#aad? ,,congress  #a/ ,session  ,h4 ,r4 
#begj  ,,an ,,act  ,to am5d title       
,,xviii ( ! ,social ,security ,act )    
respect to ! treatm5t ( pati5t enc\nt]s 
9 ambulatory surgical c5t]s 9 det]m9+   
mean+ful ,,ehr use1 e/abli% a           
demon/ration program requir+ !          
utilization ( ,value-,bas$ ,insurance   
,design to demon/rate t r$uc+ !         
copaym5ts or co9surance *>g$ to ,m$ic>e 
b5efici>ies = select$ high-value        
prescription m$ications & cl9ical       
s]vices c increase _! utilization &     
ultimately improve cl9ical outcomes &   
l[] heal? c>e exp5ditures1 & = o!r      
purposes4  #a4 ,%ort title ,?is ,act may
 be cit$ z ! ,/r5g!n+ ,m$ic>e ,advantage
 ?r\gh ,innovation & ,transp>5cy =      
,s5iors ,act ( #bjae4  #b4 ,treatm5t (  
pati5t enc\nt]s 9 ambulatory surgical   
c5t]s 9 det]m9+ mean+ful ,,ehr use      
,section #ahdh7o77#b7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7o77#b77 is am5d$ by add+ at ! 
end ( ! foll[+ new subp>agraph3  7,d7   

,treatm5t ( pati5t enc\nt]s at          
ambulatory surgical c5t]s  7i7 ,9 g5]al 
,subject to clause 7ii71 = a paym5t ye> 
aft] #bjae any pati5t enc\nt] ( an      
eligible pr(essional occurr+ at an      
ambulatory surgical c5t] 7describ$ 9    
section #ahcc7;i77#a77;,a77 %all n be   
treat$ z a pati5t enc\nt] 9 det]m9+ :e!r
 an eligible pr(essional qualifies z a  
mean+ful ,,ehr us]4 ,not)/&+ any o!r    
provision ( law1 ! ,secret>y may        
implem5t ?is clause by program          
in/ruction or o!rwise4  7ii7 ,sunset    
,clause 7i7 %all no long] apply z ( !   
fir/ paym5t ye> t beg9s m ?an #c ye>s   
aft] ! date ! ,secret>y det]m9es1 ?r\gh 
notice & comm5t rulemak+1 t c]tifi$     
,,ehr te*nology is applicable to !      
ambulatory surgical c5t] sett+4  4  #c4 
,value-bas$ insurance design            
demon/ration program  7a7 ,9 g5]al ,!   
,secret>y ( ,heal? & ,human ,s]vices 79 
?is section ref]r$ to z ! ,secret>y7    
%all e/abli% a #c-ye> demon/ration      
program to te/ ! use ( value-bas$       

insurance design me?odologies 7z def9$ 9
 subsection 7c77#a77 "u eligible ,m$ic>e
 ,advantage plans (f]$ by ,m$ic>e       
,advantage organizations "u "p ,c (     
title ,,xviii ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciew-#ba et seq474 ,! 
,secret>y may ext5d ! program to a      
duration ( #d or #e ye>s1 z det]m9$     
necess>y by ! ,secret>y 9 coord9ation ) 
! ,c5t]s = ,m$ic>e & ,m$icaid           
,innovation4  7b7 ,demon/ration program 
design  7#a7 ,selection ( ,m$ic>e       
,advantage sites & eligible ,m$ic>e     
,advantage plans ,n lat] ?an #b ye>s    
aft] ! date ( ! enactm5t ( ?is ,act1 !  
,secret>y %all--  7,a7 select at lea/   
two ,m$ic>e ,advantage sites ) respect  
to :i* to conduct ! demon/ration program
 "u ?is section2 &  7,b7 approve        
eligible ,m$ic>e ,advantage plans to    
p>ticipate 9 su* demon/ration program4  
,9 select+ ,m$ic>e ,advantage sites "u  
subp>agraph 7,a71 ! ,secret>y %all take 
into acc\nt area diff]5ces z well z !   
availability ( heal? ma9t5ance          

organization plans & pref]r$ provid]    
organization plans (f]$ 9 su* sites4    
7#b7 ,/>t ( demon/ration ,! demon/ration
 program %all beg9 n lat] ?an ! ?ird    
plan ye> beg9n+ aft] ! date ( ! enactm5t
 ( ?is ,act4  7#c7 ,eligible ,m$ic>e    
,advantage plans ,= purposes ( ?is      
section1 ! t]m eligible ,m$ic>e         
,advantage plan means a ,m$ic>e         
,advantage plan "u "p ,c ( title ,,xviii
 ( ! ,social ,security ,act 7#db        
,u4,s4,c4 #aciew-#ba et seq47 t meets ! 
foll[+ requirem5ts3  7,a7 ,! plan is an 
,m$ic>e ,advantage regional plan 7z     
def9$ 9 p>agraph 7#d7 ( section         
#ahei7;b7 ( su* ,act 7#db ,u4,s4,c4     
#aciew-#bh7;b777 or ,m$ic>e ,advantage  
local plan 7z def9$ 9 p>agraph 7#e7 (   
su* section7 (f]$ 9 ! ,m$ic>e ,advantage
 region select$ "u p>agraph 7#a77;,a74  
7,b7 ,! plan has--  7i7  7,i7 a quality 
rat+ "u section #ahec7o7 ( su* ,act 7#db
 ,u4,s4,c4 #aciew-#bc7o77 ( #d />s or   
high] bas$ on ! mo/ rec5t data available
 = su* ye>1 or  7,,ii7 9 ! case ( a     

specializ$ ,m$ic>e ,advantage plan =    
special ne$s individuals1 z def9$ 9     
section #ahei7;b77#f77;,a7 ( su* ,act   
7#db ,u4,s4,c4 #aciew-#bh7;b77#f77;,a771
 a quality rat+ "u section #ahec7o7 (   
su* ,act 7#db ,u4,s4,c4 #aciew-#bc7o77  
equal to or high] ?an ! national av]age 
= special ne$s plans 7exclud+           
,in/itutional-,special ne$s plans7 bas$ 
on ! mo/ rec5t data available = su* ye>2
 &  7ii7 at lea/ #bj p]c5t ( !          
population to :om ! plan is (f]$ 9 a    
s]vice area consi/s ( subsidy eligible  
individuals 7z def9$ 9 section          
#ahfj;,d-#ad7;a77#c77;,a7 ( ! ,social   
,security ,act 7#db ,u4,s4,c4           
#aciew-#aad7;a77#c77;,a7774  7#d7       
,disclosure to b5efici>ies ,! ,secret>y 
%all provide to ea* individual eligible 
to enroll "u a ,m$ic>e ,advantage plan  
approv$ to p>ticipate "u ! demon/ration 
program dur+ a plan ye> = :i* ! plan is 
s select$--  7,a7 notification t ! plan 
is p>ticipat+ 9 su* demon/ration        
program2  7,b7 backgr\nd in=mation on ! 

demon/ration program2  7,c7 cl9ical data
 d]iv$ f ! /udies result+ f !           
demon/ration program2 &  7,d7           
notification ( ! pot5tial b5efits t !   
individual w receive1 & ( ! o!r pot5tial
 impacts t ! individual w exp]i5ce1 on  
acc\nt ( ! p>ticipation ( ! plan 9 !    
demon/ration program4  7c7 ,value-,bas$ 
insurance design me?odologies  7#a7     
,def9ition ,= purposes ( ?is section1 ! 
t]m value-bas$ insurance design         
me?odology means a me?odology = id5tify+
 specific prescription m$ications1 &    
cl9ical s]vices t are payable "u title  
,,xviii ( ! ,social ,security ,act1 =   
:i* ! r$uction ( copaym5ts1 co9surance1 
or bo?1 w\ld improve ! managem5t (      
specific *ronic cl9ical conditions      
because ( ! high value & effectiv5ess ( 
su* m$ications & s]vices = su* specific 
*ronic cl9ical conditions1 z approv$ by 
! ,secret>y4  7#b7 ,use ( me?odologies  
to r$uce copaym5ts & co9surance ,a      
,m$ic>e ,advantage organization (f]+ an 
eligible ,m$ic>e ,advantage plan approv$

 to p>ticipate "u ! demon/ration        
program1 = ea* plan ye> = :i* ! plan is 
s select$ & us+ value-bas$ insurance    
design me?odologies--  7,a7 %all id5tify
 ea* prescription m$ication & cl9ical   
s]vice cov]$ "u su* plan = :i* ! plan   
proposes to r$uce or elim9ate ! copaym5t
 or co9surance1 ) respect to ! managem5t
 ( specific *ronic cl9ical conditions 7z
 specifi$ by ! ,secret>y7 ( ,m$ic>e     
,advantage eligible individuals 7z def9$
 9 section #ahea7;a77#c7 ( ! ,social    
,security ,act 7#db ,u4,s4,c4           
#aciew-#ba7;a77#c777 enroll$ "u su*     
plans1 = su* plan ye>2  7,b7 may1 = su* 
plan ye>1 r$uce or elim9ate copaym5ts1  
co9surance1 or bo? = su* prescription   
m$ication & cl9ical s]vices s id5tifi$ )
 respect to ! managem5t ( su* conditions
 ( su* individuals--  7i7 if su*        
r$uction or elim9ation is evid5ce-bas$ &
 = ! purpose ( enc\rag+ su* individuals 
9 su* plan to use su* prescription      
m$ications & cl9ical s]vices 7su* z     
prev5tive c>e1 prim>y c>e1 specialty    

visits1 diagno/ic te/s1 proc$ures1 &    
durable m$ical equipm5t7 ) respect to   
su* conditions2 &  7ii7 = ! purpose (   
enc\rag+ su* individuals 9 su* plan to  
use heal? c>e provid]s t su*            
organization has id5tifi$ ) respect to  
su* plan ye> z be+ high value provid]s2 
&  7,c7 if a r$uction or elim9ation is  
appli$ pursuant to subp>agraph 7,b71 )  
respect to su* m$ication & cl9ical      
s]vices1 %all1 = su* plan ye>1 c\nt t[>d
 ! d$uctible applicable to su*          
individual "u su* plan am\nts t w\ld h  
be5 payable by ! individual z copaym5t  
or co9surance = su* m$ication & s]vices 
if ! r$uction or elim9ation _h n be5    
appli$4  7#c7 ,prohibition ( increases (
 copaym5ts & co9surance ,9 no case may  
any ,m$ic>e ,advantage plan p>ticipat+ 9
 ! demon/ration program increase1 = any 
plan ye> = :i* ! plan is s p>ticipat+1 !
 am\nt ( copaym5ts or co9surance = any  
item or s]vice cov]$ "u su* plan =      
purposes ( disc\rag+ ! use ( su* item or
 s]vice4  7d7 ,report on implem5tation  

7#a7 ,9 g5]al ,n lat] ?an #a ye> aft] ! 
date on :i* ! demon/ration program "u   
?is section beg9s "u subsection 7b77#b71
 ! ,secret>y %all submit to ,congress a 
report on ! /atus ( ! implem5tation ( ! 
demon/ration program4  7#b7 ,elem5ts ,! 
report requir$ by p>agraph 7#a7 %all1 ) 
respect to eligible ,m$ic>e ,advantage  
plans p>ticipat+ 9 ! demon/ration       
program = ! fir/ plan ye> ( su* program1
 include ! foll[+3  7,a7 ,a li/ ( ea*   
m$ication & s]vice id5tifi$ pursuant to 
subsection 7c77#b77;,a7 = su* plan )    
respect to su* plan ye>4  7,b7 ,= ea*   
su* m$ication or s]vice s id5tifi$1 !   
am\nt ( ! copaym5t or co9surance requir$
 "u su* plan ) respect to su* plan ye> =
 su* m$ication or s]vice & ! am\nt ( !  
r$uction ( su* copaym5t or co9surance f 
a previ\s plan ye>4  7,c7 ,= ea* provid]
 id5tifi$ pursuant to subsection        
7c77#b77;,b77ii7 = su* plan ) respect to
 su* plan ye>1 a /atem5t ( ! am\nt ( !  
copaym5t or co9surance requir$ "u su*   
plan ) respect to su* plan ye> & ! am\nt

 ( ! r$uction ( su* copaym5t or         
co9surance f ! previ\s plan ye>4  7e7   
,review & assessm5t ( utilization (     
value-,bas$ insurance design            
me?odologies  7#a7 ,9 g5]al ,! ,secret>y
 %all ent] into a contract or agreem5t )
 an indep5d5t entity to review & assess 
! implem5tation ( ! demon/ration program
 "u ?is section4 ,! review & assessm5t  
%all include ! foll[+3  7,a7 ,an        
assessm5t ( ! utilization ( value-bas$  
insurance design me?odologies by ,m$ic>e
 ,advantage plans p>ticipat+ "u su*     
program4  7,b7 ,an analysis ( :e!r r$uc+
 or elim9at+ ! copaym5t or co9surance = 
ea* m$ication & cl9ical s]vice id5tifi$ 
pursuant to subsection 7c77#b77;,a7     
result$ 9 increas$ adh]5ce to m$ication 
regim5s1 increas$ s]vice utilization1   
improvem5t 9 quality metrics1 bett]     
heal? outcomes1 & enhanc$ b5efici>y     
exp]i5ce4  7,c7 ,an analysis ( ! ext5t  
to :i* co/s to ,m$ic>e ,advantage plans 
"u "p ,c ( title ,,xviii ( ! ,social    
,security ,act p>ticipat+ 9 !           

demon/ration program is less ?an co/s to
 ,m$ic>e ,advantage plans "u su* "p t   
are n p>ticipat+ 9 ! demon/ration       
program4  7,d7 ,an analysis ( :e!r r$uc+
 or elim9at+ ! copaym5t or co9surance = 
provid]s id5tifi$ pursuant to subsection
 7c77#b77;,b77ii7 result$ 9 improvem5t 9
 quality metrics1 bett] heal? outcomes1 
& enhanc$ b5efici>y exp]i5ce4  7,e7 ,an 
analysis1 = ea* provid] s id5tifi$1 !   
ext5t to :i* co/s to ,m$ic>e ,advantage 
plans "u "p ,c ( title ,,xviii ( !      
,social ,security ,act p>ticipat+ 9 !   
demon/ration program is less ?an co/s to
 ,m$ic>e ,advantage plans "u su* "p t   
are n p>ticipat+ 9 ! demon/ration       
program4  7,f7 ,su* o!r matt]s z !      
,secret>y consid]s appropriate4  7#b7   
,report ,! contract or agreem5t ent]$   
into "u p>agraph 7#a7 %all require su*  
entity to submit to ! ,secret>y a report
 on ! review & assessm5t conduct$ by !  
entity "u su* p>agraph 9 "t = !         
inclusion ( ! results ( su* report 9 !  
report requir$ by p>agraph 7#c74 ,su*   

report %all include a description1 9    
cle> language1 ( ! mann] 9 :i* ! entity 
conduct$ ! review & assessm5t4  7#c7    
,report to ,congress ,n lat] ?an #d ye>s
 aft] ! date on :i* ! demon/ration      
program beg9s "u subsection 7b77#b71 !  
,secret>y %all submit to ,congress a    
report on ! review & assessm5t ( !      
demon/ration program conduct$ "u ?is    
subsection4 ,! report %all include !    
foll[+3  7,a7 ,a description ( ! results
 ( ! review & assessm5t includ$ 9 !     
report submitt$ pursuant to p>agraph    
7#b74  7,b7 ,su* recomm5dations z !     
,secret>y consid]s appropriate = enhanc+
 ! utilization ( ! me?odologies appli$  
"u ! demon/ration program to all ,m$ic>e
 ,advantage plans "u "p ,c ( title      
,,xviii ( ! ,social ,security ,act s z  
to r$uce copaym5ts & co9surance "u su*  
plans paid by ,m$ic>e b5efici>ies =     
high-value prescription m$ications &    
cl9ical s]vices = :i* cov]age is provid$
 "u su* plans & to o!rwise improve !    
quality ( heal? c>e provid$ "u su*      

plans4  7#d7 ,ov]sight report ,n lat]   
?an #c ye>s aft] ! date ( ! enactm5t (  
?is ,act1 ! ,comptroll] ,g5]al ( !      
,unit$ ,/ates %all submit to ,congress a
 report on ! demon/ration program t     
includes an assessm5t1 ) respect to     
individuals enroll$ "u ,m$ic>e          
,advantage plans approv$ to p>ticipate  
"u ! demon/ration program1 ( ! impact t 
! age1 co-morbidities1 & geographic     
regions ( su* individuals _h ^u !       
implem5tation ( ! demon/ration program  
by ! plans ) respect to su* individuals4
  7f7 ,sav+s ,9 no case may any r$uction
 9 b5efici>y copaym5ts or co9surance    
result+ f ! implem5tation ( !           
demon/ration program "u ?is section     
result 9 exp5ditures "u p>ts ,a1 ,b1 &  
,d ( ! title ,,xviii ( ! ,social        
,security ,act t are great] ?an su*     
exp5ditures )\t application ( ?is       
section4  7g7 ,expansion ( demon/ration 
program ,tak+ into acc\nt ! review &    
assessm5t conduct$ "u subsection 7e71 ! 
,secret>y may1 ?r\gh notice & comm5t    

rulemak+1 exp& 7includ+ implem5tation on
 a nationwide basis7 ! duration & scope 
( ! demon/ration program "u title       
,,xviii ( ! ,social ,security ,act1 o!r 
?an "u ! orig9al m$ic>e fee-=-s]vice    
program "u p>ts ,a & ,b ( su* title1 to 
! ext5t det]m9$ appropriate by !        
,secret>y1 if ! requirem5ts ( p>agraphs 
7#a71 7#b71 & 7#c7 ( subsection 7c7 (   
section #aaae;,a ( ! ,social ,security  
,act 7#db ,u4,s4,c4 #acae;a71 z appli$  
to ! te/+ ( a model "u subsection 7b7 ( 
su* section1 appli$ to ! demon/ration "u
 ?is section4  7h7 ,waiv] au?ority ,!   
,secret>y may waive su* provisions (    
titles ,,xi & ,,xviii ( ! ,social       
,security ,act z may be necess>y to c>ry
 out ! demon/ration program "u ?is      
section4  7i7 ,implem5tation fund+ ,=   
purposes ( c>ry+ out ! demon/ration     
program "u ?is section1 ! ,secret>y %all
 provide = ! transf] f ! ,f$]al         
,hospital ,insurance ,tru/ ,fund "u     
section #ahag ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acie;i7 & ! ,f$]al     

,supplem5t>y ,insurance ,tru/ ,fund "u  
section #ahda ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciet71 includ+ !      
,m$ic>e ,prescription ,drug ,acc\nt 9   
su* ,tru/ ,fund1 9 su* proportion z     
det]m9$ appropriate by ! ,secret>y1 (   
su* sums z may be necess>y4  #d4        
,treatm5t ( infusion drugs furni%$ ?r\gh
 durable m$ical equipm5t ,section       
#ahdb7o77#a7 ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #acieu7o77#a77 is am5d$--
  7#a7 9 subp>agraph 7,c71 by ins]t+ 7& 
includ+ a drug or biological describ$ 9 
subp>agraph 7,d77i7 furni%$ on or aft]  
,janu>y #a1 #bjag7 aft] #bjje2 &  7#b7 9
 subp>agraph 7,d7--  7,a7 by /rik+      
infusion drugs & ins]t+ infusion drugs  
or biologicals ea* place x appe>s2 &    
7,b7 9 clause 7i7--  7i7 by /rik+ #bjjd 
& ins]t+ #bjjd1 & be=e ,janu>y #a1      
#bjag2 &  7ii7 by /rik+ = su* drug4  #e4
 ,s5se ( ,congress reg>d+ !             
implem5tation & di/ribution ( quality   
inc5tive paym5ts to ,m$ic>e ,advantage  
plans ,x is ! s5se ( ,congress t-- 7#a7 

! ,secret>y ( ,heal? & ,human ,s]vices  
has incorrectly int]pret$ subsection 7n7
 ( section #ahec ( ! ,social ,security  
,act 7#db ,u4,s4,c4 #aciew-#bc7 z       
prohibit+ ! provision ( any ,m$ic>e     
quality inc5tive paym5ts "u subsection  
7o7 ( su* section ) respect to ,m$ic>e  
,advantage plans t exce$ ! paym5t b5*m>k
 cap "u su* subsection 7n7 = ! area s]v$
 by su* plans2 &  7#b7 ! ,secret>y %\ld 
imm$iately apply quality inc5tive       
paym5ts "u su* subsection 7o7 ) respect 
to su* ,m$ic>e ,advantage plans )\t     
reg>d to ! limits set =? 9 su*          
subsection 7n74  #f4 ,m$ic>e ,improvem5t
 ,fund ,section #ahih7;b77#a7 ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#acie;iii7b77#a77 is am5d$ by /rik+ dur+
 & aft] fiscal ye> #bjbj1 #j & ins]t+   
aft] fiscal ye> #bjbj1 #bbj1jjj1jjj4    
#g4 ,non-inclusion ( ,,dme infusion     
drugs "u ,,dme competitive acquisition  
programs  7a7 ,9 g5]al ,section         
#ahdg7;a77#b77;,a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    

#aciew-#c7;a77#b77;,a77 is am5d$-- 7#a7 
by /rik+ & exclud+ & ins]t+ 1 exclud+2 &
  7#b7 by ins]t+ be=e ! p]iod at ! end !
 foll[+3 1 & exclud+ drugs & biologicals
 describ$ 9 section #ahdb7o77#a77;,d74  
7b7 ,con=m+ am5dm5t ,section            
#ahdb7o77#a77;,d77ii7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4           
#acieu7o77#a77;,d77ii77 is am5d$ by     
/rik+ #bjjg & ins]t+ #bjjg1 & be=e !    
date ( ! enactm5t ( ! ,/r5g!n+ ,m$ic>e  
,advantage ?r\gh ,innovation &          
,transp>5cy = ,s5iors ,act ( #bjae4     
,pass$ ! ,h\se ( ,repres5tatives ,june  
#ag1 #bjae4;,cl]k4