,i  #aad? ,,congress  #a/ ,session  ,h4 
,r4 #ajab  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,febru>y #ag1 #bjae   
,mr4 ,smi? ( ,wa%+ton 7= himself1 ,mr4  
,heck ( ,wa%+ton1 ,mr4 ,mc,dermott1 &   
,mr4 ,kilm]7 introduc$ ! foll[+ bill2   
:i* 0 ref]r$ to ! ,committee on ,ways & 
,means1 & 9 addition to ! ,committee on 
,en]gy & ,comm]ce1 = a p]iod to be      
subsequ5tly det]m9$ by ! ,speak]1 9 ea* 
case = consid]ation ( su* provisions z  
fall )9 ! jurisdiction ( ! committee    
conc]n$  ,a ,,bill  ,to am5d title      
,,xviii ( ! ,social ,security ,act to   
improve ! provision ( items & s]vices   
provid$ to ,m$ic>e b5efici>ies resid+ 9 
rural areas1 & = o!r purposes4  #a4     
,%ort ,title ,?is ,act may be cit$ z !  
,medi,fair ,act ( #bjae4  #b4 ,f9d+s    
,congress makes ! foll[+ f9d+s3  7#a7   
,regional inequities 9 ,m$ic>e          
reimbursem5t h creat$ b>ri]s to c>e =   
s5iors & ! disabl$4  7#b7 ,! regional   
inequities 9 ,m$ic>e reimbursem5t       
p5alize ,/ates t h co/-effective heal?  

c>e deliv]y sy/ems & rew>d ^? ,/ates )  
high utilization rates & t provide      
ineffici5t c>e4  7#c7 ,comp>atively1 9  
#bjjg1 ! av]age p] capita sp5d+ "u      
traditional ,m$ic>e 0 #h1fhb =          
b5efici>ies 9 ! ,unit$ ,/ates1 #g1cbj = 
b5efici>ies 9 ,seattle1 #aa1cjc = ^? 9  
,los ,angeles1 & #ag1bgd = ^? 9 ,miami4 
7#d7 ,ov] a lifetime1 regional          
inequities c mean z mu* z a #abe1jjj    
diff]5ce 9 ! co/ ( c>e provid$ p]       
b5efici>y4  7#e7 ,regional inequities h 
result$ 9 creat+ v diff]5t ,m$ic>e      
programs & am\nt ( c>e receiv$ = s5iors 
& ! disabl$ bas$ on :]e !y live4  7#f7  
,because ! ,m$ic>e ,advantage rate is   
bas$ on ! fee-=-s]vice reimbursem5t     
rate1 regional inequities h all[$ "s    
,m$ic>e b5efici>ies access to ,m$ic>e   
,advantage plans ) significantly m      
b5efits & r$uc$ co/ %>+4 ,b5efici>ies 9 
,/ates ) l[] ,m$ic>e ,advantage         
reimbursem5t rates h n b5efitt$ to !    
same degree z b5efici>ies 9 o!r p>ts ( !
 c\ntry4  7#g7 ,regional inequities 9   

,m$ic>e reimbursem5t h creat$ an unfair 
competitive advantage = hospitals & o!r 
heal? c>e provid]s 9 ,/ates t receive   
above av]age paym5ts4 ,high] paym5ts    
mean t ^? provid]s c pay high] sal>ies 9
 a tight1 competitive m>ket4  7#h7      
,regional inequities 9 ,m$ic>e          
reimbursem5t1 if left un*eck$1 w r$uce  
access to ,m$ic>e s]vices & impact      
heal?y outcomes = b5efici>ies4  #c4     
,improv+ fairness ( paym5ts to provid]s 
"u ! m$ic>e fee-=-s]vice program ,title 
,,xviii ( ! ,social ,security ,act 7#db 
,u4,s4,c4 #acie et seq47 is am5d$ by    
add+ at ! end ! foll[+ new section3     
#ahii;,c4 ,,improv+ ,,paym5t ,,equity   
,,"u ,,! ,,orig9al ,,m$ic>e             
,,fee-,,=-,,s]vice ,,program  7a7 ,9    
,g5]al ,not)/&+ any o!r provision ( law1
 ! ,secret>y %all e/abli% a sy/em = mak+
 adju/m5ts to ! am\nt ( paym5t made to  
entities & individuals = items & s]vices
 provid$ "u ! orig9al ,m$ic>e           
fee-=-s]vice program "u p>ts ,a & ,b4   
7b7 ,sy/em requirem5ts  7#a7 ,increase =

 /ates bel[ ! national av]age ,"u !     
sy/em e/abli%$ "u subsection 7a71 if a  
,/ate av]age p] b5efici>y am\nt = a ye> 
is less ?an ! national av]age p]        
b5efici>y am\nt = su* ye>1 !n !         
,secret>y 7beg9n+ 9 #bjag7 %all increase
 ! am\nt ( applicable paym5ts 9 su* a   
mann] z w result 7z e/imat$ by !        
,secret>y7 9 ! ,/ate av]age p] b5efici>y
 am\nt = ! subsequ5t ye> be+ equal to ! 
national av]age p] b5efici>y am\nt = su*
 subsequ5t ye>4  7#b7 ,r$uction = c]ta9 
/ates above ! national av]age to enhance
 quality c>e & ma9ta9 budget neutrality 
7,a7 ,9 g5]al ,! ,secret>y %all ensure t
 ! increase 9 paym5ts "u p>agraph 7#a7  
does n cause ! e/imat$ am\nt (          
exp5ditures "u ?is title = a ye> to     
increase or decrease f ! e/imat$ am\nt (
 exp5ditures "u ?is title t w\ld h be5  
made 9 su* ye> if ?is section _h n be5  
enact$ by r$uc+ ! am\nt ( applicable    
paym5ts 9 ea* ,/ate t ! ,secret>y       
det]m9es has--  7i7 a ,/ate av]age p]   
b5efici>y am\nt = a ye> t is great] ?an 

! national av]age p] b5efici>y am\nt =  
su* ye>2 &  7ii7 heal?y outcome         
measurem5ts or quality c>e measurem5ts t
 indicate t a r$uction 9 applicable     
paym5ts w\ld enc\rage m effici5t use (1 
& r$uce ov]use (1 items & s]vices = :i* 
paym5t is made "u ?is title4  7,b7      
,limitation ,! ,secret>y %all n r$uce   
applicable paym5ts "u subp>agraph 7,a7  
to a ,/ate t-- 7i7 has a ,/ate av]age p]
 b5efici>y am\nt = a ye> t is great] ?an
 ! national av]age p] b5efici>y am\nt = 
su* ye>2 &  7ii7 has heal?y outcome     
measurem5ts or quality c>e measurem5ts t
 indicate t ! applicable paym5ts are be+
 us$ to improve ! access ( b5efici>ies  
to quality c>e4  7#c7 ,det]m9ation (    
av]ages  7,a7 ,/ate av]age p] b5efici>y 
am\nt ,ea* ye> 7beg9n+ 9 #bjag71 !      
,secret>y %all det]m9e a ,/ate av]age p]
 b5efici>y am\nt = ea* ,/ate :i* %all be
 equal to ! ,secret>y's e/imate ( !     
av]age am\nt ( exp5ditures "u ! orig9al 
,m$ic>e fee-=-s]vice program "u p>ts ,a 
& ,b = ! ye> = a b5efici>y enroll$ "u   

su* p>ts t resides 9 ! ,/ate4  7,b7     
,national av]age p] b5efici>y am\nt ,ea*
 ye> 7beg9n+ 9 #bjag71 ! ,secret>y %all 
det]m9e ! national av]age p] b5efici>y  
am\nt :i* %all be equal to ! av]age ( ! 
,/ate av]age p] b5efici>y am\nt det]m9$ 
"u subp>agraph 7,a7 = ! ye>4  7#d7      
,def9itions ,9 ?is section3 7,a7        
,applicable paym5ts ,! t]m applicable   
paym5ts means paym5ts made to entities &
 individuals = items & s]vices provid$  
"u ! orig9al ,m$ic>e fee-=-s]vice       
program "u p>ts ,a & ,b to b5efici>ies  
enroll$ "u su* p>ts t reside 9 ! ,/ate4 
7,b7 ,/ate ,! t]m ,/ate has ! mean+ giv5
 su* t]m 9 section #baj7;h74  7c7       
,b5efici>ies held h>mless ,! provisions 
( ?is section %all n affect--  7#a7 !   
entitlem5t to items & s]vices ( a       
b5efici>y "u ?is title1 includ+ ! scope 
( su* items & s]vices2 or  7#b7 any     
liability ( ! b5efici>y ) respect to su*
 items & s]vices4  7d7 ,regulations     
7#a7 ,9 g5]al ,! ,secret>y1 9           
consultation ) ! ,m$ic>e ,paym5t        

,advisory ,commission1 %all promulgate  
regulations to c>ry out ?is section4    
7#b7 ,protect+ rural communities ,9     
promulgat+ ! regulations pursuant to    
p>agraph 7#a71 ! ,secret>y %all give    
special consid]ation to rural areas4  4 
#d4 ,m$pac recomm5dations on heal?y     
outcomes & quality c>e  7a7             
,recomm5dations ,! ,m$ic>e ,paym5t      
,advisory ,commission e/abli%$ "u       
section #ahje ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acie;b-#f7 %all develop
 recomm5dations on policies & practices 
t1 if implem5t$1 w\ld enc\rage--  7#a7  
heal?y outcomes & quality c>e "u !      
,m$ic>e program 9 ,/ates ) respect to   
:i* paym5ts are r$uc$ "u section        
#ahii;,b7b77#b7 ( su* ,act 7z add$ by   
section #c72 &  7#b7 ! effici5t use (   
paym5ts made "u ! ,m$ic>e program 9 su* 
,/ates4  7b7 ,submission ,n lat] ?an !  
date t is #i mon?s aft] ! date ( !      
enactm5t ( ?is ,act1 ! ,commission %all 
submit to ,congress ! recomm5dations    
develop$ "u subsection 7a74