,,ii  ,cal5d> ,no4 #ccj #aac? ,,congress
  #b;d ,session  ,s4 #babb  ,,9 ,,!     
,,s5ate ,,( ,,! ,,unit$ ,,/ates  ,m>*   
#ab1 #bjad ,mr4 ,hat* 7= himself1 ,mr4  
,mc,connell1 & ,mr4 ,cornyn7 introduc$ !
 foll[+ bill2 :i* 0 read ! fir/ "t  ,m>*
 #ac1 #bjad,read ! second "t & plac$ on 
! cal5d>  ,a ,,bill  ,to am5d titles    
,,xviii & ,,xix ( ! ,social ,security   
,act to repeal ! ,m$ic>e su/a9able gr[? 
rate & to improve ,m$ic>e & ,m$icaid    
paym5ts1 & = o!r purposes4  #a4 ,%ort   
title2 table ( cont5ts  7a7 ,%ort title 
,?is ,act may be cit$ z ! ,responsible  
,m$ic>e ,,sgr ,repeal & ,b5efici>y      
,access ,improvem5t ,act ( #bjad4  7b7  
,table ( cont5ts ,! table ( cont5ts (   
?is ,act is z foll[s3 ,sec4 #a4 ,%ort   
title2 table ( cont5ts4 ,,title         
,i--,m$ic>e ,paym5t = ,physicians'      
,s]vices ,sec4 #aja4 ,repeal+ !         
su/a9able gr[? rate 7,,sgr7 & improv+   
,m$ic>e paym5t = physicians' s]vices4   
,sec4 #ajb4 ,priorities & fund+ =       
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&+ availability ( ,m$ic>e    
data4 ,sec4 #ajh4 ,r$uc+ adm9i/rative   
burd5 & o!r provisions4 ,,title         
,,ii--,ext5sions ,subtitle ,a--,m$ic>e  
,ext5sions ,sec4 #bja4 ,"w geographic   
adju/m5t4 ,sec4 #bjb4 ,m$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$icaid & ,o!r ,ext5sions ,sec4    
#baa4 ,qualify+ individual program4     
,sec4 #bab4 ,transitional ,m$ical       
,assi/ance4 ,sec4 #bac4 ,express lane   
eligibility4 ,sec4 #bad4 ,p$iatric      
quality measures4 ,sec4 #bae4 ,special  
diabetes programs4 ,subtitle ,c--,human 
,s]vices ,ext5sions ,sec4 #bba4 ,ab/95ce
 education grants4 ,sec4 #bbb4 ,p]sonal 
responsibility education program4 ,sec4 
#bbc4 ,family-to-family heal? in=mation 
c5t]s4 ,sec4 #bbd4 ,heal? work=ce       
demon/ration project = l[-income        
individuals4 ,,title ,,iii--,m$ic>e &   
,m$icaid program integrity ,sec4 #cja4  
,r$uc+ improp] ,m$ic>e paym5ts4 ,sec4   
#cjb4 ,au?ority = ,m$icaid fraud control
 units to inve/igate & prosecute        
compla9ts ( abuse & neglect ( ,m$icaid  
pati5ts 9 home & community-bas$ sett+s4 
,sec4 #cjc4 ,improv$ use ( funds receiv$
 by ! ,,hhs ,inspector ,g5]al f ov]sight
 & inve/igative activities4 ,sec4 #cjd4 
,prev5t+ & r$uc+ improp] ,m$ic>e &      

,m$icaid exp5ditures4 ,,title ,,iv--,o!r
 ,provisions ,sec4 #dja4 ,commission on 
,improv+ ,pati5t ,direct$ ,heal? ,c>e4  
,sec4 #djb4 ,expansion ( ! def9ition (  
inpati5t hospital s]vices = c]ta9 canc] 
hospitals4 ,sec4 #djc4 ,quality measures
 = c]ta9 po/-acute c>e provid]s relat+  
to notice & transf] ( pati5t heal?      
in=mation & pati5t c>e pref]5ces4 ,sec4 
#djd4 ,crit]ia = m$ically necess>y1 %ort
 inpati5t hospital /ays4 ,sec4 #dje4    
,transp>5cy ( reasons = exclud+         
additional proc$ures f ! ,m$ic>e        
ambulatory surgical c5t] 7,,asc7 approv$
 li/4 ,sec4 #djf4 ,sup]vision 9 critical
 access hospitals4 ,sec4 #djg4 ,requir+ 
,/ate lic5sure ( bidd+ entities "u !    
competitive acquisition program = c]ta9 
durable m$ical equipm5t1 pro/hetics1    
or?otics1 & supplies 7,,dmepos74 ,sec4  
#djh4 ,recognition ( att5d+ physician   
assi/ants z att5d+ physicians ,to s]ve  
hospice pati5ts4 ,sec4 #dji4 ,remote    
pati5t monitor+ pilot projects4 ,sec4   
#daj4 ,community-,bas$ ,in/itutional    

,special ,ne$s ,plan ,demon/ration      
,program4 ,sec4 #daa4 ,apply+ ,,cmmi    
waiv] au?ority to ,,pace 9 ord] to fo/] 
innovations4 ,sec4 #dab4 ,improve &     
mod]nize ,m$icaid data sy/ems & report+4
 ,sec4 #dac4 ,fairness 9 ,m$icaid       
supplem5tal ne$s tru/s4 ,sec4 #dad4     
,help+ ,ensure ,life- & ,limb-,sav+     
,access to ,podiatric ,physicians4 ,sec4
 #dae4 ,demon/ration programs to improve
 community m5tal heal? s]vices4 ,sec4   
#daf4 ,annual ,m$icaid ,,d% report4     
,sec4 #dag4 ,implem5tation4 ,,title     
,v--,re/or+ individual lib]ty ,sec4     
#eja4 ,re/or+ individual lib]ty4  ,i    
,m$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$+ ye>2 &  7ii7 9 p>agraph     
7#b71 9 ! matt] prec$+ subp>agraph 7,a71
 by ins]t+ & end+ ) #bjac aft] beg9n+ ) 
#bjjj4  7#b7  ,update ( rates = ,april  
?r\gh ,decemb] ( #bjad1 #bjae1 &        
subsequ5t ye>s  ,subsection 7d7 (       
section #ahdh ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciew-#d7 is am5d$ by  
/rik+ p>agraph 7#ae7 & ins]t+ ! foll[+  
new p>agraphs3  7#ae7  ,update = #bjad  
?r\gh #bjah  ,! update to ! s+le        
conv]sion factor e/abli%$ 9 p>agraph    
7#a77;,c7 = #bjad & ea* subsequ5t ye>   
?r\gh #bjah %all be #j4e p]c5t4  7#af7  
,update = #bjai ?r\gh #bjbc  ,! update  
to ! s+le conv]sion factor e/abli%$ 9   
p>agraph 7#a77;,c7 = #bjai & ea*        
subsequ5t ye> ?r\gh #bjbc %all be z]o   

p]c5t4  7#ag7  ,update = #bjbd &        
subsequ5t ye>s  ,! update to ! s+le     
conv]sion factor e/abli%$ 9 p>agraph    
7#a77;,c7 = #bjbd & ea* subsequ5t ye>   
%all be--  7,a7 = items & s]vices       
furni%$ by a qualify+ ,,apm p>ticipant  
7z def9$ 9 section #ahcc7z77#b77 = su*  
ye>1 #a4j p]c5t2 &  7,b7 = o!r items &  
s]vices1 #j4e p]c5t4  4  7#c7           
,med,p,a,c reports  7,a7  ,initial      
report  ,n lat] ?an ,july #a1 #bjaf1 !  
,m$ic>e ,paym5t ,advisory ,commission   
%all submit to ,congress a report on !  
relation%ip betwe5--  7i7 physician &   
o!r heal? pr(essional utilization &     
exp5ditures 7& ! rate ( increase ( su*  
utilization & exp5ditures7 ( items &    
s]vices = :i* paym5t is made "u section 
#ahdh ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #aciew-#d72 &  7ii7 total     
utilization & exp5ditures 7& ! rate (   
increase ( su* utilization &            
exp5ditures7 "u p>ts ,a1 ,b1 & ,d (     
title ,,xviii ( su* ,act4  ,su* report  
%all include a me?odology to describe   

su* relation%ip & ! impact ( *anges 9   
su* physician & o!r heal? pr(essional   
practice & s]vice ord]+ patt]ns on total
 utilization & exp5ditures "u p>ts ,a1  
,b1 & ,d ( su* title4  7,b7  ,f9al      
report  ,n lat] ?an ,july #a1 #bjbj1 !  
,m$ic>e ,paym5t ,advisory ,commission   
%all submit to ,congress a report on !  
relation%ip describ$ 9 subp>agraph 7,a71
 includ+ ! results det]m9$ f apply+ !   
me?odology includ$ 9 ! report submitt$  
"u su* subp>agraph4  7,c7  ,report on   
update to physicians' s]vices "u ,m$ic>e
  ,n lat] ?an ,july #a1 #bjah1 ! ,m$ic>e
 ,paym5t ,advisory ,commission %all     
submit to ,congress a report on--  7i7 !
 paym5t update = pr(essional s]vices    
appli$ "u ! ,m$ic>e program "u title    
,,xviii ( ! ,social ,security ,act = !  
p]iod ( ye>s #bjad ?r\gh #bjah2  7ii7 ! 
effect ( su* update on ! effici5cy1     
economy1 & quality ( c>e provid$ "u su* 
program2  7iii7 ! effect ( su* update on
 ensur+ a suffici5t numb] ( provid]s to 
ma9ta9 access to c>e by ,m$ic>e         

b5efici>ies2 &  7iv7 recomm5dations =   
any future paym5t updates = pr(essional 
s]vices "u su* program to ensure        
adequate access to c>e is ma9ta9$ =     
,m$ic>e b5efici>ies4  7b7               
,consolidation ( c]ta9 curr5t law       
p]=mance programs ) new m]it-,bas$      
,inc5tive ,paym5t ,sy/em  7#a7  ,,ehr   
mean+ful use inc5tive program  7,a7     
,sunsett+ sep>ate mean+ful use paym5t   
adju/m5ts ,section #ahdh7;a77#g77;,a7 ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#aciew-#d7;a77#g77;,a77 is am5d$--  7i7 
9 clause 7i71 by /rik+ #bjae or any     
subsequ5t paym5t ye> & ins]t+ #bjae1    
#bjaf1 or #bjag2  7ii7 9 clause 7ii7--  
7,i7 9 ! matt] prec$+ subclause 7,i71 by
 /rik+ ,subject to clause 7iii71 = &    
ins]t+ ,=2 &  7,,ii7 9 subclause        
7,,iii71 by /rik+ & ea* subsequ5t ye>2 &
  7iii7 by /rik+ clause 7iii74  7,b7    
,cont9uation ( mean+ful use det]m9ations
 = ,,mips  ,section #ahdh7o77#b7 ( !    
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#d7o77#b77 is am5d$--  7i7 9     

subp>agraph 7,a71 9 ! matt] prec$+      
clause 7i7--  7,i7 by /rik+ ,= purposes 
( p>agraph 7#a71 an & ins]t+ ,an2 &     
7,,ii7 by ins]t+ 1 or pursuant to       
subp>agraph 7,d7 = purposes ( subsection
 7q71 = a p]=mance p]iod "u su*         
subsection = a ye> aft] "u su*          
subsection = a ye>2 &  7ii7 by add+ at !
 end ! foll[+ new subp>agraph3  7,d7    
,cont9u$ application = purposes ( ,,mips
  ,) respect to #bjah & ea* subsequ5t   
paym5t ye>1 ! ,secret>y %all1 = purposes
 ( subsection 7q7 & 9 accordance )      
p>agraph 7#a77;,f7 ( su* subsection1    
det]m9e :e!r an eligible pr(essional :o 
is a ,,mips eligible pr(essional 7z     
def9$ 9 subsection 7q77#a77;,c77 = su*  
ye> is a mean+ful ,,ehr us] "u ?is      
p>agraph = ! p]=mance p]iod "u          
subsection 7q7 = su* ye>4  4  7#b7      
,quality report+  7,a7 ,sunsett+ sep>ate
 quality report+ inc5tives ,section     
#ahdh7;a77#h77;,a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#aciew-#d7;a77#h77;,a77 is am5d$--  7i7 

9 clause 7i71 by /rik+ #bjae or any     
subsequ5t ye> & ins]t+ #bjae1 #bjaf1 or 
#bjag2 &  7ii7 9 clause 7ii77,,ii71 by  
/rik+ & ea* subsequ5t ye> & ins]t+ &    
#bjag4  7,b7  ,cont9uation ( quality    
measures & processes = ,,mips  ,section 
#ahdh ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #aciew-#d7 is am5d$--  7i7 9  
subsection 7k71 by add+ at ! end !      
foll[+ new p>agraph3  7#i7  ,cont9u$    
application = purposes ( ,,mips & =     
c]ta9 pr(essionals volunte]+ to report  
,! ,secret>y %all1 9 accordance )       
subsection 7q77#a77;,f71 c>ry out !     
provisions ( ?is subsection--  7,a7 =   
purposes ( subsection 7q72 &  7,b7 =    
eligible pr(essionals :o are n ,,mips   
eligible pr(essionals 7z def9$ 9        
subsection 7q77#a77;,c77 = ! ye>        
involv$4  2 &  7ii7 9 subsection 7m7--  
7,i7 by r$esignat+ p>agraph 7#g7 add$ by
 section #ajcbg7;a7 ( ,public ,law      
#aaa-adh z p>agraph 7#h72 &  7,,ii7 by  
add+ at ! end ! foll[+ new p>agraph3    
7#i7  ,cont9u$ application = purposes ( 

,,mips & = c]ta9 pr(essionals volunte]+ 
to report  ,! ,secret>y %all1 9         
accordance ) subsection 7q77#a77;,f71   
c>ry out ! processes "u ?is subsection--
  7,a7 = purposes ( subsection 7q72 &   
7,b7 = eligible pr(essionals :o are n   
,,mips eligible pr(essionals 7z def9$ 9 
subsection 7q77#a77;,c77 = ! ye>        
involv$4  4  7#c7  ,value-bas$ paym5ts  
7,a7  ,sunsett+ sep>ate value-bas$      
paym5ts  ,clause 7iii7 ( section        
#ahdh7p77#d77;,b7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4                     
#aciew-#d7p77#d77;,b77 is am5d$ to read 
z foll[s3  7iii7  ,application  ,!      
,secret>y %all apply ! paym5t modifi]   
e/abli%$ "u ?is subsection = items &    
s]vices furni%$ on or aft] ,janu>y #a1  
#bjae1 b be=e ,janu>y #a1 #bjah1 )      
respect to specific physicians & gr\ps (
 physicians ! ,secret>y det]m9es        
appropriate4 ,su* paym5t modifi] %all n 
be appli$ = items & s]vices furni%$ on  
or aft] ,janu>y #a1 #bjah4  4  7,b7     
,cont9uation ( value-bas$ paym5t modifi]

 measures = ,,mips  ,section #ahdh7p7 ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#aciew-#d7p77 is am5d$--  7i7 9 p>agraph
 7#b71 by add+ at ! end ! foll[+ new    
subp>agraph3  7,c7  ,cont9u$ application
 = purposes ( ,,mips  ,! ,secret>y %all1
 9 accordance ) subsection 7q77#a77;,f71
 c>ry out subp>agraph 7,b7 = purposes ( 
subsection 7q74  2 &  7ii7 9 p>agraph   
7#c71 by add+ at ! end ! foll[+3 ,)     
respect to #bjah & ea* subsequ5t ye>1 ! 
,secret>y %all1 9 accordance )          
subsection 7q77#a77;,f71 c>ry out ?is   
p>agraph = purposes ( subsection 7q744  
7c7  ,m]it-,bas$ ,inc5tive ,paym5t      
,sy/em  7#a7  ,9 g5]al  ,section #ahdh (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #aciew-#d7 is am5d$ by add+ at ! end ! 
foll[+ new subsection3  7q7  ,m]it-,bas$
 ,inc5tive ,paym5t ,sy/em  7#a7         
,e/abli%m5t  7,a7  ,9 g5]al  ,subject to
 ! succe$+ provisions ( ?is subsection1 
! ,secret>y %all e/abli% an eligible    
pr(essional ,m]it-bas$ ,inc5tive ,paym5t
 ,sy/em 79 ?is subsection ref]r$ to z ! 

,,mips7 "u :i* ! ,secret>y %all--  7i7  
develop a me?odology = assess+ ! total  
p]=mance ( ea* ,,mips eligible          
pr(essional accord+ to p]=mance /&>ds "u
 p>agraph 7#c7 = a p]=mance p]iod 7z    
e/abli%$ "u p>agraph 7#d77 = a ye>2     
7ii7 us+ su* me?odology1 provide = a    
composite p]=mance score 9 accordance ) 
p>agraph 7#e7 = ea* su* pr(essional =   
ea* p]=mance p]iod2 &  7iii7 use su*    
composite p]=mance score ( ! ,,mips     
eligible pr(essional = a p]=mance p]iod 
= a ye> to det]m9e & apply a ,,mips     
adju/m5t factor 7&1 z applicable1 an    
additional ,,mips adju/m5t factor7 "u   
p>agraph 7#f7 to ! pr(essional = ! ye>4 
7,b7  ,program implem5tation  ,! ,,mips 
%all apply to paym5ts = items & s]vices 
furni%$ on or aft] ,janu>y #a1 #bjah4   
7,c7  ,,mips eligible pr(essional def9$ 
7i7  ,9 g5]al  ,= purposes ( ?is        
subsection1 subject to clauses 7ii7 &   
7iv71 ! t]m ,,mips eligible pr(essional 
means--  7,i7 = ! fir/ & second ye>s =  
:i* ! ,,mips applies to paym5ts 7& = !  

p]=mance p]iod = su* fir/ & second ye>71
 a physician 7z def9$ 9 section         
#ahfa7r771 a physician assi/ant1 nurse  
practition]1 & cl9ical nurse speciali/  
7z su* t]ms are def9$ 9 section         
#ahfa7;aa77#e771 & a c]tifi$ regi/]$    
nurse ane/heti/ 7z def9$ 9 section      
#ahfa7;bb77#b77 & a gr\p t includes su* 
pr(essionals2 &  7,,ii7 = ! ?ird ye> =  
:i* ! ,,mips applies to paym5ts 7& = !  
p]=mance p]iod = su* ?ird ye>7 & = ea*  
succe$+ ye> 7& = ! p]=mance p]iod = ea* 
su* ye>71 ! pr(essionals describ$ 9     
subclause 7,i7 & su* o!r eligible       
pr(essionals 7z def9$ 9 subsection      
7k77#c77;,b77 z specifi$ by ! ,secret>y 
& a gr\p t includes su* pr(essionals4   
7ii7  ,exclusions  ,= purposes ( clause 
7i71 ! t]m ,,mips eligible pr(essional  
does n include1 ) respect to a ye>1 an  
eligible pr(essional 7z def9$ 9         
subsection 7k77#c77;,b77 :o--  7,i7 is a
 qualify+ ,,apm p>ticipant 7z def9$ 9   
section #ahcc7z77#b772  7,,ii7 subject  
to clause 7vii71 is a p>tial qualify+   

,,apm p>ticipant 7z def9$ 9 clause      
7iii77 = ! mo/ rec5t p]iod = :i* data   
are available & :o1 = ! p]=mance p]iod )
 respect to su* ye>1 does n report on   
applicable measures & activities        
describ$ 9 p>agraph 7#b77;,b7 t are     
requir$ to be report$ by su* a          
pr(essional "u ! ,,mips2 or  7,,iii7 = !
 p]=mance p]iod ) respect to su* ye>1   
does n exce$ ! l[-volume ?re%old        
measurem5t select$ "u clause 7iv74      
7iii7  ,p>tial qualify+ ,,apm p>ticipant
  ,= purposes ( ?is subp>agraph1 ! t]m  
p>tial qualify+ ,,apm p>ticipant means1 
) respect to a ye>1 an eligible         
pr(essional = :om ! ,secret>y det]m9es !
 m9imum paym5t p]c5tage 7or p]c5tages71 
z applicable1 describ$ 9 p>agraph 7#b7 (
 section #ahcc7z7 = su* ye> h n be5     
satisfi$1 b :o w\ld be consid]$ a       
qualify+ ,,apm p>ticipant 7z def9$ 9 su*
 p>agraph7 = su* ye> if--  7,i7 )       
respect to #bjah & #bjai1 ! ref]5ce 9   
subp>agraph 7,a7 ( su* p>agraph to #be  
p]c5t 0 in/ead a ref]5ce to #bj p]c5t2  

7,,ii7 ) respect to #bjbj & #bjba--     
7aa7 ! ref]5ce 9 subp>agraph 7,b77i7 (  
su* p>agraph to #ej p]c5t 0 in/ead a    
ref]5ce to #dj p]c5t2 &  7bb7 ! ref]5ces
 9 subp>agraph 7,b77ii7 ( su* p>agraph  
to #ej p]c5t & #be p]c5t ( su* p>agraph 
7 in/ead ref]5ces to #dj p]c5t & #bj    
p]c5t1 respectively2 &  7,,iii7 )       
respect to #bjbb & subsequ5t ye>s--     
7aa7 ! ref]5ce 9 subp>agraph 7,c77i7 (  
su* p>agraph to #ge p]c5t 0 in/ead a    
ref]5ce to #ej p]c5t2 &  7bb7 ! ref]5ces
 9 subp>agraph 7,c77ii7 ( su* p>agraph  
to #ge p]c5t & #be p]c5t ( su* p>agraph 
7 in/ead ref]5ces to #ej p]c5t & #bj    
p]c5t1 respectively4  7iv7  ,selection (
 l[-volume ?re%old measurem5t  ,!       
,secret>y %all select a l[-volume       
?re%old to apply = purposes ( clause    
7ii77,,iii71 :i* may include "o or m or 
a comb9ation ( ! foll[+3  7,i7 ,! m9imum
 numb] 7z det]m9$ by ! ,secret>y7 (     
individuals enroll$ "u ?is "p :o are    
treat$ by ! eligible pr(essional = !    
p]=mance p]iod involv$4  7,,ii7 ,!      

m9imum numb] 7z det]m9$ by ! ,secret>y7 
( items & s]vices furni%$ to individuals
 enroll$ "u ?is "p by su* pr(essional = 
su* p]=mance p]iod4  7,,iii7 ,! m9imum  
am\nt 7z det]m9$ by ! ,secret>y7 ( all[$
 *>ges bill$ by su* pr(essional "u ?is  
"p = su* p]=mance p]iod4  7v7  ,treatm5t
 ( new ,m$ic>e enroll$ eligible         
pr(essionals  ,9 ! case ( a pr(essional 
:o fir/ becomes a ,m$ic>e enroll$       
eligible pr(essional dur+ ! p]=mance    
p]iod = a ye> 7& _h n previ\sly submitt$
 claims "u ?is title su* z a p]son1 an  
entity1 or a "p ( a physician gr\p or "u
 a diff]5t bill+ numb] or tax id5tifi]71
 su* pr(essional %all n be treat$ "u ?is
 subsection z a ,,mips eligible         
pr(essional until ! subsequ5t ye> &     
p]=mance p]iod = su* subsequ5t ye>4     
7vi7  ,cl>ification  ,9 ! case ( items &
 s]vices furni%$ dur+ a ye> by an       
individual :o is n a ,,mips eligible    
pr(essional 7includ+ pursuant to clauses
 7ii7 & 7v77 ) respect to a ye>1 9 no   
case %all a ,,mips adju/m5t factor 7or  

additional ,,mips adju/m5t factor7 "u   
p>agraph 7#f7 apply to su* individual = 
su* ye>4  7vii7  ,p>tial qualify+ ,,apm 
p>ticipant cl>ifications  7,i7          
,treatm5t z ,,mips eligible pr(essional 
,9 ! case ( an eligible pr(essional :o  
is a p>tial qualify+ ,,apm p>ticipant1 )
 respect to a ye>1 & :o = ! p]=mance    
p]iod = su* ye> reports on applicable   
measures & activities describ$ 9        
p>agraph 7#b77;,b7 t are requir$ to be  
report$ by su* a pr(essional "u !       
,,mips1 su* eligible pr(essional is     
consid]$ to be a ,,mips eligible        
pr(essional ) respect to su* ye>4       
7,,ii7  ,n eligible = qualify+ ,,apm    
p>ticipant paym5ts  ,9 no case %all an  
eligible pr(essional :o is a p>tial     
qualify+ ,,apm p>ticipant1 ) respect to 
a ye>1 be consid]$ a qualify+ ,,apm     
p>ticipant 7z def9$ 9 p>agraph 7#b7 (   
section #ahcc7z77 = su* ye> or be       
eligible = ! additional paym5t "u       
p>agraph 7#a7 ( su* section = su* ye>4  
7,d7  ,application to gr\p practices    

7i7  ,9 g5]al  ,"u ! ,,mips3  7,i7      
,quality p]=mance category  ,! ,secret>y
 %all e/abli% & apply a process t       
includes features ( ! provisions (      
subsection 7m77#c77;,c7 = ,,mips        
eligible pr(essionals 9 a gr\p practice 
) respect to assess+ p]=mance ( su* gr\p
 ) respect to ! p]=mance category       
describ$ 9 clause 7i7 ( p>agraph        
7#b77;,a74  7,,ii7  ,o!r p]=mance       
categories  ,! ,secret>y may e/abli% &  
apply a process t includes features ( ! 
provisions ( subsection 7m77#c77;,c7 =  
,,mips eligible pr(essionals 9 a gr\p   
practice ) respect to assess+ ! p]=mance
 ( su* gr\p ) respect to ! p]=mance     
categories describ$ 9 clauses 7ii7 ?r\gh
 7iv7 ( su* p>agraph4  7ii7  ,ensur+    
compreh5siv5ess ( gr\p practice         
assessm5t  ,! process e/abli%$ "u clause
 7i7 %all to ! ext5t practicable reflect
 ! range ( items & s]vices furni%$ by ! 
,,mips eligible pr(essionals 9 ! gr\p   
practice involv$4  7iii7  ,cl>ification 
,,mips eligible pr(essionals elect+ to  

be a virtual gr\p "u p>agraph 7#e77;,i7 
%all n be consid]$ ,,mips eligible      
pr(essionals 9 a gr\p practice =        
purposes ( apply+ ?is subp>agraph4  7,e7
  ,use ( regi/ries  ,"u ! ,,mips1 !     
,secret>y %all enc\rage ! use ( qualifi$
 cl9ical data regi/ries pursuant to     
subsection 7m77#c77;,e7 9 c>ry+ out ?is 
subsection4  7,f7  ,application ( c]ta9 
provisions  ,9 apply+ a provision (     
subsection 7k71 7m71 7o71 or 7p7 =      
purposes ( ?is subsection1 ! ,secret>y  
%all--  7i7 adju/ ! application ( su*   
provision to ensure ! provision is      
consi/5t ) ! provisions ( ?is           
subsection2 &  7ii7 n apply su*         
provision to ! ext5t t ! provision is   
duplicative ) a provision ( ?is         
subsection4  7,g7  ,acc\nt+ = risk      
factors  7i7  ,risk factors  ,tak+ into 
acc\nt ! relevant /udies conduct$ &     
recomm5dations made 9 reports "u section
 #aja7;f77#a7 ( ! ,responsible ,m$ic>e  
,,sgr ,repeal & ,b5efici>y ,access      
,improvem5t ,act ( #bjad1 ! ,secret>y1  

on an ongo+ basis1 %all e/imate h[ an   
individual's heal? /atus & o!r risk     
factors affect quality & res\rce use    
outcome measures &1 z feasible1 %all    
incorporate in=mation f quality &       
res\rce use outcome measurem5t 7includ+ 
c>e episode & pati5t condition gr\ps7   
into ! ,,mips4  7ii7  ,acc\nt+ = o!r    
factors 9 paym5t adju/m5ts  ,tak+ into  
acc\nt ! /udies conduct$ &              
recomm5dations made 9 reports "u section
 #aja7;f77#a7 ( ! ,responsible ,m$ic>e  
,,sgr ,repeal & ,b5efici>y ,access      
,improvem5t ,act ( #bjad & o!r in=mation
 z appropriate1 ! ,secret>y %all acc\nt 
= id5tifi$ factors ) an effect on       
quality & res\rce use outcome measures  
:5 det]m9+ paym5t adju/m5ts1 composite  
p]=mance scores1 scores = p]=mance      
categories1 or scores = measures or     
activities "u ! ,,mips4  7#b7  ,measures
 & activities "u p]=mance categories    
7,a7  ,p]=mance categories  ,"u !       
,,mips1 ! ,secret>y %all use ! foll[+   
p]=mance categories 7ea* ( :i* is ref]r$

 to 9 ?is subsection z a p]=mance       
category7 9 det]m9+ ! composite p]=mance
 score "u p>agraph 7#e73  7i7 ,quality4 
7ii7 ,res\rce use4  7iii7 ,cl9ical      
practice improvem5t activities4  7iv7   
,mean+ful use ( c]tifi$ ,,ehr te*nology4
  7,b7  ,measures & activities specifi$ 
= ea* category  ,= purposes ( p>agraph  
7#c77;,a7 & subject to subp>agraph 7,c71
 measures & activities specifi$ = a     
p]=mance p]iod 7z e/abli%$ "u p>agraph  
7#d77 = a ye> are z foll[s3  7i7        
,quality  ,= ! p]=mance category        
describ$ 9 subp>agraph 7,a77i71 !       
quality measures includ$ 9 ! f9al       
measures li/ publi%$ "u subp>agraph     
7,d77i7 = su* ye> & ! li/ ( quality     
measures describ$ 9 subp>agraph 7,d77vi7
 us$ by qualifi$ cl9ical data regi/ries 
"u subsection 7m77#c77;,e74  7ii7       
,res\rce use  ,= ! p]=mance category    
describ$ 9 subp>agraph 7,a77ii71 !      
measurem5t ( res\rce use = su* p]iod "u 
subsection 7p77#c71 us+ ! me?odology "u 
subsection 7r7 z appropriate1 &1 z      

feasible & applicable1 acc\nt+ = ! co/ (
 drugs "u "p ,d4  7iii7  ,cl9ical       
practice improvem5t activities  ,= !    
p]=mance category describ$ 9 subp>agraph
 7,a77iii71 cl9ical practice improvem5t 
activities 7z def9$ 9 subp>agraph       
7,c77v77,,iii77 "u subcategories        
specifi$ by ! ,secret>y = su* p]iod1 :i*
 %all include at lea/ ! foll[+3  7,i7 ,!
 subcategory ( exp&$ practice access1   
:i* %all include activities su* z same  
day appo9tm5ts = urg5t ne$s & aft] h\rs 
access to cl9ician advice4  7,,ii7 ,!   
subcategory ( population managem5t1 :i* 
%all include activities su* z monitor+  
heal? conditions ( individuals to       
provide timely heal? c>e int]v5tions or 
p>ticipation 9 a qualifi$ cl9ical data  
regi/ry4  7,,iii7 ,! subcategory ( c>e  
coord9ation1 :i* %all include activities
 su* z timely communication ( te/       
results1 timely ex*ange ( cl9ical       
in=mation to pati5ts & o!r provid]s1 &  
use ( remote monitor+ or teleheal?4     
7,,iv7 ,! subcategory ( b5efici>y       

engagem5t1 :i* %all include activities  
su* z ! e/abli%m5t ( c>e plans =        
individuals ) complex c>e ne$s1         
b5efici>y self-managem5t assessm5t &    
tra9+1 & us+ %>$ decision-mak+          
me*anisms4  7,v7 ,! subcategory ( pati5t
 safety & practice assessm5t1 su* z     
?r\gh use ( cl9ical or surgical *eckli/s
 & practice assessm5ts relat$ to ma9ta9+
 c]tification4  7,,vi7 ,! subcategory ( 
p>ticipation 9 an alt]native paym5t     
model 7z def9$ 9 section                
#ahcc7z77#c77;,c774  ,9 e/abli%+        
activities "u ?is clause1 ! ,secret>y   
%all give consid]ation to ! circum/ances
 ( small practices 7consi/+ ( #ae or    
few] pr(essionals7 & practices locat$ 9 
rural areas & 9 heal? pr(essional       
%ortage areas 7z designat$ "u section   
#ccb7;a77#a77;,a7 ( ! ,public ,heal?    
,s]vice ,act74  7iv7  ,mean+ful ,,ehr   
use  ,= ! p]=mance category describ$ 9  
subp>agraph 7,a77iv71 ! requirem5ts     
e/abli%$ = su* p]iod "u subsection      
7o77#b7 = det]m9+ :e!r an eligible      

pr(essional is a mean+ful ,,ehr us]4    
7,c7  ,additional provisions  7i7       
,emphasiz+ outcome measures "u ! quality
 p]=mance category  ,9 apply+           
subp>agraph 7,b77i71 ! ,secret>y %all1 z
 feasible1 emphasize ! application (    
outcome measures4  7ii7  ,application ( 
additional sy/em measures  ,! ,secret>y 
may use measures us$ = a paym5t sy/em   
o!r ?an = physicians1 su* z measures =  
inpati5t hospitals1 = purposes ( !      
p]=mance categories describ$ 9 clauses  
7i7 & 7ii7 ( subp>agraph 7,a74 ,=       
purposes ( ! previ\s s5t5ce1 ! ,secret>y
 may n use measures = hospital outpati5t
 dep>tm5ts1 except 9 ! case ( em]g5cy   
physicians4  7iii7  ,global &           
population-bas$ measures  ,! ,secret>y  
may use global measures1 su* z global   
outcome measures1 & population-bas$     
measures = purposes ( ! p]=mance        
category describ$ 9 subp>agraph 7,a77i74
  7iv7  ,application ( measures &       
activities to non-pati5t-fac+           
pr(essionals  ,9 c>ry+ out ?is p>agraph1

 ) respect to measures & activities     
specifi$ 9 subp>agraph 7,b7 = p]=mance  
categories describ$ 9 subp>agraph 7,a71 
! ,secret>y--  7,i7 %all give           
consid]ation to ! circum/ances (        
pr(essional types 7or subcategories ( ^?
 types det]m9$ by practice *>act]i/ics7 
:o typically furni% s]vices t d n       
involve face-to-face int]action ) a     
pati5t2 &  7,,ii7 may1 to ! ext5t       
feasible & appropriate1 take into acc\nt
 su* circum/ances & apply "u ?is        
subsection ) respect to ,,mips eligible 
pr(essionals ( su* pr(essional types or 
subcategories1 alt]native measures or   
activities t fulfill ! goals ( !        
applicable p]=mance category4  ,9 c>ry+ 
out ! previ\s s5t5ce1 ! ,secret>y %all  
consult ) pr(essionals ( su* pr(essional
 types or subcategories4  7v7  ,cl9ical 
practice improvem5t activities  7,i7    
,reque/ = in=mation  ,9 initially apply+
 subp>agraph 7,b77iii71 ! ,secret>y %all
 use a reque/ = in=mation to solicit    
recomm5dations f /akehold]s to id5tify  

activities describ$ 9 su* subp>agraph & 
specify+ crit]ia = su* activities4      
7,,ii7  ,contract au?ority = cl9ical    
practice improvem5t activities p]=mance 
category  ,9 apply+ subp>agraph         
7,b77iii71 ! ,secret>y may contract )   
entities to assi/ ! ,secret>y 9--  7aa7 
id5tify+ activities describ$ 9          
subp>agraph 7,b77iii72  7bb7 specify+   
crit]ia = su* activities2 &  7cc7       
det]m9+ :e!r a ,,mips eligible          
pr(essional meets su* crit]ia4  7,,iii7 
,cl9ical practice improvem5t activities 
def9$  ,= purposes ( ?is subsection1 !  
t]m cl9ical practice improvem5t activity
 means an activity t relevant eligible  
pr(essional organizations & o!r relevant
 /akehold]s id5tify z improv+ cl9ical   
practice or c>e deliv]y & t ! ,secret>y 
det]m9es1 :5 effectively execut$1 is    
likely to result 9 improv$ outcomes4    
7,d7  ,annual li/ ( quality measures    
available = ,,mips assessm5t  7i7  ,9   
g5]al  ,"u ! ,,mips1 ! ,secret>y1 ?r\gh 
notice & comm5t rulemak+ & subject to ! 

succe$+ clauses ( ?is subp>agraph1 %all1
 ) respect to ! p]=mance p]iod = a ye>1 
e/abli% an annual f9al li/ ( quality    
measures f :i* ,,mips eligible          
pr(essionals may *oose = purposes (     
assessm5t "u ?is subsection = su*       
p]=mance p]iod4 ,pursuant to ! previ\s  
s5t5ce1 ! ,secret>y %all--  7,i7 n lat] 
?an ,novemb] #a ( ! ye> prior to ! fir/ 
day ( ! fir/ p]=mance p]iod "u ! ,,mips1
 e/abli% & publi% 9 ! ,f$]al ,regi/] a  
f9al li/ ( quality measures2 &  7,,ii7 n
 lat] ?an ,novemb] #a ( ! ye> prior to !
 fir/ day ( ea* subsequ5t p]=mance      
p]iod1 update ! f9al li/ ( quality      
measures f ! previ\s ye> 7& publi% su*  
updat$ f9al li/ 9 ! ,f$]al ,regi/]71    
by--  7aa7 remov+ f su* li/1 z          
appropriate1 quality measures1 :i* may  
include ! removal ( measures t are no   
long] mean+ful 7su* z measures t are    
topp$ out72  7bb7 add+ to su* li/1 z    
appropriate1 new quality measures2 &    
7cc7 det]m9+ :e!r or n quality measures 
on su* li/ t h und]gone sub/antive      

*anges %\ld be includ$ 9 ! updat$ li/4  
7ii7  ,call = quality measures  7,i7  ,9
 g5]al  ,eligible pr(essional           
organizations & o!r relevant /akehold]s 
%all be reque/$ to id5tify & submit     
quality measures to be consid]$ =       
selection "u ?is subp>agraph 9 ! annual 
li/ ( quality measures publi%$ "u clause
 7i7 & to id5tify & submit updates to ! 
measures on su* li/4 ,= purposes ( !    
previ\s s5t5ce1 measures may be submitt$
 reg>dless ( :e!r su* measures 7        
previ\sly publi%$ 9 a propos$ rule or   
endors$ by an entity ) a contract "u    
section #ahij7;a74  7,,ii7  ,eligible   
pr(essional organization def9$  ,9 ?is  
subp>agraph1 ! t]m eligible pr(essional 
organization means a pr(essional        
organization z def9$ by nationally      
recogniz$ multispecialty bo>ds (        
c]tification or equival5t c]tification  
bo>ds4  7iii7  ,requirem5ts  ,9 select+ 
quality measures = inclusion 9 ! annual 
f9al li/ "u clause 7i71 ! ,secret>y     
%all--  7,i7 provide t1 to ! ext5t      

practicable1 all quality doma9s 7z def9$
 9 subsection 7s77#a77;,b77 are address$
 by su* measures2 &  7,,ii7 ensure t su*
 selection is consi/5t ) ! process =    
selection ( measures "u subsections 7k71
 7m71 & 7p77#b74  7iv7  ,pe] review     
,be=e includ+ a new measure or a measure
 describ$ 9 clause 7i77,,ii77cc7 9 !    
f9al li/ ( measures publi%$ "u clause   
7i7 = a ye>1 ! ,secret>y %all submit =  
publication 9 applicable                
specialty-appropriate pe]-review$       
j\rnals su* measure & ! me?od = develop+
 & select+ su* measure1 includ+ cl9ical 
& o!r data support+ su* measure4  7v7   
,measures = inclusion  ,! f9al li/ (    
quality measures publi%$ "u clause 7i7  
%all include1 z applicable1 measures "u 
subsections 7k71 7m71 & 7p77#b71 includ+
 quality measures f among--  7,i7       
measures endors$ by a cons5sus-bas$     
entity2  7,,ii7 measures develop$ "u    
subsection 7s72 &  7,,iii7 measures     
submitt$ "u clause 7ii77,i74  ,any      
measure select$ = inclusion 9 su* li/ t 

is n endors$ by a cons5sus-bas$ entity  
%all h a focus t is evid5ce-bas$4  7vi7 
,exception = qualifi$ cl9ical data      
regi/ry measures  ,measures us$ by a    
qualifi$ cl9ical data regi/ry "u        
subsection 7m77#c77;,e7 %all n be       
subject to ! requirem5ts "u clauses 7i71
 7iv71 & 7v74 ,! ,secret>y %all publi% !
 li/ ( measures us$ by su* qualifi$     
cl9ical data regi/ries on ! ,int]net    
website ( ! ,c5t]s = ,m$ic>e  ,m$icaid  
,s]vices4  7vii7  ,exception = exi/+    
quality measures  ,any quality measure  
specifi$ by ! ,secret>y "u subsection   
7k7 or 7m71 includ+ "u subsection       
7m77#c77;,e71 & any measure ( quality ( 
c>e e/abli%$ "u subsection 7p77#b7 = !  
report+ p]iod "u ! respective subsection
 beg9n+ be=e ! fir/ p]=mance p]iod "u ! 
,,mips--  7,i7 %all n be subject to !   
requirem5ts "u clause 7i7 7except "u    
items 7aa7 & 7cc7 ( subclause 7,,ii7 (  
su* clause7 or to ! requirem5t "u clause
 7iv72 &  7,,ii7 %all be includ$ 9 !    
f9al li/ ( quality measures publi%$ "u  

clause 7i7 unless remov$ "u clause      
7i77,,ii77aa74  7viii7  ,consultation ) 
relevant eligible pr(essional           
organizations & o!r relevant /akehold]s 
,relevant eligible pr(essional          
organizations & o!r relevant /akehold]s1
 includ+ ,/ate & national m$ical        
societies1 %all be consult$ 9 c>ry+ out 
?is subp>agraph4  7ix7  ,optional       
application  ,! process "u section      
#ahij;,a is n requir$ to apply to !     
selection ( measures "u ?is subp>agraph4
  7#c7  ,p]=mance /&>ds  7,a7           
,e/abli%m5t  ,"u ! ,,mips1 ! ,secret>y  
%all e/abli% p]=mance /&>ds ) respect to
 measures & activities specifi$ "u      
p>agraph 7#b77;,b7 = a p]=mance p]iod 7z
 e/abli%$ "u p>agraph 7#d77 = a ye>4    
7,b7  ,consid]ations 9 e/abli%+ /&>ds   
,9 e/abli%+ su* p]=mance /&>ds ) respect
 to measures & activities specifi$ "u   
p>agraph 7#b77;,b71 ! ,secret>y %all    
consid] ! foll[+3  7i7 ,hi/orical       
p]=mance /&>ds4  7ii7 ,improvem5t4      
7iii7 ,! opportunity = cont9u$          

improvem5t4  7#d7  ,p]=mance p]iod  ,!  
,secret>y %all e/abli% a p]=mance p]iod 
7or p]iods7 = a ye> 7beg9n+ ) ! ye>     
describ$ 9 p>agraph 7#a77;,b774 ,su*    
p]=mance p]iod 7or p]iods7 %all beg9 &  
end prior to ! beg9n+ ( su* ye> & be z  
close z possible to su* ye>4 ,9 ?is     
subsection1 su* p]=mance p]iod 7or      
p]iods7 = a ye> %all be ref]r$ to z !   
p]=mance p]iod = ! ye>4  7#e7           
,composite p]=mance score  7,a7  ,9     
g5]al  ,subject to ! succe$+ provisions 
( ?is p>agraph & tak+ into acc\nt1 z    
available & applicable1 p>agraph        
7#a77;,g71 ! ,secret>y %all develop a   
me?odology = assess+ ! total p]=mance ( 
ea* ,,mips eligible pr(essional accord+ 
to p]=mance /&>ds "u p>agraph 7#c7 )    
respect to applicable measures &        
activities specifi$ 9 p>agraph 7#b77;,b7
 ) respect to ea* p]=mance category     
applicable to su* pr(essional = a       
p]=mance p]iod 7z e/abli%$ "u p>agraph  
7#d77 = a ye>4 ,us+ su* me?odology1 !   
,secret>y %all provide = a composite    

assessm5t 7us+ a scor+ scale ( #j to    
#ajj7 = ea* su* pr(essional = ! p]=mance
 p]iod = su* ye>4 ,9 ?is subsection su* 
a composite assessm5t = su* a           
pr(essional ) respect to a p]=mance     
p]iod %all be ref]r$ to z ! composite   
p]=mance score = su* pr(essional = su*  
p]=mance p]iod4  7,b7  ,inc5tive to     
report2 enc\rag+ use ( c]tifi$ ,,ehr    
te*nology = report+ quality measures    
7i7  ,inc5tive to report  ,"u !         
me?odology e/abli%$ "u subp>agraph 7,a71
 ! ,secret>y %all provide t 9 ! case ( a
 ,,mips eligible pr(essional :o fails to
 report on an applicable measure or     
activity t is requir$ to be report$ by !
 pr(essional1 ! pr(essional %all be     
treat$ z a*iev+ ! l[e/ pot5tial score   
applicable to su* measure or activity4  
7ii7  ,enc\rag+ use ( c]tifi$ ,,ehr     
te*nology & qualifi$ cl9ical data       
regi/ries = report+ quality measures    
,"u ! me?odology e/abli%$ "u subp>agraph
 7,a71 ! ,secret>y %all--  7,i7 enc\rage
 ,,mips eligible pr(essionals to report 

on applicable measures ) respect to !   
p]=mance category describ$ 9 p>agraph   
7#b77;,a77i7 ?r\gh ! use ( c]tifi$ ,,ehr
 te*nology & qualifi$ cl9ical data      
regi/ries2 &  7,,ii7 ) respect to a     
p]=mance p]iod1 ) respect to a ye>1 =   
:i* a ,,mips eligible pr(essional       
reports su* measures ?r\gh ! use ( su*  
,,ehr te*nology1 treat su* pr(essional z
 satisfy+ ! cl9ical quality measures    
report+ requirem5t describ$ 9 subsection
 7o77#b77;,a77iii7 = su* ye>4  7,c7     
,cl9ical practice improvem5t activities 
p]=mance score  7i7  ,rule =            
accr$itation  ,a ,,mips eligible        
pr(essional :o is 9 a practice t is     
c]tifi$ z a pati5t-c5t]$ m$ical home or 
comp>able specialty practice pursuant to
 subsection 7b77#h77;,b77i7 ) respect to
 a p]=mance p]iod %all be giv5 ! highe/ 
pot5tial score = ! p]=mance category    
describ$ 9 p>agraph 7#b77;,a77iii7 = su*
 p]iod4  7ii7  ,,apm p>ticipation       
,p>ticipation by a ,,mips eligible      
pr(essional 9 an alt]native paym5t model

 7z def9$ 9 section #ahcc7z77#c77;,c77 )
 respect to a p]=mance p]iod %all e>n   
su* eligible pr(essional a m9imum score 
( "o-half ( ! highe/ pot5tial score = ! 
p]=mance category describ$ 9 p>agraph   
7#b77;,a77iii7 = su* p]=mance p]iod4    
7iii7  ,subcategories  ,a ,,mips        
eligible pr(essional %all n be requir$  
to p]=m activities 9 ea* subcategory "u 
p>agraph 7#b77;,b77iii7 or p>ticipate 9 
an alt]native paym5t model 9 ord] to    
a*ieve ! highe/ pot5tial score = !      
p]=mance category describ$ 9 p>agraph   
7#b77;,a77iii74  7,d7  ,a*ievem5t &     
improvem5t  7i7  ,tak+ into acc\nt      
improvem5t  ,beg9n+ ) ! second ye> to   
:i* ! ,,mips applies1 9 addition to !   
a*ievem5t ( a ,,mips eligible           
pr(essional1 if data suffici5t to       
measure improvem5t is available1 !      
me?odology develop$ "u subp>agraph      
7,a7--  7,i7 9 ! case ( ! p]=mance score
 = ! p]=mance category describ$ 9       
clauses 7i7 & 7ii7 ( p>agraph 7#b77;,a71
 %all take into acc\nt ! improvem5t ( ! 

pr(essional2 &  7,,ii7 9 ! case (       
p]=mance scores = o!r p]=mance          
categories1 may take into acc\nt !      
improvem5t ( ! pr(essional4  7ii7       
,assign+ high] weight = a*ievem5t       
,beg9n+ ) ! f\r? ye> to :i* ! ,,mips    
applies1 "u ! me?odology develop$ "u    
subp>agraph 7,a71 ! ,secret>y may assign
 a high] scor+ weight "u subp>agraph    
7,f7 ) respect to ! a*ievem5t ( a ,,mips
 eligible pr(essional ?an ) respect to  
any improvem5t ( su* pr(essional appli$ 
"u clause 7i7 ) respect to a measure1   
activity1 or category describ$ 9        
p>agraph 7#b74  7,e7  ,weights = !      
p]=mance categories  7i7  ,9 g5]al  ,"u 
! me?odology develop$ "u subp>agraph    
7,a71 subject to subp>agraph 7,f77i7 &  
clauses 7ii7 & 7iii71 ! composite       
p]=mance score %all be det]m9$ z foll[s3
  7,i7  ,quality  7aa7  ,9 g5]al        
,subject to item 7bb71 ?irty p]c5t ( su*
 score %all be bas$ on p]=mance )       
respect to ! category describ$ 9 clause 
7i7 ( p>agraph 7#b77;,a74 ,9 apply+ !   

previ\s s5t5ce1 ! ,secret>y %all1 z     
feasible1 enc\rage ! application (      
outcome measures )9 su* category4  7bb7 
,fir/ #b ye>s  ,= ! fir/ & second ye>s =
 :i* ! ,,mips applies to paym5ts1 !     
p]c5tage applicable "u item 7aa7 %all be
 increas$ 9 a mann] su* t ! total       
p]c5tage po9ts ( ! increase "u ?is item 
= ! respective ye> equals ! total numb] 
( p]c5tage po9ts by :i* ! p]c5tage      
appli$ "u subclause 7,,ii77bb7 = !      
respective ye> is less ?an #cj p]c5t4   
7,,ii7  ,res\rce use  7aa7  ,9 g5]al    
,subject to item 7bb71 ?irty p]c5t ( su*
 score %all be bas$ on p]=mance )       
respect to ! category describ$ 9 clause 
7ii7 ( p>agraph 7#b77;,a74  7bb7  ,fir/ 
#b ye>s  ,= ! fir/ ye> = :i* ! ,,mips   
applies to paym5ts1 n m ?an #aj p]c5t ( 
su* score %all be bas$ on p]=mance )    
respect to ! category describ$ 9 clause 
7ii7 ( p>agraph 7#b77;,a74 ,= ! second  
ye> = :i* ! ,,mips applies to paym5ts1 n
 m ?an #ae p]c5t ( su* score %all be    
bas$ on p]=mance ) respect to ! category

 describ$ 9 clause 7ii7 ( p>agraph      
7#b77;,a74  7,,iii7  ,cl9ical practice  
improvem5t activities  ,fifte5 p]c5t (  
su* score %all be bas$ on p]=mance )    
respect to ! category describ$ 9 clause 
7iii7 ( p>agraph 7#b77;,a74  7,,iv7     
,mean+ful use ( c]tifi$ ,,ehr te*nology 
,tw5ty-five p]c5t ( su* score %all be   
bas$ on p]=mance ) respect to ! category
 describ$ 9 clause 7iv7 ( p>agraph      
7#b77;,a74  7ii7  ,au?ority to adju/    
p]c5tages 9 case ( high ,,ehr mean+ful  
use adoption  ,9 any ye> 9 :i* !        
,secret>y e/imates t ! proportion (     
eligible pr(essionals 7z def9$ 9        
subsection 7o77#e77 :o are mean+ful     
,,ehr us]s 7z det]m9$ "u subsection     
7o77#b77 is #ge p]c5t or great]1 !      
,secret>y may r$uce ! p]c5t applicable  
"u clause 7i77,,iv71 b n bel[ #ae p]c5t4
 ,if ! ,secret>y makes su* r$uction = a 
ye>1 subject to subclauses 7,i77bb7 &   
7,,ii77bb7 ( clause 7i71 ! p]c5tages    
applicable "u "o or m ( subclauses 7,i71
 7,,ii71 & 7,,iii7 ( clause 7i7 = su*   

ye> %all be increas$ 9 a mann] su* t !  
total p]c5tage po9ts ( ! increase "u ?is
 clause = su* ye> equals ! total numb] (
 p]c5tage po9ts r$uc$ "u ! prec$+ s5t5ce
 = su* ye>4  7,f7  ,c]ta9 flexibility = 
weight+ p]=mance categories1 measures1 &
 activities  ,"u ! me?odology "u        
subp>agraph 7,a71 if !re are n suffici5t
 measures & cl9ical practice improvem5t 
activities applicable & available to ea*
 type ( eligible pr(essional involv$1 ! 
,secret>y %all assign diff]5t scor+     
weights 7includ+ a weight ( #j7--  7i7  
:i* may v>y f ! scor+ weights specifi$ 9
 subp>agraph 7,e71 = ea* p]=mance       
category bas$ on ! ext5t to :i* !       
category is applicable to ! type (      
eligible pr(essional involv$2 &  7ii7 = 
ea* measure & activity specifi$ "u      
p>agraph 7#b77;,b7 ) respect to ea* su* 
category bas$ on ! ext5t to :i* !       
measure or activity is applicable &     
available to ! type ( eligible          
pr(essional involv$4  7,g7  ,res\rce use
  ,analysis ( ! p]=mance category       

describ$ 9 p>agraph 7#b77;,a77ii7 %all  
include results f ! me?odology describ$ 
9 subsection 7r77#e71 z appropriate4    
7,h7  ,inclusion ( quality measure data 
f o!r pay]s  ,9 apply+ subsections 7k71 
7m71 & 7p7 ) respect to measures        
describ$ 9 p>agraph 7#b77;,b77i71       
analysis ( ! p]=mance category describ$ 
9 p>agraph 7#b77;,a77i7 may include data
 submitt$ by ,,mips eligible            
pr(essionals ) respect to items &       
s]vices furni%$ to individuals :o are n 
individuals entitl$ to b5efits "u "p ,a 
or enroll$ "u "p ,b4  7,i7  ,use (      
volunt>y virtual gr\ps = c]ta9 assessm5t
 purposes  7i7  ,9 g5]al  ,9 ! case (   
,,mips eligible pr(essionals elect+ to  
be a virtual gr\p "u clause 7ii7 )      
respect to a p]=mance p]iod = a ye>1 =  
purposes ( apply+ ! me?odology "u       
subp>agraph 7,a7--  7,i7 ! assessm5t (  
p]=mance provid$ "u su* me?odology )    
respect to ! p]=mance categories        
describ$ 9 clauses 7i7 & 7ii7 ( p>agraph
 7#b77;,a7 t is to be appli$ to ea* su* 

pr(essional 9 su* gr\p = su* p]=mance   
p]iod %all be ) respect to ! comb9$     
p]=mance ( all su* pr(essionals 9 su*   
gr\p = su* p]iod2 &  7,,ii7 ! composite 
score provid$ "u ?is p>agraph = su*     
p]=mance p]iod ) respect to ea* su*     
p]=mance category = ea* su* ,,mips      
eligible pr(essional 9 su* virtual gr\p 
%all be bas$ on ! assessm5t ( ! comb9$  
p]=mance "u subclause 7,i7 = ! p]=mance 
category & p]=mance p]iod4  7ii7        
,election ( practices to be a virtual   
gr\p  ,! ,secret>y %all1 9 accordance ) 
clause 7iii71 e/abli% & h 9 place a     
process to all[ an individual ,,mips    
eligible pr(essional or a gr\p practice 
consi/+ ( n m ?an #aj ,,mips eligible   
pr(essionals to elect1 ) respect to a   
p]=mance p]iod = a ye>1 = su* individual
 ,,mips eligible pr(essional or all su* 
,,mips eligible pr(essionals 9 su* gr\p 
practice1 respectively1 to be a virtual 
gr\p "u ?is subp>agraph ) at lea/ "o o!r
 su* individual ,,mips eligible         
pr(essional or gr\p practice mak+ su* an

 election4 ,su* a virtual gr\p may be   
bas$ on geographic areas or on provid]  
specialties def9$ by nationally         
recogniz$ multispecialty bo>ds (        
c]tification or equival5t c]tification  
bo>ds & su* o!r eligible pr(essional    
gr\p+s 9 ord] to capture classifications
 ( provid]s across eligible pr(essional 
organizations & o!r practice areas or   
categories4  7iii7  ,requirem5ts  ,!    
process "u clause 7ii7--  7,i7 %all     
provide t an election "u su* clause1 )  
respect to a p]=mance p]iod1 %all be    
made be=e or dur+ ! beg9n+ ( su*        
p]=mance p]iod & may n be *ang$ dur+ su*
 p]=mance p]iod2  7,,ii7 %all provide t 
a practice describ$ 9 su* clause1 & ea* 
,,mips eligible pr(essional 9 su*       
practice1 may elect to be 9 no m ?an "o 
virtual gr\p = a p]=mance p]iod2 &      
7,,iii7 may provide t a virtual gr\p may
 be comb9$ at ! tax id5tification numb] 
level4  7#f7  ,,mips paym5ts  7,a7      
,,mips adju/m5t factor  ,tak+ into      
acc\nt p>agraph 7#a77;,g71 ! ,secret>y  

%all specify a ,,mips adju/m5t factor = 
ea* ,,mips eligible pr(essional = a ye>4
 ,su* ,,mips adju/m5t factor = a ,,mips 
eligible pr(essional = a ye> %all be 9 !
 =m ( a p]c5t & %all be det]m9$--  7i7  
by comp>+ ! composite p]=mance score ( !
 eligible pr(essional = su* ye> to !    
p]=mance ?re%old e/abli%$ "u subp>agraph
 7,d77i7 = su* ye>2  7ii7 9 a mann] su* 
t ! adju/m5t factors specifi$ "u ?is    
subp>agraph = a ye> result 9 diff]5tial 
paym5ts "u ?is p>agraph reflect+ t--    
7,i7 ,,mips eligible pr(essionals )     
composite p]=mance scores = su* ye> at  
or above su* p]=mance ?re%old = su* ye> 
receive z]o or positive inc5tive paym5t 
adju/m5t factors = su* ye> 9 accordance 
) clause 7iii71 ) su* pr(essionals hav+ 
high] composite p]=mance scores receiv+ 
high] adju/m5t factors2 &  7,,ii7 ,,mips
 eligible pr(essionals ) composite      
p]=mance scores = su* ye> bel[ su*      
p]=mance ?re%old = su* ye> receive      
negative paym5t adju/m5t factors = su*  
ye> 9 accordance ) clause 7iv71 ) su*   

pr(essionals hav+ l[] composite p]=mance
 scores receiv+ l[] adju/m5t factors2   
7iii7 9 a mann] su* t ,,mips eligible   
pr(essionals ) composite scores describ$
 9 clause 7ii77,i7 = su* ye>1 subject to
 clauses 7i7 & 7ii7 ( subp>agraph 7,f71 
receive a z]o or positive adju/m5t      
factor on a l9e> slid+ scale su* t an   
adju/m5t factor ( #j p]c5t is assign$ = 
a score at ! p]=mance ?re%old & an      
adju/m5t factor ( ! applicable p]c5t    
specifi$ 9 subp>agraph 7,b7 is assign$ =
 a score ( #ajj2 &  7iv7 9 a mann] su*  
t--  7,i7 subject to subclause 7,,ii71  
,,mips eligible pr(essionals ) composite
 p]=mance scores describ$ 9 clause      
7ii77,,ii7 = su* ye> receive a negative 
paym5t adju/m5t factor on a l9e> slid+  
scale su* t an adju/m5t factor ( #j     
p]c5t is assign$ = a score at ! p]=mance
 ?re%old & an adju/m5t factor ( !       
negative ( ! applicable p]c5t specifi$ 9
 subp>agraph 7,b7 is assign$ = a score (
 #j2 &  7,,ii7 ,,mips eligible          
pr(essionals ) composite p]=mance scores

 t are equal to or great] ?an #j1 b n   
great] ?an #a_/d ( ! p]=mance ?re%old   
specifi$ "u subp>agraph 7,d77i7 = su*   
ye>1 receive a negative paym5t adju/m5t 
factor t is equal to ! negative ( !     
applicable p]c5t specifi$ 9 subp>agraph 
7,b7 = su* ye>4  7,b7  ,applicable p]c5t
 def9$  ,= purposes ( ?is p>agraph1 !   
t]m applicable p]c5t means--  7i7 =     
#bjah1 #d p]c5t2  7ii7 = #bjai1 #e      
p]c5t2  7iii7 = #bjbj1 #g p]c5t2 &  7iv7
 = #bjba & subsequ5t ye>s1 #i p]c5t4    
7,c7  ,additional ,,mips adju/m5t       
factors = exceptional p]=mance  7i7  ,9 
g5]al  ,9 ! case ( a ,,mips eligible    
pr(essional ) a composite p]=mance score
 = a ye> at or above ! additional       
p]=mance ?re%old "u subp>agraph 7,d77ii7
 = su* ye>1 9 addition to ! ,,mips      
adju/m5t factor "u subp>agraph 7,a7 = ! 
eligible pr(essional = su* ye>1 subject 
to ! availability ( funds "u clause     
7ii71 ! ,secret>y %all specify an       
additional positive ,,mips adju/m5t     
factor = su* pr(essional & ye>4 ,su*    

additional ,,mips adju/m5t factors %all 
be det]m9$ by ! ,secret>y 9 a mann] su* 
t pr(essionals hav+ high] composite     
p]=mance scores above ! additional      
p]=mance ?re%old receive high]          
additional ,,mips adju/m5t factors4     
7ii7  ,additional fund+ pool  ,= #bjah &
 ea* subsequ5t ye> ?r\gh #bjbc1 !re is  
appropriat$ f ! ,f$]al ,supplem5t>y     
,m$ical ,insurance ,tru/ ,fund          
#ejj1jjj1jjj = ,,mips paym5ts "u ?is    
p>agraph result+ f ! application ( !    
additional ,,mips adju/m5t factors "u   
clause 7i74  7,d7  ,e/abli%m5t (        
p]=mance ?re%olds  7i7  ,p]=mance       
?re%old  ,= ea* ye> ( ! ,,mips1 !       
,secret>y %all compute a p]=mance       
?re%old ) respect to :i* ! composite    
p]=mance score ( ,,mips eligible        
pr(essionals %all be comp>$ = purposes (
 det]m9+ adju/m5t factors "u subp>agraph
 7,a7 t are positive1 negative1 & z]o4  
,su* p]=mance ?re%old = a ye> %all be ! 
mean or m$ian 7z select$ by ! ,secret>y7
 ( ! composite p]=mance scores = all    

,,mips eligible pr(essionals ) respect  
to a prior p]iod specifi$ by !          
,secret>y4 ,! ,secret>y may reassess !  
selection "u ! previ\s s5t5ce e #c ye>s4
  7ii7  ,additional p]=mance ?re%old =  
exceptional p]=mance  ,9 addition to !  
p]=mance ?re%old "u clause 7i71 = ea*   
ye> ( ! ,,mips1 ! ,secret>y %all compute
 an additional p]=mance ?re%old =       
purposes ( det]m9+ ! additional ,,mips  
adju/m5t factors "u subp>agraph 7,c77i74
 ,= ea* su* ye>1 ! ,secret>y %all apply 
ei!r ( ! foll[+ me?ods = comput+ su*    
additional p]=mance ?re%old = su* a ye>3
  7,i7 ,! ?re%old %all be ! score t is  
equal to ! #be? p]c5tile ( ! range (    
possible composite p]=mance scores above
 ! p]=mance ?re%old ) respect to ! prior
 p]iod describ$ 9 clause 7i74  7,,ii7 ,!
 ?re%old %all be ! score t is equal to !
 #be? p]c5tile ( ! actual composite     
p]=mance scores = ,,mips eligible       
pr(essionals ) composite p]=mance scores
 at or above ! p]=mance ?re%old )       
respect to ! prior p]iod describ$ 9     

clause 7i74  7iii7  ,special rule =     
initial #b ye>s  ,) respect to ea* ( !  
fir/ two ye>s to :i* ! ,,mips applies1 !
 ,secret>y %all1 prior to ! p]=mance    
p]iod = su* ye>s1 e/abli% a p]=mance    
?re%old = purposes ( det]m9+ ,,mips     
adju/m5t factors "u subp>agraph 7,a7 & a
 ?re%old = purposes ( det]m9+ additional
 ,,mips adju/m5t factors "u subp>agraph 
7,c77i74 ,ea* su* p]=mance ?re%old      
%all--  7,i7 be bas$ on a p]iod prior to
 su* p]=mance p]iods2 &  7,,ii7 take    
into acc\nt--  7aa7 data available )    
respect to p]=mance on measures &       
activities t may be us$ "u ! p]=mance   
categories "u subp>agraph 7#b77;,b72 &  
7bb7 o!r factors det]m9$ appropriate by 
! ,secret>y4  7,e7  ,application (      
,,mips adju/m5t factors  ,9 ! case (    
items & s]vices furni%$ by a ,,mips     
eligible pr(essional dur+ a ye> 7beg9n+ 
) #bjah71 ! am\nt o!rwise paid "u ?is "p
 ) respect to su* items & s]vices &     
,,mips eligible pr(essional = su* ye>1  
%all be multipli$ by--  7i7 #a1 plus    

7ii7 ! sum (--  7,i7 ! ,,mips adju/m5t  
factor det]m9$ "u subp>agraph 7,a7      
divid$ by #ajj1 &  7,,ii7 z applicable1 
! additional ,,mips adju/m5t factor     
det]m9$ "u subp>agraph 7,c77i7 divid$ by
 #ajj4  7,f7  ,aggregate application (  
,,mips adju/m5t factors  7i7            
,application ( scal+ factor  7,i7  ,9   
g5]al  ,) respect to positive ,,mips    
adju/m5t factors "u subp>agraph         
7,a77ii77,i7 = eligible pr(essionals ^: 
composite p]=mance score is above !     
p]=mance ?re%old "u subp>agraph 7,d77i7 
= su* ye>1 subject to subclause 7,,ii71 
! ,secret>y %all increase or decrease   
su* adju/m5t factors by a scal+ factor 9
 ord] to ensure t ! budget neutrality   
requirem5t ( clause 7ii7 is met4  7,,ii7
  ,scal+ factor limit  ,9 no case may be
 ! scal+ factor appli$ "u ?is clause    
exce$ #c4j4  7ii7  ,budget neutrality   
requirem5t  7,i7  ,9 g5]al  ,subject to 
clause 7iii71 ! ,secret>y %all ensure t 
! e/imat$ am\nt describ$ 9 subclause    
7,,ii7 = a ye> is equal to ! e/imat$    

am\nt describ$ 9 subclause 7,,iii7 = su*
 ye>4  7,,ii7  ,aggregate increases  ,! 
am\nt describ$ 9 ?is subclause is !     
e/imat$ increase 9 ! aggregate all[$    
*>ges result+ f ! application ( positive
 ,,mips adju/m5t factors "u subp>agraph 
7,a7 7aft] application ( ! scal+ factor 
describ$ 9 clause 7i77 to ,,mips        
eligible pr(essionals ^: composite      
p]=mance score = a ye> is above !       
p]=mance ?re%old "u subp>agraph 7,d77i7 
= su* ye>4  7,,iii7  ,aggregate         
decreases  ,! am\nt describ$ 9 ?is      
subclause is ! e/imat$ decrease 9 !     
aggregate all[$ *>ges result+ f !       
application ( negative ,,mips adju/m5t  
factors "u subp>agraph 7,a7 to ,,mips   
eligible pr(essionals ^: composite      
p]=mance score = a ye> is bel[ !        
p]=mance ?re%old "u subp>agraph 7,d77i7 
= su* ye>4  7iii7  ,exceptions  7,i7 ,9 
! case t all ,,mips eligible            
pr(essionals receive composite p]=mance 
scores = a ye> t are bel[ ! p]=mance    
?re%old "u subp>agraph 7,d77i7 = su*    

ye>1 ! negative ,,mips adju/m5t factors 
"u subp>agraph 7,a7 %all apply ) respect
 to su* ,,mips eligible pr(essionals & !
 budget neutrality requirem5t ( clause  
7ii7 %all n apply = su* ye>4  7,,ii7 ,9 
! case t1 ) respect to a ye>1 !         
application ( clause 7i7 results 9 a    
scal+ factor equal to ! maximum scal+   
factor specifi$ 9 clause 7i77,,ii71 su* 
scal+ factor %all apply & ! budget      
neutrality requirem5t ( clause 7ii7 %all
 n apply = su* ye>4  7iv7  ,additional  
inc5tive paym5t adju/m5ts  ,9 specify+ !
 ,,mips additional adju/m5t factors "u  
subp>agraph 7,c77i7 = ea* applicable    
,,mips eligible pr(essional = a ye>1 !  
,secret>y %all ensure t ! e/imat$       
increase 9 paym5ts "u ?is "p result+ f !
 application ( su* additional adju/m5t  
factors = ,,mips eligible pr(essionals 9
 a ye> %all be equal 7z e/imat$ by !    
,secret>y7 to ! additional fund+ pool   
am\nt = su* ye> "u subp>agraph 7,c77ii74
  7#g7  ,ann\ncem5t ( result ( adju/m5ts
  ,"u ! ,,mips1 ! ,secret>y %all1 n lat]

 ?an #cj days prior to ,janu>y #a ( !   
ye> involv$1 make available to ,,mips   
eligible pr(essionals ! ,,mips adju/m5t 
factor 7&1 z applicable1 ! additional   
,,mips adju/m5t factor7 "u p>agraph 7#f7
 applicable to ! eligible pr(essional = 
items & s]vices furni%$ by ! pr(essional
 = su* ye>4 ,! ,secret>y may include su*
 in=mation 9 ! confid5tial fe$back "u   
p>agraph 7#ab74  7#h7  ,no effect 9     
subsequ5t ye>s  ,! ,,mips adju/m5t      
factors & additional ,,mips adju/m5t    
factors "u p>agraph 7#f7 %all apply only
 ) respect to ! ye> involv$1 & !        
,secret>y %all n take into acc\nt su*   
adju/m5t factors 9 mak+ paym5ts to a    
,,mips eligible pr(essional "u ?is "p 9 
a subsequ5t ye>4  7#i7  ,public report+ 
7,a7  ,9 g5]al  ,! ,secret>y %all1 9 an 
easily und]/&able =mat1 make available  
on ! ,physician ,comp>e ,int]net website
 ( ! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices
 ! foll[+3  7i7 ,in=mation reg>d+ !     
p]=mance ( ,,mips eligible pr(essionals 
"u ! ,,mips1 :i*--  7,i7 %all include ! 

composite score = ea* su* ,,mips        
eligible pr(essional & ! p]=mance ( ea* 
su* ,,mips eligible pr(essional )       
respect to ea* p]=mance category2 &     
7,,ii7 may include ! p]=mance ( ea* su* 
,,mips eligible pr(essional ) respect to
 ea* measure or activity specifi$ 9     
p>agraph 7#b77;,b74  7ii7 ,! names (    
eligible pr(essionals 9 eligible        
alt]native paym5t models 7z def9$ 9     
section #ahcc7z77#c77;,d77 &1 to ! ext5t
 feasible1 ! names ( su* eligible       
alt]native paym5t models & p]=mance (   
su* models4  7,b7  ,disclosure  ,!      
in=mation made available "u ?is p>agraph
 %all indicate1 :]e appropriate1 t      
publiciz$ in=mation may n be            
repres5tative ( ! eligible pr(essional's
 entire pati5t population1 ! v>iety (   
s]vices furni%$ by ! eligible           
pr(essional1 or ! heal? conditions (    
individuals treat$4  7,c7  ,opportunity 
to review & submit corrections  ,!      
,secret>y %all provide = an opportunity 
= a pr(essional describ$ 9 subp>agraph  

7,a7 to review1 & submit corrections =1 
! in=mation to be made public ) respect 
to ! pr(essional "u su* subp>agraph     
prior to su* in=mation be+ made public4 
7,d7  ,aggregate in=mation  ,! ,secret>y
 %all p]iodically po/ on ! ,physician   
,comp>e ,int]net website aggregate      
in=mation on ! ,,mips1 includ+ ! range (
 composite scores = all ,,mips eligible 
pr(essionals & ! range ( ! p]=mance (   
all ,,mips eligible pr(essionals )      
respect to ea* p]=mance category4  7#aj7
  ,consultation  ,! ,secret>y %all      
consult ) /akehold]s 9 c>ry+ out !      
,,mips1 includ+ = ! id5tification (     
measures & activities "u p>agraph       
7#b77;,b7 & ! me?odologies develop$ "u  
p>agraphs 7#e77;,a7 & 7#f7 & reg>d+ !   
use ( qualifi$ cl9ical data regi/ries4  
,su* consultation %all include ! use ( a
 reque/ = in=mation or o!r me*anisms    
det]m9$ appropriate4  7#aa7  ,te*nical  
assi/ance to small practices & practices
 9 heal? pr(essional %ortage areas  7,a7
  ,9 g5]al  ,! ,secret>y %all ent] into 

contracts or agreem5ts ) appropriate    
entities 7su* z quality improvem5t      
organizations1 regional ext5sion c5t]s  
7z describ$ 9 section #cjab7;c7 ( !     
,public ,heal? ,s]vice ,act71 or        
regional heal? collaboratives7 to (f]   
guidance & assi/ance to ,,mips eligible 
pr(essionals 9 practices ( #ae or few]  
pr(essionals 7) priority giv5 to su*    
practices locat$ 9 rural areas1 heal?   
pr(essional %ortage areas 7z designat$  
"u 9 section #ccb7;a77#a77;,a7 ( su*    
,act71 & m$ically und]s]v$ areas1 &     
practices ) l[ composite scores7 )      
respect to--  7i7 ! p]=mance categories 
describ$ 9 clauses 7i7 ?r\gh 7iv7 (     
p>agraph 7#b77;,a72 or  7ii7 h[ to      
transition to ! implem5tation ( &       
p>ticipation 9 an alt]native paym5t     
model z describ$ 9 section              
#ahcc7z77#c77;,c74  7,b7  ,fund+ =      
implem5tation  7i7  ,9 g5]al  ,=        
purposes ( implem5t+ subp>agraph 7,a71 !
 ,secret>y %all provide = ! transf] f ! 
,f$]al ,supplem5t>y ,m$ical ,insurance  

,tru/ ,fund e/abli%$ "u section #ahda to
 ! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices  
,program ,managem5t ,acc\nt (           
#dj1jjj1jjj = ea* ( fiscal ye>s #bjae   
?r\gh #bjai4 ,am\nts transf]r$ "u ?is   
subp>agraph = a fiscal ye> %all be      
available until exp5d$4  7ii7  ,te*nical
 assi/ance  ,( ! am\nts transf]r$       
pursuant to clause 7i7 = ea* ( fiscal   
ye>s #bjae ?r\gh #bjai1 n less ?an      
#aj1jjj1jjj %all be made available = ea*
 su* ye> = te*nical assi/ance to small  
practices 9 heal? pr(essional %ortage   
areas 7z s designat$7 & m$ically        
und]s]v$ areas4  7#ab7  ,fe$back &      
in=mation to improve p]=mance  7,a7     
,p]=mance fe$back  7i7  ,9 g5]al        
,beg9n+ ,july #a1 #bjaf1 ! ,secret>y--  
7,i7 %all make available timely 7su* z  
qu>t]ly7 confid5tial fe$back to ,,mips  
eligible pr(essionals on ! p]=mance (   
su* pr(essionals ) respect to ! p]=mance
 categories "u clauses 7i7 & 7ii7 (     
p>agraph 7#b77;,a72 &  7,,ii7 may make  
available confid5tial fe$back to ea* su*

 pr(essional on ! p]=mance ( su*        
pr(essional ) respect to ! p]=mance     
categories "u clauses 7iii7 & 7iv7 ( su*
 p>agraph4  7ii7  ,me*anisms  ,!        
,secret>y may use "o or m me*anisms to  
make fe$back available "u clause 7i71   
:i* may include use ( a web-bas$ portal 
or o!r me*anisms det]m9$ appropriate by 
! ,secret>y4 ,) respect to ! p]=mance   
category describ$ 9 p>agraph            
7#b77;,a77i71 fe$back "u ?is subp>agraph
 %all1 to ! ext5t an eligible           
pr(essional *ooses to p>ticipate 9 a    
data regi/ry = purposes ( ?is subsection
 7includ+ regi/ries "u subsections 7k7 &
 7m771 be provid$ bas$ on p]=mance on   
quality measures report$ ?r\gh ! use (  
su* regi/ries4 ,) respect to any o!r    
p]=mance category describ$ 9 p>agraph   
7#b77;,a71 ! ,secret>y %all enc\rage    
provision ( fe$back ?r\gh qualifi$      
cl9ical data regi/ries z describ$ 9     
subsection 7m77#c77;,e774  7iii7  ,use (
 data  ,= purposes ( clause 7i71 !      
,secret>y may use data1 ) respect to a  

,,mips eligible pr(essional1 f p]iods   
prior to ! curr5t p]=mance p]iod & may  
use roll+ p]iods 9 ord] to make         
illu/rative calculations ab\t ! p]=mance
 ( su* pr(essional4  7iv7  ,disclosure  
exemption  ,fe$back made available "u   
?is subp>agraph %all be exempt f        
disclosure "u section #eeb ( title #e1  
,unit$ ,/ates ,code4  7v7  ,receipt (   
in=mation  ,! ,secret>y may use !       
me*anisms e/abli%$ "u clause 7ii7 to    
receive in=mation f pr(essionals1 su* z 
in=mation ) respect to ?is subsection4  
7,b7  ,additional in=mation  7i7  ,9    
g5]al  ,beg9n+ ,july #a1 #bjag1 !       
,secret>y %all make available to ea*    
,,mips eligible pr(essional in=mation1 )
 respect to individuals :o are pati5ts (
 su* ,,mips eligible pr(essional1 ab\t  
items & s]vices = :i* paym5t is made "u 
?is title t are furni%$ to su*          
individuals by o!r suppli]s & provid]s (
 s]vices1 :i* may include in=mation     
describ$ 9 clause 7ii74 ,su* in=mation  
may be made available "u ! previ\s      

s5t5ce to su* ,,mips eligible           
pr(essionals by me*anisms det]m9$       
appropriate by ! ,secret>y1 :i* may     
include use ( a web-bas$ portal4 ,su*   
in=mation may be made available 9       
accordance ) ! same or simil> t]ms z    
data are made available to acc\ntable   
c>e organizations p>ticipat+ 9 ! %>$    
sav+s program "u section #ahii1 includ+ 
a b5efici>y opt-out4  7ii7  ,type (     
in=mation  ,= purposes ( clause 7i71 !  
in=mation describ$ 9 ?is clause1 is !   
foll[+3  7,i7 ,) respect to select$     
items & s]vices 7z det]m9$ appropriate  
by ! ,secret>y7 = :i* paym5t is made "u 
?is title & t are furni%$ to            
individuals1 :o are pati5ts ( a ,,mips  
eligible pr(essional1 by ano!r suppli]  
or provid] ( s]vices dur+ ! mo/ rec5t   
p]iod = :i* data are available 7su* z ! 
mo/ rec5t ?ree-mon? p]iod71 su* z ! "n (
 su* provid]s furni%+ su* items &       
s]vices to su* pati5ts dur+ su* p]iod1 !
 types ( su* items & s]vices s furni%$1 
& ! dates su* items & s]vices 7 s       

furni%$4  7,,ii7 ,hi/orical data1 su* z 
av]ages & o!r measures ( ! di/ribution  
if appropriate1 ( ! total1 & compon5ts  
(1 all[$ *>ges 7& o!r figures z det]m9$ 
appropriate by ! ,secret>y74  7#ac7     
,review  7,a7  ,t>get$ review  ,!       
,secret>y %all e/abli% a process "u :i* 
a ,,mips eligible pr(essional may seek  
an in=mal review ( ! calculation ( !    
,,mips adju/m5t factor applicable to su*
 eligible pr(essional "u ?is subsection 
= a ye>4 ,! results ( a review conduct$ 
pursuant to ! previ\s s5t5ce %all n be  
tak5 into acc\nt = purposes ( p>agraph  
7#f7 ) respect to a ye> 7o!r ?an )      
respect to ! calculation ( su* eligible 
pr(essional's ,,mips adju/m5t factor =  
su* ye> or additional ,,mips adju/m5t   
factor = su* ye>7 aft] ! factors det]m9$
 9 subp>agraph 7,a7 & subp>agraph 7,c7 (
 su* p>agraph h be5 det]m9$ = su* ye>4  
7,b7  ,limitation  ,except z provid$ = 9
 subp>agraph 7,a71 !re %all be no       
adm9i/rative or judicial review "u      
section #ahfi1 section #ahgh1 or o!rwise

 ( ! foll[+3  7i7 ,! me?odology us$ to  
det]m9e ! am\nt ( ! ,,mips adju/m5t     
factor "u p>agraph 7#f77;,a7 & ! am\nt (
 ! additional ,,mips adju/m5t factor "u 
p>agraph 7#f77;,c77i7 & ! det]m9ation ( 
su* am\nts4  7ii7 ,! e/abli%m5t ( !     
p]=mance /&>ds "u p>agraph 7#c7 & !     
p]=mance p]iod "u p>agraph 7#d74  7iii7 
,! id5tification ( measures & activities
 specifi$ "u p>agraph 7#b77;,b7 &       
in=mation made public or po/$ on !      
,physician ,comp>e ,int]net website ( ! 
,c5t]s = ,m$ic>e  ,m$icaid ,s]vices "u  
p>agraph 7#i74  7iv7 ,! me?odology      
develop$ "u p>agraph 7#e7 t is us$ to   
calculate p]=mance scores & !           
calculation ( su* scores1 includ+ !     
weight+ ( measures & activities "u su*  
me?odology4  4  7#b7  ,,gao reports     
7,a7  ,evaluation ( eligible pr(essional
 ,,mips  ,n lat] ?an ,octob] #a1 #bjai1 
& ,octob] #a1 #bjbb1 ! ,comptroll]      
,g5]al ( ! ,unit$ ,/ates %all submit to 
,congress a report evaluat+ ! eligible  
pr(essional ,m]it-bas$ ,inc5tive ,paym5t

 ,sy/em "u subsection 7q7 ( section     
#ahdh ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #aciew-#d71 z add$ by p>agraph
 7#a74 ,su* report %all--  7i7 exam9e ! 
di/ribution ( ! composite p]=mance      
scores & ,,mips adju/m5t factors 7&     
additional ,,mips adju/m5t factors7 =   
,,mips eligible pr(essionals 7z def9$ 9 
subsection 7q77#a77;c7 ( su* section7 "u
 su* program1 & patt]ns relat+ to su*   
scores & adju/m5t factors1 includ+ bas$ 
on type ( provid]1 practice size1       
geographic location1 & pati5t mix2  7ii7
 provide recomm5dations = improv+ su*   
program2  7iii7 evaluate ! impact (     
te*nical assi/ance fund+ "u section     
#ahdh7q77#aa7 ( ! ,social ,security     
,act1 z add$ by p>agraph 7#a71 on !     
ability ( pr(essionals to improve )9 su*
 program or successfully transition to  
an alt]native paym5t model 7z def9$ 9   
section #ahcc7z77#c7 ( ! ,social        
,security ,act1 z add$ by subsection    
7e771 ) priority = su* evaluation giv5  
to practices locat$ 9 rural areas1 heal?

 pr(essional %ortage areas 7z designat$ 
9 section #ccb7;a77#a77;a7 ( ! ,public  
,heal? ,s]vice ,act71 & m$ically        
und]s]v$ areas2 &  7iv7 provide         
recomm5dations = optimiz+ ! use ( su*   
te*nical assi/ance funds4  7,b7  ,/udy  
to exam9e alignm5t ( quality measures   
us$ 9 public & private programs  7i7  ,9
 g5]al  ,n lat] ?an #ah mon?s aft] !    
date ( ! enactm5t ( ?is ,act1 !         
,comptroll] ,g5]al ( ! ,unit$ ,/ates    
%all submit to ,congress a report t--   
7,i7 comp>es ! simil>ities & diff]5ces 9
 ! use ( quality measures "u ! orig9al  
,m$ic>e fee-=-s]vice program "u p>ts ,a 
& ,b ( title ,,xviii ( ! ,social        
,security ,act1 ! ,m$ic>e ,advantage    
program "u "p ,c ( su* title1 select$   
,/ate ,m$icaid programs "u title ,,xix (
 su* ,act1 & private pay] arrangem5ts2 &
  7,,ii7 makes recomm5dations on h[ to  
r$uce ! adm9i/rative burd5 involv$ 9    
apply+ su* quality measures4  7ii7      
,requirem5ts  ,! report "u clause 7i7   
%all--  7,i7 consid] ^? measures        

applicable to individuals entitl$ to1 or
 enroll$ =1 b5efits "u su* "p ,a1 or    
enroll$ "u su* "p ,b & individuals "u ! 
age ( #fe2 &  7,,ii7 focus on ^?        
measures t comprise ! mo/ significant   
compon5t ( ! quality p]=mance category (
 ! eligible pr(essional ,,mips inc5tive 
program "u subsection 7q7 ( section     
#ahdh ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #aciew-#d71 z add$ by p>agraph
 7#a74  7,c7  ,/udy on role ( indep5d5t 
risk manag]s  ,n lat] ?an ,janu>y #a1   
#bjaf1 ! ,comptroll] ,g5]al ( ! ,unit$  
,/ates %all submit to ,congress a report
 exam9+ :e!r entities t pool f9ancial   
risk = physician practices1 su* z       
indep5d5t risk manag]s1 c play a role 9 
support+ physician practices1 p>ticul>ly
 small physician practices1 9 assum+    
f9ancial risk = ! treatm5t ( pati5ts4   
,su* report %all exam9e b>ri]s t small  
physician practices curr5tly face 9     
assum+ f9ancial risk = treat+ pati5ts1 !
 types ( risk managem5t entities t c\ld 
assi/ physician practices 9 p>ticipat+ 9

 two-sid$ risk paym5t models1 & h[ su*  
entities c\ld assi/ ) risk managem5t & )
 quality improvem5t activities4 ,su*    
report %all also include an analysis (  
any exi/+ legal b>ri]s to su*           
arrangem5ts4  7,d7  ,/udy to exam9e     
rural & heal? pr(essional %ortage area  
alt]native paym5t models  ,n lat] ?an   
,octob] #a1 #bjbj1 & ,octob] #a1 #bjbb1 
! ,comptroll] ,g5]al ( ! ,unit$ ,/ates  
%all submit to ,congress a report t     
exam9es ! transition ( pr(essionals 9   
rural areas1 heal? pr(essional %ortage  
areas 7z designat$ 9 section            
#ccb7;a77#a77;,a7 ( ! ,public ,heal?    
,s]vice ,act71 or m$ically und]s]v$     
areas to an alt]native paym5t model 7z  
def9$ 9 section #ahcc7z77#c7 ( ! ,social
 ,security ,act1 z add$ by subsection   
7e774 ,su* report %all make             
recomm5dations = remov+ adm9i/rative    
b>ri]s to practices1 includ+ small      
practices consi/+ ( #ae or few]         
pr(essionals1 9 rural areas1 heal?      
pr(essional %ortage areas1 & m$ically   

und]s]v$ areas to p>ticipation 9 su*    
models4  7#c7  ,fund+ = implem5tation   
,= purposes ( implem5t+ ! provisions ( &
 ! am5dm5ts made by ?is section1 !      
,secret>y ( ,heal? & ,human ,s]vices    
%all provide = ! transf] ( #hj1jjj1jjj f
 ! ,supplem5t>y ,m$ical ,insurance ,tru/
 ,fund e/abli%$ "u section #ahda ( !    
,social ,security ,act 7#db ,u4,s4,c4   
#aciet7 to ! ,c5t]s = ,m$ic>e  ,m$icaid 
,program ,managem5t ,acc\nt = ea* ( !   
fiscal ye>s #bjad ?r\gh #bjah4 ,am\nts  
transf]r$ "u ?is p>agraph %all be       
available until exp5d$4  7d7  ,improv+  
quality report+ = composite scores  7#a7
  ,*anges = gr\p report+ option  7,a7   
,9 g5]al  ,section #ahdh7m77#c77;,c77ii7
 ( ! ,social ,security ,act 7#db        
,u4,s4,c4 #aciew-#d7m77#c77;,c77ii77 is 
am5d$ by ins]t+ &1 = #bjae & subsequ5t  
ye>s1 may provide aft] %all provide4    
7,b7  ,cl>ification ( qualifi$ cl9ical  
data regi/ry report+ to gr\p practices  
,section #ahdh7m77#c77;,d7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4           

#aciew-#d7m77#c77;,d77 is am5d$ by      
ins]t+ &1 = #bjae & subsequ5t ye>s1     
subp>agraph 7,a7 or 7,c7 aft]           
subp>agraph 7,a74  7#b7  ,*anges =      
multiple report+ p]iods & alt]native    
crit]ia = satisfactory report+  ,section
 #ahdh7m77#e77;,f7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#aciew-#d7m77#e77;,f77 is am5d$--  7,a7 
by /rik+ & subsequ5t ye>s & ins]t+ ?r\gh
 report+ p]iods occurr+ 9 #bjad2 &  7,b7
 by ins]t+ &1 = report+ p]iods occurr+ 9
 #bjae & subsequ5t ye>s1 ! ,secret>y may
 e/abli% foll[+ %all e/abli%4  7#c7     
,physician fe$back program reports      
succe$$ by reports "u ,,mips  ,section  
#ahdh7n7 ( ! ,social ,security ,act 7#db
 ,u4,s4,c4 #aciew-#d7n77 is am5d$ by    
add+ at ! end ! foll[+ new p>agraph3    
7#aa7  ,reports end+ ) #bjaf  ,reports  
"u ! ,program %all n be provid$ aft]    
,decemb] #ca1 #bjaf4 ,see subsection    
7q77#ab7 = reports "u ! eligible        
pr(essionals ,m]it-bas$ ,inc5tive       
,paym5t ,sy/em4  4  7#d7  ,coord9ation )

 satisfy+ mean+ful ,,ehr use cl9ical    
quality measure report+ requirem5t      
,section #ahdh7o77#b77;,a77iii7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#d7o77#b77;,a77iii77 is am5d$ by 
ins]t+ & subsection                     
7q77#e77;,b77ii77,,ii7 aft] ,subject to 
subp>agraph 7,b77ii74  7e7  ,promot+    
alt]native paym5t models  7#a7          
,increas+ transp>5cy ( physician focus$ 
paym5t models  ,section #ahfh ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#acie;ee7 is am5d$ by add+ at ! end !   
foll[+ new subsection3  7c7  ,physician 
focus$ paym5t models  7#a7  ,te*nical   
advisory committee  7,a7  ,e/abli%m5t   
,!re is e/abli%$ an ad hoc committee to 
be kn[n z ! ,paym5t ,model ,te*nical    
,advisory ,committee 7ref]r$ to 9 ?is   
subsection z ! ,committee74  7,b7       
,memb]%ip  7i7  ,numb] & appo9tm5t  ,!  
,committee %all be compos$ ( #aa memb]s 
appo9t$ by ! ,comptroll] ,g5]al ( !     
,unit$ ,/ates4  7ii7  ,qualifications   
,! memb]%ip ( ! ,committee %all include 

individuals ) national recognition = _! 
exp]tise 9 paym5t models & relat$       
deliv]y ( c>e4 ,no m ?an #e memb]s ( !  
,committee %all be provid]s ( s]vices or
 suppli]s1 or repres5tatives ( provid]s 
( s]vices or suppli]s4  7iii7           
,prohibition on f$]al employm5t  ,a     
memb] ( ! ,committee %all n be an       
employee ( ! ,f$]al ,gov]nm5t4  7iv7    
,e?ics disclosure  ,! ,comptroll] ,g5]al
 %all e/abli% a sy/em = public          
disclosure by memb]s ( ! ,committee (   
f9ancial & o!r pot5tial conflicts (     
int]e/ relat+ to su* memb]s4 ,memb]s ( !
 ,committee %all be treat$ z employees (
 ,congress = purposes ( apply+ title ,i 
( ! ,e?ics 9 ,gov]nm5t ,act ( #aigh     
7,public ,law #ie-eba74  7v7  ,date (   
initial appo9tm5ts  ,! initial          
appo9tm5ts ( memb]s ( ! ,committee %all 
be made by n lat] ?an #ahj days aft] !  
date ( enactm5t ( ?is subsection4  7,c7 
,t]m2 vacancies  7i7  ,t]m  ,! t]ms (   
memb]s ( ! ,committee %all be = #c ye>s 
except t ! ,comptroll] ,g5]al %all      

designate /agg]$ t]ms = ! memb]s fir/   
appo9t$4  7ii7  ,vacancies  ,any memb]  
appo9t$ to fill a vacancy occurr+ be=e !
 expiration ( ! t]m = :i* ! memb]'s     
pr$ecessor 0 appo9t$ %all be appo9t$    
only = ! rema9d] ( t t]m4 ,a memb] may  
s]ve aft] ! expiration ( t memb]'s t]m  
until a successor has tak5 (fice4 ,a    
vacancy 9 ! ,committee %all be fill$ 9 !
 mann] 9 :i* ! orig9al appo9tm5t 0 made4
  7,d7  ,duties  ,! ,committee %all     
meet1 z ne$$1 to provide comm5ts &      
recomm5dations to ! ,secret>y1 z        
describ$ 9 p>agraph 7#b77;,c71 on       
physician-focus$ paym5t models4  7,e7   
,comp5sation ( memb]s  7i7  ,9 g5]al    
,except z provid$ 9 clause 7ii71 a memb]
 ( ! ,committee %all s]ve )\t           
comp5sation4  7ii7  ,travel exp5ses  ,a 
memb] ( ! ,committee %all be all[$      
travel exp5ses1 includ+ p] diem 9 lieu (
 subsi/5ce1 at rates au?oriz$ = an      
employee ( an ag5cy "u sub*apt] ,i (    
*apt] #eg ( title #e1 ,unit$ ,/ates     
,code1 :ile away f ! home or regul>     

place ( bus9ess ( ! memb] 9 ! p]=mance (
 ! duties ( ! ,committee4  7,f7         
,op]ational & te*nical support  7i7  ,9 
g5]al  ,! ,assi/ant ,secret>y = ,plann+ 
& ,evaluation %all provide te*nical &   
op]ational support = ! ,committee1 :i*  
may be by use ( a contractor4 ,! ,(fice 
( ! ,actu>y ( ! ,c5t]s = ,m$ic>e        
,m$icaid ,s]vices %all provide to !     
,committee actu>ial assi/ance z ne$$4   
7ii7  ,fund+  ,! ,secret>y %all provide 
= ! transf]1 f ! ,f$]al ,supplem5t>y    
,m$ical ,insurance ,tru/ ,fund "u       
section #ahda1 su* am\nts z are necess>y
 to c>ry out clause 7i7 7n to exce$     
#e1jjj1jjj7 = fiscal ye> #bjad & ea*    
subsequ5t fiscal ye>4 ,any am\nts       
transf]r$ "u ! prec$+ s5t5ce = a fiscal 
ye> %all rema9 available until exp5d$4  
7,g7  ,application  ,section #ad ( !    
,f$]al ,advisory ,committee ,act 7#e    
,u4,s4,c4 ,app47 %all n apply to !      
,committee4  7#b7  ,crit]ia & process = 
submission & review ( physician-focus$  
paym5t models  7,a7  ,crit]ia = assess+ 

physician-focus$ paym5t models  7i7     
,rulemak+  ,n lat] ?an ,novemb] #a1     
#bjae1 ! ,secret>y %all1 ?r\gh notice & 
comm5t rulemak+1 foll[+ a reque/ =      
in=mation1 e/abli% crit]ia =            
physician-focus$ paym5t models1 includ+ 
models = speciali/ physicians1 t c\ld be
 us$ by ! ,committee = mak+ comm5ts &   
recomm5dations pursuant to p>agraph     
7#a77;,d74  7ii7  ,med,p,a,c submission 
( comm5ts  ,dur+ ! comm5t p]iod = !     
propos$ rule describ$ 9 clause 7i71 !   
,m$ic>e ,paym5t ,advisory ,commission   
may submit comm5ts to ! ,secret>y on !  
propos$ crit]ia "u su* clause4  7iii7   
,updat+  ,! ,secret>y may update !      
crit]ia e/abli%$ "u ?is subp>agraph     
?r\gh rulemak+4  7,b7  ,/akehold]       
submission ( physician focus$ paym5t    
models  ,on an ongo+ basis1 individuals 
& /akehold] entities may submit to !    
,committee proposals = physician-focus$ 
paym5t models t su* individuals &       
entities believe meet ! crit]ia describ$
 9 subp>agraph 7,a74  7,c7  ,,tac review

 ( models submitt$  ,! ,committee %all1 
on a p]iodic basis1 review models       
submitt$ "u subp>agraph 7,b71 prep>e    
comm5ts & recomm5dations reg>d+ :e!r su*
 models meet ! crit]ia describ$ 9       
subp>agraph 7,a71 & submit su* comm5ts &
 recomm5dations to ! ,secret>y4  7,d7   
,secret>y review & response  ,!         
,secret>y %all review ! comm5ts &       
recomm5dations submitt$ by ! ,committee 
"u subp>agraph 7,c7 & po/ a detail$     
response to su* comm5ts & recomm5dations
 on ! ,int]net ,website ( ! ,c5t]s =    
,m$ic>e  ,m$icaid ,s]vices4  7#c7  ,rule
 ( con/ruction  ,no?+ 9 ?is subsection  
%all be con/ru$ to impact ! developm5t  
or te/+ ( models "u ?is title or titles 
,,xi1 ,,xix1 or ,,xxi4  4  7#b7         
,inc5tive paym5ts = p>ticipation 9      
eligible alt]native paym5t models       
,section #ahcc ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #aciel7 is am5d$ by 
add+ at ! end ! foll[+ new subsection3  
7z7  ,inc5tive paym5ts = p>ticipation 9 
eligible alt]native paym5t models  7#a7 

,paym5t inc5tive  7,a7  ,9 g5]al  ,9 !  
case ( cov]$ pr(essional s]vices furni%$
 by an eligible pr(essional dur+ a ye> t
 is 9 ! p]iod beg9n+ ) #bjah & end+ )   
#bjbc & = :i* ! pr(essional is a        
qualify+ ,,apm p>ticipant1 9 addition to
 ! am\nt ( paym5t t w\ld o!rwise be made
 = su* cov]$ pr(essional s]vices "u ?is 
"p = su* ye>1 !re also %all be paid to  
su* pr(essional an am\nt equal to #e    
p]c5t ( ! paym5t am\nt = ! cov]$        
pr(essional s]vices "u ?is "p = ! prec$+
 ye>4 ,= purposes ( ! previ\s s5t5ce1 ! 
paym5t am\nt = ! prec$+ ye> may be an   
e/imation = ! full prec$+ ye> bas$ on a 
p]iod ( su* prec$+ ye> t is less ?an !  
full ye>4 ,! ,secret>y %all e/abli%     
policies to implem5t ?is subp>agraph 9  
cases :]e paym5t = cov]$ pr(essional    
s]vices furni%$ by a qualify+ ,,apm     
p>ticipant 9 an alt]native paym5t model 
is made to an entity p>ticipat+ 9 !     
alt]native paym5t model r ?an directly  
to ! qualify+ ,,apm p>ticipant4  7,b7   
,=m ( paym5t  ,paym5ts "u ?is subsection

 %all be made 9 a lump sum1 on an annual
 basis1 z soon z practicable4  7,c7     
,treatm5t ( paym5t inc5tive  ,paym5ts "u
 ?is subsection %all n be tak5 into     
acc\nt = purposes ( det]m9+ actual      
exp5ditures "u an alt]native paym5t     
model & = purposes ( det]m9+ or rebas+  
any b5*m>ks us$ "u ! alt]native paym5t  
model4  7,d7  ,coord9ation  ,! am\nt ( !
 additional paym5t = an item or s]vice  
"u ?is subsection or subsection 7m7 %all
 be det]m9$ )\t reg>d to any additional 
paym5t = ! item or s]vice "u subsection 
7m7 & ?is subsection1 respectively4 ,!  
am\nt ( ! additional paym5t = an item or
 s]vice "u ?is subsection or subsection 
7x7 %all be det]m9$ )\t reg>d to any    
additional paym5t = ! item or s]vice "u 
subsection 7x7 & ?is subsection1        
respectively4 ,! am\nt ( ! additional   
paym5t = an item or s]vice "u ?is       
subsection or subsection 7y7 %all be    
det]m9$ )\t reg>d to any additional     
paym5t = ! item or s]vice "u subsection 
7y7 & ?is subsection1 respectively4     

7#b7  ,qualify+ ,,apm p>ticipant  ,=    
purposes ( ?is subsection1 ! t]m        
qualify+ ,,apm p>ticipant means !       
foll[+3  7,a7  #bjah & #bjai  ,) respect
 to #bjah & #bjai1 an eligible          
pr(essional = :om ! ,secret>y det]m9es t
 at lea/ #be p]c5t ( paym5ts "u ?is "p =
 cov]$ pr(essional s]vices furni%$ by   
su* pr(essional dur+ ! mo/ rec5t p]iod =
 :i* data are available 7:i* may be less
 ?an a ye>7 7 attributable to su*       
s]vices furni%$ "u ?is "p ?r\gh an      
entity t p>ticipates 9 an eligible      
alt]native paym5t model ) respect to su*
 s]vices4  7,b7  #bjbj & #bjba  ,)      
respect to #bjbj & #bjba1 an eligible   
pr(essional describ$ 9 ei!r ( ! foll[+  
clauses3  7i7  ,m$ic>e rev5ue ?re%old   
option  ,an eligible pr(essional = :om !
 ,secret>y det]m9es t at lea/ #ej p]c5t 
( paym5ts "u ?is "p = cov]$ pr(essional 
s]vices furni%$ by su* pr(essional dur+ 
! mo/ rec5t p]iod = :i* data are        
available 7:i* may be less ?an a ye>7 7 
attributable to su* s]vices furni%$ "u  

?is "p ?r\gh an entity t p>ticipates 9  
an eligible alt]native paym5t model )   
respect to su* s]vices4  7ii7           
,comb9ation all-pay] & ,m$ic>e rev5ue   
?re%old option  ,an eligible            
pr(essional--  7,i7 = :om ! ,secret>y   
det]m9es1 ) respect to items & s]vices  
furni%$ by su* pr(essional dur+ ! mo/   
rec5t p]iod = :i* data are available    
7:i* may be less ?an a ye>71 t at lea/  
#ej p]c5t ( ! sum (--  7aa7 paym5ts     
describ$ 9 clause 7i72 &  7bb7 all o!r  
paym5ts1 reg>dless ( pay] 7o!r ?an      
paym5ts made by ! ,secret>y ( ,def5se or
 ! ,secret>y ( ,vet]ans ,affairs "u     
*apt] #ee ( title #aj1 ,unit$ ,/ates    
,code1 or title #ch1 ,unit$ ,/ates      
,code1 or any o!r provision ( law1 & o!r
 ?an paym5ts made "u title ,,xix 9 a    
,/ate 9 :i* no m$ical home or alt]native
 paym5t model is available "u ! ,/ate   
program "u t title71  meet ! requirem5t 
describ$ 9 clause 7iii77,i7 ) respect to
 paym5ts describ$ 9 item 7aa7 & meet !  
requirem5t describ$ 9 clause 7iii77,,ii7

 ) respect to paym5ts describ$ 9 item   
7bb72  7,,ii7 = :om ! ,secret>y det]m9es
 at lea/ #be p]c5t ( paym5ts "u ?is "p =
 cov]$ pr(essional s]vices furni%$ by   
su* pr(essional dur+ ! mo/ rec5t p]iod =
 :i* data are available 7:i* may be less
 ?an a ye>7 7 attributable to su*       
s]vices furni%$ "u ?is "p ?r\gh an      
entity t p>ticipates 9 an eligible      
alt]native paym5t model ) respect to su*
 s]vices2 &  7,,iii7 :o provides to !   
,secret>y su* in=mation z is necess>y = 
! ,secret>y to make a det]m9ation "u    
subclause 7,i71 ) respect to su*        
pr(essional4  7iii7  ,requirem5t  ,=    
purposes ( clause 7ii77,i7--  7,i7 !    
requirem5t describ$ 9 ?is subclause1 )  
respect to paym5ts describ$ 9 item 7aa7 
( su* clause1 is t su* paym5ts are made 
"u an eligible alt]native paym5t model2 
&  7,,ii7 ! requirem5t describ$ 9 ?is   
subclause1 ) respect to paym5ts describ$
 9 item 7bb7 ( su* clause1 is t su*     
paym5ts are made "u an arrangem5t 9     
:i*--  7aa7 quality measures comp>able  

to measures "u ! p]=mance category      
describ$ 9 section #ahdh7q77#b77;,b77i7 
apply2  7bb7 c]tifi$ ,,ehr te*nology is 
us$2 &  7cc7 ! eligible pr(essional     
7,,aa7 be>s m ?an nom9al f9ancial risk  
if actual aggregate exp5ditures exce$s  
expect$ aggregate exp5ditures2 or 7,,bb7
 is a m$ical home 7) respect to         
b5efici>ies "u title ,,xix7 t meets     
crit]ia comp>able to m$ical homes exp&$ 
"u section #aaae;,a7c74  7,c7  ,beg9n+ 9
 #bjbb  ,) respect to #bjbb & ea*       
subsequ5t ye>1 an eligible pr(essional  
describ$ 9 ei!r ( ! foll[+ clauses3  7i7
  ,m$ic>e rev5ue ?re%old option  ,an    
eligible pr(essional = :om ! ,secret>y  
det]m9es t at lea/ #ge p]c5t ( paym5ts  
"u ?is "p = cov]$ pr(essional s]vices   
furni%$ by su* pr(essional dur+ ! mo/   
rec5t p]iod = :i* data are available    
7:i* may be less ?an a ye>7 7           
attributable to su* s]vices furni%$ "u  
?is "p ?r\gh an entity t p>ticipates 9  
an eligible alt]native paym5t model )   
respect to su* s]vices4  7ii7           

,comb9ation all-pay] & ,m$ic>e rev5ue   
?re%old option  ,an eligible            
pr(essional--  7,i7 = :om ! ,secret>y   
det]m9es1 ) respect to items & s]vices  
furni%$ by su* pr(essional dur+ ! mo/   
rec5t p]iod = :i* data are available    
7:i* may be less ?an a ye>71 t at lea/  
#ge p]c5t ( ! sum (--  7aa7 paym5ts     
describ$ 9 clause 7i72 &  7bb7 all o!r  
paym5ts1 reg>dless ( pay] 7o!r ?an      
paym5ts made by ! ,secret>y ( ,def5se or
 ! ,secret>y ( ,vet]ans ,affairs "u     
*apt] #ee ( title #aj1 ,unit$ ,/ates    
,code1 or title #ch1 ,unit$ ,/ates      
,code1 or any o!r provision ( law1 & o!r
 ?an paym5ts made "u title ,,xix 9 a    
,/ate 9 :i* no m$ical home or alt]native
 paym5t model is available "u ! ,/ate   
program "u t title71  meet ! requirem5t 
describ$ 9 clause 7iii77,i7 ) respect to
 paym5ts describ$ 9 item 7aa7 & meet !  
requirem5t describ$ 9 clause 7iii77,,ii7
 ) respect to paym5ts describ$ 9 item   
7bb72  7,,ii7 = :om ! ,secret>y det]m9es
 at lea/ #be p]c5t ( paym5ts "u ?is "p =

 cov]$ pr(essional s]vices furni%$ by   
su* pr(essional dur+ ! mo/ rec5t p]iod =
 :i* data are available 7:i* may be less
 ?an a ye>7 7 attributable to su*       
s]vices furni%$ "u ?is "p ?r\gh an      
entity t p>ticipates 9 an eligible      
alt]native paym5t model ) respect to su*
 s]vices2 &  7,,iii7 :o provides to !   
,secret>y su* in=mation z is necess>y = 
! ,secret>y to make a det]m9ation "u    
subclause 7,i71 ) respect to su*        
pr(essional4  7iii7  ,requirem5t  ,=    
purposes ( clause 7ii77,i7--  7,i7 !    
requirem5t describ$ 9 ?is subclause1 )  
respect to paym5ts describ$ 9 item 7aa7 
( su* clause1 is t su* paym5ts are made 
"u an eligible alt]native paym5t model2 
&  7,,ii7 ! requirem5t describ$ 9 ?is   
subclause1 ) respect to paym5ts describ$
 9 item 7bb7 ( su* clause1 is t su*     
paym5ts are made "u an arrangem5t 9     
:i*--  7aa7 quality measures comp>able  
to measures "u ! p]=mance category      
describ$ 9 section #ahdh7q77#b77;,b77i7 
apply2  7bb7 c]tifi$ ,,ehr te*nology is 

us$2 &  7cc7 ! eligible pr(essional     
7,,aa7 be>s m ?an nom9al f9ancial risk  
if actual aggregate exp5ditures exce$s  
expect$ aggregate exp5ditures2 or 7,,bb7
 is a m$ical home 7) respect to         
b5efici>ies "u title ,,xix7 t meets     
crit]ia comp>able to m$ical homes exp&$ 
"u section #aaae;,a7c74  7#c7           
,additional def9itions  ,9 ?is          
subsection3  7,a7  ,cov]$ pr(essional   
s]vices  ,! t]m cov]$ pr(essional       
s]vices has ! mean+ giv5 t t]m 9 section
 #ahdh7k77#c77;,a74  7,b7  ,eligible    
pr(essional  ,! t]m eligible pr(essional
 has ! mean+ giv5 t t]m 9 section       
#ahdh7k77#c77;,b74  7,c7  ,alt]native   
paym5t model 7,,apm7  ,! t]m alt]native 
paym5t model means any ( ! foll[+3  7i7 
,a model "u section #aaae;,a 7o!r ?an a 
heal? c>e innovation aw>d74  7ii7 ,! %>$
 sav+s program "u section #ahii4  7iii7 
,a demon/ration "u section #ahff;,c4    
7iv7 ,a demon/ration requir$ by ,f$]al  
law4  7,d7  ,eligible alt]native paym5t 
model 7,,apm7  7i7  ,9 g5]al  ,! t]m    

eligible alt]native paym5t model means1 
) respect to a ye>1 an alt]native paym5t
 model--  7,i7 t requires use ( c]tifi$ 
,,ehr te*nology 7z def9$ 9 subsection   
7o77#d772  7,,ii7 t provides = paym5t = 
cov]$ pr(essional s]vices bas$ on       
quality measures comp>able to measures  
"u ! p]=mance category describ$ 9       
section #ahdh7q77#b77;,b77i72 &  7,,iii7
 t satisfies ! requirem5t describ$ 9    
clause 7ii74  7ii7  ,additional         
requirem5t  ,= purposes ( clause        
7i77,,iii71 ! requirem5t describ$ 9 ?is 
clause1 ) respect to a ye> & an         
alt]native paym5t model1 is t !         
alt]native paym5t model--  7,i7 is "o 9 
:i* "o or m entities be> f9ancial risk =
 monet>y losses "u su* model t are 9    
excess ( a nom9al am\nt2 or  7,,ii7 is a
 m$ical home exp&$ "u section           
#aaae;,a7c74  7#d7  ,limitation  ,!re   
%all be no adm9i/rative or judicial     
review "u section #ahfi1 #ahgh1 or      
o!rwise1 ( ! foll[+3  7,a7 ,!           
det]m9ation t an eligible pr(essional is

 a qualify+ ,,apm p>ticipant "u p>agraph
 7#b7 & ! det]m9ation t an alt]native   
paym5t model is an eligible alt]native  
paym5t model "u p>agraph 7#c77;,d74     
7,b7 ,! det]m9ation ( ! am\nt ( ! #e    
p]c5t paym5t inc5tive "u p>agraph       
7#a77;,a71 includ+ any e/imation z "p ( 
su* det]m9ation4  4  7#c7  ,coord9ation 
con=m+ am5dm5ts  ,section #ahcc ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#aciel7 is fur!r am5d$--  7,a7 9        
subsection 7x77#c71 by add+ at ! end !  
foll[+ new s5t5ce3 ,! am\nt ( !         
additional paym5t = a s]vice "u ?is     
subsection & subsection 7z7 %all be     
det]m9$ )\t reg>d to any additional     
paym5t = ! s]vice "u subsection 7z7 &   
?is subsection1 respectively42 &  7,b7 9
 subsection 7y77#c71 by add+ at ! end ! 
foll[+ new s5t5ce3 ,! am\nt ( !         
additional paym5t = a s]vice "u ?is     
subsection & subsection 7z7 %all be     
det]m9$ )\t reg>d to any additional     
paym5t = ! s]vice "u subsection 7z7 &   
?is subsection1 respectively44  7#d7    

,enc\rag+ developm5t & te/+ ( c]ta9     
models  ,section #aaae;,a7b77#b7 ( !    
,social ,security ,act 7#db ,u4,s4,c4   
#acae;a7b77#b77 is am5d$--  7,a7 9      
subp>agraph 7,b71 by add+ at ! end !    
foll[+ new clauses3  7xxi7 ,focus+      
prim>ily on physicians' s]vices 7z def9$
 9 section #ahdh7;j77#c77 furni%$ by    
physicians :o are n prim>y c>e          
practition]s4  7xxii7 ,focus+ on        
practices ( #ae or few] pr(essionals4   
7xxiii7 ,focus+ on risk-bas$ models =   
small physician practices :i* may       
involve two-sid$ risk & prospective     
pati5t assignm5t1 & :i* exam9e          
risk-adju/$ decreases 9 mortality rates1
 hospital readmissions rates1 & o!r     
relevant & appropriate cl9ical measures4
  7xxiv7 ,focus+ prim>ily on title      
,,xix1 work+ 9 conjunction ) ! ,c5t] =  
,m$icaid & ,,*ip ,s]vices4  2 &  7,b7 9 
subp>agraph 7,c77viii71 by /rik+ o!r    
public sector or private sector pay]s & 
ins]t+ o!r public sector pay]s1 private 
sector pay]s1 or ,/atewide paym5t       

models4  7#e7  ,con/ruction reg>d+      
teleheal? s]vices  ,no?+ 9 ! provisions 
(1 or am5dm5ts made by1 ?is ,act %all be
 con/ru$ z preclud+ an alt]native paym5t
 model or a qualify+ ,,apm p>ticipant 7z
 ^? t]ms are def9$ 9 section #ahcc7z7 ( 
! ,social ,security ,act1 z add$ by     
p>agraph 7#a77 f furni%+ a teleheal?    
s]vice = :i* paym5t is n made "u section
 #ahcd7m7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #aciem7m774  7#f7        
,integrat+ ,m$ic>e ,advantage alt]native
 paym5t models  ,n lat] ?an ,july #a1   
#bjae1 ! ,secret>y ( ,heal? & ,human    
,s]vices %all submit to ,congress a /udy
 t exam9es ! feasibility ( integrat+    
alt]native paym5t models 9 ! ,m$ic>e    
,advantage paym5t sy/em4 ,! /udy %all   
include ! feasibility ( includ+ a       
value-bas$ modifi] & :e!r su* modifi]   
%\ld be budget neutral4  7#g7  ,/udy &  
report on fraud relat$ to alt]native    
paym5t models "u ! ,m$ic>e program  7,a7
  ,/udy  ,! ,secret>y ( ,heal? & ,human 
,s]vices1 9 consultation ) ! ,inspector 

,g5]al ( ! ,dep>tm5t ( ,heal? & ,human  
,s]vices1 %all conduct a /udy t--  7i7  
exam9es ! applicability ( ! ,f$]al fraud
 prev5tion laws to items & s]vices      
furni%$ "u title ,,xviii ( ! ,social    
,security ,act = :i* paym5t is made "u  
an alt]native paym5t model 7z def9$ 9   
section #ahcc7z77#c77;,c7 ( su* ,act    
7#db ,u4,s4,c4 #aciel7z77#c77;,c7772    
7ii7 id5tifies aspects ( su* alt]native 
paym5t models t are vuln]able to        
fraudul5t activity2 &  7iii7 exam9es !  
implications ( waiv]s to su* laws grant$
 9 support ( su* alt]native paym5t      
models1 includ+ "u any pot5tial         
expansion ( su* models4  7,b7  ,report  
,n lat] ?an #b ye>s aft] ! date ( !     
enactm5t ( ?is ,act1 ! ,secret>y %all   
submit to ,congress a report conta9+ !  
results ( ! /udy conduct$ "u subp>agraph
 7,a74 ,su* report %all include         
recomm5dations = actions to be tak5 to  
r$uce ! vuln]ability ( su* alt]native   
paym5t models to fraudul5t activity4    
,su* report also %all include1 z        

appropriate1 recomm5dations ( !         
,inspector ,g5]al = *anges 9 ,f$]al     
fraud prev5tion laws to r$uce su*       
vuln]ability4  7f7  ,improv+ paym5t     
accuracy  7#a7  ,/udies & reports (     
effect ( c]ta9 in=mation on quality &   
res\rce use  7,a7  ,/udy us+ exi/+      
,m$ic>e data  7i7  ,/udy  ,! ,secret>y (
 ,heal? & ,human ,s]vices 79 ?is        
subsection ref]r$ to z ! ,secret>y7 %all
 conduct a /udy t exam9es ! effect (    
individuals' socioeconomic /atus on     
quality & res\rce use outcome measures =
 individuals "u ! ,m$ic>e program 7su* z
 to recognize t less heal?y individuals 
may require m int5sive int]v5tions74 ,! 
/udy %all use in=mation collect$ on su* 
individuals 9 c>ry+ out su* program1 su*
 z urban & rural location1 eligibility =
 ,m$icaid 7recogniz+ & acc\nt+ = v>y+   
,m$icaid eligibility across ,/ates71 &  
eligibility = b5efits "u ! supplem5tal  
security income 7,,ssi7 program4 ,!     
,secret>y %all c>ry out ?is p>agraph    
act+ ?r\gh ! ,assi/ant ,secret>y =      

,plann+ & ,evaluation4  7ii7  ,report   
,n lat] ?an #b ye>s aft] ! date ( !     
enactm5t ( ?is ,act1 ! ,secret>y %all   
submit to ,congress a report on ! /udy  
conduct$ "u clause 7i74  7,b7  ,/udy us+
 o!r data  7i7  ,/udy  ,! ,secret>y %all
 conduct a /udy t exam9es ! impact (    
risk factors1 su* z ^? describ$ 9       
section #ahdh7p77#c7 ( ! ,social        
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7p77#c771 race1 heal? lit]acy1 
limit$ ,engli% pr(ici5cy 7,,lep71 &     
pati5t activation1 on quality & res\rce 
use outcome measures "u ! ,m$ic>e       
program 7su* z to recognize t less      
heal?y individuals may require m        
int5sive int]v5tions74 ,9 conduct+ su*  
/udy ! ,secret>y may use exi/+ ,f$]al   
data & collect su* additional data z may
 be necess>y to complete ! /udy4  7ii7  
,report  ,n lat] ?an #e ye>s aft] ! date
 ( ! enactm5t ( ?is ,act1 ! ,secret>y   
%all submit to ,congress a report on !  
/udy conduct$ "u clause 7i74  7,c7      
,exam9ation ( data 9 conduct+ /udies  ,9

 conduct+ ! /udies "u subp>agraphs 7,a7 
& 7,b71 ! ,secret>y %all exam9e :at     
non-,m$ic>e data sets1 su* z data f !   
,am]ican ,community ,survey 7,,acs71 c  
be useful 9 conduct+ ! types ( /udies "u
 su* p>agraphs & h[ su* data sets t are 
id5tifi$ z useful c be coord9at$ )      
,m$ic>e adm9i/rative data 9 ord] to     
improve ! ov]all data set available to d
 su* /udies & = ! adm9i/ration ( !      
,m$ic>e program4  7,d7  ,recomm5dations 
to acc\nt = in=mation 9 paym5t adju/m5t 
me*anisms  ,if ! /udies conduct$ "u     
subp>agraphs 7,a7 & 7,b7 f9d a          
relation%ip betwe5 ! factors exam9$ 9 ! 
/udies & quality & res\rce use outcome  
measures1 !n ! ,secret>y %all also      
provide recomm5dations = h[ ! ,c5t]s =  
,m$ic>e  ,m$icaid ,s]vices %\ld--  7i7  
obta9 access to ! necess>y data 7if su* 
data is n already be+ collect$7 on su*  
factors1 includ+ recomm5dations on h[ to
 address b>ri]s to ! ,c5t]s 9 access+   
su* data2 &  7ii7 acc\nt = su* factors 9
 det]m9+ paym5t adju/m5ts bas$ on       

quality & res\rce use outcome measures  
"u ! eligible pr(essional ,m]it-bas$    
,inc5tive ,paym5t ,sy/em "u section     
#ahdh7q7 ( ! ,social ,security ,act 7#db
 ,u4,s4,c4 #aciew-#d7q77 &1 z !         
,secret>y det]m9es appropriate1 o!r     
simil> provisions ( title ,,xviii ( su* 
,act4  7,e7  ,fund+  ,!re are h]eby     
appropriat$ f ! ,f$]al ,supplem5t>y     
,m$ical ,insurance ,tru/ ,fund "u       
section #ahda ( ! ,social ,security ,act
 to ! ,secret>y to c>ry out ?is p>agraph
 #f1jjj1jjj1 to rema9 available until   
exp5d$4  7#b7  ,,cms activities  7,a7   
,hi]>*al ,condition ,category 7,,hcc7   
improvem5t  ,tak+ into acc\nt ! relevant
 /udies conduct$ & recomm5dations made 9
 reports "u p>agraph 7#a71 ! ,secret>y1 
on an ongo+ basis1 %all1 z ! ,secret>y  
det]m9es appropriate1 e/imate h[ an     
individual's heal? /atus & o!r risk     
factors affect quality & res\rce use    
outcome measures &1 z feasible1 %all    
incorporate in=mation f quality &       
res\rce use outcome measurem5t 7includ+ 

c>e episode & pati5t condition gr\ps7   
into provisions ( title ,,xviii ( !     
,social ,security ,act t are simil> to !
 eligible pr(essional ,m]it-bas$        
,inc5tive ,paym5t ,sy/em "u section     
#ahdh7q7 ( su* ,act4  7,b7  ,acc\nt+ =  
o!r factors 9 paym5t adju/m5t me*anisms 
7i7  ,9 g5]al  ,tak+ into acc\nt !      
/udies conduct$ & recomm5dations made 9 
reports "u p>agraph 7#a7 & o!r in=mation
 z appropriate1 ! ,secret>y %all1 z !   
,secret>y det]m9es appropriate1 acc\nt =
 id5tifi$ factors ) an effect on quality
 & res\rce use outcome measures :5      
det]m9+ paym5t adju/m5t me*anisms "u    
provisions ( title ,,xviii ( ! ,social  
,security ,act t are simil> to !        
eligible pr(essional ,m]it-bas$         
,inc5tive ,paym5t ,sy/em "u section     
#ahdh7q7 ( su* ,act4  7ii7  ,access+    
data  ,! ,secret>y %all collect or      
o!rwise obta9 access to ! data necess>y 
to c>ry out ?is p>agraph ?r\gh exi/+ &  
new data s\rces4  7iii7  ,p]iodic       
analyses  ,! ,secret>y %all c>ry out    

p]iodic analyses1 at lea/ e #c ye>s1    
bas$ on ! factors ref]r$ to 9 clause 7i7
 s z to monitor *anges 9 possible       
relation%ips4  7,c7  ,fund+  ,!re are   
h]eby appropriat$ f ! ,f$]al            
,supplem5t>y ,m$ical ,insurance ,tru/   
,fund "u section #ahda ( ! ,social      
,security ,act to ! ,secret>y to c>ry   
out ?is p>agraph & ! application ( ?is  
p>agraph to ! ,m]it-bas$ ,inc5tive      
,paym5t ,sy/em "u section #ahdh7q7 ( su*
 ,act #aj1jjj1jjj1 to rema9 available   
until exp5d$4  7#c7  ,/rategic plan =   
access+ race & e?nicity data  ,n lat]   
?an #ah mon?s aft] ! date ( ! enactm5t (
 ?is ,act1 ! ,secret>y %all develop &   
report to ,congress on a /rategic plan =
 collect+ or o!rwise access+ data on    
race & e?nicity = purposes ( c>ry+ out !
 eligible pr(essional ,m]it-bas$        
,inc5tive ,paym5t ,sy/em "u section     
#ahdh7q7 ( ! ,social ,security ,act &1 z
 ! ,secret>y det]m9es appropriate1 o!r  
simil> provisions ( title ,,xviii ( su* 
,act4  7g7  ,collaborat+ ) ! physician1 

practition]1 & o!r /akehold] communities
 ,to improve res\rce use measurem5t     
,section #ahdh ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #aciew-#d71 z am5d$ 
by subsection 7c71 is fur!r am5d$ by    
add+ at ! end ! foll[+ new subsection3  
7r7  ,collaborat+ ) ! physician1        
practition]1 & o!r /akehold] communities
 ,to improve res\rce use measurem5t     
7#a7  ,9 g5]al  ,9 ord] to involve !    
physician1 practition]1 & o!r /akehold] 
communities 9 enhanc+ ! infra/ructure = 
res\rce use measurem5t1 includ+ =       
purposes ( ! ,m]it-bas$ ,inc5tive       
,paym5t ,sy/em "u subsection 7q7 &      
alt]native paym5t models "u section     
#ahcc7z71 ! ,secret>y %all und]take !   
/eps describ$ 9 ! succe$+ provisions (  
?is subsection4  7#b7  ,developm5t ( c>e
 episode & pati5t condition gr\ps &     
classification codes  7,a7  ,9 g5]al  ,9
 ord] to classify simil> pati5ts into   
c>e episode gr\ps & pati5t condition    
gr\ps1 ! ,secret>y %all und]take ! /eps 
describ$ 9 ! succe$+ provisions ( ?is   

p>agraph4  7,b7  ,public availability ( 
exi/+ ef=ts to design an episode gr\p]  
,n lat] ?an #abj days aft] ! date ( !   
enactm5t ( ?is subsection1 ! ,secret>y  
%all po/ on ! ,int]net website ( !      
,c5t]s = ,m$ic>e  ,m$icaid ,s]vices a   
li/ ( ! episode gr\ps develop$ pursuant 
to subsection 7n77#i77;,a7 & relat$     
descriptive in=mation4  7,c7  ,/akehold]
 input  ,! ,secret>y %all accept1 ?r\gh 
! date t is #fj days aft] ! day !       
,secret>y po/s ! li/ pursuant to        
subp>agraph 7,b71 sugge/ions f physician
 specialty societies1 applicable        
practition] organizations1 & o!r        
/akehold]s = episode gr\ps 9 addition to
 ^? po/$ pursuant to su* subp>agraph1 & 
specific cl9ical crit]ia & pati5t       
*>act]i/ics to classify pati5ts into--  
7i7 c>e episode gr\ps2 &  7ii7 pati5t   
condition gr\ps4  7,d7  ,developm5t (   
propos$ classification codes  7i7  ,9   
g5]al  ,tak+ into acc\nt ! in=mation    
describ$ 9 subp>agraph 7,b7 & !         
in=mation receiv$ "u subp>agraph 7,c71 !

 ,secret>y %all--  7,i7 e/abli% c>e     
episode gr\ps & pati5t condition gr\ps1 
:i* acc\nt = a t>get ( an e/imat$ #b_/c 
( exp5ditures "u p>ts ,a & ,b2 &  7,,ii7
 assign codes to su* gr\ps4  7ii7  ,c>e 
episode gr\ps  ,9 e/abli%+ ! c>e episode
 gr\ps "u clause 7i71 ! ,secret>y %all  
take into acc\nt--  7,i7 ! pati5t's     
cl9ical problems at ! "t items & s]vices
 are furni%$ dur+ an episode ( c>e1 su* 
z ! cl9ical conditions or diagnoses1    
:e!r or n inpati5t hospitalization is   
anticipat$ or occurs1 & ! pr9cipal      
proc$ures or s]vices plann$ or furni%$2 
&  7,,ii7 o!r factors det]m9$           
appropriate by ! ,secret>y4  7iii7      
,pati5t condition gr\ps  ,9 e/abli%+ !  
pati5t condition gr\ps "u clause 7i71 ! 
,secret>y %all take into acc\nt--  7,i7 
! pati5t's cl9ical hi/ory at ! "t ( ea* 
m$ical visit1 su* z ! pati5t's          
comb9ation ( *ronic conditions1 curr5t  
heal? /atus1 & rec5t significant hi/ory 
7su* z hospitalization & major surg]y   
dur+ a previ\s p]iod1 su* z #c mon?s72 &

  7,,ii7 o!r factors det]m9$ appropriate
 by ! ,secret>y1 su* z eligibility /atus
 "u ?is title 7includ+ eligibility "u   
section #bbf7;a71 #bbf7;b71 or #bbf;,a1 
& dual eligibility "u ?is title & title 
,,xix74  7,e7  ,draft c>e episode &     
pati5t condition gr\ps & classification 
codes  ,n lat] ?an #ahj days aft] ! end 
( ! comm5t p]iod describ$ 9 subp>agraph 
7,c71 ! ,secret>y %all po/ on ! ,int]net
 website ( ! ,c5t]s = ,m$ic>e  ,m$icaid 
,s]vices a draft li/ ( ! c>e episode &  
pati5t condition codes e/abli%$ "u      
subp>agraph 7,d7 7& ! crit]ia &         
*>act]i/ics assign$ to su* code74  7,f7 
,solicitation ( input  ,! ,secret>y %all
 seek1 ?r\gh ! date t is #fj days aft] !
 ,secret>y po/s ! li/ pursuant to       
subp>agraph 7,e71 comm5ts f physician   
specialty societies1 applicable         
practition] organizations1 & o!r        
/akehold]s1 includ+ repres5tatives (    
individuals entitl$ to b5efits "u "p ,a 
or enroll$ "u ?is "p1 reg>d+ ! c>e      
episode & pati5t condition gr\ps 7&     

codes7 po/$ "u subp>agraph 7,e74 ,9     
seek+ su* comm5ts1 ! ,secret>y %all use 
"o or m me*anisms 7o!r ?an notice &     
comm5t rulemak+7 t may include use ( op5
 door =ums1 t[n hall meet+s1 or o!r     
appropriate me*anisms4  7,g7            
,op]ational li/ ( c>e episode & pati5t  
condition gr\ps & codes  ,n lat] ?an    
#ahj days aft] ! end ( ! comm5t p]iod   
describ$ 9 subp>agraph 7,f71 tak+ into  
acc\nt ! comm5ts receiv$ "u su*         
subp>agraph1 ! ,secret>y %all po/ on !  
,int]net website ( ! ,c5t]s = ,m$ic>e   
,m$icaid ,s]vices an op]ational li/ (   
c>e episode & pati5t condition codes 7& 
! crit]ia & *>act]i/ics assign$ to su*  
code74  7,h7  ,subsequ5t revisions  ,n  
lat] ?an ,novemb] #a ( ea* ye> 7beg9n+ )
 #bjag71 ! ,secret>y %all1 ?r\gh        
rulemak+1 make revisions to ! op]ational
 li/s ( c>e episode & pati5t condition  
codes z ! ,secret>y det]m9es may be     
appropriate4 ,su* revisions may be bas$ 
on exp]i5ce1 new in=mation develop$     
pursuant to subsection 7n77#i77;,a71 &  

input f ! physician specialty societies1
 applicable practition] organizations1 &
 o!r /akehold]s1 includ+ repres5tatives 
( individuals entitl$ to b5efits "u "p  
,a or enroll$ "u ?is "p4  7#c7          
,attribution ( pati5ts to physicians or 
practition]s  7,a7  ,9 g5]al  ,9 ord] to
 facilitate ! attribution ( pati5ts &   
episodes 79 :ole or 9 "p7 to "o or m    
physicians or applicable practition]s   
furni%+ items & s]vices1 ! ,secret>y    
%all und]take ! /eps describ$ 9 !       
succe$+ provisions ( ?is p>agraph4  7,b7
  ,developm5t ( pati5t relation%ip      
categories & codes  ,! ,secret>y %all   
develop pati5t relation%ip categories & 
codes t def9e & di/+ui% ! relation%ip & 
responsibility ( a physician or         
applicable practition] ) a pati5t at !  
"t ( furni%+ an item or s]vice4 ,su*    
pati5t relation%ip categories %all      
include diff]5t relation%ips ( !        
physician or applicable practition] to !
 pati5t 7& ! codes may reflect          
comb9ations ( su* categories71 su* z a  

physician or applicable practition] :o--
  7i7 consid]s !mself to h ! prim>y     
responsibility = ! g5]al & ongo+ c>e = !
 pati5t ov] ext5d$ p]iods ( "t2  7ii7   
consid]s !mself to be ! lead physician  
or practition] & :o furni%es items &    
s]vices & coord9ates c>e furni%$ by o!r 
physicians or practition]s = ! pati5t   
dur+ an acute episode2  7iii7 furni%es  
items & s]vices to ! pati5t on a cont9u+
 basis dur+ an acute episode ( c>e1 b 9 
a supportive r ?an a lead role2  7iv7   
furni%es items & s]vices to ! pati5t on 
an occasional basis1 usually at ! reque/
 ( ano!r physician or practition]2 or   
7v7 furni%es items & s]vices only z     
ord]$ by ano!r physician or practition]4
  7,c7  ,draft li/ ( pati5t relation%ip 
categories & codes  ,n lat] ?an #bgj    
days aft] ! date ( ! enactm5t ( ?is     
subsection1 ! ,secret>y %all po/ on !   
,int]net website ( ! ,c5t]s = ,m$ic>e   
,m$icaid ,s]vices a draft li/ ( ! pati5t
 relation%ip categories & codes develop$
 "u subp>agraph 7,b74  7,d7  ,/akehold] 

,input  ,! ,secret>y %all seek1 ?r\gh ! 
date t is #fj days aft] ! ,secret>y po/s
 ! li/ pursuant to subp>agraph 7,c71    
comm5ts f physician specialty societies1
 applicable practition] organizations1 &
 o!r /akehold]s1 includ+ repres5tatives 
( individuals entitl$ to b5efits "u "p  
,a or enroll$ "u ?is "p1 reg>d+ ! pati5t
 relation%ip categories & codes po/$ "u 
subp>agraph 7,c74 ,9 seek+ su* comm5ts1 
! ,secret>y %all use "o or m me*anisms  
7o!r ?an notice & comm5t rulemak+7 t may
 include op5 door =ums1 t[n hall meet+s1
 or o!r appropriate me*anisms4  7,e7    
,op]ational li/ ( pati5t relation%ip    
categories & codes  ,n lat] ?an #ahj    
days aft] ! end ( ! comm5t p]iod        
describ$ 9 subp>agraph 7,d71 tak+ into  
acc\nt ! comm5ts receiv$ "u su*         
subp>agraph1 ! ,secret>y %all po/ on !  
,int]net website ( ! ,c5t]s = ,m$ic>e   
,m$icaid ,s]vices an op]ational li/ (   
pati5t relation%ip categories & codes4  
7,f7  ,subsequ5t revisions  ,n lat] ?an 
,novemb] #a ( ea* ye> 7beg9n+ ) #bjag71 

! ,secret>y %all1 ?r\gh rulemak+1 make  
revisions to ! op]ational li/ ( pati5t  
relation%ip categories & codes z !      
,secret>y det]m9es appropriate4 ,su*    
revisions may be bas$ on exp]i5ce1 new  
in=mation develop$ pursuant to          
subsection 7n77#i77;,a71 & input f !    
physician specialty societies1          
applicable practition] organizations1 & 
o!r /akehold]s1 includ+ repres5tatives (
 individuals entitl$ to b5efits "u "p ,a
 or enroll$ "u ?is "p4  7#d7  ,report+ (
 in=mation = res\rce use measurem5t     
,claims submitt$ = items & s]vices      
furni%$ by a physician or applicable    
practition] on or aft] ,janu>y #a1      
#bjag1 %all1 z det]m9$ appropriate by ! 
,secret>y1 include--  7,a7 applicable   
codes e/abli%$ "u p>agraphs 7#b7 & 7#c72
 &  7,b7 ! national provid] id5tifi] ( !
 ord]+ physician or applicable          
practition] 7if diff]5t f ! bill+       
physician or applicable practition]74   
7#e7  ,me?odology = res\rce use analysis
  7,a7  ,9 g5]al  ,9 ord] to evaluate ! 

res\rces us$ to treat pati5ts 7) respect
 to c>e episode & pati5t condition      
gr\ps71 ! ,secret>y %all--  7i7 use !   
pati5t relation%ip codes report$ on     
claims pursuant to p>agraph 7#d7 to     
attribute pati5ts 79 :ole or 9 "p7 to "o
 or m physicians & applicable           
practition]s2  7ii7 use ! c>e episode & 
pati5t condition codes report$ on claims
 pursuant to p>agraph 7#d7 z a basis to 
comp>e simil> pati5ts & c>e episodes &  
pati5t condition gr\ps2 &  7iii7 conduct
 an analysis ( res\rce use 7) respect to
 c>e episodes & pati5t condition gr\ps (
 su* pati5ts71 z ! ,secret>y det]m9es   
appropriate4  7,b7  ,analysis ( pati5ts 
( physicians & practition]s  ,9 conduct+
 ! analysis describ$ 9 subp>agraph      
7,a77iii7 ) respect to pati5ts attribut$
 to physicians & applicable             
practition]s1 ! ,secret>y %all1 z       
feasible--  7i7 use ! claims data       
exp]i5ce ( su* pati5ts by pati5t        
condition codes dur+ a common p]iod1 su*
 z #ab mon?s2 &  7ii7 use ! claims data 

exp]i5ce ( su* pati5ts by c>e episode   
codes--  7,i7 9 ! case ( episodes )\t a 
hospitalization1 dur+ p]iods ( "t 7su* z
 ! numb] ( days7 det]m9$ appropriate by 
! ,secret>y2 &  7,,ii7 9 ! case (       
episodes ) a hospitalization1 dur+      
p]iods ( "t 7su* z ! numb] ( days7 be=e1
 dur+1 & aft] ! hospitalization4  7,c7  
,measurem5t ( res\rce use  ,9 measur+   
su* res\rce use1 ! ,secret>y--  7i7 %all
 use p] pati5t total all[$ *>ges = all  
s]vices "u "p ,a & ?is "p 7&1 if !      
,secret>y det]m9es appropriate1 "p ,d7 =
 ! analysis ( pati5t res\rce use1 by c>e
 episode codes & by pati5t condition    
codes2 &  7ii7 may1 z det]m9$           
appropriate1 use o!r measures ( all[$   
*>ges 7su* z subtotals = categories (   
items & s]vices7 & measures (           
utilization ( items & s]vices 7su* z    
frequ5cy ( specific items & s]vices & ! 
ratio ( specific items & s]vices among  
attribut$ pati5ts or episodes74  7,d7   
,/akehold] ,input  ,! ,secret>y %all    
seek comm5ts f ! physician specialty    

societies1 applicable practition]       
organizations1 & o!r /akehold]s1 includ+
 repres5tatives ( individuals entitl$ to
 b5efits "u "p ,a or enroll$ "u ?is "p1 
reg>d+ ! res\rce use me?odology e/abli%$
 pursuant to ?is p>agraph4 ,9 seek+     
comm5ts ! ,secret>y %all use "o or m    
me*anisms 7o!r ?an notice & comm5t      
rulemak+7 t may include op5 door =ums1  
t[n hall meet+s1 or o!r appropriate     
me*anisms4  7#f7  ,implem5tation  ,to ! 
ext5t t ! ,secret>y contracts ) an      
entity to c>ry out any "p ( ! provisions
 ( ?is subsection1 ! ,secret>y may n    
contract ) an entity or an entity ) a   
subcontract if ! entity or subcontract+ 
entity curr5tly makes recomm5dations to 
! ,secret>y on relative values = s]vices
 "u ! fee s*$ule = physicians' s]vices  
"u ?is section4  7#g7  ,limitation  ,!re
 %all be no adm9i/rative or judicial    
review "u section #ahfi1 section #ahgh1 
or o!rwise (--  7,a7 c>e episode &      
pati5t condition gr\ps & codes e/abli%$ 
"u p>agraph 7#b72  7,b7 pati5t          

relation%ip categories & codes e/abli%$ 
"u p>agraph 7#c72 &  7,c7 measurem5t (1 
& analyses ( res\rce use ) respect to1  
c>e episode & pati5t condition codes &  
pati5t relation%ip codes pursuant to    
p>agraph 7#e74  7#h7  ,adm9i/ration     
,*apt] #ce ( title #dd1 ,unit$ ,/ates   
,code1 %all n apply to ?is section4     
7#i7  ,def9itions  ,9 ?is section3  7,a7
  ,physician  ,! t]m physician has !    
mean+ giv5 su* t]m 9 section            
#ahfa7r77#a74  7,b7  ,applicable        
practition]  ,! t]m applicable          
practition] means--  7i7 a physician    
assi/ant1 nurse practition]1 & cl9ical  
nurse speciali/ 7z su* t]ms are def9$ 9 
section #ahfa7;aa77#e771 & a c]tifi$    
regi/]$ nurse ane/heti/ 7z def9$ 9      
section #ahfa7;bb77#b772 &  7ii7 beg9n+ 
,janu>y #a1 #bjah1 su* o!r eligible     
pr(essionals 7z def9$ 9 subsection      
7k77#c77;,b77 z specifi$ by ! ,secret>y4
  7#aj7  ,cl>ification  ,! provisions ( 
sections #ahij7;b77#g7 & #ahij;,a %all n
 apply to ?is subsection4  4  #ajb4     

,priorities & fund+ = measure developm5t
  ,section #ahdh ( ! ,social ,security  
,act 7#db ,u4,s4,c4 #aciew-#d71 z am5d$ 
by subsections 7c7 & 7g7 ( section #aja1
 is fur!r am5d$ by ins]t+ at ! end !    
foll[+ new subsection3  7s7  ,priorities
 & fund+ = measure developm5t  7#a7     
,plan id5tify+ measure developm5t       
priorities & timel9es  7,a7  ,draft     
measure developm5t plan  ,n lat] ?an    
,janu>y #a1 #bjae1 ! ,secret>y %all     
develop1 & po/ on ! ,int]net website ( !
 ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices1 a 
draft plan = ! developm5t ( quality     
measures = application "u ! applicable  
provisions 7z def9$ 9 p>agraph 7#e774   
,"u su* plan ! ,secret>y %all--  7i7    
address h[ measures us$ by private pay]s
 & integrat$ deliv]y sy/ems c\ld be     
incorporat$ "u title ,,xviii2  7ii7     
describe h[ coord9ation1 to ! ext5t     
possible1 w occur across organizations  
develop+ su* measures2 &  7iii7 take    
into acc\nt h[ cl9ical be/ practices &  
cl9ical practice guidel9es %\ld be us$ 9

 ! developm5t ( quality measures4  7,b7 
,quality doma9s  ,= purposes ( ?is      
subsection1 ! t]m quality doma9s means  
at lea/ ! foll[+ doma9s3  7i7 ,cl9ical  
c>e4  7ii7 ,safety4  7iii7 ,c>e         
coord9ation4  7iv7 ,pati5t & c>egiv]    
exp]i5ce4  7v7 ,population heal? &      
prev5tion4  7,c7  ,consid]ation  ,9     
develop+ ! draft plan "u ?is p>agraph1 !
 ,secret>y %all consid]--  7i7 gap      
analyses conduct$ by ! entity ) a       
contract "u section #ahij7;a7 or o!r    
contractors or entities2  7ii7 :e!r     
measures are applicable across heal? c>e
 sett+s2  7iii7 cl9ical practice        
improvem5t activities submitt$ "u       
subsection 7q77#b77;,c77iv7 = id5tify+  
possible areas = future measure         
developm5t & id5tify+ exi/+ gaps )      
respect to su* measures2 &  7iv7 !      
quality doma9s appli$ "u ?is subsection4
  7,d7  ,priorities  ,9 develop+ ! draft
 plan "u ?is p>agraph1 ! ,secret>y %all 
give priority to ! foll[+ types (       
measures3  7i7 ,outcome measures1       

includ+ pati5t report$ outcome &        
functional /atus measures4  7ii7 ,pati5t
 exp]i5ce measures4  7iii7 ,c>e         
coord9ation measures4  7iv7 ,measures ( 
appropriate use ( s]vices1 includ+      
measures ( ov] use4  7,e7  ,/akehold]   
input  ,! ,secret>y %all accept ?r\gh   
,m>* #a1 #bjae1 comm5ts on ! draft plan 
po/$ "u p>agraph 7#a77;,a7 f ! public1  
includ+ heal? c>e provid]s1 pay]s1      
consum]s1 & o!r /akehold]s4  7,f7  ,f9al
 measure developm5t plan  ,n lat] ?an   
,may #a1 #bjae1 tak+ into acc\nt !      
comm5ts receiv$ "u ?is subp>agraph1 !   
,secret>y %all f9alize ! plan & po/ on !
 ,int]net website ( ! ,c5t]s = ,m$ic>e  
,m$icaid ,s]vices an op]ational plan = !
 developm5t ( quality measures = use "u 
! applicable provisions4 ,su* plan %all 
be updat$ z appropriate4  7#b7          
,contracts & o!r arrangem5ts = quality  
measure developm5t  7,a7  ,9 g5]al  ,!  
,secret>y %all ent] into contracts or   
o!r arrangem5ts ) entities = ! purpose (
 develop+1 improv+1 updat+1 or exp&+ 9  

accordance ) ! plan "u p>agraph 7#a7    
quality measures = application "u !     
applicable provisions4 ,su* entities    
%all include organizations ) quality    
measure developm5t exp]tise4  7,b7      
,prioritization  7i7  ,9 g5]al  ,9 ent]+
 into contracts or o!r arrangem5ts "u   
subp>agraph 7,a71 ! ,secret>y %all give 
priority to ! developm5t ( ! types (    
measures describ$ 9 p>agraph 7#a77;,d74 
7ii7  ,consid]ation  ,9 select+ measures
 = developm5t "u ?is subsection1 !      
,secret>y %all consid]--  7,i7 :e!r su* 
measures w\ld be electronically         
specifi$2 &  7,,ii7 cl9ical practice    
guidel9es to ! ext5t t su* guidel9es    
exi/4  7#c7  ,annual report by !        
,secret>y  7,a7  ,9 g5]al  ,n lat] ?an  
,may #a1 #bjaf1 & annually !reaft]1 !   
,secret>y %all po/ on ! ,int]net website
 ( ! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices
 a report on ! progress made 9 develop+ 
quality measures = application "u !     
applicable provisions4  7,b7            
,requirem5ts  ,ea* report submitt$      

pursuant to subp>agraph 7,a7 %all       
include ! foll[+3  7i7 ,a description ( 
! ,secret>y's ef=ts to implem5t ?is     
p>agraph4  7ii7 ,) respect to ! measures
 develop$ dur+ ! previ\s ye>--  7,i7 a  
description ( ! total numb] ( quality   
measures develop$ & ! types ( su*       
measures1 su* z an outcome or pati5t    
exp]i5ce measure2  7,,ii7 ! "n ( ea*    
measure develop$2  7,,iii7 ! "n ( !     
develop] & /ew>d ( ea* measure2  7,,iv7 
) respect to ea* type ( measure1 an     
e/imate ( ! total am\nt exp5d$ "u ?is   
title to develop all measures ( su*     
type2 &  7,v7 :e!r ! measure w\ld be    
electronically specifi$4  7iii7 ,)      
respect to measures 9 developm5t at ! "t
 ( ! report--  7,i7 ! in=mation describ$
 9 clause 7ii71 if available2 &  7,,ii7 
a timel9e = completion ( ! developm5t ( 
su* measures4  7iv7 ,a description ( any
 updates to ! plan "u p>agraph 7#a7     
7includ+ newly id5tifi$ gaps & ! /atus (
 previ\sly id5tifi$ gaps7 & ! inv5tory (
 measures applicable "u ! applicable    

provisions4  7v7 ,o!r in=mation !       
,secret>y det]m9es to be appropriate4   
7#d7  ,/akehold] input  ,) respect to   
p>agraph 7#a71 ! ,secret>y %all seek    
/akehold] input ) respect to--  7,a7 !  
id5tification ( gaps :]e no quality     
measures exi/1 p>ticul>ly ) respect to !
 types ( measures describ$ 9 p>agraph   
7#a77;,d72  7,b7 prioritiz+ quality     
measure developm5t to address su* gaps2 
&  7,c7 o!r areas relat$ to quality     
measure developm5t det]m9$ appropriate  
by ! ,secret>y4  7#e7  ,def9ition (     
applicable provisions  ,9 ?is           
subsection1 ! t]m applicable provisions 
means ! foll[+ provisions3  7,a7        
,subsection 7q77#b77;,b77i74  7,b7      
,section #ahcc7z77#b77;,c74  7#f7       
,fund+  ,= purposes ( c>ry+ out ?is     
subsection1 ! ,secret>y %all provide = !
 transf]1 f ! ,f$]al ,supplem5t>y       
,m$ical ,insurance ,tru/ ,fund "u       
section #ahda1 ( #ae1jjj1jjj to ! ,c5t]s
 = ,m$ic>e  ,m$icaid ,s]vices ,program  
,managem5t ,acc\nt = ea* ( fiscal ye>s  

#bjad ?r\gh #bjah4 ,am\nts transf]r$ "u 
?is p>agraph %all rema9 available ?r\gh 
! end ( fiscal ye> #bjba4  4  #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  7h7
  ,adju/m5t to ,m$ic>e paym5t localities
  7#a7  ,9 g5]al  ,section #ahdh7;e7 ( !
 ,social ,security ,act 7#db ,u4,s4,c4  
#aciew-#d7;e77 is am5d$ by add+ at ! end
 ! foll[+ new p>agraph3  7#f7  ,use (   
,m,s,as z fee s*$ule areas 9 ,cali=nia  
7,a7  ,9 g5]al  ,subject to ! succe$+   
provisions ( ?is p>agraph & not)/&+ !   
previ\s provisions ( ?is subsection1 =  
s]vices furni%$ on or aft] ,janu>y #a1  
#bjag1 ! fee s*$ule areas us$ = paym5t  
"u ?is section applicable to ,cali=nia  
%all be ! foll[+3  7i7 ,ea*             

,metropolitan ,/ati/ical ,area 7ea* 9   
?is p>agraph ref]r$ to z an ,,msa71 z   
def9$ by ! ,director ( ! ,(fice (       
,managem5t & ,budget z ( ,decemb] #ca ( 
! previ\s ye>1 %all be a fee s*$ule     
area4  7ii7 ,all areas n includ$ 9 an   
,,msa %all be treat$ z a s+le           
re/-(-,/ate fee s*$ule area4  7,b7      
,transition = ,m,s,as previ\sly 9       
re/-(-,/ate paym5t locality or 9        
locality #c  7i7  ,9 g5]al  ,= s]vices  
furni%$ 9 ,cali=nia dur+ a ye> beg9n+ ) 
#bjag & end+ ) #bjba 9 an ,,msa 9 a     
transition area 7z def9$ 9 subp>agraph  
7,d771 subject to subp>agraph 7,c71 !   
geographic index values to be appli$ "u 
?is subsection = su* ye> %all be equal  
to ! sum ( ! foll[+3  7,i7  ,curr5t law 
compon5t  ,! old weight+ factor         
7describ$ 9 clause 7ii77 = su* ye>      
multipli$ by ! geographic index values  
"u ?is subsection = ! fee s*$ule area t 
includ$ su* ,,msa t w\ld h appli$ 9 su* 
area 7z e/imat$ by ! ,secret>y7 if ?is  
p>agraph did n apply4  7,,ii7           

,,msa-bas$ compon5t  ,! ,,msa-bas$      
weight+ factor 7describ$ 9 clause 7iii77
 = su* ye> multipli$ by ! geographic    
index values comput$ = ! fee s*$ule area
 "u subp>agraph 7,a7 = ! ye> 7det]m9$   
)\t reg>d to ?is subp>agraph74  7ii7    
,old weight+ factor  ,! old weight+     
factor describ$ 9 ?is clause--  7,i7 =  
#bjag1 is #e_/f2 &  7,,ii7 = ea* succe$+
 ye>1 is ! old weight+ factor describ$ 9
 ?is clause = ! previ\s ye> m9us #a_/f4 
7iii7  ,,msa-bas$ weight+ factor  ,!    
,,msa-bas$ weight+ factor describ$ 9 ?is
 clause = a ye> is #a m9us ! old weight+
 factor "u clause 7ii7 = t ye>4  7,c7   
,hold h>mless  ,= s]vices furni%$ 9 a   
transition area 9 ,cali=nia dur+ a ye>  
beg9n+ ) #bjag1 ! geographic index      
values to be appli$ "u ?is subsection = 
su* ye> %all n be less ?an ! correspond+
 geographic index values t w\ld h appli$
 9 su* transition area 7z e/imat$ by !  
,secret>y7 if ?is p>agraph did n apply4 
7,d7  ,transition area def9$  ,9 ?is    
p>agraph1 ! t]m transition area means   

ea* ( ! foll[+ fee s*$ule areas = #bjac3
  7i7 ,! re/-(-,/ate paym5t locality4   
7ii7 ,paym5t locality #c4  7,e7         
,ref]5ces to fee s*$ule areas           
,effective = s]vices furni%$ on or aft] 
,janu>y #a1 #bjag1 = ,cali=nia1 any     
ref]5ce 9 ?is section to a fee s*$ule   
area %all be deem$ a ref]5ce to a fee   
s*$ule area e/abli%$ 9 accordance ) ?is 
p>agraph4  4  7#b7  ,con=m+ am5dm5t to  
def9ition ( fee s*$ule area  ,section   
#ahdh7;j77#b7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciew-#d7;j77#b77 is   
am5d$ by /rik+ ,! t]m & ins]t+ ,except z
 provid$ 9 subsection 7e77#f77;,d71 !   
t]m4  7i7  ,disclosure ( data us$ ,to   
e/abli% multiple proc$ure paym5t        
r$uction policy  ,! ,secret>y ( ,heal? &
 ,human ,s]vices %all make publicly     
available ! in=mation us$ to e/abli% !  
multiple proc$ure paym5t r$uction policy
 to ! pr(essional compon5t ( imag+      
s]vices 9 ! f9al rule publi%$ 9 ! ,f$]al
 ,regi/]1 v4 #gg1 n4 #bbb1 ,novemb] #af1
 #bjab1 pages #fhhia-fichj "u !         

physician fee s*$ule "u section #ahdh ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#aciew-#d74  #aje4  ,promot+            
evid5ce-bas$ c>e  7a7  ,9 g5]al         
,section #ahcd ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #aciem7 is am5d$ by 
add+ at ! end ! foll[+ new subsection3  
7p7  ,recogniz+ appropriate use crit]ia 
= c]ta9 imag+ s]vices  7#a7  ,program   
e/abli%$  7,a7  ,9 g5]al  ,! ,secret>y  
%all e/abli% a program to promote ! use 
( appropriate use crit]ia 7z def9$ 9    
subp>agraph 7,b77 = applicable imag+    
s]vices 7z def9$ 9 subp>agraph 7,c77    
furni%$ 9 an applicable sett+ 7z def9$ 9
 subp>agraph 7,d77 by ord]+ pr(essionals
 & furni%+ pr(essionals 7z def9$ 9      
subp>agraphs 7,e7 & 7,f71 respectively74
  7,b7  ,appropriate use crit]ia def9$  
,9 ?is subsection1 ! t]m appropriate use
 crit]ia means crit]ia1 only develop$ or
 endors$ by national pr(essional m$ical 
specialty societies or o!r provid]-l$   
entities1 to assi/ ord]+ pr(essionals & 
furni%+ pr(essionals 9 mak+ ! mo/       

appropriate treatm5t decision = a       
specific cl9ical condition4 ,to ! ext5t 
feasible1 su* crit]ia %all be           
evid5ce-bas$4  7,c7  ,applicable imag+  
s]vice def9$  ,9 ?is subsection1 ! t]m  
applicable imag+ s]vice means an advanc$
 diagno/ic imag+ s]vice 7z def9$ 9      
subsection 7e77#a77;,b77 = :i* !        
,secret>y det]m9es--  7i7 "o or m       
applicable appropriate use crit]ia      
specifi$ "u p>agraph 7#b7 apply2  7ii7  
!re are "o or m qualifi$ cl9ical        
decision support me*anisms li/$ "u      
p>agraph 7#c77;,c72 &  7iii7 "o or m (  
su* me*anisms is available free ( *>ge4 
7,d7  ,applicable sett+ def9$  ,9 ?is   
subsection1 ! t]m applicable sett+ means
 a physician's (fice1 a hospital        
outpati5t dep>tm5t 7includ+ an em]g5cy  
dep>tm5t71 an ambulatory surgical c5t]1 
& any o!r provid]-l$ outpati5t sett+    
det]m9$ appropriate by ! ,secret>y4     
7,e7  ,ord]+ pr(essional def9$  ,9 ?is  
subsection1 ! t]m ord]+ pr(essional     
means a physician 7z def9$ 9 section    

#ahfa7r77 or a practition] describ$ 9   
section #ahdb7;b77#ah77;,c7 :o ord]s an 
applicable imag+ s]vice = an individual4
  7,f7  ,furni%+ pr(essional def9$  ,9  
?is subsection1 ! t]m furni%+           
pr(essional means a physician 7z def9$ 9
 section #ahfa7r77 or a practition]     
describ$ 9 section #ahdb7;b77#ah77;,c7  
:o furni%es an applicable imag+ s]vice =
 an individual4  7#b7  ,e/abli%m5t (    
applicable appropriate use crit]ia  7,a7
  ,9 g5]al  ,n lat] ?an ,novemb] #ae1   
#bjae1 ! ,secret>y %all ?r\gh rulemak+1 
& 9 consultation ) physicians1          
practition]s1 & o!r /akehold]s1 specify 
applicable appropriate use crit]ia =    
applicable imag+ s]vices only f among   
appropriate use crit]ia develop$ or     
endors$ by national pr(essional m$ical  
specialty societies or o!r provid]-l$   
entities4  7,b7  ,consid]ations  ,9     
specify+ applicable appropriate use     
crit]ia "u subp>agraph 7,a71 ! ,secret>y
 %all take into acc\nt :e!r ! crit]ia-- 
7i7 h /akehold] cons5sus2  7ii7 are     

sci5tifically valid & evid5ce bas$2 &   
7iii7 are bas$ on /udies t are publi%$ &
 reviewable by /akehold]s4  7,c7        
,revisions  ,! ,secret>y %all review1 on
 an annual basis1 ! specifi$ applicable 
appropriate use crit]ia to det]m9e if   
!re is a ne$ to update or revise 7z     
appropriate7 su* specification (        
applicable appropriate use crit]ia &    
make su* updates or revisions ?r\gh     
rulemak+4  7,d7  ,treatm5t ( multiple   
applicable appropriate use crit]ia  ,9 !
 case :]e ! ,secret>y det]m9es t m ?an  
"o appropriate use crit]ia applies )    
respect to an applicable imag+ s]vice1 !
 ,secret>y %all p]mit "o or m applicable
 appropriate use crit]ia "u ?is p>agraph
 = ! s]vice4  7#c7  ,me*anisms =        
consultation ) applicable appropriate   
use crit]ia  7,a7  ,id5tification (     
me*anisms to consult ) applicable       
appropriate use crit]ia  7i7  ,9 g5]al  
,! ,secret>y %all specify qualifi$      
cl9ical decision support me*anisms t    
c\ld be us$ by ord]+ pr(essionals to    

consult ) applicable appropriate use    
crit]ia = applicable imag+ s]vices4     
7ii7  ,consultation  ,! ,secret>y %all  
consult ) physicians1 practition]s1     
heal? c>e te*nology exp]ts1 & o!r       
/akehold]s 9 specify+ me*anisms "u ?is  
p>agraph4  7iii7  ,inclusion ( c]ta9    
me*anisms  ,me*anisms specifi$ "u ?is   
p>agraph may include any or all ( !     
foll[+ t meet ! requirem5ts describ$ 9  
subp>agraph 7,b77ii73  7,i7 ,use (      
cl9ical decision support modules 9      
c]tifi$ ,,ehr te*nology 7z def9$ 9      
section #ahdh7o77#d774  7,,ii7 ,use (   
private sector cl9ical decision support 
me*anisms t are indep5d5t f c]tifi$     
,,ehr te*nology1 :i* may include use (  
cl9ical decision support me*anisms      
available f m$ical specialty            
organizations4  7,,iii7 ,use ( a cl9ical
 decision support me*anism e/abli%$ by !
 ,secret>y4  7,b7  ,qualifi$ cl9ical    
decision support me*anisms  7i7  ,9     
g5]al  ,= purposes ( ?is subsection1 a  
qualifi$ cl9ical decision support       

me*anism is a me*anism t ! ,secret>y    
det]m9es meets ! requirem5ts describ$ 9 
clause 7ii74  7ii7  ,requirem5ts  ,!    
requirem5ts describ$ 9 ?is clause are ! 
foll[+3  7,i7 ,! me*anism makes         
available to ! ord]+ pr(essional        
applicable appropriate use crit]ia      
specifi$ "u p>agraph 7#b7 & ! support+  
docum5tation = ! applicable imag+ s]vice
 ord]$4  7,,ii7 ,9 ! case :]e !re are m 
?an "o applicable appropriate use       
crit]ia specifi$ "u su* p>agraph = an   
applicable imag+ s]vice1 ! me*anism     
indicates ! crit]ia t x uses = ! s]vice4
  7,,iii7 ,! me*anism det]m9es ! ext5t  
to :i* an applicable imag+ s]vice ord]$ 
is consi/5t ) ! applicable appropriate  
use crit]ia s specifi$4  7,,iv7 ,!      
me*anism g5]ates & provides to ! ord]+  
pr(essional a c]tification or           
docum5tation t docum5ts t ! qualifi$    
cl9ical decision support me*anism 0     
consult$ by ! ord]+ pr(essional4  7,v7  
,! me*anism is updat$ on a timely basis 
to reflect revisions to ! specification 

( applicable appropriate use crit]ia "u 
su* p>agraph4  7,,vi7 ,! me*anism meets 
privacy & security /&>ds "u applicable  
provisions ( law4  7,,vii7 ,! me*anism  
p]=ms su* o!r functions z specifi$ by ! 
,secret>y1 :i* may include a requirem5t 
to provide aggregate fe$back to ! ord]+ 
pr(essional4  7,c7  ,li/ ( me*anisms =  
consultation ) applicable appropriate   
use crit]ia  7i7  ,initial li/  ,n lat] 
?an ,april #a1 #bjaf1 ! ,secret>y %all  
publi% a li/ ( me*anisms specifi$ "u ?is
 p>agraph4  7ii7  ,p]iodic updat+ ( li/ 
,! ,secret>y %all id5tify on an annual  
basis ! li/ ( qualifi$ cl9ical decision 
support me*anisms specifi$ "u ?is       
p>agraph4  7#d7  ,consultation )        
applicable appropriate use crit]ia  7,a7
  ,consultation by ord]+ pr(essional    
,beg9n+ ) ,janu>y #a1 #bjag1 subject to 
subp>agraph 7,c71 ) respect to an       
applicable imag+ s]vice ord]$ by an     
ord]+ pr(essional t w\ld be furni%$ 9 an
 applicable sett+ & paid = "u an        
applicable paym5t sy/em 7z def9$ 9      

subp>agraph 7,d771 an ord]+ pr(essional 
%all--  7i7 consult ) a qualifi$        
decision support me*anism li/$ "u       
p>agraph 7#c77;,c72 &  7ii7 provide to !
 furni%+ pr(essional ! in=mation        
describ$ 9 clauses 7i7 ?r\gh 7iii7 (    
subp>agraph 7,b74  7,b7  ,report+ by    
furni%+ pr(essional  ,beg9n+ ) ,janu>y  
#a1 #bjag1 subject to subp>agraph 7,c71 
) respect to an applicable imag+ s]vice 
furni%$ 9 an applicable sett+ & paid =  
"u an applicable paym5t sy/em 7z def9$ 9
 subp>agraph 7,d771 paym5t = su* s]vice 
may only be made if ! claim = ! s]vice  
includes ! foll[+3  7i7 ,in=mation ab\t 
:i* qualifi$ cl9ical decision support   
me*anism 0 consult$ by ! ord]+          
pr(essional = ! s]vice4  7ii7 ,in=mation
 reg>d+--  7,i7 :e!r ! s]vice ord]$ w\ld
 adh]e to ! applicable appropriate use  
crit]ia specifi$ "u p>agraph 7#b72      
7,,ii7 :e!r ! s]vice ord]$ w\ld n adh]e 
to su* crit]ia2 or  7,,iii7 :e!r su*    
crit]ia 0 n applicable to ! s]vice      
ord]$4  7iii7 ,! national provid]       

id5tifi] ( ! ord]+ pr(essional 7if      
diff]5t f ! furni%+ pr(essional74  7,c7 
,exceptions  ,! provisions (            
subp>agraphs 7,a7 & 7,b7 & p>agraph     
7#f77;,a7 %all n apply to ! foll[+3  7i7
  ,em]g5cy s]vices  ,an applicable imag+
 s]vice ord]$ = an individual ) an      
em]g5cy m$ical condition 7z def9$ 9     
section #ahfg7;e77#a774  7ii7  ,inpati5t
 s]vices  ,an applicable imag+ s]vice   
ord]$ = an inpati5t & = :i* paym5t is   
made "u "p ,a4  7iii7  ,alt]native      
paym5t models  ,an applicable imag+     
s]vice ord]$ by an ord]+ pr(essional )  
respect to an individual attribut$ to an
 alt]native paym5t model 7z def9$ 9     
section #ahcc7z77#c77;,c774  7iv7       
,significant h>d%ip  ,an applicable     
imag+ s]vice ord]$ by an ord]+          
pr(essional :o ! ,secret>y may1 on a    
case-by-case basis1 exempt f !          
application ( su* provisions if !       
,secret>y det]m9es1 subject to annual   
r5ewal1 t consultation ) applicable     
appropriate use crit]ia w\ld result 9 a 

significant h>d%ip1 su* z 9 ! case ( a  
pr(essional :o practices 9 a rural area 
)\t suffici5t ,int]net access4  7,d7    
,applicable paym5t sy/em def9$  ,9 ?is  
subsection1 ! t]m applicable paym5t     
sy/em means ! foll[+3  7i7 ,! physician 
fee s*$ule e/abli%$ "u section          
#ahdh7;b74  7ii7 ,! prospective paym5t  
sy/em = hospital outpati5t dep>tm5t     
s]vices "u section #ahcc7t74  7iii7 ,!  
ambulatory surgical c5t] paym5t sy/ems  
"u section #ahcc7;i74  7#e7             
,id5tification ( outli] ord]+           
pr(essionals  7,a7  ,9 g5]al  ,) respect
 to applicable imag+ s]vices furni%$    
beg9n+ ) #bjag1 ! ,secret>y %all        
det]m9e1 on an annual basis1 no m ?an   
five p]c5t ( ! total numb] ( ord]+      
pr(essionals :o are outli] ord]+        
pr(essionals4  7,b7  ,outli] ord]+      
pr(essionals  ,! det]m9ation ( an outli]
 ord]+ pr(essional %all--  7i7 be bas$  
on l[ adh]5ce to applicable appropriate 
use crit]ia specifi$ "u p>agraph 7#b71  
:i* may be bas$ on comp>ison to o!r     

ord]+ pr(essionals2 &  7ii7 include data
 = ord]+ pr(essionals = :om prior       
au?orization "u p>agraph 7#f77;,a7      
applies4  7,c7  ,use ( two ye>s ( data  
,! ,secret>y %all use two ye>s ( data to
 id5tify outli] ord]+ pr(essionals "u   
?is p>agraph4  7,d7  ,process  ,!       
,secret>y %all e/abli% a process =      
det]m9+ :5 an outli] ord]+ pr(essional  
is no long] an outli] ord]+ pr(essional4
  7,e7  ,consultation ) /akehold]s  ,!  
,secret>y %all consult ) physicians1    
practition]s & o!r /akehold]s 9 develop+
 me?ods to id5tify outli] ord]+         
pr(essionals "u ?is p>agraph4  7#f7     
,prior au?orization = ord]+ pr(essionals
 :o are outli]s  7,a7  ,9 g5]al  ,beg9n+
 ,janu>y #a1 #bjbj1 subject to p>agraph 
7#d77;,c71 ) respect to s]vices furni%$ 
dur+ a ye>1 ! ,secret>y %all1 = a p]iod 
det]m9$ appropriate by ! ,secret>y1     
apply prior au?orization = applicable   
imag+ s]vices t are ord]$ by an outli]  
ord]+ pr(essional id5tifi$ "u p>agraph  
7#e74  7,b7  ,appropriate use crit]ia 9 

prior au?orization  ,9 apply+ prior     
au?orization "u subp>agraph 7,a71 !     
,secret>y %all utilize only ! applicable
 appropriate use crit]ia specifi$ "u ?is
 subsection4  7,c7  ,fund+  ,= purposes 
( c>ry+ out ?is p>agraph1 ! ,secret>y   
%all provide = ! transf]1 f ! ,f$]al    
,supplem5t>y ,m$ical ,insurance ,tru/   
,fund "u section #ahda1 ( #e1jjj1jjj to 
! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices   
,program ,managem5t ,acc\nt = ea* (     
fiscal ye>s #bjai ?r\gh #bjba4 ,am\nts  
transf]r$ "u ! prec$+ s5t5ce %all rema9 
available until exp5d$4  7#g7           
,con/ruction  ,no?+ 9 ?is subsection    
%all be con/ru$ z grant+ ! ,secret>y !  
au?ority to develop or initiate !       
developm5t ( cl9ical practice guidel9es 
or appropriate use crit]ia4  4  7b7     
,con=m+ am5dm5t  ,section #ahcc7t77#af7 
( ! ,social ,security ,act 7#db         
,u4,s4,c4 #aciel7t77#af77 is am5d$ by   
add+ at ! end ! foll[+ new subp>agraph3 
7,e7  ,application ( appropriate use    
crit]ia = c]ta9 imag+ s]vices  ,=       

provisions relat+ to ! application (    
appropriate use crit]ia = c]ta9 imag+   
s]vices1 see section #ahcd7p74  4  7c7  
,report on exp]i5ce ( imag+ appropriate 
use crit]ia program  ,n lat] ?an #ah    
mon?s aft] ! date ( ! enactm5t ( ?is    
,act1 ! ,comptroll] ,g5]al ( ! ,unit$   
,/ates %all submit to ,congress a report
 t includes a description ( ! ext5t to  
:i* appropriate use crit]ia c\ld be us$ 
= o!r s]vices "u "p ,b ( title ,,xviii (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #acie;j et seq471 su* z radiation !rapy
 & cl9ical diagno/ic laboratory s]vices4
  #ajf4  ,emp[]+ b5efici>y *oices ?r\gh 
access to in=mation on physicians'      
s]vices  7a7  ,9 g5]al  ,! ,secret>y    
%all make publicly available on         
,physician ,comp>e ! in=mation describ$ 
9 subsection 7b7 ) respect to eligible  
pr(essionals4  7b7  ,in=mation describ$ 
,! foll[+ in=mation1 ) respect to an    
eligible pr(essional1 is describ$ 9 ?is 
subsection3  7#a7 ,in=mation on ! numb] 
( s]vices furni%$ by ! eligible         

pr(essional "u "p ,b ( title ,,xviii ( !
 ,social ,security ,act 7#db ,u4,s4,c4  
#acie;j et seq471 :i* may include       
in=mation on ! mo/ frequ5t s]vices      
furni%$ or gr\p+s ( s]vices4  7#b7      
,in=mation on submitt$ *>ges & paym5ts =
 s]vices "u su* "p4  7#c7 ,a unique     
id5tifi] = ! eligible pr(essional t is  
available to ! public1 su* z a national 
provid] id5tifi]4  7c7  ,se>*ability  ,!
 in=mation made available "u ?is section
 %all be se>*able by at lea/ ! foll[+3  
7#a7 ,! specialty or type ( ! eligible  
pr(essional4  7#b7 ,*>act]i/ics ( !     
s]vices furni%$1 su* z volume or gr\p+s 
( s]vices4  7#c7 ,! location ( !        
eligible pr(essional4  7d7  ,disclosure 
,! in=mation made available "u ?is      
section %all indicate1 :]e appropriate1 
t publiciz$ in=mation may n be          
repres5tative ( ! eligible pr(essional's
 entire pati5t population1 ! v>iety (   
s]vices furni%$ by ! eligible           
pr(essional1 or ! heal? conditions (    
individuals treat$4  7e7  ,implem5tation

  7#a7  ,initial implem5tation          
,physician ,comp>e %all include !       
in=mation describ$ 9 subsection 7b7--   
7,a7 ) respect to physicians1 by n lat] 
?an ,july #a1 #bjae2 &  7,b7 ) respect  
to o!r eligible pr(essionals1 by n lat] 
?an ,july #a1 #bjaf4  7#b7  ,annual     
updat+  ,! in=mation made available "u  
?is section %all be updat$ on ,physician
 ,comp>e n less frequ5tly ?an on an     
annual basis4  7f7  ,opportunity ,to    
review & submit corrections  ,!         
,secret>y %all provide = an opportunity 
= an eligible pr(essional to review1 &  
submit corrections =1 ! in=mation to be 
made public ) respect to ! eligible     
pr(essional "u ?is section prior to su* 
in=mation be+ made public4  7g7         
,def9itions  ,9 ?is section3  7#a7      
,eligible pr(essional2 physician2       
secret>y  ,! t]ms eligible pr(essional1 
physician1 & ,secret>y h ! mean+ giv5   
su* t]ms 9 section #ajcca7;i7 ( ,public 
,law #aaa-adh4  7#b7  ,physician ,comp>e
  ,! t]m ,physician ,comp>e means !     

,physician ,comp>e ,int]net website ( ! 
,c5t]s = ,m$ic>e  ,m$icaid ,s]vices 7or 
a successor website74  #ajg4  ,exp&+    
availability ( ,m$ic>e data  7a7  ,exp&+
 uses ( ,m$ic>e data by qualifi$        
entities  7#a7  ,additional analyses    
7,a7  ,9 g5]al  ,subject to subp>agraph 
7,b71 to ! ext5t consi/5t ) applicable  
in=mation1 privacy1 security1 &         
disclosure laws 7includ+ p>agraph 7#c771
 not)/&+ p>agraph 7#d77;,b7 ( section   
#ahgd7;e7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #aciekk7e77 & ! second   
s5t5ce ( p>agraph 7#d77;,d7 ( su*       
section1 beg9n+ ,july #a1 #bjae1 a      
qualifi$ entity may use ! comb9$ data   
describ$ 9 p>agraph 7#d77;,b77iii7 ( su*
 section receiv$ by su* entity "u su*   
section1 & in=mation d]iv$ f !          
evaluation describ$ 9 su* p>agraph      
7#d77;,d71 to conduct additional        
non-public analyses 7z det]m9$          
appropriate by ! ,secret>y7 & provide or
 sell su* analyses to au?oriz$ us]s =   
non-public use 7includ+ = ! purposes (  

assi/+ provid]s ( s]vices & suppli]s to 
develop & p>ticipate 9 quality & pati5t 
c>e improvem5t activities1 includ+      
develop+ new models ( c>e74  7,b7       
,limitations ) respect to analyses  7i7 
,employ]s  ,any analyses provid$ or sold
 "u subp>agraph 7,a7 to an employ]      
describ$ 9 p>agraph 7#i77;,a77iii7 may  
only be us$ by su* employ] = purposes ( 
provid+ heal? insurance to employees &  
retirees ( ! employ]4  7ii7  ,heal?     
insurance issu]s  ,a qualifi$ entity may
 n provide or sell an analysis to a     
heal? insurance issu] describ$ 9        
p>agraph 7#i77;,a77iv7 unless ! issu] is
 provid+ ! qualifi$ entity ) data "u    
section #ahgd7;e77#d77;,b77iii7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#aciekk7e77#d77;,b77iii774  7#b7        
,access to c]ta9 data  7,a7  ,access    
,to ! ext5t consi/5t ) applicable       
in=mation1 privacy1 security1 &         
disclosure laws 7includ+ p>agraph 7#c771
 not)/&+ p>agraph 7#d77;,b7 ( section   
#ahgd7;e7 ( ! ,social ,security ,act    

7#db ,u4,s4,c4 #aciekk7e77 & ! second   
s5t5ce ( p>agraph 7#d77;,d7 ( su*       
section1 beg9n+ ,july #a1 #bjae1 a      
qualifi$ entity may--  7i7 provide or   
sell ! comb9$ data describ$ 9 p>agraph  
7#d77;,b77iii7 ( su* section to au?oriz$
 us]s describ$ 9 clauses 7i71 7ii71 &   
7v7 ( p>agraph 7#i77;,a7 = non-public   
use1 includ+ = ! purposes describ$ 9    
subp>agraph 7,b72 or  7ii7 subject to   
subp>agraph 7,c71 provide ,m$ic>e claims
 data to au?oriz$ us]s describ$ 9       
clauses 7i71 7ii71 & 7v71 ( p>agraph    
7#i77;,a7 = non-public use1 includ+ = ! 
purposes describ$ 9 subp>agraph 7,b74   
7,b7  ,purposes describ$  ,! purposes   
describ$ 9 ?is subp>agraph are assi/+   
provid]s ( s]vices & suppli]s 9 develop+
 & p>ticipat+ 9 quality & pati5t c>e    
improvem5t activities1 includ+ develop+ 
new models ( c>e4  7,c7  ,m$ic>e claims 
data mu/ be provid$ at no co/  ,a       
qualifi$ entity may n *>ge a fee =      
provid+ ! data "u subp>agraph 7,a77ii74 
7#c7  ,protection ( in=mation  7,a7  ,9 

g5]al  ,except z provid$ 9 subp>agraph  
7,b71 an analysis or data t is provid$  
or sold "u p>agraph 7#a7 or 7#b7 %all n 
conta9 in=mation t individually         
id5tifies a pati5t4  7,b7  ,in=mation on
 pati5ts ( ! provid] ( s]vices or       
suppli]  ,to ! ext5t consi/5t )         
applicable in=mation1 privacy1 security1
 & disclosure laws1 an analysis or data 
t is provid$ or sold to a provid] (     
s]vices or suppli] "u p>agraph 7#a7 or  
7#b7 may conta9 in=mation t individually
 id5tifies a pati5t ( su* provid] or    
suppli]1 includ+ ) respect to items &   
s]vices furni%$ to ! pati5t by o!r      
provid]s ( s]vices or suppli]s4  7,c7   
,prohibition on us+ analyses or data =  
m>ket+ purposes  ,an au?oriz$ us] %all n
 use an analysis or data provid$ or sold
 "u p>agraph 7#a7 or 7#b7 = m>ket+      
purposes4  7#d7  ,data use agreem5t  ,a 
qualifi$ entity & an au?oriz$ us]       
describ$ 9 clauses 7i71 7ii71 & 7v7 (   
p>agraph 7#i77;,a7 %all ent] into an    
agreem5t reg>d+ ! use ( any data t !    

qualifi$ entity is provid+ or sell+ to !
 au?oriz$ us] "u p>agraph 7#b74 ,su*    
agreem5t %all describe ! requirem5ts =  
privacy & security ( ! data &1 z det]m9$
 appropriate by ! ,secret>y1 any        
prohibitions on us+ su* data to l9k to  
o!r individually id5tifiable s\rces (   
in=mation4 ,if ! au?oriz$ us] is n a    
cov]$ entity "u ! rules promulgat$      
pursuant to ! ,heal? ,insurance         
,portability & ,acc\ntability ,act (    
#aiif1 ! agreem5t %all id5tify !        
relevant regulations1 z det]m9$ by !    
,secret>y1 t ! us] %all comply ) z if x 
7 act+ 9 ! capacity ( su* a cov]$       
entity4  7#e7  ,no r$isclosure (        
analyses or data  7,a7  ,9 g5]al        
,except z provid$ 9 subp>agraph 7,b71 an
 au?oriz$ us] t is provid$ or sold an   
analysis or data "u p>agraph 7#a7 or    
7#b7 %all n r$isclose or make public su*
 analysis or data or any analysis us+   
su* data4  7,b7  ,p]mitt$ r$isclosure   
,a provid] ( s]vices or suppli] t is    
provid$ or sold an analysis or data "u  

p>agraph 7#a7 or 7#b7 may1 z det]m9$ by 
! ,secret>y1 r$isclose su* analysis or  
data = ! purposes ( p]=mance improvem5t 
& c>e coord9ation activities b %all n   
make public su* analysis or data or any 
analysis us+ su* data4  7#f7            
,opportunity = provid]s ( s]vices &     
suppli]s to review  ,prior to a qualifi$
 entity provid+ or sell+ an analysis to 
an au?oriz$ us] "u p>agraph 7#a71 to !  
ext5t t su* analysis w\ld individually  
id5tify a provid] ( s]vices or suppli]  
:o is n be+ provid$ or sold su*         
analysis1 su* qualifi$ entity %all      
provide su* provid] or suppli] ) !      
opportunity to appeal & correct errors 9
 ! mann] describ$ 9 section             
#ahgd7;e77#d77;,c77ii7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#aciekk7e77#d77;,c77ii774  7#g7         
,assessm5t = a brea*  7,a7  ,9 g5]al  ,9
 ! case ( a brea* ( a data use agreem5t 
"u ?is section or section #ahgd7;e7 ( ! 
,social ,security ,act 7#db ,u4,s4,c4   
#aciekk7e771 ! ,secret>y %all impose an 

assessm5t on ! qualifi$ entity bo? 9 !  
case (--  7i7 an agreem5t betwe5 !      
,secret>y & a qualifi$ entity2 &  7ii7  
an agreem5t betwe5 a qualifi$ entity &  
an au?oriz$ us]4  7,b7  ,assessm5t  ,!  
assessm5t "u subp>agraph 7,a7 %all be an
 am\nt up to #ajj = ea* individual      
entitl$ to1 or enroll$ =1 b5efits "u "p 
,a ( title ,,xviii ( ! ,social ,security
 ,act or enroll$ = b5efits "u "p ,b (   
su* title--  7i7 9 ! case ( an agreem5t 
describ$ 9 subp>agraph 7,a77i71 = :om ! 
,secret>y provid$ data on to ! qualifi$ 
entity "u p>agraph 7#b72 &  7ii7 9 !    
case ( an agreem5t describ$ 9           
subp>agraph 7,a77ii71 = :om ! qualifi$  
entity provid$ data on to ! au?oriz$ us]
 "u p>agraph 7#b74  7,c7  ,deposit (    
am\nts collect$  ,any am\nts collect$   
pursuant to ?is p>agraph %all be        
deposit$ 9 ,f$]al ,supplem5t>y ,m$ical  
,insurance ,tru/ ,fund "u section #ahda 
( ! ,social ,security ,act 7#db         
,u4,s4,c4 #aciet74  7#h7  ,annual       
reports  ,any qualifi$ entity t provides

 or sells an analysis or data "u        
p>agraph 7#a7 or 7#b7 %all annually     
submit to ! ,secret>y a report t        
includes--  7,a7 a summ>y ( ! analyses  
provid$ or sold1 includ+ ! numb] ( su*  
analyses1 ! numb] ( pur*as]s ( su*      
analyses1 & ! total am\nt ( fees receiv$
 = su* analyses2  7,b7 a description ( !
 topics & purposes ( su* analyses2  7,c7
 in=mation on ! entities :o receiv$ !   
data "u p>agraph 7#b71 ! uses ( ! data1 
& ! total am\nt ( fees receiv$ =        
provid+1 sell+1 or %>+ ! data2 &  7,d7  
o!r in=mation det]m9$ appropriate by !  
,secret>y4  7#i7  ,def9itions  ,9 ?is   
subsection & subsection 7b73  7,a7      
,au?oriz$ us]  ,! t]m au?oriz$ us] means
 ! foll[+3  7i7 ,a provid] ( s]vices4   
7ii7 ,a suppli]4  7iii7 ,an employ] 7z  
def9$ 9 section #c7e7 ( ! ,employee     
,retirem5t ,insurance ,security ,act (  
#aigd74  7iv7 ,a heal? insurance issu]  
7z def9$ 9 section #bgia ( ! ,public    
,heal? ,s]vice ,act74  7v7 ,a m$ical    
society or hospital association4  7vi7  

,any entity n describ$ 9 clauses 7i7    
?r\gh 7v7 t is approv$ by ! ,secret>y   
7o!r ?an an employ] or heal? insurance  
issu] n describ$ 9 clauses 7iii7 & 7iv71
 respectively1 z det]m9$ by !           
,secret>y74  7,b7  ,provid] ( s]vices   
,! t]m provid] ( s]vices has ! mean+    
giv5 su* t]m 9 section #ahfa7u7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#aciex7u774  7,c7  ,qualifi$ entity  ,! 
t]m qualifi$ entity has ! mean+ giv5 su*
 t]m 9 section #ahgd7;e77#b7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#aciekk7e774  7,d7  ,secret>y  ,! t]m   
,secret>y means ! ,secret>y ( ,heal? &  
,human ,s]vices4  7,e7  ,suppli]  ,! t]m
 suppli] has ! mean+ giv5 su* t]m 9     
section #ahfa7;d7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #aciex7d774  7b7    
,access to ,m$ic>e data by qualifi$     
cl9ical data regi/ries ,to facilitate   
quality improvem5t  7#a7  ,access  7,a7 
,9 g5]al  ,to ! ext5t consi/5t )        
applicable in=mation1 privacy1 security1
 & disclosure laws1 beg9n+ ,july #a1    

#bjae1 ! ,secret>y %all1 at ! reque/ ( a
 qualifi$ cl9ical data regi/ry "u       
section #ahdh7m77#c77;,e7 ( ! ,social   
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7m77#c77;,e771 provide ! data  
describ$ 9 subp>agraph 7,b7 79 a =m &   
mann] det]m9$ to be appropriate7 to su* 
qualifi$ cl9ical data regi/ry = purposes
 ( l9k+ su* data ) cl9ical outcomes data
 & p]=m+ risk-adju/$1 sci5tifically     
valid analyses & rese>* to support      
quality improvem5t or pati5t safety1    
provid$ t any public report+ ( su*      
analyses or rese>* t id5tifies a provid]
 ( s]vices or suppli] %all only be      
conduct$ ) ! opportunity ( su* provid]  
or suppli] to appeal & correct errors 9 
! mann] describ$ 9 subsection 7a77#f74  
7,b7  ,data describ$  ,! data describ$ 9
 ?is subp>agraph is--  7i7 claims data  
"u ! ,m$ic>e program "u title ,,xviii ( 
! ,social ,security ,act2 &  7ii7 if !  
,secret>y det]m9es appropriate1 claims  
data "u ! ,m$icaid program "u title     
,,xix ( su* ,act & ! ,/ate ,*ildr5's    

,heal? ,insurance ,program "u title     
,,xxi ( su* ,act4  7#b7  ,fee  ,data    
describ$ 9 p>agraph 7#a77;,b7 %all be   
provid$ to a qualifi$ cl9ical data      
regi/ry "u p>agraph 7#a7 at a fee equal 
to ! co/ ( provid+ su* data4 ,any fee   
collect$ pursuant to ! prec$+ s5t5ce    
%all be deposit$ 9 ! ,c5t]s = ,m$ic>e   
,m$icaid ,s]vices ,program ,managem5t   
,acc\nt4  7c7  ,expansion ( data        
available to qualifi$ entities  ,section
 #ahgd7;e7 ( ! ,social ,security ,act   
7#db ,u4,s4,c4 #aciekk7e77 is am5d$--   
7#a7 9 ! subsection head+1 by /rik+     
,m$ic>e2 &  7#b7 9 p>agraph 7#c7--  7,a7
 by ins]t+ aft] ! fir/ s5t5ce ! foll[+  
new s5t5ce3 ,beg9n+ ,july #a1 #bjae1 if 
! ,secret>y det]m9es appropriate1 ! data
 describ$ 9 ?is p>agraph may also       
include /&>diz$ extracts 7z det]m9$ by !
 ,secret>y7 ( claims data "u titles     
,,xix & ,,xxi = assi/ance provid$ "u su*
 titles = "o or m specifi$ geographic   
areas & "t p]iods reque/$ by a qualifi$ 
entity42 &  7,b7 9 ! la/ s5t5ce1 by     

ins]t+ or "u titles ,,xix or ,,xxi be=e 
! p]iod at ! end4  7d7  ,revision (     
placem5t ( fees  ,section               
#ahgd7;e77#d77;,a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#aciekk7e77#d77;,a77 is am5d$1 9 !      
second s5t5ce--  7#a7 by ins]t+ 1 =     
p]iods prior to ,july #a1 #bjae1 aft]   
deposit$2 &  7#b7 by ins]t+ ! foll[+    
be=e ! p]iod at ! end3 1 &1 beg9n+ ,july
 #a1 #bjae1 into ! ,c5t]s = ,m$ic>e     
,m$icaid ,s]vices ,program ,managem5t   
,acc\nt4  #ajh4  ,r$uc+ adm9i/rative    
burd5 & o!r provisions  7a7  ,m$ic>e    
physician & practition] opt-,out to     
private contract  7#a7  ,indef9ite1     
cont9u+ automatic ext5sion ( opt out    
election  7,a7  ,9 g5]al  ,section      
#ahjb7;b77#c7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acie;a7b77#c77 is      
am5d$--  7i7 9 subp>agraph 7,b77ii71 by 
/rik+ dur+ ! #b-ye> p]iod beg9n+ on !   
date ! affidavit is sign$ & ins]t+ dur+ 
! applicable #b-ye> p]iod 7z def9$ 9    
subp>agraph 7,d772  7ii7 9 subp>agraph  

7,c71 by /rik+ dur+ ! #b-ye> p]iod      
describ$ 9 subp>agraph 7,b77ii7 & ins]t+
 dur+ ! applicable #b-ye> p]iod2 &      
7iii7 by add+ at ! end ! foll[+ new     
subp>agraph3  7,d7  ,applicable #b-ye>  
p]iods = effectiv5ess ( affidavits  ,9  
?is subsection1 ! t]m applicable #b-ye> 
p]iod means1 ) respect to an affidavit (
 a physician or practition] "u          
subp>agraph 7,b71 ! #b-ye> p]iod beg9n+ 
on ! date ! affidavit is sign$ &        
includes ea* subsequ5t #b-ye> p]iod     
unless ! physician or practition]       
involv$ provides notice to ! ,secret>y  
79 a =m & mann] specifi$ by !           
,secret>y71 n lat] ?an #cj days be=e !  
end ( ! previ\s #b-ye> p]iod1 t !       
physician or practition] does n want to 
ext5d ! application ( ! affidavit = su* 
subsequ5t #b-ye> p]iod4  4  7,b7        
,effective date  ,! am5dm5ts made by    
subp>agraph 7,a7 %all apply to          
affidavits ent]$ into on or aft] ! date 
t is #fj days aft] ! date ( ! enactm5t (
 ?is ,act4  7#b7  ,public availability (

 in=mation on opt-out physicians &      
practition]s  ,section #ahjb7;b7 ( !    
,social ,security ,act 7#db ,u4,s4,c4   
#acie;a7b77 is am5d$--  7,a7 9 p>agraph 
7#e71 by add+ at ! end ! foll[+ new     
subp>agraph3  7,d7  ,opt-out physician  
or practition]  ,! t]m opt-out physician
 or practition] means a physician or    
practition] :o has 9 effect an affidavit
 "u p>agraph 7#c77;,b74  2  7,b7 by     
r$esignat+ p>agraph 7#e7 z p>agraph     
7#f72 &  7,c7 by ins]t+ aft] p>agraph   
7#d7 ! foll[+ new p>agraph3  7#e7  ,po/+
 ( in=mation on opt-out physicians &    
practition]s  7,a7  ,9 g5]al  ,beg9n+ n 
lat] ?an ,febru>y #a1 #bjae1 ! ,secret>y
 %all make publicly available ?r\gh an  
appropriate publicly accessible website 
( ! ,dep>tm5t ( ,heal? & ,human ,s]vices
 in=mation on ! numb] & *>act]i/ics (   
opt-out physicians & practition]s & %all
 update su* in=mation on su* website n  
less (t5 ?an annually4  7,b7  ,in=mation
 to be includ$  ,! in=mation to be made 
available "u subp>agraph 7,a7 %all      

include at lea/ ! foll[+ ) respect to   
opt-out physicians & practition]s3  7i7 
,_! numb]4  7ii7 ,_! physician or       
pr(essional specialty or o!r            
designation4  7iii7 ,_! geographic      
di/ribution4  7iv7 ,! tim+ ( _! becom+  
opt-out physicians & practition]s1      
relative to :5 !y fir/ ent]$ practice & 
) respect to applicable #b-ye> p]iods4  
7v7 ,! proportion ( su* physicians &    
practition]s :o bill$ = em]g5cy or urg5t
 c>e s]vices4  4  7b7  ,ga9%>+ /udy &   
report  ,n lat] ?an #f mon?s aft] ! date
 ( ! enactm5t ( ?is ,act1 ! ,secret>y ( 
,heal? & ,human ,s]vices1 9 consultation
 ) ! ,inspector ,g5]al ( ! ,dep>tm5t (  
,heal? & ,human ,s]vices1 %all submit to
 ,congress a report ) legislative       
recomm5dations to am5d exi/+ fraud &    
abuse laws1 ?r\gh exceptions1 safe      
h>bors1 or o!r n>r[ly t>get$ provisions1
 to p]mit ga9%>+ or simil> arrangem5ts  
betwe5 physicians & hospitals t improve 
c>e :ile r$uc+ wa/e & increas+          
effici5cy4 ,! report %all--  7#a7       

consid] :e!r su* provisions %\ld apply  
to own]%ip int]e/s1 comp5sation         
arrangem5ts1 or o!r relation%ips2  7#b7 
describe h[ ! recomm5dations address    
acc\ntability1 transp>5cy1 & quality1   
includ+ h[ be/ to limit inducem5ts to   
/9t on c>e1 dis*>ge pati5ts prematurely1
 or o!rwise r$uce or limit m$ically     
necess>y c>e2 &  7#c7 consid] :e!r a    
portion ( any sav+s g5]at$ by su*       
arrangem5ts %\ld accrue to ! ,m$ic>e    
program "u title ,,xviii ( ! ,social    
,security ,act4  7c7  ,promot+          
int]op]ability ( electronic heal? record
 sy/ems  7#a7  ,recomm5dations = a*iev+ 
widespread ,,ehr int]op]ability  7,a7   
,objective  ,z a consequ5ce ( a         
significant ,f$]al inve/m5t 9 !         
implem5tation ( heal? in=mation         
te*nology ?r\gh ! ,m$ic>e & ,m$icaid    
,,ehr inc5tive programs1 ,congress      
decl>es x a national objective to a*ieve
 widespread ex*ange ( heal? in=mation   
?r\gh int]op]able c]tifi$ ,,ehr         
te*nology nationwide by ,decemb] #ca1   

#bjag4  7,b7  ,def9itions  ,9 ?is       
p>agraph3  7i7  ,widespread             
int]op]ability  ,! t]m widespread       
int]op]ability means int]op]ability     
betwe5 c]tifi$ ,,ehr te*nology sy/ems   
employ$ by mean+ful ,,ehr us]s "u !     
,m$ic>e & ,m$icaid ,,ehr inc5tive       
programs & o!r cl9icians & heal? c>e    
provid]s on a nationwide basis4  7ii7   
,int]op]ability  ,! t]m int]op]ability  
means ! ability ( two or m heal?        
in=mation sy/ems or compon5ts to ex*ange
 cl9ical & o!r in=mation & to use !     
in=mation t has be5 ex*ang$ us+ common  
/&>ds z to provide access to longitud9al
 in=mation = heal? c>e provid]s 9 ord]  
to facilitate coord9at$ c>e & improv$   
pati5t outcomes4  7,c7  ,e/abli%m5t (   
metrics  ,n lat] ?an ,july #a1 #bjae1 & 
9 consultation ) /akehold]s1 ! ,secret>y
 %all e/abli% metrics to be us$ to      
det]m9e if & to ! ext5t t ! objective   
describ$ 9 subp>agraph 7,a7 has be5     
a*iev$4  7,d7  ,recomm5dations if       
objective n a*iev$  ,if ! ,secret>y (   

,heal? & ,human ,s]vices det]m9es t !   
objective describ$ 9 subp>agraph 7,a7   
has n be5 a*iev$ by ,decemb] #ca1 #bjag1
 !n ! ,secret>y %all submit to ,congress
 a report1 by n lat] ?an ,decemb] #ca1  
#bjah1 t id5tifies b>ri]s to su*        
objective & recomm5ds actions t ! ,f$]al
 ,gov]nm5t c take to a*ieve su*         
objective4 ,su* recomm5d$ actions may   
include recomm5dations--  7i7 to adju/  
paym5ts = n be+ mean+ful ,,ehr us]s "u !
 ,m$ic>e ,,ehr inc5tive programs2 &     
7ii7 = crit]ia = dec]tify+ c]tifi$ ,,ehr
 te*nology products4  7#b7  ,prev5t+    
block+ ! %>+ ( in=mation  7,a7  ,=      
mean+ful ,,ehr pr(essionals  ,section   
#ahdh7o77#b77;,a77ii7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7o77#b77;,a77ii77 is am5d$ by  
ins]t+ be=e ! p]iod at ! end ! foll[+3 1
 & ! pr(essional demon/rates 7?r\gh a   
process specifi$ by ! ,secret>y1 su* z !
 use ( an atte/ation7 t ! pr(essional   
has n kn[+ly & willfully tak5 any action
 to limit or re/rict ! compatibility or 

int]op]ability ( ! c]tifi$ ,,ehr        
te*nology4  7,b7  ,= mean+ful ,,ehr     
hospitals  ,section                     
#ahhf7n77#c77;,a77ii7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4           
#acieww7n77#c77;,a77ii77 is am5d$ by    
ins]t+ be=e ! p]iod at ! end ! foll[+3 1
 & ! hospital demon/rates 7?r\gh a      
process specifi$ by ! ,secret>y1 su* z !
 use ( an atte/ation7 t ! hospital has n
 kn[+ly & willfully tak5 any action to  
limit or re/rict ! compatibility or     
int]op]ability ( ! c]tifi$ ,,ehr        
te*nology4  7,c7  ,effective date  ,!   
am5dm5ts made by ?is subsection %all    
apply to mean+ful ,,ehr us]s z ( ! date 
t is "o ye> aft] ! date ( ! enactm5t (  
?is ,act4  7#c7  ,/udy & report on !    
feasibility ( e/abli%+ a website to     
comp>e c]tifi$ ,,ehr te*nology products 
7,a7  ,/udy  ,! ,secret>y %all conduct a
 /udy to exam9e ! feasibility ( e/abli%+
 me*anisms t includes aggregat$ results 
( surveys ( mean+ful ,,ehr us]s on !    
functionality ( c]tifi$ ,,ehr te*nology 

products to enable su* us]s to directly 
comp>e ! functionality & o!r features ( 
su* products4 ,su* in=mation may be made
 available ?r\gh contracts ) physician1 
hospital1 or o!r organizations t ma9ta9 
su* comp>ative in=mation4  7,b7  ,report
  ,n lat] ?an #a ye> aft] ! date ( !    
enactm5t ( ?is ,act1 ! ,secret>y %all   
submit to ,congress a report on !       
website4 ,! report %all include         
in=mation on ! b5efits (1 & res\rces    
ne$$ to develop & ma9ta91 su* a website4
  7#d7  ,def9itions  ,9 ?is subsection3 
7,a7 ,! t]m c]tifi$ ,,ehr te*nology has 
! mean+ giv5 su* t]m 9 section          
#ahdh7o77#d7 ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #aciew-#d7o77#d774  7,b7 
,! t]m mean+ful ,,ehr us] has ! mean+   
giv5 su* t]m "u ! ,m$ic>e ,,ehr inc5tive
 programs4  7,c7 ,! t]m ,m$ic>e &       
,m$icaid ,,ehr inc5tive programs means--
  7i7 9 ! case ( ! ,m$ic>e program "u   
title ,,xviii ( ! ,social ,security     
,act1 ! inc5tive programs "u section    
#ahad7l77#c71 section #ahdh7o71         

subsections 7l7 & 7m7 ( section #ahec1 &
 section #ahhf7n7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #acie;f7l77#c71     
#aciew-#d7o71 #aciew-#bc1 #acieww7n772 &
  7ii7 9 ! case ( ! ,m$icaid program "u 
title ,,xix ( su* ,act1 ! inc5tive      
program "u subsections 7a77#c77;,f7 &   
7t7 ( section #aijc ( su* ,act 7#db     
,u4,s4,c4 #acif;b74  7,d7 ,! t]m        
,secret>y means ! ,secret>y ( ,heal? &  
,human ,s]vices4  7d7  ,,gao /udies &   
reports on ! use ( teleheal? "u ,f$]al  
programs & on remote pati5t monitor+    
s]vices  7#a7  ,/udy on teleheal?       
s]vices  ,! ,comptroll] ,g5]al ( !      
,unit$ ,/ates %all conduct a /udy on !  
foll[+3  7,a7 ,h[ ! def9ition (         
teleheal? across v>i\s ,f$]al programs &
 ,f$]al ef=ts c in=m ! use ( teleheal? 9
 ! ,m$ic>e program "u title ,,xviii ( ! 
,social ,security ,act 7#db ,u4,s4,c4   
#acie et seq474  7,b7 ,issues t c       
facilitate or inhibit ! use ( teleheal? 
"u ! ,m$ic>e program "u su* title1      
includ+ ov]sight & pr(essional lic5sure1

 *ang+ te*nology1 privacy & security1   
infra/ructure requirem5ts1 & v>y+ ne$s  
across urban & rural areas4  7,c7       
,pot5tial implications ( great] use (   
teleheal? ) respect to paym5t & deliv]y 
sy/em trans=mations "u ! ,m$ic>e program
 "u su* title ,,xviii & ! ,m$icaid      
program "u title ,,xix ( su* ,act 7#db  
,u4,s4,c4 #acif et seq474  7,d7 ,h[ !   
,c5t]s = ,m$ic>e  ,m$icaid ,s]vices     
conducts ov]sight ( paym5ts made "u !   
,m$ic>e program "u su* title ,,xviii to 
provid]s = teleheal? s]vices4  7#b7     
,/udy on remote pati5t monitor+ s]vices 
7,a7  ,9 g5]al  ,! ,comptroll] ,g5]al ( 
! ,unit$ ,/ates %all conduct a /udy--   
7i7 ( ! dissem9ation ( remote pati5t    
monitor+ te*nology 9 ! private heal?    
insurance m>ket2  7ii7 ( ! f9ancial     
inc5tives 9 ! private heal? insurance   
m>ket relat+ to adoption ( su*          
te*nology2  7iii7 ( ! b>ri]s to adoption
 ( su* s]vices "u ! ,m$ic>e program "u  
title ,,xviii ( ! ,social ,security     
,act2  7iv7 t evaluates ! pati5ts1      

conditions1 & cl9ical circum/ances t    
c\ld mo/ b5efit f remote pati5t monitor+
 s]vices2 &  7v7 t evaluates ! *all5ges 
relat$ to e/abli%+ appropriate valuation
 = remote pati5t monitor+ s]vices "u !  
,m$ic>e physician fee s*$ule "u section 
#ahdh ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #aciew-#d7 9 ord] to          
accurately reflect ! res\rces involv$ 9 
furni%+ su* s]vices4  7,b7  ,def9itions 
,= purposes ( ?is p>agraph3  7i7        
,remote pati5t monitor+ s]vices  ,! t]m 
remote pati5t monitor+ s]vices means    
s]vices furni%$ ?r\gh remote pati5t     
monitor+ te*nology4  7ii7  ,remote      
pati5t monitor+ te*nology  ,! t]m remote
 pati5t monitor+ te*nology means a      
coord9at$ sy/em t uses "o or m home-bas$
 or mobile monitor+ devices t           
automatically transmit vital sign data  
or in=mation on activities ( daily liv+ 
& may include responses to assessm5t    
que/ions collect$ on ! devices          
wirelessly or ?r\gh a telecommunications
 connection to a s]v] t complies ) !    

,f$]al regulations 7conc]n+ ! privacy ( 
individually id5tifiable heal?          
in=mation7 promulgat$ "u section        
#bfd7;c7 ( ! ,heal? ,insurance          
,portability & ,acc\ntability ,act (    
#aiif1 z "p ( an e/abli%$ plan ( c>e = t
 pati5t t includes ! review &           
int]pretation ( t data by a heal? c>e   
pr(essional4  7#c7  ,reports  ,n lat]   
?an #bd mon?s aft] ! date ( ! enactm5t (
 ?is ,act1 ! ,comptroll] ,g5]al %all    
submit to ,congress--  7,a7 a report    
conta9+ ! results ( ! /udy conduct$ "u  
p>agraph 7#a72 &  7,b7 a report conta9+ 
! results ( ! /udy conduct$ "u p>agraph 
7#b74  ,a report requir$ "u ?is p>agraph
 %all be submitt$ toge!r )              
recomm5dations = su* legislation &      
adm9i/rative action z ! ,comptroll]     
,g5]al det]m9es appropriate4 ,!         
,comptroll] ,g5]al may submit "o report 
conta9+ ! results describ$ 9            
subp>agraphs 7,a7 & 7,b7 & !            
recomm5dations describ$ 9 ! previ\s     
s5t5ce4  7e7  ,rule ( con/ruction reg>d+

 heal?c>e provid] /&>ds ( c>e  7#a7     
,ma9t5ance ( /ate /&>ds  ,! developm5t1 
recognition1 or implem5tation ( any     
guidel9e or o!r /&>d "u any ,f$]al heal?
 c>e provision %all n be con/ru$--  7,a7
 to e/abli% ! /&>d ( c>e or duty ( c>e  
ow$ by a heal? c>e provid] to a pati5t 9
 any m$ical malpractice or m$ical       
product liability action or claim2 or   
7,b7 to preempt any /&>d ( c>e or duty (
 c>e1 ow$ by a heal? c>e provid] to a   
pati5t1 duly e/abli%$ "u ,/ate or common
 law4  7#b7  ,def9itions  ,= purposes ( 
?is subsection3  7,a7  ,f$]al heal? c>e 
provision  ,! t]m ,f$]al heal? c>e      
provision means any provision ( !       
,pati5t ,protection & ,af=dable ,c>e    
,act 7,public ,law #aaa-adh71 title ,i  
or subtitle ,b ( title ,,ii ( ! ,heal?  
,c>e & ,education ,reconciliation ,act (
 #bjaj 7,public ,law #aaa-aeb71 or title
 ,,xviii or ,,xix ( ! ,social ,security 
,act4  7,b7  ,heal? c>e provid]  ,! t]m 
heal? c>e provid] means any individual  
or entity--  7i7 lic5s$1 regi/]$1 or    

c]tifi$ "u ,f$]al or ,/ate laws or      
regulations to provide heal? c>e        
s]vices2 or  7ii7 requir$ to be s       
lic5s$1 regi/]$1 or c]tifi$ b t is      
exempt$ by o!r /atute or regulation4    
7,c7  ,m$ical malpractice or m$ical     
product liability action or claim  ,!   
t]m m$ical malpractice or m$ical product
 liability action or claim means a      
m$ical malpractice action or claim 7z   
def9$ 9 section #dca7g7 ( ! ,heal? ,c>e 
,quality ,improvem5t ,act ( #aihf 7#db  
,u4,s4,c4 #aaaea7g777 & includes a      
liability action or claim relat+ to a   
heal? c>e provid]'s prescription or     
provision ( a drug1 device1 or          
biological product 7z su* t]ms are def9$
 9 section #bja ( ! ,f$]al ,food1 ,drug1
 & ,cosmetic ,act or section #cea ( !   
,public ,heal? ,s]vice ,act74  7,d7     
,/ate  ,! t]m ,/ate includes ! ,di/rict 
( ,columbia1 ,pu]to ,rico1 & any o!r    
commonweal?1 possession1 or t]ritory ( !
 ,unit$ ,/ates4  7#c7 ,pres]vation (    
,/ate law ,no provision ( ! ,pati5t     

,protection & ,af=dable ,c>e ,act       
7,public ,law #aaa-adh71 title ,i or    
subtitle ,b ( title ,,ii ( ! ,heal? ,c>e
 & ,education ,reconciliation ,act (    
#bjaj 7,public ,law #aaa-aeb71 or title 
,,xviii or ,,xix ( ! ,social ,security  
,act %all be con/ru$ to preempt any     
,/ate or common law gov]n+ m$ical       
pr(essional or m$ical product liability 
actions or claims4  ,,ii ,ext5sions  ,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 ,april #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;,c77iii71 ?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 ( ! ,responsible ,m$ic>e ,,sgr 
,repeal & ,b5efici>y ,access ,improvem5t
 ,act ( #bjad2 &  7#b7 9 p>agraph       
7#e77;,c71 by add+ at ! end ! foll[+ new
 clause3  7iii7 ,beg9n+ on ! date (     
enactm5t ( ! ,responsible ,m$ic>e ,,sgr 
,repeal & ,b5efici>y ,access ,improvem5t
 ,act ( #bjad & end+ on ! day be=e !    
date t is #ab mon?s aft] su* date (     
enactm5t1 ! manual m$ical review process
 describ$ 9 clause 7i7 %all apply )     
respect to exp5ses incurr$ 9 a ye> =    
s]vices describ$ 9 p>agraphs 7#a7 & 7#c7
 t exce$ ! ?re%old describ$ 9 clause    
7ii7 = ! ye>4  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;e77#b71 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] ! date t 
is #ab mon?s aft] ! date ( enactm5t ( ! 
,responsible ,m$ic>e ,,sgr ,repeal &    
,b5efici>y ,access ,improvem5t ,act (   
#bjad1 focus+ on s]vices id5tifi$ "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 ab]rant 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 less        
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 o!r factors4  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 pot5tial 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 ! foll[+ %all
 apply3 7,a7 ,prior au?orization        
det]m9ation ,! ,secret>y %all make a    
det]m9ation1 prior to ! s]vice be+      
furni%$1 ( :e!r ! s]vice w\ld or w\ld n 
meet ! applicable requirem5ts ( section 
#ahfb7;a77#a77;,a74  7,b7 ,d5ial (      
paym5t ,subject to p>agraph 7#f71 no    
paym5t %all be made "u ?is "p = ! s]vice
 unless ! ,secret>y det]m9es pursuant to
 subp>agraph 7,a7 t ! s]vice w\ld meet !
 applicable requirem5ts ( su* section4  
7#e7 ,submission ( in=mation ,a !rapy   
provid] may submit ! in=mation necess>y 
= m$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 ,if ! ,secret>y does n make a
 prior au?orization det]m9ation "u      
p>agraph 7#d77;,a7 )9 #aj bus9ess days (
 ! date ( ! ,secret>y's receipt ( m$ical
 docum5tation ne$$ to make su*          
det]m9ation1 p>agraph 7#d77;,b7 %all n  
apply4  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$ical review "u ?is subsection4  7,c7  
,limitation ,!re %all be no adm9i/rative
 or judicial review "u section #ahfi1   
section #ahgh1 or o!rwise ( !           
id5tification ( s]vices = m$ical review 
or ! process = 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#a74
 ,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 #bd 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+  
,april #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$1 9 ! fir/ 
s5t5ce1 by /rik+ ,april #a1 #bjad &     
ins]t+ ,janu>y #a1 #bjai4  7b7 ,requir+ 
ambulance provid]s ,to submit co/ & o!r 
in=mation ,section #ahcd7l7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4 #aciem7l77
 is am5d$ 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 ,july #a1 #bjae1 ! ,secret>y   
%all-- 7,i7 specify ! data collection   
sy/em "u subp>agraph 7,a7 & ! "t p]iod  
dur+ :i* su* data is requir$ to be      
submitt$2 &  7,,ii7 id5tify ! provid]s &
 suppli]s ( ambulance s]vices :o w\ld be
 requir$ 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* p]iod = :i*      
report+ ( data is requir$4  7,c7 ,p5alty
 = failure to report co/ & o!r in=mation
 ,beg9n+ on ,july #a1 #bjaf1 a #e p]c5t 
r$uction to paym5ts "u ?is "p %all be   
made = a #a-ye> prospective p]iod       
specifi$ by ! ,secret>y 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=mation dur+ ! p]iod       
specifi$ "u subp>agraph 7,b77i77,i74    
7,d7 ,ongo+ data collection  7i7        
,revision ( data collection sy/em ,!    
,secret>y may1 z det]m9$ appropriate1   
p]iodically revise ! data collection    
sy/em4  7ii7 ,subsequ5t data collection 
,9 ord] to cont9ue to evaluate !        
appropriat5ess ( paym5t rates "u ?is    
subsection1 ! ,secret>y %all1 = ye>s    
aft] #bjaf 7b n less (t5 ?an once e #c  
ye>s71 require provid]s & suppli]s (    
ambulance s]vices to submit in=mation = 
a p]iod ! ,secret>y det]m9es            
appropriate4 ,! p5alty describ$ 9       
subp>agraph 7,c7 %all apply to su*      
subsequ5t data collection p]iods4  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 ,april #a1  
#bjad12 &  7,b7 9 clause 7ii77,,ii71 by 
/rik+ & be=e ,april #a1 #bjad14  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
 ,april #a1 #bjad12 &  7ii7 9 clause    
7iv71 by /rik+ ?r\gh fiscal ye> #bjac & 
! portion ( fiscal ye> #bjad be=e ,april
 #a1 #bjad & 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 ! fir/ #b qu>t]s ( fiscal   
ye> #bjad & 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 = purposes ( fiscal ye>
 #bjad1 ! ,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 ! portion ( fiscal   
ye> #bjad beg9n+ on ,april #a1 #bjad1   
fiscal ye> #bjae1 & subsequ5t ye>s2     
7#b7 9 subp>agraph 7,c77i7-- 7,a7 by    
/rik+ fiscal ye>s #bjaa1 #bjab1 & #bjac1
 & ! portion ( fiscal ye> #bjad be=e &  
ins]t+ fiscal ye> #bjaa & subsequ5t     
fiscal ye>s1 ea* place x appe>s2 &  7,b7
 by /rik+ or portion ( fiscal ye> aft]  
dur+ ! fiscal ye>2 &  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 & #bjac1 & ! portion ( fiscal ye>
 #bjad be=e ,april #a1 #bjad & ins]t+   
fiscal ye> #bjaa or a subsequ5t fiscal  
ye>2 &  7,c7 by /rik+ or ! portion (    
fiscal ye> aft] 9 ! fiscal ye>4  7b7    

,implem5tation ,not)/&+ any o!r         
provision ( law1 = purposes ( fiscal ye>
 #bjad1 ! ,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 #bjaf2 &  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$ grievances &
 appeals process  7i7  ,9 g5]al  ,n lat]
 ?an ,april #a1 #bjae1 ! ,secret>y %all 
e/abli% proc$ures unify+ ! grievances & 
appeals proc$ures "u sections #aheb7;f71
 #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  
,! 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 grievances
 & 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 
grievances & appeals processes1 su* z an
 individual's fil+ ( a grievance or     
appeal1 a plan's ackn[l$gm5t &          
resolution ( a grievance or appeal1 &   
notification ( decisions ) respect to a 
grievance or appeal4  7,,iv7 ,guidel9es 
to all[ ! plan to process1 track1 &     
resolve grievances & appeals1 to ensure 
b5efici>ies are notifi$ on a timely     

basis ( decisions t are made ?r\gh\t !  
grievance or appeals process & are able 
to easily det]m9e ! /atus ( a grievance 
or appeal4  7,c7  ,requirem5t = unifi$  
grievances & 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$icaid     
ag5cy "u ?is subsection %all require !  
use ( unifi$ grievances & 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$ grievances & 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;,b77iii7 t h a sub/antial      
portion ( enrollees :o are dually       
eligible = b5efits "u ?is title & title 
,,xix & are at risk = full b5efits "u   
title ,,xix4  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   
paym5t to ! plan "u ?is "p 9 an am\nt at
 lea/ equal to ! portion ( ! mon?ly     

rebate comput$ "u section               
#ahed7;b77#a77;,c77i7 = ! plan & ye> t  
w\ld o!rwise be kept by ! plan aft]     
application ( ! b5efici>y rebate rule "u
 section #ahed7;b77#a77;,c74  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 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 ! plan n less     
frequ5tly ?an on an annual basis4  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 & det]m9ation (    
feasability ( quality measurem5t at !   
plan level ,section #ahec7o7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#aciew-#bc7o77 is am5d$ by add+ at ! end

 ! foll[+ new p>agraphs3  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$s individuals1 ! 
,secret>y %all increase ! emphasis on ! 
plan's improvem5t or decl9e 9 p]=mance  
:5 det]m9+ ! /> rat+ ( ! plan "u ?is    
subsection = ! ye> z foll[s3 7i7 7,i7 ,=
 plan ye> #bjaf1 at lea/ #aj p]c5t1 b n 
m ?an #ab p]c5t1 ( ! total /> rat+ ( !  
plan %all be bas$ on improvem5t or      
decl9e 9 p]=mance4  7,,ii7 ,= plan ye>  
#bjag & subsequ5t plan ye>s1 at lea/ #ab
 p]c5t1 b n m ?an #ae 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 #d4e-/> 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$s
 individuals t has a rat+ t is less ?an 
two-&-"o-half />s4  7,c7 ,quality       
,measurem5t at ! ,plan ,level  7i7 ,9   
g5]al ,! ,secret>y may require report+ =
 & apply "u ?is subsection quality      
measures at ! plan level = specializ$   
,,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 /ati/ically significant or 
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  7#g7 ,det]m9ation (       
feasibility ( quality measurem5t at !   
plan level  7,a7 ,det]m9ation (         
feasibility ,! ,secret>y %all det]m9e ! 
feasibility ( requir+ report+ = & apply+
 "u ?is subsection quality measures at !
 plan level = all ,,ma plans "u ?is "p4 
7,b7 ,consid]ation ( *ange ,aft] mak+ a 
det]m9ation "u subp>agraph 7,a71 !      
,secret>y %all consid] requir+ su*      
report+ & apply+ su* quality measures at
 ! plan level z describ$ 9 su*          

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  
7ii71 ! foll[+ %all apply3 7,i7 ,not)/&+
 su* clause1 su* contract may be ext5d$ 
or r5ew$ = ! two ye>s subsequ5t to !    
previ\s ye> describ$ 9 clause 7ii74 ,!  
second ( ! two ye>s describ$ 9 ! prec$+ 
s5t5ce ) respect to a contract is ref]r$
 to 9 ?is subsection z ! la/ reasonable 
co/ reimbursem5t contract ye> = !       
contract4  7,,ii7 ,! organization may n 
enroll any new enrollees "u su* contract
 dur+ ! la/ reasonable co/ reimbursem5t 

contract ye> = ! contract4  7,,iii7 ,n  
lat] ?an a date det]m9$ appropriate by !
 ,secret>y prior to ! beg9n+ ( ! la/    
reasonable co/ reimbursem5t contract ye>
 = ! contract1 ! 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$ic>e 
,advantage plan "u "p ,c = ! ye> foll[+ 
! la/ reasonable co/ reimbursem5t       
contract ye> = ! contract4  7,,iv7 ,if !
 organization provides ! notice describ$
 9 subclause 7,,iii7 t ! contract w be  
conv]t$1 ! organization %all1 n lat] ?an
 a date det]m9$ appropriate by !        
,secret>y1 provide ! ,secret>y ) su*    
in=mation z ! ,secret>y det]m9es        
appropriate 9 ord] to c>ry out sections 
#ahea7;c77#d7 & #ahed7;a77#e71 includ+  
subp>agraph 7,c7 ( su* section4  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$1 

! foll[+ provisions %all apply3 7,i7 ,! 
deem$ enrollm5t "u section              
#ahea7;c77#d74  7,,ii7 ,! special rule =
 quality increases "u                   
#ahec7o77#c77;,a77iv74  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 
#bjag1 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$ = ! la/      
reasonable co/ reimbursem5t contract ye>
 ( ! contract 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* entity t has a common   
own]%ip int]e/ ( control7 t ent]$ into  
su* contract2 &  7,,iii7 is (f]$ 9 !    
s]vice area :]e ! individual resides2   
7v7 ! applicable ,,ma plan provides     
b5efits1 premiums1 & access to 9-network
 & out-(-network provid]s t are         
comp>able to ! b5efits1 premiums1 &     

access to 9-network & out-(-network     
provid]s "u su* reasonable co/          
reimbursem5t contract = ! previ\s plan  
ye>2 &  7vi7 ! 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 & notification (  
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 

#bjag1 ! ,secret>y %all id5tify & notify
 ! 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 %all
 require ! conv]t+ co/ plan to mail1 n  
lat] ?an #ae days prior to ! fir/ day ( 
! annual1 coord9at$ election p]iod "u   
subsection 7e77#c7 ( a ye>1 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;,f72 &  7,v7 o!r    
in=mation ! ,secret>y may specify  4    
7d7 ,treatm5t ( transition plan =       
quality rat+ = paym5t purposes ,section 
#ahec7o77#d7 ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #aciew-#bc7o77#d77 is    
am5d$ by add+ at ! end ! foll[+ new     
subp>agraph3  7,c7 ,special rule = fir/ 
#c plan ye>s = plans t 7 conv]t$ f a    
reasonable co/ reimbursem5t contract ,= 
purposes ( apply+ p>agraph 7#a7 &       

section #ahed7;b77#a77;,c7 = ! fir/ #c  
plan ye>s "u ?is "p 9 ! case ( an ,,ma  
plan to :i* deem$ enrollm5t applies "u  
section #ahea7;c77#d7-- 7i7 su* plan    
%all n be treat$ z a new plan 7z def9$ 9
 p>agraph 7#c77;,a77iii77,,ii772 &  7ii7
 9 det]m9+ ! /> rat+ ( ! plan "u        
subp>agraph 7,a71 to ! ext5t t ,m$ic>e  
,advantage data = su* plan is n         
available = a measure us$ to det]m9e su*
 /> rat+1 ! ,secret>y %all use data f ! 
p]iod 9 :i* su* plan 0 a reasonable co/ 
reimbursem5t contract4  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 on1 
or z soon z practicable aft]1 ,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 ,june #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,a71 ! 
,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 subp>agraph 7,a77i7-- 7aa7 9     
subclause 7,i71 by ins]t+ ) a contract  
"u section #ahij aft] entity2 &  7bb7 9 
subclause 7,,ii71 by /rik+ su* entity & 
ins]t+ ! entity ) a contract "u section 
#ahij2  7,,ii7 9 ! head+ ( subp>agraph  
7,b7 by ins]t+ & effici5cy aft]         
,quality2  7,,iii7 9 subp>agraph        
7,b77i77,,iii71 by /rik+ ?is ,act &     

ins]t+ ?is title2 &  7,,iv7 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;,b7a77#d771 ! entity %all 
transmit to ! ,secret>y ! input ( !     
multi-/akehold] gr\ps "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 title &      
titles ,,xix & ,,xxi ) 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,a71 ! ,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> 7or z soon z practicable aft]   
su* dates = ! fir/ ye> ( ! contract71 ! 
,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 7or z soon z practicable    
aft] su* date = ! fir/ ye> ( ! contract7
 ) respect to quality & effici5cy       
measures made available "u p>agraph 7#b7
 by ,octob] #a ( ! prec$+ ye>2 &  7ii7  
,april #a 7or z soon z practicable aft] 
su* dates = ! fir/ ye> ( ! contract7 )  
respect to quality & effici5cy measures 
made available "u p>agraph 7#b7 by      
,decemb] #ca ( ! prec$+ 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 )     
respect to ! input provid$ "u section   
#ahij;,a7b77#b77;,a7 = ^? new measures  
adopt$ = 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

 endorsem5t1 input1 & 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 ,! ,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+ on1 or z soon z practicable
 aft]1 ,octob] #a1 #bjad4  #bji4        
,p]man5t ext5sion ( fund+ outrea* &     
assi/ance = l[-income programs  7a7     
,additional fund+ = ,/ate heal?         

insurance programs  ,subsection         
7a77#a77;,b77iv7 ( 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-adh71 section #faj ( ! ,am]ican    
,taxpay] ,relief ,act ( #bjab 7,public  
,law #aab-bdj71 & section #aaaj ( !     
,pa?way = ,,sgr ,re=m ,act ( #bjac      
7,public ,law #aac-fg71 is am5d$ to read
 z foll[s3  7iv7 = fiscal ye> #bjad & = 
ea* subsequ5t fiscal ye>1 #g1ejj1jjj4  4
  7b7  ,additional fund+ = area ag5cies 
on ag+  ,subsection 7b77#a77;,b77iv7 (  
su* section #aai1 z s am5d$1 is am5d$ to
 read z foll[s3  7iv7 = fiscal ye> #bjad
 & = ea* subsequ5t fiscal ye>1          
#g1ejj1jjj4  4  7c7  ,additional fund+ =
 ag+ & disability res\rce c5t]s         
,subsection 7c77#a77;,b77iv7 ( su*      
section #aai1 z s am5d$1 is am5d$ to    
read z foll[s3  7iv7 = fiscal ye> #bjad 
& = ea* subsequ5t fiscal ye>1           

#e1jjj1jjj4  4  7d7 ,additional fund+ = 
contract ) ! national c5t] = b5efits &  
outrea* enrollm5t ,subsection           
7d77#b77;iv7 ( su* section #aai1 z s    
am5d$1 is am5d$ to read z foll[s3  7iv7 
= fiscal ye> #bjad & = ea* subsequ5t    
fiscal ye>1 #e1jjj1jjj4  4  ,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+ ,m>* #bajd & 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 ,april  
#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+ ,m>* #ca1 #bjad &    
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$74  4  7f7 ,effective date ,!     
am5dm5ts made by ?is section %all take  
effect on ,april #a1 #bjad4  #bac4      
,express lane eligibility ,section      
#aijb7;e77#ac77;,i7 ( ! ,social         
,security ,act 7#db ,u4,s4,c4           
#acif;a7e77#ac77;,i77 is am5d$ 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$-- 7#a7 9 p>agraph    
7#a77;,a71 by /rik+ clause 7iv7 & ins]t+
 ! foll[+3  7iv7 #f1jjj1jjj = ea* (     
fiscal ye>s #bjad ?r\gh #bjah4  2 &     
7#b7 by /rik+ p>agraph 7#e74  7b7       
,prev5tion ( duplicate appropriations = 
fiscal ye> #bjad ,exp5ditures made =    
fiscal ye> #bjad pursuant to section    
#eja7;c77iv7 ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #gja7;c77iv771 z am5d$ by
 section #abjc ( division ,b ( !        
,bip>tisan ,budget ,act ( #bjac 7,public
 ,law #aac-fg71 %all be *>g$ to !       
appropriation = t fiscal ye> provid$ by 
! am5dm5ts made by ?is section4  #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  ,,iii ,m$ic>e & ,m$icaid  
program integrity  #cja4 ,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$4
  7#h7 ,def9itions ,9 ?is section3 7,a7 
,demon/ration project ,! t]m            
demon/ration project means !            
demon/ration project "u ?is subsection4 
7,b7 ,provid] ( s]vices ,! t]m provid] (
 s]vices has ! mean+ giv5 t t]m 9       
section #ahfa7u74  7,c7 ,recov]y audit  
contractor ,! t]m recov]y audit         
contractor means an entity ) a contract 
"u section #ahic7;h7 ( ! ,social        
,security ,act 7#db ,u4,s4,c4           
#acie;ddd7h774  7,d7 ,secret>y ,! t]m   
,secret>y means ! ,secret>y ( ,heal? &  
,human ,s]vices4  7,e7 ,suppli] ,! t]m  
suppli] has ! mean+ giv5 t t]m 9 section
 #ahfa7;d74  #cjb4 ,au?ority = ,m$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  #cjc4 ,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$it+ (  
collections1 ! ,inspector ,g5]al ( !    
,dep>tm5t ( ,heal? & ,human ,s]vices may
 receive & reta9 = curr5t use ?ree p]c5t
 ( all am\nts collect$ pursuant to civil
 debt collection & adm9i/rative en=cem5t
 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$ z (fsett+

 collections 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 judgm5ts  
ent]$1 or f9al ag5cy decisions issu$1 on
 or aft] ! date ( ! enactm5t ( ?is ,act4
  #cjd4 ,prev5t+ & r$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 #cja1 
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 en=c+ m&atory 
& p]missive exclusions "u title ,,xi2 or
  7,,ii7 evaluat+ ! integrity ( !       
,m$ic>e program or an applicable ,/ate  
heal? subsidy program 7z def9$ 9 section
 #adac7;e7 ( ! ,pati5t ,protection &    
,af=dable ,c>e ,act74  ,! au?ority "u   
?is clause is 9 addition to any au?ority
 conf]r$ "u ! ,inspector ,g5]al ,act (  

#aigh 7#e ,u4,s4,c4 ,app74  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$ical assi/ance "u a     
,/ate plan "u title ,,xix ( su* ,act    
7#db ,u4,s4,c4 #acif et seq47 or "u a   
waiv] ( su* plan4  ,,iv ,o!r ,provisions
  #dja4 ,commission on ,improv+ ,pati5t 
,direct$ ,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]y & sp5d+1 & 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 & increas+ provid]  
engagem5t 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 sp5d+1 & ! 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$]al ,gov]nm5t4  7j7      
,detail ,n m ?an #d ,f$]al ,gov]nm5t    
employees employ$ by ! ,dep>tm5t (      
,labor1 #d ,f$]al ,gov]nm5t employees   
employ$ by ! ,social ,security          
,adm9i/ration1 & #h ,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 #c 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 
,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 #a1jjj1jjj = ! fiscal ye> 9 :i*
 ! report is requir$ to be submitt$4  4 
#djb4 ,expansion ( ! def9ition (        

inpati5t hospital s]vices = c]ta9 canc] 
hospitals ,section #ahfa7;b7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#aciex7b77 is am5d$-- 7#a7 9 p>agraph   
7#c7-- 7,a7 by ins]t+ 7,a7 aft] 7#c72   
7,b7 by add+ & aft] ! semicolon at !    
end2 &  7,c7 by add+ at ! end ! foll[+  
new subp>agraph3  7,b7 subject to ! ?ird
 s5t5ce ( ?is subsection1 ) respect to a
 hospital t-- 7i7 is describ$ 9 section 
#ahhf7;d77#a77;,b77v72 &  7ii7 z ( !    
date ( ! enactm5t ( ! ,responsible      
,m$ic>e ,,sgr ,repeal & ,b5efici>y      
,access ,improvem5t ,act ( #bjad1 is    
locat$ 9 ! same build+1 or on ! same    
campus1 z ano!r hospital 7z describ$ 9  
sections #dab4bb7;e7 & #dab4bb7;f7 (    
title #db1 ,code ( ,f$]al ,regulations1 
z 9 effect on su* date ( enactm5t 72    
items & s]vices describ$ 9 p>agraphs    
7#a7 & 7#b7 furni%$ on or aft] ,octob]  
#a1 #bjad1 by su* hospital describ$ 9   
section #ahhf7;d77#a77;,b77v7 or by o!rs
 "u arrangem5ts ) !m made by ! hospital2
  2 &  7#b7 by add+ at ! end ! foll[+   

new flu% s5t5ce3 ,p>agraph 7#c77;,b7    
%all only apply to paym5ts ) respect to 
! total numb] ( ! hospital's pati5t days
 at any satellite ( ! hospital or su*   
days at ano!r hospital provid+ s]vices  
"u arrangem5ts to ! hospital1 det]m9$ z 
( ! date ( ! enactm5t ( ! ,responsible  
,m$ic>e ,,sgr ,repeal & ,b5efici>y      
,access ,improvem5t ,act ( #bjad4 4     
#djc4  ,quality measures = c]ta9        
po/-acute c>e provid]s relat+ to notice 
& transf] ( pati5t heal? in=mation &    
pati5t c>e pref]5ces  7a7  ,developm5t  
,! ,secret>y ( ,heal? & ,human ,s]vices 
79 ?is section ref]r$ 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;aaa7a774  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    
#djd4  ,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$ic>e program "u title ,,xviii ( !    
,social ,security ,act ( an inpati5t    
hospital admission t--  7#a7 is m$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  #dje4     
,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$ure t 0 n propos$
 b 0 reque/$ to be includ$ on su* li/s  
dur+ ! public comm5t :]e ! ,secret>y    
does n f9alize 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* reque/$  

proc$ure on su* li/s44  #djf4           
,sup]vision 9 critical access hospitals 
7a7 ,g5]al sup]vision 9 critical access 
hospitals ,section #ahcd7;g7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#aciem7g77 is am5d$ 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 !    
m9imum level ( sup]vision ) respect to  
outpati5t !rapeutic 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 ( ,responsible ,m$ic>e  
,,sgr ,repeal & ,b5efici>y ,access      
,improvem5t ,act ( #bjad7 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  #djg4  ,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*
 bid = a product category4  4  #djh4    
,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] ,octob] #a1 #bjae4  #dji4  ,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  #daj4                 
,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  #daa4  ,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  #dab4 
,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 #bjai1 su* sums z may be    
necess>y to c>ry out ?is section4  #dac4
  ,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  #dad4  ,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  #dae4      
,demon/ration programs to improve       
community m5tal heal? s]vices  7a7      
,crit]ia = c]tifi$ community behavioral 
heal? cl9ics to p>ticipate 9            
demon/ration programs  7#a7 ,publication

 ,n lat] ?an ,septemb] #a1 #bjae1 !     
,secret>y %all publi% crit]ia = a cl9ic 
to be c]tifi$ by a ,/ate z a c]tifi$    
community behavioral heal? cl9ic =      
purposes ( p>ticipat+ 9 a demon/ration  
program conduct$ "u subsection 7d74     
7#b7 ,requirem5ts ,! crit]ia publi%$ "u 
?is subsection %all include crit]ia )   
respect to ! foll[+3 7,a7 ,/aff+ ,/aff+ 
requirem5ts1 includ+ crit]ia t /aff h   
div]se discipl9>y backgr\nds1 h necess>y
 ,/ate-requir$ lic5se & accr$itation1 & 
are culturally & l+ui/ically tra9$ to   
s]ve ! ne$s ( ! cl9ic's pati5t          
population4  7,b7 ,availability &       
accessibility ( s]vices ,availability & 
accessibility ( s]vices1 includ+ crisis 
managem5t s]vices t are available &     
accessible #bd h\rs a day1 ! use ( a    
slid+ scale = paym5t1 & no rejection =  
s]vices or limit+ ( s]vices on ! basis (
 a pati5t's ability to pay or a place ( 
resid5ce4  7,c7 ,c>e coord9ation ,c>e   
coord9ation1 includ+ requirem5ts to     
coord9ate c>e across sett+s & provid]s  

to ensure seamless transitions = pati5ts
 across ! full spectrum ( heal? s]vices 
includ+ acute1 *ronic1 & behavioral     
heal? ne$s4 ,c>e coord9ation requirem5ts
 %all include p>tn]%ips or =mal         
contracts ) ! foll[+3 7i7               
,f$]ally-qualifi$ heal? c5t]s 7& z      
applicable1 rural heal? cl9ics7 to      
provide ,f$]ally-qualifi$ heal? c5t]    
s]vices 7& z applicable1 rural heal?    
cl9ic s]vices7 to ! ext5t su* s]vices   
are n provid$ directly ?r\gh ! c]tifi$  
community behavioral heal? cl9ic4  7ii7 
,inpati5t psy*iatric facilities &       
sub/ance use detoxification1            
po/-detoxification /ep-d[n s]vices1 &   
resid5tial programs4  7iii7 ,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    
,/ate lic5s$ & nationally accr$it$ *ild 
plac+ ag5cies = !rapeutic fo/] c>e      
s]vice1 & o!r social & human s]vices4   

7iv7 ,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  7v7    
,inpati5t acute c>e hospitals & hospital
 outpati5t cl9ics4  7,d7 ,scope (       
s]vices ,provision 79 a mann] reflect+  
p]son-c5t]$ c>e7 ( ! foll[+ s]vices :i*1
 if n available directly ?r\gh ! c]tifi$
 community behavioral heal? cl9ic1 are  
provid$ or ref]r$ ?r\gh =mal            
relation%ips ) o!r provid]s3 7i7 ,crisis
 m5tal heal? s]vices1 includ+ #bd-;h\r  
mobile crisis teams1 em]g5cy crisis     
int]v5tion s]vices1 & crisis            
/abilization4  7ii7 ,scre5+1 assessm5t1 
& diagnosis1 includ+ risk assessm5t4    
7iii7 ,pati5t-c5t]$ treatm5t plann+ or  
simil> processes1 includ+ risk assessm5t
 & crisis plann+4  7iv7 ,outpati5t m5tal
 heal? & sub/ance use s]vices4  7v7     
,outpati5t cl9ic prim>y c>e scre5+ &    
monitor+ ( key heal? indicators & heal? 
risk4  7vi7 ,t>get$ case managem5t4     

7vii7 ,psy*iatric rehabilitation        
s]vices4  7viii7 ,pe] support & c\nselor
 s]vices & family supports4  7ix7       
,int5sive1 community-bas$ m5tal heal?   
c>e = memb]s ( ! arm$ =ces & vet]ans1   
p>ticul>ly ^? memb]s & vet]ans locat$ 9 
rural areas1 provid$ ! c>e is 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,e7 ,quality & o!r report+ ,report+ (  
enc\nt] data1 cl9ical outcomes data1    
quality data1 & su* o!r data z !        
,secret>y requires4  7,f7               
,organizational au?ority ,crit]ia t a   
cl9ic be a non-pr(it or "p ( a local    
gov]nm5t behavioral heal? au?ority or   
op]at$ "u ! au?ority ( ! ,indian ,heal? 
,s]vice1 an ,indian tribe or tribal     
organization pursuant to a contract1    
grant1 coop]ative agreem5t1 or compact )
 ! ,indian ,heal? ,s]vice pursuant to ! 
,indian ,self-,det]m9ation ,act 7#be    

,u4,s4,c4 #dej et seq471 or an urban    
,indian organization pursuant to a grant
 or contract ) ! ,indian ,heal? ,s]vice 
"u title ,v ( ! ,indian ,heal? ,c>e     
,improvem5t ,act 7#be ,u4,s4,c4 #afja et
 seq474  7b7 ,guidance on developm5t (  
prospective paym5t sy/em = te/+ "u      
demon/ration programs  7#a7 ,9 g5]al ,n 
lat] ?an ,septemb] #a1 #bjae1 !         
,secret>y1 ?r\gh ! ,adm9i/rator ( !     
,c5t]s = ,m$ic>e  ,m$icaid ,s]vices1    
%all issue guidance = ! e/abli%m5t ( a  
prospective paym5t sy/em t %all only    
apply to m$ical assi/ance = m5tal heal? 
s]vices furni%$ by a c]tifi$ community  
behavioral heal? cl9ic p>ticipat+ 9 a   
demon/ration program "u subsection 7d74 
7#b7 ,requirem5ts ,! guidance issu$ by !
 ,secret>y "u p>agraph 7#a7 %all provide
 t-- 7,a7 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 &  7,b7 no paym5t %all be    
made to satellite facilities ( c]tifi$  

community behavioral heal? cl9ics if su*
 facilities are e/abli%$ aft] ! date (  
enactm5t ( ?is ,act4  7c7 ,plann+ grants
  7#a7 ,9 g5]al ,n lat] ?an ,janu>y #a1 
#bjaf1 ! ,secret>y %all aw>d plann+     
grants to ,/ates = ! purpose ( develop+ 
proposals to p>ticipate 9 "t-limit$     
demon/ration programs describ$ 9        
subsection 7d74  7#b7 ,use ( funds ,a   
,/ate aw>d$ a plann+ grant "u ?is       
subsection %all-- 7,a7 solicit input )  
respect to ! developm5t ( su* a         
demon/ration program f pati5ts1         
provid]s1 & o!r /akehold]s2  7,b7 c]tify
 cl9ics z c]tifi$ community behavioral  
heal? cl9ics = purposes ( p>ticipat+ 9 a
 demon/ration program conduct$ "u       
subsection 7d72 &  7,c7 e/abli% a       
prospective paym5t sy/em = m5tal heal?  
s]vices furni%$ by a c]tifi$ community  
behavioral heal? cl9ic p>ticipat+ 9 a   
demon/ration program "u subsection 7d7 9
 accordance ) ! guidance issu$ "u       
subsection 7b74  7d7 ,demon/ration      
programs  7#a7 ,9 g5]al ,n lat] ?an     

,septemb] #a1 #bjag1 ! ,secret>y %all   
select ,/ates to p>ticipate 9           
demon/ration programs t are develop$    
?r\gh plann+ grants aw>d$ "u subsection 
7c71 meet ! requirem5ts ( ?is           
subsection1 & repres5t a div]se         
selection ( geographic areas1 includ+   
rural & und]s]v$ areas4  7#b7           
,application requirem5ts  7,a7 ,9 g5]al 
,! ,secret>y %all solicit applications  
to p>ticipate 9 demon/ration programs "u
 ?is subsection solely f ,/ates aw>d$   
plann+ grants "u subsection 7c74  7,b7  
,requir$ in=mation ,an application = a  
demon/ration program "u ?is subsection  
%all include ! foll[+3 7i7 ,! t>get     
,m$icaid population to be s]v$ "u !     
demon/ration program4  7ii7 ,a li/ (    
p>ticipat+ c]tifi$ community behavioral 
heal? cl9ics4  7iii7 ,v]ification t !   
,/ate has c]tifi$ a p>ticipat+ cl9ic z a
 c]tifi$ community behavioral heal?     
cl9ic 9 accordance ) ! requirem5ts (    
subsection 7b74  7iv7 ,a description ( !
 scope ( ! m5tal heal? s]vices available

 "u ! ,/ate ,m$icaid program t w be paid
 = "u ! prospective paym5t sy/em te/$ 9 
! demon/ration program4  7v7            
,v]ification t ! ,/ate has agre$ to pay 
= su* s]vices at ! rate e/abli%$ "u !   
prospective paym5t sy/em4  7vi7 ,su* o!r
 in=mation z ! ,secret>y may require    
relat+ to ! demon/ration program includ+
 ) respect to det]m9+ ! s\ndness ( !    
propos$ prospective paym5t sy/em4  7#c7 
,numb] & l5g? ( demon/ration programs ,n
 m ?an #h ,/ates %all be select$ =      
#d-ye> demon/ration programs "u ?is     
subsection4  7#d7 ,requirem5ts = select+
 demon/ration programs  7,a7 ,9 g5]al ,!
 ,secret>y %all give pref]5ce to select+
 demon/ration programs :]e p>ticipat+   
c]tifi$ community behavioral heal?      
cl9ics-- 7i7 provide ! mo/ complete     
scope ( s]vices describ$ 9 subsection   
7a77#b77;,d7 to individuals eligible =  
m$ical assi/ance "u ! ,/ate ,m$icaid    
program2  7ii7 w improve availability (1
 access to1 & p>ticipation 91 s]vices   
describ$ 9 subsection 7a77#b77;,d7 to   

individuals eligible = m$ical assi/ance 
"u ! ,/ate ,m$icaid program2  7iii7 w   
improve availability (1 access to1 &    
p>ticipation 9 assi/$ outpati5t m5tal   
heal? treatm5t 9 ! ,/ate2 or  7iv7      
demon/rate ! pot5tial to exp& available 
m5tal heal? s]vices 9 a demon/ration    
area & increase ! quality ( su* s]vices 
)\t increas+ net ,f$]al sp5d+4  7#e7    
,paym5t = m$ical assi/ance = m5tal heal?
 s]vices provid$ by c]tifi$ community   
behavioral heal? cl9ics  7,a7 ,9 g5]al  
,! ,secret>y %all pay a ,/ate p>ticipat+
 9 a demon/ration program "u ?is        
subsection ! ,f$]al mat*+ p]c5tage      
specifi$ 9 subp>agraph 7,b7 = am\nts    
exp5d$ by ! ,/ate to provide m$ical     
assi/ance = m5tal heal? s]vices describ$
 9 ! demon/ration program application 9 
accordance ) p>agraph 7#b77;,b77iv7 t   
are provid$ by c]tifi$ community        
behavioral heal? cl9ics to individuals  
:o are enroll$ 9 ! ,/ate ,m$icaid       
program4 ,paym5ts to ,/ates made "u ?is 
p>agraph %all be consid]$ to h be5 "u1 &

 are subject to ! requirem5ts (1 section
 #aijc ( ! ,social ,security ,act 7#db  
,u4,s4,c4 #acif;b74  7,b7 ,f$]al mat*+  
p]c5tage ,! ,f$]al mat*+ p]c5tage       
specifi$ 9 ?is subp>agraph is ) respect 
to m$ical assi/ance describ$ 9          
subp>agraph 7,a7 t is furni%$-- 7i7 to a
 newly eligible individual describ$ 9   
p>agraph 7#b7 ( section #aije7y7 ( !    
,social ,security ,act 7#db ,u4,s4,c4   
#acif;d7y771 ! mat*+ rate applicable "u 
p>agraph 7#a7 ( t section2 &  7ii7 to an
 individual :o is n a newly eligible    
individual 7z s describ$7 b :o is       
eligible = m$ical assi/ance "u ! ,/ate  
,m$icaid program1 ! enhanc$ ,,fmap      
applicable to ! ,/ate4  7,c7            
,limitations  7i7 ,9 g5]al ,paym5ts %all
 be made "u ?is p>agraph to a ,/ate only
 = m5tal heal? s]vices-- 7,i7 t are     
describ$ 9 ! demon/ration program       
application 9 accordance ) p>agraph     
7#b77;,b77iv72  7,,ii7 = :i* paym5t is  
available "u ! ,/ate ,m$icaid program2 &
  7,,iii7 t are provid$ to an individual

 :o is eligible = m$ical assi/ance "u ! 
,/ate ,m$icaid program4  7ii7 ,prohibit$
 paym5ts ,no paym5t %all be made "u ?is 
p>agraph-- 7,i7 = inpati5t c>e1         
resid5tial treatm5t1 room & bo>d        
exp5ses1 or any o!r non-ambulatory      
s]vices1 z det]m9$ by ! ,secret>y2 or   
7,,ii7 ) respect to paym5ts made to     
satellite facilities ( c]tifi$ community
 behavioral heal? cl9ics if su*         
facilities are e/abli%$ aft] ! date (   
enactm5t ( ?is ,act4  7#f7 ,waiv] (     
/atewid5ess requirem5t ,! ,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 programs 9 accordance ) !  
requirem5ts ( ?is subsection4  7#g7     
,annual reports  7,a7 ,9 g5]al ,n lat]  
?an #a ye> aft] ! date on :i* ! fir/    
,/ate is select$ = a demon/ration       
program "u ?is subsection1 & annually   
!reaft]1 ! ,secret>y %all submit to     
,congress an annual report on ! use (   

funds provid$ "u all demon/ration       
programs conduct$ "u ?is subsection4    
,ea* su* report %all include-- 7i7 an   
assessm5t ( access to community-bas$    
m5tal heal? s]vices "u ! ,m$icaid       
program 9 ! area or areas ( a ,/ate     
t>get$ by a demon/ration program comp>$ 
to o!r areas ( ! ,/ate2  7ii7 an        
assessm5t ( ! quality & scope ( s]vices 
provid$ by c]tifi$ community behavioral 
heal? cl9ics comp>$ to community-bas$   
m5tal heal? s]vices provid$ 9 ,/ates n  
p>ticipat+ 9 a demon/ration program "u  
?is subsection & 9 areas ( a            
demon/ration ,/ate t are n p>ticipat+ 9 
! demon/ration program2 &  7iii7 an     
assessm5t ( ! impact ( ! demon/ration   
programs on ! ,f$]al & ,/ate co/s ( a   
full range ( m5tal heal? s]vices        
7includ+ inpati5t1 em]g5cy & ambulatory 
s]vices74  7,b7 ,recomm5dations ,n lat] 
?an ,decemb] #ca1 #bjba1 ! ,secret>y    
%all submit to ,congress recomm5dations 
conc]n+ :e!r ! demon/ration programs "u 
?is section %\ld be cont9u$1 exp&$1     

modifi$1 or t]m9at$4  7e7 ,def9itions ,9
 ?is section3 7#a7 ,f$]ally-qualifi$    
heal? c5t] s]vices2 ,f$]ally-qualifi$   
heal? c5t]2 rural heal? cl9ic s]vices2  
rural heal? cl9ic ,! t]ms               
,f$]ally-qualifi$ heal? c5t] s]vices1   
,f$]ally-qualifi$ heal? c5t]1 rural     
heal? cl9ic s]vices1 & rural heal? cl9ic
 h ! mean+s giv5 ^? t]ms 9 section      
#aije7l7 ( ! ,social ,security ,act 7#db
 ,u4,s4,c4 #acif;d7l774  7#b7 ,enhanc$  
,,fmap ,! t]m enhanc$ ,,fmap has ! mean+
 giv5 t t]m 9 section #baje7;b7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#acig;dd7b7 b )\t reg>d to ! second &   
?ird s5t5ces ( t section4  7#c7         
,secret>y ,! t]m ,secret>y means !      
,secret>y ( ,heal? & ,human ,s]vices4   
7#d7 ,/ate ,! t]m ,/ate has ! mean+ giv5
 su* t]m = purposes ( title ,,xix ( !   
,social ,security ,act 7#db ,u4,s4,c4   
#acif et seq474  7f7 ,fund+  7#a7 ,9    
g5]al ,out ( any funds 9 ! ,treasury n  
o!rwise appropriat$1 !re is appropriat$ 
to ! ,secret>y-- 7,a7 = purposes ( c>ry+

 out subsections 7a71 7b71 & 7d77#g71   
#b1jjj1jjj = fiscal ye> #bjad2 &  7,b7 =
 purposes ( aw>d+ plann+ grants "u      
subsection 7c71 #be1jjj1jjj = fiscal ye>
 #bjaf4  7#b7 ,availability ,funds      
appropriat$ "u p>agraph 7#a7 %all rema9 
available until exp5d$4  #daf4  ,annual 
,m$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  #dag4   
,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  
,v ,re/or+ individual lib]ty  #eja4     
,re/or+ individual lib]ty ,sections     
#aeja & #aejb & subsections 7a71 7b71   
7c71 & 7d7 ( section #ajajf ( ! ,pati5t 
,protection & ,af=dable ,c>e ,act 7& !  
am5dm5ts made by su* sections &         
subsections7 are repeal$ & ! ,int]nal   
,rev5ue ,code ( #aihf %all be appli$ &  
adm9i/]$ z if su* provisions & am5dm5ts 
_h nev] be5 enact$4  ,m>* #ac1          
#bjad,read ! second "t & plac$ on !     
cal5d>