,i  #aac? ,,congress  #a/ ,session  ,h4 
,r4 #bhaj  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,july #bd1 #bjac ,mr4 
,burgess 7= himself1 ,mr4 ,pallone1 ,mr4
 ,upton1 ,mr4 ,waxman1 ,mr4 ,pitts1 &   
,mr4 ,d+ell7 introduc$ ! foll[+ bill2   
:i* 0 ref]r$ to ! ,committee on ,en]gy &
 ,comm]ce1 & 9 addition to ! ,committees
 on ,ways & ,means & ! ,judici>y1 = a   
p]iod to be subsequ5tly det]m9$ by !    
,speak]1 9 ea* case = consid]ation ( su*
 provisions z fall )9 ! jurisdiction ( !
 committee conc]n$  ,a ,,bill  ,to am5d 
title ,,xviii ( ! ,social ,security ,act
 to re=m ! su/a9able gr[? rate & ,m$ic>e
 paym5t = physicians' s]vices1 & = o!r  
purposes4  #a4 ,%ort title2 table (     
cont5ts  7a7 ,%ort title ,?is ,act may  
be cit$ z ! ,m$ic>e ,pati5t ,access &   
,quality ,improvem5t ,act ( #bjac4  7b7 
,table ( cont5ts ,! table ( cont5ts (   
?is ,act is z foll[s3  ,sec4 #a4 ,%ort  
title2 table ( cont5ts4 ,sec4 #b4 ,re=m 
( su/a9able gr[? rate 7,,sgr7 & ,m$ic>e 
paym5t = physicians' s]vices4 ,sec4 #c4 

,exp&+ availability ( ,m$ic>e data4     
,sec4 #d4 ,enc\rag+ c>e coord9ation &   
m$ical homes4 ,sec4 #e4 ,miscellane\s4  
#b4 ,re=m ( su/a9able gr[? rate 7,,sgr7 
& ,m$ic>e paym5t = physicians' s]vices  
7a7 ,/abiliz+ fee updates 7,phase ,i7   
7#a7 ,repeal ( ,,sgr paym5t me?odology  
,section #ahdh ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #aciew-#d7 is       
am5d$--  7,a7 9 subsection 7d7--  7i7 9 
p>agraph 7#a77;,a71 by ins]t+ or a      
subsequ5t p>agraph or section #ahdh;,a  
aft] p>agraph 7#d72 &  7ii7 9 p>agraph  
7#d7--  7,i7 9 ! head+1 by /rik+ ye>s   
beg9n+ ) #bjja & ins]t+ #bjja1 #bjjb1 & 
#bjjc2 &  7,,ii7 9 subp>agraph 7,a71 by 
/rik+ a ye> beg9n+ ) #bjja & ins]t+     
#bjja1 #bjjb1 & #bjjc2 &  7,b7 9        
subsection 7f7--  7i7 9 p>agraph        
7#a77;,b71 by ins]t+ ?r\gh #bjac aft] ( 
su* succe$+ ye>2 &  7ii7 9 p>agraph     
7#b71 by ins]t+ & end+ ) #bjac aft]     
beg9n+ ) #bjjj4  7#b7 ,update ( rates = 
#bjad ?r\gh #bjah ,subsection 7d7 (     
section #ahdh ( ! ,social ,security ,act

 7#db ,u4,s4,c4 #aciew-#d7 is am5d$ by  
add+ at ! end ! foll[+ new p>agraph3    
7#ae7 ,update = #bjad ?r\gh #bjah ,!    
update to ! s+le conv]sion factor       
e/abli%$ 9 p>agraph 7#a77;,c7 = ea* (   
#bjad ?r\gh #bjah %all be #j4e p]c5t4  4
  7b7 ,quality update inc5tive program  
7,phase ,,ii7  7#a7 ,9 g5]al ,section   
#ahdh ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #aciew-#d71 z am5d$ by        
subsection 7a71 is fur!r am5d$--  7,a7 9
 subsection 7d71 by add+ at ! end !     
foll[+ new p>agraph3  7#af7 ,update     
beg9n+ ) #bjai  7,a7 ,9 g5]al ,subject  
to subp>agraph 7,b71 ! update to ! s+le 
conv]sion factor e/abli%$ 9 p>agraph    
7#a77;,c7 = ea* ye> beg9n+ ) #bjai %all 
be #j4e p]c5t4  7,b7 ,adju/m5t ,9 ! case
 ( an eligible pr(essional 7z def9$ 9   
subsection 7k77#c77 :o does n h a paym5t
 arrangem5t describ$ 9 section          
#ahdh;,a7a7 9 effect1 ! update "u       
subp>agraph 7,a7 = a ye> beg9n+ ) #bjai 
%all be adju/$ by ! applicable quality  
adju/m5t det]m9$ "u subsection 7q77#c7 =

 ! ye> involv$4  2 &  7,b7 9 subsection 
7i77#a7--  7i7 by /rik+ & at ! end (    
subp>agraph 7,d72  7ii7 by /rik+ ! p]iod
 at ! end ( subp>agraph 7,e7 & ins]t+ 1 
&2 &  7iii7 by add+ at ! end ! foll[+   
new subp>agraph3  7,f7 ! implem5tation (
 subsection 7q74  4  7#b7 ,enhanc+      
physician quality report+ sy/em to      
support quality update inc5tive program 
,section #ahdh ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #aciew-#d7 is       
am5d$--  7,a7 9 subsection 7k77#a71 9 ! 
fir/ s5t5ce1 by ins]t+ &1 if applicable1
 cl9ical practice improvem5t activities1
 aft] quality measures2  7,b7 9         
subsection 7k77#b7--  7i7 9 subp>agraph 
7,c7--  7,i7 9 ! subp>agraph head+1 by  
/rik+ & subsequ5t ye>s & ins]t+ ?r\gh   
#bjah2 &  7,,ii7 9 clause 7i71 by ins]t+
 7be=e #bjai7 aft] subsequ5t ye>2  7ii7 
by r$esignat+ subp>agraph 7,d7 z        
subp>agraph 7,e72  7iii7 by ins]t+ aft] 
subp>agraph 7,c7 ! foll[+ new           
subp>agraph3  7,d7 ,= #bjai & subsequ5t 
ye>s ,= purposes ( report+ data on      

quality measures &1 z applicable cl9ical
 practice improvem5t activities1 = cov]$
 pr(essional s]vices furni%$ dur+ !     
p]=mance p]iod 7z def9$ 9 subsection    
7q77#b77;,b77 ) respect to #bjai & !    
p]=mance p]iod ) respect to ea*         
subsequ5t ye>1 subject to subsection    
7q77#a77;,d71 ! quality measures &      
cl9ical practice improvem5t activities  
specifi$ "u ?is p>agraph %all be1 )     
respect to an eligible pr(essional1 !   
quality measures &1 z applicable1       
cl9ical practice improvem5t activities  
)9 ! f9al core measure set "u p>agraph  
7#i77;,f7 applicable to ! pe] cohort (  
su* provid] & ye> involv$4  2 &  7iv7 9 
subp>agraph 7,e71 z r$esignat$ by       
subp>agraph 7,b77ii7 ( ?is p>agraph1 by 
/rik+ & subsequ5t ye>s2  7,c7 9         
subsection 7k77#c7--  7i7 9 ! p>agraph  
head+1 by /rik+ ,cov]$ pr(essional      
s]vices & eligible pr(essionals def9$ & 
ins]t+ ,def9itions2 &  7ii7 by add+ at !
 end ! foll[+ new subp>agraphs3  7,c7   
,cl9ical practice improvem5t activities 

,! t]m cl9ical practice improvem5t      
activity means an activity t relevant   
eligible pr(essional organizations & o!r
 relevant /akehold]s id5tify z improv+  
cl9ical practice or c>e deliv]y & t !   
,secret>y det]m9es1 :5 effectively      
execut$1 is likely to result 9 improv$  
outcomes4  7,d7 ,eligible pr(essional   
organization ,! t]m eligible pr(essional
 organization means a pr(essional       
organization t is recogniz$ by !        
,am]ican ,bo>d ( ,m$ical ,specialties1  
,am]ican ,o/eopa?ic ,association1       
,am]ican ,bo>d ( ,physician             
,specialties1 or an equival5t           
c]tification bo>d4  7,e7 ,pe] cohort ,! 
t]m pe] cohort means a pe] cohort       
id5tifi$ on ! li/ "u p>agraph 7#i77;,b71
 z updat$ "u clause 7ii7 ( su* p>agraph4
  2  7,d7 9 subsection 7k77#g71 by /rik+
 & ! application ( p>agraphs 7#d7 & 7#e7
 & ins]t+ 1 ! application ( p>agraphs   
7#d7 & 7#e71 & ! implem5tation (        
p>agraph 7#i72  7,e7 by add+ at ! end ( 
subsection 7k7 ! foll[+ new p>agraph3   

7#i7 ,e/abli%m5t ( f9al core measure    
sets  7,a7 ,9 g5]al ,"u ! sy/em "u ?is  
subsection--  7i7 = ea* pe] cohort      
id5tifi$ "u subp>agraph 7,b7 & 9        
accordance ) ?is p>agraph1 !re %all be  
publi%$ a f9al core measure set "u      
subp>agraph 7,f71 :i* %all consi/ (     
quality measures & may also consi/ (    
cl9ical practice improvem5t activities1 
) respect to :i* eligible pr(essionals  
%all1 subject to subsection             
7m77#c77;,c71 be assess$ = purposes (   
det]m9+1 = ye>s beg9n+ ) #bjai1 !       
quality adju/m5t "u subsection 7q77#c7  
applicable to su* pr(essionals2 &  7ii7 
ea* eligible pr(essional %all           
self-id5tify1 9 accordance ) subp>agraph
 7,b71 )9 su* a pe] cohort = purposes ( 
su* assessm5ts4  7,b7 ,pe] cohorts ,!   
,secret>y %all id5tify 7& publi% a li/  
(7 pe] cohorts by :i* eligible          
pr(essionals %all self-id5tify =        
purposes ( ?is subsection & subsection  
7q7 ) respect to a p]=mance p]iod 7z    
def9$ 9 subsection 7q77#b77;,b77 = a ye>

 beg9n+ ) #bjai4 ,= purposes ( ?is      
subsection & subsection 7q71 ! ,secret>y
 %all develop "o or m pe] cohorts =     
multispecialty gr\ps1 ea* ( :i* %all be 
includ$ z a pe] cohort "u ?is           
subp>agraph4 ,su* self-id5tification w  
be made ?r\gh su* a process & at su* "t 
z specifi$ "u ! sy/em "u ?is subsection4
 ,su* li/--  7i7 %all include1 z pe]    
cohorts1 provid] specialties def9$ by ! 
,am]ican ,bo>d ( ,m$ical ,specialties or
 equival5t c]tification bo>ds & su* o!r 
cohorts z e/abli%$ "u ?is section 9 ord]
 to capture classifications ( provid]s  
across eligible pr(essional             
organizations & o!r practice areas1     
gr\p+s1 or categories2 &  7ii7 %all be  
updat$ f "t to "t4  7,c7 ,quality       
measures = core measure sets  7i7       
,developm5t ,"u ! sy/em "u ?is          
subsection !re %all be e/abli%$ a       
process = ! developm5t ( quality        
measures "u ?is subp>agraph = purposes (
 pot5tial inclusion ( su* measures 9    
core measure sets "u ?is p>agraph4 ,"u  

su* process--  7,i7 !re %all be         
coord9ation1 to ! ext5t possible1 across
 organizations develop+ su* measures2   
7,,ii7 eligible pr(essional             
organizations & o!r relevant /akehold]s 
may submit be/ practices & cl9ical      
practice guidel9es = ! developm5t (     
quality measures t address quality      
doma9s 7z def9$ "u clause 7ii77 =       
pot5tial inclusion 9 su* core measure   
sets2  7,,iii7 !re is enc\rag$ to be    
develop$1 z appropriate1 mean+ful       
outcome measures 7or quality ( life     
measures 9 cases = :i* outcomes may n be
 a valid measurem5t71 functional /atus  
measures1 & pati5t exp]i5ce measures2 & 
7,,iv7 measures develop$ "u ?is clause  
%all be develop$1 to ! ext5t possible1 9
 accordance ) be/ practices & cl9ical   
practice guidel9es4  7ii7 ,quality      
doma9s ,= purposes ( ?is p>agraph1 ! t]m
 quality doma9s means at lea/ ! foll[+  
doma9s3  7,i7 ,cl9ical c>e4  7,,ii7     
,safety4  7,,iii7 ,c>e coord9ation4     
7,,iv7 ,pati5t & c>egiv] exp]i5ce4  7,v7

 ,population heal? & prev5tion4  7,d7   
,process = e/abli%+ core measure sets   
7i7 ,9 g5]al ,"u ! sy/em "u ?is         
subsection1 = purposes ( subp>agraph    
7,a71 !re %all be e/abli%$ a process to 
approve f9al core measure sets "u ?is   
p>agraph = pe] cohorts4 ,ea* su* f9al   
core measure set %all be compos$ (      
quality measures 7&1 z applicable1      
cl9ical practice improvem5t activities7 
) respect to :i* eligible pr(essionals  
)9 su* pe] cohort %all report "u ?is    
subsection & be assess$ "u subsection   
7q74 ,su* process %all provide--  7,i7 =
 ! e/abli%m5t ( crit]ia1 :i* %all be    
made publicly available be=e ! reque/ is
 made "u clause 7ii71 = select+ su*     
measures & activities = pot5tial        
inclusion 9 su* a f9al core measure set2
 &  7,,ii7 t all pe] cohorts1 & to !    
ext5t practicable all quality doma9s1   
are address$ by measures &1 z           
applicable1 cl9ical practice improvem5t 
activities select$ to be includ$ 9 a    
core measure set "u ?is p>agraph1 :i*   

may include ?r\gh ! use ( su* a measure 
or cl9ical practice improvem5t activity 
t addresses m ?an "o su* doma9 or       
cohort4  7ii7 ,solicitation ( public    
input on quality measures & cl9ical     
practice improvem5t activities ,"u !    
process e/abli%$ "u clause 7i71 relevant
 eligible pr(essional organizations &   
o!r relevant /akehold]s %all be reque/$ 
to id5tify & submit quality measures &  
cl9ical practice improvem5t activities  
7z def9$ 9 p>agraph 7#c77;,c77 =        
selection "u ?is p>agraph4 ,= purposes (
 ! previ\s s5t5ce1 measures & activities
 may be submitt$ reg>dless ( :e!r su*   
measures 7 previ\sly publi%$ 9 a propos$
 rule or endors$ by an entity ) a       
contract "u section #ahij7;a74  7,e7    
,core measure sets  7i7 ,9 g5]al ,"u !  
process e/abli%$ "u subp>agraph 7,d77i71
 ! ,secret>y--  7,i7 %all select1 f     
quality measures describ$ 9 clause 7ii7 
applicable to a pe] cohort1 quality     
measures to be includ$ 9 a core measure 
set = su* cohort2  7,,ii7 %all1 to !    

ext5t !re are insuffici5t quality       
measures applicable to a pe] cohort to  
address "o or m applicable quality      
doma9s1 select to be includ$ 9 a core   
measure set = su* cohort su* cl9ical    
practice improvem5t activities describ$ 
9 clause 7ii77,,iv7 z are ne$$ &        
available to suffici5tly address su* an 
applicable doma9 ) respect to su* pe]   
cohort2 &  7,,iii7 may select1 to !     
ext5t det]m9$ appropriate1 any          
additional cl9ical practice improvem5t  
activities describ$ 9 clause 7ii77,,iv7 
applicable to a pe] cohort to be includ$
 9 a core measure set = su* cohort4     
,activities select$ "u ?is p>agraph %all
 be select$ ) consid]ation ( be/        
practices & cl9ical practice guidel9es  
id5tifi$ "u subp>agraph 7,c77i77,,ii74  
7ii7 ,s\rces ( quality measures &       
cl9ical practice improvem5t activities  
,a quality measure or cl9ical practice  
improvem5t activity select$ = inclusion 
9 a core measure set "u ! process "u    
subp>agraph 7,d77i7 %all be--  7,i7 a   

measure endors$ by a cons5sus-bas$      
entity2  7,,ii7 a measure develop$ "u   
p>agraph 7#b77;,c7 or a measure o!rwise 
appli$ or develop$ = a simil> purpose "u
 ?is section2  7,,iii7 a measure        
develop$ "u subp>agraph 7,c72 or  7,,iv7
 a measure or activity submitt$ "u      
subp>agraph 7,d77ii74  ,a measure or    
activity may be select$ "u ?is          
subp>agraph1 reg>dless ( :e!r su*       
measure or activity 0 previ\sly publi%$ 
9 a propos$ rule4 ,a measure s select$  
%all be evid5ce-bas$ b 7o!r ?an a       
measure describ$ 9 subclause 7,i77 %all 
n be requir$ to be cons5sus-bas$4  7iii7
 ,transp>5cy ,be=e publi%+ 9 a f9al     
regulation a core measure set "u clause 
7i7 z a f9al core measure set "u        
subp>agraph 7,f71 ! ,secret>y %all--    
7,i7 submit = publication 9 applicable  
specialty-appropriate pe]-review$       
j\rnals su* core measure set "u clause  
7i7 & ! me?od = develop+ & select+      
measures )9 su* set1 includ+ cl9ical &  
o!r data support+ su* measures1 &1 z    

applicable1 ! me?od = select+ cl9ical   
practice improvem5t activities includ$  
)9 su* set2 &  7,,ii7 reg>dless ( :e!r  
or n ! core measure set or me?od is     
publi%$ 9 su* a j\rnal "u subclause     
7,i71 provide = notice ( ! propos$      
regulation 9 ! ,f$]al ,regi/]1 includ+ )
 respect to ! applicable me?ods & data  
describ$ 9 subclause 7,i71 & a p]iod =  
public comm5t !reon4  7,f7 ,f9al core   
measure sets ,n lat] ?an ,novemb] #ae ( 
! ye> prior to ! fir/ day ( a p]=mance  
p]iod1 ! ,secret>y %all publi% a f9al   
regulation 9 ! ,f$]al ,regi/] t includes
 a f9al core measure set 7& ! applicable
 me?ods & data describ$ 9 subp>agraph   
7,e77iii77,i77 = ea* pe] cohort to be   
appli$ = su* p]=mance p]iod4  7,g7      
,p]iodic review & updates  7i7 ,9 g5]al 
,9 c>ry+ out ?is p>agraph1 "u ! sy/em "u
 ?is subsection1 !re %all p]iodically be
 review$--  7,i7 ! quality measures &   
cl9ical practice improvem5t activities  
select$ = inclusion 9 f9al core measure 
sets "u ?is p>agraph = ea* ye> su*      

measures & activities are to be appli$  
"u ?is subsection or subsection 7q7 to  
ensure t su* measures & activities      
cont9ue to meet ! conditions applicable 
to su* measures & activities = su*      
selection2 &  7,,ii7 ! f9al core measure
 sets publi%$ "u subp>agraph 7,f7 = ea* 
ye> su* sets are to be appli$ to pe]    
cohorts ( eligible pr(essionals to      
ensure t ea* applicable set cont9ues to 
meet ! conditions applicable to su* sets
 be=e be+ s publi%$4  7ii7              
,collaboration ) /akehold]s ,9 c>ry+ out
 clause 7i71 relevant eligible          
pr(essional organizations & o!r relevant
 /akehold]s may id5tify & submit updates
 to quality measures & cl9ical practice 
improvem5t activities select$ "u ?is    
p>agraph = inclusion 9 f9al core measure
 sets z well z any additional quality   
measures & cl9ical practice improvem5t  
activities4 ,n lat] ?an ,novemb] #ae ( !
 ye> prior to ! fir/ day ( a p]=mance   
p]iod1 submissions "u ?is clause %all be
 review$4  7iii7 ,additional1 & updates 

to1 measures & activities ,bas$ on !    
review conduct$ "u ?is subp>agraph = a  
p]iod1 z ne$$1 !re %all be--  7,i7      
select$ additional1 & updates to1       
quality measures & cl9ical practice     
improvem5t activities select$ "u ?is    
p>agraph = pot5tial inclusion 9 f9al    
core measure sets 9 ! same mann] su*    
quality measures & cl9ical practice     
improvem5t activities are select$ "u ?is
 p>agraph = su* pot5tial inclusion2     
7,,ii7 remov$1 f f9al core measure sets1
 quality measures & cl9ical practice    
improvem5t activities t are no long]    
mean+ful2 &  7,,iii7 updat$ f9al core   
measure sets publi%$ "u subp>agraph 7,f7
 9 ! same mann] z su* sets are approv$  
"u su* subp>agraph4  ,= purposes ( ?is  
subsection & subsection 7q71 a f9al core
 measure set1 z updat$ "u ?is           
subp>agraph1 %all be treat$ 9 ! same    
mann] z a f9al core measure set publi%$ 
"u subp>agraph 7,f74  7iv7 ,transp>5cy  
7,i7 ,notification requir$ = c]ta9      
updates ,9 ! case ( an update "u        

subclause 7,,ii7 or 7,,iii7 ( clause    
7iii7 t adds1 mat]ially *anges1 or      
removes a measure or activity f a       
measure set1 su* update %all n apply "u 
?is subsection or subsection 7q7 unless 
notification ( su* update is made       
available to applicable eligible        
pr(essionals4  7,,ii7 ,public           
availability ( updat$ f9al core measure 
sets ,subp>agraph 7,e77iii7 %all apply )
 respect to measure sets updat$ "u      
subclause 7,,ii7 or 7,,iii7 ( clause    
7iii7 9 ! same mann] z su* subp>agraph  
applies to applicable core measure sets 
"u subp>agraph 7,e74  7,h7 ,coord9ation 
) exi/+ programs ,! developm5t &        
selection ( quality measures & cl9ical  
practice improvem5t activities "u ?is   
p>agraph %all1 z appropriate1 be        
coord9at$ ) ! developm5t & selection (  
exi/+ measures & requirem5ts1 su* z !   
developm5t ( ! ,physician ,comp>e       
,website "u subsection 7m77#e77;,g7 & ! 
application ( res\rce use managem5t "u  
subsection 7n74 ,to ! ext5t feasible1   

su* measures & activities %all align )  
measures us$ by o!r pay]s & ) measures &
 activities 9 use "u o!r programs 9 ord]
 to /reaml9e ! process ( su* developm5t 
& selection "u ?is p>agraph4 ,!         
,secret>y %all develop a plan to        
integrate report+ on quality measures "u
 ?is subsection ) report+ requirem5ts "u
 subsection 7o7 relat+ to ! mean+ful use
 ( c]tifi$ ,,ehr te*nology4  7,i7       
,consultation ) relevant eligible       
pr(essional organizations & o!r relevant
 /akehold]s ,relevant eligible          
pr(essional organizations 7z def9$ 9    
p>agraph 7#c77;,d77 & o!r relevant      
/akehold]s1 includ+ ,/ate & national    
m$ical societies1 %all be consult$ 9    
c>ry+ out ?is p>agraph4  7,j7 ,optional 
application ,! process "u section       
#ahij;,a is n requir$ to apply to !     
developm5t or selection ( measures "u   
?is p>agraph4  2 &  7,f7 9 subsection   
7m77#c77;,c77i71 by add+ at ! end !     
foll[+ new s5t5ce3 ,su* process %all1   
beg9n+ = #bjai1 treat eligible          

pr(essionals 9 su* a gr\p practice z    
report+ on measures = purposes (        
application ( subsections 7q7 &         
7a77#h77;,a77iii7 if1 9 lieu ( report+  
measures "u subsection 7k77#b77;,d71 !  
gr\p practice reports measures det]m9$  
appropriate by ! ,secret>y44  7#c7      
,e/abli%m5t ( quality update inc5tive   
program  7,a7 ,9 g5]al ,section #ahdh ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#aciew-#d7 is am5d$ by add+ at ! end !  
foll[+ new subsection3  7q7 ,quality    
update inc5tive program  7#a7           
,e/abli%m5t  7,a7 ,9 g5]al ,! ,secret>y 
%all e/abli% an eligible pr(essional    
quality update inc5tive program 79 ?is  
section ref]r$ to z ! quality update    
inc5tive program7 "u :i*--  7i7 !re is  
develop$ & appli$1 9 accordance )       
p>agraph 7#b71 appropriate me?odologies 
= assess+ ! p]=mance ( eligible         
pr(essionals ) respect to quality       
measures & cl9ical practice improvem5t  
activities includ$ )9 ! f9al core       
measure sets publi%$ "u subsection      

7k77#i77;,f7 applicable to ! pe] cohorts
 ( su* provid]s2  7ii7 !re is appli$1   
consi/5t ) ! sy/em "u subsection 7k71   
me?ods = collect+ in=mation ne$$ = su*  
assessm5ts 7:i* %all involve ! m9imum   
am\nt ( adm9i/rative burd5 requir$ to   
ensure reliable results72 &  7iii7 !    
applicable update adju/m5ts "u p>agraph 
7#c7 are det]m9$ by su* assessm5ts4     
7,b7 ,def9itions  7i7 ,eligible         
pr(essional ,9 ?is subsection1 ! t]m    
eligible pr(essional has ! mean+ giv5   
su* t]m 9 subsection 7k77#c71 except t  
su* t]m %all n include a pr(essional :o 
has a paym5t arrangem5t describ$ 9      
section #ahdh;,a7a77#a7 9 effect4  7ii7 
,pe] cohorts2 cl9ical practice          
improvem5t activities2 eligible         
pr(essional organizations ,9 ?is        
subsection1 ! t]ms pe] cohort1 cl9ical  
practice improvem5t activity1 & eligible
 pr(essional organization h ! mean+s    
giv5 su* t]ms 9 subsection 7k77#c74     
7,c7 ,consultation ) eligible           
pr(essional organizations & o!r relevant

 /akehold]s ,eligible pr(essional       
organizations & o!r relevant /akehold]s1
 includ+ ,/ate & national m$ical        
societies1 %all be consult$ 9 c>ry+ out 
?is subsection4  7,d7 ,application at   
gr\p practice level ,! ,secret>y %all   
e/abli% a process1 consi/5t ) subsection
 7m77#c77;,c71 "u :i* ! provisions ( ?is
 subsection are appli$ to eligible      
pr(essionals 9 a gr\p practice if ! gr\p
 practice reports measures det]m9$      
appropriate by ! ,secret>y "u su*       
subsection4  7,e7 ,coord9ation ) exi/+  
programs ,! application ( measures &    
cl9ical practice improvem5t activities &
 assessm5t ( p]=mance "u ?is subsection 
%all1 z appropriate1 be coord9at$ ) !   
application ( measures & assessm5t (    
p]=mance "u o!r provisions ( ?is        
section4  7#b7 ,assess+ p]=mance )      
respect to f9al core measure sets =     
applicable pe] cohorts  7,a7 ,e/abli%m5t
 ( me?ods = assessm5t  7i7 ,9 g5]al ,"u 
! quality update inc5tive program1 !    
,secret>y %all--  7,i7 e/abli% "o or m  

me?ods1 applicable ) respect to a       
p]=mance p]iod1 to assess 7us+ a scor+  
scale ( #j to #ajj7 ! p]=mance ( an     
eligible pr(essional ) respect to1      
subject to p>agraph 7#a77;,d71 quality  
measures & cl9ical practice improvem5t  
activities includ$ )9 ! f9al core       
measure set publi%$ "u subsection       
7k77#i77;,f7 applicable = ! p]iod to !  
pe] cohort 9 :i* ! provid] self-id5tifi$
 "u subsection 7k77#i77;,b7 = su* p]iod2
 &  7,,ii7 subject to p>agraph          
7#a77;,d71 compute a composite score =  
su* provid] = su* p]=mance p]iod )      
respect to ! measures & activities      
includ$ )9 su* f9al core measure set4   
7ii7 ,me?ods ,su* me?ods %all1 ) respect
 to an eligible pr(essional1 provide t !
 p]=mance ( su* pr(essional %all1       
subject to p>agraph 7#a77;,d71 be       
assess$ = a p]=mance p]iod ) respect to 
! quality measures & cl9ical practice   
improvem5t activities )9 ! f9al core    
measure set = su* p]iod = ! pe] cohort (
 su* pr(essional & on :i* in=mation is  

collect$ f su* pr(essional4  7iii7      
,weight+ ( measures ,su* a me?od may    
provide = ! assignm5t ( diff]5t scor+   
weights or1 z appropriate1 o!r factors--
  7,i7 = quality measures & cl9ical     
practice improvem5t activities2  7,,ii7 
bas$ on ! type or category ( measure or 
activity2 &  7,,iii7 bas$ on ! ext5t to 
:i* a quality measure or cl9ical        
practice improvem5t activity mean+fully 
assesses quality4  7iv7 ,risk adju/m5t  
,su* a me?od %all provide = appropriate 
risk adju/m5ts4  7v7 ,incorporation (   
o!r me?ods ( measur+ physician quality  
,9 e/abli%+ su* me?ods1 !re %all be1 z  
appropriate1 incorporat$ comp>able      
me?ods ( measurem5t f physician quality 
inc5tive programs "u ?is subsection4    
7,b7 ,p]=mance p]iod ,!re %all be       
e/abli%$ a p]iod 79 ?is subsection      
ref]r$ to z a p]=mance p]iod71 ) respect
 to a ye> 7beg9n+ ) #bjai7 = :i* !      
quality adju/m5t is appli$ "u p>agraph  
7#c71 to assess p]=mance on quality     
measures & cl9ical practice improvem5t  

activities4 ,ea* su* p]=mance p]iod %all
 be a p]iod ( #ab consecutive mon?s &   
%all end z close z possible to ! beg9n+ 
( ! ye> = :i* su* adju/m5t is appli$4   
7#c7 ,quality adju/m5t tak+ into acc\nt 
quality assessm5ts  7,a7 ,quality       
adju/m5t ,= purposes ( subsection       
7d77#af71 if ! composite score comput$  
"u p>agraph 7#b77;,a7 = an eligible     
pr(essional = a ye> 7beg9n+ ) #bjai7    
is--  7i7 a score ( #fg or high]1 !     
quality adju/m5t "u ?is p>agraph = !    
eligible pr(essional & ye> is #a        
p]c5tage po9t2  7ii7 a score ( at lea/  
#cd1 b bel[ #fg1 ! quality adju/m5t "u  
?is p>agraph = ! eligible pr(essional & 
ye> is z]o2 or  7iii7 a score bel[ #cd1 
! quality adju/m5t "u ?is p>agraph = !  
eligible pr(essional & ye> is #a        
p]c5tage po9t4  7,b7 ,no effect on      
subsequ5t ye>s' quality adju/m5ts ,ea*  
su* quality adju/m5t %all be made ea*   
ye> )\t reg>d to ! update adju/m5t = a  
previ\s ye> "u ?is p>agraph4  7#d7      
,transition = new eligible pr(essionals 

,9 ! case ( a physician1 practition]1 or
 o!r suppli] t dur+ a p]=mance p]iod1 ) 
respect to a ye> = :i* a quality        
adju/m5t is appli$ "u p>agraph 7#c71    
fir/ becomes an eligible pr(essional 7& 
_h n previ\sly submitt$ claims "u ?is   
title z a p]son1 z an entity1 or z "p ( 
a physician gr\p or "u a diff]5t bill+  
numb] or tax id5tifi]71 ! quality       
adju/m5t "u ?is subsection applicable to
 su* physician1 practition]1 or         
suppli]--  7,a7 = su* ye>1 ) respect to 
su* fir/ p]=mance p]iod1 %all be z]o2 & 
7,b7 = a ye>1 ) respect to a subsequ5t  
p]=mance p]iod1 %all be ! quality       
adju/m5t t w\ld o!rwise be appli$ "u ?is
 subsection4  7#e7 ,fe$back  7,a7       
,fe$back  7i7 ,ongo+ fe$back ,"u !      
process "u subsection 7m77#e77;,h71 !re 
%all be provid$1 z real "t z possible1 b
 at lea/ qu>t]ly1 to ea* eligible       
pr(essional fe$back--  7,i7 on !        
p]=mance ( su* provid] ) respect to     
quality measures & cl9ical practice     
improvem5t activities )9 ! f9al core    

measure set publi%$ "u subsection       
7k77#i77;,f7 = ! applicable p]=mance    
p]iod & ! pe] cohort ( su* pr(essional2 
&  7,,ii7 to assess ! progress ( su*    
pr(essional "u ! quality update inc5tive
 program ) respect to a p]=mance p]iod =
 a ye>4  7ii7 ,use ( regi/ries & o!r    
me*anisms ,fe$back "u ?is subp>agraph   
%all1 to ! ext5t an eligible pr(essional
 *ooses to p>ticipate 9 a data regi/ry =
 purposes ( ?is subsection 7includ+     
regi/ries "u subsections 7k7 & 7m771 be 
provid$ & bas$ on p]=mance receiv$ ?r\gh
 ! use ( su* regi/ry1 & to ! ext5t t an 
eligible pr(essional *ooses n to        
p>ticipate 9 su* a regi/ry = su*        
purposes1 be provid$ ?r\gh o!r simil>   
me*anisms t all[ = ! provision ( su*    
fe$back & receipt ( su* p]=mance        
in=mation4  7,b7 ,data me*anism ,"u !   
quality update inc5tive program1 !re    
%all be develop$ an electronic          
int]active eligible pr(essional me*anism
 ?r\gh :i* su* a pr(essional may receive
 p]=mance data1 includ+ data ) respect  

to p]=mance on ! measures & activities  
develop$ & select$ "u ?is section4 ,su* 
me*anism %all be develop$ 9 consultation
 ) private pay]s & heal? insurance      
issu]s 7z def9$ 9 section #bgia7;b77#b7 
( ! ,public ,heal? ,s]vice ,act7 z      
appropriate4  7,c7 ,transf] ( funds ,!  
,secret>y %all provide = ! transf] (    
#ajj1jjj1jjj f ! ,f$]al ,supplem5t>y    
,m$ical ,insurance ,tru/ ,fund e/abli%$ 
9 section #ahda to ! ,c5t] = ,m$ic>e    
,m$icaid ,s]vices ,program ,managem5t   
,acc\nt to support su* ef=ts to develop 
! infra/ructure z necess>y to c>ry out  
subsection 7k77#i7 & ?is subsection & = 
purposes ( section #ahhi7;h74 ,su* funds
 %all be s transf]r$ on ! date ( !      
enactm5t ( ?is subsection & %all rema9  
available until exp5d$4  4  7,b7        
,inc5tive to report "u ,quality ,update 
,inc5tive ,program ,section             
#ahdh7;a77#h77;,a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#aciew-#d7;a77#h77;,a77 is am5d$--  7i7 
9 clause 7i71 by /rik+ ,) respect to &  

ins]t+ ,subject to clause 7iii71 )      
respect to2 &  7ii7 by add+ at ! end !  
foll[+ new clause3  7iii7 ,application  
to eligible pr(essionals n report+ ,)   
respect to cov]$ pr(essional s]vices 7z 
def9$ 9 subsection 7k77#c77 furni%$ by  
an eligible pr(essional dur+ #bjai or   
any subsequ5t ye>1 if ! eligible        
pr(essional does n submit data = !      
p]=mance p]iod 7z def9$ 9 subsection    
7q77#b77;,b77 ) respect to su* ye> on1  
subject to subsection 7q77#a77;,d71 !   
quality measures &1 z applicable1       
cl9ical practice improvem5t activities  
)9 ! f9al core measure set "u subsection
 7k77#i77;,f7 applicable to ! pe] cohort
 ( su* provid]1 ! fee s*$ule am\nt = su*
 s]vices furni%$ by su* pr(essional dur+
 ! ye> 7includ+ ! fee s*$ule am\nt =    
purposes ( det]m9+ a paym5t bas$ on su* 
am\nt7 %all be equal to #ie p]c5t 79    
lieu ( ! applicable p]c5t7 ( ! fee      
s*$ule am\nt t w\ld o!rwise apply to su*
 s]vices "u ?is subsection 7det]m9$ aft]
 application ( p>agraphs 7#c71 7#e71 &  

7#g71 b )\t reg>d to ?is p>agraph74 ,!  
,secret>y %all develop a m9imum p] ye>  
caseload ?re%old1 ) respect to eligible 
pr(essionals1 & ! previ\s s5t5ce %all n 
apply to eligible pr(essionals ) a      
caseload = a ye> bel[ su* ?re%old = su* 
ye>4  4  7,c7 ,education on quality     
update inc5tive program ,section #ahhi (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #aciezz7 is am5d$ by add+ at ! end !   
foll[+ new subsection3  7h7 ,quality    
update inc5tive program ,"u ?is section1
 in=mation %all be dissem9at$ to educate
 & assi/ eligible pr(essionals 7z def9$ 
9 section #ahdh7k77#c77 ab\t ! quality  
update inc5tive program "u section      
#ahdh7q7 & quality measures "u section  
#ahdh7k77#i7 ?r\gh multiple approa*es1  
includ+ a national dissem9ation /rategy 
& outrea* by m$ic>e contractors4  4     
7#d7 ,con=m+ am5dm5ts  7,a7 ,treatm5t ( 
satisfactorily report+ ,,pqrs measures  
?r\gh p>ticipation 9 a qualifi$ cl9ical 
data regi/ry ,section #ahdh7m77#c77;,d7 
( ! ,social ,security ,act 7#db         

,u4,s4,c4 #aciew-#d7m77#c77;,d77 is     
am5d$ by /rik+ ,= #bjad & subsequ5t ye>s
 & ins]t+ ,= ea* ( #bjad ?r\gh #bjah4   
7,b7 ,coord9at+ enhanc$ ,,pqrs report+ )
 ,,ehr ,section #ahdh7o77#b77;,b77iii7 (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #aciew-#d7o77#b77;,b77iii77 is am5d$ by
 /rik+ subsection 7k77#b77;,c7 & ins]t+ 
subp>agraph 7,c7 or 7,d7 ( subsection   
7k77#b74  7,c7 ,coord9at+ ,,pqrs report+
 p]iod ) quality update inc5tive program
 p]=mance p]iod ,section                
#ahdh7m77#f77;,c7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4                     
#aciew-#d7m77#f77;,c77 is am5d$--  7i7 9
 clause 7i71 by /rik+ & 7iii7 & ins]t+ 1
 7iii71 & 7iv72 &  7ii7 by add+ at ! end
 ! foll[+ new clause3  7iv7 ,coord9ation
 ) quality update inc5tive program ,=   
#bjai & ea* subsequ5t ye> ! report+     
p]iod %all be coord9at$ ) ! p]=mance    
p]iod "u subsection 7q77#b77;,b74  4    
7,d7 ,coord9at+ ,,ehr report+ ) quality 
update inc5tive program p]=mance p]iod  
,section #ahdh7o77#e77;,b7 ( ! ,social  

,security ,act 7#db ,u4,s4,c4           
#aciew-#d7o77#e77;,b77 is am5d$ by add+ 
at ! end ! foll[+3 ,beg9n+ = #bjai1 !   
,,ehr report+ p]iod %all be coord9at$ ) 
! p]=mance p]iod "u subsection          
7q77#b77;,b744  7c7 ,advanc+ alt]native 
paym5t models  7#a7 ,9 g5]al ,"p ,b (   
title ,,xviii ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciew-#d et seq47 is   
am5d$ by add+ at ! end ! foll[+ new     
section3  #ahdh;,a4 ,advanc+ alt]native 
paym5t models  7a7 ,paym5t model *oice  
program ,paym5t = cov]$ pr(essional     
s]vices 7z def9$ 9 section #ahdh7k77 t  
are furni%$ by an eligible pr(essional  
7z def9$ 9 su* section7 "u an           
,alt]native ,paym5t ,model specifi$ on !
 li/ "u subsection 7h7 79 ?is section   
ref]r$ to z an eligible ,,apm7 %all be  
made "u ?is title 9 accordance ) !      
paym5t arrangem5t "u su* model4 ,9      
apply+ ! previ\s s5t5ce1 su* a          
pr(essional ) su* a paym5t arrangem5t 9 
effect1 %all be deem$ = purposes (      
section #ahdh7;a77#h7 to be             

satisfactorily submitt+ data on quality 
measures = su* cov]$ pr(essional        
s]vices4  7b7 ,process = implem5t+      
eligible ,a,p,ms  7#a7 ,9 g5]al ,=      
purposes ( subsection 7a7 & 9 accordance
 ) ?is section1 ! ,secret>y %all e/abli%
 a process "u :i*--  7,a7 a contract is 
ent]$ into1 9 accordance ) p>agraph     
7#b72  7,b7 proposals = pot5tial        
,alt]native ,paym5t ,models are submitt$
 9 accordance ) subsection 7c72  7,c7   
,alt]native ,paym5t ,models s propos$   
are recomm5d$1 9 accordance ) subsection
 7d71 = evaluation1 includ+ ?r\gh !     
demon/ration program "u subsection 7e71 
& approval "u subsection 7f72  7,d7     
applicable ,alt]native ,paym5t ,models  
are evaluat$ "u su* demon/ration        
program2  7,e7 models are implem5t$ z   
eligible ,a,p,ms 9 accordance )         
subsection 7f72 &  7,f7 a compreh5sive  
li/ ( all eligible ,a,p,ms is made      
publicly available1 9 accordance )      
subsection 7h71 = application "u        
subsection 7a74  7#b7 ,contract ) ,,apm 

contract+ entity  7,a7 ,9 g5]al ,=      
purposes ( p>agraph 7#a77;,a71 !        
,secret>y %all id5tify & h 9 effect a   
contract ) an indep5d5t entity t has    
appropriate exp]tise to c>ry out !      
functions applicable to su* entity "u   
?is section4 ,su* entity %all be ref]r$ 
to 9 ?is section z ! ,,apm contract+    
entity4  7,b7 ,tim+ = fir/ contract ,z  
soon z practicable1 b n lat] ?an "o ye> 
aft] ! date ( ! enactm5t ( ?is section1 
! ,secret>y %all ent] into ! fir/       
contract "u subp>agraph 7,a74  7,c7     
,competitive proc$ures ,competitive     
proc$ures 7z def9$ 9 section #d7e7 ( !  
,(fice ( ,f$]al ,procurem5t ,policy ,act
 7#da ,u4,s4,c4 #djc7e777 %all be us$ to
 ent] into a contract "u subp>agraph    
7,a74  7c7 ,submission ( propos$        
,alt]native ,paym5t ,models ,beg9n+ n   
lat] ?an #ij days aft] ! date !         
,secret>y ent]s into a contract "u      
subsection 7b77#b7 ) ! ,,apm contract+  
entity1 physicians1 eligible pr(essional
 organizations1 heal? c>e provid]       

organizations1 & o!r entities may submit
 to ! ,,apm contract+ entity proposals =
 ,alt]native ,paym5t ,models =          
application "u ?is section4 ,su* a      
proposal ( a model %all include         
sugge/ions = measures to be us$ "u      
subsection 7e77#a77;,b7 = purposes (    
evaluat+ su* model4 ,9 review+          
submissions "u ?is subsection = purposes
 ( mak+ recomm5dations "u subsection    
7d77#a71 ! contract+ entity %all focus  
on submissions = su* models t are int5d$
 to improve c>e coord9ation & quality = 
pati5ts ?r\gh modify+ ! mann] 9 :i*     
physicians & o!r provid]s are paid "u   
?is title4  7d7 ,recomm5dation by ,,apm 
contract+ entity ( propos$ models  7#a7 
,recomm5dation  7,a7 ,9 g5]al ,"u !     
process "u subsection 7b71 ! ,,apm      
contract+ entity %all at lea/ annually  
recomm5d to ! ,secret>y--  7i7 bas$ on !
 crit]ia describ$ 9 subp>agraph 7,b71   
,alt]native ,paym5t ,models submitt$ "u 
subsection 7c7 to be evaluat$ ?r\gh a   
demon/ration program "u subsection 7e72 

&  7ii7 bas$ on ! crit]ia describ$ 9    
subp>agraph 7,c71 ,alt]native ,paym5t   
,models submitt$ "u subsection 7c7 =    
purposes ( implem5tation "u subsection  
7f71 )\t evaluation ?r\gh su* a         
demon/ration program4  ,su* a           
recomm5dation may be made ) respect to a
 model = :i* a waiv] w\ld be requir$ "u 
p>agraph 7#b74  7,b7 ,crit]ia =         
recomm5d+ models = demon/ration ,! ,,apm
 contract+ entity %all make a           
recomm5dation "u subp>agraph 7,a77i71 ) 
respect to an ,alt]native ,paym5t       
,model1 only if ! entity det]m9es t !   
model satisfies ea* ( ! foll[+ crit]ia3 
7i7 ,! model has be5 support$ by        
mean+ful cl9ical & non-cl9ical data1 )  
respect to a suffici5t population       
sample1 t indicates ! model w\ld be     
successful at address+ ea* ( ! abilities
 describ$ 9 clause 7v74  7ii7 7,i7 ,9 ! 
case ( a model t has already be5        
evaluat$ & support$ by data ) respect to
 a population ( individuals enroll$ "u  
?is "p1 if ! model 7 evaluat$ "u !      

demon/ration "u subsection 7e7 su* a    
population w\ld repres5t a suffici5t    
numb] ( individuals enroll$ "u ?is "p to
 ensure mean+ful evaluation4  7,,ii7 ,9 
! case ( a model t has n be5 s evaluat$ 
& support$ by data ) respect to su* a   
population1 ! population t w\ld be      
furni%$ s]vices "u su* model if ! model 
7 evaluat$ "u ! demon/ration "u         
subsection 7e7 w\ld repres5t a suffici5t
 numb] ( individuals enroll$ "u ?is "p  
to ensure mean+ful evaluation4  7iii7   
,su* model1 includ+ if evaluat$ "u !    
demon/ration "u subsection 7e71 w\ld n  
d5y or limit ! cov]age or provision (   
b5efits "u ?is title = applicable       
individuals4  7iv7 ,! implem5tation (   
su* model z an eligible ,,apm "u ?is    
section is expect$--  7,i7 to r$uce     
sp5d+ "u ?is title )\t r$uc+ ! quality (
 c>e2 or  7,,ii7 improve ! quality (    
pati5t c>e )\t increas+ sp5d+4  7v7 ,!  
proposal = su* model demon/rates--  7,i7
 ! pot5tial to successfully manage ! co/
 ( furni%+ items & s]vices "u ?is title 

s z to n result 9 exp5ditures "u ?is    
title = individuals p>ticipat+ "u su*   
,,apm be+ great] ?an exp5ditures "u ?is 
title = su* individuals if ! ,,apm 7 n  
implem5t$2  7,,ii7 ! ability to ma9ta9  
or improve ! ov]all pati5t c>e2 &       
7,,iii7 ! ability to ma9ta9 or improve !
 quality ( c>e provid$ to individuals   
enroll$ "u ?is "p :o p>ticipate "u su*  
mode4  7vi7 ,! model provides = a paym5t
 arrangem5t--  7,i7 cov]+ at lea/ items 
& s]vices furni%$ "u ?is "p by eligible 
pr(essionals p>ticipat+ 9 ! model2      
7,,ii7 9 ! case su* paym5t arrangem5t   
does n provide = paym5t "u ! fee s*$ule 
"u section #ahdh = su* items & s]vices  
furni%$ by su* eligible pr(essionals1 t 
provides = a paym5t adju/m5t bas$ on    
mean+ful ,,ehr use comp>able to su*     
adju/m5t t w\ld o!rwise apply "u section
 #ahdh2 &  7,,iii7 t provides = a paym5t
 adju/m5t bas$ on quality measures      
comp>able to su* adju/m5t t w\ld o!rwise
 apply "u section #ahdh4  7,c7 ,crit]ia 
= recomm5d+ models = approval )\t       

evaluation "u demon/ration ,! ,,apm     
contract+ entity may make a             
recomm5dation "u subp>agraph 7,a77ii71 )
 respect to an ,alt]native ,paym5t      
,model1 only if ! entity det]m9es t !   
model has already be5 evaluat$ = a      
suffici5t en\gh p]iod & ?r\gh su*       
evaluation ! model 0 %[n--  7i7 to h    
satisfi$ ! crit]ia describ$ 9 ea* (     
clauses 7i71 7ii71 7iii71 & 7vi7 (      
subp>agraph 7,b72  7ii7 to demon/rate   
ea* ( ! abilities describ$ 9 clause 7v7 
( su* subp>agraph2 &  7iii7 7,i7 to     
r$uce sp5d+ "u ?is title )\t r$uc+ !    
quality ( c>e2 or  7,,ii7 improve !     
quality ( pati5t c>e )\t increas+ sp5d+4
  7,d7 ,transp>5cy & disclosures  7i7   
,disclosures ,n lat] ?an #ij days aft]  
receipt ( a submission ( a model "u     
subsection 7c7 by an entity1 ! ,,apm    
contract+ entity %all submit to !       
,secret>y & su* entity & make publicly  
available a notification on :e!r or n1 &
 if s h[1 ! model meets crit]ia =       
recomm5d+ su* model "u subp>agraph 7,a71

 includ+ :e!r or n su* model requires a 
waiv] "u p>agraph 7#b74 ,9 ! case t !   
,,apm contract+ entity det]m9es n to    
recomm5d su* model "u ?is p>agraph1 su* 
notification %all include an explanation
 ( ! reasons = n mak+ su* a             
recomm5dation4 ,any in=mation made      
publicly available pursuant to ! previ\s
 s5t5ce %all n include propriet>y data4 
7ii7 ,submission ( recomm5d$ models ,!  
,,apm contract+ entity %all at lea/     
qu>t]ly submit to ! ,secret>y1 ! ,m$ic>e
 ,paym5t ,advisory ,commission1 & !     
,*ief ,actu>y ( ! ,c5t]s = ,m$ic>e      
,m$icaid ,s]vices ! foll[+3  7,i7 ,!    
models recomm5d$ "u subp>agraph 7,a77i71
 includ+ any su* models t require a     
waiv] "u p>agraph 7#b71 & ! data &      
analyses on su* recomm5d$ models t      
support ! crit]ia describ$ 9 subp>agraph
 7,b74  7,,ii7 ,! models recomm5d$ "u   
subp>agraph 7,a77ii71 includ+ any su*   
models t require a waiv] "u p>agraph    
7#b71 & ! data & analyses on su*        
recomm5d$ models t support ! crit]ia    

describ$ 9 subp>agraph 7,c74  ,= any ye>
 beg9n+ ) #bjae t ! ,,apm contract+ does
 n recomm5d any models "u subp>agraph   
7,a71 ! entity %all in/ead satisfy ?is  
clause by submitt+ to ! ,secret>y & mak+
 publicly available an explanation = n  
hav+ any su* recomm5dations4  7#b7      
,models requir+ waiv] approval  7,a7 ,9 
g5]al ,9 ! case t an ,alt]native ,paym5t
 ,model recomm5d$ "u p>agraph           
7#a77;,a77i7 w\ld require a waiv] f any 
requirem5t "u ?is title1 9 det]m9+      
approval ( su* model1 ! ,secret>y may   
make su* a waiv] 9 ord] = su* model to  
be evaluat$ "u ! demon/ration program   
7if describ$ 9 clause 7i7 ( su*         
p>agraph74  7,b7 ,approval ,n lat] ?an  
#ij days aft] ! date ( ! receipt ( su*  
submission = a model1 ! ,secret>y %all  
notify ! ,,apm contract+ entity & !     
entity submitt+ su* model "u subsection 
7c7 :e!r or n su* a waiv] = su* model is
 provid$ & ! reason = any d5ial ( su* a 
waiv]4  7e7 ,demon/ration  7#a7 ,9 g5]al
 ,subject to p>agraphs 7#e71 7#f71 &    

7#g71 ! ,secret>y may conduct a         
demon/ration program1 ) respect to an   
,alt]native ,paym5t ,model approv$ "u   
p>agraph 7#b71 "u :i* p>ticipat+        
entities %all be paid "u ?is title 9    
accordance ) ! paym5t arrangem5t "u su* 
model & su* model %all be evaluat$ by ! 
indep5d5t evaluation entity "u p>agraph 
7#c74 ,! duration ( a demon/ration      
program "u ?is subsection1 ) respect to 
su* a model1 %all be #c ye>s 7or a %ort]
 p]iod1 tak+ into acc\nt ! applicable   
recomm5dation "u subsection             
7d77#a77;,a77i774  7#b7 ,approval by    
,secret>y ( models = demon/ration ,n    
lat] ?an #ij days aft] ! date ( receipt 
( a recomm5dation "u subsection         
7d77#a77;,a77i71 ) respect to an        
,alt]native ,paym5t ,model1 ! ,secret>y 
%all approve su* model = a demon/ration 
program "u ?is subsection only if !     
,secret>y det]m9es ! model satisfies !  
crit]ia describ$ 9 subsection           
7d77#a77;,b74 ,! ,secret>y %all         
p]iodically make a available a li/ ( su*

 models s approv$4  7#c7 ,p>ticipat+    
entities ,to p>ticipate "u a            
demon/ration program "u ?is subsection1 
) respect to an ,alt]native ,paym5t     
,model1 a physician1 practition]1 or o!r
 suppli] %all ent] into a contract ) !  
,adm9i/rator ( ! ,c5t]s = ,m$ic>e       
,m$icaid ,s]vices "u ?is subsection4 ,= 
purposes ( ?is section1 su* a physician1
 practition]1 or suppli] :o s           
p>ticipates "u su* an ,alt]native       
,paym5t ,model %all be ref]r$ to z a    
p>ticipat+ ,,apm provid]4  7#d7 ,report+
 & evaluation  7,a7 ,indep5d5t          
evaluation entity ,"u ?is subsection1 ! 
,secret>y %all ent] into a contract ) an
 indep5d5t entity to evaluate           
,alt]native ,paym5t ,models "u          
demon/ration programs "u ?is subsection 
bas$ on appropriate measures specifi$ "u
 subp>agraph 7,b74 ,9 ?is section1 su*  
entity %all be ref]r$ to z ! indep5d5t  
evaluation entity4 ,su* contract %all be
 ent]$ into 9 a timely mann] s z to     
ensure evaluation ( an ,alt]native      

,paym5t ,model "u a demon/ration program
 "u ?is subsection may beg9 z soon z    
possible aft] ! model is approv$ "u     
p>agraph 7#b74  7,b7 ,p]=mance measures 
,= purposes ( ?is subsection1 !         
,secret>y %all specify--  7i7 measures  
to evaluate ,alt]native ,paym5t ,models 
"u demon/ration programs "u ?is         
subsection1 :i* may include measures    
sugge/$ "u subsection 7c7 & %all be     
suffici5t to all[ = a compreh5sive      
assessm5t ( su* a model2 &  7ii7 quality
 measures on :i* p>ticipat+ entities    
%all report1 :i* %all be simil> to      
measures applicable "u section #ahdh7k74
  7,c7 ,report+ requirem5ts ,a contract 
ent]$ into ) a p>ticipat+ ,,apm provid] 
"u p>agraph 7#c7 %all require su*       
provid] to report on appropriate        
measures specifi$ "u subp>agraph 7,b74  
7,d7 ,p]iodic review ,! indep5d5t       
evaluation entity %all p]iodically      
review & analyze & submit su* analysis  
to ! ,secret>y & ! p>ticipat+ entities  
involv$ data report$ "u subp>agraph 7,c7

 & su* o!r data z deem$ necess>y to     
evaluate ! model4  7,e7 ,f9al evaluation
 ,n lat] ?an #f mon?s aft] ! date (     
completion ( a demon/ration program1 !  
indep5d5t evaluation entity %all submit 
to ! ,secret>y1 ! ,m$ic>e ,paym5t       
,advisory ,commission1 & ! ,*ief ,actu>y
 ( ! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices
 7& make publicly available7 a report on
 ea* model evaluat$ "u su* program4 ,su*
 report %all include--  7i7 outcomes on 
! cl9ical & claims data receiv$ ?r\gh   
su* program ) respect to su* model2     
7ii7 recomm5dations on--  7,i7 :e!r or n
 su* model %\ld be implem5t$ z an       
eligible ,,apm "u ?is section2 or       
7,,ii7 :e!r or n ! evaluation ( su*     
model "u ! demon/ration program %\ld be 
ext5d$ or exp&$2  7iii7 ! ju/ification =
 ea* su* recomm5dation describ$ 9 clause
 7ii72 &  7iv7 9 ! case ( a             
recomm5dation to implem5t su* model z an
 eligible ,,apm1 recomm5dations on      
/&>diz$ rules = purposes ( su*          
implem5tation4  7#e7 ,approval ( ext5d+ 

evaluation "u demon/ration ,n lat] ?an  
#ij days aft] ! date ( receipt ( a      
submission "u p>agraph 7#d77;,e71 !     
,secret>y %all1 includ+ bas$ on a       
recomm5dation submitt$ "u su* p>agraph1 
det]m9e :e!r an ,alt]native ,paym5t     
,model may be ext5d$ or exp&$ "u !      
demon/ration program4  7#f7 ,t]m9ation  
,! ,secret>y %all t]m9ate a demon/ration
 program = a model "u ?is subsection    
unless ! ,secret>y det]m9es 7& ! ,*ief  
,actu>y ( ! ,c5t]s = ,m$ic>e  ,m$icaid  
,s]vices1 ) respect to program sp5d+ "u 
?is title1 c]tifies71 aft] te/+ has     
begun1 t ! model is expect$ to--  7,a7  
improve ! quality ( c>e 7z det]m9$ by ! 
,adm9i/rator ( ! ,c5t]s = ,m$ic>e       
,m$icaid ,s]vices7 )\t increas+ sp5d+ "u
 ?is title2  7,b7 r$uce sp5d+ "u ?is    
title )\t r$uc+ ! quality ( c>e2 or     
7,c7 improve ! quality ( c>e & r$uce    
sp5d+4  ,su* t]m9ation may occur at any 
"t aft] su* te/+ has begun & be=e       
completion ( ! te/+4  7#g7 ,fund+  7,a7 
,9 g5]al ,!re are appropriat$1 f am\nts 

9 ! ,f$]al ,supplem5t>y ,m$ical         
,insurance ,tru/ ,fund "u section #ahda 
n o!rwise appropriat$1 #b1jjj1jjj1jjj = 
! purposes describ$ 9 subp>agraph 7,b71 
( :i* no m ?an #b4e p]c5t may be us$ = !
 purpose describ$ 9 clause 7iii7 ( su*  
subp>agraph4 ,am\nts transf]r$ "u ?is   
subp>agraph %all be available until     
exp5d$4  7,b7 ,purposes ,am\nts         
appropriat$ "u subp>agraph 7,a7 %all be 
us$ =--  7i7 paym5ts = items & s]vices  
furni%$ by p>ticipat+ entities "u an    
,alt]native ,paym5t ,model "u a         
demon/ration program "u ?is subsection  
t--  7,i7 w\ld n o!rwise be eligible =  
paym5t "u ?is title2 or  7,,ii7 exce$ ! 
am\nt ( paym5t t w\ld o!rwise be made = 
su* items & s]vices "u ?is title if su* 
items & s]vices 7 n furni%$ "u su*      
demon/ration program2  7ii7 !           
evaluations provid$ = "u ?is section (  
models "u su* a demon/ration program2   
7iii7 paym5t to ! contract+ entity =    
c>ry+ out its duties "u ?is section2 &  
7iv7 = o!rwise c>ry+ out ?is subsection4

  7,c7 ,limitation ,! am\nts appropriat$
 "u subp>agraph 7,a7 are ! only am\nts  
au?oriz$ or appropriat$ to c>ry out !   
purposes describ$ 9 subp>agraph 7,b74   
7f7 ,implem5tation ( recomm5d$ models z 
eligible ,a,p,ms  7#a7 ,9 g5]al ,n lat] 
?an ! applicable date "u p>agraph 7#b71 
! ,secret>y %all1 implem5t an           
,alt]native ,paym5t ,model recomm5d$ "u 
subsection 7d77#a77;,a77ii7 or          
7e77#d77;,e77ii77,i7 z an eligible ,,apm
 only if--  7,a7 ! ,secret>y det]m9es t 
su* model is expect$ to--  7i7 r$uce    
sp5d+ "u ?is title )\t r$uc+ ! quality (
 c>e2 or  7ii7 improve ! quality (      
pati5t c>e )\t increas+ sp5d+2  7,b7 !  
,*ief ,actu>y ( ! ,c5t]s = ,m$ic>e      
,m$icaid ,s]vices c]tifies t su* model  
w\ld r$uce 7or w\ld n result 9 any      
increase 97 program sp5d+ "u ?is title2 
&  7,c7 ! ,secret>y det]m9es t su* model
 w\ld n d5y or limit ! cov]age or       
provision ( b5efits "u ?is title =      
applicable individuals4  ,n lat] ?an #ij
 days aft] ! date ( issuance ( a propos$

 rule1 ) respect to an ,alt]native      
,paym5t ,model1 ! ,m$ic>e ,paym5t       
,advisory ,commission %all submit       
comm5ts to ,congress & ! ,secret>y      
evaluat+ ! reports f ! contract+ entity 
& indep5d5t evaluation entity on su*    
model reg>d+ ! model's impact on        
exp5ditures & quality ( c>e "u ?is      
title4  7#b7 ,applicable date ,=        
purposes ( p>agraph 7#a71 ! applicable  
date "u ?is p>agraph--  7,a7 = an       
,alt]native ,paym5t ,model recomm5d$ "u 
subsection 7d77#a77;,a77ii7 is #ij days 
aft] ! date ( submission ( su*          
recomm5dation2 &  7,b7 = an ,alt]native 
,paym5t ,model recomm5d$ "u subsection  
7e77#d77;,e77ii77,i7 is #ij days aft] ! 
date ( submission ( su* recomm5dation   
7#c7 ,ju/ification = disapprovals ,9 !  
case t an ,alt]native ,paym5t ,model    
recomm5d$ "u subsection 7d77#a77;,a77ii7
 or 7e77#d77;,e77ii77,i7 is n implem5t$ 
z an eligible ,,apm "u ?is subsection1 !
 ,secret>y %all make publicly available 
! rational1 9 detail1 = su* decision4   

7g7 ,p]iodic review & t]m9ation  7#a7   
,p]iodic review ,9 ! case ( an          
,alt]native ,paym5t ,model t has be5    
implem5t$1 ! ,secret>y & ! ,*ief ,actu>y
 ( ! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices
 %all review su* model e #c ye>s to     
det]m9e 7& c]tify1 9 ! case ( ! ,*ief   
,actu>y & sp5d+ "u ?is title71 = !      
previ\s #c ye>s1 :e!r ! model has--     
7,a7 r$uc$ ! quality ( c>e1 or  7,b7    
increas$ sp5d+ "u ?is title1  comp>$ to 
! quality ( c>e or sp5d+ t w\ld h       
result$ if ! model _h n be5 implem5t$4  
7#b7 ,t]m9ation  7,a7 ,quality ( c>e    
r$uction t]m9ation ,if bas$ ^u su*      
review ! ,secret>y det]m9es "u p>agraph 
7#a77;,a7 t ! model has r$uc$ ! quality 
( c>e1 ! ,secret>y may t]m9ate su*      
model4  7,b7 ,sp5d+ increase t]m9ation  
,unless su* ,*ief ,actu>y c]tifies "u   
p>agraph 7#a77;,b7 t ! exp5ditures "u   
?is title "u ! model d n exce$ !        
exp5ditures t w\ld o!rwise h be5 made if
 ! model _h n be5 implem5t$ = ! p]iod   
involv$1 ! ,secret>y %all t]m9ate su*   

model4  7h7 ,dissem9ation ( eligible    
,a,p,ms ,"u ?is section !re %all be     
e/abli%$ a process = specify+1 & mak+   
publicly available a li/ (1 all eligible
 ,a,p,ms1 :i* %all include at lea/ ^?   
implem5t$ "u subsection 7f7 &           
demon/rations c>ri$ out ) respect to    
paym5ts "u section #ahdh ?r\gh au?ority 
9 exi/5ce z ( ! day be=e ! date ( !     
enactm5t ( ?is section4 ,"u su* process 
su* li/ %all be p]iodically updat$ &1   
beg9n+ ) ,janu>y #a1 #bjae1 & annually  
!reaft]1 su* li/ %all be publi%$ 9 !    
,f$]al ,regi/]4  4  7#b7 ,con=m+ am5dm5t
 ,section #ahdh7;a77#a7 ( ! ,social     
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7;a77#a77 is am5d$ by /rik+    
%all in/ead & ins]t+ %all1 subject to   
section #ahdh;,a1 in/ead4  #c4 ,exp&+   
availability ( ,m$ic>e data  7a7 ,exp&+ 
uses ( ,m$ic>e data by qualifi$ entities
  7#a7 ,9 g5]al ,to ! ext5t consi/5t )  
applicable in=mation1 privacy1 security1
 & disclosure laws1 beg9n+ ) #bjad1     
not)/&+ ! second s5t5ce ( p>agraph      

7#d77;,d7 ( section #ahgd7;e7 ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#aciekk7e771 a qualifi$ entity may use  
data receiv$ by su* entity "u su*       
section1 & in=mation d]iv$ f !          
evaluation describ$ 9 su* p>agraph      
7#d77;,d71 = additional analyses 7z     
det]m9$ appropriate by ! ,secret>y (    
,heal? & ,human ,s]vices7 t su* entity  
may provide or sell to provid]s (       
s]vices & suppli]s 7includ+ = ! purposes
 ( assi/+ provid]s ( s]vices & suppli]s 
to develop & p>ticipate 9 quality &     
pati5t c>e improvem5t activities1       
includ+ develop+ new models ( c>e74     
7#b7 ,def9itions ,9 ?is section3  7,a7  
,! t]m qualifi$ entity has ! mean+ giv5 
su* t]m 9 section #ahgd7;e77#b7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#aciekk7e774  7,b7 ,! t]ms suppli] &    
provid] ( s]vices h ! mean+s giv5 su*   
t]ms 9 subsections 7d7 & 7u71           
respectively1 ( section #ahfa ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#aciex74  7b7 ,access to ,m$ic>e data to

 provid]s ( s]vices & suppli]s ,to      
facilitate developm5t ( alt]native      
paym5t models & to qualifi$ cl9ical data
 regi/ries ,to facilitate quality       
improvem5t ,consi/5t ) applicable laws &
 regulations ) respect to privacy & o!r 
relevant matt]s1 ! ,secret>y %all       
provide ,m$ic>e claims data = non-public
 use 79 a =m & mann] det]m9$ to be      
appropriate7 to--  7#a7 qualifi$        
entities1 t may %>e ) provid]s ( s]vices
 & suppli]s t are regi/]$ or au?oriz$   
us]s or subscrib]s1 9 ord] to facilitate
 ! developm5t ( new models ( c>e        
7includ+ developm5t ( ,alt]nate ,paym5t 
,models "u section #ahdh;,a ( ! ,social 
,security ,act1 models = small gr\p     
specialty practices1 & c>e coord9ation  
models72 &  7#b7 qualifi$ cl9ical data  
regi/ries "u section #ahdh7m77#c77;,e7 (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #aciew-#d7m77#c77;,e77 = purposes (    
l9k+ su* data ) cl9ical outcomes data & 
p]=m+ analysis & rese>* to support      
quality improvem5t4  #d4 ,enc\rag+ c>e  

coord9ation & m$ical homes ,section     
#ahdh7;b7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #aciew-#d7;b77 is am5d$  
by add+ at ! end ! foll[+ new p>agraph3 
7#h7 ,enc\rag+ c>e coord9ation & m$ical 
homes  7,a7 ,9 g5]al ,9 ord] to promote 
! coord9ation ( c>e by an applicable    
physician 7z def9$ 9 subp>agraph 7,b77 =
 individuals ) complex *ronic c>e ne$s  
:o are furni%$ items & s]vices by       
multiple physicians & o!r suppli]s &    
provid]s ( s]vices1 ! ,secret>y %all--  
7i7 develop "o or m ,,hcpcs codes =     
complex *ronic c>e managem5t s]vices =  
individuals ) complex *ronic c>e ne$s2 &
  7ii7 = su* s]vices furni%$ on or aft] 
,janu>y #a1 #bjae1 by an applicable     
physician1 make paym5t 7z ! ,secret>y   
det]m9es to be appropriate7 "u ! fee    
s*$ule "u ?is section us+ su* ,,hcpcs   
codes4  7,b7 ,applicable physician def9$
 ,= purposes ( ?is p>agraph1 ! t]m      
applicable physician means a physician  
7z def9$ 9 section #ahfa7r77#a77 :o--   
7i7 is c]tifi$ z a m$ical home 7by      

a*iev+ an accr$itation /atus ( level #c 
by ! ,national ,committee = ,quality    
,assurance72  7ii7 is recogniz$ z a     
pati5t-c5t]$ specialty practice by !    
,national ,committee = ,quality         
,assurance2  7iii7 has receiv$ equival5t
 c]tification 7z det]m9$ by !           
,secret>y72 or  7iv7 meets su* o!r      
comp>able qualifications z ! ,secret>y  
det]m9es to be appropriate4  7,c7       
,budget neutrality ,! budget neutrality 
provision "u subsection                 
7c77#b77;,b77ii77,,ii7 %all apply 9     
e/abli%+ ! paym5t "u subp>agraph        
7,a77ii74  7,d7 ,s+le applicable        
physician paym5t ,9 c>ry+ out ?is       
p>agraph1 ! ,secret>y %all only make    
paym5t to a s+le applicable physician = 
complex *ronic c>e managem5t s]vices    
furni%$ to an individual4  4  #e4       
,miscellane\s  7a7 ,solicitations1      
recomm5dations1 & reports  7#a7         
,solicitation = recomm5dations on       
episodes ( c>e def9ition ,! ,adm9i/rator
 ( ! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices

 %all reque/ eligible pr(essional       
organizations 7z def9$ 9 section        
#ahdh7k77#c7 ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #aciew-#d7k77#c777 & o!r 
relevant /akehold]s to submit           
recomm5dations = def9+ non-acute relat$ 
episodes ( c>e = purposes ( apply+ su*  
def9ition "u subsections 7k7 & 7q7 (    
section #ahdh ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciew-#d7 & section    
#ahdh;,a ( su* ,act1 z add$ by          
subsections 7b7 & 7c7 ( section #b4     
7#b7 ,solicitation = recomm5dations on  
provid] fee s*$ule paym5t bundles  7,a7 
,9 g5]al ,! ,adm9i/rator ( ! ,c5t]s =   
,m$ic>e  ,m$icaid ,s]vices %all solicit 
f eligible pr(essional organizations 7z 
def9$ 9 section #ahdh7k77#c7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#aciew-#d7k77#c777 recomm5dations =     
paym5t bundles = *ronic conditions &    
exp5sive1 high-volume s]vices = :i*     
paym5t is made "u title ,,xviii ( su*   
,act4  7,b7 ,report to ,congress ,n lat]
 ?an #bd mon?s aft] ! date ( ! enactm5t 

( ?is ,act1 ! ,adm9i/rator %all submit  
to ,congress a report proposals = su*   
paym5t bundles4  7#c7 ,reports on       
,modifi$ ,,pfs ,sy/em & paym5t sy/em    
alt]natives  7,a7 ,biannual progress    
reports ,n lat] ?an ,janu>y #ae1 #bjaf1 
& annually !reaft]1 ! ,secret>y ( ,heal?
 & ,human ,s]vices %all submit to       
,congress & po/ on ! public ,int]net    
website ( ! ,c5t]s = ,m$ic>e  ,m$icaid  
,s]vices a biannual progress report--   
7i7 on ! implem5tation ( p>agraph 7#i7 (
 section #ahdh7k7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #aciew-#d7k771 z    
add$ by section #b7;b77#b71 & ! quality 
update inc5tive program "u subsection   
7q7 ( section #ahdh ( ! ,social         
,security ,act 7#db ,u4,s4,c4           
#aciew-#d71 z add$ by section           
#b7;b77#c72  7ii7 t includes an         
evaluation ( su* p>agraph & su* quality 
update inc5tive program & recomm5dations
 ) respect to su* program & appropriate 
update me*anisms2 &  7iii7 on ! actions 
tak5 to promote & fulfill !             

id5tification ( eligible ,a,p,ms "u     
section #ahdh;,a ( ! ,social ,security  
,act1 z add$ by section #b7;c71 =       
application "u su* section #ahdh;,a4    
7,b7 ,,gao & ,med,p,a,c reports  7i7    
,,gao report on initial /ages ( program 
,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates 
%all submit to ,congress a report       
analyz+ ! ext5t to :i* ! sy/em "u       
section #ahdh7k77#i7 ( ! ,social        
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7k77#i77 & su* quality update  
inc5tive program "u section #ahdh7q7 ( !
 ,social ,security ,act1 z add$ by      
section #b7;b71 z ( su* date1 is        
successfully satisfy+ p]=mance          
objectives1 includ+ ) respect to--  7,i7
 ! process = develop+ & select+ measures
 & activities "u subsection 7k77#i7 (   
section #ahdh ( su* ,act 7#db ,u4,s4,c4 
#aciew-#d72  7,,ii7 ! process = assess+ 
p]=mance aga9/ su* measures & activities
 "u subsection 7q7 ( su* section2 &     
7,,iii7 ! adequacy ( ! measures &       
activities s select$4  7ii7 ,evaluation 

by ,,gao & ,med,p,a,c on implem5tation (
 quality update inc5tive program  7,i7  
,,gao ,! ,comptroll] ,g5]al ( ! ,unit$  
,/ates %all evaluate ! initial phase ( !
 quality update inc5tive program "u     
subsection 7q7 ( section #ahdh ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#d7 & %all submit to ,congress1 n
 lat] ?an #bjai1 a report )             
recomm5dations = improv+ su* quality    
update inc5tive program4  7,,ii7        
,med,p,a,c ,9 ! c\rse ( its ,m>* ,report
 to ,congress on ,m$ic>e paym5t policy1 
,med,p,a,c %all analyze ! initial phase 
( su* quality update inc5tive program & 
make recomm5dations1 z appropriate1 =   
improv+ su* quality update inc5tive     
program4  7iii7 ,med,p,a,c report on    
paym5t sy/em alt]natives  7,i7 ,9 g5]al 
,n lat] ?an ,june #ae1 #bjaf1 ! ,m$ic>e 
,paym5t ,advisory ,commission %all      
submit to ,congress a report t analyzes 
multiple options = alt]native paym5t    
models 9 lieu ( section #ahdh ( !       
,social ,security ,act 7#db ,u4,s4,c4   

#aciew-#d74 ,9 analyz+ su* models1 !    
,m$ic>e ,paym5t ,advisory ,commission   
%all exam9e at lea/ ! foll[+ models3    
7aa7 ,acc\ntable c>e organization paym5t
 models4  7bb7 ,prim>y c>e m$ical home  
paym5t models4  7cc7 ,bundl$ or episodic
 paym5ts = c]ta9 conditions & s]vices4  
7dd7 ,ga9%>+ arrangem5ts  7,,ii7 ,items 
to be includ$ ,su* report %all include  
in=mation on h[ ea* recomm5d$ new paym5t
 model w a*ieve maximum flexibility to  
rew>d high-quality1 effici5t c>e4  7,c7 
,track+ exp5diture gr[? & access ,beg9n+
 9 #bjae1 ! ,*ief ,actu>y ( ! ,c5t]s =  
,m$ic>e  ,m$icaid ,s]vices %all track   
exp5diture gr[? & b5efici>y access to   
physicians' s]vices "u section #ahdh ( !
 ,social ,security ,act 7#db ,u4,s4,c4  
#aciew-#d7 & %all po/ on ! public       
,int]net website ( ! ,c5t]s = ,m$ic>e   
,m$icaid ,s]vices annual reports on su* 
topics4  7b7 ,relative values "u !      
,m$ic>e physician fee s*$ule  7#a7      
,eligible physicians report+ sy/em to   
improve accuracy ( relative values      

,section #ahdh7;c7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #aciew-#d7;c77 is  
am5d$ by add+ at ! end ! foll[+ new     
p>agraph3  7#h7 ,physician report+ sy/em
 to improve accuracy ( relative values  
7,a7 ,9 g5]al ,! ,secret>y %all implem5t
 a sy/em = ! p]iodic report+ by         
physicians ( data on ! accuracy (       
relative values "u ?is subsection1 su* z
 data relat+ to s]vice volume & "t4 ,su*
 data %all be submitt$ 9 a =m & mann]   
specifi$ by ! ,secret>y & %all1 z       
appropriate1 incorporate data f exi/+   
s\rces ( data1 pati5t s*$ul+ sy/ems1 co/
 acc\nt+ sy/ems1 & o!r simil> sy/ems4   
7,b7 ,id5tification ( report+ cohort ,n 
lat] ?an ,janu>y #a1 #bjae1 ! ,secret>y 
%all e/abli% a me*anism = physicians to 
p>ticipate "u ! report+ sy/em "u ?is    
p>agraph1 all ( :om %all collectively be
 ref]r$ to "u ?is p>agraph z ! report+  
gr\p4 ,! report+ gr\p %all include      
physicians across sett+s t collectively 
repres5t a range ( specialties &        
practition] types1 furni% a range (     

physicians' s]vices1 & s]ve a range (   
pati5t populations4  7,c7 ,inc5tive to  
report ,"u ! sy/em "u ?is p>agraph1 !   
,secret>y may provide = su* paym5ts "u  
?is "p to physicians includ$ 9 ! report+
 gr\p z ! ,secret>y det]m9es appropriate
 to comp5sate su* physicians = report+  
data "u ! sy/em4 ,su* paym5ts %all be   
provid$ 9 su* =m & mann] z specifi$ by !
 ,secret>y4 ,9 c>ry+ out ?is            
subp>agraph1 report+ by su* a physician 
"u ?is p>agraph %all n be treat$ z !    
furni%+ ( physicians' s]vices = purposes
 ( apply+ ?is section4  7,d7 ,fund+ ,to 
c>ry out ?is p>agraph 7o!r ?an ) respect
 to paym5ts made "u subp>agraph 7,c771 9
 addition to funds o!rwise appropriat$1 
! ,secret>y %all provide = ! transf] f !
 ,f$]al ,supplem5t>y ,m$ical ,insurance 
,tru/ ,fund "u section #ahda (          
#a1jjj1jjj to ! ,c5t]s = ,m$ic>e        
,m$icaid ,s]vices ,program ,managem5t   
,acc\nt = ea* fiscal ye> beg9n+ ) fiscal
 ye> #bjad4 ,am\nts transf]r$ "u ?is    
subp>agraph = a fiscal ye> %all be      

available until exp5d$4  4  7#b7        
,relative value adju/m5ts = misvalu$    
physicians' s]vices  7,a7 ,9 g5]al      
,section #ahdh7;c77#b7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7;c77#b77 is am5d$ by add+ at !
 end ! foll[+ new subp>agraph3  7,m7    
,adju/m5ts = misvalu$ physicians'       
s]vices ,) respect to fee s*$ules       
e/abli%$ = #bjaf1 #bjag1 & #bjah1 !     
,secret>y %all--  7i7 id5tify1 bas$ on !
 data report$ "u p>agraph 7#h7 & o!r    
relevant data1 misvalu$ s]vices = :i*   
adju/m5ts to ! relative values e/abli%$ 
"u ?is p>agraph w\ld result 9 a net     
r$uction 9 exp5ditures "u ! fee s*$ule  
"u ?is section1 ) respect to su* ye>1 ( 
n m ?an #a p]c5t ( ! project$ am\nt (   
exp5ditures "u su* fee s*$ule = su* ye>2
 &  7ii7 make su* adju/m5ts = ea* su*   
ye> s z to result 9 su* a net r$uction =
 su* ye>4  4  7,b7 ,budget neutrality   
,section #ahdh7;c77#b77;,b77v7 ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#d7;c77#b77;,b77v77 is am5d$ by  

add+ at ! end ! foll[+ new subclause3   
7,,viii7 ,r$uctions = misvalu$          
physicians' s]vices ,r$uc$ exp5ditures  
attributable to subp>agraph 7,m74  4    
7c7 ,rule ( con/ruction reg>d+ heal? c>e
 provid] /&>ds ( c>e  7#a7 ,9 g5]al ,!  
developm5t1 recognition1 or             
implem5tation ( any guidel9e or o!r /&>d
 "u any ,f$]al heal? c>e provision %all 
n be con/ru$ to e/abli% ! /&>d ( c>e or 
duty ( c>e ow$ by a heal? c>e provid] to
 a pati5t 9 any m$ical malpractice or   
m$ical product liability action or      
claim4  7#b7 ,def9itions ,= purposes (  
?is subsection3  7,a7 ,! t]m ,f$]al     
heal? c>e provision means any provision 
( ! ,pati5t ,protection & ,af=dable ,c>e
 ,act 7,public ,law #aaa-adh71 title ,i 
& subtitle ,b ( title ,,iii ( ! ,heal?  
,c>e & ,education ,reconciliation ,act (
 #bjaj 7,public ,law #aaa-aeb71 & titles
 ,,xviii & ,,xix ( ! ,social ,security  
,act4  7,b7 ,! t]m heal? c>e provid]    
means any individual or entity--  7i7   
lic5s$1 regi/]$1 or c]tifi$ "u ,f$]al or

 ,/ate laws or regulations to provide   
heal? c>e s]vices2 or  7ii7 requir$ to  
be s lic5s$1 regi/]$1 or c]tifi$ b t is 
exempt$ by o!r /atute or regulation4    
7,c7 ,! t]m m$ical malpractice or m$ical
 liability action or claim means a      
m$ical malpractice action or claim 7z   
def9$ 9 section #dca7g7 ( ! ,heal? ,c>e 
,quality ,improvem5t ,act ( #aihf 7#db  
,u4,s4,c4 #aaaea7g777 & includes a      
liability action or claim relat+ to a   
heal? c>e provid]'s prescription or     
provision ( a drug1 device1 or          
biological product 7z su* t]ms are def9$
 9 section #bja ( ! ,f$]al ,food1 ,drug1
 & ,cosmetic ,act or section #cea ( !   
,public ,heal? ,s]vice ,act74  7,d7 ,!  
t]m ,/ate includes ! ,di/rict (         
,columbia1 ,pu]to ,rico1 & any o!r      
commonweal?1 possession1 or t]ritory ( !
 ,unit$ ,/ates4  7#c7 ,no preemption ,no
 provision ( ! ,pati5t ,protection &    
,af=dable ,c>e ,act 7,public ,law       
#aaa-adh71 title ,i or subtitle ,b (    
title ,,iii ( ! ,heal? ,c>e & ,education

 ,reconciliation ,act ( #bjaj 7,public  
,law #aaa-aeb71 or title ,,xviii or     
,,xix ( ! ,social ,security ,act %all be
 con/ru$ to preempt any ,/ate or common 
law gov]n+ m$ical pr(essional or m$ical 
product liability actions or claims4