigational (category A) medical device (as
defined in regulations under section 405.201(b)
of title 42, Code of Federal Regulations (as in
effect as of September 1, 2003));
(B) the trial meets criteria established by
the Secretary to ensure that the trial conforms
to appropriate scientific and ethical
standards; and
(C) in the case of a trial initiated before
January 1, 2010, the device involved in the
trial has been determined by the Secretary to
be intended for use in the diagnosis,
monitoring, or treatment of an immediately
life-threatening disease or condition.
(n) Requirement of a Surety Bond for Certain Providers of
Services and Suppliers.--
(1) In general.--The Secretary may require a provider
of services or supplier described in paragraph (2) to
provide the Secretary on a continuing basis with a
surety bond in a form specified by the Secretary in an
amount (not less than $50,000) that the Secretary
determines is commensurate with the volume of the
billing of the provider of services or supplier. The
Secretary may waive the requirement of a bond under the
preceding sentence in the case of a provider of
services or supplier that provides a comparable surety
bond under State law.
(2) Provider of services or supplier described.--A
provider of services or supplier described in this
paragraph is a provider of services or supplier the
Secretary determines appropriate based on the level of
risk involved with respect to the provider of services
or supplier, and consistent with the surety bond
requirements under sections 1834(a)(16)(B) and
1861(o)(7)(C).
(o) Suspension of Payments Pending Investigation of Credible
Allegations of Fraud.--
(1) In general.--The Secretary may suspend payments
to a provider of services or supplier under this title
pending an investigation of a credible allegation of
fraud against the provider of services or supplier,
unless the Secretary determines there is good cause not
to suspend such payments.
(2) Consultation.--The Secretary shall consult with
the Inspector General of the Department of Health and
Human Services in determining whether there is a
credible allegation of fraud against a provider of
services or supplier.
(3) Promulgation of regulations.--The Secretary shall
promulgate regulations to carry out this subsection,
section 1860D-12(b)(7) (including as applied pursuant
to section 1857(f)(3)(D)), and section 1903(i)(2)(C).
(4) Credible allegation of fraud.--In carrying out
this subsection, section 1860D-12(b)(7) (including as
applied pursuant to section 1857(f)(3)(D)), and section
1903(i)(2)(C), a fraud hotline tip (as defined by the
Secretary) without further evidence shall not be
treated as sufficient evidence for a credible
allegation of fraud.
* * * * * * *
independence at home medical practice demonstration program
Sec. 1866E. (a) Establishment.--
(1) In general.--The Secretary shall conduct a
demonstration program (in this section referred to as
the ``demonstration program'') to test a payment
incentive and service delivery model that utilizes
physician and nurse practitioner directed home-based
primary care teams designed to reduce expenditures and
improve health outcomes in the provision of items and
services under this title to applicable beneficiaries
(as defined in subsection (d)).
(2) Requirement.--The demonstration program shall
test whether a model described in paragraph (1), which
is accountable for providing comprehensive,
coordinated, continuous, and accessible care to high-
need populations at home and coordinating health care
across all treatment settings, results in--
(A) reducing preventable hospitalizations;
(B) preventing hospital readmissions;
(C) reducing emergency room visits;
(D) improving health outcomes commensurate
with the beneficiaries' stage of chronic
illness;
(E) improving the efficiency of care, such as
by reducing duplicative diagnostic and
laboratory tests;
(F) reducing the cost of health care services
covered under this title; and
(G) achieving beneficiary and family
caregiver satisfaction.
(b) Independence at Home Medical Practice.--
(1) Independence at home medical practice defined.--
In this section:
(A) In general.--The term ``independence at
home medical practice'' means a legal entity
that--
(i) is comprised of an individual
physician or nurse practitioner or
group of physicians and nurse
practitioners that provides care as
part of a team that includes
physicians, nurses, physician
assistants, pharmacists, and other
health and social services staff as
appropriate who have experience
providing home-based primary care to
applicable beneficiaries, make in-home
visits, and are available 24 hours per
day, 7 days per week to carry out plans
of care that are tailored to the
individual beneficiary's chronic
conditions and designed to achieve the
results in subsection (a);
(ii) is organized at least in part
for the purpose of providing
physicians' services;
(iii) has documented experience in
providing home-based primary care
services to high-cost chronically ill
beneficiaries, as determined
appropriate by the Secretary;
(iv) furnishes services to at least
200 applicable beneficiaries (as
defined in subsection (d)) during each
year of the demonstration program;
(v) has entered into an agreement
with the Secretary;
(vi) uses electronic health
information systems, remote monitoring,
and mobile diagnostic technology; and
(vii) meets such other criteria as
the Secretary determines to be
appropriate to participate in the
demonstration program.
The entity shall report on quality measures (in
such form, manner, and frequency as specified
by the Secretary, which may be for the group,
for providers of services and suppliers, or
both) and report to the Secretary (in a form,
manner, and frequency as specified by the
Secretary) such data as the Secretary
determines appropriate to monitor and evaluate
the demonstration program.
(B) Physician.--The term ``physician''
includes, except as the Secretary may otherwise
provide, any individual who furnishes services
for which payment may be made as physicians'
services and has the medical training or
experience to fulfill the physician's role
described in subparagraph (A)(i).
(2) Participation of nurse practitioners and
physician assistants.--Nothing in this section shall be
construed to prevent a nurse practitioner or physician
assistant from participating in, or leading, a home-
based primary care team as part of an independence at
home medical practice if--
(A) all the requirements of this section are
met;
(B) the nurse practitioner or physician
assistant, as the case may be, is acting
consistent with State law; and
(C) the nurse practitioner or physician
assistant has the medical training or
experience to fulfill the nurse practitioner or
physician assistant role described in paragraph
(1)(A)(i).
(3) Inclusion of providers and practitioners.--
Nothing in this subsection shall be construed as
preventing an independence at home medical practice
from including a provider of services or a
participating practitioner described in section
1842(b)(18)(C) that is affiliated with the practice
under an arrangement structured so that such provider
of services or practitioner participates in the
demonstration program and shares in any savings under
the demonstration program.
(4) Quality and performance standards.--The Secretary
shall develop quality performance standards for
independence at home medical practices participating in
the demonstration program.
(c) Payment Methodology.--
(1) Establishment of target spending level.--The
Secretary shall establish an estimated annual spending
target, for the amount the Secretary estimates would
have been spent in the absence of the demonstration,
for items and services covered under parts A and B
furnished to applicable beneficiaries for each
qualifying independence at home medical practice under
this section. Such spending targets shall be determined
on a per capita basis. Such spending targets shall
include a risk corridor that takes into account normal
variation in expenditures for items and services
covered under parts A and B furnished to such
beneficiaries with the size of the corridor being
related to the number of applicable beneficiaries
furnished services by each independence at home medical
practice. The spending targets may also be adjusted for
other factors as the Secretary determines appropriate.
(2) Incentive payments.--Subject to performance on
quality measures, a qualifying independence at home
medical practice is eligible to receive an incentive
payment under this section if actual expenditures for a
year for the applicable beneficiaries it enrolls are
less than the estimated spending target established
under paragraph (1) for such year. An incentive payment
for such year shall be equal to a portion (as
determined by the Secretary) of the amount by which
actual expenditures (including incentive payments under
this paragraph) for applicable beneficiaries under
parts A and B for such year are estimated to be less
than 5 percent less than the estimated spending target
for such year, as determined under paragraph (1).
(d) Applicable Beneficiaries.--
(1) Definition.--In this section, the term
``applicable beneficiary'' means, with respect to a
qualifying independence at home medical practice, an
individual who the practice has determined--
(A) is entitled to benefits under part A and
enrolled for benefits under part B;
(B) is not enrolled in a Medicare Advantage
plan under part C or a PACE program under
section 1894;
(C) has 2 or more chronic illnesses, such as
congestive heart failure, diabetes, other
dementias designated by the Secretary, chronic
obstructive pulmonary disease, ischemic heart
disease, stroke, Alzheimer's Disease and
neurodegenerative diseases, and other diseases
and conditions designated by the Secretary
which result in high costs under this title;
(D) within the past 12 months has had a
nonelective hospital admission;
(E) within the past 12 months has received
acute or subacute rehabilitation services;
(F) has 2 or more functional dependencies
requiring the assistance of another person
(such as bathing, dressing, toileting, walking,
or feeding); and
(G) meets such other criteria as the
Secretary determines appropriate.
(2) Patient election to participate.--The Secretary
shall determine an appropriate method of ensuring that
applicable beneficiaries have agreed to enroll in an
independence at home medical practice under the
demonstration program. Enrollment in the demonstration
program shall be voluntary.
(3) Beneficiary access to services.--Nothing in this
section shall be construed as encouraging physicians or
nurse practitioners to limit applicable beneficiary
access to services covered under this title and
applicable beneficiaries shall not be required to
relinquish access to any benefit under this title as a
condition of receiving services from an independence at
home medical practice.
(e) Implementation.--
(1) Starting date.--The demonstration program shall
begin no later than January 1, 2012. Agreements with an
independence at home medical practice under the
demonstration program may cover not more than a [7-
year] 10-year period.
(2) No physician duplication in demonstration
participation.--The Secretary shall not pay an
independence at home medical practice under this
section that participates in section 1899.
(3) No beneficiary duplication in demonstration
participation.--The Secretary shall ensure that no
applicable beneficiary enrolled in an independence at
home medical practice under this section is
participating in the programs under section 1899.
(4) Preference.--In approving an independence at home
medical practice, the Secretary shall give preference
to practices that are--
(A) located in high-cost areas of the
country;
(B) have experience in furnishing health care
services to applicable beneficiaries in the
home; and
(C) use electronic medical records, health
information technology, and individualized
plans of care.
(5) Limitation on number of practices.--In selecting
qualified independence at home medical practices to
participate under the demonstration program, the
Secretary shall limit the number of such practices so
that the number of applicable beneficiaries that may
participate in the demonstration program does not
exceed 15,000. An applicable beneficiary that
participates in the demonstration program by reason of
the increase from 10,000 to 15,000 in the preceding
sentence pursuant to the amendment made by section
50301(a)(1)(B)(i) of the Advancing Chronic Care,
Extenders, and Social Services Act shall be considered
in the spending target estimates under paragraph (1) of
subsection (c) and the incentive payment calculations
under paragraph (2) of such subsection for the sixth
and seventh years of such program.
(6) Waiver.--The Secretary may waive such provisions
of this title and title XI as the Secretary determines
necessary in order to implement the demonstration
program.
(7) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to this section.
(f) Evaluation and Monitoring.--
(1) In general.--The Secretary shall evaluate each
independence at home medical practice under the
demonstration program to assess whether the practice
achieved the results described in subsection (a).
(2) Monitoring applicable beneficiaries.--The
Secretary may monitor data on expenditures and quality
of services under this title after an applicable
beneficiary discontinues receiving services under this
title through a qualifying independence at home medical
practice.
(g) Reports to Congress.--The Secretary shall conduct an
independent evaluation of the demonstration program and submit
to Congress a final report, including best practices under the
demonstration program, including, to the extent practicable,
with respect to the use of electronic health information
systems, as described in subsection (b)(1)(A)(vi). Such report
shall include an analysis of the demonstration program on
coordination of care, expenditures under this title, applicable
beneficiary access to services, and the quality of health care
services provided to applicable beneficiaries.
(h) Funding.--For purposes of administering and carrying out
the demonstration program, other than for payments for items
and services furnished under this title and incentive payments
under subsection (c), in addition to funds otherwise
appropriated, there shall be transferred to the Secretary for
the Center for Medicare & Medicaid Services Program Management
Account from the Federal Hospital Insurance Trust Fund under
section 1817 and the Federal Supplementary Medical Insurance
Trust Fund under section 1841 (in proportions determined
appropriate by the Secretary) $5,000,000 for each of fiscal
years 2010 through 2015. Amounts transferred under this
subsection for a fiscal year shall be available until expended.
(i) Termination.--
(1) Mandatory termination.--The Secretary shall
terminate an agreement with an independence at home
medical practice if--
(A) the Secretary estimates or determines
that such practice did not achieve savings for
the third of 3 consecutive years under the
demonstration program; or
(B) such practice fails to meet quality
standards during any year of the demonstration
program.
(2) Permissive termination.--The Secretary may
terminate an agreement with an independence at home
medical practice for such other reasons determined
appropriate by the Secretary.
* * * * * * *
contract with a consensus-based entity regarding performance
measurement
Sec. 1890. (a) Contract.--
(1) In general.--For purposes of activities conducted
under this Act, the Secretary shall identify and have
in effect a contract with a consensus-based entity,
such as the National Quality Forum, that meets the
requirements described in subsection (c). Such contract
shall provide that the entity will perform the duties
described in subsection (b).
(2) Timing for first contract.--As soon as
practicable after the date of the enactment of this
subsection, the Secretary shall enter into the first
contract under paragraph (1).
(3) Period of contract.--A contract under paragraph
(1) shall be for a period of 4 years (except as may be
renewed after a subsequent bidding process).
(4) Competitive procedures.--Competitive procedures
(as defined in section 4(5) of the Office of Federal
Procurement Policy Act (41 U.S.C. 403(5))) shall be
used to enter into a contract under paragraph (1).
(b) Duties.--The duties described in this subsection are the
following:
(1) Priority setting process.--The entity shall
synthesize evidence and convene key stakeholders to
make recommendations, with respect to activities
conducted under this Act, on an integrated national
strategy and priorities for health care performance
measurement in all applicable settings. In making such
recommendations, the entity shall--
(A) ensure that priority is given to
measures--
(i) that address the health care
provided to patients with prevalent,
high-cost chronic diseases;
(ii) with the greatest potential for
improving the quality, efficiency, and
patient-centeredness of health care;
and
(iii) that may be implemented rapidly
due to existing evidence, standards of
care, or other reasons; and
(B) take into account measures that--
(i) may assist consumers and patients
in making informed health care
decisions;
(ii) address health disparities
across groups and areas; and
(iii) address the continuum of care a
patient receives, including services
furnished by multiple health care
providers or practitioners and across
multiple settings.
(2) Endorsement of measures.--The entity shall
provide for the endorsement of standardized health care
performance measures. The endorsement process under the
preceding sentence shall consider whether a measure--
(A) is evidence-based, reliable, valid,
verifiable, relevant to enhanced health
outcomes, actionable at the caregiver level,
feasible to collect and report, and responsive
to variations in patient characteristics, such
as health status, language capabilities, race
or ethnicity, and income level; and
(B) is consistent across types of health care
providers, including hospitals and physicians.
(3) Maintenance of measures.--The entity shall
establish and implement a process to ensure that
measures endorsed under paragraph (2) are updated (or
retired if obsolete) as new evidence is developed.
(4) Removal of measures.--The entity may, through the
multistakeholder groups convened under paragraph
(7)(A), provide input to the Secretary on quality and
efficiency measures described in paragraph (7)(B) that
could be considered for removal.
(5) Annual report to congress and the secretary;
secretarial publication and comment.--
(A) Annual report.--By not later than March 1
of each year (beginning with 2009), the entity
shall submit to Congress and the Secretary a
report containing the following:
(i) A description of--
(I) the implementation of
quality measurement initiatives
under this Act and the
coordination of such
initiatives with quality
initiatives implemented by
other payers;
(II) the recommendations made
under paragraph (1);
(III) the performance by the
entity of the duties required
under the contract entered into
with the Secretary under
subsection (a);
(IV) gaps in endorsed quality
measures, which shall include
measures that are within
priority areas identified by
the Secretary under the
national strategy established
under section 399HH of the
Public Health Service Act, and
where quality measures are
unavailable or inadequate to
identify or address such gaps;
(V) areas in which evidence
is insufficient to support
endorsement of quality measures
in priority areas identified by
the Secretary under the
national strategy established
under section 399HH of the
Public Health Service Act and
where targeted research may
address such gaps; and
(VI) the matters described in
clauses (i) and (ii) of
paragraph (7)(A).
(ii) An itemization of financial
information for the fiscal year ending
September 30 of the preceding year,
including--
(I) annual revenues of the
entity (including any
government funding, private
sector contributions, grants,
membership revenues, and
investment revenue);
(II) annual expenses of the
entity (including grants paid,
benefits paid, salaries or
other compensation, fundraising
expenses, and overhead costs);
and
(III) a breakdown of the
amount awarded per contracted
task order and the specific
projects funded in each task
order assigned to the entity.
(iii) Any updates or modifications of
internal policies and procedures of the
entity as they relate to the duties of
the entity under this section,
including--
(I) specifically identifying
any modifications to the
disclosure of interests and
conflicts of interests for
committees, work groups, task
forces, and advisory panels of
the entity; and
(II) information on external
stakeholder participation in
the duties of the entity under
this section (including
complete rosters for all
committees, work groups, task
forces, and advisory panels
funded through government
contracts, descriptions of
relevant interests and any
conflicts of interest for
members of all committees, work
groups, task forces, and
advisory panels, and the total
percentage by health care
sector of all convened
committees, work groups, task
forces, and advisory panels.
(B) Secretarial review and publication of
annual report.--Not later than 6 months after
receiving a report under subparagraph (A) for a
year, the Secretary shall--
(i) review such report; and
(ii) publish such report in the
Federal Register, together with any
comments of the Secretary on such
report.
(6) Review and endorsement of episode grouper under
the physician feedback program.--The entity shall
provide for the review and, as appropriate, the
endorsement of the episode grouper developed by the
Secretary under section 1848(n)(9)(A). Such review
shall be conducted on an expedited basis.
(7) Convening multi-stakeholder groups.--
(A) In general.--The entity shall convene
multi-stakeholder groups to provide input on--
(i) the selection of quality and
efficiency measures described in
subparagraph (B), from among--
(I) such measures that have
been endorsed by the entity;
and
(II) such measures that have
not been considered for
endorsement by such entity but
are used or proposed to be used
by the Secretary for the
collection or reporting of
quality and efficiency
measures; and
(ii) national priorities (as
identified under section 399HH of the
Public Health Service Act) for
improvement in population health and in
the delivery of health care services
for consideration under the national
strategy established under section
399HH of the Public Health Service Act.
(B) Quality measures.--
(i) In general.--Subject to clause
(ii), the quality and efficiency
measures described in this subparagraph
are quality and efficiency measures--
(I) for use pursuant to
sections 1814(i)(5)(D),
1833(i)(7), 1833(t)(17),
1848(k)(2)(C), 1866(k)(3),
1881(h)(2)(A)(iii),
1886(b)(3)(B)(viii),
1886(j)(7)(D), 1886(m)(5)(D),
1886(o)(2), 1886(s)(4)(D), and
1895(b)(3)(B)(v);
(II) for use in reporting
performance information to the
public; and
(III) for use in health care
programs other than for use
under this Act.
(ii) Exclusion.--Data sets (such as
the outcome and assessment information
set for home health services and the
minimum data set for skilled nursing
facility services) that are used for
purposes of classification systems used
in establishing payment rates under
this title shall not be quality and
efficiency measures described in this
subparagraph.
(C) Requirement for transparency in
process.--
(i) In general.--In convening multi-
stakeholder groups under subparagraph
(A) with respect to the selection of
quality and efficiency measures, the
entity shall provide for an open and
transparent process for the activities
conducted pursuant to such convening.
(ii) Selection of organizations
participating in multi-stakeholder
groups.--The process described in
clause (i) shall ensure that the
selection of representatives comprising
such groups provides for public
nominations for, and the opportunity
for public comment on, such selection.
(D) Multi-stakeholder group defined.--In this
paragraph, the term ``multi-stakeholder group''
means, with respect to a quality and efficiency
measure, a voluntary collaborative of
organizations representing a broad group of
stakeholders interested in or affected by the
use of such quality and efficiency measure.
(8) Transmission of multi-stakeholder input.--Not
later than February 1 of each year (beginning with
2012), the entity shall transmit to the Secretary the
input of multi-stakeholder groups provided under
paragraph (7).
(9) Prioritization of measure endorsement.--The
entity--
(A) during the period beginning on the date
of the enactment of this paragraph and ending
on December 31, 2023, shall prioritize the
endorsement of measures relating to maternal
morbidity and mortality by the entity with a
contract under subsection (a) in connection
with endorsement of measures described in
paragraph (2); and
(B) on and after January 1, 2024, may
prioritize the endorsement of such measures by
such entity.
(c) Requirements Described.--The requirements described in
this subsection are the following:
(1) Private nonprofit.--The entity is a private
nonprofit entity governed by a board.
(2) Board membership.--The members of the board of
the entity include--
(A) representatives of health plans and
health care providers and practitioners or
representatives of groups representing such
health plans and health care providers and
practitioners;
(B) health care consumers or representatives
of groups representing health care consumers;
and
(C) representatives of purchasers and
employers or representatives of groups
representing purchasers or employers.
(3) Entity membership.--The membership of the entity
includes persons who have experience with--
(A) urban health care issues;
(B) safety net health care issues;
(C) rural and frontier health care issues;
and
(D) health care quality and safety issues.
(4) Open and transparent.--With respect to matters
related to the contract with the Secretary under
subsection (a), the entity conducts its business in an
open and transparent manner and provides the
opportunity for public comment on its activities.
(5) Voluntary consensus standards setting
organization.--The entity operates as a voluntary
consensus standards setting organization as defined for
purposes of section 12(d) of the National Technology
Transfer and Advancement Act of 1995 (Public Law 104-
113) and Office of Management and Budget Revised
Circular A-119 (published in the Federal Register on
February 10, 1998).
(6) Experience.--The entity has at least 4 years of
experience in establishing national consensus
standards.
(7) Membership fees.--If the entity requires a
membership fee for participation in the functions of
the entity, such fees shall be reasonable and adjusted
based on the capacity of the potential member to pay
the fee. In no case shall membership fees pose a
barrier to the participation of individuals or groups
with low or nominal resources to participate in the
functions of the entity.
(d) Funding.--(1) For purposes of carrying out this section,
the Secretary shall provide for the transfer, from the Federal
Hospital Insurance Trust Fund under section 1817 and the
Federal Supplementary Medical Insurance Trust Fund under
section 1841 (in such proportion as the Secretary determines
appropriate), of $10,000,000 to the Centers for Medicare &
Medicaid Services Program Management Account for each of fiscal
years 2009 through 2013. Amounts transferred under the
preceding sentence shall remain available until expended.
(2) For purposes of carrying out this section and section
1890A (other than subsections (e) and (f)), the Secretary shall
provide for the transfer, from the Federal Hospital Insurance
Trust Fund under section 1817 and the Federal Supplementary
Medical Insurance Trust Fund under section 1841, in such
proportion as the Secretary determines appropriate, to the
Centers for Medicare & Medicaid Services Program Management
Account of $5,000,000 for fiscal year 2014, $30,000,000 for
each of fiscal years 2015 through 2017, [and $7,500,000]
$7,500,000 for each of fiscal years 2018 [and 2019.] and 2019,
and $30,000,000 for each of fiscal years 2020 through 2022.
Amounts transferred under the preceding sentence shall remain
available until expended. Amounts transferred for each of
fiscal years 2018 and 2019 shall be in addition to any
unobligated funds transferred for a preceding fiscal year that
are available under the preceding sentence.
(e) Annual Report by Secretary to Congress.--By not later
than March 1 of each year (beginning with 2019), the Secretary
shall submit to Congress a report containing the following:
(1) A comprehensive plan that identifies the quality
measurement needs of programs and initiatives of the
Secretary and provides a strategy for using the entity
with a contract under subsection (a) and any other
entity the Secretary has contracted with or may
contract with to perform work associated with section
1890A to help meet those needs, specifically with
respect to the programs under this title and title XIX.
In years after the first plan under this paragraph is
submitted, the requirements of this paragraph may be
met by providing an update to the plan.
(2) The amount of funding provided under subsection
(d) for purposes of carrying out this section and
section 1890A that has been obligated by the Secretary,
the amount of funding provided that has been expended,
and the amount of funding provided that remains
unobligated.
(3) With respect to the activities described under
this section or section 1890A, a description of how the
funds described in paragraph (2) have been obligated or
expended, including how much of that funding has been
obligated or expended for work performed by the
Secretary, the entity with a contract under subsection
(a), and any other entity the Secretary has contracted
with to perform work.
(4) A description of the activities for which the
funds described in paragraph (2) were used, including
task orders and activities assigned to the entity with
a contract under subsection (a), activities performed
by the Secretary, and task orders and activities
assigned to any other entity the Secretary has
contracted with to perform work related to carrying out
section 1890A.
(5) The amount of funding described in paragraph (2)
that has been obligated or expended for each of the
activities described in paragraph (4).
(6) Estimates for, and descriptions of, obligations
and expenditures that the Secretary anticipates will be
needed in the succeeding two year period to carry out
each of the quality measurement activities required
under this section and section 1890A, including any
obligations that will require funds to be expended in a
future year.
* * * * * * *
medicare improvement fund
Sec. 1898.
(a) Establishment.--The Secretary shall establish under this
title a Medicare Improvement Fund (in this section referred to
as the `Fund') which shall be available to the Secretary to
make improvements under the original Medicare fee-for-service
program under parts A and B for individuals entitled to, or
enrolled for, benefits under part or enrolled under part B
including adjustments to payments for items and services
furnished by providers of services and suppliers under such
original Medicare fee-for-service program.
(b) Funding.--
(1) In general.--There shall be available to the
Fund, for expenditures from the Fund for services
furnished [during and after fiscal year 2021, $0]
during and after fiscal year 2024, $5,000,000.
(2) Payment from trust funds.--The amount specified
under paragraph (1) shall be available to the Fund, as
expenditures are made from the Fund, from the Federal
Hospital Insurance Trust Fund and the Federal
Supplementary Medical Insurance Trust Fund in such
proportion as the Secretary determines appropriate.
(3) Funding limitation.--Amounts in the Fund shall be
available in advance of appropriations but only if the
total amount obligated from the Fund does not exceed
the amount available to the Fund under paragraph (1).
The Secretary may obligate funds from the Fund only if
the Secretary determines (and the Chief Actuary of the
Centers for Medicare & Medicaid Services and the
appropriate budget officer certify) that there are
available in the Fund sufficient amounts to cover all
such obligations incurred consistent with the previous
sentence.
(4) No effect on payments in subsequent years.--In
the case that expenditures from the Fund are applied
to, or otherwise affect, a payment rate for an item or
service under this title for a year, the payment rate
for such item or service shall be computed for a
subsequent year as if such application or effect had
never occurred.
* * * * * * *
TITLE XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS
* * * * * * *
STATE PLANS FOR MEDICAL ASSISTANCE
Sec. 1902. (a) A State plan for medical assistance must--
(1) provide that it shall be in effect in all
political subdivisions of the State, and, if
administered by them, be mandatory upon them;
(2) provide for financial participation by the State
equal to not less than 40 per centum of the non-Federal
share of the expenditures under the plan with respect
to which payments under section 1903 are authorized by
this title; and, effective July 1, 1969, provide for
financial participation by the State equal to all of
such non-Federal share or provide for distribution of
funds from Federal or State sources, for carrying out
the State plan, on an equalization or other basis which
will assure that the lack of adequate funds from local
sources will not result in lowering the amount,
duration, scope, or quality of care and services
available under the plan;
(3) provide for granting an opportunity for a fair
hearing before the State agency to any individual whose
claim for medical assistance under the plan is denied
or is not acted upon with reasonable promptness;
(4) provide (A) such methods of administration
(including methods relating to the establishment and
maintenance of personnel standards on a merit basis,
except that the Secretary shall exercise no authority
with respect to the selection, tenure of office, and
compensation of any individual employed in accordance
with such methods, and including provision for
utilization of professional medical personnel in the
administration and, where administered locally,
supervision of administration of the plan) as are found
by the Secretary to be necessary for the proper and
efficient operation of the plan, (B) for the training
and effective use of paid subprofessional staff, with
particular emphasis on the full-time or part-time
employment of recipients and other persons of low
income, as community service aides, in the
administration of the plan and for the use of nonpaid
or partially paid volunteers in a social service
volunteer program in providing services to applicants
and recipients and in assisting any advisory committees
established by the State agency, (C) that each State or
local officer, employee, or independent contractor who
is responsible for the expenditure of substantial
amounts of funds under the State plan, each individual
who formerly was such an officer, employee, or
contractor, and each partner of such an officer,
employee, or contractor shall be prohibited from
committing any act, in relation to any activity under
the plan, the commission of which, in connection with
any activity concerning the United States Government,
by an officer or employee of the United States
Government, an individual who was such an officer or
employee, or a partner of such an officer or employee
is prohibited by section 207 or 208 of title 18, United
States Code, and (D) that each State or local officer,
employee, or independent contractor who is responsible
for selecting, awarding, or otherwise obtaining items
and services under the State plan shall be subject to
safeguards against conflicts of interest that are at
least as stringent as the safeguards that apply under
section 27 of the Office of Federal Procurement Policy
Act (41 U.S.C. 423) to persons described in subsection
(a)(2) of such section of that Act;
(5) either provide for the establishment or
designation of a single State agency to administer or
to supervise the administration of the plan; or provide
for the establishment or designation of a single State
agency to administer or to supervise the administration
of the plan, except that the determination of
eligibility for medical assistance under the plan shall
be made by the State or local agency administering the
State plan approved under title I or XVI (insofar as it
relates to the aged) if the State is eligible to
participate in the State plan program established under
title XVI, or by the agency or agencies administering
the supplemental security income program established
under title XVI or the State plan approved under part A
of title IV if the State is not eligible to participate
in the State plan program established under title XVI;
(6) provide that the State agency will make such
reports, in such form and containing such information,
as the Secretary may from time to time require, and
comply with such provisions as the Secretary may from
time to time find necessary to assure the correctness
and verification of such reports;
(7) provide--
(A) safeguards which restrict the use or
disclosure of information concerning applicants
and recipients to purposes directly connected
with--
(i) the administration of the plan;
and
(ii) the exchange of information
necessary to certify or verify the
certification of eligibility of
children for free or reduced price
breakfasts under the Child Nutrition
Act of 1966 and free or reduced price
lunches under the Richard B. Russell
National School Lunch Act, in
accordance with section 9(b) of that
Act, using data standards and formats
established by the State agency; and
(B) that, notwithstanding the Express Lane
option under subsection (e)(13), the State may
enter into an agreement with the State agency
administering the school lunch program
established under the Richard B. Russell
National School Lunch Act under which the State
shall establish procedures to ensure that--
(i) a child receiving medical
assistance under the State plan under
this title whose family income does not
exceed 133 percent of the poverty line
(as defined in section 673(2) of the
Community Services Block Grant Act,
including any revision required by such
section), as determined without regard
to any expense, block, or other income
disregard, applicable to a family of
the size involved, may be certified as
eligible for free lunches under the
Richard B. Russell National School
Lunch Act and free breakfasts under the
Child Nutrition Act of 1966 without
further application; and
(ii) the State agencies responsible
for administering the State plan under
this title, and for carrying out the
school lunch program established under
the Richard B. Russell National School
Lunch Act (42 U.S.C. 1751 et seq.) or
the school breakfast program
established by section 4 of the Child
Nutrition Act of 1966 (42 U.S.C. 1773),
cooperate in carrying out paragraphs
(3)(F) and (15) of section 9(b) of that
Act;
(8) provide that all individuals wishing to make
application for medical assistance under the plan shall
have opportunity to do so, and that such assistance
shall be furnished with reasonable promptness to all
eligible individuals;
(9) provide--
(A) that the State health agency, or other
appropriate State medical agency (whichever is
utilized by the Secretary for the purpose
specified in the first sentence of section
1864(a)), shall be responsible for establishing
and maintaining health standards for private or
public institutions in which recipients of
medical assistance under the plan may receive
care or services,
(B) for the establishment or designation of a
State authority or authorities which shall be
responsible for establishing and maintaining
standards, other than those relating to health,
for such institutions,
(C) that any laboratory services paid for
under such plan must be provided by a
laboratory which meets the applicable
requirements of section 1861(e)(9) or
paragraphs (16) and (17) of section 1861(s),
or, in the case of a laboratory which is in a
rural health clinic, of section 1861(aa)(2)(G),
and
(D) that the State maintain a consumer-
oriented website providing useful information
to consumers regarding all skilled nursing
facilities and all nursing facilities in the
State, including for each facility, Form 2567
State inspection reports (or a successor form),
complaint investigation reports, the facility's
plan of correction, and such other information
that the State or the Secretary considers
useful in assisting the public to assess the
quality of long term care options and the
quality of care provided by individual
facilities;
(10) provide--
(A) for making medical assistance available,
including at least the care and services listed
in paragraphs (1) through (5), (17), (21),
(28), and (29) of section 1905(a), to--
(i) all individuals--
(I) who are receiving aid or
assistance under any plan of
the State approved under title
I, X, XIV, or XVI, or part A or
part E of title IV (including
individuals eligible under this
title by reason of section
402(a)(37), 406(h), or 473(b),
or considered by the State to
be receiving such aid as
authorized under section
482(e)(6)),
(II)(aa) with respect to whom
supplemental security income
benefits are being paid under
title XVI (or were being paid
as of the date of the enactment
of section 211(a) of the
Personal Responsibility and
Work Opportunity Reconciliation
Act of 1996 (P.L. 104-193) and
would continue to be paid but
for the enactment of that
section), (bb) who are
qualified severely impaired
individuals (as defined in
section 1905(q)), or (cc) who
are under 21 years of age and
with respect to whom
supplemental security income
benefits would be paid under
title XVI if subparagraphs (A)
and (B) of section 1611(c)(7)
were applied without regard to
the phrase ``the first day of
the month following'',
(III) who are qualified
pregnant women or children as
defined in section 1905(n),
(IV) who are described in
subparagraph (A) or (B) of
subsection (l)(1) and whose
family income does not exceed
the minimum income level the
State is required to establish
under subsection (l)(2)(A) for
such a family;
(V) who are qualified family
members as defined in section
1905(m)(1),
(VI) who are described in
subparagraph (C) of subsection
(l)(1) and whose family income
does not exceed the income
level the State is required to
establish under subsection
(l)(2)(B) for such a family,
(VII) who are described in
subparagraph (D) of subsection
(l)(1) and whose family income
does not exceed the income
level the State is required to
establish under subsection
(l)(2)(C) for such a family;
(VIII) beginning January 1,
2014, who are under 65 years of
age, not pregnant, not entitled
to, or enrolled for, benefits
under part A of title XVIII, or
enrolled for benefits under
part B of title XVIII, and are
not described in a previous
subclause of this clause, and
whose income (as determined
under subsection (e)(14)) does
not exceed 133 percent of the
poverty line (as defined in
section 2110(c)(5)) applicable
to a family of the size
involved, subject to subsection
(k); or
(IX) who--
(aa) are under 26
years of age;
(bb) are not
described in or
enrolled under any of
subclauses (I) through
(VII) of this clause or
are described in any of
such subclauses but
have income that
exceeds the level of
income applicable under
the State plan for
eligibility to enroll
for medical assistance
under such subclause;
(cc) were in foster
care under the
responsibility of the
State on the date of
attaining 18 years of
age or such higher age
as the State has
elected under section
475(8)(B)(iii); and
(dd) were enrolled in
the State plan under
this title or under a
waiver of the plan
while in such foster
care;
(ii) at the option of the State, to
any group or groups of individuals
described in section 1905(a) (or, in
the case of individuals described in
section 1905(a)(i), to any reasonable
categories of such individuals) who are
not individuals described in clause (i)
of this subparagraph but--
(I) who meet the income and
resources requirements of the
appropriate State plan
described in clause (i) or the
supplemental security income
program (as the case may be),
(II) who would meet the
income and resources
requirements of the appropriate
State plan described in clause
(i) if their work-related child
care costs were paid from their
earnings rather than by a State
agency as a service
expenditure,
(III) who would be eligible
to receive aid under the
appropriate State plan
described in clause (i) if
coverage under such plan was as
broad as allowed under Federal
law,
(IV) with respect to whom
there is being paid, or who are
eligible, or would be eligible
if they were not in a medical
institution, to have paid with
respect to them, aid or
assistance under the
appropriate State plan
described in clause (i),
supplemental security income
benefits under title XVI, or a
State supplementary payment;
(V) who are in a medical
institution for a period of not
less than 30 consecutive days
(with eligibility by reason of
this subclause beginning on the
first day of such period), who
meet the resource requirements
of the appropriate State plan
described in clause (i) or the
supplemental security income
program, and whose income does
not exceed a separate income
standard established by the
State which is consistent with
the limit established under
section 1903(f)(4)(C),
(VI) who would be eligible
under the State plan under this
title if they were in a medical
institution, with respect to
whom there has been a
determination that but for the
provision of home or community-
based services described in
subsection (c), (d), or (e) of
section 1915 they would require
the level of care provided in a
hospital, nursing facility or
intermediate care facility for
the mentally retarded the cost
of which could be reimbursed
under the State plan, and who
will receive home or community-
based services pursuant to a
waiver granted by the Secretary
under subsection (c), (d), or
(e) of section 1915,
(VII) who would be eligible
under the State plan under this
title if they were in a medical
institution, who are terminally
ill, and who will receive
hospice care pursuant to a
voluntary election described in
section 1905(o);
(VIII) who is a child
described in section
1905(a)(i)--
(aa) for whom there
is in effect an
adoption assistance
agreement (other than
an agreement under part
E of title IV) between
the State and an
adoptive parent or
parents,
(bb) who the State
agency responsible for
adoption assistance has
determined cannot be
placed with adoptive
parents without medical
assistance because such
child has special needs
for medical or
rehabilitative care,
and
(cc) who was eligible
for medical assistance
under the State plan
prior to the adoption
assistance agreement
being entered into, or
who would have been
eligible for medical
assistance at such time
if the eligibility
standards and
methodologies of the
State's foster care
program under part E of
title IV were applied
rather than the
eligibility standards
and methodologies of
the State's aid to
families with dependent
children program under
part A of title IV;
(IX) who are described in
subsection (l)(1) and are not
described in clause (i)(IV),
clause (i)(VI), or clause
(i)(VII);
(X) who are described in
subsection (m)(1);
(XI) who receive only an
optional State supplementary
payment based on need and paid
on a regular basis, equal to
the difference between the
individual's countable income
and the income standard used to
determine eligibility for such
supplementary payment (with
countable income being the
income remaining after
deductions as established by
the State pursuant to standards
that may be more restrictive
than the standards for
supplementary security income
benefits under title XVI),
which are available to all
individuals in the State (but
which may be based on different
income standards by political
subdivision according to cost
of living differences), and
which are paid by a State that
does not have an agreement with
the Commissioner of Social
Security under section 1616 or
1634;
(XII) who are described in
subsection (z)(1) (relating to
certain TB-infected
individuals);
(XIII) who are in families
whose income is less than 250
percent of the income official
poverty line (as defined by the
Office of Management and
Budget, and revised annually in
accordance with section 673(2)
of the Omnibus Budget
Reconciliation Act of 1981)
applicable to a family of the
size involved, and who but for
earnings in excess of the limit
established under section
1905(q)(2)(B), would be
considered to be receiving
supplemental security income
(subject, notwithstanding
section 1916, to payment of
premiums or other cost-sharing
charges (set on a sliding scale
based on income) that the State
may determine);
(XIV) who are optional
targeted low-income children
described in section
1905(u)(2)(B);
(XV) who, but for earnings in
excess of the limit established
under section 1905(q)(2)(B),
would be considered to be
receiving supplemental security
income, who is at least 16, but
less than 65, years of age, and
whose assets, resources, and
earned or unearned income (or
both) do not exceed such
limitations (if any) as the
State may establish;
(XVI) who are employed
individuals with a medically
improved disability described
in section 1905(v)(1) and whose
assets, resources, and earned
or unearned income (or both) do
not exceed such limitations (if
any) as the State may
establish, but only if the
State provides medical
assistance to individuals
described in subclause (XV);
(XVII) who are independent
foster care adolescents (as
defined in section 1905(w)(1)),
or who are within any
reasonable categories of such
adolescents specified by the
State;
(XVIII) who are described in
subsection (aa) (relating to
certain breast or cervical
cancer patients);
(XIX) who are disabled
children described in
subsection (cc)(1);
(XX) beginning January 1,
2014, who are under 65 years of
age and are not described in or
enrolled under a previous
subclause of this clause, and
whose income (as determined
under subsection (e)(14))
exceeds 133 percent of the
poverty line (as defined in
section 2110(c)(5)) applicable
to a family of the size
involved but does not exceed
the highest income eligibility
level established under the
State plan or under a waiver of
the plan, subject to subsection
(hh);
(XXI) who are described in
subsection (ii) (relating to
individuals who meet certain
income standards); or
(XXII) who are eligible for
home and community-based
services under needs-based
criteria established under
paragraph (1)(A) of section
1915(i), or who are eligible
for home and community-based
services under paragraph (6) of
such section, and who will
receive home and community-
based services pursuant to a
State plan amendment under such
subsection;
(B) that the medical assistance made
available to any individual described in
subparagraph (A)--
(i) shall not be less in amount,
duration, or scope than the medical
assistance made available to any other
such individual, and
(ii) shall not be less in amount,
duration, or scope than the medical
assistance made available to
individuals not described in
subparagraph (A);
(C) that if medical assistance is included
for any group of individuals described in
section 1905(a) who are not described in
subparagraph (A) or (E), then--
(i) the plan must include a
description of (I) the criteria for
determining eligibility of individuals
in the group for such medical
assistance, (II) the amount, duration,
and scope of medical assistance made
available to individuals in the group,
and (III) the single standard to be
employed in determining income and
resource eligibility for all such
groups, and the methodology to be
employed in determining such
eligibility, which shall be no more
restrictive than the methodology which
would be employed under the
supplemental security income program in
the case of groups consisting of aged,
blind, or disabled individuals in a
State in which such program is in
effect, and which shall be no more
restrictive than the methodology which
would be employed under the appropriate
State plan (described in subparagraph
(A)(i)) to which such group is most
closely categorically related in the
case of other groups;
(ii) the plan must make available
medical assistance--
(I) to individuals under the
age of 18 who (but for income
and resources) would be
eligible for medical assistance
as an individual described in
subparagraph (A)(i), and
(II) to pregnant women,
during the course of their
pregnancy, who (but for income
and resources) would be
eligible for medical assistance
as an individual described in
subparagraph (A);
(iii) such medical assistance must
include (I) with respect to children
under 18 and individuals entitled to
institutional services, ambulatory
services, and (II) with respect to
pregnant women, prenatal care and
delivery services; and
(iv) if such medical assistance
includes services in institutions for
mental diseases or in an intermediate
care facility for the mentally retarded
(or both) for any such group, it also
must include for all groups covered at
least the care and services listed in
paragraphs (1) through (5) and (17) of
section 1905(a) or the care and
services listed in any 7 of the
paragraphs numbered (1) through (24) of
such section;
(D) for the inclusion of home health services
for any individual who, under the State plan,
is entitled to nursing facility services;
(E)(i) for making medical assistance
available for medicare cost-sharing (as defined
in section 1905(p)(3)) for qualified medicare
beneficiaries described in section 1905(p)(1);
(ii) for making medical assistance available
for payment of medicare cost-sharing described
in section 1905(p)(3)(A)(i) for qualified
disabled and working individuals described in
section 1905(s);
(iii) for making medical assistance available
for medicare cost sharing described in section
1905(p)(3)(A)(ii) subject to section
1905(p)(4), for individuals who would be
qualified medicare beneficiaries described in
section 1905(p)(1) but for the fact that their
income exceeds the income level established by
the State under section 1905(p)(2) but is less
than 110 percent in 1993 and 1994, and 120
percent in 1995 and years thereafter of the
official poverty line (referred to in such
section) for a family of the size involved; and
(iv) subject to sections 1933 and 1905(p)(4),
for making medical assistance available for
medicare cost-sharing described in section
1905(p)(3)(A)(ii) for individuals who would be
qualified medicare beneficiaries described in
section 1905(p)(1) but for the fact that their
income exceeds the income level established by
the State under section 1905(p)(2) and is at
least 120 percent, but less than 135 percent,
of the official poverty line (referred to in
such section) for a family of the size involved
and who are not otherwise eligible for medical
assistance under the State plan;
(F) at the option of a State, for making
medical assistance available for COBRA premiums
(as defined in subsection (u)(2)) for qualified
COBRA continuation beneficiaries described in
section 1902(u)(1); and
(G) that, in applying eligibility criteria of
the supplemental security income program under
title XVI for purposes of determining
eligibility for medical assistance under the
State plan of an individual who is not
receiving supplemental security income, the
State will disregard the provisions of
subsections (c) and (e) of section 1613;
except that (I) the making available of the services
described in paragraph (4), (14), or (16) of section
1905(a) to individuals meeting the age requirements
prescribed therein shall not, by reason of this
paragraph (10), require the making available of any
such services, or the making available of such services
of the same amount, duration, and scope, to individuals
of any other ages, (II) the making available of
supplementary medical insurance benefits under part B
of title XVIII to individuals eligible therefor (either
pursuant to an agreement entered into under section
1843 or by reason of the payment of premiums under such
title by the State agency on behalf of such
individuals), or provision for meeting part or all of
the cost of deductibles, cost sharing, or similar
charges under part B of title XVIII for individuals
eligible for benefits under such part, shall not, by
reason of this paragraph (10), require the making
available of any such benefits, or the making available
of services of the same amount, duration, and scope, to
any other individuals, (III) the making available of
medical assistance equal in amount, duration, and scope
to the medical assistance made available to individuals
described in clause (A) to any classification of
individuals approved by the Secretary with respect to
whom there is being paid, or who are eligible, or would
be eligible if they were not in a medical institution,
to have paid with respect to them, a State
supplementary payment shall not, by reason of this
paragraph (10), require the making available of any
such assistance, or the making available of such
assistance of the same amount, duration, and scope, to
any other individuals not described in clause (A), (IV)
the imposition of a deductible, cost sharing, or
similar charge for any item or service furnished to an
individual not eligible for the exemption under section
1916(a)(2) or (b)(2) shall not require the imposition
of a deductible, cost sharing, or similar charge for
the same item or service furnished to an individual who
is eligible for such exemption, (V) the making
available to pregnant women covered under the plan of
services relating to pregnancy (including prenatal,
delivery, and postpartum services) or to any other
condition which may complicate pregnancy shall not, by
reason of this paragraph (10), require the making
available of such services, or the making available of
such services of the same amount, duration, and scope,
to any other individuals, provided such services are
made available (in the same amount, duration, and
scope) to all pregnant women covered under the State
plan, (VI) with respect to the making available of
medical assistance for hospice care to terminally ill
individuals who have made a voluntary election
described in section 1905(o) to receive hospice care
instead of medical assistance for certain other
services, such assistance may not be made available in
an amount, duration, or scope less than that provided
under title XVIII, and the making available of such
assistance shall not, by reason of this paragraph (10),
require the making available of medical assistance for
hospice care to other individuals or the making
available of medical assistance for services waived by
such terminally ill individuals, (VII) the medical
assistance made available to an individual described in
subsection (l)(1)(A) who is eligible for medical
assistance only because of subparagraph (A)(i)(IV) or
(A)(ii)(IX) shall be limited to medical assistance for
services related to pregnancy (including prenatal,
delivery, postpartum, and family planning services) and
to other conditions which may complicate pregnancy,
(VIII) the medical assistance made available to a
qualified medicare beneficiary described in section
1905(p)(1) who is only entitled to medical assistance
because the individual is such a beneficiary shall be
limited to medical assistance for medicare cost-sharing
(described in section 1905(p)(3)), subject to the
provisions of subsection (n) and section 1916(b), (IX)
the making available of respiratory care services in
accordance with subsection (e)(9) shall not, by reason
of this paragraph (10), require the making available of
such services, or the making available of such services
of the same amount, duration, and scope, to any
individuals not included under subsection (e)(9)(A),
provided such services are made available (in the same
amount, duration, and scope) to all individuals
described in such subsection, (X) if the plan provides
for any fixed durational limit on medical assistance
for inpatient hospital services (whether or not such a
limit varies by medical condition or diagnosis), the
plan must establish exceptions to such a limit for
medically necessary inpatient hospital services
furnished with respect to individuals under one year of
age in a hospital defined under the State plan,
pursuant to section 1923(a)(1)(A), as a
disproportionate share hospital and subparagraph (B)
(relating to comparability) shall not be construed as
requiring such an exception for other individuals,
services, or hospitals, (XI) the making available of
medical assistance to cover the costs of premiums,
deductibles, coinsurance, and other cost-sharing
obligations for certain individuals for private health
coverage as described in section 1906 shall not, by
reason of paragraph (10), require the making available
of any such benefits or the making available of
services of the same amount, duration, and scope of
such private coverage to any other individuals, (XII)
the medical assistance made available to an individual
described in subsection (u)(1) who is eligible for
medical assistance only because of subparagraph (F)
shall be limited to medical assistance for COBRA
continuation premiums (as defined in subsection
(u)(2)), (XIII) the medical assistance made available
to an individual described in subsection (z)(1) who is
eligible for medical assistance only because of
subparagraph (A)(ii)(XII) shall be limited to medical
assistance for TB-related services (described in
subsection (z)(2)), (XIV) the medical assistance made
available to an individual described in subsection (aa)
who is eligible for medical assistance only because of
subparagraph (A)(10)(ii)(XVIII) shall be limited to
medical assistance provided during the period in which
such an individual requires treatment for breast or
cervical cancer (XV) the medical assistance made
available to an individual described in subparagraph
(A)(i)(VIII) shall be limited to medical assistance
described in subsection (k)(1), (XVI) the medical
assistance made available to an individual described in
subsection (ii) shall be limited to family planning
services and supplies described in section
1905(a)(4)(C) including medical diagnosis and treatment
services that are provided pursuant to a family
planning service in a family planning setting and
(XVII) if an individual is described in subclause (IX)
of subparagraph (A)(i) and is also described in
subclause (VIII) of that subparagraph, the medical
assistance shall be made available to the individual
through subclause (IX) instead of through subclause
(VIII);
(11)(A) provide for entering into cooperative
arrangements with the State agencies responsible for
administering or supervising the administration of
health services and vocational rehabilitation services
in the State looking toward maximum utilization of such
services in the provision of medical assistance under
the plan, (B) provide, to the extent prescribed by the
Secretary, for entering into agreements, with any
agency, institution, or organization receiving payments
under (or through an allotment under) title V, (i)
providing for utilizing such agency, institution, or
organization in furnishing care and services which are
available under such title or allotment and which are
included in the State plan approved under this section
(ii) making such provision as may be appropriate for
reimbursing such agency, institution, or organization
for the cost of any such care and services furnished
any individual for which payment would otherwise be
made to the State with respect to the individual under
section 1903, and (iii) providing for coordination of
information and education on pediatric vaccinations and
delivery of immunization services, and (C) provide for
coordination of the operations under this title,
including the provision of information and education on
pediatric vaccinations and the delivery of immunization
services, with the State's operations under the special
supplemental nutrition program for women, infants, and
children under section 17 of the Child Nutrition Act of
1966;
(12) provide that, in determining whether an
individual is blind, there shall be an examination by a
physician skilled in the diseases of the eye or by an
optometrist, whichever the individual may select;
(13) provide--
(A) for a public process for determination of
rates of payment under the plan for hospital
services, nursing facility services, and
services of intermediate care facilities for
the mentally retarded under which--
(i) proposed rates, the methodologies
underlying the establishment of such
rates, and justifications for the
proposed rates are published,
(ii) providers, beneficiaries and
their representatives, and other
concerned State residents are given a
reasonable opportunity for review and
comment on the proposed rates,
methodologies, and justifications,
(iii) final rates, the methodologies
underlying the establishment of such
rates, and justifications for such
final rates are published, and
(iv) in the case of hospitals, such
rates take into account (in a manner
consistent with section 1923) the
situation of hospitals which serve a
disproportionate number of low-income
patients with special needs;
(B) for payment for hospice care in amounts
no lower than the amounts, using the same
methodology, used under part A of title XVIII
and for payment of amounts under section
1905(o)(3); except that in the case of hospice
care which is furnished to an individual who is
a resident of a nursing facility or
intermediate care facility for the mentally
retarded, and who would be eligible under the
plan for nursing facility services or services
in an intermediate care facility for the
mentally retarded if he had not elected to
receive hospice care, there shall be paid an
additional amount, to take into account the
room and board furnished by the facility, equal
to at least 95 percent of the rate that would
have been paid by the State under the plan for
facility services in that facility for that
individual; and
(C) payment for primary care services (as
defined in subsection (jj)) furnished in 2013
and 2014 by a physician with a primary
specialty designation of family medicine,
general internal medicine, or pediatric
medicine at a rate not less than 100 percent of
the payment rate that applies to such services
and physician under part B of title XVIII (or,
if greater, the payment rate that would be
applicable under such part if the conversion
factor under section 1848(d) for the year
involved were the conversion factor under such
section for 2009);
(14) provide that enrollment fees, premiums, or
similar charges, and deductions, cost sharing, or
similar charges, may be imposed only as provided in
section 1916;
(15) provide for payment for services described in
clause (B) or (C) of section 1905(a)(2) under the plan
in accordance with subsection (bb);
(16) provide for inclusion, to the extent required by
regulations prescribed by the Secretary, of provisions
(conforming to such regulations) with respect to the
furnishing of medical assistance under the plan to
individuals who are residents of the State but are
absent therefrom;
(17) except as provided in subsections (e)(14),
(e)(15), (l)(3), (m)(3), and (m)(4), include reasonable
standards (which shall be comparable for all groups and
may, in accordance with standards prescribed by the
Secretary, differ with respect to income levels, but
only in the case of applicants or recipients of
assistance under the plan who are not receiving aid or
assistance under any plan of the State approved under
title I, X, XIV, or XVI, or part A of title IV, and
with respect to whom supplemental security income
benefits are not being paid under title XVI, based on
the variations between shelter costs in urban areas and
in rural areas) for determining eligibility for and the
extent of medical assistance under the plan which (A)
are consistent with the objectives of this title, (B)
provide for taking into account only such income and
resources as are, as determined in accordance with
standards prescribed by the Secretary, available to the
applicant or recipient and (in the case of any
applicant or recipient who would, except for income and
resources, be eligible for aid or assistance in the
form of money payments under any plan of the State
approved under title I, X, XIV, or XVI, or part A of
title IV, or to have paid with respect to him
supplemental security income benefits under title XVI)
as would not be disregarded (or set aside for future
needs) in determining his eligibility for such aid,
assistance, or benefits, (C) provide for reasonable
evaluation of any such income or resources, and (D) do
not take into account the financial responsibility of
any individual for any applicant or recipient of
assistance under the plan unless such applicant or
recipient is such individual's spouse or such
individual's child who is under age 21 or (with respect
to States eligible to participate in the State program
established under title XVI), is blind or permanently
and totally disabled, or is blind or disabled as
defined in section 1614 (with respect to States which
are not eligible to participate in such program); and
provide for flexibility in the application of such
standards with respect to income by taking into
account, except to the extent prescribed by the
Secretary, the costs (whether in the form of insurance
premiums, payments made to the State under section
1903(f)(2)(B), or otherwise and regardless of whether
such costs are reimbursed under another public program
of the State or political subdivision thereof) incurred
for medical care or for any other type of remedial care
recognized under State law;
(18) comply with the provisions of section 1917 with
respect to liens, adjustments and recoveries of medical
assistance correctly paid, transfers of assets, and
treatment of certain trusts;
(19) provide such safeguards as may be necessary to
assure that eligibility for care and services under the
plan will be determined, and such care and services
will be provided, in a manner consistent with
simplicity of administration and the best interests of
the recipients;
(20) if the State plan includes medical assistance in
behalf of individuals 65 years of age or older who are
patients in institutions for mental diseases--
(A) provide for having in effect such
agreements or other arrangements with State
authorities concerned with mental diseases,
and, where appropriate, with such institutions,
as may be necessary for carrying out the State
plan, including arrangements for joint planning
and for development of alternate methods of
care, arrangements providing assurance of
immediate readmittance to institutions where
needed for individuals under alternate plans of
care, and arrangements providing for access to
patients and facilities, for furnishing
information, and for making reports;
(B) provide for an individual plan for each
such patient to assure that the institutional
care provided to him is in his best interests,
including, to that end, assurances that there
will be initial and periodic review of his
medical and other needs, that he will be given
appropriate medical treatment within the
institution, and that there will be a periodic
determination of his need for continued
treatment in the institution; and
(C) provide for the development of alternate
plans of care, making maximum utilization of
available resources, for recipients 65 years of
age or older who would otherwise need care in
such institutions, including appropriate
medical treatment and other aid or assistance;
for services referred to in section
3(a)(4)(A)(i) and (ii) or section
1603(a)(4)(A)(i) and (ii) which are appropriate
for such recipients and for such patients; and
for methods of administration necessary to
assure that the responsibilities of the State
agency under the State plan with respect to
such recipients and such patients will be
effectively carried out;
(21) if the State plan includes medical assistance in
behalf of individuals 65 years of age or older who are
patients in public institutions for mental diseases,
show that the State is making satisfactory progress
toward developing and implementing a comprehensive
mental health program, including provision for
utilization of community mental health centers, nursing
facilities, and other alternatives to care in public
institutions for mental diseases;
(22) include descriptions of (A) the kinds and
numbers of professional medical personnel and
supporting staff that will be used in the
administration of the plan and of the responsibilities
they will have, (B) the standards, for private or
public institutions in which recipients of medical
assistance under the plan may receive care or services,
that will be utilized by the State authority or
authorities responsible for establishing and
maintaining such standards, (C) the cooperative
arrangements with State health agencies and State
vocational rehabilitation agencies entered into with a
view to maximum utilization of and coordination of the
provision of medical assistance with the services
administered or supervised by such agencies, and (D)
other standards and methods that the State will use to
assure that medical or remedial care and services
provided to recipients of medical assistance are of
high quality;
(23) provide that (A) any individual eligible for
medical assistance (including drugs) may obtain such
assistance from any institution, agency, community
pharmacy, or person, qualified to perform the service
or services required (including an organization which
provides such services, or arranges for their
availability, on a prepayment basis), who undertakes to
provide him such services, and (B) an enrollment of an
individual eligible for medical assistance in a primary
care case-management system (described in section
1915(b)(1)), a medicaid managed care organization, or a
similar entity shall not restrict the choice of the
qualified person from whom the individual may receive
services under section 1905(a)(4)(C), except as
provided in subsection (g) and in section 1915, except
that this paragraph shall not apply in the case of
Puerto Rico, the Virgin Islands, and Guam, and except
that nothing in this paragraph shall be construed as
requiring a State to provide medical assistance for
such services furnished by a person or entity convicted
of a felony under Federal or State law for an offense
which the State agency determines is inconsistent with
the best interests of beneficiaries under the State
plan or by a provider or supplier to which a moratorium
under subsection (kk)(4) is applied during the period
of such moratorium';
(24) effective July 1, 1969, provide for consultative
services by health agencies and other appropriate
agencies of the State to hospitals, nursing facilities,
home health agencies, clinics, laboratories, and such
other institutions as the Secretary may specify in
order to assist them (A) to qualify for payments under
this Act, (B) to establish and maintain such fiscal
records as may be necessary for the proper and
efficient administration of this Act, and (C) to
provide information needed to determine payments due
under this Act on account of care and services
furnished to individuals;
(25) provide--
(A) that the State or local agency
administering such plan will take all
reasonable measures to ascertain the legal
liability of third parties (including health
insurers, self-insured plans, group health
plans (as defined in section 607(1) of the
Employee Retirement Income Security Act of
1974), service benefit plans, managed care
organizations, pharmacy benefit managers, or
other parties that are, by statute, contract,
or agreement, legally responsible for payment
of a claim for a health care item or service)
to pay for care and services available under
the plan, including--
(i) the collection of sufficient
information (as specified by the
Secretary in regulations) to enable the
State to pursue claims against such
third parties, with such information
being collected at the time of any
determination or redetermination of
eligibility for medical assistance, and
(ii) the submission to the Secretary
of a plan (subject to approval by the
Secretary) for pursuing claims against
such third parties, which plan shall be
integrated with, and be monitored as a
part of the Secretary's review of, the
State's mechanized claims processing
and information retrieval systems
required under section 1903(r);
(B) that in any case where such a legal
liability is found to exist after medical
assistance has been made available on behalf of
the individual and where the amount of
reimbursement the State can reasonably expect
to recover exceeds the costs of such recovery,
the State or local agency will seek
reimbursement for such assistance to the extent
of such legal liability;
(C) that in the case of an individual who is
entitled to medical assistance under the State
plan with respect to a service for which a
third party is liable for payment, the person
furnishing the service may not seek to collect
from the individual (or any financially
responsible relative or representative of that
individual) payment of an amount for that
service (i) if the total of the amount of the
liabilities of third parties for that service
is at least equal to the amount payable for
that service under the plan (disregarding
section 1916), or (ii) in an amount which
exceeds the lesser of (I) the amount which may
be collected under section 1916, or (II) the
amount by which the amount payable for that
service under the plan (disregarding section
1916) exceeds the total of the amount of the
liabilities of third parties for that service;
(D) that a person who furnishes services and
is participating under the plan may not refuse
to furnish services to an individual (who is
entitled to have payment made under the plan
for the services the person furnishes) because
of a third party's potential liability for
payment for the service;
(E) that in the case of preventive pediatric
care (including early and periodic screening
and diagnosis services under section
1905(a)(4)(B)) covered under the State plan,
the State shall--
(i) make payment for such service in
accordance with the usual payment
schedule under such plan for such
services without regard to the
liability of a third party for payment
for such services; and
(ii) seek reimbursement from such
third party in accordance with
subparagraph (B);
(F) that in the case of any services covered
under such plan which are provided to an
individual on whose behalf child support
enforcement is being carried out by the State
agency under part D of title IV of this Act,
the State shall--
(i) make payment for such service in
accordance with the usual payment
schedule under such plan for such
services without regard to any third-
party liability for payment for such
services, if such third-party liability
is derived (through insurance or
otherwise) from the parent whose
obligation to pay support is being
enforced by such agency, if payment has
not been made by such third party
within 30 days after such services are
furnished;
(ii) seek reimbursement from such
third party in accordance with
subparagraph (B);
(G) that the State prohibits any health
insurer (including a group health plan, as
defined in section 607(1) of the Employee
Retirement Income Security Act of 1974, a self-
insured plan, a service benefit plan, a managed
care organization, a pharmacy benefit manager,
or other party that is, by statute, contract,
or agreement, legally responsible for payment
of a claim for a health care item or service),
in enrolling an individual or in making any
payments for benefits to the individual or on
the individual's behalf, from taking into
account that the individual is eligible for or
is provided medical assistance under a plan
under this title for such State, or any other
State;
(H) that to the extent that payment has been
made under the State plan for medical
assistance in any case where a third party has
a legal liability to make payment for such
assistance, the State has in effect laws under
which, to the extent that payment has been made
under the State plan for medical assistance for
health care items or services furnished to an
individual, the State is considered to have
acquired the rights of such individual to
payment by any other party for such health care
items or services; and
(I) that the State shall provide assurances
satisfactory to the Secretary that the State
has in effect laws requiring health insurers,
including self-insured plans, group health
plans (as defined in section 607(1) of the
Employee Retirement Income Security Act of
1974), service benefit plans, managed care
organizations, pharmacy benefit managers, or
other parties that are, by statute, contract,
or agreement, legally responsible for payment
of a claim for a health care item or service,
as a condition of doing business in the State,
to--
(i) provide, with respect to
individuals who are eligible (and, at
State option, individuals who apply or
whose eligibility for medical
assistance is being evaluated in
accordance with section 1902(e)(13)(D))
for, or are provided, medical
assistance under a State plan (or under
a waiver of the plan) under this title
and child health assistance under title
XXI, upon the request of the State,
information to determine during what
period the individual or their spouses
or their dependents may be (or may have
been) covered by a health insurer and
the nature of the coverage that is or
was provided by the health insurer
(including the name, address, and
identifying number of the plan) in a
manner prescribed by the Secretary;
(ii) accept the State's right of
recovery and the assignment to the
State of any right of an individual or
other entity to payment from the party
for an item or service for which
payment has been made under the State
plan;
(iii) respond to any inquiry by the
State regarding a claim for payment for
any health care item or service that is
submitted not later than 3 years after
the date of the provision of such
health care item or service; and
(iv) agree not to deny a claim
submitted by the State solely on the
basis of the date of submission of the
claim, the type or format of the claim
form, or a failure to present proper
documentation at the point-of-sale that
is the basis of the claim, if--
(I) the claim is submitted by
the State within the 3-year
period beginning on the date on
which the item or service was
furnished; and
(II) any action by the State
to enforce its rights with
respect to such claim is
commenced within 6 years of the
State's submission of such
claim;
(26) if the State plan includes medical assistance
for inpatient mental hospital services, provide, with
respect to each patient receiving such services, for a
regular program of medical review (including medical
evaluation) of his need for such services, and for a
written plan of care;
(27) provide for agreements with every person or
institution providing services under the State plan
under which such person or institution agrees (A) to
keep such records as are necessary fully to disclose
the extent of the services provided to individuals
receiving assistance under the State plan, and (B) to
furnish the State agency or the Secretary with such
information, regarding any payments claimed by such
person or institution for providing services under the
State plan, as the State agency or the Secretary may
from time to time request;
(28) provide--
(A) that any nursing facility receiving
payments under such plan must satisfy all the
requirements of subsections (b) through (d) of
section 1919 as they apply to such facilities;
(B) for including in ``nursing facility
services'' at least the items and services
specified (or deemed to be specified) by the
Secretary under section 1919(f)(7) and making
available upon request a description of the
items and services so included;
(C) for procedures to make available to the
public the data and methodology used in
establishing payment rates for nursing
facilities under this title; and
(D) for compliance (by the date specified in
the respective sections) with the requirements
of--
(i) section 1919(e);
(ii) section 1919(g) (relating to
responsibility for survey and
certification of nursing facilities);
and
(iii) sections 1919(h)(2)(B) and
1919(h)(2)(D) (relating to
establishment and application of
remedies);
(29) include a State program which meets the
requirements set forth in section 1908, for the
licensing of administrators of nursing homes;
(30)(A) provide such methods and procedures relating
to the utilization of, and the payment for, care and
services available under the plan (including but not
limited to utilization review plans as provided for in
section 1903(i)(4)) as may be necessary to safeguard
against unnecessary utilization of such care and
services and to assure that payments are consistent
with efficiency, economy, and quality of care and are
sufficient to enlist enough providers so that care and
services are available under the plan at least to the
extent that such care and services are available to the
general population in the geographic area; and
(B) provide, under the program described in
subparagraph (A), that--
(i) each admission to a hospital,
intermediate care facility for the mentally
retarded, or hospital for mental diseases is
reviewed or screened in accordance with
criteria established by medical and other
professional personnel who are not themselves
directly responsible for the care of the
patient involved, and who do not have a
significant financial interest in any such
institution and are not, except in the case of
a hospital, employed by the institution
providing the care involved, and
(ii) the information developed from such
review or screening, along with the data
obtained from prior reviews of the necessity
for admission and continued stay of patients by
such professional personnel, shall be used as
the basis for establishing the size and
composition of the sample of admissions to be
subject to review and evaluation by such
personnel, and any such sample may be of any
size up to 100 percent of all admissions and
must be of sufficient size to serve the purpose
of (I) identifying the patterns of care being
provided and the changes occurring over time in
such patterns so that the need for modification
may be ascertained, and (II) subjecting
admissions to early or more extensive review
where information indicates that such
consideration is warranted to a hospital,
intermediate care facility for the mentally
retarded, or hospital for mental diseases;
(31) with respect to services in an intermediate care
facility for the mentally retarded (where the State
plan includes medical assistance for such services)
provide, with respect to each patient receiving such
services, for a written plan of care, prior to
admission to or authorization of benefits in such
facility, in accordance with regulations of the
Secretary, and for a regular program of independent
professional review (including medical evaluation)
which shall periodically review his need for such
services;
(32) provide that no payment under the plan for any
care or service provided to an individual shall be made
to anyone other than such individual or the person or
institution providing such care or service, under an
assignment or power of attorney or otherwise; except
that--
(A) in the case of any care or service
provided by a physician, dentist, or other
individual practitioner, such payment may be
made (i) to the employer of such physician,
dentist, or other practitioner if such
physician, dentist, or practitioner is required
as a condition of his employment to turn over
his fee for such care or service to his
employer, or (ii) (where the care or service
was provided in a hospital, clinic, or other
facility) to the facility in which the care or
service was provided if there is a contractual
arrangement between such physician, dentist, or
practitioner and such facility under which such
facility submits the bill for such care or
service;
(B) nothing in this paragraph shall be
construed (i) to prevent the making of such a
payment in accordance with an assignment from
the person or institution providing the care or
service involved if such assignment is made to
a governmental agency or entity or is
established by or pursuant to the order of a
court of competent jurisdiction, or (ii) to
preclude an agent of such person or institution
from receiving any such payment if (but only
if) such agent does so pursuant to an agency
agreement under which the compensation to be
paid to the agent for his services for or in
connection with the billing or collection of
payments due such person or institution under
the plan is unrelated (directly or indirectly)
to the amount of such payments or the billings
therefor, and is not dependent upon the actual
collection of any such payment;
(C) in the case of services furnished (during
a period that does not exceed 14 continuous
days in the case of an informal reciprocal
arrangement or 90 continuous days (or such
longer period as the Secretary may provide) in
the case of an arrangement involving per diem
or other fee-for-time compensation) by, or
incident to the services of, one physician to
the patients of another physician who submits
the claim for such services, payment shall be
made to the physician submitting the claim (as
if the services were furnished by, or incident
to, the physician's services), but only if the
claim identifies (in a manner specified by the
Secretary) the physician who furnished the
services; and
(D) in the case of payment for a childhood
vaccine administered before October 1, 1994, to
individuals entitled to medical assistance
under the State plan, the State plan may make
payment directly to the manufacturer of the
vaccine under a voluntary replacement program
agreed to by the State pursuant to which the
manufacturer (i) supplies doses of the vaccine
to providers administering the vaccine, (ii)
periodically replaces the supply of the
vaccine, and (iii) charges the State the
manufacturer's price to the Centers for Disease
Control and Prevention for the vaccine so
administered (which price includes a reasonable
amount to cover shipping and the handling of
returns);
(33) provide--
(A) that the State health agency, or other
appropriate State medical agency, shall be
responsible for establishing a plan, consistent
with regulations prescribed by the Secretary,
for the review by appropriate professional
health personnel of the appropriateness and
quality of care and services furnished to
recipients of medical assistance under the plan
in order to provide guidance with respect
thereto in the administration of the plan to
the State agency established or designated
pursuant to paragraph (5) and, where
applicable, to the State agency described in
the second sentence of this subsection; and
(B) that, except as provided in section
1919(g), the State or local agency utilized by
the Secretary for the purpose specified in the
first sentence of section 1864(a), or, if such
agency is not the State agency which is
responsible for licensing health institutions,
the State agency responsible for such
licensing, will perform for the State agency
administering or supervising the administration
of the plan approved under this title the
function of determining whether institutions
and agencies meet the requirements for
participation in the program under such plan,
except that, if the Secretary has cause to
question the adequacy of such determinations,
the Secretary is authorized to validate State
determinations and, on that basis, make
independent and binding determinations
concerning the extent to which individual
institutions and agencies meet the requirements
for participation;
(34) provide that in the case of any individual who
has been determined to be eligible for medical
assistance under the plan, such assistance will be made
available to him for care and services included under
the plan and furnished in or after the third month
before the month in which he made application (or
application was made on his behalf in the case of a
deceased individual) for such assistance if such
individual was (or upon application would have been)
eligible for such assistance at the time such care and
services were furnished;
(35) provide that any disclosing entity (as defined
in section 1124(a)(2)) receiving payments under such
plan complies with the requirements of section 1124;
(36) provide that within 90 days following the
completion of each survey of any health care facility,
laboratory, agency, clinic, or organization, by the
appropriate State agency described in paragraph (9),
such agency shall (in accordance with regulations of
the Secretary) make public in readily available form
and place the pertinent findings of each such survey
relating to the compliance of each such health care
facility, laboratory, clinic, agency, or organization
with (A) the statutory conditions of participation
imposed under this title, and (B) the major additional
conditions which the Secretary finds necessary in the
interest of health and safety of individuals who are
furnished care or services by any such facility,
laboratory, clinic, agency, or organization;
(37) provide for claims payment procedures which (A)
ensure that 90 per centum of claims for payment (for
which no further written information or substantiation
is required in order to make payment) made for services
covered under the plan and furnished by health care
practitioners through individual or group practices or
through shared health facilities are paid within 30
days of the date of receipt of such claims and that 99
per centum of such claims are paid within 90 days of
the date of receipt of such claims, and (B) provide for
procedures of prepayment and postpayment claims review,
including review of appropriate data with respect to
the recipient and provider of a service and the nature
of the service for which payment is claimed, to ensure
the proper and efficient payment of claims and
management of the program;
(38) require that an entity (other than an individual
practitioner or a group of practitioners) that
furnishes, or arranges for the furnishing of, items or
services under the plan, shall supply (within such
period as may be specified in regulations by the
Secretary or by the single State agency which
administers or supervises the administration of the
plan) upon request specifically addressed to such
entity by the Secretary or such State agency, the
information described in section 1128(b)(9);
(39) provide that the State agency shall exclude any
specified individual or entity from participation in
the program under the State plan for the period
specified by the Secretary, when required by him to do
so pursuant to section 1128 or section 1128A, terminate
the participation of any individual or entity in such
program if (subject to such exceptions as are permitted
with respect to exclusion under sections 1128(c)(3)(B)
and 1128(d)(3)(B)) participation of such individual or
entity is terminated under title XVIII, any other State
plan under this title (or waiver of the plan), or any
State child health plan under title XXI (or waiver of
the plan) and such termination is included by the
Secretary in any database or similar system developed
pursuant to section 6401(b)(2) of the Patient
Protection and Affordable Care Act, and provide that no
payment may be made under the plan with respect to any
item or service furnished by such individual or entity
during such period;
(40) require each health services facility or
organization which receives payments under the plan and
of a type for which a uniform reporting system has been
established under section 1121(a) to make reports to
the Secretary of information described in such section
in accordance with the uniform reporting system
(established under such section) for that type of
facility or organization;
(41) provide, in accordance with subsection (kk)(8)
(as applicable), that whenever a provider of services
or any other person is terminated, suspended, or
otherwise sanctioned or prohibited from participating
under the State plan, the State agency shall promptly
notify the Secretary and, in the case of a physician
and notwithstanding paragraph (7), the State medical
licensing board of such action;
(42) provide that--
(A) the records of any entity participating
in the plan and providing services reimbursable
on a cost-related basis will be audited as the
Secretary determines to be necessary to insure
that proper payments are made under the plan;
and
(B) not later than December 31, 2010, the
State shall--
(i) establish a program under which
the State contracts (consistent with
State law and in the same manner as the
Secretary enters into contracts with
recovery audit contractors under
section 1893(h), subject to such
exceptions or requirements as the
Secretary may require for purposes of
this title or a particular State) with
1 or more recovery audit contractors
for the purpose of identifying
underpayments and overpayments and
recouping overpayments under the State
plan and under any waiver of the State
plan with respect to all services for
which payment is made to any entity
under such plan or waiver; and
(ii) provide assurances satisfactory
to the Secretary that--
(I) under such contracts,
payment shall be made to such a
contractor only from amounts
recovered;
(II) from such amounts
recovered, payment--
(aa) shall be made on
a contingent basis for
collecting
overpayments; and
(bb) may be made in
such amounts as the
State may specify for
identifying
underpayments;
(III) the State has an
adequate process for entities
to appeal any adverse
determination made by such
contractors; and
(IV) such program is carried
out in accordance with such
requirements as the Secretary
shall specify, including--
(aa) for purposes of
section 1903(a)(7),
that amounts expended
by the State to carry
out the program shall
be considered amounts
expended as necessary
for the proper and
efficient
administration of the
State plan or a waiver
of the plan;
(bb) that section
1903(d) shall apply to
amounts recovered under
the program; and
(cc) that the State
and any such
contractors under
contract with the State
shall coordinate such
recovery audit efforts
with other contractors
or entities performing
audits of entities
receiving payments
under the State plan or
waiver in the State,
including efforts with
Federal and State law
enforcement with
respect to the
Department of Justice,
including the Federal
Bureau of
Investigations, the
Inspector General of
the Department of
Health and Human
Services, and the State
medicaid fraud control
unit; and
(43) provide for--
(A) informing all persons in the State who
are under the age of 21 and who have been
determined to be eligible for medical
assistance including services described in
section 1905(a)(4)(B), of the availability of
early and periodic screening, diagnostic, and
treatment services as described in section
1905(r) and the need for age-appropriate
immunizations against vaccine-preventable
diseases,
(B) providing or arranging for the provision
of such screening services in all cases where
they are requested,
(C) arranging for (directly or through
referral to appropriate agencies,
organizations, or individuals) corrective
treatment the need for which is disclosed by
such child health screening services, and
(D) reporting to the Secretary (in a uniform
form and manner established by the Secretary,
by age group and by basis of eligibility for
medical assistance, and by not later than April
1 after the end of each fiscal year, beginning
with fiscal year 1990) the following
information relating to early and periodic
screening, diagnostic, and treatment services
provided under the plan during each fiscal
year:
(i) the number of children provided
child health screening services,
(ii) the number of children referred
for corrective treatment (the need for
which is disclosed by such child health
screening services),
(iii) the number of children
receiving dental services, and other
information relating to the provision
of dental services to such children
described in section 2108(e) and
(iv) the State's results in attaining
the participation goals set for the
State under section 1905(r);
(44) in each case for which payment for inpatient
hospital services, services in an intermediate care
facility for the mentally retarded, or inpatient mental
hospital services is made under the State plan--
(A) a physician (or, in the case of skilled
nursing facility services or intermediate care
facility services, a physician, or a nurse
practitioner or clinical nurse specialist who
is not an employee of the facility but is
working in collaboration with a physician)
certifies at the time of admission, or, if
later, the time the individual applies for
medical assistance under the State plan (and a
physician, a physician assistant under the
supervision of a physician, or, in the case of
skilled nursing facility services or
intermediate care facility services, a
physician, or a nurse practitioner or clinical
nurse specialist who is not an employee of the
facility but is working in collaboration with a
physician, recertifies, where such services are
furnished over a period of time, in such cases,
at least as often as required under section
1903(g)(6) (or, in the case of services that
are services provided in an intermediate care
facility for the mentally retarded, every
year), and accompanied by such supporting
material, appropriate to the case involved, as
may be provided in regulations of the
Secretary), that such services are or were
required to be given on an inpatient basis
because the individual needs or needed such
services, and
(B) such services were furnished under a plan
established and periodically reviewed and
evaluated by a physician, or, in the case of
skilled nursing facility services or
intermediate care facility services, a
physician, or a nurse practitioner or clinical
nurse specialist who is not an employee of the
facility but is working in collaboration with a
physician;
(45) provide for mandatory assignment of rights of
payment for medical support and other medical care owed
to recipients, in accordance with section 1912;
(46)(A) provide that information is requested and
exchanged for purposes of income and eligibility
verification in accordance with a State system which
meets the requirements of section 1137 of this Act; and
(B) provide, with respect to an individual declaring
to be a citizen or national of the United States for
purposes of establishing eligibility under this title,
that the State shall satisfy the requirements of--
(i) section 1903(x); or
(ii) subsection (ee);
(47) provide--
(A) at the option of the State, for making
ambulatory prenatal care available to pregnant
women during a presumptive eligibility period
in accordance with section 1920 and provide for
making medical assistance for items and
services described in subsection (a) of section
1920A available to children during a
presumptive eligibility period in accordance
with such section and provide for making
medical assistance available to individuals
described in subsection (a) of section 1920B
during a presumptive eligibility period in
accordance with such section and provide for
making medical assistance available to
individuals described in subsection (a) of
section 1920C during a presumptive eligibility
period in accordance with such section; and
(B) that any hospital that is a participating
provider under the State plan may elect to be a
qualified entity for purposes of determining,
on the basis of preliminary information,
whether any individual is eligible for medical
assistance under the State plan or under a
waiver of the plan for purposes of providing
the individual with medical assistance during a
presumptive eligibility period, in the same
manner, and subject to the same requirements,
as apply to the State options with respect to
populations described in section 1920, 1920A,
1920B, or 1920C (but without regard to whether
the State has elected to provide for a
presumptive eligibility period under any such
sections), subject to such guidance as the
Secretary shall establish;
(48) provide a method of making cards evidencing
eligibility for medical assistance available to an
eligible individual who does not reside in a permanent
dwelling or does not have a fixed home or mailing
address;
(49) provide that the State will provide information
and access to certain information respecting sanctions
taken against health care practitioners and providers
by State licensing authorities in accordance with
section 1921;
(50) provide, in accordance with subsection (q), for
a monthly personal needs allowance for certain
institutionalized individuals and couples;
(51) meet the requirements of section 1924 (relating
to protection of community spouses);
(52) meet the requirements of section 1925 (relating
to extension of eligibility for medical assistance);
(53) provide--
(A) for notifying in a timely manner all
individuals in the State who are determined to
be eligible for medical assistance and who are
pregnant women, breastfeeding or postpartum
women (as defined in section 17 of the Child
Nutrition Act of 1966), or children below the
age of 5, of the availability of benefits
furnished by the special supplemental nutrition
program under such section, and
(B) for referring any such individual to the
State agency responsible for administering such
program;
(54) in the case of a State plan that provides
medical assistance for covered outpatient drugs (as
defined in section 1927(k)), comply with the applicable
requirements of section 1927;
(55) provide for receipt and initial processing of
applications of individuals for medical assistance
under subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI),
(a)(10)(A)(i)(VII), or (a)(10)(A)(ii)(IX)--
(A) at locations which are other than those
used for the receipt and processing of
applications for aid under part A of title IV
and which include facilities defined as
disproportionate share hospitals under section
1923(a)(1)(A) and Federally-qualified health
centers described in section 1905(1)(2)(B), and
(B) using applications which are other than
those used for applications for aid under such
part;
(56) provide, in accordance with subsection (s), for
adjusted payments for certain inpatient hospital
services;
(57) provide that each hospital, nursing facility,
provider of home health care or personal care services,
hospice program, or medicaid managed care organization
(as defined in section 1903(m)(1)(A)) receiving funds
under the plan shall comply with the requirements of
subsection (w);
(58) provide that the State, acting through a State
agency, association, or other private nonprofit entity,
develop a written description of the law of the State
(whether statutory or as recognized by the courts of
the State) concerning advance directives that would be
distributed by providers or organizations under the
requirements of subsection (w);
(59) maintain a list (updated not less often than
monthly, and containing each physician's unique
identifier provided under the system established under
subsection (x)) of all physicians who are certified to
participate under the State plan;
(60) provide that the State agency shall provide
assurances satisfactory to the Secretary that the State
has in effect the laws relating to medical child
support required under section 1908A;
(61) provide that the State must demonstrate that it
operates a medicaid fraud and abuse control unit
described in section 1903(q) that effectively carries
out the functions and requirements described in such
section, as determined in accordance with standards
established by the Secretary, unless the State
demonstrates to the satisfaction of the Secretary that
the effective operation of such a unit in the State
would not be cost-effective because minimal fraud
exists in connection with the provision of covered
services to eligible individuals under the State plan,
and that beneficiaries under the plan will be protected
from abuse and neglect in connection with the provision
of medical assistance under the plan without the
existence of such a unit;
(62) provide for a program for the distribution of
pediatric vaccines to program-registered providers for
the immunization of vaccine-eligible children in
accordance with section 1928;
(63) provide for administration and determinations of
eligibility with respect to individuals who are (or
seek to be) eligible for medical assistance based on
the application of section 1931;
(64) provide, not later than 1 year after the date of
the enactment of this paragraph, a mechanism to receive
reports from beneficiaries and others and compile data
concerning alleged instances of waste, fraud, and abuse
relating to the operation of this title;
(65) provide that the State shall issue provider
numbers for all suppliers of medical assistance
consisting of durable medical equipment, as defined in
section 1861(n), and the State shall not issue or renew
such a supplier number for any such supplier unless--
(A)(i) full and complete information as to
the identity of each person with an ownership
or control interest (as defined in section
1124(a)(3)) in the supplier or in any
subcontractor (as defined by the Secretary in
regulations) in which the supplier directly or
indirectly has a 5 percent or more ownership
interest; and
(ii) to the extent determined to be feasible
under regulations of the Secretary, the name of
any disclosing entity (as defined in section
1124(a)(2)) with respect to which a person with
such an ownership or control interest in the
supplier is a person with such an ownership or
control interest in the disclosing entity; and
(B) a surety bond in a form specified by the
Secretary under section 1834(a)(16)(B) and in
an amount that is not less than $50,000 or such
comparable surety bond as the Secretary may
permit under the second sentence of such
section;
(66) provide for making eligibility determinations
under section 1935(a);
(67) provide, with respect to services covered under
the State plan (but not under title XVIII) that are
furnished to a PACE program eligible individual
enrolled with a PACE provider by a provider
participating under the State plan that does not have a
contract or other agreement with the PACE provider that
establishes payment amounts for such services, that
such participating provider may not require the PACE
provider to pay the participating provider an amount
greater than the amount that would otherwise be payable
for the service to the participating provider under the
State plan for the State where the PACE provider is
located (in accordance with regulations issued by the
Secretary);
(68) provide that any entity that receives or makes
annual payments under the State plan of at least
$5,000,000, as a condition of receiving such payments,
shall--
(A) establish written policies for all
employees of the entity (including management),
and of any contractor or agent of the entity,
that provide detailed information about the
False Claims Act established under sections
3729 through 3733 of title 31, United States
Code, administrative remedies for false claims
and statements established under chapter 38 of
title 31, United States Code, any State laws
pertaining to civil or criminal penalties for
false claims and statements, and whistleblower
protections under such laws, with respect to
the role of such laws in preventing and
detecting fraud, waste, and abuse in Federal
health care programs (as defined in section
1128B(f));
(B) include as part of such written policies,
detailed provisions regarding the entity's
policies and procedures for detecting and
preventing fraud, waste, and abuse; and
(C) include in any employee handbook for the
entity, a specific discussion of the laws
described in subparagraph (A), the rights of
employees to be protected as whistleblowers,
and the entity's policies and procedures for
detecting and preventing fraud, waste, and
abuse;
(69) provide that the State must comply with any
requirements determined by the Secretary to be
necessary for carrying out the Medicaid Integrity
Program established under section 1936;
(70) at the option of the State and notwithstanding
paragraphs (1), (10)(B), and (23), provide for the
establishment of a non-emergency medical transportation
brokerage program in order to more cost-effectively
provide transportation for individuals eligible for
medical assistance under the State plan who need access
to medical care or services and have no other means of
transportation which--
(A) may include a wheelchair van, taxi,
stretcher car, bus passes and tickets, secured
transportation, and such other transportation
as the Secretary determines appropriate; and
(B) may be conducted under contract with a
broker who--
(i) is selected through a competitive
bidding process based on the State's
evaluation of the broker's experience,
performance, references, resources,
qualifications, and costs;
(ii) has oversight procedures to
monitor beneficiary access and
complaints and ensure that transport
personnel are licensed, qualified,
competent, and courteous;
(iii) is subject to regular auditing
and oversight by the State in order to
ensure the quality of the
transportation services provided and
the adequacy of beneficiary access to
medical care and services; and
(iv) complies with such requirements
related to prohibitions on referrals
and conflict of interest as the
Secretary shall establish (based on the
prohibitions on physician referrals
under section 1877 and such other
prohibitions and requirements as the
Secretary determines to be
appropriate);
(71) provide that the State will implement an asset
verification program as required under section 1940;
(72) provide that the State will not prevent a
Federally-qualified health center from entering into
contractual relationships with private practice dental
providers in the provision of Federally-qualified
health center services;
(73) in the case of any State in which 1 or more
Indian Health Programs or Urban Indian Organizations
furnishes health care services, provide for a process
under which the State seeks advice on a regular,
ongoing basis from designees of such Indian Health
Programs and Urban Indian Organizations on matters
relating to the application of this title that are
likely to have a direct effect on such Indian Health
Programs and Urban Indian Organizations and that--
(A) shall include solicitation of advice
prior to submission of any plan amendments,
waiver requests, and proposals for
demonstration projects likely to have a direct
effect on Indians, Indian Health Programs, or
Urban Indian Organizations; and
(B) may include appointment of an advisory
committee and of a designee of such Indian
Health Programs and Urban Indian Organizations
to the medical care advisory committee advising
the State on its State plan under this title;
(74) provide for maintenance of effort under the
State plan or under any waiver of the plan in
accordance with subsection (gg); and
(75) provide that, beginning January 2015, and
annually thereafter, the State shall submit a report to
the Secretary that contains--
(A) the total number of enrolled and newly
enrolled individuals in the State plan or under
a waiver of the plan for the fiscal year ending
on September 30 of the preceding calendar year,
disaggregated by population, including
children, parents, nonpregnant childless
adults, disabled individuals, elderly
individuals, and such other categories or sub-
categories of individuals eligible for medical
assistance under the State plan or under a
waiver of the plan as the Secretary may
require;
(B) a description, which may be specified by
population, of the outreach and enrollment
processes used by the State during such fiscal
year; and
(C) any other data reporting determined
necessary by the Secretary to monitor
enrollment and retention of individuals
eligible for medical assistance under the State
plan or under a waiver of the plan;
(76) provide that any data collected under the State
plan meets the requirements of section 3101 of the
Public Health Service Act;
(77) provide that the State shall comply with
provider and supplier screening, oversight, and
reporting requirements in accordance with subsection
(kk);
(78) provide that, not later than January 1, 2017, in
the case of a State that pursuant to its State plan or
waiver of the plan for medical assistance pays for
medical assistance on a fee-for-service basis, the
State shall require each provider furnishing items and
services to, or ordering, prescribing, referring, or
certifying eligibility for, services for individuals
eligible to receive medical assistance under such plan
to enroll with the State agency and provide to the
State agency the provider's identifying information,
including the name, specialty, date of birth, Social
Security number, national provider identifier (if
applicable), Federal taxpayer identification number,
and the State license or certification number of the
provider (if applicable);
(79) provide that any agent, clearinghouse, or other
alternate payee (as defined by the Secretary) that
submits claims on behalf of a health care provider must
register with the State and the Secretary in a form and
manner specified by the Secretary;
(80) provide that the State shall not provide any
payments for items or services provided under the State
plan or under a waiver to any financial institution or
entity located outside of the United States;
(81) provide for implementation of the payment models
specified by the Secretary under section 1115A(c) for
implementation on a nationwide basis unless the State
demonstrates to the satisfaction of the Secretary that
implementation would not be administratively feasible
or appropriate to the health care delivery system of
the State;
(82) provide that the State agency responsible for
administering the State plan under this title provides
assurances to the Secretary that the State agency is in
compliance with subparagraphs (A), (B), and (C) of
section 1128K(b)(2);
(83) provide that, not later than January 1, 2017, in
the case of a State plan (or waiver of the plan) that
provides medical assistance on a fee-for-service basis
or through a primary care case-management system
described in section 1915(b)(1) (other than a primary
care case management entity (as defined by the
Secretary)), the State shall publish (and update on at
least an annual basis) on the public website of the
State agency administering the State plan, a directory
of the physicians described in subsection (mm) and, at
State option, other providers described in such
subsection that--
(A) includes--
(i) with respect to each such
physician or provider--
(I) the name of the physician
or provider;
(II) the specialty of the
physician or provider;
(III) the address at which
the physician or provider
provides services; and
(IV) the telephone number of
the physician or provider; and
(ii) with respect to any such
physician or provider participating in
such a primary care case-management
system, information regarding--
(I) whether the physician or
provider is accepting as new
patients individuals who
receive medical assistance
under this title; and
(II) the physician's or
provider's cultural and
linguistic capabilities,
including the languages spoken
by the physician or provider or
by the skilled medical
interpreter providing
interpretation services at the
physician's or provider's
office; and
(B) may include, at State option, with
respect to each such physician or provider--
(i) the Internet website of such
physician or provider; or
(ii) whether the physician or
provider is accepting as new patients
individuals who receive medical
assistance under this title;
(84) provide that--
(A) the State shall not terminate eligibility
for medical assistance under the State plan for
an individual who is an eligible juvenile (as
defined in subsection (nn)(2)) because the
juvenile is an inmate of a public institution
(as defined in subsection (nn)(3)), but may
suspend coverage during the period the juvenile
is such an inmate;
(B) in the case of an individual who is an
eligible juvenile described in paragraph (2)(A)
of subsection (nn), the State shall, prior to
the individual's release from such a public
institution, conduct a redetermination of
eligibility for such individual with respect to
such medical assistance (without requiring a
new application from the individual) and, if
the State determines pursuant to such
redetermination that the individual continues
to meet the eligibility requirements for such
medical assistance, the State shall restore
coverage for such medical assistance to such an
individual upon the individual's release from
such public institution; and
(C) in the case of an individual who is an
eligible juvenile described in paragraph (2)(B)
of subsection (nn), the State shall process any
application for medical assistance submitted
by, or on behalf of, such individual such that
the State makes a determination of eligibility
for such individual with respect to such
medical assistance upon release of such
individual from such public institution;
(85) provide that the State is in compliance with the
drug review and utilization requirements under
subsection (oo)(1); and
(86) provide, at the option of the State, for making
medical assistance available on an inpatient or
outpatient basis at a residential pediatric recovery
center (as defined in subsection (pp)) to infants with
neonatal abstinence syndrome.
Notwithstanding paragraph (5), if on January 1, 1965, and on
the date on which a State submits its plan for approval under
this title, the State agency which administered or supervised
the administration of the plan of such State approved under
title X (or title XVI, insofar as it relates to the blind) was
different from the State agency which administered or
supervised the administration of the State plan approved under
title I (or title XVI, insofar as it relates to the aged), the
State agency which administered or supervised the
administration of such plan approved under title X (or title
XVI, insofar as it relates to the blind) may be designated to
administer or supervise the administration of the portion of
the State plan for medical assistance which relates to blind
individuals and a different State agency may be established or
designated to administer or supervise the administration of the
rest of the State plan for medical assistance; and in such case
the part of the plan which each such agency administers, or the
administration of which each such agency supervises, shall be
regarded as a separate plan for purposes of this title (except
for purposes of paragraph (10)). The provisions of paragraphs
(9)(A), (31), and (33) and of section 1903(i)(4) shall not
apply to a religious nonmedical health care institution (as
defined in section 1861(ss)(1)).
For purposes of paragraph (10) any individual who, for the
month of August 1972, was eligible for or receiving aid or
assistance under a State plan approved under title I, X, XIV,
or XVI, or part A of title IV and who for such month was
entitled to monthly insurance benefits under title II shall for
purposes of this title only be deemed to be eligible for
financial aid or assistance for any month thereafter if such
individual would have been eligible for financial aid or
assistance for such month had the increase in monthly insurance
benefits under title II resulting from enactment of Public Law
92-336 not been applicable to such individual.
The requirement of clause (A) of paragraph (37) with respect to
a State plan may be waived by the Secretary if he finds that
the State has exercised good faith in trying to meet such
requirement. For purposes of this title, any child who meets
the requirements of paragraph (1) or (2) of section 473(b)
shall be deemed to be a dependent child as defined in section
406 and shall be deemed to be a recipient of aid to families
with dependent children under part A of title IV in the State
where such child resides. Notwithstanding paragraph (10)(B) or
any other provision of this subsection, a State plan shall
provide medical assistance with respect to an alien who is not
lawfully admitted for permanent residence or otherwise
permanently residing in the United States under color of law
only in accordance with section 1903(v).
(b) The Secretary shall approve any plan which fulfills the
conditions specified in subsection (a) of this section, except
that he shall not approve any plan which imposes, as a
condition of eligibility for medical assistance under the
plan--
(1) an age requirement of more than 65 years; or
(2) any residence requirement which excludes any
individual who resides in the State, regardless of
whether or not the residence is maintained permanently
or at a fixed address; or
(3) any citizenship requirement which excludes any
citizen of the United States.
(c) Notwithstanding subsection (b), the Secretary shall not
approve any State plan for medical assistance if the State
requires individuals described in subsection (l)(1) to apply
for assistance under the State program funded under part A of
title IV as a condition of applying for or receiving medical
assistance under this title.
(d) If a State contracts with an entity which meets the
requirements of section 1152, as determined by the Secretary,
or a utilization and quality control peer review organization
having a contract with the Secretary under part B of title XI
for the performance of medical or utilization review functions
(including quality review functions described in subsection
(a)(30)(C)) required under this title of a State plan with
respect to specific services or providers (or services or
providers in a geographic area of the State), such requirements
shall be deemed to be met for those services or providers (or
services or providers in that area) by delegation to such an
entity or organization under the contract of the State's
authority to conduct such review activities if the contract
provides for the performance of activities not inconsistent
with part B of title XI and provides for such assurances of
satisfactory performance by such an entity or organization as
the Secretary may prescribe.
(e)(1) Beginning April 1, 1990, for provisions relating to
the extension of eligibility for medical assistance for certain
families who have received aid pursuant to a State plan
approved under part A of title IV and have earned income, see
section 1925.
(2)(A) In the case of an individual who is enrolled with a
medicaid managed care organization (as defined in section
1903(m)(1)(A)), with a primary care case manager (as defined in
section 1905(t)), or with an eligible organization with a
contract under section 1876 and who would (but for this
paragraph) lose eligibility for benefits under this title
before the end of the minimum enrollment period (defined in
subparagraph (B)), the State plan may provide, notwithstanding
any other provision of this title, that the individual shall be
deemed to continue to be eligible for such benefits until the
end of such minimum period, but, except for benefits furnished
under section 1905(a)(4)(C), only with respect to such benefits
provided to the individual as an enrollee of such organization
or entity or by or through the case manager.
(B) For purposes of subparagraph (A), the term ``minimum
enrollment period'' means, with respect to an individual's
enrollment with an organization or entity under a State plan, a
period, established by the State, of not more than six months
beginning on the date the individual's enrollment with the
organization or entity becomes effective.
(3) At the option of the State, any individual who--
(A) is 18 years of age or younger and qualifies as a
disabled individual under section 1614(a);
(B) with respect to whom there has been a
determination by the State that--
(i) the individual requires a level of care
provided in a hospital, nursing facility, or
intermediate care facility for the mentally
retarded,
(ii) it is appropriate to provide such care
for the individual outside such an institution,
and
(iii) the estimated amount which would be
expended for medical assistance for the
individual for such care outside an institution
is not greater than the estimated amount which
would otherwise be expended for medical
assistance for the individual within an
appropriate institution; and
(C) if the individual were in a medical institution,
would be eligible for medical assistance under the
State plan under this title,
shall be deemed, for purposes of this title only, to be
an individual with respect to whom a supplemental
security income payment, or State supplemental payment,
respectively, is being paid under title XVI.
(4) A child born to a woman eligible for and receiving
medical assistance under a State plan on the date of the
child's birth shall be deemed to have applied for medical
assistance and to have been found eligible for such assistance
under such plan on the date of such birth and to remain
eligible for such assistance for a period of one year. During
the period in which a child is deemed under the preceding
sentence to be eligible for medical assistance, the medical
assistance eligibility identification number of the mother
shall also serve as the identification number of the child, and
all claims shall be submitted and paid under such number
(unless the State issues a separate identification number for
the child before such period expires). Notwithstanding the
preceding sentence, in the case of a child who is born in the
United States to an alien mother for whom medical assistance
for the delivery of the child is made available pursuant to
section 1903(v), the State immediately shall issue a separate
identification number for the child upon notification by the
facility at which such delivery occurred of the child's birth.
(5) A woman who, while pregnant, is eligible for, has applied
for, and has received medical assistance under the State plan,
shall continue to be eligible under the plan, as though she
were pregnant, for all pregnancy-related and postpartum medical
assistance under the plan, through the end of the month in
which the 60-day period (beginning on the last day of her
pregnancy) ends.
(6) In the case of a pregnant woman described in subsection
(a)(10) who, because of a change in income of the family of
which she is a member, would not otherwise continue to be
described in such subsection, the woman shall be deemed to
continue to be an individual described in subsection
(a)(10)(A)(i)(IV) and subsection (l)(1)(A) without regard to
such change of income through the end of the month in which the
60-day period (beginning on the last day of her pregnancy)
ends. The preceding sentence shall not apply in the case of a
woman who has been provided ambulatory prenatal care pursuant
to section 1920 during a presumptive eligibility period and is
then, in accordance with such section, determined to be
ineligible for medical assistance under the State plan.
(7) In the case of an infant or child described in
subparagraph (B), (C), or (D) of subsection (l)(1) or paragraph
(2) of section 1905(n)--
(A) who is receiving inpatient services for which
medical assistance is provided on the date the infant
or child attains the maximum age with respect to which
coverage is provided under the State plan for such
individuals, and
(B) who, but for attaining such age, would remain
eligible for medical assistance under such subsection,
the infant or child shall continue to be treated as an
individual described in such respective provision until the end
of the stay for which the inpatient services are furnished.
(8) If an individual is determined to be a qualified medicare
beneficiary (as defined in section 1905(p)(1)), such
determination shall apply to services furnished after the end
of the month in which the determination first occurs. For
purposes of payment to a State under section 1903(a), such
determination shall be considered to be valid for an individual
for a period of 12 months, except that a State may provide for
such determinations more frequently, but not more frequently
than once every 6 months for an individual.
(9)(A) At the option of the State, the plan may include as
medical assistance respiratory care services for any individual
who--
(i) is medically dependent on a ventilator for life
support at least six hours per day;
(ii) has been so dependent for at least 30
consecutive days (or the maximum number of days
authorized under the State plan, whichever is less) as
an inpatient;
(iii) but for the availability of respiratory care
services, would require respiratory care as an
inpatient in a hospital, nursing facility, or
intermediate care facility for the mentally retarded
and would be eligible to have payment made for such
inpatient care under the State plan;
(iv) has adequate social support services to be cared
for at home; and
(v) wishes to be cared for at home.
(B) The requirements of subparagraph (A)(ii) may be satisfied
by a continuous stay in one or more hospitals, nursing
facilities, or intermediate care facilities for the mentally
retarded.
(C) For purposes of this paragraph, respiratory care services
means services provided on a part-time basis in the home of the
individual by a respiratory therapist or other health care
professional trained in respiratory therapy (as determined by
the State), payment for which is not otherwise included within
other items and services furnished to such individual as
medical assistance under the plan.
(10)(A) The fact that an individual, child, or pregnant woman
may be denied aid under part A of title IV pursuant to section
402(a)(43) shall not be construed as denying (or permitting a
State to deny) medical assistance under this title to such
individual, child, or woman who is eligible for assistance
under this title on a basis other than the receipt of aid under
such part.
(B) If an individual, child, or pregnant woman is receiving
aid under part A of title IV and such aid is terminated
pursuant to section 402(a)(43), the State may not discontinue
medical assistance under this title for the individual, child,
or woman until the State has determined that the individual,
child, or woman is not eligible for assistance under this title
on a basis other than the receipt of aid under such part.
(11)(A) In the case of an individual who is enrolled with a
group health plan under section 1906 and who would (but for
this paragraph) lose eligibility for benefits under this title
before the end of the minimum enrollment period (defined in
subparagraph (B)), the State plan may provide, notwithstanding
any other provision of this title, that the individual shall be
deemed to continue to be eligible for such benefits until the
end of such minimum period, but only with respect to such
benefits provided to the individual as an enrollee of such
plan.
(B) For purposes of subparagraph (A), the term ``minimum
enrollment period'' means, with respect to an individual's
enrollment with a group health plan, a period established by
the State, of not more than 6 months beginning on the date the
individual's enrollment under the plan becomes effective.
(12) At the option of the State, the plan may provide that an
individual who is under an age specified by the State (not to
exceed 19 years of age) and who is determined to be eligible
for benefits under a State plan approved under this title under
subsection (a)(10)(A) shall remain eligible for those benefits
until the earlier of--
(A) the end of a period (not to exceed 12 months)
following the determination; or
(B) the time that the individual exceeds that age.
(13) Express Lane Option.--
(A) In general.--
(i) Option to use a finding from an express
lane agency.--At the option of the State, the
State plan may provide that in determining
eligibility under this title for a child (as
defined in subparagraph (G)), the State may
rely on a finding made within a reasonable
period (as determined by the State) from an
Express Lane agency (as defined in subparagraph
(F)) when it determines whether a child
satisfies one or more components of eligibility
for medical assistance under this title. The
State may rely on a finding from an Express
Lane agency notwithstanding sections
1902(a)(46)(B) and 1137(d) or any differences
in budget unit, disregard, deeming or other
methodology, if the following requirements are
met:
(I) Prohibition on determining
children ineligible for coverage.--If a
finding from an Express Lane agency
would result in a determination that a
child does not satisfy an eligibility
requirement for medical assistance
under this title and for child health
assistance under title XXI, the State
shall determine eligibility for
assistance using its regular
procedures.
(II) Notice requirement.--For any
child who is found eligible for medical
assistance under the State plan under
this title or child health assistance
under title XXI and who is subject to
premiums based on an Express Lane
agency's finding of such child's income
level, the State shall provide notice
that the child may qualify for lower
premium payments if evaluated by the
State using its regular policies and of
the procedures for requesting such an
evaluation.
(III) Compliance with screen and
enroll requirement.--The State shall
satisfy the requirements under
subparagraphs (A) and (B) of section
2102(b)(3) (relating to screen and
enroll) before enrolling a child in
child health assistance under title
XXI. At its option, the State may
fulfill such requirements in accordance
with either option provided under
subparagraph (C) of this paragraph.
(IV) Verification of citizenship or
nationality status.--The State shall
satisfy the requirements of section
1902(a)(46)(B) or 2105(c)(9), as
applicable for verifications of
citizenship or nationality status.
(V) Coding.--The State meets the
requirements of subparagraph (E).
(ii) Option to apply to renewals and
redeterminations.--The State may apply the
provisions of this paragraph when conducting
initial determinations of eligibility,
redeterminations of eligibility, or both, as
described in the State plan.
(B) Rules of construction.--Nothing in this paragraph
shall be construed--
(i) to limit or prohibit a State from taking
any actions otherwise permitted under this
title or title XXI in determining eligibility
for or enrolling children into medical
assistance under this title or child health
assistance under title XXI; or
(ii) to modify the limitations in section
1902(a)(5) concerning the agencies that may
make a determination of eligibility for medical
assistance under this title.
(C) Options for satisfying the screen and enroll
requirement.--
(i) In general.--With respect to a child
whose eligibility for medical assistance under
this title or for child health assistance under
title XXI has been evaluated by a State agency
using an income finding from an Express Lane
agency, a State may carry out its duties under
subparagraphs (A) and (B) of section 2102(b)(3)
(relating to screen and enroll) in accordance
with either clause (ii) or clause (iii).
(ii) Establishing a screening threshold.--
(I) In general.--Under this clause,
the State establishes a screening
threshold set as a percentage of the
Federal poverty level that exceeds the
highest income threshold applicable
under this title to the child by a
minimum of 30 percentage points or, at
State option, a higher number of
percentage points that reflects the
value (as determined by the State and
described in the State plan) of any
differences between income
methodologies used by the program
administered by the Express Lane agency
and the methodologies used by the State
in determining eligibility for medical
assistance under this title.
(II) Children with income not above
threshold.--If the income of a child
does not exceed the screening
threshold, the child is deemed to
satisfy the income eligibility criteria
for medical assistance under this title
regardless of whether such child would
otherwise satisfy such criteria.
(III) Children with income above
threshold.--If the income of a child
exceeds the screening threshold, the
child shall be considered to have an
income above the Medicaid applicable
income level described in section
2110(b)(4) and to satisfy the
requirement under section 2110(b)(1)(C)
(relating to the requirement that CHIP
matching funds be used only for
children not eligible for Medicaid). If
such a child is enrolled in child
health assistance under title XXI, the
State shall provide the parent,
guardian, or custodial relative with
the following:
(aa) Notice that the child
may be eligible to receive
medical assistance under the
State plan under this title if
evaluated for such assistance
under the State's regular
procedures and notice of the
process through which a parent,
guardian, or custodial relative
can request that the State
evaluate the child's
eligibility for medical
assistance under this title
using such regular procedures.
(bb) A description of
differences between the medical
assistance provided under this
title and child health
assistance under title XXI,
including differences in cost-
sharing requirements and
covered benefits.
(iii) Temporary enrollment in chip pending
screen and enroll.--
(I) In general.--Under this clause, a
State enrolls a child in child health
assistance under title XXI for a
temporary period if the child appears
eligible for such assistance based on
an income finding by an Express Lane
agency.
(II) Determination of eligibility.--
During such temporary enrollment
period, the State shall determine the
child's eligibility for child health
assistance under title XXI or for
medical assistance under this title in
accordance with this clause.
(III) Prompt follow up.--In making
such a determination, the State shall
take prompt action to determine whether
the child should be enrolled in medical
assistance under this title or child
health assistance under title XXI
pursuant to subparagraphs (A) and (B)
of section 2102(b)(3) (relating to
screen and enroll).
(IV) Requirement for simplified
determination.--In making such a
determination, the State shall use
procedures that, to the maximum
feasible extent, reduce the burden
imposed on the individual of such
determination. Such procedures may not
require the child's parent, guardian,
or custodial relative to provide or
verify information that already has
been provided to the State agency by an
Express Lane agency or another source
of information unless the State agency
has reason to believe the information
is erroneous.
(V) Availability of chip matching
funds during temporary enrollment
period.--Medical assistance for items
and services that are provided to a
child enrolled in title XXI during a
temporary enrollment period under this
clause shall be treated as child health
assistance under such title.
(D) Option for automatic enrollment.--
(i) In general.--The State may initiate and
determine eligibility for medical assistance
under the State Medicaid plan or for child
health assistance under the State CHIP plan
without a program application from, or on
behalf of, the child based on data obtained
from sources other than the child (or the
child's family), but a child can only be
automatically enrolled in the State Medicaid
plan or the State CHIP plan if the child or the
family affirmatively consents to being enrolled
through affirmation in writing, by telephone,
orally, through electronic signature, or
through any other means specified by the
Secretary or by signature on an Express Lane
agency application, if the requirement of
clause (ii) is met.
(ii) Information requirement.--The
requirement of this clause is that the State
informs the parent, guardian, or custodial
relative of the child of the services that will
be covered, appropriate methods for using such
services, premium or other cost sharing charges
(if any) that apply, medical support
obligations (under section 1912(a)) created by
enrollment (if applicable), and the actions the
parent, guardian, or relative must take to
maintain enrollment and renew coverage.
(E) Coding; application to enrollment error rates.--
(i) In general.--For purposes of subparagraph
(A)(iv), the requirement of this subparagraph
for a State is that the State agrees to--
(I) assign such codes as the
Secretary shall require to the children
who are enrolled in the State Medicaid
plan or the State CHIP plan through
reliance on a finding made by an
Express Lane agency for the duration of
the State's election under this
paragraph;
(II) annually provide the Secretary
with a statistically valid sample (that
is approved by Secretary) of the
children enrolled in such plans through
reliance on such a finding by
conducting a full Medicaid eligibility
review of the children identified for
such sample for purposes of determining
an eligibility error rate (as described
in clause (iv)) with respect to the
enrollment of such children (and shall
not include such children in any data
or samples used for purposes of
complying with a Medicaid Eligibility
Quality Control (MEQC) review or a
payment error rate measurement (PERM)
requirement);
(III) submit the error rate
determined under subclause (II) to the
Secretary;
(IV) if such error rate exceeds 3
percent for either of the first 2
fiscal years in which the State elects
to apply this paragraph, demonstrate to
the satisfaction of the Secretary the
specific corrective actions implemented
by the State to improve upon such error
rate; and
(V) if such error rate exceeds 3
percent for any fiscal year in which
the State elects to apply this
paragraph, a reduction in the amount
otherwise payable to the State under
section 1903(a) for quarters for that
fiscal year, equal to the total amount
of erroneous excess payments determined
for the fiscal year only with respect
to the children included in the sample
for the fiscal year that are in excess
of a 3 percent error rate with respect
to such children.
(ii) No punitive action based on error
rate.--The Secretary shall not apply the error
rate derived from the sample under clause (i)
to the entire population of children enrolled
in the State Medicaid plan or the State CHIP
plan through reliance on a finding made by an
Express Lane agency, or to the population of
children enrolled in such plans on the basis of
the State's regular procedures for determining
eligibility, or penalize the State on the basis
of such error rate in any manner other than the
reduction of payments provided for under clause
(i)(V).
(iii) Rule of construction.--Nothing in this
paragraph shall be construed as relieving a
State that elects to apply this paragraph from
being subject to a penalty under section
1903(u), for payments made under the State
Medicaid plan with respect to ineligible
individuals and families that are determined to
exceed the error rate permitted under that
section (as determined without regard to the
error rate determined under clause (i)(II)).
(iv) Error rate defined.--In this
subparagraph, the term ``error rate'' means the
rate of erroneous excess payments for medical
assistance (as defined in section
1903(u)(1)(D)) for the period involved, except
that such payments shall be limited to
individuals for which eligibility
determinations are made under this paragraph
and except that in applying this paragraph
under title XXI, there shall be substituted for
references to provisions of this title
corresponding provisions within title XXI.
(F) Express lane agency.--
(i) In general.--In this paragraph, the term
``Express Lane agency'' means a public agency
that--
(I) is determined by the State
Medicaid agency or the State CHIP
agency (as applicable) to be capable of
making the determinations of one or
more eligibility requirements described
in subparagraph (A)(i);
(II) is identified in the State
Medicaid plan or the State CHIP plan;
and
(III) notifies the child's family--
(aa) of the information which
shall be disclosed in
accordance with this paragraph;
(bb) that the information
disclosed will be used solely
for purposes of determining
eligibility for medical
assistance under the State
Medicaid plan or for child
health assistance under the
State CHIP plan; and
(cc) that the family may
elect to not have the
information disclosed for such
purposes; and
(IV) enters into, or is subject to,
an interagency agreement to limit the
disclosure and use of the information
disclosed.
(ii) Inclusion of specific public agencies
and indian tribes and tribal organizations.--
Such term includes the following:
(I) A public agency that determines
eligibility for assistance under any of
the following:
(aa) The temporary assistance
for needy families program
funded under part A of title
IV.
(bb) A State program funded
under part D of title IV.
(cc) The State Medicaid plan.
(dd) The State CHIP plan.
(ee) The Food and Nutrition
Act of 2008 (7 U.S.C. 2011 et
seq.).
(ff) The Head Start Act (42
U.S.C. 9801 et seq.).
(gg) The Richard B. Russell
National School Lunch Act (42
U.S.C. 1751 et seq.).
(hh) The Child Nutrition Act
of 1966 (42 U.S.C. 1771 et
seq.).
(ii) The Child Care and
Development Block Grant Act of
1990 (42 U.S.C. 9858 et seq.).
(jj) The Stewart B. McKinney
Homeless Assistance Act (42
U.S.C. 11301 et seq.).
(kk) The United States
Housing Act of 1937 (42 U.S.C.
1437 et seq.).
(ll) The Native American
Housing Assistance and Self-
Determination Act of 1996 (25
U.S.C. 4101 et seq.).
(II) A State-specified governmental
agency that has fiscal liability or
legal responsibility for the accuracy
of the eligibility determination
findings relied on by the State.
(III) A public agency that is subject
to an interagency agreement limiting
the disclosure and use of the
information disclosed for purposes of
determining eligibility under the State
Medicaid plan or the State CHIP plan.
(IV) The Indian Health Service, an
Indian Tribe, Tribal Organization, or
Urban Indian Organization (as defined
in section 1139(c)).
(iii) Exclusions.--Such term does not include
an agency that determines eligibility for a
program established under the Social Services
Block Grant established under title XX or a
private, for-profit organization.
(iv) Rules of construction.--Nothing in this
paragraph shall be construed as--
(I) exempting a State Medicaid agency
from complying with the requirements of
section 1902(a)(4) relating to merit-
based personnel standards for employees
of the State Medicaid agency and
safeguards against conflicts of
interest); or
(II) authorizing a State Medicaid
agency that elects to use Express Lane
agencies under this subparagraph to use
the Express Lane option to avoid
complying with such requirements for
purposes of making eligibility
determinations under the State Medicaid
plan.
(v) Additional definitions.--In this
paragraph:
(I) State.--The term ``State'' means
1 of the 50 States or the District of
Columbia.
(II) State chip agency.--The term
``State CHIP agency'' means the State
agency responsible for administering
the State CHIP plan.
(III) State chip plan.--The term
``State CHIP plan'' means the State
child health plan established under
title XXI and includes any waiver of
such plan.
(IV) State medicaid agency.--The term
``State Medicaid agency'' means the
State agency responsible for
administering the State Medicaid plan.
(V) State medicaid plan.--The term
``State Medicaid plan'' means the State
plan established under title XIX and
includes any waiver of such plan.
(G) Child defined.--For purposes of this paragraph,
the term ``child'' means an individual under 19 years
of age, or, at the option of a State, such higher age,
not to exceed 21 years of age, as the State may elect.
(H) State option to rely on state income tax data or
return.--At the option of the State, a finding from an
Express Lane agency may include gross income or
adjusted gross income shown by State income tax records
or returns.
(I) Application.--This paragraph shall not apply with
respect to eligibility determinations made after
September 30, 2027.
(14) Income determined using modified adjusted gross
income.--
(A) In general.--Notwithstanding subsection
(r) or any other provision of this title,
except as provided in subparagraph (D), for
purposes of determining income eligibility for
medical assistance under the State plan or
under any waiver of such plan and for any other
purpose applicable under the plan or waiver for
which a determination of income is required,
including with respect to the imposition of
premiums and cost-sharing, a State shall use
the modified adjusted gross income of an
individual and, in the case of an individual in
a family greater than 1, the household income
of such family. A State shall establish income
eligibility thresholds for populations to be
eligible for medical assistance under the State
plan or a waiver of the plan using modified
adjusted gross income and household income that
are not less than the effective income
eligibility levels that applied under the State
plan or waiver on the date of enactment of the
Patient Protection and Affordable Care Act. For
purposes of complying with the maintenance of
effort requirements under subsection (gg)
during the transition to modified adjusted
gross income and household income, a State
shall, working with the Secretary, establish an
equivalent income test that ensures individuals
eligible for medical assistance under the State
plan or under a waiver of the plan on the date
of enactment of the Patient Protection and
Affordable Care Act, do not lose coverage under
the State plan or under a waiver of the plan.
The Secretary may waive such provisions of this
title and title XXI as are necessary to ensure
that States establish income and eligibility
determination systems that protect
beneficiaries.
(B) No income or expense disregards.--Subject
to subparagraph (I), no type of expense, block,
or other income disregard shall be applied by a
State to determine income eligibility for
medical assistance under the State plan or
under any waiver of such plan or for any other
purpose applicable under the plan or waiver for
which a determination of income is required.
(C) No assets test.--A State shall not apply
any assets or resources test for purposes of
determining eligibility for medical assistance
under the State plan or under a waiver of the
plan.
(D) Exceptions.--
(i) Individuals eligible because of
other aid or assistance, elderly
individuals, medically needy
individuals, and individuals eligible
for medicare cost-sharing.--
Subparagraphs (A), (B), and (C) shall
not apply to the determination of
eligibility under the State plan or
under a waiver for medical assistance
for the following:
(I) Individuals who are
eligible for medical assistance
under the State plan or under a
waiver of the plan on a basis
that does not require a
determination of income by the
State agency administering the
State plan or waiver, including
as a result of eligibility for,
or receipt of, other Federal or
State aid or assistance,
individuals who are eligible on
the basis of receiving (or
being treated as if receiving)
supplemental security income
benefits under title XVI, and
individuals who are eligible as
a result of being or being
deemed to be a child in foster
care under the responsibility
of the State.
(II) Individuals who have
attained age 65.
(III) Individuals who qualify
for medical assistance under
the State plan or under any
waiver of such plan on the
basis of being blind or
disabled (or being treated as
being blind or disabled)
without regard to whether the
individual is eligible for
supplemental security income
benefits under title XVI on the
basis of being blind or
disabled and including an
individual who is eligible for
medical assistance on the basis
of section 1902(e)(3).
(IV) Individuals described in
subsection (a)(10)(C).
(V) Individuals described in
any clause of subsection
(a)(10)(E).
(ii) Express lane agency findings.--
In the case of a State that elects the
Express Lane option under paragraph
(13), notwithstanding subparagraphs
(A), (B), and (C), the State may rely
on a finding made by an Express Lane
agency in accordance with that
paragraph relating to the income of an
individual for purposes of determining
the individual's eligibility for
medical assistance under the State plan
or under a waiver of the plan.
(iii) Medicare prescription drug
subsidies determinations.--
Subparagraphs (A), (B), and (C) shall
not apply to any determinations of
eligibility for premium and cost-
sharing subsidies under and in
accordance with section 1860D-14 made
by the State pursuant to section
1935(a)(2).
(iv) Long-term care.--Subparagraphs
(A), (B), and (C) shall not apply to
any determinations of eligibility of
individuals for purposes of medical
assistance for nursing facility
services, a level of care in any
institution equivalent to that of
nursing facility services, home or
community-based services furnished
under a waiver or State plan amendment
under section 1915 or a waiver under
section 1115, and services described in
section 1917(c)(1)(C)(ii).
(v) Grandfather of current enrollees
until date of next regular
redetermination.--An individual who, on
January 1, 2014, is enrolled in the
State plan or under a waiver of the
plan and who would be determined
ineligible for medical assistance
solely because of the application of
the modified adjusted gross income or
household income standard described in
subparagraph (A), shall remain eligible
for medical assistance under the State
plan or waiver (and subject to the same
premiums and cost-sharing as applied to
the individual on that date) through
March 31, 2014, or the date on which
the individual's next regularly
scheduled redetermination of
eligibility is to occur, whichever is
later.
(E) Transition planning and oversight.--Each
State shall submit to the Secretary for the
Secretary's approval the income eligibility
thresholds proposed to be established using
modified adjusted gross income and household
income, the methodologies and procedures to be
used to determine income eligibility using
modified adjusted gross income and household
income and, if applicable, a State plan
amendment establishing an optional eligibility
category under subsection (a)(10)(A)(ii)(XX).
To the extent practicable, the State shall use
the same methodologies and procedures for
purposes of making such determinations as the
State used on the date of enactment of the
Patient Protection and Affordable Care Act. The
Secretary shall ensure that the income
eligibility thresholds proposed to be
established using modified adjusted gross
income and household income, including under
the eligibility category established under
subsection (a)(10)(A)(ii)(XX), and the
methodologies and procedures proposed to be
used to determine income eligibility, will not
result in children who would have been eligible
for medical assistance under the State plan or
under a waiver of the plan on the date of
enactment of the Patient Protection and
Affordable Care Act no longer being eligible
for such assistance.
(F) Limitation on secretarial authority.--The
Secretary shall not waive compliance with the
requirements of this paragraph except to the
extent necessary to permit a State to
coordinate eligibility requirements for dual
eligible individuals (as defined in section
1915(h)(2)(B)) under the State plan or under a
waiver of the plan and under title XVIII and
individuals who require the level of care
provided in a hospital, a nursing facility, or
an intermediate care facility for the mentally
retarded.
(G) Definitions of modified adjusted gross
income and household income.--In this
paragraph, the terms ``modified adjusted gross
income'' and ``household income'' have the
meanings given such terms in section 36B(d)(2)
of the Internal Revenue Code of 1986.
(H) Continued application of medicaid rules
regarding point-in-time income and sources of
income.--The requirement under this paragraph
for States to use modified adjusted gross
income and household income to determine income
eligibility for medical assistance under the
State plan or under any waiver of such plan and
for any other purpose applicable under the plan
or waiver for which a determination of income
is required shall not be construed as affecting
or limiting the application of--
(i) the requirement under this title
and under the State plan or a waiver of
the plan to determine an individual's
income as of the point in time at which
an application for medical assistance
under the State plan or a waiver of the
plan is processed; or
(ii) any rules established under this
title or under the State plan or a
waiver of the plan regarding sources of
countable income.
(I) Treatment of portion of modified adjusted
gross income.--For purposes of determining the
income eligibility of an individual for medical
assistance whose eligibility is determined
based on the application of modified adjusted
gross income under subparagraph (A), the State
shall--
(i) determine the dollar equivalent
of the difference between the upper
income limit on eligibility for such an
individual (expressed as a percentage
of the poverty line) and such upper
income limit increased by 5 percentage
points; and
(ii) notwithstanding the requirement
in subparagraph (A) with respect to use
of modified adjusted gross income,
utilize as the applicable income of
such individual, in determining such
income eligibility, an amount equal to
the modified adjusted gross income
applicable to such individual reduced
by such dollar equivalent amount.
(J) Exclusion of parent mentor compensation
from income determination.--Any nominal amount
received by an individual as compensation,
including a stipend, for participation as a
parent mentor (as defined in paragraph (5) of
section 2113(f)) in an activity or program
funded through a grant under such section shall
be disregarded for purposes of determining the
income eligibility of such individual for
medical assistance under the State plan or any
waiver of such plan.
(K) Treatment of certain lottery winnings and
income received as a lump sum.--
(i) In general.--In the case of an
individual who is the recipient of
qualified lottery winnings (pursuant to
lotteries occurring on or after January
1, 2018) or qualified lump sum income
(received on or after such date) and
whose eligibility for medical
assistance is determined based on the
application of modified adjusted gross
income under subparagraph (A), a State
shall, in determining such eligibility,
include such winnings or income (as
applicable) as income received--
(I) in the month in which
such winnings or income (as
applicable) is received if the
amount of such winnings or
income is less than $80,000;
(II) over a period of 2
months if the amount of such
winnings or income (as
applicable) is greater than or
equal to $80,000 but less than
$90,000;
(III) over a period of 3
months if the amount of such
winnings or income (as
applicable) is greater than or
equal to $90,000 but less than
$100,000; and
(IV) over a period of 3
months plus 1 additional month
for each increment of $10,000
of such winnings or income (as
applicable) received, not to
exceed a period of 120 months
(for winnings or income of
$1,260,000 or more), if the
amount of such winnings or
income is greater than or equal
to $100,000.
(ii) Counting in equal
installments.--For purposes of
subclauses (II), (III), and (IV) of
clause (i), winnings or income to which
such subclause applies shall be counted
in equal monthly installments over the
period of months specified under such
subclause.
(iii) Hardship exemption.--An
individual whose income, by application
of clause (i), exceeds the applicable
eligibility threshold established by
the State, shall continue to be
eligible for medical assistance to the
extent that the State determines, under
procedures established by the State (in
accordance with standards specified by
the Secretary), that the denial of
eligibility of the individual would
cause an undue medical or financial
hardship as determined on the basis of
criteria established by the Secretary.
(iv) Notifications and assistance
required in case of loss of
eligibility.--A State shall, with
respect to an individual who loses
eligibility for medical assistance
under the State plan (or a waiver of
such plan) by reason of clause (i)--
(I) before the date on which
the individual loses such
eligibility, inform the
individual--
(aa) of the
individual's
opportunity to enroll
in a qualified health
plan offered through an
Exchange established
under title I of the
Patient Protection and
Affordable Care Act
during the special
enrollment period
specified in section
9801(f)(3) of the
Internal Revenue Code
of 1986 (relating to
loss of Medicaid or
CHIP coverage); and
(bb) of the date on
which the individual
would no longer be
considered ineligible
by reason of clause (i)
to receive medical
assistance under the
State plan or under any
waiver of such plan and
be eligible to reapply
to receive such medical
assistance; and
(II) provide technical
assistance to the individual
seeking to enroll in such a
qualified health plan.
(v) Qualified lottery winnings
defined.--In this subparagraph, the
term ``qualified lottery winnings''
means winnings from a sweepstakes,
lottery, or pool described in paragraph
(3) of section 4402 of the Internal
Revenue Code of 1986 or a lottery
operated by a multistate or
multijurisdictional lottery
association, including amounts awarded
as a lump sum payment.
(vi) Qualified lump sum income
defined.--In this subparagraph, the
term ``qualified lump sum income''
means income that is received as a lump
sum from monetary winnings from
gambling (as defined by the Secretary
and including gambling activities
described in section 1955(b)(4) of
title 18, United States Code).
(15) Exclusion of compensation for participation in a
clinical trial for testing of treatments for a rare
disease or condition.--The first $2,000 received by an
individual (who has attained 19 years of age) as
compensation for participation in a clinical trial
meeting the requirements of section 1612(b)(26) shall
be disregarded for purposes of determining the income
eligibility of such individual for medical assistance
under the State plan or any waiver of such plan.
(f) Notwithstanding any other provision of this title, except
as provided in subsection (e) and section 1619(b)(3) and
section 1924, except with respect to qualified disabled and
working individuals (described in section 1905(s)), and except
with respect to qualified medicare beneficiaries, qualified
severely impaired individuals, and individuals described in
subsection (m)(1), no State not eligible to participate in the
State plan program established under title XVI shall be
required to provide medical assistance to any aged, blind, or
disabled individual (within the meaning of title XVI) for any
month unless such State would be (or would have been) required
to provide medical assistance to such individual for such month
had its plan for medical assistance approved under this title
and in effect on January 1, 1972, been in effect in such month,
except that for this purpose any such individual shall be
deemed eligible for medical assistance under such State plan if
(in addition to meeting such other requirements as are or may
be imposed under the State plan) the income of any such
individual as determined in accordance with section 1903(f)
(after deducting any supplemental security income payment and
State supplementary payment made with respect to such
individual, and incurred expenses for medical care as
recognized under State law regardless of whether such expenses
are reimbursed under another public program of the State or
political subdivision thereof) is not in excess of the standard
for medical assistance established under the State plan as in
effect on January 1, 1972. In States which provide medical
assistance to individuals pursuant to paragraph (10)(C) of
subsection (a) of this section, an individual who is eligible
for medical assistance by reason of the requirements of this
section concerning the deduction of incurred medical expenses
from income shall be considered an individual eligible for
medical assistance under paragraph (10)(A) of that subsection
if that individual is, or is eligible to be (1) an individual
with respect to whom there is payable a State supplementary
payment on the basis of which similarly situated individuals
are eligible to receive medical assistance equal in amount,
duration, and scope to that provided to individuals eligible
under paragraph (10)(A), or (2) an eligible individual or
eligible spouse, as defined in title XVI, with respect to whom
supplemental security income benefits are payable; otherwise
that individual shall be considered to be an individual
eligible for medical assistance under paragraph (10)(C) of that
subsection. In States which do not provide medical assistance
to individuals pursuant to paragraph (10)(C) of that
subsection, an individual who is eligible for medical
assistance by reason of the requirements of this section
concerning the deduction of incurred medical expenses from
income shall be considered an individual eligible for medical
assistance under paragraph (10)(A) of that subsection.
(g) In addition to any other sanction available to a State, a
State may provide for a reduction of any payment amount
otherwise due with respect to a person who furnishes services
under the plan in an amount equal to up to three times the
amount of any payment sought to be collected by that person in
violation of subsection (a)(25)(C).
(h) Nothing in this title (including subsections (a)(13) and
(a)(30) of this section) shall be construed as authorizing the
Secretary to limit the amount of payment that may be made under
a plan under this title for home and community care.
(i)(1) In addition to any other authority under State law,
where a State determines that a intermediate care facility for
the mentally retarded which is certified for participation
under its plan no longer substantially meets the requirements
for such a facility under this title and further determines
that the facility's deficiencies--
(A) immediately jeopardize the health and safety of
its patients, the State shall provide for the
termination of the facility's certification for
participation under the plan and may provide, or
(B) do not immediately jeopardize the health and
safety of its patients, the State may, in lieu of
providing for terminating the facility's certification
for participation under the plan, establish alternative
remedies if the State demonstrates to the Secretary's
satisfaction that the alternative remedies are
effective in deterring noncompliance and correcting
deficiencies, and may provide
that no payment will be made under the State plan with respect
to any individual admitted to such facility after a date
specified by the State.
(2) The State shall not make such a decision with respect to
a facility until the facility has had a reasonable opportunity,
following the initial determination that it no longer
substantially meets the requirements for such a facility under
this title, to correct its deficiencies, and, following this
period, has been given reasonable notice and opportunity for a
hearing.
(3) The State's decision to deny payment may be made
effective only after such notice to the public and to the
facility as may be provided for by the State, and its
effectiveness shall terminate (A) when the State finds that the
facility is in substantial compliance (or is making good faith
efforts to achieve substantial compliance) with the
requirements for such a facility under this title, or (B) in
the case described in paragraph (1)(B), with the end of the
eleventh month following the month such decision is made
effective, whichever occurs first. If a facility to which
clause (B) of the previous sentence applies still fails to
substantially meet the provisions of the respective section on
the date specified in such clause, the State shall terminate
such facility's certification for participation under the plan
effective with the first day of the first month following the
month specified in such clause.
(j) Notwithstanding any other requirement of this title, the
Secretary may waive or modify any requirement of this title
with respect to the medical assistance program in American
Samoa and the Northern Mariana Islands, other than a waiver of
the Federal medical assistance percentage, the limitation in
section 1108(f), [or the requirement], the requirement that
payment may be made for medical assistance only with respect to
amounts expended by American Samoa or the Northern Mariana
Islands for care and services described in a numbered paragraph
of section 1905(a), or the requirement under subsection (qq)(1)
(relating to data reporting).
(k)(1) The medical assistance provided to an individual
described in subclause (VIII) of subsection (a)(10)(A)(i) shall
consist of benchmark coverage described in section 1937(b)(1)
or benchmark equivalent coverage described in section
1937(b)(2). Such medical assistance shall be provided subject
to the requirements of section 1937, without regard to whether
a State otherwise has elected the option to provide medical
assistance through coverage under that section, unless an
individual described in subclause (VIII) of subsection
(a)(10)(A)(i) is also an individual for whom, under
subparagraph (B) of section 1937(a)(2), the State may not
require enrollment in benchmark coverage described in
subsection (b)(1) of section 1937 or benchmark equivalent
coverage described in subsection (b)(2) of that section.
(2) Beginning with the first day of any fiscal year quarter
that begins on or after April 1, 2010, and before January 1,
2014, a State may elect through a State plan amendment to
provide medical assistance to individuals who would be
described in subclause (VIII) of subsection (a)(10)(A)(i) if
that subclause were effective before January 1, 2014. A State
may elect to phase-in the extension of eligibility for medical
assistance to such individuals based on income, so long as the
State does not extend such eligibility to individuals described
in such subclause with higher income before making individuals
described in such subclause with lower income eligible for
medical assistance.
(3) If an individual described in subclause (VIII) of
subsection (a)(10)(A)(i) is the parent of a child who is under
19 years of age (or such higher age as the State may have
elected) who is eligible for medical assistance under the State
plan or under a waiver of such plan (under that subclause or
under a State plan amendment under paragraph (2), the
individual may not be enrolled under the State plan unless the
individual's child is enrolled under the State plan or under a
waiver of the plan or is enrolled in other health insurance
coverage. For purposes of the preceding sentence, the term
``parent'' includes an individual treated as a caretaker
relative for purposes of carrying out section 1931.
(l)(1) Individuals described in this paragraph are--
(A) women during pregnancy (and during the 60-day
period beginning on the last day of the pregnancy),
(B) infants under one year of age,
(C) children who have attained one year of age but
have not attained 6 years of age, and
(D) children born after September 30, 1983 (or, at
the option of a State, after any earlier date), who
have attained 6 years of age but have not attained 19
years of age,
who are not described in any of subclauses (I) through (III) of
subsection (a)(10)(A)(i) and whose family income does not
exceed the income level established by the State under
paragraph (2) for a family size equal to the size of the
family, including the woman, infant, or child.
(2)(A)(i) For purposes of paragraph (1) with respect to
individuals described in subparagraph (A) or (B) of that
paragraph, the State shall establish an income level which is a
percentage (not less than the percentage provided under clause
(ii) and not more than 185 percent) of the income official
poverty line (as defined by the Office of Management and
Budget, and revised annually in accordance with section 673(2)
of the Omnibus Budget Reconciliation Act of 1981) applicable to
a family of the size involved.
(ii) The percentage provided under this clause, with respect
to eligibility for medical assistance on or after--
(I) July 1, 1989, is 75 percent, or, if greater, the
percentage provided under clause (iii), and
(II) April 1, 1990, 133 percent, or, if greater, the
percentage provided under clause (iv).
(iii) In the case of a State which, as of the date of the
enactment of this clause, has elected to provide, and provides,
medical assistance to individuals described in this subsection
or has enacted legislation authorizing, or appropriating funds,
to provide such assistance to such individuals before July 1,
1989, the percentage provided under clause (ii)(I) shall not be
less than--
(I) the percentage specified by the State in an
amendment to its State plan (whether approved or not)
as of the date of the enactment of this clause, or
(II) if no such percentage is specified as of the
date of the enactment of this clause, the percentage
established under the State's authorizing legislation
or provided for under the State's appropriations;
but in no case shall this clause require the percentage
provided under clause (ii)(I) to exceed 100 percent.
(iv) In the case of a State which, as of the date of the
enactment of this clause, has established under clause (i), or
has enacted legislation authorizing, or appropriating funds, to
provide for, a percentage (of the income official poverty line)
that is greater than 133 percent, the percentage provided under
clause (ii) for medical assistance on or after April 1, 1990,
shall not be less than--
(I) the percentage specified by the State in an
amendment to its State plan (whether approved or not)
as of the date of the enactment of this clause, or
(II) if no such percentage is specified as of the
date of the enactment of this clause, the percentage
established under the State's authorizing legislation
or provided for under the State's appropriations.
(B) For purposes of paragraph (1) with respect to individuals
described in subparagraph (C) of such paragraph, the State
shall establish an income level which is equal to 133 percent
of the income official poverty line described in subparagraph
(A) applicable to a family of the size involved.
(C) For purposes of paragraph (1) with respect to individuals
described in subparagraph (D) of that paragraph, the State
shall establish an income level which is equal to 100 percent
(or, beginning January 1, 2014, 133 percent) of the income
official poverty line described in subparagraph (A) applicable
to a family of the size involved.
(3) Notwithstanding subsection (a)(17), for individuals who
are eligible for medical assistance because of subsection
(a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), or
(a)(10)(A)(ii)(IX)--
(A) application of a resource standard shall be at
the option of the State;
(B) any resource standard or methodology that is
applied with respect to an individual described in
subparagraph (A) of paragraph (1) may not be more
restrictive than the resource standard or methodology
that is applied under title XVI;
(C) any resource standard or methodology that is
applied with respect to an individual described in
subparagraph (B), (C), or (D) of paragraph (1) may not
be more restrictive than the corresponding methodology
that is applied under the State plan under part A of
title IV;
(D) the income standard to be applied is the
appropriate income standard established under paragraph
(2); and
(E) family income shall be determined in accordance
with the methodology employed under the State plan
under part A or E of title IV (except to the extent
such methodology is inconsistent with clause (D) of
subsection (a)(17)), and costs incurred for medical
care or for any other type of remedial care shall not
be taken into account.
Any different treatment provided under this paragraph for such
individuals shall not, because of subsection (a)(17), require
or permit such treatment for other individuals.
(4)(A) In the case of any State which is providing medical
assistance to its residents under a waiver granted under
section 1115, the Secretary shall require the State to provide
medical assistance for pregnant women and infants under age 1
described in subsection (a)(10)(A)(i)(IV) and for children
described in subsection (a)(10)(A)(i)(VI) or subsection
(a)(10)(A)(i)(VII) in the same manner as the State would be
required to provide such assistance for such individuals if the
State had in effect a plan approved under this title.
(B) In the case of a State which is not one of the 50 States
or the District of Columbia, the State need not meet the
requirement of subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI),
or (a)(10)(A)(i)(VII) and, for purposes of paragraph (2)(A),
the State may substitute for the percentage provided under
clause (ii) of such paragraph any percentage.
(m)(1) Individuals described in this paragraph are
individuals--
(A) who are 65 years of age or older or are disabled
individuals (as determined under section 1614(a)(3)),
(B) whose income (as determined under section 1612
for purposes of the supplemental security income
program, except as provided in paragraph (2)(C)) does
not exceed an income level established by the State
consistent with paragraph (2)(A), and
(C) whose resources (as determined under section 1613
for purposes of the supplemental security income
program) do not exceed (except as provided in paragraph
(2)(B)) the maximum amount of resources that an
individual may have and obtain benefits under that
program.
(2)(A) The income level established under paragraph (1)(B)
may not exceed a percentage (not more than 100 percent) of the
official poverty line (as defined by the Office of Management
and Budget, and revised annually in accordance with section
673(2) of the Omnibus Budget Reconciliation Act of 1981)
applicable to a family of the size involved.
(B) In the case of a State that provides medical assistance
to individuals not described in subsection (a)(10)(A) and at
the State's option, the State may use under paragraph (1)(C)
such resource level (which is higher than the level described
in that paragraph) as may be applicable with respect to
individuals described in paragraph (1)(A) who are not described
in subsection (a)(10)(A).
(C) The provisions of section 1905(p)(2)(D) shall apply to
determinations of income under this subsection in the same
manner as they apply to determinations of income under section
1905(p).
(3) Notwithstanding subsection (a)(17), for individuals
described in paragraph (1) who are covered under the State plan
by virtue of subsection (a)(10)(A)(ii)(X)--
(A) the income standard to be applied is the income
standard described in paragraph (1)(B), and
(B) except as provided in section 1612(b)(4)(B)(ii),
costs incurred for medical care or for any other type
of remedial care shall not be taken into account in
determining income.
Any different treatment provided under this paragraph for such
individuals shall not, because of subsection (a)(17), require
or permit such treatment for other individuals.
(4) Notwithstanding subsection (a)(17), for qualified
medicare beneficiaries described in section 1905(p)(1)--
(A) the income standard to be applied is the income
standard described in section 1905(p)(1)(B), and
(B) except as provided in section 1612(b)(4)(B)(ii),
costs incurred for medical care or for any other type
of remedial care shall not be taken into account in
determining income.
Any different treatment provided under this paragraph for such
individuals shall not, because of subsection (a)(17), require
or permit such treatment for other individuals.
(n)(1) In the case of medical assistance furnished under this
title for medicare cost-sharing respecting the furnishing of a
service or item to a qualified medicare beneficiary, the State
plan may provide payment in an amount with respect to the
service or item that results in the sum of such payment amount
and any amount of payment made under title XVIII with respect
to the service or item exceeding the amount that is otherwise
payable under the State plan for the item or service for
eligible individuals who are not qualified medicare
beneficiaries.
(2) In carrying out paragraph (1), a State is not required to
provide any payment for any expenses incurred relating to
payment for deductibles, coinsurance, or copayments for
medicare cost-sharing to the extent that payment under title
XVIII for the service would exceed the payment amount that
otherwise would be made under the State plan under this title
for such service if provided to an eligible recipient other
than a medicare beneficiary.
(3) In the case in which a State's payment for medicare cost-
sharing for a qualified medicare beneficiary with respect to an
item or service is reduced or eliminated through the
application of paragraph (2)--
(A) for purposes of applying any limitation under
title XVIII on the amount that the beneficiary may be
billed or charged for the service, the amount of
payment made under title XVIII plus the amount of
payment (if any) under the State plan shall be
considered to be payment in full for the service;
(B) the beneficiary shall not have any legal
liability to make payment to a provider or to an
organization described in section 1903(m)(1)(A) for the
service; and
(C) any lawful sanction that may be imposed upon a
provider or such an organization for excess charges
under this title or title XVIII shall apply to the
imposition of any charge imposed upon the individual in
such case.
This paragraph shall not be construed as preventing payment of
any medicare cost-sharing by a medicare supplemental policy or
an employer retiree health plan on behalf of an individual.
(o) Notwithstanding any provision of subsection (a) to the
contrary, a State plan under this title shall provide that any
supplemental security income benefits paid by reason of
subparagraph (E) or (G) of section 1611(e)(1) to an individual
who--
(1) is eligible for medical assistance under the
plan, and
(2) is in a hospital, skilled nursing facility, or
intermediate care facility at the time such benefits
are paid,
will be disregarded for purposes of determining the amount of
any post-eligibility contribution by the individual to the cost
of the care and services provided by the hospital, skilled
nursing facility, or intermediate care facility.
(p)(1) In addition to any other authority, a State may
exclude any individual or entity for purposes of participating
under the State plan under this title for any reason for which
the Secretary could exclude the individual or entity from
participation in a program under title XVIII under section
1128, 1128A, or 1866(b)(2).
(2) In order for a State to receive payments for medical
assistance under section 1903(a), with respect to payments the
State makes to a medicaid managed care organization (as defined
in section 1903(m)) or to an entity furnishing services under a
waiver approved under section 1915(b)(1), the State must
provide that it will exclude from participation, as such an
organization or entity, any organization or entity that--
(A) could be excluded under section 1128(b)(8)
(relating to owners and managing employees who have
been convicted of certain crimes or received other
sanctions),
(B) has, directly or indirectly, a substantial
contractual relationship (as defined by the Secretary)
with an individual or entity that is described in
section 1128(b)(8)(B), or
(C) employs or contracts with any individual or
entity that is excluded from participation under this
title under section 1128 or 1128A for the provision of
health care, utilization review, medical social work,
or administrative services or employs or contracts with
any entity for the provision (directly or indirectly)
through such an excluded individual or entity of such
services.
(3) As used in this subsection, the term ``exclude'' includes
the refusal to enter into or renew a participation agreement or
the termination of such an agreement.
(q)(1)(A) In order to meet the requirement of subsection
(a)(50), the State plan must provide that, in the case of an
institutionalized individual or couple described in
subparagraph (B), in determining the amount of the individual's
or couple's income to be applied monthly to payment for the
cost of care in an institution, there shall be deducted from
the monthly income (in addition to other allowances otherwise
provided under the State plan) a monthly personal needs
allowance--
(i) which is reasonable in amount for clothing and
other personal needs of the individual (or couple)
while in an institution, and
(ii) which is not less (and may be greater) than the
minimum monthly personal needs allowance described in
paragraph (2).
(B) In this subsection, the term ``institutionalized
individual or couple'' means an individual or married couple--
(i) who is an inpatient (or who are inpatients) in a
medical institution or nursing facility for which
payments are made under this title throughout a month,
and
(ii) who is or are determined to be eligible for
medical assistance under the State plan.
(2) The minimum monthly personal needs allowance described in
this paragraph is $30 for an institutionalized individual and
$60 for an institutionalized couple (if both are aged, blind,
or disabled, and their incomes are considered available to each
other in determining eligibility).
(r)(1)(A) For purposes of sections 1902(a)(17) and
1924(d)(1)(D) and for purposes of a waiver under section 1915,
with respect to the post-eligibility treatment of income of
individuals who are institutionalized or receiving home or
community-based services under such a waiver, the treatment
described in subparagraph (B) shall apply, there shall be
disregarded reparation payments made by the Federal Republic of
Germany, and there shall be taken into account amounts for
incurred expenses for medical or remedial care that are not
subject to payment by a third party, including--
(i) medicare and other health insurance premiums,
deductibles, or coinsurance, and
(ii) necessary medical or remedial care recognized
under State law but not covered under the State plan
under this title, subject to reasonable limits the
State may establish on the amount of these expenses.
(B)(i) In the case of a veteran who does not have a spouse or
a child, if the veteran--
(I) receives, after the veteran has been determined
to be eligible for medical assistance under the State
plan under this title, a veteran's pension in excess of
$90 per month, and
(II) resides in a State veterans home with respect to
which the Secretary of Veterans Affairs makes per diem
payments for nursing home care pursuant to section
1741(a) of title 38, United States Code,
any such pension payment, including any payment made due to the
need for aid and attendance, or for unreimbursed medical
expenses, that is in excess of $90 per month shall be counted
as income only for the purpose of applying such excess payment
to the State veterans home's cost of providing nursing home
care to the veteran.
(ii) The provisions of clause (i) shall apply with respect to
a surviving spouse of a veteran who does not have a child in
the same manner as they apply to a veteran described in such
clause.
(2)(A) The methodology to be employed in determining income
and resource eligibility for individuals under subsection
(a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI),
(a)(10)(A)(i)(VII), (a)(10)(A)(ii), (a)(10)(C)(i)(III), or (f)
or under section 1905(p) may be less restrictive, and shall be
no more restrictive, than the methodology--
(i) in the case of groups consisting of aged, blind,
or disabled individuals, under the supplemental
security income program under title XVI, or
(ii) in the case of other groups, under the State
plan most closely categorically related.
(B) For purposes of this subsection and subsection (a)(10),
methodology is considered to be ``no more restrictive'' if,
using the methodology, additional individuals may be eligible
for medical assistance and no individuals who are otherwise
eligible are made ineligible for such assistance.
(s) In order to meet the requirements of subsection (a)(55),
the State plan must provide that payments to hospitals under
the plan for inpatient hospital services furnished to infants
who have not attained the age of 1 year, and to children who
have not attained the age of 6 years and who receive such
services in a disproportionate share hospital described in
section 1923(b)(1), shall--
(1) if made on a prospective basis (whether per diem,
per case, or otherwise) provide for an outlier
adjustment in payment amounts for medically necessary
inpatient hospital services involving exceptionally
high costs or exceptionally long lengths of stay,
(2) not be limited by the imposition of day limits
with respect to the delivery of such services to such
individuals, and
(3) not be limited by the imposition of dollar limits
(other than such limits resulting from prospective
payments as adjusted pursuant to paragraph (1)) with
respect to the delivery of such services to any such
individual who has not attained their first birthday
(or in the case of such an individual who is an
inpatient on his first birthday until such individual
is discharged).
(t) Nothing in this title (including sections 1903(a) and
1905(a)) shall be construed as authorizing the Secretary to
deny or limit payments to a State for expenditures, for medical
assistance for items or services, attributable to taxes of
general applicability imposed with respect to the provision of
such items or services.
(u)(1) Individuals described in this paragraph are
individuals--
(A) who are entitled to elect COBRA continuation
coverage (as defined in paragraph (3)),
(B) whose income (as determined under section 1612
for purposes of the supplemental security income
program) does not exceed 100 percent of the official
poverty line (as defined by the Office of Management
and Budget, and revised annually in accordance with
section 673(2) of the Omnibus Budget Reconciliation Act
of 1981) applicable to a family of the size involved,
(C) whose resources (as determined under section 1613
for purposes of the supplemental security income
program) do not exceed twice the maximum amount of
resources that an individual may have and obtain
benefits under that program, and
(D) with respect to whose enrollment for COBRA
continuation coverage the State has determined that the
savings in expenditures under this title resulting from
such enrollment is likely to exceed the amount of
payments for COBRA premiums made.
(2) For purposes of subsection (a)(10)(F) and this
subsection, the term ``COBRA premiums'' means the applicable
premium imposed with respect to COBRA continuation coverage.
(3) In this subsection, the term ``COBRA continuation
coverage'' means coverage under a group health plan provided by
an employer with 75 or more employees provided pursuant to
title XXII of the Public Health Service Act, section 4980B of
the Internal Revenue Code of 1986, or title VI of the Employee
Retirement Income Security Act of 1974.
(4) Notwithstanding subsection (a)(17), for individuals
described in paragraph (1) who are covered under the State plan
by virtue of subsection (a)(10)(A)(ii)(XI)--
(A) the income standard to be applied is the income
standard described in paragraph (1)(B), and
(B) except as provided in section 1612(b)(4)(B)(ii),
costs incurred for medical care or for any other type
of remedial care shall not be taken into account in
determining income.
Any different treatment provided under this paragraph for such
individuals shall not, because of subsection (a)(10)(B) or
(a)(17), require or permit such treatment for other
individuals.
(v) A State plan may provide for the making of determinations
of disability or blindness for the purpose of determining
eligibility for medical assistance under the State plan by the
single State agency or its designee, and make medical
assistance available to individuals whom it finds to be blind
or disabled and who are determined otherwise eligible for such
assistance during the period of time prior to which a final
determination of disability or blindness is made by the Social
Security Administration with respect to such an individual. In
making such determinations, the State must apply the
definitions of disability and blindness found in section
1614(a) of the Social Security Act.
(w)(1) For purposes of subsection (a)(57) and sections
1903(m)(1)(A) and 1919(c)(2)(E), the requirement of this
subsection is that a provider or organization (as the case may
be) maintain written policies and procedures with respect to
all adult individuals receiving medical care by or through the
provider or organization--
(A) to provide written information to each such
individual concerning--
(i) an individual's rights under State law
(whether statutory or as recognized by the
courts of the State) to make decisions
concerning such medical care, including the
right to accept or refuse medical or surgical
treatment and the right to formulate advance
directives (as defined in paragraph (3)), and
(ii) the provider's or organization's written
policies respecting the implementation of such
rights;
(B) to document in the individual's medical record
whether or not the individual has executed an advance
directive;
(C) not to condition the provision of care or
otherwise discriminate against an individual based on
whether or not the individual has executed an advance
directive;
(D) to ensure compliance with requirements of State
law (whether statutory or as recognized by the courts
of the State) respecting advance directives; and
(E) to provide (individually or with others) for
education for staff and the community on issues
concerning advance directives.
Subparagraph (C) shall not be construed as requiring the
provision of care which conflicts with an advance directive.
(2) The written information described in paragraph (1)(A)
shall be provided to an adult individual--
(A) in the case of a hospital, at the time of the
individual's admission as an inpatient,
(B) in the case of a nursing facility, at the time of
the individual's admission as a resident,
(C) in the case of a provider of home health care or
personal care services, in advance of the individual
coming under the care of the provider,
(D) in the case of a hospice program, at the time of
initial receipt of hospice care by the individual from
the program, and
(E) in the case of a medicaid managed care
organization, at the time of enrollment of the
individual with the organization.
(3) Nothing in this section shall be construed to prohibit
the application of a State law which allows for an objection on
the basis of conscience for any health care provider or any
agent of such provider which as a matter of conscience cannot
implement an advance directive.
(4) In this subsection, the term ``advance directive'' means
a written instruction, such as a living will or durable power
of attorney for health care, recognized under State law
(whether statutory or as recognized by the courts of the State)
and relating to the provision of such care when the individual
is incapacitated.
(5) For construction relating to this subsection, see section
7 of the Assisted Suicide Funding Restriction Act of 1997
(relating to clarification respecting assisted suicide,
euthanasia, and mercy killing).
(x) The Secretary shall establish a system, for
implementation by not later than July 1, 1991, which provides
for a unique identifier for each physician who furnishes
services for which payment may be made under a State plan
approved under this title.
(y)(1) In addition to any other authority under State law,
where a State determines that a psychiatric hospital which is
certified for participation under its plan no longer meets the
requirements for a psychiatric hospital (referred to in section
1905(h)) and further finds that the hospital's deficiencies--
(A) immediately jeopardize the health and safety of
its patients, the State shall terminate the hospital's
participation under the State plan; or
(B) do not immediately jeopardize the health and
safety of its patients, the State may terminate the
hospital's participation under the State plan, or
provide that no payment will be made under the State
plan with respect to any individual admitted to such
hospital after the effective date of the finding, or
both.
(2) Except as provided in paragraph (3), if a psychiatric
hospital described in paragraph (1)(B) has not complied with
the requirements for a psychiatric hospital under this title--
(A) within 3 months after the date the hospital is
found to be out of compliance with such requirements,
the State shall provide that no payment will be made
under the State plan with respect to any individual
admitted to such hospital after the end of such 3-month
period, or
(B) within 6 months after the date the hospital is
found to be out of compliance with such requirements,
no Federal financial participation shall be provided
under section 1903(a) with respect to further services
provided in the hospital until the State finds that the
hospital is in compliance with the requirements of this
title.
(3) The Secretary may continue payments, over a period of not
longer than 6 months from the date the hospital is found to be
out of compliance with such requirements, if--
(A) the State finds that it is more appropriate to
take alternative action to assure compliance of the
hospital with the requirements than to terminate the
certification of the hospital,
(B) the State has submitted a plan and timetable for
corrective action to the Secretary for approval and the
Secretary approves the plan of corrective action, and
(C) the State agrees to repay to the Federal
Government payments received under this paragraph if
the corrective action is not taken in accordance with
the approved plan and timetable.
(z)(1) Individuals described in this paragraph are
individuals not described in subsection (a)(10)(A)(i)--
(A) who are infected with tuberculosis;
(B) whose income (as determined under the State plan
under this title with respect to disabled individuals)
does not exceed the maximum amount of income a disabled
individual described in subsection (a)(10)(A)(i) may
have and obtain medical assistance under the plan; and
(C) whose resources (as determined under the State
plan under this title with respect to disabled
individuals) do not exceed the maximum amount of
resources a disabled individual described in subsection
(a)(10)(A)(i) may have and obtain medical assistance
under the plan.
(2) For purposes of subsection (a)(10), the term ``TB-related
services'' means each of the following services relating to
treatment of infection with tuberculosis:
(A) Prescribed drugs.
(B) Physicians' services and services described in
section 1905(a)(2).
(C) Laboratory and X-ray services (including services
to confirm the presence of infection).
(D) Clinic services and Federally-qualified health
center services.
(E) Case management services (as defined in section
1915(g)(2)).
(F) Services (other than room and board) designed to
encourage completion of regimens of prescribed drugs by
outpatients, including services to observe directly the
intake of prescribed drugs.
(aa) Individuals described in this subsection are individuals
who--
(1) are not described in subsection (a)(10)(A)(i);
(2) have not attained age 65;
(3) have been screened for breast and cervical cancer
under the Centers for Disease Control and Prevention
breast and cervical cancer early detection program
established under title XV of the Public Health Service
Act (42 U.S.C. 300k et seq.) in accordance with the
requirements of section 1504 of that Act (42 U.S.C.
300n) and need treatment for breast or cervical cancer;
and
(4) are not otherwise covered under creditable
coverage, as defined in section 2701(c) of the Public
Health Service Act (42 U.S.C. 300gg(c)), but applied
without regard to paragraph (1)(F) of such section.
(bb) Payment for Services Provided by Federally-Qualified
Health Centers and Rural Health Clinics.--
(1) In general.--Beginning with fiscal year 2001 with
respect to services furnished on or after January 1,
2001, and each succeeding fiscal year, the State plan
shall provide for payment for services described in
section 1905(a)(2)(C) furnished by a Federally-
qualified health center and services described in
section 1905(a)(2)(B) furnished by a rural health
clinic in accordance with the provisions of this
subsection.
(2) Fiscal year 2001.--Subject to paragraph (4), for
services furnished on and after January 1, 2001, during
fiscal year 2001, the State plan shall provide for
payment for such services in an amount (calculated on a
per visit basis) that is equal to 100 percent of the
average of the costs of the center or clinic of
furnishing such services during fiscal years 1999 and
2000 which are reasonable and related to the cost of
furnishing such services, or based on such other tests
of reasonableness as the Secretary prescribes in
regulations under section 1833(a)(3), or, in the case
of services to which such regulations do not apply, the
same methodology used under section 1833(a)(3),
adjusted to take into account any increase or decrease
in the scope of such services furnished by the center
or clinic during fiscal year 2001.
(3) Fiscal year 2002 and succeeding fiscal years.--
Subject to paragraph (4), for services furnished during
fiscal year 2002 or a succeeding fiscal year, the State
plan shall provide for payment for such services in an
amount (calculated on a per visit basis) that is equal
to the amount calculated for such services under this
subsection for the preceding fiscal year--
(A) increased by the percentage increase in
the MEI (as defined in section 1842(i)(3))
applicable to primary care services (as defined
in section 1842(i)(4)) for that fiscal year;
and
(B) adjusted to take into account any
increase or decrease in the scope of such
services furnished by the center or clinic
during that fiscal year.
(4) Establishment of initial year payment amount for
new centers or clinics.--In any case in which an entity
first qualifies as a Federally-qualified health center
or rural health clinic after fiscal year 2000, the
State plan shall provide for payment for services
described in section 1905(a)(2)(C) furnished by the
center or services described in section 1905(a)(2)(B)
furnished by the clinic in the first fiscal year in
which the center or clinic so qualifies in an amount
(calculated on a per visit basis) that is equal to 100
percent of the costs of furnishing such services during
such fiscal year based on the rates established under
this subsection for the fiscal year for other such
centers or clinics located in the same or adjacent area
with a similar case load or, in the absence of such a
center or clinic, in accordance with the regulations
and methodology referred to in paragraph (2) or based
on such other tests of reasonableness as the Secretary
may specify. For each fiscal year following the fiscal
year in which the entity first qualifies as a
Federally-qualified health center or rural health
clinic, the State plan shall provide for the payment
amount to be calculated in accordance with paragraph
(3).
(5) Administration in the case of managed care.--
(A) In general.--In the case of services
furnished by a Federally-qualified health
center or rural health clinic pursuant to a
contract between the center or clinic and a
managed care entity (as defined in section
1932(a)(1)(B)), the State plan shall provide
for payment to the center or clinic by the
State of a supplemental payment equal to the
amount (if any) by which the amount determined
under paragraphs (2), (3), and (4) of this
subsection exceeds the amount of the payments
provided under the contract.
(B) Payment schedule.--The supplemental
payment required under subparagraph (A) shall
be made pursuant to a payment schedule agreed
to by the State and the Federally-qualified
health center or rural health clinic, but in no
case less frequently than every 4 months.
(6) Alternative payment methodologies.--
Notwithstanding any other provision of this section,
the State plan may provide for payment in any fiscal
year to a Federally-qualified health center for
services described in section 1905(a)(2)(C) or to a
rural health clinic for services described in section
1905(a)(2)(B) in an amount which is determined under an
alternative payment methodology that--
(A) is agreed to by the State and the center
or clinic; and
(B) results in payment to the center or
clinic of an amount which is at least equal to
the amount otherwise required to be paid to the
center or clinic under this section.
(cc)(1) Individuals described in this paragraph are
individuals--
(A) who are children who have not attained 19 years
of age and are born--
(i) on or after January 1, 2001 (or, at the
option of a State, on or after an earlier
date), in the case of the second, third, and
fourth quarters of fiscal year 2007;
(ii) on or after October 1, 1995 (or, at the
option of a State, on or after an earlier
date), in the case of each quarter of fiscal
year 2008; and
(iii) after October 1, 1989, in the case of
each quarter of fiscal year 2009 and each
quarter of any fiscal year thereafter;
(B) who would be considered disabled under section
1614(a)(3)(C) (as determined under title XVI for
children but without regard to any income or asset
eligibility requirements that apply under such title
with respect to children); and
(C) whose family income does not exceed such income
level as the State establishes and does not exceed--
(i) 300 percent of the poverty line (as
defined in section 2110(c)(5)) applicable to a
family of the size involved; or
(ii) such higher percent of such poverty line
as a State may establish, except that--
(I) any medical assistance provided
to an individual whose family income
exceeds 300 percent of such poverty
line may only be provided with State
funds; and
(II) no Federal financial
participation shall be provided under
section 1903(a) for any medical
assistance provided to such an
individual.
(2)(A) If an employer of a parent of an individual described
in paragraph (1) offers family coverage under a group health
plan (as defined in section 2791(a) of the Public Health
Service Act), the State shall--
(i) notwithstanding section 1906, require such parent
to apply for, enroll in, and pay premiums for such
coverage as a condition of such parent's child being or
remaining eligible for medical assistance under
subsection (a)(10)(A)(ii)(XIX) if the parent is
determined eligible for such coverage and the employer
contributes at least 50 percent of the total cost of
annual premiums for such coverage; and
(ii) if such coverage is obtained--
(I) subject to paragraph (2) of section
1916(h), reduce the premium imposed by the
State under that section in an amount that
reasonably reflects the premium contribution
made by the parent for private coverage on
behalf of a child with a disability; and
(II) treat such coverage as a third party
liability under subsection (a)(25).
(B) In the case of a parent to which subparagraph (A)
applies, a State, notwithstanding section 1906 but subject to
paragraph (1)(C)(ii), may provide for payment of any portion of
the annual premium for such family coverage that the parent is
required to pay. Any payments made by the State under this
subparagraph shall be considered, for purposes of section
1903(a), to be payments for medical assistance.
(dd) Electronic Transmission of Information.--If the State
agency determining eligibility for medical assistance under
this title or child health assistance under title XXI verifies
an element of eligibility based on information from an Express
Lane Agency (as defined in subsection (e)(13)(F)), or from
another public agency, then the applicant's signature under
penalty of perjury shall not be required as to such element.
Any signature requirement for an application for medical
assistance may be satisfied through an electronic signature, as
defined in section 1710(1) of the Government Paperwork
Elimination Act (44 U.S.C. 3504 note). The requirements of
subparagraphs (A) and (B) of section 1137(d)(2) may be met
through evidence in digital or electronic form.
(ee)(1) For purposes of subsection (a)(46)(B)(ii), the
requirements of this subsection with respect to an individual
declaring to be a citizen or national of the United States for
purposes of establishing eligibility under this title, are, in
lieu of requiring the individual to present satisfactory
documentary evidence of citizenship or nationality under
section 1903(x) (if the individual is not described in
paragraph (2) of that section), as follows:
(A) The State submits the name and social security
number of the individual to the Commissioner of Social
Security as part of the program established under
paragraph (2).
(B) If the State receives notice from the
Commissioner of Social Security that the name or social
security number, or the declaration of citizenship or
nationality, of the individual is inconsistent with
information in the records maintained by the
Commissioner--
(i) the State makes a reasonable effort to
identify and address the causes of such
inconsistency, including through typographical
or other clerical errors, by contacting the
individual to confirm the accuracy of the name
or social security number submitted or
declaration of citizenship or nationality and
by taking such additional actions as the
Secretary, through regulation or other
guidance, or the State may identify, and
continues to provide the individual with
medical assistance while making such effort;
and
(ii) in the case such inconsistency is not
resolved under clause (i), the State--
(I) notifies the individual of such
fact;
(II) provides the individual with a
period of 90 days from the date on
which the notice required under
subclause (I) is received by the
individual to either present
satisfactory documentary evidence of
citizenship or nationality (as defined
in section 1903(x)(3)) or resolve the
inconsistency with the Commissioner of
Social Security (and continues to
provide the individual with medical
assistance during such 90-day period);
and
(III) disenrolls the individual from
the State plan under this title within
30 days after the end of such 90-day
period if no such documentary evidence
is presented or if such inconsistency
is not resolved.
(2)(A) Each State electing to satisfy the requirements of
this subsection for purposes of section 1902(a)(46)(B) shall
establish a program under which the State submits at least
monthly to the Commissioner of Social Security for comparison
of the name and social security number, of each individual
newly enrolled in the State plan under this title that month
who is not described in section 1903(x)(2) and who declares to
be a United States citizen or national, with information in
records maintained by the Commissioner.
(B) In establishing the State program under this paragraph,
the State may enter into an agreement with the Commissioner of
Social Security--
(i) to provide, through an on-line system or
otherwise, for the electronic submission of, and
response to, the information submitted under
subparagraph (A) for an individual enrolled in the
State plan under this title who declares to be citizen
or national on at least a monthly basis; or
(ii) to provide for a determination of the
consistency of the information submitted with the
information maintained in the records of the
Commissioner through such other method as agreed to by
the State and the Commissioner and approved by the
Secretary, provided that such method is no more
burdensome for individuals to comply with than any
burdens that may apply under a method described in
clause (i).
(C) The program established under this paragraph shall
provide that, in the case of any individual who is required to
submit a social security number to the State under subparagraph
(A) and who is unable to provide the State with such number,
shall be provided with at least the reasonable opportunity to
present satisfactory documentary evidence of citizenship or
nationality (as defined in section 1903(x)(3)) as is provided
under clauses (i) and (ii) of section 1137(d)(4)(A) to an
individual for the submittal to the State of evidence
indicating a satisfactory immigration status.
(3)(A) The State agency implementing the plan approved under
this title shall, at such times and in such form as the
Secretary may specify, provide information on the percentage
each month that the inconsistent submissions bears to the total
submissions made for comparison for such month. For purposes of
this subparagraph, a name, social security number, or
declaration of citizenship or nationality of an individual
shall be treated as inconsistent and included in the
determination of such percentage only if--
(i) the information submitted by the individual is
not consistent with information in records maintained
by the Commissioner of Social Security;
(ii) the inconsistency is not resolved by the State;
(iii) the individual was provided with a reasonable
period of time to resolve the inconsistency with the
Commissioner of Social Security or provide satisfactory
documentation of citizenship status and did not
successfully resolve such inconsistency; and
(iv) payment has been made for an item or service
furnished to the individual under this title.
(B) If, for any fiscal year, the average monthly percentage
determined under subparagraph (A) is greater than 3 percent--
(i) the State shall develop and adopt a corrective
plan to review its procedures for verifying the
identities of individuals seeking to enroll in the
State plan under this title and to identify and
implement changes in such procedures to improve their
accuracy; and
(ii) pay to the Secretary an amount equal to the
amount which bears the same ratio to the total payments
under the State plan for the fiscal year for providing
medical assistance to individuals who provided
inconsistent information as the number of individuals
with inconsistent information in excess of 3 percent of
such total submitted bears to the total number of
individuals with inconsistent information.
(C) The Secretary may waive, in certain limited cases, all or
part of the payment under subparagraph (B)(ii) if the State is
unable to reach the allowable error rate despite a good faith
effort by such State.
(D) Subparagraphs (A) and (B) shall not apply to a State for
a fiscal year if there is an agreement described in paragraph
(2)(B) in effect as of the close of the fiscal year that
provides for the submission on a real-time basis of the
information described in such paragraph.
(4) Nothing in this subsection shall affect the rights of any
individual under this title to appeal any disenrollment from a
State plan.
(ff) Notwithstanding any other requirement of this title or
any other provision of Federal or State law, a State shall
disregard the following property from resources for purposes of
determining the eligibility of an individual who is an Indian
for medical assistance under this title:
(1) Property, including real property and
improvements, that is held in trust, subject to Federal
restrictions, or otherwise under the supervision of the
Secretary of the Interior, located on a reservation,
including any federally recognized Indian Tribe's
reservation, pueblo, or colony, including former
reservations in Oklahoma, Alaska Native regions
established by the Alaska Native Claims Settlement Act,
and Indian allotments on or near a reservation as
designated and approved by the Bureau of Indian Affairs
of the Department of the Interior.
(2) For any federally recognized Tribe not described
in paragraph (1), property located within the most
recent boundaries of a prior Federal reservation.
(3) Ownership interests in rents, leases, royalties,
or usage rights related to natural resources (including
extraction of natural resources or harvesting of
timber, other plants and plant products, animals, fish,
and shellfish) resulting from the exercise of federally
protected rights.
(4) Ownership interests in or usage rights to items
not covered by paragraphs (1) through (3) that have
unique religious, spiritual, traditional, or cultural
significance or rights that support subsistence or a
traditional lifestyle according to applicable tribal
law or custom.
(gg) Maintenance of Effort.--
(1) General requirement to maintain eligibility
standards until state exchange is fully operational.--
Subject to the succeeding paragraphs of this
subsection, during the period that begins on the date
of enactment of the Patient Protection and Affordable
Care Act and ends on the date on which the Secretary
determines that an Exchange established by the State
under section 1311 of the Patient Protection and
Affordable Care Act is fully operational, as a
condition for receiving any Federal payments under
section 1903(a) for calendar quarters occurring during
such period, a State shall not have in effect
eligibility standards, methodologies, or procedures
under the State plan under this title or under any
waiver of such plan that is in effect during that
period, that are more restrictive than the eligibility
standards, methodologies, or procedures, respectively,
under the plan or waiver that are in effect on the date
of enactment of the Patient Protection and Affordable
Care Act.
(2) Continuation of eligibility standards for
children through september 30, 2027.--The requirement
under paragraph (1) shall continue to apply to a State
through September 30, 2027 (but during the period that
begins on October 1, 2019, and ends on September 30,
2027 only with respect to children in families whose
income does not exceed 300 percent of the poverty line
(as defined in section 2110(c)(5)) applicable to a
family of the size involved) with respect to the
eligibility standards, methodologies, and procedures
under the State plan under this title or under any
waiver of such plan that are applicable to determining
the eligibility for medical assistance of any child who
is under 19 years of age (or such higher age as the
State may have elected).
(3) Nonapplication.--During the period that begins on
January 1, 2011, and ends on December 31, 2013, the
requirement under paragraph (1) shall not apply to a
State with respect to nonpregnant, nondisabled adults
who are eligible for medical assistance under the State
plan or under a waiver of the plan at the option of the
State and whose income exceeds 133 percent of the
poverty line (as defined in section 2110(c)(5))
applicable to a family of the size involved if, on or
after December 31, 2010, the State certifies to the
Secretary that, with respect to the State fiscal year
during which the certification is made, the State has a
budget deficit, or with respect to the succeeding State
fiscal year, the State is projected to have a budget
deficit. Upon submission of such a certification to the
Secretary, the requirement under paragraph (1) shall
not apply to the State with respect to any remaining
portion of the period described in the preceding
sentence.
(4) Determination of compliance.--
(A) States shall apply modified adjusted
gross income.--A State's determination of
income in accordance with subsection (e)(14)
shall not be considered to be eligibility
standards, methodologies, or procedures that
are more restrictive than the standards,
methodologies, or procedures in effect under
the State plan or under a waiver of the plan on
the date of enactment of the Patient Protection
and Affordable Care Act for purposes of
determining compliance with the requirements of
paragraph (1), (2), or (3).
(B) States may expand eligibility or move
waivered populations into coverage under the
state plan.--With respect to any period
applicable under paragraph (1), (2), or (3), a
State that applies eligibility standards,
methodologies, or procedures under the State
plan under this title or under any waiver of
the plan that are less restrictive than the
eligibility standards, methodologies, or
procedures, applied under the State plan or
under a waiver of the plan on the date of
enactment of the Patient Protection and
Affordable Care Act, or that makes individuals
who, on such date of enactment, are eligible
for medical assistance under a waiver of the
State plan, after such date of enactment
eligible for medical assistance through a State
plan amendment with an income eligibility level
that is not less than the income eligibility
level that applied under the waiver, or as a
result of the application of subclause (VIII)
of section 1902(a)(10)(A)(i), shall not be
considered to have in effect eligibility
standards, methodologies, or procedures that
are more restrictive than the standards,
methodologies, or procedures in effect under
the State plan or under a waiver of the plan on
the date of enactment of the Patient Protection
and Affordable Care Act for purposes of
determining compliance with the requirements of
paragraph (1), (2), or (3).
(hh)(1) A State may elect to phase-in the extension of
eligibility for medical assistance to individuals described in
subclause (XX) of subsection (a)(10)(A)(ii) based on the
categorical group (including nonpregnant childless adults) or
income, so long as the State does not extend such eligibility
to individuals described in such subclause with higher income
before making individuals described in such subclause with
lower income eligible for medical assistance.
(2) If an individual described in subclause (XX) of
subsection (a)(10)(A)(ii) is the parent of a child who is under
19 years of age (or such higher age as the State may have
elected) who is eligible for medical assistance under the State
plan or under a waiver of such plan, the individual may not be
enrolled under the State plan unless the individual's child is
enrolled under the State plan or under a waiver of the plan or
is enrolled in other health insurance coverage. For purposes of
the preceding sentence, the term ``parent'' includes an
individual treated as a caretaker relative for purposes of
carrying out section 1931.
(ii)(1) Individuals described in this subsection are
individuals--
(A) whose income does not exceed an income
eligibility level established by the State that
does not exceed the highest income eligibility
level established under the State plan under
this title (or under its State child health
plan under title XXI) for pregnant women; and
(B) who are not pregnant.
(2) At the option of a State, individuals described
in this subsection may include individuals who, had
individuals applied on or before January 1, 2007, would
have been made eligible pursuant to the standards and
processes imposed by that State for benefits described
in clause (XVI) of the matter following subparagraph
(G) of section subsection (a)(10) pursuant to a waiver
granted under section 1115.
(3) At the option of a State, for purposes of
subsection (a)(17)(B), in determining eligibility for
services under this subsection, the State may consider
only the income of the applicant or recipient.
(jj) Primary Care Services Defined.--For purposes of
subsection (a)(13)(C), the term ``primary care services''
means--
(1) evaluation and management services that are
procedure codes (for services covered under title
XVIII) for services in the category designated
Evaluation and Management in the Healthcare Common
Procedure Coding System (established by the Secretary
under section 1848(c)(5) as of December 31, 2009, and
as subsequently modified); and
(2) services related to immunization administration
for vaccines and toxoids for which CPT codes 90465,
90466, 90467, 90468, 90471, 90472, 90473, or 90474 (as
subsequently modified) apply under such System.
(kk) Provider and Supplier Screening, Oversight, and
Reporting Requirements.--For purposes of subsection (a)(77),
the requirements of this subsection are the following:
(1) Screening.--The State complies with the process
for screening providers and suppliers under this title,
as established by the Secretary under section
1866(j)(2).
(2) Provisional period of enhanced oversight for new
providers and suppliers.--The State complies with
procedures to provide for a provisional period of
enhanced oversight for new providers and suppliers
under this title, as established by the Secretary under
section 1866(j)(3).
(3) Disclosure requirements.--The State requires
providers and suppliers under the State plan or under a
waiver of the plan to comply with the disclosure
requirements established by the Secretary under section
1866(j)(5).
(4) Temporary moratorium on enrollment of new
providers or suppliers.--
(A) Temporary moratorium imposed by the
secretary.--
(i) In general.--Subject to clause
(ii), the State complies with any
temporary moratorium on the enrollment
of new providers or suppliers imposed
by the Secretary under section
1866(j)(7).
(ii) Exceptions.--
(I) Compliance with
moratorium.--A State shall not
be required to comply with a
temporary moratorium described
in clause (i) if the State
determines that the imposition
of such temporary moratorium
would adversely impact
beneficiaries' access to
medical assistance.
(II) FFP available.--
Notwithstanding section
1903(i)(2)(E), payment may be
made to a State under this
title with respect to amounts
expended for items and services
described in such section if
the Secretary, in consultation
with the State agency
administering the State plan
under this title (or a waiver
of the plan), determines that
denying payment to the State
pursuant to such section would
adversely impact beneficiaries'
access to medical assistance.
(iii) Limitation on charges to
beneficiaries.--With respect to any
amount expended for items or services
furnished during calendar quarters
beginning on or after October 1, 2017,
the State prohibits, during the period
of a temporary moratorium described in
clause (i), a provider meeting the
requirements specified in subparagraph
(C)(iii) of section 1866(j)(7) from
charging an individual or other person
eligible to receive medical assistance
under the State plan under this title
(or a waiver of the plan) for an item
or service described in section
1903(i)(2)(E) furnished to such an
individual.
(B) Moratorium on enrollment of providers and
suppliers.--At the option of the State, the
State imposes, for purposes of entering into
participation agreements with providers or
suppliers under the State plan or under a
waiver of the plan, periods of enrollment
moratoria, or numerical caps or other limits,
for providers or suppliers identified by the
Secretary as being at high-risk for fraud,
waste, or abuse as necessary to combat fraud,
waste, or abuse, but only if the State
determines that the imposition of any such
period, cap, or other limits would not
adversely impact beneficiaries' access to
medical assistance.
(5) Compliance programs.--The State requires
providers and suppliers under the State plan or under a
waiver of the plan to establish, in accordance with the
requirements of section 1866(j)(7), a compliance
program that contains the core elements established
under subparagraph (B) of that section 1866(j)(7) for
providers or suppliers within a particular industry or
category.
(6) Reporting of adverse provider actions.--The State
complies with the national system for reporting
criminal and civil convictions, sanctions, negative
licensure actions, and other adverse provider actions
to the Secretary, through the Administrator of the
Centers for Medicare & Medicaid Services, in accordance
with regulations of the Secretary.
(7) Enrollment and npi of ordering or referring
providers.--The State requires--
(A) all ordering or referring physicians or
other professionals to be enrolled under the
State plan or under a waiver of the plan as a
participating provider; and
(B) the national provider identifier of any
ordering or referring physician or other
professional to be specified on any claim for
payment that is based on an order or referral
of the physician or other professional.
(8) Provider terminations.--
(A) In general.--Beginning on July 1, 2018,
in the case of a notification under subsection
(a)(41) with respect to a termination for a
reason specified in section 455.101 of title
42, Code of Federal Regulations (as in effect
on November 1, 2015) or for any other reason
specified by the Secretary, of the
participation of a provider of services or any
other person under the State plan (or under a
waiver of the plan), the State, not later than
30 days after the effective date of such
termination, submits to the Secretary with
respect to any such provider or person, as
appropriate--
(i) the name of such provider or
person;
(ii) the provider type of such
provider or person;
(iii) the specialty of such
provider's or person's practice;
(iv) the date of birth, Social
Security number, national provider
identifier (if applicable), Federal
taxpayer identification number, and the
State license or certification number
of such provider or person (if
applicable);
(v) the reason for the termination;
(vi) a copy of the notice of
termination sent to the provider or
person;
(vii) the date on which such
termination is effective, as specified
in the notice; and
(viii) any other information required
by the Secretary.
(B) Effective date defined.--For purposes of
this paragraph, the term ``effective date''
means, with respect to a termination described
in subparagraph (A), the later of--
(i) the date on which such
termination is effective, as specified
in the notice of such termination; or
(ii) the date on which all appeal
rights applicable to such termination
have been exhausted or the timeline for
any such appeal has expired.
(9) Other state oversight.--Nothing in this
subsection shall be interpreted to preclude or limit
the ability of a State to engage in provider and
supplier screening or enhanced provider and supplier
oversight activities beyond those required by the
Secretary.
(ll) Termination Notification Database.--In the case of a
provider of services or any other person whose participation
under this title or title XXI is terminated (as described in
subsection (kk)(8)), the Secretary shall, not later than 30
days after the date on which the Secretary is notified of such
termination under subsection (a)(41) (as applicable), review
such termination and, if the Secretary determines appropriate,
include such termination in any database or similar system
developed pursuant to section 6401(b)(2) of the Patient
Protection and Affordable Care Act (42 U.S.C. 1395cc note;
Public Law 111-148).
(mm) Directory Physician or Provider Described.--A physician
or provider described in this subsection is--
(1) in the case of a physician or provider of a
provider type for which the State agency, as a
condition on receiving payment for items and services
furnished by the physician or provider to individuals
eligible to receive medical assistance under the State
plan, requires the enrollment of the physician or
provider with the State agency, a physician or a
provider that--
(A) is enrolled with the agency as of the
date on which the directory is published or
updated (as applicable) under subsection
(a)(83); and
(B) received payment under the State plan in
the 12-month period preceding such date; and
(2) in the case of a physician or provider of a
provider type for which the State agency does not
require such enrollment, a physician or provider that
received payment under the State plan (or a waiver of
the plan) in the 12-month period preceding the date on
which the directory is published or updated (as
applicable) under subsection (a)(83).
(nn) Juvenile; Eligible Juvenile; Public Institution.--For
purposes of subsection (a)(84) and this subsection:
(1) Juvenile.--The term ``juvenile'' means an
individual who is--
(A) under 21 years of age; or
(B) described in subsection
(a)(10)(A)(i)(IX).
(2) Eligible juvenile.--The term ``eligible
juvenile'' means a juvenile who is an inmate of a
public institution and who--
(A) was determined eligible for medical
assistance under the State plan immediately
before becoming an inmate of such a public
institution; or
(B) is determined eligible for such medical
assistance while an inmate of a public
institution.
(3) Inmate of a public institution.--The term
``inmate of a public institution'' has the meaning
given such term for purposes of applying the
subdivision (A) following paragraph (30) of section
1905(a), taking into account the exception in such
subdivision for a patient of a medical institution.
(oo) Drug Review and Utilization Requirements.--
(1) In general.--For purposes of subsection (a)(85),
the drug review and utilization requirements under this
subsection are, subject to paragraph (3) and beginning
October 1, 2019, the following:
(A) Claims review limitations.--
(i) In general.--The State has in
place--
(I) safety edits (as
specified by the State) for
subsequent fills for opioids
and a claims review automated
process (as designed and
implemented by the State) that
indicates when an individual
enrolled under the State plan
(or under a waiver of the State
plan) is prescribed a
subsequent fill of opioids in
excess of any limitation that
may be identified by the State;
(II) safety edits (as
specified by the State) on the
maximum daily morphine
equivalent that can be
prescribed to an individual
enrolled under the State plan
(or under a waiver of the State
plan) for treatment of chronic
pain and a claims review
automated process (as designed
and implemented by the State)
that indicates when an
individual enrolled under the
plan (or waiver) is prescribed
the morphine equivalent for
such treatment in excess of any
limitation that may be
identified by the State; and
(III) a claims review
automated process (as designed
and implemented by the State)
that monitors when an
individual enrolled under the
State plan (or under a waiver
of the State plan) is
concurrently prescribed opioids
and--
(aa) benzodiazepines;
or
(bb) antipsychotics.
(ii) Managed care entities.--The
State requires each managed care entity
(as defined in section 1932(a)(1)(B))
with respect to which the State has a
contract under section 1903(m) or under
section 1905(t)(3) to have in place,
subject to paragraph (3), with respect
to individuals who are eligible for
medical assistance under the State plan
(or under a waiver of the State plan)
and who are enrolled with the entity,
the limitations described in subclauses
(I) and (II) of clause (i) and a claims
review automated process described in
subclause (III) of such clause.
(iii) Rules of construction.--Nothing
in this subparagraph may be construed
as prohibiting a State or managed care
entity from designing and implementing
a claims review automated process under
this subparagraph that provides for
prospective or retrospective reviews of
claims. Nothing in this subparagraph
shall be understood as prohibiting the
exercise of clinical judgment from a
provider enrolled as a participating
provider in a State plan (or waiver of
the State plan) or contracting with a
managed care entity regarding the best
items and services for an individual
enrolled under such State plan (or
waiver).
(B) Program to monitor antipsychotic
medications by children.--The State has in
place a program (as designed and implemented by
the State) to monitor and manage the
appropriate use of antipsychotic medications by
children enrolled under the State plan (or
under a waiver of the State plan) and submits
annually to the Secretary such information as
the Secretary may require on activities carried
out under such program for individuals not more
than the age of 18 years generally and children
in foster care specifically.
(C) Fraud and abuse identification.--The
State has in place a process (as designed and
implemented by the State) that identifies
potential fraud or abuse of controlled
substances by individuals enrolled under the
State plan (or under a waiver of the State
plan), health care providers prescribing drugs
to individuals so enrolled, and pharmacies
dispensing drugs to individuals so enrolled.
(D) Reports.--The State shall include in the
annual report submitted to the Secretary under
section 1927(g)(3)(D) information on the
limitations, requirement, program, and
processes applied by the State under
subparagraphs (A) through (C) in accordance
with such manner and time as specified by the
Secretary.
(E) Clarification.--Nothing shall prevent a
State from satisfying the requirement--
(i) described in subparagraph (A) by
having safety edits or a claims review
automated process described in such
subparagraph that was in place before
October 1, 2019;
(ii) described in subparagraph (B) by
having a program described in such
subparagraph that was in place before
such date; or
(iii) described in subparagraph (C)
by having a process described in such
subparagraph that was in place before
such date.
(2) Annual report by secretary.--For each fiscal year
beginning with fiscal year 2020, the Secretary shall
submit to Congress a report on the most recent
information submitted by States under paragraph (1)(D).
(3) Exceptions.--
(A) Certain individuals exempted.--The drug
review and utilization requirements under this
subsection shall not apply with respect to an
individual who--
(i) is receiving--
(I) hospice or palliative
care; or
(II) treatment for cancer;
(ii) is a resident of a long-term
care facility, of a facility described
in section 1905(d), or of another
facility for which frequently abused
drugs are dispensed for residents
through a contract with a single
pharmacy; or
(iii) the State elects to treat as
exempted from such requirements.
(B) Exception relating to ensuring access.--
In order to ensure reasonable access to health
care, the Secretary shall waive the drug review
and utilization requirements under this
subsection, with respect to a State, in the
case of natural disasters and similar
situations, and in the case of the provision of
emergency services (as defined for purposes of
section 1860D-4(c)(5)(D)(ii)(II)).
(pp) Residential Pediatric Recovery Center Defined.--
(1) In general.--For purposes of section 1902(a)(86),
the term ``residential pediatric recovery center''
means a center or facility that furnishes items and
services for which medical assistance is available
under the State plan to infants with the diagnosis of
neonatal abstinence syndrome without any other
significant medical risk factors.
(2) Counseling and services.--A residential pediatric
recovery center may offer counseling and other services
to mothers (and other appropriate family members and
caretakers) of infants receiving treatment at such
centers if such services are otherwise covered under
the State plan under this title or under a waiver of
such plan. Such other services may include the
following:
(A) Counseling or referrals for services.
(B) Activities to encourage caregiver-infant
bonding.
(C) Training on caring for such infants.
(qq) Application of Certain Data Reporting and Program
Integrity Requirements to Northern Mariana Islands, American
Samoa, and Guam.--Not later than October 1, 2023, the Northern
Mariana Islands, American Samoa, and Guam shall--
(1) implement methods, satisfactory to the Secretary,
for the collection and reporting of reliable data to
the Transformed Medicaid Statistical Information System
(T-MSIS) (or a successor system); and
(2) demonstrate progress in establishing a State
medicaid fraud control unit described in section
1903(q).
(rr) Program Integrity Requirements for Puerto Rico.--
(1) System for tracking federal funding provided to
puerto rico.--
(A) In general.--Puerto Rico shall establish
and maintain a system for tracking any amounts
paid by the Federal Government to Puerto Rico
with respect to the State plan of Puerto Rico
(or a waiver of such plan). Under such system,
Puerto Rico shall ensure that information is
available, with respect to each quarter in a
fiscal year (beginning with the first quarter
beginning on or after the date that is one year
after the date of the enactment of this
subsection), on the following:
(i) In the case of a quarter other
than the first quarter of such fiscal
year--
(I) the total amount expended
by Puerto Rico during any
previous quarter of such fiscal
year under the State plan of
Puerto Rico (or a waiver of
such plan); and
(II) a description of how
such amount was so expended.
(ii) The total amount that Puerto
Rico expects to expend during the
quarter under the State plan of Puerto
Rico (or a waiver of such plan), and a
description of how Puerto Rico expects
to expend such amount.
(B) Report to cms.--For each quarter with
respect to which Puerto Rico is required under
subparagraph (A) to ensure that information
described in such subparagraph is available,
Puerto Rico shall submit to the Administrator
of the Centers for Medicare & Medicaid Services
a report on such information for such quarter.
(2) Submission of documentation on contracts upon
request.--Puerto Rico shall, upon request, submit to
the Administrator of the Centers for Medicare &
Medicaid Services all documentation requested with
respect to contracts awarded under the State plan of
Puerto Rico (or a waiver of such plan).
payment to states
Sec. 1903. (a) From the sums appropriated therefor, the
Secretary (except as otherwise provided in this section) shall
pay to each State which has a plan approved under this title,
for each quarter, beginning with the quarter commencing January
1, 1966--
(1) an amount equal to the Federal medical assistance
percentage (as defined in section 1905(b), subject to
subsections (g) and (j) of this section and subsection
1923(f)) of the total amount expended during such
quarter as medical assistance under the State plan;
plus
(2)(A) an amount equal to 75 per centum of so much of
the sums expended during such quarter (as found
necessary by the Secretary for the proper and efficient
administration of the State plan) as are attributable
to compensation or training of skilled professional
medical personnel, and staff directly supporting such
personnel, of the State agency or any other public
agency; plus
(B) notwithstanding paragraph (1) or subparagraph
(A), with respect to amounts expended for nursing aide
training and competency evaluation programs, and
competency evaluation programs, described in section
1919(e)(1) (including the costs for nurse aides to
complete such competency evaluation programs),
regardless of whether the programs are provided in or
outside nursing facilities or of the skill of the
personnel involved in such programs, an amount equal to
50 percent (or, for calendar quarters beginning on or
after July 1, 1988, and before October 1, 1990, the
lesser of 90 percent or the Federal medical assistance
percentage plus 25 percentage points) of so much of the
sums expended during such quarter (as found necessary
by the Secretary for the proper and efficient
administration of the State plan) as are attributable
to such programs; plus
(C) an amount equal to 75 percent of so much of the
sums expended during such quarter (as found necessary
by the Secretary for the proper and efficient
administration of the State plan) as are attributable
to preadmission screening and resident review
activities conducted by the State under section
1919(e)(7); plus
(D) for each calendar quarter during--
(i) fiscal year 1991, an amount equal to 90
percent,
(ii) fiscal year 1992, an amount equal to 85
percent,
(iii) fiscal year 1993, an amount equal to 80
percent, and
(iv) fiscal year 1994 and thereafter, an
amount equal to 75 percent,
of so much of the sums expended during such quarter (as
found necessary by the Secretary for the proper and
efficient administration of the State plan) as are
attributable to State activities under section 1919(g);
plus
(E) an amount equal to 75 percent of so much of the
sums expended during such quarter (as found necessary
by the Secretary for the proper and efficient
administration of the State plan) as are attributable
to translation or interpretation services in connection
with the enrollment of, retention of, and use of
services under this title by, children of families for
whom English is not the primary language; plus
(3) an amount equal to--
(A)(i) 90 per centum of so much of the sums
expended during such quarter as are
attributable to the design, development, or
installation of such mechanized claims
processing and information retrieval systems as
the Secretary determines are likely to provide
more efficient, economical, and effective
administration of the plan and to be compatible
with the claims processing and information
retrieval systems utilized in the
administration of title XVIII, including the
State's share of the cost of installing such a
system to be used jointly in the administration
of such State's plan and the plan of any other
State approved under this title,
(ii) 90 per centum of so much of the sums
expended during any such quarter in the fiscal
year ending June 30, 1972, or the fiscal year
ending June 30, 1973, as are attributable to
the design, development, or installation of
cost determination systems for State-owned
general hospitals (except that the total amount
paid to all States under this clause for either
such fiscal year shall not exceed $150,000),
and
(iii) an amount equal to the Federal medical
assistance percentage (as defined in section
1905(b)) of so much of the sums expended during
such quarter (as found necessary by the
Secretary for the proper and efficient
administration of the State plan) as are
attributable to such developments or
modifications of systems of the type described
in clause (i) as are necessary for the
efficient collection and reporting on child
health measures; and
(B) 75 per centum of so much of the sums
expended during such quarter as are
attributable to the operation of systems
(whether such systems are operated directly by
the State or by another person under a contract
with the State) of the type described in
subparagraph (A)(i) (whether or not designed,
developed, or installed with assistance under
such subparagraph) which are approved by the
Secretary and which include provision for
prompt written notice to each individual who is
furnished services covered by the plan, or to
each individual in a sample group of
individuals who are furnished such services, of
the specific services (other than confidential
services) so covered, the name of the person or
persons furnishing the services, the date or
dates on which the services were furnished, and
the amount of the payment or payments made
under the plan on account of the services; and
(C)(i) 75 per centum of the sums expended
with respect to costs incurred during such
quarter (as found necessary by the Secretary
for the proper and efficient administration of
the State plan) as are attributable to the
performance of medical and utilization review
by a utilization and quality control peer
review organization or by an entity which meets
the requirements of section 1152, as determined
by the Secretary, under a contract entered into
under section 1902(d); and
(ii) 75 percent of the sums expended with
respect to costs incurred during such quarter
(as found necessary by the Secretary for the
proper and efficient administration of the
State plan) as are attributable to the
performance of independent external reviews
conducted under section 1932(c)(2); and
(D) 75 percent of so much of the sums
expended by the State plan during a quarter in
1991, 1992, or 1993, as the Secretary
determines is attributable to the statewide
adoption of a drug use review program which
conforms to the requirements of section
1927(g);
(E) 50 percent of the sums expended with
respect to costs incurred during such quarter
as are attributable to providing--
(i) services to identify and educate
individuals who are likely to be
eligible for medical assistance under
this title and who have Sickle Cell
Disease or who are carriers of the
sickle cell gene, including education
regarding how to identify such
individuals; or
(ii) education regarding the risks of
stroke and other complications, as well
as the prevention of stroke and other
complications, in individuals who are
likely to be eligible for medical
assistance under this title and who
have Sickle Cell Disease; and
(F)(i) 100 percent of so much of the sums
expended during such quarter as are
attributable to payments to Medicaid providers
described in subsection (t)(1) to encourage the
adoption and use of certified EHR technology;
and
(ii) 90 percent of so much of the sums
expended during such quarter as are
attributable to payments for reasonable
administrative expenses related to the
administration of payments described in clause
(i) if the State meets the condition described
in subsection (t)(9); plus
(H)(i) 90 percent of the sums expended during
the quarter as are attributable to the design,
development, or installation of such mechanized
verification and information retrieval systems
as the Secretary determines are necessary to
implement section 1902(ee) (including a system
described in paragraph (2)(B) thereof), and
(ii) 75 percent of the sums expended during
the quarter as are attributable to the
operation of systems to which clause (i)
applies, plus
(4) an amount equal to 100 percent of the sums
expended during the quarter which are attributable to
the costs of the implementation and operation of the
immigration status verification system described in
section 1137(d); plus
(5) an amount equal to 90 per centum of the sums
expended during such quarter which are attributable to
the offering, arranging, and furnishing (directly or on
a contract basis) of family planning services and
supplies;
(6) subject to subsection (b)(3), an amount equal
to--
(A) 90 per centum of the sums expended during
such a quarter within the twelve-quarter period
beginning with the first quarter in which a
payment is made to the State pursuant to this
paragraph, and
(B) 75 per centum of the sums expended during
each succeeding calendar quarter,
with respect to costs incurred during such quarter (as
found necessary by the Secretary for the elimination of
fraud in the provision and administration of medical
assistance provided under the State plan) which are
attributable to the establishment and operation of
(including the training of personnel employed by) a
State medicaid fraud control unit (described in
subsection (q)); plus
(7) subject to section 1919(g)(3)(B), an amount equal
to 50 per centum of the remainder of the amounts
expended during such quarter as found necessary by the
Secretary for the proper and efficient administration
of the State plan.
(b)(1) Notwithstanding the preceding provisions of this
section, the amount determined under subsection (a)(1) for any
State for any quarter beginning after December 31, 1969, shall
not take into account any amounts expended as medical
assistance with respect to individuals aged 65 or over and
disabled individuals entitled to hospital insurance benefits
under title XVIII which would not have been so expended if the
individuals involved had been enrolled in the insurance program
established by part B of title XVIII, other than amounts
expended under provisions of the plan of such State required by
section 1902(a)(34).
(2) For limitation on Federal participation for capital
expenditures which are out of conformity with a comprehensive
plan of a State or areawide planning agency, see section 1122.
(3) The amount of funds which the Secretary is otherwise
obligated to pay a State during a quarter under subsection
(a)(6) may not exceed the higher of--
(A) $125,000, or
(B) one-quarter of 1 per centum of the sums expended
by the Federal, State, and local governments during the
previous quarter in carrying out the State's plan under
this title.
(4) Amounts expended by a State for the use of an enrollment
broker in marketing medicaid managed care organizations and
other managed care entities to eligible individuals under this
title shall be considered, for purposes of subsection (a)(7),
to be necessary for the proper and efficient administration of
the State plan but only if the following conditions are met
with respect to the broker:
(A) The broker is independent of any such entity and
of any health care providers (whether or not any such
provider participates in the State plan under this
title) that provide coverage of services in the same
State in which the broker is conducting enrollment
activities.
(B) No person who is an owner, employee, consultant,
or has a contract with the broker either has any direct
or indirect financial interest with such an entity or
health care provider or has been excluded from
participation in the program under this title or title
XVIII or debarred by any Federal agency, or subject to
a civil money penalty under this Act.
(5) Notwithstanding the preceding provisions of this section,
the amount determined under subsection (a)(1) for any State
shall be decreased in a quarter by the amount of any health
care related taxes (described in section 1902(w)(3)(A)) that
are imposed on a hospital described in subsection (w)(3)(F) in
that quarter.
(c) Nothing in this title shall be construed as prohibiting
or restricting, or authorizing the Secretary to prohibit or
restrict, payment under subsection (a) for medical assistance
for covered services furnished to a child with a disability
because such services are included in the child's
individualized education program established pursuant to part B
of the Individuals with Disabilities Education Act or furnished
to an infant or toddler with a disability because such services
are included in the child's individualized family service plan
adopted pursuant to part C of such Act.
(d)(1) Prior to the beginning of each quarter, the Secretary
shall estimate the amount to which a State will be entitled
under subsections (a) and (b) for such quarter, such estimates
to be based on (A) a report filed by the State containing its
estimate of the total sum to be expended in such quarter in
accordance with the provisions of such subsections, and stating
the amount appropriated or made available by the State and its
political subdivisions for such expenditures in such quarter,
and if such amount is less than the State's proportionate share
of the total sum of such estimated expenditures, the source or
sources from which the difference is expected to be derived,
and (B) such other investigation as the Secretary may find
necessary.
(2)(A) The Secretary shall then pay to the State, in such
installments as he may determine, the amount so estimated,
reduced or increased to the extent of any overpayment or
underpayment which the Secretary determines was made under this
section to such State for any prior quarter and with respect to
which adjustment has not already been made under this
subsection.
(B) Expenditures for which payments were made to the State
under subsection (a) shall be treated as an overpayment to the
extent that the State or local agency administering such plan
has been reimbursed for such expenditures by a third party
pursuant to the provisions of its plan in compliance with
section 1902(a)(25).
(C) For purposes of this subsection, when an overpayment is
discovered, which was made by a State to a person or other
entity, the State shall have a period of 1 year in which to
recover or attempt to recover such overpayment before
adjustment is made in the Federal payment to such State on
account of such overpayment. Except as otherwise provided in
subparagraph (D), the adjustment in the Federal payment shall
be made at the end of the 1-year period, whether or not
recovery was made.
(D)(i) In any case where the State is unable to recover a
debt which represents an overpayment (or any portion thereof)
made to a person or other entity on account of such debt having
been discharged in bankruptcy or otherwise being uncollectable,
no adjustment shall be made in the Federal payment to such
State on account of such overpayment (or portion thereof).
(ii) In any case where the State is unable to recover a debt
which represents an overpayment (or any portion thereof) made
to a person or other entity due to fraud within 1 year of
discovery because there is not a final determination of the
amount of the overpayment under an administrative or judicial
process (as applicable), including as a result of a judgment
being under appeal, no adjustment shall be made in the Federal
payment to such State on account of such overpayment (or
portion thereof) before the date that is 30 days after the date
on which a final judgment (including, if applicable, a final
determination on an appeal) is made.
(3)(A) The pro rata share to which the United States is
equitably entitled, as determined by the Secretary, of the net
amount recovered during any quarter by the State or any
political subdivision thereof with respect to medical
assistance furnished under the State plan shall be considered
an overpayment to be adjusted under this subsection.
(B)(i) Subparagraph (A) and paragraph (2)(B) shall not apply
to any amount recovered or paid to a State as part of the
comprehensive settlement of November 1998 between manufacturers
of tobacco products, as defined in section 5702(d) of the
Internal Revenue Code of 1986, and State Attorneys General, or
as part of any individual State settlement or judgment reached
in litigation initiated or pursued by a State against one or
more such manufacturers.
(ii) Except as provided in subsection (i)(19), a State may
use amounts recovered or paid to the State as part of a
comprehensive or individual settlement, or a judgment,
described in clause (i) for any expenditures determined
appropriate by the State.
(4) Upon the making of any estimate by the Secretary under
this subsection, any appropriations available for payments
under this section shall be deemed obligated.
(5) In any case in which the Secretary estimates that there
has been an overpayment under this section to a State on the
basis of a claim by such State that has been disallowed by the
Secretary under section 1116(d), and such State disputes such
disallowance, the amount of the Federal payment in controversy
shall, at the option of the State, be retained by such State or
recovered by the Secretary pending a final determination with
respect to such payment amount. If such final determination is
to the effect that any amount was properly disallowed, and the
State chose to retain payment of the amount in controversy, the
Secretary shall offset, from any subsequent payments made to
such State under this title, an amount equal to the proper
amount of the disallowance plus interest on such amount
disallowed for the period beginning on the date such amount was
disallowed and ending on the date of such final determination
at a rate (determined by the Secretary) based on the average of
the bond equivalent of the weekly 90-day treasury bill auction
rates during such period.
(6)(A) Each State (as defined in subsection (w)(7)(D)) shall
include, in the first report submitted under paragraph (1)
after the end of each fiscal year, information related to--
(i) provider-related donations made to the State or
units of local government during such fiscal year, and
(ii) health care related taxes collected by the State
or such units during such fiscal year.
(B) Each State shall include, in the first report submitted
under paragraph (1) after the end of each fiscal year,
information related to the total amount of payment adjustments
made, and the amount of payment adjustments made to individual
providers (by provider), under section 1923(c) during such
fiscal year.
(e) A State plan approved under this title may include, as a
cost with respect to hospital services under the plan under
this title, periodic expenditures made to reflect transitional
allowances established with respect to a hospital closure or
conversion under section 1884.
(f)(1)(A) Except as provided in paragraph (4), payment under
the preceding provisions of this section shall not be made with
respect to any amount expended as medical assistance in a
calendar quarter, in any State, for any member of a family the
annual income of which exceeds the applicable income limitation
determined under this paragraph.
(B)(i) Except as provided in clause (ii) of this
subparagraph, the applicable income limitation with respect to
any family is the amount determined, in accordance with
standards prescribed by the Secretary, to be equivalent to
133\1/3\ percent of the highest amount which would ordinarily
be paid to a family of the same size without any income or
resources, in the form of money payments, under the plan of the
State approved under part A of title IV of this Act.
(ii) If the Secretary finds that the operation of a uniform
maximum limits payments to families of more than one size, he
may adjust the amount otherwise determined under clause (i) to
take account of families of different sizes.
(C) The total amount of any applicable income limitation
determined under subparagraph (B) shall, if it is not a
multiple of $100 or such other amount as the Secretary may
prescribe, be rounded to the next higher multiple of $100 or
such other amount, as the case may be.
(2)(A) In computing a family's income for purposes of
paragraph (1), there shall be excluded any costs (whether in
the form of insurance premiums or otherwise and regardless of
whether such costs are reimbursed under another public program
of the State or political subdivision thereof) incurred by such
family for medical care or for any other type of remedial care
recognized under State law or, (B) notwithstanding section 1916
at State option, an amount paid by such family, at the family's
option, to the State, provided that the amount, when combined
with costs incurred in prior months, is sufficient when
excluded from the family's income to reduce such family's
income below the applicable income limitation described in
paragraph (1). The amount of State expenditures for which
medical assistance is available under subsection (a)(1) will be
reduced by amounts paid to the State pursuant to this
subparagraph.
(3) For purposes of paragraph (1)(B), in the case of a family
consisting of only one individual, the ``highest amount which
would ordinarily be paid'' to such family under the State's
plan approved under part A of title IV of this Act shall be the
amount determined by the State agency (on the basis of
reasonable relationship to the amounts payable under such plan
to families consisting of two or more persons) to be the amount
of the aid which would ordinarily be payable under such plan to
a family (without any income or resources) consisting of one
person if such plan provided for aid to such a family.
(4) The limitations on payment imposed by the preceding
provisions of this subsection shall not apply with respect to
any amount expended by a State as medical assistance for any
individual described in section 1902(a)(10)(A)(i)(III),
1902(a)(10)(A)(i)(IV), 1902(a)(10)(A)(i)(V),
1902(a)(10)(A)(i)(VI), 1902(a)(10)(A)(i)(VII),
1902(a)(10)(A)(i)(VIII),1902(a)(10)(A)(i)(IX),
1902(a)(10)(A)(ii)(IX), 1902(a)(10)(A)(ii)(X),
1902(a)(10)(A)(ii)(XIII), 1902(a)(10)(A)(ii)(XIV), or
1902(a)(10)(A)(ii)(XV), 1902(a)(10)(A)(ii)(XVI),
1902(a)(10)(A)(ii)(XVII), 1902(a)(10)(A)(ii)(XVIII),
1902(a)(10)(A)(ii)(XIX), 1902(a)(10)(A)(ii)(XX),
1902(a)(10)(A)(ii)(XXI), 1902(a)(10)(A)(ii)(XXII), 1905(p)(1)
or for any individual--
(A) who is receiving aid or assistance under any plan
of the State approved under title I, X, XIV or XVI, or
part A of title IV, or with respect to whom
supplemental security income benefits are being paid
under title XVI, or
(B) who is not receiving such aid or assistance, and
with respect to whom such benefits are not being paid,
but (i) is eligible to receive such aid or assistance,
or to have such benefits paid with respect to him, or
(ii) would be eligible to receive such aid or
assistance, or to have such benefits paid with respect
to him if he were not in a medical institution, or
(C) with respect to whom there is being paid, or who
is eligible, or would be eligible if he were not in a
medical institution, to have paid with respect to him,
a State supplementary payment and is eligible for
medical assistance equal in amount, duration, and scope
to the medical assistance made available to individuals
described in section 1902(a)(10)(A), or who is a PACE
program eligible individual enrolled in a PACE program
under section 1934, but only if the income of such
individual (as determined under section 1612, but
without regard to subsection (b) thereof) does not
exceed 300 percent of the supplemental security income
benefit rate established by section 1611(b)(1),
at the time of the provision of the medical assistance giving
rise to such expenditure.
(g)(1) Subject to paragraph (3), with respect to amounts paid
for the following services furnished under the State plan after
June 30, 1973 (other than services furnished pursuant to a
contract with a health maintenance organization as defined in
section 1876 or which is a qualified health maintenance
organization (as defined in section 1310(d) of the Public
Health Service Act)), the Federal medical assistance percentage
shall be decreased as follows: After an individual has received
inpatient hospital services or services in an intermediate care
facility for the mentally retarded for 60 days or inpatient
mental hospital services for 90 days (whether or not such days
are consecutive), during any fiscal year, the Federal medical
assistance percentage with respect to amounts paid for any such
care furnished thereafter to such individual shall be decreased
by a per centum thereof (determined under paragraph (5)) unless
the State agency responsible for the administration of the plan
makes a showing satisfactory to the Secretary that, with
respect to each calendar quarter for which the State submits a
request for payment at the full Federal medical assistance
percentage for amounts paid for inpatient hospital services or
services in an intermediate care facility for the mentally
retarded furnished beyond 60 days (or inpatient mental hospital
services furnished beyond 90 days), such State has an effective
program of medical review of the care of patients in mental
hospitals and intermediate care facilities for the mentally
retarded pursuant to paragraphs (26) and (31) of section
1902(a) whereby the professional management of each case is
reviewed and evaluated at least annually by independent
professional review teams. In determining the number of days on
which an individual has received services described in this
subsection, there shall not be counted any days with respect to
which such individual is entitled to have payments made (in
whole or in part) on his behalf under section 1812.
(2) The Secretary shall, as part of his validation procedures
under this subsection, conduct timely sample onsite surveys of
private and public institutions in which recipients of medical
assistance may receive care and services under a State plan
approved under this title, and his findings with respect to
such surveys (as well as the showings of the State agency
required under this subsection) shall be made available for
public inspection.
(3)(A) No reduction in the Federal medical assistance
percentage of a State otherwise required to be imposed under
this subsection shall take effect--
(i) if such reduction is due to the State's
unsatisfactory or invalid showing made with respect to
a calendar quarter beginning before January 1, 1977;
(ii) before January 1, 1978;
(iii) unless a notice of such reduction has been
provided to the State at least 30 days before the date
such reduction takes effect; or
(iv) due to the State's unsatisfactory or invalid
showing made with respect to a calendar quarter
beginning after September 30, 1977, unless notice of
such reduction has been provided to the State no later
than the first day of the fourth calendar quarter
following the calendar quarter with respect to which
such showing was made.
(B) The Secretary shall waive application of any reduction in
the Federal medical assistance percentage of a State otherwise
required to be imposed under paragraph (1) because a showing by
the State, made under such paragraph with respect to a calendar
quarter ending after January 1, 1977, and before January 1,
1978, is determined to be either unsatisfactory under such
paragraph or invalid under paragraph (2), if the Secretary
determines that the State's showing made under paragraph (1)
with respect to any calendar quarter ending on or before
December 31, 1978, is satisfactory under such paragraph and is
valid under paragraph (2).
(4)(A) The Secretary may not find the showing of a State,
with respect to a calendar quarter under paragraph (1), to be
satisfactory if the showing is submitted to the Secretary later
than the 30th day after the last day of the calendar quarter,
unless the State demonstrates to the satisfaction of the
Secretary good cause for not meeting such deadline.
(B) The Secretary shall find a showing of a State, with
respect to a calendar quarter under paragraph (1), to be
satisfactory under such paragraph with respect to the
requirement that the State conduct annual onsite inspections in
mental hospitals and intermediate care facilities for the
mentally retarded under paragraphs (26) and (31) of section
1902(a), if the showing demonstrates that the State has
conducted such an onsite inspection during the 12-month period
ending on the last date of the calendar quarter--
(i) in each of not less than 98 per centum of the
number of such hospitals and facilities requiring such
inspection, and
(ii) in every such hospital or facility which has 200
or more beds,
and that, with respect to such hospitals and facilities not
inspected within such period, the State has exercised good
faith and due diligence in attempting to conduct such
inspection, or if the State demonstrates to the satisfaction of
the Secretary that it would have made such a showing but for
failings of a technical nature only.
(5) In the case of a State's unsatisfactory or invalid
showing made with respect to a type of facility or
institutional services in a calendar quarter, the per centum
amount of the reduction of the State's Federal medical
assistance percentage for that type of services under paragraph
(1) is equal to 33\1/3\ per centum multiplied by a fraction,
the denominator of which is equal to the total number of
patients receiving that type of services in that quarter under
the State plan in facilities or institutions for which a
showing was required to be made under this subsection, and the
numerator of which is equal to the number of such patients
receiving such type of services in that quarter in those
facilities or institutions for which a satisfactory and valid
showing was not made for that calendar quarter.
(6)(A) Recertifications required under section 1902(a)(44)
shall be conducted at least every 60 days in the case of
inpatient hospital services.
(B) Such recertifications in the case of services in an
intermediate care facility for the mentally retarded shall be
conducted at least--
(i) 60 days after the date of the initial
certification,
(ii) 180 days after the date of the initial
certification,
(iii) 12 months after the date of the initial
certification,
(iv) 18 months after the date of the initial
certification,
(v) 24 months after the date of the initial
certification, and
(vi) every 12 months thereafter.
(C) For purposes of determining compliance with the schedule
established by this paragraph, a recertification shall be
considered to have been done on a timely basis if it was
performed not later than 10 days after the date the
recertification was otherwise required and the State
establishes good cause why the physician or other person making
such recertification did not meet such schedule.
(i) Payment under the preceding provisions of this section
shall not be made--
(1) for organ transplant procedures unless the State
plan provides for written standards respecting the
coverage of such procedures and unless such standards
provide that--
(A) similarly situated individuals are
treated alike; and
(B) any restriction, on the facilities or
practitioners which may provide such
procedures, is consistent with the
accessibility of high quality care to
individuals eligible for the procedures under
the State plan; or
(2) with respect to any amount expended for an item
or service (other than an emergency item or service,
not including items or services furnished in an
emergency room of a hospital) furnished--
(A) under the plan by any individual or
entity during any period when the individual or
entity is excluded from participation under
title V, XVIII, or XX or under this title
pursuant to section 1128, 1128A, 1156, or
1842(j)(2);
(B) at the medical direction or on the
prescription of a physician, during the period
when such physician is excluded from
participation under title V, XVIII, or XX or
under this title pursuant to section 1128,
1128A, 1156, or 1842(j)(2) and when the person
furnishing such item or service knew or had
reason to know of the exclusion (after a
reasonable time period after reasonable notice
has been furnished to the person);
(C) by any individual or entity to whom the
State has failed to suspend payments under the
plan during any period when there is pending an
investigation of a credible allegation of fraud
against the individual or entity, as determined
by the State in accordance with regulations
promulgated by the Secretary for purposes of
section 1862(o) and this subparagraph, unless
the State determines in accordance with such
regulations there is good cause not to suspend
such payments;
(D) beginning on July 1, 2018, under the plan
by any provider of services or person whose
participation in the State plan is terminated
(as described in section 1902(kk)(8)) after the
date that is 60 days after the date on which
such termination is included in the database or
other system under section 1902(ll); or
(E) with respect to any amount expended for
such an item or service furnished during
calendar quarters beginning on or after October
1, 2017, subject to section
1902(kk)(4)(A)(ii)(II), within a geographic
area that is subject to a moratorium imposed
under section 1866(j)(7) by a provider or
supplier that meets the requirements specified
in subparagraph (C)(iii) of such section,
during the period of such moratorium; or
(3) with respect to any amount expended for inpatient
hospital services furnished under the plan (other than
amounts attributable to the special situation of a
hospital which serves a disproportionate number of low
income patients with special needs) to the extent that
such amount exceeds the hospital's customary charges
with respect to such services or (if such services are
furnished under the plan by a public institution free
of charge or at nominal charges to the public) exceeds
an amount determined on the basis of those items
(specified in regulations prescribed by the Secretary)
included in the determination of such payment which the
Secretary finds will provide fair compensation to such
institution for such services; or
(4) with respect to any amount expended for care or
services furnished under the plan by a hospital unless
such hospital has in effect a utilization review plan
which meets the requirements imposed by section 1861(k)
for purposes of title XVIII; and if such hospital has
in effect such a utilization review plan for purposes
of title XVIII, such plan shall serve as the plan
required by this subsection (with the same standards
and procedures and the same review committee or group)
as a condition of payment under this title; the
Secretary is authorized to waive the requirements of
this paragraph if the State agency demonstrates to his
satisfaction that it has in operation utilization
review procedures which are superior in their
effectiveness to the procedures required under section
1861(k); or
(5) with respect to any amount expended for any drug
product for which payment may not be made under part B
of title XVIII because of section 1862(c); or
(6) with respect to any amount expended for inpatient
hospital tests (other than in emergency situations) not
specifically ordered by the attending physician or
other responsible practitioner; or
(7) with respect to any amount expended for clinical
diagnostic laboratory tests performed by a physician,
independent laboratory, or hospital, to the extent such
amount exceeds the amount that would be recognized
under section 1833(h) for such tests performed for an
individual enrolled under part B of title XVIII; or
(8) with respect to any amount expended for medical
assistance (A) for nursing facility services to
reimburse (or otherwise compensate) a nursing facility
for payment of a civil money penalty imposed under
section 1919(h) or (B) for home and community care to
reimburse (or otherwise compensate) a provider of such
care for payment of a civil money penalty imposed under
this title or title XI or for legal expenses in defense
of an exclusion or civil money penalty under this title
or title XI if there is no reasonable legal ground for
the provider's case; or
(10)(A) with respect to covered outpatient drugs
unless there is a rebate agreement in effect under
section 1927 with respect to such drugs or unless
section 1927(a)(3) applies,
(B) with respect to any amount expended for an
innovator multiple source drug (as defined in section
1927(k)) dispensed on or after July 1, 1991, if, under
applicable State law, a less expensive multiple source
drug could have been dispensed, but only to the extent
that such amount exceeds the upper payment limit for
such multiple source drug;
(C) with respect to covered outpatient drugs
described in section 1927(a)(7), unless information
respecting utilization data and coding on such drugs
that is required to be submitted under such section is
submitted in accordance with such section;
(D) with respect to any amount expended for
reimbursement to a pharmacy under this title for the
ingredient cost of a covered outpatient drug for which
the pharmacy has already received payment under this
title (other than with respect to a reasonable
restocking fee for such drug); and
(E) with respect to any amount expended for a covered
outpatient drug for which a suspension under section
1927(c)(4)(B)(ii)(II) is in effect; or
(11) with respect to any amount expended for
physicians' services furnished on or after the first
day of the first quarter beginning more than 60 days
after the date of establishment of the physician
identifier system under section 1902(x), unless the
claim for the services includes the unique physician
identifier provided under such system; or
(12) with respect to any amounts expended for--
(A) a vacuum erection system that is not
medically necessary; or
(B) the insertion, repair, or removal and
replacement of a penile prosthetic implant
(unless such insertion, repair, or removal and
replacement is medically necessary); or
(13) with respect to any amount expended to reimburse
(or otherwise compensate) a nursing facility for
payment of legal expenses associated with any action
initiated by the facility that is dismissed on the
basis that no reasonable legal ground existed for the
institution of such action; or
(14) with respect to any amount expended on
administrative costs to carry out the program under
section 1928; or
(15) with respect to any amount expended for a
single-antigen vaccine and its administration in any
case in which the administration of a combined-antigen
vaccine was medically appropriate (as determined by the
Secretary); or
(16) with respect to any amount expended for which
funds may not be used under the Assisted Suicide
Funding Restriction Act of 1997; or
(17) with respect to any amount expended for roads,
bridges, stadiums, or any other item or service not
covered under a State plan under this title; or
(18) with respect to any amount expended for home
health care services provided by an agency or
organization unless the agency or organization provides
the State agency on a continuing basis a surety bond in
a form specified by the Secretary under paragraph (7)
of section 1861(o) and in an amount that is not less
than $50,000 or such comparable surety bond as the
Secretary may permit under the last sentence of such
section; or
(19) with respect to any amount expended on
administrative costs to initiate or pursue litigation
described in subsection (d)(3)(B);
(20) with respect to amounts expended for medical
assistance provided to an individual described in
subclause (XV) or (XVI) of section 1902(a)(10)(A)(ii)
for a fiscal year unless the State demonstrates to the
satisfaction of the Secretary that the level of State
funds expended for such fiscal year for programs to
enable working individuals with disabilities to work
(other than for such medical assistance) is not less
than the level expended for such programs during the
most recent State fiscal year ending before the date of
the enactment of this paragraph;
(21) with respect to amounts expended for covered
outpatient drugs described in section 1927(d)(2)(C)
(relating to drugs when used for cosmetic purposes or
hair growth), except where medically necessary, and
section 1927(d)(2)(K) (relating to drugs when used for
treatment of sexual or erectile dysfunction);
(22) with respect to amounts expended for medical
assistance for an individual who declares under section
1137(d)(1)(A) to be a citizen or national of the United
States for purposes of establishing eligibility for
benefits under this title, unless the requirement of
section 1902(a)(46)(B) is met;
(23) with respect to amounts expended for medical
assistance for covered outpatient drugs (as defined in
section 1927(k)(2)) for which the prescription was
executed in written (and non-electronic) form unless
the prescription was executed on a tamper-resistant
pad;
(24) if a State is required to implement an asset
verification program under section 1940 and fails to
implement such program in accordance with such section,
with respect to amounts expended by such State for
medical assistance for individuals subject to asset
verification under such section, unless--
(A) the State demonstrates to the Secretary's
satisfaction that the State made a good faith
effort to comply;
(B) not later than 60 days after the date of
a finding that the State is in noncompliance,
the State submits to the Secretary (and the
Secretary approves) a corrective action plan to
remedy such noncompliance; and
(C) not later than 12 months after the date
of such submission (and approval), the State
fulfills the terms of such corrective action
plan;
(25) with respect to any amounts expended for medical
assistance for individuals for whom the State does not
report enrollee encounter data (as defined by the
Secretary) to the Medicaid Statistical Information
System (MSIS) in a timely manner (as determined by the
Secretary);
(26) with respect to any amounts expended for medical
assistance for individuals described in subclause
(VIII) of subsection (a)(10)(A)(i) other than medical
assistance provided through benchmark coverage
described in section 1937(b)(1) or benchmark equivalent
coverage described in section 1937(b)(2); or
(27) with respect to any amounts expended by the
State on the basis of a fee schedule for items
described in section 1861(n) and furnished on or after
January 1, 2018, as determined in the aggregate with
respect to each class of such items as defined by the
Secretary, in excess of the aggregate amount, if any,
that would be paid for such items within such class on
a fee-for-service basis under the program under part B
of title XVIII, including, as applicable, under a
competitive acquisition program under section 1847 in
an area of the State.
Nothing in paragraph (1) shall be construed as permitting a
State to provide services under its plan under this title that
are not reasonable in amount, duration, and scope to achieve
their purpose. Paragraphs (1), (2), (16), (17), and (18) shall
apply with respect to items or services furnished and amounts
expended by or through a managed care entity (as defined in
section 1932(a)(1)(B)) in the same manner as such paragraphs
apply to items or services furnished and amounts expended
directly by the State.
(j) Notwithstanding the preceding provisions of this section,
the amount determined under subsection (a)(1) for any State for
any quarter shall be adjusted in accordance with section 1914.
(k) The Secretary is authorized to provide at the request of
any State (and without cost to such State) such technical and
actuarial assistance as may be necessary to assist such State
to contract with any medicaid managed care organization which
meets the requirements of subsection (m) of this section for
the purpose of providing medical care and services to
individuals who are entitled to medical assistance under this
title.
(l)(1) Subject to paragraphs (3) and (4), with respect to any
amount expended for personal care services or home health care
services requiring an in-home visit by a provider that are
provided under a State plan under this title (or under a waiver
of the plan) and furnished in a calendar quarter beginning on
or after January 1, 2020 (or, in the case of home health care
services, on or after January 1, 2023), unless a State requires
the use of an electronic visit verification system for such
services furnished in such quarter under the plan or such
waiver, the Federal medical assistance percentage shall be
reduced--
(A) in the case of personal care services--
(i) for calendar quarters in 2020, by .25
percentage points;
(ii) for calendar quarters in 2021, by .5
percentage points;
(iii) for calendar quarters in 2022, by .75
percentage points; and
(iv) for calendar quarters in 2023 and each
year thereafter, by 1 percentage point; and
(B) in the case of home health care services--
(i) for calendar quarters in 2023 and 2024,
by .25 percentage points;
(ii) for calendar quarters in 2025, by .5
percentage points;
(iii) for calendar quarters in 2026, by .75
percentage points; and
(iv) for calendar quarters in 2027 and each
year thereafter, by 1 percentage point.
(2) Subject to paragraphs (3) and (4), in implementing the
requirement for the use of an electronic visit verification
system under paragraph (1), a State shall--
(A) consult with agencies and entities that provide
personal care services, home health care services, or
both under the State plan (or under a waiver of the
plan) to ensure that such system--
(i) is minimally burdensome;
(ii) takes into account existing best
practices and electronic visit verification
systems in use in the State; and
(iii) is conducted in accordance with the
requirements of HIPAA privacy and security law
(as defined in section 3009 of the Public
Health Service Act);
(B) take into account a stakeholder process that
includes input from beneficiaries, family caregivers,
individuals who furnish personal care services or home
health care services, and other stakeholders, as
determined by the State in accordance with guidance
from the Secretary; and
(C) ensure that individuals who furnish personal care
services, home health care services, or both under the
State plan (or under a waiver of the plan) are provided
the opportunity for training on the use of such system.
(3) Paragraphs (1) and (2) shall not apply in the case of a
State that, as of the date of the enactment of this subsection,
requires the use of any system for the electronic verification
of visits conducted as part of both personal care services and
home health care services, so long as the State continues to
require the use of such system with respect to the electronic
verification of such visits.
(4)(A) In the case of a State described in subparagraph (B),
the reduction under paragraph (1) shall not apply--
(i) in the case of personal care services, for
calendar quarters in 2020; and
(ii) in the case of home health care services, for
calendar quarters in 2023.
(B) For purposes of subparagraph (A), a State described in
this subparagraph is a State that demonstrates to the Secretary
that the State--
(i) has made a good faith effort to comply with the
requirements of paragraphs (1) and (2) (including by
taking steps to adopt the technology used for an
electronic visit verification system); and
(ii) in implementing such a system, has encountered
unavoidable system delays.
(5) In this subsection:
(A) The term ``electronic visit verification system''
means, with respect to personal care services or home
health care services, a system under which visits
conducted as part of such services are electronically
verified with respect to--
(i) the type of service performed;
(ii) the individual receiving the service;
(iii) the date of the service;
(iv) the location of service delivery;
(v) the individual providing the service; and
(vi) the time the service begins and ends.
(B) The term ``home health care services'' means
services described in section 1905(a)(7) provided under
a State plan under this title (or under a waiver of the
plan).
(C) The term ``personal care services'' means
personal care services provided under a State plan
under this title (or under a waiver of the plan),
including services provided under section 1905(a)(24),
1915(c), 1915(i), 1915(j), or 1915(k) or under a wavier
under section 1115.
(6)(A) In the case in which a State requires personal care
service and home health care service providers to utilize an
electronic visit verification system operated by the State or a
contractor on behalf of the State, the Secretary shall pay to
the State, for each quarter, an amount equal to 90 per centum
of so much of the sums expended during such quarter as are
attributable to the design, development, or installation of
such system, and 75 per centum of so much of the sums for the
operation and maintenance of such system.
(B) Subparagraph (A) shall not apply in the case in which a
State requires personal care service and home health care
service providers to utilize an electronic visit verification
system that is not operated by the State or a contractor on
behalf of the State.
(m)(1)(A) The term ``medicaid managed care organization''
means a health maintenance organization, an eligible
organization with a contract under section 1876 or a
Medicare+Choice organization with a contract under part C of
title XVIII, a provider sponsored organization, or any other
public or private organization, which meets the requirement of
section 1902(w) and--
(i) makes services it provides to individuals
eligible for benefits under this title accessible to
such individuals, within the area served by the
organization, to the same extent as such services are
made accessible to individuals (eligible for medical
assistance under the State plan) not enrolled with the
organization, and
(ii) has made adequate provision against the risk of
insolvency, which provision is satisfactory to the
State, meets the requirements of subparagraph (C)(i)
(if applicable), and which assures that individuals
eligible for benefits under this title are in no case
held liable for debts of the organization in case of
the organization's insolvency.
An organization that is a qualified health maintenance
organization (as defined in section 1310(d) of the Public
Health Service Act) is deemed to meet the requirements of
clauses (i) and (ii).
(B) The duties and functions of the Secretary, insofar as
they involve making determinations as to whether an
organization is a medicaid managed care organization within the
meaning of subparagraph (A), shall be integrated with the
administration of section 1312 (a) and (b) of the Public Health
Service Act.
(C)(i) Subject to clause (ii), a provision meets the
requirements of this subparagraph for an organization if the
organization meets solvency standards established by the State
for private health maintenance organizations or is licensed or
certified by the State as a risk-bearing entity.
(ii) Clause (i) shall not apply to an organization if--
(I) the organization is not responsible for the
provision (directly or through arrangements with
providers of services) of inpatient hospital services
and physicians' services;
(II) the organization is a public entity;
(III) the solvency of the organization is guaranteed
by the State; or
(IV) the organization is (or is controlled by) one or
more Federally-qualified health centers and meets
solvency standards established by the State for such an
organization.
For purposes of subclause (IV), the term ``control'' means the
possession, whether direct or indirect, of the power to direct
or cause the direction of the management and policies of the
organization through membership, board representation, or an
ownership interest equal to or greater than 50.1 percent.
(2)(A) Except as provided in subparagraphs (B), (C), and (G),
no payment shall be made under this title to a State with
respect to expenditures incurred by it for payment (determined
under a prepaid capitation basis or under any other risk basis)
for services provided by any entity (including a health
insuring organization) which is responsible for the provision
(directly or through arrangements with providers of services)
of inpatient hospital services and any other service described
in paragraph (2), (3), (4), (5), or (7) of section 1905(a) or
for the provision of any three or more of the services
described in such paragraphs unless--
(i) the Secretary has determined that the entity is a
medicaid managed care organization organization as
defined in paragraph (1);
(iii) such services are provided for the benefit of
individuals eligible for benefits under this title in
accordance with a contract between the State and the
entity under which prepaid payments to the entity are
made on an actuarially sound basis and under which the
Secretary must provide prior approval for contracts
providing for expenditures in excess of $1,000,000 for
1998 and, for a subsequent year, the amount established
under this clause for the previous year increased by
the percentage increase in the consumer price index for
all urban consumers over the previous year;
(iv) such contract provides that the Secretary and
the State (or any person or organization designated by
either) shall have the right to audit and inspect any
books and records of the entity (and of any
subcontractor) that pertain (I) to the ability of the
entity to bear the risk of potential financial losses,
or (II) to services performed or determinations of
amounts payable under the contract;
(v) such contract provides that in the entity's
enrollment, reenrollment, or disenrollment of
individuals who are eligible for benefits under this
title and eligible to enroll, reenroll, or disenroll
with the entity pursuant to the contract, the entity
will not discriminate among such individuals on the
basis of their health status or requirements for health
care services;
(vi) such contract (I) permits individuals who have
elected under the plan to enroll with the entity for
provision of such benefits to terminate such enrollment
in accordance with section 1932(a)(4), and (II)
provides for notification in accordance with such
section of each such individual, at the time of the
individual's enrollment, of such right to terminate
such enrollment;
(vii) such contract provides that, in the case of
medically necessary services which were provided (I) to
an individual enrolled with the entity under the
contract and entitled to benefits with respect to such
services under the State's plan and (II) other than
through the organization because the services were
immediately required due to an unforeseen illness,
injury, or condition, either the entity or the State
provides for reimbursement with respect to those
services,
(viii) such contract provides for disclosure of
information in accordance with section 1124 and
paragraph (4) of this subsection;
(ix) such contract provides, in the case of an entity
that has entered into a contract for the provision of
services with a Federally-qualified health center or a
rural health clinic, that the entity shall provide
payment that is not less than the level and amount of
payment which the entity would make for the services if
the services were furnished by a provider which is not
a Federally-qualified health center or a rural health
clinic;
(x) any physician incentive plan that it operates
meets the requirements described in section 1876(i)(8);
(xi) such contract provides for maintenance of
sufficient patient encounter data to identify the
physician who delivers services to patients and for the
provision of such data to the State at a frequency and
level of detail to be specified by the Secretary;
(xii) such contract, and the entity complies with the
applicable requirements of section 1932; and
(xiii) such contract provides that (I)
covered outpatient drugs dispensed to
individuals eligible for medical assistance who
are enrolled with the entity shall be subject
to the same rebate required by the agreement
entered into under section 1927 as the State is
subject to and that the State shall collect
such rebates from manufacturers, (II)
capitation rates paid to the entity shall be
based on actual cost experience related to
rebates and subject to the Federal regulations
requiring actuarially sound rates, and (III)
the entity shall report to the State, on such
timely and periodic basis as specified by the
Secretary in order to include in the
information submitted by the State to a
manufacturer and the Secretary under section
1927(b)(2)(A), information on the total number
of units of each dosage form and strength and
package size by National Drug Code of each
covered outpatient drug dispensed to
individuals eligible for medical assistance who
are enrolled with the entity and for which the
entity is responsible for coverage of such drug
under this subsection (other than covered
outpatient drugs that under subsection (j)(1)
of section 1927 are not subject to the
requirements of that section) and such other
data as the Secretary determines necessary to
carry out this subsection.
(B) Subparagraph (A) except with respect to clause (ix) of
subparagraph (A), does not apply with respect to payments under
this title to a State with respect to expenditures incurred by
it for payment for services provided by an entity which--
(i)(I) received a grant of at least $100,000 in the
fiscal year ending June 30, 1976, under section
329(d)(1)(A) or 330(d)(1) of the Public Health Service
Act, and for the period beginning July 1, 1976, and
ending on the expiration of the period for which
payments are to be made under this title has been the
recipient of a grant under either such section; and
(II) provides to its enrollees, on a prepaid
capitation risk basis or on any other risk basis, all
of the services and benefits described in paragraphs
(1), (2), (3), (4)(C), and (5) of section 1905(a) and,
to the extent required by section 1902(a)(10)(D) to be
provided under a State plan for medical assistance, the
services and benefits described in paragraph (7) of
section 1905(a); or
(ii) is a nonprofit primary health care entity
located in a rural area (as defined by the Appalachian
Regional Commission)--
(I) which received in the fiscal year ending
June 30, 1976, at least $100,000 (by grant,
subgrant, or subcontract) under the Appalachian
Regional Development Act of 1965, and
(II) for the period beginning July 1, 1976,
and ending on the expiration of the period for
which payments are to be made under this title
either has been the recipient of a grant,
subgrant, or subcontract under such Act or has
provided services under a contract (initially
entered into during a year in which the entity
was the recipient of such a grant, subgrant, or
subcontract) with a State agency under this
title on a prepaid capitation risk basis or on
any other risk basis; or
(iii) which has contracted with the single State
agency for the provision of services (but not including
inpatient hospital services) to persons eligible under
this title on a prepaid risk basis prior to 1970.
(G) In the case of an entity which is receiving (and has
received during the previous two years) a grant of at least
$100,000 under section 329(d)(1)(A) or 330(d)(1) of the Public
Health Service Act or is receiving (and has received during the
previous two years) at least $100,000 (by grant, subgrant, or
subcontract) under the Appalachian Regional Development Act of
1965, clause (i) of subparagraph (A) shall not apply.
(H) In the case of an individual who--
(i) in a month is eligible for benefits under this
title and enrolled with a medicaid managed care
organization with a contract under this paragraph or
with a primary care case manager with a contract
described in section 1905(t)(3),
(ii) in the next month (or in the next 2 months) is
not eligible for such benefits, but
(iii) in the succeeding month is again eligible for
such benefits,
the State plan, subject to subparagraph (A)(vi), may enroll the
individual for that succeeding month with the organization
described in clause (i) if the organization continues to have a
contract under this paragraph with the State or with the
manager described in such clause if the manager continues to
have a contract described in section 1905(t)(3) with the State.
(3) No payment shall be made under this title to a State with
respect to expenditures incurred by the State for payment for
services provided by a managed care entity (as defined under
section 1932(a)(1)) under the State plan under this title (or
under a waiver of the plan) unless the State--
(A) beginning on July 1, 2018, has a contract with
such entity that complies with the requirement
specified in section 1932(d)(5); and
(B) beginning on January 1, 2018, complies with the
requirement specified in section 1932(d)(6)(A).
(4)(A) Each medicaid managed care organization which is not a
qualified health maintenance organization (as defined in
section 1310(d) of the Public Health Service Act) must report
to the State and, upon request, to the Secretary, the Inspector
General of the Department of Health and Human Services, and the
Comptroller General a description of transactions between the
organization and a party in interest (as defined in section
1318(b) of such Act), including the following transactions:
(i) Any sale or exchange, or leasing of any property
between the organization and such a party.
(ii) Any furnishing for consideration of goods,
services (including management services), or facilities
between the organization and such a party, but not
including salaries paid to employees for services
provided in the normal course of their employment.
(iii) Any lending of money or other extension of
credit between the organization and such a party.
The State or Secretary may require that information reported
respecting an organization which controls, or is controlled by,
or is under common control with, another entity be in the form
of a consolidated financial statement for the organization and
such entity.
(B) Each organization shall make the information reported
pursuant to subparagraph (A) available to its enrollees upon
reasonable request.
(5)(A) If the Secretary determines that an entity with a
contract under this subsection--
(i) fails substantially to provide medically
necessary items and services that are required (under
law or under the contract) to be provided to an
individual covered under the contract, if the failure
has adversely affected (or has substantial likelihood
of adversely affecting) the individual;
(ii) imposes premiums on individuals enrolled under
this subsection in excess of the premiums permitted
under this title;
(iii) acts to discriminate among individuals in
violation of the provision of paragraph (2)(A)(v),
including expulsion or refusal to re-enroll an
individual or engaging in any practice that would
reasonably be expected to have the effect of denying or
discouraging enrollment (except as permitted by this
subsection) by eligible individuals with the
organization whose medical condition or history
indicates a need for substantial future medical
services;
(iv) misrepresents or falsifies information that is
furnished--
(I) to the Secretary or the State under this
subsection, or
(II) to an individual or to any other entity
under this subsection, or
(v) fails to comply with the requirements of section
1876(i)(8),
the Secretary may provide, in addition to any other remedies
available under law, for any of the remedies described in
subparagraph (B).
(B) The remedies described in this subparagraph are--
(i) civil money penalties of not more than $25,000
for each determination under subparagraph (A), or, with
respect to a determination under clause (iii) or
(iv)(I) of such subparagraph, of not more than $100,000
for each such determination, plus, with respect to a
determination under subparagraph (A)(ii), double the
excess amount charged in violation of such subparagraph
(and the excess amount charged shall be deducted from
the penalty and returned to the individual concerned),
and plus, with respect to a determination under
subparagraph (A)(iii), $15,000 for each individual not
enrolled as a result of a practice described in such
subparagraph, or
(ii) denial of payment to the State for medical
assistance furnished under the contract under this
subsection for individuals enrolled after the date the
Secretary notifies the organization of a determination
under subparagraph (A) and until the Secretary is
satisfied that the basis for such determination has
been corrected and is not likely to recur.
The provisions of section 1128A (other than subsections (a) and
(b)) shall apply to a civil money penalty under clause (i) in
the same manner as such provisions apply to a penalty or
proceeding under section 1128A(a).
(6)(A) For purposes of this subsection and section
1902(e)(2)(A), in the case of the State of New Jersey, the term
``contract'' shall be deemed to include an undertaking by the
State agency, in the State plan under this title, to operate a
program meeting all requirements of this subsection.
(B) The undertaking described in subparagraph (A) must
provide--
(i) for the establishment of a separate entity
responsible for the operation of a program meeting the
requirements of this subsection, which entity may be a
subdivision of the State agency administering the State
plan under this title;
(ii) for separate accounting for the funds used to
operate such program; and
(iii) for setting the capitation rates and any other
payment rates for services provided in accordance with
this subsection using a methodology satisfactory to the
Secretary designed to ensure that total Federal
matching payments under this title for such services
will be lower than the matching payments that would be
made for the same services, if provided under the State
plan on a fee for service basis to an actuarially
equivalent population.
(C) The undertaking described in subparagraph (A) shall be
subject to approval (and annual re-approval) by the Secretary
in the same manner as a contract under this subsection.
(D) The undertaking described in subparagraph (A) shall not
be eligible for a waiver under section 1915(b).
(7) Payment shall be made under this title to a State for
expenditures for capitation payments described in section
438.6(e) of title 42, Code of Federal Regulations (or any
successor regulation).
(8)(A) The State agency administering the State plan under
this title may have reasonable access, as determined by the
State, to 1 or more prescription drug monitoring program
databases administered or accessed by the State to the extent
the State agency is permitted to access such databases under
State law.
(B) Such State agency may facilitate reasonable access, as
determined by the State, to 1 or more prescription drug
monitoring program databases administered or accessed by the
State, to same extent that the State agency is permitted under
State law to access such databases, for--
(i) any provider enrolled under the State plan to
provide services to Medicaid beneficiaries; and
(ii) any managed care entity (as defined under
section 1932(a)(1)(B)) that has a contract with the
State under this subsection or under section
1905(t)(3).
(C) Such State agency may share information in such
databases, to the same extent that the State agency is
permitted under State law to share information in such
databases, with--
(i) any provider enrolled under the State plan to
provide services to Medicaid beneficiaries; and
(ii) any managed care entity (as defined under
section 1932(a)(1)(B)) that has a contract with the
State under this subsection or under section
1905(t)(3).
(9)(A) With respect to expenditures described in subparagraph
(B) that are incurred by a State for any fiscal year after
fiscal year 2020 (and before fiscal year 2024), in determining
the pro rata share to which the United States is equitably
entitled under subsection (d)(3), the Secretary shall
substitute the Federal medical assistance percentage that
applies for such fiscal year to the State under section 1905(b)
(without regard to any adjustments to such percentage
applicable under such section or any other provision of law)
for the percentage that applies to such expenditures under
section 1905(y).
(B) Expenditures described in this subparagraph, with respect
to a fiscal year to which subparagraph (A) applies, are
expenditures incurred by a State for payment for medical
assistance provided to individuals described in subclause
(VIII) of section 1902(a)(10)(A)(i) by a managed care entity,
or other specified entity (as defined in subparagraph
(D)(iii)), that are treated as remittances because the State--
(i) has satisfied the requirement of section 438.8 of
title 42, Code of Federal Regulations (or any successor
regulation), by electing--
(I) in the case of a State described in
subparagraph (C), to apply a minimum medical
loss ratio (as defined in subparagraph (D)(ii))
that is at least 85 percent but not greater
than the minimum medical loss ratio (as so
defined) that such State applied as of May 31,
2018; or
(II) in the case of a State not described in
subparagraph (C), to apply a minimum medical
loss ratio that is equal to 85 percent; and
(ii) recovered all or a portion of the expenditures
as a result of the entity's failure to meet such ratio.
(C) For purposes of subparagraph (B), a State described in
this subparagraph is a State that as of May 31, 2018, applied a
minimum medical loss ratio (as calculated under subsection (d)
of section 438.8 of title 42, Code of Federal Regulations (as
in effect on June 1, 2018)) for payment for services provided
by entities described in such subparagraph under the State plan
under this title (or a waiver of the plan) that is equal to or
greater than 85 percent.
(D) For purposes of this paragraph:
(i) The term ``managed care entity'' means a medicaid
managed care organization described in section
1932(a)(1)(B)(i).
(ii) The term ``minimum medical loss ratio'' means,
with respect to a State, a minimum medical loss ratio
(as calculated under subsection (d) of section 438.8 of
title 42, Code of Federal Regulations (as in effect on
June 1, 2018)) for payment for services provided by
entities described in subparagraph (B) under the State
plan under this title (or a waiver of the plan).
(iii) The term ``other specified entity'' means--
(I) a prepaid inpatient health plan, as
defined in section 438.2 of title 42, Code of
Federal Regulations (or any successor
regulation); and
(II) a prepaid ambulatory health plan, as
defined in such section (or any successor
regulation).
(o) Notwithstanding the preceding provisions of this section,
no payment shall be made to a State under the preceding
provisions of this section for expenditures for medical
assistance provided for an individual under its State plan
approved under this title to the extent that a private insurer
(as defined by the Secretary by regulation and including a
group health plan (as defined in section 607(1) of the Employee
Retirement Income Security Act of 1974), a service benefit
plan, and a health maintenance organization) would have been
obligated to provide such assistance but for a provision of its
insurance contract which has the effect of limiting or
excluding such obligation because the individual is eligible
for or is provided medical assistance under the plan.
(p)(1) When a political subdivision of a State makes, for the
State of which it is a political subdivision, or one State
makes, for another State, the enforcement and collection of
rights of support or payment assigned under section 1912,
pursuant to a cooperative arrangement under such section
(either within or outside of such State), there shall be paid
to such political subdivision or such other State from amounts
which would otherwise represent the Federal share of payments
for medical assistance provided to the eligible individuals on
whose behalf such enforcement and collection was made, an
amount equal to 15 percent of any amount collected which is
attributable to such rights of support or payment.
(2) Where more than one jurisdiction is involved in such
enforcement or collection, the amount of the incentive payment
determined under paragraph (1) shall be allocated among the
jurisdictions in a manner to be prescribed by the Secretary.
(q) For the purposes of this section, the term ``State
medicaid fraud control unit'' means a single identifiable
entity of the State government which the Secretary certifies
(and annually recertifies) as meeting the following
requirements:
(1) The entity (A) is a unit of the office of the
State Attorney General or of another department of
State government which possesses statewide authority to
prosecute individuals for criminal violations, (B) is
in a State the constitution of which does not provide
for the criminal prosecution of individuals by a
statewide authority and has formal procedures, approved
by the Secretary, that (i) assure its referral of
suspected criminal violations relating to the program
under this title to the appropriate authority or
authorities in the State for prosecution and (ii)
assure its assistance of, and coordination with, such
authority or authorities in such prosecutions, or (C)
has a formal working relationship with the office of
the State Attorney General and has formal procedures
(including procedures for its referral of suspected
criminal violations to such office) which are approved
by the Secretary and which provide effective
coordination of activities between the entity and such
office with respect to the detection, investigation,
and prosecution of suspected criminal violations
relating to the program under this title.
(2) The entity is separate and distinct from the
single State agency that administers or supervises the
administration of the State plan under this title.
(3) The entity's function is conducting a statewide
program for the investigation and prosecution of
violations of all applicable State laws regarding any
and all aspects of fraud in connection with (A) any
aspect of the provision of medical assistance and the
activities of providers of such assistance under the
State plan under this title; and (B) upon the approval
of the Inspector General of the relevant Federal
agency, any aspect of the provision of health care
services and activities of providers of such services
under any Federal health care program (as defined in
section 1128B(f)(1)), if the suspected fraud or
violation of law in such case or investigation is
primarily related to the State plan under this title.
(4)(A) The entity has--
(i) procedures for reviewing complaints of
abuse or neglect of patients in health care
facilities which receive payments under the
State plan under this title;
(ii) at the option of the entity, procedures
for reviewing complaints of abuse or neglect of
patients residing in board and care facilities;
and
(iii) procedures for acting upon such
complaints under the criminal laws of the State
or for referring such complaints to other State
agencies for action.
(B) For purposes of this paragraph, the term ``board
and care facility'' means a residential setting which
receives payment (regardless of whether such payment is
made under the State plan under this title) from or on
behalf of two or more unrelated adults who reside in
such facility, and for whom one or both of the
following is provided:
(i) Nursing care services provided by, or
under the supervision of, a registered nurse,
licensed practical nurse, or licensed nursing
assistant.
(ii) A substantial amount of personal care
services that assist residents with the
activities of daily living, including personal
hygiene, dressing, bathing, eating, toileting,
ambulation, transfer, positioning, self-
medication, body care, travel to medical
services, essential shopping, meal preparation,
laundry, and housework.
(5) The entity provides for the collection, or
referral for collection to a single State agency, of
overpayments that are made under the State plan or
under any Federal health care program (as so defined)
to health care facilities and that are discovered by
the entity in carrying out its activities. All funds
collected in accordance with this paragraph shall be
credited exclusively to, and available for expenditure
under, the Federal health care program (including the
State plan under this title) that was subject to the
activity that was the basis for the collection.
(6) The entity employs such auditors, attorneys,
investigators, and other necessary personnel and is
organized in such a manner as is necessary to promote
the effective and efficient conduct of the entity's
activities.
(7) The entity submits to the Secretary an
application and annual reports containing such
information as the Secretary determines, by regulation,
to be necessary to determine whether the entity meets
the other requirements of this subsection.
(r)(1) In order to receive payments under subsection (a) for
use of automated data systems in administration of the State
plan under this title, a State must, in addition to meeting the
requirements of paragraph (3), have in operation mechanized
claims processing and information retrieval systems that meet
the requirements of this subsection and that the Secretary has
found--
(A) are adequate to provide efficient, economical,
and effective administration of such State plan;
(B) are compatible with the claims processing and
information retrieval systems used in the
administration of title XVIII, and for this purpose--
(i) have a uniform identification coding
system for providers, other payees, and
beneficiaries under this title or title XVIII;
(ii) provide liaison between States and
carriers and intermediaries with agreements
under title XVIII to facilitate timely exchange
of appropriate data;
(iii) provide for exchange of data between
the States and the Secretary with respect to
persons sanctioned under this title or title
XVIII; and
(iv) effective for claims filed on or after
October 1, 2010, incorporate compatible
methodologies of the National Correct Coding
Initiative administered by the Secretary (or
any successor initiative to promote correct
coding and to control improper coding leading
to inappropriate payment) and such other
methodologies of that Initiative (or such other
national correct coding methodologies) as the
Secretary identifies in accordance with
paragraph (4);
(C) are capable of providing accurate and timely
data;
(D) are complying with the applicable provisions of
part C of title XI;
(E) are designed to receive provider claims in
standard formats to the extent specified by the
Secretary; and
(F) effective for claims filed on or after January 1,
1999, provide for electronic transmission of claims
data in the format specified by the Secretary and
consistent with the Medicaid Statistical Information
System (MSIS) (including detailed individual enrollee
encounter data and other information that the Secretary
may find necessary and including, for data submitted to
the Secretary on or after January 1, 2010, data
elements from the automated data system that the
Secretary determines to be necessary for program
integrity, program oversight, and administration, at
such frequency as the Secretary shall determine).
(2) In order to meet the requirements of this paragraph,
mechanized claims processing and information retrieval systems
must meet the following requirements:
(A) The systems must be capable of developing
provider, physician, and patient profiles which are
sufficient to provide specific information as to the
use of covered types of services and items, including
prescribed drugs.
(B) The State must provide that information on
probable fraud or abuse which is obtained from, or
developed by, the systems, is made available to the
State's medicaid fraud control unit (if any) certified
under subsection (q) of this section.
(C) The systems must meet all performance standards
and other requirements for initial approval developed
by the Secretary.
(3) In order to meet the requirements of this paragraph, a
State must have in operation an eligibility determination
system which provides for data matching through the Public
Assistance Reporting Information System (PARIS) facilitated by
the Secretary (or any successor system), including matching
with medical assistance programs operated by other States.
(4) For purposes of paragraph (1)(B)(iv), the Secretary shall
do the following:
(A) Not later than September 1, 2010:
(i) Identify those methodologies of the
National Correct Coding Initiative administered
by the Secretary (or any successor initiative
to promote correct coding and to control
improper coding leading to inappropriate
payment) which are compatible to claims filed
under this title.
(ii) Identify those methodologies of such
Initiative (or such other national correct
coding methodologies) that should be
incorporated into claims filed under this title
with respect to items or services for which
States provide medical assistance under this
title and no national correct coding
methodologies have been established under such
Initiative with respect to title XVIII.
(iii) Notify States of--
(I) the methodologies identified
under subparagraphs (A) and (B) (and of
any other national correct coding
methodologies identified under
subparagraph (B)); and
(II) how States are to incorporate
such methodologies into claims filed
under this title.
(B) Not later than March 1, 2011, submit a report to
Congress that includes the notice to States under
clause (iii) of subparagraph (A) and an analysis
supporting the identification of the methodologies made
under clauses (i) and (ii) of subparagraph (A).
(s) Notwithstanding the preceding provisions of this section,
no payment shall be made to a State under this section for
expenditures for medical assistance under the State plan
consisting of a designated health service (as defined in
subsection (h)(6) of section 1877) furnished to an individual
on the basis of a referral that would result in the denial of
payment for the service under title XVIII if such title
provided for coverage of such service to the same extent and
under the same terms and conditions as under the State plan,
and subsections (f) and (g)(5) of such section shall apply to a
provider of such a designated health service for which payment
may be made under this title in the same manner as such
subsections apply to a provider of such a service for which
payment may be made under such title.
(t)(1) For purposes of subsection (a)(3)(F), the payments
described in this paragraph to encourage the adoption and use
of certified EHR technology are payments made by the State in
accordance with this subsection --
(A) to Medicaid providers described in paragraph
(2)(A) not in excess of 85 percent of net average
allowable costs (as defined in paragraph (3)(E)) for
certified EHR technology (and support services
including maintenance and training that is for, or is
necessary for the adoption and operation of, such
technology) with respect to such providers; and
(B) to Medicaid providers described in paragraph
(2)(B) not in excess of the maximum amount permitted
under paragraph (5) for the provider involved.
(2) In this subsection and subsection (a)(3)(F), the term
``Medicaid provider'' means--
(A) an eligible professional (as defined in paragraph
(3)(B))--
(i) who is not hospital-based and has at
least 30 percent of the professional's patient
volume (as estimated in accordance with a
methodology established by the Secretary)
attributable to individuals who are receiving
medical assistance under this title;
(ii) who is not described in clause (i), who
is a pediatrician, who is not hospital-based,
and who has at least 20 percent of the
professional's patient volume (as estimated in
accordance with a methodology established by
the Secretary) attributable to individuals who
are receiving medical assistance under this
title; and
(iii) who practices predominantly in a
Federally qualified health center or rural
health clinic and has at least 30 percent of
the professional's patient volume (as estimated
in accordance with a methodology established by
the Secretary) attributable to needy
individuals (as defined in paragraph (3)(F));
and
(B)(i) a children's hospital, or
(ii) an acute-care hospital that is not described in
clause (i) and that has at least 10 percent of the
hospital's patient volume (as estimated in accordance
with a methodology established by the Secretary)
attributable to individuals who are receiving medical
assistance under this title.
An eligible professional shall not qualify as a Medicaid
provider under this subsection unless any right to payment
under sections 1848(o) and 1853(l) with respect to the eligible
professional has been waived in a manner specified by the
Secretary. For purposes of calculating patient volume under
subparagraph (A)(iii), insofar as it is related to
uncompensated care, the Secretary may require the adjustment of
such uncompensated care data so that it would be an appropriate
proxy for charity care, including a downward adjustment to
eliminate bad debt data from uncompensated care. In applying
subparagraphs (A) and (B)(ii), the methodology established by
the Secretary for patient volume shall include individuals
enrolled in a Medicaid managed care plan (under section 1903(m)
or section 1932).
(3) In this subsection and subsection (a)(3)(F):
(A) The term ``certified EHR technology'' means a
qualified electronic health record (as defined in
3000(13) of the Public Health Service Act) that is
certified pursuant to section 3001(c)(5) of such Act as
meeting standards adopted under section 3004 of such
Act that are applicable to the type of record involved
(as determined by the Secretary, such as an ambulatory
electronic health record for office-based physicians or
an inpatient hospital electronic health record for
hospitals).
(B) The term ``eligible professional'' means a--
(i) physician;
(ii) dentist;
(iii) certified nurse mid-wife;
(iv) nurse practitioner; and
(v) physician assistant insofar as the
assistant is practicing in a rural health
clinic that is led by a physician assistant or
is practicing in a Federally qualified health
center that is so led.
(C) The term ``average allowable costs'' means, with
respect to certified EHR technology of Medicaid
providers described in paragraph (2)(A) for--
(i) the first year of payment with respect to
such a provider, the average costs for the
purchase and initial implementation or upgrade
of such technology (and support services
including training that is for, or is necessary
for the adoption and initial operation of, such
technology) for such providers, as determined
by the Secretary based upon studies conducted
under paragraph (4)(C); and
(ii) a subsequent year of payment with
respect to such a provider, the average costs
not described in clause (i) relating to the
operation, maintenance, and use of such
technology for such providers, as determined by
the Secretary based upon studies conducted
under paragraph (4)(C).
(D) The term ``hospital-based'' means, with respect
to an eligible professional, a professional (such as a
pathologist, anesthesiologist, or emergency physician)
who furnishes substantially all of the individual's
professional services in a hospital inpatient or
emergency room setting and through the use of the
facilities and equipment, including qualified
electronic health records, of the hospital. The
determination of whether an eligible professional is a
hospital-based eligible professional shall be made on
the basis of the site of service (as defined by the
Secretary) and without regard to any employment or
billing arrangement between the eligible professional
and any other provider.
(E) The term ``net average allowable costs'' means,
with respect to a Medicaid provider described in
paragraph (2)(A), average allowable costs reduced by
the average payment the Secretary estimates will be
made to such Medicaid providers (determined on a
percentage or other basis for such classes or types of
providers as the Secretary may specify) from other
sources (other than under this subsection, or by the
Federal government or a State or local government) that
is directly attributable to payment for certified EHR
technology or support services described in
subparagraph (C).
(F) The term ``needy individual'' means, with respect
to a Medicaid provider, an individual--
(i) who is receiving assistance under this
title;
(ii) who is receiving assistance under title
XXI;
(iii) who is furnished uncompensated care by
the provider; or
(iv) for whom charges are reduced by the
provider on a sliding scale basis based on an
individual's ability to pay.
(4)(A) With respect to a Medicaid provider described in
paragraph (2)(A), subject to subparagraph (B), in no case
shall--
(i) the net average allowable costs under
this subsection for the first year of payment
(which may not be later than 2016), which is
intended to cover the costs described in
paragraph (3)(C)(i), exceed $25,000 (or such
lesser amount as the Secretary determines based
on studies conducted under subparagraph (C));
(ii) the net average allowable costs under
this subsection for a subsequent year of
payment, which is intended to cover costs
described in paragraph (3)(C)(ii), exceed
$10,000; and
(iii) payments be made for costs described in
clause (ii) after 2021 or over a period of
longer than 5 years.
(B) In the case of Medicaid provider described in paragraph
(2)(A)(ii), the dollar amounts specified in subparagraph (A)
shall be \2/3\ of the dollar amounts otherwise specified.
(C) For the purposes of determining average allowable costs
under this subsection, the Secretary shall study the average
costs to Medicaid providers described in paragraph (2)(A) of
purchase and initial implementation and upgrade of certified
EHR technology described in paragraph (3)(C)(i) and the average
costs to such providers of operations, maintenance, and use of
such technology described in paragraph (3)(C)(ii). In
determining such costs for such providers, the Secretary may
utilize studies of such amounts submitted by States.
(5)(A) In no case shall the payments described in paragraph
(1)(B) with respect to a Medicaid provider described in
paragraph (2)(B) exceed--
(i) in the aggregate the product of--
(I) the overall hospital EHR amount
for the provider computed under
subparagraph (B); and
(II) the Medicaid share for such
provider computed under subparagraph
(C);
(ii) in any year 50 percent of the product described
in clause (i); and
(iii) in any 2-year period 90 percent of such
product.
(B) For purposes of this paragraph, the overall hospital EHR
amount, with respect to a Medicaid provider, is the sum of the
applicable amounts specified in section 1886(n)(2)(A) for such
provider for the first 4 payment years (as estimated by the
Secretary) determined as if the Medicare share specified in
clause (ii) of such section were 1. The Secretary shall
establish, in consultation with the State, the overall hospital
EHR amount for each such Medicaid provider eligible for
payments under paragraph (1)(B). For purposes of this
subparagraph in computing the amounts under section
1886(n)(2)(C) for payment years after the first payment year,
the Secretary shall assume that in subsequent payment years
discharges increase at the average annual rate of growth of the
most recent 3 years for which discharge data are available per
year.
(C) The Medicaid share computed under this subparagraph, for
a Medicaid provider for a period specified by the Secretary,
shall be calculated in the same manner as the Medicare share
under section 1886(n)(2)(D) for such a hospital and period,
except that there shall be substituted for the numerator under
clause (i) of such section the amount that is equal to the
number of inpatient-bed-days (as established by the Secretary)
which are attributable to individuals who are receiving medical
assistance under this title and who are not described in
section 1886(n)(2)(D)(i). In computing inpatient-bed-days under
the previous sentence, the Secretary shall take into account
inpatient-bed-days attributable to inpatient-bed-days that are
paid for individuals enrolled in a Medicaid managed care plan
(under section 1903(m) or section 1932).
(D) In no case may the payments described in paragraph (1)(B)
with respect to a Medicaid provider described in paragraph
(2)(B) be paid--
(i) for any year beginning after 2016 unless the
provider has been provided payment under paragraph
(1)(B) for the previous year; and
(ii) over a period of more than 6 years of payment.
(6) Payments described in paragraph (1) are not in accordance
with this subsection unless the following requirements are met:
(A)(i) The State provides assurances satisfactory to
the Secretary that amounts received under subsection
(a)(3)(F) with respect to payments to a Medicaid
provider are paid, subject to clause (ii), directly to
such provider (or to an employer or facility to which
such provider has assigned payments) without any
deduction or rebate.
(ii) Amounts described in clause (i) may also be paid
to an entity promoting the adoption of certified EHR
technology, as designated by the State, if
participation in such a payment arrangement is
voluntary for the eligible professional involved and if
such entity does not retain more than 5 percent of such
payments for costs not related to certified EHR
technology (and support services including maintenance
and training) that is for, or is necessary for the
operation of, such technology.
(B) A Medicaid provider described in paragraph (2)(A)
is responsible for payment of the remaining 15 percent
of the net average allowable cost and shall be
determined to have met such responsibility to the
extent that the payment to the Medicaid provider is not
in excess of 85 percent of the net average allowable
cost.
(C)(i) Subject to clause (ii), with respect to
payments to a Medicaid provider--
(I) for the first year of payment to the
Medicaid provider under this subsection, the
Medicaid provider demonstrates that it is
engaged in efforts to adopt, implement, or
upgrade certified EHR technology; and
(II) for a year of payment, other than the
first year of payment to the Medicaid provider
under this subsection, the Medicaid provider
demonstrates meaningful use of certified EHR
technology through a means that is approved by
the State and acceptable to the Secretary, and
that may be based upon the methodologies
applied under section 1848(o) or 1886(n).
(ii) In the case of a Medicaid provider who has
completed adopting, implementing, or upgrading such
technology prior to the first year of payment to the
Medicaid provider under this subsection, clause (i)(I)
shall not apply and clause (i)(II) shall apply to each
year of payment to the Medicaid provider under this
subsection, including the first year of payment.
(D) To the extent specified by the Secretary, the
certified EHR technology is compatible with State or
Federal administrative management systems.
For purposes of subparagraph (B), a Medicaid provider described
in paragraph (2)(A) may accept payments for the costs described
in such subparagraph from a State or local government. For
purposes of subparagraph (C), in establishing the means
described in such subparagraph, which may include clinical
quality reporting to the State, the State shall ensure that
populations with unique needs, such as children, are
appropriately addressed.
(7) With respect to Medicaid providers described in paragraph
(2)(A), the Secretary shall ensure coordination of payment with
respect to such providers under sections 1848(o) and 1853(l)
and under this subsection to assure no duplication of funding.
Such coordination shall include, to the extent practicable, a
data matching process between State Medicaid agencies and the
Centers for Medicare & Medicaid Services using national
provider identifiers. For such purposes, the Secretary may
require the submission of such data relating to payments to
such Medicaid providers as the Secretary may specify.
(8) In carrying out paragraph (6)(C), the State and Secretary
shall seek, to the maximum extent practicable, to avoid
duplicative requirements from Federal and State governments to
demonstrate meaningful use of certified EHR technology under
this title and title XVIII. In doing so, the Secretary may deem
satisfaction of requirements for such meaningful use for a
payment year under title XVIII to be sufficient to qualify as
meaningful use under this subsection. The Secretary may also
specify the reporting periods under this subsection in order to
carry out this paragraph.
(9) In order to be provided Federal financial participation
under subsection (a)(3)(F)(ii), a State must demonstrate to the
satisfaction of the Secretary, that the State--
(A) is using the funds provided for the purposes of
administering payments under this subsection, including
tracking of meaningful use by Medicaid providers;
(B) is conducting adequate oversight of the program
under this subsection, including routine tracking of
meaningful use attestations and reporting mechanisms;
and
(C) is pursuing initiatives to encourage the adoption
of certified EHR technology to promote health care
quality and the exchange of health care information
under this title, subject to applicable laws and
regulations governing such exchange.
(10) The Secretary shall periodically submit reports to the
Committee on Energy and Commerce of the House of
Representatives and the Committee on Finance of the Senate on
status, progress, and oversight of payments described in
paragraph (1), including steps taken to carry out paragraph
(7). Such reports shall also describe the extent of adoption of
certified EHR technology among Medicaid providers resulting
from the provisions of this subsection and any improvements in
health outcomes, clinical quality, or efficiency resulting from
such adoption.
(u)(1)(A) Notwithstanding subsection (a)(1), if the ratio of
a State's erroneous excess payments for medical assistance (as
defined in subparagraph (D)) to its total expenditures for
medical assistance under the State plan approved under this
title exceeds 0.03, for the period consisting of the third and
fourth quarters of fiscal year 1983, or for any full fiscal
year thereafter, then the Secretary shall make no payment for
such period or fiscal year with respect to so much of such
erroneous excess payments as exceeds such allowable error rate
of 0.03.
(B) The Secretary may waive, in certain limited cases, all or
part of the reduction required under subparagraph (A) with
respect to any State if such State is unable to reach the
allowable error rate for a period or fiscal year despite a good
faith effort by such State.
(C) In estimating the amount to be paid to a State under
subsection (d), the Secretary shall take into consideration the
limitation on Federal financial participation imposed by
subparagraph (A) and shall reduce the estimate he makes under
subsection (d)(1), for purposes of payment to the State under
subsection (d)(3), in light of any expected erroneous excess
payments for medical assistance (estimated in accordance with
such criteria, including sampling procedures, as he may
prescribe and subject to subsequent adjustment, if necessary,
under subsection (d)(2)).
(D)(i) For purposes of this subsection, the term ``erroneous
excess payments for medical assistance'' means the total of--
(I) payments under the State plan with respect to
ineligible individuals and families, and
(II) overpayments on behalf of eligible individuals
and families by reason of error in determining the
amount of expenditures for medical care required of an
individual or family as a condition of eligibility.
(ii) In determining the amount of erroneous excess payments
for medical assistance to an ineligible individual or family
under clause (i)(I), if such ineligibility is the result of an
error in determining the amount of the resources of such
individual or family, the amount of the erroneous excess
payment shall be the smaller of (I) the amount of the payment
with respect to such individual or family, or (II) the
difference between the actual amount of such resources and the
allowable resource level established under the State plan.
(iii) In determining the amount of erroneous excess payments
for medical assistance to an individual or family under clause
(i)(II), the amount of the erroneous excess payment shall be
the smaller of (I) the amount of the payment on behalf of the
individual or family, or (II) the difference between the actual
amount incurred for medical care by the individual or family
and the amount which should have been incurred in order to
establish eligibility for medical assistance.
(iv) In determining the amount of erroneous excess payments,
there shall not be included any error resulting from a failure
of an individual to cooperate or give correct information with
respect to third-party liability as required under section
1912(a)(1)(C) or 402(a)(26)(C) or with respect to payments made
in violation of section 1906.
(v) In determining the amount of erroneous excess payments,
there shall not be included any erroneous payments made for
ambulatory prenatal care provided during a presumptive
eligibility period (as defined in section 1920(b)(1)), for
items and services described in subsection (a) of section 1920A
provided to a child during a presumptive eligibility period
under such section, for medical assistance provided to an
individual described in subsection (a) of section 1920B during
a presumptive eligibility period under such section, or for
medical assistance provided to an individual during a
presumptive eligibility period resulting from a determination
of presumptive eligibility made by a hospital that elects under
section 1902(a)(47)(B) to be a qualified entity for such
purpose.
(E) For purposes of subparagraph (D), there shall be
excluded, in determining both erroneous excess payments for
medical assistance and total expenditures for medical
assistance--
(i) payments with respect to any individual whose
eligibility therefor was determined exclusively by the
Secretary under an agreement pursuant to section 1634
and such other classes of individuals as the Secretary
may by regulation prescribe whose eligibility was
determined in part under such an agreement; and
(ii) payments made as the result of a technical
error.
(2) The State agency administering the plan approved under
this title shall, at such times and in such form as the
Secretary may specify, provide information on the rates of
erroneous excess payments made (or expected, with respect to
future periods specified by the Secretary) in connection with
its administration of such plan, together with any other data
he requests that are reasonably necessary for him to carry out
the provisions of this subsection.
(3)(A) If a State fails to cooperate with the Secretary in
providing information necessary to carry out this subsection,
the Secretary, directly or through contractual or such other
arrangements as he may find appropriate, shall establish the
error rates for that State on the basis of the best data
reasonably available to him and in accordance with such
techniques for sampling and estimating as he finds appropriate.
(B) In any case in which it is necessary for the Secretary to
exercise his authority under subparagraph (A) to determine a
State's error rates for a fiscal year, the amount that would
otherwise be payable to such State under this title for
quarters in such year shall be reduced by the costs incurred by
the Secretary in making (directly or otherwise) such
determination.
(4) This subsection shall not apply with respect [to Puerto
Rico, Guam] to Guam, the Virgin Islands, the Northern Mariana
Islands, [or American Samoa.] or American Samoa, or, for fiscal
years before fiscal year 2023, to Puerto Rico.
(v)(1) Notwithstanding the preceding provisions of this
section, except as provided in paragraphs (2) and (4), no
payment may be made to a State under this section for medical
assistance furnished to an alien who is not lawfully admitted
for permanent residence or otherwise permanently residing in
the United States under color of law.
(2) Payment shall be made under this section for care and
services that are furnished to an alien described in paragraph
(1) only if--
(A) such care and services are necessary for the
treatment of an emergency medical condition of the
alien,
(B) such alien otherwise meets the eligibility
requirements for medical assistance under the State
plan approved under this title (other than the
requirement of the receipt of aid or assistance under
title IV, supplemental security income benefits under
title XVI, or a State supplementary payment), and
(C) such care and services are not related to an
organ transplant procedure.
(3) For purposes of this subsection, the term ``emergency
medical condition'' means a medical condition (including
emergency labor and delivery) manifesting itself by acute
symptoms of sufficient severity (including severe pain) such
that the absence of immediate medical attention could
reasonably be expected to result in--
(A) placing the patient's health in serious jeopardy,
(B) serious impairment to bodily functions, or
(C) serious dysfunction of any bodily organ or part.
(4)(A) A State may elect (in a plan amendment under this
title) to provide medical assistance under this title,
notwithstanding sections 401(a), 402(b), 403, and 421 of the
Personal Responsibility and Work Opportunity Reconciliation Act
of 1996, to children and pregnant women who are lawfully
residing in the United States (including battered individuals
described in section 431(c) of such Act) and who are otherwise
eligible for such assistance, within either or both of the
following eligibility categories:
(i) Pregnant women.--Women during pregnancy (and
during the 60-day period beginning on the last day of
the pregnancy).
(ii) Children.--Individuals under 21 years of age,
including optional targeted low-income children
described in section 1905(u)(2)(B).
(B) In the case of a State that has elected to provide
medical assistance to a category of aliens under subparagraph
(A), no debt shall accrue under an affidavit of support against
any sponsor of such an alien on the basis of provision of
assistance to such category and the cost of such assistance
shall not be considered as an unreimbursed cost.
(C) As part of the State's ongoing eligibility
redetermination requirements and procedures for an individual
provided medical assistance as a result of an election by the
State under subparagraph (A), a State shall verify that the
individual continues to lawfully reside in the United States
using the documentation presented to the State by the
individual on initial enrollment. If the State cannot
successfully verify that the individual is lawfully residing in
the United States in this manner, it shall require that the
individual provide the State with further documentation or
other evidence to verify that the individual is lawfully
residing in the United States.
(w)(1)(A) Notwithstanding the previous provisions of this
section, for purposes of determining the amount to be paid to a
State (as defined in paragraph (7)(D)) under subsection (a)(1)
for quarters in any fiscal year, the total amount expended
during such fiscal year as medical assistance under the State
plan (as determined without regard to this subsection) shall be
reduced by the sum of any revenues received by the State (or by
a unit of local government in the State) during the fiscal
year--
(i) from provider-related donations (as defined in
paragraph (2)(A)), other than--
(I) bona fide provider-related donations (as
defined in paragraph (2)(B)), and
(II) donations described in paragraph (2)(C);
(ii) from health care related taxes (as defined in
paragraph (3)(A)), other than broad-based health care
related taxes (as defined in paragraph (3)(B));
(iii) from a broad-based health care related tax, if
there is in effect a hold harmless provision (described
in paragraph (4)) with respect to the tax; or
(iv) only with respect to State fiscal years (or
portions thereof) occurring on or after January 1,
1992, and before October 1, 1995, from broad-based
health care related taxes to the extent the amount of
such taxes collected exceeds the limit established
under paragraph (5).
(B) Notwithstanding the previous provisions of this section,
for purposes of determining the amount to be paid to a State
under subsection (a)(7) for all quarters in a Federal fiscal
year (beginning with fiscal year 1993), the total amount
expended during the fiscal year for administrative expenditures
under the State plan (as determined without regard to this
subsection) shall be reduced by the sum of any revenues
received by the State (or by a unit of local government in the
State) during such quarters from donations described in
paragraph (2)(C), to the extent the amount of such donations
exceeds 10 percent of the amounts expended under the State plan
under this title during the fiscal year for purposes described
in paragraphs (2), (3), (4), (6), and (7) of subsection (a).
(C)(i) Except as otherwise provided in clause (ii),
subparagraph (A)(i) shall apply to donations received on or
after January 1, 1992.
(ii) Subject to the limits described in clause (iii) and
subparagraph (E), subparagraph (A)(i) shall not apply to
donations received before the effective date specified in
subparagraph (F) if such donations are received under programs
in effect or as described in State plan amendments or related
documents submitted to the Secretary by September 30, 1991, and
applicable to State fiscal year 1992, as demonstrated by State
plan amendments, written agreements, State budget
documentation, or other documentary evidence in existence on
that date.
(iii) In applying clause (ii) in the case of donations
received in State fiscal year 1993, the maximum amount of such
donations to which such clause may be applied may not exceed
the total amount of such donations received in the
corresponding period in State fiscal year 1992 (or not later
than 5 days after the last day of the corresponding period).
(D)(i) Except as otherwise provided in clause (ii),
subparagraphs (A)(ii) and (A)(iii) shall apply to taxes
received on or after January 1, 1992.
(ii) Subparagraphs (A)(ii) and (A)(iii) shall not apply to
impermissible taxes (as defined in clause (iii)) received
before the effective date specified in subparagraph (F) to the
extent the taxes (including the tax rate or base) were in
effect, or the legislation or regulations imposing such taxes
were enacted or adopted, as of November 22, 1991.
(iii) In this subparagraph and subparagraph (E), the term
``impermissible tax'' means a health care related tax for which
a reduction may be made under clause (ii) or (iii) of
subparagraph (A).
(E)(i) In no case may the total amount of donations and taxes
permitted under the exception provided in subparagraphs (C)(ii)
and (D)(ii) for the portion of State fiscal year 1992 occurring
during calendar year 1992 exceed the limit under paragraph (5)
minus the total amount of broad-based health care related taxes
received in the portion of that fiscal year.
(ii) In no case may the total amount of donations and taxes
permitted under the exception provided in subparagraphs (C)(ii)
and (D)(ii) for State fiscal year 1993 exceed the limit under
paragraph (5) minus the total amount of broad-based health care
related taxes received in that fiscal year.
(F) In this paragraph in the case of a State--
(i) except as provided in clause (iii), with a State
fiscal year beginning on or before July 1, the
effective date is October 1, 1992,
(ii) except as provided in clause (iii), with a State
fiscal year that begins after July 1, the effective
date is January 1, 1993, or
(iii) with a State legislature which is not scheduled
to have a regular legislative session in 1992, with a
State legislature which is not scheduled to have a
regular legislative session in 1993, or with a
provider-specific tax enacted on November 4, 1991, the
effective date is July 1, 1993.
(2)(A) In this subsection (except as provided in paragraph
(6)), the term ``provider-related donation'' means any donation
or other voluntary payment (whether in cash or in kind) made
(directly or indirectly) to a State or unit of local government
by--
(i) a health care provider (as defined in paragraph
(7)(B)),
(ii) an entity related to a health care provider (as
defined in paragraph (7)(C)), or
(iii) an entity providing goods or services under the
State plan for which payment is made to the State under
paragraph (2), (3), (4), (6), or (7) of subsection (a).
(B) For purposes of paragraph (1)(A)(i)(I), the term ``bona
fide provider-related donation'' means a provider-related
donation that has no direct or indirect relationship (as
determined by the Secretary) to payments made under this title
to that provider, to providers furnishing the same class of
items and services as that provider, or to any related entity,
as established by the State to the satisfaction of the
Secretary. The Secretary may by regulation specify types of
provider-related donations described in the previous sentence
that will be considered to be bona fide provider-related
donations.
(C) For purposes of paragraph (1)(A)(i)(II), donations
described in this subparagraph are funds expended by a
hospital, clinic, or similar entity for the direct cost
(including costs of training and of preparing and distributing
outreach materials) of State or local agency personnel who are
stationed at the hospital, clinic, or entity to determine the
eligibility of individuals for medical assistance under this
title and to provide outreach services to eligible or
potentially eligible individuals.
(3)(A) In this subsection (except as provided in paragraph
(6)), the term ``health care related tax'' means a tax (as
defined in paragraph (7)(F)) that--
(i) is related to health care items or services, or
to the provision of, the authority to provide, or
payment for, such items or services, or
(ii) is not limited to such items or services but
provides for treatment of individuals or entities that
are providing or paying for such items or services that
is different from the treatment provided to other
individuals or entities.
In applying clause (i), a tax is considered to relate to health
care items or services if at least 85 percent of the burden of
such tax falls on health care providers.
(B) In this subsection, the term ``broad-based health care
related tax'' means a health care related tax which is imposed
with respect to a class of health care items or services (as
described in paragraph (7)(A)) or with respect to providers of
such items or services and which, except as provided in
subparagraphs (D), (E), and (F)--
(i) is imposed at least with respect to all items or
services in the class furnished by all non-Federal,
nonpublic providers in the State (or, in the case of a
tax imposed by a unit of local government, the area
over which the unit has jurisdiction) or is imposed
with respect to all non-Federal, nonpublic providers in
the class; and
(ii) is imposed uniformly (in accordance with
subparagraph (C)).
(C)(i) Subject to clause (ii), for purposes of subparagraph
(B)(ii), a tax is considered to be imposed uniformly if--
(I) in the case of a tax consisting of a licensing
fee or similar tax on a class of health care items or
services (or providers of such items or services), the
amount of the tax imposed is the same for every
provider providing items or services within the class;
(II) in the case of a tax consisting of a licensing
fee or similar tax imposed on a class of health care
items or services (or providers of such services) on
the basis of the number of beds (licensed or otherwise)
of the provider, the amount of the tax is the same for
each bed of each provider of such items or services in
the class;
(III) in the case of a tax based on revenues or
receipts with respect to a class of items or services
(or providers of items or services) the tax is imposed
at a uniform rate for all items and services (or
providers of such items of services) in the class on
all the gross revenues or receipts, or net operating
revenues, relating to the provision of all such items
or services (or all such providers) in the State (or,
in the case of a tax imposed by a unit of local
government within the State, in the area over which the
unit has jurisdiction); or
(IV) in the case of any other tax, the State
establishes to the satisfaction of the Secretary that
the tax is imposed uniformly.
(ii) Subject to subparagraphs (D) and (E), a tax imposed with
respect to a class of health care items and services is not
considered to be imposed uniformly if the tax provides for any
credits, exclusions, or deductions which have as their purpose
or effect the return to providers of all or a portion of the
tax paid in a manner that is inconsistent with subclauses (I)
and (II) of subparagraph (E)(ii) or provides for a hold
harmless provision described in paragraph (4).
(D) A tax imposed with respect to a class of health care
items and services is considered to be imposed uniformly--
(i) notwithstanding that the tax is not imposed with
respect to items or services (or the providers thereof)
for which payment is made under a State plan under this
title or title XVIII, or
(ii) in the case of a tax described in subparagraph
(C)(i)(III), notwithstanding that the tax provides for
exclusion (in whole or in part) of revenues or receipts
from a State plan under this title or title XVIII.
(E)(i) A State may submit an application to the Secretary
requesting that the Secretary treat a tax as a broad-based
health care related tax, notwithstanding that the tax does not
apply to all health care items or services in class (or all
providers of such items and services), provides for a credit,
deduction, or exclusion, is not applied uniformly, or otherwise
does not meet the requirements of subparagraph (B) or (C).
Permissible waivers may include exemptions for rural or sole-
community providers.
(ii) The Secretary shall approve such an application if the
State establishes to the satisfaction of the Secretary that--
(I) the net impact of the tax and associated
expenditures under this title as proposed by the State
is generally redistributive in nature, and
(II) the amount of the tax is not directly correlated
to payments under this title for items or services with
respect to which the tax is imposed.
The Secretary shall by regulation specify types of credits,
exclusions, and deductions that will be considered to meet the
requirements of this subparagraph.
(F) In no case shall a tax not qualify as a broad-based
health care related tax under this paragraph because it does
not apply to a hospital that is described in section 501(c)(3)
of the Internal Revenue Code of 1986 and exempt from taxation
under section 501(a) of such Code and that does not accept
payment under the State plan under this title or under title
XVIII.
(4) For purposes of paragraph (1)(A)(iii), there is in effect
a hold harmless provision with respect to a broad-based health
care related tax imposed with respect to a class of items or
services if the Secretary determines that any of the following
applies:
(A) The State or other unit of government imposing
the tax provides (directly or indirectly) for a payment
(other than under this title) to taxpayers and the
amount of such payment is positively correlated either
to the amount of such tax or to the difference between
the amount of the tax and the amount of payment under
the State plan.
(B) All or any portion of the payment made under this
title to the taxpayer varies based only upon the amount
of the total tax paid.
(C)(i) The State or other unit of government imposing
the tax provides (directly or indirectly) for any
payment, offset, or waiver that guarantees to hold
taxpayers harmless for any portion of the costs of the
tax.
(ii) For purposes of clause (i), a determination of
the existence of an indirect guarantee shall be made
under paragraph (3)(i) of section 433.68(f) of title
42, Code of Federal Regulations, as in effect on
November 1, 2006, except that for portions of fiscal
years beginning on or after January 1, 2008, and before
October 1, 2011, ``5.5 percent'' shall be substituted
for ``6 percent'' each place it appears.
The provisions of this paragraph shall not prevent use of the
tax to reimburse health care providers in a class for
expenditures under this title nor preclude States from relying
on such reimbursement to justify or explain the tax in the
legislative process.
(5)(A) For purposes of this subsection, the limit under this
subparagraph with respect to a State is an amount equal to 25
percent (or, if greater, the State base percentage, as defined
in subparagraph (B)) of the non-Federal share of the total
amount expended under the State plan during a State fiscal year
(or portion thereof), as it would be determined pursuant to
paragraph (1)(A) without regard to paragraph (1)(A)(iv).
(B)(i) In subparagraph (A), the term ``State base
percentage'' means, with respect to a State, an amount
(expressed as a percentage) equal to--
(I) the total of the amount of health care related
taxes (whether or not broad-based) and the amount of
provider-related donations (whether or not bona fide)
projected to be collected (in accordance with clause
(ii)) during State fiscal year 1992, divided by
(II) the non-Federal share of the total amount
estimated to be expended under the State plan during
such State fiscal year.
(ii) For purposes of clause (i)(I), in the case of a tax that
is not in effect throughout State fiscal year 1992 or the rate
(or base) of which is increased during such fiscal year, the
Secretary shall project the amount to be collected during such
fiscal year as if the tax (or increase) were in effect during
the entire State fiscal year.
(C)(i) The total amount of health care related taxes under
subparagraph (B)(i)(I) shall be determined by the Secretary
based on only those taxes (including the tax rate or base)
which were in effect, or for which legislation or regulations
imposing such taxes were enacted or adopted, as of November 22,
1991.
(ii) The amount of provider-related donations under
subparagraph (B)(i)(I) shall be determined by the Secretary
based on programs in effect on September 30, 1991, and
applicable to State fiscal year 1992, as demonstrated by State
plan amendments, written agreements, State budget
documentation, or other documentary evidence in existence on
that date.
(iii) The amount of expenditures described in subparagraph
(B)(i)(II) shall be determined by the Secretary based on the
best data available as of the date of the enactment of this
subsection.
(6)(A) Notwithstanding the provisions of this subsection, the
Secretary may not restrict States' use of funds where such
funds are derived from State or local taxes (or funds
appropriated to State university teaching hospitals)
transferred from or certified by units of government within a
State as the non-Federal share of expenditures under this
title, regardless of whether the unit of government is also a
health care provider, except as provided in section 1902(a)(2),
unless the transferred funds are derived by the unit of
government from donations or taxes that would not otherwise be
recognized as the non-Federal share under this section.
(B) For purposes of this subsection, funds the use of which
the Secretary may not restrict under subparagraph (A) shall not
be considered to be a provider-related donation or a health
care related tax.
(7) For purposes of this subsection:
(A) Each of the following shall be considered a
separate class of health care items and services:
(i) Inpatient hospital services.
(ii) Outpatient hospital services.
(iii) Nursing facility services (other than
services of intermediate care facilities for
the mentally retarded).
(iv) Services of intermediate care facilities
for the mentally retarded.
(v) Physicians' services.
(vi) Home health care services.
(vii) Outpatient prescription drugs.
(viii) Services of managed care organizations
(including health maintenance organizations,
preferred provider organizations, and such
other similar organizations as the Secretary
may specify by regulation).
(ix) Such other classification of health care
items and services consistent with this
subparagraph as the Secretary may establish by
regulation.
(B) The term ``health care provider'' means an
individual or person that receives payments for the
provision of health care items or services.
(C) An entity is considered to be ``related'' to a
health care provider if the entity--
(i) is an organization, association,
corporation or partnership formed by or on
behalf of health care providers;
(ii) is a person with an ownership or control
interest (as defined in section 1124(a)(3)) in
the provider;
(iii) is the employee, spouse, parent, child,
or sibling of the provider (or of a person
described in clause (ii)); or
(iv) has a similar, close relationship (as
defined in regulations) to the provider.
(D) The term ``State'' means only the 50 States and
the District of Columbia but does not include any State
whose entire program under this title is operated under
a waiver granted under section 1115.
(E) The ``State fiscal year'' means, with respect to
a specified year, a State fiscal year ending in that
specified year.
(F) The term ``tax'' includes any licensing fee,
assessment, or other mandatory payment, but does not
include payment of a criminal or civil fine or penalty
(other than a fine or penalty imposed in lieu of or
instead of a fee, assessment, or other mandatory
payment).
(G) The term ``unit of local government'' means, with
respect to a State, a city, county, special purpose
district, or other governmental unit in the State.
(x)(1) For purposes of section 1902(a)(46)(B)(i), the
requirement of this subsection is, with respect to an
individual declaring to be a citizen or national of the United
States, that, subject to paragraph (2), there is presented
satisfactory documentary evidence of citizenship or nationality
(as defined in paragraph (3)) of the individual.
(2) The requirement of paragraph (1) shall not apply to an
individual declaring to be a citizen or national of the United
States who is eligible for medical assistance under this
title--
(A) and is entitled to or enrolled for benefits under
any part of title XVIII;
(B) and is receiving--
(i) disability insurance benefits under
section 223 or monthly insurance benefits under
section 202 based on such individual's
disability (as defined in section 223(d)); or
(ii) supplemental security income benefits
under title XVI;
(C) and with respect to whom--
(i) child welfare services are made available
under part B of title IV on the basis of being
a child in foster care; or
(ii) adoption or foster care assistance is
made available under part E of title IV;
(D) pursuant to the application of section 1902(e)(4)
(and, in the case of an individual who is eligible for
medical assistance on such basis, the individual shall
be deemed to have provided satisfactory documentary
evidence of citizenship or nationality and shall not be
required to provide further documentary evidence on any
date that occurs during or after the period in which
the individual is eligible for medical assistance on
such basis); or
(E) on such basis as the Secretary may specify under
which satisfactory documentary evidence of citizenship
or nationality has been previously presented.
(3)(A) For purposes of this subsection, the term
``satisfactory documentary evidence of citizenship or
nationality'' means--
(i) any document described in subparagraph (B); or
(ii) a document described in subparagraph (C) and a
document described in subparagraph (D).
(B) The following are documents described in this
subparagraph:
(i) A United States passport.
(ii) Form N-550 or N-570 (Certificate of
Naturalization).
(iii) Form N-560 or N-561 (Certificate of United
States Citizenship).
(iv) A valid State-issued driver's license or other
identity document described in section 274A(b)(1)(D) of
the Immigration and Nationality Act, but only if the
State issuing the license or such document requires
proof of United States citizenship before issuance of
such license or document or obtains a social security
number from the applicant and verifies before
certification that such number is valid and assigned to
the applicant who is a citizen.
(v)(I) Except as provided in subclause (II), a
document issued by a federally recognized Indian tribe
evidencing membership or enrollment in, or affiliation
with, such tribe (such as a tribal enrollment card or
certificate of degree of Indian blood).
(II) With respect to those federally recognized
Indian tribes located within States having an
international border whose membership includes
individuals who are not citizens of the United States,
the Secretary shall, after consulting with such tribes,
issue regulations authorizing the presentation of such
other forms of documentation (including tribal
documentation, if appropriate) that the Secretary
determines to be satisfactory documentary evidence of
citizenship or nationality for purposes of satisfying
the requirement of this subsection.
(vi) Such other document as the Secretary may
specify, by regulation, that provides proof of United
States citizenship or nationality and that provides a
reliable means of documentation of personal identity.
(C) The following are documents described in this
subparagraph:
(i) A certificate of birth in the United States.
(ii) Form FS-545 or Form DS-1350 (Certification of
Birth Abroad).
(iii) Form I-197 (United States Citizen
Identification Card).
(iv) Form FS-240 (Report of Birth Abroad of a Citizen
of the United States).
(v) Such other document (not described in
subparagraph (B)(iv)) as the Secretary may specify that
provides proof of United States citizenship or
nationality.
(D) The following are documents described in this
subparagraph:
(i) Any identity document described in section
274A(b)(1)(D) of the Immigration and Nationality Act.
(ii) Any other documentation of personal identity of
such other type as the Secretary finds, by regulation,
provides a reliable means of identification.
(E) A reference in this paragraph to a form includes a
reference to any successor form.
(4) In the case of an individual declaring to be a citizen or
national of the United States with respect to whom a State
requires the presentation of satisfactory documentary evidence
of citizenship or nationality under section 1902(a)(46)(B)(i),
the individual shall be provided at least the reasonable
opportunity to present satisfactory documentary evidence of
citizenship or nationality under this subsection as is provided
under clauses (i) and (ii) of section 1137(d)(4)(A) to an
individual for the submittal to the State of evidence
indicating a satisfactory immigration status.
(5) Nothing in subparagraph (A) or (B) of section
1902(a)(46), the preceding paragraphs of this subsection, or
the Deficit Reduction Act of 2005, including section 6036 of
such Act, shall be construed as changing the requirement of
section 1902(e)(4) that a child born in the United States to an
alien mother for whom medical assistance for the delivery of
such child is available as treatment of an emergency medical
condition pursuant to subsection (v) shall be deemed eligible
for medical assistance during the first year of such child's
life.
(y) Payments for Establishment of Alternate Non-Emergency
Services Providers.--
(1) Payments.--In addition to the payments otherwise
provided under subsection (a), subject to paragraph
(2), the Secretary shall provide for payments to States
under such subsection for the establishment of
alternate non-emergency service providers (as defined
in section 1916A(e)(5)(B)), or networks of such
providers.
(2) Limitation.--The total amount of payments under
this subsection shall not exceed $50,000,000 during the
4-year period beginning with 2006. This subsection
constitutes budget authority in advance of
appropriations Acts and represents the obligation of
the Secretary to provide for the payment of amounts
provided under this subsection.
(3) Preference.--In providing for payments to States
under this subsection, the Secretary shall provide
preference to States that establish, or provide for,
alternate non-emergency services providers or networks
of such providers that--
(A) serve rural or underserved areas where
beneficiaries under this title may not have
regular access to providers of primary care
services; or
(B) are in partnership with local community
hospitals.
(4) Form and manner of payment.--Payment to a State
under this subsection shall be made only upon the
filing of such application in such form and in such
manner as the Secretary shall specify. Payment to a
State under this subsection shall be made in the same
manner as other payments under section 1903(a).
(z) Medicaid Transformation Payments.--
(1) In general.--In addition to the payments provided
under subsection (a), subject to paragraph (4), the
Secretary shall provide for payments to States for the
adoption of innovative methods to improve the
effectiveness and efficiency in providing medical
assistance under this title.
(2) Permissible uses of funds.--The following are
examples of innovative methods for which funds provided
under this subsection may be used:
(A) Methods for reducing patient error rates
through the implementation and use of
electronic health records, electronic clinical
decision support tools, or e-prescribing
programs.
(B) Methods for improving rates of collection
from estates of amounts owed under this title.
(C) Methods for reducing waste, fraud, and
abuse under the program under this title, such
as reducing improper payment rates as measured
by annual payment error rate measurement (PERM)
project rates.
(D) Implementation of a medication risk
management program as part of a drug use review
program under section 1927(g).
(E) Methods in reducing, in clinically
appropriate ways, expenditures under this title
for covered outpatient drugs, particularly in
the categories of greatest drug utilization, by
increasing the utilization of generic drugs
through the use of education programs and other
incentives to promote greater use of generic
drugs.
(F) Methods for improving access to primary
and specialty physician care for the uninsured
using integrated university-based hospital and
clinic systems.
(3) Application; terms and conditions.--
(A) In general.--No payments shall be made to
a State under this subsection unless the State
applies to the Secretary for such payments in a
form, manner, and time specified by the
Secretary.
(B) Terms and conditions.--Such payments are
made under such terms and conditions consistent
with this subsection as the Secretary
prescribes.
(C) Annual report.--Payment to a State under
this subsection is conditioned on the State
submitting to the Secretary an annual report on
the programs supported by such payment. Such
report shall include information on--
(i) the specific uses of such
payment;
(ii) an assessment of quality
improvements and clinical outcomes
under such programs; and
(iii) estimates of cost savings
resulting from such programs.
(4) Funding.--
(A) Limitation on funds.--The total amount of
payments under this subsection shall be equal
to, and shall not exceed--
(i) $75,000,000 for fiscal year 2007;
and
(ii) $75,000,000 for fiscal year
2008.
This subsection constitutes budget authority in
advance of appropriations Acts and represents
the obligation of the Secretary to provide for
the payment of amounts provided under this
subsection.
(B) Allocation of funds.--The Secretary shall
specify a method for allocating the funds made
available under this subsection among States.
Such method shall provide preference for States
that design programs that target health
providers that treat significant numbers of
Medicaid beneficiaries. Such method shall
provide that not less than 25 percent of such
funds shall be allocated among States the
population of which (as determined according to
data collected by the United States Census
Bureau) as of July 1, 2004, was more than 105
percent of the population of the respective
State (as so determined) as of April 1, 2000.
(C) Form and manner of payment.--Payment to a
State under this subsection shall be made in
the same manner as other payments under section
1903(a). There is no requirement for State
matching funds to receive payments under this
subsection.
(5) Medication risk management program.--
(A) In general.--For purposes of this
subsection, the term ``medication risk
management program'' means a program for
targeted beneficiaries that ensures that
covered outpatient drugs are appropriately used
to optimize therapeutic outcomes through
improved medication use and to reduce the risk
of adverse events.
(B) Elements.--Such program may include the
following elements:
(i) The use of established principles
and standards for drug utilization
review and best practices to analyze
prescription drug claims of targeted
beneficiaries and identify outlier
physicians.
(ii) On an ongoing basis provide
outlier physicians--
(I) a comprehensive pharmacy
claims history for each
targeted beneficiary under
their care;
(II) information regarding
the frequency and cost of
relapses and hospitalizations
of targeted beneficiaries under
the physician's care; and
(III) applicable best
practice guidelines and
empirical references.
(iii) Monitor outlier physician's
prescribing, such as failure to refill,
dosage strengths, and provide
incentives and information to encourage
the adoption of best clinical
practices.
(C) Targeted beneficiaries.--For purposes of
this paragraph, the term ``targeted
beneficiaries'' means Medicaid eligible
beneficiaries who are identified as having high
prescription drug costs and medical costs, such
as individuals with behavioral disorders or
multiple chronic diseases who are taking
multiple medications.
(aa) Demonstration Project To Increase Substance Use Provider
Capacity.--
(1) In general.--Not later than the date that is 180
days after the date of the enactment of this
subsection, the Secretary shall, in consultation, as
appropriate, with the Director of the Agency for
Healthcare Research and Quality and the Assistant
Secretary for Mental Health and Substance Use, conduct
a 54-month demonstration project for the purpose
described in paragraph (2) under which the Secretary
shall--
(A) for the first 18-month period of such
project, award planning grants described in
paragraph (3); and
(B) for the remaining 36-month period of such
project, provide to each State selected under
paragraph (4) payments in accordance with
paragraph (5).
(2) Purpose.--The purpose described in this paragraph
is for each State selected under paragraph (4) to
increase the treatment capacity of providers
participating under the State plan (or a waiver of such
plan) to provide substance use disorder treatment or
recovery services under such plan (or waiver) through
the following activities:
(A) For the purpose described in paragraph
(3)(C)(i), activities that support an ongoing
assessment of the behavioral health treatment
needs of the State, taking into account the
matters described in subclauses (I) through
(IV) of such paragraph.
(B) Activities that, taking into account the
results of the assessment described in
subparagraph (A), support the recruitment,
training, and provision of technical assistance
for providers participating under the State
plan (or a waiver of such plan) that offer
substance use disorder treatment or recovery
services.
(C) Improved reimbursement for and expansion
of, through the provision of education,
training, and technical assistance, the number
or treatment capacity of providers
participating under the State plan (or waiver)
that--
(i) are authorized to dispense drugs
approved by the Food and Drug
Administration for individuals with a
substance use disorder who need
withdrawal management or maintenance
treatment for such disorder;
(ii) have in effect a registration or
waiver under section 303(g) of the
Controlled Substances Act for purposes
of dispensing narcotic drugs to
individuals for maintenance treatment
or detoxification treatment and are in
compliance with any regulation
promulgated by the Assistant Secretary
for Mental Health and Substance Use for
purposes of carrying out the
requirements of such section 303(g);
and
(iii) are qualified under applicable
State law to provide substance use
disorder treatment or recovery
services.
(D) Improved reimbursement for and expansion
of, through the provision of education,
training, and technical assistance, the number
or treatment capacity of providers
participating under the State plan (or waiver)
that have the qualifications to address the
treatment or recovery needs of--
(i) individuals enrolled under the
State plan (or a waiver of such plan)
who have neonatal abstinence syndrome,
in accordance with guidelines issued by
the American Academy of Pediatrics and
American College of Obstetricians and
Gynecologists relating to maternal care
and infant care with respect to
neonatal abstinence syndrome;
(ii) pregnant women, postpartum
women, and infants, particularly the
concurrent treatment, as appropriate,
and comprehensive case management of
pregnant women, post-partum women and
infants, enrolled under the State plan
(or a waiver of such plan);
(iii) adolescents and young adults
between the ages of 12 and 21 enrolled
under the State plan (or a waiver of
such plan); or
(iv) American Indian and Alaska
Native individuals enrolled under the
State plan (or a waiver of such plan).
(3) Planning grants.--
(A) In general.--The Secretary shall, with
respect to the first 18-month period of the
demonstration project conducted under paragraph
(1), award planning grants to at least 10
States selected in accordance with subparagraph
(B) for purposes of preparing an application
described in paragraph (4)(C) and carrying out
the activities described in subparagraph (C).
(B) Selection.--In selecting States for
purposes of this paragraph, the Secretary
shall--
(i) select States that have a State
plan (or waiver of the State plan)
approved under this title;
(ii) select States in a manner that
ensures geographic diversity; and
(iii) give preference to States with
a prevalence of substance use disorders
(in particular opioid use disorders)
that is comparable to or higher than
the national average prevalence, as
measured by aggregate per capita drug
overdoses, or any other measure that
the Secretary deems appropriate.
(C) Activities described.--Activities
described in this subparagraph are, with
respect to a State, each of the following:
(i) Activities that support the
development of an initial assessment of
the behavioral health treatment needs
of the State to determine the extent to
which providers are needed (including
the types of such providers and
geographic area of need) to improve the
network of providers that treat
substance use disorders under the State
plan (or waiver), including the
following:
(I) An estimate of the number
of individuals enrolled under
the State plan (or a waiver of
such plan) who have a substance
use disorder.
(II) Information on the
capacity of providers to
provide substance use disorder
treatment or recovery services
to individuals enrolled under
the State plan (or waiver),
including information on
providers who provide such
services and their
participation under the State
plan (or waiver).
(III) Information on the gap
in substance use disorder
treatment or recovery services
under the State plan (or
waiver) based on the
information described in
subclauses (I) and (II).
(IV) Projections regarding
the extent to which the State
participating under the
demonstration project would
increase the number of
providers offering substance
use disorder treatment or
recovery services under the
State plan (or waiver) during
the period of the demonstration
project.
(ii) Activities that, taking into
account the results of the assessment
described in clause (i), support the
development of State infrastructure to,
with respect to the provision of
substance use disorder treatment or
recovery services under the State plan
(or a waiver of such plan), recruit
prospective providers and provide
training and technical assistance to
such providers.
(D) Funding.--For purposes of subparagraph
(A), there is appropriated, out of any funds in
the Treasury not otherwise appropriated,
$50,000,000, to remain available until
expended.
(4) Post-planning states.--
(A) In general.--The Secretary shall, with
respect to the remaining 36-month period of the
demonstration project conducted under paragraph
(1), select not more than 5 States in
accordance with subparagraph (B) for purposes
of carrying out the activities described in
paragraph (2) and receiving payments in
accordance with paragraph (5).
(B) Selection.--In selecting States for
purposes of this paragraph, the Secretary
shall--
(i) select States that received a
planning grant under paragraph (3);
(ii) select States that submit to the
Secretary an application in accordance
with the requirements in subparagraph
(C), taking into consideration the
quality of each such application;
(iii) select States in a manner that
ensures geographic diversity; and
(iv) give preference to States with a
prevalence of substance use disorders
(in particular opioid use disorders)
that is comparable to or higher than
the national average prevalence, as
measured by aggregate per capita drug
overdoses, or any other measure that
the Secretary deems appropriate.
(C) Applications.--
(i) In general.--A State seeking to
be selected for purposes of this
paragraph shall submit to the
Secretary, at such time and in such
form and manner as the Secretary
requires, an application that includes
such information, provisions, and
assurances, as the Secretary may
require, in addition to the following:
(I) A proposed process for
carrying out the ongoing
assessment described in
paragraph (2)(A), taking into
account the results of the
initial assessment described in
paragraph (3)(C)(i).
(II) A review of
reimbursement methodologies and
other policies related to
substance use disorder
treatment or recovery services
under the State plan (or
waiver) that may create
barriers to increasing the
number of providers delivering
such services.
(III) The development of a
plan, taking into account
activities carried out under
paragraph (3)(C)(ii), that will
result in long-term and
sustainable provider networks
under the State plan (or
waiver) that will offer a
continuum of care for substance
use disorders. Such plan shall
include the following:
(aa) Specific
activities to increase
the number of providers
(including providers
that specialize in
providing substance use
disorder treatment or
recovery services,
hospitals, health care
systems, Federally
qualified health
centers, and, as
applicable, certified
community behavioral
health clinics) that
offer substance use
disorder treatment,
recovery, or support
services, including
short-term
detoxification
services, outpatient
substance use disorder
services, and evidence-
based peer recovery
services.
(bb) Strategies that
will incentivize
providers described in
subparagraphs (C) and
(D) of paragraph (2) to
obtain the necessary
training, education,
and support to deliver
substance use disorder
treatment or recovery
services in the State.
(cc) Milestones and
timeliness for
implementing activities
set forth in the plan.
(dd) Specific
measurable targets for
increasing the
substance use disorder
treatment and recovery
provider network under
the State plan (or a
waiver of such plan).
(IV) A proposed process for
reporting the information
required under paragraph
(6)(A), including information
to assess the effectiveness of
the efforts of the State to
expand the capacity of
providers to deliver substance
use disorder treatment or
recovery services during the
period of the demonstration
project under this subsection.
(V) The expected financial
impact of the demonstration
project under this subsection
on the State.
(VI) A description of all
funding sources available to
the State to provide substance
use disorder treatment or
recovery services in the State.
(VII) A preliminary plan for
how the State will sustain any
increase in the capacity of
providers to deliver substance
use disorder treatment or
recovery services resulting
from the demonstration project
under this subsection after the
termination of such
demonstration project.
(VIII) A description of how
the State will coordinate the
goals of the demonstration
project with any waiver granted
(or submitted by the State and
pending) pursuant to section
1115 for the delivery of
substance use services under
the State plan, as applicable.
(ii) Consultation.--In completing an
application under clause (i), a State
shall consult with relevant
stakeholders, including Medicaid
managed care plans, health care
providers, and Medicaid beneficiary
advocates, and include in such
application a description of such
consultation.
(5) Payment.--
(A) In general.--For each quarter occurring
during the period for which the demonstration
project is conducted (after the first 18 months
of such period), the Secretary shall pay under
this subsection, subject to subparagraph (C),
to each State selected under paragraph (4) an
amount equal to 80 percent of so much of the
qualified sums expended during such quarter.
(B) Qualified sums defined.--For purposes of
subparagraph (A), the term ``qualified sums''
means, with respect to a State and a quarter,
the amount equal to the amount (if any) by
which the sums expended by the State during
such quarter attributable to substance use
disorder treatment or recovery services
furnished by providers participating under the
State plan (or a waiver of such plan) exceeds
1/4 of such sums expended by the State during
fiscal year 2018 attributable to substance use
disorder treatment or recovery services.
(C) Non-duplication of payment.--In the case
that payment is made under subparagraph (A)
with respect to expenditures for substance use
disorder treatment or recovery services
furnished by providers participating under the
State plan (or a waiver of such plan), payment
may not also be made under subsection (a) with
respect to expenditures for the same services
so furnished.
(6) Reports.--
(A) State reports.--A State receiving
payments under paragraph (5) shall, for the
period of the demonstration project under this
subsection, submit to the Secretary a quarterly
report, with respect to expenditures for
substance use disorder treatment or recovery
services for which payment is made to the State
under this subsection, on the following:
(i) The specific activities with
respect to which payment under this
subsection was provided.
(ii) The number of providers that
delivered substance use disorder
treatment or recovery services in the
State under the demonstration project
compared to the estimated number of
providers that would have otherwise
delivered such services in the absence
of such demonstration project.
(iii) The number of individuals
enrolled under the State plan (or a
waiver of such plan) who received
substance use disorder treatment or
recovery services under the
demonstration project compared to the
estimated number of such individuals
who would have otherwise received such
services in the absence of such
demonstration project.
(iv) Other matters as determined by
the Secretary.
(B) CMS reports.--
(i) Initial report.--Not later than
October 1, 2020, the Administrator of
the Centers for Medicare & Medicaid
Services shall, in consultation with
the Director of the Agency for
Healthcare Research and Quality and the
Assistant Secretary for Mental Health
and Substance Use, submit to Congress
an initial report on--
(I) the States awarded
planning grants under paragraph
(3);
(II) the criteria used in
such selection; and
(III) the activities carried
out by such States under such
planning grants.
(ii) Interim report.--Not later than
October 1, 2022, the Administrator of
the Centers for Medicare & Medicaid
Services shall, in consultation with
the Director of the Agency for
Healthcare Research and Quality and the
Assistant Secretary for Mental Health
and Substance Use, submit to Congress
an interim report--
(I) on activities carried out
under the demonstration project
under this subsection;
(II) on the extent to which
States selected under paragraph
(4) have achieved the stated
goals submitted in their
applications under subparagraph
(C) of such paragraph;
(III) with a description of
the strengths and limitations
of such demonstration project;
and
(IV) with a plan for the
sustainability of such project.
(iii) Final report.--Not later than
October 1, 2024, the Administrator of
the Centers for Medicare & Medicaid
Services shall, in consultation with
the Director of the Agency for
Healthcare Research and Quality and the
Assistant Secretary for Mental Health
and Substance Use, submit to Congress a
final report--
(I) providing updates on the
matters reported in the interim
report under clause (ii);
(II) including a description
of any changes made with
respect to the demonstration
project under this subsection
after the submission of such
interim report; and
(III) evaluating such
demonstration project.
(C) AHRQ report.--Not later than 3 years
after the date of the enactment of this
subsection, the Director of the Agency for
Healthcare Research and Quality, in
consultation with the Administrator of the
Centers for Medicare & Medicaid Services, shall
submit to Congress a summary on the experiences
of States awarded planning grants under
paragraph (3) and States selected under
paragraph (4).
(7) Data sharing and best practices.--During the
period of the demonstration project under this
subsection, the Secretary shall, in collaboration with
States selected under paragraph (4), facilitate data
sharing and the development of best practices between
such States and States that were not so selected.
(8) CMS funding.--There is appropriated, out of any
funds in the Treasury not otherwise appropriated,
$5,000,000 to the Centers for Medicare & Medicaid
Services for purposes of implementing this subsection.
Such amount shall remain available until expended.
(bb) Public Availability of Hospital Upper Payment Limit
Demonstrations.--The Secretary shall make publicly available
upper payment limit demonstrations for hospital services that a
State submits with respect to a fiscal year of the State
(beginning with State fiscal year 2022) to the Administrator of
the Centers for Medicare & Medicaid Services.
* * * * * * *
DEFINITIONS
Sec. 1905. For purposes of this title--
(a) The term ``medical assistance'' means payment of part or
all of the cost of the following care and services or the care
and services themselves, or both (if provided in or after the
third month before the month in which the recipient makes
application for assistance or, in the case of medicare cost-
sharing with respect to a qualified medicare beneficiary
described in subsection (p)(1), if provided after the month in
which the individual becomes such a beneficiary) for
individuals, and, with respect to physicians' or dentists'
services, at the option of the State, to individuals (other
than individuals with respect to whom there is being paid, or
who are eligible, or would be eligible if they were not in a
medical institution, to have paid with respect to them a State
supplementary payment and are eligible for medical assistance
equal in amount, duration, and scope to the medical assistance
made available to individuals described in section
1902(a)(10)(A)) not receiving aid or assistance under any plan
of the State approved under title I, X, XIV, or XVI, or part A
of title IV, and with respect to whom supplemental security
income benefits are not being paid under title XVI, who are--
(i) under the age of 21, or, at the option of the
State, under the age of 20, 19, or 18 as the State may
choose,
(ii) relatives specified in section 406(b)(1) with
whom a child is living if such child is (or would, if
needy, be) a dependent child under part A of title IV,
(iii) 65 years of age or older,
(iv) blind, with respect to States eligible to
participate in the State plan program established under
title XVI,
(v) 18 years of age or older and permanently and
totally disabled, with respect to States eligible to
participate in the State plan program established under
title XVI,
(vi) persons essential (as described in the second
sentence of this subsection) to individuals receiving
aid or assistance under State plans approved under
title I, X, XIV, or XVI,
(vii) blind or disabled as defined in section 1614,
with respect to States not eligible to participate in
the State plan program established under title XVI,
(viii) pregnant women,
(ix) individuals provided extended benefits under
section 1925,
(x) individuals described in section 1902(u)(1),
(xi) individuals described in section 1902(z)(1),
(xii) employed individuals with a medically improved
disability (as defined in subsection (v)),
(xiii) individuals described in section 1902(aa),
(xiv) individuals described in section
1902(a)(10)(A)(i)(VIII) or 1902(a)(10)(A)(i)(IX),
(xv) individuals described in section
1902(a)(10)(A)(ii)(XX),
(xvi) individuals described in
section 1902(ii), or
(xvii) individuals who are eligible for home and
community-based services under needs-based criteria
established under paragraph (1)(A) of section 1915(i),
or who are eligible for home and community-based
services under paragraph (6) of such section, and who
will receive home and community-based services pursuant
to a State plan amendment under such subsection,
but whose income and resources are insufficient to meet all of
such cost--
(1) inpatient hospital services (other than services
in an institution for mental diseases);
(2)(A) outpatient hospital services, (B) consistent
with State law permitting such services, rural health
clinic services (as defined in subsection (l)(1)) and
any other ambulatory services which are offered by a
rural health clinic (as defined in subsection (l)(1))
and which are otherwise included in the plan, and (C)
Federally-qualified health center services (as defined
in subsection (l)(2)) and any other ambulatory services
offered by a Federally-qualified health center and
which are otherwise included in the plan;
(3) other laboratory and X-ray services;
(4)(A) nursing facility services (other than services
in an institution for mental diseases) for individuals
21 years of age or older; (B) early and periodic
screening, diagnostic, and treatment services (as
defined in subsection (r)) for individuals who are
eligible under the plan and are under the age of 21;
(C) family planning services and supplies furnished
(directly or under arrangements with others) to
individuals of child-bearing age (including minors who
can be considered to be sexually active) who are
eligible under the State plan and who desire such
services and supplies; and (D) counseling and
pharmacotherapy for cessation of tobacco use by
pregnant women (as defined in subsection (bb));
(5)(A) physicians' services furnished by a physician
(as defined in section 1861(r)(1)), whether furnished
in the office, the patient's home, a hospital, or a
nursing facility, or elsewhere, and (B) medical and
surgical services furnished by a dentist (described in
section 1861(r)(2)) to the extent such services may be
performed under State law either by a doctor of
medicine or by a doctor of dental surgery or dental
medicine and would be described in clause (A) if
furnished by a physician (as defined in section
1861(r)(1));
(6) medical care, or any other type of remedial care
recognized under State law, furnished by licensed
practitioners within the scope of their practice as
defined by State law;
(7) home health care services;
(8) private duty nursing services;
(9) clinic services furnished by or under the
direction of a physician, without regard to whether the
clinic itself is administered by a physician, including
such services furnished outside the clinic by clinic
personnel to an eligible individual who does not reside
in a permanent dwelling or does not have a fixed home
or mailing address;
(10) dental services;
(11) physical therapy and related services;
(12) prescribed drugs, dentures, and prosthetic
devices; and eyeglasses prescribed by a physician
skilled in diseases of the eye or by an optometrist,
whichever the individual may select;
(13) other diagnostic, screening, preventive, and
rehabilitative services, including--
(A) any clinical preventive services that are
assigned a grade of A or B by the United States
Preventive Services Task Force;
(B) with respect to an adult individual,
approved vaccines recommended by the Advisory
Committee on Immunization Practices (an
advisory committee established by the
Secretary, acting through the Director of the
Centers for Disease Control and Prevention) and
their administration; and
(C) any medical or remedial services
(provided in a facility, a home, or other
setting) recommended by a physician or other
licensed practitioner of the healing arts
within the scope of their practice under State
law, for the maximum reduction of physical or
mental disability and restoration of an
individual to the best possible functional
level;
(14) inpatient hospital services and nursing facility
services for individuals 65 years of age or over in an
institution for mental diseases;
(15) services in an intermediate care facility for
the mentally retarded (other than in an institution for
mental diseases) for individuals who are determined, in
accordance with section 1902(a)(31), to be in need of
such care;
(16) (A) effective January 1, 1973, inpatient
psychiatric hospital services for individuals under age
21, as defined in subsection (h), and, (B) for
individuals receiving services described in
subparagraph (A), early and periodic screening,
diagnostic, and treatment services (as defined in
subsection (r)), whether or not such screening,
diagnostic, and treatment services are furnished by the
provider of the services described in such
subparagraph;
(17) services furnished by a nurse-midwife (as
defined in section 1861(gg)) which the nurse-midwife is
legally authorized to perform under State law (or the
State regulatory mechanism provided by State law),
whether or not the nurse-midwife is under the
supervision of, or associated with, a physician or
other health care provider, and without regard to
whether or not the services are performed in the area
of management of the care of mothers and babies
throughout the maternity cycle;
(18) hospice care (as defined in subsection (o));
(19) case management services (as defined in section
1915(g)(2)) and TB-related services described in
section 1902(z)(2)(F);
(20) respiratory care services (as defined in section
1902(e)(9)(C));
(21) services furnished by a certified pediatric
nurse practitioner or certified family nurse
practitioner (as defined by the Secretary) which the
certified pediatric nurse practitioner or certified
family nurse practitioner is legally authorized to
perform under State law (or the State regulatory
mechanism provided by State law), whether or not the
certified pediatric nurse practitioner or certified
family nurse practitioner is under the supervision of,
or associated with, a physician or other health care
provider;
(22) home and community care (to the extent allowed
and as defined in section 1929) for functionally
disabled elderly individuals;
(23) community supported living arrangements services
(to the extent allowed and as defined in section 1930);
(24) personal care services furnished to an
individual who is not an inpatient or resident of a
hospital, nursing facility, intermediate care facility
for the mentally retarded, or institution for mental
disease that are (A) authorized for the individual by a
physician in accordance with a plan of treatment or (at
the option of the State) otherwise authorized for the
individual in accordance with a service plan approved
by the State, (B) provided by an individual who is
qualified to provide such services and who is not a
member of the individual's family, and (C) furnished in
a home or other location;
(25) primary care case management services (as
defined in subsection (t));
(26) services furnished under a PACE program under
section 1934 to PACE program eligible individuals
enrolled under the program under such section;
(27) subject to subsection (x), primary and secondary
medical strategies and treatment and services for
individuals who have Sickle Cell Disease;
(28) freestanding birth center services (as defined
in subsection (l)(3)(A)) and other ambulatory services
that are offered by a freestanding birth center (as
defined in subsection (l)(3)(B)) and that are otherwise
included in the plan;
(29) subject to paragraph (2) of subsection (ee), for
the period beginning October 1, 2020, and ending
September 30, 2025, medication-assisted treatment (as
defined in paragraph (1) of such subsection); and
(30) any other medical care, and any other type of
remedial care recognized under State law, specified by
the Secretary,
except as otherwise provided in paragraph (16), such term does
not include--
(A) any such payments with respect to care or
services for any individual who is an inmate of a
public institution (except as a patient in a medical
institution); or
(B) any such payments with respect to care or
services for any individual who has not attained 65
years of age and who is a patient in an institution for
mental diseases.
For purposes of clause (vi) of the preceding sentence, a person
shall be considered essential to another individual if such
person is the spouse of and is living with such individual, the
needs of such person are taken into account in determining the
amount of aid or assistance furnished to such individual (under
a State plan approved under title I, X, XIV, or XVI), and such
person is determined, under such a State plan, to be essential
to the well-being of such individual. The payment described in
the first sentence may include expenditures for medicare cost-
sharing and for premiums under part B of title XVIII for
individuals who are eligible for medical assistance under the
plan and (A) are receiving aid or assistance under any plan of
the State approved under title I, X, XIV, or XVI, or part A of
title IV, or with respect to whom supplemental security income
benefits are being paid under title XVI, or (B) with respect to
whom there is being paid a State supplementary payment and are
eligible for medical assistance equal in amount, duration, and
scope to the medical assistance made available to individuals
described in section 1902(a)(10)(A), and, except in the case of
individuals 65 years of age or older and disabled individuals
entitled to health insurance benefits under title XVIII who are
not enrolled under part B of title XVIII, other insurance
premiums for medical or any other type of remedial care or the
cost thereof. No service (including counseling) shall be
excluded from the definition of ``medical assistance'' solely
because it is provided as a treatment service for alcoholism or
drug dependency. In the case of a woman who is eligible for
medical assistance on the basis of being pregnant (including
through the end of the month in which the 60-day period
beginning on the last day of her pregnancy ends), who is a
patient in an institution for mental diseases for purposes of
receiving treatment for a substance use disorder, and who was
enrolled for medical assistance under the State plan
immediately before becoming a patient in an institution for
mental diseases or who becomes eligible to enroll for such
medical assistance while such a patient, the exclusion from the
definition of ``medical assistance'' set forth in the
subdivision (B) following paragraph (30) of the first sentence
of this subsection shall not be construed as prohibiting
Federal financial participation for medical assistance for
items or services that are provided to the woman outside of the
institution.
(b) Subject to subsections (y), (z), [and (aa)] (aa), and
(ff) and section 1933(d), the term ``Federal medical assistance
percentage'' for any State shall be 100 per centum less the
State percentage; and the State percentage shall be that
percentage which bears the same ratio to 45 per centum as the
square of the per capita income of such State bears to the
square of the per capita income of the continental United
States (including Alaska) and Hawaii; except that (1) the
Federal medical assistance percentage shall in no case be less
than 50 per centum or more than 83 per centum, (2) the Federal
medical assistance percentage for Puerto Rico, the Virgin
Islands, Guam, the Northern Mariana Islands, and American Samoa
shall be 55 percent, (3) for purposes of this title and title
XXI, the Federal medical assistance percentage for the District
of Columbia shall be 70 percent, (4) the Federal medical
assistance percentage shall be equal to the enhanced FMAP
described in section 2105(b) with respect to medical assistance
provided to individuals who are eligible for such assistance
only on the basis of section 1902(a)(10)(A)(ii)(XVIII), and (5)
in the case of a State that provides medical assistance for
services and vaccines described in subparagraphs (A) and (B) of
subsection (a)(13), and prohibits cost-sharing for such
services and vaccines, the Federal medical assistance
percentage, as determined under this subsection and subsection
(y) (without regard to paragraph (1)(C) of such subsection),
shall be increased by 1 percentage point with respect to
medical assistance for such services and vaccines and for items
and services described in subsection (a)(4)(D). The Federal
medical assistance percentage for any State shall be determined
and promulgated in accordance with the provisions of section
1101(a)(8)(B). Notwithstanding the first sentence of this
section, the Federal medical assistance percentage shall be 100
per centum with respect to amounts expended as medical
assistance for services which are received through an Indian
Health Service facility whether operated by the Indian Health
Service or by an Indian tribe or tribal organization (as
defined in section 4 of the Indian Health Care Improvement
Act). Notwithstanding the first sentence of this subsection, in
the case of a State plan that meets the condition described in
subsection (u)(1), with respect to expenditures (other than
expenditures under section 1923) described in subsection
(u)(2)(A) or subsection (u)(3) for the State for a fiscal year,
and that do not exceed the amount of the State's available
allotment under section 2104, the Federal medical assistance
percentage is equal to the enhanced FMAP described in section
2105(b).
(c) For definition of the term ``nursing facility'', see
section 1919(a).
(d) The term ``intermediate care facility for the mentally
retarded'' means an institution (or distinct part thereof) for
the mentally retarded or persons with related conditions if--
(1) the primary purpose of such institution (or
distinct part thereof) is to provide health or
rehabilitative services for mentally retarded
individuals and the institution meets such standards as
may be prescribed by the Secretary;
(2) the mentally retarded individual with respect to
whom a request for payment is made under a plan
approved under this title is receiving active treatment
under such a program; and
(3) in the case of a public institution, the State or
political subdivision responsible for the operation of
such institution has agreed that the non-Federal
expenditures in any calendar quarter prior to January
1, 1975, with respect to services furnished to patients
in such institution (or distinct part thereof) in the
State will not, because of payments made under this
title, be reduced below the average amount expended for
such services in such institution in the four quarters
immediately preceding the quarter in which the State in
which such institution is located elected to make such
services available under its plan approved under this
title.
(e) In the case of any State the State plan of which (as
approved under this title)--
(1) does not provide for the payment of services
(other than services covered under section 1902(a)(12))
provided by an optometrist; but
(2) at a prior period did provide for the payment of
services referred to in paragraph (1);
the term ``physicians' services'' (as used in subsection
(a)(5)) shall include services of the type which an optometrist
is legally authorized to perform where the State plan
specifically provides that the term ``physicians' services'',
as employed in such plan, includes services of the type which
an optometrist is legally authorized to perform, and shall be
reimbursed whether furnished by a physician or an optometrist.
(f) For purposes of this title, the term ``nursing facility
services'' means services which are or were required to be
given an individual who needs or needed on a daily basis
nursing care (provided directly by or requiring the supervision
of nursing personnel) or other rehabilitation services which as
a practical matter can only be provided in a nursing facility
on an inpatient basis.
(g) If the State plan includes provision of chiropractors'
services, such services include only--
(1) services provided by a chiropractor (A) who is
licensed as such by the State and (B) who meets uniform
minimum standards promulgated by the Secretary under
section 1861(r)(5); and
(2) services which consist of treatment by means of
manual manipulation of the spine which the chiropractor
is legally authorized to perform by the State.
(h)(1) For purposes of paragraph (16) of subsection (a), the
term ``inpatient psychiatric hospital services for individuals
under age 21'' includes only--
(A) inpatient services which are provided in an
institution (or distinct part thereof) which is a
psychiatric hospital as defined in section 1861(f) or
in another inpatient setting that the Secretary has
specified in regulations;
(B) inpatient services which, in the case of any
individual (i) involve active treatment which meets
such standards as may be prescribed in regulations by
the Secretary, and (ii) a team, consisting of
physicians and other personnel qualified to make
determinations with respect to mental health conditions
and the treatment thereof, has determined are necessary
on an inpatient basis and can reasonably be expected to
improve the condition, by reason of which such services
are necessary, to the extent that eventually such
services will no longer be necessary; and
(C) inpatient services which, in the case of any
individual, are provided prior to (i) the date such
individual attains age 21, or (ii) in the case of an
individual who was receiving such services in the
period immediately preceding the date on which he
attained age 21, (I) the date such individual no longer
requires such services, or (II) if earlier, the date
such individual attains age 22;
(2) Such term does not include services provided during any
calendar quarter under the State plan of any State if the total
amount of the funds expended, during such quarter, by the State
(and the political subdivisions thereof) from non-Federal funds
for inpatient services included under paragraph (1), and for
active psychiatric care and treatment provided on an outpatient
basis for eligible mentally ill children, is less than the
average quarterly amount of the funds expended, during the 4-
quarter period ending December 31, 1971, by the State (and the
political subdivisions thereof) from non-Federal funds for such
services.
(i) The term ``institution for mental diseases'' means a
hospital, nursing facility, or other institution of more than
16 beds, that is primarily engaged in providing diagnosis,
treatment, or care of persons with mental diseases, including
medical attention, nursing care, and related services.
(j) The term ``State supplementary payment'' means any cash
payment made by a State on a regular basis to an individual who
is receiving supplemental security income benefits under title
XVI or who would but for his income be eligible to receive such
benefits, as assistance based on need in supplementation of
such benefits (as determined by the Commissioner of Social
Security), but only to the extent that such payments are made
with respect to an individual with respect to whom supplemental
security income benefits are payable under title XVI, or would
but for his income be payable under that title.
(k) Increased supplemental security income benefits payable
pursuant to section 211 of Public Law 93-66 shall not be
considered supplemental security income benefits payable under
title XVI.
(l)(1) The terms ``rural health clinic services'' and ``rural
health clinic'' have the meanings given such terms in section
1861(aa), except that (A) clause (ii) of section 1861(aa)(2)
shall not apply to such terms, and (B) the physician
arrangement required under section 1861(aa)(2)(B) shall only
apply with respect to rural health clinic services and, with
respect to other ambulatory care services, the physician
arrangement required shall be only such as may be required
under the State plan for those services.
(2)(A) The term ``Federally-qualified health center
services'' means services of the type described in
subparagraphs (A) through (C) of section 1861(aa)(1) when
furnished to an individual as an patient of a Federally-
qualified health center and, for this purpose, any reference to
a rural health clinic or a physician described in section
1861(aa)(2)(B) is deemed a reference to a Federally-qualified
health center or a physician at the center, respectively.
(B) The term ``Federally-qualified health center'' means an
entity which--
(i) is receiving a grant under section 330 of the
Public Health Service Act,
(ii)(I) is receiving funding from such a grant under
a contract with the recipient of such a grant, and
(II) meets the requirements to receive a grant under
section 330 of such Act,
(iii) based on the recommendation of the Health
Resources and Services Administration within the Public
Health Service, is determined by the Secretary to meet
the requirements for receiving such a grant, including
requirements of the Secretary that an entity may not be
owned, controlled, or operated by another entity, or
(iv) was treated by the Secretary, for purposes of
part B of title XVIII, as a comprehensive Federally
funded health center as of January 1, 1990;
and includes an outpatient health program or facility operated
by a tribe or tribal organization under the Indian Self-
Determination Act (Public Law 93-638) or by an urban Indian
organization receiving funds under title V of the Indian Health
Care Improvement Act for the provision of primary health
services. In applying clause (ii), the Secretary may waive any
requirement referred to in such clause for up to 2 years for
good cause shown.
(3)(A) The term ``freestanding birth center services'' means
services furnished to an individual at a freestanding birth
center (as defined in subparagraph (B)) at such center.
(B) The term ``freestanding birth center'' means a health
facility--
(i) that is not a hospital;
(ii) where childbirth is planned to occur away from
the pregnant woman's residence;
(iii) that is licensed or otherwise approved by the
State to provide prenatal labor and delivery or
postpartum care and other ambulatory services that are
included in the plan; and
(iv) that complies with such other requirements
relating to the health and safety of individuals
furnished services by the facility as the State shall
establish.
(C) A State shall provide separate payments to providers
administering prenatal labor and delivery or postpartum care in
a freestanding birth center (as defined in subparagraph (B)),
such as nurse midwives and other providers of services such as
birth attendants recognized under State law, as determined
appropriate by the Secretary. For purposes of the preceding
sentence, the term ``birth attendant'' means an individual who
is recognized or registered by the State involved to provide
health care at childbirth and who provides such care within the
scope of practice under which the individual is legally
authorized to perform such care under State law (or the State
regulatory mechanism provided by State law), regardless of
whether the individual is under the supervision of, or
associated with, a physician or other health care provider.
Nothing in this subparagraph shall be construed as changing
State law requirements applicable to a birth attendant.
(m)(1) Subject to paragraph (2), the term ``qualified family
member'' means an individual (other than a qualified pregnant
woman or child, as defined in subsection (n)) who is a member
of a family that would be receiving aid under the State plan
under part A of title IV pursuant to section 407 if the State
had not exercised the option under section 407(b)(2)(B)(i).
(2) No individual shall be a qualified family member for any
period after September 30, 1998.
(n) The term ``qualified pregnant woman or child'' means--
(1) a pregnant woman who--
(A) would be eligible for aid to families
with dependent children under part A of title
IV (or would be eligible for such aid if
coverage under the State plan under part A of
title IV included aid to families with
dependent children of unemployed parents
pursuant to section 407) if her child had been
born and was living with her in the month such
aid would be paid, and such pregnancy has been
medically verified;
(B) is a member of a family which would be
eligible for aid under the State plan under
part A of title IV pursuant to section 407 if
the plan required the payment of aid pursuant
to such section; or
(C) otherwise meets the income and resources
requirements of a State plan under part A of
title IV; and
(2) a child who has not attained the age of 19, who
was born after September 30, 1983 (or such earlier date
as the State may designate), and who meets the income
and resources requirements of the State plan under part
A of title IV.
(o)(1)(A) Subject to subparagraphs (B) and (C), the term
``hospice care'' means the care described in section
1861(dd)(1) furnished by a hospice program (as defined in
section 1861(dd)(2)) to a terminally ill individual who has
voluntarily elected (in accordance with paragraph (2)) to have
payment made for hospice care instead of having payment made
for certain benefits described in section 1812(d)(2)(A) and for
which payment may otherwise be made under title XVIII and
intermediate care facility services under the plan. For
purposes of such election, hospice care may be provided to an
individual while such individual is a resident of a skilled
nursing facility or intermediate care facility, but the only
payment made under the State plan shall be for the hospice
care.
(B) For purposes of this title, with respect to the
definition of hospice program under section 1861(dd)(2), the
Secretary may allow an agency or organization to make the
assurance under subparagraph (A)(iii) of such section without
taking into account any individual who is afflicted with
acquired immune deficiency syndrome (AIDS).
(C) A voluntary election to have payment made for hospice
care for a child (as defined by the State) shall not constitute
a waiver of any rights of the child to be provided with, or to
have payment made under this title for, services that are
related to the treatment of the child's condition for which a
diagnosis of terminal illness has been made.
(2) An individual's voluntary election under this subsection
--
(A) shall be made in accordance with procedures that
are established by the State and that are consistent
with the procedures established under section
1812(d)(2);
(B) shall be for such a period or periods (which need
not be the same periods described in section
1812(d)(1)) as the State may establish; and
(C) may be revoked at any time without a showing of
cause and may be modified so as to change the hospice
program with respect to which a previous election was
made.
(3) In the case of an individual--
(A) who is residing in a nursing facility or
intermediate care facility for the mentally retarded
and is receiving medical assistance for services in
such facility under the plan,
(B) who is entitled to benefits under part A of title
XVIII and has elected, under section 1812(d), to
receive hospice care under such part, and
(C) with respect to whom the hospice program under
such title and the nursing facility or intermediate
care facility for the mentally retarded have entered
into a written agreement under which the program takes
full responsibility for the professional management of
the individual's hospice care and the facility agrees
to provide room and board to the individual,
instead of any payment otherwise made under the plan with
respect to the facility's services, the State shall provide for
payment to the hospice program of an amount equal to the
additional amount determined in section 1902(a)(13)(B) and, if
the individual is an individual described in section
1902(a)(10)(A), shall provide for payment of any coinsurance
amounts imposed under section 1813(a)(4).
(p)(1) The term ``qualified medicare beneficiary'' means an
individual--
(A) who is entitled to hospital insurance benefits
under part A of title XVIII (including an individual
entitled to such benefits pursuant to an enrollment
under section 1818, but not including an individual
entitled to such benefits only pursuant to an
enrollment under section 1818A),
(B) whose income (as determined under section 1612
for purposes of the supplemental security income
program, except as provided in paragraph (2)(D)) does
not exceed an income level established by the State
consistent with paragraph (2), and
(C) whose resources (as determined under section 1613
for purposes of the supplemental security income
program) do not exceed twice the maximum amount of
resources that an individual may have and obtain
benefits under that program or, effective beginning
with January 1, 2010, whose resources (as so
determined) do not exceed the maximum resource level
applied for the year under subparagraph (D) of section
1860D-14(a)(3) (determined without regard to the life
insurance policy exclusion provided under subparagraph
(G) of such section) applicable to an individual or to
the individual and the individual's spouse (as the case
may be).
(2)(A) The income level established under paragraph (1)(B)
shall be at least the percent provided under subparagraph (B)
(but not more than 100 percent) of the official poverty line
(as defined by the Office of Management and Budget, and revised
annually in accordance with section 673(2) of the Omnibus
Budget Reconciliation Act of 1981) applicable to a family of
the size involved.
(B) Except as provided in subparagraph (C), the percent
provided under this clause, with respect to eligibility for
medical assistance on or after--
(i) January 1, 1989, is 85 percent,
(ii) January 1, 1990, is 90 percent, and
(iii) January 1, 1991, is 100 percent.
(C) In the case of a State which has elected treatment under
section 1902(f) and which, as of January 1, 1987, used an
income standard for individuals age 65 or older which was more
restrictive than the income standard established under the
supplemental security income program under title XVI, the
percent provided under subparagraph (B), with respect to
eligibility for medical assistance on or after--
(i) January 1, 1989, is 80 percent,
(ii) January 1, 1990, is 85 percent,
(iii) January 1, 1991, is 95 percent, and
(iv) January 1, 1992, is 100 percent.
(D)(i) In determining under this subsection the income of an
individual who is entitled to monthly insurance benefits under
title II for a transition month (as defined in clause (ii)) in
a year, such income shall not include any amounts attributable
to an increase in the level of monthly insurance benefits
payable under such title which have occurred pursuant to
section 215(i) for benefits payable for months beginning with
December of the previous year.
(ii) For purposes of clause (i), the term ``transition
month'' means each month in a year through the month following
the month in which the annual revision of the official poverty
line, referred to in subparagraph (A), is published.
(3) The term ``medicare cost-sharing'' means (subject to
section 1902(n)(2)) the following costs incurred with respect
to a qualified medicare beneficiary, without regard to whether
the costs incurred were for items and services for which
medical assistance is otherwise available under the plan:
(A)(i) premiums under section 1818 or 1818A, and
(ii) premiums under section 1839,
(B) Coinsurance under title XVIII (including
coinsurance described in section 1813).
(C) Deductibles established under title XVIII
(including those described in section 1813 and section
1833(b)).
(D) The difference between the amount that is paid
under section 1833(a) and the amount that would be paid
under such section if any reference to ``80 percent''
therein were deemed a reference to ``100 percent''.
Such term also may include, at the option of a State, premiums
for enrollment of a qualified medicare beneficiary with an
eligible organization under section 1876.
(4) Notwithstanding any other provision of this title, in the
case of a State (other than the 50 States and the District of
Columbia)--
(A) the requirement stated in section 1902(a)(10)(E)
shall be optional, and
(B) for purposes of paragraph (2), the State may
substitute for the percent provided under subparagraph
(B) of such paragraph or 1902(a)(10)(E)(iii) any
percent.
In the case of any State which is providing medical assistance
to its residents under a waiver granted under section 1115, the
Secretary shall require the State to meet the requirement of
section 1902(a)(10)(E) in the same manner as the State would be
required to meet such requirement if the State had in effect a
plan approved under this title.
(5)(A) The Secretary shall develop and distribute to States a
simplified application form for use by individuals (including
both qualified medicare beneficiaries and specified low-income
medicare beneficiaries) in applying for medical assistance for
medicare cost-sharing under this title in the States which
elect to use such form. Such form shall be easily readable by
applicants and uniform nationally. The Secretary shall provide
for the translation of such application form into at least the
10 languages (other than English) that are most often used by
individuals applying for hospital insurance benefits under
section 226 or 226A and shall make the translated forms
available to the States and to the Commissioner of Social
Security.
(B) In developing such form, the Secretary shall consult with
beneficiary groups and the States.
(6) For provisions relating to outreach efforts to increase
awareness of the availability of medicare cost-sharing, see
section 1144.
(q) The term ``qualified severely impaired individual'' means
an individual under age 65--
(1) who for the month preceding the first month to
which this subsection applies to such individual--
(A) received (i) a payment of supplemental
security income benefits under section 1611(b)
on the basis of blindness or disability, (ii) a
supplementary payment under section 1616 of
this Act or under section 212 of Public Law 93-
66 on such basis, (iii) a payment of monthly
benefits under section 1619(a), or (iv) a
supplementary payment under section 1616(c)(3),
and
(B) was eligible for medical assistance under
the State plan approved under this title; and
(2) with respect to whom the Commissioner of Social
Security determines that--
(A) the individual continues to be blind or
continues to have the disabling physical or
mental impairment on the basis of which he was
found to be under a disability and, except for
his earnings, continues to meet all non-
disability-related requirements for eligibility
for benefits under title XVI,
(B) the income of such individual would not,
except for his earnings, be equal to or in
excess of the amount which would cause him to
be ineligible for payments under section
1611(b) (if he were otherwise eligible for such
payments),
(C) the lack of eligibility for benefits
under this title would seriously inhibit his
ability to continue or obtain employment, and
(D) the individual's earnings are not
sufficient to allow him to provide for himself
a reasonable equivalent of the benefits under
title XVI (including any federally administered
State supplementary payments), this title, and
publicly funded attendant care services
(including personal care assistance) that would
be available to him in the absence of such
earnings.
In the case of an individual who is eligible for
medical assistance pursuant to section 1619(b) in June,
1987, the individual shall be a qualified severely
impaired individual for so long as such individual
meets the requirements of paragraph (2).
(r) The term ``early and periodic screening, diagnostic, and
treatment services'' means the following items and services:
(1) Screening services--
(A) which are provided--
(i) at intervals which meet
reasonable standards of medical and
dental practice, as determined by the
State after consultation with
recognized medical and dental
organizations involved in child health
care and, with respect to immunizations
under subparagraph (B)(iii), in
accordance with the schedule referred
to in section 1928(c)(2)(B)(i) for
pediatric vaccines, and
(ii) at such other intervals,
indicated as medically necessary, to
determine the existence of certain
physical or mental illnesses or
conditions; and
(B) which shall at a minimum include--
(i) a comprehensive health and
developmental history (including
assessment of both physical and mental
health development),
(ii) a comprehensive unclothed
physical exam,
(iii) appropriate immunizations
(according to the schedule referred to
in section 1928(c)(2)(B)(i) for
pediatric vaccines) according to age
and health history,
(iv) laboratory tests (including lead
blood level assessment appropriate for
age and risk factors), and
(v) health education (including
anticipatory guidance).
(2) Vision services--
(A) which are provided--
(i) at intervals which meet
reasonable standards of medical
practice, as determined by the State
after consultation with recognized
medical organizations involved in child
health care, and
(ii) at such other intervals,
indicated as medically necessary, to
determine the existence of a suspected
illness or condition; and
(B) which shall at a minimum include
diagnosis and treatment for defects in vision,
including eyeglasses.
(3) Dental services--
(A) which are provided--
(i) at intervals which meet
reasonable standards of dental
practice, as determined by the State
after consultation with recognized
dental organizations involved in child
health care, and
(ii) at such other intervals,
indicated as medically necessary, to
determine the existence of a suspected
illness or condition; and
(B) which shall at a minimum include relief
of pain and infections, restoration of teeth,
and maintenance of dental health.
(4) Hearing services--
(A) which are provided--
(i) at intervals which meet
reasonable standards of medical
practice, as determined by the State
after consultation with recognized
medical organizations involved in child
health care, and
(ii) at such other intervals,
indicated as medically necessary, to
determine the existence of a suspected
illness or condition; and
(B) which shall at a minimum include
diagnosis and treatment for defects in hearing,
including hearing aids.
(5) Such other necessary health care, diagnostic
services, treatment, and other measures described in
section 1905(a) to correct or ameliorate defects and
physical and mental illnesses and conditions discovered
by the screening services, whether or not such services
are covered under the State plan.
Nothing in this title shall be construed as limiting providers
of early and periodic screening, diagnostic, and treatment
services to providers who are qualified to provide all of the
items and services described in the previous sentence or as
preventing a provider that is qualified under the plan to
furnish one or more (but not all) of such items or services
from being qualified to provide such items and services as part
of early and periodic screening, diagnostic, and treatment
services. The Secretary shall, not later than July 1, 1990, and
every 12 months thereafter, develop and set annual
participation goals for each State for participation of
individuals who are covered under the State plan under this
title in early and periodic screening, diagnostic, and
treatment services.
(s) The term ``qualified disabled and working individual''
means an individual--
(1) who is entitled to enroll for hospital insurance
benefits under part A of title XVIII under section
1818A (as added by 6012 of the Omnibus Budget
Reconciliation Act of 1989);
(2) whose income (as determined under section 1612
for purposes of the supplemental security income
program) does not exceed 200 percent of the official
poverty line (as defined by the Office of Management
and Budget and revised annually in accordance with
section 673(2) of the Omnibus Budget Reconciliation Act
of 1981) applicable to a family of the size involved;
(3) whose resources (as determined under section 1613
for purposes of the supplemental security income
program) do not exceed twice the maximum amount of
resources that an individual or a couple (in the case
of an individual with a spouse) may have and obtain
benefits for supplemental security income benefits
under title XVI; and
(4) who is not otherwise eligible for medical
assistance under this title.
(t)(1) The term ``primary care case management services''
means case-management related services (including locating,
coordinating, and monitoring of health care services) provided
by a primary care case manager under a primary care case
management contract.
(2) The term ``primary care case manager'' means any of the
following that provides services of the type described in
paragraph (1) under a contract referred to in such paragraph:
(A) A physician, a physician group practice, or an
entity employing or having other arrangements with
physicians to provide such services.
(B) At State option--
(i) a nurse practitioner (as described in
section 1905(a)(21));
(ii) a certified nurse-midwife (as defined in
section 1861(gg)); or
(iii) a physician assistant (as defined in
section 1861(aa)(5)).
(3) The term ``primary care case management contract'' means
a contract between a primary care case manager and a State
under which the manager undertakes to locate, coordinate, and
monitor covered primary care (and such other covered services
as may be specified under the contract) to all individuals
enrolled with the manager, and which--
(A) provides for reasonable and adequate hours of
operation, including 24-hour availability of
information, referral, and treatment with respect to
medical emergencies;
(B) restricts enrollment to individuals residing
sufficiently near a service delivery site of the
manager to be able to reach that site within a
reasonable time using available and affordable modes of
transportation;
(C) provides for arrangements with, or referrals to,
sufficient numbers of physicians and other appropriate
health care professionals to ensure that services under
the contract can be furnished to enrollees promptly and
without compromise to quality of care;
(D) prohibits discrimination on the basis of health
status or requirements for health care services in
enrollment, disenrollment, or reenrollment of
individuals eligible for medical assistance under this
title;
(E) provides for a right for an enrollee to terminate
enrollment in accordance with section 1932(a)(4); and
(F) complies with the other applicable provisions of
section 1932.
(4) For purposes of this subsection, the term ``primary
care'' includes all health care services customarily provided
in accordance with State licensure and certification laws and
regulations, and all laboratory services customarily provided
by or through, a general practitioner, family medicine
physician, internal medicine physician, obstetrician/
gynecologist, or pediatrician.
(u)(1) The conditions described in this paragraph for a State
plan are as follows:
(A) The State is complying with the requirement of
section 2105(d)(1).
(B) The plan provides for such reporting of
information about expenditures and payments
attributable to the operation of this subsection as the
Secretary deems necessary in order to carry out the
fourth sentence of subsection (b).
(2)(A) For purposes of subsection (b), the expenditures
described in this subparagraph are expenditures for medical
assistance for optional targeted low-income children described
in subparagraph (B).
(B) For purposes of this paragraph, the term ``optional
targeted low-income child'' means a targeted low-income child
as defined in section 2110(b)(1) (determined without regard to
that portion of subparagraph (C) of such section concerning
eligibility for medical assistance under this title) who would
not qualify for medical assistance under the State plan under
this title as in effect on March 31, 1997 (but taking into
account the expansion of age of eligibility effected through
the operation of section 1902(l)(1)(D)). Such term excludes any
child eligible for medical assistance only by reason of section
1902(a)(10)(A)(ii)(XIX).
(3) For purposes of subsection (b), the expenditures
described in this paragraph are expenditures for medical
assistance for children who are born before October 1, 1983,
and who would be described in section 1902(l)(1)(D) if they had
been born on or after such date, and who are not eligible for
such assistance under the State plan under this title based on
such State plan as in effect as of March 31, 1997.
(4) The limitations on payment under subsections (f) and (g)
of section 1108 shall not apply to Federal payments made under
section 1903(a)(1) based on an enhanced FMAP described in
section 2105(b).
(v)(1) The term ``employed individual with a medically
improved disability'' means an individual who--
(A) is at least 16, but less than 65, years of age;
(B) is employed (as defined in paragraph (2));
(C) ceases to be eligible for medical assistance
under section 1902(a)(10)(A)(ii)(XV) because the
individual, by reason of medical improvement, is
determined at the time of a regularly scheduled
continuing disability review to no longer be eligible
for benefits under section 223(d) or 1614(a)(3); and
(D) continues to have a severe medically determinable
impairment, as determined under regulations of the
Secretary.
(2) For purposes of paragraph (1), an individual is
considered to be ``employed'' if the individual--
(A) is earning at least the applicable minimum wage
requirement under section 6 of the Fair Labor Standards
Act (29 U.S.C. 206) and working at least 40 hours per
month; or
(B) is engaged in a work effort that meets
substantial and reasonable threshold criteria for hours
of work, wages, or other measures, as defined by the
State and approved by the Secretary.'
(w)(1) For purposes of this title, the term ``independent
foster care adolescent'' means an individual--
(A) who is under 21 years of age;
(B) who, on the individual's 18th birthday, was in
foster care under the responsibility of a State; and
(C) whose assets, resources, and income do not exceed
such levels (if any) as the State may establish
consistent with paragraph (2).
(2) The levels established by a State under paragraph (1)(C)
may not be less than the corresponding levels applied by the
State under section 1931(b).
(3) A State may limit the eligibility of independent foster
care adolescents under section 1902(a)(10)(A)(ii)(XVII) to
those individuals with respect to whom foster care maintenance
payments or independent living services were furnished under a
program funded under part E of title IV before the date the
individuals attained 18 years of age.
(x) For purposes of subsection (a)(27), the strategies,
treatment, and services described in that subsection include
the following:
(1) Chronic blood transfusion (with deferoxamine
chelation) to prevent stroke in individuals with Sickle
Cell Disease who have been identified as being at high
risk for stroke.
(2) Genetic counseling and testing for individuals
with Sickle Cell Disease or the sickle cell trait to
allow health care professionals to treat such
individuals and to prevent symptoms of Sickle Cell
Disease.
(3) Other treatment and services to prevent
individuals who have Sickle Cell Disease and who have
had a stroke from having another stroke.
(y) Increased FMAP for Medical Assistance for Newly Eligible
Mandatory Individuals.--
(1) Amount of increase.--Notwithstanding subsection
(b), the Federal medical assistance percentage for a
State that is one of the 50 States or the District of
Columbia, with respect to amounts expended by such
State for medical assistance for newly eligible
individuals described in subclause (VIII) of section
1902(a)(10)(A)(i), shall be equal to--
(A) 100 percent for calendar quarters in
2014, 2015, and 2016;
(B) 95 percent for calendar quarters in 2017;
(C) 94 percent for calendar quarters in 2018;
(D) 93 percent for calendar quarters in 2019;
and
(E) 90 percent for calendar quarters in 2020
and each year thereafter.
(2) Definitions.--In this subsection:
(A) Newly eligible.--The term ``newly
eligible'' means, with respect to an individual
described in subclause (VIII) of section
1902(a)(10)(A)(i), an individual who is not
under 19 years of age (or such higher age as
the State may have elected) and who, as of
December 1, 2009, is not eligible under the
State plan or under a waiver of the plan for
full benefits or for benchmark coverage
described in subparagraph (A), (B), or (C) of
section 1937(b)(1) or benchmark equivalent
coverage described in section 1937(b)(2) that
has an aggregate actuarial value that is at
least actuarially equivalent to benchmark
coverage described in subparagraph (A), (B), or
(C) of section 1937(b)(1), or is eligible but
not enrolled (or is on a waiting list) for such
benefits or coverage through a waiver under the
plan that has a capped or limited enrollment
that is full.
(B) Full benefits.--The term ``full
benefits'' means, with respect to an
individual, medical assistance for all services
covered under the State plan under this title
that is not less in amount, duration, or scope,
or is determined by the Secretary to be
substantially equivalent, to the medical
assistance available for an individual
described in section 1902(a)(10)(A)(i).
(z) Equitable Support for Certain States.--
(1)(A) During the period that begins on January 1,
2014, and ends on December 31, 2015, notwithstanding
subsection (b), the Federal medical assistance
percentage otherwise determined under subsection (b)
with respect to a fiscal year occurring during that
period shall be increased by 2.2 percentage points for
any State described in subparagraph (B) for amounts
expended for medical assistance for individuals who are
not newly eligible (as defined in subsection (y)(2))
individuals described in subclause (VIII) of section
1902(a)(10)(A)(i).
(B) For purposes of subparagraph (A), a State
described in this subparagraph is a State that--
(i) is an expansion State described in
paragraph (3);
(ii) the Secretary determines will not
receive any payments under this title on the
basis of an increased Federal medical
assistance percentage under subsection (y) for
expenditures for medical assistance for newly
eligible individuals (as so defined); and
(iii) has not been approved by the Secretary
to divert a portion of the DSH allotment for a
State to the costs of providing medical
assistance or other health benefits coverage
under a waiver that is in effect on July 2009.
(2)(A) For calendar quarters in 2014 and each year
thereafter, the Federal medical assistance percentage
otherwise determined under subsection (b) for an
expansion State described in paragraph (3) with respect
to medical assistance for individuals described in
section 1902(a)(10)(A)(i)(VIII) who are nonpregnant
childless adults with respect to whom the State may
require enrollment in benchmark coverage under section
1937 shall be equal to the percent specified in
subparagraph (B)(i) for such year.
(B)(i) The percent specified in this subparagraph for
a State for a year is equal to the Federal medical
assistance percentage (as defined in the first sentence
of subsection (b)) for the State increased by a number
of percentage points equal to the transition percentage
(specified in clause (ii) for the year) of the number
of percentage points by which--
(I) such Federal medical assistance
percentage for the State, is less than
(II) the percent specified in subsection
(y)(1) for the year.
(ii) The transition percentage specified in this
clause for--
(I) 2014 is 50 percent;
(II) 2015 is 60 percent;
(III) 2016 is 70 percent;
(IV) 2017 is 80 percent;
(V) 2018 is 90 percent; and
(VI) 2019 and each subsequent year is 100
percent.
(3) A State is an expansion State if, on the date of
the enactment of the Patient Protection and Affordable
Care Act, the State offers health benefits coverage
statewide to parents and nonpregnant, childless adults
whose income is at least 100 percent of the poverty
line, that includes inpatient hospital services, is not
dependent on access to employer coverage, employer
contribution, or employment and is not limited to
premium assistance, hospital-only benefits, a high
deductible health plan, or alternative benefits under a
demonstration program authorized under section 1938. A
State that offers health benefits coverage to only
parents or only nonpregnant childless adults described
in the preceding sentence shall not be considered to be
an expansion State.
(aa)(1) Notwithstanding subsection (b), beginning January 1,
2011, the Federal medical assistance percentage for a fiscal
year for a disaster-recovery FMAP adjustment State shall be
equal to the following:
(A) In the case of the first fiscal year (or part of
a fiscal year) for which this subsection applies to the
State, the State's regular FMAP shall be increased by
50 percent of the number of percentage points by which
the State's regular FMAP for such fiscal year is less
than the Federal medical assistance percentage
determined for the State for the preceding fiscal year
after the application of only subsection (a) of section
5001 of Public Law 111-5 (if applicable to the
preceding fiscal year) and without regard to this
subsection, subsections (y) and (z), and subsections
(b) and (c) of section 5001 of Public Law 111-5.
(B) In the case of the second or any succeeding
fiscal year for which this subsection applies to the
State, the State's regular FMAP for such fiscal year
shall be increased by 25 percent (or 50 percent in the
case of fiscal year 2013) of the number of percentage
points by which the State's regular FMAP for such
fiscal year is less than the Federal medical assistance
percentage received by the State during the preceding
fiscal year.
(2) In this subsection, the term ``disaster-recovery FMAP
adjustment State'' means a State that is one of the 50 States
or the District of Columbia, for which, at any time during the
preceding 7 fiscal years, the President has declared a major
disaster under section 401 of the Robert T. Stafford Disaster
Relief and Emergency Assistance Act and determined as a result
of such disaster that every county or parish in the State
warrant individual and public assistance or public assistance
from the Federal Government under such Act and for which--
(A) in the case of the first fiscal year (or part of
a fiscal year) for which this subsection applies to the
State, the State's regular FMAP for the fiscal year is
less than the Federal medical assistance percentage
determined for the State for the preceding fiscal year
after the application of only subsection (a) of section
5001 of Public Law 111-5 (if applicable to the
preceding fiscal year) and without regard to this
subsection, subsections (y) and (z), and subsections
(b) and (c) of section 5001 of Public Law 111-5, by at
least 3 percentage points; and
(B) in the case of the second or any succeeding
fiscal year for which this subsection applies to the
State, the State's regular FMAP for the fiscal year is
less than the Federal medical assistance percentage
determined for the State for the preceding fiscal year
under this subsection by at least 3 percentage points.
(3) In this subsection, the term ``regular FMAP'' means, for
each fiscal year for which this subsection applies to a State,
the Federal medical assistance percentage that would otherwise
apply to the State for the fiscal year, as determined under
subsection (b) and without regard to this subsection,
subsections (y) and (z), and section 10202 of the Patient
Protection and Affordable Care Act.
(4) The Federal medical assistance percentage determined for
a disaster-recovery FMAP adjustment State under paragraph (1)
shall apply for purposes of this title (other than with respect
to disproportionate share hospital payments described in
section 1923 and payments under this title that are based on
the enhanced FMAP described in 2105(b)) and shall not apply
with respect to payments under title IV (other than under part
E of title IV) or payments under title XXI.
(bb)(1) For purposes of this title, the term ``counseling and
pharmacotherapy for cessation of tobacco use by pregnant
women'' means diagnostic, therapy, and counseling services and
pharmacotherapy (including the coverage of prescription and
nonprescription tobacco cessation agents approved by the Food
and Drug Administration) for cessation of tobacco use by
pregnant women who use tobacco products or who are being
treated for tobacco use that is furnished--
(A) by or under the supervision of a physician; or
(B) by any other health care professional who--
(i) is legally authorized to furnish such
services under State law (or the State
regulatory mechanism provided by State law) of
the State in which the services are furnished;
and
(ii) is authorized to receive payment for
other services under this title or is
designated by the Secretary for this purpose.
(2) Subject to paragraph (3), such term is limited to--
(A) services recommended with respect to pregnant
women in ``Treating Tobacco Use and Dependence: 2008
Update: A Clinical Practice Guideline'', published by
the Public Health Service in May 2008, or any
subsequent modification of such Guideline; and
(B) such other services that the Secretary recognizes
to be effective for cessation of tobacco use by
pregnant women.
(3) Such term shall not include coverage for drugs or
biologicals that are not otherwise covered under this title.
(cc) Requirement for Certain States.--Notwithstanding
subsections (y), (z), and (aa), in the case of a State that
requires political subdivisions within the State to contribute
toward the non-Federal share of expenditures required under the
State plan under section 1902(a)(2), the State shall not be
eligible for an increase in its Federal medical assistance
percentage under such subsections if it requires that political
subdivisions pay a greater percentage of the non-Federal share
of such expenditures, or a greater percentage of the non-
Federal share of payments under section 1923, than the
respective percentages that would have been required by the
State under the State plan under this title, State law, or
both, as in effect on December 31, 2009, and without regard to
any such increase. Voluntary contributions by a political
subdivision to the non-Federal share of expenditures under the
State plan under this title or to the non-Federal share of
payments under section 1923, shall not be considered to be
required contributions for purposes of this subsection. The
treatment of voluntary contributions, and the treatment of
contributions required by a State under the State plan under
this title, or State law, as provided by this subsection, shall
also apply to the increases in the Federal medical assistance
percentage under section 5001 of the American Recovery and
Reinvestment Act of 2009.
(dd) Increased FMAP for Additional Expenditures for Primary
Care Services.--Notwithstanding subsection (b), with respect to
the portion of the amounts expended for medical assistance for
services described in section 1902(a)(13)(C) furnished on or
after January 1, 2013, and before January 1, 2015, that is
attributable to the amount by which the minimum payment rate
required under such section (or, by application, section
1932(f)) exceeds the payment rate applicable to such services
under the State plan as of July 1, 2009, the Federal medical
assistance percentage for a State that is one of the 50 States
or the District of Columbia shall be equal to 100 percent. The
preceding sentence does not prohibit the payment of Federal
financial participation based on the Federal medical assistance
percentage for amounts in excess of those specified in such
sentence.
(ee) Medication-Assisted Treatment.--
(1) Definition.--For purposes of subsection (a)(29),
the term ``medication-assisted treatment''--
(A) means all drugs approved under section
505 of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C. 355), including methadone, and all
biological products licensed under section 351
of the Public Health Service Act (42 U.S.C.
262) to treat opioid use disorders; and
(B) includes, with respect to the provision
of such drugs and biological products,
counseling services and behavioral therapy.
(2) Exception.--The provisions of paragraph (29) of
subsection (a) shall not apply with respect to a State
for the period specified in such paragraph, if before
the beginning of such period the State certifies to the
satisfaction of the Secretary that implementing such
provisions statewide for all individuals eligible to
enroll in the State plan (or waiver of the State plan)
would not be feasible by reason of a shortage of
qualified providers of medication-assisted treatment,
or facilities providing such treatment, that will
contract with the State or a managed care entity with
which the State has a contract under section 1903(m) or
under section 1905(t)(3).
(ff) Temporary Increase in FMAP for Territories for Certain
Fiscal Years.--
(1) Puerto rico.--Notwithstanding subsection (b) and
subject to subsection (z)(2), the Federal medical
assistance percentage for Puerto Rico shall be equal
to--
(A) 83 percent for fiscal years 2020 and
2021; and
(B) 76 percent for fiscal years 2022 and
2023.
(2) Virgin islands.--Notwithstanding subsection (b)
and subject to subsection (z)(2), the Federal medical
assistance percentage for the Virgin Islands shall be
equal to--
(A) 100 percent for fiscal year 2020;
(B) 83 percent for fiscal years 2021 through
2024; and
(C) 76 percent for fiscal year 2025.
(3) Other territories.--Notwithstanding subsection
(b) and subject to subsection (z)(2), the Federal
medical assistance percentage for Guam, the Northern
Mariana Islands, and American Samoa shall be equal to--
(A) 100 percent for fiscal years 2020 and
2021;
(B) 83 percent for fiscal years 2022 through
2024; and
(C) 76 percent for fiscal year 2025.
* * * * * * *
adjustment in payment for inpatient hospital services furnished by
disproportionate share hospitals
Sec. 1923. (a) Implementation of Requirement.--
(1) A State plan under this title shall not be
considered to meet the requirement of section
1902(a)(13)(A)(iv) (insofar as it requires payments to
hospitals to take into account the situation of
hospitals which serve a disproportionate number of low
income patients with special needs), as of July 1,
1988, unless the State has submitted to the Secretary,
by not later than such date, an amendment to such plan
that--
(A) specifically defines the hospitals so
described (and includes in such definition any
disproportionate share hospital described in
subsection (b)(1) which meets the requirements
of subsection (d)), and
(B) provides, effective for inpatient
hospital services provided not later than July
1, 1988, for an appropriate increase in the
rate or amount of payment for such services
provided by such hospitals, consistent with
subsection (c).
(2)(A) In order to be considered to have met such
requirement of section 1902(a)(13)(A) as of July 1,
1989, the State must submit to the Secretary by not
later than April 1, 1989, the State plan amendment
described in paragraph (1), consistent with subsection
(c), effective for inpatient hospital services provided
on or after July 1, 1989.
(B) In order to be considered to have met such
requirement of section 1902(a)(13)(A) as of July 1,
1990, the State must submit to the Secretary by not
later than April 1, 1990, the State plan amendment
described in paragraph (1), consistent with subsections
(c) and (f), effective for inpatient hospital services
provided on or after July 1, 1990.
(C) If a State plan under this title provides for
payments for inpatient hospital services on a
prospective basis (whether per diem, per case, or
otherwise), in order for the plan to be considered to
have met such requirement of section 1902(a)(13)(A) as
of July 1, 1989, the State must submit to the Secretary
by not later than April 1, 1989, a State plan amendment
that provides, in the case of hospitals defined by the
State as disproportionate share hospitals under
paragraph (1)(A), for an outlier adjustment in payment
amounts for medically necessary inpatient hospital
services provided on or after July 1, 1989, involving
exceptionally high costs or exceptionally long lengths
of stay for individuals under one year of age.
(D) A State plan under this title shall not be
considered to meet the requirements of section
1902(a)(13)(A)(iv) (insofar as it requires payments to
hospitals to take into account the situation of
hospitals that serve a disproportionate number of low-
income patients with special needs), as of October 1,
1998, unless the State has submitted to the Secretary
by such date a description of the methodology used by
the State to identify and to make payments to
disproportionate share hospitals, including children's
hospitals, on the basis of the proportion of low-income
and medicaid patients (including such patients who
receive benefits through a managed care entity) served
by such hospitals. The State shall provide an annual
report to the Secretary describing the disproportionate
share payments to each such disproportionate share
hospital.
(3) The Secretary shall, not later than 90 days after
the date a State submits an amendment under this
subsection, review each such amendment for compliance
with such requirement and by such date shall approve or
disapprove each such amendment. If the Secretary
disapproves such an amendment, the State shall
immediately submit a revised amendment which meets such
requirement.
(4) The requirement of this subsection may not be
waived under section 1915(b)(4).
(b) Hospitals Deemed Disproportionate Share.--
(1) For purposes of subsection (a)(1), a hospital
which meets the requirements of subsection (d) is
deemed to be a disproportionate share hospital if--
(A) the hospital's medicaid inpatient
utilization rate (as defined in paragraph (2))
is at least one standard deviation above the
mean medicaid inpatient utilization rate for
hospitals receiving medicaid payments in the
State; or
(B) the hospital's low-income utilization
rate (as defined in paragraph (3)) exceeds 25
percent.
(2) For purposes of paragraph (1)(A), the term
``medicaid inpatient utilization rate'' means, for a
hospital, a fraction (expressed as a percentage), the
numerator of which is the hospital's number of
inpatient days attributable to patients who (for such
days) were eligible for medical assistance under a
State plan approved under this title in a period
(regardless of whether such patients receive medical
assistance on a fee-for-service basis or through a
managed care entity), and the denominator of which is
the total number of the hospital's inpatient days in
that period. In this paragraph, the term ``inpatient
day'' includes each day in which an individual
(including a newborn) is an inpatient in the hospital,
whether or not the individual is in a specialized ward
and whether or not the individual remains in the
hospital for lack of suitable placement elsewhere.
(3) For purposes of paragraph (1)(B), the term ``low-
income utilization rate'' means, for a hospital, the
sum of--
(A) the fraction (expressed as a
percentage)--
(i) the numerator of which is the sum
(for a period) of (I) the total
revenues paid the hospital for patient
services under a State plan under this
title (regardless of whether the
services were furnished on a fee-for-
service basis or through a managed care
entity) and (II) the amount of the cash
subsidies for patient services received
directly from State and local
governments, and
(ii) the denominator of which is the
total amount of revenues of the
hospital for patient services
(including the amount of such cash
subsidies) in the period; and
(B) a fraction (expressed as a percentage)--
(i) the numerator of which is the
total amount of the hospital's charges
for inpatient hospital services which
are attributable to charity care in a
period, less the portion of any cash
subsidies described in clause (i)(II)
of subparagraph (A) in the period
reasonably attributable to inpatient
hospital services, and
(ii) the denominator of which is the
total amount of the hospital's charges
for inpatient hospital services in the
hospital in the period.
The numerator under subparagraph (B)(i) shall not
include contractual allowances and discounts (other
than for indigent patients not eligible for medical
assistance under a State plan approved under this
title).
(4) The Secretary may not restrict a State's
authority to designate hospitals as disproportionate
share hospitals under this section. The previous
sentence shall not be construed to affect the authority
of the Secretary to reduce payments pursuant to section
1903(w)(1)(A)(iii) if the Secretary determines that, as
a result of such designations, there is in effect a
hold harmless provision described in section
1903(w)(4).
(c) Payment adjustment.--Subject to subsections (f) and (g),
in order to be consistent with this subsection, a payment
adjustment for a disproportionate share hospital must either--
(1) be in an amount equal to at least the product of
(A) the amount paid under the State plan to the
hospital for operating costs for inpatient hospital
services (of the kind described in section 1886(a)(4)),
and (B) the hospital's disproportionate share
adjustment percentage (established under section
1886(d)(5)(F)(iv));
(2) provide for a minimum specified additional
payment amount (or increased percentage payment) and
(without regard to whether the hospital is described in
subparagraph (A) or (B) of subsection (b)(1)) for an
increase in such a payment amount (or percentage
payment) in proportion to the percentage by which the
hospital's medicaid utilization rate (as defined in
subsection (b)(2)) exceeds one standard deviation above
the mean medicaid inpatient utilization rate for
hospitals receiving medicaid payments in the State or
the hospital's low-income utilization rate (as defined
in paragraph (b)(3)); or
(3) provide for a minimum specified additional
payment amount (or increased percentage payment) that
varies according to type of hospital under a
methodology that--
(A) applies equally to all hospitals of each
type; and
(B) results in an adjustment for each type of
hospital that is reasonably related to the
costs, volume, or proportion of services
provided to patients eligible for medical
assistance under a State plan approved under
this title or to low-income patients,
except that, for purposes of paragraphs (1)(B) and
(2)(A) of subsection (a), the payment adjustment for a
disproportionate share hospital is consistent with this
subsection if the appropriate increase in the rate or
amount of payment is equal to at least one-third of the
increase otherwise applicable under this subsection (in
the case of such paragraph (1)(B)) and at least two-
thirds of such increase (in the case of such paragraph
(2)(A)). In the case of a hospital described in
subsection (d)(2)(A)(i) (relating to children's
hospitals), in computing the hospital's
disproportionate share adjustment percentage for
purposes of paragraph (1)(B) of this subsection, the
disproportionate patient percentage (defined in section
1886(d)(5)(F)(vi)) shall be computed by substituting
for the fraction described in subclause (I) of such
section the fraction described in subclause (II) of
that section. If a State elects in a State plan
amendment under subsection (a) to provide the payment
adjustment described in paragraph (2), the State must
include in the amendment a detailed description of the
specific methodology to be used in determining the
specified additional payment amount (or increased
percentage payment) to be made to each hospital
qualifying for such a payment adjustment and must
publish at least annually the name of each hospital
qualifying for such a payment adjustment and the amount
of such payment adjustment made for each such hospital.
(d) Requirements To Qualify as Disproportionate Share
Hospital.--
(1) Except as provided in paragraph (2), no hospital
may be defined or deemed as a disproportionate share
hospital under a State plan under this title or under
subsection (b) of this section unless the hospital has
at least 2 obstetricians who have staff privileges at
the hospital and who have agreed to provide obstetric
services to individuals who are entitled to medical
assistance for such services under such State plan.
(2)(A) Paragraph (1) shall not apply to a hospital--
(i) the inpatients of which are predominantly
individuals under 18 years of age; or
(ii) which does not offer nonemergency
obstetric services to the general population as
of the date of the enactment of this Act.
(B) In the case of a hospital located in a rural area
(as defined for purposes of section 1886), in paragraph
(1) the term ``obstetrician'' includes any physician
with staff privileges at the hospital to perform
nonemergency obstetric procedures.
(3) No hospital may be defined or deemed as a
disproportionate share hospital under a State plan
under this title or under subsection (b) or (e) of this
section unless the hospital has a medicaid inpatient
utilization rate (as defined in subsection (b)(2)) of
not less than 1 percent.
(e) Special Rule.--(1) A State plan shall be considered to
meet the requirement of section 1902(a)(13)(A)(iv) (insofar as
it requires payments to hospitals to take into account the
situation of hospitals which serve a disproportionate number of
low income patients with special needs) without regard to the
requirement of subsection (a) if (A)(i) the plan provided for
payment adjustments based on a pooling arrangement involving a
majority of the hospitals participating under the plan for
disproportionate share hospitals as of January 1, 1984, or (ii)
the plan as of January 1, 1987, provided for payment
adjustments based on a statewide pooling arrangement involving
all acute care hospitals and the arrangement provides for
reimbursement of the total amount of uncompensated care
provided by each participating hospital, (B) the aggregate
amount of the payment adjustments under the plan for such
hospitals is not less than the aggregate amount of such
adjustments otherwise required to be made under such
subsection, and (C) the plan meets the requirement of
subsection (d)(3) and such payment adjustments are made
consistent with the last sentence of subsection (c).
(2) In the case of a State that used a health insuring
organization before January 1, 1986, to administer a portion of
its plan on a state-wide basis, beginning on July 1, 1988--
(A) the requirements of subsections (b) and (c)
(other than the last sentence of subsection (c)) shall
not apply if the aggregate amount of the payment
adjustments under the plan for disproportionate share
hospitals (as defined under the State plan) is not less
than the aggregate amount of payment adjustments
otherwise required to be made if such subsections
applied,
(B) subsection (d)(2)(B) shall apply to hospitals
located in urban areas, as well as in rural areas,
(C) subsection (d)(3) shall apply, and
(D) subsection (g) shall apply.
(f) Limitation on Federal Financial Participation.--
(1) In general.--Payment under section 1903(a) shall
not be made to a State with respect to any payment
adjustment made under this section for hospitals in a
State for quarters in a fiscal year in excess of the
disproportionate share hospital (in this subsection
referred to as ``DSH'') allotment for the State for the
fiscal year, as specified in paragraphs (2), (3), and
(7).
(2) State dsh allotments for fiscal years 1998
through 2002.--Subject to paragraph (4), the DSH
allotment for a State for each fiscal year during the
period beginning with fiscal year 1998 and ending with
fiscal year 2002 is determined in accordance with the
following table:
----------------------------------------------------------------------------------------------------------------
DSH Allotment (in millions of dollars)
State or District -------------------------------------------------
FY 98 FY 99 FY 00 FY 01 FY 02
----------------------------------------------------------------------------------------------------------------
Alabama 293 269 248 246 246
Alaska 10 10 10 9 9
Arizona 81 81 81 81 81
Arkansas 2 2 2 2 2
California 1,085 1,068 986 931 877
Colorado 93 85 79 74 74
Connecticut 200 194 164 160 160
Delaware 4 4 4 4 4
District of Columbia 23 23 49 49 49
Florida 207 203 197 188 160
Georgia 253 248 241 228 215
Hawaii 0 0 0 0 0
Idaho 1 1 1 1 1
Illinois 203 199 193 182 172
Indiana 201 197 191 181 171
Iowa 8 8 8 8 8
Kansas 51 49 42 36 33
Kentucky 137 134 130 123 116
Louisiana 880 795 713 658 631
Maine 103 99 84 84 84
Maryland 72 70 68 64 61
Massachusetts 288 282 273 259 244
Michigan 249 244 237 224 212
Minnesota 16 \1\16 33 33 33
Mississippi 143 141 136 129 122
Missouri 436 423 379 379 379
Montana 0.2 0.2 0.2 0.2 0.2
Nebraska 5 5 5 5 5
Nevada 37 37 37 37 37
New Hampshire 140 136 130 130 130
New Jersey 600 582 515 515 515
New Mexico 5 \2\5 9 9 9
New York 1,512 1,482 1,436 1,361 1,285
North Carolina 278 272 264 250 236
North Dakota 1 1 1 1 1
Ohio 382 374 363 344 325
Oklahoma 16 16 16 16 16
Oregon 20 20 20 20 20
Pennsylvania 529 518 502 476 449
Rhode Island 62 60 58 55 52
South Carolina 313 303 262 262 262
South Dakota 1 1 1 1 1
Tennessee 0 0 0 0 0
Texas 979 950 806 765 765
Utah 3 3 3 3 3
Vermont 18 18 18 18 18
Virginia 70 68 66 63 59
Washington 174 171 166 157 148
West Virginia 64 63 61 58 54
Wisconsin 7 7 7 7 7
Wyoming 0 \3\0 0.1 0.1 0.1
----------------------------------------------------------------------------------------------------------------
\1\The DSH allotment for fiscal year 1999 shall be deemed to be $33,000,000 as provided for by section 702 of
Public Law 105-277 (112 Stat. 2681-389).
\2\The DSH allotment for fiscal year 1999 shall be deemed to be $9,000,000 as provided for by section 703 of
Public Law 105-277 (112 Stat. 2681-389).
\3\The DSH allotment for fiscal year 1999 shall be deemed to be $95,000 as provided for by section 704 of Public
Law 105-277 (112 Stat. 2681-389).
(3) State dsh allotments for fiscal year 2003 and
thereafter.--
(A) In general.--Except as provided in
paragraphs (6), (7), and (8) and subparagraph
(E), the DSH allotment for any State for fiscal
year 2003 and each succeeding fiscal year is
equal to the DSH allotment for the State for
the preceding fiscal year under paragraph (2)
or this paragraph, increased, subject to
subparagraphs (B) and (C) and paragraph (5), by
the percentage change in the consumer price
index for all urban consumers (all items; U.S.
city average), for the previous fiscal year.
(B) Limitation.--The DSH allotment for a
State shall not be increased under subparagraph
(A) for a fiscal year to the extent that such
an increase would result in the DSH allotment
for the year exceeding the greater of--
(i) the DSH allotment for the
previous year, or
(ii) 12 percent of the total amount
of expenditures under the State plan
for medical assistance during the
fiscal year.
(C) Special, temporary increase in allotments
on a one-time, non-cumulative basis.--The DSH
allotment for any State (other than a State
with a DSH allotment determined under paragraph
(5))--
(i) for fiscal year 2004 is equal to
116 percent of the DSH allotment for
the State for fiscal year 2003 under
this paragraph, notwithstanding
subparagraph (B); and
(ii) for each succeeding fiscal year
is equal to the DSH allotment for the
State for fiscal year 2004 or, in the
case of fiscal years beginning with the
fiscal year specified in subparagraph
(D) for that State, the DSH allotment
for the State for the previous fiscal
year increased by the percentage change
in the consumer price index for all
urban consumers (all items; U.S. city
average), for the previous fiscal year.
(D) Fiscal year specified.--For purposes of
subparagraph (C)(ii), the fiscal year specified
in this subparagraph for a State is the first
fiscal year for which the Secretary estimates
that the DSH allotment for that State will
equal (or no longer exceed) the DSH allotment
for that State under the law as in effect
before the date of the enactment of this
subparagraph.
(E) Temporary increase in allotments during
recession.--
(i) In general.--Subject to clause
(ii), the DSH allotment for any State--
(I) for fiscal year 2009 is
equal to 102.5 percent of the
DSH allotment that would be
determined under this paragraph
for the State for fiscal year
2009 without application of
this subparagraph,
notwithstanding subparagraphs
(B) and (C);
(II) for fiscal year 2010 is
equal to 102.5 percent of the
DSH allotment for the State for
fiscal year 2009, as determined
under subclause (I); and
(III) for each succeeding
fiscal year is equal to the DSH
allotment for the State under
this paragraph determined
without applying subclauses (I)
and (II).
(ii) Application.--Clause (i) shall
not apply to a State for a year in the
case that the DSH allotment for such
State for such year under this
paragraph determined without applying
clause (i) would grow higher than the
DSH allotment specified under clause
(i) for the State for such year.
(4) Special rule for fiscal years 2001 and 2002.--
(A) In general.--Notwithstanding paragraph
(2), the DSH allotment for any State for--
(i) fiscal year 2001, shall be the
DSH allotment determined under
paragraph (2) for fiscal year 2000
increased, subject to subparagraph (B)
and paragraph (5), by the percentage
change in the consumer price index for
all urban consumers (all items; U.S.
city average) for fiscal year 2000; and
(ii) fiscal year 2002, shall be the
DSH allotment determined under clause
(i) increased, subject to subparagraph
(B) and paragraph (5), by the
percentage change in the consumer price
index for all urban consumers (all
items; U.S. city average) for fiscal
year 2001.
(B) Limitation.--Subparagraph (B) of
paragraph (3) shall apply to subparagraph (A)
of this paragraph in the same manner as that
subparagraph (B) applies to paragraph (3)(A).
(C) No application to allotments after fiscal
year 2002.--The DSH allotment for any State for
fiscal year 2003 or any succeeding fiscal year
shall be determined under paragraph (3) without
regard to the DSH allotments determined under
subparagraph (A) of this paragraph.
(5) Special rule for low dsh states.--
(A) For fiscal years 2001 through 2003 for
extremely low dsh states.--In the case of a
State in which the total expenditures under the
State plan (including Federal and State shares)
for disproportionate share hospital adjustments
under this section for fiscal year 1999, as
reported to the Administrator of the Health
Care Financing Administration as of August 31,
2000, is greater than 0 but less than 1 percent
of the State's total amount of expenditures
under the State plan for medical assistance
during the fiscal year, the DSH allotment for
fiscal year 2001 shall be increased to 1
percent of the State's total amount of
expenditures under such plan for such
assistance during such fiscal year. In
subsequent fiscal years before fiscal year
2004, such increased allotment is subject to an
increase for inflation as provided in paragraph
(3)(A).
(B) For fiscal year 2004 and subsequent
fiscal years.--In the case of a State in which
the total expenditures under the State plan
(including Federal and State shares) for
disproportionate share hospital adjustments
under this section for fiscal year 2000, as
reported to the Administrator of the Centers
for Medicare & Medicaid Services as of August
31, 2003, is greater than 0 but less than 3
percent of the State's total amount of
expenditures under the State plan for medical
assistance during the fiscal year, the DSH
allotment for the State with respect to--
(i) fiscal year 2004 shall be the DSH
allotment for the State for fiscal year
2003 increased by 16 percent;
(ii) each succeeding fiscal year
before fiscal year 2009 shall be the
DSH allotment for the State for the
previous fiscal year increased by 16
percent; and
(iii) fiscal year 2009 and any
subsequent fiscal year, shall be the
DSH allotment for the State for the
previous year subject to an increase
for inflation as provided in paragraph
(3)(A).
(6) Allotment adjustments.--
(A) Tennessee.--
(i) In general.--Only with respect to
fiscal year 2007, the DSH allotment for
Tennessee for such fiscal year,
notwithstanding the table set forth in
paragraph (2) or the terms of the
TennCare Demonstration Project in
effect for the State, shall be the
greater of--
(I) the amount that the
Secretary determines is equal
to the Federal medical
assistance percentage component
attributable to
disproportionate share hospital
payment adjustments for the
demonstration year ending in
2006 that is reflected in the
budget neutrality provision of
the TennCare Demonstration
Project; and
(II) $280,000,000.
Only with respect to fiscal years 2008,
2009, 2010, and 2011, the DSH allotment
for Tennessee for the fiscal year,
notwithstanding such table or terms,
shall be the amount specified in the
previous sentence for fiscal year 2007.
Only with respect to fiscal year 2012
for the period ending on December 31,
2011, the DSH allotment for Tennessee
for such portion of the fiscal year,
notwithstanding such table or terms,
shall be \1/4\ of the amount specified
in the first sentence for fiscal year
2007.
(ii) Limitation on amount of payment
adjustments eligible for federal
financial participation.--Payment under
section 1903(a) shall not be made to
Tennessee with respect to the aggregate
amount of any payment adjustments made
under this section for hospitals in the
State for fiscal year 2007, 2008, 2009,
2010, 2011, or for period in fiscal
year 2012 described in clause (i) that
is in excess of 30 percent of the DSH
allotment for the State for such fiscal
year or period determined pursuant to
clause (i).
(iii) State plan amendment.--The
Secretary shall permit Tennessee to
submit an amendment to its State plan
under this title that describes the
methodology to be used by the State to
identify and make payments to
disproportionate share hospitals,
including children's hospitals and
institutions for mental diseases or
other mental health facilities. The
Secretary may not approve such plan
amendment unless the methodology
described in the amendment is
consistent with the requirements under
this section for making payment
adjustments to disproportionate share
hospitals. For purposes of
demonstrating budget neutrality under
the TennCare Demonstration Project,
payment adjustments made pursuant to a
State plan amendment approved in
accordance with this subparagraph shall
be considered expenditures under such
project.
(iv) Offset of federal share of
payment adjustments for fiscal years
2007 through 2011 and the first
calendar quarter of fiscal year 2012
against essential access hospital
supplemental pool payments under the
tenncare demonstration project.--
(I) The total amount of
Essential Access Hospital
supplemental pool payments that
may be made under the TennCare
Demonstration Project for
fiscal year 2007, 2008, 2009,
2010, 2011, or for a period in
fiscal year 2012 described in
clause (i) shall be reduced on
a dollar for dollar basis by
the amount of any payments made
under section 1903(a) to
Tennessee with respect to
payment adjustments made under
this section for hospitals in
the State for such fiscal year
or period.
(II) The sum of the total
amount of payments made under
section 1903(a) to Tennessee
with respect to payment
adjustments made under this
section for hospitals in the
State for fiscal year 2007,
2008, 2009, 2010, 2011, or for
a period in fiscal year 2012
described in clause (i) and the
total amount of Essential
Access Hospital supplemental
pool payments made under the
TennCare Demonstration Project
for such fiscal year or period
shall not exceed the State's
DSH allotment for such fiscal
or period year established
under clause (i).
(v) Allotment for 2d, 3rd, and 4th
quarters of fiscal year 2012 and for
fiscal year 2013.--Notwithstanding the
table set forth in paragraph (2):
(I) 2d, 3rd, and 4th quarters
of fiscal year 2012.--In the
case of a State that has a DSH
allotment of $0 for the 2d,
3rd, and 4th quarters of fiscal
year 2012, the DSH allotment
shall be $47,200,000 for such
quarters.
(II) Fiscal year 2013.--In
the case of a State that has a
DSH allotment of $0 for fiscal
year 2013, the DSH allotment
shall be $53,100,000 for such
fiscal year.
(vi) Allotment for fiscal years 2015
through 2025.--Notwithstanding any
other provision of this subsection, any
other provision of law, or the terms of
the TennCare Demonstration Project in
effect for the State, the DSH allotment
for Tennessee for fiscal year 2015, and
for each fiscal year thereafter through
fiscal year 2025, shall be $53,100,000
for each such fiscal year.
(B) Hawaii.--
(i) In general.--Only with respect to
each of fiscal years 2007 through 2011,
the DSH allotment for Hawaii for such
fiscal year, notwithstanding the table
set forth in paragraph (2), shall be
$10,000,000. Only with respect to
fiscal year 2012 for the period ending
on December 31, 2011, the DSH allotment
for Hawaii for such portion of the
fiscal year, notwithstanding the table
set forth in paragraph (2), shall be
$2,500,000.
(ii) State plan amendment.--The
Secretary shall permit Hawaii to submit
an amendment to its State plan under
this title that describes the
methodology to be used by the State to
identify and make payments to
disproportionate share hospitals,
including children's hospitals and
institutions for mental diseases or
other mental health facilities. The
Secretary may not approve such plan
amendment unless the methodology
described in the amendment is
consistent with the requirements under
this section for making payment
adjustments to disproportionate share
hospitals.
(iii) Allotment for 2d, 3rd, and 4th
quarter of fiscal year 2012, fiscal
year 2013, and succeeding fiscal
years.--Notwithstanding the table set
forth in paragraph (2):
(I) 2d, 3rd, and 4th quarter
of fiscal year 2012.--The DSH
allotment for Hawaii for the
2d, 3rd, and 4th quarters of
fiscal year 2012 shall be
$7,500,000.
(II) Treatment as a low-dsh
state for fiscal year 2013 and
succeeding fiscal years.--With
respect to fiscal year 2013,
and each fiscal year
thereafter, the DSH allotment
for Hawaii shall be increased
in the same manner as
allotments for low DSH States
are increased for such fiscal
year under clause (iii) of
paragraph (5)(B).
(III) Certain hospital
payments.--The Secretary may
not impose a limitation on the
total amount of payments made
to hospitals under the QUEST
section 1115 Demonstration
Project except to the extent
that such limitation is
necessary to ensure that a
hospital does not receive
payments in excess of the
amounts described in subsection
(g), or as necessary to ensure
that such payments under the
waiver and such payments
pursuant to the allotment
provided in this clause do not,
in the aggregate in any year,
exceed the amount that the
Secretary determines is equal
to the Federal medical
assistance percentage component
attributable to
disproportionate share hospital
payment adjustments for such
year that is reflected in the
budget neutrality provision of
the QUEST Demonstration
Project.
(7) Medicaid dsh reductions.--
(A) Reductions.--
(i) In general.--For each of fiscal
years [2020] 2022 through 2025 the
Secretary shall effect the following
reductions:
(I) Reduction in dsh
allotments.--The Secretary
shall reduce DSH allotments to
States in the amount specified
under the DSH health reform
methodology under subparagraph
(B) for the State for the
fiscal year.
(II) Reductions in
payments.--The Secretary shall
reduce payments to States under
section 1903(a) for each
calendar quarter in the fiscal
year, in the manner specified
in clause (iii), in an amount
equal to \1/4\ of the DSH
allotment reduction under
subclause (I) for the State for
the fiscal year.
(ii) Aggregate reductions.--The
aggregate reductions in DSH allotments
for all States under clause (i)(I)
shall be equal to--
(I) $4,000,000,000 for fiscal
year [2020] 2022; and
(II) $8,000,000,000 [for each
of fiscal years 2021 through
2025] for each of fiscal years
2023 through 2025.
(iii) Manner of payment reduction.--
The amount of the payment reduction
under clause (i)(II) for a State for a
quarter shall be deemed an overpayment
to the State under this title to be
disallowed against the State's regular
quarterly draw for all spending under
section 1903(d)(2). Such a disallowance
is not subject to a reconsideration
under subsections (d) and (e) of
section 1116.
(iv) Definition.--In this paragraph,
the term ``State'' means the 50 States
and the District of Columbia.
(v) Distribution of aggregate
reductions.--The Secretary shall
distribute the aggregate reductions
under clause (ii) among States in
accordance with subparagraph (B).
(B) DSH health reform methodology.--The
Secretary shall carry out subparagraph (A)
through use of a DSH Health Reform methodology
that meets the following requirements:
(i) The methodology imposes the
largest percentage reductions on the
States that--
(I) have the lowest
percentages of uninsured
individuals (determined on the
basis of data from the Bureau
of the Census, audited hospital
cost reports, and other
information likely to yield
accurate data) during the most
recent year for which such data
are available; or
(II) do not target their DSH
payments on--
(aa) hospitals with
high volumes of
Medicaid inpatients (as
defined in subsection
(b)(1)(A)); and
(bb) hospitals that
have high levels of
uncompensated care
(excluding bad debt).
(ii) The methodology imposes a
smaller percentage reduction on low DSH
States described in paragraph (5)(B).
(iii) The methodology takes into
account the extent to which the DSH
allotment for a State was included in
the budget neutrality calculation for a
coverage expansion approved under
section 1115 as of July 31, 2009.
(8) Calculation of DSH allotments after reductions
period.--The DSH allotment for a State for fiscal years
after fiscal year 2025 shall be calculated under
paragraph (3) without regard to paragraph (7).
(9) Definition of state.--In this subsection, the
term ``State'' means the 50 States and the District of
Columbia.
(g) Limit on Amount of Payment to Hospital.--
(1) Amount of adjustment subject to uncompensated
costs.--
(A) In general.--A payment adjustment during
a fiscal year shall not be considered to be
consistent with subsection (c) with respect to
a hospital if the payment adjustment exceeds
the costs incurred during the year of
furnishing hospital services (as determined by
the Secretary and net of payments under this
title, other than under this section, and by
uninsured patients) by the hospital to
individuals who either are eligible for medical
assistance under the State plan or have no
health insurance (or other source of third
party coverage) for services provided during
the year. For purposes of the preceding
sentence, payments made to a hospital for
services provided to indigent patients made by
a State or a unit of local government within a
State shall not be considered to be a source of
third party payment.
(B) Limit to public hospitals during
transition period.--With respect to payment
adjustments during a State fiscal year that
begins before January 1, 1995, subparagraph (A)
shall apply only to hospitals owned or operated
by a State (or by an instrumentality or a unit
of government within a State).
(C) Modifications for private hospitals.--
With respect to hospitals that are not owned or
operated by a State (or by an instrumentality
or a unit of government within a State), the
Secretary may make such modifications to the
manner in which the limitation on payment
adjustments is applied to such hospitals as the
Secretary considers appropriate.
(2) Additional amount during transition period for
certain hospitals with high disproportionate share.--
(A) In general.--In the case of a hospital
with high disproportionate share (as defined in
subparagraph (B)), a payment adjustment during
a State fiscal year that begins before January
1, 1995, shall be considered consistent with
subsection (c) if the payment adjustment does
not exceed 200 percent of the costs of
furnishing hospital services described in
paragraph (1)(A) during the year, but only if
the Governor of the State certifies to the
satisfaction of the Secretary that the
hospital's applicable minimum amount is used
for health services during the year. In
determining the amount that is used for such
services during a year, there shall be excluded
any amounts received under the Public Health
Service Act, title V, title XVIII, or from
third party payors (not including the State
plan under this title) that are used for
providing such services during the year.
(B) Hospitals with high disproportionate
share defined.--In subparagraph (A), a hospital
is a ``hospital with high disproportionate
share'' if--
(i) the hospital is owned or operated
by a State (or by an instrumentality or
a unit of government within a State);
and
(ii) the hospital--
(I) meets the requirement
described in subsection
(b)(1)(A), or
(II) has the largest number
of inpatient days attributable
to individuals entitled to
benefits under the State plan
of any hospital in such State
for the previous State fiscal
year.
(C) Applicable minimum amount defined.--In
subparagraph (A), the ``applicable minimum
amount'' for a hospital for a fiscal year is
equal to the difference between the amount of
the hospital's payment adjustment for the
fiscal year and the costs to the hospital of
furnishing hospital services described in
paragraph (1)(A) during the fiscal year.
(h) Limitation on Certain State DSH Expenditures.--
(1) In general.--Payment under section 1903(a) shall
not be made to a State with respect to any payment
adjustments made under this section for quarters in a
fiscal year (beginning with fiscal year 1998) to
institutions for mental diseases or other mental health
facilities, to the extent the aggregate of such
adjustments in the fiscal year exceeds the lesser of
the following:
(A) 1995 imd dsh payment adjustments.--The
total State DSH expenditures that are
attributable to fiscal year 1995 for payments
to institutions for mental diseases and other
mental health facilities (based on reporting
data specified by the State on HCFA Form 64 as
mental health DSH, and as approved by the
Secretary).
(B) Applicable percentage of 1995 total dsh
payment allotment.--The amount of such payment
adjustments which are equal to the applicable
percentage of the Federal share of payment
adjustments made to hospitals in the State
under subsection (c) that are attributable to
the 1995 DSH allotment for the State for
payments to institutions for mental diseases
and other mental health facilities (based on
reporting data specified by the State on HCFA
Form 64 as mental health DSH, and as approved
by the Secretary).
(2) Applicable percentage.--
(A) In general.--For purposes of paragraph
(1), the applicable percentage with respect
to--
(i) each of fiscal years 1998, 1999,
and 2000, is the percentage determined
under subparagraph (B); or
(ii) a succeeding fiscal year is the
lesser of the percentage determined
under subparagraph (B) or the following
percentage:
(I) For fiscal year 2001, 50
percent.
(II) For fiscal year 2002, 40
percent.
(III) For each succeeding
fiscal year, 33 percent.
(B) 1995 percentage.--The percentage
determined under this subparagraph is the ratio
(determined as a percentage) of--
(i) the Federal share of payment
adjustments made to hospitals in the
State under subsection (c) that are
attributable to the 1995 DSH allotment
for the State (as reported by the State
not later than January 1, 1997, on HCFA
Form 64, and as approved by the
Secretary) for payments to institutions
for mental diseases and other mental
health facilities, to
(ii) the State 1995 DSH spending
amount.
(C) State 1995 dsh spending amount.--For
purposes of subparagraph (B)(ii), the ``State
1995 DSH spending amount'', with respect to a
State, is the Federal medical assistance
percentage (for fiscal year 1995) of the
payment adjustments made under subsection (c)
under the State plan that are attributable to
the fiscal year 1995 DSH allotment for the
State (as reported by the State not later than
January 1, 1997, on HCFA Form 64, and as
approved by the Secretary).
(i) Requirement for Direct Payment.--
(1) In general.--No payment may be made under section
1903(a)(1) with respect to a payment adjustment made
under this section, for services furnished by a
hospital on or after October 1, 1997, with respect to
individuals eligible for medical assistance under the
State plan who are enrolled with a managed care entity
(as defined in section 1932(a)(1)(B)) or under any
other managed care arrangement unless a payment, equal
to the amount of the payment adjustment--
(A) is made directly to the hospital by the
State; and
(B) is not used to determine the amount of a
prepaid capitation payment under the State plan
to the entity or arrangement with respect to
such individuals.
(2) Exception for current arrangements.--Paragraph
(1) shall not apply to a payment adjustment provided
pursuant to a payment arrangement in effect on July 1,
1997.
(j) Annual Reports and Other Requirements Regarding Payment
Adjustments.--With respect to fiscal year 2004 and each fiscal
year thereafter, the Secretary shall require a State, as a
condition of receiving a payment under section 1903(a)(1) with
respect to a payment adjustment made under this section, to do
the following:
(1) Report.--The State shall submit an annual report
that includes the following:
(A) An identification of each
disproportionate share hospital that received a
payment adjustment under this section for the
preceding fiscal year and the amount of the
payment adjustment made to such hospital for
the preceding fiscal year.
(B) Such other information as the Secretary
determines necessary to ensure the
appropriateness of the payment adjustments made
under this section for the preceding fiscal
year.
(2) Independent certified audit.--The State shall
annually submit to the Secretary an independent
certified audit that verifies each of the following:
(A) The extent to which hospitals in the
State have reduced their uncompensated care
costs to reflect the total amount of claimed
expenditures made under this section.
(B) Payments under this section to hospitals
that comply with the requirements of subsection
(g).
(C) Only the uncompensated care costs of
providing inpatient hospital and outpatient
hospital services to individuals described in
paragraph (1)(A) of such subsection are
included in the calculation of the hospital-
specific limits under such subsection.
(D) The State included all payments under
this title, including supplemental payments, in
the calculation of such hospital-specific
limits.
(E) The State has separately documented and
retained a record of all of its costs under
this title, claimed expenditures under this
title, uninsured costs in determining payment
adjustments under this section, and any
payments made on behalf of the uninsured from
payment adjustments under this section.
* * * * * * *
special provisions relating to medicare prescription drug benefit
Sec. 1935. (a) Requirements Relating to Medicare Prescription
Drug Low-Income Subsidies Medicare Transitional Prescription
Drug Assistance, and Medicare Cost-Sharing.--As a condition of
its State plan under this title under section 1902(a)(66) and
receipt of any Federal financial assistance under section
1903(a) subject to subsection (e), a State shall do the
following:
(1) Information for transitional prescription drug
assistance verification.--The State shall provide the
Secretary with information to carry out section 1860D-
31(f)(3)(B)(i).
(2) Eligibility determinations for low-income
subsidies.--The State shall--
(A) make determinations of eligibility for
premium and cost-sharing subsidies under and in
accordance with section 1860D-14;
(B) inform the Secretary of such
determinations in cases in which such
eligibility is established; and
(C) otherwise provide the Secretary with such
information as may be required to carry out
part D, other than subpart 4, of title XVIII
(including section 1860D-14).
(3) Screening for eligibility, and enrollment of,
beneficiaries for medicare cost-sharing.--As part of
making an eligibility determination required under
paragraph (2) for an individual, the State shall make a
determination of the individual's eligibility for
medical assistance for any medicare cost-sharing
described in section 1905(p)(3) and, if the individual
is eligible for any such medicare cost-sharing, offer
enrollment to the individual under the State plan (or
under a waiver of such plan).
(4) Consideration of data transmitted by the social
security administration for purposes of medicare
savings program.--The State shall accept data
transmitted under section 1144(c)(3) and act on such
data in the same manner and in accordance with the same
deadlines as if the data constituted an initiation of
an application for benefits under the Medicare Savings
Program (as defined for purposes of such section) that
had been submitted directly by the applicant. The date
of the individual's application for the low income
subsidy program from which the data have been derived
shall constitute the date of filing of such application
for benefits under the Medicare Savings Program.
(b) Regular Federal Subsidy of Administrative Costs.--The
amounts expended by a State in carrying out subsection (a) are
expenditures reimbursable under the appropriate paragraph of
section 1903(a).
(c) Federal Assumption of Medicaid Prescription Drug Costs
for Dually Eligible Individuals.--
(1) Phased-down state contribution.--
(A) In general.--Each of the 50 States and
the District of Columbia for each month
beginning with January 2006 shall provide for
payment under this subsection to the Secretary
of the product of--
(i) the amount computed under
paragraph (2)(A) for the State and
month;
(ii) the total number of full-benefit
dual eligible individuals (as defined
in paragraph (6)) for such State and
month; and
(iii) the factor for the month
specified in paragraph (5).
(B) Form and manner of payment.--Payment
under subparagraph (A) shall be made in a
manner specified by the Secretary that is
similar to the manner in which State payments
are made under an agreement entered into under
section 1843, except that all such payments
shall be deposited into the Medicare
Prescription Drug Account in the Federal
Supplementary Medical Insurance Trust Fund.
(C) Compliance.--If a State fails to pay to
the Secretary an amount required under
subparagraph (A), interest shall accrue on such
amount at the rate provided under section
1903(d)(5). The amount so owed and applicable
interest shall be immediately offset against
amounts otherwise payable to the State under
section 1903(a), in accordance with the Federal
Claims Collection Act of 1996 and applicable
regulations.
(D) Data match.--The Secretary shall perform
such periodic data matches as may be necessary
to identify and compute the number of full-
benefit dual eligible individuals for purposes
of computing the amount under subparagraph (A).
(2) Amount.--
(A) In general.--The amount computed under
this paragraph for a State described in
paragraph (1) and for a month in a year is
equal to--
(i) \1/12\ of the product of--
(I) the base year State
medicaid per capita
expenditures for covered part D
drugs for full-benefit dual
eligible individuals (as
computed under paragraph (3));
and
(II) a proportion equal to
100 percent minus the Federal
medical assistance percentage
(as defined in section 1905(b))
applicable to the State for the
fiscal year in which the month
occurs; and
(ii) increased for each year
(beginning with 2004 up to and
including the year involved) by the
applicable growth factor specified in
paragraph (4) for that year.
(B) Notice.--The Secretary shall notify each
State described in paragraph (1) not later than
October 15 before the beginning of each year
(beginning with 2006) of the amount computed
under subparagraph (A) for the State for that
year.
(3) Base year state medicaid per capita expenditures
for covered part D drugs for full-benefit dual eligible
individuals.--
(A) In general.--For purposes of paragraph
(2)(A), the ``base year State medicaid per
capita expenditures for covered part D drugs
for full-benefit dual eligible individuals''
for a State is equal to the weighted average
(as weighted under subparagraph (C)) of--
(i) the gross per capita medicaid
expenditures for prescription drugs for
2003, determined under subparagraph
(B); and
(ii) the estimated actuarial value of
prescription drug benefits provided
under a capitated managed care plan per
full-benefit dual eligible individual
for 2003, as determined using such data
as the Secretary determines
appropriate.
(B) Gross per capita medicaid expenditures
for prescription drugs.--
(i) In general.--The gross per capita
medicaid expenditures for prescription
drugs for 2003 under this subparagraph
is equal to the expenditures, including
dispensing fees, for the State under
this title during 2003 for covered
outpatient drugs, determined per full-
benefit-dual-eligible-individual for
such individuals not receiving medical
assistance for such drugs through a
medicaid managed care plan.
(ii) Determination.--In determining
the amount under clause (i), the
Secretary shall--
(I) use data from the
Medicaid Statistical
Information System (MSIS) and
other available data;
(II) exclude expenditures
attributable to covered
outpatient prescription drugs
that are not covered part D
drugs (as defined in section
1860D-2(e), including drugs
described in subparagraph (K)
of section 1927(d)(2)); and
(III) reduce such
expenditures by the product of
such portion and the adjustment
factor (described in clause
(iii)).
(iii) Adjustment factor.--The
adjustment factor described in this
clause for a State is equal to the
ratio for the State for 2003 of--
(I) aggregate payments under
agreements under section 1927;
to
(II) the gross expenditures
under this title for covered
outpatient drugs referred to in
clause (i).
Such factor shall be determined based
on information reported by the State in
the medicaid financial management
reports (form CMS-64) for the 4
quarters of calendar year 2003 and such
other data as the Secretary may
require.
(C) Weighted average.--The weighted average
under subparagraph (A) shall be determined
taking into account--
(i) with respect to subparagraph
(A)(i), the average number of full-
benefit dual eligible individuals in
2003 who are not described in clause
(ii); and
(ii) with respect to subparagraph
(A)(ii), the average number of full-
benefit dual eligible individuals in
such year who received in 2003 medical
assistance for covered outpatient drugs
through a medicaid managed care plan.
(4) Applicable growth factor.--The applicable growth
factor under this paragraph for--
(A) each of 2004, 2005, and 2006, is the
average annual percent change (to that year
from the previous year) of the per capita
amount of prescription drug expenditures (as
determined based on the most recent National
Health Expenditure projections for the years
involved); and
(B) a succeeding year, is the annual
percentage increase specified in section 1860D-
2(b)(6) for the year.
(5) Factor.--The factor under this paragraph for a
month--
(A) in 2006 is 90 percent;
(B) in 2007 is 88\1/3\ percent;
(C) in 2008 is 86\2/3\ percent;
(D) in 2009 is 85 percent;
(E) in 2010 is 83\1/3\ percent;
(F) in 2011 is 81\2/3\ percent;
(G) in 2012 is 80 percent;
(H) in 2013 is 78\1/3\ percent;
(I) in 2014 is 76\2/3\ percent; or
(J) after December 2014, is 75 percent.
(6) Full-benefit dual eligible individual defined.--
(A) In general.--For purposes of this
section, the term ``full-benefit dual eligible
individual'' means for a State for a month an
individual who--
(i) has coverage for the month for
covered part D drugs under a
prescription drug plan under part D of
title XVIII, or under an MA-PD plan
under part C of such title; and
(ii) is determined eligible by the
State for medical assistance for full
benefits under this title for such
month under section 1902(a)(10)(A) or
1902(a)(10)(C), by reason of section
1902(f), or under any other category of
eligibility for medical assistance for
full benefits under this title, as
determined by the Secretary.
(B) Treatment of medically needy and other
individuals required to spend down.--In
applying subparagraph (A) in the case of an
individual determined to be eligible by the
State for medical assistance under section
1902(a)(10)(C) or by reason of section 1902(f),
the individual shall be treated as meeting the
requirement of subparagraph (A)(ii) for any
month if such medical assistance is provided
for in any part of the month.
(d) Coordination of Prescription Drug Benefits.--
(1) Medicare as primary payor.--In the case of a part
D eligible individual (as defined in section 1860D-
1(a)(3)(A)) who is described in subsection
(c)(6)(A)(ii), notwithstanding any other provision of
this title, medical assistance is not available under
this title for such drugs (or for any cost-sharing
respecting such drugs), and the rules under this title
relating to the provision of medical assistance for
such drugs shall not apply. The provision of benefits
with respect to such drugs shall not be considered as
the provision of care or services under the plan under
this title. No payment may be made under section
1903(a) for prescribed drugs for which medical
assistance is not available pursuant to this paragraph.
(2) Coverage of certain excludable drugs.--In the
case of medical assistance under this title with
respect to a covered outpatient drug (other than a
covered part D drug) furnished to an individual who is
enrolled in a prescription drug plan under part D of
title XVIII or an MA-PD plan under part C of such
title, the State may elect to provide such medical
assistance in the manner otherwise provided in the case
of individuals who are not full-benefit dual eligible
individuals or through an arrangement with such plan.
(e) Treatment of Territories.--
(1) In general.--In the case of a State, other than
the 50 States and the District of Columbia--
(A) the previous provisions of this section
shall not apply to residents of such State; and
(B) [if the State] subject to paragraph (4),
if the State establishes and submits to the
Secretary a plan described in paragraph (2)
(for providing medical assistance with respect
to the provision of prescription drugs to part
D eligible individuals), the amount otherwise
determined under section 1108(f) (as increased
under section 1108(g)) for the State shall be
increased by the amount for the fiscal period
specified in paragraph (3).
(2) Plan.--The Secretary shall determine that a plan
is described in this paragraph if the plan--
(A) provides medical assistance with respect
to the provision of covered part D drugs (as
defined in section 1860D-2(e)) to low-income
part D eligible individuals;
(B) provides assurances that additional
amounts received by the State that are
attributable to the operation of this
subsection shall be used only for such
assistance and related administrative expenses
and that no more than 10 percent of the amount
specified in paragraph (3)(A) for the State for
any fiscal period shall be used for such
administrative expenses; and
(C) meets such other criteria as the
Secretary may establish.
(3) Increased amount.--
(A) In general.--The amount specified in this
paragraph for a State for a year is equal to
the product of--
(i) the aggregate amount specified in
subparagraph (B); and
(ii) the ratio (as estimated by the
Secretary) of--
(I) the number of individuals
who are entitled to benefits
under part A or enrolled under
part B and who reside in the
State (as determined by the
Secretary based on the most
recent available data before
the beginning of the year); to
(II) the sum of such numbers
for all States that submit a
plan described in paragraph
(2).
(B) Aggregate amount.--The aggregate amount
specified in this subparagraph for--
(i) the last 3 quarters of fiscal
year 2006, is equal to $28,125,000;
(ii) fiscal year 2007, is equal to
$37,500,000; or
(iii) a subsequent year, is equal to
the aggregate amount specified in this
subparagraph for the previous year
increased by annual percentage increase
specified in section 1860D-2(b)(6) for
the year involved.
(4) Treatment of funding for certain fiscal years.--
(A) Puerto rico.--Notwithstanding paragraph
(1)(B), in the case that Puerto Rico
establishes and submits to the Secretary a plan
described in paragraph (2) with respect to any
of fiscal years 2020 through 2023, the amount
specified in paragraph (3) for Puerto Rico for
such a year shall be taken into account in
applying subparagraph (A)(ii) of section
1108(g)(2) for such year.
(B) Other territories.--Notwithstanding
paragraph (1)(B), in the case that the Virgin
Islands, Guam, the Northern Mariana Islands, or
American Samoa establishes and submits to the
Secretary a plan described in paragraph (2)
with respect to any of fiscal years 2020
through 2025, the amount specified in paragraph
(3) for the Virgin Islands, Guam, the Northern
Mariana Islands, or American Samoa, as the case
may be, shall be taken into account in
applying, as applicable, subparagraph (B)(ii),
(C)(ii), (D)(ii), or (E)(ii) of section
1108(g)(2) for such year.
[(4)] (5) Report.--The Secretary shall submit to
Congress a report on the application of this subsection
and may include in the report such recommendations as
the Secretary deems appropriate.
* * * * * * *
asset verification through access to information held by financial
institutions
Sec. 1940. (a) Implementation.--
(1) In general.--Subject to the provisions of this
section, each State shall implement an asset
verification program described in subsection (b), for
purposes of determining or redetermining the
eligibility of an individual for medical assistance
under the State plan under this title.
(2) Plan submittal.--In order to meet the requirement
of paragraph (1), each State shall--
(A) submit not later than a deadline
specified by the Secretary consistent with
paragraph (3), a State plan amendment under
this title that describes how the State intends
to implement the asset verification program;
and
(B) provide for implementation of such
program for eligibility determinations and
redeterminations made on or after 6 months
after the deadline established for submittal of
such plan amendment.
(3) Phase-in.--
(A) In general.--
(i) Implementation in current asset
verification demo states.--The
Secretary shall require those States
specified in subparagraph (C) (to which
an asset verification program has been
applied before the date of the
enactment of this section) to implement
an asset verification program under
this subsection by the end of fiscal
year 2009.
(ii) Implementation in other
states.--The Secretary shall require
other States to submit and implement an
asset verification program under this
subsection in such manner as is
designed to result in the application
of such programs, in the aggregate for
all such other States, to enrollment of
approximately, but not less than, the
following percentage of enrollees, in
the aggregate for all such other
States, by the end of the fiscal year
involved:
(I) 12.5 percent by the end
of fiscal year 2009.
(II) 25 percent by the end of
fiscal year 2010.
(III) 50 percent by the end
of fiscal year 2011.
(IV) 75 percent by the end of
fiscal year 2012.
(V) 100 percent by the end of
fiscal year 2013.
(iii) Implementation in puerto rico
and virgin islands.--The Secretary
shall require Puerto Rico to implement
an asset verification program under
this subsection by the end of fiscal
year 2022 and the Virgin Islands to
implement such a program by the end of
fiscal year 2023.
(B) Consideration.--In selecting States under
subparagraph (A)(ii), the Secretary shall
consult with the States involved and take into
account the feasibility of implementing asset
verification programs in each such State.
(C) States specified.--The States specified
in this subparagraph are California, New York,
and New Jersey.
(D) Construction.--Nothing in subparagraph
(A)(ii) shall be construed as preventing a
State from requesting, and the Secretary from
approving, the implementation of an asset
verification program in advance of the deadline
otherwise established under such subparagraph.
(4) [Exemption of territories] Exemption of certain
territories.--This section shall only apply to the 50
States [and the District of Columbia], the District of
Columbia, Puerto Rico, and the Virgin Islands.
(b) Asset Verification Program.--
(1) In general.--For purposes of this section, an
asset verification program means a program described in
paragraph (2) under which a State--
(A) requires each applicant for, or recipient
of, medical assistance under the State plan
under this title on the basis of being aged,
blind, or disabled to provide authorization by
such applicant or recipient (and any other
person whose resources are required by law to
be disclosed to determine the eligibility of
the applicant or recipient for such assistance)
for the State to obtain (subject to the cost
reimbursement requirements of section 1115(a)
of the Right to Financial Privacy Act but at no
cost to the applicant or recipient) from any
financial institution (within the meaning of
section 1101(1) of such Act) any financial
record (within the meaning of section 1101(2)
of such Act) held by the institution with
respect to the applicant or recipient (and such
other person, as applicable), whenever the
State determines the record is needed in
connection with a determination with respect to
such eligibility for (or the amount or extent
of) such medical assistance; and
(B) uses the authorization provided under
subparagraph (A) to verify the financial
resources of such applicant or recipient (and
such other person, as applicable), in order to
determine or redetermine the eligibility of
such applicant or recipient for medical
assistance under the State plan.
(2) Program described.--A program described in this
paragraph is a program for verifying individual assets
in a manner consistent with the approach used by the
Commissioner of Social Security under section
1631(e)(1)(B)(ii).
(c) Duration of Authorization.--Notwithstanding section
1104(a)(1) of the Right to Financial Privacy Act, an
authorization provided to a State under subsection (b)(1) shall
remain effective until the earliest of--
(1) the rendering of a final adverse decision on the
applicant's application for medical assistance under
the State's plan under this title;
(2) the cessation of the recipient's eligibility for
such medical assistance; or
(3) the express revocation by the applicant or
recipient (or such other person described in subsection
(b)(1), as applicable) of the authorization, in a
written notification to the State.
(d) Treatment of Right to Financial Privacy Act
Requirements.--
(1) An authorization obtained by the State under
subsection (b)(1) shall be considered to meet the
requirements of the Right to Financial Privacy Act for
purposes of section 1103(a) of such Act, and need not
be furnished to the financial institution,
notwithstanding section 1104(a) of such Act.
(2) The certification requirements of section 1103(b)
of the Right to Financial Privacy Act shall not apply
to requests by the State pursuant to an authorization
provided under subsection (b)(1).
(3) A request by the State pursuant to an
authorization provided under subsection (b)(1) is
deemed to meet the requirements of section 1104(a)(3)
of the Right to Financial Privacy Act and of section
1102 of such Act, relating to a reasonable description
of financial records.
(e) Required Disclosure.--The State shall inform any person
who provides authorization pursuant to subsection (b)(1)(A) of
the duration and scope of the authorization.
(f) Refusal or Revocation of Authorization.--If an applicant
for, or recipient of, medical assistance under the State plan
under this title (or such other person described in subsection
(b)(1), as applicable) refuses to provide, or revokes, any
authorization made by the applicant or recipient (or such other
person, as applicable) under subsection (b)(1)(A) for the State
to obtain from any financial institution any financial record,
the State may, on that basis, determine that the applicant or
recipient is ineligible for medical assistance.
(g) Use of Contractor.--For purposes of implementing an asset
verification program under this section, a State may select and
enter into a contract with a public or private entity meeting
such criteria and qualifications as the State determines
appropriate, consistent with requirements in regulations
relating to general contracting provisions and with section
1903(i)(2). In carrying out activities under such contract,
such an entity shall be subject to the same requirements and
limitations on use and disclosure of information as would apply
if the State were to carry out such activities directly.
(h) Technical Assistance.--The Secretary shall provide States
with technical assistance to aid in implementation of an asset
verification program under this section.
(i) Reports.--A State implementing an asset verification
program under this section shall furnish to the Secretary such
reports concerning the program, at such times, in such format,
and containing such information as the Secretary determines
appropriate.
(j) Treatment of Program Expenses.--Notwithstanding any other
provision of law, reasonable expenses of States in carrying out
the program under this section shall be treated, for purposes
of section 1903(a), in the same manner as State expenditures
specified in paragraph (7) of such section.
(k) Reduction in FMAP After 2020 For Non-compliant States.--
(1) In general.--With respect to a calendar quarter
beginning on or after January 1, 2021, the Federal
medical assistance percentage otherwise determined
under section 1905(b) for a non-compliant State shall
be reduced--
(A) for calendar quarters in 2021 and 2022,
by 0.12 percentage points;
(B) for calendar quarters in 2023, by 0.25
percentage points;
(C) for calendar quarters in 2024, by 0.35
percentage points; and
(D) for calendar quarters in 2025 and each
year thereafter, by 0.5 percentage points.
(2) Non-compliant state defined.--For purposes of
this subsection, the term ``non-compliant State'' means
a State--
(A) that is one of the 50 States or the
District of Columbia;
(B) with respect to which the Secretary has
not approved a State plan amendment submitted
under subsection (a)(2); and
(C) that is not operating, on an ongoing
basis, an asset verification program in
accordance with this section.
* * * * * * *
----------
MEDICARE IMPROVEMENTS FOR PATIENTS AND PROVIDERS ACT OF 2008
* * * * * * *
TITLE I--MEDICARE
Subtitle A--Beneficiary Improvements
* * * * * * *
PART II--LOW-INCOME PROGRAMS
* * * * * * *
SEC. 119. MEDICARE ENROLLMENT ASSISTANCE.
(a) Additional Funding for State Health Insurance Assistance
Programs.--
(1) Grants.--
(A) In general.--The Secretary of Health and
Human Services (in this section referred to as
the ``Secretary'') shall use amounts made
available under subparagraph (B) to make grants
to States for State health insurance assistance
programs receiving assistance under section
4360 of the Omnibus Budget Reconciliation Act
of 1990.
(B) Funding.--For purposes of making grants
under this subsection, the Secretary shall
provide for the transfer, from the Federal
Hospital Insurance Trust Fund under section
1817 of the Social Security Act (42 U.S.C.
1395i) and the Federal Supplementary Medical
Insurance Trust Fund under section 1841 of such
Act (42 U.S.C. 1395t), in the same proportion
as the Secretary determines under section
1853(f) of such Act (42 U.S.C. 1395w-23(f)), to
the Centers for Medicare & Medicaid Services
Program Management Account--
(i) for fiscal year 2009, of
$7,500,000;
(ii) for the period of fiscal years
2010 through 2012, of $15,000,000;
(iii) for fiscal year 2013, of
$7,500,000;
(iv) for fiscal year 2014, of
$7,500,000;
(v) for fiscal year 2015, of
$7,500,000;
(vi) for fiscal year 2016, of
$13,000,000;
(vii) for fiscal year 2017, of
$13,000,000; [and]
(viii) for fiscal year 2018, of
$13,000,000; [and]
(ix) for fiscal year 2019, of
$13,000,000[.]; and
(x) for each of fiscal years 2020
through 2022, of $15,000,000.
Amounts appropriated under this subparagraph
shall remain available until expended.
(2) Amount of grants.--The amount of a grant to a
State under this subsection from the total amount made
available under paragraph (1) shall be equal to the sum
of the amount allocated to the State under paragraph
(3)(A) and the amount allocated to the State under
subparagraph (3)(B).
(3) Allocation to states.--
(A) Allocation based on percentage of low-
income beneficiaries.--The amount allocated to
a State under this subparagraph from \2/3\ of
the total amount made available under paragraph
(1) shall be based on the number of individuals
who meet the requirement under subsection
(a)(3)(A)(ii) of section 1860D-14 of the Social
Security Act (42 U.S.C. 1395w-114) but who have
not enrolled to receive a subsidy under such
section 1860D-14 relative to the total number
of individuals who meet the requirement under
such subsection (a)(3)(A)(ii) in each State, as
estimated by the Secretary.
(B) Allocation based on percentage of rural
beneficiaries.--The amount allocated to a State
under this subparagraph from \1/3\ of the total
amount made available under paragraph (1) shall
be based on the number of part D eligible
individuals (as defined in section 1860D-
1(a)(3)(A) of such Act (42 U.S.C. 1395w-
101(a)(3)(A))) residing in a rural area
relative to the total number of such
individuals in each State, as estimated by the
Secretary.
(4) Portion of grant based on percentage of low-
income beneficiaries to be used to provide outreach to
individuals who may be subsidy eligible individuals or
eligible for the medicare savings program.--Each grant
awarded under this subsection with respect to amounts
allocated under paragraph (3)(A) shall be used to
provide outreach to individuals who may be subsidy
eligible individuals (as defined in section 1860D-
14(a)(3)(A) of the Social Security Act (42 U.S.C.
1395w-114(a)(3)(A)) or eligible for the Medicare
Savings Program (as defined in subsection (f)).
(b) Additional Funding for Area Agencies on Aging.--
(1) Grants.--
(A) In general.--The Secretary, acting
through the Assistant Secretary for Aging,
shall make grants to States for area agencies
on aging (as defined in section 102 of the
Older Americans Act of 1965 (42 U.S.C. 3002))
and Native American programs carried out under
the Older Americans Act of 1965 (42 U.S.C. 3001
et seq.).
(B) Funding.--For purposes of making grants
under this subsection, the Secretary shall
provide for the transfer, from the Federal
Hospital Insurance Trust Fund under section
1817 of the Social Security Act (42 U.S.C.
1395i) and the Federal Supplementary Medical
Insurance Trust Fund under section 1841 of such
Act (42 U.S.C. 1395t), in the same proportion
as the Secretary determines under section
1853(f) of such Act (42 U.S.C. 1395w-23(f)), to
the Administration on Aging--
(i) for fiscal year 2009, of
$7,500,000;
(ii) for the period of fiscal years
2010 through 2012, of $15,000,000;
(iii) for fiscal year 2013, of
$7,500,000;
(iv) for fiscal year 2014, of
$7,500,000;
(v) for fiscal year 2015, of
$7,500,000;
(vi) for fiscal year 2016, of
$7,500,000;
(vii) for fiscal year 2017, of
$7,500,000; [and]
(viii) for fiscal year 2018, of
$7,500,000; [and]
(ix) for fiscal year 2019, of
$7,500,000[.]; and
(x) for each of fiscal years 2020
through 2022, of $15,000,000.
Amounts appropriated under this subparagraph
shall remain available until expended.
(2) Amount of grant and allocation to states based on
percentage of low-income and rural beneficiaries.--The
amount of a grant to a State under this subsection from
the total amount made available under paragraph (1)
shall be determined in the same manner as the amount of
a grant to a State under subsection (a), from the total
amount made available under paragraph (1) of such
subsection, is determined under paragraph (2) and
subparagraphs (A) and (B) of paragraph (3) of such
subsection.
(3) Required use of funds.--
(A) All funds.--Subject to subparagraph (B),
each grant awarded under this subsection shall
be used to provide outreach to eligible
Medicare beneficiaries regarding the benefits
available under title XVIII of the Social
Security Act.
(B) Outreach to individuals who may be
subsidy eligible individuals or eligible for
the medicare savings program.--Subsection
(a)(4) shall apply to each grant awarded under
this subsection in the same manner as it
applies to a grant under subsection (a).
(c) Additional Funding for Aging and Disability Resource
Centers.--
(1) Grants.--
(A) In general.--The Secretary shall make
grants to Aging and Disability Resource Centers
under the Aging and Disability Resource Center
grant program that are established centers
under such program on the date of the enactment
of this Act.
(B) Funding.--For purposes of making grants
under this subsection, the Secretary shall
provide for the transfer, from the Federal
Hospital Insurance Trust Fund under section
1817 of the Social Security Act (42 U.S.C.
1395i) and the Federal Supplementary Medical
Insurance Trust Fund under section 1841 of such
Act (42 U.S.C. 1395t), in the same proportion
as the Secretary determines under section
1853(f) of such Act (42 U.S.C. 1395w-23(f)), to
the Administration on Aging--
(i) for fiscal year 2009, of
$5,000,000;
(ii) for the period of fiscal years
2010 through 2012, of $10,000,000;
(iii) for fiscal year 2013, of
$5,000,000;
(iv) for fiscal year 2014, of
$5,000,000;
(v) for fiscal year 2015, of
$5,000,000;
(vi) for fiscal year 2016, of
$5,000,000;
(vii) for fiscal year 2017, of
$5,000,000; [and]
(viii) for fiscal year 2018, of
$5,000,000; [and]
(ix) for fiscal year 2019, of
$5,000,000[.]; and
(x) for each of fiscal years 2020
through 2022, of $5,000,000.
Amounts appropriated under this subparagraph
shall remain available until expended.
(2) Required use of funds.--Each grant awarded under
this subsection shall be used to provide outreach to
individuals regarding the benefits available under the
Medicare prescription drug benefit under part D of
title XVIII of the Social Security Act and under the
Medicare Savings Program.
(d) Coordination of Efforts To Inform Older Americans About
Benefits Available Under Federal and State Programs.--
(1) In general.--The Secretary, acting through the
Assistant Secretary for Aging, in cooperation with
related Federal agency partners, shall make a grant to,
or enter into a contract with, a qualified, experienced
entity under which the entity shall--
(A) maintain and update web-based decision
support tools, and integrated, person-centered
systems, designed to inform older individuals
(as defined in section 102 of the Older
Americans Act of 1965 (42 U.S.C. 3002)) about
the full range of benefits for which the
individuals may be eligible under Federal and
State programs;
(B) utilize cost-effective strategies to find
older individuals with the greatest economic
need (as defined in such section 102) and
inform the individuals of the programs;
(C) develop and maintain an information
clearinghouse on best practices and the most
cost-effective methods for finding older
individuals with greatest economic need and
informing the individuals of the programs; and
(D) provide, in collaboration with related
Federal agency partners administering the
Federal programs, training and technical
assistance on the most effective outreach,
screening, and follow-up strategies for the
Federal and State programs.
(2) Funding.--For purposes of making a grant or
entering into a contract under paragraph (1), the
Secretary shall provide for the transfer, from the
Federal Hospital Insurance Trust Fund under section
1817 of the Social Security Act (42 U.S.C. 1395i) and
the Federal Supplementary Medical Insurance Trust Fund
under section 1841 of such Act (42 U.S.C. 1395t), in
the same proportion as the Secretary determines under
section 1853(f) of such Act (42 U.S.C. 1395w-23(f)), to
the Administration on Aging--
(i) for fiscal year 2009, of
$5,000,000;
(ii) for the period of fiscal years
2010 through 2012, of $5,000,000;
(iii) for fiscal year 2013, of
$5,000,000;
(iv) for fiscal year 2014, of
$5,000,000;
(v) for fiscal year 2015, of
$5,000,000;
(vi) for fiscal year 2016, of
$12,000,000;
(vii) for fiscal year 2017, of
$12,000,000; [and]
(viii) for fiscal year 2018, of
$12,000,000; [and]
(ix) for fiscal year 2019, of
$12,000,000[.]; and
(x) for each of fiscal years 2020
through 2022, of $15,000,000.
Amounts appropriated under this subparagraph
shall remain available until expended.
(e) Reprogramming Funds From Medicare, Medicaid, and SCHIP
Extension Act of 2007.--The Secretary shall only use the
$5,000,000 in funds allocated to make grants to States for Area
Agencies on Aging and Aging Disability and Resource Centers for
the period of fiscal years 2008 through 2009 under section 118
of the Medicare, Medicaid, and SCHIP Extension Act of 2007
(Public Law 110-173) for the sole purpose of providing outreach
to individuals regarding the benefits available under the
Medicare prescription drug benefit under part D of title XVIII
of the Social Security Act. The Secretary shall republish the
request for proposals issued on April 17, 2008, in order to
comply with the preceding sentence.
(f) Medicare Savings Program Defined.--For purposes of this
section, the term ``Medicare Savings Program'' means the
program of medical assistance for payment of the cost of
medicare cost-sharing under the Medicaid program pursuant to
sections 1902(a)(10)(E) and 1933 of the Social Security Act (42
U.S.C. 1396a(a)(10)(E), 1396u-3).
(g) Secretarial Authority To Enlist Support in Conducting
Certain Outreach Activities.--The Secretary may request that an
entity awarded a grant under this section support the conduct
of outreach activities aimed at preventing disease and
promoting wellness. Notwithstanding any other provision of this
section, an entity may use a grant awarded under this
subsection to support the conduct of activities described in
the preceding sentence.
* * * * * * *
----------
INTERNAL REVENUE CODE OF 1986
* * * * * * *
Subtitle D--Miscellaneous Excise Taxes
* * * * * * *
CHAPTER 34--TAXES ON CERTAIN INSURANCE POLICIES
* * * * * * *
Subchapter B--INSURED AND SELF-INSURED HEALTH PLANS
* * * * * * *
SEC. 4375. HEALTH INSURANCE.
(a) Imposition of fee.--There is hereby imposed on each
specified health insurance policy for each policy year ending
after September 30, 2012, a fee equal to the product of $2 ($1
in the case of policy years ending during fiscal year 2013)
multiplied by the average number of lives covered under the
policy.
(b) Liability for fee.--The fee imposed by subsection (a)
shall be paid by the issuer of the policy.
(c) Specified health insurance policy.--For purposes of this
section:
(1) In general.--Except as otherwise provided in this
section, the term ``specified health insurance policy''
means any accident or health insurance policy
(including a policy under a group health plan) issued
with respect to individuals residing in the United
States.
(2) Exemption for certain policies.--The term
``specified health insurance policy'' does not include
any insurance if substantially all of its coverage is
of excepted benefits described in section 9832(c).
(3) Treatment of prepaid health coverage
arrangements.--
(A) In general.--In the case of any
arrangement described in subparagraph (B), such
arrangement shall be treated as a specified
health insurance policy, and the person
referred to in such subparagraph shall be
treated as the issuer.
(B) Description of arrangements.--An
arrangement is described in this subparagraph
if under such arrangement fixed payments or
premiums are received as consideration for any
person's agreement to provide or arrange for
the provision of accident or health coverage to
residents of the United States, regardless of
how such coverage is provided or arranged to be
provided.
(d) Adjustments for increases in health care spending.--In
the case of any policy year ending in any fiscal year beginning
after September 30, 2014, the dollar amount in effect under
subsection (a) for such policy year shall be equal to the sum
of such dollar amount for policy years ending in the previous
fiscal year (determined after the application of this
subsection), plus an amount equal to the product of--
(1) such dollar amount for policy years ending in the
previous fiscal year, multiplied by
(2) the percentage increase in the projected per
capita amount of National Health Expenditures, as most
recently published by the Secretary before the
beginning of the fiscal year.
(e) Termination.--This section shall not apply to policy
years ending after September 30, [2019] 2022.
SEC. 4376. SELF-INSURED HEALTH PLANS.
(a) Imposition of fee.--In the case of any applicable self-
insured health plan for each plan year ending after September
30, 2012, there is hereby imposed a fee equal to $2 ($1 in the
case of plan years ending during fiscal year 2013) multiplied
by the average number of lives covered under the plan.
(b) Liability for fee.--
(1) In general.--The fee imposed by subsection (a)
shall be paid by the plan sponsor.
(2) Plan sponsor.--For purposes of paragraph (1) the
term ``plan sponsor'' means--
(A) the employer in the case of a plan
established or maintained by a single employer,
(B) the employee organization in the case of
a plan established or maintained by an employee
organization,
(C) in the case of--
(i) a plan established or maintained
by 2 or more employers or jointly by 1
or more employers and 1 or more
employee organizations,
(ii) a multiple employer welfare
arrangement, or
(iii) a voluntary employees'
beneficiary association described in
section 501(c)(9), the association,
committee, joint board of trustees, or
other similar group of representatives
of the parties who establish or
maintain the plan, or
(D) the cooperative or association described
in subsection (c)(2)(F) in the case of a plan
established or maintained by such a cooperative
or association.
(c) Applicable self-insured health plan.--For purposes of
this section, the term ``applicable self-insured health plan''
means any plan for providing accident or health coverage if--
(1) any portion of such coverage is provided other
than through an insurance policy, and
(2) such plan is established or maintained--
(A) by 1 or more employers for the benefit of
their employees or former employees,
(B) by 1 or more employee organizations for
the benefit of their members or former members,
(C) jointly by 1 or more employers and 1 or
more employee organizations for the benefit of
employees or former employees,
(D) by a voluntary employees' beneficiary
association described in section 501(c)(9),
(E) by any organization described in section
501(c)(6), or
(F) in the case of a plan not described in
the preceding subparagraphs, by a multiple
employer welfare arrangement (as defined in
section 3(40) of Employee Retirement Income
Security Act of 1974), a rural electric
cooperative (as defined in section 3(40)(B)(iv)
of such Act), or a rural telephone cooperative
association (as defined in section 3(40)(B)(v)
of such Act).
(d) Adjustments for increases in health care spending.--In
the case of any plan year ending in any fiscal year beginning
after September 30, 2014, the dollar amount in effect under
subsection (a) for such plan year shall be equal to the sum of
such dollar amount for plan years ending in the previous fiscal
year (determined after the application of this subsection),
plus an amount equal to the product of--
(1) such dollar amount for plan years ending in the
previous fiscal year, multiplied by
(2) the percentage increase in the projected per
capita amount of National Health Expenditures, as most
recently published by the Secretary before the
beginning of the fiscal year.
(e) Termination.--This section shall not apply to plan years
ending after September 30, [2019] 2022.
* * * * * * *
Subtitle I--Trust Fund Code
* * * * * * *
CHAPTER 98--TRUST FUND CODE
* * * * * * *
Subchapter A--ESTABLISHMENT OF TRUST FUNDS
* * * * * * *
SEC. 9511. PATIENT-CENTERED OUTCOMES RESEARCH TRUST FUND.
(a) Creation of Trust Fund.--There is established in the
Treasury of the United States a trust fund to be known as the
``Patient-Centered Outcomes Research Trust Fund'' (hereafter in
this section referred to as the ``PCORTF''), consisting of such
amounts as may be appropriated or credited to such Trust Fund
as provided in this section and section 9602(b).
(b) Transfers to Fund.--
(1) Appropriation.--There are hereby appropriated to
the Trust Fund the following:
(A) For fiscal year 2010, $10,000,000.
(B) For fiscal year 2011, $50,000,000.
(C) For fiscal year 2012, $150,000,000.
(D) For fiscal year 2013--
(i) an amount equivalent to the net
revenues received in the Treasury from
the fees imposed under subchapter B of
chapter 34 (relating to fees on health
insurance and self-insured plans) for
such fiscal year; and
(ii) $150,000,000.
(E) For each of fiscal years [2014, 2015,
2016, 2017, 2018, and 2019] 2014 through 2022--
(i) an amount equivalent to the net
revenues received in the Treasury from
the fees imposed under subchapter B of
chapter 34 (relating to fees on health
insurance and self-insured plans) for
such fiscal year; and
(ii) $150,000,000.
The amounts appropriated under subparagraphs
(A), (B), (C), (D)(ii), and (E)(ii) shall be
transferred from the general fund of the
Treasury, from funds not otherwise
appropriated.
(2) Trust Fund transfers.--In addition to the amounts
appropriated under paragraph (1), there shall be
credited to the PCORTF the amounts transferred under
section 1183 of the Social Security Act.
(3) Limitation on transfers to PCORTF.--No amount may
be appropriated or transferred to the PCORTF on and
after the date of any expenditure from the PCORTF which
is not an expenditure permitted under this section. The
determination of whether an expenditure is so permitted
shall be made without regard to--
(A) any provision of law which is not
contained or referenced in this chapter or in a
revenue Act, and
(B) whether such provision of law is a
subsequently enacted provision or directly or
indirectly seeks to waive the application of
this paragraph.
(c) Trustee.--The Secretary of the Treasury shall be a
trustee of the PCORTF.
(d) Expenditures from Fund.--
(1) Amounts available to the Patient-Centered
Outcomes Research Institute.--Subject to paragraph (2),
amounts in the PCORTF are available, without further
appropriation, to the Patient-Centered Outcomes
Research Institute established under section 1181(b) of
the Social Security Act for carrying out part D of
title XI of the Social Security Act (as in effect on
the date of enactment of such Act).
(2) Transfer of funds.--
(A) In general.--The trustee of the PCORTF
shall provide for the transfer from the PCORTF
of 20 percent of the amounts appropriated or
credited to the PCORTF for each of fiscal years
2011 through [2019] 2022 to the Secretary of
Health and Human Services to carry out section
937 of the Public Health Service Act.
(B) Availability.--Amounts transferred under
subparagraph (A) shall remain available until
expended.
(C) Requirements.--Of the amounts transferred
under subparagraph (A) with respect to a fiscal
year, the Secretary of Health and Human
Services shall distribute--
(i) 80 percent to the Office of
Communication and Knowledge Transfer of
the Agency for Healthcare Research and
Quality (or any other relevant office
designated by Agency for Healthcare
Research and Quality) to carry out the
activities described in section 937 of
the Public Health Service Act; and
(ii) 20 percent to the Secretary to
carry out the activities described in
such section 937.
(e) Net revenues.--For purposes of this section, the term
``net revenues'' means the amount estimated by the Secretary of
the Treasury based on the excess of--
(1) the fees received in the Treasury under
subchapter B of chapter 34, over
(2) the decrease in the tax imposed by chapter 1
resulting from the fees imposed by such subchapter.
(f) Termination.--No amounts shall be available for
expenditure from the PCORTF after September 30, [2019] 2022,
and any amounts in such Trust Fund after such date shall be
transferred to the general fund of the Treasury.
----------
TITLE 10, UNITED STATES CODE
SUBTITLE A--GENERAL MILITARY LAW
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PART II--PERSONNEL
* * * * * * *
CHAPTER 55--MEDICAL AND DENTAL CARE
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Sec. 1086. Contracts for health benefits for certain members, former
members, and their dependents
(a) To assure that health benefits are available for the
persons covered by subsection (c), the Secretary of Defense,
after consulting with the other administering Secretaries,
shall contract under the authority of this section for health
benefits for those persons under the same insurance, medical
service, or health plans he contracts for under section 1079(a)
of this title. However, eye examinations may not be provided
under such plans for persons covered by subsection (c).
(b) For persons covered by this section the plans contracted
for under section 1079(a) of this title shall contain the
following provisions for payment by the patient:
(1) Except as provided in paragraph (2), the first
$150 each calendar year of the charges for all types of
care authorized by this section and received while in
an outpatient status and 25 percent of all subsequent
charges for such care during a calendar year.
(2) A family group of two or more persons covered by
this section shall not be required to pay collectively
more than the first $300 each calendar year of the
charges for all types of care authorized by this
section and received while in an outpatient status and
25 percent of the additional charges for such care
during a calendar year.
(3) 25 percent of the charges for inpatient care,
except that in no case may the charges for inpatient
care for a patient exceed $535 per day during the
period beginning on April 1, 2006, and ending on
September 30, 2011. The Secretary of Defense may exempt
a patient from paying such charges if the hospital to
which the patient is admitted does not impose a legal
obligation on any of its patients to pay for inpatient
care.
(4) A member or former member of a uniformed service
covered by this section by reason of section 1074(b) of
this title, or an individual or family group of two or
more persons covered by this section, may not be
required to pay a total of more than $3,000 for health
care received during any calendar year under a plan
contracted for under section 1079(a) of this title.
(c) Except as provided in subsection (d), the following
persons are eligible for health benefits under this section:
(1) Those covered by sections 1074(b) and 1076(b) of
this title, except those covered by section 1072(2)(E)
of this title.
(2) A dependent (other than a dependent covered by
section 1072(2)(E) of this title) of a member of a
uniformed service--
(A) who died while on active duty for a
period of more than 30 days; or
(B) who died from an injury, illness, or
disease incurred or aggravated--
(i) while on active duty under a call
or order to active duty of 30 days or
less, on active duty for training, or
on inactive duty training; or
(ii) while traveling to or from the
place at which the member is to
perform, or has performed, such active
duty, active duty for training, or
inactive duty training.
(3) A dependent covered by clause (F), (G), or (H) of
section 1072(2) of this title who is not eligible under
paragraph (1).
(d)(1) A person who is entitled to hospital insurance
benefits under part A of title XVIII of the Social Security Act
(42 U.S.C. 1395c et seq.) is not eligible for health benefits
under this section.
(2) The prohibition contained in paragraph (1) shall not
apply to a person referred to in subsection (c) who--
(A) [is enrolled] except as provided by paragraph
(6), is enrolled in the supplementary medical insurance
program under part B of such title (42 U.S.C. 1395j et
seq.); and
(B) in the case of a person under 65 years of age, is
entitled to hospital insurance benefits under part A of
title XVIII of the Social Security Act pursuant to
subparagraph (A) or (C) of section 226(b)(2) of such
Act (42 U.S.C. 426(b)(2)) or section 226A(a) of such
Act (42 U.S.C. 426-1(a)).
(3)(A) Subject to subparagraph (B), if a person described in
paragraph (2) receives medical or dental care for which payment
may be made under medicare and a plan contracted for under
subsection (a), the amount payable for that care under the plan
shall be the amount of the actual out-of-pocket costs incurred
by the person for that care over the sum of--
(i) the amount paid for that care under medicare; and
(ii) the total of all amounts paid or payable by
third party payers other than medicare.
(B) The amount payable for care under a plan pursuant to
subparagraph (A) may not exceed the total amount that would be
paid under the plan if payment for that care were made solely
under the plan.
(C) In this paragraph:
(i) The term ``medicare'' means title XVIII of the
Social Security Act (42 U.S.C. 1395 et seq.).
(ii) The term ``third party payer'' has the meaning
given such term in section 1095(h)(1) of this title.
(4)(A) If a person referred to in subsection (c) and
described by paragraph (2)(B) is subject to a retroactive
determination by the Social Security Administration of
entitlement to hospital insurance benefits described in
paragraph (1), the person shall, during the period described in
subparagraph (B), be deemed for purposes of health benefits
under this section--
(i) not to have been covered by paragraph (1); and
(ii) not to have been subject to the requirements of
section 1079(i)(1) of this title, whether through the
operation of such section or subsection (g) of this
section.
(B) The period described in this subparagraph with respect to
a person covered by subparagraph (A) is the period that--
(i) begins on the date that eligibility of the person
for hospital insurance benefits referred to in
paragraph (1) is effective under the retroactive
determination of eligibility with respect to the person
as described in subparagraph (A); and
(ii) ends on the date of the issuance of such
retroactive determination of eligibility by the Social
Security Administration.
(5) The administering Secretaries shall develop a mechanism
by which persons described in subparagraph (B) of paragraph (2)
who do not satisfy the condition specified in subparagraph (A)
of such paragraph are promptly notified of their ineligibility
for health benefits under this section. In developing the
notification mechanism, the administering Secretaries shall
consult with the Administrator of the Centers for Medicare &
Medicaid Services.
(6)(A) The requirement in paragraph (2)(A) to enroll in the
supplementary medical insurance program under part B of title
XVIII of the Social Security Act (42 U.S.C. 1395j et seq.)
shall not apply to a person described in subparagraph (B)
during any month in which such person is not entitled to a
benefit described in subparagraph (A) of section 226(b)(2) of
the Social Security Act (42 U.S.C. 426(b)(2)) if such person
has received the counseling and information under subparagraph
(C).
(B) A person described in this subparagraph is a person--
(i) who is under 65 years of age;
(ii) who is entitled to hospital insurance benefits
under part A of title XVIII of the Social Security Act
pursuant to subparagraph (A) or (C) of section
226(b)(2) of such Act (42 U.S.C. 426(b)(2));
(iii) whose entitlement to a benefit described in
subparagraph (A) of such section has terminated due to
performance of substantial gainful activity; and
(iv) who is retired under chapter 61 of this title.
(C) The Secretary of Defense shall coordinate with the
Secretary of Health and Human Services and the Commissioner of
Social Security to notify persons described in subparagraph (B)
of, and provide information and counseling regarding, the
effects of not enrolling in the supplementary medical insurance
program under part B of title XVIII of the Social Security Act
(42 U.S.C. 1395j et seq.), as described in subparagraph (A).
(e) A person covered by this section may elect to receive
inpatient medical care either in (1) Government facilities,
under the conditions prescribed in sections 1074 and 1076-1078
of this title, or (2) the facilities provided under a plan
contracted for under this section. However, under joint
regulations issued by the administering Secretaries, the right
to make this election may be limited for those persons residing
in an area where adequate facilities of the uniformed service
are available. In addition, subsections (b) and (c) of section
1080 of this title shall apply in making the determination
whether to issue a nonavailability of health care statement for
a person covered by this section.
(f) The provisions of section 1079(h) of this title shall
apply to payments for services by an individual health-care
professional (or other noninstitutional health-care provider)
under a plan contracted for under subsection (a).
(g) Section 1079(i) of this title shall apply to a plan
contracted for under this section, except that no person
eligible for health benefits under this section may be denied
benefits under this section with respect to care or treatment
for any service-connected disability which is compensable under
chapter 11 of title 38 solely on the basis that such person is
entitled to care or treatment for such disability in facilities
of the Department of Veterans Affairs.
(h)(1) Subject to paragraph (2), the Secretary of Defense
may, upon request, make payments under this section for a
charge for services for which a claim is submitted under a plan
contracted for under subsection (a) to a hospital that does not
impose a legal obligation on any of its patients to pay for
such services.
(2) A payment under paragraph (1) may not exceed the average
amount paid for comparable services in the geographic area in
which the hospital is located or, if no comparable services are
available in that area, in an area similar to the area in which
the hospital is located.
(3) The Secretary of Defense shall periodically review the
billing practices of each hospital the Secretary approves for
payment under this subsection to ensure that the hospital's
practices of not billing patients for payment are not resulting
in increased costs to the Government.
(4) The Secretary of Defense may require each hospital the
Secretary approves for payment under this subsection to provide
evidence that it has sources of revenue to cover unbilled
costs.
* * * * * * *
Sec. 1110a. Notification of certain individuals regarding options for
enrollment under Medicare part B
(a) In General.--(1) As soon as practicable, the Secretary of
Defense shall notify each individual described in subsection
(b)--
(A) that the individual is no longer eligible for
health care benefits under the TRICARE program under
this chapter; and
(B) of options available for enrollment of the
individual in the supplementary medical insurance
program under part B of title XVIII of the Social
Security Act (42 U.S.C. 1395j et seq.).
(2) In carrying out this subsection, the Secretary of Defense
shall--
(A) establish procedures for identifying individuals
described in subsection (b); and
(B) consult with the Secretary of Health and Human
Services to accurately identify and notify such
individuals.
(b) Individuals Described.--An individual described in this
subsection is an individual who is--
(1) a covered beneficiary;
(2) entitled to benefits under part A of title XVIII
of the Social Security Act (42 U.S.C. 1395c) under
section 226(b) or section 226A of such Act (42 U.S.C.
426(b) and 426-1); and
(3) eligible to enroll in the supplementary medical
insurance program under part B of such title (42 U.S.C.
1395j et seq.).
(c) Certain Individuals Not Required to Enroll in Medicare
Part B.--In carrying out subsection (a), the Secretary of
Defense shall coordinate with the Secretary of Health and Human
Services and the Commissioner of Social Security to--
(1) identify persons described in subparagraph (B) of
section 1086(d)(6) of this title; and
(2) provide information and counseling pursuant to
subparagraph (C) of such section.
* * * * * * *