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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\
---------------------------------------------------------------------------
    \1\Pub. L. No. 115-123
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \6\Department of Health and Human Services, Fiscal Year 2020 Health 
Resources and Services Administration Justification of Estimates for 
Appropriations Committees, 63.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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/).
---------------------------------------------------------------------------
    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.

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    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