,i #aac? ,,congress #a/ ,session ,h4 ,r4 #egd ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,febru>y #f1 #bjac ,ms4 ,s*w>tz 7= h]self1 ,mr4 ,heck ( ,nevada1 ,mr4 ,blum5au]1 ,mrs4 ,*ri/5s51 ,mr4 ,c>ney1 ,mr4 ,c\rtney1 ,mr4 ,polis1 ,mr4 ,fattah1 & ,ms4 ,ca/or ( ,florida7 introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,en]gy & ,comm]ce1 & 9 addition to ! ,committee on ,ways & ,means1 = a p]iod to be subsequ5tly det]m9$ by ! ,speak]1 9 ea* case = consid]ation ( su* provisions z fall )9 ! jurisdiction ( ! committee conc]n$ ,a ,,bill ,to am5d "p ,b ( title ,,xviii ( ! ,social ,security ,act to re=m ,m$ic>e paym5t = physicians' s]vices by elim9at+ ! su/a9able gr[? rate sy/em & provid+ inc5tives = ! adoption ( innovative paym5t & deliv]y models to improve quality & effici5cy4 #a4 ,%ort title2 purpose 7a7 ,%ort title ,?is ,act may be cit$ z ! ,m$ic>e ,physician ,paym5t ,innovation ,act ( #bjac4 7b7 ,purpose ,! purpose ( ?is ,act is to re=m ! sy/em ( ,m$ic>e paym5t = physicians' s]vices-- 7#a7 by end+ ! application ( ! su/a9able gr[? rate 7,,sgr7 sy/em2 7#b7 to /abilize paym5ts = #bjad2 7#c7 to promote ! rapid developm5t & implem5tation ( alt]native improv$ paym5t & deliv]y models t inc5tivize high quality1 high-value c>e2 & 7#d7 to provide cont9u+ inc5tives = adoption ( su* alt]native paym5t & deliv]y models by physicians & o!r provid]s4 #b4 ,m$ic>e physician paym5t re=m 7a7 ,repeal ( ,,sgr paym5t me?odology ,section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is am5d$-- 7#a7 9 subsection 7d7-- 7,a7 9 p>agraph 7#a77;,a71 by ins]t+ or a subsequ5t p>agraph aft] p>agraph 7#d72 & 7,b7 9 p>agraph 7#d7-- 7i7 9 ! head+1 by /rik+ ye>s beg9n+ ) #bjja & ins]t+ #bjja1 #bjjb1 & #bjjc2 & 7ii7 9 subp>agraph 7,a71 by /rik+ a ye> beg9n+ ) #bjja & ins]t+ #bjja1 #bjjb1 & #bjjc2 & 7#b7 9 subsection 7f7-- 7,a7 9 p>agraph 7#a77;,b71 by ins]t+ ?r\gh #bjac aft] ( su* succe$+ ye>2 & 7,b7 9 p>agraph 7#b71 by ins]t+ & end+ ) #bjac aft] beg9n+ ) #bjjj4 7b7 ,/abiliz+ #bjad paym5t rates at curr5t level 7#a7 ,9 g5]al ,subsection 7d7 ( section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 z am5d$ by section #fja ( ! ,am]ican ,taxpay] ,relief ,act ( #bjab 7,public ,law #aab-bdj71 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#ae7 ,update = #bjad ,9 lieu ( ! update to ! s+le conv]sion factor e/abli%$ 9 p>agraph 7#a77;,c7 t w\ld o!rwise apply = #bjad1 ! update to ! s+le conv]sion factor %all be #j p]c5t = #bjad4 4 7#b7 ,te*nical am5dm5t ,effective = ye>s beg9n+ ) #bjad1 subp>agraph 7,c77i7 ( p>agraph 7#g7 ( section #ahdh7m7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#g77;,c77i72 relat+ to additional inc5tive paym5t7 is am5d$ by ins]t+ 1 ! program ( ,o/eopa?ic ,cont9u\s ,c]tification ( ! ,am]ican ,o/eopa?ic ,association1 aft] ,specialties ,ma9t5ance ( ,c]tification program4 7c7 ,e/abli%m5t ( diff]5tial updates beg9n+ ) #bjae ,to promote access to prim>y c>e s]vices 7#a7 ,e/abli%m5t ( s]vice categories ,subsection 7j7 ( section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is am5d$ by add+ at ! end ! foll[+ new p>agraphs3 7#e7 ,s]vice categories 7,a7 ,9 g5]al ,= s]vices furni%$ on or aft] ,janu>y #a1 #bjae1 ea* ( ! foll[+ categories ( s]vices %all be treat$ z a sep>ate s]vice category3 7i7 ,prim>y c>e ,prim>y c>e s]vices 7z def9$ 9 subp>agraph 7,b77 furni%$ by a qualify+ practition]4 7ii7 ,o!r s]vices ,o!r physicians' s]vices4 7,b7 ,prim>y c>e s]vices ,9 ?is subsection1 ! t]m prim>y c>e s]vices means s]vices id5tifi$1 z ( ,april #a1 #bjac1 ) ! foll[+ ,,hcpcs codes 7& z subsequ5tly modifi$ by ! ,secret>y73 7i7 ,(fice & outpati5t visits #iibja ?r\gh #iibae4 7ii7 ,hospital obs]vational s]vices #iibag ?r\gh #iibbj4 7iii7 ,hospital inpati5t visits s]vices #iibba ?r\gh #iibci4 7iv7 ,nurs+ home1 domicili>y1 re/ home or cu/odial c>e visits #iicjd ?r\gh #iicdj4 7v7 ,home s]vice visits #iicda ?r\gh #iicej4 7vi7 ,welcome to ,m$ic>e visit ,g#jdjb4 7vii7 ,annual wellness visits ,g#jdch & ,g#jdci4 7,c7 ,inclusion ( prev5tive s]vices ,su* t]m also includes prev5tive s]vices describ$ 9 section #ahfa7;ddd77#c7 & additional prev5tive s]vices describ$ 9 section #ahfa7;ddd77#a74 7,d7 ,inclusion ( additional s]vices ,su* t]m also includes s]vices1 su* z c>e coord9ation s]vices1 telem$ic9e s]vices1 non-face-to-face c>e managem5t s]vices1 prep>ation & sup]vision ( long-t]m c>e plans1 home c>e plan ov]sight s]vices1 & simil> s]vices t ! ,secret>y id5tifies1 by regulation1 z be+ simil> to ! s]vices describ$ 9 subp>agraph 7,b7 or 7,c74 7#f7 ,qualify+ practition] ,! t]m qualify+ practition] means1 ) respect to ! furni%+ ( prim>y c>e s]vices1 an individual-- 7,a7 = :om prim>y c>e s]vices has acc\nt$ = at lea/ #fj p]c5t ( ! all[$ *>ges "u ?is "p 7n c\nt+ any su* *>ges attributable to 9-(fice cl9ical laboratory s]vices7 9 a prior p]iod z det]m9$ by ! ,secret>y2 or 7,b7 :o does n h claims "u ?is "p dur+ su* a prior p]iod & :om ! ,secret>y det]m9es is likely to meet ! requirem5t ( subp>agraph 7,a7 = ! subsequ5t p]iod4 4 7#b7 ,e/abli%m5t ( sep>ate conv]sion factors = ea* s]vice category ,section #ahdh7;d77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;d77#a771 z am5d$ by subsection 7a77#a77;,a71 is fur!r am5d$-- 7,a7 9 subp>agraph 7,a7-- 7i7 by designat+ ! s5t5ce beg9n+ ,! conv]sion factor z clause 7i7 ) ! head+ ,application ( s+le conv]sion factor4-- & ) appropriate ind5tation2 7ii7 by /rik+ ,! conv]sion factor & ins]t+ ,subject to clause 7ii71 ! conv]sion factor2 & 7iii7 by add+ at ! end ! foll[+ new clause3 7ii7 ,application ( multiple conv]sion factors beg9n+ ) #bjae 7,i7 ,9 g5]al ,9 apply+ clause 7i7 = ea* ye> beg9n+ ) #bjae1 sep>ate conv]sion factors %all be e/abli%$ = ea* s]vice category ( physicians' s]vices 7z def9$ 9 subsection 7j77#e77;,a77 & any ref]5ce 9 ?is section to a conv]sion factor = su* ye>s %all be deem$ a ref]5ce to ! conv]sion factor = ea* ( su* categories4 7,,ii7 ,initial conv]sion factors ,su* factors = #bjae %all be bas$ ^u ! s+le conv]sion factor = ! previ\s ye> multipli$ by ! update e/abli%$ "u p>agraph 7#af7 = su* category = #bjae4 7,,iii7 ,updat+ ( conv]sion factors ,su* factor = a s]vice category = a subsequ5t ye> %all be bas$ ^u ! conv]sion factor = su* category = ! previ\s ye> & adju/$ by ! update e/abli%$ = su* category "u p>agraph 7#af7 or a subsequ5t p>agraph = ! ye> involv$4 2 & 7,b7 9 subp>agraph 7,d71 by /rik+ o!r physicians' s]vices & ins]t+ = physicians' s]vices 9 ! s]vice category describ$ 9 subsection 7j77#e77;,a77ii774 7#c7 ,e/abli%m5t ( sep>ate updates = conv]sion factors = ea* s]vice category ,section #ahdh7;d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;d771 z am5d$ by subsection 7b71 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#af7 ,updates by s]vice category beg9n+ ) #bjae2 updates = #bjae ?r\gh #bjah ,9 apply+ p>agraph 7#d7 = ea* ye> beg9n+ ) #bjae1 ! foll[+ rules apply3 7,a7 ,application ( sep>ate update adju/m5ts = ea* s]vice category ,pursuant to p>agraph 7#a77;,a77ii77,i71 = ea* ye> beg9n+ ) #bjad1 ! update %all be made to ! conv]sion factor = ea* s]vice category 7z def9$ 9 subsection 7j77#e77;,a774 7,b7 ,updates = #bjae ?r\gh #bjah ,! updates = #bjae1 #bjaf1 #bjag1 & #bjah = ! conv]sion factor = ! s]vices category describ$ 9-- 7i7 subsection 7j77#e77;,a77i7 %all be #b4e p]c5t2 & 7ii7 subsection 7j77#e77;,a77ii7 %all be #j4e p]c5t4 4 7d7 ,promot+ te/+ & evaluation ( new paym5t & deliv]y models 7,phase ,i7 7#a7 ,expansion ( te/+ 9 multiple geographic regions ,section #aaae;,a7a77#e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7a77#e77 is am5d$ by ins]t+ be=e ! p]iod at ! end ! foll[+3 1 b %all 7to ! maximum ext5t feasible7 includ+ te/+ ( ea* su* model 9 geographic areas 9 at lea/ #c regions4 7#b7 ,inclusion ( physician implem5tation co/s 9 evaluations ,section #aaae;,a7b77#d77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7b77#d77;,a77 is am5d$-- 7,a7 by /rik+ & at ! end ( clause 7i72 7,b7 by /rik+ ! p]iod at ! end ( clause 7ii7 & ins]t+ 2 &2 & 7,c7 by add+ at ! end ! foll[+ new clause3 7iii7 ! av]age co/1 p] physician1 ( implem5tation ( ! model ) respect to physicians' s]vices4 4 7#c7 ,accel]at+ te/+ & evaluation process ,section #aaae;,a7b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7b77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#e7 ,tim+ ,! ,secret>y1 act+ ?r\gh ! ,,cmi1 %all conduct activities "u ?is subsection 9 su* a timely mann] s t evaluations ( initial models c be initially complet$ s t physicians & o!r provid]s c beg9 to transition to implem5tation ( su* models ) respect to s]vices = :i* paym5t is made "u section #ahdh beg9n+ n lat] ?an ,janu>y #a1 #bjah4 4 7#d7 ,involvem5t ( provid] gr\ps 9 selection ( models ,section #aaae;,a7b77#d7 ( su* ,act is am5d$ by add+ at ! end ! foll[+ subp>agraph3 7,d7 ,involvem5t ( provid] gr\ps 9 model selection ,! ,secret>y %all consult & "w closely ) physician & o!r provid] gr\ps 9 ! selection ( models "u ?is subsection & subsection 7c74 4 7#e7 ,use ( o!r models ,section #aaae;,a ( su* ,act is fur!r am5d$-- 7,a7 by add+ at ! end ( subsection 7b77#b77;,b7 ! foll[+ new clause3 7xxi7 ,provid+ paym5t = outpati5t !rapy s]vices & spee* language pa?ology s]vices on ! basis ( a treatm5t session1 an episode ( c>e1 or o!r bundl$ paym5t me?odology t takes into acc\nt v>y+ levels ( sev]ity & complexity ( pati5t diagnoses1 conditions1 & comorbidities & ! v>y+ int5sity ( s]vices ne$$ = effective treatm5t ( pati5ts4 2 & 7,b7 9 subsection 7c71 9 ! matt] prec$+ p>agraph 7#a71 by-- 7i7 /rik+ or aft] te/$ "u subsection 7b7 & ins]t+ a comma2 & 7ii7 by ins]t+ 1 or o!r model 7includ+ a model t 0 n te/$ "u subsection 7b77 aft] section #ahff;,c4 7#f7 ,,gao review & /udy ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all conduct a /udy ( ! evaluations made "u subsection 7b7 ( section #aaae;,a ( ! ,social ,security ,act1 z am5d$ by ?is section4 ,su* /udy %all include an analysis ( ! alt]native paym5t & deliv]y models id5tifi$ "u su* section = paym5t = physicians' s]vices 7& o!r s]vices7 "u ! ,m$ic>e program4 ,n lat] ?an ,april #a1 #bjag1 ! ,comptroll] ,g5]al %all submit a report to ,congress on su* /udy & %all include 9 ! report su* recomm5dations z ! ,comptroll] ,g5]al deems appropriate =-- 7,a7 *anges 9 ! developm5t & implem5tation process "u su* section2 & 7,b7 alt]native paym5t & deliv]y models id5tifi$ "u su* section z be+ appropriate = expansion "u subsection 7c7 ( su* section4 7#g7 ,publication ( li/ ( successful models ,beg9n+ on ,octob] #a1 #bjag1 & ea* ye> !reaft]1 ! ,secret>y ( ,heal? & ,human ,s]vices %all publicly release a compreh5sive li/ ( su* heal? c>e deliv]y & paym5t models id5tifi$1 "u section #aaae;,a ( ! ,social ,security ,act or o!rwise1 z meet+ 7or likely to meet7 ! requirem5ts ( subsection 7c77#a7 ( su* section4 ,su* li/ %all include at lea/ #d heal? c>e deliv]y & paym5t models & may include models n te/$ "u subsection 7b7 ( su* section4 7#h7 ,consid]ations ,! ,comptroll] ,g5]al 9 mak+ recomm5dations "u p>agraph 7#f7 & ! ,secret>y 9 releas+ ! li/ ( models "u p>agraph 7#g7 %all take into acc\nt v>iations among provid]s 9 size1 specialty mix1 case mix1 & pati5t demographics1 z well z regional heal? c>e infra/ructure v>iations & v>iations 9 co/ ( liv+ among areas1 & %all specifically consid] appropriate v>iations t take into acc\nt ! special circum/ances ( provid]s 9 rural & o!r und]s]v$ areas4 7e7 ,implem5tation ( paym5t & deliv]y model options 7,phase ,,ii7 7#a7 ,9 g5]al ,bas$ on ! report ( ! ,comptroll] ,g5]al "u subsection 7d77#d7 & n lat] ?an ,octob] #a1 #bjag1 ! ,secret>y ( ,heal? & ,human ,s]vices %all provide in=mation to physicians 7& nurse practition]s & o!r provid]s = :i* paym5t is det]m9$ bas$ on ! fee s*$ule "u section #ahdh ( ! ,social ,security ,act7 or gr\p practices & in/itutions employ+ ,m$ic>e "p ,b provid]s on h[ be/ to transition to alt]native heal? c>e deliv]y & paym5t models t are aim$ at improv+ ! coord9ation1 quality & effici5cy ( heal? c>e1 includ+ ^? develop$ "u section #aaae;,a or #ahff;,e ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acae;a1 #acie;cc-#e74 7#b7 ,increas+ flexibility 9 implem5tation ,section #aaae;,a7c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7c771 z am5d$ by subsection 7c77#e71 is fur!r am5d$1 9 ! matt] prec$+ p>agraph 7#a71 by ins]t+1 aft] ?r\gh rulemak+1 ! foll[+3 7:i* may include ! issuance ( int]im f9al rules7 or ?r\gh publication ( a directive or o!r guidance4 7#c7 ,tim+ ,section #aaae;,a ( su* ,act is fur!r am5d$ by add+ at ! end ! foll[+3 ,! ,secret>y %all seek to effect su* expansion to ! maximum ext5t feasible s t physicians 7& o!r provid]s paid 9 am\nts det]m9$ bas$ on ! fee s*$ule "u section #ahdh7 may beg9 to transition to implem5tation ( su* models beg9n+ n lat] ?an ,janu>y #a1 #bjah44 7f7 ,transition dur+ #bjai 7#a7 ,freeze 9 fee s*$ule = #bjai ,subsection 7d7 ( section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 z am5d$ by subsections 7b7 & 7c77#c71 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#ag7 ,update = #bjai ,! update to bo? ( ! conv]sion factors = #bjai %all be #j p]c5t4 4 7#b7 ,exp&$ assi/ance ?r\gh regional ext5sion c5t]s & o!r qualifi$ entities ,section #aaae;,a7d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7d77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#d7 ,assi/ance 9 implem5tation 7,a7 ,9 g5]al ,us+ funds available "u subsection 7f77#a7 & consi/5t ) ?is p>agraph1 ! ,secret>y %all ent] into contracts & agreem5ts ) regional ext5sion c5t]s1 9 coord9ation ) ! ,national ,coord9ator = ,heal? ,in=mation ,te*nology1 & o!r appropriate entities to provide guidance & assi/ance on h[ physicians 7& o!r provid]s paid 9 am\nts det]m9$ bas$ on ! fee s*$ule "u section #ahdh7 may transition to implem5tation ( alt]native heal? c>e deliv]y models id5tifi$ z repres5t+ be/ practices "u ?is section4 7,b7 ,d$icat$ fund+ 7i7 ,9 g5]al ,( ! am\nts available "u subsection 7f77#a77;,b71 ! ,secret>y %all make #gbj1jjj1jjj available to ! ,(fice ( ! ,national ,coord9ator = ,heal? ,in=mation ,te*nology = ! aw>d+ ( grants & inc5tive paym5ts "u a competitive process to regional ext5sion c5t]s 7receiv+ fund+ "u section #cjab7;c7 ( ! ,public ,heal? ,s]vice ,act7 & o!r qualifi$ entities = activities describ$ 9 subp>agraph 7,a74 ,su* grants & paym5ts %all n be available = assi/ance aft] ,decemb] #ca1 #bjai4 7ii7 ,process ,"u clause 7i71 ! ,(fice %all-- 7,i7 e/abli% a competitive selection process = ! selection ( regional ext5sion c5t]s 7& o!r qualifi$ entities7 9 ! ?ird qu>t] ( #bjae2 & 7,,ii7 provide = ! initial di/ribution ( funds to su* c5t]s & entities by ,janu>y #a1 #bjaf4 7iii7 ,collaboration ,! ,c5t] %all collaborate ) ! ,(fice 9 provid+ direction to su* c5t]s & entities 9 conduct+ activities "u ?is p>agraph1 includ+ ! developm5t ( p]=mance b5*m>ks bas$ on provid] p>ticipation & progress t[>d integration4 7iv7 ,priority ,! grants & inc5tive paym5ts "u ?is subp>agraph %all be direct$ to t>get assi/ance to solo & small specialty practices z well z community heal? c5t]s & simil> provid]s ( prim>y c>e s]vices4 4 7g7 ,cont9u+ inc5tives = provid+ high-,quality1 high-,value c>e 7#a7 ,fee s*$ule adju/m5ts ,subsection 7d7 ( section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 z am5d$ by subsections 7b71 7c77#c71 & 7f71 is am5d$ by add+ at ! end ! foll[+3 7#ah7 ,updates = #bjbj ?r\gh #bjbc 7,a7 ,9 g5]al ,except z provid$ 9 ?is p>agraph1 ! update to ea* ( ! conv]sion factors-- 7i7 = #bjbj %all be m9us #b p]c5t2 7ii7 = #bjba %all be m9us #c p]c5t2 7iii7 = #bjbb %all be m9us #d p]c5t2 & 7iv7 = #bjbc %all be m9us #e p]c5t4 7,b7 ,treatm5t ( s]vices paid us+ alt]native paym5t & deliv]y models ,9 ! case ( physicians' s]vices = :i* paym5t is cov]$ "u an alt]native paym5t & deliv]y model1 su* z ^? implem5t$ "u section #aaae;,a1 subp>agraph 7,a7 does n apply4 7,c7 ,g5]al exemption ,! ,secret>y %all1 by regulation1 exempt a provid] f ! application ( ! negative paym5t update specifi$ 9 subp>agraph 7,a7 = a ye> if ! ,secret>y det]m9es t-- 7i7 ! provid]-- 7,i7 is a mean+ful ,,ehr us] 7z det]m9$ "u subsection 7o77#b7 ) respect to ! ye>72 & 7,,ii7 meets ! qualifications "u subp>agraph 7,b7 ( subsection 7m77#g7 7relat+ to additional inc5tive paym5ts7 = an additional inc5tive paym5t "u subp>agraph 7,a7 ( su* subsection 7:i* includes satisfactory p>ticipation 9 ! quality report+ sy/em & p>ticipation 9 an approv$ ,ma9t5ance ( ,c]tification program72 7ii7 ! paym5t modifi] = ! provid] "u subsection 7p71 :i* is bas$ ^u ! p]=mance ( ! provid] on measures ( quality ( c>e furni%$ comp>$ to co/ & :i* is express$ z a p]c5tage ( paym5t1 is )9 ! top #be p]c5t ( su* paym5t modifi]s = provid]s )9 ! same fee s*$ule area1 z det]m9$ by ! ,secret>y2 or 7iii7 9 ! case ( outpati5t !rapy s]vices1 ! provid] ( su* s]vices adh]es to a compreh5sive li/ ( co/1 quality1 & outcome measures z demon/rat$ by-- 7,i7 p>ticipation 9 a c]tifi$ regi/ry2 7,,ii7 if applicable1 p>ticipation 9 ! physician quality report+ sy/em "u subsection 7k72 7,,iii7 use ( an approv$ pati5t assessm5t tool2 7,,iv7 curr5t c]tification z a physical !rapi/ cl9ical speciali/ by ! ,am]ican ,physical ,!rapy ,association 7,,apta71 an occupational !rapi/ by ! ,am]ican ,occupational ,!rapy ,association1 or z an audiologi/ or a spee*-language pa?ologi/ by ! ,am]ican ,spee*-,language-,he>+ ,association2 or 7,v7 compliance ) comp>able functional measures report+ requirem5ts z recogniz$ by ! ,secret>y4 7,d7 ,case-by-case h>d%ip exemption ,! ,secret>y may1 on a case-by-case basis1 exempt a provid] f ! application ( ! negative paym5t update specifi$ 9 subp>agraph 7,a7 = a ye> if ! ,secret>y det]m9es1 subject to annual r5ewal1 t because ( limitations 9 ! nature ( a m$ical practice1 limitations 9 ! numb] ( ,m$ic>e b5efici>ies t may be s]v$ by ! provid]1 or o!r special circum/ances1 impos+ a f9ancial dis9c5tive "u su* subp>agraph = failure to adopt an alt]native paym5t & deliv]y model ref]r$ to 9 subp>agraph 7,b7 w\ld result 9 a significant h>d%ip to ! provid]4 7#ai7 ,updates beg9n+ ) #bjbd 7,a7 ,9 g5]al ,! update to bo? ( ! conv]sion factors = ea* ye> beg9n+ ) #bjbd %all be #j p]c5t4 7,b7 ,treatm5t ( s]vices paid us+ alt]native paym5t & deliv]y models ,9 ! case ( physicians' s]vices = :i* paym5t is cov]$ "u an alt]native paym5t & deliv]y model1 su* z ^? implem5t$ "u section #aaae;,a1 subp>agraph 7,a7 does n apply4 4 7#b7 ,consid]ations 9 promulgat+ gr[? rates = alt]native paym5t & deliv]y models 7,a7 ,9 g5]al ,9 det]m9+ ! gr[? rates to be recogniz$ beg9n+ ) #bjbj = alt]native paym5t & deliv]y models "u ! ,m$ic>e program t cov] physicians' s]vices1 su* z ^? implem5t$ "u section #aaae;,a ( ! ,social ,security ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all consid] 7among o!r factors7 ! foll[+3 7i7 ,ensur+ access to prim>y c>e & specialty s]vices1 includ+ p>ticipation ( prim>y c>e practition]s & speciali/s & newly graduat+ practition]s4 7ii7 ,re/ra9+ sp5d+ gr[?4 7iii7 ,ensur+ access to s]vices = vuln]able populations4 7,b7 ,limitations ,9 no case %all ! gr[? factor det]m9$ "u ?is p>agraph = a ye>-- 7i7 be less ?an #a p]c5t2 or 7ii7 be great] ?an ! p]c5tage increase 9 ! ,,mei 7z def9$ 9 section #ahdb7;i77#c7 ( ! ,social ,security ,act1 #db ,u4,s4,c4 #acieu7i77#c77 = su* ye>4 7,c7 ,application ( ,congressional ,review ,act ,*apt] #h ( title #e1 ,unit$ ,/ates ,code1 applies ) respect to ! promulgation ( a gr[? factor "u ?is p>agraph = a ye>4 7h7 ,impact report ,n lat] ?an ,janu>y #a1 #bjbc1 ! ,secret>y ( ,heal? & ,human ,s]vices %all submit to ,congress a report on ! impact on sp5d+ & on access to s]vices "u title ,,xviii ( ! ,social ,security ,act1 includ+ "u "p ,a ( su* title1 result+ f *anges to ,m$ic>e deliv]y & paym5t sy/ems1 includ+ "u ! am5dm5ts made by ?is section4