,i  #aac? ,,congress  #a/ ,session  ,h4 
,r4 #cgif  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,decemb] #ai1         
#bjac,mrs4 ,black 7= h]self & ,mr4      
,neal7 introduc$ ! foll[+ bill2 :i* 0   
ref]r$ to ! ,committee on ,ways &       
,means1 & 9 addition to ! ,committee on 
,en]gy & ,comm]ce1 = a p]iod to be      
subsequ5tly det]m9$ by ! ,speak]1 9 ea* 
case = consid]ation ( su* provisions z  
fall )9 ! jurisdiction ( ! committee    
conc]n$  ,a ,,bill  ,to am5d title      
,,xviii ( ! ,social ,security ,act to   
provide = bundl$ paym5ts = c]ta9        
episodes ( c>e surr\nd+ a               
hospitalization1 & = o!r purposes4  #a4 
,%ort title ,?is ,act may be cit$ z !   
,compreh5sive ,c>e ,paym5t ,innovation  
,act4  #b4 ,p]man5t1 national volunt>y  
paym5t bundl+ ,title ,,xviii ( ! ,social
 ,security ,act is am5d$ by ins]t+ aft] 
section #ahff;,e 7#db ,u4,s4,c4         
#acie;cc-#e7 ! foll[+ new section3      
#ahff;,f4 ,national volunt>y paym5t     
bundl+  7a7 ,e/abli%m5t & implem5tation 

7#a7 ,9 g5]al ,! ,secret>y %all provide 
= bundl$ paym5ts "u ?is section =       
integrat$ c>e furni%$ by a qualifi$     
entity dur+ an episode ( c>e to an      
applicable b5efici>y = applicable       
conditions involv+ a hospitalization4   
7#b7 ,deadl9e ,! ,secret>y %all implem5t
 ?is section n lat] ?an ,janu>y #a1     
#bjae4  7#c7 ,applicable b5efici>y def9$
 ,9 ?is section1 ! t]m applicable       
b5efici>y means an individual :o is     
entitl$ to1 or enroll$ =1 b5efits "u "p 
,a & enroll$ = b5efits "u "p ,b1 b n    
enroll$ "u "p ,c or 9 a ,,pace program  
"u section #ahid1 & :o is admitt$ to a  
hospital = an applicable condition4  7b7
 ,qualifi$ entity & application process 
7#a7 ,def9itions ,9 ?is section3 7,a7 ,9
 g5]al ,! t]m qualifi$ entity means a   
qualifi$ applicant t has an application 
approv$ by ! ,secret>y to receive bundl$
 paym5ts = furni%+ applicable s]vices to
 applicable individuals "u ?is section4 
7,b7 ,qualifi$ applicant ,! t]m qualifi$
 applicant means a corporation1         

p>tn]%ip1 or limit$ liability company1 t
 is au?oriz$ 9 writ+ by a gr\p (        
provid]s ( s]vices & suppli]s1 includ+  
at lea/ a hospital1 t are o!rwise       
p>ticipat+ "u ?is title to act z _! ag5t
 = ! purpose ( receiv+ & di/ribut+      
bundl$ paym5ts on _! behalf "u ?is      
section4 ,a qualifi$ applicant may 7b is
 n requir$ to7 be a provid] ( s]vices or
 suppli] t is o!rwise p>ticipat+ "u ?is 
title4  7#b7 ,application  7,a7 ,9 g5]al
 ,a qualifi$ applicant may submit to !  
,secret>y an application to become a    
qualifi$ entity to receive bundl$       
paym5ts "u ?is section4  7,b7 ,cont5ts  
,an application "u subp>agraph 7,a7 )   
respect to a gr\p ( provid]s ( s]vices &
 suppli]s-- 7i7 %all conta9 su*         
in=mation & assurances z ! ,secret>y may
 specify1 includ+ ) respect to !        
requirem5ts "u subsection 7c77#a72 &    
7ii7 %all indicate ! applicable         
conditions ) respect to :i* ! gr\p seeks
 to furni% applicable s]vices dur+ !    
episode ( c>e involv$ & ! bundl$ paym5t 

me?odology "u subsection 7g7 or 7h7 "u  
:i* ! gr\p w\ld be paid = su* s]vices4  
7#c7 ,*oice among applicable conditions 
,a qualifi$ entity may select "o or m   
applicable conditions = bundl$ paym5ts  
"u ?is section4 ,no?+ 9 ?is section %all
 be con/ru$ z requir+1 or au?oriz+ !    
,secret>y to require1 a qualifi$ entity 
to select any p>ticul> applicable       
condition "u ?is section4  7#d7 ,exp$it$
 application process = qualifi$         
applicants successfully p>ticipat+ 9 !  
,,cmi bundl$ paym5t demon/ration ,9 !   
case ( any qualifi$ applicant t !       
,secret>y det]m9es has successfully     
p>ticipat$ 9 any ( ! paym5t & s]vice    
deliv]y models te/$ by ! ,c5t] = ,m$ic>e
 & ,m$icaid ,innovation "u section      
#aaae;,a ?r\gh ! ,bundl$ ,paym5ts = ,c>e
 ,improvem5t 7,,bpci7 ,initiative1 !    
,secret>y %all provide = an exp$it$     
application process "u ?is subsection4  
7c7 ,requirem5ts = qualifi$ entities    
7#a7 ,requirem5ts  7,a7 ,9 g5]al ,!     
,secret>y %all develop requirem5ts =    

qualifi$ entities to receive bundl$     
paym5ts = furni%+ applicable s]vices =  
applicable conditions dur+ an episode ( 
c>e "u ?is section4  7,b7 ,agreem5t     
p]iod ,"u su* requirem5ts1 a qualifi$   
entity %all agree to receive bundl$     
paym5ts = ! furni%+ ( su* s]vices = a   
#e-ye> p]iod 7ea* su* ye> 9 su* p]iod   
ref]r$ to 9 ?is section z an agreem5t   
ye>74  7,c7 ,b5efici>y transp>5cy ,su*  
requirem5ts %all ensure transp>5cy      
betwe5 a qualifi$ entity & applicable   
b5efici>ies su* t notice is provid$ to  
an applicable b5efici>y suffici5tly 9   
advance1 to ! ext5t practicable1 ( !    
b5efici>y's inpati5t admission = !      
applicable condition & episode ( c>e    
involv$4 ,su* a notice %all include--   
7i7 appropriate notice ( bundl$ paym5ts 
= ! applicable condition = ! episode (  
c>e involv$2 &  7ii7 a /atem5t in=m+ !  
b5efici>y ( ! b5efici>y's "r to select !
 provid]s ( s]vices & suppli]s furni%+  
items & s]vices relat$ to ! episode (   
c>e4  7,d7 ,me?odology & measures =     

quality & effici5cy arrangem5ts ,ins(> z
 a qualifi$ entity uses or seeks to     
implem5t a quality & effici5cy          
arrangem5t "u subsection 7i71 ! qualifi$
 entity %all specify 9 ! application to 
! ,secret>y 9 detail ! me?odology =     
allocat+ sav+s "u ! arrangem5t & !      
specific measures to be us$ to assess ! 
quality ( c>e "u ! arrangem5t4  7#b7    
,provision ( data by ,secret>y  7,a7    
,claims data ,! ,secret>y %all furni% to
 a gr\p ( provid]s ( s]vices & suppli]s 
int]e/$ 9 submitt+ an application "u    
subsection 7b77#b7 claims data "u p>ts  
,a & ,b1 includ+ complete claims files1 
= applicable conditions relat+ to !     
provid]s & suppli]s 9 ! gr\p t are      
suffici5tly specific to p]mit su* gr\p  
to det]m9e :e!r to submit su*           
application4 ,su* claims data %all also 
be furni%$ to a qualifi$ entity mon?ly  
dur+ ! agreem5t p]iod describ$ 9        
p>agraph 7#a77;,b7 ( any approv$        
application ) respect to an applicable  
condition4  7,b7 ,quality data ,!       

,secret>y %all furni% to a qualifi$     
entity data on quality measures )       
respect to any applicable condition "u  
an approv$ application dur+ ! agreem5t  
p]iod = ! entity = ea* episode ( c>e &  
across ! cont9uum ( c>e4  7d7           
,applicable conditions  7#a7 ,initial   
conditions ,9 ?is section1 ! t]m        
applicable condition means any ( !      
foll[+ proc$ures furni%$ z "p ( inpati5t
 hospital s]vices3 7,a7 ,hip_/,knee jo9t
 replacem5t4  7,b7 ,lumb> sp9e fusion4  
7,c7 ,coron>y art]y bypass graft4  7,d7 
,he>t valve replacem5t4  7,e7           
,p]cutane\s coron>y int]v5tion ) /5t4   
7,f7 ,colon resection4  7#b7 ,discretion
 to add conditions ,su* t]m also        
includes su* additional proc$ures or    
conditions z ! ,secret>y may select4 ,9 
select+ su* proc$ures or conditions1 !  
,secret>y may take into consid]ation !  
factors describ$ 9 section              
#ahff;,d7a77#b77;,b74  7e7 ,applicable  
s]vices2 episode ( c>e ,9 ?is section3  
7#a7 ,applicable s]vices ,! t]m         

applicable s]vices means ! foll[+ items 
& s]vices3 7,a7 ,acute c>e inpati5t     
s]vices4  7,b7 ,physicians' s]vices     
deliv]$ 9 & outside ( an acute c>e      
hospital sett+4  7,c7 ,outpati5t        
hospital s]vices4  7,d7 ,po/-acute c>e  
s]vices1 includ+ home heal? s]vices1    
skill$ nurs+ s]vices1 inpati5t          
rehabilitation s]vices1 & inpati5t      
hospital s]vices furni%$ by a long-t]m  
c>e hospital4  7,e7 ,o!r s]vices !      
,secret>y det]m9es appropriate4  7#b7   
,episode ( c>e  7,a7 ,9 g5]al ,subject  
to subp>agraph 7,b71 ! t]m episode ( c>e
 means1 ) respect to an applicable      
condition & an applicable b5efici>y1 !  
p]iod consi/+ (-- 7i7 ! #c days prior to
 ! admission ( ! applicable b5efici>y to
 a hospital ) respect to ! applicable   
condition2  7ii7 ! duration ( !         
applicable b5efici>y's initial inpati5t 
/ay 9 su* hospital = ! applicable       
condition2 &  7iii7 ! #ij days foll[+ ! 
dis*>ge ( ! applicable b5efici>y f su*  
hospital4  7,b7 ,e/abli%m5t ( p]iod by !

 secret>y ,! ,secret>y1 z appropriate1  
may e/abli% a p]iod 7o!r ?an ! p]iod    
describ$ 9 subp>agraph 7,a77 = an       
episode ( c>e "u ?is section bas$ on    
data analyses4  7#c7 ,dis*>g+ hospital  
,! t]m dis*>g+ hospital means1 ) respect
 to applicable s]vices 9 an episode (   
c>e1 ! hospital ref]r$ to 9 p>agraph    
7#b77;,a74  7f7 ,bundl$ paym5t          
developm5t  7#a7 ,9 g5]al ,subject to ! 
succe$+ provisions ( ?is subsection1 !  
,secret>y %all develop bundl$ paym5ts = 
qualifi$ entities4 ,a bundl$ paym5t %all
 provide = compreh5sive paym5t = ! co/s 
( applicable s]vices furni%$ to an      
applicable b5efici>y dur+ an episode (  
c>e = an applicable condition1 includ+  
readmissions relat$ to ! applicable     
condition b exclud+ unrelat$            
readmissions1 "u ei!r a fee-=-s]vice    
model ) %>$ sav+s & losses 7"u          
subsection 7g77 or "u a prospective     
paym5t model = advanc$ qualifi$ entities
 7"u subsection 7h774 ,bundl$ paym5ts   
%all be bas$ on ! sp5d+ t>gets comput$  

"u p>agraph 7#b74  7#b7 ,computation (  
sp5d+ t>gets  7,a7 ,9 g5]al ,! ,secret>y
 %all compute "u ?is p>agraph1 = ea*    
qualifi$ entity = ea* applicable        
condition = an episode ( c>e beg9n+ 9 an
 agreem5t ye> 7beg9n+ ) #bjae7 t is     
attributable to a dis*>g+ hospital1 a   
sp5d+ t>get equal to ! updat$ am\nt     
comput$ "u subp>agraph 7,c7 = t entity1 
episode1 & ye>4  7,b7 ,initial weight$  
av]age calculation = dis*>g+ hospitals  
7i7 ,9 g5]al ,us+ fee-=-s]vice claims   
data f ! base p]iod 7z def9$ 9          
subp>agraph 7,d771 subject to clause    
7ii71 ! ,secret>y %all fir/ calculate a 
base av]age sp5d+ t>get = ea* applicable
 condition = ea* dis*>g+ hospital equal 
to a weight$ av]age ( sp5d+ "u p>ts ,a &
 ,b = all applicable s]vices = su*      
applicable condition associat$ ) initial
 admissions to su* hospital comput$ z ! 
sum ( ! foll[+ 7) respect to su*        
hospital73 7,i7 #fj p]c5t ( ! /&>diz$   
sp5d+ p] episode 9 ! mo/ rec5t ye> 9 !  
base p]iod4  7,,ii7 #cj p]c5t ( !       

/&>diz$ sp5d+ p] episode 9 ! previ\s    
ye>4  7,,iii7 #aj p]c5t ( ! /&>diz$     
sp5d+ p] episode 9 ! second previ\s ye>4
  7ii7 ,exclusion ( outli]s &           
/&>dization ,9 calculat+ ! am\nt ( !    
base av]age sp5d+ t>get = an applicable 
condition "u clause 7i7 = a dis*>g+     
hospital1 ! ,secret>y %all-- 7,i7       
exclude f ! calculation paym5ts =       
episodes ( c>e = ! applicable condition 
t exce$ ! #ie? p]c5tile ( all su* sp5d+ 
= su* episodes ( c>e & applicable       
condition1 z e/imat$ by ! ,secret>y1    
bas$ on ! mo/ rec5t data available2 &   
7,,ii7 /&>dize ! sp5d+ made 9 ea* ye> 9 
! base p]iod to ea* provid] ( s]vice or 
suppli] to remove ! sp5d+ adju/m5ts 9   
effect 9 su* ye> relat+ to provid] or   
suppli] location 7su* z area wage       
indices7 & provid] type 7su* z indirect 
m$ical education adju/m5ts &            
disproportionate %>e hospital           
adju/m5ts74  7,c7 ,tr5d+ ! sp5d+ t>gets 
bas$ on national gr[? rates to agreem5t 
ye>2 p]iodic rebas+ = new agreem5t      

p]iods  7i7 ,9 g5]al ,! ,secret>y %all  
update ! base av]age sp5d+ t>gets = all 
dis*>g+ hospitals "u subp>agraph 7,b7 = 
ea* applicable condition & agreem5t ye> 
bas$ on tr5ds 9 ! national fee-=-s]vice 
claims data = applicable s]vices furni%$
 dur+ an episode ( c>e = an applicable  
condition f ! base p]iod to ! agreem5t  
ye> involv$4 ,su* update %all n v>y by  
dis*>g+ hospital4  7ii7 ,p]iodic rebas+ 
= new agreem5t p]iods ,at ! />t ( ea*   
new agreem5t p]iod1 ! ,secret>y %all    
update ! base p]iod & calculate new     
sp5d+ t>gets "u ! previ\s provisions (  
?is p>agraph = a dis*>g+ hospital &     
applicable conditions1 includ+ provid+ =
 adju/m5ts by provid] location & provid]
 type ( ! type describ$ 9 subp>agraph   
7,b77ii77,,ii74  7,d7 ,base p]iod def9$ 
,9 ?is p>agraph1 except z provid$ 9     
subp>agraph 7,c77ii71 ! t]m base p]iod  
means ! mo/ rec5t #c-ye> p]iod = :i*    
complete data are available to c>ry out 
?is subsection4  7g7 ,fee-=-,s]vice     
bundl$ paym5t model ) %>$ sav+s & %>$   

losses  7#a7 ,fee-=-s]vice-bas$ paym5t  
,if ! paym5t model "u ?is subsection is 
select$ by a qualifi$ entity1 !         
,secret>y %all pay provid]s ( s]vices & 
suppli]s ( ! entity = applicable s]vices
 = an applicable condition dur+ an      
episode ( c>e am\nts payable "u p>ts ,a 
& ,b = su* s]vices 9 ! same mann] z su* 
provid]s & suppli]s w\ld o!rwise be paid
 "u su* p>ts 7ref]r$ to 9 ?is subsection
 z fee-=-s]vice paym5ts74  7#b7 ,%>$    
sav+s & losses  7,a7 ,computation ( ea* 
qualifi$ entity's actual /&>diz$ av]age 
sp5d+ p] episode ( c>e ,9 apply+ ?is    
subsection1 9 calculat+ ! actual /&>diz$
 av]age fee-=-s]vice sp5d+ p] episode ( 
c>e = a dis*>g+ hospital = ea*          
applicable condition 9 ea* agreem5t ye>1
 ! ,secret>y %all exclude outli]        
episodes ( c>e describ$ 9 subsection    
7f77#b77;,b77ii77,i71 z e/imat$ by !    
,secret>y1 bas$ on data applicable to   
paym5ts 9 ! agreem5t ye> & %all /&>dize 
su* sp5d+ p] episode ( c>e 9 ! mann]    
provid$ 9 subsection                    

7f77#b77;,b77ii77,,ii74 ,= ! purpose (  
id5tify+ outli] episodes ( c>e = ea*    
applicable condition1 ! p]c5tile rank+ (
 ea* episode ( c>e & applicable         
condition & ! #ie? p]c5tile %all be bas$
 on paym5ts /&>diz$ by adju/m5ts =      
provid] location & provid] type ( ! type
 describ$ 9 subsection                  
7f77#b77;,b77ii77,,ii74  7,b7           
,computation ( gross %>$ sav+s & %>$    
losses = ea* applicable condition = ea* 
dis*>g+ hospital ,= purposes ( apply+   
subp>agraph 7,c71 if actual /&>diz$     
av]age fee-=-s]vice paym5ts to a        
qualifi$ entity = all episodes ( c>e =  
an applicable condition 9 an agreem5t   
ye> = a dis*>g+ hospital1 z calculat$ "u
 subp>agraph 7,a71 are-- 7i7 less ?an ! 
applicable sp5d+ t>get "u subsection    
7f77#b77;,c7 = su* condition1 ye>1 &    
hospital1 !re %all be a gross %>$ sav+s 
= su* applicable condition1 ye>1 &      
hospital equal to #fj p]c5t ( ! diff]5ce
 betwe5 su* actual av]age paym5ts & !   
sp5d+ t>get = su* condition1 ye>1 &     

hospital2 or  7ii7 great] ?an su*       
applicable sp5d+ t>get1 !re %all be a   
gross %>$ loss = su* applicable         
condition1 ye>1 & hospital equal to #fj 
p]c5t ( su* diff]5ce4  7,c7             
,retrospective reconciliation  7i7      
,total+ gross %>$ sav+s & losses = all  
conditions & all dis*>g+ hospitals = a  
qualifi$ entity ,at ! end ( ea* agreem5t
 ye> = ea* qualifi$ entity1 = purposes (
 apply+ clauses 7ii7 & 7iii71 !         
,secret>y %all aggregate ! gross %>$    
sav+s & ! gross %>$ losses "u           
subp>agraph 7,b7 ( su* entity = ! ye> = 
all applicable conditions & = all       
dis*>g+ hospitals4  7ii7 ,paym5t to     
entity ( net sav+s ,subject to clause   
7iv7 & subsection 7j77#c7 7relat+ to    
quality p]=mance ?re%olds71 if su*      
aggregate gross %>$ sav+s exce$s su*    
aggregate gross %>$ losses = a qualifi$ 
entity = an agreem5t ye>1 ! ,secret>y   
%all pay to ! qualifi$ entity a lump sum
 am\nt equal to su* excess = su* ye>4   
7iii7 ,collection f entity ( net losses 

,subject to clause 7iv71 if su*         
aggregate gross %>$ losses exce$s su*   
aggregate gross %>$ sav+s = a qualifi$  
entity = an agreem5t ye>1 ! qualifi$    
entity %all pay to ! ,secret>y 7& !     
,secret>y %all collect f ! entity7 a    
lump sum am\nt equal to su* excess = su*
 ye>4  7iv7 ,cap on paym5ts ,9 no case  
%all ! paym5t "u clause 7ii7 or 7iii7 ) 
respect to a qualifi$ entity = an       
agreem5t ye> exce$ #aj p]c5t ( !        
aggregate sp5d+ t>get = t qualifi$      
entity = all applicable conditions & all
 dis*>g+ hospitals = t ye>4  7h7        
,prospective bundl$ paym5t model =      
advanc$ qualifi$ entities  7#a7 ,9 g5]al
 ,subject to approval by ! ,secret>y1 if
 ! paym5t model "u ?is subsection is    
select$1 a qualifi$ entity may elect to 
receive a prospective bundl$ paym5t =   
ea* episode ( c>e = ea* applicable      
condition & dis*>g+ hospital 9 !        
agreem5t ye> equal to ! sp5d+ t>get =   
su* episode1 ye>1 & hospital "u         
subsection 7f77#b7 & ! provisions (     

subsection 7g7 d n apply4 ,su* sp5d+    
t>get %all be adju/$1 9 ! same mann]    
describ$ 9 subsection 7g77#b77;,b71 9   
ord] to take into acc\nt outli] episodes
 ( c>e & /&>diz$ adju/m5ts = provid]    
location & provid] type ( ! type        
describ$ 9 subsection                   
7f77#b77;,b77ii77,,ii74  7#b7 ,rule (   
con/ruction ,no?+ 9 ?is section %all be 
con/ru$ z prohibit+ a qualifi$ entity t 
receives bundl$ paym5ts "u ?is          
subsection f p>ticipat+ 9 an acc\ntable 
c>e organization "u section #ahii4  7#c7
 ,relation%ip to ,,bpci ,! ,secret>y may
 n t]m9ate ! ,bundl$ ,paym5ts = ,c>e    
,improvem5t initiative conduct$ pursuant
 to section #aaae;,a until ! prospective
 bundl$ paym5t model is implem5t$ "u ?is
 subsection4  7i7 ,quality & effici5cy  
arrangem5ts  7#a7 ,9 g5]al ,subject to  
subsection 7c77#a77;,d7 7relat+ to      
application requirem5ts = notice (      
quality & effici5cy arrangem5ts & _!    
/ructure7 & subsection 7j77#c7 7relat+  
to m9imum quality p]=mance ?re%olds71   

qualifi$ entities p>ticipat+ 9 ei!r !   
fee-=-s]vice bundl$ paym5t model "u     
subsection 7g7 or ! prospective bundl$  
paym5t model "u subsection 7h7 may ent] 
into quality & effici5cy arrangem5ts "u 
:i* physicians & o!r heal? c>e          
practition]s "w to improve ! quality &  
effici5cy ( c>e "u ?is title4  7#b7     
,types ( arrangem5ts ,! arrangem5ts "u  
p>agraph 7#a7 %all take into acc\nt !   
utilization ( ! res\rces ( provid]s (   
s]vices & suppli]s & may provide = a    
di/ribution ( a portion ( any %>$ sav+s 
7or int]nal sav+1 z ! case may be7      
realiz$ "u ?is section to qualify+      
provid]s & suppli]s4  7j7 ,quality      
measures  7#a7 ,selection2 developm5t   
7,a7 ,selection ,= ea* applicable       
condition1 ! ,secret>y %all select      
quality measures relat$ to c>e provid$  
by provid]s ( s]vices & suppli]s ?r\gh  
qualifi$ entities to :i* bundl$ paym5ts 
are made "u ?is section4 ,9 select+     
quality measures1 to ! ext5t appropriate
 & practicable1 ! ,secret>y %all *oose  

measures t-- 7i7 are endors$ & validat$ 
by ! entity ) a contract "u section     
#ahij2  7ii7 p]ta9 to ! ,national       
,quality ,/rategy's six priorities2     
7iii7 are us$ by ! ,secret>y "u o!r     
provisions ( ?is title2 &  7iv7 m9imize 
! increm5tal data extraction & report+  
burd5 on provid]s & suppli]s4  7,b7     
,developm5t ( electronically specifi$   
episodic measures ,! ,secret>y %all     
develop longitud9al quality & effici5cy 
measures to assess p]=mance ( qualifi$  
entities ) respect to pati5t outcomes & 
! c>e provid$ = ea* applicable condition
 across ! associat$ episodes ( c>e4 ,su*
 measures %all be electronically        
specifi$ = submittal ?r\gh ! use (      
qualifi$ electronic heal? records 7z    
def9$ 9 section #cjjj7ac7 ( ! ,public   
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#cjj;jj7#ac7774  7#b7 ,report+ on       
quality measures  7,a7 ,9 g5]al ,a      
qualifi$ entity %all submit data to !   
,secret>y on quality measures select$ "u
 p>agraph 7#a7 = ea* agreem5t ye> 9 a =m

 & mann] specifi$ by ! ,secret>y        
consi/5t ) ! succe$+ provisions ( ?is   
p>agraph4  7,b7 ,submission ( data ?r\gh
 electronic heal? record ,to ! ext5t    
practicable1 su* data %all be submitt$  
?r\gh ! use ( a qualifi$ electronic     
heal? record 7z def9$ 9 section         
#cjjj7ac7 ( ! ,public ,heal? ,s]vice    
,act 7#db ,u4,s4,c4 #cjj;jj7#ac7774     
7,c7 ,submission ( data us$ 9 o!r       
programs ,ins(> z quality measures      
e/abli%$ "u p>agraph 7#a7 are ! same z  
^? measures us$ by ! ,secret>y "u o!r   
provisions ( ?is title1 su* z ^? select$
 "u section #ahhf7;b77#c77;,b77viii71 ! 
,secret>y %all use exi/+ processes = !  
submission ( data = su* measures "u ?is 
p>agraph4  7#c7 ,quality p]=mance       
?re%olds  7,a7 ,e/abli%m5t ,= ea*       
applicable condition1 ! ,secret>y %all  
e/abli% m9imum quality p]=mance ?re%olds
 = ! measures e/abli%$ "u p>agraph 7#a74
 ,9 ! case ( a quality & effici5cy      
arrangem5t1 su* p]=mance ?re%olds %all  
be develop$ us+ ! quality measures      

id5tifi$ by ! qualifi$ entity 9 its     
application "u subsection 7c77#a77;,d7  
if approv$ by ! ,secret>y4  7,b7 ,loss (
 %>$ sav+s paym5t & quality & effici5cy 
arrangem5ts = failure to meet m9imum    
quality p]=mance ?re%olds ,if a qualifi$
 entity fails to meet ! m9imum quality  
p]=mance ?re%olds e/abli%$ "u           
subp>agraph 7,a7 = an agreem5t ye>-- 7i7
 no paym5t may be made to ! entity "u   
subsection 7g77#b77;,c77ii7 ) respect to
 t ye>2 &  7ii7 ! entity may n implem5t 
any quality & effici5cy arrangem5t "u   
subsection 7i7 = t ye>4  7k7 ,waiv]s    
7#a7 ,9 g5]al ,! ,secret>y %all waive   
su* provisions ( ?is title & title ,,xi 
z may be necess>y to c>ry out ! program1
 includ+ ! foll[+3 7,a7 ,) respect to   
au?oriz+ quality & effici5cy arrangem5ts
 betwe5 qualifi$ entities & provid]s (  
s]vices & suppli]s1 section #ahgg7;a7   
7relat+ to physician self-ref]ral71     
p>agraphs 7#a7 & 7#b7 ( sections        
#aabh;,a7b7 7relat+ to ! ga9%>+ civil   
money p5alties71 & p>agraphs 7#a7 & 7#b7

 ( section #aabh;,b7b7 7relat+ to !     
anti-kickback /atute74  7,b7 ,section   
#aabh;,a7a77#e7 ( ! ,act 7relat+ to !   
inducem5t civil money p5alties74  7,c7  
,section #ahfa7;i7 7relat+ to ! #c-;day 
acute hospitalization pr]equisite be=e  
eligibility = po/-hospital ext5d$ c>e   
s]vices74  7,d7 ,) respect to home heal?
 s]vices-- 7i7 sections                 
#ahad7;a77#b77;,c7 & #ahce7;a77#b77;,a7 
7relat+ to ! requirem5t t an individual 
be conf9$ to home 9 ord] to be eligible 
= b5efits = home heal? s]vices72  7ii7  
limitations on ! am\nt1 frequ5cy1 &     
duration on home heal? s]vices2 &  7iii7
 prohibitions ( free preop]ative home   
safety assessm5ts by home heal? ag5cies 
= pati5ts s*$ul$ to und]go surg]y 7su* z
 "u ,advisory ,op9ion ,no4 #jf-ja ( !   
,inspector ,g5]al ( ! ,dep>tm5t ( ,heal?
 & ,human ,s]vices74  7#b7 ,au?ority to 
modify waiv]s "u c]ta9 circum/ances     
7,a7 ,9 g5]al ,9 ! case ( a qualifi$    
entity ) respect to :i* "o or m waiv]s  
"u p>agraph 7#a7 is 9 effect1 if ^u a   

review ( ! p]=mance or an audit ( !     
entity ! ,secret>y f9ds a patt]n (      
defici5cies or h>m to applicable        
b5efici>ies1 ! ,secret>y may modify or  
revoke any su* waiv] at any "t z appli$ 
to t qualifi$ entity4  7,b7 ,t]m9ation (
 c]ta9 waiv]s 9 ! case ( excess %>$     
losses  7i7 ,9 g5]al ,subject to !      
process describ$ 9 clause 7ii71 9 ! case
 ( a qualifi$ entity t has select$ !    
paym5t model "u subsection 7g7 & has    
gross %>$ losses exce$+ ! cap "u        
subsection 7g77#b77;,c77iv7 ) respect to
 an applicable condition1 ! ,secret>y   
%all t]m9ate waiv]s describ$ 9 p>agraphs
 7#a77;,c7 & 7#a77;,d7 ) respect to su* 
qualifi$ entity & applicable condition4 
7ii7 ,pre-t]m9ation notice ,! ,secret>y 
%all e/abli% a process :]eby a qualifi$ 
entity is furni%$ notice ( any defici5cy
 t may give rise to a t]m9ation ( waiv]s
 "u clause 7i7 n lat] ?an #f mon?s be=e 
! propos$ effective date ( ! t]m9ation4 
7l7 ,indep5d5t evaluation & reports on  
program  7#a7 ,indep5d5t evaluation ,!  

,secret>y %all conduct an indep5d5t     
evaluation ( ! impact ( provid+ bundl$  
paym5ts to qualifi$ entities "u ?is     
section4 ,su* evaluation %all include an
 exam9ation ( ! ext5t to :i* ! bundl+ ( 
paym5ts ?is section h result$ 9-- 7,a7  
improv$ heal? outcomes2  7,b7 improv$   
access to c>e = applicable b5efici>ies2 
7,c7 r$uc$ sp5d+ "u ?is title2 &  7,d7  
improvem5t 9 p]=mance on quality        
measures select$ "u subsection          
7j77#a77;,a74  7#b7 ,reports  7,a7      
,int]im report ,n lat] ?an ,m>* #a1     
#bjah1 ! ,secret>y %all submit to       
,congress a report on ! initial results 
( ! indep5d5t evaluation conduct$ "u    
p>agraph 7#a74  7,b7 ,f9al report ,n    
lat] ?an ,m>* #a1 #bjbj1 ! ,secret>y    
%all submit to ,congress a report on !  
f9al results ( ! indep5d5t evaluation   
conduct$ "u p>agraph 7#a7 & may include 
recomm5dations = ! expansion ( bundl$   
paym5t me?odologies & applicable        
conditions "u ?is section z ! ,secret>y 
det]m9es to be appropriate4  4