,,ii  #aae? ,,congress  #a/ ,session    
,s4 #aaia  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,may #bb1 #bjag,mr4    
,grassley introduc$ ! foll[+ bill2 :i* 0
 read twice & ref]r$ to ! ,committee on 
,f9ance  ,a ,,bill  ,to am5d title      
,,xviii ( ! ,social ,security ,act to   
ref9e h[ ,m$ic>e pays = or?otics &      
pro/hetics & to improve b5efici>y       
exp]i5ce & outcomes ) or?otic &         
pro/hetic c>e1 & = o!r purposes4  #a4   
,%ort title2 table ( cont5ts  7a7 ,%ort 
title ,?is ,act may be cit$ z ! ,m$ic>e 
,or?otics & ,pro/hetics ,improvem5t ,act
 ( #bjag4  7b7 ,table ( cont5ts ,! table
 ( cont5ts = ?is ,act is z foll[s3 ,sec4
 #a4 ,%ort title2 table ( cont5ts4,sec4 
#b4 ,modification ( requirem5ts         
applicable "u ,m$ic>e to ! designation (
 accr$itation organizations = suppli]s (
 or?otics & pro/hetics4,sec4 #c4        
,application ( exi/+ accr$itation &     
lic5sure requirem5ts to c]ta9 pro/hetics
 & cu/om-fabricat$ or cu/om-fitt$       
or?otics4,sec4 #d4 ,eligibility =       

,m$ic>e paym5t = or?otics & pro/hetics  
bas$ on suppli] qualifications &        
complexity ( c>e4,sec4 #e4 ,or?oti/'s & 
pro/heti/'s cl9ical notes z "p ( !      
pati5t's m$ical record4,sec4 #f4        
,di/+ui%+ or?oti/s & pro/heti/s f       
suppli]s ( durable m$ical equipm5t &    
supplies4,sec4 #g4 ,cl>ification ab\t   
m9imal self-adju/m5t = (f-!-%elf        
or?otics4,sec4 #h4 ,regulations4  #b4   
,modification ( requirem5ts applicable  
"u ,m$ic>e to ! designation (           
accr$itation organizations = suppli]s ( 
or?otics & pro/hetics  7a7 ,9 g5]al     
,section #ahcd7;a77#bj77;,b7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#aciem7a77#bj77;,b77 is am5d$-- 7#a7 by 
/rik+ organizations4--,n lat] ?an &     
ins]t+3 8organizations4--  7i7 ,9 g5]al 
,subject to clause 7ii71 n lat] ?an  2 &
  7#b7 by add+ aft] clause 7i71 z add$  
by p>agraph 7#a71 ! foll[+ new clauses3 
7ii7 ,special requirem5ts = accr$itation
 ( suppli]s ( or?otics & pro/hetics ,=  
purposes ( apply+ quality /&>ds "u      

subp>agraph 7,a7 = suppli]s 7o!r ?an    
suppli]s describ$ 9 clause 7iii77 (     
items & s]vices describ$ 9 subp>agraph  
7,d77ii71 ! ,secret>y %all designate &  
approve indep5d5t accr$itation          
organizations "u clause 7i7 only if su* 
organizations are ,bo>ds or programs    
describ$ 9 subsection 7h77#a77;,f77iv74 
,n lat] ?an ,janu>y #a1 #bjah1 !        
,secret>y %all ensure t at lea/ "o1 &   
ideally multiple1 indep5d5t accr$itation
 organizations are designat$ & approv$ 9
 accordance ) ?is clause4  7iii7        
,exception ,suppli]s describ$ 9 ?is     
clause are physicians1 occupational     
!rapi/s1 or physical !rapi/s :o are     
lic5s$ or o!rwise regulat$ by ! ,/ate 9 
:i* !y are practic+ & :o receive paym5t 
"u ?is title1 includ+ regulations       
promulgat$ pursuant to ?is subsection4  
4  7b7 ,effective date ,ea* organization
 mu/ satisfy ! requirem5t ( section     
#ahcd7;a77#bj77;,b77ii71 z add$ by      
subsection 7a77#b71 n lat] ?an ,janu>y  
#a1 #bjah1 reg>dless ( :e!r !           

organization is designat$ or approv$ z  
an indep5d5t accr$itation organization  
be=e1 on1 or aft] ! date ( ! enactm5t ( 
?is ,act4  #c4 ,application ( exi/+     
accr$itation & lic5sure requirem5ts to  
c]ta9 pro/hetics & cu/om-fabricat$ or   
cu/om-fitt$ or?otics  7a7 ,9 g5]al      
,section #ahcd7;h77#a77;,f7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#aciem7h77#a77;,f77 is am5d$-- 7#a7 9 ! 
head+1 by ins]t+ or cu/om-fitt$ aft]    
cu/om-fabricat$2  7#b7 9 clause 7i71 9 !
 matt] prec$+ subclause 7,i71 by /rik+  
an item ( cu/om-fabricat$ or?otics      
describ$ 9 clause 7ii7 or = an item (   
pro/hetics unless su* item is & ins]t+  
an item ( or?otics or pro/hetics1       
includ+ an item ( cu/om-fabricat$       
or?otics describ$ 9 clause 7ii71 unless 
su* item is2  7#c7 9 clause 7ii77,,ii71 
9 ! fir/ s5t5ce1 by /rik+ a li/ ( items 
to :i* ?is subp>agraph applies & ins]t+ 
a li/ ( items = purposes ( clause 7i72  
7#d7 9 clause 7iii77,,iii71 by /rik+ to 
provide or manage ! provision (         

pro/hetics & cu/om-design$ or -fabricat$
 or?otics & ins]t+ to provide or manage 
! provision ( or?otics & pro/hetics 7&  
cu/om-design$ or -fabricat$ or?otics1 9 
! case ( an item describ$ 9 clause      
7ii772 &  7#e7 by add+ at ! end ! foll[+
 new clause3  7v7 ,exemption ( (f-!-%elf
 or?otics includ$ 9 a competitive       
acquisition program ,?is subp>agraph    
%all n apply to an item ( or?otics      
describ$ 9 p>agraph 7#b77;,c7 ( section 
#ahdg7;a7 furni%$ on or aft] ,janu>y #a1
 #bjah1 t is includ$ 9 a competitive    
acquisition area "u su* section4  4  7b7
 ,effective date ,! am5dm5ts made by    
subsection 7a7 %all apply to or?otics & 
pro/hetics furni%$ on or aft] ,janu>y   
#a1 #bjah4  #d4 ,eligibility = ,m$ic>e  
paym5t = or?otics & pro/hetics bas$ on  
suppli] qualifications & complexity (   
c>e ,section #ahcd7;h7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4 #aciem7h77
 is am5d$-- 7#a7 9 p>agraph             
7#a77;,f77iii71 9 ! matt] prec$+        
subclause 7,i71 by /rik+ o!r individual 

:o & ins]t+ o!r individual :o1 ) respect
 to ! provision ( or?otics & pro/hetics 
furni%$ on or aft] ,janu>y #a1 #bjah1 & 
subject to p>agraph 7#e77;,a71 satisfies
 all applicable crit]ia ( ! provid]     
qualification designation = su* or?otic 
or pro/hetic1 & :o2  7#b7 9 p>agraph    
7#a77;,f77iv71 by ins]t+ be=e ! p]iod ! 
foll[+3 &1 ) respect to ! provision (   
or?otics & pro/hetics furni%$ on or aft]
 ,janu>y #a1 #bjah1 & subject to        
p>agraph 7#e77;,a71 satisfies all       
applicable crit]ia ( ! provid]          
qualification designation = su* or?otic 
or pro/hetic2 &  7#c7 by add+ at ! end !
 foll[+ new p>agraph3  7#e7 ,eligibility
 = paym5t bas$ on suppli] qualifications
 & complexity ( c>e  7,a7 ,consid]ations
 = eligibility = paym5ts  7i7 ,9 g5]al  
,9 apply+ clauses 7iii7 & 7iv7 (        
p>agraph 7#a77;,f7 = purposes ( det]m9+ 
:e!r paym5t may be made "u ?is          
subsection = or?otics & pro/hetics      
furni%$ on or aft] ,janu>y #a1 #bjah1 ! 
,secret>y %all take into acc\nt !       

complexity ( ! respective item &1       
subject to clauses 7ii71 7iii71 & 7iv71 
! qualifications ( ! individual or      
entity furni%+ & fabricat+ su*          
respective item 9 accordance ) ?is      
p>agraph4  7ii7 ,individuals & entities 
exempt$ f suppli] qualification crit]ia 
,) respect to ! provision ( or?otics or 
pro/hetics1 any crit]ia = suppli]       
qualifications %all n apply to          
physicians1 occupational !rapi/s1 or    
physical !rapi/s :o are lic5s$ or       
o!rwise regulat$ by ! ,/ate 9 :i* !y are
 practic+ & :o receive paym5t "u ?is    
title1 includ+ regulations promulgat$   
pursuant to ?is subsection1 = !         
provision ( or?otics & pro/hetics4      
7iii7 ,suppli]s ,m$ic>e-eligible prior  
to ,janu>y #a1 #bjah1 exempt$ ,9 ! case 
( a qualifi$ suppli] :o is eligible to  
receive paym5t "u ?is title be=e ,janu>y
 #a1 #bjah1 ) respect to ! provision (  
or?otics & pro/hetics1 any new crit]ia =
 provid] qualifications e/abli%$ aft]   
su* date %all n apply to su* suppli]1 = 

! furni%+ or fabrication ( su* an item4 
7iv7 ,modifications ,! ,secret>y %all1 9
 consultation ) ! ,bo>ds & programs     
describ$ 9 p>agraph 7#a77;,f77iv71      
p]iodically review ! crit]ia = suppli]  
qualifications & may implem5t by        
regulation any modifications to su*     
crit]ia1 z det]m9$ appropriate 9        
accordance ) su* consultation4 ,any su* 
modifications %all take effect no e>li] 
?an ,janu>y #a1 #bjah4  7,b7 ,assignm5t 
( bill+ codes ,= purposes ( subp>agraph 
7,a71 ! ,secret>y1 9 consultation )     
repres5tatives ( ! fields ( occupational
 !rapy1 physical !rapy1 or?otics1 &     
pro/hetics1 %all utilize & incorporate !
 set ( ,l-codes li/$1 z ( ! date (      
enactm5t ( ?is p>agraph1 9 ! ,c5t]s =   
,m$ic>e  ,m$icaid ,s]vices docum5t      
entitl$ ,transmittal #fef 7,,cms ,pub4  
#ajj-jd1 ,*ange ,reque/ #ciei1 ,augu/   
#ai1 #bjje74 ,transmittal #fef %all be !
 controll+ s\rce ( category1 product1 & 
code assignm5ts = ! or?otics &          
pro/hetics c>e1 us+ ! suppli]           

qualification designation = ea* ,,hcpcs 
code z /at$ 9 su* docum5t4 ,9 ! case t  
,transmittal #fef is updat$1 reissu$1 or
 replac$ by a subsequ5t docum5t1 !      
prec$+ s5t5ce %all be appli$ ) respect  
to ! mo/ rec5t update1 reissuance1 or   
replacem5t ( su* docum5t4  4  #e4       
,or?oti/'s & pro/heti/'s cl9ical notes z
 "p ( ! pati5t's m$ical record ,section 
#ahcd7;h7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #aciem7h771 z am5d$ by   
section #d1 is am5d$ by add+ at ! end ! 
foll[+ new p>agraph3  7#f7 ,docum5tation
 creat$ by or?oti/s & pro/heti/s ,)     
respect to claims fil$ aft] ! date ( !  
enactm5t ( ! ,m$ic>e ,or?otics &        
,pro/hetics ,improvem5t ,act ( #bjag1 = 
purposes ( det]m9+ ! reasonabl5ess1     
m$ical necessity1 & functional level    
7applicable to pro/hetics7 ( or?otics & 
pro/hetics1 docum5tation creat$ by an   
or?oti/ or pro/heti/ %all be consid]$ "p
 ( ! pati5t's m$ical record &1 consi/5t 
) ! treatm5t ( or?otic & pro/hetic      
pati5t c>e deliv]y /at$ 9 ! heal? c>e   

pr(essional exception provid$ 9 clause  
7ii7 ( subsection 7a77#bj77;,f71 %all be
 consid]$ along ) docum5tation creat$ by
 o!r heal? pr(essionals1 includ+        
physicians1 nurse practition]s1         
occupational !rapi/s1 & physical        
!rapi/s4  4  #f4 ,di/+ui%+ or?oti/s &   
pro/heti/s f suppli]s ( durable m$ical  
equipm5t & supplies  7a7 ,requirem5ts = 
suppli]s ( m$ical equipm5t & supplies   
,section #ahcd7;j77#e7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#aciem7j77#e77 is am5d$ by /rik+        
subp>agraph 7,c74  7b7 ,requirem5ts =   
or?oti/s & pro/heti/s  7#a7 ,9 g5]al    
,section #ahcd ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #aciem7 is am5d$ by 
add+ at ! end ! foll[+ new subsection3  
7v7 ,requirem5ts = or?oti/s & pro/heti/s
  7#a7 ,issuance & r5ewal ( suppli]     
numb]  7,a7 ,paym5t  7i7 ,9 g5]al ,no   
paym5t may be made "u ?is "p to an      
or?otic or pro/hetic suppli] unless su* 
or?otic or pro/hetic suppli] obta9s 7&  
r5ews at su* int]vals z ! ,secret>y may 

require7 a suppli] numb]4  7ii7         
,cl>ification reg>d+ provid]s "u "p ,a  
,no?+ 9 clause 7i7 %all prohibit a      
provid] o!rwise p]mitt$ to receive      
paym5t = or?otics & pro/hetics "u "p ,a 
f cont9u+ to receive paym5t "u su* "p   
)\t int]ruption4  7,b7 ,/&>ds = possess+
 a suppli] numb] ,an or?otic or         
pro/hetic suppli] may only obta9 a      
suppli] numb] if ! suppli] meets /&>ds  
prescrib$ by ! ,secret>y t include      
requirem5ts t ! or?otic or pro/hetic    
suppli] 7&1 :]e applicable1 ! or?oti/ or
 pro/heti/7--  7i7 lic5sure or          
accr$itation-- 7,i7 complies ) all      
applicable ,/ate & ,f$]al lic5sure &    
regulatory requirem5ts2 or  7,,ii7      
acquires accr$itation f ! ,am]ican ,bo>d
 = ,c]tification 9 ,or?otics1           
,pro/hetics & ,p$or?ics1 ,inc4 7,,abc7  
or ! ,bo>d (                            
,c]tification_/,accr$itation1           
,int]national 7,,boc71 or o!r           
accr$itation entity t ! ,secret>y       
det]m9es has /&>ds t are ess5tially     

equival5t to ! /&>ds ( su* ,bo>ds2  7ii7
 ma9ta9s a physical facility on an      
appropriate site2  7iii7 has pro( (     
appropriate liability insurance2 &  7iv7
 meets su* o!r requirem5ts z ! ,secret>y
 %all specify4  7,c7 ,prohibition aga9/ 
multiple suppli] numb]s ,! ,secret>y may
 n issue m ?an "o suppli] numb] to any  
or?otic or pro/hetic suppli] unless !   
,secret>y f9ds t ! issuance ( m ?an "o  
numb] is appropriate to id5tify o!r     
entities "u ! own]%ip or control ( !    
or?otic or pro/hetic suppli]4  7#b7     
,ord] = or?otics or pro/hetics  7,a7    
,in=mation provid$ by or?oti/s &        
pro/heti/s on detail$ writt5 ord]s =    
or?otics & pro/hetics ,an or?oti/ or    
pro/heti/ may di/ribute to physicians1  
or to an individual enroll$ "u ?is "p1 a
 detail$ writt5 ord] = or?otics or      
pro/hetics 7z def9$ 9 p>agraph 7#e77 =  
comm]cial purposes t conta9s ! foll[+   
in=mation3  7i7 ,! id5tification (--    
7,i7 ! or?otic or pro/hetic suppli]2 &  
7,,ii7 ! individual to :om ! or?otics or

 pro/hetics are furni%$4  7ii7 ,!       
id5tification ( ! treat+ physician1     
includ+ ! "n1 address1 & telephone numb]
 ( ! physician4  7iii7 ,a description ( 
! or?otics or pro/hetics ord]$4  7iv7   
,any bill+ code id5tify+ ! or?otics or  
pro/hetics4  7v7 ,diagnosis codes1 a    
description ( ! individual's m$ical &   
functional condition1 & in=mation ab\t !
 ne$ = ! or?otics or pro/hetics4  7,b7  
,in=mation on cod+ & descriptors (      
compon5ts provid$ ,if an or?oti/ or     
pro/heti/ di/ributes a detail$ writt5   
ord] = or?otics or pro/hetics describ$ 9
 subp>agraph 7,a71 ! or?oti/ or         
pro/heti/ %all also li/ on ! ord] !     
,,hcpcs codes & summ>y descriptors ( !  
items & s]vices be+ recomm5d$ prior to  
submission ( ! ord] to ! treat+         
physician = approval4  7,c7 ,signature  
by treat+ physician ,a detail$ writt5   
ord] = or?otics or pro/hetics describ$ 9
 subp>agraph 7,a7 %all be sign$ by !    
treat+ physician4  7#c7 ,limitation on  
individual liability ,except z provid$ 9

 p>agraph 7#d71 if an or?oti/ or        
pro/heti/-- 7,a7 furni%es an or?osis or 
pro/hesis to an individual = :i* no     
paym5t may be made "u ?is "p2 or  7,b7  
subject to section #ahgi1 furni%es an   
or?osis or pro/hesis to an individual = 
:i* paym5t is d5i$ "u section           
#ahfb7;a77#a71  any exp5ses incurr$ = ! 
or?osis or pro/hesis furni%$ to an      
individual by ! or?oti/ or pro/heti/ n  
on an assign$ basis %all be !           
responsibility ( su* or?oti/ or         
pro/heti/4 ,! individual %all h no      
f9ancial responsibility = su* exp5ses & 
! or?oti/ or pro/heti/ %all refund on a 
timely basis to ! individual 7& %all be 
liable to ! individual =7 any am\nts    
collect$ f ! individual = su* items &   
s]vices4 ,! provisions ( subsection     
7a77#ah7 %all apply to refunds requir$  
"u ! previ\s s5t5ce 9 ! same mann] z su*
 provisions apply to refunds "u su*     
subsection4  7#d7 ,individual liability 
,if an or?oti/ or pro/heti/ furni%es an 
or?osis or pro/hesis to an individual = 

:i* paym5t is d5i$ 9 advance "u         
subsection 7a77#ae71 exp5ses incurr$ =  
su* or?osis or pro/hesis furni%$ to !   
individual by ! or?oti/ or pro/heti/    
%all be ! responsibility ( ! individual4
  7#e7 ,def9itions ,9 ?is subsection3   
7,a7 ,detail$ writt5 ord] = or?otics or 
pro/hetics  7i7 ,9 g5]al ,! t]m detail$ 
writt5 ord] = or?otics or pro/hetics    
means a =m or o!r docum5t prep>$ by an  
or?oti/ or pro/heti/ & sign$ by !       
physician 7z def9$ by section #ahfa7r77 
t conta9s in=mation requir$ by !        
,secret>y to be submitt$ to %[ t an     
or?osis or pro/hesis is reasonable &    
necess>y = ! treatm5t ( an illness or   
injury or to improve ! function+ ( a    
mal=m$ body memb]4  7ii7 ,cl>ification  
,! detail$ writt5 "w ord] = or?otics or 
pro/hetic %all n be consid]$ alone =    
purposes ( det]m9+ ! reasonabl5ess1     
m$ical necessity1 & functional level    
7applicable to pro/hetics7 ( pro/hetic  
devices & or?otics4  7,b7 ,or?otics &   
pro/hetics ,! t]m or?otics & pro/hetics 

has ! mean+ giv5 t t]m 9 section        
#ahcd7;h77#d77;,c74  7,c7 ,or?oti/ or   
pro/heti/ ,! t]m or?oti/ or pro/heti/   
means an individual :o is specifically  
tra9$ & educat$ 9 ! provision (1 &      
pati5t c>e managem5t relat$ to1         
pro/hetics & cu/om-fabricat$ or         
cu/om-fit or?otics1 &--  7i7 9 ! case ( 
a ,/ate t provides = ! lic5s+ ( or?oti/s
 & pro/heti/s1 is lic5s$ by ! ,/ate 9   
:i* ! or?otics or pro/hetics 7 suppli$2 
or  7ii7 9 ! case ( a ,/ate t does n    
provide = ! lic5s+ ( or?oti/s &         
pro/heti/s1 is c]tifi$ by ! ,am]ican    
,bo>d ( ,c]tification 9 ,or?otics1      
,pro/hetics & ,p$or?ics1 ,inc4 or by !  
,bo>d ( ,c]tification_/,accr$itation1   
,int]national1 or is c]tifi$ & approv$  
by an entity t ! ,secret>y det]m9es has 
c]tification & approval /&>ds t are     
ess5tially equival5t to ! c]tification &
 approval /&>ds ( su* ,bo>ds4  4  7#b7  
,impact on ,,dmepos b5efit ,! am5dm5t   
made by p>agraph 7#a7-- 7,a7 %all n be  
con/ru$ to create a sep>ate b5efit      

category "u title ,,xviii ( ! ,social   
,security ,act = or?otic & pro/hetic    
devices2 b  7,b7 %all be con/ru$ z      
diff]5tiat+ ! mann] 9 :i* or?otic &     
pro/hetic devices & s]vices are provid$ 
9 contra/ to o!r durable m$ical equipm5t
 & supplies s]vices cov]$ "u su* title4 
7c7 ,def9ition ( or?otics & pro/hetics  
synonym\s ) or?oses & pro/heses ,section
 #ahcd7;h77#d77;,c7 ( ! ,social         
,security ,act 7#db ,u4,s4,c4           
#aciem7h77#d77;,c77 is am5d$ by ins]t+  
7:i* may also be ref]r$ to )\t di/9ction
 z or?oses & pro/heses7 aft] ! t]m      
or?otics & pro/hetics4  7d7 ,limitation 
( competitive acquisition = (f-!-,%elf  
or?otics ,section #ahdg7;a77#g77;,a77i7 
( ! ,social ,security ,act 7#db         
,u4,s4,c4 #aciew-#c7;a77#g77;,a77i77 is 
am5d$--  7#a7 by ins]t+ 1 or?oti/ or    
pro/heti/ 7z def9$ 9 section            
#ahcd7v77#e77;,c771 aft] by a physician2
  7#b7 by ins]t+ 1 or?oti/'s or         
pro/heti/'s1 aft] to ! physician's2 &   
7#c7 by ins]t+ 1 or?oti/'s or           

pro/heti/'s1 aft] ( ! physician's4  7e7 
,effective date ,! am5dm5ts made by ?is 
section %all take effect on ! date (    
enactm5t ( ?is ,act1 & apply to items & 
s]vices furni%$ on or aft] su* date4    
#g4 ,cl>ification ab\t m9imal           
self-adju/m5t = (f-!-%elf or?otics  7a7 
,9 g5]al ,section #ahdg7;a77#b77;,c7 ( !
 ,social ,security ,act 7#db ,u4,s4,c4  
#aciew-#c7;a77#b77;,c77 is am5d$-- 7#a7 
by ins]t+ furni%$ to a pati5t aft]      
section #ahfa7s77#i72  7#b7 by ins]t+ by
 t pati5t 7& n by any o!r p]son7 aft]   
m9imal self-adju/m5t2 &  7#c7 by /rik+  
to fit to ! individual & ins]t+ to fit  
to t pati5t4  7b7 ,inclusion 9 m$ical & 
o!r heal? s]vices ,section #ahfa7s77#i7 
( ! ,social ,security ,act 7#db         
,u4,s4,c4 #aciex7s77#i77 is am5d$-- 7#a7
 by /rik+ leg1 arm & ins]t+ 7,a7 leg1   
arm2  7#b7 9 subp>agraph 7,a71 z add$ by
 p>agraph 7#a71 by /rik+ ! semicolon at 
! end & ins]t+ 2 &2 &  7#c7 by add+ !   
foll[+ new subp>agraph3  7,b7 (f-!-%elf 
or?otics 7z def9$ 9 section             

#ahdg7;a77#b77;,c774  4  7c7 ,effective 
date ,! am5dm5ts made by ?is section    
%all take effect on ,april #a1 #bjjg1 & 
apply to items & s]vices furni%$ on or  
aft] su* date4  #h4 ,regulations ,!     
,secret>y %all promulgate-- 7#a7 n lat] 
?an #a ye> aft] ! enactm5t ( ?is ,act1  
f9al regulations to implem5t !          
provisions (1 & am5dm5ts made by1 ?is   
,act2 &  7#b7 n lat] ?an #abj days aft] 
! enactm5t ( ?is ,act1 f9al regulations 
to implem5t ! provisions (1 & am5dm5ts  
made by1 section #dbg ( ! ,m$ic>e1      
,m$icaid1 & ,,s*ip ,b5efits ,improvem5t 
& ,protections ,act ( #bjjj1 z enact$   
into law by section #a7;a77#f7 ( ,public
 ,law #ajf-eed4