,,ii  #aae? ,,congress  #a/ ,session    
,s4 #ahij  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,septemb] #bh1 #bjag   
,mr4 ,c>d9 7= himself1 ,mr4 ,blunt1 &   
,mr4 ,nelson7 introduc$ ! foll[+ bill2  
:i* 0 read twice & ref]r$ to !          
,committee on ,f9ance  ,a ,,bill  ,to   
improve ! und]/&+ (1 & promote access to
 treatm5t =1 *ronic kidney disease1 & = 
o!r purposes4  #a4 ,%ort title ,?is ,act
 may be cit$ z ! ,*ronic ,kidney        
,disease ,improvem5t 9 ,rese>* &        
,treatm5t ,act ( #bjag4  #b4 ,table (   
cont5ts ,! table ( cont5ts ( ?is ,act is
 z foll[s3 ,sec4 #a4 ,%ort title4 ,sec4 
#b4 ,table ( cont5ts4 ,,title           
,i--,improv+ pati5t lives & quality (   
c>e ?r\gh rese>* & innovation ,sec4     
#aja4 ,improv+ pati5t lives & quality ( 
c>e ?r\gh rese>* & innovation4 ,sec4    
#ajb4 ,enhanc+ c>e ?r\gh new            
te*nologies4 ,sec4 #ajc4 ,und]/&+ curr5t
 utilization ( palliative c>e s]vices4  
,sec4 #ajd4 ,und]/&+ ! progression (    
kidney disease & treatm5t ( kidney      

failure 9 m9ority populations4 ,,title  
,,ii--,emp[] pati5t decision mak+ &     
*oice ,sec4 #bja4 ,provid+ individuals )
 kidney failure access to manag$ c>e4   
,sec4 #bjb4 ,m$igap cov]age =           
b5efici>ies ) end-/age r5al disease4    
,sec4 #bjc4 ,promot+ access to home     
dialysis treatm5ts4 ,,title             
,,iii--,improv+ pati5t c>e & ensur+     
quality outcomes ,sec4 #cja4 ,ma9ta9 an 
economically /able dialysis             
infra/ructure4 ,sec4 #cjb4 ,improve     
pati5t decision mak+ & transp>5cy by    
consolidat+ & mod]niz+ quality programs4
 ,sec4 #cjc4 ,increas+ access to ,m$ic>e
 kidney disease education b5efit4 ,sec4 
#cjd4 ,c]tification ( new facilities4   
,sec4 #cje4 ,improv+ access 9 und]s]v$  
areas4  ,i ,improv+ pati5t lives &      
quality ( c>e ?r\gh rese>* & innovation 
#aja4 ,improv+ pati5t lives & quality ( 
c>e ?r\gh rese>* & innovation  7a7 ,/udy
 ,! ,secret>y ( ,heal? & ,human ,s]vices
 79 ?is section ref]r$ to z ! ,secret>y7
 %all conduct a /udy on increas+ kidney 

transplantation rates4 ,su* /udy %all   
include an analysis ( ea* ( ! foll[+3   
7#a7 ,any dis9c5tives 9 ! paym5t sy/ems 
"u ! ,m$ic>e program "u title ,,xviii ( 
! ,social ,security ,act t create b>ri]s
 to kidney transplants & po/-transplant 
c>e = b5efici>ies ) end-/age r5al       
disease4  7#b7 ,! practices us$ by      
,/ates ) high] ?an av]age donation rates
 & :e!r ^? practices & policies c\ld be 
successfully utiliz$ 9 o!r ,/ates4  7#c7
 ,practices & policies t c\ld increase  
deceas$ donation rates ( m9ority        
populations4  7#d7 ,:e!r cultural &     
policy b>ri]s exi/ to increas+ liv+     
donation rates1 includ+ an exam9ation ( 
h[ to bett] facilitate *a9$ donations4  
7#e7 ,o!r areas det]m9$ appropriate by !
 ,secret>y4  7b7 ,report ,n lat] ?an #ah
 mon?s aft] ! date ( ! enactm5t ( ?is   
,act1 ! ,secret>y %all submit to        
,congress a report on ! /udy conduct$ "u
 subsection 7a71 toge!r ) su*           
recomm5dations z ! ,secret>y det]m9es to
 be appropriate4  #ajb4 ,enhanc+ c>e    

?r\gh new te*nologies  7a7 ,agreem5t )  
,national ,academy ( ,sci5ces ,!        
,secret>y ( ,heal? & ,human ,s]vices    
%all seek to ent] into an agreem5t ) !  
,national ,academy ( ,sci5ces )9 six    
mon?s ( ! date ( ! enactm5t ( ?is ,act  
"u :i* ! ,national ,academy ( ,sci5ces w
 conduct a /udy on ! design ( paym5ts = 
r5al dialysis s]vices "u ! ,m$ic>e      
program "u title ,,xviii ( ! ,social    
,security ,act1 includ+ an analysis (   
:e!r adju/m5ts to su* paym5ts are ne$$  
to all[ = ! incorporation ( new         
te*nologies & !rapies4  7b7 ,cont5ts ,9 
conduct+ ! /udy "u subsection 7a71 !    
,national ,academy ( ,sci5ces %all      
evaluate ! curr5t paym5t sy/em = r5al   
dialysis s]vices "u ! ,m$ic>e program1  
id5tify b>ri]s to adopt+ innovative     
items1 s]vices1 & !rapies1 & make       
recomm5dations z to h[ to elim9ate su*  
b>ri]s4  #ajc4 ,und]/&+ curr5t          
utilization ( palliative c>e s]vices    
7a7 ,/udy  7#a7 ,9 g5]al ,! ,comptroll] 
,g5]al ( ! ,unit$ ,/ates 79 ?is section 

ref]r$ to z ! ,comptroll] ,g5]al7 %all  
conduct a /udy on ! utilization (       
palliative c>e 9 treat+ individuals )   
advanc$ kidney disease1 f /age #d ?r\gh 
/age #e1 includ+ individuals ) kidney   
failure on dialysis ?r\gh any           
progression ( ! disease4 ,su* /udy %all 
include an analysis (--  7,a7 h[        
palliative c>e c be utiliz$ to improve !
 quality ( life ( ^? ) kidney disease & 
facilitate c>e tailor$ to _! individual 
goals & values2  7,b7 ! successful use (
 palliative c>e 9 ! c>e ( pati5ts ) o!r 
*ronic diseases & s]i\s illnesses2  7,c7
 ! utilization ( palliative c>e at any  
po9t 9 an illness1 includ+ :5 us$ at !  
same "t z curative treatm5t2 &  7,d7 o!r
 areas det]m9$ appropriate by !         
,comptroll] ,g5]al4  7#b7 ,def9ition (  
palliative c>e ,9 ?is section1 ! t]m    
palliative c>e means pati5t & family    
c5t]$ c>e t optimizes quality ( life by 
anticipat+1 prev5t+1 & treat+ suff]+4   
,su* t]m includes c>e t is furni%$      
?r\gh\t ! cont9uum ( ! illness t        

addresses physical1 intellectual1       
emotional1 social1 & spiritual ne$s & t 
facilitates pati5t autonomy1 access to  
in=mation & *oice4  7b7 ,report ,n lat] 
?an #a ye> aft] ! date ( ! enactm5t (   
?is ,act1 ! ,comptroll] ,g5]al %all     
submit to ! ,congress a report on ! /udy
 conduct$ "u subsection 7a71 toge!r )   
su* recomm5dations z ! ,comptroll]      
,g5]al det]m9es to be appropriate4      
#ajd4 ,und]/&+ ! progression ( kidney   
disease & treatm5t ( kidney failure 9   
m9ority populations  7a7 ,/udy ,!       
,secret>y ( ,heal? & ,human ,s]vices 79 
?is section ref]r$ to z ! ,secret>y7    
%all conduct a /udy on--  7#a7 ! social1
 behavioral1 & biological factors lead+ 
to kidney disease2  7#b7 ef=ts to sl[ ! 
progression ( kidney disease 9 m9ority  
populations t are disproportionately    
affect$ by su* disease2 &  7#c7 treatm5t
 patt]ns associat$ ) provid+ c>e1 "u !  
,m$ic>e program "u title ,,xviii ( !    
,social ,security ,act1 ! ,m$icaid      
program "u title ,,xix ( su* ,act1 &    

?r\gh private heal? insurance1 to       
m9ority populations t are               
disproportionately affect$ by kidney    
failure4  7b7 ,report ,n lat] ?an #a ye>
 aft] ! date ( ! enactm5t ( ?is ,act1 ! 
,secret>y %all submit to ,congress a    
report on ! /udy conduct$ "u subsection 
7a71 toge!r ) su* recomm5dations z !    
,secret>y det]m9es to be appropriate4   
,,ii ,emp[] pati5t decision mak+ & *oice
  #bja4 ,provid+ individuals ) kidney   
failure access to manag$ c>e  7a7       
,p]man5t ext5sion ( ,m$ic>e ,advantage  
,,esrd special ne$s plans au?ority      
,section #ahei7;f77#a7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#aciew-#bh7;f77#a77 is am5d$ by ins]t+ 1
 9 ! case ( a specializ$ ,,ma plan =    
special ne$s individuals :o h n be5     
det]m9$ to h end /age r5al disease1 be=e
 = p]iods be=e ,janu>y #a1 #bjai4  7b7  
,accel]at$ access to ,m$ic>e ,advantage 
,section #agjjf7;a77#c7 ( ! #ba/ ,c5tury
 ,cures ,act 7,public ,law #aad-bee7 is 
am5d$ by /rik+ #bjba & ins]t+ #bjbj4    

7c7 ,accel]at$ ,med,p,a,c risk adju/m5t 
report ,section                         
#agjjf7;f77#b77;,a77i77,,ii7 ( ! #ba/   
,c5tury ,cures ,act 7,public ,law       
#aad-bee7 is am5d$ by /rik+ #bjbj &     
ins]t+ #bjai4  #bjb4 ,m$igap cov]age =  
b5efici>ies ) end-/age r5al disease  7a7
 ,gu>ante$ availability ( m$igap        
policies to all ,,esrd m$ic>e           
b5efici>ies  7#a7 ,9 g5]al ,section     
#ahhb7s7 ( ! ,social ,security ,act 7#db
 ,u4,s4,c4 #aciess7s77 is am5d$-- 7,a7 9
 p>agraph 7#b7--  7i7 9 subp>agraph     
7,a71 by /rik+ is #fe & ins]t+ ! foll[+3
 is-- 7i7 #fe ye>s ( age or old] & is   
enroll$ = b5efits "u "p ,b2 or  7ii7 is 
entitl$ to b5efits "u #bbf;,a7b7 & is   
enroll$ = b5efits "u "p ,b4  2 &  7ii7 9
 subp>agraph 7,d71 9 ! matt] prec$+     
clause 7i71 by ins]t+ 7or is entitl$ to 
b5efits "u #bbf;,a7b77 aft] is #fe ye>s 
( age or old]2 &  7,b7 9 p>agraph       
7#c77;,b7--  7i7 9 clause 7ii71 by      
ins]t+ 7or is entitl$ to b5efits "u     
#bbf;,a7b77 aft] is #fe ye>s ( age or   

old]2 &  7ii7 9 clause 7vi71 by ins]t+  
7or "u #bbf;,a7b77 aft] at age #fe4     
7#b7 ,effective date ,! am5dm5ts made by
 p>agraph 7#a7 %all apply to ,m$ic>e    
supplem5tal policies effective on or    
aft] ,janu>y #a1 #bjbj4  7b7 ,additional
 enrollm5t p]iod = c]ta9 individuals    
7#a7 ,"o-"t enrollm5t p]iod  7,a7 ,9    
g5]al ,9 ! case ( an individual describ$
 9 subp>agraph 7,b71 ! ,secret>y (      
,heal? & ,human ,s]vices %all e/abli% a 
"o-"t enrollm5t p]iod dur+ :i* su* an   
individual may enroll 9 any ,m$ic>e     
supplem5tal policy "u section #ahhb ( ! 
,social ,security ,act 7#db ,u4,s4,c4   
#aciess7 ( ! individual's *oos+4  7,b7  
,enrollm5t p]iod ,! enrollm5t p]iod     
e/abli%$ "u subp>agraph 7,a7 %all beg9  
on ,janu>y #a1 #bjbj1 & %all end ,june  
#cj1 #bjbj4  7#b7 ,individual describ$  
,an individual describ$ 9 ?is p>agraph  
is an individual :o-- 7,a7 is entitl$ to
 hospital insurance b5efits "u "p ,a (  
title ,,xviii ( ! ,social ,security ,act
 "u section #bbf;,a7b7 ( su* ,act 7#db  

,u4,s4,c4 #dbf-a72  7,b7 is enroll$ =   
b5efits "u "p ,b ( su* title ,,xviii2 & 
7,c7 w\ld n1 b = ! provisions (1 &      
am5dm5ts made by1 subsection 7a7 be     
eligible = ! gu>ante$ issue ( a ,m$ic>e 
supplem5tal policy "u p>agraph 7#b7 or  
7#c7 ( section #ahhb7s7 ( su* ,act 7#db 
,u4,s4,c4 #aciess7s774  #bjc4 ,promot+  
access to home dialysis treatm5ts  7a7  
,9 g5]al ,section #ahha7;b77#c7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#acierr7b77#c77 is am5d$-- 7#a7 by      
r$esignat+ subp>agraphs 7,a7 & 7,b7 z   
clauses 7i7 & 7ii71 respectively2  7#b7 
9 clause 7ii71 z r$esignat$ by          
subp>agraph 7,a71 by /rik+ on a         
compreh5sive & ins]t+ subject to        
subp>agraph 7,b71 on a compreh5sive2    
7#c7 by /rik+ ,) respect to & ins]t+    
7,a7 ,) respect to2 &  7#d7 by add+ at !
 end ! foll[+ new subp>agraph3  7,b7 ,= 
purposes ( subp>agraph 7,a77ii71 an     
individual det]m9$ to h end-/age r5al   
disease receiv+ home dialysis may *oose 
to receive ! mon?ly end-/age r5al       

disease-relat$ visits furni%$ on or aft]
 ,janu>y #a1 #bjah1 via teleheal? if !  
individual receives a face-to-face      
visit1 )\t ! use ( teleheal?1 at lea/   
once e ?ree consecutive mon?s4  4  7b7  
,orig9at+ site requirem5ts  7#a7 ,9     
g5]al ,section #ahcd7m7 ( ! ,social     
,security ,act 7#db ,u4,s4,c4 #aciem7m77
 is am5d$-- 7,a7 9 p>agraph             
7#d77;,c77ii71 by add+ at ! end ! foll[+
 new subclauses3  7,,ix7 ,a r5al        
dialysis facility1 b only = purposes (  
section #ahha7;b77#c77;,b74  7,x7 ,!    
home ( an individual1 b only = purposes 
( section #ahha7;b77#c77;,b74  2 &  7,b7
 by add+ at ! end ! foll[+ new p>agraph3
  7#e7 ,treatm5t ( home dialysis mon?ly 
,,esrd-relat$ visit ,! geographic       
requirem5ts describ$ 9 p>agraph         
7#d77;,c77i7 %all n apply ) respect to  
teleheal? s]vices furni%$ on or aft]    
,janu>y #a1 #bjah1 = purposes ( section 
#ahha7;b77#c77;,b71 at an orig9at+ site 
describ$ 9 subclause 7,,vi71 7,,ix71 or 
7,x7 ( p>agraph 7#d77;,c77ii74  4  7#b7 

,no facility fee if orig9at+ site = home
 dialysis !rapy is ! home ,section      
#ahcd7m77#b77;,b7 ( ! ,social ,security 
7#db ,u4,s4,c4 #aciem7m77#b77;,b77 is   
am5d$-- 7,a7 by r$esignat+ clauses 7i7 &
 7ii7 z subclauses 7,i7 & 7,,ii71 &     
ind5t+ appropriately2  7,b7 9 subclause 
7,,ii71 z r$esignat$ by subp>agraph     
7,a71 by /rik+ clause 7i7 or ?is clause 
& ins]t+ subclause 7,i7 or ?is          
subclause2  7,c7 by /rik+ site4--,)     
respect to & ins]t+  site4-- 7i7 ,9     
g5]al ,subject to clause 7ii71 ) respect
 to  2 &  7,d7 by add+ at ! end ! foll[+
 new clause3  7ii7 ,no facility fee if  
orig9at+ site = home dialysis !rapy is !
 home ,no facility fee %all be paid "u  
?is subp>agraph to an orig9at+ site     
describ$ 9 p>agraph 7#d77;,c77ii77,x74  
4  7c7 ,con=m+ am5dm5t ,section         
#ahha7;b77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acierr7b77#a77 is am5d$
 by /rik+ p>agraph 7#c77;,a7 & ins]t+   
p>agraph 7#c77;,a77i74  7d7 ,exclusion f
 remun]ation = purposes ( apply+ civil  

monet>y p5alties  7#a7 ,9 g5]al ,section
 #aabh;,a7i77#f7 ( ! ,social ,security  
,act 7#db ,u4,s4,c4 #acbj;a-#g;a7i77#f77
 is am5d$--  7,a7 9 subp>agraph         
7,h77iv71 by /rik+ 2 or at ! end2  7,b7 
9 subp>agraph 7,i71 by /rik+ ! p]iod at 
! end & ins]t+ 2 or2 &  7,c7 by add+ at 
! end ! foll[+ new subp>agraph3  7,j7 ! 
provision ( teleheal? or remote pati5t  
monitor+ te*nologies to individuals "u  
title ,,xviii by a heal? c>e provid] = !
 purpose ( furni%+ teleheal? or remote  
pati5t monitor+ s]vices4  4  7#b7       
,effective date ,! am5dm5ts made by ?is 
subsection %all apply to s]vices furni%$
 on or aft] ! date ( ! enactm5t ( ?is   
,act4  ,,iii ,improv+ pati5t c>e &      
ensur+ quality outcomes  #cja4 ,ma9ta9  
an economically /able dialysis          
infra/ructure  7a7 ,9 g5]al ,section    
#ahha7;b77#ad7 ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acierr7b77#ad77 is 
am5d$-- 7#a7 9 subp>agraph 7,d71 9 !    
matt] prec$+ clause 7i71 by /rik+ ,su*  
sy/em & ins]t+ ,subject to subp>agraph  

7,j71 su* sy/em2 &  7#b7 by add+ at !   
end ! foll[+ new subp>agraph3  7,j7 ,=  
paym5t = r5al dialysis s]vices furni%$  
on or aft] ,janu>y #a1 #bjah1 "u ! sy/em
 "u ?is p>agraph--  7i7 ! paym5t        
adju/m5t describ$ 9 clause 7i7 (        
subp>agraph 7,d7-- 7,i7 %all n take into
 acc\nt comorbidities2 &  7,,ii7 %all   
only take into acc\nt age = purposes (  
di/+ui%+ betwe5 individuals :o are "u   
#ah ye>s ( age & ^? :o are #ah ye>s (   
age & old] b %all n include any o!r     
adju/m5t = age2  7ii7 ! ,secret>y %all  
reassess any adju/m5ts relat$ to pati5t 
weight "u su* clause2  7iii7 ! paym5t   
adju/m5t describ$ 9 clause 7ii7 ( su*   
subp>agraph %all n be includ$2  7iv7 !  
/&>dization factor describ$ 9 ! f9al    
rule publi%$ 9 ! ,f$]al ,regi/] on      
,novemb] #h1 #bjab 7#gg ,f$4 ,reg4      
#fgdgj71 %all be e/abli%$ us+ ! mo/     
curr5tly available data 7& n hi/orical  
data7 & adju/$ on an annual basis1 bas$ 
on su* available data1 to acc\nt = any  
*ange 9 utilization ( drugs & any       

modification 9 adju/ors appli$ "u ?is   
p>agraph2 &  7v7 take into acc\nt       
reasonable co/s = det]m9+ ! paym5t rate 
consi/5t ) p>agraph 7#b77;,b74  4  7b7  
,inclusion ( network fee z an all[able  
co/ ,section #ahha7;b77#ad7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#acierr7b77#ad771 z am5d$ by subsection 
7a71 is am5d$ by add+ at ! end ! foll[+ 
new subp>agraph3  7,k7 ,n lat] ?an      
,janu>y #a1 #bjah1 ! ,secret>y %all am5d
 ! ,,esrd facility co/ report to include
 ! p] treatm5t network fee 7z describ$ 9
 p>agraph 7#g77 z an all[able co/ or    
(fset to rev5ue4  4  #cjb4 ,improve     
pati5t decision mak+ & transp>5cy by    
consolidat+ & mod]niz+ quality programs 
7a7 ,measures ,section #ahha7;h77#b7 ( !
 ,social ,security ,act 7#db ,u4,s4,c4  
#acierr7h77#b77 is am5d$ by add+ at !   
end ! foll[+ new subp>agraphs3  7,f7    
,weight+ limitation ,no s+le measure    
specifi$ by ! ,secret>y or individual   
measure )9 a composite measure s        
specifi$ may be weight$ less ?an #aj    

p]c5t ( ! total p]=mance score4  7,g7   
,/ati/ically valid & reliable ,9        
specify+ measures "u subp>agraph 7,a71 !
 ,secret>y %all only specify measures t 
h be5 %[n to be /ati/ically valid &     
reliable ?r\gh te/+4  4  7b7 ,endorsem5t
 ,section #ahha7;h77#b77;,b7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#acierr7h77#b77;,b77 is am5d$-- 7#a7 9  
clause 7ii71 by add+ at ! end ! foll[+  
new s5t5ce3 ,! exception "u ! prec$+    
s5t5ce %all n apply to a measure t !    
entity ) a contract "u section #ahij7;a7
 7or a simil> entity7 consid]$ b fail$  
to endorse42 &  7#b7 by add+ at ! end ! 
foll[+ new clause3  7iii7 ,composite    
measures ,clauses 7i7 & 7ii7 %all apply 
to composite measures 9 ! same mann] z  
su* clauses apply to individual         
measures4  4  7c7 ,requirem5ts =        
dialysis facility comp>e /> rat+ program
 ,section #ahha7;h77#f7 ( ! ,social     
,security ,act 7#db ,u4,s4,c4           
#acierr7h77#f77 is am5d$ by add+ at !   
end ! foll[+ new subp>agraph3  7,e7     

,requirem5ts = any dialysis facility    
comp>e /> rat+ program ,to ! ext5t t !  
,secret>y ma9ta9s a dialysis facility   
comp>e /> rat+ program1 "u su* a program
 ! ,secret>y--  7i7 %all assign />s us+ 
! same me?odology & total p]=mance score
 results f ! quality inc5tive program "u
 ?is subsection2  7ii7 %all det]m9e !   
/>s us+ ! same me?odology us$ "u su*    
quality inc5tive program2 &  7iii7 %all 
n use a =c$ bell curve :5 det]m9+ ! />s 
or rebasel9+ ! />s4  4  7d7 ,hospitals  
requir$ ,to provide in=mation ,section  
#ahha ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #acierr7 is am5d$ by add+ at !
 end ! foll[+ new subsection3  7i7      
,hospitals requir$ ,to provide in=mation
  7#a7 ,9 g5]al ,! ,secret>y %all       
e/abli% a process "u :i* a hospital or a
 critical access hospital %all provide a
 r5al dialysis facility ) heal? &       
treatm5t in=mation ) respect to an      
individual :o is dis*>g$ f ! hospital or
 critical access hospital & :o          
subsequ5tly receives treatm5t at        

facility4  7#b7 ,elem5ts ,"u ! process  
e/abli%$ "u p>agraph 7#a7-- 7,a7 !      
reque/ = ! heal? in=mation may be       
initiat$ by ! individual prior to       
dis*>ge or ^u reque/ by ! r5al dialysis 
facility aft] ! pati5t is dis*>g$2 &    
7,b7 ! in=mation mu/ be provid$ to !    
facility )9 #g days ( ! reque/ be+ made4
  4  7e7 ,inc5tive paym5ts ,section     
#ahha7;h77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acierr7h77#a77 is am5d$
 by add+ at ! end ! foll[+ new          
subp>agraph3  7,d7 ,inc5tive paym5ts    
7i7 ,9 g5]al ,9 ! case ( a provid] (    
s]vices or a r5al dialysis facility t ! 
,secret>y det]m9es exce$s ! atta9m5t    
p]=mance /&>ds "u p>agraph 7#d7 )       
respect to a ye>1 ! ,secret>y may make a
 bonus paym5t to ! provid] or facility  
7pursuant to a process e/abli%$ by !    
,secret>y74  7ii7 ,fund+ ,! total am\nt 
( bonus paym5ts "u clause 7i7 9 a ye>   
%all be equal to ! total am\nt ( r$uc$  
paym5ts 9 a ye> "u subp>agraph 7,a74    
7iii7 ,no effect 9 subsequ5t ye>s ,!    

provisions ( subp>agraph 7,c7 %all apply
 to a bonus paym5t "u ?is subp>agraph 9 
! same mann] subp>agraph 7,c7 applies to
 a r$uction "u su* subp>agraph4  4  7f7 
,effective date ,! am5dm5ts made by ?is 
section %all apply to items & s]vices   
furni%$ on or aft] ,janu>y #a1 #bjai4   
#cjc4 ,increas+ access to ,m$ic>e kidney
 disease education b5efit  7a7 ,9 g5]al 
,section #ahfa7;ggg7 ( ! ,social        
,security ,act 7#db ,u4,s4,c4           
#aciex7ggg77 is am5d$-- 7#a7 9 p>agraph 
7#a7--  7,a7 9 subp>agraph 7,a71 by     
ins]t+ or /age ,v aft] /age ,,iv2 &     
7,b7 9 subp>agraph 7,b71 by ins]t+ or ( 
a physician assi/ant1 nurse practition]1
 or cl9ical nurse speciali/ 7z def9$ 9  
section #ahfa7;aa77#e77 assi/+ 9 !      
treatm5t ( ! individual's kidney        
condition aft] kidney condition2 &  7#b7
 9 p>agraph 7#b7-- 7,a7 by /rik+        
subp>agraph 7,b72 &  7,b7 9 subp>agraph 
7,a7-- 7i7 by /rik+ 7,a7 aft] 7#b72     
7ii7 by /rik+ & at ! end ( clause 7i72  
7iii7 by /rik+ ! p]iod at ! end ( clause

 7ii7 & ins]t+ 2 &2  7iv7 by r$esignat+ 
clauses 7i7 & 7ii7 z subp>agraphs 7,a7 &
 7,b71 respectively2 &  7v7 by add+ at !
 end ! foll[+3  7,c7 a r5al dialysis    
facility subject to ! requirem5ts (     
section #ahha7;b77#a7 ) p]sonnel :o--   
7i7 provide ! s]vices describ$ 9        
p>agraph 7#a72 &  7ii7 is a physician 7z
 def9$ 9 subsection 7r77#a77 or a       
physician assi/ant1 nurse practition]1  
or cl9ical nurse speciali/ 7z def9$ 9   
subsection 7aa77#e774  4  7b7 ,paym5t to
 r5al dialysis facilities ,section      
#ahha7;b7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #acierr7b77 is am5d$ by  
add+ at ! end ! foll[+ new p>agraph3    
7#ae7 ,= purposes ( p>agraph 7#ad71 !   
s+le paym5t = r5al dialysis s]vices "u  
su* p>agraph %all n take into acc\nt !  
am\nt ( paym5t = kidney disease         
education s]vices 7z def9$ 9 section    
#ahfa7;ggg774 ,in/ead1 paym5t = su*     
s]vices %all be made to ! r5al dialysis 
facility on an assignm5t-relat$ basis "u
 section #ahdh4  4  7c7 ,effective date 

,! am5dm5ts made by ?is section apply to
 kidney disease education s]vices       
furni%$ on or aft] ,janu>y #a1 #bjah4   
#cjd4 ,c]tification ( new facilities    
7a7 ,c]tification  7#a7 ,9 g5]al        
,section #ahfe7;a77#a7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acie;bb7a77#a77 is am5d$ by /rik+ or ! 
conditions & requirem5ts "u section     
#ahha7;b74  7#b7 ,effective date ,!     
am5dm5t made by p>agraph 7#a7 %all take 
effect on ! date ( enactm5t ( ?is ,act &
 apply to a f9d+ made on or aft] su*    
date4  7b7 ,tim+ = acceptance ( reque/s 
f accr$itation organizations ,n lat] ?an
 #f mon?s aft] ! date ( ! enactm5t ( ?is
 ,act1 ! ,secret>y ( ,heal? & ,human    
,s]vices %all accept a complet$         
application f any national accr$itation 
body = provid]s & facilities t provide  
s]vices "u #ahha7;b71 9 accordance )    
section #ahfe7c77;,a774 ,any application
 receiv$ pursuant to ! prec$+ s5t5ce    
%all be deem$ approv$ unless !          
,secret>y1 )9 #ij days aft] ! date ( !  

submission ( ! application to !         
,secret>y1 ei!r d5ies su* reque/ 9 writ+
 or in=ms ! applicant 9 writ+ ) respect 
to any additional in=mation t is ne$$ 9 
ord] to make a f9al det]m9ation )       
respect to ! application4 ,if !         
,secret>y reque/s additional in=mation  
pursuant to ! prec$+ s5t5ce & !         
applicant submits su* in=mation1 !      
application %all be deem$ approv$ unless
 ! ,secret>y1 )9 #ij days ( ! date (    
receiv+ su* in=mation1 d5ies su* reque/4
  #cje4 ,improv+ access 9 und]s]v$ areas
  7a7 ,def9ition ( prim>y c>e s]vices   
,section #cca7;a77#c77;,d7 ( ! ,public  
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#bed;d7a77#c77;,d77 is am5d$ by ins]t+ &
 includes r5al dialysis s]vices be=e !  
p]iod at ! end4  7b7 ,national heal?    
s]vice corps s*ol>%ip program ,section  
#cch;,a7a77#b7 ( ! ,public ,heal?       
,s]vice ,act 7#db ,u4,s4,c4             
#bedl7a77#b77 is am5d$ by ins]t+ 1      
includ+ nephrology heal? pr(essionals   
be=e ! p]iod at ! end4  7c7 ,national   

heal? s]vice corps loan repaym5t program
 ,section #cch;,b7a77#b7 ( ! ,public    
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#bedl-#a7;a77#b77 is am5d$ by ins]t+ 1  
includ+ nephrology heal? pr(essionals   
be=e ! p]iod at ! end4