,,ii  #aad? ,,congress  #a/ ,session    
,h4 ,r4 #b  ,,9 ,,! ,,s5ate ,,( ,,!     
,,unit$ ,,/ates  ,m>* #bf1 #bjae,receiv$
  ,,an ,,act  ,to am5d title ,,xviii ( !
 ,social ,security ,act to repeal !     
,m$ic>e su/a9able gr[? rate & /r5g!n    
,m$ic>e access by improv+ physician     
paym5ts & mak+ o!r improvem5ts1 to      
reau?orize ! ,*ildr5's ,heal? ,insurance
 ,program1 & = o!r purposes4  #a4 ,%ort 
title2 table ( cont5ts  7a7 ,%ort title 
,?is ,act may be cit$ z ! ,m$ic>e       
,access & ,,*ip ,reau?orization ,act (  
#bjae4  7b7 ,table ( cont5ts ,! table ( 
cont5ts ( ?is ,act is z foll[s3  ,sec4  
#a4 ,%ort title2 table ( cont5ts4 ,title
 ,i--,,sgr ,repeal & ,m$ic>e ,provid]   
,paym5t ,mod]nization ,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 ,emp[]+    
b5efici>y *oices ?r\gh cont9u$ access to

 in=mation on physicians' s]vices4 ,sec4
 #aje4 ,exp&+ availability ( ,m$ic>e    
data4 ,sec4 #ajf4 ,r$uc+ adm9i/rative   
burd5 & o!r provisions4 ,title          
,,ii--,m$ic>e & ,o!r ,heal? ,ext5d]s    
,subtitle ,a--,m$ic>e ,ext5d]s ,sec4    
#bja4 ,ext5sion ( "w ,,gpci floor4 ,sec4
 #bjb4 ,ext5sion ( !rapy cap exceptions 
process4 ,sec4 #bjc4 ,ext5sion (        
ambulance add-ons4 ,sec4 #bjd4 ,ext5sion
 ( increas$ inpati5t hospital paym5t    
adju/m5t = c]ta9 l[-volume hospitals4   
,sec4 #bje4 ,ext5sion ( !               
,m$ic>e-dep5d5t hospital 7,,mdh7        
program4 ,sec4 #bjf4 ,ext5sion =        
specializ$ ,m$ic>e ,advantage plans =   
special ne$s individuals4 ,sec4 #bjg4   
,ext5sion ( fund+ = quality measure     
endorsem5t1 input1 & selection4 ,sec4   
#bjh4 ,ext5sion ( fund+ outrea* &       
assi/ance = l[-income programs4 ,sec4   
#bji4 ,ext5sion & transition (          
reasonable co/ reimbursem5t contracts4  
,sec4 #baj4 ,ext5sion ( home heal? rural
 add-on4 ,subtitle ,b--,o!r ,heal?      

,ext5d]s ,sec4 #baa4 ,p]man5t ext5sion (
 ! qualify+ individual 7,,qi7 program4  
,sec4 #bab4 ,p]man5t ext5sion (         
transitional m$ical assi/ance 7,,tma74  
,sec4 #bac4 ,ext5sion ( special diabetes
 program = type ,i diabetes & =         
,indians4 ,sec4 #bad4 ,ext5sion (       
ab/95ce education4 ,sec4 #bae4 ,ext5sion
 ( p]sonal responsibility education     
program 7,,prep74 ,sec4 #baf4 ,ext5sion 
( fund+ = family-to-family heal?        
in=mation c5t]s4 ,sec4 #bag4 ,ext5sion (
 heal? work=ce demon/ration project =   
l[-income individuals4 ,sec4 #bah4      
,ext5sion ( mat]nal1 infant1 & e>ly     
*ildhood home visit+ programs4 ,sec4    
#bai4 ,t5nessee ,,d% allotm5t = fiscal  
ye>s #bjae ?r\gh #bjbe4 ,sec4 #bbj4     
,delay 9 effective date = ,m$icaid      
am5dm5ts relat+ to b5efici>y liability  
settlem5ts4 ,sec4 #bba4 ,ext5sion (     
fund+ = community heal? c5t]s1 !        
,national ,heal? ,s]vice ,corps1 & tea*+
 heal? c5t]s4 ,title ,,iii--,,*ip ,sec4 
#cja4 #b-ye> ext5sion ( ! ,*ildr5's     

,heal? ,insurance ,program4 ,sec4 #cjb4 
,ext5sion ( express lane eligibility4   
,sec4 #cjc4 ,ext5sion ( outrea* &       
enrollm5t program4 ,sec4 #cjd4 ,ext5sion
 ( c]ta9 programs & demon/ration        
projects4 ,sec4 #cje4 ,report (         
,inspector ,g5]al ( ,,hhs on use (      
express lane option "u ,m$icaid & ,,*ip4
 ,title ,,iv--,(fsets ,subtitle         
,a--,m$ic>e ,b5efici>y ,re=ms ,sec4     
#dja4 ,limitation on c]ta9 m$igap       
policies = newly eligible ,m$ic>e       
b5efici>ies4 ,sec4 #djb4 ,income-relat$ 
premium adju/m5t = p>ts ,b & ,d4        
,subtitle ,b--,o!r ,(fsets ,sec4 #daa4  
,m$ic>e paym5t updates = po/-acute      
provid]s4 ,sec4 #dab4 ,delay ( r$uction 
to ,m$icaid ,,d% allotm5ts4 ,sec4 #dac4 
,levy on del9qu5t provid]s4 ,sec4 #dad4 
,adju/m5ts to inpati5t hospital paym5t  
rates4 ,title ,v--,miscellane\s         
,subtitle ,a--,protect+ ! ,integrity (  
,m$ic>e ,sec4 #eja4 ,prohibition (      
inclusion ( ,social ,security acc\nt    
numb]s on ,m$ic>e c>ds4 ,sec4 #ejb4     

,prev5t+ wrongful ,m$ic>e paym5ts =     
items & s]vices furni%$ to inc>c]at$    
individuals1 individuals n lawfully     
pres5t1 & deceas$ individuals4 ,sec4    
#ejc4 ,consid]ation ( measures reg>d+   
,m$ic>e b5efici>y sm>t c>ds4 ,sec4 #ejd4
 ,modify+ ,m$ic>e durable m$ical        
equipm5t face-to-face enc\nt]           
docum5tation requirem5t4 ,sec4 #eje4    
,r$uc+ improp] ,m$ic>e paym5ts4 ,sec4   
#ejf4 ,improv+ s5ior ,m$ic>e patrol &   
fraud report+ rew>ds4 ,sec4 #ejg4       
,requir+ valid prescrib] ,national      
,provid] ,id5tifi]s on ph>macy claims4  
,sec4 #ejh4 ,option to receive ,m$ic>e  
,summ>y ,notice electronically4 ,sec4   
#eji4 ,r5ewal ( ,,mac contracts4 ,sec4  
#eaj4 ,/udy on pa?way = inc5tives to    
,/ates = ,/ate p>ticipation 9 m$icaid   
data mat* program4 ,sec4 #eaa4 ,guidance
 on application ( ,common ,rule to      
cl9ical data regi/ries4 ,sec4 #eab4     
,elim9at+ c]ta9 civil money p5alties2   
ga9%>+ /udy & report4 ,sec4 #eac4       
,modification ( ,m$ic>e home heal?      

surety bond condition ( p>ticipation    
requirem5t4 ,sec4 #ead4 ,ov]sight (     
,m$ic>e cov]age ( manual manipulation ( 
! sp9e to correct subluxation4 ,sec4    
#eae4 ,national expansion ( prior       
au?orization model = repetitive s*$ul$  
non-em]g5t ambulance transport4 ,sec4   
#eaf4 ,repeal+ duplicative ,m$ic>e      
second>y payor provision4 ,sec4 #eag4   
,plan = exp&+ data 9 annual ,,c]t       
report4 ,sec4 #eah4 ,remov+ funds =     
,m$ic>e ,improvem5t ,fund add$ by       
,,impact ,act ( #bjad4 ,sec4 #eai4 ,rule
 ( con/ruction4 ,subtitle ,b--,o!r      
provisions ,sec4 #eba4 ,ext5sion (      
two-midnight ,,pama rules on c]ta9      
m$ical review activities4 ,sec4 #ebb4   
,requir+ bid surety bonds & ,/ate       
lic5sure = entities submitt+ bids "u !  
,m$ic>e ,,dmepos competitive acquisition
 program4 ,sec4 #ebc4 ,paym5t = global  
surgical packages4 ,sec4 #ebd4 ,ext5sion
 ( ,secure ,rural ,s*ools & ,community  
,self-,det]m9ation ,act ( #bjjj4 ,sec4  
#ebe4 ,exclusion f ,,paygo scorec>ds4   

,i ,,sgr ,repeal & ,m$ic>e ,provid]     
,paym5t ,mod]nization  #aja4 ,repeal+ ! 
su/a9able gr[? rate 7,,sgr7 & improv+   
,m$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$-- 7,a7 9  
subsection 7d7--  7i7 9 p>agraph        
7#a77;,a7-- 7,i7 by ins]t+ & end+ )     
#bjbe aft] beg9n+ ) #bjja2 &  7,,ii7 by 
ins]t+ or a subsequ5t p>agraph aft]     
p>agraph 7#d72 &  7ii7 9 p>agraph 7#d7--
  7,i7 9 ! head+1 by ins]t+ & end+ )    
#bjad aft] ye>s beg9n+ ) #bjja2 &       
7,,ii7 9 subp>agraph 7,a71 by ins]t+ &  
end+ ) #bjad aft] a ye> beg9n+ ) #bjja2 
&  7,b7 9 subsection 7f7-- 7i7 9        
p>agraph 7#a77;,b71 by ins]t+ ?r\gh     
#bjad aft] ( ea* succe$+ ye>2 &  7ii7 9 
p>agraph 7#b71 9 ! matt] prec$+         
subp>agraph 7,a71 by ins]t+ & end+ )    
#bjad aft] beg9n+ ) #bjjj4  7#b7 ,update
 ( rates = #bjae & subsequ5t ye>s       
,subsection 7d7 ( section #ahdh ( !     

,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#d7 is am5d$--  7,a7 9 p>agraph  
7#a77;,a71 by add+ at ! end ! foll[+3   
,!re %all be two sep>ate conv]sion      
factors = ea* ye> beg9n+ ) #bjbf1 "o =  
items & s]vices furni%$ by a qualify+   
,,apm p>ticipant 7z def9$ 9 section     
#ahcc7z77#b77 7ref]r$ to 9 ?is          
subsection z ! qualify+ ,,apm conv]sion 
factor7 & ! o!r = o!r items & s]vices   
7ref]r$ to 9 ?is subsection z !         
nonqualify+ ,,apm conv]sion factor71    
equal to ! respective conv]sion factor =
 ! previ\s ye> 7or1 9 ! case ( #bjbf1   
equal to ! s+le conv]sion factor =      
#bjbe7 multipli$ by ! update e/abli%$ "u
 p>agraph 7#bj7 = su* respective        
conv]sion factor = su* ye>42  7,b7 9    
p>agraph 7#a77;,d71 by ins]t+ 7or1      
beg9n+ ) #bjbf1 applicable conv]sion    
factor7 aft] s+le conv]sion factor2 &   
7,c7 by /rik+ p>agraph 7#af7 & ins]t+ ! 
foll[+ new p>agraphs3  7#af7 ,update =  
,janu>y ?r\gh ,june ( #bjae ,subject to 
p>agraphs 7#g77;,b71 7#h77;,b71         

7#i77;,b71 7#aj77;,b71 7#aa77;,b71      
7#ab77;,b71 7#ac77;,b71 7#ad77;,b71 &   
7#ae77;,b71 9 lieu ( ! update to ! s+le 
conv]sion factor e/abli%$ 9 p>agraph    
7#a77;,c7 t w\ld o!rwise apply = #bjae =
 ! p]iod beg9n+ on ,janu>y #a1 #bjae1 & 
end+ on ,june #cj1 #bjae1 ! update to ! 
s+le conv]sion factor %all be #j4j      
p]c5t4  7#ag7 ,update = ,july ?r\gh     
,decemb] ( #bjae ,! update to ! s+le    
conv]sion factor e/abli%$ 9 p>agraph    
7#a77;,c7 = ! p]iod beg9n+ on ,july #a1 
#bjae1 & end+ on ,decemb] #ca1 #bjae1   
%all be #j4e p]c5t4  7#ah7 ,update =    
#bjaf ?r\gh #bjai ,! update to ! s+le   
conv]sion factor e/abli%$ 9 p>agraph    
7#a77;,c7 = #bjaf & ea* subsequ5t ye>   
?r\gh #bjai %all be #j4e p]c5t4  7#ai7  
,update = #bjbj ?r\gh #bjbe ,! update to
 ! s+le conv]sion factor e/abli%$ 9     
p>agraph 7#a77;,c7 = #bjbj & ea*        
subsequ5t ye> ?r\gh #bjbe %all be #j4j  
p]c5t4  7#bj7 ,update = #bjbf &         
subsequ5t ye>s ,= #bjbf & ea* subsequ5t 
ye>1 ! update to ! qualify+ ,,apm       

conv]sion factor e/abli%$ "u p>agraph   
7#a77;,a7 is #j4ge p]c5t1 & ! update to 
! nonqualify+ ,,apm conv]sion factor    
e/abli%$ "u su* p>agraph is #j4be p]c5t4
  4  7#c7 ,med,p,a,c reports  7,a7      
,initial report ,n lat] ?an ,july #a1   
#bjag1 ! ,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 #bjba1 ! ,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$ic>e ,n lat]  
?an ,july #a1 #bjai1 ! ,m$ic>e ,paym5t  
,advisory ,commission %all submit to    
,congress a report on--  7i7 ! paym5t   
update = pr(essional s]vices appli$ "u !
 ,m$ic>e program "u title ,,xviii ( !   
,social ,security ,act = ! p]iod ( ye>s 
#bjae ?r\gh #bjai2  7ii7 ! effect ( su* 
update on ! effici5cy1 economy1 &       
quality ( c>e provid$ "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$-- 7i7 9
 clause 7i71 by /rik+ #bjae or any      
subsequ5t paym5t ye> & ins]t+ ea* (     
#bjae ?r\gh #bjah2  7ii7 9 clause       
7ii77,,iii71 by /rik+ ea* subsequ5t ye> 
& ins]t+ #bjah2 &  7iii7 9 clause       
7iii7--  7,i7 9 ! head+1 by /rik+ &     
subsequ5t ye>s2  7,,ii7 by /rik+ & ea*  
subsequ5t ye>2 &  7,,iii7 by /rik+ 1 b 9
 no case %all ! applicable p]c5t be less
 ?an #ie p]c5t4  7,b7 ,cont9uation (    
mean+ful use det]m9ations = ,,mips      
,section #ahdh7o77#b7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7o77#b77 is am5d$--  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 #bjai & 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+ ea* ( #bjae ?r\gh
 #bjah2 &  7ii7 9 clause 7ii77,,ii71 by 

/rik+ & ea* subsequ5t ye> & ins]t+ 1    
#bjag1 & #bjah4  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 ) respect to specific physicians 
& gr\ps ( physicians ! ,secret>y        
det]m9es appropriate1 & = s]vices       
furni%$ on or aft] ,janu>y #a1 #bjag1 ) 
respect to all physicians & gr\ps (     
physicians4 ,su* paym5t modifi] %all n  
be appli$ = items & s]vices furni%$ on  
or aft] ,janu>y #a1 #bjai4  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 #bjai & 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 
,not)/&+ subp>agraph 7,c77ii71 "u !     
,,mips1 ! ,secret>y %all p]mit any      
eligible pr(essional 7z def9$ 9         
subsection 7k77#c77;,b77 to report on   
applicable measures & activities        
describ$ 9 p>agraph 7#b77;,b74  7,b7    
,program implem5tation ,! ,,mips %all   
apply to paym5ts = items & s]vices      
furni%$ on or aft] ,janu>y #a1 #bjai4   
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#b771 & 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,i71 su* o!r eligible        
pr(essionals 7z def9$ 9 subsection      
7k77#c77;,b77 z specifi$ by ! ,secret>y1
 & 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 #bjai & #bjbj1 ! 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 #bjba & #bjbb-- 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 #bjbc & 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 & :o1 = ! p]=mance    
p]iod = su* ye>1 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$4 
7,e7 ,use ( regi/ries ,"u ! ,,mips1 !   
,secret>y %all enc\rage ! use ( qualifi$
 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
 #b7;d7 ( ! ,improv+ ,m$ic>e ,po/-,acute
 ,c>e ,trans=mation ,act ( #bjad1 &1 z  
appropriate1 o!r in=mation1 includ+     
in=mation collect$ be=e completion ( su*

 /udies & recomm5dations1 ! ,secret>y1  
on an ongo+ basis1 %all1 z ! ,secret>y  
det]m9es appropriate & bas$ on an       
individual's heal? /atus & o!r risk     
factors--  7,i7 assess appropriate      
adju/m5ts to quality measures1 res\rce  
use measures1 & o!r measures us$ "u !   
,,mips2 &  7,,ii7 assess & implem5t     
appropriate adju/m5ts to 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   
su* z same day appo9tm5ts = urg5t ne$s &
 aft] h\rs access to cl9ician advice4   
7,,ii7 ,! subcategory ( population      
managem5t1 su* z monitor+ heal?         
conditions ( individuals to provide     
timely heal? c>e int]v5tions or         
p>ticipation 9 a qualifi$ cl9ical data  
regi/ry4  7,,iii7 ,! subcategory ( c>e  
coord9ation1 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 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 ( items &   
s]vices furni%$ by em]g5cy physicians1  
radiologi/s1 & ane/hesiologi/s4  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$ specialty 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 9 ! f9al li/ (   
measures publi%$ "u clause 7i7 = a ye>1 
! ,secret>y %all submit = publication 9 
applicable specialty-appropriate1       
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 or p]=mance 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+ ) #bjai74   
,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 = c]tification

 ,a ,,mips eligible pr(essional :o is 9 
a practice t is c]tifi$ z a pati5t-c5t]$
 m$ical home or comp>able specialty     
practice1 z det]m9$ by ! ,secret>y1 )   
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       
,subject to clause 7i71 "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 & clause
 7ii71 ! 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$+ s5t5ce
 = su* ye>4  7,f7 ,c]ta9 flexibility =  
weight+ p]=mance categories1 measures1 &
 activities ,"u ! me?odology "u         
subp>agraph 7,a71 if !re are n suffici5t
 measures & activities 7describ$ 9      
p>agraph 7#b77;,b77 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 ) respect
 to ! p]=mance categories describ$ 9    
clauses 7i7 & 7ii7 ( p>agraph           
7#b77;,a7--  7,i7 ! assessm5t ( p]=mance
 provid$ "u su* me?odology ) respect to 
su* p]=mance categories 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 ) respect to ! composite p]=mance
 score provid$ "u ?is p>agraph = su*    
p]=mance p]iod = ea* su* ,,mips eligible
 pr(essional 9 su* virtual gr\p1 !      
compon5ts ( ! composite p]=mance score t
 assess p]=mance ) respect to su*       
p]=mance categories %all be bas$ on !   
assessm5t ( ! comb9$ p]=mance "u        
subclause 7,i7 = su* p]=mance categories
 & p]=mance p]iod4  7ii7 ,election (    
practices to be a virtual gr\p ,!       

,secret>y %all1 9 accordance ) !        
requirem5ts "u 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> to  
be a virtual gr\p "u ?is subp>agraph )  
at lea/ "o o!r su* individual ,,mips    
eligible pr(essional or gr\p practice4  
,su* a virtual gr\p may be bas$ on      
appropriate classifications ( provid]s1 
su* z by geographic areas or by provid] 
specialties def9$ by nationally         
recogniz$ specialty bo>ds ( c]tification
 or equival5t c]tification bo>ds4  7iii7
 ,requirem5ts ,! requirem5ts = ! process
 "u clause 7ii7 %all-- 7,i7 provide t an
 election "u su* clause1 ) respect to a 
p]=mance p]iod1 %all be made be=e !     
beg9n+ ( su* p]=mance p]iod & may n be  
*ang$ dur+ su* p]=mance p]iod2  7,,ii7  
provide t an individual ,,mips eligible 
pr(essional & a gr\p practice describ$ 9
 clause 7ii7 may elect to be 9 no m ?an 

"o virtual gr\p = a p]=mance p]iod & t1 
9 ! case ( su* a gr\p practice t elects 
to be 9 su* virtual gr\p = su* p]=mance 
p]iod1 su* election applies to all      
,,mips eligible pr(essionals 9 su* gr\p 
practice2  7,,iii7 provide t a virtual  
gr\p be a comb9ation ( tax id5tification
 numb]s2  7,,iv7 provide = =mal writt5  
agreem5ts among ,,mips eligible         
pr(essionals elect+ to be a virtual gr\p
 "u ?is subp>agraph2 &  7,v7 include su*
 o!r requirem5ts z ! ,secret>y det]m9es 
appropriate4  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 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 = #bjai1 #d
 p]c5t2  7ii7 = #bjbj1 #e p]c5t2  7iii7 

= #bjba1 #g p]c5t2 &  7iv7 = #bjbb &    
subsequ5t ye>s1 #i p]c5t4  7,c7         
,additional ,,mips adju/m5t factors =   
exceptional p]=mance ,= #bjai & ea*     
subsequ5t ye> ?r\gh #bjbd1 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       
subp>agraph 7,f77iv71 ! ,secret>y %all  
specify an additional positive ,,mips   
adju/m5t factor = su* pr(essional & ye>4
 ,su* additional ,,mips adju/m5t factors
 %all be 9 ! =m ( a p]c5t & 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  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 ( ! mean or    
m$ian "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,c74 ,=
 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 det]m9$ "u 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,c74 ,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+ ) #bjai71
 ! 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,c7 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 !   
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 & ! additional adju/m5t factors "u 
clause 7iv7 %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  7,i7 ,9 g5]al
 ,subject to subclause 7,,ii71 9        
specify+ ! ,,mips additional adju/m5t   
factors "u subp>agraph 7,c7 = ea*       
applicable ,,mips eligible pr(essional =
 a ye>1 ! ,secret>y %all ensure t !     

e/imat$ aggregate 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     
#ejj1jjj1jjj = ea* ye> beg9n+ ) #bjai & 
end+ ) #bjbd4  7,,ii7 ,limitation on    
additional inc5tive paym5t adju/m5ts ,! 
,,mips additional adju/m5t factor "u    
subp>agraph 7,c7 = a ye> = an applicable
 ,,mips eligible pr(essional ^:         
composite p]=mance score is above !     
additional p]=mance ?re%old "u          
subp>agraph 7,d77ii7 = su* ye> %all n   
exce$ #aj p]c5t4 ,! application ( !     
previ\s s5t5ce may result 9 an aggregate
 am\nt ( additional inc5tive paym5ts t  
are less ?an ! am\nt specifi$ 9         
subclause 7,i74  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+ =       
te*nical assi/ance ,= 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 (           
#bj1jjj1jjj = ea* ( fiscal ye>s #bjaf   

?r\gh #bjbj4 ,am\nts transf]r$ "u ?is   
subp>agraph = a fiscal ye> %all be      
available until exp5d$4  7#ab7 ,fe$back 
& in=mation to improve p]=mance  7,a7   
,p]=mance fe$back  7i7 ,9 g5]al ,beg9n+ 
,july #a1 #bjag1 ! ,secret>y-- 7,i7 %all
 make available timely 7su* z qu>t]ly7  
confid5tial fe$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$back to su*    
pr(essionals on ! p]=mance ( su*        
pr(essionals ) respect to ! p]=mance    
categories "u clauses 7iii7 & 7iv7 ( su*
 p>agraph4  7ii7 ,me*anisms ,! ,secret>y
 may use "o or m me*anisms to make      
fe$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 #bjah1 ! ,secret>y   
%all make available to ,,mips eligible  
pr(essionals in=mation1 ) respect to    
individuals :o are pati5ts ( su* ,,mips 
eligible pr(essionals1 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 #ahii4
  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 7or factors7     
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;,c7 & ! 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 #bjba1 ! ,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 #bjag1 !
 ,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 #bjba1 ! ,comptroll] ,g5]al 
( ! ,unit$ ,/ates %all submit to        
,congress a report t exam9es !          
transition ( pr(essionals 9 rural areas1
 heal? pr(essional %ortage areas 7z     
designat$ 9 section #ccb7;a77#a77;,a7 ( 

! ,public ,heal? ,s]vice ,act71 or      
m$ically und]s]v$ areas to an alt]native
 paym5t model 7z def9$ 9 section        
#ahcc7z77#c7 ( ! ,social ,security ,act1
 z add$ by subsection 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 #bjae ?r\gh #bjai4 ,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 = #bjaf & 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 = #bjaf & 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$-- 7,a7  
by /rik+ & subsequ5t ye>s & ins]t+ ?r\gh
 report+ p]iods occurr+ 9 #bjae2 &  7,b7
 by ins]t+ &1 = report+ p]iods occurr+ 9
 #bjaf & subsequ5t ye>s1 ! ,secret>y may
 e/abli% aft] %all e/abli%4  7#c7       
,physician fe$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+ ) #bjag ,reports "u 
! ,program %all n be provid$ aft]       
,decemb] #ca1 #bjag4 ,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 ! ,physician-,focus$ ,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 physician-focus$ 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 ?is p>agraph 7n to exce$   
#e1jjj1jjj7 = fiscal ye> #bjae & 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      
#bjaf1 ! ,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 ,committee   
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+ ) #bjai & end+ ) #bjbd & =
 :i* ! pr(essional is a qualify+ ,,apm  
p>ticipant ) respect to su* ye>1 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 ( ! e/imat$ aggregate
 paym5t am\nts = su* 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$+ ye> t is less ?an ! full ye>4
 ,! ,secret>y %all e/abli% policies to  
implem5t ?is subp>agraph 9 cases 9 :i*  
paym5t = cov]$ pr(essional s]vices      
furni%$ by a qualify+ ,,apm p>ticipant 9
 an alt]native paym5t model--  7i7 is   
made to an eligible alt]native paym5t   
entity r ?an directly to ! qualify+     
,,apm p>ticipant2 or  7ii7 is made on a 
basis o!r ?an a fee-=-s]vice basis 7su* 
z paym5t on a capitat$ basis74  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 "u ?is subsection or  
subsection 7m7 %all be det]m9$ )\t reg>d
 to any additional paym5t "u subsection 
7m7 & ?is subsection1 respectively4 ,!  

am\nt ( ! additional paym5t "u ?is      
subsection or subsection 7x7 %all be    
det]m9$ )\t reg>d to any additional     
paym5t "u subsection 7x7 & ?is          
subsection1 respectively4 ,! am\nt ( !  
additional paym5t "u ?is subsection or  
subsection 7y7 %all be det]m9$ )\t reg>d
 to any additional paym5t "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 #bjai & #bjbj ,) respect to
 #bjai & #bjbj1 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 eligible     
alt]native paym5t entity4  7,b7 #bjba & 
#bjbb ,) respect to #bjba & #bjbb1 an   
eligible pr(essional describ$ 9 ei!r ( !
 foll[+ clauses3  7i7 ,m$ic>e paym5t    

?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 eligible     
alt]native paym5t entity4  7ii7         
,comb9ation all-pay] & ,m$ic>e paym5t   
?re%old option ,an eligible             
pr(essional-- 7,i7 = :om ! ,secret>y    
det]m9es1 ) respect to items & s]vices  
furni%$ 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 & 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      
eligible alt]native paym5t entity2 &    
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 to an eligible     
alt]native paym5t entity2 &  7,,ii7 !   
requirem5t describ$ 9 ?is subclause1 )  
respect to paym5ts describ$ 9 item 7bb7 
( su* clause1 is t su* paym5ts are made 

"u arrangem5ts 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$2 &  7cc7 
! eligible pr(essional p>ticipates 9 an 
entity t-- 7,,aa7 be>s m ?an nom9al     
f9ancial risk if actual aggregate       
exp5ditures exce$s expect$ aggregate    
exp5ditures2 or 7,,bb7 ) respect to     
b5efici>ies "u title ,,xix1 is a m$ical 
home t meets crit]ia comp>able to m$ical
 homes exp&$ "u section #aaae;,a7c74    
7,c7 ,beg9n+ 9 #bjbc ,) respect to #bjbc
 & ea* subsequ5t ye>1 an eligible       
pr(essional describ$ 9 ei!r ( ! foll[+  
clauses3  7i7 ,m$ic>e paym5t ?re%old    
option ,an eligible pr(essional = :om ! 
,secret>y det]m9es t at lea/ #ge p]c5t (
 paym5ts "u ?is "p = cov]$ 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 eligible alt]native     

paym5t entity4  7ii7 ,comb9ation        
all-pay] & ,m$ic>e paym5t ?re%old option
 ,an eligible pr(essional-- 7,i7 = :om !
 ,secret>y det]m9es1 ) respect to items 
& s]vices furni%$ 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 & 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 eligible alt]native     
paym5t entity2 &  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 
to an eligible alt]native paym5t entity2
 &  7,,ii7 ! requirem5t describ$ 9 ?is  
subclause1 ) respect to paym5ts describ$
 9 item 7bb7 ( su* clause1 is t su*     
paym5ts are made "u arrangem5ts 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$2 &  
7cc7 ! eligible pr(essional p>ticipates 
9 an entity t-- 7,,aa7 be>s m ?an nom9al
 f9ancial risk if actual aggregate      
exp5ditures exce$s expect$ aggregate    

exp5ditures2 or 7,,bb7 ) respect to     
b5efici>ies "u title ,,xix1 is a m$ical 
home t meets crit]ia comp>able to m$ical
 homes exp&$ "u section #aaae;,a7c74    
7,d7 ,use ( pati5t approa* ,! ,secret>y 
may base ! det]m9ation ( :e!r an        
eligible pr(essional is a qualify+ ,,apm
 p>ticipant "u ?is subsection & !       
det]m9ation ( :e!r an eligible          
pr(essional is a p>tial qualify+ ,,apm  
p>ticipant "u section                   
#ahdh7q77#a77;,c77iii7 by us+ c\nts (   
pati5ts 9 lieu ( us+ paym5ts & us+ !    
same or simil> p]c5tage crit]ia 7z      
specifi$ 9 ?is subsection & su* section1
 respectively71 z ! ,secret>y det]m9es  
appropriate4  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;,b7 & includes a  
gr\p t includes su* pr(essionals4  7,c7 

,alt]native paym5t model 7,,apm7 ,! t]m 
alt]native paym5t model means1 o!r ?an =
 purposes ( subp>agraphs                
7,b77ii77,i77bb7 & 7,c77ii77,i77bb7 (   
p>agraph 7#b71 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$]al  
law4  7,d7 ,eligible alt]native paym5t  
entity ,! t]m eligible alt]native paym5t
 entity means1 ) respect to a ye>1 an   
entity t-- 7i7 p>ticipates 9 an         
alt]native paym5t model t--  7,i7       
requires p>ticipants 9 su* model to use 
c]tifi$ ,,ehr te*nology 7z def9$ 9      
subsection 7o77#d772 &  7,,ii7 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 &  7ii7
  7,i7 be>s f9ancial risk = monet>y     
losses "u su* alt]native paym5t 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 entity is an 
eligible alt]native paym5t entity "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$icaid & ,,*ip ,s]vices4  2 &  7,b7 9 
subp>agraph 7,c77viii71 by /rik+ o!r    
public sector or private sector pay]s & 
ins]t+ o!r public sector pay]s1 private 
sector pay]s1 or /atewide paym5t models4
  7#e7 ,con/ruction reg>d+ teleheal?    
s]vices ,no?+ 9 ! provisions (1 or      
am5dm5ts made by1 ?is title %all be     
con/ru$ 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$ic>e ,advantage alt]native
 paym5t models ,n lat] ?an ,july #a1    
#bjaf1 ! ,secret>y ( ,heal? & ,human    
,s]vices %all submit to ,congress a /udy
 t exam9es ! feasibility ( integrat+    
alt]native paym5t models 9 ! ,m$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$uce su*       
vuln]ability4  7f7 ,collaborat+ ) !     
physician1 practition]1 & o!r /akehold] 
communities ,to improve res\rce use     
measurem5t ,section #ahdh ( ! ,social   
,security ,act 7#db ,u4,s4,c4           
#aciew-#d71 z am5d$ 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$+    
provisions ( ?is p>agraph4  7,b7 ,public
 availability ( exi/+ ef=ts to design an
 episode gr\p] ,n lat] ?an #ahj days    
aft] ! date ( ! enactm5t ( ?is          
subsection1 ! ,secret>y %all po/ on !   
,int]net website ( ! ,c5t]s = ,m$ic>e   
,m$icaid ,s]vices a li/ ( ! episode     
gr\ps develop$ pursuant to subsection   
7n77#i77;,a7 & relat$ descriptive       
in=mation4  7,c7 ,/akehold] input ,!    
,secret>y %all accept1 ?r\gh ! date t is
 #abj 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$  ( exp5ditures "u p>ts ,a &  
,b 7) su* t>get increas+ ov] "t z       
appropriate72 &  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 occurs1 & !    
pr9cipal proc$ures or s]vices 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 ( a   
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 #bgj 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 #abj 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 #bgj 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+ ) #bjah71 
! ,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 "o ye>   
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 #abj 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 web-bas$ =ums1 or
 o!r appropriate me*anisms4  7,e7       

,op]ational li/ ( pati5t relation%ip    
categories & codes ,n lat] ?an #bdj 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+ ) #bjah71 ! ,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      
#bjah1 %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 %all1 z ! ,secret>y 
det]m9es appropriate--  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* pati5ts74  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 web-bas$ =ums1 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 subsection3  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 #bjai1 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 & 7f7 ( 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 
#bjaf1 ! ,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 #bjaf1 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 #bjaf1 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$2 &  7,,ii7 cl9ical practice    
guidel9es to ! ext5t t su* guidel9es    
exi/4  7#c7 ,annual report by !         
,secret>y  7,a7 ,9 g5]al ,n lat] ?an    
,may #a1 #bjag1 & annually !reaft]1 !   
,secret>y %all po/ on ! ,int]net website
 ( ! ,c5t]s = ,m$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 #bjae ?r\gh 
#bjai4 ,am\nts transf]r$ "u ?is p>agraph
 %all rema9 available ?r\gh ! end (     
fiscal ye> #bjbb4  7#g7 ,adm9i/ration   
,*apt] #ce ( title #dd1 ,unit$ ,/ates   
,code1 %all n apply to ! collection (   
in=mation = ! developm5t ( quality      
measures4  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 = individuals )      
*ronic c>e ne$s ! ,secret>y %all1       
subject to subp>agraph 7,b71 make paym5t
 7z ! ,secret>y det]m9es to be          
appropriate7 "u ?is section = *ronic c>e
 managem5t s]vices furni%$ on or aft]   
,janu>y #a1 #bjae1 by a physician 7z    
def9$ 9 section #ahfa7r77#a771 physician
 assi/ant or nurse practition] 7z def9$ 
9 section #ahfa7;aa77#e77;,a771 cl9ical 
nurse speciali/ 7z def9$ 9 section      
#ahfa7;aa77#e77;,b771 or c]tifi$ nurse  
midwife 7z def9$ 9 section              
#ahfa7;gg77#b774  7,b7 ,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]vices2 &  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

 ,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--  7,a7   
id5tify b>ri]s to receiv+ *ronic c>e    
managem5t s]vices2 &  7,b7 make         
recomm5dations = increas+ ! appropriate 
use ( *ronic c>e managem5t s]vices4     
#ajd4 ,emp[]+ b5efici>y *oices ?r\gh    
cont9u$ access to in=mation on          
physicians' s]vices  7a7 ,9 g5]al ,on an
 annual basis 7beg9n+ ) #bjae71 !       
,secret>y %all make publicly available1 
9 an easily und]/&able =mat1 in=mation )
 respect to physicians &1 z appropriate1
 o!r eligible pr(essionals on items &   
s]vices furni%$ to ,m$ic>e b5efici>ies  
"u title ,,xviii ( ! ,social ,security  
,act 7#db ,u4,s4,c4 #acie et seq474  7b7
 ,type & mann] ( in=mation ,! in=mation 
made available "u ?is section %all be   
simil> to ! type ( in=mation 9 ! ,m$ic>e

 ,provid] ,utilization & ,paym5t ,data3 
,physician & ,o!r ,suppli] ,public ,use 
,file releas$ by ! ,secret>y ) respect  
to #bjab & %all be made available 9 a   
mann] simil> to ! mann] 9 :i* !         
in=mation 9 su* file is made available4 
7c7 ,requirem5ts ,! in=mation made      
available "u ?is section %all include1  
at a m9imum1 ! foll[+3 7#a7 ,in=mation  
on ! numb] ( s]vices furni%$ by !       
physician or o!r 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] = ! physician or
 o!r eligible pr(essional t is available
 to ! public1 su* z a national provid]  
id5tifi]4  7d7 ,se>*ability ,! in=mation
 made available "u ?is section %all be  
se>*able by at lea/ ! foll[+3 7#a7 ,!   
specialty or type ( ! physician or o!r  
eligible pr(essional4  7#b7 ,*>act]i/ics

 ( ! s]vices furni%$1 su* z volume or   
gr\p+s ( s]vices4  7#c7 ,! location ( ! 
physician or o!r eligible pr(essional4  
7e7 ,integration on physician comp>e    
,beg9n+ ) #bjaf1 ! ,secret>y %all       
integrate ! in=mation made available "u 
?is section on ,physician ,comp>e4  7f7 
,def9itions ,9 ?is section3 7#a7        
,eligible pr(essional2 physician2       
,secret>y ,! t]ms eligible pr(essional1 
physician1 & ,secret>y h ! mean+ giv5   
su* t]ms 9 section #ajcca7;i7 ( ,public 
,law #aaa-adh4  7#b7 ,physician comp>e  
,! t]m ,physician ,comp>e means !       
,physician ,comp>e ,int]net website ( ! 
,c5t]s = ,m$ic>e  ,m$icaid ,s]vices 7or 
a successor website74  #aje4 ,exp&+     
availability ( ,m$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 #bjaf1 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 #bjaf1 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 #bjaf1 ! ,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 #bjaf1 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 #bjaf1 aft]   
deposit$2 &  7#b7 by ins]t+ ! foll[+    
be=e ! p]iod at ! end3 1 &1 beg9n+ ,july
 #a1 #bjaf1 into ! ,c5t]s = ,m$ic>e     
,m$icaid ,s]vices ,program ,managem5t   

,acc\nt4  #ajf4 ,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 #bjaf1 ! ,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      
relative1 to ! ext5t feasible1 to :5 !y 
fir/ enroll$ 9 ! program "u ?is title & 
) 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 ,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   
#bjah4  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 #bjaf1 & 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 #bjah1 !n ! ,secret>y %all
 submit to ,congress a report1 by n lat]
 ?an ,decemb] #ca1 #bjai1 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 use ,,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 action    
7su* z to disable functionality7 to     
limit or re/rict ! compatibility or     
int]op]ability ( ! c]tifi$ ,,ehr        
te*nology4  7,b7 ,= mean+ful use ,,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 action 7su* z to disable           
functionality7 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    
me*anism to comp>e c]tifi$ ,,ehr        
te*nology products  7,a7 ,/udy ,!       
,secret>y %all conduct a /udy to exam9e 
! feasibility ( e/abli%+ "o or m        
me*anisms to assi/ provid]s 9 comp>+ &  
select+ c]tifi$ ,,ehr te*nology         
products4 ,su* me*anisms may include--  
7i7 a website ) 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* products2 &  7ii7 in=mation f v5dors
 ( c]tifi$ products t is made publicly  
available 9 a /&>diz$ =mat4  ,!         
aggregat$ results ( ! surveys describ$ 9
 clause 7i7 may be made available ?r\gh 
contracts ) physicians1 hospitals1 or   

o!r organizations t ma9ta9 su*          
comp>ative in=mation describ$ 9 su*     
clause4  7,b7 ,report ,n lat] ?an #a ye>
 aft] ! date ( ! enactm5t ( ?is ,act1 ! 
,secret>y %all submit to ,congress a    
report on me*anisms t w\ld assi/        
provid]s 9 comp>+ & select+ c]tifi$     
,,ehr te*nology products4 ,! report %all
 include in=mation on ! b5efits (1 &    
res\rces ne$$ to develop & ma9ta91 su*  
me*anisms4  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$icaid program "u title ,,xix
 ( su* ,act1 ! inc5tive program "u      
subsections 7a77#c77;,f7 & 7t7 ( section
 #aijc ( su* ,act 7#db ,u4,s4,c4        
#acif;b74  7,d7 ,! t]m ,secret>y means !
 ,secret>y ( ,heal? & ,human ,s]vices4  
7c7 ,,gao /udies & reports on ! use (   
teleheal? "u ,f$]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     
monitors 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  7d7 ,rule ( con/ruction reg>d+ 
heal? c>e provid]s  7#a7 ,9 g5]al       
,subject to p>agraph 7#c71 ! developm5t1
 recognition1 or implem5tation ( any    
guidel9e or o!r /&>d "u any ,f$]al heal?

 c>e provision %all n be con/ru$ 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 claim4  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 
,act 7#db ,u4,s4,c4 #acie et seq41 #db  
,u4,s4,c4 #acif et seq474  7,b7 ,heal?  
c>e provid] ,! t]m heal? c>e provid]    
means any individual1 gr\p practice1    
corporation ( heal? c>e pr(essionals1 or
 hospital-- 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$]al ,food1 ,drug1 & ,cosmetic ,act   
7#ba ,u4,s4,c4 #cba7 or section #cea ( !
 ,public ,heal? ,s]vice ,act 7#db       
,u4,s4,c4 #bfb774  7,d7 ,/ate ,! t]m    
,/ate includes ! ,di/rict ( ,columbia1  
,pu]to ,rico1 & any o!r commonweal?1    
possession1 or t]ritory ( ! ,unit$      
,/ates4  7#c7 ,no preemption ,no?+ 9    
p>agraph 7#a7 or 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 
,act 7#db ,u4,s4,c4 #acie et seq41 #db  
,u4,s4,c4 #acif et seq47 %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 ,m$ic>e & ,o!r ,heal? ,ext5d]s  ,a 
,m$ic>e ,ext5d]s  #bja4 ,ext5sion ( "w  
,,gpci floor ,section #ahdh7;e77#a77;,e7
 ( ! ,social ,security ,act 7#db        
,u4,s4,c4 #aciew-#d7;e77#a77;,e77 is    
am5d$ by /rik+ ,april #a1 #bjae & ins]t+
 ,janu>y #a1 #bjah4  #bjb4 ,ext5sion (  
!rapy cap exceptions process  7a7 ,9    
g5]al ,section #ahcc7;g7 ( ! ,social    
,security ,act 7#db ,u4,s4,c4 #aciel7g77
 is am5d$-- 7#a7 9 p>agraph 7#e77;,a71 9
 ! fir/ s5t5ce1 by /rik+ ,m>* #ca1 #bjae
 & ins]t+ ,decemb] #ca1 #bjag2 &  7#b7 9
 p>agraph 7#f77;,a7-- 7,a7 by /rik+ ,m>*
 #ca1 #bjae & ins]t+ ,decemb] #ca1      
#bjag2 &  7,b7 by /rik+ #bjab1 #bjac1   
#bjad1 or ! fir/ ?ree mon?s ( #bjae &   

ins]t+ #bjab ?r\gh #bjag4  7b7 ,t>get$  
reviews "u manual m$ical review process 
= outpati5t !rapy s]vices  7#a7 ,9 g5]al
 ,section #ahcc7;g77#e7 ( ! ,social     
,security ,act 7#db ,u4,s4,c4           
#aciel7g77#e77 is am5d$--  7,a7 9       
subp>agraph 7,c77i71 by ins]t+ 1 subject
 to subp>agraph 7,e71 aft] manual m$ical
 review process t2 &  7,b7 by add+ at ! 
end ! foll[+ new subp>agraph3  7,e7  7i7
 ,9 place ( ! manual m$ical review      
process "u subp>agraph 7,c77i71 !       
,secret>y %all implem5t a process =     
m$ical review "u ?is subp>agraph "u :i* 
! ,secret>y %all id5tify & conduct      
m$ical review = s]vices describ$ 9      
subp>agraph 7,c77i7 furni%$ by a provid]
 ( s]vices or suppli] 79 ?is subp>agraph
 ref]r$ to z a !rapy provid]7 us+ su*   
factors z ! ,secret>y det]m9es to be    
appropriate4  7ii7 ,su* factors may     
include ! foll[+3 7,i7 ,! !rapy provid] 
has _h a high claims d5ial p]c5tage =   
!rapy s]vices "u ?is "p or is less      
compliant ) applicable requirem5ts "u   

?is title4  7,,ii7 ,! !rapy provid] has 
a patt]n ( bill+ = !rapy s]vices "u ?is 
"p t is ab]rant comp>$ to pe]s or       
o!rwise has que/ionable bill+ practices 
= su* s]vices1 su* z bill+ m$ically     
unlikely units ( s]vices 9 a day4       
7,,iii7 ,! !rapy provid] is newly       
enroll$ "u ?is title or has n previ\sly 
furni%$ !rapy s]vices "u ?is "p4  7,,iv7
 ,! s]vices are furni%$ to treat a type 
( m$ical condition4  7,v7 ,! !rapy      
provid] is "p ( gr\p t includes ano!r   
!rapy provid] id5tifi$ us+ ! factors    
det]m9$ "u ?is subp>agraph4  7iii7 ,=   
purposes ( c>ry+ out ?is subp>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 = fiscal ye>s #bjae & #bjaf1 to 
rema9 available until exp5d$4 ,su* funds
 may n be us$ by a contractor "u section
 #ahic7;h7 = m$ical reviews "u ?is      
subp>agraph4  7iv7 ,! t>get$ review     

process "u ?is subp>agraph %all n apply 
to s]vices = :i* exp5ses are incurr$    
beyond ! p]iod = :i* ! exceptions       
process "u subp>agraph 7,a7 is          
implem5t$4  4  7#b7 ,effective date ,!  
am5dm5ts made by ?is subsection %all    
apply ) respect to reque/s describ$ 9   
section #ahcc7;g77#e77;,c77i7 ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#aciel7g77#e77;,c77i77 ) respect to :i* 
! ,secret>y ( ,heal? & ,human ,s]vices  
has n conduct$ m$ical review "u su*     
section by a date 7n lat] ?an #ij days  
aft] ! date ( ! enactm5t ( ?is ,act7    
specifi$ by ! ,secret>y4  #bjc4         
,ext5sion ( ambulance add-ons  7a7      
,gr\nd ,ambulance ,section              
#ahcd7l77#ac77;,a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#aciem7l77#ac77;,a77 is am5d$ by /rik+  
,april #a1 #bjae & ins]t+ ,janu>y #a1   
#bjah ea* place x appe>s4  7b7 ,sup]    
rural gr\nd ambulance ,section          
#ahcd7l77#ab77;,a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    

#aciem7l77#ab77;,a77 is am5d$1 9 ! fir/ 
s5t5ce1 by /rik+ ,april #a1 #bjae &     
ins]t+ ,janu>y #a1 #bjah4  #bjd4        
,ext5sion ( increas$ inpati5t hospital  
paym5t adju/m5t = c]ta9 l[-volume       
hospitals ,section #ahhf7;d77#ab7 ( !   
,social ,security ,act 7#db ,u4,s4,c4   
#acieww7d77#ab77 is am5d$-- 7#a7 9      
subp>agraph 7,b71 9 ! matt] prec$+      
clause 7i71 by /rik+ 9 fiscal ye> #bjae 
7beg9n+ on ,april #a1 #bjae71 fiscal ye>
 #bjaf1 & subsequ5t fiscal ye>s & ins]t+
 9 fiscal ye> #bjah & subsequ5t fiscal  
ye>s2  7#b7 9 subp>agraph 7,c77i71 by   
/rik+ fiscal ye>s #bjaa ?r\gh #bjad &   
fiscal ye> #bjae 7be=e ,april #a1       
#bjae71 & ins]t+ fiscal ye>s #bjaa ?r\gh
 #bjag1 ea* place x appe>s2 &  7#c7 9   
subp>agraph 7,d71 by /rik+ fiscal ye>s  
#bjaa ?r\gh #bjad & fiscal ye> #bjae    
7be=e ,april #a1 #bjae71 & ins]t+ fiscal
 ye>s #bjaa ?r\gh #bjag14  #bje4        
,ext5sion ( ! ,m$ic>e-dep5d5t hospital  
7,,mdh7 program  7a7 ,9 g5]al ,section  
#ahhf7;d77#e77;,g7 ( ! ,social ,security

 ,act 7#db ,u4,s4,c4                    
#acieww7d77#e77;,g77 is am5d$-- 7#a7 9  
clause 7i71 by /rik+ ,april #a1 #bjae & 
ins]t+ ,octob] #a1 #bjag2 &  7#b7 9     
clause 7ii77,,ii71 by /rik+ ,april #a1  
#bjae & ins]t+ ,octob] #a1 #bjag4  7b7  
,con=m+ am5dm5ts  7#a7 ,ext5sion ( t>get
 am\nt ,section #ahhf7;b77#c77;,d7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#acieww7b77#c77;,d77 is am5d$--  7,a7 9 
! matt] prec$+ clause 7i71 by /rik+     
,april #a1 #bjae & ins]t+ ,octob] #a1   
#bjag2 &  7,b7 9 clause 7iv71 by /rik+  
?r\gh fiscal ye> #bjad & ! portion (    
fiscal ye> #bjae be=e ,april #a1 #bjae &
 ins]t+ ?r\gh fiscal ye> #bjag4  7#b7   
,p]mitt+ hospitals to decl9e            
reclassification ,section #aceja7;e77#b7
 ( ! ,omnibus ,budget ,reconciliation   
,act ( #aiic 7#db ,u4,s4,c4 #acieww     
note7 is am5d$ by /rik+ ?r\gh ! fir/ #b 
qu>t]s ( fiscal ye> #bjae & ins]t+ ?r\gh
 fiscal ye> #bjag4  #bjf4 ,ext5sion =   
specializ$ ,m$ic>e ,advantage plans =   
special ne$s individuals ,section       

#ahei7;f77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciew-#bh7;f77#a77 is  
am5d$ by /rik+ #bjag & ins]t+ #bjai4    
#bjg4 ,ext5sion ( fund+ = quality       
measure endorsem5t1 input1 & selection  
,section #ahij7;d77#b7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acie;aaa7d77#b77 is am5d$ by /rik+ &   
#ae1jjj1jjj = ! fir/ #f mon?s ( fiscal  
ye> #bjae & ins]t+ & #cj1jjj1jjj = ea* (
 fiscal ye>s #bjae ?r\gh #bjag4  #bjh4  
,ext5sion ( fund+ outrea* & assi/ance = 
l[-income programs  7a7 ,additional     
fund+ = /ate heal? insurance programs   
,subsection 7a77#a77;,b7 ( 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 & section #aaj (

 ! ,protect+ ,access to ,m$ic>e ,act (  
#bjad 7,public ,law #aac-ic71 is am5d$--
  7#a7 9 clause 7iv71 by /rik+ & at !   
end2  7#b7 by /rik+ clause 7v72 &  7#c7 
by add+ at ! end ! foll[+ new clauses3  
7v7 = fiscal ye> #bjae1 ( #g1ejj1jjj2   
7vi7 = fiscal ye> #bjaf1 ( #ac1jjj1jjj2 
&  7vii7 = fiscal ye> #bjag1 (          
#ac1jjj1jjj4  4  7b7 ,additional fund+ =
 area ag5cies on ag+ ,subsection        
7b77#a77;,b7 ( su* section #aai1 z s    
am5d$1 is am5d$-- 7#a7 9 clause 7iv71 by
 /rik+ & at ! end2  7#b7 by /rik+ clause
 7v72 &  7#c7 by ins]t+ aft] clause 7iv7
 ! foll[+ new clauses3  7v7 = fiscal ye>
 #bjae1 ( #g1ejj1jjj2  7vi7 = fiscal ye>
 #bjaf1 ( #g1ejj1jjj2 &  7vii7 = fiscal 
ye> #bjag1 ( #g1ejj1jjj4  4  7c7        
,additional fund+ = ag+ & disability    
res\rce c5t]s ,subsection 7c77#a77;,b7 (
 su* section #aai1 z s am5d$1 is am5d$--
  7#a7 9 clause 7iv71 by /rik+ & at !   
end2  7#b7 by /rik+ clause 7v72 &  7#c7 
by ins]t+ aft] clause 7iv7 ! foll[+ new 
clauses3  7v7 = fiscal ye> #bjae1 (     

#e1jjj1jjj2  7vi7 = fiscal ye> #bjaf1 ( 
#e1jjj1jjj2 &  7vii7 = fiscal ye> #bjag1
 ( #e1jjj1jjj4  4  7d7 ,additional fund+
 = contract ) ! national c5t] = b5efits 
& outrea* enrollm5t ,subsection 7d77#b7 
( su* section #aai1 z s am5d$1 is       
am5d$-- 7#a7 9 clause 7iv71 by /rik+ &  
at ! end2  7#b7 by /rik+ clause 7v72 &  
7#c7 by ins]t+ aft] clause 7iv7 ! foll[+
 new clauses3  7v7 = fiscal ye> #bjae1 (
 #e1jjj1jjj2  7vi7 = fiscal ye> #bjaf1 (
 #ab1jjj1jjj2 &  7vii7 = fiscal ye>     
#bjag1 ( #ab1jjj1jjj4  4  #bji4         
,ext5sion & transition ( 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 9 clause   
7iii77,i71 by ins]t+ co/ plan s]vice    
aft] ,) respect to any portion ( !2     
7#c7 9 clause 7iii77,,ii71 by ins]t+ co/

 plan s]vice aft] ,) respect to any o!r 
portion ( su*2 &  7#d7 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 or :]e   
su* contract has be5 ext5d$ or r5ew$ b !
 eligible organization has in=m$ !      
,secret>y 9 writ+ n lat] ?an a date     
det]m9$ appropriate by ! ,secret>y t su*
 organization volunt>ily plans n to seek
 r5ewal ( ! reasonable co/ reimbursem5t 
contract1 ! foll[+ %all apply3  7,i7    
,not)/&+ su* clause1 su* contract may be
 ext5d$ or r5ew$ = ! two ye>s subsequ5t 
to #bjaf4 ,! f9al ye> 9 :i* su* contract
 is ext5d$ or r5ew$ is ref]r$ to 9 ?is  
subsection z ! la/ reasonable co/       
reimbursem5t contract ye> = ! contract4 
7,,ii7 ,! organization may n enroll a   
new enrollee "u su* contract dur+ ! la/ 
reasonable co/ reimbursem5t contract ye>
 = ! contract 7b may cont9ue to enroll  
new enrollees ?r\gh ! end ( ! ye>       

imm$iately prec$+ su* ye>7 unless su*   
enrollee is any ( ! foll[+3  7aa7 ,an   
individual :o *ooses enrollm5t 9 !      
reasonable co/ contract dur+ ! annual   
election p]iod ) respect to su* la/ ye>4
  7bb7 ,an individual ^: sp\se1 at ! "t 
( ! individual's enrollm5t is an        
enrollee "u ! reasonable co/            
reimbursem5t contract4  7cc7 ,an        
individual :o is cov]$ "u an employ]    
gr\p heal? plan t (f]s cov]age ?r\gh !  
reasonable co/ reimbursem5t contract4   
7dd7 ,an individual :o becomes entitl$  
to b5efits "u "p ,a1 or enroll$ "u "p   
,b1 & 0 enroll$ 9 a plan (f]$ by !      
eligible organization imm$iately prior  
to ! individual's enrollm5t "u !        
reasonable co/ reimbursem5t contract4   
7,,iii7 ,n lat] ?an a date det]m9$      
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 ! organization w    
apply to h ! contract conv]t$ ov]1 9    

:ole or 9 "p1 & (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$1 9 :ole or 9 "p1 ! organization 
%all1 n lat] ?an a date det]m9$         
appropriate by ! ,secret>y1 provide !   
,secret>y ) su* in=mation z ! ,secret>y 
det]m9es appropriate 9 ord] to c>ry out 
section #ahea7;c77#d7 & to c>ry out     
section #ahed7;a77#e71 includ+          
subp>agraph 7,c77ii7 ( su* section4     
7,v7 ,9 ! case t ! organization enrolls 
a new enrollee "u su* contract dur+ !   
la/ reasonable co/ reimbursem5t contract
 ye> = ! contract1 ! organization %all  
provide ! individual ) a notification t 
su* ye> is ! la/ ye> = su* contract4    
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$1 9 :ole or 9 "p1 !
 foll[+ %all apply3  7,i7 ,! deem$      
enrollm5t "u section #ahea7;c77#d74     
7,,ii7 ,! special rule = quality        
increase "u section #ahec7o77#d77;,c74  
7,,iii7 ,dur+ ! la/ reasonable co/      
reimbursem5t contract ye> = ! contract &
 ! ye> imm$iately prec$+ su* ye>1 !     
eligible organization1 or ! corporate   
p>5t organization ( ! eligible          
organization1 %all be p]mitt$ to (f] an 
,,ma plan 9 ! area t su* contract is be+
 (f]$ & enroll ,m$ic>e ,advantage       
eligible individuals 9 su* ,,ma plan &  
su* co/ plan4  4  7b7 ,deem$ 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$1
 unless ! individual elects o!rwise1 to 
h elect$ 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 7z describ$ 9 
subclause 7,i7 ( section                
#ahgf7;h77#e77;,c77iv77 pursuant to su* 
section2  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 9 ! case (     
reasonable co/ reimbursem5t contracts t 
provide cov]age "u p>ts ,a & ,b 7&1 to !
 ext5t ! ,secret>y det]m9es x to be     
feasible1 contracts t provide only "p ,b
 cov]age71 ! diff]5ce betwe5 ! e/imat$  
individual co/s 7z det]m9$ applicable by
 ! ,secret>y7 = ! applicable ,,ma plan &
 su* co/s = ! pr$ecessor co/ plan does n
 exce$ a ?re%old e/abli%$ by !          
,secret>y2 &  7vi7 ! applicable ,,ma    
plan-- 7,i7 provides cov]age = enrollees
 transition+ f ! conv]t$ reasonable co/ 
reimbursem5t contract to su* plan to    
ma9ta9 curr5t provid]s ( s]vices &      
suppli]s & c\rse ( treatm5t at ! "t (   
enrollm5t = a p]iod ( at lea/ #ij days  
aft] enrollm5t2 &  7,,ii7 dur+ su*      

p]iod1 pays su* provid]s ( s]vices &    
suppli]s = items & s]vices furni%$ to ! 
enrollee an am\nt t is n less ?an !     
am\nt ( paym5t applicable = su* 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 is n1 = su* previ\s plan ye>1  
enroll$ 9 a prescription drug plan "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 is enroll$ 9 a    
prescription drug plan "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 #de 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;,f714  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#d744  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

 9 ! head+1 by /rik+ ,notification to   
newly eligible ,m$ic>e ,advantage       
eligible individuals & ins]t+ ! foll[+3 
,notifications requir$4-- 7i7           
,notification to newly eligible ,m$ic>e 
,advantage eligible individuals  2 &    
7#b7 by add+ at ! end ! foll[+ new      
clause3  7ii7 ,notification relat$ to   
c]ta9 deem$ elections ,! ,secret>y %all 
require a ,m$ic>e ,advantage            
organization t is (f]+ a ,m$ic>e        
,advantage plan t has be5 conv]t$ f a   
reasonable co/ reimbursem5t contract    
pursuant to section                     
#ahgf7;h77#e77;,c77iv7 to mail1 n lat]  
?an #cj days prior to ! fir/ day ( !    
annual1 coord9at$ election p]iod "u     
subsection 7e77#c7 ( a ye>1 to any      
individual enroll$ "u su* contract &    
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 )   
respect to su* plan 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 specify4  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 ,,ma 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  #baj4        
,ext5sion ( home heal? rural add-on     
,section #dba7;a7 ( ! ,m$ic>e           
,prescription ,drug1 ,improvem5t1 &     
,mod]nization ,act ( #bjjc 7,public ,law
 #ajh-agc2 #aag ,/at4 #bbhc2 #db        
,u4,s4,c4 #acie;fff note71 z am5d$ by   
section #ebja7;b7 ( ! ,deficit ,r$uction
 ,act ( #bjje 7,public ,law #aji-aga2   
#abj ,/at4 #df7 & by section #caca7;c7 (
 ! ,pati5t ,protection & ,af=dable ,c>e 
,act 7,public ,law #aaa-adh2 #abd ,/at4 

#dbh71 is am5d$ by /rik+ ,janu>y #a1    
#bjaf & ins]t+ ,janu>y #a1 #bjah ea*    
place x appe>s4  ,b ,o!r ,heal? ,ext5d]s
  #baa4 ,p]man5t ext5sion ( ! qualify+  
individual 7,,qi7 program  7a7 ,p]man5t 
ext5sion ,section                       
#aijb7;a77#aj77;,e77iv7 ( ! ,social     
,security ,act 7#db ,u4,s4,c4           
#acif;a7a77#aj77;,e77iv77 is am5d$ by   
/rik+ 7b only = premiums payable )      
respect to mon?s dur+ ! p]iod beg9n+ )  
,janu>y #aiih1 & end+ ) ,m>* #bjae74    
7b7 ,allocations ,section #aicc7;g7 ( ! 
,social ,security ,act 7#db ,u4,s4,c4   
#acifu-#c7;g77 is am5d$-- 7#a7 9        
p>agraph 7#b7--  7,a7 by /rik+          
subp>agraphs 7,a7 ?r\gh 7,h72  7,b7 9   
subp>agraph 7,v71 by /rik+ & at ! end2  
7,c7 9 subp>agraph 7,w71 by /rik+ !     
p]iod at ! end & ins]t+ a semicolon2    
7,d7 by r$esignat+ subp>agraphs 7,i7    
?r\gh 7,w7 z subp>agraphs 7,a7 ?r\gh    
7,o71 respectively2 &  7,e7 by add+ at !
 end ! foll[+ new subp>agraphs3  7,p7 = 
! p]iod t beg9s on ,april #a1 #bjae1 &  

ends on ,decemb] #ca1 #bjae1 ! total    
allocation am\nt is #ece1jjj1jjj2 &     
7,q7 = #bjaf &1 subject to p>agraph     
7#d71 = ea* subsequ5t ye>1 ! total      
allocation am\nt is #ihj1jjj1jjj4  2    
7#b7 9 p>agraph 7#c71 by /rik+ 7,p71    
7,r71 7,t71 or 7,v7 & ins]t+ or 7,p72 & 
7#c7 by add+ at ! end ! foll[+ new      
p>agraph3  7#d7 ,adju/m5t to allocations
 ,! ,secret>y may increase ! allocation 
am\nt "u p>agraph 7#b77,q7 = a ye>      
7beg9n+ ) #bjag7 up to an am\nt t does n
 exce$ ! product ( ! foll[+3  7,a7      
,maximum allocation am\nt = previ\s ye> 
,9 ! case ( #bjag1 ! allocation am\nt = 
#bjaf1 or 9 ! case ( a subsequ5t ye>1 ! 
maximum allocation am\nt all[$ "u ?is   
p>agraph = ! previ\s ye>4  7,b7         
,increase 9 "p ,b premium ,! mon?ly     
premium rate det]m9$ "u section #ahci = 
! ye> divid$ by ! mon?ly premium rate   
det]m9$ "u su* section = ! previ\s ye>4 
7,c7 ,increase 9 "p ,b enrollm5t ,!     
av]age numb] ( individuals 7z e/imat$ by
 ! ,*ief ,actu>y ( ! ,c5t]s = ,m$ic>e   

,m$icaid ,s]vices 9 ,septemb] ( !       
previ\s ye>7 to be enroll$ "u "p ,b (   
title ,,xviii = mon?s 9 ! ye> divid$ by 
! av]age numb] ( su* individuals 7z s   
e/imat$7 "u ?is subp>agraph ) respect to
 enrollm5ts 9 mon?s 9 ! previ\s ye>4  4 
#bab4 ,p]man5t ext5sion ( transitional  
m$ical assi/ance 7,,tma7  7a7 ,9 g5]al  
,section #aibe ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acifr-#f7 is       
am5d$-- 7#a7 by /rik+ subsection 7f72 & 
7#b7 by r$esignat+ subsection 7g7 z     
subsection 7f74  7b7 ,con=m+ am5dm5t    
,section #aijb7;e77#a7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acif;a7e77#a77 is am5d$ to read z      
foll[s3  7#a7 ,beg9n+ ,april #a1 #aiij1 
= provisions relat+ to ! ext5sion (     
eligibility = m$ical assi/ance = c]ta9  
families :o h receiv$ aid pursuant to a 
,/ate plan approv$ "u "p ,a ( title ,,iv
 & h e>n$ income1 see section #aibe4  4 
#bac4 ,ext5sion ( special diabetes      
program = type ,i diabetes & = ,indians 
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+ #bjae & ins]t+ #bjag4  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+ #bjae & ins]t+ #bjag4  #bad4      
,ext5sion ( ab/95ce education  7a7 ,9   
g5]al ,section #eaj ( ! ,social         
,security ,act 7#db ,u4,s4,c4 #gaj7 is  
am5d$-- 7#a7 9 subsection 7a71 /rik+    
#bjae & ins]t+ #bjag2 &  7#b7 9         
subsection 7d71 by ins]t+ & an          
additional #ge1jjj1jjj = ea* ( fiscal   
ye>s #bjaf & #bjag aft] #bjae4  7b7     
,budget scor+ ,not)/&+ section          
#beg7;b77#b7 ( ! ,balanc$ ,budget &     
,em]g5cy ,deficit ,control ,act ( #aihe1
 ! basel9e %all be calculat$ assum+ t no
 grant %all be made "u section #eaj ( ! 
,social ,security ,act 7#db ,u4,s4,c4   
#gaj7 aft] fiscal ye> #bjag4  7c7       

,reallocation ( unus$ fund+ ,! rema9+   
unobligat$ balances ( ! am\nt           
appropriat$ = fiscal ye>s #bjaf & #bjag 
by section #eaj7;d7 ( ! ,social         
,security ,act 7#db ,u4,s4,c4 #gaj7;d77 
= :i* no application has be5 receiv$ by 
! ,fund+ ,opportunity ,ann\ncem5t       
deadl9e1 %all be made available to      
,/ates t require ! implem5tation ( ea*  
elem5t describ$ 9 subp>agraphs 7,a7     
?r\gh 7,h7 ( ! def9ition ( ab/95ce      
education 9 section #eaj7;b77#b74 ,!    
rema9+ unobligat$ balances %all be      
reallocat$ to su* ,/ates t submit a     
valid application consi/5t ) ! orig9al  
=mula = ?is fund+4  #bae4 ,ext5sion (   
p]sonal responsibility education program
 7,,prep7 ,section #eac ( ! ,social     
,security ,act 7#db ,u4,s4,c4 #gac7 is  
am5d$-- 7#a7 9 p>agraphs 7#a77;,a7 &    
7#d77;,a7 ( subsection 7a71 by /rik+    
#bjae & ins]t+ #bjag ea* place x appe>s2
  7#b7 9 subsection 7a77#d77;,b77i71 by 
/rik+ 1 #bjac1 #bjad1 & #bjae & ins]t+  
?r\gh #bjag2 &  7#c7 9 subsection 7f71  

by /rik+ #bjae & ins]t+ #bjag4  #baf4   
,ext5sion ( fund+ = family-to-family    
heal? in=mation c5t]s ,section          
#eja7;c77#a77;,a7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #gja7;c77#a77;,a77  
is am5d$-- 7#a7 by /rik+ clause 7vi72 & 
7#b7 by add+ aft] clause 7v7 ! foll[+   
new clause3  7vi7 #e1jjj1jjj = ea* (    
fiscal ye>s #bjae ?r\gh #bjag4  4  #bag4
 ,ext5sion ( heal? work=ce demon/ration 
project = l[-income individuals ,section
 #bjjh7;c77#a7 ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acig;g7c77#a77 is  
am5d$ by /rik+ #bjae & ins]t+ #bjag4    
#bah4 ,ext5sion ( mat]nal1 infant1 &    
e>ly *ildhood home visit+ programs      
,section #eaa7;j77#a7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4 #gaa7;j77 
is am5d$--  7#a7 by /rik+ & at ! end (  
subp>agraph 7,e72  7#b7 9 subp>agraph   
7,f7--  7,a7 by /rik+ = ! p]iod beg9n+  
on ,octob] #a1 #bjad1 & end+ on ,m>*    
#ca1 #bjae & ins]t+ = fiscal ye> #bjae2 
7,b7 by /rik+ an am\nt equal to ! am\nt 
provid$ 9 subp>agraph 7,e7 & ins]t+     

#djj1jjj1jjj2 &  7,c7 by /rik+ ! p]iod  
at ! end & ins]t+ a semicolon2 &  7#c7  
by add+ at ! end ! foll[+ new           
subp>agraphs3  7,g7 = fiscal ye> #bjaf1 
#djj1jjj1jjj2 &  7,h7 = fiscal ye>      
#bjag1 #djj1jjj1jjj4  4  #bai4 ,t5nessee
 ,,d% allotm5t = fiscal ye>s #bjae ?r\gh
 #bjbe ,section #aibc7;f77#f77;,a7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#acifr-#d7;f77#f77;,a77 is am5d$ by add+
 at ! end ! foll[+3  7vi7 ,allotm5t =   
fiscal ye>s #bjae ?r\gh #bjbe ,not)/&+  
any o!r provision ( ?is subsection1 any 
o!r provision ( law1 or ! t]ms ( !      
,tenn,care ,demon/ration ,project 9     
effect = ! ,/ate1 ! ,,d% allotm5t =     
,t5nessee = fiscal ye> #bjae1 & = ea*   
fiscal ye> !reaft] ?r\gh fiscal ye>     
#bjbe1 %all be #ec1ajj1jjj = ea* su*    
fiscal ye>4  4  #bbj4 ,delay 9 effective
 date = ,m$icaid am5dm5ts relat+ to     
b5efici>y liability settlem5ts ,section 
#bjb7;c7 ( ! ,bip>tisan ,budget ,act (  
#bjac 7division ,a ( ,public ,law       
#aac-fg2 #db ,u4,s4,c4 #acif;a note71 z 

am5d$ by section #baa ( ! ,protect+     
,access to ,m$ic>e ,act ( #bjad 7,public
 ,law #aac-ic2 #abh ,/at4 #ajdg7 is     
am5d$ by /rik+ ,octob] #a1 #bjaf &      
ins]t+ ,octob] #a1 #bjag4  #bba4        
,ext5sion ( fund+ = community heal?     
c5t]s1 ! ,national ,heal? ,s]vice       
,corps1 & tea*+ heal? c5t]s  7a7 ,fund+ 
= ,community ,heal? ,c5t]s & ! ,national
 ,heal? ,s]vice ,corps  7#a7 ,community 
heal? c5t]s ,section #ajejc7;b77#a77;,e7
 ( ! ,pati5t ,protection & ,af=dable    
,c>e ,act 7#db ,u4,s4,c4                
#bed;b-#b7;b77#a77;,e77 is am5d$ by     
/rik+ = fiscal ye> #bjae & ins]t+ = ea* 
( fiscal ye>s #bjae ?r\gh #bjag4  7#b7  
,national ,heal? ,s]vice ,corps ,section
 #ajejc7;b77#b77;,e7 ( ! ,pati5t        
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #bed;b-#b7;b77#b77;,e77 is    
am5d$ by /rik+ = fiscal ye> #bjae &     
ins]t+ = ea* ( fiscal ye>s #bjae ?r\gh  
#bjag4  7b7 ,ext5sion ( tea*+ heal?     
c5t]s program ,section #cdj;,h7g7 ( !   
,public ,heal? ,s]vice ,act 7#db        

,u4,s4,c4 #bef;h7g77 is am5d$ by ins]t+ 
& #fj1jjj1jjj = ea* ( fiscal ye>s #bjaf 
& #bjag be=e ! p]iod at ! end4  7c7     
,application ,am\nts appropriat$        
pursuant to ?is section = fiscal ye>    
#bjaf & fiscal ye> #bjag are subject to 
! requirem5ts conta9$ 9 ,public ,law    
#aac-bce = funds = programs au?oriz$ "u 
sections #ccj ?r\gh #cdj ( ! ,public    
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#bed;b-#bef74  ,,iii ,,*ip  #cja4 #b-ye>
 ext5sion ( ! ,*ildr5's ,heal?          
,insurance ,program  7a7 ,fund+ ,section
 #bajd7;a7 ( ! ,social ,security ,act   
7#db ,u4,s4,c4 #acig;dd7a77 is am5d$--  
7#a7 9 p>agraph 7#ag71 by /rik+ & at !  
end2  7#b7 9 p>agraph 7#ah77;,b71 by    
/rik+ ! p]iod at ! end & ins]t+ a       
semicolon2 &  7#c7 by add+ at ! end !   
foll[+ new p>agraphs3  7#ai7 = fiscal   
ye> #bjaf1 #ai1cjj1jjj1jjj2 &  7#bj7 =  
fiscal ye> #bjag1 = purposes ( mak+ #b  
semi-annual allotm5ts--  7,a7           
#b1hej1jjj1jjj = ! p]iod beg9n+ on      
,octob] #a1 #bjaf1 & end+ on ,m>* #ca1  

#bjag2 &  7,b7 #b1hej1jjj1jjj = ! p]iod 
beg9n+ on ,april #a1 #bjag1 & end+ on   
,septemb] #cj1 #bjag4  4  7b7 ,allotm5ts
  7#a7 ,9 g5]al ,section #bajd7m7 ( !   
,social ,security ,act 7#db ,u4,s4,c4   
#acig;dd7m77 is am5d$-- 7,a7 9 !        
subsection head+1 by /rik+ ,?r\gh #bjae 
& ins]t+ & ,!reaft]2  7,b7 9 p>agraph   
7#b7-- 7i7 9 ! p>agraph head+1 by /rik+ 
#bjad & ins]t+ #bjaf2 &  7ii7 by /rik+  
subp>agraph 7,b7 & ins]t+ ! foll[+ new  
subp>agraph3  7,b7 ,fiscal ye> #bjac &  
ea* succe$+ fiscal ye> ,subject to      
p>agraphs 7#e7 & 7#g71 f ! am\nt made   
available "u p>agraphs 7#af7 ?r\gh 7#ai7
 ( subsection 7a7 = fiscal ye> #bjac &  
ea* succe$+ fiscal ye>1 respectively1 ! 
,secret>y %all compute a ,/ate allotm5t 
= ea* ,/ate 7includ+ ! ,di/rict (       
,columbia & ea* commonweal? & t]ritory7 
= ea* su* fiscal ye> z foll[s3  7i7     
,rebas+ 9 fiscal ye> #bjac & ea* succe$+
 odd-numb]$ fiscal ye> ,= fiscal ye>    
#bjac & ea* succe$+ odd-numb]$ fiscal   
ye> 7o!r ?an fiscal ye>s #bjae & #bjag71

 ! allotm5t ( ! ,/ate is equal to !     
,f$]al paym5ts to ! ,/ate t are         
attributable to 7& c\ntable t[>d7 !     
total am\nt ( allotm5ts available "u ?is
 section to ! ,/ate 9 ! prec$+ fiscal   
ye> 7includ+ paym5ts made to ! ,/ate "u 
subsection 7n7 = su* prec$+ fiscal ye> z
 well z am\nts r$i/ribut$ to ! ,/ate 9  
su* prec$+ fiscal ye>71 multipli$ by !  
allotm5t increase factor "u p>agraph    
7#f7 = su* odd-numb]$ fiscal ye>4  7ii7 
,gr[? factor update = fiscal ye> #bjad &
 ea* succe$+ ev5-numb]$ fiscal ye>      
,except z provid$ 9 clauses 7iii7 &     
7iv71 = fiscal ye> #bjad & ea* succe$+  
ev5-numb]$ fiscal ye>1 ! allotm5t ( !   
,/ate is equal to ! sum (--  7,i7 !     
am\nt ( ! ,/ate allotm5t "u clause 7i7 =
 ! prec$+ fiscal ye>2 &  7,,ii7 ! am\nt 
( any paym5ts made to ! ,/ate "u        
subsection 7n7 = su* prec$+ fiscal ye>1 
multipli$ by ! allotm5t increase factor 
"u p>agraph 7#f7 = su* ev5-numb]$ fiscal
 ye>4  7iii7 ,special rule = #bjaf ,=   
fiscal ye> #bjaf1 ! allotm5t ( ! ,/ate  

is equal to ! ,f$]al paym5ts to ! ,/ate 
t are attributable to 7& c\ntable t[>d7 
! total am\nt ( allotm5ts available "u  
?is section to ! ,/ate 9 ! prec$+ fiscal
 ye> 7includ+ paym5ts made to ! ,/ate "u
 subsection 7n7 = su* prec$+ fiscal ye> 
z well z am\nts r$i/ribut$ to ! ,/ate 9 
su* prec$+ fiscal ye>71 b det]m9$ z if !
 la/ two s5t5ces ( section #baje7;b7 7 9
 effect 9 su* prec$+ fiscal ye> & !n    
multiply+ ! result by ! allotm5t        
increase factor "u p>agraph 7#f7 =      
fiscal ye> #bjaf4  7iv7 ,r$uction 9     
#bjah ,= fiscal ye> #bjah1 ) respect to 
! allotm5t ( ! ,/ate = fiscal ye> #bjag1
 any am\nts ( su* allotm5t t rema9      
available = exp5diture by ! ,/ate 9     
fiscal ye> #bjah %all be r$uc$ by       
"o-?ird4  2  7,c7 9 p>agraph 7#d71 by   
ins]t+ or #bjag aft] #bjae2  7,d7 9     
p>agraph 7#f7--  7i7 9 subp>agraph 7,a71
 by /rik+ #bjae & ins]t+ #bjag2 &  7ii7 
9 ! second s5t5ce1 by /rik+ or fiscal   
ye> #bjad & ins]t+ fiscal ye> #bjad1 or 
fiscal ye> #bjaf2  7,e7 9 p>agraph      

7#h7-- 7i7 9 ! p>agraph head+1 by /rik+ 
fiscal ye> #bjae & ins]t+ fiscal ye>s   
#bjae & #bjag2 &  7ii7 by ins]t+ or     
fiscal ye> #bjag aft] #bjae2  7,f7 by   
r$esignat+ p>agraphs 7#d7 ?r\gh 7#h7 z  
p>agraphs 7#e7 ?r\gh 7#i71 respectively2
 &  7,g7 by ins]t+ aft] p>agraph 7#c7 ! 
foll[+ new p>agraph3  7#d7 ,= fiscal ye>
 #bjag  7,a7 ,fir/ half ,subject to     
p>agraphs 7#e7 & 7#g71 f ! am\nt made   
available "u subp>agraph 7,a7 ( p>agraph
 7#bj7 ( subsection 7a7 = ! semi-annual 
p]iod describ$ 9 su* p>agraph1 increas$ 
by ! am\nt ( ! appropriation = su* p]iod
 "u section #cja7;b77#c7 ( ! ,m$ic>e    
,access & ,,*ip ,reau?orization ,act (  
#bjae1 ! ,secret>y %all compute a ,/ate 
allotm5t = ea* ,/ate 7includ+ ! ,di/rict
 ( ,columbia & ea* commonweal? &        
t]ritory7 = su* semi-annual p]iod 9 an  
am\nt equal to ! fir/ half ratio        
7describ$ 9 subp>agraph 7,d77 ( ! am\nt 
describ$ 9 subp>agraph 7,c74  7,b7      
,second half  ,subject to p>agraphs 7#e7
 & 7#g71 f ! am\nt made available "u    

subp>agraph 7,b7 ( p>agraph 7#bj7 (     
subsection 7a7 = ! semi-annual p]iod    
describ$ 9 su* p>agraph1 ! ,secret>y    
%all compute a ,/ate allotm5t = ea*     
,/ate 7includ+ ! ,di/rict ( ,columbia & 
ea* commonweal? & t]ritory7 = su*       
semi-annual p]iod 9 an am\nt equal to ! 
am\nt made available "u su* subp>agraph1
 multipli$ by ! ratio (--  7i7 ! am\nt (
 ! allotm5t to su* ,/ate "u subp>agraph 
7,a72 to  7ii7 ! total ( ! am\nt ( all (
 ! allotm5ts made available "u su*      
subp>agraph4  7,c7  ,full ye> am\nt bas$
 on rebas$ am\nt  ,! am\nt describ$ 9   
?is subp>agraph = a ,/ate is equal to ! 
,f$]al paym5ts to ! ,/ate t are         
attributable to 7& c\ntable t[>ds7 !    
total am\nt ( allotm5ts available "u ?is
 section to ! ,/ate 9 fiscal ye> #bjaf  
7includ+ paym5ts made to ! ,/ate "u     
subsection 7n7 = fiscal ye> #bjaf z well
 z am\nts r$i/ribut$ to ! ,/ate 9 fiscal
 ye> #bjaf71 multipli$ by ! allotm5t    
increase factor "u p>agraph 7#f7 =      
fiscal ye> #bjag4  7,d7  ,fir/ half     

ratio  ,! fir/ half ratio describ$ 9 ?is
 subp>agraph is ! ratio (-- 7i7 ! sum   
(--  7,i7 ! am\nt made available "u     
subsection 7a77#bj77;,a72 &  7,,ii7 !   
am\nt ( ! appropriation = su* p]iod "u  
section #cja7;b77#c7 ( ! ,m$ic>e ,access
 & ,,*ip ,reau?orization ,act ( #bjae2  
to  7ii7 ! sum ( !-- 7,i7 am\nt describ$
 9 clause 7i72 &  7,,ii7 ! am\nt made   
available "u subsection 7a77#bj77;,b74  
4  7#b7 ,con=m+ am5dm5ts  7,a7 ,section 
#bajd7;c77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acig;dd7c77#a77 is     
am5d$ by /rik+ 7m77#d7 & ins]t+ 7m77#e74
  7,b7 ,section #bajd7m7 ( su* ,act 7#db
 ,u4,s4,c4 #acig;dd7m771 z am5d$ by     
p>agraph 7#a71 is fur!r am5d$-- 7i7 9   
p>agraph 7#a7--  7,i7 by /rik+ p>agraph 
7#d7 ea* place x appe>s 9 subp>agraphs  
7,a7 & 7,b7 & ins]t+ p>agraph 7#e72 &   
7,,ii7 by /rik+ ! allotm5t increase     
factor det]m9$ "u p>agraph 7#e7 ea*     
place x appe>s & ins]t+ ! allotm5t      
increase factor det]m9$ "u p>agraph     
7#f72  7ii7 9 p>agraph 7#b77;,a71 by    

/rik+ ! allotm5t increase factor "u     
p>agraph 7#e7 & ins]t+ ! allotm5t       
increase factor "u p>agraph 7#f72  7iii7
 9 p>agraph 7#c7--  7,i7 by /rik+       
p>agraphs 7#d7 & 7#f7 & ins]t+ p>agraphs
 7#e7 & 7#g7 ea* place x appe>s2 &      
7,,ii7 by /rik+ ! allotm5t increase     
factor "u p>agraph 7#e7 & ins]t+ !      
allotm5t increase factor "u p>agraph    
7#f72  7iv7 9 p>agraph 7#e7 7z          
r$esignat$ by p>agraph 7#a77;,f771 by   
/rik+ p>agraph 7#a71 7#b71 or 7#c7 &    
ins]t+ p>agraph 7#a71 7#b71 7#c71 or    
7#d72  7v7 9 p>agraph 7#g7 7z r$esignat$
 by p>agraph 7#a77;,f771 by /rik+       
subject to p>agraph 7#d7 & ins]t+       
subject to p>agraph 7#e72 &  7vi7 9     
p>agraph 7#i71 7z r$esignat$ by p>agraph
 7#a77;,f771 by /rik+ p>agraph 7#c7 &   
ins]t+ p>agraph 7#c7 or 7#d74  7,c7     
,section #bajd7n77#c77;,b77ii7 ( su*    
,act 7#db ,u4,s4,c4                     
#acig;dd7n77#c77;,b77ii77 is am5d$ by   
/rik+ subsection 7m77#e77;,b7 & ins]t+  
subsection 7m77#f77;,b74  7,d7 ,section 

#baaa7;b77#b77;,b77i7 ( su* ,act 7#db   
,u4,s4,c4 #acigkk7b77#b77;,b77i77 is    
am5d$ by /rik+ section #bajd7m77#d7 &   
ins]t+ section #bajd7m77#e74  7#c7      
,"o-"t appropriation = fiscal ye> #bjag 
,!re is appropriat$ to ! ,secret>y (    
,heal? & ,human ,s]vices1 out ( any     
money 9 ! ,treasury n o!rwise           
appropriat$1 #ad1gjj1jjj1jjj to         
accompany ! allotm5t made = ! p]iod     
beg9n+ on ,octob] #a1 #bjaf1 & end+ on  
,m>* #ca1 #bjag1 "u p>agraph 7#bj77;,a7 
( section #bajd7;a7 ( ! ,social         
,security ,act 7#db ,u4,s4,c4           
#acig;dd7a77 7z add$ by subsection      
7a77#a771 to rema9 available until      
exp5d$4 ,su* am\nt %all be us$ to       
provide allotm5ts to ,/ates "u p>agraph 
7#d7 ( section #bajd7m7 ( su* ,act 7#db 
,u4,s4,c4 #acig;dd7m77 7z am5d$ by      
p>agraph7#a77;,g77 = ! fir/ #f mon?s (  
fiscal ye> #bjag 9 ! same mann] z       
allotm5ts are provid$ "u subsection     
7a77#bj77;,a7 ( su* section #bajd &     
subject to ! same t]ms & conditions z   

apply to ! allotm5ts provid$ f su*      
subsection 7a77#bj77;,a74  7c7 ,ext5sion
 ( qualify+ /ates option ,section       
#baje7;g77#d7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acig;ee7g77#d77 is     
am5d$-- 7#a7 9 ! p>agraph head+1 by     
/rik+ #bjae & ins]t+ #bjag2 &  7#b7 9   
subp>agraph 7,a71 by /rik+ #bjae &      
ins]t+ #bjag4  7d7 ,ext5sion ( ! *ild   
enrollm5t cont+5cy fund  7#a7 ,9 g5]al  
,section #bajd7n7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #acig;dd7n77 is     
am5d$--  7,a7 9 p>agraph 7#b7-- 7i7 9   
subp>agraph 7,a77ii7--  7,i7 by /rik+   
#bjaj ?r\gh #bjad & ins]t+ #bjaj1 #bjaa1
 #bjab1 #bjac1 #bjad1 & #bjaf2 &  7,,ii7
 by ins]t+ & fiscal ye> #bjag aft]      
#bjae2 &  7ii7 9 subp>agraph 7,b7-- 7,i7
 by /rik+ #bjaj ?r\gh #bjad & ins]t+    
#bjaj1 #bjaa1 #bjab1 #bjac1 #bjad1 &    
#bjaf2 &  7,,ii7 by ins]t+ & fiscal ye> 
#bjag aft] #bjae2 &  7,b7 9 p>agraph    
7#c77;,a71 9 ! matt] prec$+ clause 7i71 
by /rik+ fiscal ye> #bjji1 fiscal ye>   
#bjaj1 fiscal ye> #bjaa1 fiscal ye>     

#bjab1 fiscal ye> #bjac1 fiscal ye>     
#bjad1 or a semi-annual allotm5t p]iod =
 fiscal ye> #bjae & ins]t+ any ( fiscal 
ye>s #bjji ?r\gh #bjad1 fiscal ye>      
#bjaf1 or a semi-annual allotm5t p]iod =
 fiscal ye> #bjae or #bjag4  #cjb4      
,ext5sion ( express lane eligibility    
,section #aijb7;e77#ac77;,i7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#acif;a7e77#ac77;,i77 is am5d$ by /rik+ 
#bjae & ins]t+ #bjag4  #cjc4 ,ext5sion (
 outrea* & enrollm5t program ,section   
#baac ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #acigmm7 is am5d$-- 7#a7 9    
subsection 7a77#a71 by /rik+ #bjae &    
ins]t+ #bjag2 &  7#b7 9 subsection 7g71 
by ins]t+ & #dj1jjj1jjj = ! p]iod (     
fiscal ye>s #bjaf & #bjag aft] #bjae4   
#cjd4 ,ext5sion ( c]ta9 programs &      
demon/ration projects  7a7 ,*ildhood    
obesity demon/ration project ,section   
#aaci;,a7e77#h7 ( ! ,social ,security   
,act 7#db ,u4,s4,c4 #acbj;b-#i;a7e77#h77
 is am5d$ by ins]t+ 1 & #aj1jjj1jjj = ! 
p]iod ( fiscal ye>s #bjaf & #bjag aft]  

#bjad4  7b7 ,p$iatric quality measures  
program ,section #aaci;,a7i7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#acbj;b-#i;a7i77 is am5d$ 9 ! fir/      
s5t5ce by ins]t+ be=e ! p]iod at ! end !
 foll[+3 1 & !re is appropriat$ = !     
p]iod ( fiscal ye>s #bjaf & #bjag1      
#bj1jjj1jjj = ! purpose ( c>ry+ out ?is 
section 7o!r ?an subsections 7e71 7f71 &
 7g774  #cje4 ,report ( ,inspector      
,g5]al ( ,,hhs on use ( express lane    
option "u ,m$icaid & ,,*ip ,n lat] ?an  
#ah mon?s aft] ! date ( ! enactm5t ( ?is
 ,act1 ! ,inspector ,g5]al ( ! ,dep>tm5t
 ( ,heal? & ,human ,s]vices %all submit 
to ! ,committee on ,en]gy & ,comm]ce ( !
 ,h\se ( ,repres5tatives & ! ,committee 
on ,f9ance ( ! ,s5ate a report t--  7#a7
 provides data on ! numb] ( individuals 
enroll$ 9 ! ,m$icaid program "u title   
,,xix ( ! ,social ,security ,act 7ref]r$
 to 9 ?is section z ,m$icaid7 & !       
,*ildr5's ,heal? ,insurance ,program "u 
title ,,xxi ( su* ,act 7ref]r$ to 9 ?is 
section z ,,*ip7 ?r\gh ! use ( !        

,express ,lane option "u section        
#aijb7;e77#ac7 ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acif;a7e77#ac772   
7#b7 assesses ! ext5t to :i* individuals
 s enroll$ meet ! eligibility           
requirem5ts "u ,m$icaid or ,,*ip 7z     
applicable72 &  7#c7 provides data on   
,f$]al & ,/ate exp5ditures "u ,m$icaid &
 ,,*ip = individuals s enroll$ &        
disaggregates su* data betwe5           
exp5ditures made = individuals :o meet !
 eligibility requirem5ts "u ,m$icaid or 
,,*ip 7z applicable7 & exp5ditures made 
= individuals :o d n meet su*           
requirem5ts4  ,,iv ,(fsets  ,a ,m$ic>e  
,b5efici>y ,re=ms  #dja4 ,limitation on 
c]ta9 m$igap policies = newly eligible  
,m$ic>e b5efici>ies ,section #ahhb ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#aciess7 is am5d$ by add+ at ! end !    
foll[+ new subsection3  7z7 ,limitation 
on c]ta9 m$igap policies = newly        
eligible ,m$ic>e b5efici>ies  7#a7 ,9   
g5]al ,not)/&+ any o!r provision ( ?is  
section1 on or aft] ,janu>y #a1 #bjbj1 a

 m$ic>e supplem5tal policy t provides   
cov]age ( ! "p ,b d$uctible1 includ+ any
 su* policy 7or rid] to su* a policy7   
issu$ "u a waiv] grant$ "u subsection   
7p77#f71 may n be sold or issu$ to a    
newly eligible ,m$ic>e b5efici>y4  7#b7 
,newly eligible ,m$ic>e b5efici>y def9$ 
,9 ?is subsection1 ! t]m newly eligible 
,m$ic>e b5efici>y means an individual :o
 is nei!r ( ! foll[+3 7,a7 ,an          
individual :o has atta9$ age #fe be=e   
,janu>y #a1 #bjbj4  7,b7 ,an individual 
:o 0 entitl$ to b5efits "u "p ,a        
pursuant to section #bbf7;b7 or #bbf;,a1
 or deem$ to be eligible = b5efits "u   
section #bbf7;a71 be=e ,janu>y #a1      
#bjbj4  7#c7 ,treatm5t ( waiv]$ ,/ates  
,9 ! case ( a ,/ate describ$ 9          
subsection 7p77#f71 no?+ 9 ?is section  
%all be con/ru$ z prev5t+ ! ,/ate f     
modify+ its alt]native simplification   
program "u su* subsection s z to        
elim9ate ! cov]age ( ! "p ,b d$uctible =
 any m$ical supplem5tal policy sold or  
issu$ "u su* program to a newly eligible

 ,m$ic>e b5efici>y on or aft] ,janu>y   
#a1 #bjbj4  7#d7 ,treatm5t ( ref]5ces to
 c]ta9 policies ,9 ! case ( a newly     
eligible ,m$ic>e b5efici>y1 except z !  
,secret>y may o!rwise provide1 any      
ref]5ce 9 ?is section to a m$ic>e       
supplem5tal policy :i* has a b5efit     
package classifi$ z ,c or ,f %all be    
deem$1 z ( ,janu>y #a1 #bjbj1 to be a   
ref]5ce to a m$ic>e supplem5tal policy  
:i* has a b5efit package classifi$ z ,d 
or ,g1 respectively4  7#e7 ,en=cem5t ,! 
p5alties describ$ 9 clause 7ii7 (       
subsection 7d77#c77;,a7 %all apply )    
respect to a violation ( p>agraph 7#a7 9
 ! same mann] z x applies to a violation
 ( clause 7i7 ( su* subsection4  4      
#djb4 ,income-relat$ premium adju/m5t = 
p>ts ,b & ,d  7a7 ,9 g5]al ,section     
#ahci7;i77#c77;,c77i7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4           
#acier7i77#c77;,c77i77 is am5d$-- 7#a7  
by ins]t+ aft] ,9 g5]al4-- ! foll[+3    
7,i7 ,subject to p>agraphs 7#e7 & 7#f71 
= ye>s be=e #bjah3  2 &  7#b7 by add+ at

 ! end ! foll[+3  7,,ii7 ,subject to    
p>agraph 7#e71 = ye>s beg9n+ ) #bjah3   
,if ! modifi$ adju/$ gross income is3,! 
applicable p]c5tage is3 ,m ?an #he1jjj b
 n m ?an #ajg1jjjce p]c5t ,m ?an        
#ajg1jjj b n m ?an #acc1ejjej p]c5t ,m  
?an #acc1ejj b n m ?an #afj1jjj #fe     
p]c5t ,m ?an #afj1jjjhj p]c5t4  4  7b7  
,con=m+ am5dm5ts ,section #ahci7;i7 ( ! 
,social ,security ,act 7#db ,u4,s4,c4   
#acier7i77 is am5d$--  7#a7 9 p>agraph  
7#b77;,a71 by ins]t+ 7or1 beg9n+ )      
#bjah1 #he1jjj7 aft] #hj1jjj2  7#b7 9   
p>agraph 7#c77;,a77i71 by ins]t+        
applicable be=e table2  7#c7 9 p>agraph 
7#e77;,a7-- 7,a7 9 ! matt] be=e clause  
7i71 by ins]t+ 7o!r ?an #bjah & #bjai7  
aft] #bjjg2 &  7,b7 9 clause 7ii71 by   
ins]t+ 7or1 9 ! case ( a cal5d> ye>     
beg9n+ ) #bjbj1 ,augu/ #bjah7 aft]      
,augu/ #bjjf2 &  7#d7 9 p>agraph 7#f71 9
 ! matt] be=e subp>agraph 7,a71 by /rik+
 #bjai & ins]t+ #bjag4  ,b ,o!r ,(fsets 
#daa4 ,m$ic>e paym5t updates = po/-acute
 provid]s  7a7 ,s,n,fs ,section         

#ahhh7;e7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #acieyy7e77-- 7#a7 9     
p>agraph 7#e77;,b7--  7,a7 9 clause 7i71
 by /rik+ clause 7ii7 & ins]t+ clauses  
7ii7 & 7iii72  7,b7 9 clause 7ii71 by   
ins]t+ subject to clause 7iii71 aft] ea*
 subsequ5t fiscal ye>12 &  7,c7 by add+ 
at ! end ! foll[+ new clause3  7iii7    
,special rule = fiscal ye> #bjah ,=     
fiscal ye> #bjah 7or o!r simil> annual  
p]iod specifi$ 9 clause 7i771 ! skill$  
nurs+ facility m>ket basket p]c5tage1   
aft] application ( clause 7ii71 is equal
 to #a p]c5t4  2 &  7#b7 9 p>agraph     
7#f77;,a71 by /rik+ p>agraph            
7#e77;,b77ii7 & ins]t+ clauses 7ii7 &   
7iii7 ( p>agraph 7#e77;,b7 ea* place x  
appe>s4  7b7 ,i,r,fs ,section #ahhf7;j7 
( ! ,social ,security ,act 7#db         
,u4,s4,c4 #acieww7j77 is am5d$--  7#a7 9
 p>agraph 7#c77;,c7-- 7,a7 9 clause 7i71
 by /rik+ clause 7ii7 & ins]t+ clauses  
7ii7 & 7iii72  7,b7 9 clause 7ii71 by   
/rik+ ,aft] & ins]t+ ,subject to clause 
7iii71 aft]2 &  7,c7 by add+ at ! end ! 

foll[+ new clause3  7iii7 ,special rule 
= fiscal ye> #bjah ,! increase factor to
 be appli$ "u ?is subp>agraph = fiscal  
ye> #bjah1 aft] ! application ( clause  
7ii71 %all be #a p]c5t4  2 &  7#b7 9    
p>agraph 7#g77;,a77i71 by /rik+ p>agraph
 7#c77;,d7 & ins]t+ subp>agraphs        
7,c77iii7 & 7,d7 ( p>agraph 7#c74  7c7  
,h,h,as ,section #ahie7;b77#c77;,b7 ( ! 
,social ,security ,act 7#db ,u4,s4,c4   
#acie;fff7b77#c77;,b77 is am5d$--  7#a7 
9 clause 7iii71 by add+ at ! end !      
foll[+3 ,not)/&+ ! previ\s s5t5ce1 !    
home heal? m>ket basket p]c5tage        
increase = #bjah %all be #a p]c5t42 &   
7#b7 9 clause 7vi77,i71 by ins]t+       
7except #bjah7 aft] ea* subsequ5t ye>4  
7d7 ,hospice ,section #ahad7;i7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#acie;f7i77 is am5d$--  7#a7 9 p>agraph 
7#a77;,c7-- 7,a7 9 clause 7ii77,,vii71  
by /rik+ clause 7iv711 & ins]t+ clauses 
7iv7 & 7vi712  7,b7 9 clause 7iii71 by  
/rik+ clause 7iv71 & ins]t+ clauses 7iv7
 & 7vi712  7,c7 9 clause 7iv71 by /rik+ 

,aft] det]m9+ & ins]t+ ,subject to      
clause 7vi71 aft] det]m9+2 &  7,d7 by   
add+ at ! end ! foll[+ new clause3  7vi7
 ,= fiscal ye> #bjah1 ! m>ket basket    
p]c5tage increase "u clause 7ii77,,vii7 
or 7iii71 z applicable1 aft] application
 ( clause 7iv71 %all be #a p]c5t4  2 &  
7#b7 9 p>agraph 7#e77;,a77i71 by /rik+  
p>agraph 7#a77;,c77iv7 & ins]t+ clauses 
7iv7 & 7vi7 ( p>agraph 7#a77;,c74  7e7  
,l,t,c,hs ,section #ahhf7m77#c7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#acieww7m77#c77 is am5d$--  7#a7 9      
subp>agraph 7,a71 9 ! matt] prec$+      
clause 7i71 by /rik+ ,9 implem5t+ &     
ins]t+ ,subject to subp>agraph 7,c71 9  
implem5t+2 &  7#b7 by add+ at ! end !   
foll[+ new subp>agraph3  7,c7           
,additional special rule ,= fiscal ye>  
#bjah1 ! annual update "u subp>agraph   
7,a7 = ! fiscal ye>1 aft] application ( 
clauses 7i7 & 7ii7 ( subp>agraph 7,a71  
%all be #a p]c5t4  4  #dab4 ,delay (    
r$uction to ,m$icaid ,,d% allotm5ts     
,section #aibc7;f7 ( ! ,social ,security

 ,act 7#db ,u4,s4,c4 #acifr-#d7;f77 is  
am5d$-- 7#a7 9 p>agraph 7#g77;,a7--     
7,a7 9 clause 7i71 by /rik+ #bjag ?r\gh 
#bjbd & ins]t+ #bjah ?r\gh #bjbe2  7,b7 
by /rik+ clause 7ii7 & ins]t+ ! foll[+  
new clause3  7ii7 ,aggregate r$uctions  
,! aggregate r$uctions 9 ,,d% allotm5ts 
= all ,/ates "u clause 7i77,i7 %all be  
equal to-- 7,i7 #b1jjj1jjj1jjj = fiscal 
ye> #bjah2  7,,ii7 #c1jjj1jjj1jjj =     
fiscal ye> #bjai2  7,,iii7              
#d1jjj1jjj1jjj = fiscal ye> #bjbj2      
7,,iv7 #e1jjj1jjj1jjj = fiscal ye>      
#bjba2  7,v7 #f1jjj1jjj1jjj = fiscal ye>
 #bjbb2  7,,vi7 #g1jjj1jjj1jjj = fiscal 
ye> #bjbc2  7,,vii7 #h1jjj1jjj1jjj =    
fiscal ye> #bjbd2 &  7,,viii7           
#h1jjj1jjj1jjj = fiscal ye> #bjbe4  2 & 
7,c7 by add+ at ! end ! foll[+ new      
clause3  7v7 ,di/ribution ( aggregate   
r$uctions ,! ,secret>y %all di/ribute ! 
aggregate r$uctions "u clause 7ii7 among
 ,/ates 9 accordance ) subp>agraph 7,b74
  2 &  7#b7 9 p>agraph 7#h71 by /rik+   
#bjbd & ins]t+ #bjbe4  #dac4 ,levy on   

del9qu5t provid]s  7a7 ,9 g5]al         
,p>agraph 7#c7 ( section #fcca7;h7 ( !  
,int]nal ,rev5ue ,code ( #aihf is am5d$ 
by /rik+ #cj p]c5t & ins]t+ #ajj p]c5t4 
7b7 ,effective date ,! am5dm5t made by  
?is section %all apply to paym5ts made  
aft] #ahj days aft] ! date ( ! enactm5t 
( ?is ,act4  #dad4 ,adju/m5ts to        
inpati5t hospital paym5t rates  ,section
 #g7;b7 ( ! ,,tma1 ,ab/95ce ,education1 
& ,,qi ,programs ,ext5sion ,act ( #bjjg 
7,public ,law #aaj-ij71 z am5d$ by      
section #fca7;b7 ( ! ,am]ican ,taxpay]  
,relief ,act ( #bjab 7,public ,law      
#aab-bdj71 is am5d$--  7#a7 9 p>agraph  
7#a7-- 7,a7 9 ! matt] prec$+ subp>agraph
 7,a71 by /rik+ 1 #bjji1 or #bjaj &     
ins]t+ or #bjji2 &  7,b7 9 subp>agraph  
7,b7-- 7i7 9 clause 7i71 by /rik+ & at !
 end2  7ii7 9 clause 7ii71 by /rik+ !   
p]iod at ! end & ins]t+ 2 &2 &  7iii7 by
 add+ at ! end ! foll[+ new clause3     
7iii7 make an additional adju/m5t to !  
/&>diz$ am\nts "u su* section #ahhf7;d7 
( an increase ( #j4e p]c5tage po9ts =   

dis*>ges occurr+ dur+ ea* ( fiscal ye>s 
#bjah ?r\gh #bjbc & n make ! adju/m5t   
7e/imat$ to be an increase ( #c4b p]c5t7
 t w\ld o!rwise apply = dis*>ges occurr+
 dur+ fiscal ye> #bjah by reason ( !    
completion ( ! adju/m5ts requir$ "u     
clause 7ii74  2  7#b7 9 p>agraph 7#c7-- 
7,a7 by /rik+ %all be con/ru$ & all t   
foll[s ?r\gh provid+ au?ority & ins]t+  
%all be con/ru$ z provid+ au?ority2 &   
7,b7 by ins]t+ & ea* succe$+ fiscal ye> 
?r\gh fiscal ye> #bjbc aft] #bjag2  7#c7
 by r$esignat+ p>agraphs 7#c7 & 7#d7 z  
p>agraphs 7#d7 & 7#e71 respectively2 &  
7#d7 by ins]t+ aft] p>agraph 7#b7 !     
foll[+ new p>agraph3  7#c7 ,prohibition 
,! ,secret>y %all n make an additional  
prospective adju/m5t 7e/imat$ to be a   
decrease ( #j4ee p]c5t7 to ! /&>diz$    
am\nts "u su* section #ahhf7;d7 to (fset
 ! am\nt ( ! increase 9 aggregate       
paym5ts relat$ to docum5tation & cod+   
*anges = dis*>ges occurr+ dur+ fiscal   
ye> #bjaj4  4  ,v ,miscellane\s  ,a     
,protect+ ! ,integrity ( ,m$ic>e  #eja4 

,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  #ejb4 ,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 subsection 7a71 t h 
be5 conduct$ s9ce su* date ( enactm5t4  
#ejc4 ,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$+ s5t5ce1 ! ,secret>y
 %all submit to ! ,committees on ,ways &
 ,means & ,en]gy & ,comm]ce ( ! ,h\se ( 
,repres5tatives1 & to ! ,committee on   
,f9ance ( ! ,s5ate1 a report outl9+ !   
consid]ations und]tak5 by ! ,secret>y "u
 su* s5t5ce4  #ejd4 ,modify+ ,m$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  #eje4 ,r$uc+    
improp] ,m$ic>e paym5ts  7a7 ,m$ic>e    
adm9i/rative contractor improp] paym5t  
outrea* & education ,program ,section   
#ahgd;,a ( ! ,social ,security ,act 7#db
 ,u4,s4,c4 #aciekk-#a7 is am5d$-- 7#a7 9
 subsection 7a77#d7--  7,a7 by          
r$esignat+ subp>agraph 7,g7 z           
subp>agraph 7,h72 &  7,b7 by ins]t+ aft]
 subp>agraph 7,f7 ! foll[+ new          
subp>agraph3  7,g7 ,improp] paym5t      
outrea* & education program ,hav+ 9     
place an improp] paym5t outrea* &       
education program describ$ 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 appropriate1 :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 
#ead7;b7 ( ! ,m$ic>e ,access & ,,*ip    
,reau?orization ,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  #ejf4 ,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  #ejg4 
,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>agraph 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     
#ejh4 ,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  #eji4 
,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      
#eaj4 ,/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  #eaa4 ,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  #eab4 ,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$ic>e program 
"u title ,,xviii ( ! ,social ,security  
,act4  #eac4 ,modification ( ,m$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  #ead4 ,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 p>agraph 7#aj7 (      
section #ahic7;h7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #acie;ddd7h771 z    
add$ by section #eje1 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  #eae4 ,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 #eae7;a7 ( ! ,m$ic>e    
,access & ,,*ip ,reau?orization ,act (  
#bjae meets ! requirem5ts describ$ 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  #eaf4 ,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  #eag4   
,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 & ,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 & :]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  #eah4 ,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  #eai4 ,rule ( con/ruction ,except z
 explicitly provid$ 9 ?is subtitle1 no?+
 9 ?is subtitle1 includ+ ! am5dm5ts made
 by ?is subtitle1 %all be con/ru$ z     
prev5t+ ! use ( notice & comm5t rulemak+
 9 ! implem5tation ( ! provisions (1 & !
 am5dm5ts made by1 ?is subtitle4  ,b    
,o!r provisions  #eba4 ,ext5sion (      
two-midnight ,,pama rules on c]ta9      
m$ical review activities ,section #aaa (
 ! ,protect+ ,access to ,m$ic>e ,act (  
#bjad 7,public ,law #aac-ic2 #db        
,u4,s4,c4 #acie;ddd note7 is am5d$--    
7#a7 9 subsection 7a71 by /rik+ ! fir/  

#f mon?s ( fiscal ye> #bjae & ins]t+    
?r\gh ! end ( fiscal ye> #bjae2  7#b7 9 
subsection 7b71 by /rik+ ,m>* #ca1 #bjae
 & ins]t+ ,septemb] #cj1 #bjae2 &  7#c7 
by add+ at ! end ! foll[+ new           
subsection3  7c7 ,con/ruction ,except z 
provid$ 9 subsections 7a7 & 7b71 no?+ 9 
?is section %all be con/ru$ z limit+ !  
,secret>y's au?ority to pursue fraud &  
abuse activities "u su* section         
#ahic7;h7 or o!rwise4  4  #ebb4 ,requir+
 bid surety bonds & ,/ate lic5sure =    
entities submitt+ bids "u ! ,m$ic>e     
,,dmepos competitive acquisition program
  7a7 ,bid surety bonds ,section        
#ahdg7;a77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciew-#c7;a77#a77 is   
am5d$ by add+ at ! end ! foll[+ new     
subp>agraphs3  7,g7 ,requir+ bid bonds =
 bidd+ entities ,) respect to r\nds (   
competitions beg9n+ "u ?is subsection = 
contracts beg9n+ n e>li] ?an ,janu>y #a1
 #bjag1 & n lat] ?an ,janu>y #a1 #bjai1 
an entity may n submit a bid = a        
competitive acquisition area unless1 z (

 ! deadl9e = bid submission1 ! entity   
has obta9$ 7& provid$ ! ,secret>y ) pro(
 ( hav+ obta9$7 a bid surety bond 79 ?is
 p>agraph ref]r$ to z a bid bond7 9 a =m
 specifi$ by ! ,secret>y consi/5t )     
subp>agraph 7,h7 & 9 an am\nt t is n    
less ?an #ej1jjj & n m ?an #ajj1jjj =   
ea* competitive acquisition area 9 :i* !
 entity submits ! bid4  7,h7 ,treatm5t (
 bid bonds submitt$  7i7 ,= bidd]s t    
submit bids at or bel[ ! m$ian & are    
(f]$ b d n accept ! contract ,9 ! case (
 a bidd+ entity t is (f]$ a contract =  
any product category = a competitive    
acquisition area1 if--  7,i7 ! entity's 
composite bid = su* product category &  
area 0 at or bel[ ! m$ian composite bid 
rate = all bidd+ entities includ$ 9 !   
calculation ( ! s+le paym5t am\nts = su*
 product category & area2 &  7,,ii7 !   
entity does n accept ! contract (f]$ =  
su* product category & area1  ! bid bond
 submitt$ by su* entity = su* area %all 
be =feit$ by ! entity & ! ,secret>y %all
 collect on x4  7ii7 ,treatm5t ( o!r    

bidd]s ,9 ! case ( a bidd+ entity = any 
product category = a competitive        
acquisition area1 if ! entity does n    
meet ! bid =feiture conditions 9        
subclauses 7,i7 & 7,,ii7 ( clause 7i7 = 
any product category = su* area1 ! bid  
bond submitt$ by su* entity = su* area  
%all be return$ )9 #ij days ( ! public  
ann\ncem5t ( ! contract suppli]s = su*  
area4  4  7b7 ,/ate lic5sure  7#a7 ,9   
g5]al ,section #ahdg7;b77#b77;,a7 ( !   
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#c7;b77#b77;,a77 is am5d$ by add+
 at ! end ! foll[+ new clause3  7v7 ,!  
entity meets applicable ,/ate lic5sure  
requirem5ts4  4  7#b7 ,con/ruction ,no?+
 9 ! am5dm5t made by p>agraph 7#a7 %all 
be con/ru$ z affect+ ! au?ority ( !     
,secret>y ( ,heal? & ,human ,s]vices to 
require ,/ate lic5sure ( an entity "u ! 
,m$ic>e competitive acquisition program 
"u section #ahdg ( ! ,social ,security  
,act 7#db ,u4,s4,c4 #aciew-#c7 be=e !   
date ( ! enactm5t ( ?is ,act4  7c7 ,,gao
 report on bid bond impact on small     

suppli]s  7#a7 ,/udy ,! ,comptroll]     
,g5]al ( ! ,unit$ ,/ates %all conduct a 
/udy t evaluates ! effect ( ! bid surety
 bond requirem5t "u ! am5dm5t made by   
subsection 7a7 on ! p>ticipation ( small
 suppli]s 9 ! ,m$ic>e ,,dmepos          
competitive acquisition program "u      
section #ahdg ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciew-#c74  7#b7       
,report ,n lat] ?an #f mon?s aft] ! date
 contracts are fir/ aw>d$ subject to su*
 bid surety bond requirem5t1 !          
,comptroll] ,g5]al %all submit to       
,congress a report on ! /udy conduct$ "u
 p>agraph 7#a74 ,su* report %all include
 recomm5dations = *anges 9 su*          
requirem5t 9 ord] to ensure robu/       
p>ticipation by legitimate small        
suppli]s 9 ! ,m$ic>e ,,dmepos           
competition acquisition program4  #ebc4 
,paym5t = global surgical packages  7a7 
,9 g5]al ,section #ahdh7;c7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7;c77 is am5d$ by add+ at ! end
 ! foll[+ new p>agraph3  7#h7 ,global   

surgical packages  7,a7 ,prohibition (  
implem5tation ( rule reg>d+ global      
surgical packages  7i7 ,9 g5]al ,!      
,secret>y %all n implem5t ! policy      
e/abli%$ 9 ! f9al rule publi%$ on       
,novemb] #ac1 #bjad 7#gi ,f$4 ,reg4     
#fgedh et seq471 t requires ! transition
 ( all #aj-;day & #ij-;day global surg]y
 packages to #j-;day global p]iods4     
7ii7 ,con/ruction ,no?+ 9 clause 7i7    
%all be con/ru$ to prev5t ! ,secret>y f 
revalu+ misvalu$ codes = specific       
surgical s]vices or assign+ values to   
new or revis$ codes = surgical s]vices4 
7,b7 ,collection ( data on s]vices      
includ$ 9 global surgical packages  7i7 
,9 g5]al ,subject to clause 7ii71 !     
,secret>y %all ?r\gh rulemak+ develop & 
implem5t a process to ga!r1 f a         
repres5tative sample ( physicians1      
beg9n+ n lat] ?an ,janu>y #a1 #bjag1    
in=mation ne$$ to value surgical        
s]vices4 ,su* in=mation %all include !  
numb] & level ( m$ical visits furni%$   
dur+ ! global p]iod & o!r items &       

s]vices relat$ to ! surg]y & furni%$    
dur+ ! global p]iod1 z appropriate4 ,su*
 in=mation %all be report$ on claims at 
! end ( ! global p]iod or 9 ano!r mann] 
specifi$ by ! ,secret>y4 ,= purposes (  
c>ry+ out ?is p>agraph 7o!r ?an clause  
7iii771 ! ,secret>y %all transf] f !    
,f$]al ,supplem5tal ,m$ical ,insurance  
,tru/ ,fund "u section #ahda #b1jjj1jjj 
to ! ,c5t] = ,m$ic>e  ,m$icaid ,s]vices 
,program ,managem5t ,acc\nt = fiscal ye>
 #bjae4 ,am\nts transf]r$ "u ! previ\s  
s5t5ce %all rema9 available until       
exp5d$4  7ii7 ,reassessm5t & pot5tial   
sunset ,e #d ye>s1 ! ,secret>y %all     
reassess ! value ( ! in=mation collect$ 
pursuant to clause 7i74 ,bas$ on su* a  
reassessm5t & by regulation1 ! ,secret>y
 may discont9ue ! requirem5t =          
collection ( in=mation "u su* clause if 
! ,secret>y det]m9es t ! ,secret>y has  
adequate in=mation f o!r s\rces1 su* z  
qualifi$ cl9ical data regi/ries1        
surgical logs1 bill+ sy/ems or o!r      
practice or facility records1 &         

electronic heal? records1 9 ord] to     
accurately value global surgical s]vices
 "u ?is section4  7iii7 ,inspector      
,g5]al audit ,! ,inspector ,g5]al ( !   
,dep>tm5t ( ,heal? & ,human ,s]vices    
%all audit a sample ( ! in=mation       
report$ "u clause 7i7 to v]ify !        
accuracy ( ! in=mation s report$4  7,c7 
,improv+ accuracy ( pric+ = surgical    
s]vices ,= ye>s beg9n+ ) #bjai1 !       
,secret>y %all use ! in=mation report$  
"u subp>agraph 7,b77i7 z appropriate &  
o!r available data = ! purpose ( improv+
 ! accuracy ( valuation ( surgical      
s]vices "u ! physician fee s*$ule "u ?is
 section4  4  7b7 ,inc5tive = report+   
in=mation on global surgical s]vices    
,section #ahdh7;a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #aciew-#d7;a77 is  
am5d$ by add+ at ! end ! foll[+ new     
p>agraph3  7#i7 ,in=mation report+ on   
s]vices includ$ 9 global surgical       
packages ,) respect to s]vices = :i* a  
physician is requir$ to report in=mation
 9 accordance ) subsection              

7c77#h77;,b77i71 ! ,secret>y may ?r\gh  
rulemak+ delay paym5t ( #e p]c5t ( !    
am\nt t w\ld o!rwise be payable "u !    
physician fee s*$ule "u ?is section =   
su* s]vices until ! in=mation s requir$ 
is report$4  4  #ebd4 ,ext5sion (       
,secure ,rural ,s*ools & ,community     
,self-,det]m9ation ,act ( #bjjj  7a7    
,paym5ts = fiscal ye>s #bjad & #bjae    
7#a7 ,paym5ts requir$ ,section #aja ( ! 
,secure ,rural ,s*ools & ,community     
,self-,det]m9ation ,act ( #bjjj 7#af    
,u4,s4,c4 #gaaa7 is am5d$ by /rik+ #bjac
 bo? places x appe>s & ins]t+ #bjae4    
7#b7 ,prompt paym5t ,paym5ts = fiscal   
ye> #bjad "u title ,i ( ! ,secure ,rural
 ,s*ools & ,community ,self-,det]m9ation
 ,act ( #bjjj 7#af ,u4,s4,c4 #gaaa et   
seq471 z am5d$ by ?is section1 %all be  
made n lat] ?an #de days aft] ! date ( !
 enactm5t ( ?is ,act4  7#c7 ,r$uction 9 
fiscal ye> #bjad paym5ts on acc\nt (    
previ\s #be- & #ej-p]c5t paym5ts        
,section #aja ( ! ,secure ,rural ,s*ools
 & ,community ,self-,det]m9ation ,act ( 

#bjjj 7#af ,u4,s4,c4 #gaaa7 is am5d$ by 
add+ at ! end ! foll[+ new subsection3  
7c7 ,special ,rule = fiscal ye> #bjad   
paym5ts  7#a7 ,/ate paym5t ,if an       
eligible c\nty 9 a ,/ate t w receive a  
%>e ( ! ,/ate paym5t = fiscal ye> #bjad 
has already receiv$1 or w receive1 a %>e
 ( ! #be-p]c5t paym5t = fiscal ye> #bjad
 di/ribut$ to ! ,/ate be=e ! date ( !   
enactm5t ( ?is subsection1 ! am\nt ( !  
,/ate paym5t %all be r$uc$ by ! am\nt ( 
t eligible c\nty's %>e ( ! #be-p]c5t    
paym5t4  7#b7 ,c\nty paym5t ,if an      
eligible c\nty t w receive a c\nty      
paym5t = fiscal ye> #bjad has already   
receiv$ a #ej-p]c5t paym5t = t fiscal   
ye>1 ! am\nt ( ! c\nty paym5t %all be   
r$uc$ by ! am\nt ( ! #ej-p]c5t paym5t4  
4  7#d7 ,%>es ( ,cali=nia /ate paym5t   
,section #ajc7;d77#b7 ( ! ,secure ,rural
 ,s*ools & ,community ,self-,det]m9ation
 ,act ( #bjjj 7#af ,u4,s4,c4            
#gaac7;d77#b77 is am5d$ by /rik+ #bjac &
 ins]t+ #bjae4  7b7 ,use ( fiscal ye>   
#bjac elections & res]vations = fiscal  

ye>s #bjad & #bjae ,section #ajb ( !    
,secure ,rural ,s*ools & ,community     
,self-,det]m9ation ,act ( #bjjj 7#af    
,u4,s4,c4 #gaab7 is am5d$--  7#a7 9     
subsection 7b77#a71 by add+ at ! end !  
foll[+ new subp>agraph3  7,c7 ,effect ( 
late paym5t = fiscal ye>s #bjad & #bjae 
,! election o!rwise requir$ by          
subp>agraph 7,a7 %all n apply = fiscal  
ye> #bjad or #bjae4  2  7#b7 9          
subsection 7b77#b7-- 7,a7 9 subp>agraph 
7,a71 by add+ at ! end ! foll[+ new     
s5t5ce3 ,if su* two-fiscal ye> p]iod    
includ$ fiscal ye> #bjac1 ! c\nty       
election to receive a %>e ( ! #be-p]c5t 
paym5t or #ej-p]c5t paym5t1 z           
applicable1 also %all be effective =    
fiscal ye>s #bjad & #bjae42 &  7,b7 9   
subp>agraph 7,b71 by /rik+ #bjac !      
second place x appe>s & ins]t+ #bjae2 & 
7#c7 9 subsection 7d7--  7,a7 by add+ at
 ! end ( p>agraph 7#a7 ! foll[+ new     
subp>agraph3  7,e7 ,effect ( late paym5t
 = fiscal ye> #bjad ,! election made by 
an eligible c\nty "u subp>agraph 7,b71  

7,c71 or 7,d7 = fiscal ye> #bjac1 or    
deem$ to be made by ! c\nty "u p>agraph 
7#c77;,b7 = t fiscal ye>1 %all be       
effective = fiscal ye>s #bjad & #bjae4  
2 &  7,b7 by add+ at ! end ( p>agraph   
7#c7 ! foll[+ new subp>agraph3  7,c7    
,effect ( late paym5t = fiscal ye> #bjad
 ,?is p>agraph does n apply = fiscal    
ye>s #bjad & #bjae4  4  7c7 ,special    
projects on ,f$]al l& ,title ,,ii ( !   
,secure ,rural ,s*ools & ,community     
,self-,det]m9ation ,act ( #bjjj 7#af    
,u4,s4,c4 #gaba et seq47 is am5d$--     
7#a7 9 section #bjc7;a77#a7 7#af        
,u4,s4,c4 #gabc7;a77#a771 by /rik+      
,septemb] #cj = fiscal ye> #bjjh 7or z  
soon !reaft] z ! ,secret>y conc]n$      
det]m9es is practicable71 & ea*         
,septemb] #cj !reaft] = ea* succe$+     
fiscal ye> ?r\gh fiscal ye> #bjac &     
ins]t+ ,septemb] #cj ( ea* fiscal ye>   
7or a lat] date specifi$ by ! ,secret>y 
conc]n$ = ! fiscal ye>72  7#b7 9 section
 #bjd7;e77#c77;,b77iii7 7#af ,u4,s4,c4  
#gabd7;e77#c77;,b77iii771 by /rik+ ea* (

 fiscal ye>s #bjaj ?r\gh #bjac & ins]t+ 
fiscal ye> #bjaj & fiscal ye>s !reaft]2 
7#c7 9 section #bjg7;a7 7#af ,u4,s4,c4  
#gabg7;a771 by /rik+ ,septemb] #cj1     
#bjjh 7or z soon !reaft] z ! ,secret>y  
conc]n$ det]m9es is practicable71 & ea* 
,septemb] #cj !reaft] = ea* succe$+     
fiscal ye> ?r\gh fiscal ye> #bjac &     
ins]t+ ,septemb] #cj ( ea* fiscal ye>   
7or a lat] date specifi$ by ! ,secret>y 
conc]n$ = ! fiscal ye>72 &  7#d7 9      
section #bjh 7#af ,u4,s4,c4 #gabh7--    
7,a7 9 subsection 7a71 by /rik+ #bjac & 
ins]t+ #bjag2 &  7,b7 9 subsection 7b71 
by /rik+ #bjad & ins]t+ #bjah4  7d7     
,c\nty funds ,section #cjd ( ! ,secure  
,rural ,s*ools & ,community             
,self-,det]m9ation ,act ( #bjjj 7#af    
,u4,s4,c4 #gadd7 is am5d$--  7#a7 9     
subsection 7a71 by /rik+ #bjac & ins]t+ 
#bjag2 &  7#b7 9 subsection 7b71 by     
/rik+ #bjad & ins]t+ #bjah4  7e7        
,au?orization ( appropriations ,section 
#djb ( ! ,secure ,rural ,s*ools &       
,community ,self-,det]m9ation ,act (    

#bjjj 7#af ,u4,s4,c4 #gaeb7 is am5d$ by 
/rik+ = ea* ( fiscal ye>s #bjjh ?r\gh   
#bjac4  #ebe4 ,exclusion f ,,paygo      
scorec>ds  7a7 ,/atutory ,pay-,z-,y-,g  
scorec>ds ,! budget>y effects ( ?is ,act
 %all n be ent]$ on ei!r ,,paygo        
scorec>d ma9ta9$ pursuant to section    
#d7;d7 ( ! ,/atutory ,pay-,z-,y-,g ,act 
( #bjaj4  7b7 ,s5ate ,,paygo scorec>ds  
,! budget>y effects ( ?is ,act %all n be
 ent]$ on any ,,paygo scorec>d ma9ta9$ =
 purposes ( section #bja ( ,s4 ,con4    
,res4 #ba 7#aaj? ,congress74  ,pass$ !  
,h\se ( ,repres5tatives ,m>* #bf1       
#bjae4,k>5 ,l4 ,haas1,cl]k