,,ii  #aai? ,,congress  #b;d ,session   
,s4 #efgb  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,septemb] #cj1         
#bjbf,mr4 ,m>%all introduc$ ! foll[+    
bill2 :i* 0 read twice & ref]r$ to !    
,committee on ,f9ance  ,a ,,bill  ,to   
am5d title ,,xviii ( ! ,social ,security
 ,act to modify c]ta9 physician paym5ts 
"u ! ,m$ic>e program4  #a4 ,%ort title2 
table ( cont5ts  7a7 ,%ort title ,?is   
,act may be cit$ z ! ,pati5ts ,fir/ ,act
 ( #bjbf4  7b7 ,table ( cont5ts  ,sec4  
#a4 ,%ort title2 table ( cont5ts4,,title
 ,i--,/r5g!n+ reimbursem5t & pati5t     
access,sec4 #aja4 ,modify+ ! conv]sion  
factor updates applicable to physicians'
 s]vices "u ! ,m$ic>e program4,sec4     
#ajb4 ,hybrid paym5t model = prim>y c>e 
s]vices4,sec4 #ajc4 ,"w geographic floor
 adju/m5t = high inflation>y            
ye>s4,,title ,,ii--,p,o,i,n,t,s,sec4    
#bja4 ,implem5tation ( ! ,pati5t        
,outcome ,improvem5t ,national          
,tabulation ,sy/em4,sec4 #bjb4 ,paym5t  
re=m4,sec4 #bjc4 ,quality ,re=m ,task   

,=ce4,sec4 #bjd4 ,modification ( ,,mips 
paym5t adju/m5ts4,sec4 #bje4 ,modify+   
requirem5ts & approval p]iods = qualifi$
 cl9ical data regi/ries4,sec4 #bjf4     
,exp&$ access to claims data to         
facilitate rese>* & quality             
improvem5t4,sec4 #bjg4 ,modification (  
appropriate use crit]ia data collection 
= applicable imag+ s]vices4,sec4 #bjh4  
,rules ( con/ruction4,,title            
,,iii--,,apm improvement,sec4 #cja4     
,qualify+ ,,apm p>ticipant ?re%old      
freeze4,sec4 #cjb4 ,,cmi model          
requirem5ts4,sec4 #cjc4 ,report on      
b>ri]s to p>ticipation 9 value-bas$     
paym5t models4,,title ,,iv--,physician  
paym5t improvements,sec4 #dja4 ,updat+ !
 budget neutrality ?re%old4,sec4 #djb4  
,budget neutrality corrections relat+ to
 e/imat$ utilization4,sec4 #djc4 ,timely
 updates to direct co/s us$ to calculate
 practice exp5se ,r,v,us4,sec4 #djd4    
,limitation on ye>-to-ye> conv]sion     
factor v>iance4  ,i ,/r5g!n+            
reimbursem5t & pati5t access  #aja4     

,modify+ ! conv]sion factor updates     
applicable to physicians' s]vices "u !  
,m$ic>e program  7a7 ,9 g5]al ,section  
#ahdh7;d7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #aciew-#d7;d77 is am5d$--
 7#a7 9 p>agraph 7#a77;,a71 9 ! second  
s5t5ce1 by ins]t+ or 7#ba7 aft] p>agraph
 7#bj72  7#b7 9 p>agraph 7#bj7-- 7,a7 9 
! head]1 by /rik+ & subsequ5t ye>s2 &   
7,b7 by /rik+ & ea* subsequ5t ye>2 &    
7#c7 by add+ at ! end ! foll[+ new      
p>agraph3  7#ba7 ,update = #bjbg &      
subsequ5t ye>s  7,a7 ,9 g5]al ,= #bjbg &
 ea* subsequ5t ye>1 ! update to !       
nonqualify+ ,,apm conv]sion factor      
e/abli%$ "u p>agraph 7#a77;,a7 is1      
subject to subp>agraph 7,b71 !          
,secret>y's e/imate ( ! p]c5tage        
increase 9 ! ,,mei 7z def9$ 9 section   
#ahdb7;i77#c77 = ! ye>1 less #a p]c5tage
 po9t1 & ! update to ! qualify+ ,,apm   
conv]sion factor e/abli%$ "u su*        
p>agraph is ! update to ! nonqualify+   
,,apm conv]sion factor = ! ye>1 increas$
 by #j4e p]c5tage po9t4  7,b7 ,floor &  

ceil+ on nonqualify+ ,,apm conv]sion    
factor update ,9 ! case t ! update to ! 
nonqualify+ ,,apm conv]sion factor = a  
ye> z calculat$ "u subp>agraph 7,a7 is--
 7i7 less ?an #be p]c5t ( ! ,secret>y's 
e/imate ( ! p]c5tage increase 9 ! ,,mei 
7z def9$ 9 section #ahdb7;i77#c77 = !   
ye>1 su* update %all be deem$ to be     
equal to #be p]c5t ( su* e/imate2 or    
7ii7 m ?an #ge p]c5t ( su* e/imate1 su* 
update %all be deem$ to be equal to #ge 
p]c5t ( su* e/imate4  4  7b7 ,reports ,!
 ,secret>y ( ,heal? & ,human ,s]vices   
%all1 = #bjbg & ea* ye> !reaft]1 submit 
to ,congress a report on ! updates to ! 
qualify+ ,,apm conv]sion factor &       
nonqualify+ ,,apm conv]sion factor "u   
section #ahdh7;d7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #aciew-#d7;d77 = su*
 ye>4 ,su* report %all include an       
analysis ( ! impact ( su* updates on    
,m$ic>e b5efici>ies' access to s]vices  
"u ! ,m$ic>e program & on !             
consolidation ( physician practices4    
#ajb4 ,hybrid paym5t model = prim>y c>e 

s]vices ,"p ,e ( title ,,xviii ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#aciex et seq47 is am5d$ by ins]t+ aft] 
section #ahff;,g ! foll[+ new section3  
#ahff;,h4 ,hybrid paym5t model = prim>y 
c>e s]vices  7a7 ,9 g5]al ,! ,secret>y  
%all1 = #bjbg & ea* subsequ5t ye> ?r\gh 
#bjca1 c>ry out a hybrid paym5t model = 
prim>y c>e s]vices 79 ?is section ref]r$
 to z ! model7 "u :i* ! ,secret>y %all  
make a mon?ly paym5t to ea* qualify+    
suppli] = ea* individual attribut$ to   
su* practice = su* ye> 9 lieu ( paym5t =
 any designat$ prim>y c>e s]vices       
furni%$ by su* suppli] to su*           
individuals dur+ su* ye> t w\ld o!rwise 
be made "u ! paym5t s*$ule e/abli%$ "u  
section #ahdh 7or on ! basis ( su*      
s*$ule74  7b7 ,paym5t am\nt  7#a7 ,9    
g5]al ,! mon?ly am\nt payable to a      
qualify+ suppli] = a ye> "u ! model is  
equal to #a_/ab ( ! national av]age     
am\nt t ! ,secret>y e/imates w be       
payable "u ! paym5t basis e/abli%$ "u   
section #ahdh = designat$ prim>y c>e    

s]vices furni%$ dur+ su* ye> 7s e/imat$ 
z if no co/ %>+ requirem5ts appli$ to   
individuals enroll$ "u "p ,b71 adju/$ by
 a geographic index det]m9$ appropriate 
by ! ,secret>y & risk adju/$ 9 a mann]  
det]m9$ appropriate by ! ,secret>y4     
7#b7 ,nonapplication ( co/ %>+ ,no co/  
%>+ requirem5t %all apply ) respect to a
 mon?ly paym5t made "u ! model to a     
qualify+ suppli] = an individual        
attribut$ to su* suppli]4  7c7          
,attribution process  7#a7 ,9 g5]al ,!  
,secret>y %all e/abli% a process "u :i*1
 = ea* ye> ( ! model1 individuals       
enroll$ "u "p ,b :o are n enroll$ "u an 
,,ma plan "u "p ,c may designate a      
qualify+ suppli] z su* individual's     
prim>y c>e provid] = su* ye>4  7#b7     
,attribution bas$ on prior claims ,9 !  
case ( an individual describ$ 9 p>agraph
 7#a7 :o fails to make a designation = a
 ye> b = :om ! ,secret>y det]m9es1 bas$ 
on claims hi/ory ( items & s]vices      
furni%$ "u ?is title1 t su* individual  
has a prim>y c>e provid] :o is a        

qualify+ suppli]1 ! ,secret>y may       
designate su* suppli] z su* individual's
 prim>y c>e provid] = su* ye>4  7#c7    
,treat$ z attribut$ ,= purposes ( ?is   
section1 ea* individual :o makes a      
designation "u p>agraph 7#a7 7or = :om  
su* a designation is made "u p>agraph   
7#b77 ) respect to a qualify+ suppli] = 
a ye> %all be treat$ z attribut$ to su* 
suppli] = su* ye>4  7d7 ,no effect on   
,,pfs budget neutrality ,section        
#ahdh7;c77#b77;,b7 %all be appli$ =     
#bjbg & ea* subsequ5t ye> z if ! model  
_h nev] appli$4  7e7 ,fund+ ,paym5ts "u 
! model %all be made f ! ,f$]al         
,supplem5t>y ,m$ical ,insurance ,tru/   
,fund e/abli%$ "u section #ahda4  7f7   
,def9itions ,9 ?is section3 7#a7        
,designat$ heal? c>e practition] ,! t]m 
designat$ heal? c>e practition] means a 
physician assi/ant1 a nurse practition]1
 a cl9ical nurse speciali/1 a physical  
!rapi/1 an occupational !rapi/1 or su*  
o!r heal? c>e practition] z ! ,secret>y 
may specify4  7#b7 ,designat$ prim>y c>e

 s]vices ,! t]m designat$ prim>y c>e    
s]vices means-- 7,a7 c>e managem5t      
s]vices2  7,b7 behavioral heal?         
integration s]vices2  7,c7 (fice-bas$   
evaluation & managem5t s]vices 7:e!r    
furni%$ 9 p]son or via teleheal?72 &    
7,d7 communications su* z telephone     
calls1 emails & pati5t portals betwe5   
pati5ts & _! c>e giv]s4  7#c7 ,exclud$  
practice  7,a7 ,9 g5]al ,! t]m exclud$  
practice means1 subject to subp>agraph  
7,b71 any practice-- 7i7 9 :i* any      
entity t is n a physician or designat$  
heal? c>e practition] or a pr(essional  
corporation1 pr(essional association1   
limit$ liability company1 or o!r        
pr(essional body t is majority own$ &   
controll$ by physicians or designat$    
heal? c>e practition]s has an own]%ip   
int]e/2  7ii7 9 :i* any entity describ$ 
9 subp>agraph 7,a7 ex]cises de facto    
control ov] employm5t decisions 7includ+
 rates ( pay & t]ms ( employm5t71       
cl9ical /aff+ levels1 am\nt ( "t sp5t   
betwe5 a suppli] & a pati5t1 diagno/ic  

or proc$ural cod+ decisions1 cl9ical    
/&>ds or policy1 bill+ & collection1    
prices = items & s]vices1 contract+ )   
?ird p>ty payors1 or controll+ or       
re/rict+ ! practice's assets2  7iii7 9  
:i* physicians or designat$ heal? c>e   
practition]s hold #ej p]c5t or less (   
vot+ %>es or memb]%ip int]e/s2  7iv7 t  
has a gov]n+ bo>d 9 :i* physicians or   
designat$ heal? c>e practition]s        
con/itute less ?an #ej p]c5t ( ! memb]s2
 or  7v7 9 ! case su* practice is a     
corporation or pr(essional association1 
t p]mits ! removal ( directors or (fic]s
 t are physicians or designat$ heal? c>e
 practition]s except by majority vote ( 
/akehold]s t are physicians or designat$
 heal? c>e practition]s4  7,b7          
,exception ,! t]m exclud$ practice does 
n include any practice consi/+ ( #ae or 
few] designat$ heal? c>e practition]s4  
7#d7 ,specifi$ practition] ,! t]m       
specifi$ practition] means-- 7,a7 a     
physician ) a prim>y specialty or       
practice area ( family m$ic9e1 int]nal  

m$ic9e1 g]iatric m$ic9e1 or p$iatric    
m$ic9e2 or  7,b7 a physician assi/ant1 a
 nurse practition]1 or a cl9ical nurse  
speciali/4  7#e7 ,qualify+ suppli] ,!   
t]m qualify+ suppli] means1 ) respect to
 a ye>1 a specifi$ practition]-- 7,a7 :o
 is n "p ( an exclud$ practice2  7,b7 :o
 furni%$ items & s]vices "u ?is title   
dur+ ! prec$+ ye>2  7,c7 = :om1 )       
respect to paym5ts "u ?is title = all   
items & s]vices furni%$ by su*          
practition] dur+ ! prec$+ ye>1 at lea/  
#fj p]c5t ( su* paym5ts 7 = designat$   
prim>y c>e s]vices2 &  7,d7 :o has      
elect$ to p>ticipate 9 ! model = su* ye>
 ?r\gh su* process z ! ,secret>y %all   
e/abli%4  4  #ajc4 ,"w geographic floor 
adju/m5t = high inflation>y ye>s  7a7 ,9
 g5]al ,section #ahdh7;e77#a77;,e7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#d7;e77#a77;,e77 is am5d$-- 7#a7 
by /rik+ ! head] & ins]t+ ,"w geographic
 index2  7#b7 by /rik+ ,aft] calculat+ &
 ins]t+ ! foll[+3  7i7 ,9 g5]al ,aft]   
calculat+  2  7#c7 9 clause 7i7 7z s    

ins]t$7-- 7,a7 by ins]t+ 7or #a4jbe1 9 !
 case su* ye> is a high inflation>y ye> 
7z def9$ 9 clause 7iii777 aft] to #a4jj2
 &  7,b7 by /rik+ #bjbg & ins]t+ #bjcb2 
&  7#d7 by add+ at ! end ! foll[+ new   
clauses3  7ii7 ,increase 9 high         
inflation>y ye>s = o!r localities ,aft] 
calculat+ ! "w geographic index 9       
subp>agraph 7,a77iii71 = purposes (     
paym5t = s]vices furni%$ on or aft]     
,janu>y #a1 #bjbg1 & be=e ,janu>y #a1   
#bjcc1 ! ,secret>y %all increase ! "w   
geographic index by 4#jb po9ts if su*   
ye> is a high inflation>y ye>1 unless   
su* "w geographic index is subject to an
 increase "u clause 7i7 = su* ye>4      
7iii7 ,def9ition ,9 ?is subp>agraph1 !  
t]m high inflation>y ye> means a ye> if1
 ov] ! #ab-mon? p]iod end+ on ! la/ day 
( ! prec$+ ye>1 ! consum] price index = 
all urban consum]s 7,u4,s4 city av]age7 
increas$ by m ?an #b p]c5t4  7iv7       
,publication ,m$ic>e adm9i/rative       
contractors %all publi% ! geographically
 adju/$ "w relative value units = bo? ! 

inflation adju/m5ts "u clauses 7i7 &    
7ii7 & ! "w geographic adju/m5t = all   
s]vices on a qu>t]ly basis effective    
,janu>y #a1 #bjbg1 = ea* ( _! geographic
 areas4  4  7b7 ,report ,n lat] ?an #a  
ye> aft] ! date ( ! enactm5t ( ?is ,act1
 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates 
%all submit to ! ,committee on ,en]gy & 
,comm]ce & ! ,committee on ,ways &      
,means ( ! ,h\se ( ,repres5tatives & !  
,committee on ,f9ance ( ! ,s5ate a /udy 
on ! economic factors t are impact+     
physician *oice1 by specialty1 reg>d+ ! 
geographic area 9 :i* su* physicians    
*oose to practice1 includ+ sal>ies1     
contract t]ms1 co/ ( liv+1 availability 
( capital1 volume ( s]vices1 & co/s to  
conduct a practice4  ,,ii ,,po9ts  #bja4
 ,implem5tation ( ! ,pati5t ,outcome    
,improvem5t ,national ,tabulation ,sy/em
  7a7 ,9 g5]al ,effective ,janu>y #a1   
#bjcb1 !re is e/abli%$ ! ,pati5t        
,outcome ,improvem5t ,national          
,tabulation ,sy/em1 :i* %all consi/ ( ! 
paym5t sy/em "u section #ahdh7q7 ( !    

,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#d7q771 includ+ z am5d$ by ?is   
title4  7b7 ,ref]5ces ,subject to       
subsection 7c71 any ref]5ce to ! paym5t 
sy/em "u section #ahdh7q7 ( ! ,social   
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7q771 includ+ ! t]ms ,m]it-bas$
 ,inc5tive ,paym5t ,sy/em & ,,mips1 %all
 be deem$ a ref]5ce to ! ,pati5t        
,outcome ,improvem5t ,national          
,tabulation ,sy/em & ,,po9ts1           
respectively4  7c7 ,transition ,9 ord]  
to provide = an ord]ly transition &     
avoid provid] confusion1 ! ,secret>y (  
,heal? & ,human ,s]vices %all provide = 
an appropriate transition 9 ! use ( !   
t]ms ,m]it-bas$ ,inc5tive ,paym5t ,sy/em
 7& ,,mips7 & ,pati5t ,outcome          
,improvem5t ,national ,tabulation ,sy/em
 7& ,,po9ts7 9 ref]5ce to ! paym5t sy/em
 "u section #ahdh7q7 ( ! ,social        
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7q774 ,be=e ! completion ( su* 
transition1 any ref]5ce to ! ,pati5t    
,outcome ,improvem5t ,national          

,tabulation ,sy/em 7or ,,po9ts7 %all be 
deem$ to include a ref]5ce to !         
,m]it-bas$ ,inc5tive ,paym5t ,sy/em4    
#bjb4 ,paym5t re=m  7a7 ,9 g5]al        
,section #ahdh7q7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #aciew-#d7q77 is    
am5d$-- 7#a7 9 p>agraph                 
7#a77;,d77i77,,ii71 by /rik+ 7iv7 &     
ins]t+ 7v72  7#b7 9 p>agraph 7#b7-- 7,a7
 9 subp>agraph 7,a7-- 7i7 9 clause      
7iii71 by /rik+ ,cl9ical practice &     
ins]t+ ,= p]=mance p]iods beg9n+ be=e   
,janu>y #a1 #bjcb1 cl9ical practice2    
7ii7 9 clause 7iv71 by /rik+ ,mean+ful  
use & ins]t+ ,= p]=mance p]iods be=e    
,janu>y #a1 #bjcb1 mean+ful use2 &      
7iii7 by add+ at ! end ! foll[+ new     
clause3  7v7 ,= p]=mance p]iods beg9n+  
on or aft] ,janu>y #a1 #bjcb1 c>e       
effici5cy4  2  7,b7 9 subp>agraph 7,b7--
 7i7 9 clause 7ii7-- 7,i7 by /rik+      
subp>agraph 7,a77ii71 ! measurem5t &    
ins]t+ ! foll[+3 subp>agraph 7,a77ii7-- 
7,i7 = p]=mance p]iods beg9n+ be=e      
,janu>y #a1 #bjcb1 ! measurem5t  2 &    

7,,ii7 by /rik+ ! p]iod at ! end &      
ins]t+ ! foll[+3 2 & 7,,ii7 = p]=mance  
p]iods beg9n+ on or aft] ,janu>y #a1    
#bjcb1 ! measurem5t describ$ 9 subclause
 7,i7 & any res\rce use measures includ$
 9 ! f9al measures li/ publi%$ "u       
subp>agraph 7,d77i7 = su* p]iod4  2 &   
7ii7 by ins]t+ aft] clause 7iv7 ! foll[+
 new clause3  7v7 ,c>e effici5cy ,= !   
p]=mance category describ$ 9 subp>agraph
 7,a77v71 c>e effici5cy measures 7su* z 
measures relat+ to r$uctions 9 avoidable
 hospitalizations1 r$uctions 9 m$ication
 burd5 7:5 cl9ically appropriate71      
r$uctions 9 complications f *ronic      
diseases1 & ref]ral patt]ns to !        
l[e/-co/ cl9ically appropriate sett+s7  
includ$ 9 ! f9al measures li/ publi%$ "u
 subp>agraph 7,d77i7 = su* p]iod4  2 &  
7,c7 9 subp>agraph 7,d7-- 7i7 9 ! head]1
 by /rik+ quality2  7ii7 9 clause 7i7-- 
7,i7 9 ! matt] prec$+ subclause 7,i71 by
 ins]t+ 7or1 ) respect to p]=mance      
p]iods beg9n+ on or aft] ,janu>y #a1    
#bjcb1 an annual f9al li/ ( quality     

measures1 res\rce use measures 7if      
det]m9$ appropriate by ! ,secret>y71 &  
c>e effici5cy measures7 aft] quality    
measures2 &  7,,ii7 9 subclause 7,,ii7--
 7aa7 9 item 7aa71 by /rik+ quality     
measures & ins]t+ measures2  7bb7 9 item
 7bb71 by ins]t+ 7or1 ) respect to a    
f9al li/ = a p]=mance p]iod beg9n+ on or
 aft] ,janu>y #a1 #bjcb1 new quality    
measures1 res\rce use measures1 or c>e  
effici5cy measures7 aft] quality        
measures2 &  7cc7 9 item 7cc71 by /rik+ 
quality measures & ins]t+ measures2     
7iii7 9 clause 7ii7-- 7,i7 9 ! head]1 by
 /rik+ quality2 &  7,,ii7 9 subclause   
7,i7-- 7aa7 by ins]t+ 7or1 ) respect to 
su* an annual li/ = a p]=mance p]iod    
beg9n+ on or aft] ,janu>y #a1 #bjcb1    
quality measures1 res\rce use measures1 
& c>e effici5cy measures7 aft] submit   
quality measures2 &  7bb7 by /rik+      
quality measures publi%$ & ins]t+       
measures publi%$2  7iv7 9 clause 7iii7--
 7,i7 9 ! matt] prec$+ subclause 7,i71  
by /rik+ quality2  7,,ii7 9 subclause   

7,i71 by /rik+ & at ! end2  7,,iii7 9   
subclause 7,,ii7-- 7aa7 by /rik+ ensure 
t & ins]t+ ) respect to su* an annual   
f9al li/ = a p]=mance p]iod beg9n+ be=e 
,janu>y #a1 #bjcb1 ensure t2 &  7bb7 by 
/rik+ ! p]iod at ! end & ins]t+ 2 &2 &  
7,,iv7 by add+ at ! end ! foll[+ new    
subclause3  7,,iii7 ) respect to su* an 
annual f9al li/ = a p]=mance p]iod      
beg9n+ on or aft] ,janu>y #a1 #bjcb1    
provide t-- 7aa7 no quality measure     
applicable to a m$ical specialty is     
includ$ on su* li/ if-- 7,,aa7 ! ,task  
,=ce e/abli%$ "u subp>agraph 7,e7 has   
issu$ recomm5dations on quality measures
 = use "u ?is subsection ) respect to   
su* specialty2 & 7,,bb7 ! quality       
measure does n h 9 effect su* a         
recomm5dation2 &  7bb7 no res\rce use   
measure or c>e effici5cy measure is     
includ$ on su* li/ unless su* measure   
has 9 effect a recomm5dation f su* ,task
 ,=ce4  2  7v7 9 clause 7v71 9 ! matt]  
prec$+ subclause 7,i71 by ins]t+ = a    
p]=mance p]iod beg9n+ be=e ,janu>y #a1  

#bjcb1 aft] publi%$ "u clause 7i72  7vi7
 9 clause 7vi71 by /rik+ "u clauses 7i71
 7iv71 & 7v7 & ins]t+ "u ?is            
subp>agraph2 &  7vii7 9 clause          
7vii77,,ii71 by /rik+ %all be & ins]t+  
subject to clause 7iii77,,iii77aa71 %all
 be2  7#c7 9 p>agraph 7#e7-- 7,a7 9     
subp>agraph 7,b7-- 7i7 9 clause 7ii7--  
7,i7 9 subclause 7,i7-- 7aa7 by /rik+   
enc\rage & ins]t+ ) respect to a        
p]=mance p]iod beg9n+ be=e ,janu>y #a1  
#bjcb1 enc\rage2 &  7bb7 by /rik+ & at !
 end2  7,,ii7 9 subclause 7,,ii71 by    
/rik+ ! p]iod & ins]t+ 2 &2 &  7,,iii7  
by add+ at ! end ! foll[+ new subclause3
  7,,iii7 ) respect to a p]=mance p]iod 
beg9n+ on or aft] ,janu>y #a1 #bjcb1 )  
respect to a ye>1 provide t 9 ! case ( a
 ,,mips eligible pr(essional :o fails to
 report on an applicable quality measure
 ?r\gh ! use ( c]tifi$ ,,ehr te*nology  
or cl9ical data regi/ries1 ! pr(essional
 %all be treat$ z a*iev+ ! l[e/ pot5tial
 score applicable to su* measure4  2 &  
7ii7 by add+ at ! end ! foll[+ new      

clause3  7iii7 ,inc5tive to report on   
c]ta9 measures  7,i7 ,9 g5]al ,) respect
 to p]=mance p]iods = ye>s beg9n+ on or 
aft] ,janu>y #a1 #bjbg1 9 ! case a      
,,mips eligible pr(essional elects to   
report on a measure = su* p]iod t1 )    
respect to su* pr(essional & su* p]iod1 
is a new measure describ$ 9 subclause   
7,,ii71 a sub/antively *ang$ measure    
describ$ 9 subclause 7,,iii71 or a      
measure describ$ 9 p>agraph 7#b77;,b77i7
 = :i* ! ,secret>y is unable to e/abli% 
a b5*m>k1 su* pr(essional %all be treat$
 z a*iev+ ! highe/ possible score )     
respect to su* measure4  7,,ii7 ,new    
measures ,= purposes ( subclause 7,i71 a
 new measure describ$ 9 ?is subclause1 )
 respect to a ,,mips eligible           
pr(essional & p]=mance p]iod = a ye>1 is
 a measure applicable to su* pr(essional
 ) respect to ! p]=mance category       
describ$ 9 p>agraph 7#b77;,a77i7 t is   
includ$ 9 ! f9al li/ ( quality measures 
publi%$ "u p>agraph 7#b77;,d77i7 7or !  
li/ ( quality measures describ$ 9       

p>agraph 7#b77;,d77vi7 us$ by qualifi$  
cl9ical data regi/ries "u subsection    
7m77#c77;,e77 = su* ye> b 0 n includ$ 9 
su* f9al li/ "u p>agraph 7#b77;,d77i7   
7or ! li/ "u p>agraph 7#b77;,d77vi77 =  
any ( ! previ\s #c ye>s4  7,,iii7       
,sub/antively *ang$ measure  ,= purposes
 ( subclause 7,i71 a sub/antively *ang$ 
measure describ$ 9 ?is subclause1 )     
respect to a ,,mips eligible pr(essional
 & p]=mance p]iod = a ye>1 is a measure 
applicable to su* pr(essional ) respect 
to ! p]=mance category describ$ 9       
p>agraph 7#b77;,a77i7 t is includ$ 9 !  
f9al li/ ( quality measures publi%$ "u  
p>agraph 7#b77;,d77i7 7or ! li/ (       
quality measures describ$ 9 p>agraph    
7#b77;,d77vi7 us$ by qualifi$ cl9ical   
data regi/ries "u subsection            
7m77#c77;,e77 = su* ye> & ea* ( !       
previ\s #c ye>s b t und]w5t a sub/antive
 *ange 7z def9$ by ! ,secret>y7 dur+ any
 ( su* previ\s #c ye>s4  2 &  7,b7 9    
subp>agraph 7,e7-- 7i7 9 clause 7i7--   
7,i7 9 subclause 7,i77aa71 by ins]t+    

7or1 ) respect to #bjcb & subsequ5t     
ye>s1 #fe p]c5t7 aft] ?irty p]c5t2      
7,,ii7 9 subclause 7,,ii77aa71 by ins]t+
 7or1 ) respect to #bjcb & subsequ5t    
ye>s1 #bj p]c5t7 aft] ?irty p]c5t2      
7,,iii7 9 subclause 7,,iii71 by ins]t+  
7or1 ) respect to #bjcb & subsequ5t     
ye>s1 #j p]c5t7 aft] fifte5 p]c5t2      
7,,iv7 9 subclause 7,,iv71 by ins]t+    
7or1 ) respect to #bjcb & subsequ5t     
ye>s1 #j p]c5t7 aft] tw5ty-five p]c5t2 &
  7,v7 by add+ at ! end ! foll[+ new    
subclause3  7,v7 ,c>e effici5cy ,)      
respect to #bjcb & subsequ5t ye>s1 #ae  
p]c5t ( su* score %all be bas$ on       
p]=mance ) respect to ! category        
describ$ 9 clause 7v7 ( p>agraph        
7#b77;,a74  2 &  7ii7 9 clause 7ii71 by 
ins]t+ 7be=e #bjcb7 aft] ,9 any ye>2    
7#d7 9 p>agraph 7#aa77;,a77i71 by /rik+ 
clauses 7i7 ?r\gh 7iv7 (2 &  7#e7 9     
p>agraph 7#ab77;,a77i77,,ii71 by /rik+ &
 7iv7 & ins]t+ ?r\gh 7v74  7b7          
,improvem5ts to res\rce use p]=mance    
category ,section #ahdh7r7 ( ! ,social  

,security ,act 7#db ,u4,s4,c4           
#aciew-#d7r77 is am5d$-- 7#a7 9 p>agraph
 7#b77;,h71 by add+ at ! end ! foll[+   
new s5t5ce3 ,9 mak+ su* revisions =     
#bjbg & subsequ5t ye>s1 ! ,secret>y %all
 revise c>e episode gr\ps & pati5t      
condition gr\ps )\t reg>d to any t>get  
describ$ 9 subp>agraph 7,d77i77,i742 &  
7#b7 9 p>agraph 7#e77;,c77i7-- 7,a7 by  
ins]t+ 1 = ye>s be=e #bjbg1 aft] %all2 &
  7,b7 by ins]t+ & %all1 = #bjbg &      
subsequ5t ye>s1 use su* c>e episode     
codes & pati5t condition codes be=e !   
semicolon4  #bjc4 ,quality re=m task =ce
 ,section #ahdh7q77#b7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7q77#b77 is am5d$ by add+ at ! 
end ! foll[+ new subp>agraph3  7,e7     
,quality ,re=m ,task ,=ce  7i7 ,9 g5]al 
,n lat] ?an #f mon?s aft] ! date ( !    
enactm5t ( ?is subp>agraph1 ! ,secret>y 
%all e/abli% a ,quality ,re=m ,task ,=ce
 79 ?is subp>agraph ref]r$ to z ! ,task 
,=ce7 = purposes ( issu+ recomm5dations 
) respect to ! use ( quality1 res\rce   

use1 & c>e effici5cy measures "u ?is    
subsection4  7ii7 ,memb]%ip  7,i7 ,9    
g5]al ,memb]s ( ! ,task ,=ce %all be    
appo9t$ by ! ,secret>y & %all include-- 
7aa7 repres5tatives ( ! ,dep>tm5t (     
,heal? & ,human ,s]vices2  7bb7         
repres5tatives ( eligible pr(essional   
organizations 7z def9$ 9 subp>agraph    
7,d77ii77,,ii772 &  7cc7 o!r exp]ts     
det]m9$ appropriate by ! ,secret>y4     
7,,ii7 ,appropriate repres5tation ,9    
mak+ appo9tm5ts "u subclause 7,i71 !    
,secret>y %all ensure t-- 7aa7 ea*      
m$ical specialty or subspecialty z      
det]m9$ appropriate by ! ,secret>y 9 :i*
 a ,,mips eligible pr(essional may      
practice is adequately repres5t$ on !   
,task ,=ce ?r\gh a relevant organization
 describ$ 9 subclause 7,i77bb7 if a     
measure relat+ to su* specialty or      
subspecialty is "u consid]ation2  7bb7 a
 majority ( ! ,task ,=ce is compris$ (  
designat$ heal? c>e practition]s 7z     
def9$ 9 section #ahff;,h7f77 or         
repres5tatives ( eligible pr(essional   

organizations describ$ 9 subclause      
7,i77bb72  7cc7 n m ?an #c memb]s ( !   
,task ,=ce are repres5tatives ( gr\p    
heal? plans1 heal? insurance issu]s1 or 
,m$ic>e ,advantage organizations2 &     
7dd7 at lea/ #a designat$ heal? c>e     
practition] :o is n "p ( an exclud$     
practice 7z def9$ 9 section #ahff;,h7f77
 :o practices 9 a m$ical specialty or   
subspecialty is includ$ on ! ,task ,=ce 
:5 ! ,task ,=ce is consid]+ measures    
relat+ to su* specialty or subspecialty4
  7,,iii7 ,maximum numb] ( memb]s ,!    
numb] ( memb]s ( ! ,task ,=ce may n     
exce$ #be4  7iii7 ,duties  7,i7 ,9 g5]al
 ,! ,task ,=ce %all1 ) respect to ea*   
p]=mance p]iod beg9n+ on or aft] ,janu>y
 #a1 #bjcb-- 7aa7 issue recomm5dations  
on quality1 res\rce use1 & c>e effici5cy
 measures = use "u ?is subsection2 &    
7bb7 update any recomm5dations previ\sly
 issu$ by ! ,task ,=ce z det]m9$        
appropriate by ! ,task ,=ce4  7,,ii7    
,requirem5ts ,! ,task ,=ce-- 7aa7 %all  
ensure t any measure recomm5d$ "u       

subclause 7,i7 con=ms ) applicable      
cl9ical guidel9es develop$ by a         
pr(essional organization repres5t+ !    
m$ical specialty or subspecialty to be  
subject to su* measure & is design$ to  
promote quality ( c>e1 improve res\rce  
use1 or r$uce co/s2  7bb7 may only      
recomm5d a quality measure to ! ext5t t 
data = su* measure c be submitt$ ?r\gh  
c]tifi$ ,,ehr te*nology1 adm9i/rative or
 bill+ claims1 or a qualifi$ cl9ical    
data regi/ry2  7cc7 %all take into      
acc\nt ! circum/ances ( practition]s 9  
specialty types t furni% s]vices t d n  
typically involve face-to-face          
int]action ) pati5ts 7or t typically    
involve su* int]action only at !        
direction ( ano!r practition] ord]+ su* 
s]vices72  7dd7 %all1 9 review+ measures
 & mak+ recomm5dations1 take into       
acc\nt-- 7,,aa7 h[ ! measure relates to 
an episode ( c>e or a cont9uum ( heal?  
c>e1 z applicable1 involv$2 7,,bb7 !    
context ( ! respective p]=mance category
 ( su* measure & h[ ! measure may s]ve  

to complem5t or align ) measures        
applicable 9 o!r p]=mance categories "u 
?is subsection2 7,,cc7 measures develop$
 by qualifi$ cl9ical data regi/ries2 &  
7,,dd7 consult ) su* regi/ries z        
necess>y 9 ! developm5t & evaluation (  
measures2 &  7ee7 ensure t ! role (     
qualifi$ cl9ical data regi/ries 9 !     
developm5t1 ma9t5ance1 & ref9em5t (     
measures is pres]v$ or /r5g!n$4  7iv7   
,secret>ial response to recomm5dations  
7,i7 ,9 g5]al ,n lat] ?an #abj days aft]
 ! ,task ,=ce issues recomm5dations )   
respect to measures = a p]=mance p]iod1 
! ,secret>y %all transmit to ! ,task    
,=ce & to ! ,committee on ,ways & ,means
 & ! ,committee on ,en]gy & ,comm]ce ( !
 ,h\se ( ,repres5tatives & ! ,committee 
on ,f9ance ( ! ,s5ate a =mal writt5     
response t1 ) respect to ea* su*        
recomm5dation1 affirmatively /ates "o ( 
! foll[+3 7aa7 ,! ,secret>y w implem5t !
 recomm5dation z issu$4  7bb7 ,!        
,secret>y w implem5t ! recomm5dation )  
specifi$ modifications1 accompani$ by a 

writt5 explanation ( ! modifications & !
 cl9ical1 adm9i/rative1 or program      
integrity basis = ea* su* modification4 
7cc7 ,! ,secret>y w implem5t !          
recomm5dation 9 "p1 accompani$ by a     
writt5 explanation ( :i* elem5ts w be   
implem5t$ & ! basis = decl9+ ! rema9d]4 
7dd7 ,! ,secret>y decl9es to implem5t ! 
recomm5dation1 accompani$ by a detail$  
writt5 explanation ( ! cl9ical1         
adm9i/rative1 or program integrity basis
 = ! decision4  7,,ii7 ,inclusion (     
measures  7aa7 ,9 g5]al ,! ,secret>y    
%all include a measure receiv+ a        
recomm5dation f ! ,task ,=ce = a        
p]=mance p]iod 9 ! f9al measures li/    
publi%$ "u subp>agraph 7,d77i7 = su*    
p]=mance p]iod unless ! ,secret>y1 n    
lat] ?an #ij days aft] receiv+ !        
recomm5dation1 publi%es 9 ! ,f$]al      
,regi/] a writt5 det]m9ation expla9+ !  
specific cl9ical1 adm9i/rative1 or      
program integrity basis = exclud+ !     
measure4  7bb7 ,fur!r requirem5ts =     
c]ta9 recomm5dations ,not)/&+ item 7aa71

 ) respect to any measure recomm5d$ by !
 ,task ,=ce = a p]=mance p]iod ) !      
support ( n few] ?an #ge p]c5t ( !      
memb]s ( ! ,task ,=ce1 ! ,secret>y may n
 exclude su* measure f ! f9al measures  
li/ publi%$ "u subp>agraph 7,d77i7 = su*
 p]=mance p]iod unless ! ,secret>y--    
7,,aa7 consults ) ! ,task ,=ce reg>d+   
su* propos$ exclusion2 & 7,,bb7 includes
 9 ! writt5 det]m9ation "u subclause    
7,i7 a response to ! ,task ,=ce's       
position & a specific f9d+ t ! basis =  
exclusion outweighs ! cl9ical judgm5t ( 
! ,task ,=ce4  7,,iii7 ,annual report ,n
 lat] ?an ,m>* #a ( ea* ye> beg9n+ ) !  
fir/ cal5d> ye> aft] ! ,task ,=ce issues
 its initial recomm5dations1 ! ,secret>y
 %all submit to ! ,committee on ,ways & 
,means & ! ,committee on ,en]gy &       
,comm]ce ( ! ,h\se ( ,repres5tatives & !
 ,committee on ,f9ance ( ! ,s5ate1 &    
%all make publicly available on !       
website ( ! ,c5t]s = ,m$ic>e  ,m$icaid  
,s]vices1 a report t includes1 = ea*    
recomm5dation issu$ by ! ,task ,=ce dur+

 ! prec$+ cal5d> ye>-- 7aa7 ! text ( !  
recomm5dation & ! vote ( ! ,task ,=ce2  
7bb7 ! ,secret>y's response "u subclause
 7,i72  7cc7 ! outcome ) respect to !   
f9al measures li/ publi%$ "u subp>agraph
 7,d77i71 includ+ :e!r ! recomm5d$      
measure 0 includ$1 includ$ )            
modifications1 or exclud$2 &  7dd7 if ! 
measure 0 exclud$ or modifi$1 ! writt5  
ju/ification provid$ "u subclause 7,i74 
4  #bjd4 ,modification ( ,,mips paym5t  
adju/m5ts  7a7 ,9 g5]al ,section        
#ahdh7q77#f77;,b7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4                     
#aciew-#d7q77#f77;,b77 is am5d$-- 7#a7 9
 clause 7iii71 by /rik+ & at ! end2     
7#b7 9 clause 7iv71 by am5d+ su* clause 
to read z foll[s3  7iv7 = #bjbb ?r\gh   
#bjbf1 #i p]c5t2  2 &  7#c7 by add+ at !
 end ! foll[+ new clauses3  7v7 = #bjbg 
?r\gh #bjca1 #b p]c5t2  7vi7 = #bjcb1 #c
 p]c5t2  7vii7 = #bjcc1 #d p]c5t2 &     
7viii7 = #bjcd1 #e p]c5t4  4  7b7 ,no   
r$uction 9 case ( failure ,to provide   
fe$back  7#a7 ,9 g5]al ,section         

#ahdh7q77#f7 ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #aciew-#d7q77#f77 is     
am5d$ by add+ at ! end ! foll[+ new     
subp>agraph3  7,g7 ,no r$uction 9       
paym5ts 9 case ( failure to provide     
fe$back ,not)/&+ ! prec$+ provisions (  
?is p>agraph1 9 ! case t ! ,secret>y    
fails to provide a ,,mips eligible      
pr(essional fe$back requir$ "u p>agraph 
7#ab7 ) respect to ! p]=mance ( su*     
pr(essional = a p]=mance p]iod ) respect
 to a ye> = adm9i/rative claims-bas$    
measures includ$ 9 ! p]=mance categories
 describ$ 9 subp>agraph 7,a77i77,,ii7 ( 
su* p>agraph1 if application (          
subp>agraph 7,e7 w\ld result 9 a        
negative adju/m5t to paym5t = cov]$     
pr(essional s]vices furni%$ by su*      
pr(essional dur+ su* ye>1 ! product     
o!rwise det]m9$ "u su* subp>agraph = su*
 pr(essional & ye> %all be deem$ to be  
z]o4  4  7#b7 ,modification ( fe$back   
requirem5ts ,section #ahdh7q77#ab7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#d7q77#ab77 is am5d$-- 7,a7 9    

subp>agraph 7,a77i77,,ii71 by ins]t+ 7&1
 beg9n+ ) #bjcb1 %all1 on a qu>t]ly     
basis & ) respect to adm9i/rative       
claims-bas$ measures 9 accordance )     
clause 7vi77 aft] may2 &  7,b7 by add+  
at ! end ! foll[+ new clause3  7vi7     
,fe$back on adm9i/rative-claims bas$    
measures ,) respect to qu>t]s beg9n+ on 
or aft] ,janu>y #a1 #bjcb1 ! ,secret>y  
%all1 n lat] ?an #fj days aft] ea* su*  
qu>t]1 provide to ea* ,,mips eligible   
pr(essional1 ) respect to adm9i/rative  
claims-bas$ measures includ$ 9 !        
p]=mance categories describ$ 9          
subp>agraph 7,a77i77,,ii71 fe$back on   
su* pr(essional's p]=mance1 includ+--   
7,i7 a description ( ! pati5ts &        
episodes attribut$ ) respect to su*     
measures = purposes ( assess+ ! p]=mance
 ( su* pr(essional dur+ su* qu>t]2      
7,,ii7 an id5tification ( ! items &     
s]vices furni%$ by su* pr(essional or   
ano!r individual t w contribute to !    
assessm5t ( ! p]=mance ( su* pr(essional
 dur+ su* qu>t] ) respect to su*        

measures2 &  7,,iii7 an id5tification ( 
:e!r ea* item or s]vice id5tifi$ "u     
subclause 7,,ii7 = ! qu>t] 0 furni%$ by 
su* pr(essional or ano!r individual 7&1 
9 ! case t ! p]=mance ( su* pr(essional 
= su* qu>t] ) respect to su* measures is
 assess$ bas$ on p>ticipation 9 a gr\p  
practice or o!r gr\p1 :e!r ea* su* item 
or s]vice 0 furni%$ by su* pr(essional1 
ano!r individual 9 su* gr\p1 or ano!r   
individual outside ( su* gr\p74  4  7c7 
,ext5sion ( additional inc5tive paym5ts 
= c]ta9 pr(essionals ,section           
#ahdh7q77#f7 ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #aciew-#d7q77#f77 is     
am5d$-- 7#a7 9 subp>agraph 7,c7-- 7,a7  
by ins]t+ & = #bjcb & ea* subsequ5t ye> 
aft] #bjbd12 &  7,b7 by ins]t+ 7o!r ?an1
 ) respect to #bjcb & ea* subsequ5t ye>1
 su* a pr(essional t is "p ( an exclud$ 
practice 7z def9$ 9 section             
#ahff;,h7f777 aft] ,,mips eligible      
pr(essional2 &  7#b7 9 subp>agraph      
7,f77iv77,i71 by ins]t+ & = #bjcb & ea* 
subsequ5t ye> be=e ! p]iod4  7d7        

,r$uction 9 positive adju/m5ts = c]ta9  
pr(essionals ,section #ahdh7q77#f7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#d7q77#f771 z am5d$ by subsection
 7b77#a71 is fur!r am5d$ by add+ at !   
end ! foll[+ new subp>agraph3  7,h7     
,r$uction 9 positive adju/m5ts = c]ta9  
pr(essionals ,! ,secret>y %all r$uce ea*
 positive ,,mips adju/m5t factor o!rwise
 det]m9$ "u ?is p>agraph = a ye> 7beg9n+
 ) #bjcb7 = a ,,mips eligible           
pr(essional :o is "p ( an exclud$       
practice 7z def9$ 9 section #ahff;,h7f77
 by #ej p]c5t4 ,! prec$+ s5t5ce %all be 
appli$ 9 a budget neutral mann]4  4     
#bje4 ,modify+ requirem5ts & approval   
p]iods = qualifi$ cl9ical data regi/ries
 ,section #ahdh7m77#c77;,e7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7m77#c77;,e77 is am5d$-- 7#a7 9
 clause 7i71 by add+ at ! end ! foll[+3 
,beg9n+ ,janu>y #a1 #bjbg1 su*          
requirem5ts %all include a requirem5t t 
! entity-- 7,i7 be e/abli%$ & op]at$ by 
a pr(essional society t is controll$ or 

l$ by a designat$ practition] 7z def9$ 9
 section #ahff;,h7 & t has demon/rat$   
exp]tise 9 develop+ evid5ce-bas$ cl9ical
 practice guidel9es & quality measures =
 improv+ pati5t outcomes2  7,,ii7       
demon/rates adh]5ce to data quality &   
fidelity /&>ds1 includ+ /&>ds relat+ to 
data elem5ts1 data complet5ess1 &       
validation processes2  7,,iii7          
demon/rates capacity to g5]ate timely1  
actionable fe$back to p>ticipat+        
practition]s to support cont9u\s quality
 improvem5t & track practition] use (   
su* fe$back2  7,,iv7 demon/rates        
transp>5cy 9 measure developm5t 7includ+
 ! me?odology us$ 9 su* measures & any  
risk adju/m5t us$ 9 su* measures72 &    
7,v7 has e/abli%$ self-audit or review  
processes focus+ on data accuracy1      
measure integrity1 & appropriate use (  
results4  2 &  7#b7 9 clause 7v71 by    
add+ ! foll[+ flu% matt] at ! end3 ,a   
det]m9ation or designation made "u ?is  
clause on or aft] ,janu>y #a1 #bjbg1    
%all be effective = a p]iod ( #c ye>s4  

,at ! end ( su* p]iod1 ! ,secret>y 7or1 
9 ! case ( a designation made by an     
organization1 su* organization7 may     
ext5d su* det]m9ation or designation 7z 
applicable7 = subsequ5t #c-ye> p]iods   
bas$ on a %[+ by su* entity t su* entity
 cont9ues to meet ! requirem5ts ( clause
 7i74 4  #bjf4 ,exp&$ access to claims  
data to facilitate rese>* & quality     
improvem5t  7a7 ,9 g5]al ,n lat] ?an    
,janu>y #a1 #bjbg1 ! ,secret>y ( ,heal? 
& ,human ,s]vices %all e/abli% a process
 to all[ a qualifi$ cl9ical data regi/ry
 "u section #ahdh7m77#c77;,e7 ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#d7m77#c77;,e77 or a cl9ician-l$ 
cl9ical data regi/ry "u section #djje ( 
! #ba/ ,c5tury ,cures ,act 7#db         
,u4,s4,c4 #cjj;jj-#ad note7 to reque/   
claims data describ$ 9 subsection 7b7 79
 a =m & mann] det]m9$ to be appropriate 
by ! ,secret>y7 = ! purposes (-- 7#a7   
l9k+ su* data ) cl9ical outcomes data2  
7#b7 conduct+ quality assessm5ts &      
quality improvem5t activities ( provid]s

 ( s]vices 7z def9$ 9 subsection 7u7 (  
section #ahfa ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciex7 & suppli]s 7z   
def9$ 9 subsection 7d7 ( su* section771 
report+ ! results ( su* assessm5ts &    
activities to su* provid]s & suppli]s1 &
 p]=m+ risk-adju/$1 sci5tifically valid 
analyses & rese>* to support quality    
improvem5t or pati5t safety2 &  7#c7    
publi%+ rese>* & quality improvem5t     
analyses1 :i* may include deid5tifi$    
comb9$ claims & cl9ical outcomes data4  
7b7 ,claims data describ$ ,= purposes ( 
subsection 7a71 ! claims data describ$ 9
 ?is subsection-- 7#a7 are-- 7,a7 claims
 data "u ! ,m$ic>e program "u title     
,,xviii ( ! ,social ,security ,act 7#db 
,u4,s4,c4 #acie et seq472 &  7,b7 if !  
,secret>y det]m9es appropriate1 claims  
data "u ! ,m$icaid program "u title     
,,xix ( su* ,act 7#db ,u4,s4,c4 #acif et
 seq47 & ! ,/ate ,*ildr5's ,heal?       
,insurance ,program "u title ,,xxi ( su*
 ,act 7#db ,u4,s4,c4 #acig;aa et seq472 
&  7#b7 may include provid]-specific    

claims data1 cl9ical specialty-specific 
claims data1 ,/ate-specific claims data1
 or nationwide claims data4  7c7        
,treatm5t ( qualifi$ cl9ical data       
regi/ries & cl9ician-,l$ cl9ical data   
regi/ries ,= ! purposes ( ?is section1  
qualifi$ cl9ical data regi/ries &       
cl9ician-l$ cl9ical data regi/ries %all 
n be requir$ to be qualifi$ entities1 z 
def9$ 9 section #ahgd7;e77#b7 ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#aciekk7e77#b771 or quasi-qualifi$      
entities1 to access claims data pursuant
 to subsection 7a74  7d7 ,fee ,data     
describ$ 9 subsection 7b7 %all be made  
available to a qualifi$ cl9ical data    
regi/ry or cl9ician-l$ cl9ical data     
regi/ry "u ?is section at a reasonable  
fee equal to ! co/ ( mak+ su* data      
available4 ,any fee collect$ pursuant to
 ! prec$+ s5t5ce %all be deposit$ into !
 ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices    
,program ,managem5t ,acc\nt4  #bjg4     
,modification ( appropriate use crit]ia 
data collection = applicable imag+      

s]vices  7a7 ,9 g5]al ,section #ahcd7q7 
( ! ,social ,security ,act 7#db         
,u4,s4,c4 #aciem7q77 is am5d$-- 7#a7 9  
p>agraph 7#c77;,b77ii7-- 7,a7 9         
subclause 7,,iv71 by /rik+ g5]ates &    
provides to ! ord]+ pr(essional a       
c]tification or docum5tation t2 &  7,b7 
by add+ at ! end ! foll[+ new subclause3
  7,,viii7 ,beg9n+ ,janu>y #a1 #bjbg1 ! 
me*anism provides to ! ,secret>y-- 7aa7 
! in=mation describ$ 9 subclauses       
7,,iii7 & 7,,iv72  7bb7 ! in=mation     
describ$ 9 p>agraph 7#d77;,b72 &  7cc7  
su* o!r in=mation z ! ,secret>y det]m9es
 to be appropriate1 at su* "t1 & 9 su*  
=m & mann]1 z ! ,secret>y may specify4  
2  7#b7 9 p>agraph 7#d7-- 7,a7 9        
subp>agraph 7,a71 by /rik+ clause 7ii7 &
 ins]t+ ! foll[+3  7ii7 beg9n+ ,janu>y  
#a1 #bjbg1 comply ) su* requirem5ts z ! 
,secret>y may e/abli%4  2  7,b7 9       
subp>agraph 7,b7-- 7i7 9 ! head+1 by    
/rik+ furni%+ pr(essional & ins]t+      
qualifi$ cl9ical decision support       
me*anism2  7ii7 9 ! matt] prec$+ clause 

7i7-- 7,i7 by /rik+ ) ,janu>y #a1 #bjag 
& ins]t+ ,janu>y #a1 #bjbg2 &  7,,ii7 by
 /rik+ paym5t = su* s]vice may only be  
made if ! claim = ! s]vice includes &   
ins]t+ ! qualifi$ decision support      
me*anism %all ma9ta9 & report to !      
,secret>y "u subp>agraph 7,f72 &  7iii7 
9 clause 7iii71 by /rik+ 7if diff]5t f !
 furni%+ pr(essional72  7,c7 9          
subp>agraph 7,c71 by add+ at ! end !    
foll[+ new clauses3  7iv7 ,cl9ical      
trials ,an applicable imag+ s]vice t is 
ord]$ = an individual z "p ( a cl9ical  
trial4  7v7 ,small & rural practices ,an
 applicable imag+ s]vice ord]$ by an    
ord]+ pr(essional practic+ 9 a small    
practice 7consi/+ ( #ae or few] ord]+   
pr(essionals71 or a practice 9 a heal?  
pr(essional %ortage area 7z designat$ "u
 section #ccb7;a77#a77;,a7 ( ! ,public  
,heal? ,s]vice ,act7 locat$ 9 a rural   
area4  7vi7 ,specifi$ exemptions ,!     
foll[+ types ( applicable imag+ s]vices3
 7,i7 ,a mammography4  7,,ii7 ,a lung   
canc] scre5+ p]=m$ us+ comput$          

tomography4  7,,iii7 ,a colonography    
p]=m$ us+ comput$ tomography4  7,,iv7   
,su* a s]vice furni%$ to treat an       
em]g5cy m$ical condition or a suspect$  
em]g5cy m$ical condition4  7,v7 ,su* o!r
 prev5tive or scre5+ imag+ s]vices z !  
,secret>y det]m9es appropriate4  2  7,d7
 9 subp>agraph 7,d71 by add+ at ! end ! 
foll[+ new clause3  7iv7 ,any o!r paym5t
 sy/em det]m9$ appropriate by !         
,secret>y4  2 &  7,e7 by add+ at ! end !
 foll[+ new subp>agraphs3  7,e7 ,furni%+
 pr(essional requirem5t ,beg9n+ ,janu>y 
#a1 #bjbg1 ) respect to an applicable   
imag+ s]vice furni%$ 9 an applicable    
sett+ & paid = "u an applicable paym5t  
sy/em 7z def9$ 9 subp>agraph 7,d771 !   
furni%+ pr(essional %all include !      
national provid] id5tifi] ( ! ord]+     
pr(essional 7if diff]5t f ! furni%+     
pr(essional7 on ! claim = ! s]vice4     
7,f7 ,report+ requirem5ts ,! ,secret>y  
%all provide1 ?r\gh guidance or         
rulemak+1 in=mation on appropriate ways 
t ea* qualifi$ cl9ical decision support 

me*anism may report ! in=mation ma9ta9$ 
"u subp>agraph 7,b7 to ! ,secret>y to   
support ! ,secret>y 9 implem5t+         
p>agraphs 7#e7 & 7#f74  2  7#c7 9       
p>agraph 7#e7-- 7,a7 9 ! head+1 by /rik+
 outli] & ins]t+ l[ compliant2  7,b7 by 
/rik+ subp>agraphs 7,a7 & 7,b7 & ins]t+ 
! foll[+3  7,a7 ,9 g5]al ,) respect to  
applicable imag+ s]vices furni%$ on or  
aft] ,janu>y #a1 #bjbg1 ! ,secret>y %all
 det]m9e on an annual basis ! total     
numb] ( ord]+ pr(essionals :o are       
designat$ z l[ compliant ord]+          
pr(essionals "u subp>agraph 7,b74  7,b7 
,l[ compliant ord]+ pr(essionals ,!     
,secret>y %all designate ord]+          
pr(essionals ) a compliance rate 7z     
det]m9$ "u subp>agraph 7,d77 l[] ?an an 
am\nt det]m9$ by ! ,secret>y z l[       
compliant ord]+ pr(essionals4  2  7,c7 9
 p>agraph 7,c71 by /rik+ outli] & ins]t+
 l[ compliant2  7,d7 by /rik+           
subp>agraph 7,d7 & ins]t+ ! foll[+3     
7,d7 ,det]m9ation ( compliance rate  7i7
 ,9 g5]al  7,i7 ,compliance rates ,=    

applicable imag+ s]vices furni%$ on or  
aft] ,janu>y #a1 #bjbg1 ! ,secret>y %all
 det]m9e a compliance rate 7z def9$ 9   
clause 7ii77 = ea* ord]+ pr(essional = a
 p]iod specifi$ by ! ,secret>y4  7,,ii7 
,use ( data ,9 det]m9+ a compliance rate
 = an ord]+ pr(essional "u subclause    
7,i71 ! ,secret>y %all use data made    
available to ! ,secret>y by qualifi$    
cl9ical decision support me*anisms      
publi%$ 9 ! li/ "u p>agraph 7#c77;,c7 t 
7 consult$ by ! ord]+ pr(essional = !   
p]iod specifi$ by ! ,secret>y "u        
subclause 7,i74  7ii7 ,def9ition (      
compliance rate  7,i7 ,9 g5]al ,9 ?is   
subp>agraph1 ! t]m #8compliance rate'   
means1 ) respect to ! requirem5t "u     
p>agraph 7#d77;,a7 t an ord] f an ord]+ 
pr(essional = an applicable imag+ s]vice
 0 ! subject ( consultation ) a qualifi$
 decision support me*anism1 ! ratio     
7express$ z a p]c5tage7 (-- 7aa7 ! numb]
 ( ord]s f su* ord]+ pr(essional includ$
 9 a report f "o or m qualifi$ decision 
support me*anisms describ$ 9 p>agraph   

7#c77;,b72 &  7bb7 ! aggregate numb] (  
su* ord]s f su* ord]+ pr(essional = su* 
p]iod4  7,,ii7 ,exclusion ( except$     
ord]s ,9 calculat+ ! compliance rate =  
an ord]+ pr(essional "u subclause 7,i71 
! ,secret>y %all exclude f ! total numb]
 ( ord]s 9 item 7bb7 ( su* subclause any
 ord] = an applicable imag+ s]vice      
describ$ 9 p>agraph 7#d77;,c74  2 &     
7,e7 9 subp>agraph 7,e71 by /rik+ outli]
 & ins]t+ l[ compliant2  7#d7 by /rik+  
p>agraph 7#f7 & ins]t+ ! foll[+3  7#f7  
,/udy & report on l[ compliant ord]+    
pr(essionals & utilization ( applicable 
imag+ s]vices  7,a7 ,9 g5]al ,n lat] ?an
 ,janu>y #a1 #bjca1 & e #e ye>s !reaft]1
 ! ,secret>y %all conduct a /udy reg>d+ 
! compliance rates calculat$ "u p>agraph
 7#e7 & submit a report to ,congress t--
 7i7 discusses-- 7,i7 su* rates &       
compliance ) ?is subsection2  7,,ii7 !  
impact ?is subsection has on !          
utilization ( applicable imag+ s]vices2 
&  7,,iii7 pot5tial me*anisms = improv+ 
compliance ) ?is subsection1 includ+--  

7aa7 prior au?orization = applicable    
imag+ s]vices ord]$ by l[ compliant     
ord]+ pr(essionals2  7bb7 any paym5t    
adju/m5t relat$ to ! s]vices1 or a      
subset ( s]vices1 t ! ,secret>y may     
designate "u ! fee s*$ule "u section    
#ahdh2 or  7cc7 o!r me*anisms det]m9$   
appropriate by ! ,secret>y2 &  7ii7     
proposes alt]native compliance rate     
?re%olds = l[ compliant ord]+           
pr(essionals = purposes ( p>agraph      
7#e77;,b74  2 &  7#e7 by add+ at ! end !
 foll[+ new p>agraph3  7#h7 ,specialty  
society endorsem5t ,9 specify+          
applicable appropriate use crit]ia =    
applicable imag+ s]vices "u p>agraph    
7#b7 & qualifi$ cl9ical decision support
 me*anisms "u p>agraph 7#c71 ! ,secret>y
 %all sub/antially adh]e to ! approa*   
describ$ 9 section #dad4id ( title #db1 
,code ( ,f$]al ,regulations 7z 9 effect 
on ,janu>y #a1 #bjbc74  4  7b7          
,effective date ,! am5dm5ts made by     
subsection 7a7 %all apply ) respect to  
items & s]vices furni%$ on or aft]      

,janu>y #a1 #bjbg4  #bjh4 ,rules (      
con/ruction  7a7 ,9 g5]al ,none ( !     
am5dm5ts made by ?is title may be       
con/ru$ to-- 7#a7 transf] own]%ip ( a   
measure develop$ by a qualifi$ cl9ical  
data regi/ry to ! ,secret>y or any o!r  
entity )\t ! au?orization ( ! qualifi$  
cl9ical data regi/ry2 or  7#b7 require a
 qualifi$ cl9ical data regi/ry to       
rel9qui% intellectual prop]ty rights z a
 condition ( hav+ a measure consid]$ =  
inclusion 9 ! annual f9al li/ (         
measures4  7b7 ,,ip ,! ,secret>y (      
,heal? & ,human ,s]vices %all recognize 
t measures develop$ by qualifi$ cl9ical 
data regi/ries are ! intellectual       
prop]ty ( su* regi/ries1 includ+ any    
specifications1 me?odologies1 scor+     
algori?ms1 specialty or subspecialty    
guidel9es1 & relat$ mat]ials associat$ )
 su* measures4 ,no?+ 9 ?is title %all   
prohibit a qualifi$ cl9ical data regi/ry
 f volunt>ily lic5s+ a measure to !     
,secret>y or o!r entities "u t]ms agre$ 
to by su* regi/ry4  ,,iii ,,apm         

improvem5t  #cja4 ,qualify+ ,,apm       
p>ticipant ?re%old freeze  7a7 ,9 g5]al 
,section #ahcc7z77#b7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4           
#aciel7z77#b77 is am5d$-- 7#a7 9        
subp>agraph 7,b7-- 7,a7 9 ! head]1 by   
/rik+ #bjbf & #bjbh & ins]t+ #bjbi2 &   
7,b7 9 ! matt] prec$+ clause 7i71 by    
/rik+ #bjbf & #bjbh & ins]t+ #bjbi2 &   
7#b7 9 subp>agraph 7,c7-- 7,a7 9 !      
head]1 by /rik+ #bjbg & #bjbi & ins]t+  
#bjcj2 &  7,b7 9 ! matt] prec$+ clause  
7i71 by /rik+ #bjbg & #bjbi & ins]t+    
#bjcj4  7b7 ,con=m+ am5dm5ts ,section   
#ahdh7q77#a77;,c77iii7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7q77#a77;,c77iii77 is am5d$--  
7#a7 9 subclause 7,,ii71 9 ! matt]      
prec$+ item 7aa71 by /rik+ #bjbf & #bjbh
 & ins]t+ #bjbi2 &  7#b7 9 subclause    
7,,iii71 ! matt] prec$+ item 7aa71 by   
/rik+ #bjbg & #bjbi & ins]t+ #bjcj4  7c7
 ,au?ority ,to modify ?re%olds ,section 
#ahdh7q77#a77;,c77iii7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           

#aciew-#d7q77#a77;,c77iii77 is am5d$--  
7#a7 9 subclause 7,,ii7-- 7,a7 9 item   
7aa71 by ins]t+ 7or su* l[] p]c5tage z  
may be specifi$ by ! ,secret>y7 aft] #dj
 p]c5t2 &  7,b7 9 item 7bb71 by ins]t+  
7or su* l[] p]c5tages z may be specifi$ 
by ! ,secret>y7 aft] respectively2 &    
7#b7 9 subclause 7,,iii7-- 7,a7 9 item  
7aa71 by ins]t+ 7or su* l[] p]c5tage z  
may be specifi$ by ! ,secret>y7 aft] #ej
 p]c5t2 &  7,b7 9 item 7bb71 by ins]t+  
7or su* l[] p]c5tages z may be specifi$ 
by ! ,secret>y7 aft] respectively4      
#cjb4 ,,cmi model requirem5ts ,section  
#aaae;,a ( ! ,social ,security ,act 7#db
 ,u4,s4,c4 #acae;a7 is am5d$-- 7#a7 9   
subsection 7b77#c77;,b71 by ins]t+ 1    
pursuant to notice-&-comm5t rulemak+1   
aft] ,! ,secret>y %all2  7#b7 9         
subsection 7c71 9 ! flu% matt] at ! end1
 by add+ at ! end ! foll[+ new s5t5ce3  
,! ,secret>y may t]m9ate a model exp&$  
"u ?is subsection prior to ! date set = 
su* t]m9ation at ! "t ( su* expansion   
only pursuant to notice & comm5t        

rulemak+42 &  7#c7 9 subsection 7g71 by 
add+ at ! end ! foll[+ new s5t5ce3 ,ea* 
su* report submitt$ 9 #bjbg or a        
subsequ5t ye> %all conta91 ) respect to 
ea* model te/$ "u subsection 7b71 a     
description ( any sav+s g5]at$ by su*   
model44  #cjc4 ,report on b>ri]s to     
p>ticipation 9 value-bas$ paym5t models 
,n lat] ?an ,decemb] #ca1 #bjbi1 !      
,comptroll] ,g5]al ( ! ,unit$ ,/ates1 9 
consultation ) ! ,m$ic>e ,paym5t        
,advisory ,commission1 %all submit to ! 
,committees on ,en]gy & ,comm]ce & ,ways
 & ,means ( ! ,h\se ( ,repres5tatives1 &
 ! ,committee on ,f9ance ( ! ,s5ate1 a  
report on ongo+ b>ri]s to p>ticipation 9
 value-bas$ paym5t models = specialty   
provid]s "u ! ,m$ic>e program4 ,su*     
report %all conta9 specific policy      
recomm5dations to r$uce su* b>ri]s4     
,,iv ,physician paym5t improvem5ts      
#dja4 ,updat+ ! budget neutrality       
?re%old ,section                        
#ahdh7;c77#b77;,b77ii77,,ii7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          

#aciew-#d7;c77#b77;,b77ii77,,ii77 is    
am5d$-- 7#a7 by /rik+ ,subject to &     
ins]t+ ! foll[+3  7aa7 ,9 g5]al ,subject
 to  2  7#b7 9 item 7aa71 z ins]t$ by   
p>agraph 7#a71 by /rik+ #bj1jjj1jjj &   
ins]t+ ! am\nt specifi$ 9 item 7bb7 =   
su* ye>2 &  7#c7 by add+ at ! end !     
foll[+ new items3  7bb7 ,am\nt specifi$ 
,= purposes ( item 7aa71 subject to item
 7cc71 ! am\nt specifi$ 9 ?is item is-- 
7,,aa7 = ye>s be=e #bjbh1 #bj1jjj1jjj2  
7,,bb7 = #bjbh1 #eg1fdj1jjj2 & 7,,cc7 = 
#bjbi & ea* subsequ5t ye>1 ! am\nt      
specifi$ 9 ?is item = ! prec$+ ye>4     
7cc7 ,index+ limitation on annual       
adju/m5ts ,= #bjcc & e subsequ5t fif?   
ye>1 ! ,secret>y %all increase ! am\nt  
specifi$ 9 item 7bb7 = su* ye> by !     
cumulative p]c5tage increase 9 ! ,,mei  
7z def9$ 9 section #ahdb7;i77#c77       
applicable to physicians' s]vices = ea* 
ye> occurr+ dur+ ! #e-ye> p]iod end+ on 
! la/ day ( ! prec$+ ye>4  4  #djb4     
,budget neutrality corrections relat+ to
 e/imat$ utilization  7a7 ,9 g5]al      

,section #ahdh7;c77#b77;,b7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7;c77#b77;,b77 is am5d$ by add+
 at ! end ! foll[+ new clause3  7vii7   
,budget neutrality corrections relat+ to
 e/imat$ utilization  7,i7 ,9 g5]al ,9 !
 case ( a budget neutrality adju/m5t    
appli$ pursuant to clause 7ii77,,ii7 = a
 ye> 7beg9n+ ) #bjbi7 t is det]m9$ 9 "p 
us+ e/imat$ utilization 7z def9$ 9      
subclause 7,,ii77bb77 ) respect to a    
specifi$ s]vice 7z def9$ 9 subclause    
7,,ii77cc771 ! ,secret>y %all1 z "p ( ! 
f9al rule e/abli%+ ! physician fee      
s*$ule "u ?is section = ! assumption    
correction p]iod 7z def9$ 9 subclause   
7,,ii77aa77 ) respect to su* ye>-- 7aa7 
det]m9e ! diff]5ce betwe5 exp5ditures = 
su* s]vice 9 su* ye> us+ e/imat$        
utilization & actual utilization = su*  
s]vice 79 a mann] det]m9$ appropriate by
 ! ,secret>y72 &  7bb7 9 ! case t !     
,secret>y det]m9es ! diff]5ce describ$ 9
 item 7aa7 is great] ?an ! ?re%old am\nt
 7z def9$ 9 subclause 7,,ii77dd77 = su* 

ye>1 adju/ ! conv]sion factor "u ?is    
section = su* assumption correction     
p]iod by su* am\nt to reconcile su*     
diff]5ce 7:i* may be positive or        
negative71 z det]m9$ by ! ,secret>y4    
7,,ii7 ,def9itions ,= purposes ( ?is    
clause3 7aa7 ,assumption correction     
p]iod ,! t]m assumption correction p]iod
 means1 ) respect to a ye>1 ! second ye>
 beg9n+ aft] su* ye>4  7bb7 ,e/imat$    
utilization ,! t]m e/imat$ utilization  
means an e/imate ( utilization us$ =    
purposes ( apply+ clause 7ii77,,ii74    
7cc7 ,specifi$ s]vice ,! t]m specifi$   
s]vice means1 ) respect to a ye>1 a     
s]vice-- 7,,aa7 ) expect$ exp5ditures = 
su* ye> "u ?is section bas$ on e/imat$  
utilization t exce$ ! ?re%old am\nt 7z  
def9$ 9 item 7dd77 = su* ye>2 & 7,,bb7 =
 :i* paym5t _h be5 bundl$ into paym5t = 
ano!r s]vice dur+ ! prec$+ ye> & = :i* a
 sep>ate paym5t or add-on paym5t is made
 dur+ su* ye>4  7dd7 ,?re%old am\nt ,!  
t]m ?re%old am\nt means1 ) respect to a 
ye>1 #j4a p]c5t ( ! total e/imat$       

exp5ditures "u ?is "p = s]vices furni%$ 
"u ?is section dur+ su* ye>4  4  7b7    
,nonapplication ( budget neutrality to  
reconciliation adju/m5ts ,section       
#ahdh7;c77#b77;,b7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#aciew-#d7;c77#b77;,b77 is am5d$-- 7#a7 
9 clause 7iv7-- 7,a7 9 subclause 7,v71  
by /rik+ & at ! end2  7,b7 9 subclause  
7,,vi71 by /rik+ ! p]iod & ins]t+ 2 &2 &
  7,c7 by add+ at ! end ! foll[+ new    
subclause3  7,,vii7 clause 7vii77,i77bb7
 = an assumption correction p]iod 7z    
def9$ 9 clause 7vii77,,ii77 %all n be   
tak5 into acc\nt 9 apply+ clause        
7ii77,,ii7 ) respect to su* p]iod4  2 & 
7#b7 9 clause 7v71 by add+ at ! end !   
foll[+ new subclause3  7,,xii7          
,r$uctions attributable to an assumption
 correction ,= an assumption correction 
p]iod 7z def9$ 9 clause 7vii77,,ii771   
r$uc$ exp5ditures attributable to       
application ( clause 7vii77,i77bb7 )    
respect to su* p]iod4  4  #djc4 ,timely 
updates to direct co/s us$ to calculate 

practice exp5se ,r,v,us ,section        
#ahdh7;c77#b77;,b7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#aciew-#d7;c77#b77;,b771 z am5d$ by     
section #djb1 is fur!r am5d$ by add+ at 
! end ! foll[+ new clause3  7viii7      
,timely updates to direct co/s us$ to   
calculate practice exp5se relative value
 units  7,i7 ,simultane\s updates to    
direct co/ inputs at lea/ once e #e ye>s
 ,! ,secret>y %all1 n less (t5 ?an e #e 
ye>s1 update ! prices & rates1 z        
applicable1 on a category-wide basis =  
ea* ( ! categories ( direct co/ inputs  
describ$ 9 subclause 7,,ii7 us$ 9 !     
me?odology = calculat+ ! practice exp5se
 relative value units "u ?is subsection 
= physicians' s]vices4 ,updates made    
pursuant to ! previ\s s5t5ce %all be    
made 9 ! same ye> = all categories (    
direct co/ inputs describ$ 9 su*        
subclause4  7,,ii7 ,direct co/ inputs   
categories describ$ ,= purposes ( ?is   
clause1 ! categories ( direct co/ inputs
 describ$ 9 ?is subclause are cl9ical   

/aff wage rates1 prices ( m$ical        
supplies1 prices ( equipm5t1 & any o!r  
category ( su* inputs us$ 9 ! me?odology
 describ$ 9 subclause 7,i7 7z specifi$  
by ! ,secret>y74  7,,iii7 ,consultation 
,9 mak+ ! updates "u ?is clause1 !      
,secret>y %all consult ) relevant       
/akehold]s1 includ+ physician specialty 
societies4  4  #djd4 ,limitation on     
ye>-to-ye> conv]sion factor v>iance     
,section #ahdh7;c77#b77;,b7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#aciew-#d7;c77#b77;,b771 z am5d$ by     
sections #djb & #djc1 is fur!r am5d$ by 
add+ at ! end ! foll[+ new clause3  7ix7
 ,limitation on conv]sion factor v>iance
  7,i7 ,9 g5]al ,beg9n+ ) #bjbg1 !      
,secret>y may n1 = purposes ( comply+ ) 
clause 7ii77,,ii71 apply a budget       
neutrality adju/m5t to a conv]sion      
factor e/abli%$ "u subsection 7d7 = su* 
ye> t w\ld cause su* factor1 n tak+ into
 acc\nt any adju/m5t to su* factor = su*
 ye> provid$ "u su* subsection1 to v>y  
by m ?an #b4e p]c5t comp>$ to su* factor

 s e/abli%$ = ! prec$+ ye>4  7,,ii7     
,cont9u$ applicability ( budget         
neutrality requirem5t ,no?+ 9 subclause 
7,i7 may be con/ru$ to alt] ! requirem5t
 describ$ 9 clause 7ii77,,ii74  4