,i #aacth ,,congress #b;d ,session ,h4 ,r4 #dcjb ,,in ,,the ,,house ,,of ,,representatives ,march #bf1 #bjad ,mr4 ,pitts introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committees on ,ways and ,means and the ,budget1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to amend the ,social ,security ,act to extend ,medicare payments to physicians and other provisions of the ,medicare and ,medicaid programs1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,protecting ,access to ,medicare ,act of #bjad4 7b7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4 ,title ,i--,medicare ,extenders ,sec4 #aja4 ,physician payment update4 ,sec4 #ajb4 ,extension of work ,,gpci floor4 ,sec4 #ajc4 ,extension of therapy cap exceptions process4 ,sec4 #ajd4 ,extension of ambulance add-ons4 ,sec4 #aje4 ,extension of increased inpatient hospital payment adjustment for certain low-volume hospitals4 ,sec4 #ajf4 ,extension of the ,medicare-dependent hospital 7,,mdh7 program4 ,sec4 #ajg4 ,extension for specialized ,medicare ,advantage plans for special needs individuals4 ,sec4 #ajh4 ,extension of ,medicare reasonable cost contracts4 ,sec4 #aji4 ,extension of funding for quality measure endorsement1 input1 and selection4 ,sec4 #aaj4 ,extension of funding outreach and assistance for low-income programs4 ,sec4 #aaa4 ,extension of two-midnight rule4 ,sec4 #aab4 ,technical changes to ,medicare ,,ltch amendments4 ,title ,,ii--,other ,health ,provisions ,sec4 #bja4 ,extension of the qualifying individual 7,,qi7 program4 ,sec4 #bjb4 ,temporary extension of transitional medical assistance 7,,tma74 ,sec4 #bjc4 ,extension of ,medicaid and ,,chip express lane option4 ,sec4 #bjd4 ,extension of special diabetes program for type ,i diabetes and for ,indians4 ,sec4 #bje4 ,extension of abstinence education4 ,sec4 #bjf4 ,extension of personal responsibility education program 7,,prep74 ,sec4 #bjg4 ,extension of funding for family-to-family health information centers4 ,sec4 #bjh4 ,extension of health workforce demonstration project for low-income individuals4 ,sec4 #bji4 ,extension of maternal1 infant1 and early childhood home visiting programs4 ,sec4 #baj4 ,pediatric quality measures4 ,sec4 #baa4 ,delay of effective date for ,medicaid amendments relating to beneficiary liability settlements4 ,sec4 #bab4 ,delay in transition from ,,icd-#i ,,to ,,icd-#aj code sets4 ,sec4 #bac4 ,elimination of limitation on deductibles for employer-sponsored health plans4 ,sec4 #bad4 ,,gao report on the ,children's ,hospital ,graduate ,medical ,education ,program4 ,sec4 #bae4 ,skilled nursing facility value-based purchasing4 ,sec4 #baf4 ,improving ,medicare policies for clinical diagnostic laboratory tests4 ,sec4 #bag4 ,revisions under the ,medicare ,,esrd prospective payment system4 ,sec4 #bah4 ,quality incentives for computed tomography diagnostic imaging and promoting evidence-based care4 ,sec4 #bai4 ,using funding from ,transitional ,fund for ,sustainable ,growth ,rate 7,,sgr7 ,reform4 ,sec4 #bbj4 ,ensuring accurate valuation of services under the physician fee schedule4 ,sec4 #bba4 ,medicaid ,,dsh4 ,sec4 #bbb4 ,realignment of the ,medicare sequester for fiscal year #bjbd4 ,sec4 #bbc4 ,demonstration programs to improve community mental health services4 ,sec4 #bbd4 ,assisted outpatient treatment grant program for individuals with serious mental illness4 ,sec4 #bbe4 ,exclusion from ,,paygo scorecards4 ,i ,medicare ,extenders #aja4 ,physician payment update ,section #ahdh7;d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;d77 is amended-- 7#a7 in paragraph 7#ae7-- 7,a7 in the heading1 by striking ,january through ,march of2 7,b7 in subparagraph 7,a71 by striking for the period beginning on ,january #a1 #bjad1 and ending on ,march #ca1 #bjad2 and 7,c7 in subparagraph 7,b7-- 7i7 in the heading1 by striking remaining portion of #bjad and2 and 7ii7 by striking the period beginning on ,april #a1 #bjad1 and ending on ,december #ca1 #bjad1 and for2 and 7#b7 by adding at the end the following new paragraph3 7#af7 ,update for ,january through ,march of #bjae 7,a7 ,in general ,subject to paragraphs 7#g77;,b71 7#h77;,b71 7#i77;,b71 7#aj77;,b71 7#aa77;,b71 7#ab77;,b71 7#ac77;,b71 7#ad77;,b71 and 7#ae77;,b71 in lieu of the update to the single conversion factor established in paragraph 7#a77;,c7 that would otherwise apply for #bjae for the period beginning on ,january #a1 #bjae1 and ending on ,march #ca1 #bjae1 the update to the single conversion factor shall be #j4j percent4 7,b7 ,no effect on computation of conversion factor for remaining portion of #bjae and subsequent years ,the conversion factor under this subsection shall be computed under paragraph 7#a77;,a7 for the period beginning on ,april #a1 #bjae1 and ending on ,december #ca1 #bjae1 and for #bjaf and subsequent years as if subparagraph 7,a7 had never applied4 4 #ajb4 ,extension of work ,,gpci floor ,section #ahdh7;e77#a77;,e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;e77#a77;,e77 is amended by striking ,april #a1 #bjad and inserting ,april #a1 #bjae4 #ajc4 ,extension of therapy cap exceptions process ,section #ahcc7;g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7g77 is amended-- 7#a7 in paragraph 7#e77;,a71 in the first sentence1 by striking ,march #ca1 #bjad and inserting ,march #ca1 #bjae2 and 7#b7 in paragraph 7#f77;,a7-- 7,a7 by striking ,march #ca1 #bjad and inserting ,march #ca1 #bjae2 and 7,b7 by striking #bjab1 #bjac1 or the first three months of #bjad and inserting #bjab1 #bjac1 #bjad1 or the first three months of #bjae4 #ajd4 ,extension of ambulance add-ons 7a7 ,ground ,ambulance ,section #ahcd7l77#ac77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l77#ac77;,a77 is amended by striking ,april #a1 #bjad and inserting ,april #a1 #bjae each place it appears4 7b7 ,super rural ground ambulance ,section #ahcd7l77#ab77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l77#ab77;,a77 is amended1 in the first sentence1 by striking ,april #a1 #bjad and inserting ,april #a1 #bjae4 #aje4 ,extension of increased inpatient hospital payment adjustment for certain low-volume hospitals ,section #ahhf7;d77#ab7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#ab77 is amended-- 7#a7 in subparagraph 7,b71 in the matter preceding clause 7i71 by striking in the portion of fiscal year #bjad beginning on ,april #a1 #bjad1 fiscal year #bjae1 and subsequent fiscal years and inserting in fiscal year #bjae 7beginning on ,april #a1 #bjae71 fiscal year #bjaf1 and subsequent fiscal years2 7#b7 in subparagraph 7,c77i71 by striking fiscal years #bjaa1 #bjab1 and #bjac1 and the portion of fiscal year #bjad before and inserting fiscal years #bjaa through #bjad and fiscal year #bjae 7before ,april #a1 #bjae71 each place it appears2 and 7#c7 in subparagraph 7,d71 by striking fiscal years #bjaa1 #bjab1 and #bjac1 and the portion of fiscal year #bjad before ,april #a1 #bjad1 and inserting fiscal years #bjaa through #bjad and fiscal year #bjae 7before ,april #a1 #bjae714 #ajf4 ,extension of the ,medicare-dependent hospital 7,,mdh7 program 7a7 ,in general ,section #ahhf7;d77#e77;,g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,g77 is amended-- 7#a7 in clause 7i71 by striking ,april #a1 #bjad and inserting ,april #a1 #bjae2 and 7#b7 in clause 7ii77,,ii71 by striking ,april #a1 #bjad and inserting ,april #a1 #bjae4 7b7 ,conforming amendments 7#a7 ,extension of target amount ,section #ahhf7;b77#c77;,d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7b77#c77;,d77 is amended-- 7,a7 in the matter preceding clause 7i71 by striking ,april #a1 #bjad and inserting ,april #a1 #bjae2 and 7,b7 in clause 7iv71 by striking through fiscal year #bjac and the portion of fiscal year #bjad before ,april #a1 #bjad and inserting through fiscal year #bjad and the portion of fiscal year #bjae before ,april #a1 #bjae4 7#b7 ,permitting hospitals to decline reclassification ,section #aceja7;e77#b7 of the ,omnibus ,budget ,reconciliation ,act of #aiic 7#db ,u4,s4,c4 #acieww note7 is amended by striking through the first #b quarters of fiscal year #bjad and inserting through the first #b quarters of fiscal year #bjae4 #ajg4 ,extension for specialized ,medicare ,advantage plans for special needs individuals ,section #ahei7;f77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;f77#a77 is amended by striking #bjaf and inserting #bjag4 #ajh4 ,extension of ,medicare reasonable cost contracts ,section #ahgf7;h77#e77;,c77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciemm7h77#e77;,c77ii77 is amended1 in the matter preceding subclause 7,i71 by striking ,january #a1 #bjae and inserting ,january #a1 #bjaf4 #aji4 ,extension of funding for quality measure endorsement1 input1 and selection ,section #ahij7;d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;aaa7d77 is amended-- 7#a7 by inserting 7#a7 before ,for purposes2 and 7#b7 by adding at the end the following new paragraph3 7#b7 ,for purposes of carrying out this section and section #ahij;,a 7other than subsections 7e7 and 7f771 the ,secretary shall provide for the transfer1 from the ,federal ,hospital ,insurance ,trust ,fund under section #ahag and the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda1 in such proportion as the ,secretary determines appropriate1 to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account of #e1jjj1jjj for fiscal year #bjad and #ae1jjj1jjj for the first #f months of fiscal year #bjae4 ,amounts transferred under the preceding sentence shall remain available until expended4 4 #aaj4 ,extension of funding outreach and assistance for low-income programs 7a7 ,additional funding for state health insurance programs ,subsection 7a77#a77;,b7 of section #aai of the ,medicare ,improvements for ,patients and ,providers ,act of #bjjh 7#db ,u4,s4,c4 #acie;b-#c note71 as amended by section #ccjf of the ,patient ,protection and ,affordable ,care ,act ,public ,law #aaa-adh71 section #faj of the ,american ,taxpayer ,relief ,act of #bjab 7,public ,law #aab-bdj71 and section #aaaj of the ,pathway for ,,sgr ,reform ,act of #bjac 7,public ,law #aac-fg71 is amended-- 7#a7 in clause 7iii71 by striking and at the end2 7#b7 by striking clause 7iv72 and 7#c7 by adding at the end the following new clauses3 7iv7 for fiscal year #bjad1 of #g1ejj1jjj2 and 7v7 for the portion of fiscal year #bjae before ,april #a1 #bjae1 of #c1gej1jjj4 4 7b7 ,additional funding for area agencies on aging ,subsection 7b77#a77;,b7 of such section #aai1 as so amended1 is amended-- 7#a7 in clause 7iii71 by striking and at the end2 7#b7 by striking clause 7iv72 and 7#c7 by inserting after clause 7iii7 the following new clauses3 7iv7 for fiscal year #bjad1 of #g1ejj1jjj2 and 7v7 for the portion of fiscal year #bjae before ,april #a1 #bjae1 of #c1gej1jjj4 4 7c7 ,additional funding for aging and disability resource centers ,subsection 7c77#a77;,b7 of such section #aai1 as so amended1 is amended-- 7#a7 in clause 7iii71 by striking and at the end2 7#b7 by striking clause 7iv72 and 7#c7 by inserting after clause 7iii7 the following new clauses3 7iv7 for fiscal year #bjad1 of #e1jjj1jjj2 and 7v7 for the portion of fiscal year #bjae before ,april #a1 #bjae1 of #b1ejj1jjj4 4 7d7 ,additional funding for contract with the national center for benefits and outreach enrollment ,subsection 7d77#b7 of such section #aai1 as so amended1 is amended-- 7#a7 in clause 7iii71 by striking and at the end2 7#b7 by striking clause 7iv72 and 7#c7 by inserting after clause 7iii7 the following new clauses3 7iv7 for fiscal year #bjad1 of #e1jjj1jjj2 and 7v7 for the portion of fiscal year #bjae before ,april #a1 #bjae1 of #b1ejj1jjj4 4 #aaa4 ,extension of two-midnight rule 7a7 ,continuation of certain medical review activities ,the ,secretary of ,health and ,human ,services may continue medical review activities described in the notice entitled ,selecting ,hospital ,claims for ,patient ,status ,reviews3 ,admissions ,on or ,after ,october #a1 #bjac1 posted on the ,internet website of the ,centers for ,medicare ,medicaid ,services1 through the first #f months of fiscal year #bjae for such additional hospital claims as the ,secretary determines appropriate4 7b7 ,limitation ,the ,secretary of ,health and ,human ,services shall not conduct patient status reviews 7as described in such notice7 on a post-payment review basis through recovery audit contractors under section #ahic7;h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77 for inpatient claims with dates of admission ,october #a1 #bjac1 through ,march #ca1 #bjae1 unless there is evidence of systematic gaming1 fraud1 abuse1 or delays in the provision of care by a provider of services 7as defined in section #ahfa7u7 of such ,act 7#db ,u4,s4,c4 #aciex7u7774 #aab4 ,technical changes to ,medicare ,,ltch amendments 7a7 ,in general ,subclauses 7,i7 and 7,,ii7 of section #ahhf7m77#f77;,c77iv7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7m77#f77;,c77iv77 are each amended by striking discharges and inserting ,medicare fee-for-service discharges4 7b7 ,,mmsea correction ,section #aad7;d7 of the ,medicare1 ,medicaid1 and ,,schip ,extension ,act of #bjjg 7#db ,u4,s4,c4 #acieww note71 as amended by sections #cajf7;b7 and #ajcab7;b7 of ,public ,law #aaa-adh and by section #abjf7;b77#b7 of the ,pathway for ,,sgr ,reform ,act of #bjac 7division ,b of ,public ,law #aac-fg71 is amended-- 7#a7 in paragraph 7#a71 in the matter preceding subparagraph 7,a71 by striking ,january #a1 #bjae1 and inserting on the date of the enactment of paragraph 7#g7 of this subsection2 7#b7 in paragraph 7#f71 by striking ,january #a1 #bjae1 and inserting on the date of the enactment of paragraph 7#g7 of this subsection2 and 7#c7 by adding at the end the following new paragraph3 7#g7 ,additional exception for certain long-term care hospitals ,the moratorium under paragraph 7#a77;,a7 shall not apply to a long-term care hospital that-- 7,a7 began its qualifying period for payment as a long-term care hospital under section #dab4bc7;e7 of title #db1 ,code of ,federal ,regulations1 on or before the date of enactment of this paragraph2 7,b7 has a binding written agreement as of the date of the enactment of this paragraph with an outside1 unrelated party for the actual construction1 renovation1 lease1 or demolition for a long-term care hospital1 and has expended1 before such date of enactment1 at least #aj percent of the estimated cost of the project 7or1 if less1 #b1ejj1jjj72 or 7,c7 has obtained an approved certificate of need in a ,state where one is required on or before such date of enactment4 4 7c7 ,additional amendments ,section #abjf7;a7 of the ,pathway for ,,sgr ,reform ,act of #bjac 7division ,b of ,public ,law #aac-fg7 is amended-- 7#a7 in paragraph 7#b77;,a71 by striking ,assessment and inserting ,advisory2 and 7#b7 in paragraph 7#c77;,b71 by striking shall not apply to a hospital that is classified as of ,december #aj1 #bjac1 as a subsection 7d7 hospital 7as defined in section #ahhf7;d77#a77;,b7 of the ,social ,security ,act1 #db ,u4,s4,c4 #acieww7d77#a77;,b77 and inserting shall only apply to a hospital that is classified as of ,december #aj1 #bjac1 as a long-term care hospital 7as defined in section #ahfa7;ccc7 of the ,social ,security ,act1 #db ,u4,s4,c4 #aciex7ccc774 7d7 ,effective date ,the amendments made by this section are effective as of the date of the enactment of this ,act4 ,,ii ,other ,health ,provisions #bja4 ,extension of the qualifying individual 7,,qi7 program 7a7 ,extension ,section #aijb7;a77#aj77;,e77iv7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77#aj77;,e77iv77 is amended by striking ,march #bjad and inserting ,march #bjae4 7b7 ,extending total amount available for allocation ,section #aicc7;g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#c7;g77 is amended-- 7#a7 in paragraph 7#b7-- 7,a7 in subparagraph 7,t71 by striking and at the end2 7,b7 in subparagraph 7,u7-- 7i7 by striking ,march #ca1 #bjad and inserting ,september #cj1 #bjad2 and 7ii7 by striking #bjj1jjj1jjj4 and inserting #dhe1jjj1jjj22 and 7,c7 by adding at the end the following new subparagraphs3 7,v7 for the period that begins on ,october #a1 #bjad1 and ends on ,december #ca1 #bjad1 the total allocation amount is #cjj1jjj1jjj2 and 7,w7 for the period that begins on ,january #a1 #bjae1 and ends on ,march #ca1 #bjae1 the total allocation amount is #bej1jjj1jjj4 2 and 7#b7 in paragraph 7#c71 in the matter preceding subparagraph 7,a71 by striking or 7,t7 and inserting 7,t71 or 7,v74 #bjb4 ,temporary extension of transitional medical assistance 7,,tma7 ,sections #aijb7;e77#a77;,b7 and #aibe7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7e77#a77;,b71 #acifr-#f7;f77 are each amended by striking ,march #ca1 #bjad and inserting ,march #ca1 #bjae4 #bjc4 ,extension of ,medicaid and ,,chip express lane option ,section #aijb7;e77#ac77;,i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7e77#ac77;,i77 is amended by striking ,september #cj1 #bjad and inserting ,september #cj1 #bjae4 #bjd4 ,extension of special diabetes program for type ,i diabetes and for ,indians 7a7 ,special ,diabetes ,programs for ,type ,i ,diabetes ,section #ccj;,b7b77#b77;,c7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bed;c-#b7;b77#b77;,c77 is amended by striking #bjad and inserting #bjae4 7b7 ,special ,diabetes ,programs for ,indians ,section #ccj;,c7c77#b77;,c7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bed;c-#c7;c77#b77;,c77 is amended by striking #bjad and inserting #bjae4 #bje4 ,extension of abstinence education ,subsections 7a7 and 7d7 of section #eaj of the ,social ,security ,act 7#db ,u4,s4,c4 #gaj7 are each amended by striking #bjad and inserting #bjae4 #bjf4 ,extension of personal responsibility education program 7,,prep7 ,section #eac of the ,social ,security ,act 7#db ,u4,s4,c4 #gac7 is amended-- 7#a7 in paragraphs 7#a77;,a7 and 7#d77;,a7 of subsection 7a71 by striking #bjad and inserting #bjae each place it appears2 7#b7 in subsection 7a77#d77;,b77i71 by striking and #bjad and inserting #bjad1 and #bjae2 and 7#c7 in subsection 7f71 by striking #bjad and inserting #bjae4 #bjg4 ,extension of funding for family-to-family health information centers ,section #eja7;c77#a77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #gja7;c77#a77;,a77 is amended-- 7#a7 in clause 7iii71 by striking at the end and2 7#b7 in clause 7iv71 by striking the period at the end and inserting a semicolon and by moving the margin to align with the margin for clause 7iii72 and 7#c7 by adding at the end the following new clauses3 7v7 #b1ejj1jjj for the portion of fiscal year #bjad on or after ,april #a1 #bjad2 and 7vi7 #b1ejj1jjj for the portion of fiscal year #bjae before ,april #a1 #bjae4 4 #bjh4 ,extension of health workforce demonstration project for low-income individuals ,section #bjjh7;c77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;g7c77#a77 is amended by striking #bjad and inserting #bjae4 #bji4 ,extension of maternal1 infant1 and early childhood home visiting programs ,section #eaa7;j7 of the ,social ,security ,act 7#db ,u4,s4,c4 #gaa7;j77 is amended-- 7#a7 in paragraph 7#a7-- 7,a7 by striking and at the end of subparagraph 7,d72 7,b7 by striking the period at the end of subparagraph 7,e7 and inserting 2 and2 and 7,c7 by adding at the end the following new subparagraph3 7,f7 for the period beginning on ,october #a1 #bjad1 and ending on ,march #ca1 #bjae1 an amount equal to the amount provided in subparagraph 7,e74 2 and 7#b7 in paragraphs 7#b7 and 7#c71 by inserting 7or portion of a fiscal year7 after for a fiscal year each place it appears4 #baj4 ,pediatric quality measures 7a7 ,continuation of funding for pediatric quality measures for improving the quality of children's health care ,section #aaci;,b7e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;b-#i;b7e77 is amended by adding at the end the following3 ,of the funds appropriated under this subsection1 not less than #ae1jjj1jjj shall be used to carry out section #aaci;,a7b744 7b7 ,elimination of restriction on ,medicaid quality measurement program ,section #aaci;,b7b77#e77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;b-#i;b7b77#e77;,a77 is amended by striking ,the aggregate amount awarded by the ,secretary for grants and contracts for the development1 testing1 and validation of emerging and innovative evidence-based measures under such program shall equal the aggregate amount awarded by the ,secretary for grants under section #aaci;,a7b77#d77;,a74 #baa4 ,delay of effective date for ,medicaid amendments relating to beneficiary liability settlements ,effective as if included in the enactment of the ,bipartisan ,budget ,act of #bjac 7,public ,law #aac-fg71 section #bjb7;c7 of such ,act is amended by striking ,october #a1 #bjad and inserting ,october #a1 #bjaf4 #bab4 ,delay in transition from ,,icd-#i ,,to ,,icd-#aj code sets ,the ,secretary of ,health and ,human ,services may not1 prior to ,october #a1 #bjae1 adopt ,,icd-#aj code sets as the standard for code sets under section #aagc7;c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;d-#b7;c77 and section #afb4ajjb of title #de1 ,code of ,federal ,regulations4 #bac4 ,elimination of limitation on deductibles for employer-sponsored health plans 7a7 ,in general ,section #acjb7;c7 of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh2 #db ,u4,s4,c4 #ahjbb7;c77 is amended-- 7#a7 by striking paragraph 7#b72 and 7#b7 in paragraph 7#d77;,a71 by striking paragraphs 7#a77;,b77i7 and 7#b77;,b77i7 and inserting paragraph 7#a77;,b77i74 7b7 ,conforming amendment ,section #bgjg7;b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#f7;b77 is amended by striking paragraphs 7#a7 and 7#b7 and inserting paragraph 7#a74 7c7 ,effective date ,the amendments made by this ,act shall be effective as if included in the enactment of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh74 #bad4 ,,gao report on the ,children's ,hospital ,graduate ,medical ,education ,program 7a7 ,in general ,in the case that the ,children's ,hospital ,,gme ,support ,reauthorization ,act of #bjac is enacted into law1 the ,comptroller ,general of the ,united ,states shall1 not later than ,november #cj1 #bjag1 conduct an independent evaluation1 and submit to the appropriate committees of ,congress a report1 concerning the implementation of section #cdj;,e7h7 of the ,public ,health ,service ,act1 as added by section #c of the ,children's ,hospital ,,gme ,support ,reauthorization ,act of #bjac4 7b7 ,content ,the report described in subsection 7a7 shall review and assess each of the following1 with respect to hospitals receiving payments under such section #cdj;,e7h7 during the period of fiscal years #bjae through #bjag3 7#a7 ,the number and type of such hospitals that applied for such payments4 7#b7 ,the number and type of such hospitals receiving such payments4 7#c7 ,the amount of such payments awarded to such hospitals4 7#d7 ,how such hospitals used such payments4 7#e7 ,the impact of such payments on-- 7,a7 the number of pediatric providers2 and 7,b7 health care needs of children4 #bae4 ,skilled nursing facility value-based purchasing 7a7 ,in general ,section #ahhh of the ,social ,security ,act 7#db ,u4,s4,c4 #acieyy7 is amended by adding at the end the following new subsection3 7g7 ,skilled nursing facility readmission measure 7#a7 ,readmission measure ,not later than ,october #a1 #bjae1 the ,secretary shall specify a skilled nursing facility all-cause all-condition hospital readmission measure 7or any successor to such a measure74 7#b7 ,resource use measure ,not later than ,october #a1 #bjaf1 the ,secretary shall specify a measure to reflect an all-condition risk-adjusted potentially preventable hospital readmission rate for skilled nursing facilities4 7#c7 ,measure adjustments ,when specifying the measures under paragraphs 7#a7 and 7#b71 the ,secretary shall devise a methodology to achieve a high level of reliability and validity1 especially for skilled nursing facilities with a low volume of readmissions4 7#d7 ,pre-rulemaking process 7measure application partnership process7 ,the application of the provisions of section #ahij;,a shall be optional in the case of a measure specified under paragraph 7#a7 and a measure specified under paragraph 7#b74 7#e7 ,feedback reports to skilled nursing facilities ,beginning ,october #a1 #bjaf1 and every quarter thereafter1 the ,secretary shall provide confidential feedback reports to skilled nursing facilities on the performance of such facilities with respect to a measure specified under paragraph 7#a7 or 7#b74 7#f7 ,public reporting of skilled nursing facilities 7,a7 ,in general ,subject to subparagraphs 7,b7 and 7,c71 the ,secretary shall establish procedures for making available to the public by posting on the ,nursing ,home ,compare ,medicare website 7or a successor website7 described in section #ahai7;i7 information on the performance of skilled nursing facilities with respect to a measure specified under paragraph 7#a7 and a measure specified under paragraph 7#b74 7,b7 ,opportunity to review ,the procedures under subparagraph 7,a7 shall ensure that a skilled nursing facility has the opportunity to review and submit corrections to the information that is to be made public with respect to the facility prior to such information being made public4 7,c7 ,timing ,such procedures shall provide that the information described in subparagraph 7,a7 is made publicly available beginning not later than ,october #a1 #bjag4 7#g7 ,non-application of ,paperwork ,reduction ,act ,chapter #ce of title #dd1 ,united ,states ,code 7commonly referred to as the #8,paperwork ,reduction ,act of #aiie'7 shall not apply to this subsection4 4 7b7 ,value-,based purchasing program for skilled nursing facilities ,section #ahhh of the ,social ,security ,act 7#db ,u4,s4,c4 #acieyy71 as amended by subsection 7a71 is further amended by adding at the end the following new subsection3 7h7 ,skilled nursing facility value-,based purchasing program 7#a7 ,establishment 7,a7 ,in general ,subject to the succeeding provisions of this subsection1 the ,secretary shall establish a skilled nursing facility value-based purchasing program 7in this subsection referred to as the ,,snf ,,vbp ,program7 under which value-based incentive payments are made in a fiscal year to skilled nursing facilities4 7,b7 ,program to begin in fiscal year #bjai ,the ,,snf ,,vbp ,program shall apply to payments for services furnished on or after ,october #a1 #bjah4 7#b7 ,application of measures 7,a7 ,in general ,the ,secretary shall apply the measure specified under subsection 7g77#a7 for purposes of the ,,snf ,,vbp ,program4 7,b7 ,replacement ,for purposes of the ,,snf ,,vbp ,program1 the ,secretary shall apply the measure specified under 7g77#b7 instead of the measure specified under 7g77#a7 as soon as practicable4 7#c7 ,performance standards 7,a7 ,establishment ,the ,secretary shall establish performance standards with respect to the measure applied under paragraph 7#b7 for a performance period for a fiscal year4 7,b7 ,higher of achievement and improvement ,the performance standards established under subparagraph 7,a7 shall include levels of achievement and improvement4 ,in calculating the ,,snf performance score under paragraph 7#d71 the ,secretary shall use the higher of either improvement or achievement4 7,c7 ,timing ,the ,secretary shall establish and announce the performance standards established under subparagraph 7,a7 not later than #fj days prior to the beginning of the performance period for the fiscal year involved4 7#d7 ,,snf performance score 7,a7 ,in general ,the ,secretary shall develop a methodology for assessing the total performance of each skilled nursing facility based on performance standards established under paragraph 7#c7 with respect to the measure applied under paragraph 7#b74 ,using such methodology1 the ,secretary shall provide for an assessment 7in this subsection referred to as the ,,snf performance score7 for each skilled nursing facility for each such performance period4 7,b7 ,ranking of ,,snf performance scores ,the ,secretary shall1 for the performance period for each fiscal year1 rank the ,,snf performance scores determined under subparagraph 7,a7 from low to high4 7#e7 ,calculation of value-based incentive payments 7,a7 ,in general ,with respect to a skilled nursing facility1 based on the ranking under paragraph 7#d77;,b7 for a performance period for a fiscal year1 the ,secretary shall increase the adjusted ,federal per diem rate determined under subsection 7e77#d77;,g7 otherwise applicable to such skilled nursing facility 7and after application of paragraph 7#f77 for services furnished by such facility during such fiscal year by the value-based incentive payment amount under subparagraph 7,b74 7,b7 ,value-based incentive payment amount ,the value-based incentive payment amount for services furnished by a skilled nursing facility in a fiscal year shall be equal to the product of-- 7i7 the adjusted ,federal per diem rate determined under subsection 7e77#d77;,g7 otherwise applicable to such skilled nursing facility for such services furnished by the skilled nursing facility during such fiscal year2 and 7ii7 the value-based incentive payment percentage specified under subparagraph 7,c7 for the skilled nursing facility for such fiscal year4 7,c7 ,value-based incentive payment percentage 7i7 ,in general ,the ,secretary shall specify a value-based incentive payment percentage for a skilled nursing facility for a fiscal year which may include a zero percentage4 7ii7 ,requirements ,in specifying the value-based incentive payment percentage for each skilled nursing facility for a fiscal year under clause 7i71 the ,secretary shall ensure that-- 7,i7 such percentage is based on the ,,snf performance score of the skilled nursing facility provided under paragraph 7#d7 for the performance period for such fiscal year2 7,,ii7 the application of all such percentages in such fiscal year results in an appropriate distribution of value-based incentive payments under subparagraph 7,b7 such that-- 7aa7 skilled nursing facilities with the highest rankings under paragraph 7#d77;,b7 receive the highest value-based incentive payment amounts under subparagraph 7,b72 7bb7 skilled nursing facilities with the lowest rankings under paragraph 7#d77;,b7 receive the lowest value-based incentive payment amounts under subparagraph 7,b72 and 7cc7 in the case of skilled nursing facilities in the lowest #dj percent of the ranking under paragraph 7#d77;,b71 the payment rate under subparagraph 7,a7 for services furnished by such facility during such fiscal year shall be less than the payment rate for such services for such fiscal year that would otherwise apply under subsection 7e77#d77;,g7 without application of this subsection2 and 7,,iii7 the total amount of value-based incentive payments under this paragraph for all skilled nursing facilities in such fiscal year shall be greater than or equal to #ej percent1 but not greater than #gj percent1 of the total amount of the reductions to payments for such fiscal year under paragraph 7#f71 as estimated by the ,secretary4 7#f7 ,funding for value-based incentive payments 7,a7 ,in general ,the ,secretary shall reduce the adjusted ,federal per diem rate determined under subsection 7e77#d77;,g7 otherwise applicable to a skilled nursing facility for services furnished by such facility during a fiscal year 7beginning with fiscal year #bjai7 by the applicable percent 7as defined in subparagraph 7,b774 ,the ,secretary shall make such reductions for all skilled nursing facilities in the fiscal year involved1 regardless of whether or not the skilled nursing facility has been determined by the ,secretary to have earned a value-based incentive payment under paragraph 7#e7 for such fiscal year4 7,b7 ,applicable percent ,for purposes of subparagraph 7,a71 the term applicable percent means1 with respect to fiscal year #bjai and succeeding fiscal years1 #b percent4 7#g7 ,announcement of net result of adjustments ,under the ,,snf ,,vbp ,program1 the ,secretary shall1 not later than #fj days prior to the fiscal year involved1 inform each skilled nursing facility of the adjustments to payments to the skilled nursing facility for services furnished by such facility during the fiscal year under paragraphs 7#e7 and 7#f74 7#h7 ,no effect in subsequent fiscal years ,the value-based incentive payment under paragraph 7#e7 and the payment reduction under paragraph 7#f7 shall each apply only with respect to the fiscal year involved1 and the ,secretary shall not take into account such value-based incentive payment or payment reduction in making payments to a skilled nursing facility under this section in a subsequent fiscal year4 7#i7 ,public reporting 7,a7 ,,snf specific information ,the ,secretary shall make available to the public1 by posting on the ,nursing ,home ,compare ,medicare website 7or a successor website7 described in section #ahai7;i7 in an easily understandable format1 information regarding the performance of individual skilled nursing facilities under the ,,snf ,,vbp ,program1 with respect to a fiscal year1 including-- 7i7 the ,,snf performance score of the skilled nursing facility for such fiscal year2 and 7ii7 the ranking of the skilled nursing facility under paragraph 7#d77;,b7 for the performance period for such fiscal year4 7,b7 ,aggregate information ,the ,secretary shall periodically post on the ,nursing ,home ,compare ,medicare website 7or a successor website7 described in section #ahai7;i7 aggregate information on the ,,snf ,,vbp ,program1 including-- 7i7 the range of ,,snf performance scores provided under paragraph 7#d77;,a72 and 7ii7 the number of skilled nursing facilities receiving value-based incentive payments under paragraph 7#e7 and the range and total amount of such value-based incentive payments4 7#aj7 ,limitation on review ,there shall be no administrative or judicial review under section #ahfi1 section #ahgh1 or otherwise of the following3 7,a7 ,the methodology used to determine the value-based incentive payment percentage and the amount of the value-based incentive payment under paragraph 7#e74 7,b7 ,the determination of the amount of funding available for such value-based incentive payments under paragraph 7#e77;,c77ii77,,iii7 and the payment reduction under paragraph 7#f74 7,c7 ,the establishment of the performance standards under paragraph 7#c7 and the performance period4 7,d7 ,the methodology developed under paragraph 7#d7 that is used to calculate ,,snf performance scores and the calculation of such scores4 7,e7 ,the ranking determinations under paragraph 7#d77;,b74 7#aa7 ,funding for program management ,the ,secretary shall provide for the one time transfer from the ,federal ,hospital ,insurance ,trust ,fund established under section #ahag to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account of-- 7,a7 for purposes of subsection 7g77#b71 #b1jjj1jjj2 and 7,b7 for purposes of implementing this subsection1 #aj1jjj1jjj4 ,such funds shall remain available until expended4 4 7c7 ,med,p,a,c study ,not later than ,june #cj1 #bjba1 the ,medicare ,payment ,advisory ,commission shall submit to ,congress a report that reviews the progress of the skilled nursing facility value-based purchasing program established under section #ahhh7;h7 of the ,social ,security ,act1 as added by subsection 7b71 and makes recommendations1 as appropriate1 on any improvements that should be made to such program4 ,for purposes of the previous sentence1 the ,medicare ,payment ,advisory ,commission shall consider any unintended consequences with respect to such skilled nursing facility value-based purchasing program and any potential adjustments to the readmission measure specified under section #ahhh7;g77#a7 of such ,act1 as added by subsection 7a71 for purposes of determining the effect of the socio-economic status of a beneficiary under the ,medicare program under title ,,xviii of the ,social ,security ,act for the ,,snf performance score of a skilled nursing facility provided under section #ahhh7;h77#d7 of such ,act1 as added by subsection 7b74 #baf4 ,improving ,medicare policies for clinical diagnostic laboratory tests 7a7 ,in general ,title ,,xviii of the ,social ,security ,act is amended by inserting after section #ahcd 7#db ,u4,s4,c4 #aciem7 the following new section3 #ahcd;,a4 ,improving policies for clinical diagnostic laboratory tests 7a7 ,reporting of private sector payment rates for establishment of ,medicare payment rates 7#a7 ,in general ,beginning ,january #a1 #bjaf1 and every #c years thereafter 7or1 annually1 in the case of reporting with respect to an advanced diagnostic laboratory test1 as defined in subsection 7d77#e771 an applicable laboratory 7as defined in paragraph 7#b77 shall report to the ,secretary1 at a time specified by the ,secretary1 applicable information 7as defined in paragraph 7#c77 for a data collection period 7as defined in paragraph 7#d77 for each clinical diagnostic laboratory test that the laboratory furnishes during such period for which payment is made under this part4 7#b7 ,definition of applicable laboratory ,in this section1 the term applicable laboratory means a laboratory that1 with respect to its revenues under this title1 a majority of such revenues are from this section1 section #ahcc7;h71 or section #ahdh4 ,the ,secretary may establish a low volume or low expenditure threshold for excluding a laboratory from the definition of applicable laboratory under this paragraph1 as the ,secretary determines appropriate4 7#c7 ,applicable information defined 7,a7 ,in general ,in this section1 subject to subparagraph 7,b71 the term applicable information means1 with respect to a laboratory test for a data collection period1 the following3 7i7 ,the payment rate 7as determined in accordance with paragraph 7#e77 that was paid by each private payor for the test during the period4 7ii7 ,the volume of such tests for each such payor for the period4 7,b7 ,exception for certain contractual arrangements ,such term shall not include information with respect to a laboratory test for which payment is made on a capitated basis or other similar payment basis during the data collection period4 7#d7 ,data collection period defined ,in this section1 the term data collection period means a period of time1 such as a previous #ab month period1 specified by the ,secretary4 7#e7 ,treatment of discounts ,the payment rate reported by a laboratory under this subsection shall reflect all discounts1 rebates1 coupons1 and other price concessions1 including those described in section #ahdg;,a7c77#c74 7#f7 ,ensuring complete reporting ,in the case where an applicable laboratory has more than one payment rate for the same payor for the same test or more than one payment rate for different payors for the same test1 the applicable laboratory shall report each such payment rate and the volume for the test at each such rate under this subsection4 ,beginning with ,january #a1 #bjai1 the ,secretary may establish rules to aggregate reporting with respect to the situations described in the preceding sentence4 7#g7 ,certification ,an officer of the laboratory shall certify the accuracy and completeness of the information reported under this subsection4 7#h7 ,private payor defined ,in this section1 the term private payor means the following3 7,a7 ,a health insurance issuer and a group health plan 7as such terms are defined in section #bgia of the ,public ,health ,service ,act74 7,b7 ,a ,medicare ,advantage plan under part ,c4 7,c7 ,a medicaid managed care organization 7as defined in section #aijc7m774 7#i7 ,civil money penalty 7,a7 ,in general ,if the ,secretary determines that an applicable laboratory has failed to report or made a misrepresentation or omission in reporting information under this subsection with respect to a clinical diagnostic laboratory test1 the ,secretary may apply a civil money penalty in an amount of up to #aj1jjj per day for each failure to report or each such misrepresentation or omission4 7,b7 ,application ,the provisions of section #aabh;,a 7other than subsections 7a7 and 7b77 shall apply to a civil money penalty under this paragraph in the same manner as they apply to a civil money penalty or proceeding under section #aabh;,a7a74 7#aj7 ,confidentiality of information ,notwithstanding any other provision of law1 information disclosed by a laboratory under this subsection is confidential and shall not be disclosed by the ,secretary or a ,medicare contractor in a form that discloses the identity of a specific payor or laboratory1 or prices charged or payments made to any such laboratory1 except-- 7,a7 as the ,secretary determines to be necessary to carry out this section2 7,b7 to permit the ,comptroller ,general to review the information provided2 7,c7 to permit the ,director of the ,congressional ,budget ,office to review the information provided2 and 7,d7 to permit the ,medicare ,payment ,advisory ,commission to review the information provided4 7#aa7 ,protection from public disclosure ,a payor shall not be identified on information reported under this subsection4 ,the name of an applicable laboratory under this subsection shall be exempt from disclosure under section #eeb7;b77#c7 of title #e1 ,united ,states ,code4 7#ab7 ,regulations ,not later than ,june #cj1 #bjae1 the ,secretary shall establish through notice and comment rulemaking parameters for data collection under this subsection4 7b7 ,payment for clinical diagnostic laboratory tests 7#a7 ,use of private payor rate information to determine ,medicare payment rates 7,a7 ,in general ,subject to paragraph 7#c7 and subsections 7c7 and 7d71 in the case of a clinical diagnostic laboratory test furnished on or after ,january #a1 #bjag1 the payment amount under this section shall be equal to the weighted median determined for the test under paragraph 7#b7 for the most recent data collection period4 7,b7 ,application of payment amounts to hospital laboratories ,the payment amounts established under this section shall apply to a clinical diagnostic laboratory test furnished by a hospital laboratory if such test is paid for separately1 and not as part of a bundled payment under section #ahcc7t74 7#b7 ,calculation of weighted median ,for each laboratory test with respect to which information is reported under subsection 7a7 for a data collection period1 the ,secretary shall calculate a weighted median for the test for the period1 by arraying the distribution of all payment rates reported for the period for each test weighted by volume for each payor and each laboratory4 7#c7 ,phase-in of reductions from private payor rate implementation 7,a7 ,in general ,payment amounts determined under this subsection for a clinical diagnostic laboratory test for each of #bjag through #bjbb shall not result in a reduction in payments for a clinical diagnostic laboratory test for the year of greater than the applicable percent 7as defined in subparagraph 7,b77 of the amount of payment for the test for the preceding year4 7,b7 ,applicable percent defined ,in this paragraph1 the term applicable percent means-- 7i7 for each of #bjag through #bjai1 #aj percent2 and 7ii7 for each of #bjbj through #bjbb1 #ae percent4 7,c7 ,no application to new tests ,this paragraph shall not apply to payment amounts determined under this section for either of the following4 7i7 ,a new test under subsection 7c74 7ii7 ,a new advanced diagnostic test 7as defined in subsection 7d77#e77 under subsection 7d74 7#d7 ,application of market rates 7,a7 ,in general ,subject to paragraph 7#c71 once established for a year following a data collection period1 the payment amounts under this subsection shall continue to apply until the year following the next data collection period4 7,b7 ,other adjustments not applicable ,the payment amounts under this section shall not be subject to any adjustment 7including any geographic adjustment1 budget neutrality adjustment1 annual update1 or other adjustment74 7#e7 ,sample collection fee ,in the case of a sample collected from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency1 the nominal fee that would otherwise apply under section #ahcc7;h77#c77;,a7 shall be increased by #b4 7c7 ,payment for new tests that are not advanced diagnostic laboratory tests 7#a7 ,payment during initial period ,in the case of a clinical diagnostic laboratory test that is assigned a new or substantially revised ,,hcpcs code on or after the date of enactment of this section1 and which is not an advanced diagnostic laboratory test 7as defined in subsection 7d77#e771 during an initial period until payment rates under subsection 7b7 are established for the test1 payment for the test shall be determined-- 7,a7 using cross-walking 7as described in section #dad4ejh7;a7 of title #db1 ,code of ,federal ,regulations1 or any successor regulation7 to the most appropriate existing test under the fee schedule under this section during that period2 or 7,b7 if no existing test is comparable to the new test1 according to the gapfilling process described in paragraph 7#b74 7#b7 ,gapfilling process described ,the gapfilling process described in this paragraph shall take into account the following sources of information to determine gapfill amounts1 if available3 7,a7 ,charges for the test and routine discounts to charges4 7,b7 ,resources required to perform the test4 7,c7 ,payment amounts determined by other payors4 7,d7 ,charges1 payment amounts1 and resources required for other tests that may be comparable or otherwise relevant4 7,e7 ,other criteria the ,secretary determines appropriate4 7#c7 ,additional consideration ,in determining the payment amount under crosswalking or gapfilling processes under this subsection1 the ,secretary shall consider recommendations from the panel established under subsection 7f77#a74 7#d7 ,explanation of payment rates ,in the case of a clinical diagnostic laboratory test for which payment is made under this subsection1 the ,secretary shall make available to the public an explanation of the payment rate for the test1 including an explanation of how the criteria described in paragraph 7#b7 and paragraph 7#c7 are applied4 7d7 ,payment for new advanced diagnostic laboratory tests 7#a7 ,payment during initial period 7,a7 ,in general ,in the case of an advanced diagnostic laboratory test for which payment has not been made under the fee schedule under section #ahcc7;h7 prior to the date of enactment of this section1 during an initial period of three quarters1 the payment amount for the test for such period shall be based on the actual list charge for the laboratory test4 7,b7 ,actual list charge ,for purposes of subparagraph 7,a71 the term actual list charge1 with respect to a laboratory test furnished during such period1 means the publicly available rate on the first day at which the test is available for purchase by a private payor4 7#b7 ,special rule for timing of initial reporting ,with respect to an advanced diagnostic laboratory test described in paragraph 7#a77;,a71 an applicable laboratory shall initially be required to report under subsection 7a7 not later than the last day of the second quarter of the initial period under such paragraph4 7#c7 ,application of market rates after initial period ,subject to paragraph 7#d71 data reported under paragraph 7#b7 shall be used to establish the payment amount for an advanced diagnostic laboratory test after the initial period under paragraph 7#a77;,a7 using the methodology described in subsection 7b74 ,such payment amount shall continue to apply until the year following the next data collection period4 7#d7 ,recoupment if actual list charge exceeds market rate ,with respect to the initial period described in paragraph 7#a77;,a71 if1 after such period1 the ,secretary determines that the payment amount for an advanced diagnostic laboratory test under paragraph 7#a77;,a7 that was applicable during the period was greater than #acj percent of the payment amount for the test established using the methodology described in subsection 7b7 that is applicable after such period1 the ,secretary shall recoup the difference between such payment amounts for tests furnished during such period4 7#e7 ,advanced diagnostic laboratory test defined ,in this subsection1 the term advanced diagnostic laboratory test means a clinical diagnostic laboratory test covered under this part that is offered and furnished only by a single laboratory and not sold for use by a laboratory other than the original developing laboratory 7or a successor owner7 and meets one of the following criteria3 7,a7 ,the test is an analysis of multiple biomarkers of ,,dna1 ,,rna1 or proteins combined with a unique algorithm to yield a single patient-specific result4 7,b7 ,the test is cleared or approved by the ,food and ,drug ,administration4 7,c7 ,the test meets other similar criteria established by the ,secretary4 7e7 ,coding 7#a7 ,temporary codes for certain new tests 7,a7 ,in general ,the ,secretary shall adopt temporary ,,hcpcs codes to identify new advanced diagnostic laboratory tests 7as defined in subsection 7d77#e77 and new laboratory tests that are cleared or approved by the ,food and ,drug ,administration4 7,b7 ,duration 7i7 ,in general ,subject to clause 7ii71 the temporary code shall be effective until a permanent ,,hcpcs code is established 7but not to exceed #b years74 7ii7 ,exception ,the ,secretary may extend the temporary code or establish a permanent ,,hcpcs code1 as the ,secretary determines appropriate4 7#b7 ,existing tests ,not later than ,january #a1 #bjaf1 for each existing advanced diagnostic laboratory test 7as so defined7 and each existing clinical diagnostic laboratory test that is cleared or approved by the ,food and ,drug ,administration for which payment is made under this part as of the date of enactment of this section1 if such test has not already been assigned a unique ,,hcpcs code1 the ,secretary shall-- 7,a7 assign a unique ,,hcpcs code for the test2 and 7,b7 publicly report the payment rate for the test4 7#c7 ,establishment of unique identifier for certain tests ,for purposes of tracking and monitoring1 if a laboratory or a manufacturer requests a unique identifier for an advanced diagnostic laboratory test 7as so defined7 or a laboratory test that is cleared or approved by the ,food and ,drug ,administration1 the ,secretary shall utilize a means to uniquely track such test through a mechanism such as a ,,hcpcs code or modifier4 7f7 ,input from clinicians and technical experts 7#a7 ,in general ,the ,secretary shall consult with an expert outside advisory panel1 established by the ,secretary not later than ,july #a1 #bjae1 composed of an appropriate selection of individuals with expertise1 which may include molecular pathologists1 researchers1 and individuals with expertise in laboratory science or health economics1 in issues related to clinical diagnostic laboratory tests1 which may include the development1 validation1 performance1 and application of such tests1 to provide-- 7,a7 input on-- 7i7 the establishment of payment rates under this section for new clinical diagnostic laboratory tests1 including whether to use crosswalking or gapfilling processes to determine payment for a specific new test2 and 7ii7 the factors used in determining coverage and payment processes for new clinical diagnostic laboratory tests2 and 7,b7 recommendations to the ,secretary under this section4 7#b7 ,compliance with ,,faca ,the panel shall be subject to the ,federal ,advisory ,committee ,act 7#e ,u4,s4,c4 ,app474 7#c7 ,continuation of annual meeting ,the ,secretary shall continue to convene the annual meeting described in section #ahcc7;h77#h77;,b77iii7 after the implementation of this section for purposes of receiving comments and recommendations 7and data on which the recommendations are based7 as described in such section on the establishment of payment amounts under this section4 7g7 ,coverage 7#a7 ,issuance of coverage policies 7,a7 ,in general ,a medicare administrative contractor shall only issue a coverage policy with respect to a clinical diagnostic laboratory test in accordance with the process for making a local coverage determination 7as defined in section #ahfi7;f77#b77;,b771 including the appeals and review process for local coverage determinations under part #dbf of title #db1 ,code of ,federal ,regulations 7or successor regulations74 7,b7 ,no effect on national coverage determination process ,this paragraph shall not apply to the national coverage determination process 7as defined in section #ahfi7;f77#a77;,b774 7,c7 ,effective date ,this paragraph shall apply to coverage policies issued on or after ,january #a1 #bjae4 7#b7 ,designation of one or more medicare administrative contractors for clinical diagnostic laboratory tests ,the ,secretary may designate one or more 7not to exceed #d7 medicare administrative contractors to either establish coverage policies or establish coverage policies and process claims for payment for clinical diagnostic laboratory tests1 as determined appropriate by the ,secretary4 7h7 ,implementation 7#a7 ,implementation ,there shall be no administrative or judicial review under section #ahfi1 section #ahgh1 or otherwise1 of the establishment of payment amounts under this section4 7#b7 ,administration ,chapter #ce of title #dd1 ,united ,states ,code1 shall not apply to information collected under this section4 7#c7 ,funding ,for purposes of implementing this section1 the ,secretary shall provide for the transfer1 from the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda1 to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account1 for each of fiscal years #bjad through #bjah1 #d1jjj1jjj1 and for each of fiscal years #bjai through #bjbc1 #c1jjj1jjj4 ,amounts transferred under the preceding sentence shall remain available until expended4 7i7 ,transitional rule ,during the period beginning on the date of enactment of this section and ending on ,december #ca1 #bjaf1 with respect to advanced diagnostic laboratory tests under this part1 the ,secretary shall use the methodologies for pricing1 coding1 and coverage in effect on the day before such date of enactment1 which may include cross-walking or gapfilling methods4 4 7b7 ,conforming amendments 7#a7 ,section #ahcc7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7a77 is amended-- 7,a7 in paragraph 7#a77;,d7-- 7i7 by striking 7i7 on the basis and inserting 7i77,i7 on the basis2 7ii7 in subclause 7,i71 as added by clause 7i71 by striking subsection 7h77#a7 and inserting subsection 7h77#a7 7for tests furnished before ,january #a1 #bjag72 7iii7 by striking or 7ii7 and inserting or 7,,ii7 under section #ahcd;,a 7for tests furnished on or after ,january #a1 #bjag71 the amount paid shall be equal to #hj percent 7or #ajj percent1 in the case of such tests for which payment is made on an assignment-related basis7 of the lesser of the amount determined under such section or the amount of the charges billed for the tests1 or 7ii72 and 7iv7 in clause 7ii71 by striking on the basis and inserting for tests furnished before ,january #a1 #bjag1 on the basis2 7,b7 in paragraph 7#b77;,d7-- 7i7 by striking 7i7 on the basis and inserting 7i77,i7 on the basis2 7ii7 in subclause 7,i71 as added by clause 7i71 by striking subsection 7h77#a7 and inserting subsection 7h77#a7 7for tests furnished before ,january #a1 #bjag72 7iii7 by striking or 7ii7 and inserting or 7,,ii7 under section #ahcd;,a 7for tests furnished on or after ,january #a1 #bjag71 the amount paid shall be equal to #hj percent 7or #ajj percent1 in the case of such tests for which payment is made on an assignment-related basis or to a provider having an agreement under section #ahff7 of the lesser of the amount determined under such section or the amount of the charges billed for the tests1 or 7ii72 and 7iv7 in clause 7ii71 by striking on the basis and inserting for tests furnished before ,january #a1 #bjag1 on the basis2 7,c7 in subsection 7b77#c77;,b71 by striking on the basis and inserting for tests furnished before ,january #a1 #bjag1 on the basis2 7,d7 in subsection 7h77#b77;,a77i71 by striking and subject to and inserting and1 for tests furnished before the date of enactment of section #ahcd;,a1 subject to2 7,e7 in subsection 7h77#c71 in the matter preceding subparagraph 7,a71 by striking fee schedules and inserting fee schedules 7for tests furnished before ,january #a1 #bjag7 or under section #ahcd;,a 7for tests furnished on or after ,january #a1 #bjag71 subject to subsection 7b77#e7 of such section2 7,f7 in subsection 7h77#f71 by striking ,in the case and inserting ,for tests furnished before ,january #a1 #bjag1 in the case2 and 7,g7 in subsection 7h77#g71 in the first sentence-- 7i7 by striking and 7#d7 and inserting and 7#d7 and section #ahcd;,a2 and 7ii7 by striking under this subsection and inserting under this part4 7#b7 ,section #ahfi7;f77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7f77#b77 is amended by adding at the end the following new subparagraph3 7,c7 ,local coverage determinations for clinical diagnostic laboratory tests ,for provisions relating to local coverage determinations for clinical diagnostic laboratory tests1 see section #ahcd;,a7g74 4 7c7 ,,gao study and report2 ,monitoring of ,medicare expenditures and implementation of new payment system for laboratory tests 7#a7 ,,gao study and report on implementation of new payment rates for clinical diagnostic laboratory tests 7,a7 ,study ,the ,comptroller ,general of the ,united ,states 7in this subsection referred to as the ,comptroller ,general7 shall conduct a study on the implementation of section #ahcd;,a of the ,social ,security ,act1 as added by subsection 7a74 ,the study shall include an analysis of-- 7i7 payment rates paid by private payors for laboratory tests furnished in various settings1 including-- 7,i7 how such payment rates compare across settings2 7,,ii7 the trend in payment rates over time2 and 7,,iii7 trends by private payors to move to alternative payment methodologies for laboratory tests2 7ii7 the conversion to the new payment rate for laboratory tests under such section2 7iii7 the impact of such implementation on beneficiary access under title ,,xviii of the ,social ,security ,act2 7iv7 the impact of the new payment system on laboratories that furnish a low volume of services and laboratories that specialize in a small number of tests2 7v7 the number of new ,healthcare ,common ,procedure ,coding ,system 7,,hcpcs7 codes issued for laboratory tests2 7vi7 the spending trend for laboratory tests under such title2 7vii7 whether the information reported by laboratories and the new payment rates for laboratory tests under such section accurately reflect market prices2 7viii7 the initial list price for new laboratory tests and the subsequent reported rates for such tests under such section2 7ix7 changes in the number of advanced diagnostic laboratory tests and laboratory tests cleared or approved by the ,food and ,drug ,administration for which payment is made under such section2 and 7x7 healthcare economic information on downstream cost impacts for such tests and decision making based on accepted methodologies4 7,b7 ,report ,not later than ,october #a1 #bjah1 the ,comptroller ,general shall submit to the ,committee on ,ways and ,means and the ,committee on ,energy and ,commerce of the ,house of ,representatives and the ,committee on ,finance of the ,senate a report on the study under subparagraph 7,a71 including recommendations for such legislation and administrative action as the ,comptroller ,general determines appropriate4 7#b7 ,monitoring of ,medicare expenditures and implementation of new payment system for laboratory tests ,the ,inspector ,general of the ,department of ,health and ,human ,services shall-- 7,a7 publicly release an annual analysis of the top #be laboratory tests by expenditures under title ,,xviii of the ,social ,security ,act2 and 7,b7 conduct analyses the ,inspector ,general determines appropriate with respect to the implementation and effect of the new payment system for laboratory tests under section #ahcd;,a of the ,social ,security ,act1 as added by subsection 7a74 #bag4 ,revisions under the ,medicare ,,esrd prospective payment system 7a7 ,delay of implementation of oral-,only policy ,section #fcb7;b77#a7 of the ,american ,taxpayer ,relief ,act of #bjab 7#db ,u4,s4,c4 #acierr note7 is amended-- 7#a7 by striking #bjaf and inserting #bjbd2 and 7#b7 by adding at the end the following new sentence3 ,notwithstanding section #ahha7;b77#ad77;,a77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acierr7b77#ad77;,a77ii771 implementation of the policy described in the previous sentence shall be based on data from the most recent year available44 7b7 ,mitigation of the application of adjustment to ,,esrd bundled payment rate ,to account for changes in the utilization of certain drugs and biologicals 7#a7 ,in general ,section #ahha7;b77#ad77;,i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acierr7b77#ad77;,i77 is amended by inserting and before ,january #a1 #bjae1 after ,january #a1 #bjad14 7#b7 ,market basket ,section #ahha7;b77#ad77;,f77i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acierr7b77#ad77;,f77i77 is amended-- 7,a7 in subclause 7,i7-- 7i7 by striking subclause 7,,ii7 and inserting subclauses 7,,ii7 and 7,,iii72 and 7ii7 by adding at the end the following new sentence3 ,in order to accomplish the purposes of subparagraph 7,i7 with respect to #bjaf1 #bjag1 and #bjah1 after determining the increase factor described in the preceding sentence for each of #bjaf1 #bjag1 and #bjah1 the ,secretary shall reduce such increase factor by #a4be percentage points for each of #bjaf and #bjag and by #a percentage point for #bjah42 7,b7 in subclause 7,,ii71 by striking ,for #bjab and inserting ,subject to subclause 7,,iii71 for #bjab2 and 7,c7 by adding at the end the following new subclause3 7,,iii7 ,notwithstanding subclauses 7,i7 and 7,,ii71 in order to accomplish the purposes of subparagraph 7,i7 with respect to #bjae1 the increase factor described in subclause 7,i7 for #bjae shall be #j4j percent pursuant to the regulation issued by the ,secretary on ,december #b1 #bjac1 entitled ,medicare ,program2 ,end-,stage ,renal ,disease ,prospective ,payment ,system1 ,quality ,incentive ,program1 and ,durable ,medical ,equipment1 ,prosthetics1 ,orthotics1 and ,supplies2 ,final ,rule 7#gh ,fed4 ,reg4 #gbaef74 4 7c7 ,drug designations ,as part of the promulgation of annual rule for the ,medicare end stage renal disease prospective payment system under section #ahha7;b77#ad7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acierr7b77#ad77 for calendar year #bjaf1 the ,secretary of ,health and ,human ,services 7in this subsection referred to as the ,secretary7 shall establish a process for-- 7#a7 determining when a product is no longer an oral-only drug2 and 7#b7 including new injectable and intravenous products into the bundled payment under such system4 7d7 ,quality measures related to conditions treated by oral-,only drugs under the ,,esrd quality incentive program ,section #ahha7;h77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acierr7h77#b77 is amended-- 7#a7 in subparagraph 7,a7-- 7,a7 in clause 7ii71 by striking and at the end2 7,b7 by redesignating clause 7iii7 as clause 7iv72 and 7,c7 by inserting after clause 7ii7 the following new clause3 7iii7 for #bjaf and subsequent years1 measures described in subparagraph 7,e77i72 and 2 7#b7 in subparagraph 7,b77i71 by striking 7,a77iii7 and inserting 7,a77iv72 and 7#c7 by adding at the end the following new subparagraph3 7,e7 ,measures specific to the conditions treated with oral-only drugs 7i7 ,in general ,the measures described in this subparagraph are measures specified by the ,secretary that are specific to the conditions treated with oral-only drugs4 ,to the extent feasible1 such measures shall be outcomes-based measures4 7ii7 ,consultation ,in specifying the measures under clause 7i71 the ,secretary shall consult with interested stakeholders4 7iii7 ,use of endorsed measures 7,i7 ,in general ,subject to subclause 7,i71 any measures specified under clause 7i7 must have been endorsed by the entity with a contract under section #ahij7;a74 7,,ii7 ,exception ,if the entity with a contract under section #ahij7;a7 has not endorsed a measure for a specified area or topic related to measures described in clause 7i7 that the ,secretary determines appropriate1 the ,secretary may specify a measure that is endorsed or adopted by a consensus organization recognized by the ,secretary that has expertise in clinical guidelines for kidney disease4 4 7e7 ,audits of cost reports of ,,esrd providers as recommended by ,med,p,a,c 7#a7 ,in general ,the ,secretary of ,health and ,human ,services shall conduct audits of ,medicare cost reports beginning during #bjab for a representative sample of providers of services and renal dialysis facilities furnishing renal dialysis services4 7#b7 ,funding ,for purposes of carrying out paragraph 7#a71 the ,secretary of ,health and ,human ,services shall provide for the transfer from the ,federal ,supplementary ,medical ,insurance ,trust ,fund established under section #ahda of the ,social ,security ,act 7#db ,u4,s4,c4 #aciet7 to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account of #ah1jjj1jjj for fiscal year #bjad4 ,amounts transferred under this paragraph for a fiscal year shall be available until expended4 #bah4 ,quality incentives for computed tomography diagnostic imaging and promoting evidence-based care 7a7 ,quality incentives ,to promote patient safety and public health in computed tomography diagnostic imaging 7#a7 ,in general ,section #ahcd of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7 is amended by adding at the end the following new subsection3 7p7 ,quality incentives ,to promote patient safety and public health in computed tomography 7#a7 ,quality incentives ,in the case of an applicable computed tomography service 7as defined in paragraph 7#b77 for which payment is made under an applicable payment system 7as defined in paragraph 7#c77 and that is furnished on or after ,january #a1 #bjaf1 using equipment that is not consistent with the ,,ct equipment standard 7described in paragraph 7#d771 the payment amount for such service shall be reduced by the applicable percentage 7as defined in paragraph 7#e774 7#b7 ,applicable computed tomography services defined ,in this subsection1 the term applicable computed tomography service means a service billed using diagnostic radiological imaging codes for computed tomography 7identified as of ,january #a1 #bjad1 by ,,hcpcs codes #gjdej-gjdih1 #gabej-gabge1 #gbabe-gbacc1 #gbaia-gbaid1 #gcbjj-gcbjf1 #gcgjj-gcgjf1 #gdaej-gdagh1 #gdbfa-gdbfc1 and #geega-geegd 7and any succeeding codes74 7#c7 ,applicable payment system defined ,in this subsection1 the term applicable payment system means the following3 7,a7 ,the technical component and the technical component of the global fee under the fee schedule established under section #ahdh7;b74 7,b7 ,the prospective payment system for hospital outpatient department services under section #ahcc7t74 7#d7 ,consistency with ,,ct equipment standard ,in this subsection1 the term not consistent with the ,,ct equipment standard means1 with respect to an applicable computed tomography service1 that the service was furnished using equipment that does not meet each of the attributes of the ,national ,electrical ,manufacturers ,association 7,,nema7 ,standard ,,xr-#bi-bjac1 entitled ,standard ,attributes on ,,ct ,equipment ,related to ,dose ,optimization and ,management4 ,through rulemaking1 the ,secretary may apply successor standards4 7#e7 ,applicable percentage defined ,in this subsection1 the term applicable percentage means-- 7,a7 for #bjaf1 #e percent2 and 7,b7 for #bjag and subsequent years1 #ae percent4 7#f7 ,implementation 7,a7 ,information ,the ,secretary shall require that information be provided and attested to by a supplier and a hospital outpatient department that indicates whether an applicable computed tomography service was furnished that was not consistent with the ,,ct equipment standard 7described in paragraph 7#d774 ,such information may be included on a claim and may be a modifier4 ,such information shall be verified1 as appropriate1 as part of the periodic accreditation of suppliers under section #ahcd7;e7 and hospitals under section #ahfe7;a74 7,b7 ,administration ,chapter #ce of title #dd1 ,united ,states ,code1 shall not apply to information described in subparagraph 7,a74 4 7#b7 ,conforming amendments 7,a7 ,prospective payment system for hospital outpatient department services ,section #ahcc7t7 of the ,social ,security ,act 7#db #aciel7t77 is amended by adding at the end the following new paragraph3 7#bj7 ,not budget neutral application of reduced expenditures resulting from quality incentives for computed tomography ,the ,secretary shall not take into account the reduced expenditures that result from the application of section #ahcd7p7 in making any budget neutrality adjustments this subsection4 4 7,b7 ,physician fee schedule ,section #ahdh7;c77#b77;,b77v7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77;,b77v77 is amended by adding at the end the following new subclause3 7,,viii7 ,reduced expenditures attributable to application of quality incentives for computed tomography ,effective for fee schedules established beginning with #bjaf1 reduced expenditures attributable to the application of the quality incentives for computed tomography under section #ahcd7p7 4 7b7 ,promoting evidence-,based care 7#a7 ,in general ,section #ahcd of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem71 as amended by subsection 7a71 is amended by adding at the end the following new subsection3 7q7 ,recognizing appropriate use criteria for certain imaging services 7#a7 ,program established 7,a7 ,in general ,the ,secretary shall establish a program to promote the use of appropriate use criteria 7as defined in subparagraph 7,b77 for applicable imaging services 7as defined in subparagraph 7,c77 furnished in an applicable setting 7as defined in subparagraph 7,d77 by ordering professionals and furnishing professionals 7as defined in subparagraphs 7,e7 and 7,f71 respectively74 7,b7 ,appropriate use criteria defined ,in this subsection1 the term appropriate use criteria means criteria1 only developed or endorsed by national professional medical specialty societies or other provider-led entities1 to assist ordering professionals and furnishing professionals in making the most appropriate treatment decision for a specific clinical condition for an individual4 ,to the extent feasible1 such criteria shall be evidence-based4 7,c7 ,applicable imaging service defined ,in this subsection1 the term applicable imaging service means an advanced diagnostic imaging service 7as defined in subsection 7e77#a77;,b77 for which the ,secretary determines-- 7i7 one or more applicable appropriate use criteria specified under paragraph 7#b7 apply2 7ii7 there are one or more qualified clinical decision support mechanisms listed under paragraph 7#c77;,c72 and 7iii7 one or more of such mechanisms is available free of charge4 7,d7 ,applicable setting defined ,in this subsection1 the term applicable setting means a physician's office1 a hospital outpatient department 7including an emergency department71 an ambulatory surgical center1 and any other provider-led outpatient setting determined appropriate by the ,secretary4 7,e7 ,ordering professional defined ,in this subsection1 the term ordering professional means a physician 7as defined in section #ahfa7r77 or a practitioner described in section #ahdb7;b77#ah77;,c7 who orders an applicable imaging service4 7,f7 ,furnishing professional defined ,in this subsection1 the term furnishing professional means a physician 7as defined in section #ahfa7r77 or a practitioner described in section #ahdb7;b77#ah77;,c7 who furnishes an applicable imaging service4 7#b7 ,establishment of applicable appropriate use criteria 7,a7 ,in general ,not later than ,november #ae1 #bjae1 the ,secretary shall through rulemaking1 and in consultation with physicians1 practitioners1 and other stakeholders1 specify applicable appropriate use criteria for applicable imaging services only from among appropriate use criteria developed or endorsed by national professional medical specialty societies or other provider-led entities4 7,b7 ,considerations ,in specifying applicable appropriate use criteria under subparagraph 7,a71 the ,secretary shall take into account whether the criteria-- 7i7 have stakeholder consensus2 7ii7 are scientifically valid and evidence based2 and 7iii7 are based on studies that are published and reviewable by stakeholders4 7,c7 ,revisions ,the ,secretary shall review1 on an annual basis1 the specified applicable appropriate use criteria to determine if there is a need to update or revise 7as appropriate7 such specification of applicable appropriate use criteria and make such updates or revisions through rulemaking4 7,d7 ,treatment of multiple applicable appropriate use criteria ,in the case where the ,secretary determines that more than one appropriate use criterion applies with respect to an applicable imaging service1 the ,secretary shall apply one or more applicable appropriate use criteria under this paragraph for the service4 7#c7 ,mechanisms for consultation with applicable appropriate use criteria 7,a7 ,identification of mechanisms to consult with applicable appropriate use criteria 7i7 ,in general ,the ,secretary shall specify qualified clinical decision support mechanisms that could be used by ordering professionals to consult with applicable appropriate use criteria for applicable imaging services4 7ii7 ,consultation ,the ,secretary shall consult with physicians1 practitioners1 health care technology experts1 and other stakeholders in specifying mechanisms under this paragraph4 7iii7 ,inclusion of certain mechanisms ,mechanisms specified under this paragraph may include any or all of the following that meet the requirements described in subparagraph 7,b77ii73 7,i7 ,use of clinical decision support modules in certified ,,ehr technology 7as defined in section #ahdh7o77#d774 7,,ii7 ,use of private sector clinical decision support mechanisms that are independent from certified ,,ehr technology1 which may include use of clinical decision support mechanisms available from medical specialty organizations4 7,,iii7 ,use of a clinical decision support mechanism established by the ,secretary4 7,b7 ,qualified clinical decision support mechanisms 7i7 ,in general ,for purposes of this subsection1 a qualified clinical decision support mechanism is a mechanism that the ,secretary determines meets the requirements described in clause 7ii74 7ii7 ,requirements ,the requirements described in this clause are the following3 7,i7 ,the mechanism makes available to the ordering professional applicable appropriate use criteria specified under paragraph 7#b7 and the supporting documentation for the applicable imaging service ordered4 7,,ii7 ,in the case where there is more than one applicable appropriate use criterion specified under such paragraph for an applicable imaging service1 the mechanism indicates the criteria that it uses for the service4 7,,iii7 ,the mechanism determines the extent to which an applicable imaging service ordered is consistent with the applicable appropriate use criteria so specified4 7,,iv7 ,the mechanism generates and provides to the ordering professional a certification or documentation that documents that the qualified clinical decision support mechanism was consulted by the ordering professional4 7,v7 ,the mechanism is updated on a timely basis to reflect revisions to the specification of applicable appropriate use criteria under such paragraph4 7,,vi7 ,the mechanism meets privacy and security standards under applicable provisions of law4 7,,vii7 ,the mechanism performs such other functions as specified by the ,secretary1 which may include a requirement to provide aggregate feedback to the ordering professional4 7,c7 ,list of mechanisms for consultation with applicable appropriate use criteria 7i7 ,initial list ,not later than ,april #a1 #bjaf1 the ,secretary shall publish a list of mechanisms specified under this paragraph4 7ii7 ,periodic updating of list ,the ,secretary shall identify on an annual basis the list of qualified clinical decision support mechanisms specified under this paragraph4 7#d7 ,consultation with applicable appropriate use criteria 7,a7 ,consultation by ordering professional ,beginning with ,january #a1 #bjag1 subject to subparagraph 7,c71 with respect to an applicable imaging service ordered by an ordering professional that would be furnished in an applicable setting and paid for under an applicable payment system 7as defined in subparagraph 7,d771 an ordering professional shall-- 7i7 consult with a qualified decision support mechanism listed under paragraph 7#c77;,c72 and 7ii7 provide to the furnishing professional the information described in clauses 7i7 through 7iii7 of subparagraph 7,b74 7,b7 ,reporting by furnishing professional ,beginning with ,january #a1 #bjag1 subject to subparagraph 7,c71 with respect to an applicable imaging service furnished in an applicable setting and paid for under an applicable payment system 7as defined in subparagraph 7,d771 payment for such service may only be made if the claim for the service includes the following3 7i7 ,information about which qualified clinical decision support mechanism was consulted by the ordering professional for the service4 7ii7 ,information regarding-- 7,i7 whether the service ordered would adhere to the applicable appropriate use criteria specified under paragraph 7#b72 7,,ii7 whether the service ordered would not adhere to such criteria2 or 7,,iii7 whether such criteria was not applicable to the service ordered4 7iii7 ,the national provider identifier of the ordering professional 7if different from the furnishing professional74 7,c7 ,exceptions ,the provisions of subparagraphs 7,a7 and 7,b7 and paragraph 7#f77;,a7 shall not apply to the following3 7i7 ,emergency services ,an applicable imaging service ordered for an individual with an emergency medical condition 7as defined in section #ahfg7;e77#a774 7ii7 ,inpatient services ,an applicable imaging service ordered for an inpatient and for which payment is made under part ,a4 7iii7 ,significant hardship ,an applicable imaging service ordered by an ordering professional who the ,secretary may1 on a case-by-case basis1 exempt from the application of such provisions if the ,secretary determines1 subject to annual renewal1 that consultation with applicable appropriate use criteria would result in a significant hardship1 such as in the case of a professional who practices in a rural area without sufficient ,internet access4 7,d7 ,applicable payment system defined ,in this subsection1 the term applicable payment system means the following3 7i7 ,the physician fee schedule established under section #ahdh7;b74 7ii7 ,the prospective payment system for hospital outpatient department services under section #ahcc7t74 7iii7 ,the ambulatory surgical center payment systems under section #ahcc7;i74 7#e7 ,identification of outlier ordering professionals 7,a7 ,in general ,with respect to applicable imaging services furnished beginning with #bjag1 the ,secretary shall determine1 on an annual basis1 no more than five percent of the total number of ordering professionals who are outlier ordering professionals4 7,b7 ,outlier ordering professionals ,the determination of an outlier ordering professional shall-- 7i7 be based on low adherence to applicable appropriate use criteria specified under paragraph 7#b71 which may be based on comparison to other ordering professionals2 and 7ii7 include data for ordering professionals for whom prior authorization under paragraph 7#f77;,a7 applies4 7,c7 ,use of two years of data ,the ,secretary shall use two years of data to identify outlier ordering professionals under this paragraph4 7,d7 ,process ,the ,secretary shall establish a process for determining when an outlier ordering professional is no longer an outlier ordering professional4 7,e7 ,consultation with stakeholders ,the ,secretary shall consult with physicians1 practitioners and other stakeholders in developing methods to identify outlier ordering professionals under this paragraph4 7#f7 ,prior authorization for ordering professionals who are outliers 7,a7 ,in general ,beginning ,january #a1 #bjbj1 subject to paragraph 7#d77;,c71 with respect to services furnished during a year1 the ,secretary shall1 for a period determined appropriate by the ,secretary1 apply prior authorization for applicable imaging services that are ordered by an outlier ordering professional identified under paragraph 7#e74 7,b7 ,appropriate use criteria in prior authorization ,in applying prior authorization under subparagraph 7,a71 the ,secretary shall utilize only the applicable appropriate use criteria specified under this subsection4 7,c7 ,funding ,for purposes of carrying out this paragraph1 the ,secretary shall provide for the transfer1 from the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda1 of #e1jjj1jjj to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account for each of fiscal years #bjai through #bjba4 ,amounts transferred under the preceding sentence shall remain available until expended4 7#g7 ,construction ,nothing in this subsection shall be construed as granting the ,secretary the authority to develop or initiate the development of clinical practice guidelines or appropriate use criteria4 4 7#b7 ,conforming amendment ,section #ahcc7t77#af7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77#af77 is amended by adding at the end the following new subparagraph3 7,e7 ,application of appropriate use criteria for certain imaging services ,for provisions relating to the application of appropriate use criteria for certain imaging services1 see section #ahcd7q74 4 7#c7 ,report on experience of imaging appropriate use criteria program ,not later than #ah months after the date of the enactment of this ,act1 the ,comptroller ,general of the ,united ,states shall submit to ,congress a report that includes a description of the extent to which appropriate use criteria could be used for other services under part ,b of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;j et seq471 such as radiation therapy and clinical diagnostic laboratory services4 #bai4 ,using funding from ,transitional ,fund for ,sustainable ,growth ,rate 7,,sgr7 ,reform ,section #ahih7;b77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;iii7b77#a77 is amended by striking #b1cjj1jjj1jjj and inserting #j4 #bbj4 ,ensuring accurate valuation of services under the physician fee schedule 7a7 ,authority ,to collect and use information on physicians' services in the determination of relative values 7#a7 ,in general ,section #ahdh7;c77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is amended by adding at the end the following new subparagraph3 7,m7 ,authority to collect and use information on physicians' services in the determination of relative values 7i7 ,collection of information ,notwithstanding any other provision of law1 the ,secretary may collect or obtain information on the resources directly or indirectly related to furnishing services for which payment is made under the fee schedule established under subsection 7b74 ,such information may be collected or obtained from any eligible professional or any other source4 7ii7 ,use of information ,notwithstanding any other provision of law1 subject to clause 7v71 the ,secretary may 7as the ,secretary determines appropriate7 use information collected or obtained pursuant to clause 7i7 in the determination of relative values for services under this section4 7iii7 ,types of information ,the types of information described in clauses 7i7 and 7ii7 may1 at the ,secretary's discretion1 include any or all of the following3 7,i7 ,time involved in furnishing services4 7,,ii7 ,amounts and types of practice expense inputs involved with furnishing services4 7,,iii7 ,prices 7net of any discounts7 for practice expense inputs1 which may include paid invoice prices or other documentation or records4 7,,iv7 ,overhead and accounting information for practices of physicians and other suppliers4 7,v7 ,any other element that would improve the valuation of services under this section4 7iv7 ,information collection mechanisms ,information may be collected or obtained pursuant to this subparagraph from any or all of the following3 7,i7 ,surveys of physicians1 other suppliers1 providers of services1 manufacturers1 and vendors4 7,,ii7 ,surgical logs1 billing systems1 or other practice or facility records4 7,,iii7 ,electronic health records4 7,,iv7 ,any other mechanism determined appropriate by the ,secretary4 7v7 ,transparency of use of information 7,i7 ,in general ,subject to subclauses 7,,ii7 and 7,,iii71 if the ,secretary uses information collected or obtained under this subparagraph in the determination of relative values under this subsection1 the ,secretary shall disclose the information source and discuss the use of such information in such determination of relative values through notice and comment rulemaking4 7,,ii7 ,thresholds for use ,the ,secretary may establish thresholds in order to use such information1 including the exclusion of information collected or obtained from eligible professionals who use very high resources 7as determined by the ,secretary7 in furnishing a service4 7,,iii7 ,disclosure of information ,the ,secretary shall make aggregate information available under this subparagraph but shall not disclose information in a form or manner that identifies an eligible professional or a group practice1 or information collected or obtained pursuant to a nondisclosure agreement4 7vi7 ,incentive to participate ,the ,secretary may provide for such payments under this part to an eligible professional that submits such solicited information under this subparagraph as the ,secretary determines appropriate in order to compensate such eligible professional for such submission4 ,such payments shall be provided in a form and manner specified by the ,secretary4 7vii7 ,administration ,chapter #ce of title #dd1 ,united ,states ,code1 shall not apply to information collected or obtained under this subparagraph4 7viii7 ,definition of eligible professional ,in this subparagraph1 the term eligible professional has the meaning given such term in subsection 7k77#c77;,b74 7ix7 ,funding ,for purposes of carrying out this subparagraph1 in addition to funds otherwise appropriated1 the ,secretary shall provide for the transfer1 from the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda1 of #b1jjj1jjj to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account for each fiscal year beginning with fiscal year #bjad4 ,amounts transferred under the preceding sentence for a fiscal year shall be available until expended4 4 7#b7 ,limitation on review ,section #ahdh7;i77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;i77#a77 is amended-- 7,a7 in subparagraph 7,d71 by striking and at the end2 7,b7 in subparagraph 7,e71 by striking the period at the end and inserting 1 and2 and 7,c7 by adding at the end the following new subparagraph3 7,f7 the collection and use of information in the determination of relative values under subsection 7c77#b77,m74 4 7b7 ,authority for alternative approaches ,to establishing practice expense relative values ,section #ahdh7;c77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b771 as amended by subsection 7a71 is amended by adding at the end the following new subparagraph3 7,n7 ,authority for alternative approaches to establishing practice expense relative values ,the ,secretary may establish or adjust practice expense relative values under this subsection using cost1 charge1 or other data from suppliers or providers of services1 including information collected or obtained under subparagraph 7,m74 4 7c7 ,revised and expanded identification of potentially misvalued codes ,section #ahdh7;c77#b77,k77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77,k77ii77 is amended to read as follows3 7ii7 ,identification of potentially misvalued codes ,for purposes of identifying potentially misvalued codes pursuant to clause 7i77,i71 the ,secretary shall examine codes 7and families of codes as appropriate7 based on any or all of the following criteria3 7,i7 ,codes that have experienced the fastest growth4 7,,ii7 ,codes that have experienced substantial changes in practice expenses4 7,,iii7 ,codes that describe new technologies or services within an appropriate time period 7such as #c years7 after the relative values are initially established for such codes4 7,,iv7 ,codes which are multiple codes that are frequently billed in conjunction with furnishing a single service4 7,v7 ,codes with low relative values1 particularly those that are often billed multiple times for a single treatment4 7,,vi7 ,codes that have not been subject to review since implementation of the fee schedule4 7,,vii7 ,codes that account for the majority of spending under the physician fee schedule4 7,,viii7 ,codes for services that have experienced a substantial change in the hospital length of stay or procedure time4 7,,ix7 ,codes for which there may be a change in the typical site of service since the code was last valued4 7,x7 ,codes for which there is a significant difference in payment for the same service between different sites of service4 7,,xi7 ,codes for which there may be anomalies in relative values within a family of codes4 7,,xii7 ,codes for services where there may be efficiencies when a service is furnished at the same time as other services4 7,,xiii7 ,codes with high intra-service work per unit of time4 7,,xiv7 ,codes with high practice expense relative value units4 7,,xv7 ,codes with high cost supplies4 7,,xvi7 ,codes as determined appropriate by the ,secretary4 4 7d7 ,target for relative value adjustments for misvalued services 7#a7 ,in general ,section #ahdh7;c77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b771 as amended by subsections 7a7 and 7b71 is amended by adding at the end the following new subparagraph3 7,o7 ,target for relative value adjustments for misvalued services ,with respect to fee schedules established for each of #bjag through #bjbj1 the following shall apply3 7i7 ,determination of net reduction in expenditures ,for each year1 the ,secretary shall determine the estimated net reduction in expenditures under the fee schedule under this section with respect to the year as a result of adjustments to the relative values established under this paragraph for misvalued codes4 7ii7 ,budget neutral redistribution of funds if target met and counting overages towards the target for the succeeding year ,if the estimated net reduction in expenditures determined under clause 7i7 for the year is equal to or greater than the target for the year-- 7,i7 reduced expenditures attributable to such adjustments shall be redistributed for the year in a budget neutral manner in accordance with subparagraph 7,b77ii77,,ii72 and 7,,ii7 the amount by which such reduced expenditures exceeds the target for the year shall be treated as a reduction in expenditures described in clause 7i7 for the succeeding year1 for purposes of determining whether the target has or has not been met under this subparagraph with respect to that year4 7iii7 ,exemption from budget neutrality if target not met ,if the estimated net reduction in expenditures determined under clause 7i7 for the year is less than the target for the year1 reduced expenditures in an amount equal to the target recapture amount shall not be taken into account in applying subparagraph 7,b77ii77,,ii7 with respect to fee schedules beginning with #bjag4 7iv7 ,target recapture amount ,for purposes of clause 7iii71 the target recapture amount is1 with respect to a year1 an amount equal to the difference between-- 7,i7 the target for the year2 and 7,,ii7 the estimated net reduction in expenditures determined under clause 7i7 for the year4 7v7 ,target ,for purposes of this subparagraph1 with respect to a year1 the target is calculated as #j4e percent of the estimated amount of expenditures under the fee schedule under this section for the year4 4 7#b7 ,conforming amendment ,section #ahdh7;c77#b77;,b77v7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77;,b77v77 is amended by adding at the end the following new subclause3 7,,viii7 ,reductions for misvalued services if target not met ,effective for fee schedules beginning with #bjag1 reduced expenditures attributable to the application of the target recapture amount described in subparagraph 7,o77iii74 4 7e7 ,phase-,in of significant relative value unit 7,,rvu7 reductions 7#a7 ,in general ,section #ahdh7;c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77 is amended by adding at the end the following new paragraph3 7#g7 ,phase-in of significant relative value unit 7,,rvu7 reductions ,effective for fee schedules established beginning with #bjag1 for services that are not new or revised codes1 if the total relative value units for a service for a year would otherwise be decreased by an estimated amount equal to or greater than #bj percent as compared to the total relative value units for the previous year1 the applicable adjustments in work1 practice expense1 and malpractice relative value units shall be phased-in over a #b-year period4 4 7#b7 ,conforming amendments ,section #ahdh7;c77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is amended-- 7,a7 in subparagraph 7,b77ii77,i71 by striking subclause 7,,ii7 and inserting subclause 7,,ii7 and paragraph 7#g72 and 7,b7 in subparagraph 7,k77iii77,,vi7-- 7i7 by striking provisions of subparagraph 7,b77ii77,,ii7 and inserting provisions of subparagraph 7,b77ii77,,ii7 and paragraph 7#g72 and 7ii7 by striking under subparagraph 7,b77ii77,,ii7 and inserting under subparagraph 7,b77ii77,i74 7f7 ,authority ,to smooth relative values within groups of services ,section #ahdh7;c77#b77;,c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77;,c77 is amended-- 7#a7 in each of clauses 7i7 and 7iii71 by striking the service and inserting the service or group of services each place it appears2 and 7#b7 in the first sentence of clause 7ii71 by inserting or group of services before the period4 7g7 ,,gao study and report on ,relative ,value ,scale ,update ,committee 7#a7 ,study ,the ,comptroller ,general of the ,united ,states 7in this subsection referred to as the ,comptroller ,general7 shall conduct a study of the processes used by the ,relative ,value ,scale ,update ,committee 7,,ruc7 to provide recommendations to the ,secretary of ,health and ,human ,services regarding relative values for specific services under the ,medicare physician fee schedule under section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d74 7#b7 ,report ,not later than #a year after the date of the enactment of this ,act1 the ,comptroller ,general shall submit to ,congress a report containing the results of the study conducted under paragraph 7#a74 7h7 ,adjustment to ,medicare payment localities 7#a7 ,in general ,section #ahdh7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;e77 is amended by adding at the end the following new paragraph3 7#f7 ,use of ,m,s,as as fee schedule areas in ,california 7,a7 ,in general ,subject to the succeeding provisions of this paragraph and notwithstanding the previous provisions of this subsection1 for services furnished on or after ,january #a1 #bjag1 the fee schedule areas used for payment under this section applicable to ,california shall be the following3 7i7 ,each ,metropolitan ,statistical ,area 7each in this paragraph referred to as an ,,msa71 as defined by the ,director of the ,office of ,management and ,budget as of ,december #ca of the previous year1 shall be a fee schedule area4 7ii7 ,all areas not included in an ,,msa shall be treated as a single rest-of-,state fee schedule area4 7,b7 ,transition for ,m,s,as previously in rest-of-,state payment locality or in locality #c 7i7 ,in general ,for services furnished in ,california during a year beginning with #bjag and ending with #bjba in an ,,msa in a transition area 7as defined in subparagraph 7,d771 subject to subparagraph 7,c71 the geographic index values to be applied under this subsection for such year shall be equal to the sum of the following3 7,i7 ,current law component ,the old weighting factor 7described in clause 7ii77 for such year multiplied by the geographic index values under this subsection for the fee schedule area that included such ,,msa that would have applied in such area 7as estimated by the ,secretary7 if this paragraph did not apply4 7,,ii7 ,,msa-based component ,the ,,msa-based weighting factor 7described in clause 7iii77 for such year multiplied by the geographic index values computed for the fee schedule area under subparagraph 7,a7 for the year 7determined without regard to this subparagraph74 7ii7 ,old weighting factor ,the old weighting factor described in this clause-- 7,i7 for #bjag1 is #e_/f2 and 7,,ii7 for each succeeding year1 is the old weighting factor described in this clause for the previous year minus #a_/f4 7iii7 ,,msa-based weighting factor ,the ,,msa-based weighting factor described in this clause for a year is #a minus the old weighting factor under clause 7ii7 for that year4 7,c7 ,hold harmless ,for services furnished in a transition area in ,california during a year beginning with #bjag1 the geographic index values to be applied under this subsection for such year shall not be less than the corresponding geographic index values that would have applied in such transition area 7as estimated by the ,secretary7 if this paragraph did not apply4 7,d7 ,transition area defined ,in this paragraph1 the term transition area means each of the following fee schedule areas for #bjac3 7i7 ,the rest-of-,state payment locality4 7ii7 ,payment locality #c4 7,e7 ,references to fee schedule areas ,effective for services furnished on or after ,january #a1 #bjag1 for ,california1 any reference in this section to a fee schedule area shall be deemed a reference to a fee schedule area established in accordance with this paragraph4 4 7#b7 ,conforming amendment to definition of fee schedule area ,section #ahdh7;j77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;j77#b77 is amended by striking ,the term and inserting ,except as provided in subsection 7e77#f77;,d71 the term4 7i7 ,disclosure of data used ,to establish multiple procedure payment reduction policy ,the ,secretary of ,health and ,human ,services shall make publicly available the information used to establish the multiple procedure payment reduction policy to the professional component of imaging services in the final rule published in the ,federal ,register1 v4 #gg1 n4 #bbb1 ,november #af1 #bjab1 pages #fhhia-fichj under the physician fee schedule under section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d74 #bba4 ,medicaid ,,dsh 7a7 ,modifications of reductions to allotments ,section #aibc7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#d7;f77 is amended-- 7#a7 in paragraph 7#g77;,a7-- 7,a7 in clause 7i71 by striking #bjaf through #bjbj and inserting #bjag through #bjbd2 and 7,b7 in clause 7ii71 by striking subclauses 7,i7 through 7,,iv71 and inserting the following3 7,i7 #a1hjj1jjj1jjj for fiscal year #bjag2 7,,ii7 #d1gjj1jjj1jjj for fiscal year #bjah2 7,,iii7 #d1gjj1jjj1jjj for fiscal year #bjai2 7,,iv7 #d1gjj1jjj1jjj for fiscal year #bjbj2 7,v7 #d1hjj1jjj1jjj for fiscal year #bjba2 7,,vi7 #e1jjj1jjj1jjj for fiscal year #bjbb2 7,,vii7 #e1jjj1jjj1jjj for fiscal year #bjbc2 and 7,,viii7 #d1djj1jjj1jjj for fiscal year #bjbd4 2 and 7#b7 by striking paragraph 7#h7 and inserting the following3 7#h7 ,calculation of ,,dsh allotments after reductions period ,the ,,dsh allotment for a ,state for fiscal years after fiscal year #bjbd shall be calculated under paragraph 7#c7 without regard to paragraph 7#g74 4 7b7 ,,macpac review and report ,section #aijj7;b77#f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif7;b77#f77 is amended-- 7#a7 by striking ,,macpac shall consult and inserting the following3 7,a7 ,in general ,,macpac shall consult 2 and 7#b7 by adding at the end the following3 7,b7 ,review and reports regarding ,medicaid ,,dsh 7i7 ,in general ,,macpac shall review and submit an annual report to ,congress on disproportionate share hospital payments under section #aibc4 ,each report shall include the information specified in clause 7ii74 7ii7 ,required report information ,each report required under this subparagraph shall include the following3 7,i7 ,data relating to changes in the number of uninsured individuals4 7,,ii7 ,data relating to the amount and sources of hospitals' uncompensated care costs1 including the amount of such costs that are the result of providing unreimbursed or under-reimbursed services1 charity care1 or bad debt4 7,,iii7 ,data identifying hospitals with high levels of uncompensated care that also provide access to essential community services for low-income1 uninsured1 and vulnerable populations1 such as graduate medical education1 and the continuum of primary through quarternary care1 including the provision of trauma care and public health services4 7,,iv7 ,state-specific analyses regarding the relationship between the most recent ,state ,,dsh allotment and the projected ,state ,,dsh allotment for the succeeding year and the data reported under subclauses 7,i71 7,,ii71 and 7,,iii7 for the ,state4 7iii7 ,data ,notwithstanding any other provision of law1 the ,secretary regularly shall provide ,,macpac with the most recent ,state reports and most recent independent certified audits submitted under section #aibc7;j71 cost reports submitted under title ,,xviii1 and such other data as ,,macpac may request for purposes of conducting the reviews and preparing and submitting the annual reports required under this subparagraph4 7iv7 ,submission deadlines ,the first report required under this subparagraph shall be submitted to ,congress not later than ,february #a1 #bjaf4 ,subsequent reports shall be submitted as part of1 or with1 each annual report required under paragraph 7#a77;,c7 during the period of fiscal years #bjag through #bjbd4 4 #bbb4 ,realignment of the ,medicare sequester for fiscal year #bjbd ,paragraph 7#f7 7relating to implementing direct spending reductions7 of section #bea;,a of the ,balanced ,budget and ,emergency ,deficit ,control ,act of #aihe 7#b ,u4,s4,c4 #ija;a7 is amended by adding at the end the following new subparagraph3 7,d7 ,notwithstanding the #b percent limit specified in subparagraph 7,a7 for payments for the ,medicare programs specified in section #bef7;d71 the sequestration order of the ,president under such subparagraph for fiscal year #bjbd shall be applied to such payments so that-- 7i7 with respect to the first #f months in which such order is effective for such fiscal year1 the payment reduction shall be #d4j percent2 and 7ii7 with respect to the second #f months in which such order is so effective for such fiscal year1 the payment reduction shall be #j4j percent4 4 #bbc4 ,demonstration programs to improve community mental health services 7a7 ,criteria for certified community behavioral health clinics ,to participate in demonstration programs 7#a7 ,publication ,not later than ,september #a1 #bjae1 the ,secretary shall publish criteria for a clinic to be certified by a ,state as a certified community behavioral health clinic for purposes of participating in a demonstration program conducted under subsection 7d74 7#b7 ,requirements ,the criteria published under this subsection shall include criteria with respect to the following3 7,a7 ,staffing ,staffing requirements1 including criteria that staff have diverse disciplinary backgrounds1 have necessary ,state-required license and accreditation1 and are culturally and linguistically trained to serve the needs of the clinic's patient population4 7,b7 ,availability and accessibility of services ,availability and accessibility of services1 including crisis management services that are available and accessible #bd hours a day1 the use of a sliding scale for payment1 and no rejection for services or limiting of services on the basis of a patient's ability to pay or a place of residence4 7,c7 ,care coordination ,care coordination1 including requirements to coordinate care across settings and providers to ensure seamless transitions for patients across the full spectrum of health services including acute1 chronic1 and behavioral health needs4 ,care coordination requirements shall include partnerships or formal contracts with the following3 7i7 ,federally-qualified health centers 7and as applicable1 rural health clinics7 to provide ,federally-qualified health center services 7and as applicable1 rural health clinic services7 to the extent such services are not provided directly through the certified community behavioral health clinic4 7ii7 ,inpatient psychiatric facilities and substance use detoxification1 post-detoxification step-down services1 and residential programs4 7iii7 ,other community or regional services1 supports1 and providers1 including schools1 child welfare agencies1 juvenile and criminal justice agencies and facilities1 ,indian ,health ,service youth regional treatment centers1 ,state licensed and nationally accredited child placing agencies for therapeutic foster care service1 and other social and human services4 7iv7 ,department of ,veterans ,affairs medical centers1 independent outpatient clinics1 drop-in centers1 and other facilities of the ,department as defined in section #ahja of title #ch1 ,united ,states ,code4 7v7 ,inpatient acute care hospitals and hospital outpatient clinics4 7,d7 ,scope of services ,provision 7in a manner reflecting person-centered care7 of the following services which1 if not available directly through the certified community behavioral health clinic1 are provided or referred through formal relationships with other providers3 7i7 ,crisis mental health services1 including #bd-;hour mobile crisis teams1 emergency crisis intervention services1 and crisis stabilization4 7ii7 ,screening1 assessment1 and diagnosis1 including risk assessment4 7iii7 ,patient-centered treatment planning or similar processes1 including risk assessment and crisis planning4 7iv7 ,outpatient mental health and substance use services4 7v7 ,outpatient clinic primary care screening and monitoring of key health indicators and health risk4 7vi7 ,targeted case management4 7vii7 ,psychiatric rehabilitation services4 7viii7 ,peer support and counselor services and family supports4 7ix7 ,intensive1 community-based mental health care for members of the armed forces and veterans1 particularly those members and veterans located in rural areas1 provided the care is consistent with minimum clinical mental health guidelines promulgated by the ,veterans ,health ,administration including clinical guidelines contained in the ,uniform ,mental ,health ,services ,handbook of such ,administration4 7,e7 ,quality and other reporting ,reporting of encounter data1 clinical outcomes data1 quality data1 and such other data as the ,secretary requires4 7,f7 ,organizational authority ,criteria that a clinic be a non-profit or part of a local government behavioral health authority or operated under the authority of the ,indian ,health ,service1 an ,indian tribe or tribal organization pursuant to a contract1 grant1 cooperative agreement1 or compact with the ,indian ,health ,service pursuant to the ,indian ,self-,determination ,act 7#be ,u4,s4,c4 #dej et seq471 or an urban ,indian organization pursuant to a grant or contract with the ,indian ,health ,service under title ,v of the ,indian ,health ,care ,improvement ,act 7#be ,u4,s4,c4 #afja et seq474 7b7 ,guidance on development of prospective payment system for testing under demonstration programs 7#a7 ,in general ,not later than ,september #a1 #bjae1 the ,secretary1 through the ,administrator of the ,centers for ,medicare ,medicaid ,services1 shall issue guidance for the establishment of a prospective payment system that shall only apply to medical assistance for mental health services furnished by a certified community behavioral health clinic participating in a demonstration program under subsection 7d74 7#b7 ,requirements ,the guidance issued by the ,secretary under paragraph 7#a7 shall provide that-- 7,a7 no payment shall be made for inpatient care1 residential treatment1 room and board expenses1 or any other non-ambulatory services1 as determined by the ,secretary2 and 7,b7 no payment shall be made to satellite facilities of certified community behavioral health clinics if such facilities are established after the date of enactment of this ,act4 7c7 ,planning grants 7#a7 ,in general ,not later than ,january #a1 #bjaf1 the ,secretary shall award planning grants to ,states for the purpose of developing proposals to participate in time-limited demonstration programs described in subsection 7d74 7#b7 ,use of funds ,a ,state awarded a planning grant under this subsection shall-- 7,a7 solicit input with respect to the development of such a demonstration program from patients1 providers1 and other stakeholders2 7,b7 certify clinics as certified community behavioral health clinics for purposes of participating in a demonstration program conducted under subsection 7d72 and 7,c7 establish a prospective payment system for mental health services furnished by a certified community behavioral health clinic participating in a demonstration program under subsection 7d7 in accordance with the guidance issued under subsection 7b74 7d7 ,demonstration programs 7#a7 ,in general ,not later than ,september #a1 #bjag1 the ,secretary shall select ,states to participate in demonstration programs that are developed through planning grants awarded under subsection 7c71 meet the requirements of this subsection1 and represent a diverse selection of geographic areas1 including rural and underserved areas4 7#b7 ,application requirements 7,a7 ,in general ,the ,secretary shall solicit applications to participate in demonstration programs under this subsection solely from ,states awarded planning grants under subsection 7c74 7,b7 ,required information ,an application for a demonstration program under this subsection shall include the following3 7i7 ,the target ,medicaid population to be served under the demonstration program4 7ii7 ,a list of participating certified community behavioral health clinics4 7iii7 ,verification that the ,state has certified a participating clinic as a certified community behavioral health clinic in accordance with the requirements of subsection 7b74 7iv7 ,a description of the scope of the mental health services available under the ,state ,medicaid program that will be paid for under the prospective payment system tested in the demonstration program4 7v7 ,verification that the ,state has agreed to pay for such services at the rate established under the prospective payment system4 7vi7 ,such other information as the ,secretary may require relating to the demonstration program including with respect to determining the soundness of the proposed prospective payment system4 7#c7 ,number and length of demonstration programs ,not more than #h ,states shall be selected for #b-year demonstration programs under this subsection4 7#d7 ,requirements for selecting demonstration programs 7,a7 ,in general ,the ,secretary shall give preference to selecting demonstration programs where participating certified community behavioral health clinics-- 7i7 provide the most complete scope of services described in subsection 7a77#b77;,d7 to individuals eligible for medical assistance under the ,state ,medicaid program2 7ii7 will improve availability of1 access to1 and participation in1 services described in subsection 7a77#b77;,d7 to individuals eligible for medical assistance under the ,state ,medicaid program2 7iii7 will improve availability of1 access to1 and participation in assisted outpatient mental health treatment in the ,state2 or 7iv7 demonstrate the potential to expand available mental health services in a demonstration area and increase the quality of such services without increasing net ,federal spending4 7#e7 ,payment for medical assistance for mental health services provided by certified community behavioral health clinics 7,a7 ,in general ,the ,secretary shall pay a ,state participating in a demonstration program under this subsection the ,federal matching percentage specified in subparagraph 7,b7 for amounts expended by the ,state to provide medical assistance for mental health services described in the demonstration program application in accordance with paragraph 7#b77;,b77iv7 that are provided by certified community behavioral health clinics to individuals who are enrolled in the ,state ,medicaid program4 ,payments to ,states made under this paragraph shall be considered to have been under1 and are subject to the requirements of1 section #aijc of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b74 7,b7 ,federal matching percentage ,the ,federal matching percentage specified in this subparagraph is with respect to medical assistance described in subparagraph 7,a7 that is furnished-- 7i7 to a newly eligible individual described in paragraph 7#b7 of section #aije7y7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7y771 the matching rate applicable under paragraph 7#a7 of that section2 and 7ii7 to an individual who is not a newly eligible individual 7as so described7 but who is eligible for medical assistance under the ,state ,medicaid program1 the enhanced ,,fmap applicable to the ,state4 7,c7 ,limitations 7i7 ,in general ,payments shall be made under this paragraph to a ,state only for mental health services-- 7,i7 that are described in the demonstration program application in accordance with paragraph 7#b77;iv72 7,,ii7 for which payment is available under the ,state ,medicaid program2 and 7,,iii7 that are provided to an individual who is eligible for medical assistance under the ,state ,medicaid program4 7ii7 ,prohibited payments ,no payment shall be made under this paragraph-- 7,i7 for inpatient care1 residential treatment1 room and board expenses1 or any other non-ambulatory services1 as determined by the ,secretary2 or 7,,ii7 with respect to payments made to satellite facilities of certified community behavioral health clinics if such facilities are established after the date of enactment of this ,act4 7#f7 ,waiver of statewideness requirement ,the ,secretary shall waive section #aijb7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77#a77 7relating to statewideness7 as may be necessary to conduct demonstration programs in accordance with the requirements of this subsection4 7#g7 ,annual reports 7,a7 ,in general ,not later than #a year after the date on which the first ,state is selected for a demonstration program under this subsection1 and annually thereafter1 the ,secretary shall submit to ,congress an annual report on the use of funds provided under all demonstration programs conducted under this subsection4 ,each such report shall include-- 7i7 an assessment of access to community-based mental health services under the ,medicaid program in the area or areas of a ,state targeted by a demonstration program compared to other areas of the ,state2 7ii7 an assessment of the quality and scope of services provided by certified community behavioral health clinics compared to community-based mental health services provided in ,states not participating in a demonstration program under this subsection and in areas of a demonstration ,state that are not participating in the demonstration program2 and 7iii7 an assessment of the impact of the demonstration programs on the ,federal and ,state costs of a full range of mental health services 7including inpatient1 emergency and ambulatory services74 7,b7 ,recommendations ,not later than ,december #ca1 #bjba1 the ,secretary shall submit to ,congress recommendations concerning whether the demonstration programs under this section should be continued1 expanded1 modified1 or terminated4 7e7 ,definitions ,in this section3 7#a7 ,federally-qualified health center services2 ,federally-qualified health center2 rural health clinic services2 rural health clinic ,the terms ,federally-qualified health center services1 ,federally-qualified health center1 rural health clinic services1 and rural health clinic have the meanings given those terms in section #aije7l7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7l774 7#b7 ,enhanced ,,fmap ,the term enhanced ,,fmap has the meaning given that term in section #baje7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;dd7b77 but without regard to the second and third sentences of that section4 7#c7 ,secretary ,the term ,secretary means the ,secretary of ,health and ,human ,services4 7#d7 ,state ,the term ,state has the meaning given such term for purposes of title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq474 7f7 ,funding 7#a7 ,in general ,out of any funds in the ,treasury not otherwise appropriated1 there is appropriated to the ,secretary-- 7,a7 for purposes of carrying out subsections 7a71 7b71 and 7d77#g71 #b1jjj1jjj for fiscal year #bjad2 and 7,b7 for purposes of awarding planning grants under subsection 7c71 #be1jjj1jjj for fiscal year #bjaf4 7#b7 ,availability ,funds appropriated under paragraph 7#a7 shall remain available until expended4 #bbd4 ,assisted outpatient treatment grant program for individuals with serious mental illness 7a7 ,in general ,the ,secretary shall establish a #d-year pilot program to award not more than #ej grants each year to eligible entities for assisted outpatient treatment programs for individuals with serious mental illness4 7b7 ,consultation ,the ,secretary shall carry out this section in consultation with the ,director of the ,national ,institute of ,mental ,health1 the ,attorney ,general of the ,united ,states1 the ,administrator of the ,administration for ,community ,living1 and the ,administrator of the ,substance ,abuse and ,mental ,health ,services ,administration4 7c7 ,selecting among applicants ,the ,secretary-- 7#a7 may only award grants under this section to applicants that have not previously implemented an assisted outpatient treatment program2 and 7#b7 shall evaluate applicants based on their potential to reduce hospitalization1 homelessness1 incarceration1 and interaction with the criminal justice system while improving the health and social outcomes of the patient4 7d7 ,use of grant ,an assisted outpatient treatment program funded with a grant awarded under this section shall include-- 7#a7 evaluating the medical and social needs of the patients who are participating in the program2 7#b7 preparing and executing treatment plans for such patients that-- 7,a7 include criteria for completion of court-ordered treatment2 and 7,b7 provide for monitoring of the patient's compliance with the treatment plan1 including compliance with medication and other treatment regimens2 7#c7 providing for such patients case management services that support the treatment plan2 7#d7 ensuring appropriate referrals to medical and social service providers2 7#e7 evaluating the process for implementing the program to ensure consistency with the patient's needs and ,state law2 and 7#f7 measuring treatment outcomes1 including health and social outcomes such as rates of incarceration1 health care utilization1 and homelessness4 7e7 ,report ,not later than the end of each of fiscal years #bjaf1 #bjag1 and #bjah1 the ,secretary shall submit a report to the appropriate congressional committees on the grant program under this section4 ,each such report shall include an evaluation of the following3 7#a7 ,cost savings and public health outcomes such as mortality1 suicide1 substance abuse1 hospitalization1 and use of services4 7#b7 ,rates of incarceration by patients4 7#c7 ,rates of homelessness among patients4 7#d7 ,patient and family satisfaction with program participation4 7f7 ,definitions ,in this section3 7#a7 ,the term assisted outpatient treatment means medically prescribed mental health treatment that a patient receives while living in a community under the terms of a law authorizing a ,state or local court to order such treatment4 7#b7 ,the term eligible entity means a county1 city1 mental health system1 mental health court1 or any other entity with authority under the law of the ,state in which the grantee is located to implement1 monitor1 and oversee assisted outpatient treatment programs4 7#c7 ,the term ,secretary means the ,secretary of ,health and ,human ,services4 7g7 ,funding 7#a7 ,amount of grants ,a grant under this section shall be in an amount that is not more than #a1jjj1jjj for each of fiscal years #bjae through #bjah4 ,subject to the preceding sentence1 the ,secretary shall determine the amount of each grant based on the population of the area1 including estimated patients1 to be served under the grant4 7#b7 ,authorization of appropriations ,there is authorized to be appropriated to carry out this section #ae1jjj1jjj for each of fiscal years #bjae through #bjah4 #bbe4 ,exclusion from ,,paygo scorecards 7a7 ,statutory ,pay-,as-,you-,go scorecards ,the budgetary effects of this ,act shall not be entered on either ,,paygo scorecard maintained pursuant to section #d7;d7 of the ,statutory ,pay-,as-,you-,go ,act of #bjaj4 7b7 ,senate ,,paygo scorecards ,the budgetary effects of this ,act shall not be entered on any ,,paygo scorecard maintained for purposes of section #bja of ,s4 ,con4 ,res4 #ba 7#aajth ,congress74