,i #aafth ,,congress #ast ,session ,h4 ,r4 #bdjh ,,in ,,the ,,house ,,of ,,representatives ,april #cj1 #bjai,mr4 ,sensenbrenner 7for himself and ,mr4 ,higgins of ,new ,york7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committee on ,ways and ,means1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to update and clarify the classification of and applicable payment methodology for complex rehabilitation technology items under the ,medicare program1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,ensuring ,access to ,quality ,complex ,rehabilitation ,technology ,act of #bjai4 #b4 ,findings ,congress finds the following3 7#a7 ,there is a small and specific population of ,medicare beneficiaries who have significant disabilities and medical conditions who require complex and individually configured medical equipment1 items1 and technologies4 ,these items and technologies are referred to as complex rehabilitation technology 7or ,,crt7 and include specialized wheelchairs1 specialized seating and positioning1 and other types of adaptive equipment and items that are uniquely configured and fitted to the specific individual4 ,individuals in this population often qualify for ,medicare based on their disability 7rather than their age7 and have significant disabilities and medical conditions that may include1 but are not limited to1 cerebral palsy1 muscular dystrophy1 multiple sclerosis1 spinal cord injury1 amyotrophic lateral sclerosis 7,,als71 traumatic brain injury1 and spina bifida4 ,this small population comprises less than #ae percent of the ,medicare beneficiaries who receive wheelchairs4 7#b7 ,current provisions addressing ,medicare benefit categories and related definitions do not sufficiently define certain complex rehabilitation technology items and do not adequately describe and distinguish these items as compared to other types of ,medicare-covered medical items and equipment4 7#c7 ,this current lack of definitional clarity for complex rehabilitation technology items results in access challenges for beneficiaries with significant disabilities and medical conditions1 as these items are often grouped with standardized1 nonspecialized products that significantly differ with respect to the complexity and the individualized configuration involved1 as well as certain evaluation requirements1 clinical coverage criteria1 and other considerations4 7#d7 ,to provide adequate access for the small population of ,medicare beneficiaries with significant disabilities and medical conditions who require these complex1 specialized1 and individually configured items a distinct ,medicare benefit category for complex rehabilitative technology items is needed4 ,this will allow for related improvements to clarify applicable coding1 coverage1 payment1 and supplier standards for such items4 ,a separate benefit category is needed to ensure appropriate access to these items for individuals with significant disabilities and medical conditions1 and will help prevent potential overutilization of ,,crt by individuals for whom such items are not medically necessary4 #c4 ,establishing separate benefit category for complex rehabilitation technologies within medicare ,section #ahfa of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7 is amended-- 7#a7 in subsection 7s77#b7-- 7,a7 in subparagraph 7,,gg71 by striking and at the end2 7,b7 in subparagraph 7,,hh71 by inserting and at the end2 and 7,c7 by inserting after subparagraph 7,,hh7 the following new paragraph3 7,,ii7 complex rehabilitation technology items 7as defined in subsection 7kkk772 2 and 7#b7 by adding at the end1 the following new subsections3 7kkk7 ,complex ,rehabilitation ,technology ,item 7#a7 ,the terms complex rehabilitation technology item and ,,crt item mean an item that-- 7,a7 is designed1 manufactured1 individually configured1 adjusted1 or modified for a specific individual to meet the individual's unique medical1 physical1 or functional needs and capacities2 7,b7 is primarily used to serve a medical1 physical1 or functional purpose and is generally not useful to a person in the absence of disability1 illness1 injury1 or other medical condition2 and 7,c7 requires certain services to ensure appropriate use of such item1 including one or more of the following-- 7i7 an evaluation of the features and functions of ,,crt items to the specific individual who will use such an item1 as required under section #ahcd7x77#b77;,b77ii77,,ii72 or 7ii7 configuring1 fitting1 programming1 adjusting1 or adapting the particular complex rehabilitation technology item for use by such individual4 7#b7 7,a7 ,,crt items shall include-- 7i7 complex rehabilitation manual and power wheelchairs1 options1 and accessories2 7ii7 specialized seating and positioning items1 options1 and accessories2 7iii7 adaptive equipment such as standing frames and gait trainers and options and accessories2 and 7iv7 other items that meet the definition in subparagraph 7#a71 as determined by the ,secretary4 7,b7 ,in determining which items meet the definition of a ,,crt item under this subsection1 the ,secretary shall review existing and new technologies on at least a yearly basis1 and in a manner that takes into consideration technological differences in available items and equipment1 as well as the varying clinical needs of individuals who rely on such items and equipment4 7#c7 7,a7 ,not later than six months after the date of enactment of this subsection1 the ,secretary shall publish a list of ,,hcpcs codes that meet the definition of ,,crt items under this subsection4 ,in considering and publishing the list of codes that meet such definition1 the ,secretary must ensure that the ,,hcpcs code set provides adequate and appropriate access to existing and new technologies that may improve medical1 physical1 or functional outcomes for beneficiaries with significant disabilities and medical conditions1 taking into consideration technological differences1 clinical application1 and the unique medical1 physical1 and functional needs of beneficiaries who rely on medically necessary ,,crt items4 7,b7 ,in establishing the list under subparagraph 7,a71 the ,secretary shall-- 7i7 identify and include existing ,,hcpcs codes that are exclusively ,,crt items1 including items that1 as of ,january #a1 #bjai1 were classified within the following ,,hcpcs codes3 ,e#jfcg1 ,e#jfch1 ,e#jfda1 ,e#jfdb1 ,e#jiec1 ,e#jied1 ,e#jihf1 ,e#ajjb1 ,e#ajjc1 ,e#ajjd1 ,e#ajje1 ,e#ajjf1 ,e#ajjg1 ,e#ajjh1 ,e#ajji1 ,e#ajaj1 ,e#ajaa1 ,e#ajab1 ,e#ajad1 ,e#ajcg1 ,e#aafa1 ,e#abbj1 ,e#abbh1 ,e#abbi1 ,e#abca1 ,e#abcb1 ,e#abcc1 ,e#abcd1 ,e#abce1 ,e#abcf1 ,e#abcg1 ,e#abch1 ,e#abci1 ,e#bbji1 ,e#bbia1 ,e#bbib1 ,e#bbic1 ,e#bbid1 ,e#bbie1 ,e#bcjj1 ,e#bcja1 ,e#bcaj1 ,e#bcaa1 ,e#bcab1 ,e#bcac1 ,e#bcba1 ,e#bcbb1 ,e#bcbc1 ,e#bcbd1 ,e#bcbe1 ,e#bcbf1 ,e#bcbg1 ,e#bcbh1 ,e#bcbi1 ,e#bccj1 ,e#bcca1 ,e#bcea1 ,e#bcgc1 ,e#bcgd1 ,e#bcgf1 ,e#bcgg1 ,e#bfji1 ,e#bfaj1 ,e#bfag1 ,e#hjjj1 ,e#hjja1 ,e#hjjb1 ,k#jjje1 ,k#jhce1 ,k#jhcf1 ,k#jhcg1 ,k#jhch1 ,k#jhci1 ,k#jhdj1 ,k#jhda1 ,k#jhdb1 ,k#jhdc1 ,k#jhdh1 ,k#jhdi1 ,k#jhej1 ,k#jhea1 ,k#jheb1 ,k#jhec1 ,k#jhed1 ,k#jhee1 ,k#jhef1 ,k#jheg1 ,k#jheh1 ,k#jhei1 ,k#jhfj1 ,k#jhfa1 ,k#jhfb1 ,k#jhfc1 ,k#jhfd1 ,k#jhfh1 ,k#jhfi1 ,k#jhgj1 ,k#jhga1 ,k#jhgg1 ,k#jhgh1 ,k#jhgi1 ,k#jhhj1 ,k#jhhd1 ,k#jhhe1 ,k#jhhf1 ,k#jhij1 ,k#jhia1 and ,k#jhih2 7ii7 create and include in the list new ,,hcpcs codes and appropriate code descriptors for ,,crt items that are currently considered to be included in existing ,,hcpcs codes that include both ,,crt and non-,,crt items1 including ,,crt items that1 as of ,january #a1 #bjai1 were classified within the following ,,hcpcs codes3 ,e#jadc1 ,e#jiej1 ,e#jiea1 ,e#jieb1 ,e#jiee1 ,e#jief1 ,e#jieg1 ,e#jifj1 ,e#jifg1 ,e#jigh1 ,e#jiij1 ,e#jiie1 ,e#ajae1 ,e#ajaf1 ,e#ajbh1 ,e#ajbi1 ,e#ajcj1 ,e#bbje1 ,e#bbjh1 ,e#bbca1 ,e#bcfh1 ,e#bcfi1 ,e#bcgj1 ,e#bfje1 ,e#bfjf1 ,e#bfjg1 ,e#bfjh1 ,e#bfac1 ,e#bfad1 ,e#bfae1 ,e#bfaf1 ,e#bfbj1 ,e#bfba1 ,e#bfbb1 ,e#bfbc1 ,e#bfbd1 ,e#bfbe1 ,k#jjjd1 ,k#jjji1 ,k#jjdj1 ,k#jajh1 and ,k#jffi2 and 7iii7 create new ,,hcpcs codes for other miscellaneous1 otherwise not classified1 or custom ,,crt items4 7,c7 ,for each year subsequent to the year during which the ,secretary publishes the list under subparagraph 7,a71 the ,secretary shall publish any necessary updates to such list 7including additions of new ,,crt items and any changes in applicable ,,hcpcs codes and_/or code descriptors7 as needed to ensure appropriate access to the full range of medically necessary ,,crt items and technologies4 4 #d4 ,payment rules ,section #ahcd of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7 is amended by adding at the end the following3 7x7 ,payment for ,,crt items 7#a7 ,general rule for payment 7,a7 ,in general ,not later than the date that is one year after the date of the enactment of this subsection1 subject to subparagraph 7,b71 the ,secretary shall establish a fee schedule that shall apply to ,,crt items as defined at section #ahfa7kkk7 and shall ensure that such fee schedule considers the potential impact on quality1 access1 and beneficiary liability1 including the likely effects on assignment rates and participation rates1 and facilitates appropriate access to medically necessary ,,crt items and technologies4 7,b7 ,methodology ,in establishing the ,,crt fee schedule payment system under subparagraph 7,a71 the ,secretary shall include in such fee schedule1 at a minimum1 the allowance of purchase of items identified at section #ahfa7kkk77#c7 and-- 7i7 shall set the ,,crt fee schedule payment amounts for ,,crt items identified by the codes listed in section #ahfa7kkk77#c77;,b77i7 at a purchase price derived from payment amounts from the ,january #a1 #bjae ,medicare fee schedule plus annual ,consumer ,price ,index-,urban ,all ,item updates for each subsequent year to such items1 as applicable1 under this section2 7ii7 shall calculate the payment amounts for ,,crt items identified by the codes created pursuant to section #ahfa7kkk77#c77;,b77ii7 in accordance with the methodology described in subparagraph 7,c72 7iii7 shall permit the payment amounts for ,,crt items identified by codes for miscellaneous1 otherwise not classified1 or custom items1 created pursuant to section #ahfa7kkk77#c77;,b77iii71 to be calculated based on the methodology described in subparagraph 7,c7 applied to the specific item billed under this subsection2 and 7iv7 shall require that payment amounts for ,,crt items be adjusted annually by the increase in the ,consumer ,price ,index-,urban ,all ,item for the #ab-month period ending the preceding ,june #cjth4 7,c7 ,payment amount calculation ,for purposes of subparagraph 7,b77ii71 the methodology described in this subparagraph for calculating payment amounts for ,,crt items identified by the codes specified in such subparagraph is as follows3 7i7 ,identify commercial price information 7such as manufacturer suggested retail price lists1 but not mail order prices or internet retail prices7 for ,,crt items in the applicable code in effect during the base year 7which1 for purposes of this subparagraph is the calendar year ending ,december #aihf71 except that if the only available commercial price information is from a period other than the base year1 the ,secretary shall use the oldest available pricing for the items and deflate the pricing data to the mid-point of the base year using the deflation factors used by the ,centers for ,medicare ,medicaid ,services for durable medical equipment at the time of enactment of this section4 7ii7 ,using the base year prices1 identify the median price for all ,,crt items in the code4 7iii7 ,increase the median price by #a4g percent and inflate to the payment year using the durable medical equipment fee schedule update factors required by law through #bjje and full consumer price index for all urban consumers update factors starting in #bjjf and for each subsequent year1 adjusted to reflect applicable sales tax circumstances1 if applicable4 7,d7 ,used equipment ,for used equipment1 the ,secretary shall set payment at #ge percent of the ,,crt fee schedule amount for the ,,crt item as determined pursuant to the methodology set forth in subparagraph 7,b74 7,e7 ,payment for temporary rental 7i7 ,in general ,if a ,,crt item owned by a qualified individual needs to be repaired1 payment may be made under this subsection for the temporary rental of a ,,crt item while the ,,crt item owned by such individual is being repaired4 7ii7 ,basis2 limitation ,payment permitted under clause 7i7 shall be made on a monthly basis1 and the period of rental may not exceed one month4 7iii7 ,payment amount ,the amount of payment allowed under clause 7i7 for a month for the rental of a ,,crt item shall be #aj percent of the purchase price for the ,,crt item4 7,f7 ,replacement of items 7i7 ,establishment of reasonable useful lifetime ,in accordance with clause 7ii71 not later than two years of the date of enactment of this subsection1 the ,secretary shall determine and establish1 through a rulemaking process involving advance public notice and an opportunity for stakeholder input and public comments1 a reasonable useful lifetime for ,,crt items for which payment may be made under this paragraph4 7ii7 ,length of reasonable useful lifetime ,the reasonable useful lifetime of items of ,,crt items under this subsection shall be established based on the intended use and continued efficacy1 but shall not in any event exceed five years for any ,,crt item4 ,the ,secretary shall ensure that the length of reasonable useful lifetime is appropriate for each sub-category of items within the ,,crt category4 7,g7 ,exclusive payment rule ,this subsection shall constitute the exclusive provision under this title for payment for ,,crt items under this part4 7#b7 ,conditions for payment 7,a7 ,limitation on payment ,no payment shall be made under this subsection for a ,,crt item unless such ,,crt item-- 7i7 meets the clinical conditions for payment set forth under subparagraph 7,b72 and 7ii7 is furnished by a supplier accredited pursuant to subparagraph 7,d7 and meets the supplier and quality standards specified under subparagraph 7,c74 7,b7 ,clinical conditions for payment 7i7 ,in general ,the ,secretary shall establish standards for clinical conditions for payment for ,,crt items under this subsection4 7ii7 ,requirements ,the standards established under clause 7,b77i7 shall require the following3 7,i7 ,written order ,a qualified ordering practitioner1 as defined in section #ahfa7mmm7 of the ,act1 shall provide a written order for a ,,crt item for a specific individual before the ,secretary may provide payment for such item for such individual under this subsection4 7,,ii7 ,,crt evaluation ,in the case of a ,,crt item that is categorized by the ,secretary1 for purposes of the program under this title1 as a manual wheelchair or a power wheelchair1 the qualified ordering practitioner may not provide a written order under subclause 7,i7 unless the individual has undergone a ,,crt evaluation conducted by a licensed physical therapist or occupational therapist who has no financial relationship with the ,,crt supplier4 ,the performance of such a ,,crt evaluation by a licensed physical or occupational therapist shall not be subject 7or counted towards7 the limitation on certain therapy services under section #ahcc7;g74 7,,iii7 ,documentation of medical necessity ,a qualified ordering practitioner who provides a written order under subclause 7,i7 shall maintain documentation of the medical necessity of such order for a period of seven years and shall make such documentation available to the ,secretary upon request4 ,the documentation of medical necessity under this clause shall include evidence that the individual for whom the order was written has medical1 physical1 and_/or functional needs and capacities that require the use of the prescribed ,,crt item4 7,,iv7 ,coverage ,in developing the standards under subparagraph 7,b71 the coverage of ,,crt items shall be based on the individual's specific medical1 physical1 or functional needs and capacities for basic and instrumental activities of daily living in any setting in which life activities take place4 ,for purposes of this subclause1 basic and instrumental activities of daily living include1 but are not limited to1 moving from place to place2 transferring2 maintaining or changing body position2 caring for one's self 7such as toileting1 bathing1 dressing1 eating1 housekeeping and household management72 acquiring necessities1 goods and services2 engaging in education1 employment and economic life2 or using transportation4 7,v7 ,coverage requirement ,nothing in this subsection or section #ahfa7s77#b77;,,ii7 shall be construed as requiring the ,secretary to provide for coverage under this title of any item that would not otherwise be covered under this title without application of the amendments made by the ,ensuring ,access to ,quality ,complex ,rehabilitation ,technology ,act of #bjai1 or as changing any coverage requirements in existence as of the date of the enactment of this subsection1 including any prior authorization coverage requirements or advance determinations of ,medicare coverage requirements that may apply to ,,crt items4 7,c7 ,establishment of supplier and quality standards for ,,crt 7i7 ,establishment ,the ,secretary shall establish and implement supplier and quality standards for suppliers of ,,crt items to be applied by recognized independent accreditation organizations 7as designated under subparagraph 7,d771 which as set forth below1 incorporate existing standards as well as creating new ,,crt-specific standards4 ,such standards shall be applied prospectively and shall be published on the ,internet website of the ,centers for ,medicare ,medicaid ,services4 7ii7 ,requirements of standards ,in establishing the supplier and quality standards under clause 7i71 the ,secretary shall require that each supplier of ,,crt items meets the following requirements3 7,i7 ,,dme and medical equipment and supplies standards ,the supplier complies with all of the standards that are applicable to suppliers of durable medical equipment under subsection 7a77#bj7 and suppliers of medical equipment and supplies under subsection 7j74 7,,ii7 ,qualified ,,crt professional standards ,the supplier of a ,,crt item makes available1 in each service area served by such supplier1 at least one qualified ,,crt professional to analyze the needs and capacities of individuals for a ,,crt item in collaboration with the clinical team2 assist in selecting any appropriate ,,crt items for such an individual1 given such needs and capacities2 and provide technology-related training to such an individual in the proper use and maintenance of the ,,crt items4 7,,iii7 ,service and repair standards ,the supplier of the ,,crt item-- 7aa7 makes available1 in each service area served by such supplier1 at least one qualified ,,crt service technician to service and repair ,,crt items that are furnished by such supplier2 and 7bb7 provides the individual with written information on accessing service and repair for the ,,crt item before the ,,crt item is ordered for the individual involved4 7,d7 ,accreditation for suppliers of ,,crt items 7i7 ,requirement for provider or supplier number ,the ,secretary shall not provide a supplier of ,,crt items with a provider or supplier number to submit claims for payment under this subsection unless the supplier is in compliance with the requirements under this subparagraph4 7ii7 ,application of accreditation requirement ,in implementing supplier and quality standards under paragraph 7,c71 the ,secretary shall require suppliers furnishing ,,crt items1 on or after one year after the standards are published under such paragraph1 directly or as a subcontractor for another entity-- 7,i7 to comply with such standards2 and 7,,ii7 to have submitted to the ,secretary evidence of accreditation by an accreditation organization designated under subparagraph 7iii7 demonstrating that the supplier is complying with such standards4 7iii7 ,designation of independent accreditation organizations ,not later than the date that is one year after the date on which the ,secretary implements the supplier and quality standards under subparagraph 7,c71 the ,secretary shall designate and approve one or more independent accreditation organizations that-- 7,i7 are approved under subsection 7a77#bj77;,b71 which set forth the designation of independent accreditation organizations for suppliers of durable medical equipment2 and 7,,ii7 have the capability to assess whether suppliers of ,,crt items meet the supplier and quality standards established under subparagraph 7,c74 7#c7 ,definitions ,for purposes of this subsection3 7,a7 ,qualified ,,crt professional 7i7 ,in general ,the term qualified ,,crt professional means an individual who-- 7,i7 is certified by the ,rehabilitation ,engineering and ,assistive ,technology ,society of ,north ,america as an assistive technology professional or is certified by another organization designated by the ,secretary 7acting in consultation with relevant parties1 including manufacturers and suppliers of ,,crt items1 relevant consumer organizations1 and clinicians with knowledge of ,,crt items and direct experience working with individuals who use ,,crt items7 as providing a certification that is equivalent to1 or more stringent than1 the assistive technology professional certification2 and 7,,ii7 beginning #b years after the establishment of the designation under clause 7ii71 subject to clause 7ii77,,ii71 achieves an additional designation that demonstrates the individual's competencies and experience in supplying ,,crt items4 7ii7 ,additional designation 7,i7 ,not later than one year after the date of the enactment of this subparagraph1 the ,secretary1 with stakeholder input1 including manufacturers and suppliers of ,,crt items1 relevant consumer organizations1 and clinicians with knowledge of ,,crt items and direct experience working with patients who use ,,crt items1 shall establish the additional designation under clause 7i77,,ii74 7,,ii7 ,until such time as the additional designation is established1 the term qualified ,,crt professional shall include an individual meeting the requirements in clause 7i77,i7 only4 7,b7 ,qualified ,,crt service technician ,the term qualified ,,crt service technician means an individual who1 with respect to a ,,crt item-- 7i7 has successfully completed a training program approved by the manufacturer of the ,,crt item2 7ii7 is trained and educated 7including through on-the-job training7 to assemble1 program1 adjust1 service1 and repair ,,crt items2 and 7iii7 on an annual basis1 completes at least #aj hours of education specific to the assembly1 programming1 service1 adjusting1 and repairing of ,,crt items4 7,c7 ,qualified ordering practitioner ,the term qualified ordering practitioner means a physician 7as defined in section #ahfa7r771 a physician assistant1 nurse practitioner1 or a clinical nurse specialist 7as those terms are defined in section #ahfa7;aa77#e774 4 #e4 ,conforming amendments 7a7 ,exemption from competitive acquisition ,section #ahdg7;a77#g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c7;a77#g77 is amended by adding at the end the following new subparagraph3 7,c7 ,,crt items ,for calendar year #bjbj and subsequent years1 complex rehabilitation technology items 7as defined in section #ahfa7kkk774 4 7b7 ,payment exclusions ,section #ahcd7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7a77 is amended-- 7#a7 in paragraph 7#d71 by adding at the end the following sentence ,for calendar year #bjbj and subsequent years1 the items covered by this paragraph shall not include ,,crt items 7as defined in section #ahfa7kkk771 which shall be paid pursuant to the fee schedule and methodology for ,,crt items described in section #ahcd7x7 beginning on ,january #a1 #bjbj1 and in subsequent years42 7#b7 in paragraph 7#g77;,a71 by adding at the end the following3 ,for calendar year #bjbj and subsequent years1 this paragraph shall not apply to ,,crt items under section #ahfa7kkk742 and 7#c7 in paragraph 7#af71 by inserting at the end the following3 ,the ,secretary shall impose 7and1 may1 as allowed by the second sentence of this paragraph1 waive7 the requirements of the first sentence of this paragraph to suppliers of complex rehabilitation technology items1 except that1 in order to avoid duplicate bonds1 the ,secretary shall not impose such requirements with respect to suppliers of complex rehabilitation technology items if such suppliers also participate in the ,medicare program as suppliers of durable medical equipment44 7c7 ,requirements for suppliers of medical equipment and supplies ,section #ahcd7;j77#e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7j77#e77 is amended-- 7#a7 by redesignating subparagraphs 7,e7 and 7,f7 as subparagraphs 7,f7 and 7,g71 respectively2 and 7#b7 by inserting after subparagraph 7,d7 the following new subparagraph3 7,e7 complex rehabilitation technology items 7as defined in section #ahfa7kkk772 4 #f4 ,continued coverage of ,,crt items ,the amendments made by this ,act do not change the availability of coverage in existence as of the date of the enactment of this ,act1 including prior authorization coverage requirements1 for ,,crt items under title ,,xviii of the ,social ,security ,act or title ,,xix of such ,act1 or any other payor or program1 including in the case in which ,,crt items are covered1 as of such date of enactment1 as durable medical equipment or under a home health benefit1 including the home health benefit under section #aijb of such ,act and the regulations implementing such section2 nor do the amendments made by this ,act change the existing definitions of durable medical equipment or medical equipment and supplies under such ,act or as established by any other payor or program1 including where ,,crt items may also fit those definitions4 ,in the case that a ,,crt item also satisfies the definition of durable medical equipment1 or medical equipment and supplies1 or another benefit category as defined by an applicable payor1 the amendments of this ,act shall apply only for purposes of payment of the ,,crt item under title ,,xviii of such ,act4 #g4 ,effective date ,the amendments made by this ,act shall be effective beginning on the date that is #cj days after the date of the enactment of this ,act1 unless otherwise specified in a provision of1 including amendment made by1 this ,act4