,,ib  ,union ,cal5d> ,no4 #bi  #aad?    
,,congress  #a/ ,session  ,h4 ,r4 #ajba 
,report ,no4 #aad-df1 ,"p ,i  ,,9 ,,!   
,,h\se ,,( ,,repres5tatives  ,febru>y   
#bd1 #bjae ,mr4 ,brady ( ,texas 7=      
himself1 ,mr4 ,mc,dermott1 ,mr4 ,lev91  
,mr4 ,rangel1 ,mr4 ,lewis1 ,mr4 ,neal1  
,mr4 ,sam ,johnson ( ,texas1 ,mr4       
,doggett1 ,mr4 ,blum5au]1 ,mr4 ,danny   
,k4 ,davis ( ,ill9ois1 ,mr4 ,pascrell1  
,mr4 ,tib]i1 ,mr4 ,nunes1 ,ms4 ,l9da ,t4
 ,sn*ez ( ,cali=nia1 ,mr4 ,b\/any1 ,mr4 
,rei*]t1 ,mr4 ,bu*anan1 ,mr4 ,roskam1   
,mr4 ,smi? ( ,nebraska1 ,mr4 ,re$1 ,mrs4
 ,black1 ,mr4 ,kelly ( ,p5nsylvania1    
,mr4 ,r5acci1 ,mr4 ,meehan1 ,mr4 ,"y (  
,indiana1 ,mr4 ,hold+1 & ,mr4 ,c>ney7   
introduc$ ! 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$    
,m>* #ah1 #bjae ,additional sponsors3   

,mr4 ,diaz-,bal>t1 ,mr4 ,pauls51 ,mrs4  
,noem1 ,mr4 ,rodney ,davis ( ,ill9ois1 &
 ,mr4 ,ross  ,m>* #ah1 #bjae ,report$ f 
! ,committee on ,ways & ,means ) an     
am5dm5t ,/rike out all aft] ! enact+    
clause & ins]t ! "p pr9t$ 9 italic  ,m>*
 #ah1 #bjae ,! ,committee on ,en]gy &   
,comm]ce dis*>g$2 committ$ to !         
,committee ( ! ,:ole ,h\se on ! ,/ate ( 
! ,union & ord]$ to be pr9t$ ,= text (  
introduc$ bill1 see copy ( bill z       
introduc$ on ,febru>y #bd1 #bjae  ,a    
,,bill  ,to am5d title ,,xviii ( !      
,social ,security ,act to improve !     
integrity ( ! ,m$ic>e program1 & = o!r  
purposes4  #a4 ,%ort title2 table (     
cont5ts  7a7 ,%ort title ,?is ,act may  
be cit$ z ! ,protect+ ! ,integrity (    
,m$ic>e ,act ( #bjae4  7b7 ,table (     
cont5ts ,! table ( cont5ts = ?is ,act is
 z foll[s3  ,sec4 #a4 ,%ort title2 table
 ( cont5ts4 ,sec4 #b4 ,prohibition (    
inclusion ( ,social ,security acc\nt    
numb]s on ,m$ic>e c>ds4 ,sec4 #c4       
,prev5t+ wrongful ,m$ic>e paym5ts =     

items & s]vices furni%$ to inc>c]at$    
individuals1 individuals n lawfully     
pres5t1 & deceas$ individuals4 ,sec4 #d4
 ,consid]ation ( measures reg>d+ ,m$ic>e
 b5efici>y sm>t c>ds4 ,sec4 #e4 ,modify+
 m$ic>e durable m$ical equipm5t         
face-to-face enc\nt] docum5tation       
requirem5t4 ,sec4 #f4 ,r$uc+ improp]    
,m$ic>e paym5ts4 ,sec4 #g4 ,improv+     
s5ior ,m$ic>e patrol & fraud report+    
rew>ds4 ,sec4 #h4 ,requir+ valid        
prescrib] ,national ,provid] ,id5tifi]s 
on ph>macy claims4 ,sec4 #i4 ,option to 
receive ,m$ic>e ,summ>y ,notice         
electronically4 ,sec4 #aj4 ,r5ewal (    
,,mac contracts4 ,sec4 #aa4 ,/udy on    
pa?way = inc5tives to ,/ates = ,/ate    
p>ticipation 9 m$icaid data mat*        
program4 ,sec4 #ab4 ,programs to prev5t 
prescription drug abuse "u ,m$ic>e "p   
,d4 ,sec4 #ac4 ,guidance on application 
( ,common ,rule to cl9ical data         
regi/ries4 ,sec4 #ad4 ,elim9at+ c]ta9   
civil money p5alties2 ga9%>+ /udy &     
report4 ,sec4 #ae4 ,modification (      

,m$ic>e home heal? surety bond condition
 ( p>ticipation requirem5t4 ,sec4 #af4  
,ov]sight ( ,m$ic>e cov]age ( manual    
manipulation ( ! sp9e to correct        
subluxation4 ,sec4 #ag4 ,national       
expansion ( prior au?orization model =  
repetitive s*$ul$ non-em]g5t ambulance  
transport4 ,sec4 #ah4 ,repeal+          
duplicative ,m$ic>e second>y payor      
provision4 ,sec4 #ai4 ,plan = exp&+ data
 9 annual ,,c]t report4 ,sec4 #bj4      
,remov+ funds = ,m$ic>e ,improvem5t     
,fund add$ by ,,impact ,act ( #bjad4    
,sec4 #ba4 ,rule ( con/ruction4  #b4    
,prohibition ( inclusion ( ,social      
,security acc\nt numb]s on ,m$ic>e c>ds 
7a7 ,9 g5]al ,section #bje7;c77#b77;,c7 
( ! ,social ,security ,act 7#db         
,u4,s4,c4 #dje7;c77#b77;,c77 is am5d$-- 
7#a7 by mov+ clause 7x71 z add$ by      
section #adad7;a77#b7 ( ! ,pati5t       
,protection & ,af=dable ,c>e ,act1 #f   
ems to ! left2  7#b7 by r$esignat+      
clause 7x71 z add$ by section #b7;a77#a7
 ( ! ,social ,security ,numb]           

,protection ,act ( #bjaj1 & clause 7xi7 
z clauses 7xi7 & 7xii71 respectively2 & 
7#c7 by add+ at ! end ! foll[+ new      
clause3  7xiii7 ,! ,secret>y ( ,heal? & 
,human ,s]vices1 9 consultation ) !     
,commission] ( ,social ,security1 %all  
e/abli% co/-effective proc$ures to      
ensure t a ,social ,security acc\nt     
numb] 7or d]ivative !re(7 is n display$1
 cod$1 or emb$d$ on ! ,m$ic>e c>d issu$ 
to an individual :o is entitl$ to       
b5efits "u "p ,a ( title ,,xviii or     
enroll$ "u "p ,b ( title ,,xviii & t any
 o!r id5tifi] display$ on su* c>d is n  
id5tifiable z a ,social ,security acc\nt
 numb] 7or d]ivative !re(74  4  7b7     
,implem5tation ,9 implem5t+ clause      
7xiii7 ( section #bje7;c77#b77;,c7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#dje7;c77#b77;,c771 z add$ by subsection
 7a77#c71 ! ,secret>y ( ,heal? & ,human 
,s]vices %all d ! foll[+3  7#a7 ,9 g5]al
 ,e/abli% a co/-effective process t     
involves ! lea/ am\nt ( disruption to1 z
 well z necess>y assi/ance =1 ,m$ic>e   

b5efici>ies & heal? c>e provid]s1 su* z 
a process t provides su* b5efici>ies )  
access to assi/ance ?r\gh a toll-free   
telephone numb] & provides outrea* to   
provid]s4  7#b7 ,consid]ation ( ,m$ic>e 
b5efici>y id5tifi$ ,consid] implem5t+ a 
process1 simil> to ! process involv+    
,railroad ,retirem5t ,bo>d b5efici>ies1 
"u :i* a ,m$ic>e b5efici>y id5tifi] :i* 
is n a ,social ,security acc\nt numb]   
7or d]ivative !re(7 is us$ ext]nal to ! 
,dep>tm5t ( ,heal? & ,human ,s]vices &  
is conv]tible ov] to a ,social ,security
 acc\nt numb] 7or d]ivative !re(7 = use 
int]nal to su* ,dep>tm5t & ! ,social    
,security ,adm9i/ration4  7c7 ,fund+ =  
implem5tation ,= purposes ( implem5t+ ! 
provisions ( & ! am5dm5ts made by ?is   
section1 ! ,secret>y ( ,heal? & ,human  
,s]vices %all provide = ! foll[+        
transf]s f ! ,f$]al ,hospital ,insurance
 ,tru/ ,fund "u section #ahag ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#acie;i7 & f ! ,f$]al ,supplem5t>y      
,m$ical ,insurance ,tru/ ,fund e/abli%$ 

"u section #ahda ( su* ,act 7#db        
,u4,s4,c4 #aciet71 9 su* proportions z !
 ,secret>y det]m9es appropriate3  7#a7  
,to ! ,c5t]s = ,m$ic>e  ,m$icaid        
,program ,managem5t ,acc\nt1 transf]s ( 
! foll[+ am\nts3 7,a7 ,= fiscal ye>     
#bjae1 #fe1jjj1jjj1 to be made available
 ?r\gh fiscal ye> #bjah4  7,b7 ,= ea* ( 
fiscal ye>s #bjaf & #bjag1 #ec1jjj1jjj1 
to be made available ?r\gh fiscal ye>   
#bjah4  7,c7 ,= fiscal ye> #bjah1       
#dh1jjj1jjj1 to be made available until 
exp5d$4  7#b7 ,to ! ,social ,security   
,adm9i/ration ,limitation on            
,adm9i/ration ,acc\nt1 transf]s ( !     
foll[+ am\nts3  7,a7 ,= fiscal ye>      
#bjae1 #bg1jjj1jjj1 to be made available
 ?r\gh fiscal ye> #bjah4  7,b7 ,= ea* ( 
fiscal ye>s #bjaf & #bjag1 #bb1jjj1jjj1 
to be made available ?r\gh fiscal ye>   
#bjah4  7,c7 ,= fiscal ye> #bjah1       
#bg1jjj1jjj1 to be made available until 
exp5d$4  7#c7 ,to ! ,railroad ,retirem5t
 ,bo>d ,limitation on ,adm9i/ration     
,acc\nt1 ! foll[+ am\nt3  7,a7 ,= fiscal

 ye> #bjae1 #c1jjj1jjj1 to be made      
available until exp5d$4  7d7 ,effective 
date  7#a7 ,9 g5]al ,clause 7xiii7 (    
section #bje7;c77#b77;,c7 ( ! ,social   
,security ,act 7#db ,u4,s4,c4           
#dje7;c77#b77;,c771 z add$ by subsection
 7a77#c71 %all apply ) respect to       
,m$ic>e c>ds issu$ on & aft] an         
effective date specifi$ by ! ,secret>y (
 ,heal? & ,human ,s]vices1 b 9 no case  
%all su* effective date be lat] ?an !   
date t is f\r ye>s aft] ! date ( !      
enactm5t ( ?is ,act4  7#b7 ,reissuance  
,! ,secret>y %all provide = ! reissuance
 ( ,m$ic>e c>ds t comply ) ! requirem5ts
 ( su* clause n lat] ?an f\r ye>s aft] !
 effective date specifi$ by ! ,secret>y 
"u p>agraph 7#a74  #c4 ,prev5t+ wrongful
 ,m$ic>e paym5ts = items & s]vices      
furni%$ to inc>c]at$ individuals1       
individuals n lawfully pres5t1 & deceas$
 individuals  7a7 ,requirem5t = !       
,secret>y to e/abli% policies & claims  
edits relat+ to inc>c]at$ individuals1  
individuals n lawfully pres5t1 & deceas$

 individuals ,section #ahgd ( ! ,social 
,security ,act 7#db ,u4,s4,c4 #aciekk7  
is am5d$ by add+ at ! end ! foll[+ new  
subsection3  7f7 ,requirem5t = !        
,secret>y to e/abli% policies & claims  
edits relat+ to inc>c]at$ individuals1  
individuals n lawfully pres5t1 & deceas$
 individuals ,! ,secret>y %all e/abli% &
 ma9ta9 proc$ures1 includ+ proc$ures =  
us+ claims process+ edits1 updat+       
eligibility in=mation to improve provid]
 accessibility1 & conduct+ rec\pm5t     
activities su* z ?r\gh recov]y audit    
contractors1 9 ord] to ensure t paym5t  
is n made "u ?is title = items & s]vices
 furni%$ to an individual :o is "o ( !  
foll[+3  7#a7 ,an individual :o is      
inc>c]at$4  7#b7 ,an individual :o is n 
lawfully pres5t 9 ! ,unit$ ,/ates & :o  
is n eligible = cov]age "u ?is title4   
7#c7 ,a deceas$ individual4  4  7b7     
,report ,n lat] ?an #ah mon?s aft] !    
date ( ! enactm5t ( ?is section1 &      
p]iodically !reaft] z det]m9$ necess>y  
by ! ,(fice ( ,inspector ,g5]al ( !     

,dep>tm5t ( ,heal? & ,human ,s]vices1   
su* ,(fice %all submit to ,congress a   
report on ! activities describ$ 9       
subsection 7f7 ( section #ahgd ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#aciekk71 z add$ by subp>agraph 7a71 t h
 be5 conduct$ s9ce su* date ( enactm5t4 
#d4 ,consid]ation ( measures reg>d+     
,m$ic>e b5efici>y sm>t c>ds ,to ! ext5t 
! ,secret>y ( ,heal? & ,human ,s]vices  
det]m9es t x is co/ effective &         
te*nologically viable to use electronic 
,m$ic>e b5efici>y & provid] c>ds 7su* z 
c>ds t use sm>t c>d te*nology1 includ+  
an emb$d$ & secure integrat$ circuit    
*ip71 z pres5t$ 9 ! ,gov]nm5t           
,acc\ntability ,(fice report requir$ by 
! conf]5ce report accompany+ !          
,consolidat$ ,appropriations ,act1 #bjad
 7,public ,law #aac-gf71 ! ,secret>y    
%all consid] su* measures z det]m9$     
appropriate by ! ,secret>y to implem5t  
su* use ( su* c>ds = b5efici>y & provid]
 use "u title ,,xviii ( ! ,social       
,security ,act 7#db ,u4,s4,c4 #acie et  

seq474 ,9 ! case t ! ,secret>y consid]s 
measures "u ! prec$+ s5t5ce1 ! ,secret>y
 %all submit to ! ,committees on ,ways &
 ,means & on ,en]gy & ,comm]ce ( ! ,h\se
 ( ,repres5tatives1 & to ! ,committee on
 ,f9ance ( ! ,s5ate1 a report outl9+ !  
consid]ations und]tak5 by ! ,secret>y "u
 su* s5t5ce4  #e4 ,modify+ m$ic>e       
durable m$ical equipm5t face-to-face    
enc\nt] docum5tation requirem5t  7a7 ,9 
g5]al ,section #ahcd7;a77#aa77;,b77ii7 (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #aciem7a77#aa77;,b77ii77 is am5d$--    
7#a7 by /rik+ ! physician docum5t+ t2 & 
7#b7 by /rik+ has _h a face-to-face     
enc\nt] & ins]t+ docum5t+ su* physician1
 physician assi/ant1 practition]1 or    
speciali/ has _h a face-to-face enc\nt]4
  7b7 ,implem5tation ,not)/&+ any o!r   
provision ( law1 ! ,secret>y ( ,heal? & 
,human ,s]vices may implem5t ! am5dm5ts 
made by subsection 7a7 by program       
in/ruction or o!rwise4  #f4 ,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 or o!r 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#b74 ,! activities 

describ$ 9 ! prec$+ s5t5ce %all be      
conduct$ on a regul> basis4  7#b7       
,in=mation to be provid$ ?r\gh          
activities ,! in=mation to be provid$ "u
 su* paym5t outrea* & education program 
%all include in=mation ! ,secret>y      
det]m9es to be appropriate :i* may      
include ! 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 ( 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#c7 ,priority ,a m$ic>e    
adm9i/rative contractor %all give       
priority to activities "u su* program t 
w r$uce improp] paym5ts t are "o or m ( 
! foll[+3  7,a7 ,are = items & s]vices t
 h ! highe/ rate ( improp] paym5t4  7,b7

 ,are = items & s]vice t h ! greate/    
total doll> am\nt ( improp] paym5ts4    
7,c7 ,are due to cle> misapplication or 
mis9t]pretation ( ,m$ic>e policies4     
7,d7 ,are cle>ly due to common &        
inadv]t5t cl]ical or adm9i/rative       
errors4  7,e7 ,are due to o!r types (   
errors t ! ,secret>y det]m9es c\ld be   
prev5t$ ?r\gh activities "u ! program4  
7#d7 ,in=mation on improp] paym5ts f    
recov]y audit contractors  7,a7 ,9 g5]al
 ,9 ord] to assi/ m$ic>e adm9i/rative   
contractors 9 c>ry+ out improp] paym5t  
outrea* & education programs1 !         
,secret>y %all provide ea* contractor ) 
a complete li/ ( ! types ( improp]      
paym5ts id5tifi$ 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 "t frame ! ,secret>y       
det]m9es appropriate :i* may be on a    
qu>t]ly basis4  7,b7 ,in=mation ,!      
in=mation describ$ 9 subp>agraph 7,a7   

%all include in=mation su* z ! foll[+3  
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 ! program4  7#e7              
,communications ,communications )       
provid]s ( s]vices & suppli]s "u an     
improp] paym5t outrea* & education      
program are subject to ! /&>ds &        
requirem5ts ( subsection 7g74  4  7b7   
,use ( c]ta9 funds recov]$ by ,r,a,cs   
,section #ahic7;h7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acie;ddd7h77 is   
am5d$-- 7#a7 9 p>agraph 7#b71 by ins]t+ 
or p>agraph 7#aj7 aft] p>agraph         
7#a77;,c72 &  7#b7 by add+ at ! end !   
foll[+ new p>agraph3  7#aj7 ,use ( c]ta9

 recov]$ funds  7,a7 ,9 g5]al ,aft]     
application ( p>agraph 7#a77;,c71 !     
,secret>y %all reta9 a portion ( !      
am\nts recov]$ by recov]y audit         
contractors = ea* ye> "u ?is section :i*
 %all be available to ! program         
managem5t acc\nt ( ! ,c5t]s = ,m$ic>e   
,m$icaid ,s]vices = purposes (1 subject 
to subp>agraph 7,b71 c>ry+ out sections 
#ahcc7z71 #ahcd7l77#af71 &              
#ahgd;,a7a77#d77;,g71 c>ry+ out section 
#af7;b7 ( ! ,protect+ ! ,integrity (    
,m$ic>e ,act ( #bjae1 & implem5t+       
/rategies 7su* z claims process+ edits7 
to help r$uce ! error rate ( paym5ts "u 
?is title4 ,! am\nts reta9$ "u ! prec$+ 
s5t5ce %all n exce$ an am\nt equal to   
#ae p]c5t ( ! am\nts recov]$ "u ?is     
subsection1 & %all rema9 available until
 exp5d$4  7,b7 ,limitation ,except =    
uses t support claims process+ 7includ+ 
edits7 or sy/em functionality = detect+ 
fraud1 am\nts reta9$ "u subp>agraph 7,a7
 may n be us$ = te*nological-relat$     
infra/ructure1 capital inve/m5ts1 or    

in=mation sy/ems4  7,c7 ,no r$uction 9  
paym5ts to recov]y audit contractors    
,no?+ 9 subp>agraph 7,a7 %all r$uce     
am\nts available = paym5ts to recov]y   
audit contractors "u ?is subsection4  4 
#g4 ,improv+ s5ior ,m$ic>e patrol &     
fraud report+ rew>ds  7a7 ,9 g5]al ,!   
,secret>y ( ,heal? & ,human ,s]vices 79 
?is section ref]r$ to z ! ,secret>y7    
%all develop a plan to revise ! inc5tive
 program "u section #bjc7;b7 ( ! ,heal? 
,insurance ,portability & ,acc\ntability
 ,act ( #aiif 7#db ,u4,s4,c4 #acie;b-   
#e7;b77 to enc\rage great] p>ticipation 
by individuals to report fraud & abuse 9
 ! ,m$ic>e program4 ,su* plan %all      
include recomm5dations =--  7#a7 ways to
 enhance rew>ds = individuals report+ "u
 ! inc5tive program1 includ+ rew>ds bas$
 on in=mation t leads to an adm9i/rative
 action2 &  7#b7 ext5d+ ! inc5tive      
program to ! ,m$icaid program4  7b7     
,public ,aw>5ess & ,education ,campaign 
,! plan develop$ "u subsection 7a7 %all 
also include recomm5dations = ! use ( ! 

,s5ior ,m$ic>e ,patrols au?oriz$ "u     
section #daa ( ! ,old] ,am]icans ,act ( 
#aife 7#db ,u4,s4,c4 #cjcb7 to conduct a
 public aw>5ess & education campaign to 
enc\rage p>ticipation 9 ! revis$        
inc5tive program "u subsection 7a74  7c7
 ,submission ( ,plan ,n lat] ?an #ahj   
days aft] ! date ( enactm5t ( ?is ,act1 
! ,secret>y %all submit to ,congress !  
plan develop$ "u subsection 7a74  #h4   
,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> #bjaf &       
subsequ5t plan ye>s1 ! ,secret>y %all   
require a claim = a cov]$ "p ,d drug = a
 "p ,d eligible individual enroll$ 9 a  
prescription drug plan "u ?is "p or an  
,,ma-,,pd plan "u "p ,c to include a    
prescrib] ,national ,provid] ,id5tifi] t

 is det]m9$ to be valid "u ! proc$ures  
e/abli%$ "u subp>agraph 7,b77i74  7,b7  
,proc$ures  7i7 ,validity ( prescrib]   
,national ,provid] ,id5tifi]s ,!        
,secret>y1 9 consultation ) appropriate 
/akehold]s1 %all e/abli% proc$ures =    
det]m9+ ! validity ( prescrib] ,national
 ,provid] ,id5tifi]s "u subp>agraph     
7,a74  7ii7 ,in=m+ b5efici>ies ( reason 
= d5ial ,! ,secret>y %all e/abli%       
proc$ures to ensure t1 9 ! case t a     
claim = a cov]$ "p ,d drug ( an         
individual describ$ 9 subp>agaph 7,a7 is
 d5i$ because ! claim does n meet !     
requirem5ts ( ?is p>agraph1 ! individual
 is prop]ly in=m$ at ! po9t ( s]vice ( !
 reason = ! d5ial4  7,c7 ,report ,n lat]
 ?an ,janu>y #a1 #bjah1 ! ,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,b77i74  4  #i4
 ,option to receive ,m$ic>e ,summ>y     
,notice electronically  7a7 ,9 g5]al    
,section #ahjf ( ! ,social ,security    

,act 7#db ,u4,s4,c4 #acie;b-#g7 is am5d$
 by add+ at ! end ! foll[+ new          
subsection3  7c7 ,=mat ( /atem5ts f     
,secret>y  7#a7 ,electronic option      
beg9n+ 9 #bjaf ,subject to p>agraph     
7#b71 = /atem5ts describ$ 9 subsection  
7a7 t are furni%$ = a p]iod 9 #bjaf or a
 subsequ5t ye>1 9 ! case t an individual
 describ$ 9 subsection 7a7 elects1 9    
accordance ) su* =m1 mann]1 & "t        
specifi$ by ! ,secret>y1 to receive su* 
/atem5t 9 an electronic =mat1 su*       
/atem5t %all be furni%$ to su*          
individual = ea* p]iod subsequ5t to su* 
election 9 su* a =mat & %all n be mail$ 
to ! individual4  7#b7 ,limitation on   
revocation option  7,a7 ,9 g5]al        
,subject to subp>agraph 7,b71 !         
,secret>y may det]m9e a maximum numb] ( 
elections describ$ 9 p>agraph 7#a7 by an
 individual t may be revok$ by !        
individual4  7,b7 ,m9imum ( "o          
revocation option ,9 no case may !      
,secret>y det]m9e a maximum numb] "u    
subp>agraph 7,a7 t is less ?an "o4  7#c7

 ,notification ,! ,secret>y %all ensure 
t1 9 ! mo/ co/ effective mann] & beg9n+ 
,janu>y #a1 #bjag1 a cle> notification (
 ! option to elect to receive /atem5ts  
describ$ 9 subsection 7a7 9 an          
electronic =mat is made available1 su* z
 ?r\gh ! notices di/ribut$ "u section   
#ahjd1 to individuals describ$ 9        
subsection 7a74  4  7b7 ,enc\rag$       
expansion ( electronic /atem5ts ,to !   
ext5t to :i* ! ,secret>y ( ,heal? &     
,human ,s]vices det]m9es appropriate1 ! 
,secret>y %all--  7#a7 apply an option  
simil> to ! option describ$ 9 subsection
 7c77#a7 ( section #ahjf ( ! ,social    
,security ,act 7#db ,u4,s4,c4           
#acie;b-#g7 7relat+ to ! provision ( !  
,m$ic>e ,summ>y ,notice 9 an electronic 
=mat71 z add$ by subsection 7a71 to o!r 
/atem5ts & notifications "u title       
,,xviii ( su* ,act 7#db ,u4,s4,c4 #acie 
et seq472 &  7#b7 provide su* ,m$ic>e   
,summ>y ,notice & any su* o!r /atem5ts &
 notifications on a m frequ5t basis ?an 
is o!rwise requir$ "u su* title4  #aj4  

,r5ewal ( ,,mac contracts  7a7 ,9 g5]al 
,section #ahgd;,a7b77#a77;,b7 ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#aciekk-#a7;b77#a77;,b77 is am5d$ by    
/rik+ #e ye>s & ins]t+ #aj ye>s4  7b7   
,application ,! am5dm5ts made by        
subsection 7a7 %all apply to contracts  
ent]$ into on or aft]1 & to contracts 9 
effect z (1 ! date ( ! enactm5t ( ?is   
,act4  7c7 ,contractor p]=mance         
transp>5cy ,section #ahgd;,a7b77#c77;,a7
 ( ! ,social ,security ,act 7#db        
,u4,s4,c4 #aciekk-#a7;b77#c77;,a77 is   
am5d$ by add+ at ! end ! foll[+ new     
clause3  7iv7 ,contractor p]=mance      
transp>5cy ,to ! ext5t possible )\t     
compromis+ ! process = ent]+ into &     
r5ew+ contracts ) m$ic>e adm9i/rative   
contractors "u ?is section1 ! ,secret>y 
%all make available to ! public !       
p]=mance ( ea* m$ic>e adm9i/rative      
contractor ) respect to su* p]=mance    
requirem5ts & measurem5t /&>ds4  4  #aa4
 ,/udy on pa?way = inc5tives to ,/ates =
 ,/ate p>ticipation 9 m$icaid data mat* 

program ,section #ahic7;g7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4           
#acie;ddd7g77 is am5d$ by add+ at ! end 
! foll[+ new p>agraph3  7#c7 ,inc5tives 
= ,/ates ,! ,secret>y %all /udy &1 z    
appropriate1 may specify inc5tives =    
,/ates to "w ) ! ,secret>y = ! purposes 
describ$ 9 p>agraph 7#a77;,a77ii74 ,!   
application ( ! previ\s s5t5ce may      
include use ( ! waiv] au?ority describ$ 
9 p>agraph 7#b74  4  #ab4 ,programs to  
prev5t prescription drug abuse "u       
,m$ic>e "p ,d  7a7 ,drug managem5t      
program = at-risk b5efici>ies  7#a7 ,9  
g5]al ,section #ahfj;,d-#d7;c7 ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#aj7;c771 z am5d$ by section #h1 
is fur!r am5d$ by add+ at ! end !       
foll[+3  7#e7 ,drug managem5t program = 
at-risk b5efici>ies  7,a7 ,au?ority to  
e/abli% ,a ,,pdp sponsor may e/abli% a  
drug managem5t program = at-risk        
b5efici>ies "u :i*1 subject to          
subp>agraph 7,b71 ! ,,pdp sponsor may1 9
 ! case ( an at-risk b5efici>y =        

prescription drug abuse :o is an        
enrollee 9 a prescription drug plan (   
su* ,,pdp sponsor1 limit su* b5efici>y's
 access to cov]age = frequ5tly abus$    
drugs "u su* plan to frequ5tly abus$    
drugs t are prescrib$ = su* b5efici>y by
 a prescrib] select$ "u subp>agraph     
7,d71 & disp5s$ = su* b5efici>y by a    
ph>macy select$ "u su* subp>agraph4     
7,b7 ,requirem5t = notices  7i7 ,9 g5]al
 ,a ,,pdp sponsor may n limit ! access (
 an at-risk b5efici>y = prescription    
drug abuse to cov]age = frequ5tly abus$ 
drugs "u a prescription drug plan until 
su* sponsor--  7,i7 provides to !       
b5efici>y an initial notice describ$ 9  
clause 7ii7 & a second notice describ$ 9
 clause 7iii72 &  7,,ii7 v]ifies ) !    
provid]s ( ! b5efici>y t ! b5efici>y is 
an at-risk b5efici>y = prescription drug
 abuse4  7ii7 ,initial notice ,an       
initial notice describ$ 9 ?is clause is 
a notice t provides to ! b5efici>y--    
7,i7 notice t ! ,,pdp sponsor has       
id5tifi$ ! b5efici>y z pot5tially be+ an

 at-risk b5efici>y = prescription drug  
abuse2  7,,ii7 in=mation describ+ all   
,/ate & ,f$]al public heal? res\rces t  
are design$ to address prescription drug
 abuse to :i* ! b5efici>y has access1   
includ+ m5tal heal? s]vices & o!r       
c\nsel+ s]vices2  7,,iii7 notice (1 &   
in=mation ab\t1 ! "r ( ! b5efici>y to   
appeal su* id5tification "u subsection  
7h7 & ! option ( an automatic escalation
 to ext]nal review2  7,,iv7 a reque/ = !
 b5efici>y to submit to ! ,,pdp sponsor 
pref]5ces = :i* prescrib]s & ph>macies !
 b5efici>y w\ld pref] ! ,,pdp sponsor to
 select "u subp>agraph 7,d7 9 ! case t !
 b5efici>y is id5tifi$ z an at-risk     
b5efici>y = prescription drug abuse z   
describ$ 9 clause 7iii77,i72  7,v7 an   
explanation ( ! mean+ & consequ5ces ( ! 
id5tification ( ! b5efici>y z pot5tially
 be+ an at-risk b5efici>y = prescription
 drug abuse1 includ+ an explanation ( ! 
drug managem5t program e/abli%$ by !    
,,pdp sponsor pursuant to subp>agraph   
7,a72  7,,vi7 cle> in/ructions t expla9 

h[ ! b5efici>y c contact ! ,,pdp sponsor
 9 ord] to submit to ! ,,pdp sponsor !  
pref]5ces describ$ 9 subclause 7,,iv7 & 
any o!r communications relat+ to ! drug 
managem5t program = at-risk b5efici>ies 
e/abli%$ by ! ,,pdp sponsor2 &  7,,vii7 
contact in=mation = o!r organizations t 
c provide ! b5efici>y ) assi/ance reg>d+
 su* drug managem5t program 7simil> to !
 in=mation provid$ by ! ,secret>y 9 o!r 
/&>diz$ notices provid$ to "p ,d        
eligible individuals enroll$ 9          
prescription drug plans "u ?is "p74     
7iii7 ,second notice ,a second notice   
describ$ 9 ?is clause is a notice t     
provides to ! b5efici>y notice-- 7,i7 t 
! ,,pdp sponsor has id5tifi$ ! b5efici>y
 z an at-risk b5efici>y = prescription  
drug abuse2  7,,ii7 t su* b5efici>y is  
subject to ! requirem5ts ( ! drug       
managem5t program = at-risk b5efici>ies 
e/abli%$ by su* ,,pdp sponsor = su*     
plan2  7,,iii7 ( ! prescrib] & ph>macy  
select$ = su* individual "u subp>agraph 
7,d72  7,,iv7 (1 & in=mation ab\t1 !    

b5efici>y's "r to appeal su*            
id5tification "u subsection 7h7 & !     
option ( an automatic escalation to     
ext]nal review2  7,v7 t ! b5efici>y c1 9
 ! case t ! b5efici>y has n previ\sly   
submitt$ to ! ,,pdp sponsor pref]5ces = 
:i* prescrib]s & ph>macies ! b5efici>y  
w\ld pref] ! ,,pdp sponsor select "u    
subp>agraph 7,d71 submit su* pref]5ces  
to ! ,,pdp sponsor2 &  7,,vi7 t includes
 cle> in/ructions t expla9 h[ !         
b5efici>y c contact ! ,,pdp sponsor4    
7iv7 ,tim+ ( notices  7,i7 ,9 g5]al     
,subject to subclause 7,,ii71 a second  
notice describ$ 9 clause 7iii7 %all be  
provid$ to ! b5efici>y on a date t is n 
less ?an #fj days aft] an initial notice
 describ$ 9 clause 7ii7 is provid$ to ! 
b5efici>y4  7,,ii7 ,exception ,9 ! case 
t ! ,,pdp sponsor1 9 conjunction ) !    
,secret>y1 det]m9es t conc]ns id5tifi$  
?r\gh rulemak+ by ! ,secret>y reg>d+ !  
heal? or safety ( ! b5efici>y or reg>d+ 
significant drug div]sion activities    
require ! ,,pdp sponsor to provide a    

second notice describ$ 9 clause 7iii7 to
 ! b5efici>y on a date t is e>li] ?an ! 
date describ$ 9 subclause 7,,ii71 !     
,,pdp sponsor may provide su* second    
notice on su* e>li] date4  7,c7 ,at-risk
 b5efici>y = prescription drug abuse    
7i7 ,9 g5]al ,= purposes ( ?is p>agraph1
 ! t]m at-risk b5efici>y = prescription 
drug abuse means a "p ,d eligible       
individual :o is n an exempt$ individual
 describ$ 9 clause 7ii7 &-- 7,i7 :o is  
id5tifi$ ?r\gh ! use ( cl9ical guidel9es
 develop$ by ! ,secret>y 9 consultation 
) ,,pdp sponsors & o!r /akehold]s       
describ$ 9 section #ab7;f77#b77;,a7 ( ! 
,protect+ ! ,integrity ( ,m$ic>e ,act ( 
#bjae2 or  7,,ii7 ) respect to :om !    
,,pdp sponsor ( a prescription drug     
plan1 ^u enroll+ su* individual 9 su*   
plan1 receiv$ notice f ! ,secret>y t su*
 individual 0 id5tifi$ "u ?is p>agraph  
to be an at-risk b5efici>y =            
prescription drug abuse "u !            
prescription drug plan 9 :i* su*        
individual 0 mo/ rec5tly previ\sly      

enroll$ & su* id5tification has n be5   
t]m9at$ "u subp>agraph 7,f74  7ii7      
,exempt$ individual describ$ ,an exempt$
 individual describ$ 9 ?is clause is an 
individual :o-- 7,i7 receives hospice   
c>e "u ?is title2 or  7,,ii7 ! ,secret>y
 elects to treat z an exempt$ individual
 = purposes ( clause 7i74  7,d7         
,selection ( prescrib]s  7i7 ,9 g5]al ,)
 respect to ea* at-risk b5efici>y =     
prescription drug abuse enroll$ 9 a     
prescription drug plan (f]$ by su*      
sponsor1 a ,,pdp sponsor %all1 bas$ on !
 pref]5ces submitt$ to ! ,,pdp sponsor  
by ! b5efici>y pursuant to clauses      
7ii77,,iv7 & 7iii77,v7 ( subp>agraph    
7,b71 select--  7,i7 "o or m individuals
 :o are au?oriz$ to prescribe frequ5tly 
abus$ drugs 7ref]r$ to 9 ?is p>agraph z 
prescrib]s7 :o may write prescriptions =
 su* drugs = su* b5efici>y2 &  7,,ii7 "o
 or m ph>macies t may disp5se su* drugs 
to su* b5efici>y4  7ii7 ,reasonable     
access ,9 mak+ ! selection "u ?is       
subp>agraph1 a ,,pdp sponsor %all ensure

 t ! b5efici>y cont9ues to h reasonable 
access to drugs describ$ 9 subp>agraph  
7,g71 tak+ into acc\nt geographic       
location1 b5efici>y pref]5ce1 impact on 
co/-%>+1 & reasonable travel "t4  7iii7 
,b5efici>y pref]5ces  7,i7 ,9 g5]al ,if 
an at-risk b5efici>y = prescription drug
 abuse submits pref]5ces = :i* 9-network
 prescrib]s & ph>macies ! b5efici>y w\ld
 pref] ! ,,pdp sponsor select 9 response
 to a notice "u subp>agraph 7,b71 !     
,,pdp sponsor %all--  7aa7 review su*   
pref]5ces2  7bb7 select or *ange !      
selection ( a prescrib] or ph>macy = !  
b5efici>y bas$ on su* pref]5ces2 &  7cc7
 in=m ! b5efici>y ( su* selection or    
*ange ( selection4  7,,ii7 ,exception ,9
 ! case t ! ,,pdp sponsor det]m9es t a  
*ange to ! selection ( a prescrib] or   
ph>macy "u item 7bb7 by ! ,,pdp sponsor 
is contribut+ or w\ld contribute to     
prescription drug abuse or drug div]sion
 by ! b5efici>y1 ! ,,pdp sponsor may    
*ange ! selection ( a prescrib] or      
ph>macy = ! b5efici>y )\t reg>d to !    

pref]5ces ( ! b5efici>y describ$ 9      
subclause 7,i74  7iv7 ,confirmation     
,be=e select+ a prescrib] or ph>macy "u 
?is subp>agraph1 a ,,pdp sponsor mu/    
reque/ & receive confirmation f !       
prescrib] or ph>macy ackn[l$g+ & accept+
 t ! b5efici>y involv$ is 9 ! drug      
managem5t program = at-risk b5efici>ies4
  7,e7 ,t]m9ations & appeals ,!         
id5tification ( an individual z an      
at-risk b5efici>y = prescription drug   
abuse "u ?is p>agraph1 a cov]age        
det]m9ation made "u a drug managem5t    
program = at-risk b5efici>ies1 & !      
selection ( a prescrib] or ph>macy "u   
subp>agraph 7,d7 ) respect to su*       
individual %all be subject to           
reconsid]ation & appeal "u subsection   
7h7 & ! option ( an automatic escalation
 to ext]nal review to ! ext5t provid$ by
 ! ,secret>y4  7,f7 ,t]m9ation (        
id5tification  7i7 ,9 g5]al ,! ,secret>y
 %all develop /&>ds = ! t]m9ation (     
id5tification ( an individual z an      
at-risk b5efici>y = prescription drug   

abuse "u ?is p>agraph4 ,"u su* /&>ds su*
 id5tification %all t]m9ate z ( ! e>li] 
(--  7,i7 ! date ! individual           
demon/rates t ! individual is no long]  
likely1 9 ! abs5ce ( ! re/rictions "u   
?is p>agraph1 to be an at-risk b5efici>y
 = prescription drug abuse describ$ 9   
subp>agraph 7,c77i72 or  7,,ii7 ! end ( 
su* maximum p]iod ( id5tification z !   
,secret>y may specify4  7ii7 ,rule (    
con/ruction ,no?+ 9 clause 7i7 %all be  
con/ru$ z prev5t+ a plan f id5tify+ an  
individual z an at-risk b5efici>y =     
prescription drug abuse "u subp>agraph  
7,c77i7 aft] su* t]m9ation on ! basis ( 
additional in=mation on drug use occurr+
 aft] ! date ( notice ( su* t]m9ation4  
7,g7 ,frequ5tly abus$ drug ,= purposes (
 ?is subsection1 ! t]m frequ5tly abus$  
drug means a drug t is det]m9$ by !     
,secret>y to be frequ5tly abus$ or      
div]t$ & t is-- 7i7 a ,controll$ ,drug  
,sub/ance 9 ,s*$ule ,,cii2 or  7ii7 )9 !
 same class or category ( drugs z a     
,controll$ ,drug ,sub/ance 9 ,s*$ule    

,,cii1 z det]m9$ ?r\gh notice & comm5t  
rulemak+4  7,h7 ,data disclosure ,9 !   
case ( an at-risk b5efici>y =           
prescription drug abuse ^: access to    
cov]age = frequ5tly abus$ drugs "u a    
prescription drug plan has be5 limit$ by
 a ,,pdp sponsor "u ?is p>agraph1 su*   
,,pdp sponsor %all disclose data1       
includ+ any necess>y individually       
id5tifiable heal? in=mation1 9 a =m &   
mann] specifi$ by ! ,secret>y1 ab\t !   
decision to impose su* limitations & !  
limitations impos$ by ! sponsor "u ?is  
"p4  7,i7 ,education ,! ,secret>y %all  
provide education to enrollees 9        
prescription drug plans ( ,,pdp sponsors
 & provid]s reg>d+ ! drug managem5t     
program = at-risk b5efici>ies describ$ 9
 ?is p>agraph1 includ+ education--  7i7 
provid$ by m$ic>e adm9i/rative          
contractors ?r\gh ! improp] paym5t      
outrea* & education program describ$ 9  
section #ahgd;,a7h72 &  7ii7 ?r\gh      
curr5t education ef=ts 7su* z ,/ate     
heal? insurance assi/ance programs      

describ$ 9 subsection 7a77#a77;,a7 (    
section #aai ( ! ,m$ic>e ,improvem5ts = 
,pati5ts & ,provid]s ,act ( #bjjh 7#db  
,u4,s4,c4 #acie;b-#c note77 & mat]ials  
direct$ t[>d su* enrollees4  4  7#b7    
,in=mation = consum]s ,section          
#ahfj;,d-#d7;a77#a77;,b7 ( ! ,social    
,security ,act 7#db ,u4,s4,c4           
#aciew-#ajd7;a77#a77;,b77 is am5d$ by   
add+ at ! end ! foll[+3  7v7 ,! drug    
managem5t program = at-risk b5efici>ies 
"u subsection 7c77#e74  4  7b7          
,utilization managem5t programs ,section
 #ahfj;,d-#d7;c7 ( ! ,social ,security  
,act 7#db ,u4,s4,c4 #aciew-#ajd7;c771 z 
am5d$ by subsection 7a77#a7 & section   
#h1 is fur!r am5d$--  7#a7 9 p>agraph   
7#a71 by ins]t+ aft] subp>agraph 7,d7 ! 
foll[+ new subp>agraph3  7,e7 ,a        
utilization managem5t tool to prev5t    
drug abuse 7z describ$ 9 p>agraph       
7#f77;,a774  2 &  7#b7 by add+ at ! end 
! foll[+ new p>agraph3  7#f7            
,utilization managem5t tool to prev5t   
drug abuse  7,a7 ,9 g5]al ,a tool       

describ$ 9 ?is p>agraph is any ( !      
foll[+3  7i7 ,a utilization tool design$
 to prev5t ! abuse ( frequ5tly abus$    
drugs by individuals & to prev5t !      
div]sion ( su* drugs at ph>macies4  7ii7
 ,retrospective utilization review to   
id5tify-- 7,i7 individuals t receive    
frequ5tly abus$ drugs at a frequ5cy or 9
 am\nts t are n cl9ically appropriate2 &
  7,,ii7 provid]s ( s]vices or suppli]s 
t may facilitate ! abuse or div]sion (  
frequ5tly abus$ drugs by b5efici>ies4   
7iii7 ,consultation ) ! ,contractor     
describ$ 9 subp>agraph 7,b7 to v]ify if 
an individual enroll+ 9 a prescription  
drug plan (f]$ by a ,,pdp sponsor has   
be5 previ\sly id5tifi$ by ano!r ,,pdp   
sponsor z an individual describ$ 9      
clause 7ii77,i74  7,b7 ,report+ ,a ,,pdp
 sponsor (f]+ a prescription drug plan 9
 a ,/ate %all submit to ! ,secret>y & ! 
,m$ic>e drug integrity contractor ) :i* 
! ,secret>y has ent]$ into a contract "u
 section #ahic ) respect to su* ,/ate a 
report1 on a mon?ly basis1 conta9+      

in=mation on--  7i7 any provid] (       
s]vices or suppli] describ$ 9           
subp>agraph 7,a77ii77,,ii7 t is id5tifi$
 by su* plan sponsor dur+ ! #cj-;day    
p]iod be=e su* report is submitt$2 &    
7ii7 ! "n & prescription records (      
individuals describ$ 9 p>agraph         
7#e77;,c74  4  7c7 ,exp&+ ,activities ( 
,m$ic>e ,drug ,integrity ,contractors   
7,m,e,d,i,cs7 ,section #ahic ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#acie;ddd7 is am5d$ by add+ at ! end !  
foll[+ new subsection3  7j7 ,exp&+      
,activities ( ,m$ic>e ,drug ,integrity  
,contractors 7,m,e,d,i,cs7  7#a7 ,access
 to in=mation ,"u contracts ent]$ into  
"u ?is section ) ,m$ic>e drug integrity 
contractors1 ! ,secret>y %all au?orize  
su* contractors to directly accept      
prescription & necess>y m$ical records f
 entities su* z ph>macies1 prescription 
drug plans1 & physicians ) respect to an
 individual 9 ord] = su* contractors to 
provide in=mation relevant to !         
det]m9ation ( :e!r su* individual is an 

at-risk b5efici>y = prescription drug   
abuse1 z def9$ 9 section                
#ahfj;,d-#d7;c77#e77;,c74  7#b7         
,requirem5t = ackn[l$gm5t ( ref]rals ,if
 a ,,pdp sponsor ref]s in=mation to a   
contractor describ$ 9 p>agraph 7#a7 9   
ord] = su* contractor to assi/ 9 !      
det]m9ation describ$ 9 su* p>agraph1 !  
contractor %all--  7,a7 ackn[l$ge to !  
,,pdp sponsor receipt ( ! ref]ral2 &    
7,b7 9 ! case t any ,,pdp sponsor       
contacts ! contractor reque/+ to "k !   
det]m9ation by ! contractor ( :e!r or n 
an individual has be5 det]m9$ to be an  
individual describ$ su* p>agraph1 %all  
in=m su* ,,pdp sponsor ( su* det]m9ation
 on a date t is n lat] ?an #ae days aft]
 ! date on :i* ! ,,pdp sponsor contacts 
! contractor4  7#c7 ,mak+ data available
 to o!r entities  7,a7 ,9 g5]al ,=      
purposes ( c>ry+ out ?is subsection1    
subject to subp>agraph 7,b71 ! ,secret>y
 %all au?orize ,m,e,d,i,cs to respond to
 reque/s = in=mation f ,,pdp sponsors1  
,/ate prescription drug monitor+        

programs1 & o!r entities delegat$ by    
,,pdp sponsors us+ available programs & 
sy/ems 9 ! ef=t to prev5t fraud1 wa/e1 &
 abuse4  7,b7 ,,hipaa compliant         
in=mation only ,in=mation may only be   
disclos$ by a ,,m$ic "u subp>agraph 7,a7
 if ! disclosure ( su* in=mation is     
p]mitt$ "u ! ,f$]al regulations 7conc]n+
 ! privacy ( individually id5tifiable   
heal? in=mation7 promulgat$ "u section  
#bfd7;c7 ( ! ,heal? ,insurance          
,portability & ,acc\ntability ,act (    
#aiif 7#db ,u4,s4,c4 #acbj;d-#b note74  
4  7d7 ,treatm5t ( c]ta9 compla9ts =    
purposes ( quality or p]=mance assessm5t
 ,section #ahfj;,d-#db ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#aciew-#aeb7 is am5d$ by add+ at ! end !
 foll[+ new subsection3  7d7 ,treatm5t (
 c]ta9 compla9ts = purposes ( quality or
 p]=mance assessm5t ,9 conduct+ a       
quality or p]=mance assessm5t ( a ,,pdp 
sponsor1 ! ,secret>y %all develop or    
utilize exi/+ scre5+ me?ods = review+ & 
consid]+ compla9ts t are receiv$ f      

enrollees 9 a prescription drug plan    
(f]$ by su* ,,pdp sponsor & t are       
compla9ts reg>d+ ! lack ( access by !   
individual to prescription drugs due to 
a drug managem5t program = at-risk      
b5efici>ies4  4  7e7 ,,gao /udies &     
reports  7#a7 ,/udies ,! ,comptroll]    
,g5]al ( ! ,unit$ ,/ates %all conduct a 
/udy on ea* ( ! foll[+3 7,a7 ,!         
implem5tation ( ! am5dm5ts made by ?is  
section4  7,b7 ,! effectiv5ess ( !      
at-risk b5efici>ies = prescription drug 
abuse drug managem5t programs au?oriz$  
by section #ahfj;,d-#d7;c77#e7 ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#aj7;c77#e771 z add$ by          
subsection 7a77#a71 includ+ an analysis 
(--  7i7 ! imp$im5ts1 if any1 t impair !
 ability ( individuals describ$ 9       
subp>agraph 7,c7 ( su* section          
#ahfj;,d-#d7;c77#e7 to access cl9ically 
appropriate levels ( prescription drugs2
 &  7ii7 ! types (-- 7,i7 individuals   
:o1 9 ! implem5tation ( su* section1 are
 det]m9$ to be individuals describ$ 9   

su* subp>agraph2 &  7,,ii7 prescrib]s & 
ph>macies t are select$ "u subp>agraph  
7,d7 ( su* section4  7#b7 ,reports ,n   
lat] ?an ,janu>y #a1 #bjaf1 !           
,comptroll] ,g5]al ( ! ,unit$ ,/ates    
%all beg9 "w1 ) respect to ea* /udy     
describ$ 9 p>agraph 7#a71 on a report t 
describes ! result ( su* /udy4 ,^u !    
completion ( ea* su* report1 su*        
,comptroll] ,g5]al %all submit ! report 
to ea* ( ! committees describ$ 9        
p>agraph 7#c74  7#c7 ,committees        
describ$ ,! committees describ$ 9 ?is   
p>agraph are ! foll[+3 7,a7 ,!          
,committee on ,ways & ,means ( ! ,h\se (
 ,repres5tatives4  7,b7 ,! ,committee on
 ,en]gy & ,comm]ce ( ! ,h\se (          
,repres5tatives4  7,c7 ,! ,committee on 
,f9ance ( ! ,s5ate4  7,d7 ,! ,committee 
on ,heal?1 ,education1 ,labor1 &        
,p5sions ( ! ,s5ate4  7,e7 ,! ,special  
,committee on ,ag+ ( ! ,s5ate4  7f7     
,effective date  7#a7 ,9 g5]al ,!       
am5dm5ts made by ?is section %all apply 
to prescription drug plans = plan ye>s  

beg9n+ on or aft] ,janu>y #a1 #bjag4    
7#b7 ,/akehold] meet+s prior to         
effective date  7,a7 ,9 g5]al ,n lat]   
?an ,janu>y #a1 #bjaf1 ! ,secret>y %all 
conv5e /akehold]s1 includ+ individuals  
entitl$ to b5efits "u "p ,a ( title     
,,xviii ( ! ,social ,security ,act or   
enroll$ "u "p ,b ( su* title ( su* ,act1
 advocacy gr\ps repres5t+ su*           
individuals1 cl9icians1 plan sponsors1  
entities delegat$ by plan sponsors1 &   
bioph>maceutical manufactur]s = input   
reg>d+ ! topics describ$ 9 subp>agraph  
7,b74  7,b7 ,topics describ$ ,! topics  
describ$ 9 ?is subp>agraph are ! topics 
(-- 7i7 ! impact on co/-%>+ & ensur+    
accessibility to prescription drugs =   
enrollees 9 prescription drug plans (   
,,pdp sponsors :o are at-risk           
b5efici>ies = prescription drug abuse 7z
 def9$ 9 p>agraph 7#e77;,c7 ( section   
#ahfj;,d-#d7;c7 ( ! ,social ,security   
,act 7#db ,u4,s4,c4 #aciew-#aj7;c7772   
7ii7 ! use ( an exp$it$ appeals process 
"u :i* su* an enrollee may appeal an    

id5tification ( su* enrollee z an       
at-risk b5efici>y = prescription drug   
abuse "u su* p>agraph 7simil> to !      
processes e/abli%$ "u ! ,m$ic>e         
,advantage program "u "p ,c ( title     
,,xviii ( ! ,social ,security ,act t    
all[ an automatic escalation to ext]nal 
review ( claims submitt$ "u su* "p72    
7iii7 ! types ( enrollees t %\ld be     
treat$ z exempt$ individuals1 z describ$
 9 clause 7ii7 ( su* p>agraph2  7iv7 !  
mann] 9 :i* t]ms & def9itions 9 p>agraph
 7#e7 ( su* section #ahfj;,d-#d7;c7 %\ld
 be appli$1 su* z ! use ( cl9ical       
appropriat5ess 9 det]m9+ :e!r an        
enrollee is an at-risk b5efici>y =      
prescription drug abuse z def9$ 9       
subp>agraph 7,c7 ( su* p>agraph 7#e72   
7v7 ! in=mation to be includ$ 9 !       
notices describ$ 9 subp>agraph 7,b7 (   
su* section & ! /&>dization ( su*       
notices2 &  7vi7 ) respect to a ,,pdp   
sponsor t e/abli%es a drug managem5t    
program = at-risk b5efici>ies "u su*    
p>agraph 7#e71 ! responsibilities ( su* 

,,pdp sponsor ) respect to !            
implem5tation ( su* program4  7g7       
,rulemak+ ,! ,secret>y %all promulgate  
regulations bas$ on ! input ga!r$       
pursuant to subsection 7f77#b77;,a74    
#ac4 ,guidance on application ( ,common 
,rule to cl9ical data regi/ries ,n lat] 
?an "o ye> aft] ! date ( ! enactm5t (   
?is section1 ! ,secret>y ( ,heal? &     
,human ,s]vices %all issue a            
cl>ification or modification ) respect  
to ! application ( subp>t ,a ( "p #df ( 
title #de1 ,code ( ,f$]al ,regulations1 
gov]n+ ! protection ( human subjects 9  
rese>* 7& commonly kn[n z ! ,common     
,rule71 to activities1 includ+ quality  
improvem5t activities1 involv+ cl9ical  
data regi/ries1 includ+ entities t are  
qualifi$ cl9ical data regi/ries pursuant
 to section #ahdh7m77#c77;,e7 ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#d7m77#c77;,e774  #ad4 ,elim9at+ 
c]ta9 civil money p5alties2 ga9%>+ /udy 
& report  7a7 ,elim9at+ civil money     
p5alties = inducem5ts to physicians to  

limit s]vices t are n m$ically necess>y 
7#a7 ,9 g5]al ,section #aabh;,a7b77#a7 (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #acbj;a-#g;a7b77#a77 is am5d$ by ins]t+
 m$ically necess>y aft] r$uce or limit4 
7#b7 ,effective date ,! am5dm5t made by 
p>agraph 7#a7 %all apply to paym5ts made
 on or aft] ! date ( ! enactm5t ( ?is   
,act4  7b7 ,ga9%>+ /udy & report ,n lat]
 ?an #ab 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 ) options = am5d+    
exi/+ fraud & abuse laws 91 &           
regulations relat$ to1 titles ,,xi &    
,,xviii ( ! ,social ,security ,act 7#db 
,u4,s4,c4 #cja et seq471 ?r\gh          
exceptions1 safe h>bors1 or o!r n>r[ly  
t>get$ provisions1 to p]mit ga9%>+      
arrangem5ts t o!rwise w\ld be subject to
 ! civil money p5alties describ$ 9      
p>agraphs 7#a7 & 7#b7 ( section         
#aabh;,a7b7 ( su* ,act 7#db ,u4,s4,c4   

#acbj;a-#g;a7b771 or simil> arrangem5ts 
betwe5 physicians & hospitals1 & 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 7z comp>$ to an hi/orical   
b5*m>k or o!r metric specifi$ by !      
,secret>y to det]m9e ! impact ( deliv]y 
& paym5t sy/em *anges "u su* title      
,,xviii on exp5ditures made "u su*      
title7 %\ld accrue to ! ,m$ic>e program 
"u title ,,xviii ( ! ,social ,security  
,act4  #ae4 ,modification ( ,m$ic>e home
 heal? surety bond condition (          
p>ticipation requirem5t ,section        
#ahfa7o77#g7 ( ! ,social ,security ,act 

7#db ,u4,s4,c4 #aciex7o77#g77 is am5d$  
to read z foll[s3  7#g7 provides !      
,secret>y ) a surety bond-- 7,a7 9 a =m 
specifi$ by ! ,secret>y & 9 an am\nt t  
is n less ?an ! m9imum ( #ej1jjj2 &     
7,b7 t ! ,secret>y det]m9es is          
comm5surate ) ! volume ( paym5ts to !   
home heal? ag5cy2 &  4  #af4 ,ov]sight (
 ,m$ic>e cov]age ( manual manipulation (
 ! sp9e to correct subluxation  7a7 ,9  
g5]al ,section #ahcc ( ! ,social        
,security ,act 7#db ,u4,s4,c4 #aciel7 is
 am5d$ by add+ at ! end ! foll[+ new    
subsection3  7z7 ,m$ical review ( sp9al 
subluxation s]vices  7#a7 ,9 g5]al ,!   
,secret>y %all implem5t a process = !   
m$ical review 7z describ$ 9 p>agraph    
7#b77 ( treatm5t by a *iropractor       
describ$ 9 section #ahfa7r77#e7 by means
 ( manual manipulation ( ! sp9e to      
correct a subluxation 7z describ$ 9 su* 
section7 ( an individual :o is enroll$  
"u ?is "p & apply su* process to su*    
s]vices furni%$ on or aft] ,janu>y #a1  
#bjag1 focus+ on s]vices su* z--  7,a7  

s]vices furni%$ by a su* a *iropractor  
^: patt]n ( bill+ is ab]rant comp>$ to  
pe]s2 &  7,b7 s]vices furni%$ by su* a  
*iropractor :o1 9 a prior p]iod1 has a  
s]vices d5ial p]c5tage 9 ! #he? p]c5tile
 or great]1 tak+ into consid]ation !    
ext5t t s]vice d5ials are ov]turn$ on   
appeal4  7#b7 ,m$ical review  7,a7      
,prior au?orization m$ical review  7i7  
,9 g5]al ,subject to clause 7ii71 !     
,secret>y %all use prior au?orization   
m$ical review = s]vices describ$ 9      
p>agraph 7#a7 t are furni%$ to an       
individual by a *iropractor describ$ 9  
section #ahfa7r77#e7 t are "p ( an      
episode ( treatm5t t includes m ?an #ab 
s]vices4 ,= purposes ( ! prec$+ s5t5ce1 
an episode ( treatm5t %all be det]m9$ by
 ! und]ly+ cause t ju/ifies ! ne$ =     
s]vices1 su* z a diagnosis code4  7ii7  
,end+ application ( prior au?orization  
m$ical review ,! ,secret>y %all end !   
application ( prior au?orization m$ical 
review "u clause 7i7 to s]vices describ$
 9 p>agraph 7#a7 by su* a *iropractor if

 ! ,secret>y det]m9es t ! *iropractor   
has a l[ d5ial rate "u su* prior        
au?orization m$ical review4 ,! ,secret>y
 may subsequ5tly reapply prior          
au?orization m$ical review to su*       
*iropractor if ! ,secret>y det]m9es x to
 be appropriate & ! *iropractor has1 9 !
 "t p]iod subsequ5t to ! det]m9ation by 
! ,secret>y ( a l[ d5ial rate ) respect 
to ! *iropractor1 furni%$ su* s]vices   
describ$ 9 p>agraph 7#a74  7iii7 ,e>ly  
reque/ = prior au?orization review      
p]mitt$ ,no?+ 9 ?is subsection %all be  
con/ru$ to prev5t su* a *iropractor f   
reque/+ prior au?orization = s]vices    
describ$ 9 p>agraph 7#a7 t are to be    
furni%$ to an individual be=e !         
*iropractor furni%es ! twelf? su* s]vice
 to su* individual = an episode (       
treatm5t4  7,b7 ,type ( review ,!       
,secret>y may use pre-paym5t review or  
po/-paym5t review ( s]vices describ$ 9  
section #ahfa7r77#e7 t are n subject to 
prior au?orization m$ical review "u     
subp>agraph 7,a74  7,c7 ,relation%ip to 

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$4  7#c7 ,no
 paym5t )\t prior au?orization ,)       
respect to a s]vice describ$ 9 p>agraph 
7#a7 = :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%$1 ( :e!r ! s]vice w\ld
 or w\ld n meet ! applicable requirem5ts
 ( section #ahfb7;a77#a77;,a74  7,b7    
,d5ial ( paym5t ,subject to p>agraph    
7#e71 no paym5t may be made "u ?is "p = 
! s]vice unless ! ,secret>y det]m9es    
pursuant to subp>agraph 7,a7 t ! s]vice 
w\ld meet ! applicable requirem5ts ( su*
 section #ahfb7;a77#a77;,a74  7#d7      
,submission ( in=mation ,a *iropractor  
describ$ 9 section #ahfa7r77#e7 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$+ 
s5t5ce z soon z practicable4  7#e7      
,timel9ess ,if ! ,secret>y does n make a
 prior au?orization det]m9ation "u      
p>agraph 7#c77;,a7 )9 #ad bus9ess days (
 ! date ( ! receipt ( m$ical            
docum5tation ne$$ to make su*           
det]m9ation1 p>agraph 7#c77;,b7 %all n  
apply4  7#f7 ,application ( limitation  
on b5efici>y liability ,:]e paym5t may n
 be made z a result ( ! application (   
p>agraph 7#b77;,b71 section #ahgi %all  
apply 9 ! same mann] z su* section      
applies to a d5ial t is made by reason (
 section #ahfb7;a77#a74  7#g7 ,review by
 contractors ,! m$ical review describ$ 9
 p>agraph 7#b7 may be conduct$ by m$ic>e
 adm9i/rative contractors pursuant to   
section #ahgd;,a7a77#d77;,g7 or by any  
o!r contractor det]m9$ appropriate by ! 
,secret>y t is n a recov]y audit        
contractor4  7#h7 ,multiple s]vices ,!  
,secret>y %all1 :]e practicable1 apply !
 m$ical review "u ?is subsection 9 a    
mann] s z to all[ an individual describ$

 9 p>agraph 7#a7 to obta91 at a s+le "t 
r ?an on a s]vice-by-s]vice basis1 an   
au?orization 9 accordance ) p>agraph    
7#c77;,a7 = multiple s]vices4  7#i7     
,con/ruction ,) respect to a s]vice     
describ$ 9 p>agraph 7#a7 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#aj7 ,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$ical review "u ?is    
subsection4  4  7b7 ,improv+            
docum5tation ( s]vices  7#a7 ,9 g5]al ,!
 ,secret>y ( ,heal? & ,human ,s]vices   
%all1 9 consultation ) /akehold]s       
7includ+ ! ,am]ican ,*iropractic        
,association7 & repres5tatives ( m$ic>e 
adm9i/rative contractors 7z def9$ 9     
section #ahgd;,a7a77#c77;,a7 ( ! ,social

 ,security ,act 7#db ,u4,s4,c4          
#aciekk-#a7;a77#c77;,a7771 develop      
educational & tra9+ programs to improve 
! ability ( *iropractors to provide     
docum5tation to ! ,secret>y ( s]vices   
describ$ 9 section #ahfa7r77#e7 9 a     
mann] t demon/rates t su* s]vices are1 9
 accordance ) section #ahfb7;a77#a7 (   
su* ,act 7#db ,u4,s4,c4 #aciey7a77#a771 
reasonable & necess>y = ! diagnosis or  
treatm5t ( illness or injury or to      
improve ! function+ ( a mal=m$ body     
memb]4  7#b7 ,tim+ ,! ,secret>y %all    
make ! educational & tra9+ programs     
describ$ 9 p>agraph 7#a7 publicly       
available n lat] ?an ,janu>y #a1 #bjaf4 
7#c7 ,fund+ ,! ,secret>y %all use funds 
made available "u section #ahic7;h77#aj7
 ( ! ,social ,security ,act 7#db        
,u4,s4,c4 #acie;ddd7h77#aj771 z add$ by 
section #f1 to c>ry out ?is subsection4 
7c7 ,,gao /udy & report  7#a7 ,/udy ,!  
,comptroll] ,g5]al ( ! ,unit$ ,/ates    
%all conduct a /udy on ! effectiv5ess ( 
! process = m$ical review ( s]vices     

furni%$ z "p ( a treatm5t by means (    
manual manipulation ( ! sp9e to correct 
a subluxation implem5t$ "u subsection   
7z7 ( section #ahcc ( ! ,social         
,security ,act 7#db ,u4,s4,c4 #aciel71 z
 add$ by subsection 7a74 ,su* /udy %all 
include an analysis (--  7,a7 aggregate 
data on-- 7i7 ! numb] ( individuals1    
*iropractors1 & claims = s]vices subject
 to su* review2 &  7ii7 ! numb] (       
reviews conduct$ "u su* section2 &  7,b7
 ! outcomes ( su* reviews4  7#b7 ,report
 ,n lat] ?an f\r ye>s aft] ! date (     
enactm5t ( ?is ,act1 ! ,comptroll]      
,g5]al %all submit to ,congress a report
 conta9+ ! results ( ! /udy conduct$ "u 
p>agraph 7#a71 includ+ recomm5dations = 
su* legislation & adm9i/rative action ) 
respect to ! process = m$ical review    
implem5t$ "u subsection 7z7 ( section   
#ahcc ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #aciel7 z ! ,comptroll] ,g5]al
 det]m9es appropriate4  #ag4 ,national  
expansion ( prior au?orization model =  
repetitive s*$ul$ non-em]g5t ambulance  

transport  7a7 ,initial expansion  7#a7 
,9 g5]al ,9 implem5t+ ! model describ$ 9
 p>agraph 7#b7 propos$ to be te/$ "u    
subsection 7b7 ( section #aaae;,a ( !   
,social ,security ,act 7#db ,u4,s4,c4   
#acae;a71 ! ,secret>y ( ,heal? & ,human 
,s]vices %all revise ! te/+ "u          
subsection 7b7 ( su* section to cov]1   
effective n lat] ?an ,janu>y #a1 #bjaf1 
,/ates locat$ 9 m$ic>e adm9i/rative     
contractor 7,,mac7 regions ,l & #aa     
7consi/+ ( ,delaw>e1 ! ,di/rict (       
,columbia1 ,m>yl&1 ,new ,j]sey1         
,p5nsylvania1 ,nor? ,c>ol9a1 ,s\?       
,c>ol9a1 ,we/ ,virg9ia1 & ,virg9ia74    
7#b7 ,model describ$ ,! model describ$ 9
 ?is p>agraph is ! te/+ ( a model (     
prior au?orization = repetitive s*$ul$  
non-em]g5t ambulance transport propos$  
to be c>ri$ out 9 ,new ,j]sey1          
,p5nsylvania1 & ,s\? ,c>ol9a4  7#c7     
,fund+ ,! ,secret>y %all allocate funds 
made available "u section               
#aaae;,a7f77#a77;,b7 ( ! ,social        
,security ,act 7#db ,u4,s4,c4           

#acae;a7f77#a77;,b77 to c>ry out ?is    
subsection4  7b7 ,national expansion    
,section #ahcd7l7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #aciem7l77 is am5d$ 
by add+ at ! end ! foll[+ new p>agraph3 
7#af7 ,prior au?orization = repetitive  
s*$ul$ non-em]g5t ambulance transports  
7,a7 ,9 g5]al ,beg9n+ ,janu>y #a1 #bjag1
 if ! expansion to all ,/ates ( ! model 
( prior au?orization describ$ 9 p>agraph
 7#b7 ( section #ah7;a7 ( ! ,protect+ ! 
,integrity ( ,m$ic>e ,act ( #bjae meets 
! requirem5ts describ$ 9 p>agraphs 7#a7 
?r\gh 7#c7 ( section #aaae;,a7c71 !n !  
,secret>y %all exp& su* model to all    
,/ates4  7,b7 ,fund+ ,! ,secret>y %all  
use funds made available "u section     
#ahic7;h77#aj7 to c>ry out ?is p>agraph4
  7,c7 ,cl>ification reg>d+ budget      
neutrality ,no?+ 9 ?is p>agraph may be  
con/ru$ to limit or modify ! application
 ( section #aaae;,a7b77#c77;,b7 to      
models describ$ 9 su* section1 includ+ )
 respect to ! model describ$ 9          
subp>agraph 7,a7 & exp&$ beg9n+ on      

,janu>y #a1 #bjag1 "u su* subp>agraph4  
4  #ah4 ,repeal+ duplicative ,m$ic>e    
second>y payor provision  7a7 ,9 g5]al  
,section #ahfb7;b77#e7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#aciey7b77#e77 is am5d$ by ins]t+ at !  
end ! foll[+ new subp>agraph3  7,e7 ,end
 date ,! provisions ( ?is p>agraph %all 
n apply to in=mation requir$ to be      
provid$ on or aft] ,july #a1 #bjaf4  4  
7b7 ,effective date ,! am5dm5t made by  
subsection 7a7 %all take effect on !    
date ( ! enactm5t ( ?is ,act & %all     
apply to in=mation requir$ to be provid$
 on or aft] ,janu>y #a1 #bjaf4  #ai4    
,plan = exp&+ data 9 annual ,,c]t report
 ,n lat] ?an ,june #cj1 #bjae1 !        
,secret>y ( ,heal? & ,human ,s]vices    
%all submit to ! ,committee on ,f9ance (
 ! ,s5ate1 & to ! ,committees on ,en]gy 
& ,comm]ce & on ,ways & ,means ( ! ,h\se
 ( ,repres5tatives--  7#a7 a plan =     
includ+1 9 ! annual report ( !          
,compreh5sive ,error ,rate ,te/+ 7,,c]t7
 program1 data on s]vices 7or gr\p+s (  

s]vices7 7o!r ?an m$ical visits7 paid "u
 ! physician fee s*$ule "u section #ahdh
 ( ! ,social ,security ,act 7#db        
,u4,s4,c4 #aciew-#d7 :]e ! fee s*$ule   
am\nt is 9 excess ( #bej doll>s & :]e ! 
error rate is 9 excess ( #bj p]c5t2 &   
7#b7 to ! ext5t practicable by su* date1
 specific examples ( s]vices describ$ 9 
p>agraph 7#a74  #bj4 ,remov+ funds =    
,m$ic>e ,improvem5t ,fund add$ by       
,,impact ,act ( #bjad ,section          
#ahih7;b77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acie;iii7b77#a771 z    
am5d$ by section #c7;e77#c7 ( ! ,,impact
 ,act ( #bjad 7,public ,law #aac-ahe71  
is am5d$ by /rik+ #aie1jjj1jjj & ins]t+ 
#j4  #ba4 ,rule ( con/ruction ,except z 
explicitly provid$ 9 ?is ,act1 no?+ 9   
?is ,act1 includ+ ! am5dm5ts made by ?is
 ,act1 %all be con/ru$ z prev5t+ ! use (
 notice & comm5t rulemak+ 9 !           
implem5tation ( ! provisions (1 & !     
am5dm5ts made by1 ?is ,act4  ,m>* #ah1  
#bjae,report$ f ! ,committee on ,ways & 
,means ) an amendment,march #ah1 #bjae  

,! ,committee on ,en]gy & ,comm]ce      
dis*>g$2 committ$ to ! ,committee ( !   
,:ole ,h\se on ! ,/ate ( ! ,union &     
ord]$ to be pr9t$