,,ii ,cal5d> ,no4 #bhj #aac? ,,congress #a/ ,session ,s4 #ahga ,,9 ,,! ,,s5ate ,,( ,,! ,,unit$ ,,/ates ,decemb] #ai1 #bjac,mr4 ,baucus1 f ! ,committee on ,f9ance1 report$ ! foll[+ orig9al bill2 :i* 0 read twice & plac$ on ! cal5d> ,a ,,bill ,to am5d title ,,xviii ( ! ,social ,security ,act to repeal ! ,m$ic>e su/a9able gr[? rate =mula & to improve b5efici>y access "u ! ,m$ic>e program1 & = o!r purposes4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,,sgr ,repeal & ,m$ic>e ,b5efici>y ,access ,act ( #bjac4 7b7 ,table ( cont5ts ,! table ( cont5ts ( ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4,,title ,i--,m$ic>e ,paym5t = ,physicians' ,services,sec4 #aja4 ,repeal+ ! su/a9able gr[? rate 7,,sgr7 & improv+ ,m$ic>e paym5t = physicians' s]vices4,sec4 #ajb4 ,priorities & fund+ = quality measure developm5t4,sec4 #ajc4 ,enc\rag+ c>e managem5t = individuals ) *ronic c>e ne$s4,sec4 #ajd4 ,ensur+ accurate valuation ( s]vices "u ! physician fee s*$ule4,sec4 #aje4 ,promot+ evid5ce-bas$ c>e4,sec4 #ajf4 ,emp[]+ b5efici>y *oices ?r\gh access to in=mation on physicians' s]vices4,sec4 #ajg4 ,exp&+ claims data availability to improve c>e4,,title ,,ii--,ext5sions & ,o!r ,provisions,subtitle ,a--,m$ic>e ,extensions,sec4 #bja4 ,"w geographic adju/m5t4,sec4 #bjb4 ,m$ic>e paym5t = !rapy s]vices4,sec4 #bjc4 ,m$ic>e ambulance s]vices4,sec4 #bjd4 ,revision ( ! ,m$ic>e-dep5d5t hospital 7,,mdh7 program4,sec4 #bje4 ,revision ( ,m$ic>e inpati5t hospital paym5t adju/m5t = l[-volume hospitals4,sec4 #bjf4 ,specializ$ ,m$ic>e ,advantage plans = special ne$s individuals4,sec4 #bjg4 ,reasonable co/ reimbursem5t contracts4,sec4 #bjh4 ,quality measure endorsem5t & selection4,sec4 #bji4 ,p]man5t ext5sion ( fund+ outrea* & assi/ance = l[-income programs4,subtitle ,b--,m$icaid & ,o!r ,extensions,sec4 #baa4 ,qualify+ individual program4,sec4 #bab4 ,transitional ,m$ical ,assi/ance4,sec4 #bac4 ,express lane eligibility4,sec4 #bad4 ,p$iatric quality measures4,sec4 #bae4 ,special diabetes programs4,subtitle ,c--,human ,s]vices ,extensions,sec4 #bba4 ,ab/95ce education grants4,sec4 #bbb4 ,p]sonal responsibility education program4,sec4 #bbc4 ,family-to-family heal? in=mation c5t]s4,sec4 #bbd4 ,heal? work=ce demon/ration project = l[-income individuals4,subtitle ,d--,program ,integrity,sec4 #bca4 ,r$uc+ improp] ,m$ic>e paym5ts4,sec4 #bcb4 ,au?ority = ,m$icaid fraud control units to inve/igate & prosecute compla9ts ( abuse & neglect ( ,m$icaid pati5ts 9 home & community-bas$ sett+s4,sec4 #bcc4 ,improv$ use ( funds receiv$ by ! ,,hhs ,inspector ,g5]al f ov]sight & inve/igative activities4,sec4 #bcd4 ,prev5t+ & r$uc+ improp] ,m$ic>e & ,m$icaid exp5ditures4,subtitle ,e--,o!r ,provisions,sec4 #bda4 ,commission on ,improv+ ,pati5t ,direct$ ,heal? ,c>e4,sec4 #bdb4 ,expansion ( ! def9ition ( inpati5t hospital s]vices = c]ta9 canc] hospitals4,sec4 #bdc4 ,quality measures = c]ta9 po/-acute c>e provid]s relat+ to notice & transf] ( pati5t heal? in=mation & pati5t c>e pref]5ces4,sec4 #bdd4 ,crit]ia = m$ically necess>y1 %ort inpati5t hospital /ays4,sec4 #bde4 ,transp>5cy ( reasons = exclud+ additional proc$ures f ! ,m$ic>e ambulatory surgical c5t] 7,,asc7 approv$ li/4,sec4 #bdf4 ,sup]vision 9 critical access hospitals4,sec4 #bdg4 ,requir+ ,/ate lic5sure ( bidd+ entities "u ! competitive acquisition program = c]ta9 durable m$ical equipm5t1 pro/hetics1 or?otics1 & supplies 7,,dmepos74,sec4 #bdh4 ,recognition ( att5d+ physician assi/ants z att5d+ physicians to s]ve hospice pati5ts4,sec4 #bdi4 ,remote pati5t monitor+ pilot projects4,sec4 #bej4 ,community-,bas$ ,in/itutional ,special ,ne$s ,plan ,demon/ration ,program4,sec4 #bea4 ,apply+ ,,cmmi waiv] au?ority to ,,pace 9 ord] to fo/] innovations4,sec4 #beb4 ,improve & mod]nize ,m$icaid data sy/ems & report+4,sec4 #bec4 ,fairness 9 ,m$icaid supplem5tal ne$s tru/s4,sec4 #bed4 ,help+ ,ensure ,life- & ,limb-,sav+ ,access to ,podiatric ,physicians4,sec4 #bee4 ,demon/ration program to improve community m5tal heal? s]vices4,sec4 #bef4 ,annual ,m$icaid ,,d% report4,sec4 #beg4 ,implem5tation4 ,i ,m$ic>e ,paym5t = ,physicians' ,s]vices #aja4 ,repeal+ ! su/a9able gr[? rate 7,,sgr7 & improv+ ,m$ic>e paym5t = physicians' s]vices 7a7 ,/abiliz+ fee updates 7#a7 ,repeal ( ,,sgr paym5t me?odology ,section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is am5d$-- 7,a7 9 subsection 7d7-- 7i7 9 p>agraph 7#a77;,a71 by ins]t+ or a subsequ5t p>agraph aft] p>agraph 7#d72 & 7ii7 9 p>agraph 7#d7-- 7,i7 9 ! head+1 by ins]t+ & end+ ) #bjac aft] ye>s beg9n+ ) #bjja2 & 7,,ii7 9 subp>agraph 7,a71 by ins]t+ & end+ ) #bjac aft] a ye> beg9n+ ) #bjja2 & 7,b7 9 subsection 7f7-- 7i7 9 p>agraph 7#a77;,b71 by ins]t+ ?r\gh #bjac aft] ( ea* succe$+ ye>2 & 7ii7 9 p>agraph 7#b71 by ins]t+ & end+ ) #bjac aft] beg9n+ ) #bjjj4 7#b7 ,update ( rates = #bjad & subsequ5t ye>s ,subsection 7d7 ( section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is am5d$ by add+ at ! end ! foll[+ new p>agraphs3 7#ae7 ,update = #bjad ?r\gh #bjbc ,! update to ! s+le conv]sion factor e/abli%$ 9 p>agraph 7#a77;,c7 = ea* ( #bjad ?r\gh #bjbc %all be z]o p]c5t4 7#af7 ,update = #bjbd & subsequ5t ye>s ,! update to ! s+le conv]sion factor e/abli%$ 9 p>agraph 7#a77;,c7 = #bjbd & ea* subsequ5t ye> %all be-- 7,a7 = items & s]vices furni%$ by a qualify+ ,,apm p>ticipant 7z def9$ 9 section #ahcc7z77#b77 = su* ye>1 #b p]c5t2 & 7,b7 = o!r items & s]vices1 #a p]c5t4 4 7#c7 ,med,p,a,c reports 7,a7 ,initial report ,n lat] ?an ,july #a1 #bjaf1 ! ,m$ic>e ,paym5t ,advisory ,commission %all submit to ,congress a report on ! relation%ip betwe5-- 7i7 physician & o!r heal? pr(essional utilization & exp5ditures 7& ! rate ( increase ( su* utilization & exp5ditures7 ( items & s]vices = :i* paym5t is made "u section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d72 & 7ii7 total utilization & exp5ditures 7& ! rate ( increase ( su* utilization & exp5ditures7 "u p>ts ,a1 ,b1 & ,d ( title ,,xviii ( su* ,act4 ,su* report %all include a me?odology to describe su* relation%ip & ! impact ( *anges 9 su* physician & o!r heal? pr(essional practice & s]vice ord]+ patt]ns on total utilization & exp5ditures "u p>ts ,a1 ,b1 & ,d ( su* title4 7,b7 ,f9al report ,n lat] ?an ,july #a1 #bjbj1 ! ,m$ic>e ,paym5t ,advisory ,commission %all submit to ,congress a report on ! relation%ip describ$ 9 subp>agraph 7,a71 includ+ ! results det]m9$ f apply+ ! me?odology includ$ 9 ! report submitt$ "u su* subp>agraph4 7b7 ,consolidation ( c]ta9 curr5t law p]=mance programs ) new value-bas$ p]=mance inc5tive program 7#a7 ,,ehr mean+ful use inc5tive program 7,a7 ,sunsett+ sep>ate mean+ful use paym5t adju/m5ts ,section #ahdh7;a77#g77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;a77#g77;,a77 is am5d$-- 7i7 9 clause 7i71 by /rik+ or any subsequ5t paym5t ye> & ins]t+ or #bjaf2 7ii7 9 clause 7ii7-- 7,i7 9 ! matt] prec$+ subclause 7,i71 by /rik+ ,subject to clause 7iii71 = & ins]t+ ,=2 7,,ii7 9 subclause 7,i71 by add+ at ! end &2 7,,iii7 9 subclause 7,,ii71 by /rik+ 2 & & ins]t+ a p]iod2 & 7,,iv7 by /rik+ subclause 7,,iii72 & 7iii7 by /rik+ clause 7iii74 7,b7 ,cont9uation ( mean+ful use det]m9ations = ,,vbp program ,section #ahdh7o77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7o77#b77 is am5d$-- 7i7 9 subp>agraph 7,a71 9 ! matt] prec$+ clause 7i7-- 7,i7 by /rik+ ,= purposes ( p>agraph 7#a71 an & ins]t+ ,an2 & 7,,ii7 by ins]t+ 1 or pursuant to subp>agraph 7,d7 = purposes ( subsection 7q71 = a p]=mance p]iod "u su* subsection = a ye> aft] "u su* subsection = a ye>2 & 7ii7 by add+ at ! end ! foll[+ new subp>agraph3 7,d7 ,cont9u$ application = purposes ( ,,vbp program ,) respect to #bjag & ea* subsequ5t paym5t ye>1 ! ,secret>y %all1 = purposes ( subsection 7q7 & 9 accordance ) p>agraph 7#a77;,f7 ( su* subsection1 det]m9e :e!r an eligible pr(essional :o is a ,,vbp eligible pr(essional 7z def9$ 9 subsection 7q77#a77;,c77 = su* ye> is a mean+ful ,,ehr us] "u ?is p>agraph = ! p]=mance p]iod "u subsection 7q7 = su* ye>4 4 7#b7 ,quality report+ 7,a7 ,sunsett+ sep>ate quality report+ inc5tives ,section #ahdh7;a77#h77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;a77#h77;,a77 is am5d$-- 7i7 9 clause 7i71 by /rik+ or any subsequ5t ye> & ins]t+ or #bjaf2 & 7ii7 9 clause 7ii77,,ii71 by /rik+ & ea* subsequ5t ye>4 7,b7 ,cont9uation ( quality measures & processes = ,,vbp program ,section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is am5d$-- 7i7 9 subsection 7k71 by add+ at ! end ! foll[+ new p>agraph3 7#i7 ,cont9u$ application = purposes ( ,,vbp program ,! ,secret>y %all1 9 accordance ) subsection 7q77#a77;,f71 c>ry out ! provisions ( ?is subsection = purposes ( subsection 7q74 2 & 7ii7 9 subsection 7m7-- 7,i7 by r$esignat+ ! p>agraph 7#g7 add$ by section #ajcbg7;a7 ( ,public ,law #aaa-adh z p>agraph 7#h72 & 7,,ii7 by add+ at ! end ! foll[+ new p>agraph3 7#i7 ,cont9u$ application = purposes ( ,,vbp program ,! ,secret>y %all1 9 accordance ) subsection 7q77#a77;,f71 c>ry out ! processes "u ?is subsection = purposes ( subsection 7q74 4 7#c7 ,value-bas$ paym5ts 7,a7 ,sunsett+ sep>ate value-bas$ paym5ts ,clause 7iii7 ( section #ahdh7p77#d77;,b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7p77#d77;,b77 is am5d$ to read z foll[s3 7iii7 ,application ,! ,secret>y %all apply ! paym5t modifi] e/abli%$ "u ?is subsection = items & s]vices furni%$ on or aft] ,janu>y #a1 #bjae1 b be=e ,janu>y #a1 #bjag1 ) respect to specific physicians & gr\ps ( physicians ! ,secret>y det]m9es appropriate4 ,su* paym5t modifi] %all n be appli$ = items & s]vices furni%$ on or aft] ,janu>y #a1 #bjag4 4 7,b7 ,cont9uation ( value-bas$ paym5t modifi] measures = ,,vbp program ,section #ahdh7p7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7p77 is am5d$-- 7i7 9 p>agraph 7#b71 by add+ at ! end ! foll[+ new subp>agraph3 7,c7 ,cont9u$ application = purposes ( ,,vbp program ,! ,secret>y %all1 9 accordance ) subsection 7q77#a77;,f71 c>ry out subp>agraph 7,b7 = purposes ( subsection 7q74 2 & 7ii7 9 p>agraph 7#c71 by add+ at ! end ! foll[+3 ,) respect to #bjag & ea* subsequ5t ye>1 ! ,secret>y %all1 9 accordance ) subsection 7q77#a77;,f71 c>ry out ?is p>agraph = purposes ( subsection 7q744 7c7 ,value-bas$ p]=mance inc5tive program 7#a7 ,9 g5]al ,section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7q7 ,value-bas$ p]=mance inc5tive program 7#a7 ,e/abli%m5t 7,a7 ,9 g5]al ,subject to ! succe$+ provisions ( ?is subsection1 ! ,secret>y %all e/abli% an eligible pr(essional value-bas$ p]=mance inc5tive program 79 ?is subsection ref]r$ to z ! ,,vbp program7 "u :i* ! ,secret>y %all-- 7i7 develop a me?odology = assess+ ! total p]=mance ( ea* ,,vbp eligible pr(essional accord+ to p]=mance /&>ds "u p>agraph 7#c7 = a p]=mance p]iod 7z e/abli%$ "u p>agraph 7#d77 = a ye>2 7ii7 us+ su* me?odology1 provide = a composite p]=mance score 9 accordance ) p>agraph 7#e7 = ea* su* pr(essional = ea* p]=mance p]iod2 & 7iii7 use su* composite p]=mance score ( ! ,,vbp eligible pr(essional = a p]=mance p]iod = a ye> to make ,,vbp program inc5tive paym5ts "u p>agraph 7#g7 to ! pr(essional = ! ye>4 7,b7 ,program implem5tation ,! ,,vbp program %all apply to paym5ts = items & s]vices furni%$ on or aft] ,janu>y #a1 #bjag4 7,c7 ,,vbp eligible pr(essional def9$ 7i7 ,9 g5]al ,= purposes ( ?is subsection1 subject to clauses 7ii7 & 7iv71 ! t]m ,,vbp eligible pr(essional means-- 7,i7 = ! fir/ & second ye>s = :i* ! ,,vbp program applies to paym5ts 7& = ! p]=mance p]iod = su* fir/ & second ye>71 a physician 7z def9$ 9 section #ahfa7r771 a physician assi/ant1 nurse practition]1 & cl9ical nurse speciali/ 7z su* t]ms are def9$ 9 section #ahfa7;aa77#e771 & a c]tifi$ regi/]$ nurse ane/heti/ 7z def9$ 9 section #ahfa7;bb77#b772 & 7,,ii7 = ! ?ird ye> = :i* ! ,,vbp program applies to paym5ts 7& = ! p]=mance p]iod = su* ?ird ye>7 & = ea* succe$+ ye> 7& = ! p]=mance p]iod = ea* su* ye>71 ! pr(essionals describ$ 9 subclause 7,i7 & su* o!r eligible pr(essionals 7z def9$ 9 subsection 7k77#c77;,b77 z specifi$ by ! ,secret>y4 7ii7 ,exclusions ,= purposes ( clause 7i71 ! t]m ,,vbp eligible pr(essional does n include1 ) respect to a ye>1 an eligible pr(essional 7z def9$ 9 subsection 7k77#c77;,b77-- 7,i7 :o is a qualify+ ,,apm p>ticipant 7z def9$ 9 section #ahcc7z77#b772 7,,ii7 :o1 subject to clause 7vii71 is a p>tial qualify+ ,,apm p>ticipant 7z def9$ 9 clause 7iii77 = ! mo/ rec5t p]iod = :i* data are available & :o1 = ! p]=mance p]iod ) respect to su* ye>1 does n report on applicable measures & activities describ$ 9 p>agraph 7#b77;,b7 t are requir$ to be report$ by su* a pr(essional "u ! ,,vbp program2 or 7,,iii7 :o1 = ! p]=mance p]iod ) respect to su* ye>1 does n exce$ ! l[-volume ?re%old measurem5t select$ "u clause 7iv74 7iii7 ,p>tial qualify+ ,,apm p>ticipant ,= purposes ( ?is subp>agraph1 ! t]m p>tial qualify+ ,,apm p>ticipant means1 ) respect to a ye>1 an eligible pr(essional = :om ! ,secret>y det]m9es ! m9imum paym5t p]c5tage 7or p]c5tages71 z applicable1 describ$ 9 p>agraph 7#b7 ( section #ahcc7z7 = su* ye> h n be5 satisfi$1 b :o w\ld be consid]$ a qualify+ ,,apm p>ticipant 7z def9$ 9 su* p>agraph7 = su* ye> if-- 7,i7 ) respect to #bjag & #bjah1 ! ref]5ce 9 subp>agraph 7,a7 ( su* p>agraph to #be p]c5t 0 in/ead a ref]5ce to #bj p]c5t2 7,,ii7 ) respect to #bjai & #bjbj-- 7aa7 ! ref]5ce 9 subp>agraph 7,b77i7 ( su* p>agraph to #ej p]c5t 0 in/ead a ref]5ce to #dj p]c5t2 & 7bb7 ! ref]5ces 9 subp>agraph 7,b77ii7 ( su* p>agraph to #ej p]c5t & #be p]c5t ( su* p>agraph 7 in/ead ref]5ces to #dj p]c5t & #bj p]c5t1 respectively2 & 7,,iii7 ) respect to #bjba & subsequ5t ye>s-- 7aa7 ! ref]5ce 9 subp>agraph 7,c77i7 ( su* p>agraph to #ge p]c5t 0 in/ead a ref]5ce to #ej p]c5t2 & 7bb7 ! ref]5ces 9 subp>agraph 7,c77ii7 ( su* p>agraph to #ge p]c5t & #be p]c5t ( su* p>agraph 7 in/ead ref]5ces to #ej p]c5t & #bj p]c5t1 respectively4 7iv7 ,selection ( l[-volume ?re%old measurem5t ,! ,secret>y %all select "o ( ! foll[+ l[-volume ?re%old measurem5ts to apply = purposes ( clause 7ii77,,iii73 7,i7 ,! m9imum numb] 7z det]m9$ by ! ,secret>y7 ( individuals enroll$ "u ?is "p :o are treat$ by ! ,,vbp eligible pr(essional = ! p]=mance p]iod involv$4 7,,ii7 ,! m9imum numb] 7z det]m9$ by ! ,secret>y7 ( items & s]vices furni%$ to individuals enroll$ "u ?is "p by su* pr(essional = su* p]=mance p]iod4 7,,iii7 ,! m9imum am\nt 7z det]m9$ by ! ,secret>y7 ( all[$ *>ges bill$ by su* pr(essional "u ?is "p = su* p]=mance p]iod4 7v7 ,treatm5t ( new ,m$ic>e enroll$ eligible pr(essionals ,9 ! case ( a pr(essional :o fir/ becomes a ,m$ic>e enroll$ eligible pr(essional dur+ ! p]=mance p]iod = a ye> 7& _h n previ\sly submitt$ claims "u ?is title su* z a p]son1 an entity1 or a "p ( a physician gr\p or "u a diff]5t bill+ numb] or tax id5tifi]71 su* pr(essional %all n be treat$ "u ?is subsection z a ,,vbp eligible pr(essional until ! subsequ5t ye> & p]=mance p]iod = su* subsequ5t ye>4 7vi7 ,cl>ification ,9 ! case ( items & s]vices furni%$ dur+ a ye> by an individual :o is n a ,,vbp eligible pr(essional 7includ+ pursuant to clauses 7ii7 & 7v77 ) respect to a ye>1 9 no case %all a r$uction "u p>agraph 7#f7 or a ,,vbp program inc5tive paym5t "u p>agraph 7#g7 apply to su* individual = su* ye>4 7vii7 ,p>tial qualify+ ,,apm p>ticipant cl>ification ,9 ! case ( an eligible pr(essional :o is a p>tial qualify+ ,,apm p>ticipant1 ) respect to a ye>1 & :o = ! p]=mance p]iod = su* ye> reports on applicable measures & activities describ$ 9 p>agraph 7#b77;,b7 t are requir$ to be report$ by su* a pr(essional "u ! ,,vbp program1 su* eligible pr(essional is consid]$ to be a ,,vbp eligible pr(essional ) respect to su* ye>4 7,d7 ,application to gr\p practices 7i7 ,9 g5]al ,"u ! ,,vbp program3 7,i7 ,quality p]=mance category ,! ,secret>y %all e/abli% & apply a process t includes features ( ! provisions ( subsection 7m77#c77;,c7 = ,,vbp eligible pr(essionals 9 a gr\p practice ) respect to assess+ p]=mance ( su* gr\p ) respect to ! p]=mance category describ$ 9 clause 7i7 ( p>agraph 7#b77;,a74 7,,ii7 ,o!r p]=mance categories ,! ,secret>y may e/abli% & apply a process t includes features ( ! provisions ( subsection 7m77#c77;,c7 = ,,vbp eligible pr(essionals 9 a gr\p practice ) respect to assess+ ! p]=mance ( su* gr\p ) respect to ! p]=mance categories describ$ 9 clauses 7ii7 ?r\gh 7iv7 ( su* p>agraph4 7ii7 ,ensur+ compreh5siv5ess ( gr\p practice assessm5t ,! process e/abli%$ "u clause 7i7 %all to ! ext5t practicable reflect ! full range ( items & s]vices furni%$ by ! ,,vbp eligible pr(essionals 9 ! gr\p practice involv$4 7iii7 ,cl>ification ,,vbp eligible pr(essionals elect+ to be a virtual gr\p "u p>agraph 7#e77;,j7 %all n be consid]$ ,,vbp eligible pr(essionals 9 a gr\p practice = purposes ( apply+ ?is subp>agraph4 7,e7 ,use ( regi/ries ,"u ! ,,vbp program1 ! ,secret>y %all enc\rage ! use ( qualifi$ cl9ical data regi/ries pursuant to subsection 7m77#c77;,e7 9 c>ry+ out ?is subsection4 7,f7 ,application ( c]ta9 provisions ,9 apply+ a provision ( subsection 7k71 7m71 7o71 or 7p7 = purposes ( ?is subsection1 ! ,secret>y %all-- 7i7 adju/ ! application ( su* provision to ensure ! provision is consi/5t ) ! provisions ( ?is subsection2 & 7ii7 n apply su* provision to ! ext5t t ! provision is duplicative ) a provision ( ?is subsection4 7#b7 ,measures & activities "u p]=mance categories 7,a7 ,p]=mance categories ,"u ! ,,vbp program1 ! ,secret>y %all use ! foll[+ p]=mance categories 7ea* ( :i* is ref]r$ to 9 ?is subsection z a p]=mance category7 9 det]m9+ ! composite p]=mance score "u p>agraph 7#e73 7i7 ,quality4 7ii7 ,res\rce use4 7iii7 ,cl9ical practice improvem5t activities4 7iv7 ,mean+ful use ( c]tifi$ ,,ehr te*nology4 7,b7 ,measures & activities specifi$ = ea* category ,= purposes ( p>agraph 7#c77;,a7 & subject to subp>agraph 7,c71 measures & activities specifi$ = a p]=mance p]iod 7z e/abli%$ "u p>agraph 7#d77 = a ye> are z foll[s3 7i7 ,quality ,= ! p]=mance category describ$ 9 subp>agraph 7,a77i71 ! quality measures e/abli%$ = su* p]iod "u subsections 7k7 & 7m71 includ+ "u subsection 7m77#c77;,e71 & ! measures ( quality ( c>e e/abli%$ = su* p]iod "u subsection 7p77#b74 7ii7 ,res\rce use ,= ! p]=mance category describ$ 9 subp>agraph 7,a77ii71 ! measurem5t ( res\rce use = su* p]iod "u subsection 7p77#c71 us+ ! me?odology "u subsection 7r71 z appropriate1 &1 z feasible & applicable1 acc\nt+ = ! co/ ( cov]$ "p ,d drugs4 7iii7 ,cl9ical practice improvem5t activities ,= ! p]=mance category describ$ 9 subp>agraph 7,a77iii71 cl9ical practice improvem5t activities "u subcategories specifi$ by ! ,secret>y = su* p]iod1 :i* %all include at lea/ ! foll[+3 7,i7 ,! subcategory ( exp&$ practice access1 :i* %all include activities su* z same day appo9tm5ts = urg5t ne$s & aft] h\rs access to cl9ician advice4 7,,ii7 ,! subcategory ( population managem5t1 :i* %all include activities su* z monitor+ heal? conditions ( individuals to provide timely heal? c>e int]v5tions or p>ticipation 9 a qualifi$ cl9ical data regi/ry4 7,,iii7 ,! subcategory ( c>e coord9ation1 :i* %all include activities su* z timely communication ( te/ results1 timely ex*ange ( cl9ical in=mation to pati5ts & o!r provid]s1 & use ( remote monitor+ or teleheal?4 7,,iv7 ,! subcategory ( b5efici>y engagem5t1 :i* %all include activities su* z ! e/abli%m5t ( c>e plans = individuals ) complex c>e ne$s1 b5efici>y self-managem5t tra9+1 & us+ %>$ decision-mak+ me*anisms4 7,v7 ,! subcategory ( pati5t safety & practice assessm5t1 su* z ?r\gh use ( cl9ical or surgical *eckli/s & practice assessm5ts relat$ to ma9ta9+ c]tification4 7,,vi7 ,! subcategory ( p>ticipation 9 an alt]native paym5t model 7z def9$ 9 section #ahcc7z77#c77;,c774 ,9 e/abli%+ activities "u ?is clause1 ! ,secret>y %all give consid]ation to ! circum/ances ( small practices 7consi/+ ( #aj or few] pr(essionals7 & practices locat$ 9 rural areas & 9 heal? pr(essional %ortage areas 7z designat$ "u section #ccb7;a77#a77;,a7 ( ! ,public ,heal? ,s]vice ,act74 7iv7 ,mean+ful ,,ehr use ,= ! p]=mance category describ$ 9 subp>agraph 7,a77iv71 ! requirem5ts e/abli%$ = su* p]iod "u subsection 7o77#b7 = det]m9+ :e!r an eligible pr(essional is a mean+ful ,,ehr us]4 7,c7 ,additional provisions 7i7 ,emphasiz+ outcome measures "u quality p]=mance category ,9 apply+ subp>agraph 7,b77i71 ! ,secret>y %all1 z feasible1 emphasize ! application ( outcome measures4 7ii7 ,application ( additional sy/em measures ,! ,secret>y may use measures us$ = a paym5t sy/em o!r ?an = physicians = purposes ( ! p]=mance category describ$ 9 subp>agraph 7,a77i74 7iii7 ,global & population-bas$ measures ,! ,secret>y may use global measures1 su* z global outcome measures1 & population-bas$ measures = purposes ( ! p]=mance category describ$ 9 subp>agraph 7,a77i74 7iv7 ,reque/ = in=mation = cl9ical practice improvem5t activities ,9 initially apply+ subp>agraph 7,b77iii71 ! ,secret>y %all use a reque/ = in=mation to solicit recomm5dations f /akehold]s = id5tify+ activities describ$ 9 su* subp>agraph & specify+ crit]ia = su* activities4 7v7 ,contract au?ority = cl9ical practice improvem5t activities p]=mance category ,9 apply+ subp>agraph 7,b77iii71 ! ,secret>y may contract ) entities to assi/ ! ,secret>y 9-- 7,i7 id5tify+ activities describ$ 9 subp>agraph 7,b77iii72 7,,ii7 specify+ crit]ia = su* activities2 & 7,,iii7 det]m9+ :e!r a ,,vbp eligible pr(essional meets su* crit]ia4 7#c7 ,p]=mance /&>ds 7,a7 ,e/abli%m5t ,"u ! ,,vbp program1 ! ,secret>y %all e/abli% p]=mance /&>ds ) respect to measures & activities specifi$ "u p>agraph 7#b77;,b7 = a p]=mance p]iod 7z e/abli%$ "u p>agraph 7#d77 = a ye>4 7,b7 ,consid]ations 9 e/abli%+ /&>ds ,9 e/abli%+ su* p]=mance /&>ds ) respect to measures & activities specifi$ "u p>agraph 7#b77;,b71 ! ,secret>y %all take into acc\nt ! foll[+3 7i7 ,hi/orical p]=mance /&>ds4 7ii7 ,improvem5t rates4 7iii7 ,! opportunity = cont9u$ improvem5t4 7#d7 ,p]=mance p]iod ,! ,secret>y %all e/abli% a p]=mance p]iod 7or p]iods7 = a ye> 7beg9n+ ) ! ye> describ$ 9 p>agraph 7#a77;,b774 ,su* p]=mance p]iod 7or p]iods7 %all beg9 & end prior to ! beg9n+ ( su* ye> & be z close z possible to su* ye>4 ,9 ?is subsection1 su* p]=mance p]iod 7or p]iods7 = a ye> %all be ref]r$ to z ! p]=mance p]iod = ! ye>4 7#e7 ,composite p]=mance score 7,a7 ,9 g5]al ,subject to ! succe$+ provisions ( ?is p>agraph1 ! ,secret>y %all develop a me?odology = assess+ ! total p]=mance ( ea* ,,vbp eligible pr(essional accord+ to p]=mance /&>ds "u p>agraph 7#c7 ) respect to applicable measures & activities specifi$ 9 p>agraph 7#b77;,b7 ) respect to ea* p]=mance category applicable to su* pr(essional = a p]=mance p]iod 7z e/abli%$ "u p>agraph 7#d77 = a ye>4 ,us+ su* me?odology1 ! ,secret>y %all provide = a composite assessm5t 79 ?is subsection ref]r$ to z ! composite p]=mance score7 = ea* su* pr(essional = ea* p]=mance p]iod4 7,b7 ,weight+ p]=mance categories1 measures1 & activities ,"u ! me?odology "u subp>agraph 7,a71 ! ,secret>y-- 7i7 may assign diff]5t scor+ weights 7includ+ a weight ( #j7 =-- 7,i7 ea* p]=mance category bas$ on ! ext5t to :i* ! category is applicable to ! type ( eligible pr(essional involv$2 & 7,,ii7 ea* measure & activity specifi$ "u p>agraph 7#b77;,b7 ) respect to ea* su* category bas$ on ! ext5t to :i* ! measure or activity is applicable to ! type ( eligible pr(essional involv$2 & 7ii7 ) respect to ! p]=mance category describ$ 9 p>agraph 7#b77;,a77i7-- 7,i7 %all assign a high] scor+ weight to outcomes measures ?an to o!r measures & increase ! scor+ weight = outcome measures ov] "t2 & 7,,ii7 may assign a high] scor+ weight to pati5t exp]i5ce measures4 7,c7 ,inc5tive to report2 enc\rag+ use ( c]tifi$ ,,ehr te*nology = report+ quality measures 7i7 ,inc5tive to report ,"u ! me?odology e/abli%$ "u subp>agraph 7,a71 ! ,secret>y %all provide t 9 ! case ( a ,,vbp eligible pr(essional :o fails to report on an applicable measure or activity t is requir$ to be report$ by ! pr(essional1 ! pr(essional %all be treat$ z a*iev+ ! l[e/ pot5tial score applicable to su* measure or activity4 7ii7 ,enc\rag+ use ( c]tifi$ ,,ehr te*nology = report+ quality measures ,"u ! me?odology e/abli%$ "u subp>agraph 7,a71 ! ,secret>y %all-- 7,i7 enc\rage ,,vbp eligible pr(essionals to report on applicable measures ) respect to ! p]=mance category describ$ 9 p>agraph 7#b77;,a77i7 ?r\gh ! use ( c]tifi$ ,,ehr te*nology2 & 7,,ii7 ) respect to a p]=mance p]iod1 ) respect to a ye>1 = :i* a ,,vbp eligible pr(essional reports su* measures ?r\gh ! use ( su* ,,ehr te*nology1 treat su* pr(essional z satisfy+ ! cl9ical quality measures report+ requirem5t describ$ 9 subsection 7o77#b77;,a77iii7 = su* ye>4 7,d7 ,cl9ical practice improvem5t activities p]=mance score 7i7 ,rule = accr$itation ,a ,,vbp eligible pr(essional :o is 9 a practice t is c]tifi$ z a pati5t-c5t]$ m$ical home or comp>able specialty practice pursuant to subsection 7b77#h77;,b77i7 ) respect to a p]=mance p]iod %all be giv5 ! highe/ pot5tial score = ! p]=mance category describ$ 9 p>agraph 7#b77;,a77iii7 = su* p]iod4 7ii7 ,,apm p>ticipation ,p>ticipation by a ,,vbp eligible pr(essional 9 an alt]native paym5t model 7z def9$ 9 section #ahcc7z77#c77;,c77 ) respect to a p]=mance p]iod %all e>n su* eligible pr(essional "o-half ( ! highe/ pot5tial score = ! p]=mance category describ$ 9 p>agraph 7#b77;,a77iii7 = su* p]=mance p]iod4 ,no?+ 9 ! previ\s s5t5ce %all prev5t su* pr(essional f e>n+ m ?an "o-half ( su* highe/ pot5tial score = su* p]=mance p]iod by p]=m+ additional activities ) respect to su* p]=mance category4 7iii7 ,subcategories ,a ,,vbp eligible pr(essional %all n be requir$ to p]=m activities 9 ea* subcategory "u p>agraph 7#b77;,b77iii7 to a*ieve ! highe/ pot5tial score = ! p]=mance category describ$ 9 p>agraph 7#b77;,a77iii74 7,e7 ,di/ribution ,! ,secret>y %all ensure t ! application ( ! me?odology develop$ "u subp>agraph 7,a7 results 9 a cont9u\s di/ribution ( p]=mance scores1 :i* %all result 9 diff]5tial paym5ts "u p>agraph 7#g74 7,f7 ,a*ievem5t & improvem5t 7i7 ,tak+ into acc\nt improvem5t ,beg9n+ ) ! second ye> to :i* ! ,,vbp program applies1 9 addition to ! a*ievem5t score ( a ,,vbp eligible pr(essional1 ! me?odology develop$ "u subp>agraph 7,a7-- 7,i7 9 ! case ( ! p]=mance score = ! p]=mance category describ$ 9 clauses 7i7 & 7ii7 ( p>agraph 7#b77;,a71 %all take into acc\nt ! improvem5t ( ! pr(essional2 & 7,,ii7 9 ! case ( p]=mance scores = o!r p]=mance categories1 may take into acc\nt ! improvem5t ( ! pr(essional4 7ii7 ,assign+ high] weight = a*ievem5t ,beg9n+ ) ! f\r? ye> to :i* ! ,,vbp program applies1 "u ! me?odology develop$ "u subp>agraph 7,a71 ! ,secret>y %all assign a high] scor+ weight "u subp>agraph 7,b7 ) respect to ! a*ievem5t score ( a ,,vbp eligible pr(essional ) respect to a measure or activity specifi$ "u p>agraph 7#b77;,b7 7or ) respect to su* a measure or activity & ) respect to categories describ$ 9 p>agraph 7#b77;,a77 ?an to any improvem5t score appli$ "u clause 7i7 ) respect to su* measure or activity 7or su* measure or activity & categories74 7,g7 ,weights = ! p]=mance categories 7i7 ,9 g5]al ,"u ! me?odology develop$ "u subp>agraph 7,a71 subject to clauses 7ii7 & 7iii71 ! composite p]=mance score %all be det]m9$ z foll[s3 7,i7 ,quality ,?irty p]c5t ( su* score %all be bas$ on p]=mance ) respect to ! category describ$ 9 clause 7i7 ( p>agraph 7#b77;,a74 7,,ii7 ,res\rce use ,?irty p]c5t ( su* score %all be bas$ on p]=mance ) respect to ! category describ$ 9 clause 7ii7 ( p>agraph 7#b77;,a74 7,,iii7 ,cl9ical practice improvem5t activities ,fifte5 p]c5t ( su* score %all be bas$ on p]=mance ) respect to ! category describ$ 9 clause 7iii7 ( p>agraph 7#b77;,a74 7,,iv7 ,mean+ful use ( c]tifi$ ,,ehr te*nology ,tw5ty-five p]c5t ( su* score %all be bas$ on p]=mance ) respect to ! category describ$ 9 clause 7iv7 ( p>agraph 7#b77;,a74 7ii7 ,au?ority to adju/ p]c5tages 9 case ( high ehr mean+ful use adoption ,9 any ye> 9 :i* ! ,secret>y e/imates t ! proportion ( eligible pr(essionals 7z def9$ 9 subsection 7o77#e77 :o are mean+ful ,,ehr us]s 7z det]m9$ "u subsection 7o77#b77 is #ge p]c5t or great]1 ! ,secret>y may r$uce ! p]c5t applicable "u clause 7i77,,iv71 b n bel[ #ae p]c5t4 ,if ! ,secret>y makes su* r$uction = a ye>1 ! p]c5tages applicable "u "o or m ( subclauses 7,i71 7,,ii71 & 7,,iii7 ( clause 7i7 = su* ye> %all be increas$ 9 a mann] su* t ! total p]c5tage po9ts ( ! increase "u ?is clause = su* ye> equals ! total numb] ( p]c5tage po9ts r$uc$ "u ! prec$+ s5t5ce = su* ye>4 7iii7 ,au?ority to adju/ p]c5tages = quality & res\rce use 7,i7 ,9 g5]al ,subject to subclause 7,,ii71 ! p]c5tages describ$ 9 subclauses 7,i7 & 7,,ii7 ( clause 7i71 includ+ aft] application ( clause 7ii71 %all be equal4 7,,ii7 ,exception ,= ! fir/ #b ye>s = :i* ! ,,vbp program applies1 aft] application ( clause 7ii71 ! ,secret>y may increase ! p]c5tage applicable "u subclause 7,i7 or 7,,ii7 ( clause 7i7 z long z ! ,secret>y decreases ! p]c5tage applicable "u ! o!r subclause by an equal numb] ( p]c5tage po9ts & ! numb] ( p]c5tage po9ts applicable "u ea* ( subclauses 7,i7 & 7,,ii7 is n less ?an #ae4 7,h7 ,res\rce use ,analysis ( ! p]=mance category describ$ 9 p>agraph 7#b77;,a77ii7 %all include results f ! me?odology describ$ 9 subsection 7r77#e71 z appropriate4 7,i7 ,inclusion ( quality measure data f multiple pay]s ,9 apply+ subsections 7k71 7m71 & 7p7 ) respect to measures describ$ 9 p>agraph 7#b77;,b77i71 analysis ( ! p]=mance category describ$ 9 p>agraph 7#b77;,a77i7 may include data submitt$ by ,,vbp eligible pr(essionals ) respect to multiple pay]s4 7,j7 ,use ( volunt>y virtual gr\ps = c]ta9 assessm5t purposes 7i7 ,9 g5]al ,9 ! case ( ,,vbp eligible pr(essionals elect+ to be a virtual gr\p "u clause 7ii7 ) respect to a p]=mance p]iod = a ye>1 = purposes ( apply+ ! me?odology "u subp>agraph 7,a7-- 7,i7 ! assessm5t ( p]=mance provid$ "u su* me?odology ) respect to ! p]=mance categories describ$ 9 clauses 7i7 & 7ii7 ( p>agraph 7#b77;,a7 t is to be appli$ to ea* su* pr(essional 9 su* gr\p = su* p]=mance p]iod %all be ) respect to ! comb9$ p]=mance ( all su* pr(essionals 9 su* gr\p = su* p]iod2 & 7,,ii7 ! composite score provid$ "u ?is p>agraph = su* p]=mance p]iod ) respect to ea* su* p]=mance category = ea* su* ,,vbp eligible pr(essional 9 su* virtual gr\p %all be bas$ on ! assessm5t ( ! comb9$ p]=mance "u subclause 7,i7 = ! p]=mance category & p]=mance p]iod4 7ii7 ,election ( practices to be a virtual gr\p ,! ,secret>y %all1 9 accordance ) clause 7iii71 e/abli% & h 9 place a process to all[ an individual ,,vbp eligible pr(essional or a gr\p practice consi/+ ( n m ?an #aj ,,vbp eligible pr(essionals to elect1 ) respect to a p]=mance p]iod = a ye>1 = su* individual ,,vbp eligible pr(essional or all su* ,,vbp eligible pr(essionals 9 su* gr\p practice1 respectively1 to be a virtual gr\p "u ?is subp>agraph ) at lea/ "o o!r su* individual ,,vbp eligible pr(essional or gr\p practice mak+ su* an election4 7iii7 ,requirem5ts ,! process "u clause 7ii7 %all provide t-- 7,i7 an election "u su* clause1 ) respect to a p]=mance p]iod1 %all be made be=e ! beg9n+ ( su* p]=mance p]iod & may n be *ang$ dur+ su* p]=mance p]iod2 & 7,,ii7 a practice describ$ 9 su* clause1 & ea* ,,vbp eligible pr(essional 9 su* practice1 may elect to be 9 no m ?an "o virtual gr\p = a p]=mance p]iod4 7#f7 ,fund+ = ,,vbp program inc5tive paym5ts 7,a7 ,total am\nt = inc5tive paym5ts ,! total am\nt = ,,vbp program inc5tive paym5ts "u p>agraph 7#g7 = all ,,vbp eligible pr(essionals = a ye> %all be equal to ! total am\nt ( ! p]=mance fund+ pool = all ,,vbp eligible pr(essionals "u subp>agraph 7,b7 = su* ye>1 z e/imat$ by ! ,secret>y4 7,b7 ,p]=mance fund+ pool 7i7 ,9 g5]al ,9 ! case ( items & s]vices furni%$ by a ,,vbp eligible pr(essional dur+ a ye> 7beg9n+ ) #bjag71 ! o!rwise applicable fee s*$ule am\nt 7z def9$ 9 clause 7iii77 ) respect to su* items & s]vices & eligible pr(essional = su* ye> %all be r$uc$ by ! applicable p]c5t "u clause 7ii74 ,! total am\nt ( su* r$uctions = a ye> %all be ref]r$ to 9 ?is subsection z ! p]=mance fund+ pool = su* ye>4 7ii7 ,applicable p]c5t def9$ ,= purposes ( clause 7i71 ! t]m applicable p]c5t means-- 7,i7 = #bjag1 #d p]c5t2 7,,ii7 = #bjah1 #f p]c5t2 7,,iii7 = #bjai1 #h p]c5t2 7,,iv7 = #bjbj1 #aj p]c5t2 & 7,v7 = #bjba & subsequ5t ye>s1 a p]c5t specifi$ by ! ,secret>y 7b 9 no case less ?an #aj p]c5t or m ?an #ab p]c5t74 7iii7 ,o!rwise applicable fee s*$ule am\nt ,= purposes ( ?is subp>agraph & p>agraph 7#g71 ! t]m o!rwise applicable fee s*$ule am\nt means1 ) respect to items & s]vices furni%$ by a ,,vbp eligible pr(essional dur+ a ye>1 ! fee s*$ule am\nt = su* items & s]vices & ye> t w\ld o!rwise apply 7)\t application ( ?is subp>agraph or p>agraph 7#g77 ) respect to su* eligible pr(essional "u subsection 7b71 aft] application ( subsection 7a77#c71 or "u ano!r fee s*$ule "u ?is "p4 7#g7 ,,vbp program inc5tive paym5ts 7,a7 ,,vbp program inc5tive paym5t adju/m5t factor ,! ,secret>y %all specify a ,,vbp program inc5tive paym5t adju/m5t factor = ea* ,,vbp eligible pr(essional = a ye>4 ,su* ,,vbp program inc5tive paym5t adju/m5t factor = a ,,vbp eligible pr(essional = a ye> %all be det]m9$-- 7i7 by ! composite p]=mance score ( ! eligible pr(essional = su* ye>2 7ii7 9 a mann] su* t ! adju/m5t factors specifi$ "u ?is subp>agraph = a ye> results 9 diff]5tial paym5ts "u ?is p>agraph reflect+ ! full range ( ! di/ribution ( composite p]=mance scores ( ,,vbp eligible pr(essionals det]m9$ "u p>agraph 7#e77;,e7 = su* ye>1 ) su* pr(essionals hav+ high] composite p]=mance scores receiv+ high] paym5t2 & 7iii7 9 a mann] su* t ! adju/m5t factors specifi$ "u ?is subp>agraph = a ye>-- 7,i7 d n result 9 a paym5t r$uction = su* ye> by an am\nt t exce$s ! applicable p]c5t describ$ 9 p>agraph 7#f77;,b77ii7 = su* ye>2 & 7,,ii7 d n result 9 a paym5t increase = su* ye> by an am\nt t exce$s ! applicable p]c5t describ$ 9 p>agraph 7#f77;,b77ii7 = su* ye>4 7,b7 ,calculation ( ,,vbp program inc5tive paym5t am\nts ,! ,,vbp program inc5tive paym5t am\nt ) respect to items & s]vices furni%$ by a ,,vbp eligible pr(essional dur+ a ye> %all be equal to ! diff]5ce betwe5-- 7i7 ! product (-- 7,i7 ! ,,vbp program inc5tive paym5t adju/m5t factor det]m9$ "u subp>agraph 7,a7 = su* ,,vbp eligible pr(essional = su* ye>2 & 7,,ii7 ! o!rwise applicable fee s*$ule am\nt 7z def9$ 9 p>agraph 7#f77;,b77iii77 ) respect to su* items & s]vices & eligible pr(essional = su* ye>2 & 7ii7 ! o!rwise applicable fee s*$ule am\nt1 z r$uc$ "u p>agraph 7#f77;,b71 ) respect to su* items & s]vices1 eligible pr(essional1 & ye>4 ,! application ( ! prec$+ s5t5ce may result 9 ! ,,vbp program inc5tive paym5t am\nt be+ #j4j ) respect to an item or s]vice furni%$ by a ,,vbp eligible pr(essional4 7,c7 ,application ( ,,vbp program inc5tive paym5t am\nt ,9 ! case ( items & s]vices furni%$ by a ,,vbp eligible pr(essional dur+ a ye> 7beg9n+ ) #bjag71 ! o!rwise applicable fee s*$ule am\nt1 z r$uc$ "u p>agraph 7#f77;,b71 ) respect to su* items & s]vices & eligible pr(essional = su* ye> %all be increas$1 if applicable1 by ! ,,vbp program inc5tive paym5t am\nt det]m9$ "u subp>agraph 7,b7 ) respect to su* items & s]vices1 pr(essional1 & ye>4 7,d7 ,budget neutrality ,9 specify+ ! ,,vbp program inc5tive paym5t adju/m5t factor = ea* ,,vbp eligible pr(essional = a ye> "u subp>agraph 7,a71 ! ,secret>y %all ensure t ! total am\nt ( ,,vbp program inc5tive paym5t am\nts "u ?is p>agraph = all ,,vbp eligible pr(essionals 9 a ye> %all be equal to ! p]=mance fund+ pool = su* ye> "u p>agraph 7#f71 z e/imat$ by ! ,secret>y4 7#h7 ,ann\ncem5t ( result ( adju/m5ts ,"u ! ,,vbp program1 ! ,secret>y %all1 n lat] ?an #fj days prior to ! ye> involv$1 make available to ea* ,,vbp eligible pr(essional ! ,,vbp program inc5tive paym5t adju/m5t factor "u p>agraph 7#g7 & ! paym5t r$uction "u p>agraph 7#f7 applicable to ! eligible pr(essional = items & s]vices furni%$ by ! pr(essional 9 su* ye>4 ,! ,secret>y may include su* in=mation 9 ! confid5tial fe$back "u p>agraph 7#ac74 7#i7 ,no effect 9 subsequ5t ye>s ,! ,,vbp program inc5tive paym5t "u p>agraph 7#g7 & ! paym5t r$uction "u p>agraph 7#f7 %all ea* apply only ) respect to ! ye> involv$1 & ! ,secret>y %all n take into acc\nt su* ,,vbp program inc5tive paym5t or paym5t r$uction 9 mak+ paym5ts to a ,,vbp eligible pr(essional "u ?is "p 9 a subsequ5t ye>4 7#aj7 ,public report+ 7,a7 ,9 g5]al ,! ,secret>y %all1 9 an easily und]/&able =mat1 make available on ! ,physician ,comp>e ,int]net website "u subsection 7t7 ! foll[+3 7i7 ,in=mation reg>d+ ! p]=mance ( ,,vbp eligible pr(essionals "u ! ,,vbp program1 :i*-- 7,i7 %all include ! composite score = ea* su* ,,vbp eligible pr(essional & ! p]=mance ( ea* su* ,,vbp eligible pr(essional ) respect to ea* p]=mance category2 & 7,,ii7 may include ! p]=mance ( ea* su* ,,vbp eligible pr(essional ) respect to ea* measure or activity specifi$ 9 p>agraph 7#b77;,b74 7ii7 ,! names ( eligible pr(essionals 9 eligible alt]native paym5t models 7z def9$ 9 section #ahcc7z77#c77;,d77 &1 to ! ext5t feasible1 ! names ( su* eligible alt]native paym5t models & p]=mance ( su* models4 7,b7 ,opportunity to review & submit corrections ,! ,secret>y %all provide = an opportunity = a pr(essional describ$ 9 subp>agraph 7,a7 to review1 & submit corrections =1 ! in=mation to be made public ) respect to ! pr(essional "u su* subp>agraph prior to su* in=mation be+ made public4 7,c7 ,aggregate in=mation ,! ,secret>y %all p]iodically po/ on ! ,physician ,comp>e ,int]net website aggregate in=mation on ! ,,vbp program1 includ+ ! range ( composite scores = all ,,vbp eligible pr(essionals & ! range ( ! p]=mance ( all ,,vbp eligible pr(essionals ) respect to ea* p]=mance category4 7#aa7 ,consultation ,! ,secret>y %all consult ) /akehold]s 9 c>ry+ out ! ,,vbp program1 includ+ = ! id5tification ( measures & activities "u p>agraph 7#b77;,b7 & ! me?odologies develop$ "u p>agraphs 7#e77;,a7 & 7#g74 ,su* consultation %all include ! use ( a reque/ = in=mation or o!r me*anisms det]m9$ appropriate4 7#ab7 ,te*nical assi/ance to small practices & practices 9 heal? pr(essional %ortage areas 7,a7 ,9 g5]al ,! ,secret>y %all ent] into contracts or agreem5ts ) appropriate entities 7su* z quality improvem5t organizations1 regional ext5sion c5t]s 7z describ$ 9 section #cjab7;c7 ( ! ,public ,heal? ,s]vice ,act71 or regional heal? collaboratives7 to (f] guidance & assi/ance to ,,vbp eligible pr(essionals 9 practices ( #aj or few] pr(essionals 7) priority giv5 to su* practices locat$ 9 rural areas1 heal? pr(essional %ortage areas 7z designat$ 9 section #ccb7;a77#a77;,a7 ( ! ,public ,heal? ,s]vice ,act71 m$ically und]s]v$ areas1 or practices ) l[ composite scores7 ) respect to-- 7i7 ! p]=mance categories describ$ 9 clauses 7i7 ?r\gh 7iv7 ( p>agraph 7#b77;,a72 or 7ii7 h[ to transition to ! implem5tation ( & p>ticipation 9 an alt]native paym5t model z describ$ 9 section #ahcc7z77#c77;,c74 7,b7 ,fund+ = implem5tation ,= purposes ( implem5t+ subp>agraph 7,a71 ! ,secret>y %all provide = ! transf] f ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund e/abli%$ "u section #ahda to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt ( #be1jjj1jjj = ea* ( fiscal ye>s #bjad ?r\gh #bjah4 ,( am\nts transf]r$ "u ! prec$+ s5t5ce1 n less ?an #aj1jjj1jjj %all be available = te*nical assi/ance to small practices 7consi/+ ( #aj or few] pr(essionals7 9 heal? pr(essional %ortage areas 7z s designat$74 ,am\nts transf]r$ "u ?is subp>agraph = a fiscal ye> %all be available until exp5d$4 7#ac7 ,fe$back & in=mation to improve p]=mance 7,a7 ,p]=mance fe$back 7i7 ,9 g5]al ,beg9n+ ,july #a1 #bjae1 ! ,secret>y-- 7,i7 %all make available timely 7su* z qu>t]ly7 confid5tial fe$back to ea* ,,vbp eligible pr(essional on ! p]=mance ( su* pr(essional ) respect to ! p]=mance categories "u clauses 7i7 & 7ii7 ( p>agraph 7#b77;,a72 & 7,,ii7 may make available confid5tial fe$back to ea* su* pr(essional on ! p]=mance ( su* pr(essional ) respect to ! p]=mance categories "u clauses 7iii7 & 7iv7 ( su* p>agraph4 7ii7 ,me*anisms ,! ,secret>y may use "o or m me*anisms to make fe$back available "u clause 7i71 :i* may include use ( a web-bas$ portal or o!r me*anisms det]m9$ appropriate by ! ,secret>y4 ,! ,secret>y %all enc\rage provision ( fe$back ?r\gh qualifi$ cl9ical data regi/ries1 z describ$ 9 subsection 7m77#c77;,e74 7iii7 ,use ( data ,= purposes ( clause 7i71 ! ,secret>y may use data1 ) respect to a ,,vbp eligible pr(essional1 f p]iods prior to ! curr5t p]=mance p]iod & may use roll+ p]iods 9 ord] to make illu/rative calculations ab\t ! p]=mance ( su* pr(essional4 7iv7 ,disclosure exemption ,fe$back made available "u ?is subp>agraph %all be exempt f disclosure "u section #eeb ( title #e1 ,unit$ ,/ates ,code4 7v7 ,receipt ( in=mation ,! ,secret>y may use ! me*anisms e/abli%$ "u clause 7ii7 to receive in=mation f pr(essionals1 su* z in=mation ) respect to ?is subsection4 7,b7 ,additional in=mation 7i7 ,9 g5]al ,beg9n+ ,july #a1 #bjaf1 ! ,secret>y %all make available to ea* ,,vbp eligible pr(essional in=mation1 ) respect to individuals :o are pati5ts ( su* ,,vbp eligible pr(essional1 ab\t items & s]vices = :i* paym5t is made "u ?is title t are furni%$ to su* individuals by o!r suppli]s & provid]s ( s]vices1 :i* may include in=mation describ$ 9 clause 7ii74 ,su* in=mation %all be made available "u ! previ\s s5t5ce to su* ,,vbp eligible pr(essionals by me*anisms det]m9$ appropriate by ! ,secret>y1 :i* may include use ( a web-bas$ portal4 ,su* in=mation %all be made available 9 accordance ) ! same or simil> t]ms z data are made available to acc\ntable c>e organizations "u section #ahii1 includ+ a b5efici>y opt-out4 7ii7 ,type ( in=mation ,= purposes ( clause 7i71 ! in=mation describ$ 9 ?is clause1 is ! foll[+3 7,i7 ,) respect to select$ items & s]vices 7z det]m9$ appropriate by ! ,secret>y7 = :i* paym5t is made "u ?is title & t are furni%$ to individuals1 :o are pati5ts ( a ,,vbp eligible pr(essional1 by ano!r suppli] or provid] ( s]vices dur+ ! mo/ rec5t p]iod = :i* data are available 7su* z ! mo/ rec5t ?ree-mon? p]iod71 ! "n ( su* provid]s furni%+ su* items & s]vices to su* pati5ts dur+ su* p]iod1 ! types ( su* items & s]vices s furni%$1 & ! dates su* items & s]vices 7 s furni%$4 7,,ii7 ,hi/orical av]ages 7& o!r measures ( ! di/ribution if appropriate7 ( ! total1 & compon5ts (1 all[$ *>ges 7& o!r figures z det]m9$ appropriate by ! ,secret>y7 = c>e episodes = su* p]iod4 7#ad7 ,review 7,a7 ,t>get$ review ,! ,secret>y %all e/abli% a process "u :i* a ,,vbp eligible pr(essional may seek an in=mal review ( ! calculation ( ! ,,vbp program inc5tive paym5t adju/m5t factor applicable to su* eligible pr(essional "u ?is subsection = a ye>4 ,! results ( a review conduct$ pursuant to ! previ\s s5t5ce %all n be tak5 into acc\nt = purposes ( p>agraph 7#g7 ) respect to a ye> 7o!r ?an ) respect to ! calculation ( su* eligible pr(essional's ,,vbp program inc5tive paym5t adju/m5t factor = su* ye>7 aft] ! factors det]m9$ 9 subp>agraph 7,a7 ( su* p>agraph h be5 det]m9$ = su* ye>4 7,b7 ,limitation ,except z provid$ = 9 subp>agraph 7,a71 !re %all be no adm9i/rative or judicial review "u section #ahfi1 section #ahgh1 or o!rwise ( ! foll[+3 7i7 ,! me?odology us$ to det]m9e ! am\nt ( ! ,,vbp program inc5tive paym5t adju/m5t factor "u p>agraph 7#g7 & ! det]m9ation ( su* am\nt4 7ii7 ,! det]m9ation ( ! am\nt ( fund+ available = su* ,,vbp program inc5tive paym5ts "u p>agraph 7#f77;,a7 & ! paym5t r$uction "u p>agraph 7#f77;,b77i74 7iii7 ,! e/abli%m5t ( ! p]=mance /&>ds "u p>agraph 7#c7 & ! p]=mance p]iod "u p>agraph 7#d74 7iv7 ,! id5tification ( measures & activities specifi$ "u p>agraph 7#b77;,b7 & in=mation made public or po/$ on ! ,physician ,comp>e ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices "u p>agraph 7#aj74 7v7 ,! me?odology develop$ "u p>agraph 7#e7 t is us$ to calculate p]=mance scores & ! calculation ( su* scores1 includ+ ! weight+ ( measures & activities "u su* me?odology4 4 7#b7 ,,gao reports 7,a7 ,evaluation ( eligible pr(essional ,,vbp program ,n lat] ?an ,octob] #a1 #bjah1 & ,octob] #a1 #bjba1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report evaluat+ ! eligible pr(essional value-bas$ p]=mance inc5tive program "u subsection 7q7 ( section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 z add$ by p>agraph 7#a74 ,su* report %all-- 7i7 exam9e ! di/ribution ( ! p]=mance & inc5tive paym5ts = ,,vbp eligible pr(essionals 7z def9$ 9 subsection 7q77#a77;,c7 ( su* section7 "u su* program1 & patt]ns relat+ to su* p]=mance & inc5tive paym5ts1 includ+ ^? bas$ on type ( provid]1 practice size1 geographic location1 & pati5t mix2 7ii7 provide recomm5dations = improv+ su* program2 7iii7 evaluate ! impact ( te*nical assi/ance fund+ "u section #ahdh7q77#ab7 ( ! ,social ,security ,act1 z add$ by p>agraph 7#a71 on ! ability ( pr(essionals to improve )9 su* program or successfully transition to an alt]native paym5t model 7z def9$ 9 section #ahcc7z77#c7 ( ! ,social ,security ,act1 z add$ by subsection 7e77#a771 ) priority = su* evaluation giv5 to practices locat$ 9 rural areas1 heal? pr(essional %ortage areas 7z designat$ 9 section #ccb7;a77#a77;,a7 ( ! ,public ,heal? ,s]vice ,act71 & m$ically und]s]v$ areas2 & 7iv7 provide recomm5dations = optimiz+ ! use ( su* te*nical assi/ance funds4 7,b7 ,/udy to exam9e alignm5t ( quality measures us$ 9 public & private programs 7i7 ,9 g5]al ,n lat] ?an #ah mon?s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report t-- 7,i7 comp>es ! simil>ities & diff]5ces 9 ! use ( quality measures "u ! orig9al m$ic>e fee-=-s]vice program "u p>ts ,a & ,b ( title ,,xviii ( ! ,social ,security ,act1 ! ,m$ic>e ,advantage program "u "p ,c ( su* title1 select$ ,/ate ,m$icaid programs "u title ,,xix ( su* ,act1 & private pay] arrangem5ts2 & 7,,ii7 makes recomm5dations on h[ to r$uce ! adm9i/rative burd5 involv$ 9 apply+ su* quality measures4 7ii7 ,requirem5ts ,! report "u clause 7i7 %all-- 7,i7 consid] ^? measures applicable to individuals entitl$ to1 or enroll$ =1 b5efits "u su* "p ,a1 or enroll$ "u su* "p ,b & individuals "u ! age ( #fe2 & 7,,ii7 focus on ^? measures t comprise ! mo/ significant compon5t ( ! quality p]=mance category ( ! eligible pr(essional value-bas$ p]=mance inc5tive program "u subsection 7q7 ( section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 z add$ by p>agraph 7#a74 7,c7 ,/udy to exam9e rural & heal? pr(essional %ortage area alt]native paym5t models ,n lat] ?an ,octob] #a1 #bjai1 & ,octob] #a1 #bjba1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report t exam9es ! transition ( pr(essionals 9 rural areas1 heal? pr(essional %ortage areas 7z designat$ 9 section #ccb7;a77#a77;,a7 ( ! ,public ,heal? ,s]vice ,act71 or m$ically und]s]v$ areas to an alt]native paym5t model 7z def9$ 9 section #ahcc7z77#c7 ( ! ,social ,security ,act1 z add$ by subsection 7e77#a774 ,su* report %all make recomm5dations = remov+ adm9i/rative b>ri]s to practices 9 rural areas1 heal? pr(essional %ortage areas1 & m$ically und]s]v$ areas to p>ticipation 9 su* models4 7#c7 ,fund+ = implem5tation ,= purposes ( implem5t+ ! provisions ( & ! am5dm5ts made by ?is section1 ! ,secret>y ( ,heal? & ,human ,s]vices %all provide = ! transf] ( #ej1jjj1jjj f ! ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund e/abli%$ "u section #ahda ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciet7 to ! ,c5t]s = ,m$ic>e ,m$icaid ,program ,managem5t ,acc\nt = ea* ( ! fiscal ye>s #bjad ?r\gh #bjag4 ,am\nts transf]r$ "u ?is p>agraph %all be available until exp5d$4 7d7 ,improv+ quality report+ = composite scores 7#a7 ,*anges = gr\p report+ option 7,a7 ,9 g5]al ,section #ahdh7m77#c77;,c77ii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#c77;,c77ii77 is am5d$ by ins]t+ &1 = #bjad & subsequ5t ye>s1 may provide aft] %all provide4 7,b7 ,cl>ification ( qualifi$ cl9ical data regi/ry report+ to gr\p practices ,section #ahdh7m77#c77;,d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#c77;,d77 is am5d$ by ins]t+ &1 = #bjae & subsequ5t ye>s1 subp>agraph 7,a7 or 7,c7 aft] subp>agraph 7,a74 7#b7 ,*anges = multiple report+ p]iods & alt]native crit]ia = satisfactory report+ ,section #ahdh7m77#e77;,f7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#e77;,f77 is am5d$-- 7,a7 by /rik+ & subsequ5t ye>s & ins]t+ ?r\gh report+ p]iods occurr+ 9 #bjac2 & 7,b7 by ins]t+ &1 = report+ p]iods occurr+ 9 #bjad & subsequ5t ye>s1 ! ,secret>y may e/abli% foll[+ %all e/abli%4 7#c7 ,physician fe$back program reports succe$$ by reports "u ,,vbp program ,section #ahdh7n7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7n77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#aa7 ,reports end+ ) #bjaf ,reports "u ! ,program %all n be provid$ aft] ,decemb] #ca1 #bjaf4 ,see subsection 7q77#ac7 = reports beg9n+ ) #bjag4 4 7#d7 ,coord9ation ) satisfy+ mean+ful ,,ehr use cl9ical quality measure report+ requirem5t ,section #ahdh7o77#b77;,a77iii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7o77#b77;,a77iii77 is am5d$ by ins]t+ & subsection 7q77#e77;,c77ii77,,ii7 aft] ,subject to subp>agraph 7,b77ii74 7e7 ,promot+ alt]native paym5t models 7#a7 ,inc5tive paym5ts = p>ticipation 9 eligible alt]native paym5t models ,section #ahcc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7z7 ,inc5tive paym5ts = p>ticipation 9 eligible alt]native paym5t models 7#a7 ,paym5t inc5tive 7,a7 ,9 g5]al ,9 ! case ( cov]$ pr(essional s]vices furni%$ by an eligible pr(essional dur+ a ye> t is 9 ! p]iod beg9n+ ) #bjag & end+ ) #bjbb & = :i* ! pr(essional is a qualify+ ,,apm p>ticipant1 9 addition to ! am\nt ( paym5t t w\ld o!rwise be made = su* cov]$ pr(essional s]vices "u ?is "p = su* ye>1 !re also %all be paid to su* pr(essional an am\nt equal to #e p]c5t ( ! paym5t am\nt = ! cov]$ pr(essional s]vices "u ?is "p = ! prec$+ ye>4 ,= purposes ( ! previ\s s5t5ce1 ! paym5t am\nt = ! prec$+ ye> may be an e/imation = ! full prec$+ ye> bas$ on a p]iod ( su* prec$+ ye> t is less ?an ! full ye>4 ,! ,secret>y %all e/abli% policies to implem5t ?is subp>agraph 9 cases :]e paym5t = cov]$ pr(essional s]vices furni%$ by a qualify+ ,,apm p>ticipant 9 an alt]native paym5t model is made to an entity p>ticipat+ 9 ! alt]native paym5t model r ?an directly to ! qualify+ ,,apm p>ticipant4 7,b7 ,=m ( paym5t ,paym5ts "u ?is subsection %all be made 9 a lump sum1 on an annual basis1 z soon z practicable4 7,c7 ,treatm5t ( paym5t inc5tive ,paym5ts "u ?is subsection %all n be tak5 into acc\nt = purposes ( det]m9+ actual exp5ditures "u an alt]native paym5t model & = purposes ( det]m9+ or rebas+ any b5*m>ks us$ "u ! alt]native paym5t model4 7,d7 ,coord9ation ,! am\nt ( ! additional paym5t = an item or s]vice "u ?is subsection or subsection 7m7 %all be det]m9$ )\t reg>d to any additional paym5t = ! item or s]vice "u subsection 7m7 & ?is subsection1 respectively4 ,! am\nt ( ! additional paym5t = an item or s]vice "u ?is subsection or subsection 7x7 %all be det]m9$ )\t reg>d to any additional paym5t = ! item or s]vice "u subsection 7x7 & ?is subsection1 respectively4 ,! am\nt ( ! additional paym5t = an item or s]vice "u ?is subsection or subsection 7y7 %all be det]m9$ )\t reg>d to any additional paym5t = ! item or s]vice "u subsection 7y7 & ?is subsection1 respectively4 7#b7 ,qualify+ ,,apm p>ticipant ,= purposes ( ?is subsection1 ! t]m qualify+ ,,apm p>ticipant means ! foll[+3 7,a7 #bjag & #bjah ,) respect to #bjag & #bjah1 an eligible pr(essional = :om ! ,secret>y det]m9es t at lea/ #be p]c5t ( paym5ts "u ?is "p = cov]$ pr(essional s]vices furni%$ by su* pr(essional dur+ ! mo/ rec5t p]iod = :i* data are available 7:i* may be less ?an a ye>7 7 attributable to su* s]vices furni%$ "u ?is "p ?r\gh an entity t p>ticipates 9 an eligible alt]native paym5t model ) respect to su* s]vices4 7,b7 #bjai & #bjbj ,) respect to #bjai & #bjbj1 an eligible pr(essional describ$ 9 ei!r ( ! foll[+ clauses3 7i7 ,m$ic>e rev5ue ?re%old option ,an eligible pr(essional = :om ! ,secret>y det]m9es t at lea/ #ej p]c5t ( paym5ts "u ?is "p = cov]$ pr(essional s]vices furni%$ by su* pr(essional dur+ ! mo/ rec5t p]iod = :i* data are available 7:i* may be less ?an a ye>7 7 attributable to su* s]vices furni%$ "u ?is "p ?r\gh an entity t p>ticipates 9 an eligible alt]native paym5t model ) respect to su* s]vices4 7ii7 ,comb9ation all-pay] & ,m$ic>e rev5ue ?re%old option ,an eligible pr(essional-- 7,i7 = :om ! ,secret>y det]m9es1 ) respect to items & s]vices furni%$ by su* pr(essional dur+ ! mo/ rec5t p]iod = :i* data are available 7:i* may be less ?an a ye>71 t at lea/ #ej p]c5t ( ! sum (-- 7aa7 paym5ts describ$ 9 clause 7i72 & 7bb7 all o!r paym5ts1 reg>dless ( pay] 7o!r ?an paym5ts made by ! ,secret>y ( ,def5se or ! ,secret>y ( ,vet]ans ,affairs "u *apt] #ee ( title #aj1 ,unit$ ,/ates ,code1 or title #ch1 ,unit$ ,/ates ,code1 or any o!r provision ( law1 & o!r ?an paym5ts made "u title ,,xix 9 a ,/ate 9 :i* no m$ical home or alt]native paym5t model is available "u ! ,/ate program "u t title74 meet ! requirem5t describ$ 9 clause 7iii77,i7 ) respect to paym5ts describ$ 9 item 7aa7 & meet ! requirem5t describ$ 9 clause 7iii77,,ii7 ) respect to paym5ts describ$ 9 item 7bb72 7,,ii7 = :om ! ,secret>y det]m9es at lea/ #be p]c5t ( paym5ts "u ?is "p = cov]$ pr(essional s]vices furni%$ by su* pr(essional dur+ ! mo/ rec5t p]iod = :i* data are available 7:i* may be less ?an a ye>7 7 attributable to su* s]vices furni%$ "u ?is "p ?r\gh an entity t p>ticipates 9 an eligible alt]native paym5t model ) respect to su* s]vices2 & 7,,iii7 :o provides to ! ,secret>y su* in=mation z is necess>y = ! ,secret>y to make a det]m9ation "u subclause 7,i71 ) respect to su* pr(essional4 7iii7 ,requirem5t ,= purposes ( clause 7ii77,i7-- 7,i7 ! requirem5t describ$ 9 ?is subclause1 ) respect to paym5ts describ$ 9 item 7aa7 ( su* clause1 is t su* paym5ts are made "u an eligible alt]native paym5t model2 & 7,,ii7 ! requirem5t describ$ 9 ?is subclause1 ) respect to paym5ts describ$ 9 item 7bb7 ( su* clause1 is t su* paym5ts are made "u an arrangem5t 9 :i*-- 7aa7 quality measures comp>able to measures "u ! p]=mance category describ$ 9 section #ahdh7q77#b77;,b77i7 apply2 7bb7 c]tifi$ ,,ehr te*nology is us$2 & 7cc7 ! eligible pr(essional 7,,aa7 be>s m ?an nom9al f9ancial risk if actual aggregate exp5ditures exce$s expect$ aggregate exp5ditures2 or 7,,bb7 is a m$ical home 7) respect to b5efici>ies "u title ,,xix7 t meets crit]ia comp>able to m$ical homes exp&$ "u section #aaae;,a7c74 7,c7 ,beg9n+ 9 #bjba ,) respect to #bjba & ea* subsequ5t ye>1 an eligible pr(essional describ$ 9 ei!r ( ! foll[+ clauses3 7i7 ,m$ic>e rev5ue ?re%old option ,an eligible pr(essional = :om ! ,secret>y det]m9es t at lea/ #ge p]c5t ( paym5ts "u ?is "p = cov]$ pr(essional s]vices furni%$ by su* pr(essional dur+ ! mo/ rec5t p]iod = :i* data are available 7:i* may be less ?an a ye>7 7 attributable to su* s]vices furni%$ "u ?is "p ?r\gh an entity t p>ticipates 9 an eligible alt]native paym5t model ) respect to su* s]vices4 7ii7 ,comb9ation all-pay] & ,m$ic>e rev5ue ?re%old option ,an eligible pr(essional-- 7,i7 = :om ! ,secret>y det]m9es1 ) respect to items & s]vices furni%$ by su* pr(essional dur+ ! mo/ rec5t p]iod = :i* data are available 7:i* may be less ?an a ye>71 t at lea/ #ge p]c5t ( ! sum (-- 7aa7 paym5ts describ$ 9 clause 7i72 & 7bb7 all o!r paym5ts1 reg>dless ( pay] 7o!r ?an paym5ts made by ! ,secret>y ( ,def5se or ! ,secret>y ( ,vet]ans ,affairs "u *apt] #ee ( title #aj1 ,unit$ ,/ates ,code1 or title #ch1 ,unit$ ,/ates ,code1 or any o!r provision ( law1 & o!r ?an paym5ts made "u title ,,xix 9 a ,/ate 9 :i* no m$ical home or alt]native paym5t model is available "u ! ,/ate program "u t title4 meet ! requirem5t describ$ 9 clause 7iii77,i7 ) respect to paym5ts describ$ 9 item 7aa7 & meet ! requirem5t describ$ 9 clause 7iii77,,ii7 ) respect to paym5ts describ$ 9 item 7bb72 7,,ii7 = :om ! ,secret>y det]m9es at lea/ #be p]c5t ( paym5ts "u ?is "p = cov]$ pr(essional s]vices furni%$ by su* pr(essional dur+ ! mo/ rec5t p]iod = :i* data are available 7:i* may be less ?an a ye>7 7 attributable to su* s]vices furni%$ "u ?is "p ?r\gh an entity t p>ticipates 9 an eligible alt]native paym5t model ) respect to su* s]vices2 & 7,,iii7 :o provides to ! ,secret>y su* in=mation z is necess>y = ! ,secret>y to make a det]m9ation "u subclause 7,i71 ) respect to su* pr(essional4 7iii7 ,requirem5t ,= purposes ( clause 7ii77,i7-- 7,i7 ! requirem5t describ$ 9 ?is subclause1 ) respect to paym5ts describ$ 9 item 7aa7 ( su* clause1 is t su* paym5ts are made "u an eligible alt]native paym5t model2 & 7,,ii7 ! requirem5t describ$ 9 ?is subclause1 ) respect to paym5ts describ$ 9 item 7bb7 ( su* clause1 is t su* paym5ts are made "u an arrangem5t 9 :i*-- 7aa7 quality measures comp>able to measures "u ! p]=mance category describ$ 9 section #ahdh7q77#b77;,b77i7 apply2 7bb7 c]tifi$ ,,ehr te*nology is us$2 & 7cc7 ! eligible pr(essional 7,,aa7 be>s m ?an nom9al f9ancial risk if actual aggregate exp5ditures exce$s expect$ aggregate exp5ditures2 or 7,,bb7 is a m$ical home 7) respect to b5efici>ies "u title ,,xix7 t meets crit]ia comp>able to m$ical homes exp&$ "u section #aaae;,a7c74 7#c7 ,additional def9itions ,9 ?is subsection3 7,a7 ,cov]$ pr(essional s]vices ,! t]m cov]$ pr(essional s]vices has ! mean+ giv5 t t]m 9 section #ahdh7k77#c77;,a74 7,b7 ,eligible pr(essional ,! t]m eligible pr(essional has ! mean+ giv5 t t]m 9 section #ahdh7k77#c77;,b74 7,c7 ,alt]native paym5t model 7,,apm7 ,! t]m alt]native paym5t model means any ( ! foll[+3 7i7 ,a model "u section #aaae;,a 7o!r ?an a heal? c>e innovation aw>d74 7ii7 ,an acc\ntable c>e organization "u section #ahii4 7iii7 ,a demon/ration "u section #ahff;,c4 7iv7 ,a demon/ration requir$ by ,f$]al law4 7,d7 ,eligible alt]native paym5t model 7,,apm7 7i7 ,9 g5]al ,! t]m eligible alt]native paym5t model means1 ) respect to a ye>1 an alt]native paym5t model-- 7,i7 t requires use ( c]tifi$ ,,ehr te*nology 7z def9$ 9 subsection 7o77#d772 7,,ii7 t provides = paym5t = cov]$ pr(essional s]vices bas$ on quality measures comp>able to measures "u ! p]=mance category describ$ 9 section #ahdh7q77#b77;,b77i72 & 7,,iii7 t satisfies ! requirem5t describ$ 9 clause 7ii74 7ii7 ,additional requirem5t ,= purposes ( clause 7i77,,iii71 ! requirem5t describ$ 9 ?is clause1 ) respect to a ye> & an alt]native paym5t model1 is t ! alt]native paym5t model-- 7,i7 is "o 9 :i* "o or m entities be> f9ancial risk = monet>y losses "u su* model t are 9 excess ( a nom9al am\nt2 or 7,,ii7 is a m$ical home exp&$ "u section #aaae;,a7c74 7#d7 ,limitation ,!re %all be no adm9i/rative or judicial review "u section #ahfi1 #ahgh1 or o!rwise1 ( ! foll[+3 7,a7 ,! det]m9ation t an eligible pr(essional is a qualify+ ,,apm p>ticipant "u p>agraph 7#b7 & ! det]m9ation t an alt]native paym5t model is an eligible alt]native paym5t model "u p>agraph 7#c77;,d74 7,b7 ,! det]m9ation ( ! am\nt ( ! #e p]c5t paym5t inc5tive "u p>agraph 7#a77;,a71 includ+ any e/imation z "p ( su* det]m9ation4 4 7#b7 ,coord9ation con=m+ am5dm5ts ,section #ahcc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7 is fur!r am5d$-- 7,a7 9 subsection 7x77#c71 by add+ at ! end ! foll[+ new s5t5ce3 ,! am\nt ( ! additional paym5t = a s]vice "u ?is subsection & subsection 7z7 %all be det]m9$ )\t reg>d to any additional paym5t = ! s]vice "u subsection 7z7 & ?is subsection1 respectively42 & 7,b7 9 subsection 7y77#c71 by add+ at ! end ! foll[+ new s5t5ce3 ,! am\nt ( ! additional paym5t = a s]vice "u ?is subsection & subsection 7z7 %all be det]m9$ )\t reg>d to any additional paym5t = ! s]vice "u subsection 7z7 & ?is subsection1 respectively44 7#c7 ,enc\rag+ developm5t & te/+ ( c]ta9 models ,section #aaae;,a7b77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7b77#b77 is am5d$-- 7,a7 9 subp>agraph 7,b71 by add+ at ! end ! foll[+ new clauses3 7xxi7 ,focus+ prim>ily on physicians' s]vices 7z def9$ 9 section #ahdh7;j77#c77 furni%$ by physicians :o are n prim>y c>e practition]s4 7xxii7 ,focus+ on practices ( #aj or few] pr(essionals4 7xxiii7 ,focus+ prim>ily on title ,,xix1 work+ 9 conjunction ) ! ,c5t] = ,m$icaid & ,,*ip ,s]vices )9 ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices4 2 & 7,b7 9 subp>agraph 7,c77viii71 by /rik+ o!r public sector or private sector pay]s & ins]t+ o!r public sector pay]s1 private sector pay]s1 or ,/atewide paym5t models4 7#d7 ,con/ruction reg>d+ teleheal? s]vices ,no?+ 9 ! provisions (1 or am5dm5ts made by1 ?is ,act %all be con/ru$ z preclud+ an alt]native paym5t model or a qualify+ ,,apm p>ticipant 7z ^? t]ms are def9$ 9 section #ahcc7z7 ( ! ,social ,security ,act1 z add$ by p>agraph 7#a77 f furni%+ a teleheal? s]vice = :i* paym5t is n made "u section #ahcd7m7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7m774 7#e7 ,plan = integrat+ ,m$ic>e advantage alt]native paym5t models ,n lat] ?an ,july #a1 #bjae1 ! ,secret>y ( ,heal? & ,human ,s]vices %all submit to ,congress a plan to integrate ,m$ic>e ,advantage alt]native paym5t models t take into acc\nt a budget neutral value-bas$ modifi]4 7f7 ,/udy & report on fraud relat$ to alt]native paym5t models "u ! ,m$ic>e program 7#a7 ,/udy ,! ,secret>y ( ,heal? & ,human ,s]vices1 9 consultation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 %all conduct a /udy t-- 7,a7 exam9es ! applicability ( ! ,f$]al fraud prev5tion laws to items & s]vices furni%$ "u title ,,xviii ( ! ,social ,security ,act = :i* paym5t is made "u an alt]native paym5t model 7z def9$ 9 section #ahcc7z77#c77;,c7 ( su* ,act 7#db ,u4,s4,c4 #aciel7z77#c77;,c7772 7,b7 id5tifies aspects ( su* alt]native paym5t models t are vuln]able to fraudul5t activity2 & 7,c7 exam9es ! implications ( waiv]s to su* laws grant$ 9 support ( su* alt]native paym5t models1 includ+ "u any pot5tial expansion ( su* models4 7#b7 ,report ,n lat] ?an #b ye>s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y %all submit to ,congress a report conta9+ ! results ( ! /udy conduct$ "u p>agraph 7#a74 ,su* report %all include recomm5dations = actions to be tak5 to r$uce ! vuln]ability ( su* alt]native paym5t models to fraudul5t activity4 ,su* report also %all include1 z appropriate1 recomm5dations ( ! ,inspector ,g5]al = *anges 9 ,f$]al fraud prev5tion laws to r$uce su* vuln]ability4 7g7 ,improv+ paym5t accuracy 7#a7 ,/udies & reports ( effect ( c]ta9 in=mation on quality & res\rce use 7,a7 ,/udy us+ exi/+ ,m$ic>e data 7i7 ,/udy ,! ,secret>y ( ,heal? & ,human ,s]vices 79 ?is subsection ref]r$ to z ! ,secret>y7 %all conduct a /udy t exam9es ! effect ( individuals' socioeconomic /atus on quality & res\rce use outcome measures = individuals "u ! ,m$ic>e program4 ,! /udy %all use in=mation collect$ on su* individuals 9 c>ry+ out su* program1 su* z urban & rural location1 eligibility = ,m$icaid 7recogniz+ & acc\nt+ = v>y+ ,m$icaid eligibility across ,/ates71 & eligibility = b5efits "u ! supplem5tal security income 7,,ssi7 program4 ,! ,secret>y %all c>ry out ?is p>agraph act+ ?r\gh ! ,assi/ant ,secret>y = ,plann+ & ,evaluation4 7ii7 ,report ,n lat] ?an #b ye>s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y %all submit to ,congress a report on ! /udy conduct$ "u clause 7i74 7,b7 ,/udy us+ o!r data 7i7 ,/udy ,! ,secret>y %all conduct a /udy t exam9es ! impact ( risk factors1 su* z ^? describ$ 9 section #ahdh7p77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7p77#c771 race1 heal? lit]acy1 limit$ ,engli% pr(ici5cy 7,,lep71 & pati5t activation1 on quality & res\rce use outcome measures "u ! ,m$ic>e program4 ,9 conduct+ su* /udy ! ,secret>y may use exi/+ ,f$]al data & collect su* additional data z may be necess>y to complete ! /udy4 7ii7 ,report ,n lat] ?an #e ye>s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y %all submit to ,congress a report on ! /udy conduct$ "u clause 7i74 7,c7 ,exam9ation ( data 9 conduct+ /udies ,9 conduct+ ! /udies "u subp>agraphs 7,a7 & 7,b71 ! ,secret>y %all exam9e :at non-,m$ic>e data sets1 su* z data f ! ,am]ican ,community ,survey 7,,acs71 c be useful 9 conduct+ ! types ( /udies "u su* p>agraphs & h[ su* data sets t are id5tifi$ z useful c be coord9at$ ) ,m$ic>e adm9i/rative data 9 ord] to improve ! ov]all data set available to d su* /udies & = ! adm9i/ration ( ! ,m$ic>e program4 7,d7 ,recomm5dations to acc\nt = in=mation 9 paym5t adju/m5t me*anisms ,if ! /udies conduct$ "u subp>agraphs 7,a7 & 7,b7 f9d a relation%ip betwe5 ! factors exam9$ 9 ! /udies & quality & res\rce use outcome measures1 !n ! ,secret>y %all also provide recomm5dations = h[ ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices %\ld-- 7i7 obta9 access to ! necess>y data 7if su* data is n already be+ collect$7 on su* factors1 includ+ recomm5dations on h[ to address b>ri]s to ! ,c5t]s 9 access+ su* data2 & 7ii7 acc\nt = su* factors 9 det]m9+ paym5t adju/m5ts bas$ on quality & res\rce use outcome measures "u ! eligible pr(essional value-bas$ p]=mance inc5tive program "u section #ahdh7q7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q77 &1 z ! ,secret>y det]m9es appropriate1 o!r simil> provisions ( title ,,xviii ( su* ,act4 7,e7 ,fund+ ,!re are h]eby appropriat$ f ! ,f$]al ,supplem5tal ,m$ical ,insurance ,tru/ ,fund to ! ,secret>y to c>ry out ?is p>agraph #f1jjj1jjj1 to rema9 available until exp5d$4 7#b7 ,,cms activities 7,a7 ,hi]>*al ,condition ,category 7,,hcc7 improvem5t ,tak+ into acc\nt ! relevant /udies conduct$ & recomm5dations made 9 reports "u p>agraph 7#a71 ! ,secret>y1 on an ongo+ basis1 %all e/imate h[ an individual's heal? /atus & o!r risk factors affect quality & res\rce use outcome measures &1 z feasible1 %all incorporate in=mation f quality & res\rce use outcome measurem5t 7includ+ c>e episode & pati5t condition gr\ps7 into ! eligible pr(essional value-bas$ p]=mance inc5tive program "u section #ahdh7q7 ( ! ,social ,security ,act &1 z ! ,secret>y det]m9es appropriate1 o!r simil> provisions ( title ,,xviii ( su* ,act4 7,b7 ,acc\nt+ = o!r factors 9 paym5t adju/m5t me*anisms 7i7 ,9 g5]al ,tak+ into acc\nt ! /udies conduct$ & recomm5dations made 9 reports "u p>agraph 7#a71 ! ,secret>y %all acc\nt = id5tifi$ factors 7o!r ?an ^? appli$ "u subp>agraph 7,a77 ) an effect on quality & res\rce use outcome measures :5 det]m9+ paym5t adju/m5ts "u ! eligible pr(essional value-bas$ p]=mance inc5tive program "u section #ahdh7q7 ( ! ,social ,security ,act &1 z ! ,secret>y det]m9es appropriate1 o!r simil> provisions ( title ,,xviii ( su* ,act4 7ii7 ,access+ data ,! ,secret>y %all collect or o!rwise obta9 access to ! data necess>y to c>ry out ?is p>agraph ?r\gh exi/+ & new data s\rces4 7iii7 ,p]iodic analyses ,! ,secret>y %all c>ry out p]iodic analyses1 at lea/ e #c ye>s1 bas$ on ! factors ref]r$ to 9 clause 7i7 s z to monitor *anges 9 possible relation%ips4 7,c7 ,fund+ ,!re are h]eby appropriat$ f ! ,f$]al ,supplem5tal ,m$ical ,insurance ,tru/ ,fund to ! ,secret>y to c>ry out ?is p>agraph #aj1jjj1jjj1 to rema9 available until exp5d$4 7#c7 ,/rategic plan = access+ race & e?nicity data ,n lat] ?an #ah mon?s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y %all develop & report to ,congress on a /rategic plan = collect+ or o!rwise access+ data on race & e?nicity = purposes ( c>ry+ out ! ,m$ic>e program4 7h7 ,collaborat+ ) ! physician1 practition]1 & o!r /akehold] communities to improve res\rce use measurem5t ,section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 z am5d$ by subsection 7c71 is fur!r am5d$ by add+ at ! end ! foll[+ new subsection3 7r7 ,collaborat+ ) ! physician1 practition]1 & o!r /akehold] communities ,to improve res\rce use measurem5t 7#a7 ,9 g5]al ,9 ord] to involve ! physician1 practition]1 & o!r /akehold] communities 9 enhanc+ ! infra/ructure = res\rce use measurem5t1 includ+ = purposes ( ! value-bas$ p]=mance inc5tive program "u subsection 7q7 & alt]native paym5t models "u section #ahcc7z71 ! ,secret>y %all und]take ! /eps describ$ 9 ! succe$+ provisions ( ?is subsection4 7#b7 ,developm5t ( c>e episode & pati5t condition gr\ps & classification codes 7,a7 ,9 g5]al ,9 ord] to classify simil> pati5ts into di/9ct c>e episode gr\ps & di/9ct pati5t condition gr\ps1 ! ,secret>y %all und]take ! /eps describ$ 9 ! succe$+ provisions ( ?is p>agraph4 7,b7 ,public availability ( exi/+ ef=ts to design an episode gr\p] ,n lat] ?an #fj days aft] ! date ( ! enactm5t ( ?is subsection1 ! ,secret>y %all po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices a li/ ( ! episode gr\ps develop$ pursuant to subsection 7n77#i77;,a7 & relat$ descriptive in=mation4 7,c7 ,/akehold] input ,! ,secret>y %all accept1 ?r\gh ! date t is #fj days aft] ! day ! ,secret>y po/s ! li/ pursuant to subp>agraph 7,b71 sugge/ions f physician specialty societies1 applicable practition] organizations1 & o!r /akehold]s = episode gr\ps 9 addition to ^? po/$ pursuant to su* subp>agraph1 & specific cl9ical crit]ia & pati5t *>act]i/ics to classify pati5ts into-- 7i7 di/9ct c>e episode gr\ps2 & 7ii7 di/9ct pati5t condition gr\ps4 7,d7 ,developm5t ( propos$ classification codes 7i7 ,9 g5]al ,tak+ into acc\nt ! in=mation describ$ 9 subp>agraph 7,b7 & ! in=mation receiv$ "u subp>agraph 7,c71 ! ,secret>y %all-- 7,i7 e/abli% di/9ct c>e episode gr\ps & di/9ct pati5t condition gr\ps1 :i* acc\nt = at lea/ an e/imat$ two-?irds ( exp5ditures "u p>ts ,a & ,b2 & 7,,ii7 assign codes to su* gr\ps4 7ii7 ,c>e episode gr\ps ,9 e/abli%+ ! c>e episode gr\ps "u clause 7i71 ! ,secret>y %all take into acc\nt-- 7,i7 ! pati5t's cl9ical problems at ! "t items & s]vices are furni%$ dur+ an episode ( c>e1 su* z ! cl9ical conditions or diagnoses1 :e!r or n inpati5t hospitalization is anticipat$ or occurs1 & ! pr9cipal proc$ures or s]vices plann$ or furni%$2 & 7,,ii7 o!r factors det]m9$ appropriate by ! ,secret>y4 7iii7 ,pati5t condition gr\ps ,9 e/abli%+ ! pati5t condition gr\ps "u clause 7i71 ! ,secret>y %all take into acc\nt-- 7,i7 ! pati5t's cl9ical hi/ory at ! "t ( ea* m$ical visit1 su* z ! pati5t's comb9ation ( *ronic conditions1 curr5t heal? /atus1 & rec5t significant hi/ory 7su* z hospitalization & major surg]y dur+ a previ\s p]iod1 su* z #c mon?s72 & 7,,ii7 o!r factors det]m9$ appropriate by ! ,secret>y1 su* z eligibility /atus "u ?is title 7includ+ eligibility "u section #bbf7;a71 #bbf7;b71 or #bbf;,a1 & dual eligibility "u ?is title & title ,,xix74 7,e7 ,draft c>e episode & pati5t condition gr\ps & classification codes ,n lat] ?an #abj days aft] ! end ( ! comm5t p]iod describ$ 9 subp>agraph 7,c71 ! ,secret>y %all po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices a draft li/ ( ! c>e episode & pati5t condition codes e/abli%$ "u subp>agraph 7,d7 7& ! crit]ia & *>act]i/ics assign$ to su* code74 7,f7 ,solicitation ( input ,! ,secret>y %all seek1 ?r\gh ! date t is #fj days aft] ! ,secret>y po/s ! li/ pursuant to subp>agraph 7,e71 comm5ts f physician specialty societies1 applicable practition] organizations1 & o!r /akehold]s1 includ+ individuals entitl$ to b5efits "u "p ,a or enroll$ "u ?is "p1 reg>d+ ! c>e episode & pati5t condition gr\ps 7& codes7 po/$ "u subp>agraph 7,e74 ,9 seek+ su* comm5ts1 ! ,secret>y %all use "o or m me*anisms 7o!r ?an notice & comm5t rulemak+7 t may include use ( op5 door =ums1 t[n hall meet+s1 or o!r appropriate me*anisms4 7,g7 ,op]ational li/ ( c>e episode & pati5t condition gr\ps & codes ,n lat] ?an #abj days aft] ! end ( ! comm5t p]iod describ$ 9 subp>agraph 7,f71 tak+ into acc\nt ! comm5ts receiv$ "u su* subp>agraph1 ! ,secret>y %all po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices an op]ational li/ ( c>e episode & pati5t condition codes 7& ! crit]ia & *>act]i/ics assign$ to su* code74 7,h7 ,subsequ5t revisions ,n lat] ?an ,novemb] #a ( ea* ye> 7beg9n+ ) #bjaf71 ! ,secret>y %all1 ?r\gh rulemak+1 make revisions to ! op]ational li/s ( c>e episode & pati5t condition codes z ! ,secret>y det]m9es may be appropriate4 ,su* revisions may be bas$ on exp]i5ce1 new in=mation develop$ pursuant to subsection 7n77#i77;,a71 & input f ! physician specialty societies1 applicable practition] organizations1 & o!r /akehold]s1 includ+ individuals entitl$ to b5efits "u "p ,a or enroll$ "u ?is "p4 7#c7 ,attribution ( pati5ts to physicians or practition]s 7,a7 ,9 g5]al ,9 ord] to facilitate ! attribution ( pati5ts & episodes 79 :ole or 9 "p7 to "o or m physicians or applicable practition]s furni%+ items & s]vices1 ! ,secret>y %all und]take ! /eps describ$ 9 ! succe$+ provisions ( ?is p>agraph4 7,b7 ,developm5t ( pati5t relation%ip categories & codes ,! ,secret>y %all develop pati5t relation%ip categories & codes t def9e & di/+ui% ! relation%ip & responsibility ( a physician or applicable practition] ) a pati5t at ! "t ( furni%+ an item or s]vice4 ,su* pati5t relation%ip categories %all include diff]5t relation%ips ( ! physician or applicable practition] to ! pati5t 7& ! codes may reflect comb9ations ( su* categories71 su* z a physician or applicable practition] :o-- 7i7 consid]s !mself to h ! prim>y responsibility = ! g5]al & ongo+ c>e = ! pati5t ov] ext5d$ p]iods ( "t2 7ii7 consid]s !mself to be ! lead physician or practition] & :o furni%es items & s]vices & coord9ates c>e furni%$ by o!r physicians or practition]s = ! pati5t dur+ an acute episode2 7iii7 furni%es items & s]vices to ! pati5t on a cont9u+ basis dur+ an acute episode ( c>e1 b 9 a supportive r ?an a lead role2 7iv7 furni%es items & s]vices to ! pati5t on an occasional basis1 usually at ! reque/ ( ano!r physician or practition]2 or 7v7 furni%es items & s]vices only z ord]$ by ano!r physician or practition]4 7,c7 ,draft li/ ( pati5t relation%ip categories & codes ,n lat] ?an #ahj days aft] ! date ( ! enactm5t ( ?is subsection1 ! ,secret>y %all po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices a draft li/ ( ! pati5t relation%ip categories & codes develop$ "u subp>agraph 7,b74 7,d7 ,/akehold] ,input ,! ,secret>y %all seek1 ?r\gh ! date t is #fj days aft] ! ,secret>y po/s ! li/ pursuant to subp>agraph 7,c71 comm5ts f physician specialty societies1 applicable practition] organizations1 & o!r /akehold]s1 includ+ individuals entitl$ to b5efits "u "p ,a or enroll$ "u ?is "p1 reg>d+ ! pati5t relation%ip categories & codes po/$ "u subp>agraph 7,c74 ,9 seek+ su* comm5ts1 ! ,secret>y %all use "o or m me*anisms 7o!r ?an notice & comm5t rulemak+7 t may include op5 door =ums1 t[n hall meet+s1 or o!r appropriate me*anisms4 7,e7 ,op]ational li/ ( pati5t relation%ip categories & codes ,n lat] ?an #abj days aft] ! end ( ! comm5t p]iod describ$ 9 subp>agraph 7,d71 tak+ into acc\nt ! comm5ts receiv$ "u su* subp>agraph1 ! ,secret>y %all po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices an op]ational li/ ( pati5t relation%ip categories & codes4 7,f7 ,subsequ5t revisions ,n lat] ?an ,novemb] #a ( ea* ye> 7beg9n+ ) #bjaf71 ! ,secret>y %all1 ?r\gh rulemak+1 make revisions to ! op]ational li/ ( pati5t relation%ip categories & codes z ! ,secret>y det]m9es appropriate4 ,su* revisions may be bas$ on exp]i5ce1 new in=mation develop$ pursuant to subsection 7n77#i77;,a71 & input f ! physician specialty societies1 applicable practition] organizations1 & o!r /akehold]s1 includ+ individuals entitl$ to b5efits "u "p ,a or enroll$ "u ?is "p4 7#d7 ,report+ ( in=mation = res\rce use measurem5t ,claims submitt$ = items & s]vices furni%$ by a physician or applicable practition] on or aft] ,janu>y #a1 #bjaf1 %all1 z det]m9$ appropriate by ! ,secret>y1 include-- 7,a7 applicable codes e/abli%$ "u p>agraphs 7#b7 & 7#c72 & 7,b7 ! national provid] id5tifi] ( ! ord]+ physician or applicable practition] 7if diff]5t f ! bill+ physician or applicable practition]74 7#e7 ,me?odology = res\rce use analysis 7,a7 ,9 g5]al ,9 ord] to evaluate ! res\rces us$ to treat pati5ts 7) respect to c>e episode & pati5t condition gr\ps71 ! ,secret>y %all-- 7i7 use ! pati5t relation%ip codes report$ on claims pursuant to p>agraph 7#d7 to attribute pati5ts 79 :ole or 9 "p7 to "o or m physicians & applicable practition]s2 7ii7 use ! c>e episode & pati5t condition codes report$ on claims pursuant to p>agraph 7#d7 z a basis to comp>e simil> pati5ts & c>e episodes & pati5t condition gr\ps2 & 7iii7 conduct an analysis ( res\rce use 7) respect to c>e episodes & pati5t condition gr\ps ( su* pati5ts71 z ! ,secret>y det]m9es appropriate4 7,b7 ,analysis ( pati5ts ( physicians & practition]s ,9 conduct+ ! analysis describ$ 9 subp>agraph 7,a77iii7 ) respect to pati5ts attribut$ to physicians & applicable practition]s1 ! ,secret>y %all1 z feasible-- 7i7 use ! claims data exp]i5ce ( su* pati5ts by pati5t condition codes dur+ a common p]iod1 su* z #ab mon?s2 & 7ii7 use ! claims data exp]i5ce ( su* pati5ts by c>e episode codes-- 7,i7 9 ! case ( episodes )\t a hospitalization1 dur+ p]iods ( "t 7su* z ! numb] ( days7 det]m9$ appropriate by ! ,secret>y2 & 7,,ii7 9 ! case ( episodes ) a hospitalization1 dur+ p]iods ( "t 7su* z ! numb] ( days7 be=e1 dur+1 & aft] ! hospitalization4 7,c7 ,measurem5t ( res\rce use ,9 measur+ su* res\rce use1 ! ,secret>y-- 7i7 %all use p] pati5t total all[$ am\nts = all s]vices "u "p ,a & ?is "p 7&1 if ! ,secret>y det]m9es appropriate1 "p ,d7 = ! analysis ( pati5t res\rce use1 by c>e episode codes & by pati5t condition codes2 & 7ii7 may1 z det]m9$ appropriate1 use o!r measures ( all[$ am\nts 7su* z subtotals = categories ( items & s]vices7 & measures ( utilization ( items & s]vices 7su* z frequ5cy ( specific items & s]vices & ! ratio ( specific items & s]vices among attribut$ pati5ts or episodes74 7,d7 ,/akehold] ,input ,! ,secret>y %all seek comm5ts f ! physician specialty societies1 applicable practition] organizations1 & o!r /akehold]s1 includ+ individuals entitl$ to b5efits "u "p ,a or enroll$ "u ?is "p1 reg>d+ ! res\rce use me?odology e/abli%$ pursuant to ?is p>agraph4 ,9 seek+ comm5ts ! ,secret>y %all use "o or m me*anisms 7o!r ?an notice & comm5t rulemak+7 t may include op5 door =ums1 t[n hall meet+s1 or o!r appropriate me*anisms4 7#f7 ,limitation ,!re %all be no adm9i/rative or judicial review "u section #ahfi1 section #ahgh1 or o!rwise (-- 7,a7 c>e episode & pati5t condition gr\ps & codes e/abli%$ "u p>agraph 7#b72 7,b7 pati5t relation%ip categories & codes e/abli%$ "u p>agraph 7#c72 & 7,c7 measurem5t (1 & analyses ( res\rce use ) respect to1 c>e episode & pati5t condition codes & pati5t relation%ip codes pursuant to p>agraph 7#e74 7#g7 ,adm9i/ration ,*apt] #ce ( title #dd1 ,unit$ ,/ates ,code1 %all n apply to ?is section4 7#h7 ,def9itions ,9 ?is section3 7,a7 ,physician ,! t]m physician has ! mean+ giv5 su* t]m 9 section #ahfa7r74 7,b7 ,applicable practition] ,! t]m applicable practition] means-- 7i7 a physician assi/ant1 nurse practition]1 & cl9ical nurse speciali/ 7z su* t]ms are def9$ 9 section #ahfa7;aa77#e772 & 7ii7 beg9n+ ,janu>y #a1 #bjag1 su* o!r eligible pr(essionals 7z def9$ 9 subsection 7k77#c77;,b77 z specifi$ by ! ,secret>y4 7#i7 ,cl>ification ,! provisions ( sections #ahij;,a7b77#b7 & #ahij;,b %all n apply to ?is subsection4 4 #ajb4 ,priorities & fund+ = quality measure developm5t ,section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 z am5d$ by subsections 7c7 & 7h7 ( section #aja1 is fur!r am5d$ by ins]t+ at ! end ! foll[+ new subsection3 7s7 ,priorities & fund+ = quality measure developm5t 7#a7 ,plan id5tify+ measure developm5t priorities & timel9es 7,a7 ,draft measure developm5t plan 7i7 ,draft plan 7,i7 ,9 g5]al ,n lat] ?an ,octob] #a1 #bjad1 ! ,secret>y %all develop1 & po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices1 a draft plan = ! developm5t ( quality measures = application "u ! applicable provisions4 7,,ii7 ,requirem5t ,su* plan %all address h[ measures us$ by private pay]s & integrat$ deliv]y sy/ems c\ld be incorporat$ "u su* subsection4 7ii7 ,consid]ation ,9 develop+ ! draft plan "u subp>agraph 7,a71 ! ,secret>y %all consid]-- 7,i7 gap analyses conduct$ by ! entity ) a contract "u section #ahij7;a7 or o!r contractors or entities2 & 7,,ii7 :e!r measures are applicable across heal? c>e sett+s4 7iii7 ,priorities ,9 develop+ ! draft plan "u subp>agraph 7,a71 ! ,secret>y %all give priority to ! foll[+ types ( measures3 7,i7 ,outcome measures includ+ pati5t report$ outcome & functional /atus measures4 7,,ii7 ,pati5t exp]i5ce measures4 7,,iii7 ,c>e coord9ation measures4 7,,iv7 ,measures ( appropriate use ( s]vices1 includ+ measures ( ov] use4 7iv7 ,def9ition ( applicable provisions ,9 ?is subsection1 ! t]m applicable provisions means ! foll[+ provisions3 7,i7 ,subsection 7q77#b77;,b77i74 7,,ii7 ,section #ahcc7z77#b77;,c74 7,b7 ,/akehold] input ,! ,secret>y %all accept ?r\gh ,decemb] #a1 #bjad1 comm5ts on ! draft plan po/$ "u p>agraph 7#a77;,a7 f ! public1 includ+ heal? c>e provid]s1 pay]s1 consum]s1 & o!r /akehold]s4 7,c7 ,op]ational measure developm5t plan ,n lat] ?an ,febru>y #a1 #bjae1 tak+ into acc\nt ! comm5ts receiv$ "u subp>agraph 7,b71 ! ,secret>y %all po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices an op]ational plan = ! developm5t ( quality measures = use "u subsection 7q77#b77;,a77i74 7#b7 ,contracts & o!r arrangem5ts = quality measure developm5t 7,a7 ,9 g5]al ,! ,secret>y %all ent] into contracts or o!r arrangem5ts ) entities = ! purpose ( develop+1 improv+1 updat+1 or exp&+ quality measures = application "u ! applicable provisions4 ,su* entities may include physician specialty societies & o!r practition] organizations4 7,b7 ,prioritization 7i7 ,9 g5]al ,9 ent]+ into contracts or o!r arrangem5ts "u subp>agraph 7,a71 ! ,secret>y %all give priority to ! developm5t ( ! types ( measures describ$ 9 p>agraph 7#a77;,a77iii74 7ii7 ,consid]ation ,9 select+ measures = developm5t "u ?is subsection1 ! ,secret>y %all consid] :e!r su* measures w\ld be electronically specifi$4 7#c7 ,annual report by ! ,secret>y 7,a7 ,9 g5]al ,n lat] ?an ,febru>y #a1 #bjaf1 & annually !reaft]1 ! ,secret>y %all po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices a report on ! progress made 9 develop+ quality measures = application "u ! applicable provisions4 7,b7 ,requirem5ts ,ea* report submitt$ pursuant to p>agraph 7#a7 %all include ! foll[+3 7i7 ,a description ( ! ,secret>y's ef=ts to implem5t ?is subsection4 7ii7 ,) respect to ! measures develop$ dur+ ! previ\s ye>-- 7,i7 a description ( ! total numb] ( quality measures develop$ & ! types ( su* measures1 su* z an outcome or pati5t exp]i5ce measure2 7,,ii7 ! "n ( ea* measure develop$2 7,,iii7 ! "n ( ! develop] & /ew>d ( ea* measure2 7,,iv7 ) respect to ea* type ( measure1 an e/imate ( ! total am\nt exp5d$ "u ?is title to develop all measures ( su* type2 & 7,v7 :e!r ! measure w\ld be electronically specifi$4 7iii7 ,) respect to measures 9 developm5t at ! "t ( ! report-- 7,i7 ! in=mation describ$ 9 clause 7ii71 if available2 & 7,,ii7 a timel9e = completion ( ! developm5t ( su* measures4 7iv7 ,an update on ! progress 9 develop+ ! types ( measures describ$ 9 p>agraph 7#a77;,a77iii71 includ+ a description ( issues affect+ su* progress4 7v7 ,a li/ ( quality topics & concepts t are be+ consid]$ = developm5t ( measures & ! rationale = ! selection ( topics & concepts includ+ _! relation%ip to gap analyses4 7vi7 ,a description ( any updates to ! plan "u p>agraph 7#a7 7includ+ newly id5tifi$ gaps & ! /atus ( previ\sly id5tifi$ gaps7 & ! inv5tory ( measures applicable "u ! applicable provisions4 7vii7 ,o!r in=mation ! ,secret>y det]m9es to be appropriate4 7#d7 ,/akehold] input ,) respect to measures applicable "u ! applicable provisions1 ! ,secret>y %all seek /akehold] input ) respect to-- 7,a7 ! id5tification ( gaps :]e no quality measures exi/1 p>ticul>ly ) respect to ! types ( measures describ$ 9 p>agraph 7#a77;,a77iii72 7,b7 prioritiz+ quality measure developm5t to address su* gaps2 & 7,c7 o!r areas relat$ to quality measure developm5t det]m9$ appropriate by ! ,secret>y4 7#e7 ,fund+ ,= purposes ( c>ry+ out ?is subsection1 ! ,secret>y %all provide = ! transf]1 f ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda1 ( #ae1jjj1jjj to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt = ea* ( fiscal ye>s #bjad ?r\gh #bjah4 ,am\nts transf]r$ "u ?is p>agraph %all rema9 available ?r\gh ! end ( fiscal ye> #bjba4 4 #ajc4 ,enc\rag+ c>e managem5t = individuals ) *ronic c>e ne$s 7a7 ,9 g5]al ,section #ahdh7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;b77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#h7 ,enc\rag+ c>e managem5t = individuals ) *ronic c>e ne$s 7,a7 ,9 g5]al ,9 ord] to enc\rage ! managem5t ( c>e by an applicable provid] 7z def9$ 9 subp>agraph 7,b77 = individuals ) *ronic c>e ne$s ! ,secret>y %all-- 7i7 e/abli% "o or m ,,hcpcs codes = *ronic c>e managem5t s]vices = su* individuals2 & 7ii7 subject to subp>agraph 7,d71 make paym5t 7z ! ,secret>y det]m9es to be appropriate7 "u ?is section = su* managem5t s]vices furni%$ on or aft] ,janu>y #a1 #bjae1 by an applicable provid]4 7,b7 ,applicable provid] def9$ ,= purposes ( ?is p>agraph1 ! t]m applicable provid] means a physician 7z def9$ 9 section #ahfa7r77#a771 physician assi/ant or nurse practition] 7z def9$ 9 section #ahfa7;aa77#e77;,a771 or cl9ical nurse speciali/ 7z def9$ 9 section #ahfa7;aa77#e77;,b77 :o furni%es s]vices z "p ( a pati5t-c5t]$ m$ical home or a comp>able specialty practice t-- 7i7 is recogniz$ z su* a m$ical home or comp>able specialty practice by an organization t is recogniz$ by ! ,secret>y = purposes ( su* recognition z su* a m$ical home or practice2 or 7ii7 meets su* o!r comp>able qualifications z ! ,secret>y det]m9es to be appropriate4 7,c7 ,budget neutrality ,! budget neutrality provision "u subsection 7c77#b77;,b77ii77,,ii7 %all apply 9 e/abli%+ ! paym5t "u subp>agraph 7,a77ii74 7,d7 ,policies relat+ to paym5t ,9 c>ry+ out ?is p>agraph1 ) respect to *ronic c>e managem5t s]vices1 ! ,secret>y %all-- 7i7 make paym5t to only "o applicable provid] = su* s]vices furni%$ to an individual dur+ a p]iod2 7ii7 n make paym5t "u subp>agraph 7,a7 if su* paym5t w\ld be duplicative ( paym5t t is o!rwise made "u ?is title = su* s]vices 7su* z 9 ! case ( hospice c>e or home heal? s]vices72 & 7iii7 n require t an annual wellness visit 7z def9$ 9 section #ahfa7;hhh77 or an initial prev5tive physical exam9ation 7z def9$ 9 section #ahfa7ww77 be furni%$ z a condition ( paym5t = su* managem5t s]vices4 4 7b7 ,education & outrea* 7#a7 ,campaign 7,a7 ,9 g5]al ,! ,secret>y ( ,heal? & ,human ,s]vices 79 ?is subsection ref]r$ to z ! ,secret>y7 %all conduct an education & outrea* campaign to in=m pr(essionals :o furni% items & s]vices "u "p ,b ( title ,,xviii ( ! ,social ,security ,act & individuals enroll$ "u su* "p ( ! b5efits ( *ronic c>e managem5t s]vices describ$ 9 section #ahdh7;b77#h7 ( ! ,social ,security ,act1 z add$ by subsection 7a71 & enc\rage su* individuals ) *ronic c>e ne$s to receive su* s]vices4 7,b7 ,requirem5ts ,su* campaign %all-- 7i7 be direct$ by ! ,(fice ( ,rural ,heal? ,policy ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices & ! ,(fice ( ,m9ority ,heal? ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices2 & 7ii7 focus on enc\rag+ p>ticipation by und]s]v$ rural populations & racial & e?nic m9ority populations4 7#b7 ,report 7,a7 ,9 g5]al ,n lat] ?an ,decemb] #ca1 #bjag1 ! ,secret>y %all submit to ,congress a report on ! use ( *ronic c>e managem5t s]vices describ$ 9 su* section #ahdh7;b77#h7 by individuals liv+ 9 rural areas & by racial & e?nic m9ority populations4 ,su* report %all-- 7i7 id5tify b>ri]s to receiv+ *ronic c>e managem5t s]vices2 & 7ii7 make recomm5dations = increas+ ! appropriate use ( *ronic c>e managem5t s]vices4 #ajd4 ,ensur+ accurate valuation ( s]vices "u ! physician fee s*$ule 7a7 ,au?ority ,to collect & use in=mation on physicians' s]vices 9 ! det]m9ation ( relative values 7#a7 ,9 g5]al ,section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,m7 ,au?ority to collect & use in=mation on physicians' s]vices 9 ! det]m9ation ( relative values 7i7 ,collection ( in=mation ,not)/&+ any o!r provision ( law1 ! ,secret>y may collect or obta9 in=mation on ! res\rces directly or indirectly relat$ to furni%+ s]vices = :i* paym5t is made "u ! fee s*$ule e/abli%$ "u subsection 7b74 ,su* in=mation may be collect$ or obta9$ f any eligible pr(essional or any o!r s\rce4 7ii7 ,use ( in=mation ,not)/&+ any o!r provision ( law1 subject to clause 7v71 ! ,secret>y may 7z ! ,secret>y det]m9es appropriate7 use in=mation collect$ or obta9$ pursuant to clause 7i7 9 ! det]m9ation ( relative values = s]vices "u ?is section4 7iii7 ,types ( in=mation ,! types ( in=mation describ$ 9 clauses 7i7 & 7ii7 may1 at ! ,secret>y's discretion1 include any or all ( ! foll[+3 7,i7 ,"t involv$ 9 furni%+ s]vices4 7,,ii7 ,am\nts & types ( practice exp5se inputs involv$ ) furni%+ s]vices4 7,,iii7 ,prices 7net ( any disc\nts7 = practice exp5se inputs1 :i* may include paid invoice prices or o!r docum5tation or records4 7,,iv7 ,ov]head & acc\nt+ in=mation = practices ( physicians & o!r suppli]s4 7,v7 ,any o!r elem5t t w\ld improve ! valuation ( s]vices "u ?is section4 7iv7 ,in=mation collection me*anisms ,in=mation may be collect$ or obta9$ pursuant to ?is subp>agraph f any or all ( ! foll[+3 7,i7 ,surveys ( physicians1 o!r suppli]s1 provid]s ( s]vices1 manufactur]s1 & v5dors4 7,,ii7 ,surgical logs1 bill+ sy/ems1 or o!r practice or facility records4 7,,iii7 ,electronic heal? records4 7,,iv7 ,any o!r me*anism det]m9$ appropriate by ! ,secret>y4 7v7 ,transp>5cy ( use ( in=mation 7,i7 ,9 g5]al ,subject to subclauses 7,,ii7 & 7,,iii71 if ! ,secret>y uses in=mation collect$ or obta9$ "u ?is subp>agraph 9 ! det]m9ation ( relative values "u ?is subsection1 ! ,secret>y %all disclose ! in=mation s\rce & discuss ! use ( su* in=mation 9 su* det]m9ation ( relative values ?r\gh notice & comm5t rulemak+4 7,,ii7 ,?re%olds = use ,! ,secret>y may e/abli% ?re%olds 9 ord] to use su* in=mation1 includ+ ! exclusion ( in=mation collect$ or obta9$ f eligible pr(essionals :o use v high res\rces 7z det]m9$ by ! ,secret>y7 9 furni%+ a s]vice4 7,,iii7 ,disclosure ( in=mation ,! ,secret>y %all make aggregate in=mation available "u ?is subp>agraph b %all n disclose in=mation 9 a =m or mann] t id5tifies an eligible pr(essional or a gr\p practice1 or in=mation collect$ or obta9$ pursuant to a nondisclosure agreem5t4 7vi7 ,inc5tive to p>ticipate ,! ,secret>y may provide = su* paym5ts "u ?is "p to an eligible pr(essional t submits su* solicit$ in=mation "u ?is subp>agraph z ! ,secret>y det]m9es appropriate 9 ord] to comp5sate su* eligible pr(essional = su* submission4 ,su* paym5ts %all be provid$ 9 a =m & mann] specifi$ by ! ,secret>y4 7vii7 ,adm9i/ration ,*apt] #ce ( title #dd1 ,unit$ ,/ates ,code1 %all n apply to in=mation collect$ or obta9$ "u ?is subp>agraph4 7viii7 ,def9ition ( eligible pr(essional ,9 ?is subp>agraph1 ! t]m eligible pr(essional has ! mean+ giv5 su* t]m 9 subsection 7k77#c77;,b74 7ix7 ,fund+ ,= purposes ( c>ry+ out ?is subp>agraph1 9 addition to funds o!rwise appropriat$1 ! ,secret>y %all provide = ! transf]1 f ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda1 ( #b1jjj1jjj to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt = ea* fiscal ye> beg9n+ ) fiscal ye> #bjad4 ,am\nts transf]r$ "u ! prec$+ s5t5ce = a fiscal ye> %all be available until exp5d$4 4 7#b7 ,limitation on review ,section #ahdh7;i77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;i77#a77 is am5d$-- 7,a7 9 subp>agraph 7,d71 by /rik+ & at ! end2 7,b7 9 subp>agraph 7,e71 by /rik+ ! p]iod at ! end & ins]t+ 1 &2 & 7,c7 by add+ at ! end ! foll[+ new subp>agraph3 7,f7 ! collection & use ( in=mation 9 ! det]m9ation ( relative values "u subsection 7c77#b77,m74 4 7b7 ,au?ority = alt]native approa*es ,to e/abli%+ practice exp5se relative values ,section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b771 z am5d$ by subsection 7a71 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,n7 ,au?ority = alt]native approa*es to e/abli%+ practice exp5se relative values ,! ,secret>y may e/abli% or adju/ practice exp5se relative values "u ?is subsection us+ co/1 *>ge1 or o!r data f suppli]s or provid]s ( s]vices1 includ+ in=mation collect$ or obta9$ "u subp>agraph 7,m74 4 7c7 ,revis$ & exp&$ id5tification ( pot5tially misvalu$ codes ,section #ahdh7;c77#b77,k77ii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77,k77ii77 is am5d$ to read z foll[s3 7ii7 ,id5tification ( pot5tially misvalu$ codes ,= purposes ( id5tify+ pot5tially misvalu$ codes pursuant to clause 7i77,i71 ! ,secret>y %all exam9e codes 7& families ( codes z appropriate7 bas$ on any or all ( ! foll[+ crit]ia3 7,i7 ,codes t h exp]i5c$ ! fa/e/ gr[?4 7,,ii7 ,codes t h exp]i5c$ sub/antial *anges 9 practice exp5ses4 7,,iii7 ,codes t describe new te*nologies or s]vices )9 an appropriate "t p]iod 7su* z #c ye>s7 aft] ! relative values are initially e/abli%$ = su* codes4 7,,iv7 ,codes :i* are multiple codes t are frequ5tly bill$ 9 conjunction ) furni%+ a s+le s]vice4 7,v7 ,codes ) l[ relative values1 p>ticul>ly ^? t are (t5 bill$ multiple times = a s+le treatm5t4 7,,vi7 ,codes t h n be5 subject to review s9ce implem5tation ( ! fee s*$ule4 7,,vii7 ,codes t acc\nt = ! majority ( sp5d+ "u ! physician fee s*$ule4 7,,viii7 ,codes = s]vices t h exp]i5c$ a sub/antial *ange 9 ! hospital l5g? ( /ay or proc$ure "t4 7,,ix7 ,codes = :i* !re may be a *ange 9 ! typical site ( s]vice s9ce ! code 0 la/ valu$4 7,x7 ,codes = :i* !re is a significant diff]5ce 9 paym5t = ! same s]vice betwe5 diff]5t sites ( s]vice4 7,,xi7 ,codes = :i* !re may be anomalies 9 relative values )9 a family ( codes4 7,,xii7 ,codes = s]vices :]e !re may be effici5cies :5 a s]vice is furni%$ at ! same "t z o!r s]vices4 7,,xiii7 ,codes ) high intra-s]vice "w p] unit ( "t4 7,,xiv7 ,codes ) high practice exp5se relative value units4 7,,xv7 ,codes ) high co/ supplies4 7,,xvi7 ,codes z det]m9$ appropriate by ! ,secret>y4 4 7d7 ,t>get = relative value adju/m5ts = misvalu$ s]vices 7#a7 ,9 g5]al ,section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b771 z am5d$ by subsections 7a7 & 7b71 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,o7 ,t>get = relative value adju/m5ts = misvalu$ s]vices ,) respect to fee s*$ules e/abli%$ = ea* ( #bjae ?r\gh #bjah1 ! foll[+ %all apply3 7i7 ,det]m9ation ( net r$uction 9 exp5ditures ,= ea* ye>1 ! ,secret>y %all det]m9e ! e/imat$ net r$uction 9 exp5ditures "u ! fee s*$ule "u ?is section ) respect to ! ye> z a result ( adju/m5ts to ! relative values e/abli%$ "u ?is p>agraph = misvalu$ codes4 7ii7 ,budget neutral r$i/ribution ( funds if t>get met & c\nt+ ov]ages t[>ds ! t>get = ! succe$+ ye> ,if ! e/imat$ net r$uction 9 exp5ditures det]m9$ "u clause 7i7 = ! ye> is equal to or great] ?an ! t>get = ! ye>-- 7,i7 r$uc$ exp5ditures attributable to su* adju/m5ts %all be r$i/ribut$ = ! ye> 9 a budget neutral mann] 9 accordance ) subp>agraph 7,b77ii77,,ii72 & 7,,ii7 ! am\nt by :i* su* r$uc$ exp5ditures exce$s ! t>get = ! ye> %all be treat$ z a r$uction 9 exp5ditures describ$ 9 clause 7i7 = ! succe$+ ye>1 = purposes ( det]m9+ :e!r ! t>get has or has n be5 met "u ?is subp>agraph ) respect to t ye>4 7iii7 ,exemption f budget neutrality if t>get n met ,if ! e/imat$ net r$uction 9 exp5ditures det]m9$ "u clause 7i7 = ! ye> is less ?an ! t>get = ! ye>1 r$uc$ exp5ditures 9 an am\nt equal to ! t>get recapture am\nt %all n be tak5 into acc\nt 9 apply+ subp>agraph 7,b77ii77,,ii7 ) respect to fee s*$ules beg9n+ ) #bjae4 7iv7 ,t>get recapture am\nt ,= purposes ( clause 7iii71 ! t>get recapture am\nt is1 ) respect to a ye>1 an am\nt equal to ! diff]5ce betwe5-- 7,i7 ! t>get = ! ye>2 & 7,,ii7 ! e/imat$ net r$uction 9 exp5ditures det]m9$ "u clause 7i7 = ! ye>4 7v7 ,t>get ,= purposes ( ?is subp>agraph1 ) respect to a ye>1 ! t>get is calculat$ z #j4e p]c5t ( ! e/imat$ am\nt ( exp5ditures "u ! fee s*$ule "u ?is section = ! ye>4 4 7#b7 ,con=m+ am5dm5t ,section #ahdh7;c77#b77;,b77v7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77;,b77v77 is am5d$ by add+ at ! end ! foll[+ new subclause3 7,,viii7 ,r$uctions = misvalu$ s]vices if t>get n met ,effective = fee s*$ules beg9n+ ) #bjae1 r$uc$ exp5ditures attributable to ! application ( ! t>get recapture am\nt describ$ 9 subp>agraph 7,o77iii74 4 7e7 ,phase-9 ( significant relative value unit 7,,rvu7 r$uctions 7#a7 ,9 g5]al ,section #ahdh7;c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#g7 ,phase-9 ( significant relative value unit 7,,rvu7 r$uctions ,effective = fee s*$ules e/abli%$ beg9n+ ) #bjae1 if ! total relative value units = a s]vice = a ye> w\ld o!rwise be decreas$ by an e/imat$ am\nt equal to or great] ?an #bj p]c5t z comp>$ to ! total relative value units = ! previ\s ye>1 ! applicable adju/m5ts 9 "w1 practice exp5se1 & malpractice relative value units %all be phas$-9 ov] a #b-ye> p]iod4 4 7#b7 ,con=m+ am5dm5ts ,section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is am5d$-- 7,a7 9 subp>agraph 7,b77ii77,i71 by /rik+ subclause 7,,ii7 & ins]t+ subclause 7,,ii7 & p>agraph 7#g72 & 7,b7 9 subp>agraph 7,k77iii77,,vi7-- 7i7 by /rik+ provisions ( subp>agraph 7,b77ii77,,ii7 & ins]t+ provisions ( subp>agraph 7,b77ii77,,ii7 & p>agraph 7#g72 & 7ii7 by /rik+ "u subp>agraph 7,b77ii77,,ii7 & ins]t+ "u subp>agraph 7,b77ii77,i74 7f7 ,au?ority ,to smoo? relative values )9 gr\ps ( s]vices ,section #ahdh7;c77#b77;,c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77;,c77 is am5d$-- 7#a7 9 ea* ( clauses 7i7 & 7iii71 by /rik+ ! s]vice & ins]t+ ! s]vice or gr\p ( s]vices ea* place x appe>s2 & 7#b7 9 ! fir/ s5t5ce ( clause 7ii71 by ins]t+ or gr\p ( s]vices be=e ! p]iod4 7g7 ,,gao /udy & report on ,relative ,value ,scale ,update ,committee 7#a7 ,/udy ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates 79 ?is subsection ref]r$ to z ! ,comptroll] ,g5]al7 %all conduct a /udy ( ! processes us$ by ! ,relative ,value ,scale ,update ,committee 7,,ruc7 to provide recomm5dations to ! ,secret>y ( ,heal? & ,human ,s]vices reg>d+ relative values = specific s]vices "u ! ,m$ic>e physician fee s*$ule "u section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d74 7#b7 ,report ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al %all submit to ,congress a report conta9+ ! results ( ! /udy conduct$ "u p>agraph 7#a74 #aje4 ,promot+ evid5ce-bas$ c>e 7a7 ,recogniz+ appropriate use crit]ia = c]ta9 imag+ s]vices 7#a7 ,9 g5]al ,section #ahcd ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7p7 ,recogniz+ appropriate use crit]ia = c]ta9 imag+ s]vices 7#a7 ,program e/abli%$ 7,a7 ,9 g5]al ,! ,secret>y %all e/abli% a program to promote ! use ( appropriate use crit]ia 7z def9$ 9 subp>agraph 7,b77 = applicable imag+ s]vices 7z def9$ 9 subp>agraph 7,c77 furni%$ 9 an applicable sett+ 7z def9$ 9 subp>agraph 7,d77 by ord]+ pr(essionals & furni%+ pr(essionals 7z def9$ 9 subp>agraphs 7,e7 & 7,f71 respectively74 7,b7 ,appropriate use crit]ia def9$ ,9 ?is subsection1 ! t]m appropriate use crit]ia means crit]ia1 only develop$ or endors$ by national pr(essional m$ical specialty societies or o!r provid]-l$ entities1 to assi/ ord]+ pr(essionals & furni%+ pr(essionals 9 mak+ ! mo/ appropriate treatm5t decision = a specific cl9ical condition4 ,to ! ext5t feasible1 su* crit]ia %all be evid5ce-bas$4 7,c7 ,applicable imag+ s]vice def9$ ,9 ?is subsection1 ! t]m applicable imag+ s]vice means an advanc$ diagno/ic imag+ s]vice 7z def9$ 9 subsection 7e77#a77;,b77 = :i* ! ,secret>y det]m9es-- 7i7 "o or m applicable appropriate use crit]ia specifi$ "u p>agraph 7#b7 apply2 7ii7 !re are "o or m qualifi$ cl9ical decision support me*anisms li/$ "u p>agraph 7#c77;,c72 & 7iii7 "o or m ( su* me*anisms is available free ( *>ge4 7,d7 ,applicable sett+ def9$ ,9 ?is subsection1 ! t]m applicable sett+ means a physician's (fice1 a hospital outpati5t dep>tm5t 7includ+ an em]g5cy dep>tm5t71 an ambulatory surgical c5t]1 & any o!r provid]-l$ outpati5t sett+ det]m9$ appropriate by ! ,secret>y4 7,e7 ,ord]+ pr(essional def9$ ,9 ?is subsection1 ! t]m ord]+ pr(essional means a physician 7z def9$ 9 section #ahfa7r77 or a practition] describ$ 9 section #ahdb7;b77#ah77;,c7 :o ord]s an applicable imag+ s]vice = an individual4 7,f7 ,furni%+ pr(essional def9$ ,9 ?is subsection1 ! t]m furni%+ pr(essional means a physician 7z def9$ 9 section #ahfa7r77 or a practition] describ$ 9 section #ahdb7;b77#ah77;,c7 :o furni%es an applicable imag+ s]vice = an individual4 7#b7 ,e/abli%m5t ( applicable appropriate use crit]ia 7,a7 ,9 g5]al ,n lat] ?an ,novemb] #ae1 #bjae1 ! ,secret>y %all ?r\gh rulemak+1 & 9 consultation ) physicians1 practition]s1 & o!r /akehold]s1 specify applicable appropriate use crit]ia = applicable imag+ s]vices only f among appropriate use crit]ia develop$ or endors$ by national pr(essional m$ical specialty societies or o!r provid]-l$ entities4 7,b7 ,consid]ations ,9 specify+ applicable appropriate use crit]ia "u subp>agraph 7,a71 ! ,secret>y %all take into acc\nt :e!r ! crit]ia-- 7i7 h /akehold] cons5sus2 7ii7 h be5 det]m9$ to be sci5tifically valid & are evid5ce bas$2 & 7iii7 are bas$ on /udies t are publi%$ & reviewable by /akehold]s4 7,c7 ,revisions ,! ,secret>y %all p]iodically update & revise 7z appropriate7 su* specification ( applicable appropriate use crit]ia4 7,d7 ,treatm5t ( multiple applicable appropriate use crit]ia ,9 ! case :]e ! ,secret>y det]m9es t m ?an "o appropriate use crit]ia applies ) respect to an applicable imag+ s]vice1 ! ,secret>y %all specify "o or m applicable appropriate use crit]ia "u ?is p>agraph = ! s]vice4 7#c7 ,me*anisms = consultation ) applicable appropriate use crit]ia 7,a7 ,id5tification ( me*anisms to consult ) applicable appropriate use crit]ia 7i7 ,9 g5]al ,! ,secret>y %all specify "o or m qualifi$ cl9ical decision support me*anisms t c\ld be us$ by ord]+ pr(essionals to consult ) applicable appropriate use crit]ia = applicable imag+ s]vices4 7ii7 ,consultation ,! ,secret>y %all consult ) physicians1 practition]s1 & o!r /akehold]s 9 specify+ me*anisms "u ?is p>agraph4 7iii7 ,inclusion ( c]ta9 me*anisms ,me*anisms specifi$ "u ?is p>agraph may include any or all ( ! foll[+ t meet ! requirem5ts describ$ 9 subp>agraph 7,b77ii73 7,i7 ,use ( cl9ical decision support modules 9 c]tifi$ ,,ehr te*nology 7z def9$ 9 section #ahdh7o77#d774 7,,ii7 ,use ( private sector cl9ical decision support me*anisms t are indep5d5t f c]tifi$ ,,ehr te*nology1 :i* may include use ( cl9ical decision support me*anisms available f m$ical specialty organizations4 7,,iii7 ,use ( a cl9ical decision support me*anism e/abli%$ by ! ,secret>y4 7,b7 ,qualifi$ cl9ical decision support me*anisms 7i7 ,9 g5]al ,= purposes ( ?is subsection1 a qualifi$ cl9ical decision support me*anism is a me*anism t ! ,secret>y det]m9es meets ! requirem5ts describ$ 9 clause 7ii74 7ii7 ,requirem5ts ,! requirem5ts describ$ 9 ?is clause are ! foll[+3 7,i7 ,! me*anism makes available to ! ord]+ pr(essional applicable appropriate use crit]ia specifi$ "u p>agraph 7#b7 & ! support+ docum5tation = ! applicable imag+ s]vice ord]$4 7,,ii7 ,9 ! case :]e !re are m ?an "o applicable appropriate use crit]ia specifi$ "u su* p>agraph = an applicable imag+ s]vice1 ! me*anism indicates ! crit]ia t x uses = ! s]vice4 7,,iii7 ,! me*anism det]m9es ! ext5t to :i* an applicable imag+ s]vice ord]$ is consi/5t ) ! applicable appropriate use crit]ia s specifi$4 7,,iv7 ,! me*anism g5]ates & provides to ! ord]+ pr(essional a c]tification or docum5tation t docum5ts t ! qualifi$ cl9ical decision support me*anism 0 consult$ by ! ord]+ pr(essional4 7,v7 ,! me*anism is updat$ on a timely basis to reflect revisions to ! specification ( applicable appropriate use crit]ia "u su* p>agraph4 7,,vi7 ,! me*anism meets privacy & security /&>ds "u applicable provisions ( law4 7,,vii7 ,! me*anism p]=ms su* o!r functions z specifi$ by ! ,secret>y1 :i* may include a requirem5t to provide aggregate fe$back to ! ord]+ pr(essional4 7,c7 ,li/ ( me*anisms = consultation ) applicable appropriate use crit]ia 7i7 ,initial li/ ,n lat] ?an ,april #a1 #bjaf1 ! ,secret>y %all publi% a li/ ( me*anisms specifi$ "u ?is p>agraph4 7ii7 ,p]iodic updat+ ( li/ ,! ,secret>y %all p]iodically update ! li/ ( qualifi$ cl9ical decision support me*anisms specifi$ "u ?is p>agraph4 7#d7 ,consultation ) applicable appropriate use crit]ia 7,a7 ,consultation by ord]+ pr(essional ,beg9n+ ) ,janu>y #a1 #bjag1 subject to subp>agraph 7,c71 ) respect to an applicable imag+ s]vice ord]$ by an ord]+ pr(essional t w\ld be furni%$ 9 an applicable sett+ & paid = "u an applicable paym5t sy/em 7z def9$ 9 subp>agraph 7,d771 an ord]+ pr(essional %all-- 7i7 consult ) a qualifi$ decision support me*anism li/$ "u p>agraph 7#c77;,c72 & 7ii7 provide to ! furni%+ pr(essional ! in=mation describ$ 9 clauses 7i7 ?r\gh 7iii7 ( subp>agraph 7,b74 7,b7 ,report+ by furni%+ pr(essional ,beg9n+ ) ,janu>y #a1 #bjag1 subject to subp>agraph 7,c71 ) respect to an applicable imag+ s]vice furni%$ 9 an applicable sett+ & paid = "u an applicable paym5t sy/em 7z def9$ 9 subp>agraph 7,d771 paym5t = su* s]vice may only be made if ! claim = ! s]vice includes ! foll[+3 7i7 ,in=mation ab\t :i* qualifi$ cl9ical decision support me*anism 0 consult$ by ! ord]+ pr(essional = ! s]vice4 7ii7 ,in=mation reg>d+-- 7,i7 :e!r ! s]vice ord]$ w\ld adh]e to ! applicable appropriate use crit]ia specifi$ "u p>agraph 7#b72 7,,ii7 :e!r ! s]vice ord]$ w\ld n adh]e to su* crit]ia2 or 7,,iii7 :e!r su* crit]ia 0 n applicable to ! s]vice ord]$4 7iii7 ,! national provid] id5tifi] ( ! ord]+ pr(essional 7if diff]5t f ! furni%+ pr(essional74 7,c7 ,exceptions ,! provisions ( subp>agraphs 7,a7 & 7,b7 & p>agraph 7#f77;,a7 %all n apply to ! foll[+3 7i7 ,em]g5cy s]vices ,an applicable imag+ s]vice ord]$ = an individual ) an em]g5cy m$ical condition 7z def9$ 9 section #ahfg7;e77#a774 7ii7 ,inpati5t s]vices ,an applicable imag+ s]vice ord]$ = an inpati5t & = :i* paym5t is made "u "p ,a4 7iii7 ,alt]native paym5t models ,an applicable imag+ s]vice ord]$ by an ord]+ pr(essional ) respect to an individual attribut$ to an alt]native paym5t model 7z def9$ 9 section #ahcc7z77#c77;,c774 7iv7 ,significant h>d%ip ,an applicable imag+ s]vice ord]$ by an ord]+ pr(essional :o ! ,secret>y may1 on a case-by-case basis1 exempt f ! application ( su* provisions if ! ,secret>y det]m9es1 subject to annual r5ewal1 t consultation ) applicable appropriate use crit]ia w\ld result 9 a significant h>d%ip1 su* z 9 ! case ( a pr(essional :o practices 9 a rural area )\t suffici5t ,int]net access4 7,d7 ,applicable paym5t sy/em def9$ ,9 ?is subsection1 ! t]m applicable paym5t sy/em means ! foll[+3 7i7 ,! physician fee s*$ule e/abli%$ "u section #ahdh7;b74 7ii7 ,! prospective paym5t sy/em = hospital outpati5t dep>tm5t s]vices "u section #ahcc7t74 7iii7 ,! ambulatory surgical c5t] paym5t sy/ems "u section #ahcc7;i74 7#e7 ,id5tification ( outli] ord]+ pr(essionals 7,a7 ,9 g5]al ,) respect to applicable imag+ s]vices furni%$ beg9n+ ) #bjag1 ! ,secret>y %all det]m9e1 on a p]iodic basis 7:i* may be annually71 ord]+ pr(essionals :o are outli] ord]+ pr(essionals4 7,b7 ,outli] ord]+ pr(essionals ,! det]m9ation ( an outli] ord]+ pr(essional %all-- 7i7 be bas$ on l[ adh]5ce to applicable appropriate use crit]ia specifi$ "u p>agraph 7#b71 :i* may be bas$ on comp>ison to o!r ord]+ pr(essionals2 & 7ii7 include data = ord]+ pr(essionals = :om prior au?orization "u p>agraph 7#f77;,a7 applies4 7,c7 ,use ( two ye>s ( data ,! ,secret>y %all use two ye>s ( data to id5tify outli] ord]+ pr(essionals "u ?is p>agraph4 7,d7 ,consultation ) /akehold]s ,! ,secret>y %all consult ) physicians1 practition]s & o!r /akehold]s 9 develop+ me?ods to id5tify outli] ord]+ pr(essionals "u ?is p>agraph4 7#f7 ,prior au?orization = ord]+ pr(essionals :o are outli]s 7,a7 ,9 g5]al ,beg9n+ ,janu>y #a1 #bjbj1 subject to p>agraph 7#d77;,c71 ) respect to s]vices furni%$ dur+ a ye>1 ! ,secret>y %all1 = a p]iod det]m9$ appropriate by ! ,secret>y1 apply prior au?orization = applicable imag+ s]vices t are ord]$ by an outli] ord]+ pr(essional id5tifi$ "u p>agraph 7#e74 7,b7 ,fund+ ,= purposes ( c>ry+ out ?is p>agraph1 ! ,secret>y %all provide = ! transf]1 f ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda1 ( #e1jjj1jjj to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt = ea* ( fiscal ye>s #bjai ?r\gh #bjba4 ,am\nts transf]r$ "u ! prec$+ s5t5ce %all rema9 available until exp5d$4 4 7#b7 ,con=m+ am5dm5t ,section #ahcc7t77#af7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77#af77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,e7 ,application ( appropriate use crit]ia = c]ta9 imag+ s]vices ,= provisions relat+ to ! application ( appropriate use crit]ia = c]ta9 imag+ s]vices1 see section #ahcd7p74 4 7b7 ,e/abli%m5t ( appropriate use program = o!r "p ,b s]vices ,section #ahcd ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem71 z am5d$ by subsection 7a71 is am5d$ by add+ at ! end ! foll[+ new subsection3 7q7 ,e/abli%m5t ( appropriate use program = o!r "p b s]vices 7#a7 ,e/abli%m5t 7,a7 ,9 g5]al ,! ,secret>y may e/abli% an appropriate use program = s]vices "u ?is "p 7o!r ?an applicable imag+ s]vices "u subsection 7p77 us+ a process t is comp>able to ! process "u su* subsection4 ,) respect to appropriate use crit]ia1 su* process %all replicate ! provid]-develop$ or provid]-endors$ crit]ia framework = appropriate use crit]ia = applicable imag+ s]vices "u su* subsection4 7,b7 ,requirem5ts ,9 det]m9+ :e!r to e/abli% a program "u subp>agraph 7,a71 ! ,secret>y %all take into consid]ation-- 7i7 ! applicability ( ! provid]-develop$ or provid]-endors$ crit]ia framework = appropriate use crit]ia = applicable imag+ s]vices "u subsection 7p72 7ii7 ! implem5tation ( provid]-develop$ or provid]-endors$ appropriate use crit]ia = su* applicable imag+ s]vices2 & 7iii7 ! report "u p>agraph 7#b74 7,c7 ,input f /akehold]s 9 advance ( rulemak+ ,be=e issu+ a notice ( propos$ rulemak+ to e/abli% a program "u subp>agraph 7,a71 ! ,secret>y %all issue an advance notice ( propos$ rulemak+4 7#b7 ,report on exp]i5ce ( imag+ appropriate use crit]ia program ,n lat] ?an #ah mon?s aft] ! date ( ! enactm5t ( ?is subsection1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report t includes a description ( ! ext5t to :i* appropriate use crit]ia c\ld be us$ = o!r s]vices "u ?is "p1 su* z radiation !rapy & cl9ical diagno/ic laboratory s]vices4 4 #ajf4 ,emp[]+ b5efici>y *oices ?r\gh access to in=mation on physicians' s]vices 7a7 ,transf]r+ free/&+ physician comp>e provision to ! ,social ,security ,act 7#a7 ,9 g5]al ,section #ajcca ( ,public ,law #aaa-adh is transf]r$ & r$esignat$ z subsection 7t7 ( section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 z am5d$ by subsections 7c7 & 7h7 ( section #aja & by section #ajb4 7#b7 ,con=m+ r$esignations ,section #ahdh7t7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7t771 z transf]r$ & r$esignat$ by p>agraph 7#a71 is fur!r am5d$-- 7,a7 by /rik+ ! subsection head+ & ins]t+ ! foll[+ new subsection head+3 ,public report+ ( p]=mance & o!r in=mation on ,physician ,comp>e2 7,b7 by r$esignat+ subsections 7a7 ?r\gh 7i7 z p>agraphs 7#a7 ?r\gh 7#i71 respectively1 & ind5t+ appropriately2 7,c7 9 p>agraph 7#a71 z r$esignat$ by subp>agraph 7,b7-- 7i7 by r$esignat+ p>agraphs 7#a7 & 7#b7 z subp>agraphs 7,a7 & 7,b71 respectively1 & ind5t+ appropriately2 7ii7 9 subp>agraph 7,b71 z r$esignat$ by clause 7i71 by r$esignat+ subp>agraphs 7,a7 ?r\gh 7,g7 z clauses 7i7 ?r\gh 7vii71 respectively1 & ind5t+ appropriately2 7,d7 9 p>agraph 7#b71 z r$esignat$ by subp>agraph 7,b71 by r$esignat+ p>agraphs 7#a7 ?r\gh 7#g7 z subp>agraphs 7,a7 ?r\gh 7,g71 respectively1 & ind5t+ appropriately2 & 7,e7 9 p>agraph 7#i71 z r$esignat$ by subp>agraph 7,b71 by r$esignat+ p>agraphs 7#a7 ?r\gh 7#d7 z subp>agraphs 7,a7 ?r\gh 7,d71 respectively1 & ind5t+ appropriately4 7#c7 ,con=m+ am5dm5ts ,section #ahdh7t7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7t771 z am5d$ by p>agraph 7#b71 is fur!r am5d$-- 7,a7 9 p>agraph 7#a7-- 7i7 9 subp>agraph 7,a7-- 7,i7 by /rik+ ! ,m$ic>e program "u section #ahff7;j7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7j77 & ins]t+ ! program "u ?is title "u section #ahff7;j72 & 7,,ii7 by /rik+ ( su* ,act 7#db ,u4,s4,c4 #aciew-#d72 & 7ii7 9 subp>agraph 7,b71 9 ! matt] prec$+ clause 7i7-- 7,i7 by /rik+ subsection 7c7 & ins]t+ p>agraph 7#c72 7,,ii7 by /rik+ ! ,m$ic>e program "u su* section #ahff7;j7 & ins]t+ ! program "u ?is title "u section #ahff7;j72 & 7,,iii7 by /rik+ ?is section & ins]t+ ?is subsection2 7,b7 9 p>agraph 7#b7-- 7i7 9 ! matt] prec$+ subp>agraph 7,a71 by /rik+ subsection 7a77#b7 & ins]t+ p>agraph 7#a77;,b72 7ii7 9 subp>agraph 7,d71 by /rik+ ! ,m$ic>e program & ins]t+ ! program "u ?is title2 & 7iii7 9 ea* ( subp>agraphs 7,f7 & 7,g71 by /rik+ ?is section & ins]t+ ?is subsection2 7,c7 9 p>agraph 7#c71 by /rik+ ?is section & ins]t+ ?is subsection2 7,d7 9 p>agraph 7#d7-- 7i7 by /rik+ ( ! ,social ,security ,act1 z add$ by section #cjad ( ?is ,act2 & 7ii7 by /rik+ ?is section & ins]t+ ?is subsection2 7,e7 9 p>agraph 7#e7-- 7i7 by /rik+ ?is subsection 7a77#b7 & ins]t+ p>agraph 7#a77;,b72 & 7ii7 by /rik+ 7,public ,law #aaj-bge72 7,f7 9 p>agraph 7#f71 by /rik+ subsection 7a77#a7 & ins]t+ p>agraph 7#a77;,a72 7,g7 9 p>agraph 7#g7-- 7i7 by /rik+ subsection 7f7 & ins]t+ p>agraph 7#f72 & 7ii7 by /rik+ title ,,xviii ( ! ,social ,security ,act & ins]t+ ?is title2 7,h7 9 p>agraph 7#h7-- 7i7 by /rik+ subp>agraphs 7,a7 ?r\gh 7,g7 ( subsection 7a77#b7 & ins]t+ clauses 7i7 ?r\gh 7vii7 ( p>agraph 7#a77;,b72 7ii7 by /rik+ title ,,xviii ( ! ,social ,security ,act & ins]t+ ?is title2 & 7iii7 by /rik+ su* title & ins]t+ ?is title2 & 7,i7 9 p>agraph 7#i7-- 7i7 9 ! matt] prec$+ subp>agraph 7#h71 by /rik+ ?is section & ins]t+ ?is subsection2 7ii7 9 subp>agraph 7,a71 by /rik+ ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d72 7iii7 9 subp>agraph 7,b71 by /rik+ ( su* ,act 7#db ,u4,s4,c4 #aciex7r772 7iv7 9 subp>agraph 7,c71 by /rik+ subsection 7a77#a7 & ins]t+ p>agraph 7#a77;,a72 & 7v7 by /rik+ subp>agraph 7,d74 7b7 ,public availability ( ,m$ic>e data ,section #ahdh7t7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7t771 z am5d$ by subsection 7a71 is fur!r am5d$-- 7#a7 by r$esignat+ p>agraph 7#i7 z p>agraph 7#aj72 7#b7 by ins]t+ aft] p>agraph 7#h7 ! foll[+ new p>agraph3 7#i7 ,public availability ( eligible pr(essional claims data 7,a7 ,9 g5]al ,! ,secret>y %all make publicly available on ,physician ,comp>e ! in=mation describ$ 9 subp>agraph 7,b7 ) respect to eligible pr(essionals4 7,b7 ,in=mation describ$ ,! foll[+ in=mation1 ) respect to an eligible pr(essional1 is describ$ 9 ?is subp>agraph3 7i7 ,in=mation on ! numb] ( s]vices furni%$ by ! eligible pr(essional1 :i* may include in=mation on ! mo/ frequ5t s]vices furni%$ or gr\p+s ( s]vices4 7ii7 ,in=mation on submitt$ *>ges & paym5ts = s]vices "u ?is "p4 7iii7 ,a unique id5tifi] = ! eligible pr(essional t is available to ! public1 su* z a national provid] id5tifi]4 7,c7 ,se>*ability ,! in=mation made available "u ?is p>agraph %all be se>*able by at lea/ ! foll[+3 7i7 ,! specialty or type ( ! eligible pr(essional4 7ii7 ,*>act]i/ics ( ! s]vices furni%$1 su* z volume or gr\p+s ( s]vices4 7iii7 ,! location ( ! eligible pr(essional4 7,d7 ,disclosure ,! in=mation made available "u ?is p>agraph %all indicate1 :]e appropriate1 t publiciz$ in=mation may n be repres5tative ( ! eligible pr(essional's entire pati5t population1 ! v>iety ( s]vices furni%$ by ! eligible pr(essional1 or ! heal? conditions ( individuals treat$4 7,e7 ,implem5tation 7i7 ,initial implem5tation ,physician ,comp>e %all include ! in=mation describ$ 9 subp>agraph 7,b7-- 7,i7 ) respect to physicians1 by n lat] ?an ,july #a1 #bjae2 & 7,,ii7 ) respect to o!r eligible pr(essionals1 by n lat] ?an ,july #a1 #bjaf4 7ii7 ,annual updat+ ,! in=mation made available "u ?is p>agraph %all be updat$ on ,physician ,comp>e n less frequ5tly ?an on an annual basis4 7,f7 ,opportunity to review & submit corrections ,! ,secret>y %all provide = an opportunity = an eligible pr(essional to review1 & submit corrections =1 ! in=mation to be made public ) respect to ! eligible pr(essional "u ?is p>agraph prior to su* in=mation be+ made public4 2 & 7#c7 9 p>agraph 7#aj77;,c71 z r$esignat$ by p>agraph 7#a71 by ins]t+ 7or a successor website7 be=e ! p]iod at ! end4 #ajg4 ,exp&+ claims data availability to improve c>e 7a7 ,expansion ( uses ( claims data by qualifi$ entities ,section #ahgd7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77 is am5d$ by add+ at ! end ! foll[+ new p>agraphs3 7#e7 ,expansion ( uses ( claims data by qualifi$ entities 7,a7 ,expansion ,to ! ext5t consi/5t ) applicable in=mation1 privacy1 security1 & disclosure laws1 beg9n+ ,july #a1 #bjad1 not)/&+ p>agraph 7#d77;,b7 7o!r ?an clause 7iii7 ( su* p>agraph7 & ! second s5t5ce ( p>agraph 7#d77;,d71 a qualifi$ entity may1 z det]m9$ appropriate by ! ,secret>y1 d any or all ( ! foll[+3 7i7 7,i7 ,use ! comb9$ data describ$ 9 p>agraph 7#d77;,b77iii7 to conduct analyses1 o!r ?an = reports describ$ 9 p>agraph 7#d71 = entities describ$ 9 subp>agraph 7,b7 = non-public uses1 z det]m9$ appropriate by ! ,secret>y1 su* z = ! purposes describ$ 9 subclause 7,,ii74 7,,ii7 ,! purposes describ$ 9 ?is subclause are assi/+ provid]s ( s]vices & suppli]s 9 develop+ & p>ticipat+ 9 quality & pati5t c>e improvem5t activities 7includ+ develop+ new models ( c>e71 population heal? managem5t1 & disease monitor+1 & ! purposes describ$ 9 subp>agraph 7,c74 7ii7 ,provide or sell su* analyses to entities describ$ 9 subp>agraph 7,b74 7iii7 ,provide entities describ$ 9 clauses 7i71 7ii71 7v71 & 7vi7 ( subp>agraph 7,b7 ) access to ! comb9$ data describ$ 9 p>agraph 7#d77;,b77iii7 ?r\gh a qualifi$ data enclave 7z def9$ 9 subp>agraph 7,f77 t is ma9ta9$ by ! qualifi$ entity1 or ?r\gh an approv$ alt]native me?od 7z def9$ 9 subp>agraph 7,g771 9 ord] = entities describ$ 9 su* clauses to conduct analyses = non-public uses1 su* z = ! purposes describ$ 9 clause 7i77,,ii7 7b exclud+ ! purposes describ$ 9 subp>agraph 7,c774 7,b7 ,entities describ$ ,= ! purpose ( subp>agraph 7,a7 clauses 7i7 & 7ii71 ! entities describ$ 9 ?is subp>agraph are ! foll[+3 7i7 ,a provid] ( s]vices4 7ii7 ,a suppli]4 7iii7 ,subject to subp>agraph 7,c71 an employ] 7z def9$ 9 section #c7e7 ( ! ,employee ,retirem5t ,insurance ,security ,act ( #aigd74 7iv7 ,a heal? insurance issu] 7z def9$ 9 section #bgia ( ! ,public ,heal? ,s]vice ,act7 t provides data "u p>agraph 7#d77;,b77iii74 7v7 ,a m$ical society or hospital association4 7vi7 ,o!r entities approv$ by ! ,secret>y 7o!r ?an an employ] 7z s def9$7 & a heal? insurance issu] 7z s def9$774 7,c7 ,limitation = employ]s ) respect to analyses ,any analyses provid$ or sold "u ?is p>agraph to an employ] 7z s def9$7 may only be us$ by su* employ] = purposes ( provid+ heal? insurance to employees & retirees ( ! employ]4 7,d7 ,protection ( pati5t id5tification 9 analyses 7i7 ,9 g5]al ,except z provid$ 9 clause 7ii71 an analysis provid$ or sold "u ?is p>agraph %all n conta9 in=mation t individually id5tifies a pati5t4 7ii7 ,in=mation on pati5ts ( ! provid] ( s]vices or suppli] ,an analysis t is provid$ or sold "u ?is p>agraph to a provid] ( s]vices or suppli] may conta9 data t individually id5tifies a pati5t ( su* provid] or suppli] b only ) respect to items & s]vices furni%$ by su* provid] or suppli] to su* pati5t4 7iii7 ,opportunity = provid]s ( s]vices & suppli]s to review ,prior to a qualifi$ entity provid+ or sell+ an analysis "u ?is p>agraph to an entity describ$ 9 subp>agraph 7,b71 to ! ext5t t su* analysis w\ld individually id5tify a provid] ( s]vices or suppli] :o is n be+ provid$ or sold su* analysis1 su* qualifi$ entity %all provide an opportunity = su* provid] or suppli] to review & submit corrections to su* analysis4 7,e7 ,no r$isclosure ( analyses or data ,an entity describ$ 9 subp>agraph 7,b7 t is provid$ or sold analyses "u ?is p>agraph1 or an entity describ$ 9 subp>agraph 7,a77iii7 t receives data "u ?is p>agraph ?r\gh a qualifi$ data enclave or an approv$ alt]native me?od1 %all n r$isclose or make public su* analyses1 su* data1 or analyses us+ su* data4 7,f7 ,requirem5ts = a qualifi$ data enclave 7i7 ,def9ition ,= purposes ( ?is p>agraph1 ! t]m qualifi$ data enclave means a data enclave t ! ,secret>y det]m9es meets ! foll[+3 7,i7 ,! data enclave is a virtual private network or comp>able me*anism4 7,,ii7 ,subject to ! requirem5ts describ$ 9 clause 7ii7 & su* o!r requirem5ts z ! ,secret>y may specify1 ! data enclave is capable ( provid+ access to ! comb9$ data describ$ 9 subp>agraph 7,a77iii74 7ii7 ,enclave access requirem5ts ,! requirem5ts describ$ 9 ?is clause are ! foll[+3 7,i7 ,a qualifi$ data enclave %all preclude any entity t obta9s access to ! data f remov+ or extract+ ! data f su* enclave4 7,,ii7 ,subject to ! succe$+ s5t5ce1 ! enclave %all preclude access to data t individually id5tifies a pati5t1 includ+ data on ! pati5t's "n & date ( bir? & su* o!r data z ! ,secret>y %all specify4 ,su* data enclave may provide provid]s ( s]vices & suppli]s ) access to su* individually id5tifiable pati5t data b only ) respect to items & s]vices furni%$ by su* provid] or suppli] to su* pati5t4 7,,iii7 ,access to data 9 ! enclave %all n be provid$ to any entity unless ! qualifi$ entity & ! entity h ent]$ into a data use agreem5t1 ! t]ms ( :i* conta9 ! requirem5ts ( ?is p>agraph & p>agraph 7#f7 & su* o!r t]ms ! ,secret>y may specify4 7,g7 ,approv$ alt]native me?od ,= purposes ( ?is p>agraph1 ! t]m approv$ alt]native me?od means a me?od ( provid+ access to ! data describ$ 9 subp>agraph 7,a77iii7 7o!r ?an ?r\gh a qualifi$ data enclave7 to entities describ$ 9 su* p>agraph t ! ,secret>y det]m9es meets ! foll[+3 7i7 ,! me?od is z secure z a qualifi$ data enclave4 7ii7 ,! me?od meets ! requirem5ts applicable to a qualifi$ data enclave "u subclauses 7,,ii7 & 7,,iii7 ( subp>agraph 7,f77ii74 7iii7 ,! me?od meets o!r requirem5ts det]m9$ appropriate by ! ,secret>y4 7,h7 ,annual reports ,any qualifi$ entity t provides or sells analyses pursuant to subp>agraph 7,a77ii71 or provides access to a data ?r\gh an approv$ data enclave or an approv$ alt]native me?od1 %all annually submit to ! ,secret>y a report t includes-- 7i7 a summ>y ( ! analyses provid$ or sold1 includ+ ! numb] ( su* analyses1 ! numb] ( pur*as]s ( su* analyses1 & ! total am\nt ( fees receiv$ = su* analyses2 7ii7 a description ( ! topics & purposes ( su* analyses2 7iii7 in=mation on ! entities :o obta9$ access to data pursuant to subp>agraph 7,a77iii71 ! uses ( ! data1 & ! total am\nt ( fees receiv$ = provid+ su* access2 & 7iv7 o!r in=mation det]m9$ appropriate by ! ,secret>y4 7#f7 ,civil monet>y p5alties = a brea* ( a data use agreem5t ,a data use agreem5t "u ?is subsection %all provide = civil monet>y p5alties 7z det]m9$ appropriate by ! ,secret>y7 = a brea* ( su* agreem5t4 4 7b7 ,expansion ( data available to qualifi$ entities ,section #ahgd7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77 is am5d$-- 7#a7 9 ! subsection head+1 by /rik+ ,m$ic>e2 & 7#b7 9 p>agraph 7#c7-- 7,a7 by ins]t+ aft] ! fir/ s5t5ce ! foll[+ new s5t5ce3 ,effective ,july #a1 #bjad1 if ! ,secret>y det]m9es appropriate1 ! data describ$ 9 ?is p>agraph may also include /&>diz$ extracts 7z det]m9$ by ! ,secret>y7 ( claims data "u titles ,,xix & ,,xxi = assi/ance provid$ "u su* titles = "o or m specifi$ geographic areas & "t p]iods reque/$ by a qualifi$ entity42 & 7,b7 9 ! la/ s5t5ce1 by ins]t+ or "u titles ,,xix or ,,xxi be=e ! p]iod at ! end4 7c7 ,access to ,m$ic>e data by qualifi$ cl9ical data regi/ries ,to facilitate quality improvem5t ,section #ahdh7m77#c77;,e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#c77;,e77 is am5d$ by add+ at ! end ! foll[+ new clause3 7vi7 ,access to m$ic>e data to facilitate quality improvem5t 7,i7 ,9 g5]al ,to ! ext5t consi/5t ) applicable in=mation1 privacy1 security1 & disclosure laws1 & subject to o!r requirem5ts z ! ,secret>y may specify1 beg9n+ ,july #a1 #bjad1 ! ,secret>y %all1 if reque/$ by a qualifi$ cl9ical data regi/ry "u ?is subp>agraph1 subject to subclauses 7,,ii7 & 7,,iii71 provide data z describ$ 9 section #ahgd7;e77#c7 79 a =m & mann] det]m9$ to be appropriate7 to su* regi/ry = purposes ( l9k+ su* data ) cl9ical data & p]=m+ analyses & rese>* to support quality improvem5t or pati5t safety4 7,,ii7 ,protection ,a qualifi$ cl9ical data regi/ry may n publicly report any data made available "u subclause 7,i7 7or any analyses or rese>* describ$ 9 su* subclause7 t individually id5tifies a provid] ( s]vices1 suppli]1 or individual unless ! regi/ry obta9s ! cons5t ( su* provid]1 suppli]1 or individual prior to su* report+4 7,,iii7 ,fee ,! data describ$ 9 subclause 7,i7 %all be made available to qualifi$ cl9ical data regi/ries at a fee equal to ! co/ ( mak+ su* data available4 ,any fee collect$ pursuant to ! prec$+ s5t5ce %all be deposit$ 9 ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt4 4 7d7 ,revision ( placem5t ( fees ,section #ahgd7;e77#d77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77#d77;,a77 is am5d$1 9 ! second s5t5ce-- 7#a7 by ins]t+ 1 = p]iods prior to ,july #a1 #bjad1 aft] deposit$2 & 7#b7 by ins]t+ ! foll[+ be=e ! p]iod at ! end3 1 &1 beg9n+ ,july #a1 #bjad1 into ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt4 ,,ii ,ext5sions & ,o!r ,provisions ,a ,m$ic>e ,ext5sions #bja4 ,"w geographic adju/m5t ,section #ahdh7;e77#a77;,e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;e77#a77;,e77 is am5d$ by /rik+ & be=e ,janu>y #a1 #bjad14 #bjb4 ,m$ic>e paym5t = !rapy s]vices 7a7 ,repeal ( !rapy cap & #a-ye> ext5sion ( ?re%old = manual m$ical review ,section #ahcc7;g7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7g77 is am5d$-- 7#a7 9 p>agraph 7#d7-- 7,a7 by /rik+ ,?is subsection & ins]t+ ,except z provid$ 9 p>agraph 7#e77;,c71 ?is subsection2 & 7,b7 by ins]t+ ! foll[+ be=e ! p]iod at ! end3 or ) respect to s]vices furni%$ on or aft] ! date ( enactm5t ( ! ,,sgr ,repeal & ,m$ic>e ,b5efici>y ,access ,act ( #bjac4 7#b7 9 p>agraph 7#e77;,c7-- 7,a7 9 clause 7i71 by ins]t+ & be=e ,janu>y #a1 #bjae1 aft] #bjab12 & 7,b7 by add+ at ! end ! foll[+ new clause3 7iii7 ,) respect to s]vices furni%$ dur+ ! p]iod beg9n+ on ! date ( enactm5t ( ! ,,sgr ,repeal & ,m$ic>e ,b5efici>y ,access ,act ( #bjac1 & end+ on ,decemb] #ca1 #bjad1 ! provisions ( ?is p>agraph %all only apply to ! ext5t necess>y to c>ry out ! manual m$ical review process "u ?is subp>agraph4 4 7b7 ,m$ical review ( outpati5t !rapy s]vices 7#a7 ,m$ical review ( outpati5t !rapy s]vices ,section #ahcc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel71 z am5d$ by section #aja7;e71 is am5d$ by add+ at ! end ! foll[+ new subsection3 7aa7 ,m$ical review ( outpati5t !rapy s]vices 7#a7 ,9 g5]al 7,a7 ,process = m$ical review ,! ,secret>y %all implem5t a process = ! m$ical review 7z describ$ 9 p>agraph 7#b77 ( outpati5t !rapy s]vices 7z def9$ 9 p>agraph 7#aj77 &1 subject to p>agraph 7#ab71 apply su* process to su* s]vices furni%$ on or aft] ,janu>y #a1 #bjae1 focus+ on s]vices id5tifi$ "u subp>agraph 7,b74 7,b7 ,id5tification ( s]vices = review ,"u ! process1 ! ,secret>y %all id5tify s]vices = m$ical review1 us+ su* factors z ! ,secret>y det]m9es appropriate1 :i* may include ! foll[+3 7i7 ,s]vices furni%$ by a !rapy provid] 7z def9$ 9 p>agraph 7#aj77 ^: patt]n ( bill+ is high] comp>$ to pe]s4 7ii7 ,s]vices furni%$ by a !rapy provid] :o1 9 a prior p]iod1 has a high claims d5ial p]c5tage or is lea/ compliant ) o!r applicable requirem5ts "u ?is title4 7iii7 ,s]vices furni%$ by a !rapy provid] t is newly enroll$ "u ?is title4 7iv7 ,s]vices furni%$ by a !rapy provid] :o has que/ionable bill+ practices1 su* z bill+ m$ically unlikely units ( s]vices 9 a day4 7v7 ,s]vices furni%$ to treat a type ( m$ical condition4 7vi7 ,s]vices id5tifi$ by use ( ! /&>diz$ data elem5ts requir$ to be report$ "u section #ahcd7p74 7vii7 ,s]vices furni%$ by a s+le !rapy provid] or a gr\p t includes a !rapy provid] id5tifi$ by factors describ$ 9 ?is subp>agraph4 7viii7 ,o!r s]vices z det]m9$ appropriate by ! ,secret>y4 7#b7 ,m$ical review 7,a7 ,prior au?orization m$ical review 7i7 ,9 g5]al ,subject to ! succe$+ provisions ( ?is subp>agraph1 ! ,secret>y %all use prior au?orization m$ical review = outpati5t !rapy s]vices furni%$ to an individual above "o or m ?re%olds e/abli%$ by ! ,secret>y1 su* z a doll> ?re%old or a ?re%old bas$ on factors su* z ! type ( outpati5t !rapy s]vice or sett+4 7ii7 ,end+ application ( prior au?orization = a !rapy provid] ,! ,secret>y %all end ! application ( prior au?orization m$ical review to outpati5t !rapy s]vices furni%$ by a !rapy provid] if ! ,secret>y det]m9es t ! provid] has a l[ d5ial rate "u su* prior au?orization4 ,! ,secret>y may subsequ5tly reapply prior au?orization m$ical review to su* !rapy provid] if ! ,secret>y det]m9es x to be appropriate4 7iii7 ,prior au?orization ( multiple s]vices ,! ,secret>y %all1 :]e practicable1 provide = prior au?orization m$ical review = multiple s]vices at a s+le "t1 su* z s]vices 9 a !rapy plan ( c>e describ$ 9 section #ahfa7p77#b74 7,b7 ,o!r types ( m$ical review ,! ,secret>y may use pre-paym5t review or po/-paym5t review = s]vices id5tifi$ "u p>agraph 7#a77;,b7 t are n subject to prior au?orization m$ical review "u subp>agraph 7,a74 7,c7 ,limitation = law en=cem5t activities ,! ,secret>y may det]m9e t m$ical review "u ?is subsection does n apply 9 ! case :]e fraud may be involv$4 7#c7 ,review contractors ,! ,secret>y %all conduct prior au?orization m$ical review ( outpati5t !rapy s]vices "u ?is subsection us+ m$ic>e adm9i/rative contractors 7z describ$ 9 section #ahgd;,a7 or o!r review contractors 7o!r ?an contractors "u section #ahic7;h7 or contractors paid on a cont+5t basis74 7#d7 ,no paym5t )\t prior au?orization ,) respect to an outpati5t !rapy s]vice = :i* prior au?orization m$ical review "u ?is subsection applies1 no paym5t %all be made "u ?is "p = ! s]vice unless a prior au?orization det]m9ation is made1 9 advance ( furni%+ su* s]vice1 t su* s]vice w\ld meet ! applicable requirem5ts ( section #ahfb7;a77#a77;,a74 7#e7 ,submission ( in=mation ,a !rapy provid] may submit ! in=mation necess>y = m$ical review by fax1 by mail1 or by electronic means4 ,! ,secret>y %all make available ! electronic means describ$ 9 ! prec$+ s5t5ce z soon z practicable1 b n lat] ?an #bd mon?s aft] ! date ( enactm5t ( ?is subsection4 7#f7 ,timel9ess ,! ,secret>y %all make a prior au?orization det]m9ation "u ?is subsection )9 #aj bus9ess days ( ! date ( ! ,secret>y's receipt ( m$ical docum5tation ne$$ to make su* det]m9ation or ! ,secret>y %all be deem$ to h f\nd ! s]vices to meet ! applicable requirem5ts ( section #ahfb7;a77#a77;,a74 7#g7 ,con/ruction ,) respect to an outpati5t !rapy s]vice t has be5 affirm$ by m$ical review "u ?is subsection1 no?+ 9 ?is subsection %all be con/ru$ to preclude ! subsequ5t d5ial ( a claim = su* s]vice t does n meet o!r applicable requirem5ts "u ?is ,act4 7#h7 ,b5efici>y protections ,) respect to s]vices furni%$ on or aft] ,janu>y #a1 #bjae1 :]e paym5t may n be made z a result ( application ( m$ical review "u ?is subsection1 section #ahgi %all apply 9 ! same mann] z su* section applies to a d5ial t is made by reason ( section #ahfb7;a77#a74 7#i7 ,implem5tation 7,a7 ,au?ority ,! ,secret>y may implem5t ! provisions ( ?is subsection by int]im f9al rule ) comm5t p]iod4 7,b7 ,adm9i/ration ,*apt] #ce ( title #dd1 ,unit$ ,/ates ,code1 %all n apply to m$ical review "u ?is subsection4 7#aj7 ,def9itions ,= purposes ( ?is subsection3 7,a7 ,outpati5t !rapy s]vices ,! t]m outpati5t !rapy s]vices means ! foll[+ s]vices = :i* paym5t is made "u section #ahdh1 #ahcd7;g71 or #ahcd7k73 7i7 ,physical !rapy s]vices ( ! type describ$ 9 section #ahfa7p74 7ii7 ,spee*-language pa?ology s]vices ( ! type describ$ 9 su* section ?\gh ! application ( section #ahfa7ll77#b74 7iii7 ,occupational !rapy s]vices ( ! type describ$ 9 section #ahfa7p7 ?r\gh ! op]ation ( section #ahfa7;g74 7,b7 ,!rapy provid] ,! t]m !rapy provid] means a provid] ( s]vices 7z def9$ 9 section #ahfa7u77 or a suppli] 7z def9$ 9 section #ahfa7;d77 :o submits a claim = outpati5t !rapy s]vices4 7#aa7 ,fund+ ,= purposes ( implem5t+ ?is subsection1 ! ,secret>y %all provide = ! transf]1 f ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda1 ( #ce1jjj1jjj to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt = ea* fiscal ye> 7beg9n+ ) fiscal ye> #bjad74 ,am\nts transf]r$ "u ?is p>agraph %all rema9 available until exp5d$4 7#ab7 ,scal+ back 7,a7 ,p]iodic det]m9ations ,beg9n+ ) #bjag1 & e two ye>s !reaft]1 ! ,secret>y %all-- 7i7 make a det]m9ation ( ! improp] paym5t rate = outpati5t !rapy s]vices = a #ab-mon? p]iod2 & 7ii7 make su* det]m9ation publicly available4 7,b7 ,scal+ back ,if ! improp] paym5t rate = outpati5t !rapy s]vices det]m9$ = a #ab-mon? p]iod "u subp>agraph 7,a7 is #ej p]c5t or less ( ! ,m$ic>e fee-=-s]vice improp] paym5t rate = su* p]iod1 ! ,secret>y %all-- 7i7 r$uce ! am\nt & ext5t ( m$ical review conduct$ = a prospective ye> "u ! process e/abli%$ 9 ?is subsection2 & 7ii7 return an appropriate portion ( ! fund+ provid$ = su* ye> "u p>agraph 7#aa74 4 7#b7 ,,gao /udy & report 7,a7 ,/udy ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all conduct a /udy on ! effectiv5ess ( m$ical review ( outpati5t !rapy s]vices "u section #ahcc7;aa7 ( ! ,social ,security ,act1 z add$ by p>agraph 7#b74 ,su* /udy %all include an analysis (-- 7i7 aggregate data on-- 7,i7 ! numb] ( individuals1 !rapy provid]s1 & claims subject to su* review2 & 7,,ii7 ! numb] ( reviews conduct$ "u su* section2 & 7ii7 ! outcomes ( su* reviews4 7,b7 ,report ,n lat] ?an #c ye>s aft] ! date ( enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al %all submit to ,congress a report conta9+ ! results ( ! /udy "u subp>agraph 7,a71 toge!r ) recomm5dations = su* legislation & adm9i/rative action z ! ,comptroll] ,g5]al det]m9es appropriate4 7c7 ,collection ( /&>diz$ data elem5ts = outpati5t !rapy s]vices 7#a7 ,collection ( /&>diz$ data elem5ts = outpati5t !rapy s]vices ,section #ahcd ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7p7 ,collection ( /&>diz$ data elem5ts = outpati5t !rapy s]vices 7#a7 ,/&>diz$ data elem5ts 7,a7 ,9 g5]al ,n lat] ?an #f mon?s aft] ! date ( enactm5t ( ?is subsection1 ! ,secret>y %all po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices a draft li/ ( /&>diz$ data elem5ts = individuals receiv+ outpati5t !rapy s]vices4 7,b7 ,doma9s ,su* /&>diz$ data elem5ts %all include in=mation ) respect to ! foll[+ doma9s1 z det]m9$ appropriate by ! ,secret>y3 7i7 ,demographic in=mation4 7ii7 ,diagnosis4 7iii7 ,sev]ity4 7iv7 ,affect$ body /ructures & functions4 7v7 ,limitations ) activities ( daily liv+ & p>ticipation4 7vi7 ,functional /atus4 7vii7 ,o!r doma9s det]m9$ to be appropriate by ! ,secret>y4 7,c7 ,solicitation ( input ,! ,secret>y %all accept comm5ts f /akehold]s ?r\gh ! date t is #fj days aft] ! date ! ,secret>y po/s ! draft li/ ( /&>diz$ data elem5ts pursuant to subp>agraph 7,a74 ,9 seek+ su* comm5ts1 ! ,secret>y %all use "o or m me*anisms to solicit input f /akehold]s t may include use ( op5 door =ums1 t[n hall meet+s1 reque/s = in=mation1 or o!r me*anisms det]m9$ appropriate by ! ,secret>y4 7,d7 ,op]ational li/ ( /&>diz$ data elem5ts ,n lat] ?an #abj days aft] ! end ( ! comm5t p]iod describ$ 9 subp>agraph 7,c71 ! ,secret>y1 tak+ into acc\nt su* comm5ts1 %all po/ on ! ,int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices an op]ational li/ ( /&>diz$ data elem5ts4 7,e7 ,subsequ5t revisions ,subsequ5t revisions to ! op]ational li/ ( /&>diz$ data elem5ts %all be made ?r\gh rulemak+4 ,su* revisions may be bas$ on exp]i5ce & input f /akehold]s4 7#b7 ,sy/em to report /&>diz$ data elem5ts 7,a7 ,9 g5]al ,n lat] ?an #ah mon?s aft] ! date ! ,secret>y po/s ! op]ational li/ ( /&>diz$ data elem5ts pursuant to p>agraph 7#a77;,d71 ! ,secret>y %all develop & implem5t an electronic sy/em 7:i* may be a web portal7 = !rapy provid]s to report ! /&>diz$ data elem5ts = individuals ) respect to outpati5t !rapy s]vices4 7,b7 ,consultation ,! ,secret>y %all seek comm5ts f /akehold]s reg>d+ ! be/ way to report ! /&>diz$ data elem5ts4 7#c7 ,report+ 7,a7 ,frequ5cy ( report+ ,! ,secret>y %all specify ! frequ5cy ( report+ /&>diz$ data elem5ts4 ,! ,secret>y %all seek comm5ts f /akehold]s reg>d+ ! frequ5cy ( ! report+ ( su* data elem5ts4 7,b7 ,report+ requirem5t ,beg9n+ on ! date ! sy/em to report /&>diz$ data elem5ts "u ?is subsection is op]ational1 no paym5t %all be made "u ?is "p = outpati5t !rapy s]vices furni%$ to an individual unless a !rapy provid] reports ! /&>diz$ data elem5ts = su* individual4 7#d7 ,report on new paym5t sy/em = outpati5t !rapy s]vices 7,a7 ,9 g5]al ,n lat] ?an #ah mon?s aft] ! date describ$ 9 p>agraph 7#c77;,b71 ! ,secret>y %all submit to ,congress a report on ! design ( a new paym5t sy/em = outpati5t !rapy s]vices4 ,! report %all include an analysis ( ! /&>diz$ data elem5ts collect$ & o!r appropriate data & in=mation4 7,b7 ,features ,su* report %all consid]-- 7i7 appropriate adju/m5ts to paym5t 7su* z case mix & outli]s72 7ii7 paym5ts on an episode ( c>e basis2 & 7iii7 r$uc$ paym5t = multiple episodes4 7,c7 ,consultation ,! ,secret>y %all consult ) /akehold]s reg>d+ ! design ( su* a new paym5t sy/em4 7#e7 ,implem5tation 7,a7 ,fund+ ,= purposes ( implem5t+ ?is subsection1 ! ,secret>y %all provide = ! transf]1 f ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda1 ( #g1jjj1jjj to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt = ea* ( fiscal ye>s #bjad ?r\gh #bjah4 ,am\nts transf]r$ "u ?is subp>agraph %all rema9 available until exp5d$4 7,b7 ,adm9i/ration ,*apt] #ce ( title #dd1 ,unit$ ,/ates ,code1 %all n apply to specification ( ! /&>diz$ data elem5ts & implem5tation ( ! sy/em to report su* /&>diz$ data elem5ts "u ?is subsection4 7,c7 ,limitation ,!re %all be no adm9i/rative or judicial review "u section #ahfi1 section #ahgh1 or o!rwise ( ! specification ( /&>diz$ data elem5ts requir$ "u ?is subsection or ! sy/em to report su* /&>diz$ data elem5ts4 7,d7 ,def9ition ( outpati5t !rapy s]vices & !rapy provid] ,9 ?is subsection1 ! t]ms outpati5t !rapy s]vices & !rapy provid] h ! mean+ giv5 ^? t]m 9 section #ahcc7;aa74 4 7#b7 ,sunset ( curr5t claims-bas$ collection ( !rapy data ,section #cjje7;g77#a7 ( ! ,middle ,class ,tax ,ext5sion & ,job ,creation ,act ( #bjab 7#db ,u4,s4,c4 #aciel note7 is am5d$1 9 ! fir/ s5t5ce1 by ins]t+ & end+ on ! date ! sy/em to report /&>diz$ data elem5ts "u section #ahcd7p7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7p77 is implem5t$1 aft] ,janu>y #a1 #bjac14 7d7 ,report+ ( c]ta9 in=mation ,section #ahdb7t7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieu7t77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#c7 ,ea* reque/ = paym5t1 or bill submitt$1 by a !rapy provid] 7z def9$ 9 section #ahcc7;aa77#aj77 = an outpati5t !rapy s]vice 7z def9$ 9 su* section7 furni%$ by a !rapy assi/ant on or aft] ,janu>y #a1 #bjae1 %all include 79 a =m & mann] specifi$ by ! ,secret>y7 an indication t ! s]vice 0 furni%$ by a !rapy assi/ant4 4 #bjc4 ,m$ic>e ambulance s]vices 7a7 ,ext5sion ( c]ta9 ambulance add-on paym5ts 7#a7 ,gr\nd ,ambulance ,section #ahcd7l77#ac77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l77#ac77;,a77 is am5d$ by /rik+ ,janu>y #a1 #bjad & ins]t+ ,janu>y #a1 #bjai ea* place x appe>s4 7#b7 ,sup] ,rural ,ambulance ,section #ahcd7l77#ab77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l77#ab77;,a77 is am5d$1 9 ! fir/ s5t5ce1 by /rik+ ,janu>y #a1 #bjad & ins]t+ ,janu>y #a1 #bjai4 7b7 ,requir+ ambulance provid]s ,to submit co/ & o!r in=mation ,section #ahcd7l7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#af7 ,submission ( co/ & o!r in=mation 7,a7 ,developm5t ( data collection sy/em ,! ,secret>y %all develop a data collection sy/em 7:i* may include use ( a co/ survey & /&>diz$ def9itions7 = provid]s & suppli]s ( ambulance s]vices to collect co/1 rev5ue1 utilization1 & o!r in=mation det]m9$ appropriate by ! ,secret>y4 ,su* sy/em %all be design$ to submit in=mation-- 7i7 ne$$ to evaluate ! appropriat5ess ( paym5t rates "u ?is subsection2 7ii7 on ! utilization ( capital equipm5t & ambulance capacity2 & 7iii7 on diff]5t types ( ambulance s]vices furni%$ 9 diff]5t geographic locations1 includ+ rural areas & l[ population d5sity areas describ$ 9 p>agraph 7#ab74 7,b7 ,specification ( data collection sy/em 7i7 ,9 g5]al ,n lat] ?an ,janu>y #a1 #bjae1 ! ,secret>y %all-- 7,i7 specify ! data collection sy/em "u subp>agraph 7,a72 & 7,,ii7 id5tify ! provid]s & suppli]s ( ambulance s]vices :o w\ld be requir$ to submit ! in=mation "u su* data collection sy/em4 7ii7 ,respond5ts ,subject to subp>agraph 7,d77ii71 ! ,secret>y %all det]m9e an appropriate sample ( provid]s & suppli]s ( ambulance s]vices to submit in=mation "u ! data collection sy/em ea* ye>4 7,c7 ,report+ ( co/ in=mation ,beg9n+ ,july #a1 #bjae1 a #e p]c5t r$uction to paym5ts "u ?is "p %all be made = a #a-ye> p]iod to a provid] or suppli] ( ambulance s]vices :o-- 7i7 is id5tifi$ "u subp>agraph 7,b77i77,,ii7 z be+ requir$ to submit ! in=mation "u ! data collection sy/em2 & 7ii7 does n submit su* in=mation4 7,d7 ,ongo+ data collection 7i7 ,revision ( data collection sy/em ,! ,secret>y may revise1 z ! ,secret>y det]m9es appropriate1 ! data collection sy/em4 ,! ,secret>y %all consult ) provid]s & suppli]s ( ambulance s]vices :5 revis+ su* sy/em4 7ii7 ,subsequ5t data collection ,9 ord] to cont9ue to evaluate ! appropriat5ess ( paym5t rates "u ?is subsection1 ! ,secret>y %all require provid]s & suppli]s ( ambulance s]vices to submit in=mation = ye>s aft] #bjae z ! ,secret>y det]m9es appropriate1 b 9 no case less (t5 ?an once e #c ye>s4 7,e7 ,consultation ,! ,secret>y %all consult ) /akehold]s 9 c>ry+ out ! developm5t ( ! sy/em & collection ( in=mation "u ?is p>agraph1 includ+ ! activities describ$ 9 subp>agraphs 7,a7 & 7,d74 ,su* consultation %all include ! use ( reque/s = in=mation & o!r me*anisms det]m9$ appropriate by ! ,secret>y4 7,f7 ,adm9i/ration ,*apt] #ce ( title #dd1 ,unit$ ,/ates ,code1 %all n apply to ! collection ( in=mation requir$ "u ?is subsection4 7,g7 ,limitations on review ,!re %all be no adm9i/rative or judicial review "u section #ahfi1 section #ahgh1 or o!rwise ( ! data collection sy/em or id5tification ( respond5ts "u ?is p>agraph4 7,h7 ,fund+ = implem5tation ,= purposes ( c>ry+ out subp>agraph 7,a71 ! ,secret>y %all provide = ! transf]1 f ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda1 ( #a1jjj1jjj to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt = fiscal ye> #bjad4 ,am\nts transf]r$ "u ?is subp>agraph %all rema9 available until exp5d$4 4 #bjd4 ,revision ( ! ,m$ic>e-dep5d5t hospital 7,,mdh7 program 7a7 ,p]man5t ext5sion ( paym5t me?odology 7#a7 ,9 g5]al ,section #ahhf7;d77#e77;,g7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,g77 is am5d$-- 7,a7 9 clause 7i71 by /rik+ & be=e ,octob] #a1 #bjac12 & 7,b7 9 clause 7ii77,,ii71 by /rik+ & be=e ,octob] #a1 #bjac14 7#b7 ,con=m+ am5dm5ts 7,a7 ,t>get am\nt ,section #ahhf7;b77#c77;,d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7b77#c77;,d77 is am5d$-- 7i7 9 ! matt] prec$+ clause 7i71 by /rik+ & be=e ,octob] #a1 #bjac12 & 7ii7 9 clause 7iv71 by /rik+ ?r\gh fiscal ye> #bjac & ins]t+ or a subsequ5t fiscal ye>4 7,b7 ,hospital value-bas$ pur*as+ program ,section #ahhf7o77#g77;,d77ii77,i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7o77#g77;,d77ii77,i77 is am5d$ by /rik+ 7) respect to dis*>ges occurr+ dur+ fiscal ye> #bjab & #bjac74 7,c7 ,hospital readmission r$uction program ,section #ahhf7q77#b77;,b77i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7q77#b77;,b77i77 is am5d$ by /rik+ 7) respect to dis*>ges occurr+ dur+ fiscal ye>s #bjab & #bjac74 7,d7 ,p]mitt+ hospitals to decl9e reclassification ,section #aceja7;e77#b7 ( ! ,omnibus ,budget ,reconciliation ,act ( #aiic 7#db ,u4,s4,c4 #acieww note7 is am5d$ by /rik+ fiscal ye> #aiih1 fiscal ye> #aiii1 or fiscal ye> #bjjj ?r\gh fiscal ye> #bjac & ins]t+ or fiscal ye> #aiih or a subsequ5t fiscal ye>4 7b7 ,,gao /udy & report on ,m$ic>e-dep5d5t hospitals 7#a7 ,/udy ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all conduct a /udy on ! foll[+3 7,a7 ,! payor mix ( m$ic>e-dep5d5t1 small rural hospitals 7z def9$ 9 section #ahhf7;d77#e77;,g77iv771 h[ su* mix w tr5d 9 future ye>s1 & :e!r or n ! requirem5t "u subclause 7,,iv7 ( su* section %\ld be revis$4 7,b7 ,! *>act]i/ics ( m$ic>e-dep5d5t1 small rural hospitals t meet ! requirem5t ( su* subclause 7,,iv7 ?r\gh ! application ( p>agraph 7a77iii77,a7 or 7a77iii77,b7 ( section #dab4ajh ( ! ,code ( ,f$]al ,regulations1 includ+ ,m$ic>e inpati5t & outpati5t utilization1 payor mix1 & f9ancial /atus1 includ+ ,m$ic>e & total m>g9s1 & :e!r or n ,m$ic>e paym5ts = su* hospitals %\ld be revis$4 7,c7 ,su* o!r items relat$ to m$ic>e-dep5d5t1 small rural hospitals z ! ,comptroll] ,g5]al det]m9es appropriate4 7#b7 ,report ,n lat] ?an #ab mon?s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report on ! /udy conduct$ "u p>agraph 7#a71 toge!r ) recomm5dations = su* legislation & adm9i/rative action z ! ,comptroll] ,g5]al det]m9es appropriate4 7c7 ,implem5tation ,not)/&+ any o!r provision ( law1 ! ,secret>y ( ,heal? & ,human ,s]vices may implem5t ! provisions (1 & ! am5dm5ts made by1 ?is section ?r\gh program in/ruction or o!rwise4 #bje4 ,revision ( ,m$ic>e inpati5t hospital paym5t adju/m5t = l[-volume hospitals 7a7 ,9 g5]al ,section #ahhf7;d77#ab7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#ab77 is am5d$-- 7#a7 9 subp>agraph 7,b7-- 7,a7 9 ! subp>agraph head+1 by ins]t+ = fiscal ye>s #bjje ?r\gh #bjaj aft] increase2 & 7,b7 9 ! matt] prec$+ clause 7i71 by /rik+ & = dis*>ges occurr+ 9 fiscal ye> #bjad & subsequ5t ye>s2 7#b7 9 subp>agraph 7,c77i71 by /rik+ fiscal ye>s #bjaa1 #bjab1 & #bjac & ins]t+ fiscal ye> #bjaa & subsequ5t fiscal ye>s ea* place x appe>s2 & 7#c7 9 subp>agraph 7,d7-- 7,a7 9 ! head+1 by /rik+ ,tempor>y applicable p]c5tage increase & ins]t+ ,applicable p]c5tage increase = fiscal ye> #bjaa & subsequ5t fiscal ye>s2 & 7,b7 by /rik+ fiscal ye>s #bjaa1 #bjab1 & #bjac & ins]t+ fiscal ye> #bjaa or a subsequ5t fiscal ye>2 7b7 ,implem5tation ,not)/&+ any o!r provision ( law1 ! ,secret>y ( ,heal? & ,human ,s]vices may implem5t ! provisions (1 & ! am5dm5ts made by1 ?is section ?r\gh program in/ruction or o!rwise4 #bjf4 ,specializ$ ,m$ic>e ,advantage plans = special ne$s individuals 7a7 ,ext5sion ,section #ahei7;f77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;f77#a77 is am5d$-- 7#a7 by /rik+ enrollm5t4--,9 ! case & ins]t+ 8enrollm5t4-- 7,a7 ,9 g5]al ,subject to subp>agraphs 7,b7 & 7,c71 9 ! case 2 7#b7 9 subp>agraph 7,a71 z add$ by p>agraph 7#a71 by /rik+ & = p]iods be=e ,janu>y #a1 #bjae2 & 7#c7 by add+ at ! end ! foll[+ new subp>agraphs3 7,b7 ,application to dual ,s,n,ps ,subp>agraph 7,a7 %all only apply to a specializ$ ,,ma plan = special ne$s individuals describ$ 9 subsection 7b77#f77;,b77ii7 = p]iods be=e ,janu>y #a1 #bjba4 7,c7 ,application to sev]e or disabl+ *ronic condition ,s,n,ps ,subp>agraph 7,a7 %all only apply to a specializ$ ,,ma plan = special ne$s individuals describ$ 9 subsection 7b77#f77;,b77iii7 = p]iods be=e ,janu>y #a1 #bjah4 4 7b7 ,increas$ integration ( dual ,s,n,ps 7#a7 ,9 g5]al ,section #ahei7;f7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;f77 is am5d$-- 7,a7 9 p>agraph 7#c71 by add+ at ! end ! foll[+ new subp>agraph3 7,f7 ,! plan meets ! requirem5ts applicable "u p>agraph 7#h74 2 & 7,b7 by add+ at ! end ! foll[+ new p>agraph3 7#h7 ,increas$ integration ( dual ,s,n,ps 7,a7 ,designat$ contact ,! ,secret>y1 act+ ?r\gh ! ,f$]al ,coord9at$ ,heal? ,c>e ,(fice 7,m$ic>e-,m$icaid ,coord9ation ,(fice7 e/abli%$ "u section #bfjb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 79 ?is p>agraph ref]r$ to z ! ,,mmco71 %all s]ve z a d$icat$ po9t ( contact = ,/ates to address misalignm5ts t arise ) ! integration ( specializ$ ,,ma plans = special ne$s individuals describ$ 9 subsection 7b77#f77;,b77ii7 "u ?is p>agraph4 ,consi/5t ) su* role1 ! ,,mmco %all-- 7i7 e/abli% a uni=m process = dissem9at+ to ,/ate ,m$icaid ag5cies in=mation "u ?is title impact+ contracts betwe5 su* ag5cies & su* plans "u ?is subsection2 & 7ii7 e/abli% basic res\rces = ,/ates int]e/$ 9 explor+ su* plans z a plat=m = integration4 7,b7 ,unifi$ appeals process 7i7 ,9 g5]al ,n lat] ?an ,april #a1 #bjae1 ! ,secret>y %all e/abli% proc$ures unify+ ! appeals proc$ures "u sections #aheb7;g71 #aijb7;a77#c71 & #aijb7;a77#e7 = items & s]vices provid$ by specializ$ ,,ma plans = special ne$s individuals describ$ 9 subsection 7b77#f77;,b77ii7 "u ?is title & title ,,xix4 ,! ,secret>y %all solicit comm5t 9 develop+ su* proc$ures f ,/ates1 plans1 b5efici>y repres5tatives1 & o!r relevant /akehold]s4 7ii7 ,proc$ures ,to ! ext5t compatible ) a unifi$ process1 ! proc$ures e/abli%$ "u clause 7i7 %all-- 7,i7 adopt ! mo/ protective provisions = ! enrollee "u curr5t law1 includ+ cont9uation ( b5efits "u title ,,xix p5d+ appeal if an appeal is fil$ 9 a timely mann]2 7,,ii7 take into acc\nt diff]5ces 9 ,/ate plans "u title ,,xix2 7,,iii7 be easily navigable by an enrollee2 & 7,,iv7 include ! elem5ts describ$ 9 clause 7iii74 7iii7 ,elem5ts describ$ ,! foll[+ elem5ts are describ$ 9 ?is clause3 7,i7 ,s+le notification ( all applicable appeal rights "u ?is title & title ,,xix4 7,,ii7 ,notices writt5 9 pla9 language & available 9 a language & =mat t is accessible to ! enrollee4 7,,iii7 ,unifi$ timeframes = int]nal & ext]nal appeals processes1 su* z an individual's fil+ ( appeals1 a plan's ackn[l$gm5t & resolution ( appeals1 & notification ( appeals decisions4 7,,iv7 ,me*anisms to all[ ! plan to track & resolve grievances4 7,c7 ,requirem5t = unifi$ appeals 7i7 ,9 g5]al ,= #bjaf & subsequ5t ye>s1 ! contract ( a specializ$ ,,ma plan = special ne$s individuals describ$ 9 subsection 7b77#f77;,b77ii7 ) a ,/ate ,m$icaid ag5cy "u ?is subsection %all require ! use ( unifi$ appeals proc$ures z describ$ 9 subp>agraph 7,b74 7ii7 ,consid]ation ( application = o!r ,s,n,ps ,! ,secret>y %all consid] apply+ ! unifi$ appeals process describ$ 9 subp>agraph 7,b7 to specializ$ ,,ma plans = special ne$s individuals describ$ 9 subsection 7b77#f77;,b77i7 & subsection 7b77#f77;,b77iii74 7,d7 ,requirem5t = full integration = c]ta9 dual ,s,n,ps 7i7 ,requirem5t ,subject to ! succe$+ provisions ( ?is subp>agraph1 = #bjah & subsequ5t ye>s1 a specializ$ ,,ma plan = special ne$s individuals describ$ 9 subsection 7b77#f77;,b77ii7 %all-- 7,i7 integrate all b5efits "u ?is title & title ,,xix2 & 7,,ii7 meet ! requirem5ts ( a fully integrat$ plan describ$ 9 section #ahec7;a77#a77;,b77iv77,,ii7 7o!r ?an ! requirem5t t ! plan h simil> av]age levels ( frailty1 z det]m9$ by ! ,secret>y1 z ! ,,pace program71 includ+ ) respect to long-t]m c>e s]vices or behavioral heal? s]vices to ! ext5t ,/ate law p]mits capitation ( ^? s]vices "u su* plan4 7ii7 ,initial sanctions = failure to meet requirem5t = #bjah or #bjai ,= ea* ( #bjah & #bjai1 if ! ,secret>y det]m9es t a plan has fail$ to meet ! requirem5t describ$ 9 clause 7i71 ! ,secret>y %all impose "o ( ! foll[+ on ! plan3 7,i7 ,a r$uction 9 paym5ts "u ?is "p4 7,,ii7 ,clos+ enrollm5t 9 ! plan4 7,,iii7 ,sanction+ ! plan 9 accordance ) section #aheg7;g74 7,,iv7 ,o!r reasonable action 7o!r ?an ! sanction describ$ 9 clause 7iii77 ! ,secret>y det]m9es appropriate4 7iii7 ,sanctions = failure to meet requirem5t = #bjbj & subsequ5t ye>s ,= #bjbj & subsequ5t ye>s1 if ! ,secret>y det]m9es t a plan has fail$ to meet ! requirem5t describ$ 9 clause 7i71 ! plan %all be deem$ to no long] meet ! def9ition ( a specializ$ ,,ma plan = special ne$s individuals describ$ 9 subsection 7b77#f77;,b77ii74 7iv7 ,limitation ,?is subp>agraph %all n apply to a specializ$ ,,ma plan = special ne$s individuals describ$ 9 subsection 7b77#f77;,b77ii7 t only enrolls individuals = :om ! only m$ical assi/ance to :i* ! individuals are entitl$ "u ! ,/ate plan is m$ic>e co/ %>+ describ$ 9 section #aije7p77#c77;,a77ii74 4 7#b7 ,con=m+ am5dm5t to responsibilities ( ,f$]al ,coord9at$ ,heal? ,c>e ,(fice 7,,mmco7 ,section #bfjb7;d7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #acae;b7d77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#f7 ,to act z a designat$ contact = ,/ates "u subsection 7f77#h77;,a7 ( section #ahei ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7 ) respect to ! integration ( specializ$ ,,ma plans = special ne$s individuals describ$ 9 subsection 7b77#f77;,b77ii7 ( su* section4 4 7c7 ,improvem5ts to c>e managem5t requirem5ts = sev]e or disabl+ *ronic condition ,s,n,ps ,section #ahei7;f77#e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;f77#e77 is am5d$-- 7#a7 by /rik+ all ,s,n,ps4--,! requirem5ts & ins]t+ 8all ,s,n,ps4-- 7,a7 ,9 g5]al ,subject to subp>agraph 7,b71 ! requirem5ts 2 7#b7 by r$esignat+ subp>agraphs 7,a7 & 7,b7 z clauses 7i7 & 7ii71 respectively1 & ind5t+ appropriately2 7#c7 9 clause 7ii71 z r$esignat$ by p>agraph 7#b71 by r$esignat+ clauses 7i7 ?r\gh 7iii7 z subclauses 7,i7 ?r\gh 7,,iii71 respectively1 & ind5t+ appropriately2 & 7#d7 by add+ at ! end ! foll[+ new subp>agraph3 7,b7 ,improvem5ts to c>e managem5t requirem5ts = sev]e or disabl+ *ronic condition ,s,n,ps ,= #bjaf & subsequ5t ye>s1 9 ! case ( a specializ$ ,,ma plan = special ne$s individuals describ$ 9 subsection 7b77#f77;,b77iii71 ! requirem5ts describ$ 9 ?is p>agraph include ! foll[+3 7i7 ,! int]discipl9>y team "u subp>agraph 7,a77ii77,,iii7 includes a team ( provid]s ) demon/rat$ exp]tise1 includ+ tra9+ 9 an applicable specialty1 9 treat+ individuals simil> to ! t>get$ population ( ! plan4 7ii7 ,requirem5ts develop$ by ! ,secret>y to provide face-to-face enc\nt]s ) individuals enroll$ 9 ! plan4 7iii7 ,z "p ( ! model ( c>e "u clause 7i7 ( subp>agraph 7,a71 ! results ( ! initial assessm5t & annual reassessm5t "u clause 7ii77,i7 ( su* subp>agraph ( ea* individual enroll$ 9 ! plan are address$ 9 ! individual's individualiz$ c>e plan "u clause 7ii77,,ii7 ( su* subp>agraph4 7iv7 ,z "p ( ! annual evaluation & approval ( su* model ( c>e1 ! ,secret>y %all take into acc\nt :e!r ! plan fulfill$ ! previ\s ye>'s goals 7z requir$ "u ! model ( c>e74 7v7 ,! ,secret>y %all e/abli% a m9imum b5*m>k = ea* elem5t ( ! model ( c>e ( a plan4 ,! ,secret>y %all only approve a plan's model ( c>e "u ?is p>agraph if ea* elem5t ( ! model ( c>e meets ! m9imum b5*m>k applicable "u ! prec$+ s5t5ce4 4 7d7 ,,gao ,/udy on ,quality ,improvem5t 7#a7 ,/udy ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all conduct a /udy on h[ ! ,secret>y ( ,heal? & ,human ,s]vices c\ld *ange ! quality measurem5t sy/em "u ! ,m$ic>e ,advantage program "u "p ,c ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba et seq47 to all[ an accurate comp>ison ( ! quality ( c>e provid$ by specializ$ ,,ma plans = special ne$s individuals 7z def9$ 9 section #ahei7;b77#f7 ( su* ,act 7#db ,u4,s4,c4 #aciew-#bh7;b77#f771 bo? = individual plans & su* plans ov]all1 comp>$ to ! quality ( c>e deliv]$ by ! orig9al ,m$ic>e fee-=-s]vice program "u p>ts ,a & ,b ( su* title & o!r ,m$ic>e ,advantage plans "u su* "p ,c across simil> populations4 7#b7 ,report ,n lat] ?an ,july #a1 #bjaf1 ! ,comptroll] ,g5]al %all submit to ,congress a report conta9+ ! results ( ! /udy "u p>agraph 7#a71 toge!r ) recomm5dations = su* legislation & adm9i/rative action z ! ,comptroll] ,g5]al det]m9es appropriate4 7e7 ,*anges to quality rat+s & measurem5t ( ,s,n,ps ,section #ahec7o7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7o77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#f7 ,*anges to quality rat+s ( ,s,n,ps 7,a7 ,emphasis on improvem5t across ,s,n,ps ,subject to subp>agraph 7,b71 beg9n+ 9 plan ye> #bjaf1 9 ! case ( a specializ$ ,,ma plan = special ne$s individuals1 ! ,secret>y %all increase ! emphasis on ! plan's improvem5t or decl9e 9 p]=mance :5 det]m9+ ! /> rat+ ( ! plan "u ?is subsection = ! ye> z foll[s3 7i7 ,at lea/ #be p]c5t1 b n m ?an #cc p]c5t1 ( ! total /> rat+ ( ! plan %all be bas$ on improvem5t or decl9e 9 p]=mance4 7ii7 ,improvem5t or decl9e 9 p]=mance "u ?is subp>agraph %all be measur$ bas$ on net *ange 9 ! individual /> rat+ measures ( ! plan1 ) appropriate weight giv5 to specific individual /> rat+s measures1 su* z readmission rates1 z det]m9$ by ! ,secret>y4 7iii7 ,! ,secret>y %all make an appropriate adju/m5t to ! improvem5t rat+ ( a plan "u ?is subp>agraph if ! plan has a*iev$ a #e-/> rat+ or ! highe/ rat+ possible ov]all or = an individual measure 9 ord] to ensure t ! plan is n puni%$ 9 cases :]e x is n possible to improve4 7,b7 ,no application to c]ta9 plans ,subp>agraph 7,a7 %all n apply1 ) respect to a ye>1 to a specializ$ ,,ma plan = special ne$s individuals t has a rat+ t does n exce$ two-&-"o-half />s4 7,c7 ,quality ,measurem5t at ! ,plan ,level 7i7 ,9 g5]al ,! ,secret>y may require report+ = & apply "u ?is subsection quality measures at ! plan level = specializ$ ,,ma plan = special ne$s individuals in/ead ( at ! contract level4 7ii7 ,consid]ation ,! ,secret>y %all take into consid]ation ! m9imum numb] ( enrollees 9 a specializ$ ,,ma plan = special ne$s individuals 9 ord] to det]m9e if a valid measurem5t ( quality at ! plan level is possible "u clause 7i74 7iii7 ,application ,if ! ,secret>y applies quality measurem5t at ! plan level "u ?is subp>agraph-- 7,i7 su* quality measurem5t %all include ,m$ic>e ,heal? ,outcomes ,survey 7,,hos71 ,heal?c>e ,effectiv5ess ,data & ,in=mation ,set 7,,h$is71 & ,consum] ,assessm5t ( ,heal?c>e ,provid]s & ,sy/ems 7,,cahps7 measures2 & 7,,ii7 paym5t & o!r adm9i/rative actions l9k$ to quality measurem5t 7includ+ ! #e-/> rat+ sy/em "u ?is subsection7 %all be appli$ at ! plan level 9 accordance ) ?is subp>agraph4 4 #bjg4 ,reasonable co/ reimbursem5t contracts 7a7 ,"o-ye> transition & notice reg>d+ transition ,section #ahgf7;h77#e77;,c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciemm7h77#e77;,c77 is am5d$-- 7#a7 9 clause 7ii71 9 ! matt] prec$+ subclause 7,i71 by /rik+ ,= any & ins]t+ ,subject to clause 7iv71 = any2 & 7#b7 by add+ at ! end ! foll[+ new clauses3 7iv7 ,9 ! case ( an eligible organization t is (f]+ a reasonable co/ reimbursem5t contract t may no long] be ext5d$ or r5ew$ because ( ! application ( clause 7ii7-- 7,i7 not)/&+ su* clause1 su* contract may be ext5d$ or r5ew$ = "o la/ reasonable co/ reimbursem5t contract ye>2 7,,ii7 ! organization may n enroll any new enrollees "u su* contract dur+ su* la/ reasonable co/ reimbursem5t contract ye>2 & 7,,iii7 on a date det]m9$ by ! ,secret>y prior to ! beg9n+ ( su* la/ reasonable co/ reimbursem5t contract ye>1 ! organization %all provide notice to ! ,secret>y z to :e!r or n ! organization w apply to h ! contract conv]t$ ov] & (f]$ z a ,m$ic>e ,advantage plan "u "p ,c = ! ye> foll[+ su* la/ reasonable co/ reimbursem5t contract ye>4 7v7 ,if an eligible organization t is (f]+ a reasonable co/ reimbursem5t contract t is ext5d$ or r5ew$ pursuant to clause 7iv7 provides ! notice describ$ 9 clause 7iv77,,iii7 t ! contract w be conv]t$-- 7,i7 ! deem$ enrollm5t "u section #ahea7;c77#d7 %all apply2 & 7,,ii7 ! special rule = quality increases "u #ahec7o77#c77;,a77iv7 %all apply4 4 7b7 ,deem$ enrollm5t f reasonable co/ reimbursem5t contracts conv]t$ to ,m$ic>e ,advantage plans 7#a7 ,9 g5]al ,section #ahea7;c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba7;c77 is am5d$-- 7,a7 9 p>agraph 7#a71 by /rik+ ,su* elections & ins]t+ ,subject to p>agraph 7#d71 su* elections2 & 7,b7 by add+ at ! end ! foll[+3 7#d7 ,deem$ enrollm5t relat+ to conv]t$ reasonable co/ reimbursem5t contracts 7,a7 ,9 g5]al ,on ! fir/ day ( ! annual1 coord9at$ election p]iod "u subsection 7e77#c7 = plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjaf1 an ,,ma eligible individual describ$ 9 clause 7i7 or 7ii7 ( subp>agraph 7,b7 is deem$ to h elect$ to receive b5efits "u ?is title ?r\gh an applicable ,,ma plan 7& %all be enroll$ 9 su* plan7 beg9n+ ) su* plan ye>1 if-- 7i7 ! individual is enroll$ 9 a reasonable co/ reimbursem5t contract "u section #ahgf7;h7 9 ! previ\s plan ye>2 7ii7 su* reasonable co/ reimbursem5t contract 0 ext5d$ or r5ew$ = "o la/ reasonable co/ reimbursem5t contract ye> pursuant to section #ahgf7;h77#e77;,c77iv72 7iii7 ! eligible organization t is (f]+ su* reasonable co/ reimbursem5t contract provid$ ! notice describ$ 9 subclause 7,,iii7 ( su* section t ! contract 0 to be conv]t$2 7iv7 ! applicable ,,ma plan-- 7,i7 is ! plan t 0 conv]t$ f ! reasonable co/ reimbursem5t contract describ$ 9 clause 7iii72 7,,ii7 is (f]$ by ! same entity 7or an organization affiliat$ ) su* entity7 t ent]$ into su* contract2 & 7,,iii7 is (f]$ 9 ! s]vice area :]e ! individual resides2 7v7 ! am\nt ( ! ,,ma mon?ly basic b5efici>y premium = su* applicable ,,ma plan ) respect to ! plan ye> does n exce$ mon?ly premiums "u su* reasonable co/ reimbursem5t contract = ! previ\s plan ye> by m ?an #aj p]c5t2 7vi7 ! applicable ,,ma plan provides b5efits1 premiums1 & access to provid]s t are comp>able to ! b5efits1 premiums1 & access to provid]s "u su* reasonable co/ reimbursem5t contract = ! previ\s plan ye>2 & 7vii7 ! applicable ,,ma plan-- 7,i7 all[s enrollees transition+ f ! conv]t$ reasonable co/ contract to su* plan to ma9ta9 curr5t provid]s & c\rse ( treatm5t at ! "t ( enrollm5t = at lea/ #ij days aft] enrollm5t2 & 7,,ii7 dur+ su* p]iod1 pays non-contract+ provid]s = items & s]vices furni%$ to ! enrollee an am\nt t is n less ?an ! am\nt ( paym5t applicable = ^? items & s]vices "u ! orig9al m$ic>e fee-=-s]vice program "u p>ts ,a & ,b4 7,b7 ,,ma eligible individuals describ$ 7i7 ,)\t prescription drug cov]age ,an ,,ma eligible individual describ$ 9 ?is clause1 ) respect to a plan ye>1 is an ,,ma eligible individual :o is enroll$ 9 a reasonable co/ reimbursem5t contract "u section #ahgf7;h7 9 ! previ\s plan ye> & :o does n1 = su* previ\s plan ye>1 receive any prescription drug cov]age "u "p ,d1 includ+ cov]age "u section #ahfj;,d-#bb4 7ii7 ,) prescription drug cov]age ,an ,,ma eligible individual describ$ 9 ?is clause1 ) respect to a plan ye>1 is an ,,ma eligible individual :o is enroll$ 9 a reasonable co/ reimbursem5t contract "u section #ahgf7;h7 9 ! previ\s plan ye> & :o1 = su* previ\s plan ye>1 receives prescription drug cov]age "u "p ,d-- 7,i7 ?r\gh su* contract2 or 7,,ii7 ?r\gh a prescription drug plan1 if ! sponsor ( su* plan is ! same entity 7or an organization affiliat$ ) su* entity7 t ent]$ into su* contract4 7,c7 ,applicable ,,ma plan def9$ ,9 ?is p>agraph1 ! t]m applicable ,,ma plan means1 9 ! case ( an individual describ$ 9-- 7i7 subp>agraph 7,b77i71 an ,,ma plan t is n an ,,ma-,,pd plan2 & 7ii7 subp>agraph 7,b77ii71 an ,,ma-,,pd plan4 7,d7 ,id5tification ( deem$ individuals ,n lat] ?an #cj days be=e ! fir/ day ( ! annual1 coord9at$ election p]iod "u subsection 7e77#c7 = plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjaf1 ! ,secret>y %all id5tify ! individuals :o w be subject to deem$ elections "u subp>agraph 7,a7 on ! fir/ day ( su* p]iod4 4 7#b7 ,b5efici>y option to discont9ue or *ange ,,ma plan or ,,ma-,,pd plan aft] deem$ enrollm5t 7,a7 ,9 g5]al ,section #ahea7;e77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba7;e77#d77 is am5d$ by add+ at ! end ! foll[+3 7,f7 ,special p]iod = c]ta9 deem$ elections 7i7 ,9 g5]al ,at any "t dur+ ! p]iod beg9n+ aft] ! la/ day ( ! annual1 coord9at$ election p]iod "u p>agraph 7#c7 9 :i* an individual is deem$ to h elect$ to enroll 9 an ,,ma plan or ,,ma-,,pd plan "u subsection 7c77#d7 & end+ on ! la/ day ( ,febru>y ( ! fir/ plan ye> = :i* ! individual is enroll$ 9 su* plan1 su* individual may *ange ! election "u subsection 7a77#a7 7includ+ *ang+ ! ,,ma plan or ,,ma-,,pd plan 9 :i* ! individual is enroll$74 7ii7 ,limitation ( "o *ange ,an individual may ex]cise ! "r "u clause 7i7 only once dur+ ! applicable p]iod describ$ 9 su* clause4 ,! limitation "u ?is clause %all n apply to *anges 9 elections effect$ dur+ an annual1 coord9at$ election p]iod "u p>agraph 7#c7 or dur+ a special enrollm5t p]iod "u p>agraph 7#d74 4 7,b7 ,con=m+ am5dm5ts 7i7 ,plan requirem5t = op5 enrollm5t ,section #ahea7;e77#f77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba7;e77#f77;,a77 is am5d$ by /rik+ p>agraph 7#a71 & ins]t+ p>agraph 7#a71 dur+ ! p]iod describ$ 9 p>agraph 7#b77;,f71 4 7ii7 ,"p ,d ,section #ahfj;,d-#a7;b77#a77;,b7 ( su* ,act 7#db ,u4,s4,c4 #aciew-#aja7;b77#a77;,b77 is am5d$-- 7,i7 9 clause 7ii71 by add+ & p>agraph 7#d7 aft] p>agraph 7#c77;,a72 & 7,,ii7 9 clause 7iii7 by /rik+ & 7,e7 & ins]t+ 7,e71 & 7,f74 7#c7 ,treatm5t ( ,,esrd = deem$ enrollm5t ,section #ahea7;a77#c77;,b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba7;a77#c77;,b77 is am5d$ by add+ at ! end ! foll[+ flu% s5t5ce3 ,an individual :o develops end-/age r5al disease :ile enroll$ 9 a reasonable co/ reimbursem5t contract "u section #ahgf7;h7 %all be treat$ z an ,,ma eligible individual = purposes ( apply+ ! deem$ enrollm5t "u subsection 7c77#d74 4 7c7 ,in=mation requirem5ts ,section #ahea7;d77#b77;,b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba7;d77#b77;,b77 is am5d$-- 7#a7 by /rik+ ! subp>agraph head+ & ins]t+ ! foll[+3 7i7 ,notification to newly eligible ,m$ic>e ,advantage eligible individuals4--2 & 7#b7 by add+ at ! end ! foll[+3 7ii7 ,notification relat$ to c]ta9 deem$ elections ,! ,secret>y %all1 n lat] ?an #ae days prior to ! fir/ day ( ! annual1 coord9at$ election p]iod "u subsection 7e77#c7 ( a ye>1 mail to any individual id5tifi$ by ! ,secret>y "u subsection 7c77#d77;,d7 = su* ye>-- 7,i7 a notification t su* individual w1 on su* day1 be deem$ to h made an election to receive b5efits "u ?is title ?r\gh an ,,ma plan or ,,ma-,,pd plan 7& %all be enroll$ 9 su* plan7 = ! next plan ye> "u subsection 7c77#d77;,a71 b t ! individual may make a diff]5t election dur+ ! annual1 coord9at$ election p]iod = su* ye>2 7,,ii7 ! in=mation describ$ 9 subp>agraph 7,a72 7,,iii7 a description ( ! diff]5ces betwe5 su* ,,ma plan or ,,ma-,,pd plan & ! reasonable co/ reimbursem5t contract 9 :i* ! individual 0 mo/ rec5tly enroll$ ) respect to b5efits cov]$ "u su* plans1 includ+ co/-%>+1 premiums1 drug cov]age1 & provid] networks2 & 7,,iv7 in=mation ab\t ! special p]iod = elections "u subsection 7e77#b77;,f74 4 7d7 ,treatm5t ( transition plan = quality rat+ = paym5t purposes ,section #ahec7o77#c77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7o77#c77;,a77 is am5d$ by add+ at ! end ! foll[+ new clause3 7iv7 ,special rule = fir/ #b plan ye>s = plans t 7 conv]t$ f a reasonable co/ reimbursem5t contract ,9 apply+ p>agraph 7#a7 = ! fir/ #b plan ye>s "u ?is "p 9 ! case ( a plan t is a new ,,ma plan 7z def9$ 9 clause 7iii77,,ii77 to :i* deem$ enrollm5t applies "u section #ahea7;e77#d71 ! ,secret>y %all use ! /> rat+ t appli$ to ! conv]t$ reasonable co/ reimbursem5t contract = ! ye> prec$+ ! fir/ plan ye> = su* plan "u ?is "p4 4 #bjh4 ,quality measure endorsem5t & selection 7a7 ,contract ) an entity reg>d+ input on ! selection ( measures 7#a7 ,9 g5]al ,title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq47 is am5d$-- 7,a7 by r$esignat+ section #ahij;,a z section #ahij;,b2 & 7,b7 by ins]t+ aft] section #ahij ! foll[+ new section3 #ahij;,a ,contract ) an entity reg>d+ input on ! selection ( measures 7a7 ,contract 7#a7 ,9 g5]al ,= purposes ( activities conduct$ "u ?is ,act1 ! ,secret>y %all id5tify & h 9 effect a contract ) an entity t meets ! requirem5ts describ$ 9 subsection 7c74 ,su* contract %all provide t ! entity w p]=m ! duties describ$ 9 subsection 7b74 7#b7 ,tim+ = fir/ contract ,! fir/ contract "u p>agraph 7#a7 %all beg9 on ,octob] #a1 #bjad4 7#c7 ,p]iod ( contract ,a contract "u p>agraph 7#a7 %all be = a p]iod ( #c ye>s 7except z may be r5ew$ aft] a subsequ5t bidd+ process74 7#d7 ,competitive proc$ures ,competitive proc$ures 7z def9$ 9 section #d7e7 ( ! ,(fice ( ,f$]al ,procurem5t ,policy ,act 7#da ,u4,s4,c4 #djc7e777 %all be us$ to ent] into a contract "u p>agraph 7#a74 7b7 ,duties ,! duties describ$ 9 ?is subsection are ! foll[+3 7c7 ,requirem5ts describ$ ,! requirem5ts describ$ 9 ?is subsection are ! foll[+3 7#a7 ,private nonpr(it1 bo>d memb]%ip1 memb]%ip fees1 & n a measure develop] ,! requirem5ts describ$ 9 p>agraphs 7#a71 7#b71 7#g71 & 7#h7 ( section #ahij7;c74 7#b7 ,exp]i5ce ,! entity has at lea/ #d ye>s ( exp]i5ce work+ ) quality & effici5cy measures4 4 7#b7 ,duties ( entity 7,a7 ,transf] ( priority sett+ process ,p>agraph 7#a7 ( section #ahij7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;aaa7b77 is r$esignat$ z p>agraph 7#a7 ( section #ahij;,a7b7 ( su* ,act1 z add$ by p>agraph 7#a74 7,b7 ,transf] ( multi-/akehold] process ,p>agraphs 7#g7 & 7#h7 ( su* section #ahij7;b7 are r$esignat$ z p>agraphs 7#b7 & 7#c71 respectively1 ( section #ahij;,a7b7 ( su* ,act1 z add$ by p>agraph 7#a7 & am5d$ by subp>agraph 7,a74 7,c7 ,additional duties ,section #ahij;,a7b7 ( su* ,act1 z add$ by p>agraph 7#a7 & am5d$ by subp>agraphs 7,a7 & 7,b71 is am5d$ by add+ at ! end ! foll[+ new p>agraphs3 7#d7 ,facilitation to bett] coord9ate & align public & private sector use ( quality measures 7,a7 ,9 g5]al ,! entity %all facilitate increas$ coord9ation & alignm5t betwe5 ! public & private sector ) respect to quality & effici5cy measures4 7,b7 ,reports ,! entity %all prep>e & make available to ! public annual reports on its f9d+s "u ?is p>agraph4 ,su* public availability %all include po/+ ea* report on ! ,int]net website ( ! entity4 7#e7 ,gap analysis ,! entity %all conduct an ongo+ analysis (-- 7,a7 gaps 9 endors$ quality & effici5cy measures1 :i* %all include measures t are )9 priority areas id5tifi$ by ! ,secret>y "u ! national /rategy e/abli%$ "u section #cii;,,hh ( ! ,public ,heal? ,s]vice ,act2 & 7,b7 areas :]e quality measures are unavailable or inadequate to id5tify or address su* gaps4 7#f7 ,annual report to congress & ! ,secret>y2 ,secret>ial publication & comm5t 7,a7 ,annual report ,by n lat] ?an ,m>* #a ( ea* ye>1 ! entity %all submit to ,congress & ! ,secret>y a report conta9+-- 7i7 a description (-- 7,i7 ! recomm5dations made "u p>agraph 7#a72 7,,ii7 ! matt]s describ$ 9 clauses 7i7 & 7ii7 ( p>agraph 7#b77;,a72 7,,iii7 ! results ( ! analysis "u p>agraph 7#e72 & 7,,iv7 ! p]=mance by ! entity ( ! duties requir$ "u ! contract ent]$ into ) ! ,secret>y "u subsection 7a72 & 7ii7 any o!r items det]m9$ appropriate by ! ,secret>y4 7,b7 ,secret>ial review & publication ( annual report ,n lat] ?an #f mon?s aft] receiv+ a report "u subp>agraph 7,a7 = a ye>1 ! ,secret>y %all-- 7i7 review su* report2 & 7ii7 publi% su* report 9 ! ,f$]al ,regi/]1 toge!r ) any comm5ts ( ! ,secret>y on su* report4 4 7,d7 ,additional am5dm5ts ,section #ahij;,a7b7 ( su* ,act1 z s add$ & am5d$1 is am5d$-- 7i7 9 p>agraph 7#b7-- 7,i7 9 ! head+ ( subp>agraph 7,b7 by ins]t+ & effici5cy aft] ,quality2 7,,ii7 9 subp>agraph 7,b77i77,,iii71 by /rik+ ?is ,act & ins]t+ ?is title2 & 7,,iii7 by add+ at ! end ! foll[+ new subp>agraphs3 7,e7 ,input ,9 provid+ ! input describ$ 9 subp>agraph 7,a71 ! multi-/akehold] gr\ps-- 7i7 %all include a detail$ description ( ! rationale = ea* recomm5dation made by ! multi-/akehold] gr\p1 includ+ 9 areas relat+ to-- 7,i7 ! expect$ impact t implem5t+ ! measure w h on individuals2 7,,ii7 ! burd5 on provid]s ( s]vices & suppli]s2 7,,iii7 ! expect$ influ5ce ov] ! behavior ( provid]s ( s]vices & suppli]s2 7,,iv7 ! applicability ( a measure = m ?an "o sett+ or program2 & 7,v7 o!r areas det]m9$ 9 consultation ) ! ,secret>y2 & 7ii7 may consid] :e!r x is appropriate to provide sep>ate recomm5dations ) respect to measures = int]nal use1 public report+1 & paym5t provisions4 7,f7 ,equal repres5tation ,9 conv5+ multi-/akehold] gr\ps pursuant to ?is p>agraph1 ! entity %all1 to ! ext5t feasible1 make e ef=t to ensure su* gr\ps are balanc$ across /akehold]s4 2 & 7ii7 9 p>agraph 7#c71 by /rik+ ,n lat] & all t foll[s ?r\gh ! p]iod at ! end & ins]t+ ! foll[+3 ,n lat] ?an ! applicable dates describ$ 9 section #ahij;,b7a77#c7 ( ea* ye> 7or1 z applicable1 ! timeframe describ$ 9 section #ahij;,a7a77#d771 ! entity %all transmit to ! ,secret>y ! input ( ! multi-/akehold] gr\p "u p>agraph 7#b744 7b7 ,revisions to contract ) cons5sus-bas$ entity 7#a7 ,contract ,section #ahij7;a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;aaa7a77 is am5d$-- 7,a7 9 p>agraph 7#a71 by /rik+ 1 su* z ! ,national ,quality ,=um12 & 7,b7 9 p>agraph 7#c71 by /rik+ #d ye>s & ins]t+ #c ye>s4 7#b7 ,duties ,section #ahij7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;aaa7b771 z am5d$ by subsection 7a77#b71 is am5d$-- 7,a7 by r$esignat+ p>agraphs 7#b7 & 7#c7 z p>agraphs 7#a7 & 7#b71 respectively2 7,b7 9 p>agraph 7#b71 z r$esignat$ by subp>agraph 7,a71 by /rik+ p>agraph 7#b7 & ins]t+ p>agraph 7#a72 7,c7 by /rik+ p>agraphs 7#e7 & 7#f72 & 7,d7 by add+ at ! end ! foll[+ new p>agraphs3 7#c7 ,facilitation to bett] coord9ate & align public & private sector use ( quality measures 7,a7 ,9 g5]al ,! entity %all facilitate increas$ coord9ation & alignm5t betwe5 ! public & private sector ) respect to quality & effici5cy measures4 7,b7 ,reports ,! entity %all prep>e & make available to ! public annual reports on its f9d+s "u ?is p>agraph4 ,su* public availability %all include po/+ ea* report on ! ,int]net website ( ! entity4 7#d7 ,annual report to congress & ! ,secret>y2 secret>ial publication & comm5t 7,a7 ,annual report ,by n lat] ?an ,m>* #a ( ea* ye>1 ! entity %all submit to ,congress & ! ,secret>y a report conta9+-- 7i7 a description (-- 7,i7 ! coord9ation ( quality initiatives "u ?is ,act ) quality initiatives implem5t$ by o!r pay]s2 7,,ii7 areas 9 :i* evid5ce is insuffici5t to support endorsem5t ( quality measures 9 priority areas id5tifi$ by ! ,secret>y "u ! national /rategy e/abli%$ "u section #cii;,,hh ( ! ,public ,heal? ,s]vice ,act & :]e t>get$ rese>* may address su* gaps2 & 7,,iii7 ! p]=mance by ! entity ( ! duties requir$ "u ! contract ent]$ into ) ! ,secret>y "u subsection 7a72 & 7ii7 any o!r items det]m9$ appropriate by ! ,secret>y4 7,b7 ,secret>ial review & publication ( annual report ,n lat] ?an #f mon?s aft] receiv+ a report "u subp>agraph 7,a7 = a ye>1 ! ,secret>y %all-- 7i7 review su* report2 & 7ii7 publi% su* report 9 ! ,f$]al ,regi/]1 toge!r ) any comm5ts ( ! ,secret>y on su* report4 4 7#c7 ,requirem5ts ,section #ahij7;c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;aaa7c77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#h7 ,n a measure develop] ,! entity is n a measure develop]4 4 7c7 ,revisions to duties ( ! ,secret>y reg>d+ use ( measures 7#a7 ,9 g5]al ,section #ahij;,b7a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;aaa-#a7;a771 z r$esignat$ by subsection 7a77#a77;,a71 is am5d$-- 7,a7 by /rik+ section #ahij7;b77#g77;,b7 ea* place x appe>s & ins]t+ section #ahij;,a7b77#b77;,b72 7,b7 9 p>agraph 7#a7-- 7i7 by /rik+ section #ahij7;b77#g7 & ins]t+ section #ahij;,a7b77#b72 & 7ii7 by /rik+ section #ahij & ins]t+ section #ahij;,a2 7,c7 by /rik+ p>agraphs 7#b7 & 7#c7 & ins]t+ ! foll[+3 7#b7 ,public availability ( measures consid]$ = selection ,subject to p>agraph 7#d71 n lat] ?an ,octob] #a or ,decemb] #ca ( ea* ye>1 ! ,secret>y %all make available to ! public a li/ ( quality & effici5cy measures describ$ 9 section #ahij;,a7b77#b77;,b7 t ! ,secret>y is consid]+ "u ?is title4 ,! ,secret>y %all provide = an appropriate balance ( ! numb] ( measures to be made available by ea* su* date 9 a ye>4 7#c7 ,transmission ( multi-/akehold] input 7,a7 ,9 g5]al ,subject to p>agraph 7#d71 n lat] ?an ! applicable date describ$ 9 subp>agraph 7,b7 ( ea* ye>1 ! entity ) a contract "u section #ahij;,a %all1 pursuant to subsection 7b77#c7 ( su* section1 transmit to ! ,secret>y ! input ( multi-/akehold] gr\ps describ$ 9 p>agraph 7#a74 7,b7 ,applicable date describ$ ,! applicable date describ$ 9 ?is subp>agraph = a ye> is-- 7i7 ,febru>y #a ) respect to quality & effici5cy measures made available "u p>agraph 7#b7 by ,octob] #a ( ! prec$+ ye>2 & 7ii7 ,april #a ) respect to quality & effici5cy measures made available "u p>agraph 7#b7 by ,decemb] #ca ( ! prec$+ ye>4 2 7,d7 by r$esignat+-- 7i7 p>agraph 7#f7 z p>agraph 7#h72 & 7ii7 p>agraphs 7#d7 & 7#e7 z p>agraphs 7#e7 & 7#f71 respectively2 7,e7 by ins]t+ aft] p>agraph 7#c7 ! foll[+ new p>agraph3 7#d7 ,limit$ process = additional multi-/akehold] input ,9 addition to ! ,secret>y mak+ measures publically available pursuant to ! dates describ$ 9 p>agraph 7#b7 & multi-/akehold] gr\ps transmitt+ ! input pursuant to ! applicable dates describ$ 9 p>agraph 7#c7-- 7,a7 ! ,secret>y may1 at times t d n meet ! "t requirem5ts describ$ 9 p>agraph 7#b71 make available to ! public a limit$ numb] ( quality & effici5cy measures describ$ 9 section #ahij;,a7b77#b7 t ! ,secret>y is consid]+ "u ?is title2 & 7,b7 if ! ,secret>y uses ! au?ority "u subp>agraph 7,a71 ! entity ) a contract "u section #ahij;,a %all1 pursuant to section #ahij;,a7b77#c71 transmit to ! ,secret>y on a timely basis ! input f a multi-/akehold] gr\p describ$ 9 p>agraph 7#a7 ) respect to su* measures4 2 7,f7 9 p>agraph 7#f71 z r$esignat$ by subp>agraph 7,d77ii71 by ins]t+ or t has n be5 recomm5d$ by ! multi-/akehold] gr\p "u section #ahij;,a7b77#b7 be=e ! p]iod at ! end2 & 7,g7 by ins]t+ aft] p>agraph 7#f7 ! foll[+ new p>agraph3 7#g7 ,concordance rates ,= ea* ye> 7beg9n+ ) #bjae71 ! ,secret>y %all include a li/ ( concordance rates = ea* type ( provid] ( s]vices & suppli] 9 ! annual f9al rule applicable to su* type ( provid] or suppli]4 4 7#b7 ,review ,section #ahij;,b7c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;aaa-#a7;c771 z r$esignat$ by subsection 7a77#a77;,a71 is am5d$-- 7,a7 9 p>agraph 7#a77;,a71 by /rik+ section #ahij7;b77#g77;,b7 & ins]t+ section #ahij;,a7b77#b77;,b72 & 7,b7 9 p>agraph 7#b7-- 7i7 9 subp>agraph 7,a71 by /rik+ & at ! end2 7ii7 9 subp>agraph 7,b71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 & 7iii7 by add+ at ! end ! foll[+ new subp>agraph3 7,c7 take into consid]ation ! b5efits ( ! alignm5t ( measures betwe5 ! public & private sector4 4 7d7 ,fund+ = quality measure endorsem5t & selection 7#a7 ,fiscal ye> #bjad ,9 addition to am\nts transf]r$ "u section #cjad7;c7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh71 = purposes ( c>ry+ out section #ahij & section #ahij;,a 7o!r ?an subsections 7e7 & 7f771 ! ,secret>y %all provide = ! transf]1 f ! ,f$]al ,hospital ,insurance ,tru/ ,fund "u section #ahag & ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda1 9 su* proportion z ! ,secret>y det]m9es appropriate1 to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt ( #g1jjj1jjj = fiscal ye> #bjad4 ,am\nts transf]r$ "u ! prec$+ s5t5ce %all rema9 available until exp5d$4 7#b7 ,fiscal ye>s #bjae ?r\gh #bjag ,section #ahij;,b ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;aaa-#a71 z r$esignat$ by subsection 7a77#a77;,a71 is am5d$ by add+ at ! end ! foll[+ new subsection3 7g7 ,fund+ 7#a7 ,9 g5]al ,= purposes ( c>ry+ out ?is section 7o!r ?an subsections 7e7 & 7f77 & sections #ahij & #ahij;,a1 ! ,secret>y %all provide = ! transf]1 f ! ,f$]al ,hospital ,insurance ,tru/ ,fund "u section #ahag & ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda1 9 su* proportion z ! ,secret>y det]m9es appropriate1 to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt ( #be1jjj1jjj = ea* ( fiscal ye>s #bjae ?r\gh #bjag4 7#b7 ,availability ,am\nts transf]r$ "u p>agraph 7#a7 %all rema9 available until exp5d$4 4 7#c7 ,con=m+ am5dm5t ,subsection 7d7 ( section #ahij ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;aaa7 is repeal$4 7e7 ,con=m+ am5dm5ts 7#a7 ,section #ahdh7m77#c77;,e77iii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#c77;,e77iii77 is am5d$ by /rik+ section #ahij7;b77#g7 & #ahij;,a7a7 & ins]t+ section #ahij;,a7b77#b7 & #ahij;,b7a74 7#b7 ,section #ahff;,d7b77#b77;,c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc-#d7;b77#b77;,c77 is am5d$ by /rik+ section #ahij & #ahij;,a & ins]t+ sections #ahij1 #ahij;,a1 & #ahij;,b4 7#c7 ,section #ahii;,a7n77#b77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc-#d7n77#b77;,a77 is am5d$ by /rik+ section #ahij7;b77#g77;,b7 & ins]t+ section #ahij;,a7b77#b77;,b74 7f7 ,effective date 7#a7 ,9 g5]al ,! am5dm5ts made by ?is section %all take effect on ,octob] #a1 #bjad1 & %all apply ) respect to contract p]iods "u sections #ahij & #ahij;,a ( ! ,social ,security ,act t beg9 on or aft] su* date4 7#b7 ,new contracts beg9n+ ) fiscal ye> #bjae ,! ,secret>y ( ,heal? & ,human ,s]vices %all ent] into a new contract "u bo? sections #ahij & #ahij;,a ( ! ,social ,security ,act1 z am5d$ by ?is ,act1 = a contract p]iod beg9n+ on ,octob] #a1 #bjad4 #bji4 ,p]man5t ext5sion ( fund+ outrea* & assi/ance = l[-income programs 7a7 ,additional fund+ = ,/ate heal? insurance programs ,subsection 7a77#a77;,b77iii7 ( section #aai ( ! ,m$ic>e ,improvem5ts = ,pati5ts & ,provid]s ,act ( #bjjh 7#db ,u4,s4,c4 #acie;b-#c note71 z am5d$ by section #ccjf ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh7 & section #faj ( ! ,am]ican ,taxpay] ,relief ,act ( #bjab 7,public ,law #aab-bdj71 is am5d$ by ins]t+ & = ea* subsequ5t fiscal ye> aft] fiscal ye> #bjac4 7b7 ,additional fund+ = area ag5cies on ag+ ,subsection 7b77#a77;,b7 ( su* section #aai1 z s am5d$1 is am5d$ by ins]t+ & = ea* subsequ5t fiscal ye> aft] fiscal ye> #bjac4 7c7 ,additional fund+ = ag+ & disability res\rce c5t]s ,subsection 7c77#a77;,b7 ( su* section #aai1 z s am5d$1 is am5d$ by ins]t+ & = ea* subsequ5t fiscal ye> aft] fiscal ye> #bjac4 7d7 ,additional fund+ = contract ) ! national c5t] = b5efits & outrea* enrollm5t ,subsection 7d77#b7 ( su* section #aai1 z s am5d$1 is am5d$ by ins]t+ & = ea* subsequ5t fiscal ye> aft] fiscal ye> #bjac4 ,b ,m$icaid & ,o!r ,ext5sions #baa4 ,qualify+ individual program 7a7 ,ext5sion ,section #aijb7;a77#aj77;,e77iv7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77#aj77;,e77iv77 is am5d$ by /rik+ ,decemb] #bjac & ins]t+ ,decemb] #bjah4 7b7 ,elim9at+ limitations on eligibility ,section #aicc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#c7 is am5d$ by /rik+ subsections 7b7 & 7e74 7c7 ,elim9at+ allocations ,section #aicc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#c7 is am5d$ by /rik+ subsections 7c7 & 7g74 7d7 ,con=m+ am5dm5ts 7#a7 ,9 g5]al ,section #aicc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#c71 z am5d$ by subsections 7b7 & 7c71 is fur!r am5d$-- 7,a7 by /rik+ subsection 7a7 & ins]t+ ! foll[+ new subsection3 7a7 ,applicable ,,fmap ,) respect to assi/ance describ$ 9 section #aijb7;a77#aj77;,e77iv7 furni%$ 9 a ,/ate1 ! ,f$]al m$ical assi/ance p]c5tage %all be equal to #ajj p]c5t4 2 7,b7 by /rik+ subsection 7d72 & 7,c7 by r$esignat+ subsection 7f7 z subsection 7b74 7#b7 ,def9ition ( ,,fmap ,section #aije7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7b77 is am5d$ by /rik+ section #aicc7;d7 & ins]t+ section #aicc7;a74 7e7 ,effective date ,! am5dm5ts made by ?is section %all take effect on ,janu>y #a1 #bjad1 & %all apply ) respect to cal5d> qu>t]s beg9n+ on or aft] su* date4 #bab4 ,transitional ,m$ical ,assi/ance 7a7 ,ext5sion ,sections #aijb7;e77#a77;,b7 & #aibe7;f7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7e77#a77;,b71 #acifr-#f7;f77 are ea* am5d$ by /rik+ ,decemb] #ca1 #bjac & ins]t+ ,decemb] #ca1 #bjah4 7b7 ,opt-out option = ,/ates t exp& adult cov]age & provide #ab-mon? cont9u\s eligibility "u ,m$icaid & ,,*ip 7#a7 ,9 g5]al ,section #aibe ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#f71 z am5d$ by subsection 7a71 is fur!r am5d$-- 7,a7 9 subsection 7a7-- 7i7 9 p>agraph 7#a77;,a71 by /rik+ p>agraph 7#e7 & ins]t+ p>agraphs 7#e7 & 7#f72 & 7ii7 by add+ at ! end ! foll[+3 7#f7 ,opt-out option = ,/ates t exp& adult cov]age & provide #ab-mon? cont9u\s eligibility "u ,m$icaid & ,,*ip 7,a7 ,9 g5]al ,9 ! case ( a ,/ate describ$ 9 subp>agraph 7,b71 ! ,/ate may elect ?r\gh a ,/ate plan am5dm5t to h ?is section & sections #djh7;a77#aa77;,a71 #aijb7;a77#eb71 #aijb7;e77#a71 & #aica7;c77#b7 n apply to ! ,/ate4 7,b7 ,/ate describ$ ,a ,/ate is describ$ 9 ?is subp>agraph if ! ,/ate is "o ( ! #ej ,/ates or ! ,di/rict ( ,columbia &-- 7i7 has elect$ to provide m$ical assi/ance to individuals "u subclause 7,,viii7 ( section #aijb7;a77#aj77;,a77i72 7ii7 has elect$ "u section #aijb7;e77#ab77;,a7 ! option to provide cont9u\s eligibility = a #ab-mon? p]iod = individuals "u #ai ye>s ( age2 7iii7 has elect$ "u section #aijb7;e77#ab77;,b7 ! option to provide cont9u\s eligibility = a #ab-mon? p]iod = all categories ( individuals describ$ 9 t section2 & 7iv7 has elect$ to apply section #aijb7;e77#ab77;,a7 to ! ,/ate *ild heal? plan "u title ,,xxi4 2 & 7,b7 9 subsection 7b77#a71 by /rik+ subsection 7a77#e7 & ins]t+ p>agraphs 7#e7 & 7#f7 ( subsection 7a74 7#b7 ,con=m+ am5dm5t to #d-mon? requirem5t ,section #aijb7;e77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7e77#a771 z am5d$ by subsection 7a71 is fur!r am5d$-- 7,a7 9 subp>agraph 7,b71 by /rik+ ,subp>agraph 7,a7 & ins]t+ ,subject to subp>agraph 7,c71 subp>agraph 7,a72 & 7,b7 by add+ at ! end ! foll[+3 7,c7 ,if a ,/ate has made an election "u section #aibe7;a77#f71 subp>agraph 7,a7 & section #aibe %all n apply to ! ,/ate4 4 7c7 ,ext5sion ( #ab-mon? cont9u\s eligibility option to c]ta9 adult enrollees "u ,m$icaid2 cl>ification ( application to ,,*ip 7#a7 ,9 g5]al ,section #aijb7;e77#ab7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7e77#ab77 is am5d$-- 7,a7 by r$esignat+ subp>agraphs 7,a7 & 7,b7 z clauses 7i7 & 7ii71 respectively2 7,b7 by ins]t+ 7,a7 aft] 7#ab72 & 7,c7 by add+ at ! end ! foll[+3 7,b7 ,at ! option ( ! ,/ate1 ! plan may provide t an individual :o is det]m9$ to be eligible = b5efits "u a ,/ate plan approv$ "u ?is title "u any ( ! foll[+ eligibility categories1 or :o is r$et]m9$ to be eligible = su* b5efits "u any ( su* categories1 %all be consid]$ to meet ! eligibility requirem5ts met on ! date ( application & %all rema9 eligible = ^? b5efits until ! end ( ! #ab-mon? p]iod foll[+ ! date ( ! det]m9ation or r$et]m9ation ( eligibility3 7i7 ,section #aijb7;a77#aj77;,a77i77,,viii74 7ii7 ,section #aica4 4 7#b7 ,application to ,,*ip ,section #bajg7;e77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acig;gg7e77#a77 is am5d$-- 7,a7 by r$esignat+ subp>agraphs 7,e7 ?r\gh 7,o7 z subp>agraphs 7,f7 ?r\gh 7,p71 respectively2 & 7,b7 by ins]t+ aft] subp>agraph 7,d71 ! foll[+3 7,e7 ,section #aijb7;e77#ab77;,a7 7relat+ to ! ,/ate option = #ab-mon? cont9u\s eligibility & enrollm5t74 4 7d7 ,con=m+ & te*nical am5dm5ts relat+ to section #aica transitional cov]age requirem5ts 7#a7 ,9 g5]al ,section #aica7;c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#a7;c77 is am5d$-- 7,a7 9 p>agraph 7#a7-- 7i7 9 ! p>agraph head+1 by /rik+ *ild & ins]t+ sp\sal2 7ii7 by /rik+ ,! provisions & ins]t+ ,subject to p>agraph 7#c71 ! provisions2 & 7iii7 by /rik+ *ild or2 7,b7 9 p>agraph 7#b71 by /rik+ ,= cont9u$ & ins]t+ ,subject to p>agraph 7#c71 = cont9u$2 & 7,c7 by add+ at ! end ! foll[+3 7#c7 ,opt-out option = ,/ates t exp& adult cov]age & provide #ab-mon? cont9u\s eligibility "u ,m$icaid & ,,*ip 7,a7 ,9 g5]al ,9 ! case ( a ,/ate describ$ 9 subp>agraph 7,b71 ! ,/ate may elect ?r\gh a ,/ate plan am5dm5t to h p>agraphs 7#a7 & 7#b7 ( ?is subsection & sections #djh7;a77#aa71 #aijb7;a77#eb71 #aijb7;e77#a71 & #aibe n apply to ! ,/ate4 7,b7 ,/ate describ$ ,a ,/ate is describ$ 9 ?is subp>agraph if ! ,/ate is "o ( ! #ej ,/ates or ! ,di/rict ( ,columbia &-- 7i7 has elect$ to provide m$ical assi/ance to individuals "u subclause 7,,viii7 ( section #aijb7;a77#aj77;,a77i72 7ii7 has elect$ "u section #aijb7;e77#ab77;,a7 ! option to provide cont9u\s eligibility = a #ab-mon? p]iod = individuals "u #ai ye>s ( age2 7iii7 has elect$ "u section #aijb7;e77#ab77;,b7 ! option to provide cont9u\s eligibility = a #ab-mon? p]iod = all categories ( individuals describ$ 9 t section2 & 7iv7 has elect$ to apply section #aijb7;e77#ab77;,a7 to ! ,/ate *ild heal? plan "u title ,,xxi4 4 7#b7 ,con=m+ am5dm5t to section #djh ,section #djh7;a77#aa7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #fjh7;a77#aa7 is am5d$-- 7,a7 9 ! p>agraph head+1 by /rik+ *ild & ins]t+ sp\sal2 & 7,b7 9 subp>agraph 7,b7-- 7i7 9 ! subp>agraph head+1 by /rik+ ,*ild & ins]t+ ,sp\sal2 & 7ii7 by /rik+ *ild or4 7e7 ,con=m+ am5dm5t relat+ to ma9t5ance ( ef=t = *ildr5 ,section #aijb7;gg77#d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7gg77#d77 is am5d$ by add+ at ! end ! foll[+3 7,c7 ,/ates t exp& adult cov]age & elect to opt-out ( transitional cov]age 7i7 ,9 g5]al ,= purposes ( det]m9+ compliance ) ! requirem5ts ( p>agraph 7#b71 a ,/ate :i* ex]cises ! option "u sections #aibe7;a77#f7 & #aica7;c77#c7 to provide no transitional m$ical assi/ance or o!r ext5d$ eligibility 7z applicable7 %all n1 z a result ( ex]cis+ su* option1 be consid]$ to h 9 effect eligibility /&>ds1 me?odologies1 or proc$ures describ$ 9 clause 7ii7 t are m re/rictive ?an ! /&>ds1 me?odologies1 or proc$ures 9 effect "u ! ,/ate plan or "u a waiv] ( ! plan on ! date ( enactm5t ( ! ,pati5t ,protection & ,af=dable ,c>e ,act4 7ii7 ,/&>ds1 me?odologies1 or proc$ures describ$ ,! eligibility /&>ds1 me?odologies1 or proc$ures describ$ 9 ?is clause are ^? /&>ds1 me?odologies1 or proc$ures applicable to det]m9+ ! eligibility = m$ical assi/ance ( any *ild "u #ai ye>s ( age 7or su* high] age z ! ,/ate may h elect$74 4 7f7 ,effective date ,! am5dm5ts made by ?is section %all take effect on ,janu>y #a1 #bjad4 #bac4 ,express lane eligibility ,section #aijb7;e77#ac77;,i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7e77#ac77;,i77 is am5d$ by /rik+ ,septemb] #cj1 #bjad & ins]t+ ,septemb] #cj1 #bjae4 #bad4 ,p$iatric quality measures 7a7 ,cont9uation ( fund+ = p$iatric quality measures = improv+ ! quality ( *ildr5's heal? c>e ,section #aaci;,b7e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;b-#i;b7e77 is am5d$ by add+ at ! end ! foll[+3 ,( ! funds appropriat$ "u ?is subsection1 n less ?an #ae1jjj1jjj %all be us$ to c>ry out section #aaci;,a7b744 7b7 ,elim9ation ( re/riction on m$icaid quality measurem5t program ,section #aaci;,b7b77#e77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;b-#i;b7b77#e77;,a77 is am5d$ by /rik+ ,! aggregate am\nt aw>d$ by ! ,secret>y = grants & contracts = ! developm5t1 te/+1 & validation ( em]g+ & innovative evid5ce-bas$ measures "u su* program %all equal ! aggregate am\nt aw>d$ by ! ,secret>y = grants "u section #aaci;,a7b77#d77;,a7 4 #bae4 ,special diabetes programs 7a7 ,special diabetes programs = type ,i diabetes ,section #ccj;,b7b77#b77;,c7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bed;c-#b7;b77#b77;,c77 is am5d$ by /rik+ #bjad & ins]t+ #bjai4 7b7 ,special diabetes programs = indians ,section #ccj;,c7c77#b77;,c7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bed;c-#c7;c77#b77;,c77 is am5d$ by /rik+ #bjad & ins]t+ #bjai4 ,c ,human ,s]vices ,ext5sions #bba4 ,ab/95ce education grants 7a7 ,9 g5]al ,section #eaj ( ! ,social ,security ,act 7#db ,u4,s4,c4 #gaj7 is am5d$-- 7#a7 9 subsection 7a71 9 ! matt] prec$+ p>agraph 7#a71 by /rik+ #bjaj ?r\gh #bjad & ins]t+ #bjae ?r\gh #bjai2 & 7#b7 9 subsection 7d7-- 7,a7 by /rik+ #bjaj ?r\gh #bjad & ins]t+ #bjae ?r\gh #bjai2 & 7,b7 by /rik+ ! second s5t5ce4 7b7 ,effective date ,! am5dm5ts made by ?is section %all take effect on ,octob] #a1 #bjad4 #bbb4 ,p]sonal responsibility education program 7a7 ,9 g5]al ,section #eac ( ! ,social ,security ,act 7#db ,u4,s4,c4 #gac7 is am5d$-- 7#a7 9 subsection 7a7-- 7,a7 9 p>agraph 7#a77;,a71 by /rik+ #bjaj ?r\gh #bjad & ins]t+ #bjae ?r\gh #bjai2 7,b7 9 p>agraph 7#d7-- 7i7 9 subp>agraph 7,a7-- 7,i7 by /rik+ #bjaj or #bjaa & ins]t+ #bjae or #bjaf2 7,,ii7 by /rik+ #bjaj ?r\gh #bjad & ins]t+ #bjae ?r\gh #bjai2 & 7,,iii7 by /rik+ #bjab ?r\gh #bjad & ins]t+ #bjag ?r\gh #bjai2 & 7ii7 9 subp>agraph 7,b77i7-- 7,i7 by /rik+ #bjab1 #bjac1 & #bjad & ins]t+ #bjag1 #bjah1 & #bjai2 & 7,,ii7 by /rik+ #bjaj or #bjaa & ins]t+ #bjae or #bjaf2 & 7,c7 9 p>agraph 7#e71 by /rik+ #bjji & ins]t+ #bjad2 7#b7 9 subsection 7b77#b77;,a71 9 ! matt] prec$+ clause 7i71 by ins]t+ & y\? at risk ( becom+ victims ( sex traffick+ 7z def9$ 9 section #ajc7aj7 ( ! ,traffick+ ,victims ,protection ,act ( #bjjj 7#bb ,u4,s4,c4 #gajb7aj777 or victims ( a sev]e =m ( traffick+ 9 p]sons describ$ 9 p>agraph 7#i77;,a7 ( t ,act 7#bb ,u4,s4,c4 #gajb7i77;,a7 aft] adolesc5ts2 7#c7 9 subsection7c77#a71 by ins]t+ y\? at risk ( becom+ victims ( sex traffick+ 7z def9$ 9 section #ajc7aj7 ( ! ,traffick+ ,victims ,protection ,act ( #bjjj 7#bb ,u4,s4,c4 #gajb7aj777 or victims ( a sev]e =m ( traffick+ 9 p]sons describ$ 9 p>agraph 7#i77;,a7 ( t ,act 7#bb ,u4,s4,c4 #gajb7i77;,a71 aft] y\? 9 fo/] c>e12 & 7#d7 9 subsection 7f71 by /rik+ #bjaj ?r\gh #bjad & ins]t+ #bjae ?r\gh #bjai4 7b7 ,effective date ,! am5dm5ts made by ?is section %all take effect on ,octob] #a1 #bjad4 #bbc4 ,family-to-family heal? in=mation c5t]s 7a7 ,9 g5]al ,section #eja7;c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #gja7;c77 is am5d$-- 7#a7 9 p>agraph 7#a77;,a7-- 7,a7 9 clause 7ii71 by /rik+ & aft] ! semicolon2 7,b7 9 clause 7iii71 by /rik+ ! p]iod & ins]t+ 2 &2 & 7,c7 by add+ at ! end ! foll[+3 7iv7 #f1jjj1jjj = ea* ( fiscal ye>s #bjad ?r\gh #bjah4 2 & 7#b7 by /rik+ p>agraph 7#e74 7b7 ,effective date ,! am5dm5ts made by ?is section %all take effect z if enact$ on ,octob] #a1 #bjac4 #bbd4 ,heal? work=ce demon/ration project = l[-income individuals ,section #bjjh7;c77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acig;g7c77#a77 is am5d$ by /rik+ ?r\gh #bjad & ins]t+ #bjab1 & only to c>ry out subsection 7a71 #he1jjj1jjj = ea* ( fiscal ye>s #bjac ?r\gh #bjaf4 ,d ,program ,integrity #bca4 ,r$uc+ improp] ,m$ic>e paym5ts 7a7 ,m$ic>e adm9i/rative contractor improp] paym5t outrea* & education program 7#a7 ,9 g5]al ,section #ahgd;,a ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciekk-#a7 is am5d$-- 7,a7 9 subsection 7a77#d7-- 7i7 by r$esignat+ subp>agraph 7,g7 z subp>agraph 7,h72 & 7ii7 by ins]t+ aft] subp>agraph 7,f7 ! foll[+ new subp>agraph3 7,g7 ,improp] paym5t outrea* & education program ,hav+ 9 place an improp] paym5t outrea* & education program describ$ 9 subsection 7h74 2 & 7,b7 by add+ at ! end ! foll[+ new subsection3 7h7 ,improp] paym5t outrea* & education program 7#a7 ,9 g5]al ,9 ord] to r$uce improp] paym5ts "u ?is title1 ea* m$ic>e adm9i/rative contractor %all e/abli% & h 9 place an improp] paym5t outrea* & education program "u :i* ! contractor1 ?r\gh outrea*1 education1 tra9+1 & te*nical assi/ance activities1 %all provide provid]s ( s]vices & suppli]s locat$ 9 ! region cov]$ by ! contract "u ?is section ) ! in=mation describ$ 9 p>agraph 7#c74 ,! activities describ$ 9 ! prec$+ s5t5ce %all be conduct$ on a regul> basis4 7#b7 ,=ms ( outrea*1 education1 tra9+1 & te*nical assi/ance activities ,! outrea*1 education1 tra9+1 & te*nical assi/ance activities "u a paym5t outrea* & education program %all be c>ri$ out ?r\gh any ( ! foll[+3 7,a7 ,emails & o!r electronic communications4 7,b7 ,web9>s4 7,c7 ,telephone calls4 7,d7 ,9-p]son tra9+4 7,e7 ,o!r =ms ( communications det]m9$ appropriate by ! ,secret>y4 7#c7 ,in=mation to be provid$ ?r\gh activities ,! in=mation to be provid$ to provid]s ( s]vices & suppli]s "u a paym5t outrea* & education program %all include all ( ! foll[+ in=mation3 7,a7 ,a li/ ( ! provid]'s or suppli]'s mo/ frequ5t & exp5sive paym5t errors ov] ! la/ qu>t]4 7,b7 ,specific in/ructions reg>d+ h[ to correct or avoid su* errors 9 ! future4 7,c7 ,a notice ( all new topics t h be5 approv$ by ! ,secret>y = audits conduct$ by recov]y audit contractors "u section #ahic7;h74 7,d7 ,specific in/ructions to prev5t future issues relat$ to su* new audits4 7,e7 ,o!r in=mation det]m9$ appropriate by ! ,secret>y4 7#d7 ,error rate r$uction tra9+ 7,a7 ,9 g5]al ,! activities "u a paym5t outrea* & education program %all include error rate r$uction tra9+4 7,b7 ,requirem5ts 7i7 ,9 g5]al ,! tra9+ describ$ 9 subp>agraph 7,a7 %all-- 7,i7 be provid$ at lea/ annually2 & 7,,ii7 focus on r$uc+ ! improp] paym5ts describ$ 9 p>agraph 7#e74 7,c7 ,invitation ,a m$ic>e adm9i/rative contractor %all ensure t all provid]s ( s]vices & suppli]s locat$ 9 ! region cov]$ by ! contract "u ?is section are invit$ to att5d ! tra9+ describ$ 9 subp>agraph 7,a7 ei!r 9 p]son or onl9e4 7#e7 ,priority ,a m$ic>e adm9i/rative contractor %all give priority to activities "u ! improp] paym5t outrea* & education program t w r$uce improp] paym5ts = items & s]vices t-- 7,a7 h ! highe/ rate ( improp] paym5t2 7,b7 h ! greate/ total doll> am\nt ( improp] paym5ts2 7,c7 are due to cle> misapplication or mis9t]pretation ( ,m$ic>e policies2 7,d7 are cle>ly due to common & inadv]t5t cl]ical or adm9i/rative errors2 or 7,e7 are due to o!r types ( errors t ! ,secret>y det]m9es c\ld be prev5t$ ?r\gh activities "u ! program4 7#f7 ,in=mation on improp] paym5ts f recov]y audit contractors 7,a7 ,9 g5]al ,9 ord] to assi/ m$ic>e adm9i/rative contractors 9 c>ry+ out improp] paym5t outrea* & education programs1 ! ,secret>y %all provide ea* contractor ) a complete li/ ( improp] paym5ts id5tifi$ by recov]y audit contractors "u section #ahic7;h7 ) respect to provid]s ( s]vices & suppli]s locat$ 9 ! region cov]$ by ! contract "u ?is section4 ,su* in=mation %all be provid$ on a qu>t]ly basis4 7,b7 ,in=mation ,! in=mation describ$ 9 subp>agraph 7,a7 %all include ! foll[+ in=mation3 7i7 ,! provid]s ( s]vices & suppli]s t h ! highe/ rate ( improp] paym5ts4 7ii7 ,! provid]s ( s]vices & suppli]s t h ! greate/ total doll> am\nts ( improp] paym5ts4 7iii7 ,! items & s]vices furni%$ 9 ! region t h ! highe/ rates ( improp] paym5ts4 7iv7 ,! items & s]vices furni%$ 9 ! region t are responsible = ! greate/ total doll> am\nt ( improp] paym5ts4 7v7 ,o!r in=mation ! ,secret>y det]m9es w\ld assi/ ! contractor 9 c>ry+ out ! improp] paym5t outrea* & education program4 7,c7 ,=mat ( in=mation ,! in=mation furni%$ to m$ic>e adm9i/rative contractors by ! ,secret>y "u ?is p>agraph %all be transmitt$ 9 a mann] t p]mits ! contractor to easily id5tify ! areas ( ! ,m$ic>e program 9 :i* t>get$ outrea*1 education1 tra9+1 & te*nical assi/ance w\ld be mo/ effective4 ,9 c>ry+ out ! prec$+ s5t5ce1 ! ,secret>y %all ensure t-- 7i7 ! in=mation ) respect to improp] paym5ts made to a provid] ( s]vices or suppli] cle>ly displays ! "n & address ( ! provid] or suppli]1 ! am\nt ( ! improp] paym5t1 & any o!r in=mation ! ,secret>y det]m9es appropriate2 & 7ii7 ! in=mation is 9 an electronic1 easily se>*able database4 7#g7 ,communications ,all communications ) provid]s ( s]vices & suppli]s "u a paym5t outrea* & education program are subject to ! /&>ds & requirem5ts ( subsection 7g74 7#h7 ,fund+ ,aft] application ( p>agraph 7#a77;,c7 ( section #ahic7;h71 ! ,secret>y %all reta9 a portion ( ! am\nts recov]$ by recov]y audit contractors "u su* section :i* %all be available to ! program managem5t acc\nt ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices = purposes ( c>ry+ out ?is subsection & to implem5t corrective actions to help r$uce ! error rate ( paym5ts "u ?is title4 ,! am\nt reta9$ "u ! prec$+ s5t5ce %all n exce$ an am\nt equal to #be p]c5t ( ! am\nts recov]$ "u section #ahic7;h74 4 7#b7 ,fund+ con=m+ am5dm5t ,section #ahic7;h77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77#b77 is am5d$ by ins]t+ or section #ahgd7;h77#h7 aft] p>agraph 7#a77;,c74 7#c7 ,effective date ,! am5dm5ts made by ?is subsection take effect on ,janu>y #a1 #bjae4 7b7 ,transp>5cy ,section #ahic7;h77#h7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77#h77 is am5d$-- 7#a7 by /rik+ report4--,! ,secret>y & ins]t+ 8report4-- 7,a7 ,9 g5]al ,! ,secret>y 2 & 7#b7 by add+ at ! end ! foll[+ new subp>agraph3 7,b7 ,inclusion ( c]ta9 in=mation 7i7 ,9 g5]al ,= reports submitt$ "u ?is p>agraph = #bjae or a subsequ5t ye>1 ea* su* report %all include ! in=mation describ$ 9 clause 7ii7 ) respect to ea* ( ! foll[+ categories ( audits c>ri$ out by recov]y audit contractors "u ?is subsection3 7,i7 ,automat$4 7,,ii7 ,complex4 7,,iii7 ,m$ical necessity review4 7,,iv7 ,"p ,a4 7,v7 ,"p ,b4 7,,vi7 ,durable m$ical equipm5t4 7ii7 ,in=mation describ$ ,= purposes ( clause 7i71 ! in=mation describ$ 9 ?is clause1 ) respect to a category ( audit describ$ 9 clause 7i71 is ! result ( all appeals = ea* individual level ( appeals 9 su* category4 4 7c7 ,recov]y ,audit ,contractor ,demon/ration ,project 7#a7 ,9 g5]al ,! ,secret>y %all conduct a demon/ration project "u title ,,xviii ( ! ,social ,security ,act t-- 7,a7 t>gets audits by recov]y audit contractors "u section #ahic7;h7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77 ) respect to high error provid]s ( s]vices & suppli]s id5tifi$ "u p>agraph 7#c72 & 7,b7 rew>ds l[ error provid]s ( s]vices & suppli]s id5tifi$ "u su* p>agraph4 7#b7 ,scope 7,a7 ,duration ,! demon/ration project %all be implem5t$ n lat] ?an ,janu>y #a1 #bjae1 & %all be conduct$ = a p]iod ( ?ree ye>s4 7,b7 ,demon/ration area ,9 det]m9+ ! geographic area ( ! demon/ration project1 ! ,secret>y %all consid] ! foll[+3 7i7 ,! total numb] ( provid]s ( s]vices & suppli]s 9 ! region4 7ii7 ,! div]sity ( types ( provid]s ( s]vices & suppli]s 9 ! region4 7iii7 ,! level & v>iation ( improp] paym5t rates ( & among individual provid]s ( s]vices & suppli]s 9 ! region4 7iv7 ,! inclusion ( a mix ( bo? urban & rural areas4 7#c7 ,id5tification ( l[ error & high error provid]s ( s]vices & suppli]s 7,a7 ,9 g5]al ,9 conduct+ ! demon/ration project1 ! ,secret>y %all id5tify ! foll[+ two gr\ps ( provid]s 9 accordance ) ?is p>agraph3 7i7 ,l[ error provid]s ( s]vices & suppli]s4 7ii7 ,high error provid]s ( s]vices & suppli]s4 7,b7 ,analysis ,= purposes ( id5tify+ ! gr\ps "u subp>agraph 7,a71 ! ,secret>y %all analyze ! foll[+ z !y relate to ! total numb] & am\nt ( claims submitt$ 9 ! area & by ea* provid]3 7i7 ,! improp] paym5t rates ( individual provid]s ( s]vices & suppli]s4 7ii7 ,! am\nt ( improp] paym5ts made to individual provid]s ( s]vices & suppli]s4 7iii7 ,! frequ5cy ( errors made by ! provid] ( s]vices or suppli] ov] "t4 7iv7 ,o!r in=mation det]m9$ appropriate by ! ,secret>y4 7,c7 ,assignm5t bas$ on composite score ,! ,secret>y %all assign select$ provid]s ( s]vices & suppli]s "u ! demon/ration program bas$ on a composite score det]m9$ us+ ! analysis "u subp>agraph 7,b7 z foll[s3 7i7 ,provid]s ( s]vices & suppli]s ) high1 exp5sive1 & frequ5t errors %all receive a high score & be id5tifi$ z high error provid]s ( s]vices & suppli]s "u subp>agraph 7,a74 7ii7 ,provid]s ( s]vices & suppli]s ) few1 inexp5sive1 & infrequ5t errors %all receive a l[ score & be id5tifi$ z l[ error provid]s ( s]vices & suppli]s "u su* subp>agraph4 7iii7 ,only a small proportion ( ! total provid]s ( s]vices & suppli]s & individual types ( provid]s ( s]vices & suppli]s 9 ! geographic area ( ! demon/ration project %all be assign$ to ei!r gr\p id5tifi$ "u su* subp>agraph4 7,d7 ,timeframe ( id5tification 7i7 ,9 g5]al ,any id5tification ( a provid] ( s]vices or a suppli] "u subp>agraph 7,a7 %all be = a p]iod ( #ab mon?s4 7ii7 ,reevaluation ,! ,secret>y %all reevaluate ea* su* id5tification at ! end ( su* p]iod4 7iii7 ,use ( mo/ curr5t in=mation ,9 c>ry+ out ! reevaluation "u clause 7ii7 ) respect to a provid] ( s]vices or suppli]1 ! ,secret>y %all-- 7,i7 consid] ! mo/ curr5t in=mation available ) respect to ! provid] ( s]vices or suppli] "u ! analysis "u subp>agraph 7,b72 & 7,,ii7 take into acc\nt improvem5t or regression ( ! provid] ( s]vices or suppli]4 7#d7 ,adju/m5t ( record reque/ maximum ,"u ! demon/ration project1 ! ,secret>y %all e/abli% proc$ures to-- 7,a7 increase ! maximum record reque/ made by recov]y audit contractors to provid]s ( s]vices & suppli]s id5tifi$ z high error provid]s ( s]vices & suppli]s "u p>agraph 7#c72 & 7,b7 decrease ! maximum record reque/ made by recov]y audit contractors to provid]s ( s]vices & suppli]s id5tifi$ z l[ error provid]s ( s]vices & suppli] "u su* p>agraph4 7#e7 ,additional adju/m5ts 7,a7 ,9 g5]al ,"u ! demon/ration project1 ! ,secret>y may make additional adju/m5ts to requirem5ts = recov]y audit contractors "u section #ahic7;h7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77 & ! conduct ( audits ) respect to l[ error provid]s ( s]vices & suppli]s id5tifi$ "u p>agraph 7#c7 & high error provid]s ( s]vices & suppli]s id5tifi$ "u su* p>agraph z ! ,secret>y det]m9es necess>y 9 ord] to inc5tivize r$uctions 9 improp] paym5t rates "u title ,,xviii ( su* ,act 7#db ,u4,s4,c4 #acie et seq474 7,b7 ,limitation ,! ,secret>y %all n exempt any gr\p ( provid]s ( s]vices or suppli]s 9 ! demon/ration project f be+ subject to audit by a recov]y audit contractor "u su* section #ahic7;h74 7#f7 ,evaluation & report 7,a7 ,evaluation ,! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices %all conduct an evaluation ( ! demon/ration project "u ?is subsection4 ,! evaluation %all include an analysis (-- 7i7 ! error rates ( provid]s ( s]vices & suppli]s-- 7,i7 id5tifi$ "u p>agraph 7#c7 z l[ error provid]s ( s]vices & suppli]s2 7,,ii7 id5tifi$ "u su* p>agraph z high error provid]s ( s]vices & suppli]s2 & 7,,iii7 t are locat$ 9 ! geographic area ( ! demon/ration project & are n id5tifi$ z ei!r a l[ error or high error provid] ( s]vices or suppli] "u su* p>agraph2 & 7ii7 any improvem5ts 9 ! error rates ( ^? high error provid]s ( s]vices & suppli]s id5tifi$ "u su* p>agraph4 7,b7 ,report ,n lat] ?an #ab mon?s aft] completion ( ! demon/ration project1 ! ,inspector ,g5]al %all submit to ,congress a report conta9+ ! results ( ! evaluation conduct$ "u subp>agraph 7,a71 toge!r ) recomm5dations on :e!r ! demon/ration project %\ld be cont9u$ or exp&$1 includ+ on a p]man5t or nationwide basis4 7#g7 ,fund+ 7,a7 ,fund+ = implem5tation ,= purposes ( c>ry+ out ! demon/ration project "u ?is subsection 7o!r ?an ! evaluation & report "u p>agraph 7#f771 ! ,secret>y %all provide = ! transf]1 f ! ,f$]al ,hospital ,insurance ,tru/ ,fund "u section #ahag 7#db ,u4,s4,c4 #acie;i7 & ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda 7#db ,u4,s4,c4 #aciet71 9 su* proportion z ! ,secret>y det]m9es appropriate1 ( #aj1jjj1jjj to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt4 7,b7 ,fund+ = ,inspector ,g5]al evaluation & report ,= purposes ( c>ry+ out ! evaluation & report "u p>agraph 7#f71 ! ,secret>y %all provide = ! transf]1 f ! ,f$]al ,hospital ,insurance ,tru/ ,fund "u su* section #ahag & ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u su* section #ahda1 9 su* proportion z ! ,secret>y det]m9es appropriate1 ( #bde1jjj to ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices4 7,c7 ,availability ,am\nts transf]r$ "u subp>agraph 7,a7 or 7,b7 %all rema9 available until exp5d$4 7#h7 ,def9itions ,9 ?is section3 7,a7 ,demon/ration project ,! t]m demon/ration project means ! demon/ration project "u ?is subsection4 7,b7 ,provid] ( s]vices ,! t]m provid] ( s]vices has ! mean+ giv5 t t]m 9 section #ahfa7u74 7,c7 ,recov]y audit contractor ,! t]m recov]y audit contractor means an entity ) a contract "u section #ahic7;h7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h774 7,d7 ,secret>y ,! t]m ,secret>y means ! ,secret>y ( ,heal? & ,human ,s]vices4 7,e7 ,suppli] ,! t]m suppli] has ! mean+ giv5 t t]m 9 section #ahfa7;d74 #bcb4 ,au?ority = ,m$icaid fraud control units to inve/igate & prosecute compla9ts ( abuse & neglect ( ,m$icaid pati5ts 9 home & community-bas$ sett+s 7a7 ,9 g5]al ,section #aijc7q77#d77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7q77#d77;,a77 is am5d$ to read z foll[s3 7#d7 7,a7 ,! entity's function includes a /atewide program = !-- 7i7 inve/igation & prosecution1 or ref]ral = prosecution or o!r action1 ( compla9ts ( abuse or neglect ( pati5ts 9 heal? c>e facilities :i* receive paym5ts "u ! ,/ate plan "u ?is title or "u a waiv] ( su* plan2 7ii7 at ! option ( ! entity1 inve/igation & prosecution1 or ref]ral = prosecution or o!r action1 ( compla9ts ( abuse or neglect ( individuals 9 connection ) any aspect ( ! provision ( m$ical assi/ance & ! activities ( provid]s ( su* assi/ance 9 a home or community bas$ sett+ t is paid = "u ! ,/ate plan "u ?is title or "u a waiv] ( su* plan2 & 7iii7 at ! option ( ! entity1 inve/igation & prosecution1 or ref]ral = prosecution or o!r action1 ( compla9ts ( abuse or neglect ( pati5ts resid+ 9 bo>d & c>e facilities4 4 7b7 ,effective date ,! am5dm5t made by subsection 7a7 %all take effect on ,janu>y #a1 #bjae4 #bcc4 ,improv$ use ( funds receiv$ by ! ,,hhs ,inspector ,g5]al f ov]sight & inve/igative activities 7a7 ,9 g5]al ,section #aabh;,c7b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;c7b77 is am5d$ to read z foll[s3 7b7 ,additional use ( funds by ,inspector ,g5]al 7#a7 ,collections f ,m$ic>e & ,m$icaid recov]y actions ,not)/&+ section #ccjb ( title #ca1 ,unit$ ,/ates ,code1 or any o!r provision ( law affect+ ! cr$it+ ( collections1 ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices may receive & reta9 ?ree p]c5t ( all am\nts collect$ pursuant to civil debt collection actions relat$ to false claims or frauds involv+ ! ,m$ic>e program "u title ,,xviii or ! ,m$icaid program "u title ,,xix4 7#b7 ,cr$it+ ,funds receiv$ by ! ,inspector ,g5]al "u p>agraph 7#a7 %all be deposit$ to ! cr$it ( any appropriation available = ov]sight & en=cem5t activities ( ! ,inspector ,g5]al p]mitt$ "u subsection 7a71 & %all rema9 available until exp5d$4 4 7b7 ,effective date ,! am5dm5t made by subsection 7a7 %all apply to funds receiv$ f settlem5ts f9aliz$1 or judgem5ts ent]$1 on or aft] ! date ( ! enactm5t ( ?is ,act4 #bcd4 ,prev5t+ & r$uc+ improp] ,m$ic>e & ,m$icaid exp5ditures 7a7 ,requir+ valid prescrib] ,national ,provid] ,id5tifi]s on ph>macy claims ,section #ahfj;,d-#d7;c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ajd7;c77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#d7 ,requir+ valid prescrib] ,national ,provid] ,id5tifi]s on ph>macy claims 7,a7 ,9 g5]al ,= plan ye> #bjae & subsequ5t plan ye>s1 subject to subp>agraph 7,b71 ! ,secret>y %all prohibit ,,pdp sponsors ( prescription drug plans f pay+ claims = prescription drugs "u ?is "p t d n include a valid prescrib] ,national ,provid] ,id5tifi]4 7,b7 ,proc$ures ,! ,secret>y %all e/abli% proc$ures = det]m9+ ! validity ( prescrib] ,national ,provid] ,id5tifi]s "u subp>agraph 7,a74 7,c7 ,report ,n lat] ?an ,janu>y #a1 #bjag1 ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices %all submit to ,congress a report on ! effectiv5ess ( ! proc$ures e/abli%$ "u subp>agraph 7,b74 4 7b7 ,re=m+ h[ ,,cms tracks & corrects ! vuln]abilities id5tifi$ by ,recov]y ,audit ,contractors ,section #ahic7;h7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77 is am5d$-- 7#a7 9 p>agraph 7#h71 z am5d$ by section #bca1 by add+ at ! end ! foll[+ new subp>agraphs3 7,c7 ,inclusion ( improp] paym5t vuln]abilities id5tifi$ ,= reports submitt$ "u ?is p>agraph = #bjae or a subsequ5t ye>1 ea* su* report %all include-- 7i7 a description (-- 7,i7 ! types & f9ancial co/ to ! program "u ?is title ( improp] paym5t vuln]abilities id5tifi$ by recov]y audit contractors "u ?is subsection2 & 7,,ii7 h[ ! ,secret>y is address+ su* improp] paym5t vuln]abilities2 & 7ii7 an assessm5t ( ! effectiv5ess ( *anges made to paym5t policies & proc$ures "u ?is title 9 ord] to address ! vuln]abilities s id5tifi$4 7,d7 ,limitation ,! ,secret>y %all ensure t ea* report submitt$ "u subp>agraph 7,a7 does n include in=mation t ! ,secret>y det]m9es w\ld be s5sitive or w\ld o!rwise negatively impact program integrity4 2 & 7#b7 by add+ at ! end ! foll[+ new p>agraph3 7#aj7 ,address+ improp] paym5t vuln]abilities ,! ,secret>y %all address improp] paym5t vuln]abilities id5tifi$ by recov]y audit contractors "u ?is subsection 9 a timely mann]1 prioritiz$ bas$ on ! risk to ! program "u ?is title4 4 7c7 ,/r5g!n+ ,m$icaid program integrity ?r\gh flexibility ,section #aicf ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#f7 is am5d$-- 7#a7 9 subsection 7a71 by ins]t+ 1 or o!rwise1 aft] entities2 & 7#b7 9 subsection 7e7-- 7,a7 9 p>agraph 7#a71 9 ! matt] prec$+ subp>agraph 7,a71 by ins]t+ 7includ+ ! co/s ( equipm5t1 sal>ies & b5efits1 & travel & tra9+7 aft] ,program "u ?is section2 & 7,b7 9 p>agraph 7#c71 by /rik+ by #ajj & ins]t+ by #ajj1 or su* numb] z det]m9$ necess>y by ! ,secret>y to c>ry out ! ,program "u ?is section14 7d7 ,access to ! ,national ,directory ( ,new ,hires ,section #dec7;j7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #fec7;j77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#ab7 ,in=mation comp>isons & disclosures to assi/ 9 adm9i/ration ( ! ,m$ic>e program & ,/ate heal? subsidy programs 7,a7 ,disclosure to ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid %all h access to ! in=mation 9 ! ,national ,directory ( ,new ,hires = purposes ( det]m9+ ! eligibility ( an applicant =1 or enrollee 91 ! ,m$ic>e program "u title ,,xviii or an applicable ,/ate heal? subsidy program 7z def9$ 9 section #adac7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjhc7;e774 7,b7 ,disclosure to ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices 7i7 ,9 g5]al ,if ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices transmits to ! ,secret>y ! names & social security acc\nt numb]s ( individuals1 ! ,secret>y %all disclose to ! ,inspector ,g5]al in=mation on su* individuals & _! employ]s ma9ta9$ 9 ! ,national ,directory ( ,new ,hires4 7ii7 ,use ( in=mation ,! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices may use in=mation provid$ "u clause 7i7 only = purposes ( -- 7,i7 det]m9+ ! eligibility ( an applicant =1 or enrollee 91 ! ,m$ic>e program "u title ,,xviii or an applicable ,/ate heal? subsidy program 7z def9$ 9 section #adac7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjhc7;e772 or 7,,ii7 evaluat+ ! integrity ( ! ,m$ic>e program or an applicable ,/ate heal? subsidy program 7z s def9$74 7,c7 ,disclosure to ,/ate ag5cies 7i7 ,9 g5]al ,if1 = purposes ( det]m9+ ! eligibility ( an applicant =1 or an enrollee 91 an applicable ,/ate heal? subsidy program 7z def9$ 9 section #adac7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjhc7;e771 a ,/ate ag5cy responsible = adm9i/]+ su* program transmits to ! ,secret>y ! names1 dates ( bir?1 & social security acc\nt numb]s ( individuals1 ! ,secret>y %all disclose to su* ,/ate ag5cy in=mation on su* individuals & _! employ]s ma9ta9$ 9 ! ,national ,directory ( ,new ,hires1 subject to ?is subp>agraph4 7ii7 ,condition on disclosure by ! ,secret>y ,! ,secret>y %all make a disclosure "u clause 7i7 only to ! ext5t t ! ,secret>y det]m9es t ! disclosure w\ld n int]f]e ) ! effective op]ation ( ! program "u ?is "p4 7iii7 ,use & disclosure ( in=mation by ,/ate ag5cies 7,i7 ,9 g5]al ,a ,/ate ag5cy may n use or disclose in=mation provid$ "u clause 7i7 except = purposes ( det]m9+ ! eligibility ( an applicant =1 or an enrollee 91 a program ref]r$ to 9 clause 7i74 7,,ii7 ,in=mation security ,! ,/ate ag5cy %all h 9 effect data security & control policies t ! ,secret>y f9ds adequate to ensure ! security ( in=mation obta9$ "u clause 7i7 & to ensure t access to su* in=mation is re/rict$ to au?oriz$ p]sons = purposes ( au?oriz$ uses & disclosures4 7,,iii7 ,p5alty = misuse ( in=mation ,an (fic] or employee ( ! ,/ate ag5cy :o fails to comply ) ?is clause %all be subject to ! sanctions "u subsection 7l77#b7 to ! same ext5t z if su* (fic] or employee 7 an (fic] or employee ( ! ,unit$ ,/ates4 7iv7 ,proc$ural requirem5ts ,/ate ag5cies reque/+ in=mation "u clause 7i7 %all adh]e to uni=m proc$ures e/abli%$ by ! ,secret>y gov]n+ in=mation reque/s & data mat*+ "u ?is p>agraph4 7v7 ,reimbursem5t ( co/s ,! ,/ate ag5cy %all reimburse ! ,secret>y1 9 accordance ) subsection 7k77#c71 = ! co/s incurr$ by ! ,secret>y 9 furni%+ ! in=mation reque/$ "u ?is subp>agraph4 4 7e7 ,improv+ ! %>+ ( data betwe5 ! ,f$]al ,gov]nm5t & ,/ate ,m$icaid programs 7#a7 ,9 g5]al ,! ,secret>y ( ,heal? & ,human ,s]vices 79 ?is subsection ref]r$ to z ! ,secret>y7 %all e/abli% a plan to enc\rage & facilitate ! p>ticipation ( ,/ates 9 ! ,m$ic>e-,m$icaid ,data ,mat* ,program 7commonly ref]r$ to z ! ,m$i-,m$i ,program7 "u section #ahic7;g7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7g774 7#b7 ,program revisions ,to improve ,m$i-,m$i ,data ,mat* ,program p>ticipation by ,/ates ,section #ahic7;g77#a77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7g77#a77;,a77 is am5d$-- 7,a7 9 ! matt] prec$+ clause 7i71 by ins]t+ or o!rwise aft] eligible entities2 7,b7 9 clause 7i7-- 7i7 by ins]t+ to review claims data aft] algori?ms2 & 7ii7 by /rik+ s]vice1 "t1 or pati5t & ins]t+ provid]1 s]vice1 "t1 or pati5t2 7,c7 9 clause 7ii7-- 7i7 by ins]t+ to inve/igate & recov] am\nts ) respect to suspect claims aft] appropriate actions2 & 7ii7 by /rik+ 2 & & ins]t+ a semicolon2 7,d7 9 clause 7iii71 by /rik+ ! p]iod & ins]t+ 2 &2 & 7,e7 by add+ at end ! foll[+ new clause3 7iv7 fur!r+ ! ,secret>y's design1 developm5t1 in/allation1 or enhancem5t ( an automat$ data sy/em ar*itecture-- 7,i7 to collect1 integrate1 & assess data = purposes ( program integrity1 program ov]sight1 & adm9i/ration1 includ+ ! ,m$i-,m$i ,program2 & 7,,ii7 t improves ! coord9ation ( reque/s = data f ,/ates4 4 7#c7 ,provid+ /ates ) data on improp] paym5ts made = items or s]vices provid$ to dual eligible individuals 7,a7 ,9 g5]al ,! ,secret>y %all develop & implem5t a plan t all[s ea* ,/ate ag5cy responsible = adm9i/]+ a ,/ate plan = m$ical assi/ance "u title ,,xix ( ! ,social ,security ,act access to relevant data on improp] or fraudul5t paym5ts made "u ! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq47 = heal? c>e items or s]vices provid$ to dual eligible individuals4 7,b7 ,dual eligible individual def9$ ,9 ?is p>agraph1 ! t]m dual eligible individual means an individual :o is entitl$ to1 or enroll$ =1 b5efits "u "p ,a ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;c et seq471 or enroll$ = b5efits "u "p ,b ( title ,,xviii ( su* ,act 7#db ,u4,s4,c4 #acie;j et seq471 & is eligible = m$ical assi/ance "u a ,/ate plan "u title ,,xix ( su* ,act 7#db ,u4,s4,c4 #acif et seq47 or "u a waiv] ( su* plan4 ,e ,o!r ,provisions #bda4 ,commission on ,improv+ ,pati5t ,direct$ ,heal? ,c>e 7a7 ,f9d+s ,congress f9ds ! foll[+3 7#a7 ,9 ord] to elevate ! role ( pati5t *oices 9 ! heal? c>e sy/em1 ! ,am]ican public mu/ engage 9 an in=m$1 national1 public debate on h[ ! curr5t heal? c>e sy/em emp[]s & in=ms heal? c>e decision-mak+1 & :at c be done to improve ! likelihood pati5ts receive ! c>e !y want & ne$4 7#b7 ,rese>* sugge/s t pati5ts (t5 d n receive ! c>e !y want4 ,z a result1 ! end ( life is associat$ ) a sub/antial burd5 ( suff]+ by ! pati5t & negative heal? & f9ancial consequ5ces t ext5d to family memb]s & society4 7#c7 ,pati5ts face a complex & fragm5t$ heal? c>e sy/em t may decrease ! likelihood t heal? c>e *oices are kn[n & c>ri$ out4 ,! heal? c>e sy/em %\ld emb$ pr9ciples t take into acc\nt pati5t wi%es4 7#d7 ,decisions conc]n+ heal? c>e1 includ+ end-(-life issues1 affect an increas+ numb] ( ,am]icans4 7#e7 ,m$ical advances are prolong+ life expectancy 9 ! ,unit$ ,/ates bo? 9 acute life-?reat5+ situations & protract$ battles ) illness4 ,^! advances raise new *all5ges surr\nd+ heal? c>e decision-mak+4 7#f7 ,! ,unit$ ,/ates heal? c>e sy/em %\ld promote consid]ation ( a p]son's pref]5ce 9 heal? c>e decision-mak+ & end-(-life *oices4 7b7 ,commission ,! ,social ,security ,act is am5d$ by ins]t+ aft] section #aaej;,b 7#db ,u4,s4,c4 #acbj;b-#bd7 ! foll[+ new section3 #aaej;,c4 ,commission on ,improv+ ,pati5t ,direct$ ,heal? ,c>e 7a7 ,purposes ,! purposes ( ?is section are to-- 7#a7 provide a =um = a nationwide public debate on improv+ pati5t self-det]m9ation 9 heal? c>e decision-mak+2 7#b7 id5tify /rategies t ensure e ,am]ican has ! heal? c>e !y want2 & 7#c7 provide recomm5dations to ,congress t result f ! debate4 7b7 ,e/abli%m5t ,! ,secret>y %all e/abli% an entity to be kn[n z ! ,commission on ,improv+ ,pati5t ,direct$ ,heal? ,c>e 7ref]r$ to 9 ?is section z ! ,commission74 7c7 ,memb]%ip 7#a7 ,numb] & appo9tm5t ,! ,commission %all be compos$ ( #ae memb]s4 ,"o memb] %all be ! ,secret>y4 ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all appo9t #ad memb]s4 7#b7 ,qualifications ,! memb]%ip ( ! ,commission %all include-- 7,a7 heal? c>e consum]s impact$ by decision-mak+ 9 advance ( a heal? c>e crisis1 su* z individuals ( advanc$ age1 individuals ) *ronic1 t]m9al & m5tal illnesses1 family c>e giv]s1 & individuals ) disabilities2 7,b7 provid]s 9 sett+s :]e crucial heal? c>e decision-mak+ occurs1 su* z ^? work+ 9 int5sive c>e sett+s1 em]g5cy room dep>tm5ts1 prim>y c>e sett+s1 nurs+ homes1 hospice1 or palliative c>e sett+s2 7,c7 payors ensur+ pati5ts get ! level ( c>e !y want2 7,d7 exp]ts 9 advance c>e plann+1 hospice1 palliative c>e1 in=mation te*nology1 bioe?ics1 ag+ policy1 disability policy1 p$iatric e?ics1 cultural s5sitivity1 psy*ology1 & heal? c>e f9anc+2 7,e7 individuals :o repres5t culturally div]se p]spectives on pati5t self-det]m9ation & end-(-life issues2 & 7,f7 memb]s ( ! fai? community4 7d7 ,p]iod ( appo9tm5t ,memb]s ( ! ,commission %all be appo9t$ = ! life ( ! ,commission4 ,any vacancies %all n affect ! p[] & duties ( ! ,commission b %all be fill$ 9 ! same mann] z ! orig9al appo9tm5t4 7e7 ,designation ( ! *airp]son ,n lat] ?an #ae days aft] ! date on :i* all memb]s ( ! ,commission h be5 appo9t$1 ! ,comptroll] ,g5]al %all designate ! *airp]son ( ! ,commission4 7f7 ,subcommittees ,! ,commission may e/abli% subcommittees if do+ s increases ! effici5cy ( ! ,commission 9 complet+ tasks4 7g7 ,duties 7#a7 ,he>+s ,n lat] ?an #ij days aft] ! date ( designation ( ! *airp]son "u subsection 7e71 ! ,commission %all hold no few] ?an #h he>+s to exam9e-- 7,a7 ! curr5t /ate ( heal? c>e decision-mak+ & advance c>e plann+ laws 9 ! ,unit$ ,/ates at ! ,f$]al level & across ! ,/ates1 z well z options = improv+ advance c>e plann+ tools1 especially ) reg>d to use1 portability1 & /orage2 7,b7 consum]-focus$ approa*es t educate ! ,am]ican public ab\t pati5t *oices1 c>e plann+1 & o!r end-(-life issues2 7,c7 ! use ( compreh5sive1 pati5t-c5t]$ c>e plans by provid]s1 ! impact c>e plans h on heal? c>e deliv]y1 & me?ods to exp& ! use ( high quality c>e plann+ tools 9 bo? public & private heal? c>e sy/ems2 7,d7 ! role ( electronic m$ical records & o!r te*nologies 9 improv+ pati5t-direct$ heal? c>e2 7,e7 innovative tools = improv+ pati5t exp]i5ce ) advanc$ illness1 su* z palliative c>e1 hospice1 & o!r models2 7,f7 ! role social det]m9ants ( heal?1 su* z socio-economic /atus1 play 9 pati5t self-direction 9 heal? c>e2 7,g7 ! use ( culturally-compet5t tools = heal? c>e decision-mak+2 7,h7 /rategies = educat+ provid]s on c>e plann+1 palliative c>e1 hospice c>e1 & o!r issues surr\nd+ honor+ pati5t *oices2 7,i7 ! sociological & psy*ological factors t influ5ce heal? c>e decision-mak+ & end-(-life *oices2 & 7,j7 ! role ( spirituality & religion 9 pati5t self-det]m9ation 9 heal? c>e4 7#b7 ,additional he>+s ,! ,commission may hold additional he>+s on subjects o!r ?an ^? li/$ 9 p>agraph 7#a7 s long z su* he>+s are det]m9$ necess>y by ! ,commission 9 c>ry+ out ! purposes ( ?is section4 ,su* additional he>+s d n h to be complet$ )9 ! "t p]iod specifi$ b %all n delay ! o!r activities ( ! ,commission "u ?is section4 7#c7 ,numb] & location ( he>+s & additional he>+s ,! ,commission %all hold no few] ?an #h he>+s z indicat$ 9 p>agraph 7#a7 & 9 suffici5t numb] 9 ord] to receive in=mation t reflects-- 7,a7 ! geographic diff]5ces ?r\gh\t ! ,unit$ ,/ates2 7,b7 div]se populations2 & 7,c7 a balance among urban & rural populations4 7#d7 ,int]active te*nology ,! ,commission may enc\rage public p>ticipation 9 he>+s ?r\gh int]active te*nology & o!r means z det]m9$ appropriate by ! ,commission4 7#e7 ,report to ! am]ican p on pati5t direct$ heal? c>e ,n lat] ?an #ij days aft] ! he>+s describ$ 9 p>agraphs 7#a7 & 7#b7 are complet$1 ! ,commission %all prep>e & make available to heal? c>e consum]s ?r\gh ! ,int]net & o!r appropriate public *annels1 a report to be entitl$1 ,report to ! ,am]ican ,p on ,pati5t ,direct$ ,heal? ,c>e4 ,su* a report %all be und]/&able to ! g5]al public & include-- 7,a7 a summ>y (-- 7i7 ! he>+s describ$ 9 su* p>agraphs2 7ii7 h[ ! curr5t heal? c>e sy/em emp[]s & in=ms decision-mak+ 9 advance ( a heal? c>e crisis2 7iii7 factors t contribute to ! provision ( heal? c>e t does n adh]e to pati5t wi%es2 7iv7 ! impact ( c>e t does n foll[ pati5t *oices1 p>ticul>ly at ! end-(-life1 on pati5ts1 families1 provid]s1 & ! heal? c>e sy/em2 7v7 ! laws surr\nd+ advance c>e plann+ & heal? c>e decision-mak+ includ+ issues ( portability1 use1 & /orage2 7vi7 consum]-focus$ approa*es to education ( ! ,am]ican public ab\t pati5t *oices1 c>e plann+1 & o!r end-(-life issues2 7vii7 ! role ( c>e plans 9 heal? c>e decision-mak+2 7viii7 ! role ( provid]s 9 ensur+ pati5ts receive ! c>e !y want2 7ix7 ! role ( electronic m$ical records & o!r te*nologies 9 improv+ pati5t direct$ heal? c>e2 7x7 ! impact ( social det]m9ants on pati5t self-direction 9 heal? c>e s]vices2 7xi7 ! use ( culturally compet5t me?ods = heal? c>e decision-mak+2 7xii7 ! sociological & psy*ological factors t influ5ce pati5t self-det]m9ation2 & 7xiii7 ! role ( spirituality & religion 9 heal? c>e decision-mak+ & end-(-life c>e2 7,b7 be/ practices f communities1 provid]s1 & payors t docum5t pati5t wi%es & provide heal? c>e t adh]es to ^? wi%es2 & 7,c7 in=mation on educat+ provid]s ab\t heal? c>e decision-mak+ & end-(-life issues4 7#f7 ,int]im requirem5ts ,n lat] ?an #ahj days aft] ! date ( completion ( ! he>+s1 ! ,commission %all prep>e & make available to ! public ?r\gh ! ,int]net & o!r appropriate public *annels1 an int]im set ( recomm5dations on pati5t self-det]m9ation 9 heal? c>e & ways to improve & /r5g!n ! heal? c>e sy/em bas$ on ! in=mation & pref]5ces express$ at ! community meet+s4 ,!re %all be a #ij-;day public comm5t p]iod on su* recomm5dations4 7h7 ,recomm5dations ,n lat] ?an #abj days aft] ! expiration ( ! public comm5t p]iod describ$ 9 subsection 7g77#f71 ! ,commission %all submit to ,congress & ! ,presid5t a f9al set ( recomm5dations4 ,! recomm5dations mu/ be compreh5sive & detail$4 ,! recomm5dations mu/ conta9 recomm5dations or proposals = legislative or adm9i/rative action z ! ,commission deems appropriate1 includ+ propos$ legislative language to c>ry out ! recomm5dations or proposals4 7i7 ,adm9i/ration 7#a7 ,executive director ,!re %all be an ,executive ,director ( ! ,commission :o %all be appo9t$ by ! *airp]son ( ! ,commission 9 consultation ) ! memb]s ( ! ,commission4 7#b7 ,comp5sation ,:ile s]v+ on ! bus9ess ( ! ,commission 7includ+ travel "t71 a memb] ( ! ,commission %all be entitl$ to comp5sation at ! p] diem equival5t ( ! rate provid$ = level ,,iv ( ! ,executive ,s*$ule "u section #ecae ( title #e1 ,unit$ ,/ates ,code1 & :ile s s]v+ away f home & ! memb]'s regul> place ( bus9ess1 a memb] may be all[$ travel exp5ses1 z au?oriz$ by ! *airp]son ( ! ,commission4 ,= purposes ( pay & employm5t b5efits1 rights1 & privileges1 all p]sonnel ( ! ,commission %all be treat$ z if !y 7 employees ( ! ,s5ate4 7#c7 ,in=mation f f$]al ag5cies ,! ,commission may secure directly f any ,f$]al dep>tm5t or ag5cy su* in=mation z ! ,commission consid]s necess>y to c>ry out ?is section4 ,^u reque/ ( ! ,commission ! head ( su* dep>tm5t or ag5cy %all furni% su* in=mation4 7#d7 ,po/al s]vices ,! ,commission may use ! ,unit$ ,/ates mails 9 ! same mann] & "u ! same conditions z o!r dep>tm5ts & ag5cies ( ! ,f$]al ,gov]nm5t4 7j7 ,detail ,n m ?an #e ,f$]al ,gov]nm5t employees employ$ by ! ,dep>tm5t ( ,labor1 #e ,f$]al ,gov]nm5t employees employ$ by ! ,social ,security ,adm9i/ration1 & #aj ,f$]al ,gov]nm5t employees employ$ by ! ,dep>tm5t ( ,heal? & ,human ,s]vices may be detail$ to ! ,commission "u ?is section )\t fur!r reimbursem5t4 ,any detail ( an employee %all be )\t int]ruption or loss ( civil s]vice /atus or privilege4 7k7 ,tempor>y & int]mitt5t s]vices ,! *airp]son ( ! ,commission may procure tempor>y & int]mitt5t s]vices "u section #caji7;b7 ( title #e1 ,unit$ ,/ates ,code1 at rates = individuals :i* d n exce$ ! daily equival5t ( ! annual rate ( basic pay prescrib$ = level ,v ( ! ,executive ,s*$ule "u section #ecaf ( su* title4 7l7 ,annual report ,n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is ,act1 & annually !reaft] dur+ ! exi/5ce ( ! ,commission1 ! ,commission %all report to ,congress & make public a detail$ description ( ! exp5ditures ( ! ,commission us$ to c>ry out its duties "u ?is section4 7m7 ,sunset ( commission ,! ,commission %all t]m9ate on ! date t is #d ye>s aft] ! date on :i* all ! memb]s ( ! ,commission h be5 appo9t$ "u subsection 7c77#a7 & appropriations are fir/ made available to c>ry out ?is section4 7n7 ,adm9i/ration review & comm5ts ,n lat] ?an #de days aft] receiv+ ! f9al recomm5dations ( ! ,commission "u subsection 7h71 ! ,presid5t %all submit a report to ,congress :i* %all conta9-- 7#a7 additional views & comm5ts on su* recomm5dations2 & 7#b7 recomm5dations = su* legislation & adm9i/rative action z ! ,presid5t consid]s appropriate4 7o7 ,requir$ congressional action ,n lat] ?an #de days aft] receiv+ ! report submitt$ by ! ,presid5t "u subsection 7n71 ea* committee ( jurisdiction ( ,congress1 ! ,committee on ,f9ance ( ! ,s5ate1 ! ,committee on ,heal?1 ,education1 ,labor1 & ,p5sions ( ! ,s5ate1 ! ,committee on ,ways & ,means ( ! ,h\se ( ,repres5tatives1 ! ,committee on ,en]gy & ,comm]ce ( ! ,h\se ( ,repres5tatives1 & ! ,committee on ,education & ! ,work=ce ( ! ,h\se ( ,repres5tatives1 %all hold at lea/ #a he>+ on su* report & on ! f9al recomm5dations ( ! ,commission submitt$ "u subsection 7h74 7p7 ,au?orization ( appropriations 7#a7 ,9 g5]al ,!re are au?oriz$ to be appropriat$ to c>ry out ?is section1 #c1jjj1jjj = ea* ( fiscal ye>s #bjad & #bjae4 7#b7 ,report to ! ,am]ican p on pati5t direct$ heal? c>e ,!re are au?oriz$ to be appropriat$ = ! prep>ation & dissem9ation ( ! ,report to ! ,am]ican ,p on ,pati5t ,direct$ ,heal? ,c>e describ$ 9 subsection 7g77#e71 su* sums z may be necess>y = ! fiscal ye> 9 :i* ! report is requir$ to be submitt$4 4 #bdb4 ,expansion ( ! def9ition ( inpati5t hospital s]vices = c]ta9 canc] hospitals ,section #ahfa7;b77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7b77#c77 is am5d$-- 7#a7 by ins]t+ 7,a7 aft] 7#c72 & 7#b7 by add+ & aft] ! semicolon at ! end2 & 7#c7 by add+ at ! end ! foll[+ new subp>agraph3 7,b7 ) respect to a hospital t is describ$ 9 section #ahhf7;d77#a77;,b77v7 & t1 z ( ! date ( ! enactm5t ( ! ,,sgr ,repeal & ,m$ic>e ,b5efici>y ,access ,act ( #bjac1 is locat$ 9 ! same build+1 or on ! same campus1 z ano!r hospital1 items & s]vices describ$ 9 p>agraphs 7#a7 & 7#b7 furni%$ on or aft] su* date ( enactm5t by ! hospital describ$ 9 su* section or by o!rs "u arrangem5ts ) !m made by ! hospital2 4 #bdc4 ,quality measures = c]ta9 po/-acute c>e provid]s relat+ to notice & transf] ( pati5t heal? in=mation & pati5t c>e pref]5ces 7a7 ,developm5t ,! ,secret>y ( ,heal? & ,human ,s]vices 79 ?is section ref]r$ to z ! ,secret>y7 %all provide = ! developm5t ( "o or m quality measures "u title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq47 to accurately communicate ! exi/5ce & provide = ! transf] ( pati5t heal? in=mation & pati5t c>e pref]5ces :5 an individual transitions f a hospital to return home or move to o!r po/-acute c>e sett+s4 7b7 ,use ( measure develop]s ,! ,secret>y %all arrange = ! developm5t ( su* measures by appropriate measure develop]s4 7c7 ,endorsem5t ,! ,secret>y %all arrange = su* develop$ measures to be submitt$ = endorsem5t to a cons5sus-bas$ entity z describ$ 9 section #ahij7;a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;aaa7a771 z am5d$ by section #bjh4 7d7 ,use ( measures ,! ,secret>y %all1 ?r\gh notice & comm5t rulemak+1 use su* measures "u ! quality report+ programs ) respect to-- 7#a7 inpati5t hospitals "u section #ahhf7;b77#c77;,b77viii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7b77#c77;,b77viii772 7#b7 skill$ nurs+ facilities "u section #ahhh7;e7 ( su* ,act 7#db ,u4,s4,c4 #acieyy7e772 7#c7 home heal? s]vices "u section #ahie7;b77#c77;,b77v7 ( su* ,act 7#db ,u4,s4,c4 #acie;fff7b77#c77;,b77v772 & 7#d7 o!r provid]s ( s]vices 7z def9$ 9 section #ahfa7u7 ( su* ,act7 & suppli]s 7z def9$ 9 section #ahfa7;d7 ( su* ,act7 t ! ,secret>y det]m9es appropriate4 #bdd4 ,crit]ia = m$ically necess>y1 %ort inpati5t hospital /ays 7a7 ,9 g5]al ,! ,secret>y ( ,heal? & ,human ,s]vices %all consult )1 & seek input f1 int]e/$ /akehold]s to det]m9e appropriate crit]ia = paym5t "u ! ,m$ic>e program "u title ,,viii ( ! ,social ,security ,act ( an inpati5t hospital admission t-- 7#a7 is m$ically necess>y2 & 7#b7 is an inpati5t hospital /ay t is less ?an two midnights1 z describ$ 9 section #dab4c ( title #db1 ,code ( ,f$]al ,regulation1 z f9aliz$ 9 ! f9al rule publi%$ by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices 9 ! ,f$]al ,regi/] on ,augu/ #ai1 #bjac 7#gh ,f$]al ,regi/] #ejdif7 entitl$ ,m$ic>e ,program2 ,hospital ,inpati5t ,prospective ,paym5t ,sy/ems = ,acute ,c>e ,hospitals & ! ,long-,t]m ,c>e ,hospital ,prospective ,paym5t ,sy/em & ,fiscal ,ye> #bjad ,rates2 ,quality ,report+ ,requirem5ts = ,specific ,provid]s2 ,hospital ,conditions ( ,p>ticipation2 ,paym5t ,policies ,relat$ to ,pati5t ,/atus4 7b7 ,int]e/$ /akehold]s ,9 subsection 7a71 ! t]m int]e/$ /akehold]s means ! foll[+3 7#a7 ,hospitals4 7#b7 ,physicians 7#c7 ,m$ic>e adm9i/rative contractors "u section #ahgd;,a ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciekk-#a74 7#d7 ,recov]y audit contractors "u section #ahic7;h7 ( su* ,act 7#db ,u4,s4,c4 #acie;ddd7h774 7#e7 ,o!r p>ties det]m9$ appropriate by ! ,secret>y4 #bde4 ,transp>5cy ( reasons = exclud+ additional proc$ures f ! ,m$ic>e ambulatory surgical c5t] 7,,asc7 approv$ li/ ,section #ahcc7;i77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7i77#a77 is am5d$ by add+ at ! end ! foll[+3 ,9 updat+ su* li/s = application 9 ye>s beg9n+ aft] ,decemb] #ca1 #bjad1 = ea* proc$ure t 0 reque/$ to be includ$ on su* li/s dur+ ! public comm5t p]iod b :i* ! ,secret>y does n propose 79 ! f9al rule updat+ su* li/s7 to s include1 ! ,secret>y %all describe 9 su* f9al rule ! specific safety crit]ia = n includ+ su* proc$ure on su* li/s44 #bdf4 ,sup]vision 9 critical access hospitals 7a7 ,g5]al sup]vision 9 critical access hospitals ,section #ahcd7;g7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7g77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#f7 ,sup]vision ,9 ! case ( s]vices furni%$ on or aft] ! date ( ! enactm5t ( ?is p>agraph1 ! level ( sup]vision ) respect to outpati5t critical access hospital s]vices %all be g5]al sup]vision 7z def9$ by ! ,secret>y74 4 7b7 ,sup]vision ( c>diac & pulmon>y rehabilitation programs 9 critical access hospitals ,section #ahfa7;eee77#b77;,b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7eee77#b77;,b77 is am5d$ by ins]t+ 1 or 9 ! case ( a critical access hospital1 a physician1 or 7beg9n+ on ! date ( enactm5t ( ! ,,sgr ,repeal & ,m$ic>e ,b5efici>y ,access ,act ( #bjac7 a nurse practition]1 cl9ical nurse speciali/1 or physician assi/ant 7z su* t]ms are def9$ 9 subsection 7aa77#e771 aft] a physician4 #bdg4 ,requir+ ,/ate lic5sure ( bidd+ entities "u ! competitive acquisition program = c]ta9 durable m$ical equipm5t1 pro/hetics1 or?otics1 & supplies 7,,dmepos7 ,section #ahdg7;a77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c7;a77#a77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,g7 ,requir+ ,/ate lic5sure ( bidd+ entities ,) respect to r\nds ( competitions beg9n+ on or aft] ! date ( enactm5t ( ?is subp>agraph1 ! ,secret>y may only accept a bid f an entity = an area if ! entity meets applicable ,/ate lic5sure requirem5ts = su* area = all items 9 su* bid4 4 #bdh4 ,recognition ( att5d+ physician assi/ants z att5d+ physicians ,to s]ve hospice pati5ts 7a7 ,recognition ( att5d+ physician assi/ants z att5d+ physicians ,to s]ve hospice pati5ts 7#a7 ,9 g5]al ,section #ahfa7;dd77#c77;,b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7dd77#c77;,b77 is am5d$-- 7,a7 by /rik+ or nurse & ins]t+ 1 ! nurse2 & 7,b7 by ins]t+ 1 or ! physician assi/ant 7z def9$ 9 su* subsection7 aft] subsection 7aa77#e774 7#b7 ,cl>ification ( hospice role ( physician assi/ants ,section #ahad7;a77#g77;,a77i77,i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a77#g77;,a77i77,i77 is am5d$ by ins]t+ or a physician assi/ant aft] a nurse practition]4 7b7 ,effective date ,! am5dm5ts made by ?is section %all apply to items & s]vices furni%$ on or aft] ,janu>y #a1 #bjae4 #bdi4 ,remote pati5t monitor+ pilot projects 7a7 ,pilot projects 7#a7 ,9 g5]al ,n lat] ?an #i mon?s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y %all conduct pilot projects "u title ,,xviii ( ! ,social ,security ,act = ! purpose ( provid+ inc5tives to home heal? ag5cies to furni% remote pati5t monitor+ s]vices t r$uce exp5ditures "u su* title4 7#b7 ,site requirem5ts 7,a7 ,urban & ,rural ,! ,secret>y %all conduct ! pilot projects "u ?is section 9 bo? urban & rural areas4 7,b7 ,site 9 a small /ate ,! ,secret>y %all conduct at lea/ #a ( ! pilot projects 9 a ,/ate ) a population ( less ?an #a1jjj1jjj4 7b7 ,m$ic>e b5efici>ies )9 ! scope ( projects 7#a7 ,9 g5]al ,! ,secret>y %all specify ! crit]ia = id5tify+ ^? ,m$ic>e b5efici>ies :o %all be consid]$ )9 ! scope ( ! pilot projects "u ?is section = purposes ( ! application ( subsection 7c7 & = ! assessm5t ( ! effectiv5ess ( ! home heal? ag5cy 9 a*iev+ ! objectives ( ?is section4 7#b7 ,crit]ia ,! crit]ia specifi$ "u p>agraph 7#a7-- 7,a7 %all include conditions & cl9ical circum/ances1 includ+ conge/ive he>t failure1 diabetes1 & *ronic pulmon>y ob/ructive disease1 & o!r conditions det]m9$ appropriate by ! ,secret>y2 & 7,b7 may provide = ! inclusion 9 ! projects ( ,m$ic>e b5efici>ies :o beg9 receiv+ home heal? s]vices "u title ,,xviii ( ! ,social ,security ,act aft] ! date ( ! implem5tation ( ! projects4 7c7 ,inc5tives 7#a7 ,p]=mance t>gets ,! ,secret>y %all e/abli% = ea* home heal? ag5cy p>ticipat+ 9 a pilot project "u ?is section a p]=mance t>get us+ "o ( ! foll[+ me?odologies1 z det]m9$ appropriate by ! ,secret>y3 7,a7 ,adju/$ hi/orical p]=mance t>get ,! ,secret>y %all e/abli% = ! ag5cy-- 7i7 a base exp5diture am\nt equal to ! av]age total paym5ts made "u p>ts ,a1 ,b1 & ,d ( title ,,xviii ( ! ,social ,security ,act = ,m$ic>e b5efici>ies det]m9$ to be )9 ! scope ( ! pilot project 9 a base p]iod det]m9$ by ! ,secret>y2 & 7ii7 an annual p] capita exp5diture t>get = su* b5efici>ies1 reflect+ ! base exp5diture am\nt adju/$ = risk1 *anges 9 co/s1 & gr[? rates4 7,b7 ,comp>ative p]=mance t>get ,! ,secret>y %all e/abli% = ! ag5cy a comp>ative p]=mance t>get equal to ! av]age total paym5ts made "u su* p>ts ,a1 ,b1 & ,d dur+ ! pilot project = comp>able individuals 9 ! same geographic area t are n det]m9$ to be )9 ! scope ( ! pilot project4 7#b7 ,paym5t ,subject to p>agraph 7#c71 ! ,secret>y %all pay to ea* home heal? ag5cy p>ticipat+ 9 a pilot project a paym5t = ea* ye> "u ! pilot project equal to a #ge p]c5t %>e ( ! total ,m$ic>e co/ sav+s realiz$ = su* ye> relative to ! p]=mance t>get "u p>agraph 7#a74 7#c7 ,limitation on exp5ditures ,! ,secret>y %all limit paym5ts "u ?is section 9 ord] to ensure t ! aggregate exp5ditures "u title ,,xviii ( ! ,social ,security ,act 7includ+ paym5ts "u ?is subsection7 d n exce$ ! am\nt t ! ,secret>y e/imates w\ld h be5 exp5d$ if ! pilot projects "u ?is section _h n be5 implem5t$1 includ+ any reasonable co/s incurr$ by ! ,secret>y 9 ! adm9i/ration ( ! pilot projects4 7#d7 ,no duplication 9 p>ticipation 9 %>$ sav+s programs ,a home heal? ag5cy t p>ticipates 9 any ( ! foll[+ %all n be eligible to p>ticipate 9 ! pilot projects "u ?is section3 7,a7 ,a model te/$ or exp&$ "u section #aaae;,a ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7 t involves %>$ sav+s "u title ,,xviii ( su* ,act or any o!r program or demon/ration project t involves su* %>$ sav+s4 7,b7 ,! indep5d5ce at home m$ical practice demon/ration program "u section #ahff;,e ( su* ,act 7#db ,u4,s4,c4 #acie;cc-#e74 7d7 ,waiv] au?ority ,! ,secret>y may waive su* provisions ( titles ,,xi & ,,xviii ( ! ,social ,security ,act z ! ,secret>y det]m9es to be appropriate = ! conduct ( ! pilot projects "u ?is section4 7e7 ,report to ,congress ,n lat] ?an #c ye>s aft] ! date t ! fir/ pilot project "u ?is section is implem5t$1 ! ,secret>y %all submit to ,congress a report on ! projects4 ,su* report %all conta9-- 7#a7 a detail$ description ( ! projects1 includ+ any *anges 9 cl9ical outcomes = ,m$ic>e b5efici>ies "u ! projects1 ,m$ic>e b5efici>y satisfaction "u ! projects1 utilization ( items & s]vices "u p>ts ,a1 ,b1 & ,d ( title ,,xviii ( ! ,social ,security ,act by ,m$ic>e b5efici>ies "u ! projects1 & ,m$ic>e p]-b5efici>y & ,m$ic>e aggregate sp5d+ "u ! projects2 7#b7 a detail$ description ( issues relat$ to ! expansion ( ! projects "u subsection 7f72 7#c7 recomm5dations = su* legislation & adm9i/rative actions z ! ,secret>y consid]s appropriate2 & 7#d7 o!r items consid]$ appropriate by ! ,secret>y4 7f7 ,expansion ,if ! ,secret>y det]m9es t any ( ! pilot projects "u ?is section enhance heal? outcomes = ,m$ic>e b5efici>ies & r$uce exp5ditures "u title ,,xviii ( ! ,social ,security ,act1 ! ,secret>y %all initiate comp>able projects 9 additional areas4 7g7 ,paym5ts h no effect on o!r ,m$ic>e paym5ts to home heal? ag5cies ,a paym5t "u ?is section %all h no effect on ! am\nt ( paym5ts t a home heal? ag5cy w\ld o!rwise receive "u title ,,xviii ( ! ,social ,security ,act = ! provision ( home heal? s]vices4 7h7 ,/udy & report on ! appropriate valuation = remote pati5t monitor+ s]vices "u ! ,m$ic>e physician fee s*$ule 7#a7 ,/udy ,! ,secret>y %all conduct a /udy on ! appropriate valuation = remote pati5t monitor+ s]vices "u ! ,m$ic>e physician fee s*$ule "u section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 9 ord] to accurately reflect ! res\rces involv$ 9 furni%+ su* s]vices4 7#b7 ,report ,n lat] ?an #f mon?s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y %all submit to ,congress a report on ! /udy conduct$ "u p>agraph 7#a71 toge!r ) su* recomm5dations z ! ,secret>y det]m9es appropriate4 7i7 ,def9itions ,9 ?is section3 7#a7 ,home heal? ag5cy ,! t]m home heal? ag5cy has ! mean+ giv5 t t]m 9 section #ahfa7o7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7o774 7#b7 ,remote pati5t monitor+ s]vices 7,a7 ,9 g5]al ,! t]m remote pati5t monitor+ s]vices means s]vices furni%$ 9 ! home us+ remote pati5t monitor+ te*nology :i*-- 7i7 %all include pati5t monitor+ or pati5t assessm5t2 & 7ii7 may include 9-home te*nology-bas$ pr(essional consultations1 pati5t tra9+ s]vices1 cl9ical obs]vation1 treatm5t1 & any additional s]vices t utilize te*nologies specifi$ by ! ,secret>y4 7,b7 ,limitation ,! t]m remote pati5t monitor+ s]vices %all n include a telecommunication t consi/s solely ( a telephone audio conv]sation1 facsimile1 or electronic text mail betwe5 a heal? c>e pr(essional & a pati5t4 7#c7 ,remote pati5t monitor+ te*nology ,! t]m remote pati5t monitor+ te*nology means a coord9at$ sy/em t uses "o or m home-bas$ or mobile monitor+ devices t automatically transmit vital sign data or in=mation on activities ( daily liv+ & may include responses to assessm5t que/ions collect$ on ! devices wirelessly or ?r\gh a telecommunications connection to a s]v] t complies ) ! ,f$]al regulations 7conc]n+ ! privacy ( individually id5tifiable heal? in=mation7 promulgat$ "u section #bfd7;c7 ( ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif1 z "p ( an e/abli%$ plan ( c>e = t pati5t t includes ! review & int]pretation ( t data by a heal? c>e pr(essional4 7#d7 ,secret>y ,! t]m ,secret>y means ! ,secret>y ( ,heal? & ,human ,s]vices4 #bej4 ,community-,bas$ ,in/itutional ,special ,ne$s ,plan ,demon/ration ,program 7a7 ,9 g5]al ,! ,secret>y ( ,heal? & ,human ,s]vices 7ref]r$ to 9 ?is section z ! ,secret>y7 %all e/abli% a ,community-,bas$ ,in/itutional ,special ,ne$s ,plan 7,,cbi-,,snp7 demon/ration program to prev5t & delay in/itutionalization "u ,m$icaid among t>get$ l[-income ,m$ic>e b5efici>ies4 7b7 ,e/abli%m5t ,! ,secret>y %all ent] into agreem5ts ) n m ?an #e specializ$ ,,ma plans = special ne$s individuals1 z def9$ 9 section #ahei7;b77#f77;,b77i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;b77#f77;,b77i771 to conduct ! ,,cbi-,,snp demon/ration program4 ,"u ! ,,cbi-,,snp demon/ration program1 a t>get$ l[-income ,m$ic>e b5efici>y %all receive1 z supplem5tal b5efits "u section #aheb7;a77#c7 ( su* ,act 7#db ,u4,s4,c4 #aciew-#bb7;a77#c771 long-t]m c>e s]vices or supports t-- 7#a7 ! ,secret>y det]m9es appropriate = ! purposes ( ! ,,cbi-,,snp demon/ration program2 & 7#b7 = :i* paym5t may be made "u ! ,/ate plan "u title ,,xix ( su* ,act 7#db ,u4,s4,c4 #acif et seq47 ( ! ,/ate 9 :i* ! t>get$ l[-income ,m$ic>e b5efici>y is locat$4 7c7 ,eligible plans ,to be eligible to p>ticipate 9 ! ,,cbi-,,snp demon/ration program1 a specializ$ ,,ma plan = special ne$s individuals mu/-- 7#a7 s]ve special ne$s individuals 7z def9$ 9 section #ahei7;b77#f77;,b77i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;b77#f77;,b77i772 7#b7 h exp]i5ce 9 (f]+ special ne$s plans = nurs+ home-eligible1 non-in/itutionaliz$ ,m$ic>e b5efici>ies :o live 9 ! community2 7#c7 be locat$ 9 a ,/ate t ! ,secret>y has det]m9$ w p>ticipate 9 ! ,,cbi-,,snp demon/ration program by agree+ to make available data necess>y = purposes ( conduct+ ! indep5d5t evaluation requir$ "u subsection 7f72 & 7#d7 meet su* o!r crit]ia z ! ,secret>y may require4 7d7 ,t>get$ l[-income ,m$ic>e b5efici>y def9$ ,9 ?is section1 ! t]m t>get$ l[-income ,m$ic>e b5efici>y means a ,m$ic>e b5efici>y :o-- 7#a7 is enroll$ 9 a specializ$ ,,ma plan = special ne$s individuals t has be5 select$ to p>ticipate 9 ! ,,cbi-,,snp demon/ration program2 7#b7 is a subsidy eligible individual 7z def9$ 9 section #ahfj;,d-#ad7;a77#c77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aad7;a77#c77;,a772 & 7#c7 is unable to p]=m #b or m activities ( daily liv+ 7z def9$ 9 section #ggjb;,b7c77#b77;,b7 ( ! ,int]nal ,rev5ue ,code ( #aihf74 7e7 ,implem5tation deadl9e2 duration ,! ,,cbi-,,snp demon/ration program %all be implem5t$ n lat] ?an ,janu>y #a1 #bjaf1 & %all be conduct$ = a p]iod ( #c ye>s4 7f7 ,indep5d5t evaluation & reports 7#a7 ,indep5d5t evaluation ,n lat] ?an #b ye>s aft] ! completion ( ! ,,cbi-,,snp demon/ration program1 ! ,secret>y %all provide = ! evaluation ( ! ,,cbi-,,snp demon/ration program by an indep5d5t ?ird p>ty4 ,! evaluation %all det]m9e :e!r ! ,,cbi-,,snp demon/ration program has improv$ pati5t c>e & quality ( life = ! t>get$ l[-income ,m$ic>e b5efici>ies p>ticipat+ 9 ! ,,cbi-,,snp demon/ration program4 ,specifically1 ! evaluation %all det]m9e if ! ,,cbi-,,snp demon/ration program has-- 7,a7 r$uc$ hospitalizations or re-hospitalizations2 7,b7 r$uc$ ,m$icaid nurs+ home facility /ays2 & 7,c7 r$uc$ sp5dd[n ( income & assets = purposes ( becom+ eligible = ,m$icaid4 7#b7 ,reports ,n lat] ?an #c ye>s aft] ! completion ( ! ,,cbi-,,snp demon/ration program1 ! ,secret>y %all submit to ,congress a report conta9+ ! results ( ! evaluation conduct$ "u p>agraph 7#a71 toge!r ) su* recomm5dations = legislative or adm9i/rative action z ! ,secret>y det]m9es appropriate4 7g7 ,fund+ 7#a7 ,fund+ = implem5tation ,= purposes ( c>ry+ out ! demon/ration program "u ?is section 7o!r ?an ! evaluation & report "u subsection 7f771 ! ,secret>y %all provide = ! transf] f ! ,f$]al ,hospital ,insurance ,tru/ ,fund "u section #ahag ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;i7 & ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda ( su* ,act 7#db ,u4,s4,c4 #aciet71 9 su* proportion z ! ,secret>y det]m9es appropriate1 ( #c1jjj1jjj to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ,program ,managem5t ,acc\nt4 7#b7 ,fund+ = evaluation & report ,= purposes ( c>ry+ out ! evaluation & report "u subsection 7f71 ! ,secret>y %all provide = ! transf] f ! ,f$]al ,hospital ,insurance ,tru/ ,fund "u su* section #ahag & ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u su* section #ahda1 9 su* proportion z ! ,secret>y det]m9es appropriate1 ( #ejj1jjj4 7#c7 ,availability ,am\nts transf]r$ "u p>agraph 7#a7 or 7#b7 %all rema9 available until exp5d$4 7h7 ,budget neutrality ,9 conduct+ ! ,,cbi-,,snp demon/ration program1 ! ,secret>y %all ensure t ! aggregate paym5ts made by ! ,secret>y d n exce$ ! am\nt :i* ! ,secret>y e/imates w\ld h be5 exp5d$ "u titles ,,xviii & ,,xix ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq41 #acif et seq47 if ! ,,cbi-,,snp demon/ration program _h n be5 implem5t$4 7i7 ,pap]work ,r$uction ,act ,*apt] #ce ( title #dd1 ,unit$ ,/ates ,code1 %all n apply to ! te/+ & evaluation ( ! ,,cbi-,,snp demon/ration program "u ?is section4 #bea4 ,apply+ ,,cmmi waiv] au?ority to ,,pace 9 ord] to fo/] innovations 7a7 ,,cmmi waiv] au?ority ,subsection 7d77#a7 ( section #aaae;,a ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7 is am5d$-- 7#a7 by ins]t+ 7o!r ?an subsections 7b77#a77;,a7 & 7c77#e7 ( section #ahid7 aft] ,,xviii2 & 7#b7 by /rik+ & #aijc7m77#b77;,a77iii7 & ins]t+ #aijc7m77#b77;,a77iii71 & #aicd 7o!r ?an subsections 7b77#a77;,a7 & 7c77#e7 ( su* section74 7b7 ,s5se ( ! ,s5ate ,x is ! s5se ( ! ,s5ate t ! ,secret>y ( ,heal? & ,human ,s]vices %\ld use ! waiv] au?ority provid$ "u ! am5dm5ts made by ?is section to provide1 9 a budget neutral mann]1 programs ( all-inclusive c>e = ! eld]ly 7,,pace programs7 ) increas$ op]ational flexibility to support ! ability ( su* programs to improve & innovate & to r$uce te*nical & adm9i/rative b>ri]s t h h9d]$ enrollm5t 9 su* programs4 #beb4 ,improve & mod]nize ,m$icaid data sy/ems & report+ 7a7 ,9 g5]al ,! ,secret>y ( ,heal? & ,human ,s]vices %all implem5t a /rategic plan to increase ! usefulness ( data ab\t ,/ate ,m$icaid programs report$ by ,/ates to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices4 ,! /rategic plan %all address r$undancies & gaps 9 ,m$icaid data sy/ems & report+ ?r\gh improvem5ts to1 & mod]nization (1 comput] & data sy/ems4 ,areas = improvem5t "u ! plan %all include 7b n be limit$ to7 ! foll[+3 7#a7 ,! report+ ( enc\nt] data by manag$ c>e plans4 7#b7 ,! timel9ess & quality ( report$ data1 includ+ enrollm5t data4 7#c7 ,! consi/5cy ( data report$ f multiple s\rces4 7#d7 ,in=mation ab\t ,/ate program policies4 7b7 ,implem5tation /atus report ,n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all submit a report to ,congress on ! /atus ( ! implem5tation ( ! /rategic plan requir$ "u subsection 7a74 7c7 ,au?orization ( appropriations ,!re is au?oriz$ to be appropriat$ to ! ,secret>y ( ,heal? & ,human ,s]vices = ! p]iod ( fiscal ye>s #bjae ?r\gh #baji1 su* sums z may be necess>y to c>ry out ?is section4 #bec4 ,fairness 9 ,m$icaid supplem5tal ne$s tru/s 7a7 ,9 g5]al ,section #aiag7;d77#d77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifp7d77#d77;,a77 is am5d$ by ins]t+ ! individual1 aft] = ! b5efit ( su* individual by4 7b7 ,effective date ,! am5dm5t made by subsection 7a7 %all apply to tru/s e/abli%$ on or aft] ! date ( ! enactm5t ( ?is ,act4 #bed4 ,help+ ,ensure ,life- & ,limb-,sav+ ,access to ,podiatric ,physicians 7a7 ,includ+ podiatri/s z physicians "u ! ,m$icaid program 7#a7 ,9 g5]al ,section #aije7;a77#e77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7a77#e77;,a77 is am5d$ by /rik+ section #ahfa7r77#a7 & ins]t+ p>agraphs 7#a7 & 7#c7 ( section #ahfa7r74 7#b7 ,effective date 7,a7 ,9 g5]al ,except z provid$ 9 subp>agraph 7,b71 ! am5dm5t made by p>agraph 7#a7 %all apply to s]vices furni%$ on or aft] ! date ( enactm5t ( ?is ,act4 7,b7 ,ext5sion ( effective date = ,/ate law am5dm5t ,9 ! case ( a ,/ate plan "u title ,,xix ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 :i* ! ,secret>y ( ,heal? & ,human ,s]vices det]m9es requires ,/ate legislation 9 ord] = ! plan to meet ! additional requirem5t impos$ by ! am5dm5t made by p>agraph 7#a71 ! ,/ate plan %all n be reg>d$ z fail+ to comply ) ! requirem5ts ( su* title solely on ! basis ( its failure to meet ^! additional requirem5ts be=e ! fir/ day ( ! fir/ cal5d> qu>t] beg9n+ aft] ! close ( ! fir/ regul> session ( ! ,/ate legislature t beg9s aft] ! date ( enactm5t ( ?is ,act4 ,= purposes ( ! previ\s s5t5ce1 9 ! case ( a ,/ate t has a #b-ye> legislative session1 ea* ye> ( ! session is consid]$ to be a sep>ate regul> session ( ! ,/ate legislature4 7b7 ,modifications to requirem5ts = diabetic %oes to be includ$ "u m$ical & o!r heal? s]vices "u ,m$ic>e 7#a7 ,9 g5]al ,section #ahfa7s77#ab7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7s77#ab77 is am5d$ to read z foll[s3 7#ab7 subject to section #djgb7;e7 ( ! ,omnibus ,budget ,reconciliation ,act ( #aihg1 extra-dep? %oes ) ins]ts or cu/om mold$ %oes 79 ?is p>agraph ref]r$ to z !rapeutic %oes7 ) ins]ts = an individual ) diabetes1 if-- 7,a7 ! physician :o is manag+ ! individual's diabetic condition-- 7i7 docum5ts t ! individual has diabetes2 7ii7 c]tifies t ! individual is "u a compreh5sive plan ( c>e relat$ to ! individual's diabetic condition2 & 7iii7 docum5ts agreem5t ) ! prescrib+ podiatri/ or o!r qualifi$ physician 7z e/abli%$ by ! ,secret>y7 t x is m$ically necess>y = ! individual to h su* extra-dep? %oes ) ins]ts or cu/om mold$ %oes ) ins]ts2 7,b7 ! !rapeutic %oes are prescrib$ by a podiatri/ or o!r qualifi$ physician 7z e/abli%$ by ! ,secret>y7 :o-- 7i7 exam9es ! individual & det]m9es ! m$ical necessity = ! individual to receive ! !rapeutic %oes2 & 7ii7 communicates 9 writ+ ! m$ical necessity to ! physician describ$ 9 subp>agraph 7,a7 = ! individual to h !rapeutic %oes along ) f9d+s t ! individual has p]iph]al neuropa?y ) evid5ce ( callus =mation1 a hi/ory ( pre-ulc]ative calluses1 a hi/ory ( previ\s ulc]ation1 foot de=mity1 previ\s amputation1 or poor circulation2 & 7,c7 ! !rapeutic %oes are fitt$ & furni%$ by a podiatri/ or o!r qualifi$ suppli] 7z e/abli%$ by ! ,secret>y71 su* z a p$or?i/ or or?oti/1 :o is n ! physician describ$ 9 subp>agraph 7,a7 7unless ! ,secret>y f9ds t ! physician is ! only su* qualifi$ individual 9 ! area72 4 7#b7 ,effective date ,! am5dm5t made by p>agraph 7#a7 %all apply ) respect to items & s]vices furni%$ on or aft] ,janu>y #a1 #bjae4 #bee4 ,demon/ration program to improve community m5tal heal? s]vices 7a7 ,e/abli%m5t ,n lat] ?an ,janu>y #a1 #bjaf1 ! ,secret>y ( ,heal? & ,human ,s]vices 7ref]r$ to 9 ?is section z ! ,secret>y71 9 coord9ation ) ! ,adm9i/rator ( ! ,sub/ance ,abuse & ,m5tal ,heal? ,s]vices ,adm9i/ration1 %all aw>d plann+ grants to n to exce$ #aj ,/ates to enable su* ,/ates to c>ry out #e-ye> demon/ration programs to improve ! provision ( behavioral heal? s]vices provid$ by c]tifi$ community behavioral heal? cl9ics 9 ! ,/ate4 7b7 ,eligibility 7#a7 ,application ,to be eligible to receive a grant "u subsection 7a71 a ,/ate %all-- 7,a7 submit to ! ,secret>y an application at su* "t1 9 su* mann]1 & conta9+ su* in=mation z ! ,secret>y may require2 7,b7 c]tify to ! ,secret>y t behavioral heal? provid]s t are provid$ assi/ance "u ! demon/ration program meet ! crit]ia = c]tifi$ community behavioral heal? cl9ics "u subsection 7c72 7,c7 conduct a f9ancial assessm5t ( ! demon/ration program to be c>ri$ out "u ! grant by provid+ a detail$ e/imate ( eligible cl9ics & ,m$icaid exp5ditures ov] ! entire project$ p]iod ( ! demon/ration program2 & 7,d7 comply ) any o!r requirem5t det]m9$ appropriate by ! ,secret>y4 7#b7 ,waiv] ( ,m$icaid requirem5t ,9 approv+ ,/ates to conduct demon/ration programs "u ?is section1 ! ,secret>y %all waive section #aijb7;a77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77#a77 7relat+ to /atewid5ess7 z may be necess>y to conduct ! demon/ration program 9 accordance ) ! requirem5ts ( ?is section 7c7 ,crit]ia 7#a7 ,crit]ia = c]tifi$ community behavioral heal? cl9ics ,! crit]ia ref]r$ to 9 subsection 7b77#a77;,b7 are t ! c5t] p]=ms ea* ( ! foll[+3 7,a7 ,provide s]vices 9 locations t ensure s]vices w be available & accessible promptly & 9 a mann] :i* pres]ves human dignity & assures cont9uity ( c>e4 7,b7 ,provide s]vices 9 a mode ( s]vice deliv]y appropriate = ! t>get population4 7,c7 ,provide individuals ) a *oice ( s]vice options1 includ+ developm5tally appropriate evid5ce bas$ int]v5tions1 :]e !re is m ?an "o efficaci\s treatm5t4 7,d7 ,employ a core cl9ical /aff t is tra9$ to provide evid5ce-bas$ practices & is multidiscipl9>y & culturally & l+ui/ically compet5t1 includ+ ! availability ( translation or simil> s]vices & arrangem5ts if ! cl9ic is locat$ 9 a geographic area ( limit$ ,engli%-speak+ ability4 7,e7 ,e/abli% an em]g5cy plan to support cont9uity ( s]vices = individuals dur+ an em]g5cy or disa/]4 7,f7 ,demon/rate ! capacity to comply ) behavioral heal? & relat$ heal? c>e quality measures promulgat$ by su* entities z ! ,national ,quality ,=um1 ! ,national ,committee = ,quality ,assurance1 or o!r nationally recogniz$ accr$it+ bodies4 7,g7 ,provide s]vices to any individual resid+ or employ$ 9 ! s]vice area ( ! cl9ic & ensure t no pati5t or consum] w be d5i$ m5tal heal? or o!r heal? c>e s]vices due to an individual's inability to pay = su* s]vices4 7,h7 ,ensure t any fees or paym5ts requir$ by ! cl9ic = su* s]vices w be impos$ = individuals eligible = m$ical assi/ance "u ! ,/ate ,m$icaid plan "u title ,,xix ( ! ,social ,security ,act 9 accordance ) ! requirem5ts ( su* ,/ate plan & = any o!r individuals w be r$uc$ or waiv$ to enable ! cl9ic to comply ) subp>agraph 7,g71 includ+ prep>+ a s*$ule ( fees or paym5ts = ! provision ( s]vices t is consi/5t ) locally prevail+ rates or *>ges design$ to cov] ! reasonable co/s to ! cl9ic ( op]ation along ) a correspond+ s*$ule ( disc\nts to be appli$ to ! paym5t ( su* fees or paym5ts1 su* disc\nts to be adju/$ on ! basis ( ! pati5t's ability to pay4 7,i7 ,report requir$ enc\nt] data1 cl9ical outcomes data1 & quality data4 7,j7 ,provide1 directly or ?r\gh contract1 to ! ext5t cov]$ = adults 9 ! ,/ate ,m$icaid plan "u title ,,xix ( ! ,social ,security ,act & = *ildr5 9 accordance ) section #aije7r7 ( su* ,act reg>d+ e>ly & p]iodic scre5+1 diagnosis1 & treatm5t1 ea* ( ! foll[+ s]vices3 7i7 ,scre5+1 assessm5t1 & diagnosis1 includ+ risk assessm5t4 7ii7 ,p]son-c5t]$ treatm5t plann+ or simil> processes1 includ+ risk assessm5t & crisis plann+4 7iii7 ,outpati5t m5tal heal? & sub/ance use s]vices1 includ+ scre5+1 assessm5t1 diagnosis1 psy*o!rapy1 cognitive behavioral !rapy1 appli$ behavioral analysis1 m$ication managem5t1 & integrat$ treatm5t = trauma1 m5tal illness1 & sub/ance abuse :i* %all be evid5ce-bas$ 7includ+ cognitive behavioral !rapy1 long act+ injectable m$ications1 & o!r su* !rapies :i* are evid5ce-bas$74 7iv7 ,outpati5t cl9ic prim>y c>e scre5+ & monitor+ ( key heal? indicators & heal? risk 7includ+ scre5+ = diabetes1 hyp]t5sion1 & c>diovascul> disease & monitor+ ( weight1 height1 body mass index 7,,bmi71 blood pressure1 blood glucose or ,hb,a#a;,c1 & lipid pr(ile74 7v7 ,crisis m5tal heal? s]vices1 includ+ #bd-;h\r mobile crisis teams1 em]g5cy crisis int]v5tion s]vices1 & crisis /abilization4 7vi7 ,t>get$ case managem5t 7s]vices to assi/ individuals ga9+ access to ne$$ m$ical1 social1 educational1 & o!r s]vices & apply+ = income security & o!r b5efits to :i* !y may be entitl$71 & c>e coord9ation4 7vii7 ,psy*iatric rehabilitation s]vices includ+ skills tra9+1 ass]tive community treatm5t1 family psy*o$ucation1 disability self-managem5t1 support$ employm5t1 support$ h\s+ s]vices1 !rapeutic fo/] c>e s]vices1 & su* o!r evid5ce-bas$ practices z ! ,secret>y may require4 7viii7 ,pe] support & c\nselor s]vices & family supports4 7,k7 ,ma9ta9 l9kages1 & :]e possible ent] into =mal contracts1 agreem5ts1 or p>tn]%ips ) at lea/ "o f$]ally qualifi$ heal? c5t]1 unless !re is no su* c5t] s]v+ ! s]vice area1 9 ord] to ensure t ! deliv]y ( behavioral heal? c>e is integrat$ ) prim>y & prev5tive c>e s]vices1 s long z su* l9kages1 contract1 agreem5t1 or p>tn]%ip meets requirem5ts z prescrib$ by ! ,secret>y2 7,l7 ,ma9ta9 additional l9kages & :]e possible ent] into =mal contracts ) ! foll[+3 7i7 ,inpati5t psy*iatric facilities & sub/ance use detoxification1 po/-detoxification /ep-d[n s]vices1 & resid5tial programs4 7ii7 ,adult & y\? pe] support & c\nselor s]vices4 7iii7 ,family support s]vices = families ( *ildr5 ) s]i\s m5tal or sub/ance use disord]s4 7iv7 ,o!r community or regional s]vices1 supports1 & provid]s1 includ+ s*ools1 *ild welf>e ag5cies1 juv5ile & crim9al ju/ice ag5cies & facilities1 ,indian ,heal? ,s]vice y\? regional treatm5t c5t]s1 h\s+ ag5cies & programs1 employ]s1 ,/ate lic5s$ & nationally accr$it$ *ild plac+ ag5cies = !rapeutic fo/] c>e s]vice1 & o!r social & human s]vices4 7v7 ,onsite or (fsite access to prim>y c>e s]vices4 7vi7 ,enabl+ s]vices1 includ+ outrea*1 transportation1 & translation4 7vii7 ,heal? & wellness s]vices1 includ+ s]vices = tobacco cessation4 7viii7 ,dep>tm5t ( ,vet]ans ,affairs m$ical c5t]s1 indep5d5t outpati5t cl9ics1 drop-9 c5t]s1 & o!r facilities ( ! ,dep>tm5t z def9$ 9 section #ahja ( title #ch1 ,unit$ ,/ates ,code4 7ix7 ,inpati5t acute c>e hospitals & hospital outpati5t cl9ics4 7,m7 ,:]e feasible1 provide outrea* & engagem5t to enc\rage individuals :o c\ld b5efit f m5tal heal? c>e to freely p>ticipate 9 receiv+ ! adm9i/rative s]vices describ$ 9 ?is subsection4 7,n7 ,:]e feasible1 provide int5sive1 community-bas$ m5tal heal? c>e = memb]s ( ! arm$ =ces & vet]ans1 p>ticul>ly ^? memb]s & vet]ans locat$ 9 rural areas1 su* c>e to be consi/5t ) m9imum cl9ical m5tal heal? guidel9es promulgat$ by ! ,vet]ans ,heal? ,adm9i/ration includ+ cl9ical guidel9es conta9$ 9 ! ,uni=m ,m5tal ,heal? ,s]vices ,h&book ( su* ,adm9i/ration4 7,o7 ,:]e feasible1 require c]tifi$ community behavioral heal? cl9ics to provide valid & reliable trauma scre5+ & functional or developm5tal assessm5t to det]m9e ne$1 mat* s]vices to ne$s1 & to measure progress ov] "t4 7#b7 ,regulations ,prior to ! selection ( p>ticipat+ ,/ates1 & n lat] ?an #ah mon?s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y1 9 consultation ) ! ,sub/ance ,abuse & ,m5tal ,heal? ,s]vices ,adm9i/ration & ! ,/ate ,m5tal ,heal? & ,sub/ance ,abuse ,au?orities1 %all issue f9al regulations = c]tify+ non-pr(it & local gov]nm5t behavioral heal? au?orities & ,indian ,heal? ,s]vice tribal facilities z community behavioral heal? cl9ics4 7d7 ,requirem5ts ,9 aw>d+ grants "u ?is section1 ! ,secret>y %all-- 7#a7 ensure ! geographic div]sity ( grantee ,/ates2 7#b7 ensure t c]tifi$ community behavioral heal? cl9ics 9 su* ,/ates t are locat$ 9 rural areas1 z def9$ by ! ,secret>y1 & o!r m5tal heal? pr(essional %ortage areas are fairly & appropriately consid]$ ) ! objective ( facilitat+ access to m5tal heal? s]vices 9 su* areas2 7#c7 take into acc\nt ! ability ( cl9ics 9 su* ,/ates to provide requir$ s]vices1 & ! ability ( su* cl9ics to report requir$ data z requir$ "u ?is section2 & 7#d7 take into acc\nt ! ability ( su* ,/ates to provide su* requir$ s]vices on a /atewide basis4 7e7 ,exemption ,= purposes ( ?is section1 c]tifi$ community behavioral heal? cl9ics t receive paym5ts "u section #aijb7;bb7 ( ! ,social ,security ,act :i* are locat$ 9 rural areas1 z def9$ by ! ,secret>y1 %all be exempt f ! requirem5ts conta9$ 9 subp>agraphs 7,a7 & 7,j77v7 ( subsection 7c77#a74 7f7 ,treatm5t ( c]ta9 s]vices provid$ by community behavioral heal? cl9ics z m$ical assi/ance 7#a7 ,9 g5]al ,= purposes ( ! demon/ration program "u ?is section1 community behavioral heal? cl9ic s]vices 7z def9$ 9 subsection 7h77#a77 t are provid$ by c]tifi$ community behavioral heal? cl9ics receiv+ assi/ance "u ?is section %all be consid]$ m$ical assi/ance = purposes ( paym5ts to ,/ates "u p>agraph 7#c77;,c74 7#b7 ,grant condition ,z a condition ( receiv+ a grant "u ?is section1 a ,/ate %all agree to provide = paym5t = community behavioral heal? cl9ic s]vices 9 accordance ) ! prospective paym5t sy/em e/abli%$ by ! ,secret>y "u p>agraph 7#c74 7#c7 ,prospective paym5t sy/em 7,a7 ,9 g5]al ,n lat] ?an #ah mon?s aft] ! date ( enactm5t ( ?is ,act1 ! ,secret>y %all e/abli% a prospective paym5t sy/em = community behavioral heal? cl9ic s]vices furni%$ by a community behavioral heal? cl9ic receiv+ assi/ance "u ?is section 9 ! same mann] z paym5ts are requir$ to be made "u section #aijb7;bb7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7bb77 = s]vices describ$ 9 section #aije7;a77#b77;,c7 ( su* ,act 7#db ,u4,s4,c4 #acif;d7a77#b77;,c77 furni%$ by a ,f$]ally-qualifi$ heal? c5t] & s]vices describ$ 9 section #aije7;a77#b77;,b7 ( su* ,act 7#db ,u4,s4,c4 #acif;d7a77#b77;,b77 furni%$ by a rural heal? cl9ic4 7,b7 ,requirem5ts ,! prospective paym5t sy/em e/abli%$ by ! ,secret>y "u subp>agraph 7,a7 %all provide t-- 7i7 no paym5t %all be made = inpati5t c>e1 resid5tial treatm5t1 room & bo>d exp5ses1 or any o!r non-ambulatory s]vices1 z det]m9$ by ! ,secret>y2 & 7ii7 no paym5t %all be made to satellite facilities ( community behavioral heal? cl9ics if su* facilities are e/abli%$ aft] ! date ( enactm5t ( ?is ,act4 7,c7 ,paym5ts to /ates ,! ,secret>y %all pay ea* ,/ate aw>d$ a grant "u ?is section an am\nt ea* qu>t] equal to ! enhanc$ ,,fmap 7z def9$ 9 section #baje7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acig;dd7b77 b )\t reg>d to ! second & ?ird s5t5ces ( t section7 ( ! ,/ate's exp5ditures 9 ! qu>t] = m$ical assi/ance = community behavioral heal? cl9ic s]vices provid$ by c]tifi$ community behavioral heal? cl9ics 9 ! ,/ate t receive assi/ance "u ?is section4 ,paym5ts to ,/ates made "u ?is subp>agraph %all be consid]$ to h be5 "u1 & are subject to ! requirem5ts (1 section #aijc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;b74 7g7 ,annual report 7#a7 ,9 g5]al ,n lat] ?an #a ye> aft] ! date on :i* ! fir/ grants are aw>d$ "u ?is section1 & annually !reaft]1 ! ,secret>y %all submit to ,congress an annual report on ! use ( funds provid$ "u ! demon/ration program4 ,ea* su* report %all include-- 7,a7 an assessm5t ( access to community-bas$ m5tal heal? s]vices "u ! ,m$icaid program 9 ! ,/ates aw>d$ su* grants2 7,b7 an assessm5t ( ! quality & scope ( s]vices provid$ by c]tifi$ community behavioral heal? cl9ics "u ! grants z comp>$ aga9/ community-bas$ m5tal heal? s]vices provid$ 9 ,/ates t are n receiv+ su* grants2 & 7,c7 an assessm5t ( ! impact ( ! demon/ration programs on ! co/s ( a full range ( m5tal heal? s]vices 7includ+ inpati5t1 em]g5cy & ambulatory s]vices74 7#b7 ,recomm5dations ,n lat] ?an ,decemb] #ca1 #bjai1 ! ,secret>y %all submit to ,congress recomm5dations conc]n+ :e!r ! demon/ration programs "u ?is section %\ld be cont9u$ & exp&$ on a national basis4 7h7 ,def9itions ,9 ?is section3 7#a7 ,community behavioral heal? cl9ic s]vices ,! t]m community behavioral heal? cl9ic s]vices means ambulatory behavioral heal? s]vices ( ! type describ$ 9 subp>agraphs 7,j71 7,m71 7,n71 & 7,o7 ( subsection 7c77#a7 t are provid$ by c]tifi$ community behavioral heal? cl9ics receiv+ assi/ance "u ?is section4 7#b7 ,/ate ,! t]m ,/ate has ! mean+ giv5 su* t]m = purposes ( title ,,xix ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq474 7i7 ,au?orization ( appropriations ,!re is au?oriz$ to be appropriat$ to c>ry out ?is section1 #ej1jjj1jjj = fiscal ye> #bjaf1 to rema9 available until exp5d$4 #bef4 ,annual ,m$icaid ,,d% report ,section #aibc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#d7 is am5d$ by add+ at ! end ! foll[+3 7k7 ,annual report to ,congress 7#a7 ,9 g5]al ,beg9n+ ,janu>y #a1 #bjae1 & annually !reaft]1 ! ,secret>y %all submit a report to ,congress on ! program e/abli%$ "u ?is section = mak+ paym5t adju/m5ts to disproportionate %>e hospitals = ! purpose ( provid+ ,congress ) in=mation relevant to det]m9+ an appropriate level ( ov]all fund+ = su* paym5t adju/m5ts dur+ & aft] ! p]iod 9 :i* aggregate r$uctions 9 ! ,,d% allotm5ts to ,/ates are requir$ "u p>agraphs 7#g7 & 7#h7 ( subsection 7f74 7#b7 ,requir$ report in=mation ,except z o!rwise provid$1 ea* report submitt$ "u ?is subsection %all include ! foll[+3 7,a7 ,in=mation & data relat+ to *anges 9 ! numb] ( un9sur$ individuals = ! mo/ rec5t ye> = :i* su* data are available z comp>$ to #bjac & z comp>$ to ! ,congressional ,budget ,(fice e/imates ( un9sur$ individuals made at ! "t ( ! enactm5t ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh7 & ! ,heal? ,c>e & ,education ,reconciliation ,act ( #bjaj 7,public ,law #aaa-aeb74 7,b7 ,in=mation & data relat+ to ! ext5t to :i* hospitals cont9ue to incur uncomp5sat$ c>e co/s f provid+ unreimburs$ or "u-reimburs$ s]vices to individuals :o ei!r are eligible = m$ical assi/ance "u ! ,/ate plan "u ?is title or "u a waiv] ( su* plan or :o h no heal? insurance 7or o!r s\rce ( ?ird p>ty cov]age7 = su* s]vices4 7,c7 ,in=mation & data relat+ to ! ext5t to :i* hospitals cont9ue to provide *>ity c>e & unreimburs$ or "u-reimburs$ s]vices1 or o!rwise incur bad debt1 "u ! program e/abli%$ "u ?is title1 ! ,/ate ,*ildr5's ,heal? ,insurance ,program e/abli%$ "u title ,,xxi1 & ,/ate or local indig5t c>e programs1 z report$ on co/ reports submitt$ "u title ,,xviii or su* o!r data z ! ,secret>y det]m9es appropriate4 7,d7 ,9 ! fir/ report submitt$ "u ?is section1 a me?odology = e/imat+ ! am\nt ( unpaid pati5t d$uctibles1 copaym5ts & co9surance incurr$ by hospitals = pati5ts enroll$ 9 qualifi$ heal? plans ?r\gh an ,am]ican ,heal? ,b5efits ,ex*ange1 us+ exi/+ data & m9imiz+ ! adm9i/rative burd5 on hospitals to ! ext5t possible1 & 9 subsequ5t reports1 data reg>d+ su* uncomp5sat$ c>e co/s collect$ pursuant to su* me?odology4 7,e7 ,= ea* ,/ate1 in=mation & data relat+ to ! diff]5ce betwe5 ! ,,d% allotm5t = ! ,/ate = ! fiscal ye> t began on ,octob] #a ( ! ye> prec$+ ! ye> 9 :i* ! report is submitt$ & ! aggregate am\nt ( uncomp5sat$ c>e co/s = all disproportionate %>e hospitals 9 ! ,/ate4 7,f7 ,in=mation & data relat+ to ! ext5t to :i* !re are c]ta9 vital hospital sy/ems t are disproportionately exp]i5c+ high levels ( uncomp5sat$ c>e & t h multiple o!r missions1 su* z a commitm5t to graduate m$ical education1 ! provision ( t]ti>y & trauma c>e s]vices1 provid+ public heal? & ess5tial community s]vices1 & provid+ compreh5sive1 coord9at$ c>e4 7,g7 ,su* o!r in=mation & data relevant to ! det]m9ation ( ! level ( fund+ =1 & am\nt (1 ,/ate ,,d% allotm5ts z ! ,secret>y det]m9es appropriate 7#c7 ,au?orization ( appropriations ,!re is au?oriz$ to be appropriat$ to ! ,secret>y = ! p]iod ( fiscal ye>s #bjae ?r\gh #baji1 su* sums z may be necess>y to c>ry out ?is subsection4 4 #beg4 ,implem5tation ,to ! ext5t ! ,secret>y ( ,heal? & ,human ,s]vices issues a regulation to c>ry out ! provisions ( ?is ,act1 ! ,secret>y %all1 unless o!rwise specifi$ 9 ?is ,act-- 7#a7 issue a notice ( propos$ rulemak+ t includes ! propos$ regulation2 7#b7 provide a p]iod ( n less ?an #fj cal5d> days = comm5ts on ! propos$ regulation2 7#c7 n m ?an #bd mon?s foll[+ ! date ( publication ( ! propos$ rule1 publi% ! f9al regulation or take alt]native action 7su* z )draw+ ! rule or propos+ a revis$ rule ) a new comm5t p]iod7 on ! propos$ regulation2 & 7#d7 n less ?an #cj days be=e ! effective date ( ! f9al regulation1 publi% ! f9al regulation or take alt]native action 7su* z )draw+ ! rule or propos+ a revis$ rule ) a new comm5t p]iod7 on ! propos$ regulation4 ,decemb] #ai1 #bjac,read twice & plac$ on ! cal5d>