,i #aac? ,,congress #b;d ,session ,h4 ,r4 #dbji ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,m>* #ab1 #bjad ,mr4 ,ti]ney introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,en]gy & ,comm]ce1 & 9 addition to ! ,committees on ,ways & ,means1 ! ,judici>y1 & ! ,budget1 = 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 repeal ! ,m$ic>e su/a9able gr[? rate & improve ,m$ic>e paym5ts = physicians & o!r pr(essionals1 & = o!r purposes4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,,sgr ,repeal & ,m$ic>e ,provid] ,paym5t ,mod]nization ,act ( #bjad4 7b7 ,table ( cont5ts ,! table ( cont5ts ( ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4 ,sec4 #b4 ,repeal+ ! su/a9able gr[? rate 7,,sgr7 & improv+ ,m$ic>e paym5t = physicians' s]vices4 ,sec4 #c4 ,priorities & fund+ = 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&+ availability ( ,m$ic>e data4 ,sec4 #i4 ,r$uc+ adm9i/rative burd5 & o!r provisions4 ,sec4 #aj4 ,sav+s f ov]seas cont+5cy & relat$ activities4 #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$+ ye>2 & 7ii7 9 p>agraph 7#b71 9 ! matt] prec$+ subp>agraph 7,a71 by ins]t+ & end+ ) #bjac aft] beg9n+ ) #bjjj4 7#b7 ,update ( rates = ,april ?r\gh ,decemb] ( #bjad1 #bjae1 & subsequ5t ye>s ,subsection 7d7 ( section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is am5d$ by /rik+ p>agraph 7#ae7 & ins]t+ ! foll[+ new p>agraphs3 7#ae7 ,update = #bjad ?r\gh #bjah ,! update to ! s+le conv]sion factor e/abli%$ 9 p>agraph 7#a77;,c7 = #bjad & ea* subsequ5t ye> ?r\gh #bjah %all be #j4e p]c5t4 7#af7 ,update = #bjai ?r\gh #bjbc ,! update to ! s+le conv]sion factor e/abli%$ 9 p>agraph 7#a77;,c7 = #bjai & ea* subsequ5t ye> ?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 #a4j p]c5t2 & 7,b7 = o!r items & s]vices1 #j4e 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 7,c7 ,report on update to physicians' s]vices "u ,m$ic>e ,n lat] ?an ,july #a1 #bjah1 ! ,m$ic>e ,paym5t ,advisory ,commission %all submit to ,congress a report on-- 7i7 ! paym5t update = pr(essional s]vices appli$ "u ! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act = ! p]iod ( ye>s #bjad ?r\gh #bjah2 7ii7 ! effect ( su* update on ! effici5cy1 economy1 & quality ( c>e provid$ "u su* program2 7iii7 ! effect ( su* update on ensur+ a suffici5t numb] ( provid]s to ma9ta9 access to c>e by ,m$ic>e b5efici>ies2 & 7iv7 recomm5dations = any future paym5t updates = pr(essional s]vices "u su* program to ensure adequate access to c>e is ma9ta9$ = ,m$ic>e b5efici>ies4 7b7 ,consolidation ( c]ta9 curr5t law p]=mance programs ) new m]it-,bas$ ,inc5tive ,paym5t ,sy/em 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$-- 7i7 9 clause 7i71 by /rik+ or any subsequ5t paym5t ye> & ins]t+ or #bjag2 7ii7 9 clause 7ii7-- 7,i7 9 ! matt] prec$+ 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 = ,,mips ,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 ( ,,mips ,) respect to #bjah & 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 ,,mips 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$-- 7i7 9 clause 7i71 by /rik+ or any subsequ5t ye> & ins]t+ or #bjag2 & 7ii7 9 clause 7ii77,,ii71 by /rik+ & ea* subsequ5t ye>4 7,b7 ,cont9uation ( quality measures & processes = ,,mips ,section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is am5d$-- 7i7 9 subsection 7k71 by add+ at ! end ! foll[+ new p>agraph3 7#i7 ,cont9u$ application = purposes ( ,,mips & = c]ta9 pr(essionals volunte]+ to report ,! ,secret>y %all1 9 accordance ) subsection 7q77#a77;,f71 c>ry out ! provisions ( ?is subsection-- 7,a7 = purposes ( subsection 7q72 & 7,b7 = eligible pr(essionals :o are n ,,mips eligible pr(essionals 7z def9$ 9 subsection 7q77#a77;,c77 = ! ye> involv$4 2 & 7ii7 9 subsection 7m7-- 7,i7 by r$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 ( ,,mips & = c]ta9 pr(essionals volunte]+ to report ,! ,secret>y %all1 9 accordance ) subsection 7q77#a77;,f71 c>ry out ! processes "u ?is subsection-- 7,a7 = purposes ( subsection 7q72 & 7,b7 = eligible pr(essionals :o are n ,,mips eligible pr(essionals 7z def9$ 9 subsection 7q77#a77;,c77 = ! ye> involv$4 4 7#c7 ,value-bas$ 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 #bjah1 ) 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 #bjah4 4 7,b7 ,cont9uation ( value-bas$ paym5t modifi] measures = ,,mips ,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 ( ,,mips ,! ,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 #bjah & ea* subsequ5t ye>1 ! ,secret>y %all1 9 accordance ) subsection 7q77#a77;,f71 c>ry out ?is p>agraph = purposes ( subsection 7q744 7c7 ,m]it-,bas$ ,inc5tive ,paym5t ,sy/em 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 ,m]it-,bas$ ,inc5tive ,paym5t ,sy/em 7#a7 ,e/abli%m5t 7,a7 ,9 g5]al ,subject to ! succe$+ provisions ( ?is subsection1 ! ,secret>y %all e/abli% an eligible pr(essional ,m]it-bas$ ,inc5tive ,paym5t ,sy/em 79 ?is subsection ref]r$ to z ! ,,mips7 "u :i* ! ,secret>y %all-- 7i7 develop a me?odology = assess+ ! total p]=mance ( ea* ,,mips 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 ( ! ,,mips eligible pr(essional = a p]=mance p]iod = a ye> to det]m9e & apply a ,,mips adju/m5t factor 7&1 z applicable1 an additional ,,mips adju/m5t factor7 "u p>agraph 7#f7 to ! pr(essional = ! ye>4 7,b7 ,program implem5tation ,! ,,mips %all apply to paym5ts = items & s]vices furni%$ on or aft] ,janu>y #a1 #bjah4 7,c7 ,,mips eligible pr(essional def9$ 7i7 ,9 g5]al ,= purposes ( ?is subsection1 subject to clauses 7ii7 & 7iv71 ! t]m ,,mips eligible pr(essional means-- 7,i7 = ! fir/ & second ye>s = :i* ! ,,mips applies to paym5ts 7& = ! p]=mance p]iod = su* fir/ & second ye>71 a physician 7z def9$ 9 section #ahfa7r771 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#b77 & a gr\p t includes su* pr(essionals2 & 7,,ii7 = ! ?ird ye> = :i* ! ,,mips 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>y & a gr\p t includes su* pr(essionals4 7ii7 ,exclusions ,= purposes ( clause 7i71 ! t]m ,,mips eligible pr(essional does n include1 ) respect to a ye>1 an eligible pr(essional 7z def9$ 9 subsection 7k77#c77;,b77 :o-- 7,i7 is a qualify+ ,,apm p>ticipant 7z def9$ 9 section #ahcc7z77#b772 7,,ii7 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 ! ,,mips2 or 7,,iii7 = ! 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 #bjah & #bjai1 ! 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 #bjbj & #bjba-- 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 #bjbb & 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 a l[-volume ?re%old to apply = purposes ( clause 7ii77,,iii71 :i* may include "o or m or a comb9ation ( ! foll[+3 7,i7 ,! m9imum numb] 7z det]m9$ by ! ,secret>y7 ( individuals enroll$ "u ?is "p :o are treat$ by ! 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 ,,mips 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 ,,mips eligible pr(essional 7includ+ pursuant to clauses 7ii7 & 7v77 ) respect to a ye>1 9 no case %all a ,,mips adju/m5t factor 7or additional ,,mips adju/m5t factor7 "u p>agraph 7#f7 apply to su* individual = su* ye>4 7vii7 ,p>tial qualify+ ,,apm p>ticipant cl>ifications 7,i7 ,treatm5t z ,,mips eligible pr(essional ,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 ! ,,mips1 su* eligible pr(essional is consid]$ to be a ,,mips eligible pr(essional ) respect to su* ye>4 7,,ii7 ,n eligible = qualify+ ,,apm p>ticipant paym5ts ,9 no case %all an eligible pr(essional :o is a p>tial qualify+ ,,apm p>ticipant1 ) respect to a ye>1 be consid]$ a qualify+ ,,apm p>ticipant 7z def9$ 9 p>agraph 7#b7 ( section #ahcc7z77 = su* ye> or be eligible = ! additional paym5t "u p>agraph 7#a7 ( su* section = su* ye>4 7,d7 ,application to gr\p practices 7i7 ,9 g5]al ,"u ! ,,mips3 7,i7 ,quality p]=mance category ,! ,secret>y %all e/abli% & apply a process t includes features ( ! provisions ( subsection 7m77#c77;,c7 = ,,mips 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 = ,,mips 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 ! range ( items & s]vices furni%$ by ! ,,mips eligible pr(essionals 9 ! gr\p practice involv$4 7iii7 ,cl>ification ,,mips eligible pr(essionals elect+ to be a virtual gr\p "u p>agraph 7#e77;,i7 %all n be consid]$ ,,mips eligible pr(essionals 9 a gr\p practice = purposes ( apply+ ?is subp>agraph4 7,e7 ,use ( regi/ries ,"u ! ,,mips1 ! ,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,g7 ,acc\nt+ = risk factors 7i7 ,risk factors ,tak+ into acc\nt ! relevant /udies conduct$ & recomm5dations made 9 reports "u section #b7;f77#a7 ( ! ,,sgr ,repeal & ,m$ic>e ,provid] ,paym5t ,mod]nization ,act ( #bjad1 ! ,secret>y1 on an ongo+ basis1 %all e/imate h[ an individual's heal? /atus & o!r risk factors affect quality & res\rce use outcome measures &1 z feasible1 %all incorporate in=mation f quality & res\rce use outcome measurem5t 7includ+ c>e episode & pati5t condition gr\ps7 into ! ,,mips4 7ii7 ,acc\nt+ = o!r factors 9 paym5t adju/m5ts ,tak+ into acc\nt ! /udies conduct$ & recomm5dations made 9 reports "u section #b7;f77#a7 ( ! ,,sgr ,repeal & ,m$ic>e ,provid] ,paym5t ,mod]nization ,act ( #bjad & o!r in=mation z appropriate1 ! ,secret>y %all acc\nt = id5tifi$ factors ) an effect on quality & res\rce use outcome measures :5 det]m9+ paym5t adju/m5ts1 composite p]=mance scores1 scores = p]=mance categories1 or scores = measures or activities "u ! ,,mips4 7#b7 ,measures & activities "u p]=mance categories 7,a7 ,p]=mance categories ,"u ! ,,mips1 ! ,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 includ$ 9 ! f9al measures li/ publi%$ "u subp>agraph 7,d77i7 = su* ye> & ! li/ ( quality measures describ$ 9 subp>agraph 7,d77vi7 us$ by qualifi$ cl9ical data regi/ries "u subsection 7m77#c77;,e74 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 7r7 z appropriate1 &1 z feasible & applicable1 acc\nt+ = ! co/ ( drugs "u "p ,d4 7iii7 ,cl9ical practice improvem5t activities ,= ! p]=mance category describ$ 9 subp>agraph 7,a77iii71 cl9ical practice improvem5t activities 7z def9$ 9 subp>agraph 7,c77v77,,iii77 "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$s1 b5efici>y self-managem5t assessm5t & tra9+1 & us+ %>$ 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/+ ( #ae or few] 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 = physicians1 su* z measures = inpati5t hospitals1 = purposes ( ! p]=mance categories describ$ 9 clauses 7i7 & 7ii7 ( subp>agraph 7,a74 ,= purposes ( ! previ\s s5t5ce1 ! ,secret>y may n use measures = hospital outpati5t dep>tm5ts1 except 9 ! case ( em]g5cy physicians4 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 ,application ( measures & activities to non-pati5t-fac+ pr(essionals ,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 furni% 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 ,,mips eligible pr(essionals ( su* pr(essional types or subcategories1 alt]native measures or activities t fulfill ! goals ( ! applicable p]=mance category4 ,9 c>ry+ out ! previ\s s5t5ce1 ! ,secret>y %all consult ) pr(essionals ( su* pr(essional types or subcategories4 7v7 ,cl9ical practice improvem5t activities 7,i7 ,reque/ = in=mation ,9 initially apply+ subp>agraph 7,b77iii71 ! ,secret>y %all use a reque/ = in=mation to solicit recomm5dations f /akehold]s to id5tify activities describ$ 9 su* subp>agraph & specify+ crit]ia = su* activities4 7,,ii7 ,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-- 7aa7 id5tify+ activities describ$ 9 subp>agraph 7,b77iii72 7bb7 specify+ crit]ia = su* activities2 & 7cc7 det]m9+ :e!r a ,,mips eligible pr(essional meets su* crit]ia4 7,,iii7 ,cl9ical practice improvem5t activities def9$ ,= purposes ( ?is subsection1 ! 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 ,annual li/ ( quality measures available = ,,mips assessm5t 7i7 ,9 g5]al ,"u ! ,,mips1 ! ,secret>y1 ?r\gh notice & comm5t rulemak+ & subject to ! succe$+ clauses ( ?is subp>agraph1 %all1 ) respect to ! p]=mance p]iod = a ye>1 e/abli% an annual f9al li/ ( quality measures f :i* ,,mips eligible pr(essionals may *oose = purposes ( assessm5t "u ?is subsection = su* p]=mance p]iod4 ,pursuant to ! previ\s s5t5ce1 ! ,secret>y %all-- 7,i7 n lat] ?an ,novemb] #a ( ! ye> prior to ! fir/ day ( ! fir/ p]=mance p]iod "u ! ,,mips1 e/abli% & publi% 9 ! ,f$]al ,regi/] a f9al li/ ( quality measures2 & 7,,ii7 n lat] ?an ,novemb] #a ( ! ye> prior to ! fir/ day ( ea* subsequ5t p]=mance p]iod1 update ! f9al li/ ( quality measures f ! previ\s ye> 7& publi% su* updat$ f9al li/ 9 ! ,f$]al ,regi/]71 by-- 7aa7 remov+ f su* li/1 z appropriate1 quality measures1 :i* may include ! removal ( measures t are no long] mean+ful 7su* z measures t are topp$ out72 7bb7 add+ to su* li/1 z appropriate1 new quality measures2 & 7cc7 det]m9+ :e!r or n quality measures on su* li/ t h und]gone sub/antive *anges %\ld be includ$ 9 ! updat$ li/4 7ii7 ,call = quality measures 7,i7 ,9 g5]al ,eligible pr(essional organizations & o!r relevant /akehold]s %all be reque/$ to id5tify & submit quality measures to be consid]$ = selection "u ?is subp>agraph 9 ! annual li/ ( quality measures publi%$ "u clause 7i7 & to id5tify & submit updates to ! measures on su* li/4 ,= purposes ( ! previ\s s5t5ce1 measures 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,,ii7 ,eligible pr(essional organization def9$ ,9 ?is subp>agraph1 ! 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 7iii7 ,requirem5ts ,9 select+ quality measures = inclusion 9 ! annual f9al li/ "u clause 7i71 ! ,secret>y %all-- 7,i7 provide t1 to ! ext5t practicable1 all quality doma9s 7z def9$ 9 subsection 7s77#a77;,b77 are address$ by su* measures2 & 7,,ii7 ensure t su* selection is consi/5t ) ! process = selection ( measures "u subsections 7k71 7m71 & 7p77#b74 7iv7 ,pe] review ,be=e includ+ a new measure or a measure describ$ 9 clause 7i77,,ii77cc7 9 ! f9al li/ ( measures publi%$ "u clause 7i7 = a ye>1 ! ,secret>y %all submit = publication 9 applicable specialty-appropriate pe]-review$ j\rnals su* measure & ! me?od = develop+ & select+ su* measure1 includ+ cl9ical & o!r data support+ su* measure4 7v7 ,measures = inclusion ,! f9al li/ ( quality measures publi%$ "u clause 7i7 %all include1 z applicable1 measures "u subsections 7k71 7m71 & 7p77#b71 includ+ quality measures f among-- 7,i7 measures endors$ by a cons5sus-bas$ entity2 7,,ii7 measures develop$ "u subsection 7s72 & 7,,iii7 measures submitt$ "u clause 7ii77,i74 ,any measure select$ = inclusion 9 su* li/ t is n endors$ by a cons5sus-bas$ entity %all h a focus t is evid5ce-bas$4 7vi7 ,exception = qualifi$ cl9ical data regi/ry measures ,measures us$ by a qualifi$ cl9ical data regi/ry "u subsection 7m77#c77;,e7 %all n be subject to ! requirem5ts "u clauses 7i71 7iv71 & 7v74 ,! ,secret>y %all publi% ! li/ ( measures us$ by su* qualifi$ cl9ical data regi/ries on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices4 7vii7 ,exception = exi/+ quality measures ,any quality measure specifi$ by ! ,secret>y "u subsection 7k7 or 7m71 includ+ "u subsection 7m77#c77;,e71 & any measure ( quality ( c>e e/abli%$ "u subsection 7p77#b7 = ! report+ p]iod "u ! respective subsection beg9n+ be=e ! fir/ p]=mance p]iod "u ! ,,mips-- 7,i7 %all n be subject to ! requirem5ts "u clause 7i7 7except "u items 7aa7 & 7cc7 ( subclause 7,,ii7 ( su* clause7 or to ! requirem5t "u clause 7iv72 & 7,,ii7 %all be includ$ 9 ! f9al li/ ( quality measures publi%$ "u clause 7i7 unless remov$ "u clause 7i77,,ii77aa74 7viii7 ,consultation ) relevant eligible pr(essional organizations & o!r relevant /akehold]s ,relevant eligible pr(essional organizations & o!r relevant /akehold]s1 includ+ ,/ate & national m$ical societies1 %all be consult$ 9 c>ry+ out ?is subp>agraph4 7ix7 ,optional application ,! process "u section #ahij;,a is n requir$ to apply to ! selection ( measures "u ?is subp>agraph4 7#c7 ,p]=mance /&>ds 7,a7 ,e/abli%m5t ,"u ! ,,mips1 ! ,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 consid] ! foll[+3 7i7 ,hi/orical p]=mance /&>ds4 7ii7 ,improvem5t4 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$+ provisions ( ?is p>agraph & tak+ into acc\nt1 z available & applicable1 p>agraph 7#a77;,g71 ! ,secret>y %all develop a me?odology = assess+ ! total p]=mance ( ea* ,,mips eligible pr(essional accord+ to p]=mance /&>ds "u p>agraph 7#c7 ) respect to applicable measures & activities specifi$ 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 7us+ a scor+ scale ( #j to #ajj7 = ea* su* pr(essional = ! p]=mance p]iod = su* ye>4 ,9 ?is subsection su* a composite assessm5t = su* a pr(essional ) respect to a p]=mance p]iod %all be ref]r$ to z ! composite p]=mance score = su* pr(essional = su* p]=mance p]iod4 7,b7 ,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 ,,mips 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 & qualifi$ cl9ical data regi/ries = report+ quality measures ,"u ! me?odology e/abli%$ "u subp>agraph 7,a71 ! ,secret>y %all-- 7,i7 enc\rage ,,mips 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*nology & qualifi$ cl9ical data regi/ries2 & 7,,ii7 ) respect to a p]=mance p]iod1 ) respect to a ye>1 = :i* a ,,mips 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,c7 ,cl9ical practice improvem5t activities p]=mance score 7i7 ,rule = accr$itation ,a ,,mips eligible pr(essional :o is 9 a practice t is c]tifi$ 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 ,,mips 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 a m9imum score ( "o-half ( ! highe/ pot5tial score = ! p]=mance category describ$ 9 p>agraph 7#b77;,a77iii7 = su* p]=mance p]iod4 7iii7 ,subcategories ,a ,,mips eligible pr(essional %all n be requir$ to p]=m activities 9 ea* subcategory "u p>agraph 7#b77;,b77iii7 or p>ticipate 9 an alt]native paym5t model 9 ord] to a*ieve ! highe/ pot5tial score = ! p]=mance category describ$ 9 p>agraph 7#b77;,a77iii74 7,d7 ,a*ievem5t & improvem5t 7i7 ,tak+ into acc\nt improvem5t ,beg9n+ ) ! second ye> to :i* ! ,,mips applies1 9 addition to ! a*ievem5t ( a ,,mips eligible pr(essional1 if data suffici5t to measure improvem5t is available1 ! 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* ! ,,mips applies1 "u ! me?odology develop$ "u subp>agraph 7,a71 ! ,secret>y may assign a high] scor+ weight "u subp>agraph 7,f7 ) respect to ! a*ievem5t ( a ,,mips eligible pr(essional ?an ) respect to any improvem5t ( su* pr(essional appli$ "u clause 7i7 ) respect to a measure1 activity1 or category describ$ 9 p>agraph 7#b74 7,e7 ,weights = ! p]=mance categories 7i7 ,9 g5]al ,"u ! me?odology develop$ "u subp>agraph 7,a71 subject to subp>agraph 7,f77i7 & 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 ?irty p]c5t ( su* score %all be bas$ on p]=mance ) respect to ! category describ$ 9 clause 7i7 ( p>agraph 7#b77;,a74 ,9 apply+ ! previ\s s5t5ce1 ! ,secret>y %all1 z feasible1 enc\rage ! application ( outcome measures )9 su* category4 7bb7 ,fir/ #b ye>s ,= ! fir/ & second ye>s = :i* ! ,,mips applies to paym5ts1 ! p]c5tage applicable "u item 7aa7 %all be increas$ 9 a mann] su* t ! total p]c5tage po9ts ( ! increase "u ?is item = ! respective ye> equals ! total numb] ( p]c5tage po9ts by :i* ! p]c5tage appli$ "u subclause 7,,ii77bb7 = ! respective ye> is less ?an #cj p]c5t4 7,,ii7 ,res\rce use 7aa7 ,9 g5]al ,subject to item 7bb71 ?irty 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 ,= ! fir/ ye> = :i* ! ,,mips applies to paym5ts1 n m ?an #aj p]c5t ( su* score %all be bas$ on p]=mance ) respect to ! category describ$ 9 clause 7ii7 ( p>agraph 7#b77;,a74 ,= ! second ye> = :i* ! ,,mips applies to paym5ts1 n m ?an #ae p]c5t ( su* score %all be bas$ on p]=mance ) respect to ! category describ$ 9 clause 7ii7 ( p>agraph 7#b77;,a74 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 subject to subclauses 7,i77bb7 & 7,,ii77bb7 ( clause 7i71 ! p]c5tages applicable "u "o or m ( subclauses 7,i71 7,,ii71 & 7,,iii7 ( clause 7i7 = su* ye> %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 7,f7 ,c]ta9 flexibility = weight+ p]=mance categories1 measures1 & activities ,"u ! me?odology "u subp>agraph 7,a71 if !re are n suffici5t measures & cl9ical practice improvem5t activities applicable & available to ea* type ( eligible pr(essional involv$1 ! ,secret>y %all assign diff]5t scor+ weights 7includ+ a weight ( #j7-- 7i7 :i* may v>y f ! scor+ weights specifi$ 9 subp>agraph 7,e71 = ea* p]=mance category bas$ on ! ext5t to :i* ! category is applicable to ! type ( eligible pr(essional involv$2 & 7ii7 = ea* measure & activity specifi$ "u p>agraph 7#b77;,b7 ) respect to ea* su* category bas$ on ! ext5t to :i* ! measure or activity is applicable & available to ! type ( eligible pr(essional involv$4 7,g7 ,res\rce use ,analysis ( ! p]=mance category describ$ 9 p>agraph 7#b77;,a77ii7 %all include results f ! me?odology describ$ 9 subsection 7r77#e71 z appropriate4 7,h7 ,inclusion ( quality measure data f o!r 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 ,,mips eligible pr(essionals ) respect to items & s]vices furni%$ to individuals :o are n individuals entitl$ to b5efits "u "p ,a or enroll$ "u "p ,b4 7,i7 ,use ( volunt>y virtual gr\ps = c]ta9 assessm5t purposes 7i7 ,9 g5]al ,9 ! case ( ,,mips 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* ,,mips 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 ,,mips eligible pr(essional or a gr\p practice consi/+ ( n m ?an #aj ,,mips eligible pr(essionals to elect1 ) respect to a p]=mance p]iod = a ye>1 = su* individual ,,mips eligible pr(essional or all su* ,,mips 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 ,,mips eligible pr(essional or gr\p practice mak+ su* an election4 ,su* a virtual gr\p may be bas$ on geographic areas or on provid] specialties def9$ by nationally recogniz$ multispecialty bo>ds ( c]tification or equival5t c]tification bo>ds & su* o!r eligible pr(essional gr\p+s 9 ord] to capture classifications ( provid]s across eligible pr(essional organizations & o!r practice areas or categories4 7iii7 ,requirem5ts ,! process "u clause 7ii7-- 7,i7 %all provide t an election "u su* clause1 ) respect to a p]=mance p]iod1 %all be made be=e or dur+ ! beg9n+ ( su* p]=mance p]iod & may n be *ang$ dur+ su* p]=mance p]iod2 7,,ii7 %all provide t a practice describ$ 9 su* clause1 & ea* ,,mips eligible pr(essional 9 su* practice1 may elect to be 9 no m ?an "o virtual gr\p = a p]=mance p]iod2 & 7,,iii7 may provide t a virtual gr\p may be comb9$ at ! tax id5tification numb] level4 7#f7 ,,mips paym5ts 7,a7 ,,mips adju/m5t factor ,tak+ into acc\nt p>agraph 7#a77;,g71 ! ,secret>y %all specify a ,,mips adju/m5t factor = ea* ,,mips eligible pr(essional = a ye>4 ,su* ,,mips adju/m5t factor = a ,,mips eligible pr(essional = a ye> %all be 9 ! =m ( a p]c5t & %all be det]m9$-- 7i7 by comp>+ ! composite p]=mance score ( ! eligible pr(essional = su* ye> to ! p]=mance ?re%old e/abli%$ "u subp>agraph 7,d77i7 = su* ye>2 7ii7 9 a mann] su* t ! adju/m5t factors specifi$ "u ?is subp>agraph = a ye> result 9 diff]5tial paym5ts "u ?is p>agraph reflect+ t-- 7,i7 ,,mips eligible pr(essionals ) composite p]=mance scores = su* ye> at or above su* p]=mance ?re%old = su* ye> receive z]o or positive inc5tive paym5t adju/m5t factors = su* ye> 9 accordance ) clause 7iii71 ) su* pr(essionals hav+ high] composite p]=mance scores receiv+ high] adju/m5t factors2 & 7,,ii7 ,,mips eligible pr(essionals ) composite p]=mance scores = su* ye> bel[ su* p]=mance ?re%old = su* ye> receive negative paym5t adju/m5t factors = su* ye> 9 accordance ) clause 7iv71 ) su* pr(essionals hav+ l[] composite p]=mance scores receiv+ l[] adju/m5t factors2 7iii7 9 a mann] su* t ,,mips eligible pr(essionals ) composite scores describ$ 9 clause 7ii77,i7 = su* ye>1 subject to clauses 7i7 & 7ii7 ( subp>agraph 7,f71 receive a z]o or positive adju/m5t factor on a l9e> slid+ scale su* t an adju/m5t factor ( #j p]c5t is assign$ = a score at ! p]=mance ?re%old & an adju/m5t factor ( ! applicable p]c5t specifi$ 9 subp>agraph 7,b7 is assign$ = a score ( #ajj2 & 7iv7 9 a mann] su* t-- 7,i7 subject to subclause 7,,ii71 ,,mips eligible pr(essionals ) composite p]=mance scores describ$ 9 clause 7ii77,,ii7 = su* ye> receive a negative paym5t adju/m5t factor on a l9e> slid+ scale su* t an adju/m5t factor ( #j p]c5t is assign$ = a score at ! p]=mance ?re%old & an adju/m5t factor ( ! negative ( ! applicable p]c5t specifi$ 9 subp>agraph 7,b7 is assign$ = a score ( #j2 & 7,,ii7 ,,mips eligible pr(essionals ) composite p]=mance scores t are equal to or great] ?an #j1 b n great] ?an #a_/d ( ! p]=mance ?re%old specifi$ "u subp>agraph 7,d77i7 = su* ye>1 receive a negative paym5t adju/m5t factor t is equal to ! negative ( ! applicable p]c5t specifi$ 9 subp>agraph 7,b7 = su* ye>4 7,b7 ,applicable p]c5t def9$ ,= purposes ( ?is p>agraph1 ! t]m applicable p]c5t means-- 7i7 = #bjah1 #d p]c5t2 7ii7 = #bjai1 #e p]c5t2 7iii7 = #bjbj1 #g p]c5t2 & 7iv7 = #bjba & subsequ5t ye>s1 #i p]c5t4 7,c7 ,additional ,,mips adju/m5t factors = exceptional p]=mance 7i7 ,9 g5]al ,9 ! case ( a ,,mips eligible pr(essional ) a composite p]=mance score = a ye> at or above ! additional p]=mance ?re%old "u subp>agraph 7,d77ii7 = su* ye>1 9 addition to ! ,,mips adju/m5t factor "u subp>agraph 7,a7 = ! eligible pr(essional = su* ye>1 subject to ! availability ( funds "u clause 7ii71 ! ,secret>y %all specify an additional positive ,,mips adju/m5t factor = su* pr(essional & ye>4 ,su* additional ,,mips adju/m5t factors %all be det]m9$ by ! ,secret>y 9 a mann] su* t pr(essionals hav+ high] composite p]=mance scores above ! additional p]=mance ?re%old receive high] additional ,,mips adju/m5t factors4 7ii7 ,additional fund+ pool ,= #bjah & ea* subsequ5t ye> ?r\gh #bjbc1 !re is appropriat$ f ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund #ejj1jjj1jjj = ,,mips paym5ts "u ?is p>agraph result+ f ! application ( ! additional ,,mips adju/m5t factors "u clause 7i74 7,d7 ,e/abli%m5t ( p]=mance ?re%olds 7i7 ,p]=mance ?re%old ,= ea* ye> ( ! ,,mips1 ! ,secret>y %all compute a p]=mance ?re%old ) respect to :i* ! composite p]=mance score ( ,,mips eligible pr(essionals %all be comp>$ = purposes ( det]m9+ adju/m5t factors "u subp>agraph 7,a7 t are positive1 negative1 & z]o4 ,su* p]=mance ?re%old = a ye> %all be ! mean or m$ian 7z select$ by ! ,secret>y7 ( ! composite p]=mance scores = all ,,mips eligible pr(essionals ) respect to a prior p]iod specifi$ by ! ,secret>y4 ,! ,secret>y may reassess ! selection "u ! previ\s s5t5ce e #c ye>s4 7ii7 ,additional p]=mance ?re%old = exceptional p]=mance ,9 addition to ! p]=mance ?re%old "u clause 7i71 = ea* ye> ( ! ,,mips1 ! ,secret>y %all compute an additional p]=mance ?re%old = purposes ( det]m9+ ! additional ,,mips adju/m5t factors "u subp>agraph 7,c77i74 ,= ea* su* ye>1 ! ,secret>y %all apply ei!r ( ! foll[+ me?ods = comput+ su* additional p]=mance ?re%old = su* a ye>3 7,i7 ,! ?re%old %all be ! score t is equal to ! #be? p]c5tile ( ! range ( possible composite p]=mance scores above ! p]=mance ?re%old ) respect to ! prior p]iod describ$ 9 clause 7i74 7,,ii7 ,! ?re%old %all be ! score t is equal to ! #be? p]c5tile ( ! actual composite p]=mance scores = ,,mips eligible pr(essionals ) composite p]=mance scores at or above ! p]=mance ?re%old ) respect to ! prior p]iod describ$ 9 clause 7i74 7iii7 ,special rule = initial #b ye>s ,) respect to ea* ( ! fir/ two ye>s to :i* ! ,,mips applies1 ! ,secret>y %all1 prior to ! p]=mance p]iod = su* ye>s1 e/abli% a p]=mance ?re%old = purposes ( det]m9+ ,,mips adju/m5t factors "u subp>agraph 7,a7 & a ?re%old = purposes ( det]m9+ additional ,,mips adju/m5t factors "u subp>agraph 7,c77i74 ,ea* su* p]=mance ?re%old %all-- 7,i7 be bas$ on a p]iod prior to su* p]=mance p]iods2 & 7,,ii7 take into acc\nt-- 7aa7 data available ) respect to p]=mance on measures & activities t may be us$ "u ! p]=mance categories "u subp>agraph 7#b77;,b72 & 7bb7 o!r factors det]m9$ appropriate by ! ,secret>y4 7,e7 ,application ( ,,mips adju/m5t factors ,9 ! case ( items & s]vices furni%$ by a ,,mips eligible pr(essional dur+ a ye> 7beg9n+ ) #bjah71 ! am\nt o!rwise paid "u ?is "p ) respect to su* items & s]vices & ,,mips eligible pr(essional = su* ye>1 %all be multipli$ by-- 7i7 #a1 plus 7ii7 ! sum (-- 7,i7 ! ,,mips adju/m5t factor det]m9$ "u subp>agraph 7,a7 divid$ by #ajj1 & 7,,ii7 z applicable1 ! additional ,,mips adju/m5t factor det]m9$ "u subp>agraph 7,c77i7 divid$ by #ajj4 7,f7 ,aggregate application ( ,,mips adju/m5t factors 7i7 ,application ( scal+ factor 7,i7 ,9 g5]al ,) respect to positive ,,mips adju/m5t factors "u subp>agraph 7,a77ii77,i7 = eligible pr(essionals ^: composite p]=mance score is above ! p]=mance ?re%old "u subp>agraph 7,d77i7 = su* ye>1 subject to subclause 7,,ii71 ! ,secret>y %all increase or decrease su* adju/m5t factors by a scal+ factor 9 ord] to ensure t ! budget neutrality requirem5t ( clause 7ii7 is met4 7,,ii7 ,scal+ factor limit ,9 no case may be ! scal+ factor appli$ "u ?is clause exce$ #c4j4 7ii7 ,budget neutrality requirem5t 7,i7 ,9 g5]al ,subject to clause 7iii71 ! ,secret>y %all ensure t ! e/imat$ am\nt describ$ 9 subclause 7,,ii7 = a ye> is equal to ! e/imat$ am\nt describ$ 9 subclause 7,,iii7 = su* ye>4 7,,ii7 ,aggregate increases ,! am\nt describ$ 9 ?is subclause is ! e/imat$ increase 9 ! aggregate all[$ *>ges result+ f ! application ( positive ,,mips adju/m5t factors "u subp>agraph 7,a7 7aft] application ( ! scal+ factor describ$ 9 clause 7i77 to ,,mips eligible pr(essionals ^: composite p]=mance score = a ye> is above ! p]=mance ?re%old "u subp>agraph 7,d77i7 = su* ye>4 7,,iii7 ,aggregate decreases ,! am\nt describ$ 9 ?is subclause is ! e/imat$ decrease 9 ! aggregate all[$ *>ges result+ f ! application ( negative ,,mips adju/m5t factors "u subp>agraph 7,a7 to ,,mips eligible pr(essionals ^: composite p]=mance score = a ye> is bel[ ! p]=mance ?re%old "u subp>agraph 7,d77i7 = su* ye>4 7iii7 ,exceptions 7,i7 ,9 ! case t all ,,mips eligible pr(essionals receive composite p]=mance scores = a ye> t are bel[ ! p]=mance ?re%old "u subp>agraph 7,d77i7 = su* ye>1 ! negative ,,mips adju/m5t factors "u subp>agraph 7,a7 %all apply ) respect to su* ,,mips eligible pr(essionals & ! budget neutrality requirem5t ( clause 7ii7 %all n apply = su* ye>4 7,,ii7 ,9 ! case t1 ) respect to a ye>1 ! application ( clause 7i7 results 9 a scal+ factor equal to ! maximum scal+ factor specifi$ 9 clause 7i77,,ii71 su* scal+ factor %all apply & ! budget neutrality requirem5t ( clause 7ii7 %all n apply = su* ye>4 7iv7 ,additional inc5tive paym5t adju/m5ts ,9 specify+ ! ,,mips additional adju/m5t factors "u subp>agraph 7,c77i7 = ea* applicable ,,mips eligible pr(essional = a ye>1 ! ,secret>y %all ensure t ! e/imat$ increase 9 paym5ts "u ?is "p result+ f ! application ( su* additional adju/m5t factors = ,,mips eligible pr(essionals 9 a ye> %all be equal 7z e/imat$ by ! ,secret>y7 to ! additional fund+ pool am\nt = su* ye> "u subp>agraph 7,c77ii74 7#g7 ,ann\ncem5t ( result ( adju/m5ts ,"u ! ,,mips1 ! ,secret>y %all1 n lat] ?an #cj days prior to ,janu>y #a ( ! ye> involv$1 make available to ,,mips eligible pr(essionals ! ,,mips adju/m5t factor 7&1 z applicable1 ! additional ,,mips adju/m5t factor7 "u p>agraph 7#f7 applicable to ! eligible pr(essional = items & s]vices furni%$ by ! pr(essional = su* ye>4 ,! ,secret>y may include su* in=mation 9 ! confid5tial fe$back "u p>agraph 7#ab74 7#h7 ,no effect 9 subsequ5t ye>s ,! ,,mips adju/m5t factors & additional ,,mips adju/m5t factors "u p>agraph 7#f7 %all apply only ) respect to ! ye> involv$1 & ! ,secret>y %all n take into acc\nt su* adju/m5t factors 9 mak+ paym5ts to a ,,mips eligible pr(essional "u ?is "p 9 a subsequ5t ye>4 7#i7 ,public report+ 7,a7 ,9 g5]al ,! ,secret>y %all1 9 an easily und]/&able =mat1 make available on ! ,physician ,comp>e ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ! foll[+3 7i7 ,in=mation reg>d+ ! p]=mance ( ,,mips eligible pr(essionals "u ! ,,mips1 :i*-- 7,i7 %all include ! composite score = ea* su* ,,mips eligible pr(essional & ! p]=mance ( ea* su* ,,mips eligible pr(essional ) respect to ea* p]=mance category2 & 7,,ii7 may include ! p]=mance ( ea* su* ,,mips eligible pr(essional ) respect to ea* measure or activity specifi$ 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 ! ,,mips1 includ+ ! range ( composite scores = all ,,mips eligible pr(essionals & ! range ( ! p]=mance ( all ,,mips eligible pr(essionals ) respect to ea* p]=mance category4 7#aj7 ,consultation ,! ,secret>y %all consult ) /akehold]s 9 c>ry+ out ! ,,mips1 includ+ = ! id5tification ( measures & activities "u p>agraph 7#b77;,b7 & ! me?odologies develop$ "u p>agraphs 7#e77;,a7 & 7#f7 & reg>d+ ! use ( qualifi$ cl9ical data regi/ries4 ,su* consultation %all include ! use ( a reque/ = in=mation or o!r me*anisms det]m9$ appropriate4 7#aa7 ,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 ,,mips eligible pr(essionals 9 practices ( #ae or few] 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 ( su* ,act71 & m$ically und]s]v$ areas1 & 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 7i7 ,9 g5]al ,= 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 ( #dj1jjj1jjj = ea* ( fiscal ye>s #bjae ?r\gh #bjai4 ,am\nts transf]r$ "u ?is subp>agraph = a fiscal ye> %all be available until exp5d$4 7ii7 ,te*nical assi/ance ,( ! am\nts transf]r$ pursuant to clause 7i7 = ea* ( fiscal ye>s #bjae ?r\gh #bjai1 n less ?an #aj1jjj1jjj %all be made available = ea* su* ye> = te*nical assi/ance to small practices 9 heal? pr(essional %ortage areas 7z s designat$7 & m$ically und]s]v$ areas4 7#ab7 ,fe$back & in=mation to improve p]=mance 7,a7 ,p]=mance fe$back 7i7 ,9 g5]al ,beg9n+ ,july #a1 #bjaf1 ! ,secret>y-- 7,i7 %all make available timely 7su* z qu>t]ly7 confid5tial fe$back to ,,mips eligible pr(essionals on ! p]=mance ( su* pr(essionals ) respect to ! p]=mance categories "u clauses 7i7 & 7ii7 ( p>agraph 7#b77;,a72 & 7,,ii7 may make available confid5tial fe$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 ,) respect to ! p]=mance category describ$ 9 p>agraph 7#b77;,a77i71 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 on quality measures report$ ?r\gh ! use ( su* regi/ries4 ,) respect to any o!r p]=mance category describ$ 9 p>agraph 7#b77;,a71 ! ,secret>y %all enc\rage provision ( fe$back ?r\gh qualifi$ cl9ical data regi/ries z describ$ 9 subsection 7m77#c77;,e74 7iii7 ,use ( data ,= purposes ( clause 7i71 ! ,secret>y may use data1 ) respect to a ,,mips 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 #bjag1 ! ,secret>y %all make available to ea* ,,mips eligible pr(essional in=mation1 ) respect to individuals :o are pati5ts ( su* ,,mips 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 may be made available "u ! previ\s s5t5ce to su* ,,mips eligible pr(essionals by me*anisms det]m9$ appropriate by ! ,secret>y1 :i* may include use ( a web-bas$ portal4 ,su* in=mation may be made available 9 accordance ) ! same or simil> t]ms z data are made available to acc\ntable c>e organizations p>ticipat+ 9 ! %>$ sav+s program "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 ,,mips 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 su* z ! "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%$4 7,,ii7 ,hi/orical data1 su* z av]ages & o!r measures ( ! di/ribution if appropriate1 ( ! total1 & compon5ts (1 all[$ *>ges 7& o!r figures z det]m9$ appropriate by ! ,secret>y74 7#ac7 ,review 7,a7 ,t>get$ review ,! ,secret>y %all e/abli% a process "u :i* a ,,mips eligible pr(essional may seek an in=mal review ( ! calculation ( ! ,,mips 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#f7 ) respect to a ye> 7o!r ?an ) respect to ! calculation ( su* eligible pr(essional's ,,mips adju/m5t factor = su* ye> or additional ,,mips adju/m5t factor = su* ye>7 aft] ! factors det]m9$ 9 subp>agraph 7,a7 & subp>agraph 7,c7 ( 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 ( ! ,,mips adju/m5t factor "u p>agraph 7#f77;,a7 & ! am\nt ( ! additional ,,mips adju/m5t factor "u p>agraph 7#f77;,c77i7 & ! det]m9ation ( su* am\nts4 7ii7 ,! e/abli%m5t ( ! p]=mance /&>ds "u p>agraph 7#c7 & ! p]=mance p]iod "u p>agraph 7#d74 7iii7 ,! 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#i74 7iv7 ,! 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 ,,mips ,n lat] ?an ,octob] #a1 #bjai1 & ,octob] #a1 #bjbb1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report evaluat+ ! eligible pr(essional ,m]it-bas$ ,inc5tive ,paym5t ,sy/em "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 ( ! composite p]=mance scores & ,,mips adju/m5t factors 7& additional ,,mips adju/m5t factors7 = ,,mips eligible pr(essionals 7z def9$ 9 subsection 7q77#a77;c7 ( su* section7 "u su* program1 & patt]ns relat+ to su* scores & adju/m5t factors1 includ+ bas$ on type ( provid]1 practice size1 geographic location1 & pati5t mix2 7ii7 provide recomm5dations = improv+ su* program2 7iii7 evaluate ! impact ( te*nical assi/ance fund+ "u section #ahdh7q77#aa7 ( ! ,social ,security ,act1 z add$ by p>agraph 7#a71 on ! ability ( pr(essionals to improve )9 su* program or successfully transition to an alt]native paym5t model 7z def9$ 9 section #ahcc7z77#c7 ( ! ,social ,security ,act1 z add$ by subsection 7e771 ) priority = su* evaluation giv5 to practices locat$ 9 rural areas1 heal? pr(essional %ortage areas 7z designat$ 9 section #ccb7;a77#a77;a7 ( ! ,public ,heal? ,s]vice ,act71 & m$ically und]s]v$ areas2 & 7iv7 provide recomm5dations = optimiz+ ! use ( su* te*nical assi/ance funds4 7,b7 ,/udy to exam9e alignm5t ( quality measures us$ 9 public & private programs 7i7 ,9 g5]al ,n lat] ?an #ah mon?s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report t-- 7,i7 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 select$ ,/ate ,m$icaid programs "u title ,,xix ( su* ,act1 & private pay] arrangem5ts2 & 7,,ii7 makes recomm5dations on h[ to r$uce ! adm9i/rative burd5 involv$ 9 apply+ su* quality measures4 7ii7 ,requirem5ts ,! report "u clause 7i7 %all-- 7,i7 consid] ^? measures applicable to individuals entitl$ to1 or enroll$ =1 b5efits "u su* "p ,a1 or enroll$ "u su* "p ,b & individuals "u ! age ( #fe2 & 7,,ii7 focus on ^? measures t comprise ! mo/ significant compon5t ( ! quality p]=mance category ( ! eligible pr(essional ,,mips inc5tive program "u subsection 7q7 ( section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 z add$ by p>agraph 7#a74 7,c7 ,/udy on role ( indep5d5t risk manag]s ,n lat] ?an ,janu>y #a1 #bjaf1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report exam9+ :e!r entities t pool f9ancial risk = physician practices1 su* z indep5d5t risk manag]s1 c play a role 9 support+ physician practices1 p>ticul>ly small physician practices1 9 assum+ f9ancial risk = ! treatm5t ( pati5ts4 ,su* report %all exam9e b>ri]s t small physician practices curr5tly face 9 assum+ f9ancial risk = treat+ pati5ts1 ! types ( risk managem5t entities t c\ld assi/ physician practices 9 p>ticipat+ 9 two-sid$ risk paym5t models1 & h[ su* entities c\ld assi/ ) risk managem5t & ) quality improvem5t activities4 ,su* report %all also include an analysis ( any exi/+ legal b>ri]s to su* arrangem5ts4 7,d7 ,/udy to exam9e rural & heal? pr(essional %ortage area alt]native paym5t models ,n lat] ?an ,octob] #a1 #bjbj1 & ,octob] #a1 #bjbb1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report t exam9es ! transition ( pr(essionals 9 rural areas1 heal? pr(essional %ortage areas 7z designat$ 9 section #ccb7;a77#a77;,a7 ( ! ,public ,heal? ,s]vice ,act71 or m$ically und]s]v$ areas to an alt]native paym5t model 7z def9$ 9 section #ahcc7z77#c7 ( ! ,social ,security ,act1 z add$ by subsection 7e774 ,su* report %all make recomm5dations = remov+ adm9i/rative b>ri]s to practices1 includ+ small practices consi/+ ( #ae or few] pr(essionals1 9 rural areas1 heal? pr(essional %ortage areas1 & m$ically und]s]v$ areas to p>ticipation 9 su* models4 7#c7 ,fund+ = implem5tation ,= purposes ( implem5t+ ! provisions ( & ! am5dm5ts made by ?is section1 ! ,secret>y ( ,heal? & ,human ,s]vices %all provide = ! transf] ( #hj1jjj1jjj 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 #bjah4 ,am\nts transf]r$ "u ?is p>agraph %all be available until exp5d$4 7d7 ,improv+ quality report+ = composite scores 7#a7 ,*anges = gr\p report+ option 7,a7 ,9 g5]al ,section #ahdh7m77#c77;,c77ii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#c77;,c77ii77 is am5d$ by ins]t+ &1 = #bjae & 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;,f7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#e77;,f77 is am5d$-- 7,a7 by /rik+ & subsequ5t ye>s & ins]t+ ?r\gh report+ p]iods occurr+ 9 #bjad2 & 7,b7 by ins]t+ &1 = report+ p]iods occurr+ 9 #bjae & subsequ5t ye>s1 ! ,secret>y may e/abli% foll[+ %all e/abli%4 7#c7 ,physician fe$back program reports succe$$ by reports "u ,,mips ,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#ab7 = reports "u ! eligible pr(essionals ,m]it-bas$ ,inc5tive ,paym5t ,sy/em4 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;,b77ii77,,ii7 aft] ,subject to subp>agraph 7,b77ii74 7e7 ,promot+ alt]native paym5t models 7#a7 ,increas+ transp>5cy ( physician focus$ paym5t models ,section #ahfh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ee7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7c7 ,physician focus$ paym5t models 7#a7 ,te*nical advisory committee 7,a7 ,e/abli%m5t ,!re is e/abli%$ an ad hoc committee to be kn[n z ! ,paym5t ,model ,te*nical ,advisory ,committee 7ref]r$ to 9 ?is subsection z ! ,committee74 7,b7 ,memb]%ip 7i7 ,numb] & appo9tm5t ,! ,committee %all be compos$ ( #aa memb]s appo9t$ by ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates4 7ii7 ,qualifications ,! memb]%ip ( ! ,committee %all include individuals ) national recognition = _! exp]tise 9 paym5t models & relat$ deliv]y ( c>e4 ,no m ?an #e memb]s ( ! ,committee %all be provid]s ( s]vices or suppli]s1 or repres5tatives ( provid]s ( s]vices or suppli]s4 7iii7 ,prohibition on f$]al employm5t ,a memb] ( ! ,committee %all n be an employee ( ! ,f$]al ,gov]nm5t4 7iv7 ,e?ics disclosure ,! ,comptroll] ,g5]al %all e/abli% a sy/em = public disclosure by memb]s ( ! ,committee ( f9ancial & o!r pot5tial conflicts ( int]e/ relat+ to su* memb]s4 ,memb]s ( ! ,committee %all be treat$ z employees ( ,congress = purposes ( apply+ title ,i ( ! ,e?ics 9 ,gov]nm5t ,act ( #aigh 7,public ,law #ie-eba74 7v7 ,date ( initial appo9tm5ts ,! initial appo9tm5ts ( memb]s ( ! ,committee %all be made by n lat] ?an #ahj days aft] ! date ( enactm5t ( ?is subsection4 7,c7 ,t]m2 vacancies 7i7 ,t]m ,! t]ms ( memb]s ( ! ,committee %all be = #c ye>s except t ! ,comptroll] ,g5]al %all designate /agg]$ t]ms = ! memb]s fir/ appo9t$4 7ii7 ,vacancies ,any memb] appo9t$ to fill a vacancy occurr+ be=e ! expiration ( ! t]m = :i* ! memb]'s pr$ecessor 0 appo9t$ %all be appo9t$ only = ! rema9d] ( t t]m4 ,a memb] may s]ve aft] ! expiration ( t memb]'s t]m until a successor has tak5 (fice4 ,a vacancy 9 ! ,committee %all be fill$ 9 ! mann] 9 :i* ! orig9al appo9tm5t 0 made4 7,d7 ,duties ,! ,committee %all meet1 z ne$$1 to provide comm5ts & recomm5dations to ! ,secret>y1 z describ$ 9 p>agraph 7#b77;,c71 on physician-focus$ paym5t models4 7,e7 ,comp5sation ( memb]s 7i7 ,9 g5]al ,except z provid$ 9 clause 7ii71 a memb] ( ! ,committee %all s]ve )\t comp5sation4 7ii7 ,travel exp5ses ,a memb] ( ! ,committee %all be all[$ travel exp5ses1 includ+ p] diem 9 lieu ( subsi/5ce1 at rates au?oriz$ = an employee ( an ag5cy "u sub*apt] ,i ( *apt] #eg ( title #e1 ,unit$ ,/ates ,code1 :ile away f ! home or regul> place ( bus9ess ( ! memb] 9 ! p]=mance ( ! duties ( ! ,committee4 7,f7 ,op]ational & te*nical support 7i7 ,9 g5]al ,! ,assi/ant ,secret>y = ,plann+ & ,evaluation %all provide te*nical & op]ational support = ! ,committee1 :i* may be by use ( a contractor4 ,! ,(fice ( ! ,actu>y ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices %all provide to ! ,committee actu>ial assi/ance z ne$$4 7ii7 ,fund+ ,! ,secret>y %all provide = ! transf]1 f ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda1 su* am\nts z are necess>y to c>ry out clause 7i7 7n to exce$ #e1jjj1jjj7 = fiscal ye> #bjad & ea* subsequ5t fiscal ye>4 ,any am\nts transf]r$ "u ! prec$+ s5t5ce = a fiscal ye> %all rema9 available until exp5d$4 7,g7 ,application ,section #ad ( ! ,f$]al ,advisory ,committee ,act 7#e ,u4,s4,c4 ,app47 %all n apply to ! ,committee4 7#b7 ,crit]ia & process = submission & review ( physician-focus$ paym5t models 7,a7 ,crit]ia = assess+ physician-focus$ paym5t models 7i7 ,rulemak+ ,n lat] ?an ,novemb] #a1 #bjae1 ! ,secret>y %all1 ?r\gh notice & comm5t rulemak+1 foll[+ a reque/ = in=mation1 e/abli% crit]ia = physician-focus$ paym5t models1 includ+ models = speciali/ physicians1 t c\ld be us$ by ! ,committee = mak+ comm5ts & recomm5dations pursuant to p>agraph 7#a77;,d74 7ii7 ,med,p,a,c submission ( comm5ts ,dur+ ! comm5t p]iod = ! propos$ rule describ$ 9 clause 7i71 ! ,m$ic>e ,paym5t ,advisory ,commission may submit comm5ts to ! ,secret>y on ! propos$ crit]ia "u su* clause4 7iii7 ,updat+ ,! ,secret>y may update ! crit]ia e/abli%$ "u ?is subp>agraph ?r\gh rulemak+4 7,b7 ,/akehold] submission ( physician focus$ paym5t models ,on an ongo+ basis1 individuals & /akehold] entities may submit to ! ,committee proposals = physician-focus$ paym5t models t su* individuals & entities believe meet ! crit]ia describ$ 9 subp>agraph 7,a74 7,c7 ,,tac review ( models submitt$ ,! ,committee %all1 on a p]iodic basis1 review models submitt$ "u subp>agraph 7,b71 prep>e comm5ts & recomm5dations reg>d+ :e!r su* models meet ! crit]ia describ$ 9 subp>agraph 7,a71 & submit su* comm5ts & recomm5dations to ! ,secret>y4 7,d7 ,secret>y review & response ,! ,secret>y %all review ! comm5ts & recomm5dations submitt$ by ! ,committee "u subp>agraph 7,c7 & po/ a detail$ response to su* comm5ts & recomm5dations on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices4 7#c7 ,rule ( con/ruction ,no?+ 9 ?is subsection %all be con/ru$ to impact ! developm5t or te/+ ( models "u ?is title or titles ,,xi1 ,,xix1 or ,,xxi4 4 7#b7 ,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+ ) #bjah & end+ ) #bjbc & = :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 #bjah & #bjai ,) respect to #bjah & #bjai1 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 #bjbj & #bjba ,) respect to #bjbj & #bjba1 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 ( law1 & o!r ?an paym5ts made "u title ,,xix 9 a ,/ate 9 :i* no m$ical home or alt]native paym5t model is available "u ! ,/ate program "u t title71 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 7,,aa7 be>s m ?an nom9al f9ancial risk if actual aggregate exp5ditures exce$s expect$ aggregate exp5ditures2 or 7,,bb7 is a m$ical home 7) respect to b5efici>ies "u title ,,xix7 t meets crit]ia comp>able to m$ical homes exp&$ "u section #aaae;,a7c74 7,c7 ,beg9n+ 9 #bjbb ,) respect to #bjbb & 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 ( law1 & o!r ?an paym5ts made "u title ,,xix 9 a ,/ate 9 :i* no m$ical home or alt]native paym5t model is available "u ! ,/ate program "u t title71 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 7,,aa7 be>s m ?an nom9al f9ancial risk if actual aggregate exp5ditures exce$s expect$ aggregate exp5ditures2 or 7,,bb7 is a m$ical home 7) respect to b5efici>ies "u title ,,xix7 t meets crit]ia comp>able to m$ical homes exp&$ "u section #aaae;,a7c74 7#c7 ,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 ,! %>$ sav+s program "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#d7 ,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#c7 ,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#d7 ,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 ( #ae or few] pr(essionals4 7xxiii7 ,focus+ on risk-bas$ models = small physician practices :i* may involve two-sid$ risk & prospective pati5t assignm5t1 & :i* exam9e risk-adju/$ decreases 9 mortality rates1 hospital readmissions rates1 & o!r relevant & appropriate cl9ical measures4 7xxiv7 ,focus+ prim>ily on title ,,xix1 work+ 9 conjunction ) ! ,c5t] = ,m$icaid & ,,*ip ,s]vices4 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 7#e7 ,con/ruction reg>d+ teleheal? s]vices ,no?+ 9 ! provisions (1 or am5dm5ts made by1 ?is ,act %all be con/ru$ z preclud+ an alt]native paym5t model or a qualify+ ,,apm p>ticipant 7z ^? t]ms are def9$ 9 section #ahcc7z7 ( ! ,social ,security ,act1 z add$ by p>agraph 7#a77 f furni%+ a teleheal? s]vice = :i* paym5t is n made "u section #ahcd7m7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7m774 7#f7 ,integrat+ ,m$ic>e ,advantage alt]native paym5t models ,n lat] ?an ,july #a1 #bjae1 ! ,secret>y ( ,heal? & ,human ,s]vices %all submit to ,congress a /udy t exam9es ! feasibility ( integrat+ alt]native paym5t models 9 ! ,m$ic>e ,advantage paym5t sy/em4 ,! /udy %all include ! feasibility ( includ+ a value-bas$ modifi] & :e!r su* modifi] %\ld be budget neutral4 7#g7 ,/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-- 7i7 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 7ii7 id5tifies aspects ( su* alt]native paym5t models t are vuln]able to fraudul5t activity2 & 7iii7 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 subp>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 7f7 ,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 ,m]it-bas$ ,inc5tive ,paym5t ,sy/em "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 ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda ( ! ,social ,security ,act 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 %all1 z ! ,secret>y det]m9es appropriate1 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 provisions ( title ,,xviii ( ! ,social ,security ,act t are simil> to ! eligible pr(essional ,m]it-bas$ ,inc5tive ,paym5t ,sy/em "u section #ahdh7q7 ( 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#a7 & o!r in=mation z appropriate1 ! ,secret>y %all1 z ! ,secret>y det]m9es appropriate1 acc\nt = id5tifi$ factors ) an effect on quality & res\rce use outcome measures :5 det]m9+ paym5t adju/m5t me*anisms "u provisions ( title ,,xviii ( ! ,social ,security ,act t are simil> to ! eligible pr(essional ,m]it-bas$ ,inc5tive ,paym5t ,sy/em "u section #ahdh7q7 ( 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 ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda ( ! ,social ,security ,act to ! ,secret>y to c>ry out ?is p>agraph & ! application ( ?is p>agraph to ! ,m]it-bas$ ,inc5tive ,paym5t ,sy/em "u section #ahdh7q7 ( su* ,act #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 ,m]it-bas$ ,inc5tive ,paym5t ,sy/em "u section #ahdh7q7 ( ! ,social ,security ,act &1 z ! ,secret>y det]m9es appropriate1 o!r simil> provisions ( title ,,xviii ( su* ,act4 7g7 ,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 c>e episode gr\ps & 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 #abj 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 c>e episode gr\ps2 & 7ii7 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% c>e episode gr\ps & pati5t condition gr\ps1 :i* acc\nt = a t>get ( an e/imat$ #b_/c ( 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 #ahj 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 #ahj 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+ ) #bjag71 ! ,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 #bgj 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 #ahj 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+ ) #bjag71 ! ,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 #bjag1 %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[$ *>ges = 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[$ *>ges 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 ,implem5tation ,to ! ext5t t ! ,secret>y contracts ) an entity to c>ry out any "p ( ! provisions ( ?is subsection1 ! ,secret>y may n contract ) an entity or an entity ) a subcontract if ! entity or subcontract+ entity curr5tly makes recomm5dations to ! ,secret>y on relative values = s]vices "u ! fee s*$ule = physicians' s]vices "u ?is section4 7#g7 ,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#h7 ,adm9i/ration ,*apt] #ce ( title #dd1 ,unit$ ,/ates ,code1 %all n apply to ?is section4 7#i7 ,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#e771 & a c]tifi$ regi/]$ nurse ane/heti/ 7z def9$ 9 section #ahfa7;bb77#b772 & 7ii7 beg9n+ ,janu>y #a1 #bjah1 su* o!r eligible pr(essionals 7z def9$ 9 subsection 7k77#c77;,b77 z specifi$ by ! ,secret>y4 7#aj7 ,cl>ification ,! provisions ( sections #ahij7;b77#g7 & #ahij;,a %all n apply to ?is subsection4 4 #c4 ,priorities & fund+ = measure developm5t ,section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 z am5d$ by subsections 7c7 & 7g7 ( section #b1 is fur!r am5d$ by ins]t+ at ! end ! foll[+ new subsection3 7s7 ,priorities & fund+ = measure developm5t 7#a7 ,plan id5tify+ measure developm5t priorities & timel9es 7,a7 ,draft measure developm5t plan ,n lat] ?an ,janu>y #a1 #bjae1 ! ,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 provisions 7z def9$ 9 p>agraph 7#e774 ,"u su* plan ! ,secret>y %all-- 7i7 address h[ measures us$ by private pay]s & integrat$ deliv]y sy/ems c\ld be incorporat$ "u title ,,xviii2 7ii7 describe h[ coord9ation1 to ! ext5t possible1 w occur across organizations develop+ su* measures2 & 7iii7 take into acc\nt h[ cl9ical be/ practices & cl9ical practice guidel9es %\ld be us$ 9 ! developm5t ( quality measures4 7,b7 ,quality doma9s ,= purposes ( ?is subsection1 ! t]m quality doma9s means at lea/ ! foll[+ doma9s3 7i7 ,cl9ical c>e4 7ii7 ,safety4 7iii7 ,c>e coord9ation4 7iv7 ,pati5t & c>egiv] exp]i5ce4 7v7 ,population heal? & prev5tion4 7,c7 ,consid]ation ,9 develop+ ! draft plan "u ?is p>agraph1 ! ,secret>y %all consid]-- 7i7 gap analyses conduct$ by ! entity ) a contract "u section #ahij7;a7 or o!r contractors or entities2 7ii7 :e!r measures are applicable across heal? c>e sett+s2 7iii7 cl9ical practice improvem5t activities submitt$ "u subsection 7q77#b77;,c77iv7 = id5tify+ possible areas = future measure developm5t & id5tify+ exi/+ gaps ) respect to su* measures2 & 7iv7 ! quality doma9s appli$ "u ?is subsection4 7,d7 ,priorities ,9 develop+ ! draft plan "u ?is p>agraph1 ! ,secret>y %all give priority to ! foll[+ types ( measures3 7i7 ,outcome measures1 includ+ pati5t report$ outcome & functional /atus measures4 7ii7 ,pati5t exp]i5ce measures4 7iii7 ,c>e coord9ation measures4 7iv7 ,measures ( appropriate use ( s]vices1 includ+ measures ( ov] use4 7,e7 ,/akehold] input ,! ,secret>y %all accept ?r\gh ,m>* #a1 #bjae1 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,f7 ,f9al measure developm5t plan ,n lat] ?an ,may #a1 #bjae1 tak+ into acc\nt ! comm5ts receiv$ "u ?is subp>agraph1 ! ,secret>y %all f9alize ! plan & po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices an op]ational plan = ! developm5t ( quality measures = use "u ! applicable provisions4 ,su* plan %all be updat$ z appropriate4 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&+ 9 accordance ) ! plan "u p>agraph 7#a7 quality measures = application "u ! applicable provisions4 ,su* entities %all include organizations ) quality measure developm5t exp]tise4 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;,d74 7ii7 ,consid]ation ,9 select+ measures = developm5t "u ?is subsection1 ! ,secret>y %all consid]-- 7,i7 :e!r su* measures w\ld be electronically specifi$2 & 7,,ii7 cl9ical practice guidel9es to ! ext5t t su* guidel9es exi/4 7#c7 ,annual report by ! ,secret>y 7,a7 ,9 g5]al ,n lat] ?an ,may #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 subp>agraph 7,a7 %all include ! foll[+3 7i7 ,a description ( ! ,secret>y's ef=ts to implem5t ?is p>agraph4 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 ,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 7v7 ,o!r in=mation ! ,secret>y det]m9es to be appropriate4 7#d7 ,/akehold] input ,) respect to p>agraph 7#a71 ! ,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;,d72 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 ,def9ition ( applicable provisions ,9 ?is subsection1 ! t]m applicable provisions means ! foll[+ provisions3 7,a7 ,subsection 7q77#b77;,b77i74 7,b7 ,section #ahcc7z77#b77;,c74 7#f7 ,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 7a7 ,9 g5]al ,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 7b7 ,education & outrea* 7#a7 ,campaign 7,a7 ,9 g5]al ,! ,secret>y ( ,heal? & ,human ,s]vices 79 ?is subsection ref]r$ to z ! ,secret>y7 %all conduct an education & outrea* campaign to in=m pr(essionals :o furni% items & s]vices "u "p ,b ( title ,,xviii ( ! ,social ,security ,act & individuals enroll$ "u su* "p ( ! b5efits ( *ronic c>e managem5t s]vices describ$ 9 section #ahdh7;b77#h7 ( ! ,social ,security ,act1 z add$ by subsection 7a71 & enc\rage su* individuals ) *ronic c>e ne$s to receive su* s]vices4 7,b7 ,requirem5ts ,su* campaign %all-- 7i7 be direct$ by ! ,(fice ( ,rural ,heal? ,policy ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices & ! ,(fice ( ,m9ority ,heal? ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices2 & 7ii7 focus on enc\rag+ p>ticipation by und]s]v$ rural populations & racial & e?nic m9ority populations4 7#b7 ,report 7,a7 ,9 g5]al ,n lat] ?an ,decemb] #ca1 #bjag1 ! ,secret>y %all submit to ,congress a report on ! use ( *ronic c>e managem5t s]vices describ$ 9 su* section #ahdh7;b77#h7 by individuals liv+ 9 rural areas & by racial & e?nic m9ority populations4 ,su* report %all-- 7i7 id5tify b>ri]s to receiv+ *ronic c>e managem5t s]vices2 & 7ii7 make recomm5dations = increas+ ! appropriate use ( *ronic c>e managem5t s]vices4 #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 7i7 ,disclosure ( data us$ ,to e/abli% multiple proc$ure paym5t r$uction policy ,! ,secret>y ( ,heal? & ,human ,s]vices %all make publicly available ! in=mation 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 #f4 ,promot+ evid5ce-bas$ c>e 7a7 ,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]ia1 only develop$ or endors$ by national pr(essional m$ical specialty societies or o!r provid]-l$ entities1 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 provid]-l$ 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 only f among appropriate use crit]ia develop$ or endors$ by national pr(essional m$ical specialty societies or o!r provid]-l$ 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 are sci5tifically valid & evid5ce bas$2 & 7iii7 are bas$ on /udies t are publi%$ & reviewable by /akehold]s4 7,c7 ,revisions ,! ,secret>y %all review1 on an annual basis1 ! specifi$ applicable appropriate use crit]ia to det]m9e if !re is a ne$ to update or revise 7z appropriate7 su* specification ( applicable appropriate use crit]ia & make su* updates or revisions ?r\gh rulemak+4 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 p]mit "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 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 heal? c>e te*nology exp]ts1 & 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 id5tify on an annual basis ! 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 an annual basis1 no m ?an five p]c5t ( ! total numb] ( 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 ,process ,! ,secret>y %all e/abli% a process = det]m9+ :5 an outli] ord]+ pr(essional is no long] an outli] ord]+ pr(essional4 7,e7 ,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 ,appropriate use crit]ia 9 prior au?orization ,9 apply+ prior au?orization "u subp>agraph 7,a71 ! ,secret>y %all utilize only ! applicable appropriate use crit]ia specifi$ "u ?is subsection4 7,c7 ,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 7#g7 ,con/ruction ,no?+ 9 ?is subsection %all be con/ru$ z grant+ ! ,secret>y ! au?ority to develop or initiate ! developm5t ( cl9ical practice guidel9es or appropriate use crit]ia4 4 7b7 ,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 7c7 ,report on exp]i5ce ( imag+ appropriate use crit]ia program ,n lat] ?an #ah mon?s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,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 "p ,b ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;j et seq471 su* z radiation !rapy & cl9ical diagno/ic laboratory s]vices4 #g4 ,emp[]+ b5efici>y *oices ?r\gh access to in=mation on physicians' s]vices 7a7 ,9 g5]al ,! ,secret>y %all make publicly available on ,physician ,comp>e ! in=mation describ$ 9 subsection 7b7 ) respect to eligible pr(essionals4 7b7 ,in=mation describ$ ,! foll[+ in=mation1 ) respect to an eligible pr(essional1 is describ$ 9 ?is subsection3 7#a7 ,in=mation on ! numb] ( s]vices furni%$ by ! eligible pr(essional "u "p ,b ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;j et seq471 :i* may include in=mation on ! mo/ frequ5t s]vices furni%$ or gr\p+s ( s]vices4 7#b7 ,in=mation on submitt$ *>ges & paym5ts = s]vices "u su* "p4 7#c7 ,a unique id5tifi] = ! eligible pr(essional t is available to ! public1 su* z a national provid] id5tifi]4 7c7 ,se>*ability ,! in=mation made available "u ?is section %all be se>*able by at lea/ ! foll[+3 7#a7 ,! specialty or type ( ! eligible pr(essional4 7#b7 ,*>act]i/ics ( ! s]vices furni%$1 su* z volume or gr\p+s ( s]vices4 7#c7 ,! location ( ! eligible pr(essional4 7d7 ,disclosure ,! in=mation made available "u ?is section %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 7e7 ,implem5tation 7#a7 ,initial implem5tation ,physician ,comp>e %all include ! in=mation describ$ 9 subsection 7b7-- 7,a7 ) respect to physicians1 by n lat] ?an ,july #a1 #bjae2 & 7,b7 ) respect to o!r eligible pr(essionals1 by n lat] ?an ,july #a1 #bjaf4 7#b7 ,annual updat+ ,! in=mation made available "u ?is section %all be updat$ on ,physician ,comp>e n less frequ5tly ?an on an annual basis4 7f7 ,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 section prior to su* in=mation be+ made public4 7g7 ,def9itions ,9 ?is section3 7#a7 ,eligible pr(essional2 physician2 secret>y ,! t]ms eligible pr(essional1 physician1 & ,secret>y h ! mean+ giv5 su* t]ms 9 section #ajcca7;i7 ( ,public ,law #aaa-adh4 7#b7 ,physician ,comp>e ,! t]m ,physician ,comp>e means ! ,physician ,comp>e ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices 7or a successor website74 #h4 ,exp&+ availability ( ,m$ic>e data 7a7 ,exp&+ uses ( ,m$ic>e data by qualifi$ entities 7#a7 ,additional analyses 7,a7 ,9 g5]al ,subject to subp>agraph 7,b71 to ! ext5t consi/5t ) applicable in=mation1 privacy1 security1 & disclosure laws 7includ+ p>agraph 7#c771 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 beg9n+ ,july #a1 #bjae1 a qualifi$ entity may use ! comb9$ data describ$ 9 p>agraph 7#d77;,b77iii7 ( su* section receiv$ by su* entity "u su* section1 & in=mation d]iv$ f ! evaluation describ$ 9 su* p>agraph 7#d77;,d71 to conduct additional non-public analyses 7z det]m9$ appropriate by ! ,secret>y7 & provide or sell su* analyses to au?oriz$ us]s = 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 ,limitations ) respect to analyses 7i7 ,employ]s ,any analyses provid$ or sold "u subp>agraph 7,a7 to an employ] describ$ 9 p>agraph 7#i77;,a77iii7 may only be us$ by su* employ] = purposes ( provid+ heal? insurance to employees & retirees ( ! employ]4 7ii7 ,heal? insurance issu]s ,a qualifi$ entity may n provide or sell an analysis to a heal? insurance issu] describ$ 9 p>agraph 7#i77;,a77iv7 unless ! issu] is provid+ ! qualifi$ entity ) data "u section #ahgd7;e77#d77;,b77iii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77#d77;,b77iii774 7#b7 ,access to c]ta9 data 7,a7 ,access ,to ! ext5t consi/5t ) applicable in=mation1 privacy1 security1 & disclosure laws 7includ+ p>agraph 7#c771 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 beg9n+ ,july #a1 #bjae1 a qualifi$ entity may-- 7i7 provide or sell ! comb9$ data describ$ 9 p>agraph 7#d77;,b77iii7 ( su* section to au?oriz$ us]s describ$ 9 clauses 7i71 7ii71 & 7v7 ( p>agraph 7#i77;,a7 = non-public use1 includ+ = ! purposes describ$ 9 subp>agraph 7,b72 or 7ii7 subject to subp>agraph 7,c71 provide ,m$ic>e claims data to au?oriz$ us]s describ$ 9 clauses 7i71 7ii71 & 7v71 ( p>agraph 7#i77;,a7 = non-public use1 includ+ = ! purposes describ$ 9 subp>agraph 7,b74 7,b7 ,purposes describ$ ,! purposes describ$ 9 ?is subp>agraph are assi/+ provid]s ( s]vices & suppli]s 9 develop+ & p>ticipat+ 9 quality & pati5t c>e improvem5t activities1 includ+ develop+ new models ( c>e4 7,c7 ,m$ic>e claims data mu/ be provid$ at no co/ ,a qualifi$ entity may n *>ge a fee = provid+ ! data "u subp>agraph 7,a77ii74 7#c7 ,protection ( in=mation 7,a7 ,9 g5]al ,except z provid$ 9 subp>agraph 7,b71 an analysis or data t is provid$ or sold "u p>agraph 7#a7 or 7#b7 %all n conta9 in=mation t individually id5tifies a pati5t4 7,b7 ,in=mation on pati5ts ( ! provid] ( s]vices or suppli] ,to ! ext5t consi/5t ) applicable in=mation1 privacy1 security1 & disclosure laws1 an analysis or data t is provid$ or sold to a provid] ( s]vices or suppli] "u p>agraph 7#a7 or 7#b7 may conta9 in=mation t individually id5tifies a pati5t ( su* provid] or suppli]1 includ+ ) respect to items & s]vices furni%$ to ! pati5t by o!r provid]s ( s]vices or suppli]s4 7,c7 ,prohibition on us+ analyses or data = m>ket+ purposes ,an au?oriz$ us] %all n use an analysis or data provid$ or sold "u p>agraph 7#a7 or 7#b7 = m>ket+ purposes4 7#d7 ,data use agreem5t ,a qualifi$ entity & an au?oriz$ us] describ$ 9 clauses 7i71 7ii71 & 7v7 ( p>agraph 7#i77;,a7 %all ent] into an agreem5t reg>d+ ! use ( any data t ! qualifi$ entity is provid+ or sell+ to ! au?oriz$ us] "u p>agraph 7#b74 ,su* agreem5t %all describe ! requirem5ts = privacy & security ( ! data &1 z det]m9$ appropriate by ! ,secret>y1 any prohibitions on us+ su* data to l9k to o!r individually id5tifiable s\rces ( in=mation4 ,if ! au?oriz$ us] is n a cov]$ entity "u ! rules promulgat$ pursuant to ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif1 ! agreem5t %all id5tify ! relevant regulations1 z det]m9$ by ! ,secret>y1 t ! us] %all comply ) z if x 7 act+ 9 ! capacity ( su* a cov]$ entity4 7#e7 ,no r$isclosure ( analyses or data 7,a7 ,9 g5]al ,except z provid$ 9 subp>agraph 7,b71 an au?oriz$ us] t is provid$ or sold an analysis or data "u p>agraph 7#a7 or 7#b7 %all n r$isclose or make public su* analysis or data or any analysis us+ su* data4 7,b7 ,p]mitt$ r$isclosure ,a provid] ( s]vices or suppli] t is provid$ or sold an analysis or data "u p>agraph 7#a7 or 7#b7 may1 z det]m9$ by ! ,secret>y1 r$isclose su* analysis or data = ! purposes ( p]=mance improvem5t & c>e coord9ation activities b %all n make public su* analysis or data or any analysis us+ su* data4 7#f7 ,opportunity = provid]s ( s]vices & suppli]s to review ,prior to a qualifi$ entity provid+ or sell+ an analysis to an au?oriz$ us] "u p>agraph 7#a71 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 su* provid] or suppli] ) ! opportunity to appeal & correct errors 9 ! mann] describ$ 9 section #ahgd7;e77#d77;,c77ii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77#d77;,c77ii774 7#g7 ,assessm5t = a brea* 7,a7 ,9 g5]al ,9 ! case ( a brea* ( a data use agreem5t "u ?is section or section #ahgd7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e771 ! ,secret>y %all impose an assessm5t on ! qualifi$ entity bo? 9 ! case (-- 7i7 an agreem5t betwe5 ! ,secret>y & a qualifi$ entity2 & 7ii7 an agreem5t betwe5 a qualifi$ entity & an au?oriz$ us]4 7,b7 ,assessm5t ,! assessm5t "u subp>agraph 7,a7 %all be an am\nt up to #ajj = ea* individual entitl$ to1 or enroll$ =1 b5efits "u "p ,a ( title ,,xviii ( ! ,social ,security ,act or enroll$ = b5efits "u "p ,b ( su* title-- 7i7 9 ! case ( an agreem5t describ$ 9 subp>agraph 7,a77i71 = :om ! ,secret>y provid$ data on to ! qualifi$ entity "u p>agraph 7#b72 & 7ii7 9 ! case ( an agreem5t describ$ 9 subp>agraph 7,a77ii71 = :om ! qualifi$ entity provid$ data on to ! au?oriz$ us] "u p>agraph 7#b74 7,c7 ,deposit ( am\nts collect$ ,any am\nts collect$ pursuant to ?is p>agraph %all be deposit$ 9 ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciet74 7#h7 ,annual reports ,any qualifi$ entity t provides or sells an analysis or data "u p>agraph 7#a7 or 7#b7 %all annually submit to ! ,secret>y a report t includes-- 7,a7 a summ>y ( ! analyses provid$ or sold1 includ+ ! numb] ( su* analyses1 ! numb] ( pur*as]s ( su* analyses1 & ! total am\nt ( fees receiv$ = su* analyses2 7,b7 a description ( ! topics & purposes ( su* analyses2 7,c7 in=mation on ! entities :o receiv$ ! data "u p>agraph 7#b71 ! uses ( ! data1 & ! total am\nt ( fees receiv$ = provid+1 sell+1 or %>+ ! data2 & 7,d7 o!r in=mation det]m9$ appropriate by ! ,secret>y4 7#i7 ,def9itions ,9 ?is subsection & subsection 7b73 7,a7 ,au?oriz$ us] ,! t]m au?oriz$ us] means ! foll[+3 7i7 ,a provid] ( s]vices4 7ii7 ,a suppli]4 7iii7 ,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 ,act74 7v7 ,a m$ical society or hospital association4 7vi7 ,any entity n describ$ 9 clauses 7i7 ?r\gh 7v7 t is approv$ by ! ,secret>y 7o!r ?an an employ] or heal? insurance issu] n describ$ 9 clauses 7iii7 & 7iv71 respectively1 z det]m9$ by ! ,secret>y74 7,b7 ,provid] ( s]vices ,! t]m provid] ( s]vices has ! mean+ giv5 su* t]m 9 section #ahfa7u7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7u774 7,c7 ,qualifi$ entity ,! 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,d7 ,secret>y ,! t]m ,secret>y means ! ,secret>y ( ,heal? & ,human ,s]vices4 7,e7 ,suppli] ,! t]m suppli] has ! mean+ giv5 su* t]m 9 section #ahfa7;d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7d774 7b7 ,access to ,m$ic>e data by qualifi$ cl9ical data regi/ries ,to facilitate quality improvem5t 7#a7 ,access 7,a7 ,9 g5]al ,to ! ext5t consi/5t ) applicable in=mation1 privacy1 security1 & disclosure laws1 beg9n+ ,july #a1 #bjae1 ! ,secret>y %all1 at ! reque/ ( a qualifi$ cl9ical data regi/ry "u section #ahdh7m77#c77;,e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#c77;,e771 provide ! data describ$ 9 subp>agraph 7,b7 79 a =m & mann] det]m9$ to be appropriate7 to su* qualifi$ cl9ical data regi/ry = purposes ( l9k+ su* data ) cl9ical outcomes data & p]=m+ risk-adju/$1 sci5tifically valid analyses & rese>* to support quality improvem5t or pati5t safety1 provid$ t any public report+ ( su* analyses or rese>* t id5tifies a provid] ( s]vices or suppli] %all only be conduct$ ) ! opportunity ( su* provid] or suppli] to appeal & correct errors 9 ! mann] describ$ 9 subsection 7a77#f74 7,b7 ,data describ$ ,! data describ$ 9 ?is subp>agraph is-- 7i7 claims data "u ! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act2 & 7ii7 if ! ,secret>y det]m9es appropriate1 claims data "u ! ,m$icaid program "u title ,,xix ( su* ,act & ! ,/ate ,*ildr5's ,heal? ,insurance ,program "u title ,,xxi ( su* ,act4 7#b7 ,fee ,data describ$ 9 p>agraph 7#a77;,b7 %all be provid$ to a qualifi$ cl9ical data regi/ry "u p>agraph 7#a7 at a fee equal to ! co/ ( provid+ su* data4 ,any fee collect$ pursuant to ! prec$+ s5t5ce %all be deposit$ 9 ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt4 7c7 ,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 ,beg9n+ ,july #a1 #bjae1 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 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 #bjae1 aft] deposit$2 & 7#b7 by ins]t+ ! foll[+ be=e ! p]iod at ! end3 1 &1 beg9n+ ,july #a1 #bjae1 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 ,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 7c7 ,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 & ,m$icaid ,,ehr inc5tive programs1 ,congress decl>es x a national objective to a*ieve widespread ex*ange ( heal? in=mation ?r\gh int]op]able c]tifi$ ,,ehr te*nology nationwide by ,decemb] #ca1 #bjag4 7,b7 ,def9itions ,9 ?is p>agraph3 7i7 ,widespread int]op]ability ,! t]m widespread int]op]ability means int]op]ability betwe5 c]tifi$ ,,ehr te*nology sy/ems employ$ by mean+ful ,,ehr us]s "u ! ,m$ic>e & ,m$icaid ,,ehr inc5tive programs & o!r cl9icians & heal? c>e provid]s on a nationwide basis4 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 ,july #a1 #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 = n be+ 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/ation7 t ! pr(essional has n kn[+ly & willfully tak5 any action to limit or re/rict ! compatibility 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/ation7 t ! hospital has n kn[+ly & willfully tak5 any action to limit or re/rict ! compatibility 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 "o ye> 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%+ me*anisms 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 (1 & res\rces ne$$ to develop & ma9ta91 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 us] has ! mean+ giv5 su* t]m "u ! ,m$ic>e ,,ehr inc5tive programs4 7,c7 ,! t]m ,m$ic>e & ,m$icaid ,,ehr inc5tive programs means-- 7i7 9 ! case ( ! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act1 ! inc5tive programs "u section #ahad7l77#c71 section #ahdh7o71 subsections 7l7 & 7m7 ( section #ahec1 & section #ahhf7n7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7l77#c71 #aciew-#d7o71 #aciew-#bc1 #acieww7n772 & 7ii7 9 ! case ( ! ,m$icaid program "u title ,,xix ( su* ,act1 ! inc5tive program "u subsections 7a77#c77;,f7 & 7t7 ( section #aijc ( su* ,act 7#db ,u4,s4,c4 #acif;b74 7,d7 ,! t]m ,secret>y means ! ,secret>y ( ,heal? & ,human ,s]vices4 7d7 ,,gao /udies & reports on ! use ( teleheal? "u ,f$]al programs & on remote pati5t monitor+ s]vices 7#a7 ,/udy on teleheal? s]vices ,! ,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 ,/udy on remote pati5t monitor+ s]vices 7,a7 ,9 g5]al ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all conduct a /udy-- 7i7 ( ! dissem9ation ( remote pati5t monitor+ te*nology 9 ! private heal? insurance m>ket2 7ii7 ( ! f9ancial inc5tives 9 ! private heal? insurance m>ket relat+ to adoption ( su* te*nology2 7iii7 ( ! b>ri]s to adoption ( su* s]vices "u ! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act2 7iv7 t evaluates ! pati5ts1 conditions1 & cl9ical circum/ances t c\ld mo/ b5efit f remote pati5t monitor+ s]vices2 & 7v7 t evaluates ! *all5ges relat$ to e/abli%+ appropriate valuation = remote pati5t monitor+ s]vices "u ! ,m$ic>e physician fee s*$ule "u section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 9 ord] to accurately reflect ! res\rces involv$ 9 furni%+ su* s]vices4 7,b7 ,def9itions ,= purposes ( ?is p>agraph3 7i7 ,remote pati5t monitor+ s]vices ,! t]m remote pati5t monitor+ s]vices means s]vices furni%$ ?r\gh remote pati5t monitor+ te*nology4 7ii7 ,remote pati5t monitor+ te*nology ,! t]m remote pati5t monitor+ te*nology means a coord9at$ sy/em t uses "o or m home-bas$ or mobile monitor+ devices t automatically transmit vital sign data or in=mation on activities ( daily liv+ & may include responses to assessm5t que/ions collect$ on ! devices wirelessly or ?r\gh a telecommunications connection to a s]v] t complies ) ! ,f$]al regulations 7conc]n+ ! privacy ( individually id5tifiable heal? in=mation7 promulgat$ "u section #bfd7;c7 ( ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif1 z "p ( an e/abli%$ plan ( c>e = t pati5t t includes ! review & int]pretation ( t data by a heal? c>e pr(essional4 7#c7 ,reports ,n lat] ?an #bd mon?s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al %all submit to ,congress-- 7,a7 a report conta9+ ! results ( ! /udy conduct$ "u p>agraph 7#a72 & 7,b7 a report conta9+ ! results ( ! /udy conduct$ "u p>agraph 7#b74 ,a report requir$ "u ?is p>agraph %all be submitt$ toge!r ) recomm5dations = su* legislation & adm9i/rative action z ! ,comptroll] ,g5]al det]m9es appropriate4 ,! ,comptroll] ,g5]al may submit "o report conta9+ ! results describ$ 9 subp>agraphs 7,a7 & 7,b7 & ! recomm5dations describ$ 9 ! previ\s s5t5ce4 7e7 ,rule ( con/ruction reg>d+ heal?c>e provid] /&>ds ( c>e 7#a7 ,ma9t5ance ( /ate /&>ds ,! developm5t1 recognition1 or implem5tation ( any guidel9e or o!r /&>d "u any ,f$]al heal? c>e provision %all n be con/ru$-- 7,a7 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 claim2 or 7,b7 to preempt any /&>d ( c>e or duty ( c>e1 ow$ by a heal? c>e provid] to a pati5t1 duly e/abli%$ "u ,/ate or common law4 7#b7 ,def9itions ,= purposes ( ?is subsection3 7,a7 ,f$]al heal? c>e provision ,! t]m ,f$]al heal? c>e provision means any provision ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh71 title ,i or subtitle ,b ( title ,,ii ( ! ,heal? ,c>e & ,education ,reconciliation ,act ( #bjaj 7,public ,law #aaa-aeb71 or title ,,xviii or ,,xix ( ! ,social ,security ,act4 7,b7 ,heal? c>e provid] ,! 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 ,m$ical malpractice or m$ical product liability action or claim ,! t]m m$ical malpractice or m$ical product 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$]al ,food1 ,drug1 & ,cosmetic ,act or section #cea ( ! ,public ,heal? ,s]vice ,act74 7,d7 ,/ate ,! t]m ,/ate includes ! ,di/rict ( ,columbia1 ,pu]to ,rico1 & any o!r commonweal?1 possession1 or t]ritory ( ! ,unit$ ,/ates4 7#c7 ,pres]vation ( ,/ate law ,no provision ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh71 title ,i or subtitle ,b ( title ,,ii ( ! ,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 #aj4 ,sav+s f ov]seas cont+5cy & relat$ activities 7a7 ,9 g5]al ,section #bea ( ! ,balanc$ ,budget & ,em]g5cy ,deficit ,control ,act ( #aihe 7#b ,u4,s4,c4 #ija7 is am5d$-- 7#a7 9 subsection 7b77#b77;,a77ii71 by ins]t+ = fiscal ye>s #bjab ?r\gh #bjae1 be=e ! ,congress2 & 7#b7 by add+ at ! end ! foll[+3 7,e7 ,ov]seas cont+5cy op]ations_/global w> on t]rorism ,if1 = fiscal ye>s #bjaf ?r\gh #bjba1 appropriations = discretion>y acc\nts are enact$ t ,congress designates = ,ov]seas ,cont+5cy ,op]ations_/,global ,w> on ,t]rorism 9 /atute on an acc\nt by acc\nt basis & ! ,presid5t subsequ5tly s designates1 ! adju/m5t = ! fiscal ye> %all be ! total ( su* appropriations = ! fiscal ye> 9 discretion>y acc\nts designat$ z be+ = ,ov]seas ,cont+5cy ,op]ations_/,global ,w> on ,t]rorism1 b n to exce$-- 7i7 ,= fiscal ye> #bjaf1 #bi1idf1jjj1jjj 9 budget au?ority4 7ii7 ,= fiscal ye> #bjag1 #bi1idf1jjj1jjj 9 budget au?ority4 7iii7 ,= fiscal ye> #bjah1 #bi1idf1jjj1jjj 9 budget au?ority4 7iv7 ,= fiscal ye> #bjai1 #bi1idf1jjj1jjj 9 budget au?ority4 7v7 ,= fiscal ye> #bjbj1 #bi1idf1jjj1jjj 9 budget au?ority4 7vi7 ,= fiscal ye> #bjba1 #bi1idf1jjj1jjj 9 budget au?ority4 4 7b7 ,brea* ,section #bea7;a77#b7 ( su* ,act 7#b ,u4,s4,c4 #ija7;a77#b77 is am5d$ to read z foll[s3 7#b7 ,elim9at+ a brea* 7,a7 ,9 g5]al ,ea* non-exempt acc\nt )9 a category %all be r$uc$ by a doll> am\nt calculat$ by multiply+ ! enact$ level ( seque/rable budget>y res\rces 9 t acc\nt by ! uni=m p]c5tage necess>y to elim9ate a brea* )9 t category4 7,b7 ,ov]seas cont+5cies ,any am\nt ( budget au?ority = ,ov]seas ,cont+5cy ,op]ations_/,global ,w> on ,t]rorism = fiscal ye>s #bjaf ?r\gh #bjba 9 excess ( ! levels set 9 subsection #bea7;b77#b77;,e7 %all be c\nt$ 9 det]m9+ :e!r a brea* has occurr$ 9 ! security category & ! nonsecurity category on a proportional basis to ! total sp5d+ = ov]seas cont+5cy op]ations 9 ! security category & ! nonsecurity category4 4