,,ib ,union ,cal5d> ,no4 #bhc #aac? ,,congress #b;d ,session ,h4 ,r4 #bhaj ,report ,no4 #aac-beg1 ,p>ts ,i & ,,ii ,,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$ ,novemb] #ab1 #bjac ,report$ f ! ,committee on ,en]gy & ,comm]ce ) an am5dm5t ,/rike out all aft] ! enact+ clause & ins]t ! "p pr9t$ 9 italic ,novemb] #ab1 #bjac ,! ,committee on ! ,judici>y dis*>g$ ,novemb] #ab1 #bjac ,ref]ral to ! ,committee on ,ways & ,means ext5d$ = a p]iod end+ n lat] ?an ,decemb] #b1 #bjac ,decemb] #b1 #bjac ,ref]ral to ! ,committee on ,ways & ,means ext5d$ = a p]iod end+ n lat] ?an ,janu>y #aj1 #bjad ,janu>y #aj1 #bjad ,ref]ral to ! ,committee on ,ways & ,means ext5d$ = a p]iod end+ n lat] ?an ,m>* #ad1 #bjad ,m>* #ad1 #bjad ,additional sponsors3 ,mr4 ,cassidy1 ,mr4 ,buc%on1 ,mrs4 ,*ri/5s51 ,mr4 ,g+rey ( ,georgia1 ,mr4 ,/ockman1 ,mr4 ,?ornb]ry1 ,mr4 ,b5i%ek1 ,mr4 ,murphy ( ,p5nsylvania1 ,mr4 ,gos>1 ,ms4 ,matsui1 ,ms4 ,ca/or ( ,florida1 ,mr4 ,engel1 ,mr4 ,cuell>1 ,mr4 ,sessions1 ,mr4 ,"y ( ,alaska1 ,mr4 ,g5e ,gre5 ( ,texas1 ,mr4 ,olson1 ,mrs4 ,ellm]s1 ,mr4 ,roe ( ,t5nessee1 ,mrs4 ,blackburn1 ,mr4 ,latta1 ,mrs4 ,mc,morris ,rodg]s1 ,mr4 ,t]ry1 ,mr4 ,rog]s ( ,mi*igan1 ,mr4 ,wald51 ,mr4 ,bilirakis1 ,ms4 ,s*ak[sky1 ,mr4 ,braley ( ,i[a1 ,mrs4 ,capps1 ,mr4 ,c>t]1 ,mr4 ,b>ton1 ,mr4 ,:itfield1 ,mr4 ,lance1 ,mr4 ,hold+1 ,mr4 ,we/morel&1 ,mr4 ,la?am1 ,mrs4 ,brooks ( ,indiana1 ,mr4 ,walb]g1 ,mr4 ,rice ( ,s\? ,c>ol9a1 ,mr4 ,loebsack1 ,mr4 ,c(fman1 ,mr4 ,b]a ( ,cali=nia1 ,mr4 ,ruiz1 ,mr4 ,/iv]s1 ,mr4 ,mc,kinley1 ,mr4 ,k5n$y1 ,mr4 ,b5 ,ray ,lujn ( ,new ,mexico1 ,mr4 ,ru%1 ,mr4 ,yod]1 ,mr4 ,m>9o1 ,mr4 ,mc,nerney1 & ,mr4 ,langev9 ,m>* #ad1 #bjad ,report$ f ! ,committee on ,ways & ,means ) an am5dm5t1 committ$ to ! ,committee ( ! ,:ole ,h\se on ! ,/ate ( ! ,union1 & ord]$ to be pr9t$ ,/rike out all aft] ! enact+ clause & ins]t ! "p pr9t$ 9 boldface roman ,= text ( introduc$ bill1 see copy ( bill z introduc$ on ,july #bd1 #bjac ,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$ic>e paym5t = physicians' s]vices 7a7 ,/abiliz+ fee updates 7phase ,i7 7#a7 ,repeal ( ,,sgr paym5t me?odology ,section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is am5d$-- 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] ( ea* 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 7phase ,,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 z def9$ by nationally recogniz$ multispecialty bo>ds ( c]tification or equival5t c]tification bo>ds4 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 nationally recogniz$ multispecialty bo>ds ( c]tification 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 ! quality 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 beg9n+ n lat] ?an #f mon?s aft] ! fir/ day ( ! fir/ p]=mance p]iod1 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 = te/+ & evaluation1 includ+ ?r\gh ! demon/ration program "u subsection 7e71 & approval "u subsection 7f72 7,d7 applicable ,alt]native ,paym5t ,models are te/$ & 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 ,! ,secret>y %all ent] into ! fir/ contract "u subp>agraph 7,a7 to be 9 effect ,janu>y #a1 #bjai4 7,c7 ,competitive proc$ures ,competitive proc$ures 7z def9$ 9 section #d7e7 ( ! ,(fice ( ,f$]al ,procurem5t ,policy ,act 7#da ,u4,s4,c4 #djc7e77 %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 ,recomm5dations to ,secret>y 7i7 ,9 g5]al ,"u ! process "u subsection 7b71 ! ,,apm contract+ entity %all at lea/ qu>t]ly recomm5d1 9 accordance ) clause 7ii71 to ! ,secret>y-- 7,i7 ,alt]native ,paym5t ,models submitt$ "u subsection 7c7 to be te/$ & evaluat$ ?r\gh a demon/ration program "u subsection 7e72 & 7,,ii7 ,alt]native ,paym5t ,models submitt$ "u subsection 7c7 to be implem5t$ "u subsection 7f7 )\t te/+ & evaluation ?r\gh su* a demon/ration program4 ,su* a recomm5dation "u subclause 7,i7 may be made ) respect to a model = :i* a waiv] w\ld be requir$ "u p>agraph 7#b74 ,any ref]5ce 9 ?is subsection to an ,alt]native ,paym5t ,model "u ?is clause is a ref]5ce to su* model z may be modifi$ "u clause 7iii74 7ii7 ,requirem5ts ,9 recomm5d+ an ,alt]native ,paym5t ,model "u clause 7i71 ea* ( ! foll[+ %all apply3 7,i7 ,! ,,apm contract+ entity may recomm5d an ,alt]native ,paym5t ,model "u clause 7i77,i7 only if ! entity det]m9es t ! model satisfies ! crit]ia describ$ 9 subp>agraph 7,b71 includ+ ! crit]ia describ$ 9 subp>agraph 7,b77iv74 7,,ii7 ,! ,,apm contract+ entity may recomm5d an ,alt]native ,paym5t ,model "u clause 7i77,,ii7 only if ! entity det]m9es t ! model satisfies ! crit]ia describ$ 9 subp>agraph 7,c71 includ+ ! crit]ia describ$ 9 subp>agraph 7,c77iii74 7,,iii7 ,! ,,apm contract+ entity %all include ) ! recomm5d$ ,alt]native ,paym5t ,model recomm5dations = rules ( coord9ation describ$ 9 clause 7v74 7iii7 ,modifications by ,,apm contract+ entity ,= purposes ( ?is subp>agraph1 to ! ext5t necess>y to meet ! applicable requirem5ts ( clause 7ii71 ! ,,apm contract+ entity may modify an ,alt]native ,paym5t ,model submitt$ "u subsection 7c7 to ensure t ! model w\ld-- 7,i7 r$uce sp5d+ "u ?is title )\t r$uc+ ! quality ( c>e2 or 7,,ii7 improve ! quality ( c>e )\t increas+ sp5d+ "u ?is title4 7iv7 ,=ms ( modifications ,su* a modification "u clause 7iii7 may include "o or m ( ! foll[+3 7,i7 ,a *ange to ! paym5t arrangem5t "u :i* eligible pr(essionals p>ticipat+ 9 su* model w\ld be paid = cov]$ pr(essional s]vices furni%$ "u su* model4 7,,ii7 ,a *ange to ! crit]ia = eligible pr(essionals to be eligible to p>ticipate "u su* model 9 ord] to ensure t ! requirem5t describ$ 9 subclause 7,i7 or 7,,ii7 is satisfi$4 7,,iii7 ,a *ange to ! rules ( coord9ation describ$ 9 clause 7v74 7,,iv7 ,! application ( a )hold me*anism "u ! paym5t arrangem5t "u :i* ! di/ribution ( )held am\nts is bas$ on ! success ( ! model 9 meet+ sp5d+ r$uction requirem5ts4 7,v7 ,su* o!r *ange z ! contract+ entity may specify4 7v7 ,rules ( coord9ation = application ( paym5t arrangem5ts "u models 7,i7 ,9 g5]al ,rules ( coord9ation describ$ 9 ?is clause = an ,alt]native ,paym5t ,model %all be design$ to det]m9e1 = purposes ( apply+ subsection 7a7 & section #ahdh7;d77#af71 "u :at circum/ances an eligible pr(essional is treat$ z hav+ a paym5t arrangem5t "u a p>ticul> model4 7,,ii7 ,nonduplication ( paym5t ,su* rules ( coord9ation %all ensure coord9ation & nonduplication ( paym5t ( s]vices t might be cov]$ "u m ?an "o paym5t arrangem5t or "u section #ahdh7;d77#af74 7,,iii7 ,application to non-,,apm paym5t ,9 apply+ su* rules ( coord9ation = purposes ( section #ahdh7;d77#af71 an eligible pr(essional %all n be treat$ z hav+ a paym5t arrangem5t 9 effect "u su* a model = any cov]$ pr(essional s]vices n treat$ z furni%$ "u ! model4 7,b7 ,crit]ia = recomm5d+ models = demon/ration ,= purposes ( subp>agraph 7,a77ii77,i71 ! crit]ia describ$ 9 ?is subp>agraph1 ) respect to an ,alt]native ,paym5t ,model1 are ea* ( ! foll[+3 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 7iv74 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 a mean+ful evaluation ( ! likely effect ( exp&+ ! demon/ration4 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 a mean+ful evaluation ( ! likely effect ( exp&+ ! demon/ration4 7iii7 ,su* model1 includ+ if te/$ & evaluat$ "u ! demon/ration "u subsection 7e71 w\ld n d5y or limit ! cov]age or provision ( b5efits "u ?is title = applicable individuals4 7iv7 ,! proposal = su* model demon/rates-- 7,i7 ! significant likelihood to successfully manage ! co/ ( furni%+ items & s]vices "u ?is title s z to n result 9 exp5ditures "u ?is title be+ great] ?an exp5ditures "u ?is title if ! ,,apm 7 n implem5t$2 & 7,,ii7 ! ability to ma9ta9 or improve ! ov]all quality ( pati5t c>e provid$ to individuals enroll$ "u ?is "p4 7v7 ,! model provides = a paym5t arrangem5t-- 7,i7 t specifies ! items & s]vices cov]$ "u ! arrangem5t & specifies rules ( coord9ation describ$ 9 subp>agraph 7,a77v7 betwe5 ! items & s]vices cov]$ "u ! arrangem5t & o!r items & s]vices n cov]$ "u ! arrangem5t2 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 ,= purposes ( subp>agraph 7,a77ii77,,ii71 ! crit]ia describ$ 9 ?is subp>agraph1 ) respect to an ,alt]native ,paym5t ,model1 is t ! model has already be5 te/$ & evaluat$ = a suffici5t en\gh p]iod & ?r\gh su* te/+ & evaluation ! model 0 %[n-- 7i7 to h satisfi$ ! crit]ia describ$ 9 ea* ( clauses 7i71 7ii71 7iii71 & 7v7 ( subp>agraph 7,b72 & 7ii7 7,i7 to h r$uc$ sp5d+ "u ?is title )\t r$uc+ ! quality ( c>e2 or 7,,ii7 to h improv$ ! quality ( pati5t c>e )\t increas+ su* sp5d+4 7,d7 ,transp>5cy & disclosures 7i7 ,disclosures ,n lat] ?an #ij days aft] receipt ( a submission ( a model "u subsection 7c7 by ! ,,apm contract+ entity1 ! ,,apm contract+ entity %all submit to ! ,secret>y & ! model submitt] & 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,a77i77,i71 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,a77i77,,ii7 & ! data & analyses on su* recomm5d$ models t support ! crit]ia describ$ 9 subp>agraph 7,c74 7iii7 ,explanation = no recomm5dations ,= any ye> beg9n+ ) #bjae t ! ,,apm contract+ entity does n recomm5d any models "u subp>agraph 7,a77i71 ! entity %all in/ead satisfy ?is clause by submitt+ to ! ,secret>y & mak+ publicly available an explanation = n hav+ any su* recomm5dations4 7iv7 ,ju/ifications = recomm5dations ,9 submitt+ data & analyses "u subclause 7,i7 or 7,,ii7 ( clause 7ii7 ) respect to a model1 ! ,,apm contract+ entity %all include a specific explanation ( h[ ! model w\ld 7& recomm5dations = ensur+ t ! model w7 meet ! crit]ia describ$ 9 subp>agraph 7,b7 or 7,c71 respectively4 7v7 ,confirmation ( sp5d+ e/imates by ,,cms ,*ief ,actu>y ,= ea* ,alt]native ,paym5t ,model describ$ 9 subclause 7,i7 or 7,,ii7 ( clause 7ii71 ! ,*ief ,actu>y ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices %all submit to ! ,secret>y a det]m9ation ( :e!r or n ! ,*ief ,actu>y confirms t ! model satisfies ! crit]ion describ$ 9 subp>agraph 7,b77iv77,i7 or 7,c77ii71 respectively4 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] solely 9 ord] = su* model to be te/$ & evaluat$ "u ! demon/ration program4 7,b7 ,approval ,n lat] ?an #ahj 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 approv$ & ! 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+ ,,apm provid]s %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#d74 ,! duration ( a demon/ration program "u ?is subsection1 ) respect to su* a model1 %all be #c ye>s4 7#b7 ,approval by ,secret>y ( models = demon/ration 7,a7 ,9 g5]al ,n lat] ?an #ahj days aft] ! date ( receipt ( a submission "u subsection 7d77#a77;,d77ii71 ) respect to an ,alt]native ,paym5t ,model recomm5d$ "u subsection 7d77#a77;,a77i77,i71 ! ,secret>y %all-- 7i7 review ! basis = su* recomm5dation 9 ord] to assess1 tak+ into acc\nt ! det]m9ation ( ! ,*ief ,actu>y "u subsection 7d77#a77;,d77v7 ) respect to su* model1 if ! model is significantly likely to-- 7,i7 r$uce sp5d+ "u ?is title )\t r$uc+ ! quality ( c>e2 or 7,,ii7 improve ! quality ( c>e )\t increas+ sp5d+ "u ?is title2 7ii7 assess :e!r ! model is significantly likely to result 9 p>ticipation "u su* model ( a suffici5t numb] ( ^? eligible pr(essionals = :om ! model 0 design$ consi/5t ) clause 7i7 to be able to evaluate ! likely effect ( exp&+ ! demon/ration2 & 7iii7 approve su* model = a demon/ration program "u ?is subsection1 includ+ z modifi$ "u subp>agraph 7,b71 only if ! ,secret>y det]m9es-- 7,i7 ! model is significantly likely to satisfy ! crit]ion describ$ 9 subclause 7,i7 or 7,,ii7 ( clause 7i72 7,,ii7 ! model is significantly likely to result 9 ! p>ticipation ( a suffici5t numb] ( eligible pr(essionals describ$ 9 clause 7ii72 7,,iii7 ! model applies rules ( coord9ation describ$ 9 subp>agraph 7,c7 applicable to su* model2 & 7,,iv7 ! model satisfies ! crit]ia describ$ 9 subsection 7d77#a77;,b74 ,! ,secret>y %all p]iodically make available a li/ ( su* models approv$ "u clause 7iii74 7,b7 ,modifications by ,secret>y 7i7 ,be=e approval ,= purposes ( subp>agraph 7,a71 ! ,secret>y may modify an ,alt]native ,paym5t ,model recomm5d$ "u subsection 7d77#a77;,a77i77,i7 to ensure t ! model meets ! requirem5ts describ$ 9 subp>agraph 7,a77iii74 ,su* a modification may include "o or m ( ! foll[+3 7,i7 ,a *ange to ! paym5t arrangem5t "u :i* eligible pr(essionals p>ticipat+ 9 su* model w\ld be paid = cov]$ pr(essional s]vices furni%$ "u su* model4 7,,ii7 ,a *ange to ! crit]ia = eligible pr(essionals to be eligible to p>ticipate "u su* model 9 ord] to ensure t su* requirem5ts are satisfi$4 7,,iii7 ,a *ange to ! rules ( coord9ation describ$ 9 subp>agraph 7,c74 7,,iv7 ,! application ( a )hold me*anism "u ! paym5t arrangem5t "u :i* ! di/ribution ( )held am\nts is bas$ on ! success ( ! model 9 meet+ sp5d+ r$uction requirem5ts4 7,v7 ,su* o!r *ange z ! ,secret>y may specify4 7ii7 ,t]m9ation or modification dur+ demon/ration ,! ,secret>y %all t]m9ate or modify ! design & implem5tation ( an ,alt]native ,paym5t ,model approv$ "u subp>agraph 7,a77iii7 = a demon/ration program1 aft] te/+ has begun1 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]tifies7 t ! model is expect$ to cont9ue to satisfy ! requirem5ts describ$ 9 su* p>agraph relat+ to quality ( c>e & r$uc$ sp5d+4 ,su* t]m9ation may occur at any "t aft] su* te/+ has begun & be=e completion ( ! te/+4 7,c7 ,rules ( coord9ation = application ( paym5t arrangem5ts "u models 7i7 ,9 g5]al ,rules ( coord9ation describ$ 9 ?is subp>agraph = an ,alt]native ,paym5t ,model %all be design$ to det]m9e1 = purposes ( apply+ subsection 7a7 & section #ahdh7;d77#af71 "u :at circum/ances an eligible pr(essional is treat$ z hav+ a paym5t arrangem5t "u a p>ticul> model4 7ii7 ,nonduplication ( paym5t ,su* rules ( coord9ation %all ensure coord9ation & nonduplication ( paym5t ( s]vices t might be cov]$ "u m ?an "o paym5t arrangem5t or "u section #ahdh7;d77#af74 7iii7 ,application to non-,,apm paym5t ,9 apply+ su* rules = purposes ( section #ahdh7;d77#af71 an eligible pr(essional %all n be treat$ z hav+ a paym5t arrangem5t 9 effect "u su* a model = any cov]$ pr(essional s]vices n treat$ z furni%$ "u ! model4 7#c7 ,p>ticipat+ ,,apm provid]s 7,a7 ,9 g5]al ,to p>ticipate "u a demon/ration program "u ?is subsection1 ) respect to an ,alt]native ,paym5t ,model1 an eligible pr(essional %all ent] into a contract ) ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices "u ?is subsection4 ,= purposes ( ?is section1 su* an eligible pr(essional :o s p>ticipates "u su* an ,alt]native ,paym5t ,model 9 ?is section is ref]r$ to z a p>ticipat+ ,,apm provid]4 7,b7 ,requirem5ts ,! ,secret>y %all e/abli% crit]ia = eligible pr(essionals to ent] into contracts "u ?is p>agraph = purposes ( p>ticipation "u a demon/ration program ) respect to an ,alt]native ,paym5t ,model4 ,su* crit]ia %all ensure p>ticipation "u su* model ( a suffici5t numb] ( eligible pr(essionals = :om ! model 0 design$ 9 ord] to satisfy ! crit]ion describ$ 9 p>agraph 7#b77;,a77iii77,,ii74 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+ ,,apm provid]s %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+ ,,apm provid]s 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 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$ & z ( ! date ( ! enactm5t ( ?is section1 #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 appropriat$ "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+ ,,apm provid]s "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 ! ,,apm 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 ,assessm5t ,) respect to ea* ,alt]native ,paym5t ,model recomm5d$ "u subsection 7d77#a77;,a77i77,,ii7 or 7e77#d77;,e77ii77,i71 ! ,secret>y %all review ! basis = su* recomm5dation & assess & det]m9e1 9 consultation ) ! ,*ief ,actu>y ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices1 :e!r ! model is significantly likely to cont9ue to result 9 meet+ ! crit]ion describ$ 9 subsection 7e77#b77;,a77iii77,i71 ) or )\t a modification describ$ 9 p>agraph 7#e74 7#b7 ,implem5tation ?r\gh rulemak+ 7,a7 ,publication ( ,,nprm ,if ! ,secret>y det]m9es t su* a model is significantly likely to meet su* crit]ion1 ! ,secret>y %all publi% z "p ( ! applicable physician fee s*$ule rulemak+ process 7specifi$ 9 p>agraph 7#c77 a notice ( propos$ rulemak+ to implem5t su* model1 includ+ z modifi$ "u p>agraph 7#e74 7,b7 ,comm5ts by ,med,p,a,c ,n lat] ?an #ij days aft] ! date ( issuance ( su* notice ) respect to a model1 ! ,m$ic>e ,paym5t ,advisory ,commission %all submit comm5ts on ! propos$ rule = su* model to ,congress & to ! ,secret>y4 ,su* comm5ts %all include an evaluation ( ! reports f ! contract+ entity & indep5d5t evaluation entity on su* model reg>d+ ! model's impact on exp5ditures & quality ( c>e "u ?is title4 7,c7 ,f9al rule & conditions ,! ,secret>y %all publi% z "p ( ! applicable physician fee s*$ule rulemak+ process 7specifi$ 9 p>agraph 7#c77 a f9al notice implem5t+ su* propos$ rule1 includ+ z modifi$ "u p>agraph 7#e71 z an eligible ,,apm only if-- 7i7 ! ,secret>y det]m9es t su* model is expect$ to-- 7,i7 r$uce sp5d+ "u ?is title )\t r$uc+ ! quality ( c>e2 or 7,,ii7 improve ! quality ( pati5t c>e )\t increas+ sp5d+2 7ii7 ! ,*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 sp5d+ "u ?is title2 7iii7 ! ,secret>y det]m9es t su* model w\ld n d5y or limit ! cov]age or provision ( b5efits "u ?is title = applicable individuals2 7iv7 ! ,secret>y det]m9es t ! model is significantly likely to result 9 ! p>ticipation ( a suffici5t numb] ( appropriate eligible pr(essionals = :om ! model 0 design$ 9 ord] to satisfy ! crit]ion describ$ 9 subsection 7d77#b77;,a77iii77,,ii72 7v7 ! ,secret>y det]m9es t ! model applies rules ( coord9ation describ$ 9 p>agraph 7#f72 & 7vi7 ! ,secret>y det]m9es t model meets su* o!r crit]ia z ! ,secret>y may det]m9e4 7#c7 ,applicable physician fee s*$ule rulemak+ process ,= purposes ( p>agraph 7#b71 9 ! case ( an ,alt]native ,paym5t ,model recomm5d$ "u subsection 7d77#a77;,a77ii7 or 7e77#d77;,e77ii77,i7-- 7,a7 on or be=e ,april #a ( a ye>1 ! applicable physician fee s*$ule rulemak+ process is ! process = publication by ,novemb] #a ( t ye> ( ! fee s*$ule am\nts "u ?is section = ! succe$+ ye>2 or 7,b7 aft] ,april #a ( a ye>1 ! applicable physician fee s*$ule rulemak+ process is ! process = publication by ,novemb] #a ( ! foll[+ ye> ( ! fee s*$ule am\nts "u ?is section = ! second succe$+ ye>4 7#d7 ,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 7#e7 ,modifications by ,secret>y ,= purposes ( ?is subsection1 ! ,secret>y may modify an ,alt]native ,paym5t ,model recomm5d$ "u subsection 7d77#a77;,a77i77,,ii7 or 7e77#d77;,e77ii77,i7 to ensure t ! model meets ! requirem5ts "u p>agraph 7#a77;,b74 ,su* a modification may include "o or m ( ! foll[+3 7,a7 ,a *ange to ! paym5t arrangem5t "u :i* eligible pr(essionals p>ticipat+ 9 su* model w\ld be paid = cov]$ pr(essional s]vices furni%$ "u su* model4 7,b7 ,a *ange to ! crit]ia = eligible pr(essionals to be eligible to p>ticipate "u su* model 9 ord] to ensure t su* requirem5ts are satisfi$4 7,c7 ,a *ange to ! rules ( coord9ation describ$ 9 p>agraph 7#f74 7,d7 ,! application ( a )hold me*anism "u ! paym5t arrangem5t "u :i* ! di/ribution ( )held am\nts is bas$ on ! success ( ! model 9 meet+ sp5d+ r$uction requirem5ts4 7,e7 ,su* o!r *ange z ! ,secret>y may specify4 7#f7 ,rules ( coord9ation = application ( paym5t arrangem5ts "u models 7,a7 ,9 g5]al ,rules ( coord9ation describ$ 9 ?is p>agraph = an ,alt]native ,paym5t ,model %all be design$ to det]m9e1 = purposes ( apply+ subsection 7a7 & section #ahdh7;d77#af71 "u :at circum/ances an eligible pr(essional is treat$ z hav+ a paym5t arrangem5t "u a p>ticul> model4 7,b7 ,nonduplication ( paym5t ,su* rules ( coord9ation %all ensure coord9ation & nonduplication ( paym5t ( s]vices t might be cov]$ "u m ?an "o paym5t arrangem5t or "u section #ahdh7;d77#af74 7,c7 ,application to non-,,apm paym5t ,9 apply+ su* rules = purposes ( section #ahdh7;d77#af71 an eligible pr(essional %all n be treat$ z hav+ a paym5t arrangem5t 9 effect "u su* a model = any cov]$ pr(essional s]vices n treat$ z furni%$ "u ! model4 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 7d7 ,adju/m5t to ,m$ic>e paym5t localities 7#a7 ,9 g5]al ,section #ahdh7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;e77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#f7 ,use ( ,m,s,as z fee s*$ule areas 9 ,cali=nia 7,a7 ,9 g5]al ,subject to ! succe$+ provisions ( ?is p>agraph & not)/&+ ! previ\s provisions ( ?is subsection1 = s]vices furni%$ on or aft] ,janu>y #a1 #bjag1 ! fee s*$ule areas us$ = paym5t "u ?is section applicable to ,cali=nia %all be ! foll[+3 7i7 ,ea* ,metropolitan ,/ati/ical ,area 7ea* 9 ?is p>agraph ref]r$ to z an ,,msa71 z def9$ by ! ,director ( ! ,(fice ( ,managem5t & ,budget z ( ,decemb] #ca ( ! previ\s ye>1 %all be a fee s*$ule area4 7ii7 ,all areas n includ$ 9 an ,,msa %all be treat$ z a s+le re/-(-,/ate fee s*$ule area4 7,b7 ,transition = ,m,s,as previ\sly 9 re/-(-,/ate paym5t locality or 9 locality #c 7i7 ,9 g5]al ,= s]vices furni%$ 9 ,cali=nia dur+ a ye> beg9n+ ) #bjag & end+ ) #bjba 9 an ,,msa 9 a transition area 7z def9$ 9 subp>agraph 7,d771 subject to subp>agraph 7,c71 ! geographic index values to be appli$ "u ?is subsection = su* ye> %all be equal to ! sum ( ! foll[+3 7,i7 ,curr5t law compon5t ,! old weight+ factor 7describ$ 9 clause 7ii77 = su* ye> multipli$ by ! geographic index values "u ?is subsection = ! fee s*$ule area t includ$ su* ,,msa t w\ld h appli$ 9 su* area 7z e/imat$ by ! ,secret>y7 if ?is p>agraph did n apply4 7,,ii7 ,,msa-bas$ compon5t ,! ,,msa-bas$ weight+ factor 7describ$ 9 clause 7iii77 = su* ye> multipli$ by ! geographic index values comput$ = ! fee s*$ule area "u subp>agraph 7,a7 = ! ye> 7det]m9$ )\t reg>d to ?is subp>agraph74 7ii7 ,old weight+ factor ,! old weight+ factor describ$ 9 ?is clause-- 7,i7 = #bjag1 is #e_/f2 & 7,,ii7 = ea* succe$+ ye>1 is ! old weight+ factor describ$ 9 ?is clause = ! previ\s ye> m9us #a_/f4 7iii7 ,,msa-bas$ weight+ factor ,! ,,msa-bas$ weight+ factor describ$ 9 ?is clause = a ye> is #a m9us ! old weight+ factor "u clause 7ii7 = t ye>4 7,c7 ,hold h>mless ,= s]vices furni%$ 9 a transition area 9 ,cali=nia dur+ a ye> beg9n+ ) #bjag1 ! geographic index values to be appli$ "u ?is subsection = su* ye> %all n be less ?an ! correspond+ geographic index values t w\ld h appli$ 9 su* transition area 7z e/imat$ by ! ,secret>y7 if ?is p>agraph did n apply4 7,d7 ,transition area def9$ ,9 ?is p>agraph1 ! t]m transition area means ea* ( ! foll[+ fee s*$ule areas = #bjac3 7i7 ,! re/-(-,/ate paym5t locality4 7ii7 ,paym5t locality #c4 7,e7 ,ref]5ces to fee s*$ule areas ,effective = s]vices furni%$ on or aft] ,janu>y #a1 #bjag1 = ,cali=nia1 any ref]5ce 9 ?is section to a fee s*$ule area %all be deem$ a ref]5ce to a fee s*$ule area e/abli%$ 9 accordance ) ?is p>agraph4 4 7#b7 ,con=m+ am5dm5t to def9ition ( fee s*$ule area ,section #ahdh7;j77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;j77#b77 is am5d$ by /rik+ ,! t]m & ins]t+ ,except z provid$ 9 subsection 7e77#f77;,d71 ! t]m4 7e7 ,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#g7 ,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 7i7 ,9 g5]al ,only ) respect to fee s*$ules e/abli%$ = #bjaf1 #bjag1 & #bjah 7& n = subsequ5t ye>s71 ! ,secret>y %all-- 7,i7 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 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 & 7,,ii7 make su* adju/m5ts = ea* su* ye> s z only to result 9 su* a r$uction = su* ye>4 7ii7 ,no effect on subsequ5t ye>s ,a r$uction "u ?is subp>agraph = a ye> %all n affect any r$uction = any subsequ5t ye>4 7iii7 ,rule ( con/ruction relat+ to und]valu$ codes ,no?+ 9 ?is subp>agraph %all be con/ru$ z prev5t+ ! ,secret>y f increas+ ! relative values = codes t are und]valu$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,m7 = fiscal ye>s #bjaf1 #bjag1 & #bjah4 4 7#c7 ,disclosure ( data us$ to e/abli% multiple proc$ure paym5t r$uction policy ,! ,secret>y ( ,heal? & ,human ,s]vices %all make publicly available ! data us$ to e/abli% ! multiple proc$ure paym5t r$uction policy to ! pr(essional compon5t ( imag+ s]vices 9 ! f9al rule publi%$ 9 ! ,f$]al ,regi/]1 v4 #gg1 n4 #bbb1 ,novemb] #af1 #bjab1 pages #fhhia-fichj "u ! physician fee s*$ule "u section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d74 #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)/&+ p>agraph 7#d77;,b7 ( section #ahgd7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77 & ! second s5t5ce ( p>agraph 7#d77;,d7 ( su* section1 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 non-public analyses 7z det]m9$ appropriate by ! ,secret>y ( ,heal? & ,human ,s]vices7 or provide or sell su* data to regi/]$ or au?oriz$ us]s & subscrib]s1 includ+ to provid]s ( s]vices & suppli]s1 = non-public use 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 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 = non-public use includ+ 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;,e77 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#c77;,e77 = purposes ( l9k+ su* data ) cl9ical outcomes data & p]=m+ & dissem9at+ risk-adju/$1 sci5tifically valid analysis & rese>* to support quality improvem5t or pati5t safety1 provid$ t any public report+ ( id5tifiable provid] data %all only be conduct$ ) prior cons5t ( su* provid]4 #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 provid] 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 provid]1 make paym5t 7z ! ,secret>y det]m9es to be appropriate7 "u ! fee s*$ule "u ?is section us+ su* ,,hcpcs codes4 7,b7 ,applicable provid] def9$ ,= purposes ( ?is p>agraph1 ! t]m applicable provid] means a physician 7z def9$ 9 section #ahfa7r77#a77 or a physician assi/ant or nurse practition] 7z def9$ 9 section #ahfa7;aa77#e77;,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 provid] paym5t ,9 c>ry+ out ?is p>agraph1 ! ,secret>y %all only make paym5t to a s+le applicable provid] = 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 on 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 = #bjai & ea* subsequ5t ye> 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;b7 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 7#d7 ,report on cl9ical decision support me*anisms ,n lat] ?an "o ye> aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all submit to ,congress a report on ! ext5t to :i* cl9ical decision support me*anisms & o!r provid] support tools c\ld be us$ to fur!r program objectives "u section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d77 & recomm5dation = h[ su* me*anisms & tools %\ld be s us$4 7b7 ,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 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,,sgr ,repeal & ,m$ic>e ,b5efici>y ,access ,act ( #bjac4 7b7 ,table ( cont5ts ,! table ( cont5ts = ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4 ,sec4 #b4 ,repeal+ ! su/a9able gr[? rate 7,,sgr7 & improv+ m$ic>e paym5t = physicians' s]vices4 ,sec4 #c4 ,priorities & fund+ = quality measure developm5t4 ,sec4 #d4 ,enc\rag+ c>e managem5t = individuals ) *ronic c>e ne$s4 ,sec4 #e4 ,ensur+ accurate valuation ( s]vices "u ! physician fee s*$ule4 ,sec4 #f4 ,promot+ evid5ce-bas$ c>e4 ,sec4 #g4 ,emp[]+ b5efici>y *oices ?r\gh access to in=mation on physicians' s]vices4 ,sec4 #h4 ,exp&+ claims data availability to improve c>e4 ,sec4 #i4 ,r$uc+ adm9i/rative burd5 & o!r provisions4 #b4 ,repeal+ ! su/a9able gr[? rate 7,,sgr7 & improv+ m$ic>e paym5t = physicians' s]vices 7a7 ,/abiliz+ fee updates 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 aft] p>agraph 7#d72 & 7ii7 9 p>agraph 7#d7-- 7,i7 9 ! head+1 by ins]t+ & end+ ) #bjac aft] ye>s beg9n+ ) #bjja2 & 7,,ii7 9 subp>agraph 7,a71 by ins]t+ & end+ ) #bjac aft] a ye> beg9n+ ) #bjja2 & 7,b7 9 subsection 7f7-- 7i7 9 p>agraph 7#a77;,b71 by ins]t+ ?r\gh #bjac aft] ( ea* succe$+ ye>2 & 7ii7 9 p>agraph 7#b71 by ins]t+ & end+ ) #bjac aft] beg9n+ ) #bjjj4 7#b7 ,update ( rates = #bjad & subsequ5t ye>s ,subsection 7d7 ( section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is am5d$ by add+ at ! end ! foll[+ new p>agraphs3 7#ae7 ,update = #bjad ?r\gh #bjaf ,! update to ! s+le conv]sion factor e/abli%$ 9 p>agraph 7#a77;,c7 = ea* ( #bjad ?r\gh #bjaf %all be #j4e p]c5t4 7#af7 ,update = #bjag ?r\gh #bjbc ,! update to ! s+le conv]sion factor e/abli%$ 9 p>agraph 7#a77;,c7 = ea* ( #bjag ?r\gh #bjbc %all be z]o p]c5t4 7#ag7 ,update = #bjbd & subsequ5t ye>s ,! update to ! s+le conv]sion factor e/abli%$ 9 p>agraph 7#a77;,c7 = #bjbd & ea* subsequ5t ye> %all be-- 7,a7 = items & s]vices furni%$ by a qualify+ ,,apm p>ticipant 7z def9$ 9 section #ahcc7z77#b77 = su* ye>1 #b p]c5t2 & 7,b7 = o!r items & s]vices1 #a p]c5t4 4 7#c7 ,med,p,a,c reports 7,a7 ,initial report ,n lat] ?an ,july #a1 #bjaf1 ! ,m$ic>e ,paym5t ,advisory ,commission %all submit to ,congress a report on ! relation%ip betwe5-- 7i7 physician & o!r heal? pr(essional utilization & exp5ditures 7& ! rate ( increase ( su* utilization & exp5ditures7 ( items & s]vices = :i* paym5t is made "u section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d72 & 7ii7 total utilization & exp5ditures 7& ! rate ( increase ( su* utilization & exp5ditures7 "u p>ts ,a1 ,b1 & ,d ( title ,,xviii ( su* ,act4 ,su* report %all include a me?odology to describe su* relation%ip & ! impact ( *anges 9 su* physician & o!r heal? pr(essional practice & s]vice ord]+ patt]ns on total utilization & exp5ditures "u p>ts ,a1 ,b1 & ,d ( su* title4 7,b7 ,f9al report ,n lat] ?an ,july #a1 #bjbj1 ! ,m$ic>e ,paym5t ,advisory ,commission %all submit to ,congress a report on ! relation%ip describ$ 9 subp>agraph 7,a71 includ+ ! results det]m9$ f apply+ ! me?odology includ$ 9 ! report submitt$ "u su* subp>agraph4 7b7 ,consolidation ( c]ta9 curr5t law p]=mance programs ) new value-bas$ p]=mance inc5tive program 7#a7 ,,ehr mean+ful use inc5tive program 7,a7 ,sunsett+ sep>ate mean+ful use paym5t adju/m5ts ,section #ahdh7;a77#g77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;a77#g77;,a77 is am5d$-- 7i7 9 clause 7i71 by /rik+ or any subsequ5t paym5t ye> & ins]t+ or #bjaf2 7ii7 9 clause 7ii7-- 7,i7 9 ! matt] prec$+ subclause 7,i71 by /rik+ ,subject to clause 7iii71 = & ins]t+ ,=2 7,,ii7 9 subclause 7,i71 by add+ at ! end &2 7,,iii7 9 subclause 7,,ii71 by /rik+ 2 & & ins]t+ a p]iod2 & 7,,iv7 by /rik+ subclause 7,,iii72 & 7iii7 by /rik+ clause 7iii74 7,b7 ,cont9uation ( mean+ful use det]m9ations = ,,vbp program ,section #ahdh7o77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7o77#b77 is am5d$-- 7i7 9 subp>agraph 7,a71 9 ! matt] prec$+ clause 7i7-- 7,i7 by /rik+ ,= purposes ( p>agraph 7#a71 an & ins]t+ ,an2 & 7,,ii7 by ins]t+ 1 or pursuant to subp>agraph 7,d7 = purposes ( subsection 7q71 = a p]=mance p]iod "u su* subsection = a ye> aft] "u su* subsection = a ye>2 & 7ii7 by add+ at ! end ! foll[+ new subp>agraph3 7,d7 ,cont9u$ application = purposes ( ,,vbp program ,) respect to #bjag & ea* subsequ5t paym5t ye>1 ! ,secret>y %all1 = purposes ( subsection 7q7 & 9 accordance ) p>agraph 7#a77;,f7 ( su* subsection1 det]m9e :e!r an eligible pr(essional :o is a ,,vbp eligible pr(essional 7z def9$ 9 subsection 7q77#a77;,c77 = su* ye> is a mean+ful ,,ehr us] "u ?is p>agraph = ! p]=mance p]iod "u subsection 7q7 = su* ye>4 4 7#b7 ,quality report+ 7,a7 ,sunsett+ sep>ate quality report+ inc5tives ,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+ or any subsequ5t ye> & ins]t+ or #bjaf2 & 7ii7 9 clause 7ii77,,ii71 by /rik+ & ea* subsequ5t ye>4 7,b7 ,cont9uation ( quality measures & processes = ,,vbp program ,section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is am5d$-- 7i7 9 subsection 7k71 by add+ at ! end ! foll[+ new p>agraph3 7#i7 ,cont9u$ application = purposes ( ,,vbp program ,! ,secret>y %all1 9 accordance ) subsection 7q77#a77;,f71 c>ry out ! provisions ( ?is subsection = purposes ( subsection 7q74 2 & 7ii7 9 subsection 7m7-- 7,i7 by r$esignat+ ! p>agraph 7#g7 add$ by section #ajcbg7;a7 ( ,public ,law #aaa-adh z p>agraph 7#h72 & 7,,ii7 by add+ at ! end ! foll[+ new p>agraph3 7#i7 ,cont9u$ application = purposes ( ,,vbp program ,! ,secret>y %all1 9 accordance ) subsection 7q77#a77;,f71 c>ry out ! processes "u ?is subsection = purposes ( subsection 7q74 4 7#c7 ,value-bas$ paym5ts 7,a7 ,sunsett+ sep>ate value-bas$ paym5ts ,clause 7iii7 ( section #ahdh7p77#d77;,b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7p77#d77;,b77 is am5d$ to read z foll[s3 7iii7 ,application ,! ,secret>y %all apply ! paym5t modifi] e/abli%$ "u ?is subsection = items & s]vices furni%$ on or aft] ,janu>y #a1 #bjae1 b be=e ,janu>y #a1 #bjag1 ) respect to specific physicians & gr\ps ( physicians ! ,secret>y det]m9es appropriate4 ,su* paym5t modifi] %all n be appli$ = items & s]vices furni%$ on or aft] ,janu>y #a1 #bjag4 4 7,b7 ,cont9uation ( value-bas$ paym5t modifi] measures = ,,vbp program ,section #ahdh7p7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7p77 is am5d$-- 7i7 9 p>agraph 7#b71 by add+ at ! end ! foll[+ new subp>agraph3 7,c7 ,cont9u$ application = purposes ( ,,vbp program ,! ,secret>y %all1 9 accordance ) subsection 7q77#a77;,f71 c>ry out subp>agraph 7,b7 = purposes ( subsection 7q74 2 & 7ii7 9 p>agraph 7#c71 by add+ at ! end ! foll[+3 ,) respect to #bjag & ea* subsequ5t ye>1 ! ,secret>y %all1 9 accordance ) subsection 7q77#a77;,f71 c>ry out ?is p>agraph = purposes ( subsection 7q744 7c7 ,value-bas$ p]=mance 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 ,value-bas$ p]=mance inc5tive program 7#a7 ,e/abli%m5t 7,a7 ,9 g5]al ,subject to ! succe$+ provisions ( ?is subsection1 ! ,secret>y %all e/abli% an eligible pr(essional value-bas$ p]=mance inc5tive program 79 ?is subsection ref]r$ to z ! ,,vbp program7 "u :i* ! ,secret>y %all-- 7i7 develop a me?odology = assess+ ! total p]=mance ( ea* ,,vbp eligible pr(essional accord+ to p]=mance /&>ds "u p>agraph 7#c7 = a p]=mance p]iod 7z e/abli%$ "u p>agraph 7#d77 = a ye>2 7ii7 us+ su* me?odology1 provide = a composite p]=mance score 9 accordance ) p>agraph 7#e7 = ea* su* pr(essional = ea* p]=mance p]iod2 & 7iii7 use su* composite p]=mance score ( ! ,,vbp eligible pr(essional = a p]=mance p]iod = a ye> to make ,,vbp program inc5tive paym5ts "u p>agraph 7#g7 to ! pr(essional = ! ye>4 7,b7 ,program implem5tation ,! ,,vbp program %all apply to paym5ts = items & s]vices furni%$ on or aft] ,janu>y #a1 #bjag4 7,c7 ,,vbp eligible pr(essional def9$ 7i7 ,9 g5]al ,= purposes ( ?is subsection1 subject to clauses 7ii7 & 7iv71 ! t]m ,,vbp eligible pr(essional means-- 7,i7 = ! fir/ & second ye>s = :i* ! ,,vbp program applies to paym5ts 7& = ! p]=mance p]iod = su* fir/ & second ye>71 a physician 7z def9$ 9 section #ahfa7r77#a771 a physician assi/ant1 nurse practition]1 & cl9ical nurse speciali/ 7z su* t]ms are def9$ 9 section #ahfa7;aa77#e771 & a c]tifi$ regi/]$ nurse ane/heti/ 7z def9$ 9 section #ahfa7;bb77#b772 & 7,,ii7 = ! ?ird ye> = :i* ! ,,vbp program applies to paym5ts 7& = ! p]=mance p]iod = su* ?ird ye>7 & = ea* succe$+ ye> 7& = ! p]=mance p]iod = ea* su* ye>71 ! pr(essionals describ$ 9 subclause 7,i7 & su* o!r eligible pr(essionals 7z def9$ 9 subsection 7k77#c77;,b77 z specifi$ by ! ,secret>y4 7ii7 ,exclusions ,= purposes ( clause 7i71 ! t]m ,,vbp eligible pr(essional does n include1 ) respect to a ye>1 an eligible pr(essional 7z def9$ 9 subsection 7k77#c77;,b77-- 7,i7 :o is a qualify+ ,,apm p>ticipant 7z def9$ 9 section #ahcc7z77#b772 7,,ii7 :o1 subject to clause 7vii71 is a p>tial qualify+ ,,apm p>ticipant 7z def9$ 9 clause 7iii77 = ! mo/ rec5t p]iod = :i* data are available & :o1 = ! p]=mance p]iod ) respect to su* ye>1 does n report on applicable measures & activities describ$ 9 p>agraph 7#b77;,b7 t are requir$ to be report$ by su* a pr(essional "u ! ,,vbp program2 or 7,,iii7 :o1 = ! p]=mance p]iod ) respect to su* ye>1 does n exce$ ! l[-volume ?re%old measurem5t select$ "u clause 7iv74 7iii7 ,p>tial qualify+ ,,apm p>ticipant ,= purposes ( ?is subp>agraph1 ! t]m p>tial qualify+ ,,apm p>ticipant means1 ) respect to a ye>1 an eligible pr(essional = :om ! ,secret>y det]m9es ! m9imum paym5t p]c5tage 7or p]c5tages71 z applicable1 describ$ 9 p>agraph 7#b7 ( section #ahcc7z7 = su* ye> h n be5 satisfi$1 b :o w\ld be consid]$ a qualify+ ,,apm p>ticipant 7z def9$ 9 su* p>agraph7 = su* ye> if-- 7,i7 ) respect to #bjag & #bjah1 ! ref]5ce 9 subp>agraph 7,a7 ( su* p>agraph to #be p]c5t 0 in/ead a ref]5ce to #bj p]c5t2 7,,ii7 ) respect to #bjai & #bjbj-- 7aa7 ! ref]5ce 9 subp>agraph 7,b77i7 ( su* p>agraph to #ej p]c5t 0 in/ead a ref]5ce to #dj p]c5t2 & 7bb7 ! ref]5ces 9 subp>agraph 7,b77ii7 ( su* p>agraph to #ej p]c5t & #be p]c5t ( su* p>agraph 7 in/ead ref]5ces to #dj p]c5t & #bj p]c5t1 respectively2 & 7,,iii7 ) respect to #bjba & subsequ5t ye>s-- 7aa7 ! ref]5ce 9 subp>agraph 7,c77i7 ( su* p>agraph to #ge p]c5t 0 in/ead a ref]5ce to #ej p]c5t2 & 7bb7 ! ref]5ces 9 subp>agraph 7,c77ii7 ( su* p>agraph to #ge p]c5t & #be p]c5t ( su* p>agraph 7 in/ead ref]5ces to #ej p]c5t & #bj p]c5t1 respectively4 7iv7 ,selection ( l[-volume ?re%old measurem5t ,! ,secret>y %all select "o ( ! foll[+ l[-volume ?re%old measurem5ts to apply = purposes ( clause 7ii77,,iii73 7,i7 ,! m9imum numb] 7z det]m9$ by ! ,secret>y7 ( individuals enroll$ "u ?is "p :o are treat$ by ! ,,vbp eligible pr(essional = ! p]=mance p]iod involv$4 7,,ii7 ,! m9imum numb] 7z det]m9$ by ! ,secret>y7 ( items & s]vices furni%$ to individuals enroll$ "u ?is "p by su* pr(essional = su* p]=mance p]iod4 7,,iii7 ,! m9imum am\nt 7z det]m9$ by ! ,secret>y7 ( all[$ *>ges bill$ by su* pr(essional "u ?is "p = su* p]=mance p]iod4 7v7 ,treatm5t ( new ,m$ic>e enroll$ eligible pr(essionals ,9 ! case ( a pr(essional :o fir/ becomes a ,m$ic>e enroll$ eligible pr(essional dur+ ! p]=mance p]iod = a ye> 7& _h n previ\sly submitt$ claims "u ?is title su* z a p]son1 an entity1 or a "p ( a physician gr\p or "u a diff]5t bill+ numb] or tax id5tifi]71 su* pr(essional %all n be treat$ "u ?is subsection z a ,,vbp eligible pr(essional until ! subsequ5t ye> & p]=mance p]iod = su* subsequ5t ye>4 7vi7 ,cl>ification ,9 ! case ( items & s]vices furni%$ dur+ a ye> by an individual :o is n a ,,vbp eligible pr(essional 7includ+ pursuant to clauses 7ii7 & 7v77 ) respect to a ye>1 9 no case %all a r$uction "u p>agraph 7#f7 or a ,,vbp program inc5tive paym5t "u p>agraph 7#g7 apply to su* individual = su* ye>4 7vii7 ,p>tial qualify+ ,,apm p>ticipant cl>ification ,9 ! case ( an eligible pr(essional :o is a p>tial qualify+ ,,apm p>ticipant1 ) respect to a ye>1 & :o = ! p]=mance p]iod = su* ye> reports on applicable measures & activities describ$ 9 p>agraph 7#b77;,b7 t are requir$ to be report$ by su* a pr(essional "u ! ,,vbp program1 su* eligible pr(essional is consid]$ to be a ,,vbp eligible pr(essional ) respect to su* ye>4 7,d7 ,application to gr\p practices 7i7 ,9 g5]al ,"u ! ,,vbp program3 7,i7 ,quality p]=mance category ,! ,secret>y %all e/abli% & apply a process t includes features ( ! provisions ( subsection 7m77#c77;,c7 = ,,vbp eligible pr(essionals 9 a gr\p practice ) respect to assess+ p]=mance ( su* gr\p ) respect to ! p]=mance category describ$ 9 clause 7i7 ( p>agraph 7#b77;,a74 7,,ii7 ,o!r p]=mance categories ,! ,secret>y may e/abli% & apply a process t includes features ( ! provisions ( subsection 7m77#c77;,c7 = ,,vbp eligible pr(essionals 9 a gr\p practice ) respect to assess+ ! p]=mance ( su* gr\p ) respect to ! p]=mance categories describ$ 9 clauses 7ii7 ?r\gh 7iv7 ( su* p>agraph4 7ii7 ,ensur+ compreh5siv5ess ( gr\p practice assessm5t ,! process e/abli%$ "u clause 7i7 %all to ! ext5t practicable reflect ! full range ( items & s]vices furni%$ by ! ,,vbp eligible pr(essionals 9 ! gr\p practice involv$4 7iii7 ,cl>ification ,,vbp eligible pr(essionals elect+ to be a virtual gr\p "u p>agraph 7#e77;,j7 %all n be consid]$ ,,vbp eligible pr(essionals 9 a gr\p practice = purposes ( apply+ ?is subp>agraph4 7,e7 ,use ( regi/ries ,"u ! ,,vbp program1 ! ,secret>y %all enc\rage ! use ( qualifi$ cl9ical data regi/ries pursuant to subsection 7m77#c77;,e7 9 c>ry+ out ?is subsection4 7,f7 ,application ( c]ta9 provisions ,9 apply+ a provision ( subsection 7k71 7m71 7o71 or 7p7 = purposes ( ?is subsection1 ! ,secret>y %all-- 7i7 adju/ ! application ( su* provision to ensure ! provision is consi/5t ) ! provisions ( ?is subsection2 & 7ii7 n apply su* provision to ! ext5t t ! provision is duplicative ) a provision ( ?is subsection4 7#b7 ,measures & activities "u p]=mance categories 7,a7 ,p]=mance categories ,"u ! ,,vbp program1 ! ,secret>y %all use ! foll[+ p]=mance categories 7ea* ( :i* is ref]r$ to 9 ?is subsection z a p]=mance category7 9 det]m9+ ! composite p]=mance score "u p>agraph 7#e73 7i7 ,quality4 7ii7 ,res\rce use4 7iii7 ,cl9ical practice improvem5t activities4 7iv7 ,mean+ful use ( c]tifi$ ,,ehr te*nology4 7,b7 ,measures & activities specifi$ = ea* category ,= purposes ( p>agraph 7#c77;,a7 & subject to subp>agraph 7,c71 measures & activities specifi$ = a p]=mance p]iod 7z e/abli%$ "u p>agraph 7#d77 = a ye> are z foll[s3 7i7 ,quality ,= ! p]=mance category describ$ 9 subp>agraph 7,a77i71 ! quality measures e/abli%$ = su* p]iod "u subsections 7k7 & 7m71 includ+ "u subsection 7m77#c77;,e71 & ! measures ( quality ( c>e e/abli%$ = su* p]iod "u subsection 7p77#b74 7ii7 ,res\rce use ,= ! p]=mance category describ$ 9 subp>agraph 7,a77ii71 ! measurem5t ( res\rce use = su* p]iod "u subsection 7p77#c71 us+ ! me?odology "u subsection 7r71 z appropriate1 &1 z feasible & applicable1 acc\nt+ = ! co/ ( cov]$ "p ,d drugs4 7iii7 ,cl9ical practice improvem5t activities ,= ! p]=mance category describ$ 9 subp>agraph 7,a77iii71 cl9ical practice improvem5t activities "u subcategories specifi$ by ! ,secret>y = su* p]iod1 :i* %all include at lea/ ! foll[+3 7,i7 ,! subcategory ( exp&$ practice access1 :i* %all include activities su* z same day appo9tm5ts = urg5t ne$s & aft] h\rs access to cl9ician advice4 7,,ii7 ,! subcategory ( population managem5t1 :i* %all include activities su* z monitor+ heal? conditions ( individuals to provide timely heal? c>e int]v5tions or p>ticipation 9 a qualifi$ cl9ical data regi/ry4 7,,iii7 ,! subcategory ( c>e coord9ation1 :i* %all include activities su* z timely communication ( te/ results1 timely ex*ange ( cl9ical in=mation to pati5ts & o!r provid]s1 & use ( remote monitor+ or teleheal?4 7,,iv7 ,! subcategory ( b5efici>y engagem5t1 :i* %all include activities su* z ! e/abli%m5t ( c>e plans = individuals ) complex c>e ne$s1 b5efici>y self-managem5t tra9+1 & us+ %>$ decision-mak+ me*anisms4 7,v7 ,! subcategory ( pati5t safety & practice assessm5t1 su* z ?r\gh use ( cl9ical or surgical *eckli/s & practice assessm5ts relat$ to ma9ta9+ c]tification4 7,,vi7 ,! subcategory ( p>ticipation 9 an alt]native paym5t model 7z def9$ 9 section #ahcc7z77#c77;,c774 ,9 e/abli%+ activities "u ?is clause1 ! ,secret>y %all give consid]ation to ! circum/ances ( small practices 7consi/+ ( few] ?an #bj pr(essionals7 & practices locat$ 9 rural areas & 9 heal? pr(essional %ortage areas 7z designat$ "u section #ccb7;a77#a77;,a7 ( ! ,public ,heal? ,s]vice ,act74 7iv7 ,mean+ful ,,ehr use ,= ! p]=mance category describ$ 9 subp>agraph 7,a77iv71 ! requirem5ts e/abli%$ = su* p]iod "u subsection 7o77#b7 = det]m9+ :e!r an eligible pr(essional is a mean+ful ,,ehr us]4 7,c7 ,additional provisions 7i7 ,emphasiz+ outcome measures "u quality p]=mance category ,9 apply+ subp>agraph 7,b77i71 ! ,secret>y %all1 z feasible1 emphasize ! application ( outcome measures4 7ii7 ,application ( additional sy/em measures ,! ,secret>y may use measures us$ = a paym5t sy/em o!r ?an = physicians = purposes ( ! p]=mance category describ$ 9 subp>agraph 7,a77i74 7iii7 ,global & population-bas$ measures ,! ,secret>y may use global measures1 su* z global outcome measures1 & population-bas$ measures = purposes ( ! p]=mance category describ$ 9 subp>agraph 7,a77i74 7iv7 ,reque/ = in=mation = cl9ical practice improvem5t activities ,9 initially apply+ subp>agraph 7,b77iii71 ! ,secret>y %all use a reque/ = in=mation to solicit recomm5dations f /akehold]s = id5tify+ activities describ$ 9 su* subp>agraph & specify+ crit]ia = su* activities4 7v7 ,contract au?ority = cl9ical practice improvem5t activities p]=mance category ,9 apply+ subp>agraph 7,b77iii71 ! ,secret>y may contract ) entities to assi/ ! ,secret>y 9-- 7,i7 id5tify+ activities describ$ 9 subp>agraph 7,b77iii72 7,,ii7 specify+ crit]ia = su* activities2 & 7,,iii7 det]m9+ :e!r a ,,vbp eligible pr(essional meets su* crit]ia4 7vi7 ,application ( measures & activities to non-pati5t-fac+ provid]s ,9 c>ry+ out ?is p>agraph1 ) respect to measures & activities specifi$ 9 subp>agraph 7,b7 = p]=mance categories describ$ 9 subp>agraph 7,a71 ! ,secret>y-- 7,i7 %all give consid]ation to ! circum/ances ( pr(essional types 7or subcategories ( ^? types det]m9$ by practice *>act]i/ics7 :o typically provide s]vices t d n involve face-to-face int]action ) a pati5t2 & 7,,ii7 may1 to ! ext5t feasible & appropriate1 take into acc\nt su* circum/ances & apply "u ?is subsection ) respect to ,,vbp eligible pr(essionals ( su* pr(essional types or subcategories1 9 lieu ( su* a measure or activity1 a comp>able measure or activity t fulfills ! goals ( ! applicable p]=mance category4 ,9 c>ry+ out ! previ\s s5t5ce1 ! ,secret>y %all consult ) pr(essionals ( su* pr(essional types or subcategories4 7#c7 ,p]=mance /&>ds 7,a7 ,e/abli%m5t ,"u ! ,,vbp program1 ! ,secret>y %all e/abli% p]=mance /&>ds ) respect to measures & activities specifi$ "u p>agraph 7#b77;,b7 = a p]=mance p]iod 7z e/abli%$ "u p>agraph 7#d77 = a ye>4 7,b7 ,consid]ations 9 e/abli%+ /&>ds ,9 e/abli%+ su* p]=mance /&>ds ) respect to measures & activities specifi$ "u p>agraph 7#b77;,b71 ! ,secret>y %all take into acc\nt ! foll[+3 7i7 ,hi/orical p]=mance /&>ds4 7ii7 ,improvem5t rates4 7iii7 ,! opportunity = cont9u$ improvem5t4 7#d7 ,p]=mance p]iod ,! ,secret>y %all e/abli% a p]=mance p]iod 7or p]iods7 = a ye> 7beg9n+ ) ! ye> describ$ 9 p>agraph 7#a77;,b774 ,su* p]=mance p]iod 7or p]iods7 %all beg9 & end prior to ! beg9n+ ( su* ye> & be z close z possible to su* ye>4 ,9 ?is subsection1 su* p]=mance p]iod 7or p]iods7 = a ye> %all be ref]r$ to z ! p]=mance p]iod = ! ye>4 7#e7 ,composite p]=mance score 7,a7 ,9 g5]al ,subject to ! succe$+ provisions ( ?is p>agraph & consi/5t ) section #b7;g77#b7 ( ! ,,sgr ,repeal & ,m$ic>e ,b5efici>y ,access ,act ( #bjac1 ! ,secret>y %all develop a me?odology = assess+ ! total p]=mance ( ea* ,,vbp eligible pr(essional accord+ to p]=mance /&>ds "u p>agraph 7#c7 ) respect to applicable measures & activities specifi$ 9 p>agraph 7#b77;,b7 ) respect to ea* p]=mance category applicable to su* pr(essional = a p]=mance p]iod 7z e/abli%$ "u p>agraph 7#d77 = a ye>4 ,us+ su* me?odology1 ! ,secret>y %all provide = a composite assessm5t 79 ?is subsection ref]r$ to z ! composite p]=mance score7 = ea* su* pr(essional = ea* p]=mance p]iod4 7,b7 ,weight+ p]=mance categories1 measures1 & activities ,"u ! me?odology "u subp>agraph 7,a71 ! ,secret>y-- 7i7 may assign diff]5t scor+ weights 7includ+ a weight ( #j7 =-- 7,i7 ea* p]=mance category bas$ on ! ext5t to :i* ! category is applicable to ! type ( eligible pr(essional involv$2 & 7,,ii7 ea* measure & activity specifi$ "u p>agraph 7#b77;,b7 ) respect to ea* su* category bas$ on ! ext5t to :i* ! measure or activity is applicable to ! type ( eligible pr(essional involv$2 & 7ii7 ) respect to ! p]=mance category describ$ 9 p>agraph 7#b77;,a77i7-- 7,i7 %all assign a high] scor+ weight to outcomes measures ?an to o!r measures & increase ! scor+ weight = outcome measures ov] "t2 & 7,,ii7 may assign a high] scor+ weight to pati5t exp]i5ce measures4 7,c7 ,inc5tive to report2 enc\rag+ use ( c]tifi$ ,,ehr te*nology = report+ quality measures 7i7 ,inc5tive to report ,"u ! me?odology e/abli%$ "u subp>agraph 7,a71 ! ,secret>y %all provide t 9 ! case ( a ,,vbp eligible pr(essional :o fails to report on an applicable measure or activity t is requir$ to be report$ by ! pr(essional1 ! pr(essional %all be treat$ z a*iev+ ! l[e/ pot5tial score applicable to su* measure or activity4 7ii7 ,enc\rag+ use ( c]tifi$ ,,ehr te*nology = report+ quality measures ,"u ! me?odology e/abli%$ "u subp>agraph 7,a71 ! ,secret>y %all-- 7,i7 enc\rage ,,vbp eligible pr(essionals to report on applicable measures ) respect to ! p]=mance category describ$ 9 p>agraph 7#b77;,a77i7 ?r\gh ! use ( c]tifi$ ,,ehr te*nology2 & 7,,ii7 ) respect to a p]=mance p]iod1 ) respect to a ye>1 = :i* a ,,vbp eligible pr(essional reports su* measures ?r\gh ! use ( su* ,,ehr te*nology1 treat su* pr(essional z satisfy+ ! cl9ical quality measures report+ requirem5t describ$ 9 subsection 7o77#b77;,a77iii7 = su* ye>4 7,d7 ,cl9ical practice improvem5t activities p]=mance score 7i7 ,rule = accr$itation ,a ,,vbp eligible pr(essional :o is 9 a practice t is c]tifi$ z a pati5t-c5t]$ m$ical home or comp>able specialty practice pursuant to subsection 7b77#h77;,b77i7 ) respect to a p]=mance p]iod %all be giv5 ! highe/ pot5tial score = ! p]=mance category describ$ 9 p>agraph 7#b77;,a77iii7 = su* p]iod4 7ii7 ,,apm p>ticipation ,p>ticipation by a ,,vbp eligible pr(essional 9 an alt]native paym5t model 7z def9$ 9 section #ahcc7z77#c77;,c77 ) respect to a p]=mance p]iod %all e>n su* eligible pr(essional "o-half ( ! highe/ pot5tial score = ! p]=mance category describ$ 9 p>agraph 7#b77;,a77iii7 = su* p]=mance p]iod4 ,no?+ 9 ! previ\s s5t5ce %all prev5t su* pr(essional f e>n+ m ?an "o-half ( su* highe/ pot5tial score = su* p]=mance p]iod by p]=m+ additional activities ) respect to su* p]=mance category4 7iii7 ,subcategories ,a ,,vbp eligible pr(essional %all n be requir$ to p]=m activities 9 ea* subcategory "u p>agraph 7#b77;,b77iii7 to a*ieve ! highe/ pot5tial score = ! p]=mance category describ$ 9 p>agraph 7#b77;,a77iii74 7,e7 ,di/ribution ,! ,secret>y %all ensure t ! application ( ! me?odology develop$ "u subp>agraph 7,a7 results 9 a cont9u\s di/ribution ( p]=mance scores1 :i* %all result 9 diff]5tial paym5ts "u p>agraph 7#g74 7,f7 ,a*ievem5t & improvem5t 7i7 ,tak+ into acc\nt improvem5t ,beg9n+ ) ! second ye> to :i* ! ,,vbp program applies1 9 addition to ! a*ievem5t score ( a ,,vbp eligible pr(essional1 ! me?odology develop$ "u subp>agraph 7,a7-- 7,i7 9 ! case ( ! p]=mance score = ! p]=mance category describ$ 9 clauses 7i7 & 7ii7 ( p>agraph 7#b77;,a71 %all take into acc\nt ! improvem5t ( ! pr(essional2 & 7,,ii7 9 ! case ( p]=mance scores = o!r p]=mance categories1 may take into acc\nt ! improvem5t ( ! pr(essional4 7ii7 ,assign+ high] weight = a*ievem5t ,beg9n+ ) ! f\r? ye> to :i* ! ,,vbp program applies1 "u ! me?odology develop$ "u subp>agraph 7,a71 ! ,secret>y may assign a high] scor+ weight "u subp>agraph 7,b7 ) respect to ! a*ievem5t score ( a ,,vbp eligible pr(essional ) respect to a measure or activity specifi$ "u p>agraph 7#b77;,b7 7or ) respect to su* a measure or activity & ) respect to categories describ$ 9 p>agraph 7#b77;,a77 ?an to any improvem5t score appli$ "u clause 7i7 ) respect to su* measure or activity 7or su* measure or activity & categories74 7,g7 ,weights = ! p]=mance categories 7i7 ,9 g5]al ,"u ! me?odology develop$ "u subp>agraph 7,a71 subject to clauses 7ii7 & 7iii71 ! composite p]=mance score %all be det]m9$ z foll[s3 7,i7 ,quality 7aa7 ,9 g5]al ,subject to item 7bb71 #cj p]c5t ( su* score %all be bas$ on p]=mance ) respect to ! category describ$ 9 clause 7i7 ( p>agraph 7#b77;,a74 7bb7 ,fir/ #b ye>s & te/ ye> ,= ! fir/ & second ye>s = :i* ! ,,vbp program applies to paym5ts1 #fj p]c5t ( su* score %all be bas$ on p]=mance ) respect to ! category describ$ 9 clause 7i7 ( p>agraph 7#b77;,a74 ,) respect to ! subsequ5t ye>1 ! p]c5t describ$ 9 item 7aa7 ( su* score %all be bas$ on p]=mance ) respect to su* category only = purposes ( fe$back & #fj p]c5t ( su* score %all be bas$ on p]=mance ) respect to su* category = any o!r purpose "u ?is subsection4 7,,ii7 ,res\rce use 7aa7 ,9 g5]al ,subject to item 7bb71 #cj p]c5t ( su* score %all be bas$ on p]=mance ) respect to ! category describ$ 9 clause 7ii7 ( p>agraph 7#b77;,a74 7bb7 ,fir/ #b ye>s & te/ ye> ,= ! fir/ & second ye>s = :i* ! ,,vbp program applies to paym5ts1 z]o p]c5t ( su* score %all be bas$ on p]=mance ) respect to ! category describ$ 9 clause 7ii7 ( p>agraph 7#b77;,a74 ,) respect to ! subsequ5t ye>1 ! p]c5t describ$ 9 item 7aa7 ( su* score %all be bas$ on p]=mance ) respect to su* category only = purposes ( fe$back & z]o p]c5t ( su* score %all be bas$ on p]=mance ) respect to su* category = any o!r purpose "u ?is subsection4 7,,iii7 ,cl9ical practice improvem5t activities ,fifte5 p]c5t ( su* score %all be bas$ on p]=mance ) respect to ! category describ$ 9 clause 7iii7 ( p>agraph 7#b77;,a74 7,,iv7 ,mean+ful use ( c]tifi$ ,,ehr te*nology ,tw5ty-five p]c5t ( su* score %all be bas$ on p]=mance ) respect to ! category describ$ 9 clause 7iv7 ( p>agraph 7#b77;,a74 7ii7 ,au?ority to adju/ p]c5tages 9 case ( high ehr mean+ful use adoption ,9 any ye> 9 :i* ! ,secret>y e/imates t ! proportion ( eligible pr(essionals 7z def9$ 9 subsection 7o77#e77 :o are mean+ful ,,ehr us]s 7z det]m9$ "u subsection 7o77#b77 is #ge p]c5t or great]1 ! ,secret>y may r$uce ! p]c5t applicable "u clause 7i77,,iv71 b n bel[ #ae p]c5t4 ,if ! ,secret>y makes su* r$uction = a ye>1 ! p]c5tages applicable "u "o or m ( subclauses 7,i71 7,,ii71 & 7,,iii7 ( clause 7i7 = su* ye> 7or1 9 ! case ( a ye> describ$ 9 clause 7i77,,ii77bb71 applicable "u "o or m ( subclauses 7,i7 & 7,,iii77 %all be increas$ 9 a mann] su* t ! total p]c5tage po9ts ( ! increase "u ?is clause = su* ye> equals ! total numb] ( p]c5tage po9ts r$uc$ "u ! prec$+ s5t5ce = su* ye>4 7iii7 ,au?ority to adju/ p]c5tages = quality & res\rce use ,o!r ?an = a ye> describ$ 9 clause 7i77,,ii77bb71 ! p]c5tages describ$ 9 subclauses 7,i7 & 7,,ii7 ( clause 7i71 includ+ aft] application ( clause 7ii71 %all be equal4 7,h7 ,res\rce use ,analysis ( ! p]=mance category describ$ 9 p>agraph 7#b77;,a77ii7 %all include results f ! me?odology describ$ 9 subsection 7r77#e71 z appropriate4 7,i7 ,inclusion ( quality measure data f multiple pay]s ,9 apply+ subsections 7k71 7m71 & 7p7 ) respect to measures describ$ 9 p>agraph 7#b77;,b77i71 analysis ( ! p]=mance category describ$ 9 p>agraph 7#b77;,a77i7 may include data submitt$ by ,,vbp eligible pr(essionals ) respect to multiple pay]s4 7,j7 ,use ( volunt>y virtual gr\ps = c]ta9 assessm5t purposes 7i7 ,9 g5]al ,9 ! case ( ,,vbp eligible pr(essionals elect+ to be a virtual gr\p "u clause 7ii7 ) respect to a p]=mance p]iod = a ye>1 = purposes ( apply+ ! me?odology "u subp>agraph 7,a7-- 7,i7 ! assessm5t ( p]=mance provid$ "u su* me?odology ) respect to ! p]=mance categories describ$ 9 clauses 7i7 & 7ii7 ( p>agraph 7#b77;,a7 t is to be appli$ to ea* su* pr(essional 9 su* gr\p = su* p]=mance p]iod %all be ) respect to ! comb9$ p]=mance ( all su* pr(essionals 9 su* gr\p = su* p]iod2 & 7,,ii7 ! composite score provid$ "u ?is p>agraph = su* p]=mance p]iod ) respect to ea* su* p]=mance category = ea* su* ,,vbp eligible pr(essional 9 su* virtual gr\p %all be bas$ on ! assessm5t ( ! comb9$ p]=mance "u subclause 7,i7 = ! p]=mance category & p]=mance p]iod4 7ii7 ,election ( practices to be a virtual gr\p ,! ,secret>y %all1 9 accordance ) clause 7iii71 e/abli% & h 9 place a process to all[ an individual ,,vbp eligible pr(essional or a gr\p practice consi/+ ( n m ?an #aj ,,vbp eligible pr(essionals to elect1 ) respect to a p]=mance p]iod = a ye>1 = su* individual ,,vbp eligible pr(essional or all su* ,,vbp eligible pr(essionals 9 su* gr\p practice1 respectively1 to be a virtual gr\p "u ?is subp>agraph ) at lea/ "o o!r su* individual ,,vbp eligible pr(essional or gr\p practice mak+ su* an election4 7iii7 ,requirem5ts ,! process "u clause 7ii7 %all provide t-- 7,i7 an election "u su* clause1 ) respect to a p]=mance p]iod1 %all be made be=e ! beg9n+ ( su* p]=mance p]iod & may n be *ang$ dur+ su* p]=mance p]iod2 & 7,,ii7 a practice describ$ 9 su* clause1 & ea* ,,vbp eligible pr(essional 9 su* practice1 may elect to be 9 no m ?an "o virtual gr\p = a p]=mance p]iod4 7#f7 ,fund+ = ,,vbp program inc5tive paym5ts 7,a7 ,total am\nt = inc5tive paym5ts ,! total am\nt = ,,vbp program inc5tive paym5ts "u p>agraph 7#g7 = all ,,vbp eligible pr(essionals = a ye> %all be equal to ! total am\nt ( ! p]=mance fund+ pool = all ,,vbp eligible pr(essionals "u subp>agraph 7,b7 = su* ye>1 z e/imat$ by ! ,secret>y4 7,b7 ,p]=mance fund+ pool 7i7 ,9 g5]al ,9 ! case ( items & s]vices furni%$ by a ,,vbp eligible pr(essional dur+ a ye> 7beg9n+ ) #bjag71 ! o!rwise applicable fee s*$ule am\nt 7z def9$ 9 clause 7iii77 ) respect to su* items & s]vices & eligible pr(essional = su* ye> %all be r$uc$ by ! applicable p]c5t "u clause 7ii74 ,! total am\nt ( su* r$uctions = a ye> %all be ref]r$ to 9 ?is subsection z ! p]=mance fund+ pool = su* ye>4 7ii7 ,applicable p]c5t def9$ ,= purposes ( clause 7i71 ! t]m applicable p]c5t means-- 7,i7 = #bjag1 #d p]c5t2 7,,ii7 = #bjah1 #f p]c5t2 7,,iii7 = #bjai1 #h p]c5t2 7,,iv7 = #bjbj1 #aj p]c5t2 & 7,v7 = #bjba & subsequ5t ye>s1 a p]c5t specifi$ by ! ,secret>y 7b 9 no case less ?an #aj p]c5t or m ?an #ab p]c5t74 7iii7 ,o!rwise applicable fee s*$ule am\nt ,= purposes ( ?is subp>agraph & p>agraph 7#g71 ! t]m o!rwise applicable fee s*$ule am\nt means1 ) respect to items & s]vices furni%$ by a ,,vbp eligible pr(essional dur+ a ye>1 ! fee s*$ule am\nt = su* items & s]vices & ye> t w\ld o!rwise apply 7)\t application ( ?is subp>agraph or p>agraph 7#g77 ) respect to su* eligible pr(essional "u subsection 7b71 aft] application ( subsection 7a77#c71 or "u ano!r fee s*$ule "u ?is "p4 7#g7 ,,vbp program inc5tive paym5ts 7,a7 ,,vbp program inc5tive paym5t adju/m5t factor ,consi/5t ) section #b7;g77#b7 ( ! ,,sgr ,repeal & ,m$ic>e ,b5efici>y ,access ,act ( #bjac1 ! ,secret>y %all specify a ,,vbp program inc5tive paym5t adju/m5t factor = ea* ,,vbp eligible pr(essional = a ye>4 ,su* ,,vbp program inc5tive paym5t adju/m5t factor = a ,,vbp eligible pr(essional = a ye> %all be det]m9$-- 7i7 by ! composite p]=mance score ( ! eligible pr(essional = su* ye>2 7ii7 9 a mann] su* t ! adju/m5t factors specifi$ "u ?is subp>agraph = a ye> results 9 diff]5tial paym5ts "u ?is p>agraph reflect+ ! full range ( ! di/ribution ( composite p]=mance scores ( ,,vbp eligible pr(essionals det]m9$ "u p>agraph 7#e77;,e7 = su* ye>1 ) su* pr(essionals hav+ high] composite p]=mance scores receiv+ high] paym5t2 & 7iii7 9 a mann] su* t ! adju/m5t factors specifi$ "u ?is subp>agraph = a ye>-- 7,i7 does n result 9 a paym5t r$uction = su* ye> by an am\nt t exce$s ! applicable p]c5t describ$ 9 p>agraph 7#f77;,b77ii7 = su* ye>2 & 7,,ii7 does n result 9 a paym5t increase = su* ye> by an am\nt t exce$s ! applicable p]c5t describ$ 9 p>agraph 7#f77;,b77ii7 = su* ye>4 7,b7 ,calculation ( ,,vbp program inc5tive paym5t am\nts ,! ,,vbp program inc5tive paym5t am\nt ) respect to items & s]vices furni%$ by a ,,vbp eligible pr(essional dur+ a ye> %all be equal to ! diff]5ce betwe5-- 7i7 ! product (-- 7,i7 ! ,,vbp program inc5tive paym5t adju/m5t factor det]m9$ "u subp>agraph 7,a7 = su* ,,vbp eligible pr(essional = su* ye>2 & 7,,ii7 ! o!rwise applicable fee s*$ule am\nt 7z def9$ 9 p>agraph 7#f77;,b77iii77 ) respect to su* items & s]vices & eligible pr(essional = su* ye>2 & 7ii7 ! o!rwise applicable fee s*$ule am\nt1 z r$uc$ "u p>agraph 7#f77;,b71 ) respect to su* items & s]vices1 eligible pr(essional1 & ye>4 ,! application ( ! prec$+ s5t5ce may result 9 ! ,,vbp program inc5tive paym5t am\nt be+ #j4j ) respect to an item or s]vice furni%$ by a ,,vbp eligible pr(essional4 7,c7 ,application ( ,,vbp program inc5tive paym5t am\nt ,9 ! case ( items & s]vices furni%$ by a ,,vbp eligible pr(essional dur+ a ye> 7beg9n+ ) #bjag71 ! o!rwise applicable fee s*$ule am\nt1 z r$uc$ "u p>agraph 7#f77;,b71 ) respect to su* items & s]vices & eligible pr(essional = su* ye> %all be increas$1 if applicable1 by ! ,,vbp program inc5tive paym5t am\nt det]m9$ "u subp>agraph 7,b7 ) respect to su* items & s]vices1 pr(essional1 & ye>4 7,d7 ,budget neutrality ,9 specify+ ! ,,vbp program inc5tive paym5t adju/m5t factor = ea* ,,vbp eligible pr(essional = a ye> "u subp>agraph 7,a71 ! ,secret>y %all ensure t ! total am\nt ( ,,vbp program inc5tive paym5t am\nts "u ?is p>agraph = all ,,vbp eligible pr(essionals 9 a ye> %all be equal to ! p]=mance fund+ pool = su* ye> "u p>agraph 7#f71 z e/imat$ by ! ,secret>y4 7#h7 ,ann\ncem5t ( result ( adju/m5ts ,"u ! ,,vbp program1 ! ,secret>y %all1 n lat] ?an #fj days prior to ! ye> involv$1 make available to ea* ,,vbp eligible pr(essional ! ,,vbp program inc5tive paym5t adju/m5t factor "u p>agraph 7#g7 & ! paym5t r$uction "u p>agraph 7#f7 applicable to ! eligible pr(essional = items & s]vices furni%$ by ! pr(essional 9 su* ye>4 ,! ,secret>y may include su* in=mation 9 ! confid5tial fe$back "u p>agraph 7#ac74 7#i7 ,no effect 9 subsequ5t ye>s ,! ,,vbp program inc5tive paym5t "u p>agraph 7#g7 & ! paym5t r$uction "u p>agraph 7#f7 %all ea* apply only ) respect to ! ye> involv$1 & ! ,secret>y %all n take into acc\nt su* ,,vbp program inc5tive paym5t or paym5t r$uction 9 mak+ paym5ts to a ,,vbp eligible pr(essional "u ?is "p 9 a subsequ5t ye>4 7#aj7 ,public report+ 7,a7 ,9 g5]al ,! ,secret>y %all1 9 an easily und]/&able =mat1 make available on ! ,physician ,comp>e ,int]net website "u subsection 7t7 ! foll[+3 7i7 ,in=mation reg>d+ ! p]=mance ( ,,vbp eligible pr(essionals "u ! ,,vbp program1 :i*-- 7,i7 %all include ! composite score = ea* su* ,,vbp eligible pr(essional & ! p]=mance ( ea* su* ,,vbp eligible pr(essional ) respect to ea* p]=mance category2 & 7,,ii7 may include ! p]=mance ( ea* su* ,,vbp eligible pr(essional ) respect to ea* measure or activity specifi$ 9 p>agraph 7#b77;,b74 7ii7 ,! names ( eligible pr(essionals 9 eligible alt]native paym5t models 7z def9$ 9 section #ahcc7z77#c77;,d77 &1 to ! ext5t feasible1 ! names ( su* eligible alt]native paym5t models & p]=mance ( su* models4 7,b7 ,disclosure ,! in=mation made available "u ?is p>agraph %all indicate1 :]e appropriate1 t publiciz$ in=mation may n be repres5tative ( ! eligible pr(essional's entire pati5t population1 ! v>iety ( s]vices furni%$ by ! eligible pr(essional1 or ! heal? conditions ( individuals treat$4 7,c7 ,opportunity to review & submit corrections ,! ,secret>y %all provide = an opportunity = a pr(essional describ$ 9 subp>agraph 7,a7 to review1 & submit corrections =1 ! in=mation to be made public ) respect to ! pr(essional "u su* subp>agraph prior to su* in=mation be+ made public4 7,d7 ,aggregate in=mation ,! ,secret>y %all p]iodically po/ on ! ,physician ,comp>e ,int]net website aggregate in=mation on ! ,,vbp program1 includ+ ! range ( composite scores = all ,,vbp eligible pr(essionals & ! range ( ! p]=mance ( all ,,vbp eligible pr(essionals ) respect to ea* p]=mance category4 7#aa7 ,consultation ,! ,secret>y %all consult ) /akehold]s 9 c>ry+ out ! ,,vbp program1 includ+ = ! id5tification ( measures & activities "u p>agraph 7#b77;,b7 & ! me?odologies develop$ "u p>agraphs 7#e77;,a7 & 7#g74 ,su* consultation %all include ! use ( a reque/ = in=mation or o!r me*anisms det]m9$ appropriate4 7#ab7 ,te*nical assi/ance to small practices & practices 9 heal? pr(essional %ortage areas 7,a7 ,9 g5]al ,! ,secret>y %all ent] into contracts or agreem5ts ) appropriate entities 7su* z quality improvem5t organizations1 regional ext5sion c5t]s 7z describ$ 9 section #cjab7;c7 ( ! ,public ,heal? ,s]vice ,act71 or regional heal? collaboratives7 to (f] guidance & assi/ance to ,,vbp eligible pr(essionals 9 practices ( few] ?an #bj pr(essionals 7) priority giv5 to su* practices locat$ 9 rural areas1 heal? pr(essional %ortage areas 7z designat$ "u 9 section #ccb7;a77#a77;,a7 ( ! ,public ,heal? ,s]vice ,act71 or practices ) l[ composite scores7 ) respect to-- 7i7 ! p]=mance categories describ$ 9 clauses 7i7 ?r\gh 7iv7 ( p>agraph 7#b77;,a72 or 7ii7 h[ to transition to ! implem5tation ( & p>ticipation 9 an alt]native paym5t model z describ$ 9 section #ahcc7z77#c77;,c74 7,b7 ,fund+ = implem5tation ,= purposes ( implem5t+ subp>agraph 7,a71 ! ,secret>y %all provide = ! transf] f ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund e/abli%$ "u section #ahda to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt ( #ej1jjj1jjj = ea* ( fiscal ye>s #bjad ?r\gh #bjah4 ,am\nts transf]r$ "u ?is subp>agraph = a fiscal ye> %all be available until exp5d$4 7#ac7 ,fe$back & in=mation to improve p]=mance 7,a7 ,p]=mance fe$back 7i7 ,9 g5]al ,beg9n+ ,july #a1 #bjae1 ! ,secret>y-- 7,i7 %all make available timely 7su* z qu>t]ly7 confid5tial fe$back to ea* ,,vbp eligible pr(essional on ! p]=mance ( su* pr(essional ) respect to ! p]=mance categories "u clauses 7i7 & 7ii7 ( p>agraph 7#b77;,a72 & 7,,ii7 may make available confid5tial fe$back to ea* su* pr(essional on ! p]=mance ( su* pr(essional ) respect to ! p]=mance categories "u clauses 7iii7 & 7iv7 ( su* p>agraph4 7ii7 ,me*anisms ,! ,secret>y may use "o or m me*anisms to make fe$back available "u clause 7i71 :i* may include use ( a web-bas$ portal or o!r me*anisms det]m9$ appropriate by ! ,secret>y4 ,! ,secret>y %all enc\rage provision ( fe$back ?r\gh qualifi$ cl9ical data regi/ries z describ$ 9 subsection 7m77#c77;,e774 7iii7 ,use ( data ,= purposes ( clause 7i71 ! ,secret>y may use data1 ) respect to a ,,vbp eligible pr(essional1 f p]iods prior to ! curr5t p]=mance p]iod & may use roll+ p]iods 9 ord] to make illu/rative calculations ab\t ! p]=mance ( su* pr(essional4 7iv7 ,disclosure exemption ,fe$back made available "u ?is subp>agraph %all be exempt f disclosure "u section #eeb ( title #e1 ,unit$ ,/ates ,code4 7v7 ,receipt ( in=mation ,! ,secret>y may use ! me*anisms e/abli%$ "u clause 7ii7 to receive in=mation f pr(essionals1 su* z in=mation ) respect to ?is subsection4 7,b7 ,additional in=mation 7i7 ,9 g5]al ,beg9n+ ,july #a1 #bjaf1 ! ,secret>y %all make available to ea* ,,vbp eligible pr(essional in=mation1 ) respect to individuals :o are pati5ts ( su* ,,vbp eligible pr(essional1 ab\t items & s]vices = :i* paym5t is made "u ?is title t are furni%$ to su* individuals by o!r suppli]s & provid]s ( s]vices1 :i* may include in=mation describ$ 9 clause 7ii74 ,su* in=mation %all be made available "u ! previ\s s5t5ce to su* ,,vbp eligible pr(essionals by me*anisms det]m9$ appropriate by ! ,secret>y1 :i* may include use ( a web-bas$ portal4 ,su* in=mation %all be made available 9 accordance ) ! same or simil> t]ms z data are made available to acc\ntable c>e organizations "u section #ahii1 includ+ a b5efici>y opt-out4 7ii7 ,type ( in=mation ,= purposes ( clause 7i71 ! in=mation describ$ 9 ?is clause1 is ! foll[+3 7,i7 ,) respect to select$ items & s]vices 7z det]m9$ appropriate by ! ,secret>y7 = :i* paym5t is made "u ?is title & t are furni%$ to individuals1 :o are pati5ts ( a ,,vbp eligible pr(essional1 by ano!r suppli] or provid] ( s]vices dur+ ! mo/ rec5t p]iod = :i* data are available 7su* z ! mo/ rec5t ?ree-mon? p]iod71 ! "n ( su* provid]s furni%+ su* items & s]vices to su* pati5ts dur+ su* p]iod1 ! types ( su* items & s]vices s furni%$1 & ! dates su* items & s]vices 7 s furni%$4 7,,ii7 ,hi/orical av]ages 7& o!r measures ( ! di/ribution if appropriate7 ( ! total1 & compon5ts (1 all[$ *>ges 7& o!r figures z det]m9$ appropriate by ! ,secret>y7 = c>e episodes = su* p]iod4 7#ad7 ,review 7,a7 ,t>get$ review ,! ,secret>y %all e/abli% a process "u :i* a ,,vbp eligible pr(essional may seek an in=mal review ( ! calculation ( ! ,,vbp program inc5tive paym5t adju/m5t factor applicable to su* eligible pr(essional "u ?is subsection = a ye>4 ,! results ( a review conduct$ pursuant to ! previ\s s5t5ce %all n be tak5 into acc\nt = purposes ( p>agraph 7#g7 ) respect to a ye> 7o!r ?an ) respect to ! calculation ( su* eligible pr(essional's ,,vbp program inc5tive paym5t adju/m5t factor = su* ye>7 aft] ! factors det]m9$ 9 subp>agraph 7,a7 ( su* p>agraph h be5 det]m9$ = su* ye>4 7,b7 ,limitation ,except z provid$ = 9 subp>agraph 7,a71 !re %all be no adm9i/rative or judicial review "u section #ahfi1 section #ahgh1 or o!rwise ( ! foll[+3 7i7 ,! me?odology us$ to det]m9e ! am\nt ( ! ,,vbp program inc5tive paym5t adju/m5t factor "u p>agraph 7#g7 & ! det]m9ation ( su* am\nt4 7ii7 ,! det]m9ation ( ! am\nt ( fund+ available = su* ,,vbp program inc5tive paym5ts "u p>agraph 7#f77;,a7 & ! paym5t r$uction "u p>agraph 7#f77;,b77i74 7iii7 ,! e/abli%m5t ( ! p]=mance /&>ds "u p>agraph 7#c7 & ! p]=mance p]iod "u p>agraph 7#d74 7iv7 ,! id5tification ( measures & activities specifi$ "u p>agraph 7#b77;,b7 & in=mation made public or po/$ on ! ,physician ,comp>e ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices "u p>agraph 7#aj74 7v7 ,! me?odology develop$ "u p>agraph 7#e7 t is us$ to calculate p]=mance scores & ! calculation ( su* scores1 includ+ ! weight+ ( measures & activities "u su* me?odology4 4 7#b7 ,,gao reports 7,a7 ,evaluation ( eligible pr(essional ,,vbp program ,n lat] ?an ,octob] #a1 #bjah1 & ,octob] #a1 #bjba1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report evaluat+ ! eligible pr(essional value-bas$ p]=mance inc5tive program "u subsection 7q7 ( section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 z add$ by p>agraph 7#a74 ,su* report %all-- 7i7 exam9e ! di/ribution ( ! p]=mance & inc5tive paym5ts = ,,vbp eligible pr(essionals 7z def9$ 9 subsection 7q77#a77;,c7 ( su* section7 "u su* program1 & patt]ns relat+ to su* p]=mance & inc5tive paym5ts1 includ+ bas$ on type ( provid]1 practice size1 geographic location1 & pati5t mix2 & 7ii7 provide recomm5dations = improv+ su* program4 7,b7 ,/udy to exam9e alignm5t ( quality measures us$ 9 public & private programs ,n lat] ?an #ah mon?s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report t-- 7i7 comp>es ! simil>ities & diff]5ces 9 ! use ( quality measures "u ! orig9al m$ic>e fee-=-s]vice program "u p>ts ,a & ,b ( title ,,xviii ( ! ,social ,security ,act1 ! ,m$ic>e ,advantage program "u "p ,c ( su* title1 & private pay] arrangem5ts2 & 7ii7 makes recomm5dations on h[ to r$uce ! adm9i/rative burd5 involv$ 9 apply+ su* quality measures4 7#c7 ,fund+ = implem5tation ,= purposes ( implem5t+ ! provisions ( & ! am5dm5ts made by ?is section1 ! ,secret>y ( ,heal? & ,human ,s]vices %all provide = ! transf] ( #ej1jjj1jjj f ! ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund e/abli%$ "u section #ahda ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciet7 to ! ,c5t]s = ,m$ic>e ,m$icaid ,program ,managem5t ,acc\nt = ea* ( ! fiscal ye>s #bjad ?r\gh #bjag4 ,am\nts transf]r$ "u ?is p>agraph %all be available until exp5d$4 7d7 ,improv+ quality report+ = composite scores 7#a7 ,*anges = gr\p report+ option 7,a7 ,9 g5]al ,section #ahdh7m77#c77;,c77ii77 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#c77;,c77ii77 is am5d$ by ins]t+ &1 = #bjad & subsequ5t ye>s1 may provide aft] %all provide4 7,b7 ,cl>ification ( qualifi$ cl9ical data regi/ry report+ to gr\p practices ,section #ahdh7m77#c77;,d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#c77;,d77 is am5d$ by ins]t+ &1 = #bjae & subsequ5t ye>s1 subp>agraph 7,a7 or 7,c7 aft] subp>agraph 7,a74 7#b7 ,*anges = multiple report+ p]iods & alt]native crit]ia = satisfactory report+ ,section #ahdh7m77#e77;,f77 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#e77;,f77 is am5d$-- 7,a7 by /rik+ & subsequ5t ye>s & ins]t+ ?r\gh report+ p]iods occurr+ 9 #bjac2 & 7,b7 by ins]t+ &1 = report+ p]iods occurr+ 9 #bjad & subsequ5t ye>s1 ! ,secret>y may e/abli% foll[+ %all e/abli%4 7#c7 ,physician fe$back program reports succe$$ by reports "u ,,vbp program ,section #ahdh7n7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7n77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#aa7 ,reports end+ ) #bjaf ,reports "u ! ,program %all n be provid$ aft] ,decemb] #ca1 #bjaf4 ,see subsection 7q77#ac7 = reports beg9n+ ) #bjag4 4 7#d7 ,coord9ation ) satisfy+ mean+ful ,,ehr use cl9ical quality measure report+ requirem5t ,section #ahdh7o77#b77;,a77iii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7o77#b77;,a77iii77 is am5d$ by ins]t+ & subsection 7q77#e77;,c77ii77,,ii7 aft] ,subject to subp>agraph 7,b77ii74 7e7 ,promot+ alt]native paym5t models 7#a7 ,inc5tive paym5ts = p>ticipation 9 eligible alt]native paym5t models ,section #ahcc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7z7 ,inc5tive paym5ts = p>ticipation 9 eligible alt]native paym5t models 7#a7 ,paym5t inc5tive 7,a7 ,9 g5]al ,9 ! case ( cov]$ pr(essional s]vices furni%$ by an eligible pr(essional dur+ a ye> t is 9 ! p]iod beg9n+ ) #bjag & end+ ) #bjbb & = :i* ! pr(essional is a qualify+ ,,apm p>ticipant1 9 addition to ! am\nt ( paym5t t w\ld o!rwise be made = su* cov]$ pr(essional s]vices "u ?is "p = su* ye>1 !re also %all be paid to su* pr(essional an am\nt equal to #e p]c5t ( ! paym5t am\nt = ! cov]$ pr(essional s]vices "u ?is "p = ! prec$+ ye>4 ,= purposes ( ! previ\s s5t5ce1 ! paym5t am\nt = ! prec$+ ye> may be an e/imation = ! full prec$+ ye> bas$ on a p]iod ( su* prec$+ ye> t is less ?an ! full ye>4 ,! ,secret>y %all e/abli% policies to implem5t ?is subp>agraph 9 cases :]e paym5t = cov]$ pr(essional s]vices furni%$ by a qualify+ ,,apm p>ticipant 9 an alt]native paym5t model is made to an entity p>ticipat+ 9 ! alt]native paym5t model r ?an directly to ! qualify+ ,,apm p>ticipant4 7,b7 ,=m ( paym5t ,paym5ts "u ?is subsection %all be made 9 a lump sum1 on an annual basis1 z soon z practicable4 7,c7 ,treatm5t ( paym5t inc5tive ,paym5ts "u ?is subsection %all n be tak5 into acc\nt = purposes ( det]m9+ actual exp5ditures "u an alt]native paym5t model & = purposes ( det]m9+ or rebas+ any b5*m>ks us$ "u ! alt]native paym5t model4 7,d7 ,coord9ation ,! am\nt ( ! additional paym5t = an item or s]vice "u ?is subsection or subsection 7m7 %all be det]m9$ )\t reg>d to any additional paym5t = ! item or s]vice "u subsection 7m7 & ?is subsection1 respectively4 ,! am\nt ( ! additional paym5t = an item or s]vice "u ?is subsection or subsection 7x7 %all be det]m9$ )\t reg>d to any additional paym5t = ! item or s]vice "u subsection 7x7 & ?is subsection1 respectively4 ,! am\nt ( ! additional paym5t = an item or s]vice "u ?is subsection or subsection 7y7 %all be det]m9$ )\t reg>d to any additional paym5t = ! item or s]vice "u subsection 7y7 & ?is subsection1 respectively4 7#b7 ,qualify+ ,,apm p>ticipant ,= purposes ( ?is subsection1 ! t]m qualify+ ,,apm p>ticipant means ! foll[+3 7,a7 #bjag & #bjah ,) respect to #bjag & #bjah1 an eligible pr(essional = :om ! ,secret>y det]m9es t at lea/ #be p]c5t ( paym5ts "u ?is "p = cov]$ pr(essional s]vices furni%$ by su* pr(essional dur+ ! mo/ rec5t p]iod = :i* data are available 7:i* may be less ?an a ye>7 7 attributable to su* s]vices furni%$ "u ?is "p ?r\gh an entity t p>ticipates 9 an eligible alt]native paym5t model ) respect to su* s]vices4 7,b7 #bjai & #bjbj ,) respect to #bjai & #bjbj1 an eligible pr(essional describ$ 9 ei!r ( ! foll[+ clauses3 7i7 ,m$ic>e rev5ue ?re%old option ,an eligible pr(essional = :om ! ,secret>y det]m9es t at lea/ #ej p]c5t ( paym5ts "u ?is "p = cov]$ pr(essional s]vices furni%$ by su* pr(essional dur+ ! mo/ rec5t p]iod = :i* data are available 7:i* may be less ?an a ye>7 7 attributable to su* s]vices furni%$ "u ?is "p ?r\gh an entity t p>ticipates 9 an eligible alt]native paym5t model ) respect to su* s]vices4 7ii7 ,comb9ation all-pay] & ,m$ic>e rev5ue ?re%old option ,an eligible pr(essional-- 7,i7 = :om ! ,secret>y det]m9es1 ) respect to items & s]vices furni%$ by su* pr(essional dur+ ! mo/ rec5t p]iod = :i* data are available 7:i* may be less ?an a ye>71 t at lea/ #ej p]c5t ( ! sum (-- 7aa7 paym5ts describ$ 9 clause 7i72 & 7bb7 all o!r paym5ts1 reg>dless ( pay] 7o!r ?an paym5ts made by ! ,secret>y ( ,def5se or ! ,secret>y ( ,vet]ans ,affairs "u *apt] #ee ( title #aj1 ,unit$ ,/ates ,code1 or title #ch1 ,unit$ ,/ates ,code1 or any o!r provision ( law71 meet ! requirem5t describ$ 9 clause 7iii77,i7 ) respect to paym5ts describ$ 9 item 7aa7 & meet ! requirem5t describ$ 9 clause 7iii77,,ii7 ) respect to paym5ts describ$ 9 item 7bb72 7,,ii7 = :om ! ,secret>y det]m9es at lea/ #be p]c5t ( paym5ts "u ?is "p = cov]$ pr(essional s]vices furni%$ by su* pr(essional dur+ ! mo/ rec5t p]iod = :i* data are available 7:i* may be less ?an a ye>7 7 attributable to su* s]vices furni%$ "u ?is "p ?r\gh an entity t p>ticipates 9 an eligible alt]native paym5t model ) respect to su* s]vices2 & 7,,iii7 :o provides to ! ,secret>y su* in=mation z is necess>y = ! ,secret>y to make a det]m9ation "u subclause 7,i71 ) respect to su* pr(essional4 7iii7 ,requirem5t ,= purposes ( clause 7ii77,i7-- 7,i7 ! requirem5t describ$ 9 ?is subclause1 ) respect to paym5ts describ$ 9 item 7aa7 ( su* clause1 is t su* paym5ts are made "u an eligible alt]native paym5t model2 & 7,,ii7 ! requirem5t describ$ 9 ?is subclause1 ) respect to paym5ts describ$ 9 item 7bb7 ( su* clause1 is t su* paym5ts are made "u an arrangem5t 9 :i*-- 7aa7 quality measures comp>able to measures "u ! p]=mance category describ$ 9 section #ahdh7q77#b77;,b77i7 apply2 7bb7 c]tifi$ ,,ehr te*nology is us$2 & 7cc7 ! eligible pr(essional be>s m ?an nom9al f9ancial risk if actual aggregate exp5ditures exce$s expect$ aggregate exp5ditures4 7,c7 ,beg9n+ 9 #bjba ,) respect to #bjba & ea* subsequ5t ye>1 an eligible pr(essional describ$ 9 ei!r ( ! foll[+ clauses3 7i7 ,m$ic>e rev5ue ?re%old option ,an eligible pr(essional = :om ! ,secret>y det]m9es t at lea/ #ge p]c5t ( paym5ts "u ?is "p = cov]$ pr(essional s]vices furni%$ by su* pr(essional dur+ ! mo/ rec5t p]iod = :i* data are available 7:i* may be less ?an a ye>7 7 attributable to su* s]vices furni%$ "u ?is "p ?r\gh an entity t p>ticipates 9 an eligible alt]native paym5t model ) respect to su* s]vices4 7ii7 ,comb9ation all-pay] & ,m$ic>e rev5ue ?re%old option ,an eligible pr(essional-- 7,i7 = :om ! ,secret>y det]m9es1 ) respect to items & s]vices furni%$ by su* pr(essional dur+ ! mo/ rec5t p]iod = :i* data are available 7:i* may be less ?an a ye>71 t at lea/ #ge p]c5t ( ! sum (-- 7aa7 paym5ts describ$ 9 clause 7i72 & 7bb7 all o!r paym5ts1 reg>dless ( pay] 7o!r ?an paym5ts made by ! ,secret>y ( ,def5se or ! ,secret>y ( ,vet]ans ,affairs "u *apt] #ee ( title #aj1 ,unit$ ,/ates ,code1 or title #ch1 ,unit$ ,/ates ,code1 or any o!r provision ( law71 meet ! requirem5t describ$ 9 clause 7iii77,i7 ) respect to paym5ts describ$ 9 item 7aa7 & meet ! requirem5t describ$ 9 clause 7iii77,,ii7 ) respect to paym5ts describ$ 9 item 7bb72 7,,ii7 = :om ! ,secret>y det]m9es at lea/ #be p]c5t ( paym5ts "u ?is "p = cov]$ pr(essional s]vices furni%$ by su* pr(essional dur+ ! mo/ rec5t p]iod = :i* data are available 7:i* may be less ?an a ye>7 7 attributable to su* s]vices furni%$ "u ?is "p ?r\gh an entity t p>ticipates 9 an eligible alt]native paym5t model ) respect to su* s]vices2 & 7,,iii7 :o provides to ! ,secret>y su* in=mation z is necess>y = ! ,secret>y to make a det]m9ation "u subclause 7,i71 ) respect to su* pr(essional4 7iii7 ,requirem5t ,= purposes ( clause 7ii77,i7-- 7,i7 ! requirem5t describ$ 9 ?is subclause1 ) respect to paym5ts describ$ 9 item 7aa7 ( su* clause1 is t su* paym5ts are made "u an eligible alt]native paym5t model2 & 7,,ii7 ! requirem5t describ$ 9 ?is subclause1 ) respect to paym5ts describ$ 9 item 7bb7 ( su* clause1 is t su* paym5ts are made "u an arrangem5t 9 :i*-- 7aa7 quality measures comp>able to measures "u ! p]=mance category describ$ 9 section #ahdh7q77#b77;,b77i7 apply2 7bb7 c]tifi$ ,,ehr te*nology is us$2 & 7cc7 ! eligible pr(essional be>s m ?an nom9al f9ancial risk if actual aggregate exp5ditures exce$s expect$ aggregate exp5ditures4 7#b7 ,additional def9itions ,9 ?is subsection3 7,a7 ,cov]$ pr(essional s]vices ,! t]m cov]$ pr(essional s]vices has ! mean+ giv5 t t]m 9 section #ahdh7k77#c77;,a74 7,b7 ,eligible pr(essional ,! t]m eligible pr(essional has ! mean+ giv5 t t]m 9 section #ahdh7k77#c77;,b74 7,c7 ,alt]native paym5t model 7,,apm7 ,! t]m alt]native paym5t model means any ( ! foll[+3 7i7 ,a model "u section #aaae;,a 7o!r ?an a heal? c>e innovation aw>d74 7ii7 ,an acc\ntable c>e organization "u section #ahii4 7iii7 ,a demon/ration "u section #ahff;,c4 7iv7 ,a demon/ration requir$ by ,f$]al law4 7,d7 ,eligible alt]native paym5t model 7,,apm7 7i7 ,9 g5]al ,! t]m eligible alt]native paym5t model means1 ) respect to a ye>1 an alt]native paym5t model-- 7,i7 t requires use ( c]tifi$ ,,ehr te*nology 7z def9$ 9 subsection 7o77#d772 7,,ii7 t provides = paym5t = cov]$ pr(essional s]vices bas$ on quality measures comp>able to measures "u ! p]=mance category describ$ 9 section #ahdh7q77#b77;,b77i72 & 7,,iii7 t satisfies ! requirem5t describ$ 9 clause 7ii74 7ii7 ,additional requirem5t ,= purposes ( clause 7i77,,iii71 ! requirem5t describ$ 9 ?is clause1 ) respect to a ye> & an alt]native paym5t model1 is t ! alt]native paym5t model-- 7,i7 is "o 9 :i* "o or m entities be> f9ancial risk = monet>y losses "u su* model t are 9 excess ( a nom9al am\nt2 or 7,,ii7 is a m$ical home exp&$ "u section #aaae;,a7c74 7#c7 ,limitation ,!re %all be no adm9i/rative or judicial review "u section #ahfi1 #ahgh1 or o!rwise1 ( ! foll[+3 7,a7 ,! det]m9ation t an eligible pr(essional is a qualify+ ,,apm p>ticipant "u p>agraph 7#b7 & ! det]m9ation t an alt]native paym5t model is an eligible alt]native paym5t model "u p>agraph 7#c77;,d74 7,b7 ,! det]m9ation ( ! am\nt ( ! #e p]c5t paym5t inc5tive "u p>agraph 7#a77;,a71 includ+ any e/imation z "p ( su* det]m9ation4 4 7#b7 ,coord9ation con=m+ am5dm5ts ,section #ahcc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7 is fur!r am5d$-- 7,a7 9 subsection 7x77#c71 by add+ at ! end ! foll[+ new s5t5ce3 ,! am\nt ( ! additional paym5t = a s]vice "u ?is subsection & subsection 7z7 %all be det]m9$ )\t reg>d to any additional paym5t = ! s]vice "u subsection 7z7 & ?is subsection1 respectively42 & 7,b7 9 subsection 7y77#c71 by add+ at ! end ! foll[+ new s5t5ce3 ,! am\nt ( ! additional paym5t = a s]vice "u ?is subsection & subsection 7z7 %all be det]m9$ )\t reg>d to any additional paym5t = ! s]vice "u subsection 7z7 & ?is subsection1 respectively44 7#c7 ,enc\rag+ developm5t & te/+ ( c]ta9 models ,section #aaae;,a7b77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7b77#b77 is am5d$-- 7,a7 9 subp>agraph 7,b71 by add+ at ! end ! foll[+ new clauses3 7xxi7 ,focus+ prim>ily on physicians' s]vices 7z def9$ 9 section #ahdh7;j77#c77 furni%$ by physicians :o are n prim>y c>e practition]s4 7xxii7 ,focus+ on practices ( few] ?an #bj pr(essionals4 2 & 7,b7 9 subp>agraph 7,c77viii71 by /rik+ o!r public sector or private sector pay]s & ins]t+ o!r public sector pay]s1 private sector pay]s1 or ,/atewide paym5t models4 7f7 ,/udy & report on fraud relat$ to alt]native paym5t models "u ! ,m$ic>e program 7#a7 ,/udy ,! ,secret>y ( ,heal? & ,human ,s]vices1 9 consultation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 %all conduct a /udy t-- 7,a7 exam9es ! applicability ( ! ,f$]al fraud prev5tion laws to items & s]vices furni%$ "u title ,,xviii ( ! ,social ,security ,act = :i* paym5t is made "u an alt]native paym5t model 7z def9$ 9 section #ahcc7z77#c77;,c7 ( su* ,act 7#db ,u4,s4,c4 #aciel7z77#c77;,c7772 7,b7 id5tifies aspects ( su* alt]native paym5t models t are vuln]able to fraudul5t activity2 & 7,c7 exam9es ! implications ( waiv]s to su* laws grant$ 9 support ( su* alt]native paym5t models1 includ+ "u any pot5tial expansion ( su* models4 7#b7 ,report ,n lat] ?an #b ye>s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y %all submit to ,congress a report conta9+ ! results ( ! /udy conduct$ "u p>agraph 7#a74 ,su* report %all include recomm5dations = actions to be tak5 to r$uce ! vuln]ability ( su* alt]native paym5t models to fraudul5t activity4 ,su* report also %all include1 z appropriate1 recomm5dations ( ! ,inspector ,g5]al = *anges 9 ,f$]al fraud prev5tion laws to r$uce su* vuln]ability4 7g7 ,improv+ paym5t accuracy 7#a7 ,/udies & reports ( effect ( c]ta9 in=mation on quality & res\rce use 7,a7 ,/udy us+ exi/+ ,m$ic>e data 7i7 ,/udy ,! ,secret>y ( ,heal? & ,human ,s]vices 79 ?is subsection ref]r$ to z ! ,secret>y7 %all conduct a /udy t exam9es ! effect ( individuals' socioeconomic /atus on quality & res\rce use outcome measures = individuals "u ! ,m$ic>e program 7su* z to recognize t less heal?y individuals may require m int5sive int]v5tions74 ,! /udy %all use in=mation collect$ on su* individuals 9 c>ry+ out su* program1 su* z urban & rural location1 eligibility = ,m$icaid 7recogniz+ & acc\nt+ = v>y+ ,m$icaid eligibility across ,/ates71 & eligibility = b5efits "u ! supplem5tal security income 7,,ssi7 program4 ,! ,secret>y %all c>ry out ?is p>agraph act+ ?r\gh ! ,assi/ant ,secret>y = ,plann+ & ,evaluation4 7ii7 ,report ,n lat] ?an #b ye>s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y %all submit to ,congress a report on ! /udy conduct$ "u clause 7i74 7,b7 ,/udy us+ o!r data 7i7 ,/udy ,! ,secret>y %all conduct a /udy t exam9es ! impact ( risk factors1 su* z ^? describ$ 9 section #ahdh7p77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7p77#c771 race1 heal? lit]acy1 limit$ ,engli% pr(ici5cy 7,,lep71 & pati5t activation1 on quality & res\rce use outcome measures "u ! ,m$ic>e program 7su* z to recognize t less heal?y individuals may require m int5sive int]v5tions74 ,9 conduct+ su* /udy ! ,secret>y may use exi/+ ,f$]al data & collect su* additional data z may be necess>y to complete ! /udy4 7ii7 ,report ,n lat] ?an #e ye>s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y %all submit to ,congress a report on ! /udy conduct$ "u clause 7i74 7,c7 ,exam9ation ( data 9 conduct+ /udies ,9 conduct+ ! /udies "u subp>agraphs 7,a7 & 7,b71 ! ,secret>y %all exam9e :at non-,m$ic>e data sets1 su* z data f ! ,am]ican ,community ,survey 7,,acs71 c be useful 9 conduct+ ! types ( /udies "u su* p>agraphs & h[ su* data sets t are id5tifi$ z useful c be coord9at$ ) ,m$ic>e adm9i/rative data 9 ord] to improve ! ov]all data set available to d su* /udies & = ! adm9i/ration ( ! ,m$ic>e program4 7,d7 ,recomm5dations to acc\nt = in=mation 9 paym5t adju/m5t me*anisms ,if ! /udies conduct$ "u subp>agraphs 7,a7 & 7,b7 f9d a relation%ip betwe5 ! factors exam9$ 9 ! /udies & quality & res\rce use outcome measures1 !n ! ,secret>y %all also provide recomm5dations = h[ ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices %\ld-- 7i7 obta9 access to ! necess>y data 7if su* data is n already be+ collect$7 on su* factors1 includ+ recomm5dations on h[ to address b>ri]s to ! ,c5t]s 9 access+ su* data2 & 7ii7 acc\nt = su* factors 9 det]m9+ paym5t adju/m5ts bas$ on quality & res\rce use outcome measures "u ! eligible pr(essional value-bas$ p]=mance inc5tive program "u section #ahdh7q7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q77 &1 z ! ,secret>y det]m9es appropriate1 o!r simil> provisions ( title ,,xviii ( su* ,act4 7,e7 ,fund+ ,!re are h]eby appropriat$ f ! ,f$]al ,supplem5tal ,m$ical ,insurance ,tru/ ,fund to ! ,secret>y to c>ry out ?is p>agraph #f1jjj1jjj1 to rema9 available until exp5d$4 7#b7 ,,cms activities 7,a7 ,hi]>*al ,condition ,category 7,,hcc7 improvem5t ,tak+ into acc\nt ! relevant /udies conduct$ & recomm5dations made 9 reports "u p>agraph 7#a71 ! ,secret>y1 on an ongo+ basis1 %all e/imate h[ an individual's heal? /atus & o!r risk factors affect quality & res\rce use outcome measures &1 z feasible1 %all incorporate in=mation f quality & res\rce use outcome measurem5t 7includ+ c>e episode & pati5t condition gr\ps7 into ! eligible pr(essional value-bas$ p]=mance inc5tive program "u section #ahdh7q7 ( ! ,social ,security ,act &1 z ! ,secret>y det]m9es appropriate1 o!r simil> provisions ( title ,,xviii ( su* ,act4 7,b7 ,acc\nt+ = o!r factors 9 paym5t adju/m5t me*anisms 7i7 ,9 g5]al ,tak+ into acc\nt ! /udies conduct$ & recomm5dations made 9 reports "u p>agraph 7#a71 ! ,secret>y %all acc\nt = id5tifi$ factors 7o!r ?an ^? appli$ "u subp>agraph 7,a77 ) an effect on quality & res\rce use outcome measures :5 det]m9+ paym5t adju/m5ts "u ! eligible pr(essional value-bas$ p]=mance inc5tive program "u section #ahdh7q7 ( ! ,social ,security ,act &1 z ! ,secret>y det]m9es appropriate1 o!r simil> provisions ( title ,,xviii ( su* ,act4 7ii7 ,access+ data ,! ,secret>y %all collect or o!rwise obta9 access to ! data necess>y to c>ry out ?is p>agraph ?r\gh exi/+ & new data s\rces4 7iii7 ,p]iodic analyses ,! ,secret>y %all c>ry out p]iodic analyses1 at lea/ e #c ye>s1 bas$ on ! factors ref]r$ to 9 clause 7i7 s z to monitor *anges 9 possible relation%ips4 7,c7 ,fund+ ,!re are h]eby appropriat$ f ! ,f$]al ,supplem5tal ,m$ical ,insurance ,tru/ ,fund to ! ,secret>y to c>ry out ?is p>agraph #aj1jjj1jjj1 to rema9 available until exp5d$4 7#c7 ,/rategic plan = access+ race & e?nicity data ,n lat] ?an #ah mon?s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y %all develop & report to ,congress on a /rategic plan = collect+ or o!rwise access+ data on race & e?nicity = purposes ( c>ry+ out ! eligible pr(essional value-bas$ p]=mance inc5tive program "u section #ahdh7q7 ( ! ,social ,security ,act &1 z ! ,secret>y det]m9es appropriate1 o!r simil> provisions ( title ,,xviii ( su* ,act4 7h7 ,collaborat+ ) ! physician1 practition]1 & o!r /akehold] communities to improve res\rce use measurem5t ,section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 z am5d$ by subsection 7c71 is fur!r am5d$ by add+ at ! end ! foll[+ new subsection3 7r7 ,collaborat+ ) ! physician1 practition]1 & o!r /akehold] communities ,to improve res\rce use measurem5t 7#a7 ,9 g5]al ,9 ord] to involve ! physician1 practition]1 & o!r /akehold] communities 9 enhanc+ ! infra/ructure = res\rce use measurem5t1 includ+ = purposes ( ! value-bas$ p]=mance inc5tive program "u subsection 7q7 & alt]native paym5t models "u section #ahcc7z71 ! ,secret>y %all und]take ! /eps describ$ 9 ! succe$+ provisions ( ?is subsection4 7#b7 ,developm5t ( c>e episode & pati5t condition gr\ps & classification codes 7,a7 ,9 g5]al ,9 ord] to classify simil> pati5ts into di/9ct c>e episode gr\ps & di/9ct pati5t condition gr\ps1 ! ,secret>y %all und]take ! /eps describ$ 9 ! succe$+ provisions ( ?is p>agraph4 7,b7 ,public availability ( exi/+ ef=ts to design an episode gr\p] ,n lat] ?an #fj days aft] ! date ( ! enactm5t ( ?is subsection1 ! ,secret>y %all po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices a li/ ( ! episode gr\ps develop$ pursuant to subsection 7n77#i77;,a7 & relat$ descriptive in=mation4 7,c7 ,/akehold] input ,! ,secret>y %all accept1 ?r\gh ! date t is #fj days aft] ! day ! ,secret>y po/s ! li/ pursuant to subp>agraph 7,b71 sugge/ions f physician specialty societies1 applicable practition] organizations1 & o!r /akehold]s = episode gr\ps 9 addition to ^? po/$ pursuant to su* subp>agraph1 & specific cl9ical crit]ia & pati5t *>act]i/ics to classify pati5ts into-- 7i7 di/9ct c>e episode gr\ps2 & 7ii7 di/9ct pati5t condition gr\ps4 7,d7 ,developm5t ( propos$ classification codes 7i7 ,9 g5]al ,tak+ into acc\nt ! in=mation describ$ 9 subp>agraph 7,b7 & ! in=mation receiv$ "u subp>agraph 7,c71 ! ,secret>y %all-- 7,i7 e/abli% di/9ct c>e episode gr\ps & di/9ct pati5t condition gr\ps1 :i* acc\nt = at lea/ an e/imat$ two-?irds ( exp5ditures "u p>ts ,a & ,b2 & 7,,ii7 assign codes to su* gr\ps4 7ii7 ,c>e episode gr\ps ,9 e/abli%+ ! c>e episode gr\ps "u clause 7i71 ! ,secret>y %all take into acc\nt-- 7,i7 ! pati5t's cl9ical problems at ! "t items & s]vices are furni%$ dur+ an episode ( c>e1 su* z ! cl9ical conditions or diagnoses1 :e!r or n inpati5t hospitalization is anticipat$ or occurs1 & ! pr9cipal proc$ures or s]vices plann$ or furni%$2 & 7,,ii7 o!r factors det]m9$ appropriate by ! ,secret>y4 7iii7 ,pati5t condition gr\ps ,9 e/abli%+ ! pati5t condition gr\ps "u clause 7i71 ! ,secret>y %all take into acc\nt-- 7,i7 ! pati5t's cl9ical hi/ory at ! "t ( ea* m$ical visit1 su* z ! pati5t's comb9ation ( *ronic conditions1 curr5t heal? /atus1 & rec5t significant hi/ory 7su* z hospitalization & major surg]y dur+ a previ\s p]iod1 su* z #c mon?s72 & 7,,ii7 o!r factors det]m9$ appropriate by ! ,secret>y1 su* z eligibility /atus "u ?is title 7includ+ eligibility "u section #bbf7;a71 #bbf7;b71 or #bbf;,a1 & dual eligibility "u ?is title & title ,,xix74 7,e7 ,draft c>e episode & pati5t condition gr\ps & classification codes ,n lat] ?an #abj days aft] ! end ( ! comm5t p]iod describ$ 9 subp>agraph 7,c71 ! ,secret>y %all po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices a draft li/ ( ! c>e episode & pati5t condition codes e/abli%$ "u subp>agraph 7,d7 7& ! crit]ia & *>act]i/ics assign$ to su* code74 7,f7 ,solicitation ( input ,! ,secret>y %all seek1 ?r\gh ! date t is #fj days aft] ! ,secret>y po/s ! li/ pursuant to subp>agraph 7,e71 comm5ts f physician specialty societies1 applicable practition] organizations1 & o!r /akehold]s1 includ+ repres5tatives ( individuals entitl$ to b5efits "u "p ,a or enroll$ "u ?is "p1 reg>d+ ! c>e episode & pati5t condition gr\ps 7& codes7 po/$ "u subp>agraph 7,e74 ,9 seek+ su* comm5ts1 ! ,secret>y %all use "o or m me*anisms 7o!r ?an notice & comm5t rulemak+7 t may include use ( op5 door =ums1 t[n hall meet+s1 or o!r appropriate me*anisms4 7,g7 ,op]ational li/ ( c>e episode & pati5t condition gr\ps & codes ,n lat] ?an #abj days aft] ! end ( ! comm5t p]iod describ$ 9 subp>agraph 7,f71 tak+ into acc\nt ! comm5ts receiv$ "u su* subp>agraph1 ! ,secret>y %all po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices an op]ational li/ ( c>e episode & pati5t condition codes 7& ! crit]ia & *>act]i/ics assign$ to su* code74 7,h7 ,subsequ5t revisions ,n lat] ?an ,novemb] #a ( ea* ye> 7beg9n+ ) #bjaf71 ! ,secret>y %all1 ?r\gh rulemak+1 make revisions to ! op]ational li/s ( c>e episode & pati5t condition codes z ! ,secret>y det]m9es may be appropriate4 ,su* revisions may be bas$ on exp]i5ce1 new in=mation develop$ pursuant to subsection 7n77#i77;,a71 & input f ! physician specialty societies1 applicable practition] organizations1 & o!r /akehold]s1 includ+ repres5tatives ( individuals entitl$ to b5efits "u "p ,a or enroll$ "u ?is "p4 7#c7 ,attribution ( pati5ts to physicians or practition]s 7,a7 ,9 g5]al ,9 ord] to facilitate ! attribution ( pati5ts & episodes 79 :ole or 9 "p7 to "o or m physicians or applicable practition]s furni%+ items & s]vices1 ! ,secret>y %all und]take ! /eps describ$ 9 ! succe$+ provisions ( ?is p>agraph4 7,b7 ,developm5t ( pati5t relation%ip categories & codes ,! ,secret>y %all develop pati5t relation%ip categories & codes t def9e & di/+ui% ! relation%ip & responsibility ( a physician or applicable practition] ) a pati5t at ! "t ( furni%+ an item or s]vice4 ,su* pati5t relation%ip categories %all include diff]5t relation%ips ( ! physician or applicable practition] to ! pati5t 7& ! codes may reflect comb9ations ( su* categories71 su* z a physician or applicable practition] :o-- 7i7 consid]s !mself to h ! prim>y responsibility = ! g5]al & ongo+ c>e = ! pati5t ov] ext5d$ p]iods ( "t2 7ii7 consid]s !mself to be ! lead physician or practition] & :o furni%es items & s]vices & coord9ates c>e furni%$ by o!r physicians or practition]s = ! pati5t dur+ an acute episode2 7iii7 furni%es items & s]vices to ! pati5t on a cont9u+ basis dur+ an acute episode ( c>e1 b 9 a supportive r ?an a lead role2 7iv7 furni%es items & s]vices to ! pati5t on an occasional basis1 usually at ! reque/ ( ano!r physician or practition]2 or 7v7 furni%es items & s]vices only z ord]$ by ano!r physician or practition]4 7,c7 ,draft li/ ( pati5t relation%ip categories & codes ,n lat] ?an #ahj days aft] ! date ( ! enactm5t ( ?is subsection1 ! ,secret>y %all po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices a draft li/ ( ! pati5t relation%ip categories & codes develop$ "u subp>agraph 7,b74 7,d7 ,/akehold] ,input ,! ,secret>y %all seek1 ?r\gh ! date t is #fj days aft] ! ,secret>y po/s ! li/ pursuant to subp>agraph 7,c71 comm5ts f physician specialty societies1 applicable practition] organizations1 & o!r /akehold]s1 includ+ repres5tatives ( individuals entitl$ to b5efits "u "p ,a or enroll$ "u ?is "p1 reg>d+ ! pati5t relation%ip categories & codes po/$ "u subp>agraph 7,c74 ,9 seek+ su* comm5ts1 ! ,secret>y %all use "o or m me*anisms 7o!r ?an notice & comm5t rulemak+7 t may include op5 door =ums1 t[n hall meet+s1 or o!r appropriate me*anisms4 7,e7 ,op]ational li/ ( pati5t relation%ip categories & codes ,n lat] ?an #abj days aft] ! end ( ! comm5t p]iod describ$ 9 subp>agraph 7,d71 tak+ into acc\nt ! comm5ts receiv$ "u su* subp>agraph1 ! ,secret>y %all po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices an op]ational li/ ( pati5t relation%ip categories & codes4 7,f7 ,subsequ5t revisions ,n lat] ?an ,novemb] #a ( ea* ye> 7beg9n+ ) #bjaf71 ! ,secret>y %all1 ?r\gh rulemak+1 make revisions to ! op]ational li/ ( pati5t relation%ip categories & codes z ! ,secret>y det]m9es appropriate4 ,su* revisions may be bas$ on exp]i5ce1 new in=mation develop$ pursuant to subsection 7n77#i77;,a71 & input f ! physician specialty societies1 applicable practition] organizations1 & o!r /akehold]s1 includ+ repres5tatives ( individuals entitl$ to b5efits "u "p ,a or enroll$ "u ?is "p4 7#d7 ,report+ ( in=mation = res\rce use measurem5t ,claims submitt$ = items & s]vices furni%$ by a physician or applicable practition] on or aft] ,janu>y #a1 #bjaf1 %all1 z det]m9$ appropriate by ! ,secret>y1 include-- 7,a7 applicable codes e/abli%$ "u p>agraphs 7#b7 & 7#c72 & 7,b7 ! national provid] id5tifi] ( ! ord]+ physician or applicable practition] 7if diff]5t f ! bill+ physician or applicable practition]74 7#e7 ,me?odology = res\rce use analysis 7,a7 ,9 g5]al ,9 ord] to evaluate ! res\rces us$ to treat pati5ts 7) respect to c>e episode & pati5t condition gr\ps71 ! ,secret>y %all-- 7i7 use ! pati5t relation%ip codes report$ on claims pursuant to p>agraph 7#d7 to attribute pati5ts 79 :ole or 9 "p7 to "o or m physicians & applicable practition]s2 7ii7 use ! c>e episode & pati5t condition codes report$ on claims pursuant to p>agraph 7#d7 z a basis to comp>e simil> pati5ts & c>e episodes & pati5t condition gr\ps2 & 7iii7 conduct an analysis ( res\rce use 7) respect to c>e episodes & pati5t condition gr\ps ( su* pati5ts71 z ! ,secret>y det]m9es appropriate4 7,b7 ,analysis ( pati5ts ( physicians & practition]s ,9 conduct+ ! analysis describ$ 9 subp>agraph 7,a77iii7 ) respect to pati5ts attribut$ to physicians & applicable practition]s1 ! ,secret>y %all1 z feasible-- 7i7 use ! claims data exp]i5ce ( su* pati5ts by pati5t condition codes dur+ a common p]iod1 su* z #ab mon?s2 & 7ii7 use ! claims data exp]i5ce ( su* pati5ts by c>e episode codes-- 7,i7 9 ! case ( episodes )\t a hospitalization1 dur+ p]iods ( "t 7su* z ! numb] ( days7 det]m9$ appropriate by ! ,secret>y2 & 7,,ii7 9 ! case ( episodes ) a hospitalization1 dur+ p]iods ( "t 7su* z ! numb] ( days7 be=e1 dur+1 & aft] ! hospitalization4 7,c7 ,measurem5t ( res\rce use ,9 measur+ su* res\rce use1 ! ,secret>y-- 7i7 %all use p] pati5t total all[$ am\nts = all s]vices "u "p ,a & ?is "p 7&1 if ! ,secret>y det]m9es appropriate1 "p ,d7 = ! analysis ( pati5t res\rce use1 by c>e episode codes & by pati5t condition codes2 & 7ii7 may1 z det]m9$ appropriate1 use o!r measures ( all[$ am\nts 7su* z subtotals = categories ( items & s]vices7 & measures ( utilization ( items & s]vices 7su* z frequ5cy ( specific items & s]vices & ! ratio ( specific items & s]vices among attribut$ pati5ts or episodes74 7,d7 ,/akehold] ,input ,! ,secret>y %all seek comm5ts f ! physician specialty societies1 applicable practition] organizations1 & o!r /akehold]s1 includ+ repres5tatives ( individuals entitl$ to b5efits "u "p ,a or enroll$ "u ?is "p1 reg>d+ ! res\rce use me?odology e/abli%$ pursuant to ?is p>agraph4 ,9 seek+ comm5ts ! ,secret>y %all use "o or m me*anisms 7o!r ?an notice & comm5t rulemak+7 t may include op5 door =ums1 t[n hall meet+s1 or o!r appropriate me*anisms4 7#f7 ,limitation ,!re %all be no adm9i/rative or judicial review "u section #ahfi1 section #ahgh1 or o!rwise (-- 7,a7 c>e episode & pati5t condition gr\ps & codes e/abli%$ "u p>agraph 7#b72 7,b7 pati5t relation%ip categories & codes e/abli%$ "u p>agraph 7#c72 & 7,c7 measurem5t (1 & analyses ( res\rce use ) respect to1 c>e episode & pati5t condition codes & pati5t relation%ip codes pursuant to p>agraph 7#e74 7#g7 ,adm9i/ration ,*apt] #ce ( title #dd1 ,unit$ ,/ates ,code1 %all n apply to ?is section4 7#h7 ,def9itions ,9 ?is section3 7,a7 ,physician ,! t]m physician has ! mean+ giv5 su* t]m 9 section #ahfa7r77#a74 7,b7 ,applicable practition] ,! t]m applicable practition] means-- 7i7 a physician assi/ant1 nurse practition]1 & cl9ical nurse speciali/ 7z su* t]ms are def9$ 9 section #ahfa7;aa77#e772 & 7ii7 beg9n+ ,janu>y #a1 #bjag1 su* o!r eligible pr(essionals 7z def9$ 9 subsection 7k77#c77;,b77 z specifi$ by ! ,secret>y4 7#i7 ,cl>ification ,! provisions ( sections #ahij7;b77#g7 & #ahij;,a %all n apply to ?is subsection4 4 #c4 ,priorities & fund+ = quality measure developm5t ,section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 z am5d$ by subsections 7c7 & 7h7 ( section #b1 is fur!r am5d$ by ins]t+ at ! end ! foll[+ new subsection3 7s7 ,priorities & fund+ = quality measure developm5t 7#a7 ,plan id5tify+ measure developm5t priorities & timel9es 7,a7 ,draft measure developm5t plan 7i7 ,draft plan 7,i7 ,9 g5]al ,n lat] ?an ,octob] #a1 #bjad1 ! ,secret>y %all develop1 & po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices1 a draft plan = ! developm5t ( quality measures = application "u ! applicable provisions4 7,,ii7 ,requirem5t ,su* plan %all address h[ measures us$ by private pay]s & integrat$ deliv]y sy/ems c\ld be incorporat$ "u su* subsection4 7ii7 ,consid]ation ,9 develop+ ! draft plan "u subp>agraph 7,a71 ! ,secret>y %all consid]-- 7,i7 gap analyses conduct$ by ! entity ) a contract "u section #ahij7;a7 or o!r contractors or entities2 & 7,,ii7 :e!r measures are applicable across heal? c>e sett+s4 7iii7 ,priorities ,9 develop+ ! draft plan "u subp>agraph 7,a71 ! ,secret>y %all give priority to ! foll[+ types ( measures3 7,i7 ,outcome measures includ+ pati5t report$ outcome & functional /atus measures4 7,,ii7 ,pati5t exp]i5ce measures4 7,,iii7 ,c>e coord9ation measures4 7,,iv7 ,measures ( appropriate use ( s]vices1 includ+ measures ( ov] use4 7iv7 ,def9ition ( applicable provisions ,9 ?is subsection1 ! t]m applicable provisions means ! foll[+ provisions3 7,i7 ,subsection 7q77#b77;,b77i74 7,,ii7 ,section #ahcc7z77#b77;,c74 7,b7 ,/akehold] input ,! ,secret>y %all accept ?r\gh ,decemb] #a1 #bjad1 comm5ts on ! draft plan po/$ "u p>agraph 7#a77;,a7 f ! public1 includ+ heal? c>e provid]s1 pay]s1 consum]s1 & o!r /akehold]s4 7,c7 ,op]ational measure developm5t plan ,n lat] ?an ,febru>y #a1 #bjae1 tak+ into acc\nt ! comm5ts receiv$ "u subp>agraph 7,b71 ! ,secret>y %all po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices an op]ational plan = ! developm5t ( quality measures = use "u subsection 7q77#b77;,a77i74 7#b7 ,contracts & o!r arrangem5ts = quality measure developm5t 7,a7 ,9 g5]al ,! ,secret>y %all ent] into contracts or o!r arrangem5ts ) entities = ! purpose ( develop+1 improv+1 updat+1 or exp&+ quality measures = application "u ! applicable provisions4 ,su* entities may include physician specialty societies & o!r practition] organizations4 7,b7 ,prioritization 7i7 ,9 g5]al ,9 ent]+ into contracts or o!r arrangem5ts "u subp>agraph 7,a71 ! ,secret>y %all give priority to ! developm5t ( ! types ( measures describ$ 9 p>agraph 7#a77;,a77iii74 7ii7 ,consid]ation ,9 select+ measures = developm5t "u ?is subsection1 ! ,secret>y %all consid] :e!r su* measures w\ld be electronically specifi$4 7#c7 ,annual report by ! ,secret>y 7,a7 ,9 g5]al ,n lat] ?an ,febru>y #a1 #bjaf1 & annually !reaft]1 ! ,secret>y %all po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices a report on ! progress made 9 develop+ quality measures = application "u ! applicable provisions4 7,b7 ,requirem5ts ,ea* report submitt$ pursuant to p>agraph 7#a7 %all include ! foll[+3 7i7 ,a description ( ! ,secret>y's ef=ts to implem5t ?is subsection4 7ii7 ,) respect to ! measures develop$ dur+ ! previ\s ye>-- 7,i7 a description ( ! total numb] ( quality measures develop$ & ! types ( su* measures1 su* z an outcome or pati5t exp]i5ce measure2 7,,ii7 ! "n ( ea* measure develop$2 7,,iii7 ! "n ( ! develop] & /ew>d ( ea* measure2 7,,iv7 ) respect to ea* type ( measure1 an e/imate ( ! total am\nt exp5d$ "u ?is title to develop all measures ( su* type2 & 7,v7 :e!r ! measure w\ld be electronically specifi$4 7iii7 ,) respect to measures 9 developm5t at ! "t ( ! report-- 7,i7 ! in=mation describ$ 9 clause 7ii71 if available2 & 7,,ii7 a timel9e = completion ( ! developm5t ( su* measures4 7iv7 ,an update on ! progress 9 develop+ ! types ( measures describ$ 9 p>agraph 7#a77;,a77iii71 includ+ a description ( issues affect+ su* progress4 7v7 ,a li/ ( quality topics & concepts t are be+ consid]$ = developm5t ( measures & ! rationale = ! selection ( topics & concepts includ+ _! relation%ip to gap analyses4 7vi7 ,a description ( any updates to ! plan "u p>agraph 7#a7 7includ+ newly id5tifi$ gaps & ! /atus ( previ\sly id5tifi$ gaps7 & ! inv5tory ( measures applicable "u ! applicable provisions4 7vii7 ,o!r in=mation ! ,secret>y det]m9es to be appropriate4 7#d7 ,/akehold] input ,) respect to measures applicable "u ! applicable provisions1 ! ,secret>y %all seek /akehold] input ) respect to-- 7,a7 ! id5tification ( gaps :]e no quality measures exi/1 p>ticul>ly ) respect to ! types ( measures describ$ 9 p>agraph 7#a77;,a77iii72 7,b7 prioritiz+ quality measure developm5t to address su* gaps2 & 7,c7 o!r areas relat$ to quality measure developm5t det]m9$ appropriate by ! ,secret>y4 7#e7 ,fund+ ,= purposes ( c>ry+ out ?is subsection1 ! ,secret>y %all provide = ! transf]1 f ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda1 ( #ae1jjj1jjj to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt = ea* ( fiscal ye>s #bjad ?r\gh #bjah4 ,am\nts transf]r$ "u ?is p>agraph %all rema9 available ?r\gh ! end ( fiscal ye> #bjba4 4 #d4 ,enc\rag+ c>e managem5t = individuals ) *ronic c>e ne$s ,section #ahdh7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;b77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#h7 ,enc\rag+ c>e managem5t = individuals ) *ronic c>e ne$s 7,a7 ,9 g5]al ,9 ord] to enc\rage ! managem5t ( c>e by an applicable provid] 7z def9$ 9 subp>agraph 7,b77 = individuals ) *ronic c>e ne$s ! ,secret>y %all-- 7i7 e/abli% "o or m ,,hcpcs codes = *ronic c>e managem5t s]vices = su* individuals2 & 7ii7 subject to subp>agraph 7,d71 make paym5t 7z ! ,secret>y det]m9es to be appropriate7 "u ?is section = su* managem5t s]vices furni%$ on or aft] ,janu>y #a1 #bjae1 by an applicable provid]4 7,b7 ,applicable provid] def9$ ,= purposes ( ?is p>agraph1 ! t]m applicable provid] means a physician 7z def9$ 9 section #ahfa7r77#a771 physician assi/ant or nurse practition] 7z def9$ 9 section #ahfa7;aa77#e77;,a771 or cl9ical nurse speciali/ 7z def9$ 9 section #ahfa7;aa77#e77;,b77 :o furni%es s]vices z "p ( a pati5t-c5t]$ m$ical home or a comp>able specialty practice t-- 7i7 is recogniz$ z su* a m$ical home or comp>able specialty practice by an organization t is recogniz$ by ! ,secret>y = purposes ( su* recognition z su* a m$ical home or practice2 or 7ii7 meets su* o!r comp>able qualifications z ! ,secret>y det]m9es to be appropriate4 7,c7 ,budget neutrality ,! budget neutrality provision "u subsection 7c77#b77;,b77ii77,,ii7 %all apply 9 e/abli%+ ! paym5t "u subp>agraph 7,a77ii74 7,d7 ,policies relat+ to paym5t ,9 c>ry+ out ?is p>agraph1 ) respect to *ronic c>e managem5t s]vices1 ! ,secret>y %all-- 7i7 make paym5t to only "o applicable provid] = su* s]vices furni%$ to an individual dur+ a p]iod2 7ii7 n make paym5t "u subp>agraph 7,a7 if su* paym5t w\ld be duplicative ( paym5t t is o!rwise made "u ?is title = su* s]vices 7su* z 9 ! case ( hospice c>e or home heal? s]vices72 & 7iii7 n require t an annual wellness visit 7z def9$ 9 section #ahfa7;hhh77 or an initial prev5tive physical exam9ation 7z def9$ 9 section #ahfa7ww77 be furni%$ z a condition ( paym5t = su* managem5t s]vices4 4 #e4 ,ensur+ accurate valuation ( s]vices "u ! physician fee s*$ule 7a7 ,au?ority ,to collect & use in=mation on physicians' s]vices 9 ! det]m9ation ( relative values 7#a7 ,9 g5]al ,section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,m7 ,au?ority to collect & use in=mation on physicians' s]vices 9 ! det]m9ation ( relative values 7i7 ,collection ( in=mation ,not)/&+ any o!r provision ( law1 ! ,secret>y may collect or obta9 in=mation on ! res\rces directly or indirectly relat$ to furni%+ s]vices = :i* paym5t is made "u ! fee s*$ule e/abli%$ "u subsection 7b74 ,su* in=mation may be collect$ or obta9$ f any eligible pr(essional or any o!r s\rce4 7ii7 ,use ( in=mation ,not)/&+ any o!r provision ( law1 subject to clause 7v71 ! ,secret>y may 7z ! ,secret>y det]m9es appropriate7 use in=mation collect$ or obta9$ pursuant to clause 7i7 9 ! det]m9ation ( relative values = s]vices "u ?is section4 7iii7 ,types ( in=mation ,! types ( in=mation describ$ 9 clauses 7i7 & 7ii7 may1 at ! ,secret>y's discretion1 include any or all ( ! foll[+3 7,i7 ,"t involv$ 9 furni%+ s]vices4 7,,ii7 ,am\nts & types ( practice exp5se inputs involv$ ) furni%+ s]vices4 7,,iii7 ,prices 7net ( any disc\nts7 = practice exp5se inputs1 :i* may include paid invoice prices or o!r docum5tation or records4 7,,iv7 ,ov]head & acc\nt+ in=mation = practices ( physicians & o!r suppli]s4 7,v7 ,any o!r elem5t t w\ld improve ! valuation ( s]vices "u ?is section4 7iv7 ,in=mation collection me*anisms ,in=mation may be collect$ or obta9$ pursuant to ?is subp>agraph f any or all ( ! foll[+3 7,i7 ,surveys ( physicians1 o!r suppli]s1 provid]s ( s]vices1 manufactur]s1 & v5dors4 7,,ii7 ,surgical logs1 bill+ sy/ems1 or o!r practice or facility records4 7,,iii7 ,electronic heal? records4 7,,iv7 ,any o!r me*anism det]m9$ appropriate by ! ,secret>y4 7v7 ,transp>5cy ( use ( in=mation 7,i7 ,9 g5]al ,subject to subclauses 7,,ii7 & 7,,iii71 if ! ,secret>y uses in=mation collect$ or obta9$ "u ?is subp>agraph 9 ! det]m9ation ( relative values "u ?is subsection1 ! ,secret>y %all disclose ! in=mation s\rce & discuss ! use ( su* in=mation 9 su* det]m9ation ( relative values ?r\gh notice & comm5t rulemak+4 7,,ii7 ,?re%olds = use ,! ,secret>y may e/abli% ?re%olds 9 ord] to use su* in=mation1 includ+ ! exclusion ( in=mation collect$ or obta9$ f eligible pr(essionals :o use v high res\rces 7z det]m9$ by ! ,secret>y7 9 furni%+ a s]vice4 7,,iii7 ,disclosure ( in=mation ,! ,secret>y %all make aggregate in=mation available "u ?is subp>agraph b %all n disclose in=mation 9 a =m or mann] t id5tifies an eligible pr(essional or a gr\p practice1 or in=mation collect$ or obta9$ pursuant to a nondisclosure agreem5t4 7vi7 ,inc5tive to p>ticipate ,! ,secret>y may provide = su* paym5ts "u ?is "p to an eligible pr(essional t submits su* solicit$ in=mation "u ?is subp>agraph z ! ,secret>y det]m9es appropriate 9 ord] to comp5sate su* eligible pr(essional = su* submission4 ,su* paym5ts %all be provid$ 9 a =m & mann] specifi$ by ! ,secret>y4 7vii7 ,adm9i/ration ,*apt] #ce ( title #dd1 ,unit$ ,/ates ,code1 %all n apply to in=mation collect$ or obta9$ "u ?is subp>agraph4 7viii7 ,def9ition ( eligible pr(essional ,9 ?is subp>agraph1 ! t]m eligible pr(essional has ! mean+ giv5 su* t]m 9 subsection 7k77#c77;,b74 7ix7 ,fund+ ,= purposes ( c>ry+ out ?is subp>agraph1 9 addition to funds o!rwise appropriat$1 ! ,secret>y %all provide = ! transf]1 f ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda1 ( #b1jjj1jjj to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt = ea* fiscal ye> beg9n+ ) fiscal ye> #bjad4 ,am\nts transf]r$ "u ! prec$+ s5t5ce = a fiscal ye> %all be available until exp5d$4 4 7#b7 ,limitation on review ,section #ahdh7;i77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;i77#a77 is am5d$-- 7,a7 9 subp>agraph 7,d71 by /rik+ & at ! end2 7,b7 9 subp>agraph 7,e71 by /rik+ ! p]iod at ! end & ins]t+ 1 &2 & 7,c7 by add+ at ! end ! foll[+ new subp>agraph3 7,f7 ! collection & use ( in=mation 9 ! det]m9ation ( relative values "u subsection 7c77#b77,m74 4 7b7 ,au?ority = alt]native approa*es ,to e/abli%+ practice exp5se relative values ,section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b771 z am5d$ by subsection 7a71 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,n7 ,au?ority = alt]native approa*es to e/abli%+ practice exp5se relative values ,! ,secret>y may e/abli% or adju/ practice exp5se relative values "u ?is subsection us+ co/1 *>ge1 or o!r data f suppli]s or provid]s ( s]vices1 includ+ in=mation collect$ or obta9$ "u subp>agraph 7,m74 4 7c7 ,revis$ & exp&$ id5tification ( pot5tially misvalu$ codes ,section #ahdh7;c77#b77,k77ii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77,k77ii77 is am5d$ to read z foll[s3 7ii7 ,id5tification ( pot5tially misvalu$ codes ,= purposes ( id5tify+ pot5tially misvalu$ codes pursuant to clause 7i77,i71 ! ,secret>y %all exam9e codes 7& families ( codes z appropriate7 bas$ on any or all ( ! foll[+ crit]ia3 7,i7 ,codes t h exp]i5c$ ! fa/e/ gr[?4 7,,ii7 ,codes t h exp]i5c$ sub/antial *anges 9 practice exp5ses4 7,,iii7 ,codes t describe new te*nologies or s]vices )9 an appropriate "t p]iod 7su* z #c ye>s7 aft] ! relative values are initially e/abli%$ = su* codes4 7,,iv7 ,codes :i* are multiple codes t are frequ5tly bill$ 9 conjunction ) furni%+ a s+le s]vice4 7,v7 ,codes ) l[ relative values1 p>ticul>ly ^? t are (t5 bill$ multiple times = a s+le treatm5t4 7,,vi7 ,codes t h n be5 subject to review s9ce implem5tation ( ! fee s*$ule4 7,,vii7 ,codes t acc\nt = ! majority ( sp5d+ "u ! physician fee s*$ule4 7,,viii7 ,codes = s]vices t h exp]i5c$ a sub/antial *ange 9 ! hospital l5g? ( /ay or proc$ure "t4 7,,ix7 ,codes = :i* !re may be a *ange 9 ! typical site ( s]vice s9ce ! code 0 la/ valu$4 7,x7 ,codes = :i* !re is a significant diff]5ce 9 paym5t = ! same s]vice betwe5 diff]5t sites ( s]vice4 7,,xi7 ,codes = :i* !re may be anomalies 9 relative values )9 a family ( codes4 7,,xii7 ,codes = s]vices :]e !re may be effici5cies :5 a s]vice is furni%$ at ! same "t z o!r s]vices4 7,,xiii7 ,codes ) high intra-s]vice "w p] unit ( "t4 7,,xiv7 ,codes ) high practice exp5se relative value units4 7,,xv7 ,codes ) high co/ supplies4 7,,xvi7 ,codes z det]m9$ appropriate by ! ,secret>y4 4 7d7 ,t>get = relative value adju/m5ts = misvalu$ s]vices 7#a7 ,9 g5]al ,section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b771 z am5d$ by subsections 7a7 & 7b71 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,o7 ,t>get = relative value adju/m5ts = misvalu$ s]vices ,) respect to fee s*$ules e/abli%$ = ea* ( #bjae ?r\gh #bjah1 ! foll[+ %all apply3 7i7 ,det]m9ation ( net r$uction 9 exp5ditures ,= ea* ye>1 ! ,secret>y %all det]m9e ! e/imat$ net r$uction 9 exp5ditures "u ! fee s*$ule "u ?is section ) respect to ! ye> z a result ( adju/m5ts to ! relative values e/abli%$ "u ?is p>agraph = misvalu$ codes4 7ii7 ,budget neutral r$i/ribution ( funds if t>get met & c\nt+ ov]ages t[>ds ! t>get = ! succe$+ ye> ,if ! e/imat$ net r$uction 9 exp5ditures det]m9$ "u clause 7i7 = ! ye> is equal to or great] ?an ! t>get = ! ye>-- 7,i7 r$uc$ exp5ditures attributable to su* adju/m5ts %all be r$i/ribut$ = ! ye> 9 a budget neutral mann] 9 accordance ) subp>agraph 7,b77ii77,,ii72 & 7,,ii7 ! am\nt by :i* su* r$uc$ exp5ditures exce$s ! t>get = ! ye> %all be treat$ z a r$uction 9 exp5ditures describ$ 9 clause 7i7 = ! succe$+ ye>1 = purposes ( det]m9+ :e!r ! t>get has or has n be5 met "u ?is subp>agraph ) respect to t ye>4 7iii7 ,exemption f budget neutrality if t>get n met ,if ! e/imat$ net r$uction 9 exp5ditures det]m9$ "u clause 7i7 = ! ye> is less ?an ! t>get = ! ye>1 r$uc$ exp5ditures 9 an am\nt equal to ! t>get recapture am\nt %all n be tak5 into acc\nt 9 apply+ subp>agraph 7,b77ii77,,ii7 ) respect to fee s*$ules beg9n+ ) #bjae4 7iv7 ,t>get recapture am\nt ,= purposes ( clause 7iii71 ! t>get recapture am\nt is1 ) respect to a ye>1 an am\nt equal to ! diff]5ce betwe5-- 7,i7 ! t>get = ! ye>2 & 7,,ii7 ! e/imat$ net r$uction 9 exp5ditures det]m9$ "u clause 7i7 = ! ye>4 7v7 ,t>get ,= purposes ( ?is subp>agraph1 ) respect to a ye>1 ! t>get is calculat$ z #j4e p]c5t ( ! e/imat$ am\nt ( exp5ditures "u ! fee s*$ule "u ?is section = ! ye>4 4 7#b7 ,con=m+ am5dm5t ,section #ahdh7;c77#b77;,b77v7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77;,b77v77 is am5d$ by add+ at ! end ! foll[+ new subclause3 7,,viii7 ,r$uctions = misvalu$ s]vices if t>get n met ,effective = fee s*$ules beg9n+ ) #bjae1 r$uc$ exp5ditures attributable to ! application ( ! t>get recapture am\nt describ$ 9 subp>agraph 7,o77iii74 4 7e7 ,phase-9 ( significant relative value unit 7,,rvu7 r$uctions 7#a7 ,9 g5]al ,section #ahdh7;c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#g7 ,phase-9 ( significant relative value unit 7,,rvu7 r$uctions ,effective = fee s*$ules e/abli%$ beg9n+ ) #bjae1 if ! total relative value units = a s]vice = a ye> w\ld o!rwise be decreas$ by an e/imat$ am\nt equal to or great] ?an #bj p]c5t z comp>$ to ! total relative value units = ! previ\s ye>1 ! applicable adju/m5ts 9 "w1 practice exp5se1 & malpractice relative value units %all be phas$-9 ov] a #b-ye> p]iod4 4 7#b7 ,con=m+ am5dm5ts ,section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is am5d$-- 7,a7 9 subp>agraph 7,b77ii77,i71 by /rik+ subclause 7,,ii7 & ins]t+ subclause 7,,ii7 & p>agraph 7#g72 & 7,b7 9 subp>agraph 7,k77iii77,,vi7-- 7i7 by /rik+ provisions ( subp>agraph 7,b77ii77,,ii7 & ins]t+ provisions ( subp>agraph 7,b77ii77,,ii7 & p>agraph 7#g72 & 7ii7 by /rik+ "u subp>agraph 7,b77ii77,,ii7 & ins]t+ "u subp>agraph 7,b77ii77,i74 7f7 ,au?ority ,to smoo? relative values )9 gr\ps ( s]vices ,section #ahdh7;c77#b77;,c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77;,c77 is am5d$-- 7#a7 9 ea* ( clauses 7i7 & 7iii71 by /rik+ ! s]vice & ins]t+ ! s]vice or gr\p ( s]vices ea* place x appe>s2 & 7#b7 9 ! fir/ s5t5ce ( clause 7ii71 by ins]t+ or gr\p ( s]vices be=e ! p]iod4 7g7 ,,gao /udy & report on ,relative ,value ,scale ,update ,committee 7#a7 ,/udy ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates 79 ?is subsection ref]r$ to z ! ,comptroll] ,g5]al7 %all conduct a /udy ( ! processes us$ by ! ,relative ,value ,scale ,update ,committee 7,,ruc7 to provide recomm5dations to ! ,secret>y ( ,heal? & ,human ,s]vices reg>d+ relative values = specific s]vices "u ! ,m$ic>e physician fee s*$ule "u section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d74 7#b7 ,report ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al %all submit to ,congress a report conta9+ ! results ( ! /udy conduct$ "u p>agraph 7#a74 7h7 ,adju/m5t to ,m$ic>e paym5t localities 7#a7 ,9 g5]al ,section #ahdh7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;e77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#f7 ,use ( ,m,s,as z fee s*$ule areas 9 ,cali=nia 7,a7 ,9 g5]al ,subject to ! succe$+ provisions ( ?is p>agraph & not)/&+ ! previ\s provisions ( ?is subsection1 = s]vices furni%$ on or aft] ,janu>y #a1 #bjag1 ! fee s*$ule areas us$ = paym5t "u ?is section applicable to ,cali=nia %all be ! foll[+3 7i7 ,ea* ,metropolitan ,/ati/ical ,area 7ea* 9 ?is p>agraph ref]r$ to z an ,,msa71 z def9$ by ! ,director ( ! ,(fice ( ,managem5t & ,budget z ( ,decemb] #ca ( ! previ\s ye>1 %all be a fee s*$ule area4 7ii7 ,all areas n includ$ 9 an ,,msa %all be treat$ z a s+le re/-(-,/ate fee s*$ule area4 7,b7 ,transition = ,m,s,as previ\sly 9 re/-(-,/ate paym5t locality or 9 locality #c 7i7 ,9 g5]al ,= s]vices furni%$ 9 ,cali=nia dur+ a ye> beg9n+ ) #bjag & end+ ) #bjba 9 an ,,msa 9 a transition area 7z def9$ 9 subp>agraph 7,d771 subject to subp>agraph 7,c71 ! geographic index values to be appli$ "u ?is subsection = su* ye> %all be equal to ! sum ( ! foll[+3 7,i7 ,curr5t law compon5t ,! old weight+ factor 7describ$ 9 clause 7ii77 = su* ye> multipli$ by ! geographic index values "u ?is subsection = ! fee s*$ule area t includ$ su* ,,msa t w\ld h appli$ 9 su* area 7z e/imat$ by ! ,secret>y7 if ?is p>agraph did n apply4 7,,ii7 ,,msa-bas$ compon5t ,! ,,msa-bas$ weight+ factor 7describ$ 9 clause 7iii77 = su* ye> multipli$ by ! geographic index values comput$ = ! fee s*$ule area "u subp>agraph 7,a7 = ! ye> 7det]m9$ )\t reg>d to ?is subp>agraph74 7ii7 ,old weight+ factor ,! old weight+ factor describ$ 9 ?is clause-- 7,i7 = #bjag1 is #e_/f2 & 7,,ii7 = ea* succe$+ ye>1 is ! old weight+ factor describ$ 9 ?is clause = ! previ\s ye> m9us #a_/f4 7iii7 ,,msa-bas$ weight+ factor ,! ,,msa-bas$ weight+ factor describ$ 9 ?is clause = a ye> is #a m9us ! old weight+ factor "u clause 7ii7 = t ye>4 7,c7 ,hold h>mless ,= s]vices furni%$ 9 a transition area 9 ,cali=nia dur+ a ye> beg9n+ ) #bjag1 ! geographic index values to be appli$ "u ?is subsection = su* ye> %all n be less ?an ! correspond+ geographic index values t w\ld h appli$ 9 su* transition area 7z e/imat$ by ! ,secret>y7 if ?is p>agraph did n apply4 7,d7 ,transition area def9$ ,9 ?is p>agraph1 ! t]m transition area means ea* ( ! foll[+ fee s*$ule areas = #bjac3 7i7 ,! re/-(-,/ate paym5t locality4 7ii7 ,paym5t locality #c4 7,e7 ,ref]5ces to fee s*$ule areas ,effective = s]vices furni%$ on or aft] ,janu>y #a1 #bjag1 = ,cali=nia1 any ref]5ce 9 ?is section to a fee s*$ule area %all be deem$ a ref]5ce to a fee s*$ule area e/abli%$ 9 accordance ) ?is p>agraph4 4 7#b7 ,con=m+ am5dm5t to def9ition ( fee s*$ule area ,section #ahdh7;j77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;j77#b77 is am5d$ by /rik+ ,! t]m & ins]t+ ,except z provid$ 9 subsection 7e77#f77;,d71 ! t]m4 #f4 ,promot+ evid5ce-bas$ c>e 7a7 ,recogniz+ appropriate use crit]ia = c]ta9 imag+ s]vices 7#a7 ,9 g5]al ,section #ahcd ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7p7 ,recogniz+ appropriate use crit]ia = c]ta9 imag+ s]vices 7#a7 ,program e/abli%$ 7,a7 ,9 g5]al ,! ,secret>y %all e/abli% a program to promote ! use ( appropriate use crit]ia 7z def9$ 9 subp>agraph 7,b77 = applicable imag+ s]vices 7z def9$ 9 subp>agraph 7,c77 furni%$ 9 an applicable sett+ 7z def9$ 9 subp>agraph 7,d77 by ord]+ pr(essionals & furni%+ pr(essionals 7z def9$ 9 subp>agraphs 7,e7 & 7,f71 respectively74 7,b7 ,appropriate use crit]ia def9$ ,9 ?is subsection1 ! t]m appropriate use crit]ia means crit]ia to assi/ ord]+ pr(essionals & furni%+ pr(essionals 9 mak+ ! mo/ appropriate treatm5t decision = a specific cl9ical condition4 ,to ! ext5t feasible1 su* crit]ia %all be evid5ce-bas$4 7,c7 ,applicable imag+ s]vice def9$ ,9 ?is subsection1 ! t]m applicable imag+ s]vice means an advanc$ diagno/ic imag+ s]vice 7z def9$ 9 subsection 7e77#a77;,b77 = :i* ! ,secret>y det]m9es-- 7i7 "o or m applicable appropriate use crit]ia specifi$ "u p>agraph 7#b7 apply2 7ii7 !re are "o or m qualifi$ cl9ical decision support me*anisms li/$ "u p>agraph 7#c77;,c72 & 7iii7 "o or m ( su* me*anisms is available free ( *>ge4 7,d7 ,applicable sett+ def9$ ,9 ?is subsection1 ! t]m applicable sett+ means a physician's (fice1 a hospital outpati5t dep>tm5t 7includ+ an em]g5cy dep>tm5t71 an ambulatory surgical c5t]1 & any o!r outpati5t sett+ det]m9$ appropriate by ! ,secret>y4 7,e7 ,ord]+ pr(essional def9$ ,9 ?is subsection1 ! t]m ord]+ pr(essional means a physician 7z def9$ 9 section #ahfa7r77 or a practition] describ$ 9 section #ahdb7;b77#ah77;,c7 :o ord]s an applicable imag+ s]vice = an individual4 7,f7 ,furni%+ pr(essional def9$ ,9 ?is subsection1 ! t]m furni%+ pr(essional means a physician 7z def9$ 9 section #ahfa7r77 or a practition] describ$ 9 section #ahdb7;b77#ah77;,c7 :o furni%es an applicable imag+ s]vice = an individual4 7#b7 ,e/abli%m5t ( applicable appropriate use crit]ia 7,a7 ,9 g5]al ,n lat] ?an ,novemb] #ae1 #bjae1 ! ,secret>y %all ?r\gh rulemak+1 & 9 consultation ) physicians1 practition]s1 & o!r /akehold]s1 specify applicable appropriate use crit]ia = applicable imag+ s]vices f among appropriate use crit]ia develop$ or endors$ by national pr(essional m$ical specialty societies or o!r entities4 7,b7 ,consid]ations ,9 specify+ applicable appropriate use crit]ia "u subp>agraph 7,a71 ! ,secret>y %all take into acc\nt :e!r ! crit]ia-- 7i7 h /akehold] cons5sus2 7ii7 h be5 det]m9$ to be sci5tifically valid & are evid5ce bas$2 & 7iii7 are 9 ! public doma94 7,c7 ,revisions ,! ,secret>y %all p]iodically update & revise 7z appropriate7 su* specification ( applicable appropriate use crit]ia4 7,d7 ,treatm5t ( multiple applicable appropriate use crit]ia ,9 ! case :]e ! ,secret>y det]m9es t m ?an "o appropriate use crit]ia applies ) respect to an applicable imag+ s]vice1 ! ,secret>y %all specify "o or m applicable appropriate use crit]ia "u ?is p>agraph = ! s]vice4 7#c7 ,me*anisms = consultation ) applicable appropriate use crit]ia 7,a7 ,id5tification ( me*anisms to consult ) applicable appropriate use crit]ia 7i7 ,9 g5]al ,! ,secret>y %all specify "o or m qualifi$ cl9ical decision support me*anisms t c\ld be us$ by ord]+ pr(essionals to consult ) applicable appropriate use crit]ia = applicable imag+ s]vices4 7ii7 ,consultation ,! ,secret>y %all consult ) physicians1 practition]s1 & o!r /akehold]s 9 specify+ me*anisms "u ?is p>agraph4 7iii7 ,inclusion ( c]ta9 me*anisms ,me*anisms specifi$ "u ?is p>agraph may include any or all ( ! foll[+ t meet ! requirem5ts describ$ 9 subp>agraph 7,b77ii73 7,i7 ,use ( cl9ical decision support modules 9 c]tifi$ ,,ehr te*nology 7z def9$ 9 section #ahdh7o77#d774 7,,ii7 ,use ( private sector cl9ical decision support me*anisms t are indep5d5t f c]tifi$ ,,ehr te*nology1 :i* may include use ( cl9ical decision support me*anisms available f m$ical specialty organizations4 7,,iii7 ,use ( a cl9ical decision support me*anism e/abli%$ by ! ,secret>y4 7,b7 ,qualifi$ cl9ical decision support me*anisms 7i7 ,9 g5]al ,= purposes ( ?is subsection1 a qualifi$ cl9ical decision support me*anism is a me*anism t ! ,secret>y det]m9es meets ! requirem5ts describ$ 9 clause 7ii74 7ii7 ,requirem5ts ,! requirem5ts describ$ 9 ?is clause are ! foll[+3 7,i7 ,! me*anism makes available to ! ord]+ pr(essional applicable appropriate use crit]ia specifi$ "u p>agraph 7#b7 & ! support+ docum5tation = ! applicable imag+ s]vice ord]$4 7,,ii7 ,9 ! case :]e !re are m ?an "o applicable appropriate use crit]ia specifi$ "u su* p>agraph = an applicable imag+ s]vice1 ! me*anism indicates ! crit]ia t x uses = ! s]vice4 7,,iii7 ,! me*anism det]m9es ! ext5t to :i* an applicable imag+ s]vice ord]$ is consi/5t ) ! applicable appropriate use crit]ia s specifi$4 7,,iv7 ,! me*anism g5]ates & provides to ! ord]+ pr(essional a c]tification or docum5tation t docum5ts t ! qualifi$ cl9ical decision support me*anism 0 consult$ by ! ord]+ pr(essional4 7,v7 ,! me*anism is updat$ on a timely basis to reflect revisions to ! specification ( applicable appropriate use crit]ia "u su* p>agraph4 7,,vi7 ,! me*anism meets privacy & security /&>ds "u applicable provisions ( law4 7,,vii7 ,! me*anism p]=ms su* o!r functions z specifi$ by ! ,secret>y1 :i* may include a requirem5t to provide aggregate fe$back to ! ord]+ pr(essional4 7,c7 ,li/ ( me*anisms = consultation ) applicable appropriate use crit]ia 7i7 ,initial li/ ,n lat] ?an ,april #a1 #bjaf1 ! ,secret>y %all publi% a li/ ( me*anisms specifi$ "u ?is p>agraph4 7ii7 ,p]iodic updat+ ( li/ ,! ,secret>y %all p]iodically update ! li/ ( qualifi$ cl9ical decision support me*anisms specifi$ "u ?is p>agraph4 7#d7 ,consultation ) applicable appropriate use crit]ia 7,a7 ,consultation by ord]+ pr(essional ,beg9n+ ) ,janu>y #a1 #bjag1 subject to subp>agraph 7,c71 ) respect to an applicable imag+ s]vice ord]$ by an ord]+ pr(essional t w\ld be furni%$ 9 an applicable sett+ & paid = "u an applicable paym5t sy/em 7z def9$ 9 subp>agraph 7,d771 an ord]+ pr(essional %all-- 7i7 consult ) a qualifi$ decision support me*anism li/$ "u p>agraph 7#c77;,c72 & 7ii7 provide to ! furni%+ pr(essional ! in=mation describ$ 9 clauses 7i7 ?r\gh 7iii7 ( subp>agraph 7,b74 7,b7 ,report+ by furni%+ pr(essional ,beg9n+ ) ,janu>y #a1 #bjag1 subject to subp>agraph 7,c71 ) respect to an applicable imag+ s]vice furni%$ 9 an applicable sett+ & paid = "u an applicable paym5t sy/em 7z def9$ 9 subp>agraph 7,d771 paym5t = su* s]vice may only be made if ! claim = ! s]vice includes ! foll[+3 7i7 ,in=mation ab\t :i* qualifi$ cl9ical decision support me*anism 0 consult$ by ! ord]+ pr(essional = ! s]vice4 7ii7 ,in=mation reg>d+-- 7,i7 :e!r ! s]vice ord]$ w\ld adh]e to ! applicable appropriate use crit]ia specifi$ "u p>agraph 7#b72 7,,ii7 :e!r ! s]vice ord]$ w\ld n adh]e to su* crit]ia2 or 7,,iii7 :e!r su* crit]ia 0 n applicable to ! s]vice ord]$4 7iii7 ,! national provid] id5tifi] ( ! ord]+ pr(essional 7if diff]5t f ! furni%+ pr(essional74 7,c7 ,exceptions ,! provisions ( subp>agraphs 7,a7 & 7,b7 & p>agraph 7#f77;,a7 %all n apply to ! foll[+3 7i7 ,em]g5cy s]vices ,an applicable imag+ s]vice ord]$ = an individual ) an em]g5cy m$ical condition 7z def9$ 9 section #ahfg7;e77#a774 7ii7 ,inpati5t s]vices ,an applicable imag+ s]vice ord]$ = an inpati5t & = :i* paym5t is made "u "p ,a4 7iii7 ,alt]native paym5t models ,an applicable imag+ s]vice ord]$ by an ord]+ pr(essional ) respect to an individual attribut$ to an alt]native paym5t model 7z def9$ 9 section #ahcc7z77#c77;,c774 7iv7 ,significant h>d%ip ,an applicable imag+ s]vice ord]$ by an ord]+ pr(essional :o ! ,secret>y may1 on a case-by-case basis1 exempt f ! application ( su* provisions if ! ,secret>y det]m9es1 subject to annual r5ewal1 t consultation ) applicable appropriate use crit]ia w\ld result 9 a significant h>d%ip1 su* z 9 ! case ( a pr(essional :o practices 9 a rural area )\t suffici5t ,int]net access4 7,d7 ,applicable paym5t sy/em def9$ ,9 ?is subsection1 ! t]m applicable paym5t sy/em means ! foll[+3 7i7 ,! physician fee s*$ule e/abli%$ "u section #ahdh7;b74 7ii7 ,! prospective paym5t sy/em = hospital outpati5t dep>tm5t s]vices "u section #ahcc7t74 7iii7 ,! ambulatory surgical c5t] paym5t sy/ems "u section #ahcc7;i74 7#e7 ,id5tification ( outli] ord]+ pr(essionals 7,a7 ,9 g5]al ,) respect to applicable imag+ s]vices furni%$ beg9n+ ) #bjag1 ! ,secret>y %all det]m9e1 on a p]iodic basis 7:i* may be annually71 ord]+ pr(essionals :o are outli] ord]+ pr(essionals4 7,b7 ,outli] ord]+ pr(essionals ,! det]m9ation ( an outli] ord]+ pr(essional %all-- 7i7 be bas$ on l[ adh]5ce to applicable appropriate use crit]ia specifi$ "u p>agraph 7#b71 :i* may be bas$ on comp>ison to o!r ord]+ pr(essionals2 & 7ii7 include data = ord]+ pr(essionals = :om prior au?orization "u p>agraph 7#f77;,a7 applies4 7,c7 ,use ( two ye>s ( data ,! ,secret>y %all use two ye>s ( data to id5tify outli] ord]+ pr(essionals "u ?is p>agraph4 7,d7 ,consultation ) /akehold]s ,! ,secret>y %all consult ) physicians1 practition]s & o!r /akehold]s 9 develop+ me?ods to id5tify outli] ord]+ pr(essionals "u ?is p>agraph4 7#f7 ,prior au?orization = ord]+ pr(essionals :o are outli]s 7,a7 ,9 g5]al ,beg9n+ ,janu>y #a1 #bjbj1 subject to p>agraph 7#d77;,c71 ) respect to s]vices furni%$ dur+ a ye>1 ! ,secret>y %all1 = a p]iod det]m9$ appropriate by ! ,secret>y1 apply prior au?orization = applicable imag+ s]vices t are ord]$ by an outli] ord]+ pr(essional id5tifi$ "u p>agraph 7#e74 7,b7 ,fund+ ,= purposes ( c>ry+ out ?is p>agraph1 ! ,secret>y %all provide = ! transf]1 f ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda1 ( #e1jjj1jjj to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt = ea* ( fiscal ye>s #bjai ?r\gh #bjba4 ,am\nts transf]r$ "u ! prec$+ s5t5ce %all rema9 available until exp5d$4 4 7#b7 ,con=m+ am5dm5t ,section #ahcc7t77#af7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77#af77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,e7 ,application ( appropriate use crit]ia = c]ta9 imag+ s]vices ,= provisions relat+ to ! application ( appropriate use crit]ia = c]ta9 imag+ s]vices1 see section #ahcd7p74 4 7b7 ,e/abli%m5t ( appropriate use program = o!r "p ,b s]vices ,section #ahcd ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem71 z am5d$ by subsection 7a71 is am5d$ by add+ at ! end ! foll[+ new subsection3 7q7 ,e/abli%m5t ( appropriate use program = o!r "p b s]vices 7#a7 ,e/abli%m5t 7,a7 ,9 g5]al ,! ,secret>y may e/abli% an appropriate use program = s]vices "u ?is "p 7o!r ?an applicable imag+ s]vices "u subsection 7p77 us+ a process simil> to ! process "u su* subsection4 7,b7 ,requirem5ts ,9 det]m9+ :e!r to e/abli% a program "u subp>agraph 7,a71 ! ,secret>y %all take into consid]ation-- 7i7 ! implem5tation ( appropriate use crit]ia = applicable imag+ s]vices "u subsection 7p72 & 7ii7 ! report "u p>agraph 7#b74 7,c7 ,input f /akehold]s 9 advance ( rulemak+ ,be=e issu+ a notice ( propos$ rulemak+ to e/abli% a program "u subp>agraph 7,a71 ! ,secret>y %all issue an advance notice ( propos$ rulemak+4 7#b7 ,report on exp]i5ce ( imag+ appropriate use crit]ia program ,n lat] ?an #ah mon?s aft] ! date ( ! enactm5t ( ?is subsection1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report t includes a description ( ! ext5t to :i* appropriate use crit]ia c\ld be us$ = o!r s]vices "u ?is "p1 su* z radiation !rapy & cl9ical diagno/ic laboratory s]vices4 4 #g4 ,emp[]+ b5efici>y *oices ?r\gh access to in=mation on physicians' s]vices 7a7 ,transf]r+ free/&+ physician comp>e provision to ! ,social ,security ,act 7#a7 ,9 g5]al ,section #ajcca ( ,public ,law #aaa-adh is transf]r$ & r$esignat$ z subsection 7t7 ( section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 z am5d$ by subsections 7c7 & 7h7 ( section #b & by section #c4 7#b7 ,con=m+ r$esignations ,section #ahdh7t7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7t771 z transf]r$ & r$esignat$ by p>agraph 7#a71 is fur!r am5d$-- 7,a7 by /rik+ ! subsection head+ & ins]t+ ! foll[+ new subsection head+3 ,public report+ ( p]=mance & o!r in=mation on ,physician ,comp>e4--2 7,b7 by r$esignat+ subsections 7a7 ?r\gh 7i7 z p>agraphs 7#a7 ?r\gh 7#i71 respectively1 & ind5t+ appropriately2 7,c7 9 p>agraph 7#a71 z r$esignat$ by subp>agraph 7,b7-- 7i7 by r$esignat+ p>agraphs 7#a7 & 7#b7 z subp>agraphs 7,a7 & 7,b71 respectively1 & ind5t+ appropriately2 7ii7 9 subp>agraph 7,b71 z r$esignat$ by clause 7i71 by r$esignat+ subp>agraphs 7,a7 ?r\gh 7,g7 z clauses 7i7 ?r\gh 7vii71 respectively1 & ind5t+ appropriately2 7,d7 9 p>agraph 7#b71 z r$esignat$ by subp>agraph 7,b71 by r$esignat+ p>agraphs 7#a7 ?r\gh 7#g7 z subp>agraphs 7,a7 ?r\gh 7,g71 respectively1 & ind5t+ appropriately2 & 7,e7 9 p>agraph 7#i71 z r$esignat$ by subp>agraph 7,b71 by r$esignat+ p>agraphs 7#a7 ?r\gh 7#d7 z subp>agraphs 7,a7 ?r\gh 7,d71 respectively1 & ind5t+ appropriately4 7#c7 ,con=m+ am5dm5ts ,section #ahdh7t7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7t771 z am5d$ by p>agraph 7#b71 is fur!r am5d$-- 7,a7 9 p>agraph 7#a7-- 7i7 9 subp>agraph 7,a7-- 7,i7 by /rik+ ! ,m$ic>e program "u section #ahff7;j7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7j77 & ins]t+ ! program "u ?is title "u section #ahff7;j72 & 7,,ii7 by /rik+ ( su* ,act 7#db ,u4,s4,c4 #aciew-#d72 & 7ii7 9 subp>agraph 7,b71 9 ! matt] prec$+ clause 7i7-- 7,i7 by /rik+ subsection 7c7 & ins]t+ p>agraph 7#c72 7,,ii7 by /rik+ ! ,m$ic>e program "u su* section #ahff7;j7 & ins]t+ ! program "u ?is title "u section #ahff7;j72 & 7,,iii7 by /rik+ ?is section & ins]t+ ?is subsection2 7,b7 9 p>agraph 7#b7-- 7i7 9 ! matt] prec$+ subp>agraph 7,a71 by /rik+ subsection 7a77#b7 & ins]t+ p>agraph 7#a77;,b72 7ii7 9 subp>agraph 7,d71 by /rik+ ! ,m$ic>e program & ins]t+ ! program "u ?is title2 & 7iii7 9 ea* ( subp>agraphs 7,f7 & 7,g71 by /rik+ ?is section & ins]t+ ?is subsection2 7,c7 9 p>agraph 7#c71 by /rik+ ?is section & ins]t+ ?is subsection2 7,d7 9 p>agraph 7#d7-- 7i7 by /rik+ ( ! ,social ,security ,act1 z add$ by section #cjad ( ?is ,act2 & 7ii7 by /rik+ ?is section & ins]t+ ?is subsection2 7,e7 9 p>agraph 7#e7-- 7i7 by /rik+ ?is subsection 7a77#b7 & ins]t+ p>agraph 7#a77;,b72 & 7ii7 by /rik+ 7,public ,law #aaj-bge72 7,f7 9 p>agraph 7#f71 by /rik+ subsection 7a77#a7 & ins]t+ p>agraph 7#a77;,a72 7,g7 9 p>agraph 7#g7-- 7i7 by /rik+ subsection 7f7 & ins]t+ p>agraph 7#f72 & 7ii7 by /rik+ title ,,xviii ( ! ,social ,security ,act & ins]t+ ?is title2 7,h7 9 p>agraph 7#h7-- 7i7 by /rik+ subp>agraphs 7,a7 ?r\gh 7,g7 ( subsection 7a77#b7 & ins]t+ clauses 7i7 ?r\gh 7vii7 ( p>agraph 7#a77;,b72 7ii7 by /rik+ title ,,xviii ( ! ,social ,security ,act & ins]t+ ?is title2 & 7iii7 by /rik+ su* title & ins]t+ ?is title2 & 7,i7 9 p>agraph 7#i7-- 7i7 9 ! matt] prec$+ subp>agraph 7,a71 by /rik+ ?is section & ins]t+ ?is subsection2 7ii7 9 subp>agraph 7,a71 by /rik+ ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d72 7iii7 9 subp>agraph 7,b71 by /rik+ ( su* ,act 7#db ,u4,s4,c4 #aciex7r772 7iv7 9 subp>agraph 7,c71 by /rik+ subsection 7a77#a7 & ins]t+ p>agraph 7#a77;,a72 & 7v7 by /rik+ subp>agraph 7,d74 7b7 ,public availability ( ,m$ic>e data ,section #ahdh7t7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7t771 z am5d$ by subsection 7a71 is fur!r am5d$-- 7#a7 by r$esignat+ p>agraph 7#i7 z p>agraph 7#aj72 7#b7 by ins]t+ aft] p>agraph 7#h7 ! foll[+ new p>agraph3 7#i7 ,public availability ( eligible pr(essional claims data 7,a7 ,9 g5]al ,! ,secret>y %all make publicly available on ,physician ,comp>e ! in=mation describ$ 9 subp>agraph 7,b7 ) respect to eligible pr(essionals4 7,b7 ,in=mation describ$ ,! foll[+ in=mation1 ) respect to an eligible pr(essional1 is describ$ 9 ?is subp>agraph3 7i7 ,in=mation on ! numb] ( s]vices furni%$ by ! eligible pr(essional1 :i* may include in=mation on ! mo/ frequ5t s]vices furni%$ or gr\p+s ( s]vices4 7ii7 ,in=mation on submitt$ *>ges & paym5ts = s]vices "u ?is "p4 7iii7 ,a unique id5tifi] = ! eligible pr(essional t is available to ! public1 su* z a national provid] id5tifi]4 7,c7 ,se>*ability ,! in=mation made available "u ?is p>agraph %all be se>*able by at lea/ ! foll[+3 7i7 ,! specialty or type ( ! eligible pr(essional4 7ii7 ,*>act]i/ics ( ! s]vices furni%$1 su* z volume or gr\p+s ( s]vices4 7iii7 ,! location ( ! eligible pr(essional4 7,d7 ,disclosure ,! in=mation made available "u ?is p>agraph %all indicate1 :]e appropriate1 t publiciz$ in=mation may n be repres5tative ( ! eligible pr(essional's entire pati5t population1 ! v>iety ( s]vices furni%$ by ! eligible pr(essional1 or ! heal? conditions ( individuals treat$4 7,e7 ,implem5tation 7i7 ,initial implem5tation ,physician ,comp>e %all include ! in=mation describ$ 9 subp>agraph 7,b7-- 7,i7 ) respect to physicians1 by n lat] ?an ,july #a1 #bjae2 & 7,,ii7 ) respect to o!r eligible pr(essionals1 by n lat] ?an ,july #a1 #bjaf4 7ii7 ,annual updat+ ,! in=mation made available "u ?is p>agraph %all be updat$ on ,physician ,comp>e n less frequ5tly ?an on an annual basis4 7,f7 ,opportunity to review & submit corrections ,! ,secret>y %all provide = an opportunity = an eligible pr(essional to review1 & submit corrections =1 ! in=mation to be made public ) respect to ! eligible pr(essional "u ?is p>agraph prior to su* in=mation be+ made public4 2 & 7#c7 9 p>agraph 7#aj77;,c71 z r$esignat$ by p>agraph 7#a71 by ins]t+ 7or a successor website7 be=e ! p]iod at ! end4 #h4 ,exp&+ claims data availability to improve c>e 7a7 ,expansion ( uses ( claims data by qualifi$ entities ,section #ahgd7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#e7 ,expansion ( uses ( claims data by qualifi$ entities 7,a7 ,expansion ,to ! ext5t consi/5t ) applicable in=mation1 privacy1 security1 & disclosure laws1 beg9n+ ,july #a1 #bjad1 not)/&+ p>agraph 7#d77;,b7 7o!r ?an clause 7iii7 ( su* p>agraph7 & ! second s5t5ce ( p>agraph 7#d77;,d71 a qualifi$ entity may1 z det]m9$ appropriate by ! ,secret>y1 d any or all ( ! foll[+3 7i7 7,i7 ,use ! comb9$ data describ$ 9 p>agraph 7#d77;,b77iii7 to conduct analyses1 o!r ?an = reports describ$ 9 p>agraph 7#d71 = entities describ$ 9 subp>agraph 7,b7 = non-public uses1 z det]m9$ appropriate by ! ,secret>y1 su* z = ! purposes describ$ 9 subclause 7,,ii74 7,,ii7 ,! purposes describ$ 9 ?is subclause are assi/+ provid]s ( s]vices & suppli]s 9 develop+ & p>ticipat+ 9 quality & pati5t c>e improvem5t activities 7includ+ develop+ new models ( c>e71 population heal? managem5t1 & disease monitor+1 & ! purposes describ$ 9 subp>agraph 7,c74 7ii7 ,provide or sell su* analyses to entities describ$ 9 subp>agraph 7,b74 7iii7 ,provide entities describ$ 9 clauses 7i71 7ii71 7v71 & 7vi7 ( subp>agraph 7,b7 ) access to ! comb9$ data describ$ 9 p>agraph 7#d77;,b77iii7 ?r\gh a qualifi$ data enclave 7z def9$ 9 subp>agraph 7,f77 t is ma9ta9$ by ! qualifi$ entity 9 ord] = entities describ$ 9 su* clauses to conduct analyses = non-public uses1 su* z = ! purposes describ$ 9 clause 7i77,,ii74 7,b7 ,entities describ$ ,= ! purpose ( subp>agraph 7,a7 clauses 7i7 & 7ii71 ! entities describ$ 9 ?is subp>agraph are ! foll[+3 7i7 ,a provid] ( s]vices4 7ii7 ,a suppli]4 7iii7 ,subject to subp>agraph 7,c71 an employ] 7z def9$ 9 section #c7e7 ( ! ,employee ,retirem5t ,insurance ,security ,act ( #aigd74 7iv7 ,a heal? insurance issu] 7z def9$ 9 section #bgia ( ! ,public ,heal? ,s]vice ,act7 t provides data "u p>agraph 7#d77;,b77iii74 7v7 ,a m$ical society or hospital association4 7vi7 ,o!r entities approv$ by ! ,secret>y 7o!r ?an an employ] 7z s def9$7 & a heal? insurance issu] 7z s def9$774 7,c7 ,limitation ) respect to employ]s ,any analyses provid$ or sold "u ?is p>agraph to an employ] 7z s def9$7 may only be us$ by su* employ] = purposes ( provid+ heal? insurance to employees & retirees ( ! employ]4 7,d7 ,protection ( pati5t id5tification 7i7 ,9 g5]al ,except z provid$ 9 clause 7ii71 an analysis provid$ or sold "u ?is p>agraph %all n conta9 in=mation t individually id5tifies a pati5t4 7ii7 ,in=mation on pati5ts ( ! provid] ( s]vices or suppli] ,an analysis t is provid$ or sold "u ?is p>agraph to a provid] ( s]vices or suppli] may conta9 data t individually id5tifies a pati5t ( su* provid] or suppli] b only ) respect to items & s]vices furni%$ by su* provid] or suppli] to su* pati5t4 7iii7 ,opportunity = provid]s ( s]vices & suppli]s to review ,prior to a qualifi$ entity provid+ or sell+ an analysis "u ?is p>agraph to an entity describ$ 9 subp>agraph 7,b71 to ! ext5t t su* analysis w\ld individually id5tify a provid] ( s]vices or suppli] :o is n be+ provid$ or sold su* analysis1 su* qualifi$ entity %all provide an opportunity = su* provid] or suppli] to review & submit corrections to su* analysis4 7,e7 ,no r$isclosure ,an entity describ$ 9 subp>agraph 7,b7 t is provid$ or sold an analysis "u ?is p>agraph %all n r$isclose or make public su* an analysis4 7,f7 ,requirem5ts = a qualifi$ data enclave 7i7 ,def9ition ,= purposes ( ?is p>agraph1 ! t]m qualifi$ data enclave means a data enclave t ! ,secret>y det]m9es meets ! foll[+3 7,i7 ,! data enclave is a web-bas$ portal or comp>able me*anism4 7,,ii7 ,subject to ! requirem5ts describ$ 9 clause 7ii7 & su* o!r requirem5ts z ! ,secret>y may specify1 ! data enclave is capable ( provid+ access to ! comb9$ data describ$ 9 subp>agraph 7,a77iii74 7ii7 ,enclave access requirem5ts ,! requirem5ts describ$ 9 ?is clause are ! foll[+3 7,i7 ,a qualifi$ data enclave %all preclude any entity t obta9s access to ! data f remov+ or extract+ ! data f su* enclave4 7,,ii7 ,subject to ! succe$+ s5t5ce1 ! enclave %all preclude access to data t individually id5tifies a pati5t1 includ+ data on ! pati5t's "n & date ( bir? & su* o!r data z ! ,secret>y %all specify4 ,su* data enclave may provide provid]s ( s]vices & suppli]s ) access to su* individually id5tifiable pati5t data b only ) respect to items & s]vices furni%$ by su* provid] or suppli] to su* pati5t4 7,,iii7 ,access to data 9 ! enclave %all n be provid$ to any entity unless ! qualifi$ entity & ! entity h ent]$ into a data use agreem5t1 ! t]ms ( :i* conta9 ! requirem5ts ( ?is p>agraph & su* o!r t]ms ! ,secret>y may specify4 7,g7 ,annual reports ,any qualifi$ entity t provides or sells analyses pursuant to subp>agraph 7,a77ii7 or provides access to a qualifi$ data enclave pursuant to subp>agraph 7,a77iii7 %all annually submit to ! ,secret>y a report t includes-- 7i7 a summ>y ( ! analyses provid$ or sold1 includ+ ! numb] ( su* analyses1 ! numb] ( pur*as]s ( su* analyses1 & ! total am\nt ( fees receiv$ = su* analyses2 7ii7 a description ( ! topics & purposes ( su* analyses2 7iii7 in=mation on ! entities :o obta9$ access to ! qualifi$ data enclave1 ! uses ( ! data1 & ! total am\nt ( fees receiv$ = provid+ su* access2 & 7iv7 o!r in=mation det]m9$ appropriate by ! ,secret>y4 4 7b7 ,expansion ( data available to qualifi$ entities ,section #ahgd7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77 is am5d$-- 7#a7 9 ! subsection head+1 by /rik+ ,m$ic>e2 & 7#b7 9 p>agraph 7#c7-- 7,a7 by ins]t+ aft] ! fir/ s5t5ce ! foll[+ new s5t5ce3 ,effective ,july #a1 #bjad1 if ! ,secret>y det]m9es appropriate1 ! data describ$ 9 ?is p>agraph may also include /&>diz$ extracts 7z det]m9$ by ! ,secret>y7 ( claims data "u titles ,,xix & ,,xxi = assi/ance provid$ "u su* titles = "o or m specifi$ geographic areas & "t p]iods reque/$ by a qualifi$ entity42 & 7,b7 9 ! la/ s5t5ce1 by ins]t+ or "u titles ,,xix or ,,xxi be=e ! p]iod at ! end4 7c7 ,access to ,m$ic>e data by qualifi$ cl9ical data regi/ries to facilitate quality improvem5t ,section #ahdh7m77#c77;,e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#c77;,e77 is am5d$ by add+ at ! end ! foll[+ new clause3 7vi7 ,access to m$ic>e data to facilitate quality improvem5t 7,i7 ,9 g5]al ,to ! ext5t consi/5t ) applicable in=mation1 privacy1 security1 & disclosure laws1 & subject to o!r requirem5ts z ! ,secret>y may specify1 beg9n+ ,july #a1 #bjad1 ! ,secret>y %all1 if reque/$ by a qualifi$ cl9ical data regi/ry "u ?is subp>agraph1 subject to subclauses 7,,ii7 & 7,,iii71 provide data z describ$ 9 section #ahgd7;e77#c7 79 a =m & mann] det]m9$ to be appropriate7 to su* regi/ry = purposes ( l9k+ su* data ) cl9ical data & p]=m+ analyses & rese>* to support quality improvem5t or pati5t safety4 7,,ii7 ,protection ,a qualifi$ cl9ical data regi/ry may n publicly report any data made available "u subclause 7,i7 7or any analyses or rese>* describ$ 9 su* subclause7 t individually id5tifies a provid] ( s]vices1 suppli]1 or individual unless ! regi/ry obta9s ! cons5t ( su* provid]1 suppli]1 or individual prior to su* report+4 7,,iii7 ,fee ,! data describ$ 9 subclause 7,i7 %all be made available to qualifi$ cl9ical data regi/ries at a fee equal to ! co/ ( mak+ su* data available4 ,any fee collect$ pursuant to ! prec$+ s5t5ce %all be deposit$ 9 ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt4 4 7d7 ,revision ( placem5t ( fees ,section #ahgd7;e77#d77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77#d77;,a77 is am5d$1 9 ! second s5t5ce-- 7#a7 by ins]t+ 1 = p]iods prior to ,july #a1 #bjad1 aft] deposit$2 & 7#b7 by ins]t+ ! foll[+ be=e ! p]iod at ! end3 1 &1 beg9n+ ,july #a1 #bjad1 into ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt4 #i4 ,r$uc+ adm9i/rative burd5 & o!r provisions 7a7 ,m$ic>e physician & practition] opt-out to private contract 7#a7 ,indef9ite1 cont9u+ automatic ext5sion ( opt out election 7,a7 ,9 g5]al ,section #ahjb7;b77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;a7b77#c77 is am5d$-- 7i7 9 subp>agraph 7,b77ii71 by /rik+ dur+ ! #b-ye> p]iod beg9n+ on ! date ! affidavit is sign$ & ins]t+ dur+ ! applicable #b-ye> p]iod 7z def9$ 9 subp>agraph 7,d772 7ii7 9 subp>agraph 7,c71 by /rik+ dur+ ! #b-ye> p]iod describ$ 9 subp>agraph 7,b77ii7 & ins]t+ dur+ ! applicable #b-ye> p]iod2 & 7iii7 by add+ at ! end ! foll[+ new subp>agraph3 7,d7 ,applicable #b-ye> p]iods = effectiv5ess ( affidavits ,9 ?is subsection1 ! t]m applicable #b-ye> p]iod means1 ) respect to an affidavit ( a physician or practition] "u subp>agraph 7,b71 ! #b-ye> p]iod beg9n+ on ! date ! affidavit is sign$ & includes ea* subsequ5t #b-ye> p]iod unless ! physician or practition] involv$ provides notice to ! ,secret>y 79 a =m & mann] specifi$ by ! ,secret>y71 n lat] ?an #cj days be=e ! end ( ! previ\s #b-ye> p]iod1 t ! physician or practition] does n want to ext5d ! application ( ! affidavit = su* subsequ5t #b-ye> p]iod4 4 7,b7 ,effective date ,! am5dm5ts made by subp>agraph 7,a7 %all apply to affidavits ent]$ into on or aft] ! date t is #fj days aft] ! date ( ! enactm5t ( ?is ,act4 7#b7 ,public availability ( in=mation on opt-out physicians & practition]s ,section #ahjb7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;a7b77 is am5d$-- 7,a7 9 p>agraph 7#e71 by add+ at ! end ! foll[+ new subp>agraph3 7,d7 ,opt-out physician or practition] ,! t]m opt-out physician or practition] means a physician or practition] :o has 9 effect an affidavit "u p>agraph 7#c77;,b74 2 7,b7 by r$esignat+ p>agraph 7#e7 z p>agraph 7#f72 & 7,c7 by ins]t+ aft] p>agraph 7#d7 ! foll[+ new p>agraph3 7#e7 ,po/+ ( in=mation on opt-out physicians & practition]s 7,a7 ,9 g5]al ,beg9n+ n lat] ?an ,febru>y #a1 #bjae1 ! ,secret>y %all make publicly available ?r\gh an appropriate publicly accessible website ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices in=mation on ! numb] & *>act]i/ics ( opt-out physicians & practition]s & %all update su* in=mation on su* website n less (t5 ?an annually4 7,b7 ,in=mation to be includ$ ,! in=mation to be made available "u subp>agraph 7,a7 %all include at lea/ ! foll[+ ) respect to opt-out physicians & practition]s3 7i7 ,_! numb]4 7ii7 ,_! physician or pr(essional specialty or o!r designation4 7iii7 ,_! geographic di/ribution4 7iv7 ,! tim+ ( _! becom+ opt-out physicians & practition]s1 relative to :5 !y fir/ ent]$ practice & ) respect to applicable #b-ye> p]iods4 7v7 ,! proportion ( su* physicians & practition]s :o bill$ = em]g5cy or urg5t c>e s]vices4 4 7b7 ,m$ic>e non-p>ticipat+ physicians demon/ration project 7#a7 ,9 g5]al ,! ,secret>y ( ,heal? & ,human ,s]vices 79 ?is subsection ref]r$ to z ! ,secret>y7 %all e/abli% & implem5t a demon/ration project 79 ?is section ref]r$ to z ! demon/ration project7 "u title ,,xviii ( ! ,social ,security ,act to provide t paym5ts = s]vices "u su* title furni%$ by non-p>ticipat+ physicians 7z def9$ 9 section #ahfa7r77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7r77#a777 to individuals entitl$ to b5efits "u "p ,a or enroll$ "u "p ,b ( su* title are paid directly to su* physicians4 ,! ,secret>y %all c>ry out ! demon/ration project 9 a geographic area t is a /ati/ically significant area no l>g] ?an a ,/ate4 7#b7 ,advance notice to physicians ,! ,secret>y %all1 9 a timely mann] & prior to ! beg9n+ ( ! ye> 9 :i* paym5t w be made "u ! demon/ration project1 notify physicians 9 ! geographic area describ$ 9 p>agraph 7#a7 ( ! option to p>ticipate 9 ! demon/ration project4 7#c7 ,timetable = implem5tation 7,a7 ,demon/ration />t date ,! demon/ration project %all apply ) respect to s]vices furni%$ beg9n+ on ,janu>y #a1 #bjae4 7,b7 #a-ye> duration ,! ,secret>y %all implem5t ! demon/ration project su* t paym5ts are made "u su* demon/ration project = a p]iod ( #a ye>4 7#d7 ,report ,n lat] ?an #ah mon?s aft] ! date ( ! conclusion ( ! demon/ration project1 ! ,secret>y %all submit to ,congress a report analyz+ ! impact ( ! demon/ration project4 ,su* report %all include an analysis ( ! impact1 if any1 ( ! demon/ration project ^u !-- 7,a7 p]c5tage & numb] ( physicians :o *oose n to p>ticipate "u title ,,xviii ( ! ,social ,security ,act & a comp>ison ( su* p]c5tage & numb] to ! previ\s ye>2 7,b7 p]c5tage ( claims submitt$ by & paym5ts made to physicians 9 ! demon/ration t are unassign$ & a comp>ison ( unassign$ claims & paym5ts by non-p>ticipat+ physicians 9 ! previ\s ye>2 7,c7 p]c5tage & numb] ( ! physicians 9 ! demon/ration by specialty designation2 & 7,d7 access to s]vices = :i* paym5t is made "u su* title = individuals entitl$ to b5efits "u "p ,a or enroll$ "u "p ,b ( su* title4 7#e7 ,b5efici>y notice 7,a7 ,notice by ,secret>y to b5efici>ies ,! ,secret>y %all notify individuals entitl$ to b5efits "u "p ,a or enroll$ "u "p ,b ( title ,,xviii ( ! ,social ,security ,act 9 ! geographic area 9 :i* ! demon/ration project is conduct$ ( ! implications ( physician p>ticipation 9 ! demon/ration project4 7,b7 ,notice by physicians to pati5ts ,a physician :o elects to p>ticipate 9 ! demon/ration project %all notify individuals to :om ! physician furni%es s]vices = :i* paym5t w be provid$ "u ! demon/ration project ( su* election4 ,su* notification %all be provid$ prior to ! provision ( s]vice & include a notification1 ) respect to ea* su* individual1 t-- 7i7 ! "r ( ! individual to paym5t is be+ reassign$ to ! physician2 7ii7 paym5t = s]vices furni%$ by ! physician to su* individual w be made directly to ! physician2 & 7iii7 ! individual is responsible = ! rema9+ am\nt1 :i* may be high] ?an w\ld be ! case if ! physician p>ticipat$ 9 ! ,m$ic>e program4 7c7 ,ga9%>+ /udy & report ,n lat] ?an #f mon?s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices1 9 consultation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 %all submit to ,congress a report ) legislative recomm5dations to am5d exi/+ fraud & abuse laws1 ?r\gh exceptions1 safe h>bors1 or o!r n>r[ly t>get$ provisions1 to p]mit ga9%>+ or simil> arrangem5ts betwe5 physicians & hospitals t improve c>e :ile r$uc+ wa/e & increas+ effici5cy4 ,! report %all-- 7#a7 consid] :e!r su* provisions %\ld apply to own]%ip int]e/s1 comp5sation arrangem5ts1 or o!r relation%ips2 & 7#b7 describe h[ ! recomm5dations address acc\ntability1 transp>5cy1 & quality1 includ+ h[ be/ to limit inducem5ts to /9t on c>e1 dis*>ge pati5ts prematurely1 or o!rwise r$uce or limit m$ically necess>y c>e2 & 7#c7 consid] :e!r a portion ( any sav+s g5]at$ by su* arrangem5ts %\ld accrue to ! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act4 7d7 ,promot+ int]op]ability ( electronic heal? record sy/ems 7#a7 ,recomm5dations = a*iev+ widespread ,,ehr int]op]ability 7,a7 ,objective ,z a consequ5ce ( a significant ,f$]al inve/m5t 9 ! implem5tation ( heal? in=mation te*nology ?r\gh ! ,m$ic>e ,,ehr inc5tive programs1 ,congress decl>es x a national objective to a*ieve widespread & nationwide ex*ange ( heal? in=mation ?r\gh int]op]able c]tifi$ ,,ehr te*nology by ,decemb] #ca1 #bjai4 7,b7 ,def9itions ,9 ?is p>agraph3 7i7 ,widespread int]op]ability ,! t]m widespread int]op]ability means nationwide int]op]ability betwe5 c]tifi$ ,,ehr te*nology sy/ems employ$ by mean+ful ,,ehr us]s "u ! ,m$ic>e ,,ehr inc5tive programs & o!r cl9icians & heal? c>e provid]s4 7ii7 ,int]op]ability ,! t]m int]op]ability means ! ability ( two or m heal? in=mation sy/ems or compon5ts to ex*ange cl9ical & o!r in=mation & to use ! in=mation t has be5 ex*ang$ us+ common /&>ds z to provide access to longitud9al in=mation = heal? c>e provid]s 9 ord] to facilitate coord9at$ c>e & improv$ pati5t outcomes4 7,c7 ,e/abli%m5t ( metrics ,n lat] ?an ,decemb] #ca1 #bjae1 & 9 consultation ) /akehold]s1 ! ,secret>y %all e/abli% metrics to be us$ to det]m9e if & to ! ext5t t ! objective describ$ 9 subp>agraph 7,a7 has be5 a*iev$4 7,d7 ,recomm5dations if objective n a*iev$ ,if ! ,secret>y ( ,heal? & ,human ,s]vices det]m9es t ! objective describ$ 9 subp>agraph 7,a7 has n be5 a*iev$ by ,decemb] #ca1 #bjag1 !n ! ,secret>y %all submit to ,congress a report1 by n lat] ?an ,decemb] #ca1 #bjah1 t id5tifies b>ri]s to su* objective & recomm5ds actions t ! ,f$]al ,gov]nm5t c take to a*ieve su* objective4 ,su* recomm5d$ actions may include recomm5dations-- 7i7 to adju/ paym5ts = mean+ful ,,ehr us]s "u ! ,m$ic>e ,,ehr inc5tive programs2 & 7ii7 = crit]ia = dec]tify+ c]tifi$ ,,ehr te*nology products4 7#b7 ,prev5t+ block+ ! %>+ ( in=mation 7,a7 ,= mean+ful ,,ehr pr(essionals ,section #ahdh7o77#b77;,a77ii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7o77#b77;,a77ii77 is am5d$ by ins]t+ be=e ! p]iod at ! end ! foll[+3 1 & ! pr(essional demon/rates 7?r\gh a process specifi$ by ! ,secret>y1 su* z ! use ( an atte/ation simil> to t requir$ 9 ! heal? in=mation te*nology donation safe h>bor e/abli%$ "u regulations "u section #aabh;,b7b77#c77;,e77 t ! pr(essional has n & w n take any delib]ate action to limit or re/rict ! use1 compatibility1 or int]op]ability ( ! c]tifi$ ,,ehr te*nology4 7,b7 ,= mean+ful ,,ehr hospitals ,section #ahhf7n77#c77;,a77ii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7n77#c77;,a77ii77 is am5d$ by ins]t+ be=e ! p]iod at ! end ! foll[+3 1 & ! hospital demon/rates 7?r\gh a process specifi$ by ! ,secret>y1 su* z ! use ( an atte/ation ref]r$ to 9 section #ahdh7o77#b77;,a77ii77 t ! hospital has n & w n take any delib]ate action to limit or re/rict ! use1 compatibility1 or int]op]ability ( ! c]tifi$ ,,ehr te*nology4 7,c7 ,effective date ,! am5dm5ts made by ?is subsection %all apply to mean+ful ,,ehr us]s z ( ! date t is #f mon?s aft] ! date ( ! enactm5t ( ?is ,act4 7#c7 ,/udy & report on ! feasibility ( e/abli%+ a website to comp>e c]tifi$ ,,ehr te*nology products 7,a7 ,/udy ,! ,secret>y %all conduct a /udy to exam9e ! feasibility ( e/abli%+ a website 79 ?is subsection ref]r$ to z ! website7 t includes aggregat$ results ( surveys ( mean+ful ,,ehr us]s on ! functionality ( c]tifi$ ,,ehr te*nology products to enable su* us]s to directly comp>e ! functionality & o!r features ( su* products4 ,su* in=mation may be made available ?r\gh contracts ) physician1 hospital1 or o!r organizations t ma9ta9 su* comp>ative in=mation4 7,b7 ,report ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y %all submit to ,congress a report on ! website4 ,! report %all include in=mation on ! b5efits & res\rces ( su* a website4 7#d7 ,def9itions ,9 ?is subsection3 7,a7 ,! t]m c]tifi$ ,,ehr te*nology has ! mean+ giv5 su* t]m 9 section #ahdh7o77#d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7o77#d774 7,b7 ,! t]m mean+ful ,,ehr hospital means an eligible hospital 7z def9$ 9 section #ahhf7n77#f77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7n77#f77;,a77 t is a mean+ful ,,ehr us]4 7,c7 ,! t]m mean+ful ,,ehr pr(essional means an eligible pr(essional 7z def9$ 9 section #ahdh7o77#e77;,c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7o77#e77;,c77 :o is a mean+ful ,,ehr us]4 7,d7 ,! t]m mean+ful ,,ehr us] has ! mean+ giv5 su* t]m "u ! ,m$ic>e ,,ehr inc5tive programs4 7,e7 ,! t]m ,m$ic>e ,,ehr inc5tive programs means ! inc5tive programs "u section #ahdh7o71 subsections 7l7 & 7m7 ( section #ahec1 & section #ahhf7n7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7o71 #aciew-#bc1 #acieww7n774 7,f7 ,! t]m ,secret>y means ! ,secret>y ( ,heal? & ,human ,s]vices4 7e7 ,,gao /udy & report on ! use ( teleheal? "u ,f$]al programs 7#a7 ,/udy ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all conduct a /udy on ! foll[+3 7,a7 ,h[ ! def9ition ( teleheal? across v>i\s ,f$]al programs & f$]al ef=ts c in=m ! use ( teleheal? 9 ! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq474 7,b7 ,issues t c facilitate or inhibit ! use ( teleheal? "u ! ,m$ic>e program "u su* title1 includ+ ov]sight & pr(essional lic5sure1 *ang+ te*nology1 privacy & security1 infra/ructure requirem5ts1 & v>y+ ne$s across urban & rural areas4 7,c7 ,pot5tial implications ( great] use ( teleheal? ) respect to paym5t & deliv]y sy/em trans=mations "u ! ,m$ic>e program "u su* title ,,xviii & ! ,m$icaid program "u title ,,xix ( su* ,act 7#db ,u4,s4,c4 #acif et seq474 7,d7 ,h[ ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices conducts ov]sight ( paym5ts made "u ! ,m$ic>e program "u su* title ,,xviii to provid]s = teleheal? s]vices4 7#b7 ,report ,n lat] ?an #bd mon?s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al %all submit to ,congress a report conta9+ ! results ( ! /udy conduct$ "u p>agraph 7#a71 toge!r ) recomm5dations = su* legislation & adm9i/rative action z ! ,comptroll] ,g5]al det]m9es appropriate4 7f7 ,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 ,m>* #ad1 #bjad ,report$ f ! ,committee on ,ways & ,means ) an am5dm5t1 committ$ to ! ,committee ( ! ,:ole ,h\se on ! ,/ate ( ! ,union1 & ord]$ to be pr9t$