[House Report 116-691] [From the U.S. Government Publishing Office] 116th Congress } { Rept. 116-691 HOUSE OF REPRESENTATIVES 2d Session } { Part 1 _______________________________________________________________________ BENEFICIARY EDUCATION TOOLS, TELEHEALTH, AND EXTENDERS REAUTHORIZATION ACT OF 2019 ---------- R E P O R T of the COMMITTEE ON WAYS AND MEANS HOUSE OF REPRESENTATIVES on H.R. 3417 [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] December 24, 2020.--Ordered to be printed BENEFICIARY EDUCATION TOOLS, TELEHEALTH, AND EXTENDERS REAUTHORIZATION ACT OF 2019 116th Congress } { Rept. 116-691 HOUSE OF REPRESENTATIVES 2d Session } { Part 1 ====================================================================== BENEFICIARY EDUCATION TOOLS, TELEHEALTH, AND EXTENDERS REAUTHORIZATION ACT OF 2019 _______ December 24, 2020.--Committed to the Committee of the Whole House on the State of the Union and ordered to be printed _______ Mr. Neal, from the Committee on Ways and Means, submitted the following R E P O R T [To accompany H.R. 3417] [Including cost estimate of the Congressional Budget Office] The Committee on Ways and Means, to whom was referred the bill (H.R. 3417) to amend title XVIII of the Social Security Act to provide for patient improvements and rural and quality improvements under the Medicare program, having considered the same, reports favorably thereon with an amendment and recommends that the bill as amended do pass. CONTENTS Page I. SUMMARY AND BACKGROUND..........................................11 A. Purpose and Summary................................. 11 B. Background and Need for Legislation................. 12 C. Legislative History................................. 14 II. EXPLANATION OF ACT..............................................15 A. Title I--Patient Improvements....................... 15 Section 101. Beneficiary Enrollment Notification and Eligibility Simplification..................... 15 Section 103. Medicare Coverage of Certain Mental Health Telehealth Services......................... 19 Section 104. Requiring Prescription Drug Plan Sponsors to Include Real-Time Benefit Information as Part of Such Sponsor's Electronic Prescription Program under the Medicare Program................. 21 Section 105. Transitional Coverage and Retroactive Medicare Part D Coverage for Certain Low-Income Beneficiaries...................................... 23 B. Title II: Rural and Quality Improvements............ 24 Section 201. Medicare GME Treatment of Hospitals Establishing New Medical Residency Training Programs after Hosting Medical Resident Rotators for Short Durations................................ 24 Section. 202. Extension of the Work Geographic Index Floor under the Medicare Program............. 26 Section 203. Extension of Funding for Quality Measure Endorsement, Input, and Selection under Medicare Program................................... 26 Section 204. Improving Measurements under the Skilled Nursing Facility Value-Based Purchasing Program under the Medicare Program................. 28 III. VOTES OF THE COMMITTEE..........................................30 IV. BUDGET EFFECTS OF THE BILL......................................31 A. Committee Estimate of Budgetary Effects............. 31 B. Statement Regarding New Budget Authority and Tax Expenditures Budget Authority...................... 31 C. Cost Estimate Prepared by the Congressional Budget Office............................................. 31 V. OTHER MATTERS TO BE DISCUSSED UNDER THE RULES OF THE HOUSE......36 A. Committee Oversight Findings and Recommendations.... 36 B. Statement of General Performance Goals and Objectives......................................... 36 C. Information Relating to Unfunded Mandates........... 36 D. Congressional Earmarks, Limited Tax Benefits, and Limited Tariff Benefits............................ 36 E. Duplication of Federal Programs..................... 36 F. Hearings............................................ 37 VI. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED...........37 The amendment is as follows: Strike all after the enacting clause and insert the following: SECTION 1. SHORT TITLE; TABLE OF CONTENTS. (a) Short Title.--This Act may be cited as the ``Beneficiary Education Tools, Telehealth, and Extenders Reauthorization Act of 2019'' or the ``BETTER Act of 2019''. (b) Table of Contents.--The table of contents for this Act is as follows: Sec. 1. Short title; table of contents. TITLE I--PATIENT IMPROVEMENTS Sec. 101. Beneficiary enrollment notification and eligibility simplification. Sec. 102. Extension of funding outreach and assistance for low-income programs. Sec. 103. Medicare coverage of certain mental health telehealth services. Sec. 104. Requiring prescription drug plan sponsors to include real- time benefit information as part of such sponsor's electronic prescription program under the Medicare program. Sec. 105. Transitional coverage and retroactive Medicare part D coverage for certain low-income beneficiaries. TITLE II--RURAL AND QUALITY IMPROVEMENTS Sec. 201. Medicare GME treatment of hospitals establishing new medical residency training programs after hosting medical resident rotators for short durations. Sec. 202. Extension of the work geographic index floor under the Medicare program. Sec. 203. Extension of funding for quality measure endorsement, input, and selection under Medicare program. Sec. 204. Improving measurements under the skilled nursing facility value-based purchasing program under the Medicare program. TITLE I--PATIENT IMPROVEMENTS SEC. 101. BENEFICIARY ENROLLMENT NOTIFICATION AND ELIGIBILITY SIMPLIFICATION. (a) Eligibility and Enrollment Notices.-- (1) As part of social security account statement for individuals attaining ages 63 to 65.--Section 1143(a) of the Social Security Act (42 U.S.C. 1320b-13(a)) is amended by adding at the end the following new paragraph: ``(4) Medicare Eligibility Information.-- ``(A) In general.--In the case of statements provided on or after the date that is 2 years after the date of the enactment of this paragraph to individuals who are attaining ages 63, 64, and 65, the statement shall also include a notice containing the information described in subparagraph (B). ``(B) Contents of notice.--The notice required under subparagraph (A) shall include a clear, simple explanation of-- ``(i) eligibility for benefits under the Medicare program under title XVIII, and in particular benefits under part B of such title; ``(ii) the reasons a late enrollment penalty for failure to timely enroll could be assessed and how such late enrollment penalty is calculated, in particular for benefits under part B; ``(iii) the availability of relief from the late enrollment penalty and retroactive enrollment under section 1837(h) (including as such section is applied under sections 1818(c) and 1818A(c)(3)), with examples of circumstances under which such relief may be granted and examples of circumstances under which such relief would not be granted; ``(iv) coordination of benefits (including primary and secondary coverage scenarios) pursuant to section 1862(b), in particular for benefits under part B of such title; and ``(v) information for populations, such as residents of Puerto Rico and veterans, for whom there are special considerations with respect to enrollment, eligibility, and coordination of benefits under title XVIII. ``(C) Development of notice.-- ``(i) In general.--The Secretary, in coordination with the Commissioner of Social Security, and taking into consideration information collected pursuant to clause (ii), shall, not later than 12 months after the last day of the period for the request of information described in clause (ii), develop the notice to be provided pursuant to subparagraph (A). ``(ii) Request for information.--Not later than 6 months after the date of the enactment of this paragraph, the Secretary shall request written information, including recommendations, from stakeholders (including the groups described in subparagraph (D)) on the information to be included in the notice. ``(iii) Notice improvement.--Beginning 4 years after the date of enactment of this paragraph, and not less than once every two years thereafter, the Secretary, in coordination with the Commissioner of Social Security, shall-- ``(I) review the content of the notice to be provided under subparagraph (A); ``(II) solicit recommendations on the notice through a request for information process as described in clause (ii); and ``(III) update and revise such notice as the Secretary deems appropriate. ``(D) Groups for consultation.--For purposes of subparagraph (C)(ii), the groups described in this clause include the following: ``(i) Individuals who are 60 years of age or older. ``(ii) Veterans. ``(iii) Individuals with disabilities. ``(iv) Individuals with end stage renal disease. ``(v) Low-income individuals and families. ``(vi) Employers (including human resources professionals). ``(vii) States (including representatives of State- run Health Insurance Exchanges, Medicaid offices, and Departments of Insurance). ``(viii) State Health Insurance Assistance Programs. ``(ix) Health insurers. ``(x) Health insurance agents and brokers. ``(xi) Such other groups as specified by the Secretary. ``(E) Posting of notice on websites.--The Commissioner of Social Security and the Secretary shall post the notice required under subparagraph (A) in a prominent location on the public Internet website of the Social Security Administration and on the public Internet website of the Centers for Medicare & Medicaid Services, respectively. ``(F) Reimbursement of costs.-- ``(i) In general.--Effective for fiscal years beginning in the year in which the date of enactment of this paragraph occurs, the Commissioner of Social Security and the Secretary shall enter into an agreement which shall provide funding to cover the administrative costs of the Commissioner's activities under this paragraph. Such agreement shall-- ``(I) provide funds to the Commissioner for the full cost of the Social Security Administration's work related to the implementation of this paragraph, including any costs incurred prior to the finalization of such agreement; ``(II) provide such funding quarterly in advance of the applicable quarter based on estimating methodology agreed to by the Commissioner and the Secretary; and ``(III) require an annual accounting and reconciliation of the actual costs incurred and funds provided under this paragraph. ``(ii) Limitation.--In no case shall funds from the Social Security Administration's Limitation on Administrative Expenses be used to carry out activities related to the implementation of this paragraph, except as the Commissioner determines is necessary in developing the agreement under clause (i). ``(G) No effect on obligation to mail statements.--Nothing in this paragraph shall be construed to relieve the Commissioner of Social Security from any requirement under subsection (c), including the requirement to mail a statement on an annual basis to each eligible individual who is not receiving benefits under title II and for whom a mailing address can be determined through such methods as the Commissioner determines to be appropriate.''. (2) Individuals in medicare waiting period.--Title XI of the Social Security Act (42 U.S.C. 1301 et seq.) is amended by inserting after section 1144 the following new section: ``medicare enrollment notification and eligibility notices for individuals in medicare waiting period ``Notices ``Sec. 1144A. (a) ``(1) In General.--The Commissioner of Social Security shall distribute the notice to be provided pursuant to section 1143(a)(4), as may be modified under paragraph (2), to individuals in the 24-month waiting period under section 226(b). ``(2) Authority to Modify Notice.--The Secretary, in coordination with the Commissioner of Social Security, may modify the notice to be distributed under paragraph (1) as necessary to take into account the individuals described in such paragraph. ``(3) Posting of Notice on Websites.--The Commissioner of Social Security and the Secretary shall post the notice required to be distributed under paragraph (1) in a prominent location on the public Internet website of the Social Security Administration and on the public Internet website of the Centers for Medicare & Medicaid Services, respectively. ``Timing ``(b) Beginning not later than 2 years after the date of the enactment of this section, a notice required under subsection (a)(1) shall be mailed to an individual no less than two times in accordance with the following: ``(1) The notice shall be provided to such individual not later than 3 months prior to the date on which such individual's enrollment period begins as provided under section 1837. ``(2) The notice shall subsequently be provided to such individual not later than one month prior to such date. ``Reimbursement of Costs ``(c) ``(1) In General.--Effective for fiscal years beginning in the year in which the date of enactment of this section occurs, the Commissioner of Social Security and the Secretary shall enter into an agreement which shall provide funding to cover the administrative costs of the Commissioner's activities under this section. Such agreement shall-- ``(A) provide funds to the Commissioner for the full cost of the Social Security Administration's work related to the implementation of this section, including any costs incurred prior to the finalization of such agreement; ``(B) provide such funding quarterly in advance of the applicable quarter based on estimating methodology agreed to by the Commissioner and the Secretary; and ``(C) require an annual accounting and reconciliation of the actual costs incurred and funds provided under this section. ``(2) Limitation.--In no case shall funds from the Social Security Administration's Limitation on Administrative Expenses be used to carry out activities related to the implementation of this section, except as the Commissioner determines is necessary in developing the agreement under paragraph (1).''. (b) Beneficiary Enrollment Simplification.-- (1) Effective date of coverage.--Section 1838(a) of the Social Security Act (42 U.S.C. 1395q(a)) is amended-- (A) by amending paragraph (2) to read as follows: ``(2)(A) in the case of an individual who enrolls pursuant to subsection (d) of section 1837 before the month in which he first satisfies paragraph (1) or (2) of section 1836, the first day of such month, ``(B) in the case of an individual who first satisfies such paragraph in a month beginning before January 2021 and who enrolls pursuant to such subsection (d)-- ``(i) in such month in which he first satisfies such paragraph, the first day of the month following the month in which he so enrolls, ``(ii) in the month following such month in which he first satisfies such paragraph, the first day of the second month following the month in which he so enrolls, or ``(iii) more than one month following such month in which he satisfies such paragraph, the first day of the third month following the month in which he so enrolls, ``(C) in the case of an individual who first satisfies such paragraph in a month beginning on or after January 1, 2021, and who enrolls pursuant to such subsection (d) in such month in which he first satisfies such paragraph or in any subsequent month of his initial enrollment period, the first day of the month following the month in which he so enrolls, or ``(D) in the case of an individual who enrolls pursuant to subsection (e) of section 1837 in a month beginning-- ``(i) before January 1, 2021, the July 1 following the month in which he so enrolls, or ``(ii) on or after January 1, 2021, the first day of the month following the month in which he so enrolls, or''; and (B) by amending paragraph (3) to read as follows: ``(3) in the case of an individual who is deemed to have enrolled-- ``(A) on or before the last day of the third month of his initial enrollment period, the first day of the month in which he first meets the applicable requirements of section 1836 or July 1, 1973, whichever is later, or ``(B) on or after the first day of the fourth month of his initial enrollment period, and where such month begins-- ``(i) before January 1, 2021, as prescribed under subparagraphs (B)(i), (B)(ii), (B)(iii), and (D) of paragraph (2), or ``(ii) on or after January 1, 2021, as prescribed under paragraph (2)(C).''. (2) Special enrollment periods for exceptional circumstances.-- (A) Enrollment.--Section 1837 of the Social Security Act (42 U.S.C. 1395p) is amended by adding at the end the following new subsection: ``(m) Beginning January 1, 2021, the Secretary may establish special enrollment periods in the case of individuals who meet such exceptional conditions as the Secretary may provide, such as individuals who reside in an area with an emergency or disaster as determined by the Secretary.''. (B) Coverage period.--Section 1838 of the Social Security Act (42 U.S.C. 1395q) is amended by adding at the end the following new subsection: ``(g) Notwithstanding subsection (a), in the case of an individual who enrolls during a special enrollment period pursuant to section 1837(m), the coverage period shall begin on a date the Secretary provides in a manner consistent (to the extent practicable) with protecting continuity of health benefit coverage.''. (C) Conforming amendment.--Section 1839(b) of the Social Security Act (42 U.S.C. 1395r(b)) is amended, in the first sentence, by striking ``or (l)'' and inserting ``, (l), or (m)''. (3) Technical correction.--Section 1839(b) of the Social Security Act (42 U.S.C. 1395r(b)) is amended by adding at the end the following new sentence: ``For purposes of determining any increase under this subsection for individuals whose enrollment occurs on or after January 1, 2021, the second sentence of this subsection shall be applied by substituting `close of the month' for `close of the enrollment period' each place it appears.''. (4) Report.--Not later than January 1, 2021, the Secretary of Health and Human Services shall submit to the Committee on Ways and Means and Committee on Energy and Commerce of the House of Representatives and the Committee on Finance and Special Committee on Aging of the Senate a report including recommendations on how to align existing Medicare enrollment periods under title XVIII of the Social Security Act, including the general enrollment period under part B of such title and the annual election period under the Medicare Advantage program under part C of such title and under the prescription drug program under part D of such title. Such recommendations shall be consistent with the goals of maximizing coverage continuity and choice and easing beneficiary transition. SEC. 102. EXTENSION OF FUNDING OUTREACH AND ASSISTANCE FOR LOW-INCOME PROGRAMS. (a) Additional Funding for State Health Insurance Programs.-- Subsection (a)(1)(B) of section 119 of the Medicare Improvements for Patients and Providers Act of 2008 (42 U.S.C. 1395b-3 note), as amended by section 3306 of the Patient Protection and Affordable Care Act (Public Law 111-148), section 610 of the American Taxpayer Relief Act of 2012 (Public Law 112-240), section 1110 of the Pathway for SGR Reform Act of 2013 (Public Law 113-67), section 110 of the Protecting Access to Medicare Act of 2014 (Public Law 113-93), section 208 of the Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 114- 10), and section 50207 of the Bipartisan Budget Act of 2018 (Public Law 115-123), is amended-- (1) in clause (vii), by striking ``and'' at the end; (2) in clause (viii), by striking ``and'' at the end; (3) in clause (ix), by striking the period at the end and inserting ``; and''; and (4) by inserting after clause (ix) the following new clause: ``(x) for each of fiscal years 2020 through 2022, of $15,000,000.''. (b) Additional Funding for Area Agencies on Aging.--Subsection (b)(1)(B) of such section 119, as so amended, is amended-- (1) in clause (vii), by striking ``and'' at the end; (2) in clause (viii), by striking ``and'' at the end; (3) in clause (ix), by striking the period at the end and inserting ``; and''; and (4) by inserting after clause (ix) the following new clause: ``(x) for each of fiscal years 2020 through 2022, of $15,000,000.''. (c) Additional Funding for Aging and Disability Resource Centers.-- Subsection (c)(1)(B) of such section 119, as so amended, is amended-- (1) in clause (vii), by striking ``and'' at the end; (2) in clause (viii), by striking ``and'' at the end; (3) in clause (ix), by striking the period at the end and inserting ``; and''; and (4) by inserting after clause (ix) the following new clause: ``(x) for each of fiscal years 2020 through 2022, of $5,000,000.''. (d) Additional Funding for Contract With the National Center for Benefits and Outreach Enrollment.--Subsection (d)(2) of such section 119, as so amended, is amended-- (1) in clause (vii), by striking ``and'' at the end; (2) in clause (viii), by striking ``and'' at the end; (3) in clause (ix), by striking the period at the end and inserting ``; and''; and (4) by inserting after clause (ix) the following new clause: ``(x) for each of fiscal years 2020 through 2022, of $15,000,000.''. SEC. 103. MEDICARE COVERAGE OF CERTAIN MENTAL HEALTH TELEHEALTH SERVICES. Section 1834(m) of the Social Security Act (42 U.S.C. 1395m(m)) is amended-- (1) in paragraph (2)(B)(i), by striking ``and paragraph (6)(C)'' and inserting ``, paragraph (6)(C), and paragraph (8)(C)''; (2) in paragraph (4)(C)(i), by striking ``and (7)'' and inserting ``(7), and (8)''; (3) in paragraph (4)(F)(i), by inserting ``services identified by CPT codes 90832, 90834, and 90837 (and as subsequently modified by the Secretary),'' before ``and any additional service''; (4) in paragraph (6)(A), by striking ``paragraph (4)(C)'' and inserting ``paragraph (4)(C)(i)''; (5) in paragraph (7), by striking ``The geographic requirements'' and inserting ``Subject to paragraph (8)(D), the geographic requirements''; and (6) by adding at the end the following new paragraph: ``(8) Treatment of mental health telehealth services.-- ``(A) Non-application of originating site requirements.--The requirements described in paragraph (4)(C)(i) shall not apply with respect to telehealth services furnished on or after January 1, 2021, that are mental health telehealth services. Nothing in the previous sentence shall waive any applicable State law requirements. ``(B) Inclusion of certain sites.--With respect to telehealth services described in subparagraph (A), the term `originating site' shall include the home of the eligible telehealth individual at which the individual is located at the time the service is furnished via a telecommunications system. ``(C) No originating site facility fee.--No facility fee shall be paid under paragraph (2)(B) to an originating site with respect to a telehealth service described in subparagraph (A) if the originating site does not otherwise meet the requirements for an originating site under paragraph (4)(C). ``(D) Face-to-face initial assessment; reassessments.--Payment may not be made for mental health telehealth services under this paragraph (if such payment would not otherwise be allowed under this subsection without application of this paragraph or paragraph (7)) furnished to an eligible telehealth individual unless-- ``(i) within the 6-month period prior to the provision of such mental health telehealth services, the individual receives a face-to- face clinical assessment, without the use of telehealth, by a physician described in subparagraph (F)(i) or a practitioner described in subparagraph (F)(ii) of the needs of such individual for such services; and ``(ii) the individual receives a reassessment (at a frequency specified by the Secretary) by a physician so described or a practitioner so described of the needs of such individual for such services. ``(E) Mental health telehealth services defined.--For purposes of this paragraph, the term `mental health telehealth service' means services identified by CPT codes 90832, 90834, and 90837 (and as subsequently modified by the Secretary). ``(F) Physician and practitioner described.--For purposes of subparagraph (D): ``(i) Physician.--A physician described in this clause is a physician, as defined in section 1861(r)(1). ``(ii) Practitioner.--A practitioner described in this clause is a practitioner described in any of clauses (i), (iv), or (v) of section 1842(b)(18)(C).''. SEC. 104. REQUIRING PRESCRIPTION DRUG PLAN SPONSORS TO INCLUDE REAL- TIME BENEFIT INFORMATION AS PART OF SUCH SPONSOR'S ELECTRONIC PRESCRIPTION PROGRAM UNDER THE MEDICARE PROGRAM. Section 1860D-4(e)(2) of the Social Security Act (42 U.S.C. 1395w- 104(e)(2)) is amended-- (1) in subparagraph (D), by striking ``To the extent'' and inserting ``Except as provided in subparagraph (F), to the extent''; and (2) by adding at the end the following new subparagraph: ``(F) Real-time benefit information.-- ``(i) In general.--Not later than January 1, 2021, the program shall implement real-time benefit tools that are capable of integrating with a prescribing health care professional's electronic prescribing or electronic health record system for the transmission of formulary and benefit information in real time to prescribing health care professionals. With respect to a covered part D drug, such tools shall be capable of transmitting such information specific to an individual enrolled in a prescription drug plan. Such information shall include the following: ``(I) A list of any clinically- appropriate alternatives to such drug included in the formulary of such plan. ``(II) Cost-sharing information for such drug and such alternatives, including a description of any variance in cost sharing based on the pharmacy dispensing such drug or such alternatives. ``(III) Information relating to whether such drug is included in the formulary of such plan and any prior authorization or other utilization management requirements applicable to such drug and such alternatives so included. ``(ii) Electronic transmission.--The provisions of subclauses (I) and (II) of clause (ii) of subparagraph (E) shall apply to an electronic transmission described in clause (i) in the same manner as such provisions apply with respect to an electronic transmission described in clause (i) of such subparagraph. ``(iii) Special rule for 2021.--The program shall be deemed to be in compliance with clause (i) for 2021 if the program complies with the provisions of section 423.160(b)(7) of title 42, Code of Federal Regulations (or a successor regulation), for such year.''. SEC. 105. TRANSITIONAL COVERAGE AND RETROACTIVE MEDICARE PART D COVERAGE FOR CERTAIN LOW-INCOME BENEFICIARIES. Section 1860D-14 of the Social Security Act (42 U.S.C. 1395w-114) is amended-- (1) by redesignating subsection (e) as subsection (f); and (2) by adding after subsection (d) the following new subsection: ``(e) Limited Income Newly Eligible Transition Program.-- ``(1) In general.--Beginning not later than January 1, 2021, the Secretary shall carry out a program to provide transitional coverage for covered part D drugs for LI NET eligible individuals in accordance with this subsection. ``(2) LI net eligible individual defined.--For purposes of this subsection, the term `LI NET eligible individual' means a part D eligible individual who-- ``(A) meets the requirements of clauses (ii) and (iii) of subsection (a)(3)(A); and ``(B) has not yet enrolled in a prescription drug plan or an MA-PD plan, or, who has so enrolled, but with respect to whom coverage under such plan has not yet taken effect. ``(3) Transitional coverage.--For purposes of this subsection, the term `transitional coverage' means with respect to an LI NET eligible individual-- ``(A) immediate access to covered part D drugs at the point of sale during the period that begins on the first day of the month such individual is determined to meet the requirements of clauses (ii) and (iii) of subsection (a)(3)(A) and ends on the date that coverage under a prescription drug plan or MA-PD plan takes effect with respect to such individual; and ``(B) in the case of an LI NET eligible individual who is a full-benefit dual eligible individual (as defined in section 1935(c)(6)) or a recipient of supplemental security income benefits under title XVI, retroactive coverage (in the form of reimbursement of the amounts that would have been paid under this part had such individual been enrolled in a prescription drug plan or MA-PD plan) of covered part D drugs purchased by such individual during the period that begins on the date that is the later of-- ``(i) the date that such individual was first eligible for a low-income subsidy under this part; or ``(ii) the date that is 36 months prior to the date such individual enrolls in a prescription drug plan or MA-PD plan, and ends on the date that coverage under such plan takes effect. ``(4) Program administration.-- ``(A) Single point of contact.--The Secretary shall, to the extent feasible, administer the program under this subsection through a contract with a single program administrator. ``(B) Benefit design.--The Secretary shall ensure that the transitional coverage provided to LI NET eligible individuals under this subsection-- ``(i) provides access to all covered part D drugs under an open formulary; ``(ii) permits all pharmacies determined by the Secretary to be in good standing to process claims under the program; ``(iii) is consistent with such requirements as the Secretary considers necessary to improve patient safety and ensure appropriate dispensing of medication; and ``(iv) meets such other requirements as the Secretary may establish. ``(5) Relationship to other provisions of this title; waiver authority.-- ``(A) In general.--The following provisions shall not apply with respect to the program under this subsection: ``(i) Paragraphs (1) and (3)(B) of section 1860D-4(a) (relating to dissemination of general information; availability of information on changes in formulary through the internet). ``(ii) Subparagraphs (A) and (B) of section 1860D-4(b)(3) (relating to requirements on development and application of formularies; formulary development). ``(iii) Paragraphs (1)(C) and (2) of section 1860D-4(c) (relating to medication therapy management program). ``(B) Waiver authority.--The Secretary may waive such other requirements of title XI and this title as may be necessary to carry out the purposes of the program established under this subsection.''. TITLE II--RURAL AND QUALITY IMPROVEMENTS SEC. 201. MEDICARE GME TREATMENT OF HOSPITALS ESTABLISHING NEW MEDICAL RESIDENCY TRAINING PROGRAMS AFTER HOSTING MEDICAL RESIDENT ROTATORS FOR SHORT DURATIONS. (a) Redetermination of Approved FTE Resident Amount.--Section 1886(h)(2)(F) of the Social Security Act (42 U.S.C. 1395ww(h)(2)(F)) is amended-- (1) by inserting ``(i)'' before ``In the case of''; and (2) by adding at the end the following: ``(ii) In applying this subparagraph in the case of a hospital that trains residents and has not entered into a GME affiliation agreement (as defined by the Secretary for purposes of paragraph (4)(H)(ii)), on or after the date of the enactment of this clause, the Secretary shall not establish an FTE resident amount until such time as the Secretary determines that the hospital has trained at least 1.0 full-time-equivalent resident in an approved medical residency training program in a cost reporting period. ``(iii) In applying this subparagraph for cost reporting periods beginning on or after the date of enactment of this clause, in the case of a hospital that, as of such date of enactment, has an approved FTE resident amount based on the training in an approved medical residency program or programs of-- ``(I) less than 1.0 full-time-equivalent resident in any cost reporting period beginning before October 1, 1997, as determined by the Secretary; or ``(II) no more than 3.0 full-time-equivalent residents in any cost reporting period beginning on or after October 1, 1997, and before the date of the enactment of this clause, as determined by the Secretary, in lieu of such FTE resident amount the Secretary shall, in accordance with the methodology described in section 413.77(e) of title 42 of the Code of Federal Regulations (or any successor regulation), establish a new FTE resident amount if the hospital trains at least 1.0 full-time-equivalent resident (in the case of a hospital described in subclause (I)) or more than 3.0 full-time-equivalent residents (in the case of a hospital described in subclause (II)) in a cost reporting period beginning on or after such date of enactment and before the date that is 5 years after such date of enactment. ``(iv) For purposes of carrying out this subparagraph for cost reporting periods beginning on or after the date of the enactment of this clause, a hospital shall report full-time-equivalent residents on its cost report for a cost reporting period if the hospital trains at least 1.0 full-time-equivalent residents in an approved medical residency training program or programs in such period. ``(v) As appropriate, the Secretary may consider information from any cost reporting period necessary to establish a new FTE resident amount as described in clause (iii).''. (b) Redetermination of FTE Resident Limitation.--Section 1886(h)(4)(H)(i) of the Social Security Act (42 U.S.C. 1395ww(h)(4)(H)(i)) is amended-- (1) by inserting ``(I)'' before ``The Secretary''; and (2) by adding at the end the following: ``(II) In applying this clause in the case of a hospital that, on or after the date of the enactment of this subclause, begins training residents in a new approved medical residency training program or programs (as defined by the Secretary), the Secretary shall not determine a limitation applicable to the hospital under subparagraph (F) until such time as the Secretary determines that the hospital has trained at least 1.0 full-time-equivalent resident in such new approved medical residency training program or programs in a cost reporting period. ``(III) In applying this clause in the case of a hospital that, as of the date of the enactment of this subclause, has a limitation under subparagraph (F), based on a cost reporting period beginning before October 1, 1997, of less than 1.0 full-time-equivalent resident, the Secretary shall adjust the limitation in the manner applicable to a new approved medical residency training program if the Secretary determines the hospital begins training at least 1.0 full-time-equivalent residents in a program year beginning on or after such date of enactment and before the date that is 5 years after such date of enactment. ``(IV) In applying this clause in the case of a hospital that, as of the date of the enactment of this subclause, has a limitation under subparagraph (F), based on a cost reporting period beginning on or after October 1, 1997, and before such date of enactment, of no more than 3.0 full-time-equivalent residents, the Secretary shall adjust the limitation in the manner applicable to a new approved medical residency training program if the Secretary determines the hospital begins training more than 3.0 full-time-equivalent residents in a program year beginning on or after such date of enactment and before the date that is 5 years after such date of enactment. ``(V) An adjustment to the limitation applicable to a hospital made pursuant to subclause (III) or (IV) shall be made in a manner consistent with the methodology, as appropriate, in section 413.79(e) of title 42, Code of Federal Regulations (or any successor regulation). As appropriate, the Secretary may consider information from any cost reporting periods necessary to make such an adjustment to the limitation.''. (c) Technical and Conforming Amendments.--Section 1886 of the Social Security Act (42 U.S.C. 1395ww) is amended-- (1) in subsection (d)(5)(B)(viii), by striking ``subsection (h)(4)(H)'' and inserting ``paragraphs (2)(F)(iv) and (4)(H) of subsection (h)''; and (2) in subsection (h)-- (A) in paragraph (4)(H)(iv), by striking ``an rural area'' and inserting ``a rural area''; and (B) in paragraph (7)(E), by striking ``under this'' and all that follows through the period at the end and inserting the following: ``under this paragraph, paragraph (8), clause (i), (ii), (iii), or (v) of paragraph (2)(F), or clause (i) or (vi) of paragraph (4)(H).''. (d) Effective Date.--The amendments made by this section shall apply to payment under section 1886 of the Social Security Act (42 U.S.C. 1395ww) for cost reporting periods beginning on or after the date of the enactment of this Act. SEC. 202. EXTENSION OF THE WORK GEOGRAPHIC INDEX FLOOR UNDER THE MEDICARE PROGRAM. Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w- 4(e)(1)(E)) is amended by striking ``2020'' and inserting ``2023''. SEC. 203. EXTENSION OF FUNDING FOR QUALITY MEASURE ENDORSEMENT, INPUT, AND SELECTION UNDER MEDICARE PROGRAM. (a) In General.--Section 1890(d)(2) of the Social Security Act (42 U.S.C. 1395aaa(d)(2)) is amended-- (1) by striking ``and $7,500,000'' and inserting ``$7,500,000''; and (2) by striking ``and 2019.'' and inserting ``and 2019, and $30,000,000 for each of fiscal years 2020 through 2022.''. (b) Input for Removal of Measures.--Section 1890(b) of the Social Security Act (42 U.S.C. 1395aaa(b)) is amended by inserting after paragraph (3) the following: ``(4) Removal of measures.--The entity may provide input to the Secretary on quality and efficiency measures described in paragraph (7)(B) that could be considered for removal.''. (c) Prioritization of Measure Endorsement.--Section 1890(b) of the Social Security Act (42 U.S.C. 1395aaa(b)) is amended by adding at the end the following: ``(9) Prioritization of measure endorsement.--The entity-- ``(A) during the period beginning on the date of the enactment of this paragraph and ending on December 31, 2023, shall prioritize the endorsement of measures relating to maternal morbidity and mortality by the entity with a contract under subsection (a) in connection with endorsement of measures described in paragraph (2); and ``(B) on and after January 1, 2024, may prioritize the endorsement of such measures by such entity.''. SEC. 204. IMPROVING MEASUREMENTS UNDER THE SKILLED NURSING FACILITY VALUE-BASED PURCHASING PROGRAM UNDER THE MEDICARE PROGRAM. (a) In General.--Section 1888(h) of the Social Security Act (42 U.S.C. 1395yy(h)) is amended-- (1) in paragraph (1), by adding at the end the following new subparagraph: ``(C) Exclusions.--With respect to payments for services furnished on or after October 1, 2021, this subsection shall not apply to a facility for which there are not a minimum number (as determined by the Secretary) of-- ``(i) cases for the measures that apply to the facility for the performance period for the applicable fiscal year; or ``(ii) measures that apply to the facility for the performance period for the applicable fiscal year.''; (2) in paragraph (2)(A)-- (A) by striking ``The Secretary shall apply'' and inserting ``The Secretary-- ``(i) shall apply''; (B) by striking the period at the end and inserting ``; and''; and (C) by adding at the end the following: ``(ii) may, with respect to payments for services furnished on or after October 1, 2022, apply additional measures determined appropriate by the Secretary, which may include measures of functional status, patient safety, care coordination, or patient experience. Subject to the succeeding sentence, in the case that the Secretary applies additional measures under clause (ii), the Secretary shall consider and apply, as appropriate, quality measures specified under section 1899B(c)(1). In no case may the Secretary apply more than 10 measures under this subparagraph.''; (3) in subparagraph (A) of each of paragraphs (3) and (4), by striking ``measure'' and inserting ``measures''; and (4) by adding at the end the following new paragraph: ``(12) Validation.-- ``(A) In general.--The Secretary shall apply to the measures applied under this subsection and the data submitted under subsection (e)(6) a process to validate such measures and data, as appropriate, which may be similar to the process specified in section 1886(b)(3)(B)(viii)(XI) for validating inpatient hospital measures. ``(B) Funding.--For purposes of carrying out this paragraph, the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund established under section 1817, of $5,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for each of fiscal years 2022 through 2024.''. (b) Report by MedPAC.--Not later than March 15, 2021, the Medicare Payment Advisory Commission shall submit to Congress a report on establishing a prototype value-based payment program under a unified prospective payment system for post-acute care services under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.). Such report-- (1) shall-- (A) consider design elements such as-- (i) measures that are important to the Medicare program and to beneficiaries under such program; (ii) methodologies for scoring provider performance and effects on payment; and (iii) other elements determined appropriate by the Commission; and (B) analyze the effects of implementing such prototype program; and (2) may-- (A) discuss the possible effects, with respect to the Medicare program, on program spending, post-acute care providers, patient outcomes, and other effects determined appropriate by the Commission; and (B) include recommendations with respect to such prototype program, as determined appropriate by the Commission, to Congress and the Secretary of Health and Human Services. I. SUMMARY AND BACKGROUND A. Purpose and Summary The bill, H.R. 3417, the ``Beneficiary Education Tools, Telehealth, and Extenders Reauthorization (BETTER) Act of 2019,'' as amended and ordered reported by the Committee on Ways and Means on June 26, 2019, simplifies and improves Medicare enrollment, enhances access to care, and improves quality. It also extends four expiring Medicare provisions. The BETTER Act includes provisions from nine bipartisan bills in the 116th Congress that improve outreach, communication, and access to Medicare services. It also includes provisions aimed at improving quality measurement, physician payment, and physician training. This bill was introduced by Ways and Means Chairman Richard E. Neal (D-MA) and Ranking Member Kevin Brady (R-TX). Section 101 is based on H.R. 2477, the Beneficiary Enrollment Notification and Eligibility Simplification (BENES) Act of 2019, introduced by Representatives Raul Ruiz (D-CA), Jackie Walorski (R-IN), Brad Schneider (D-IL), and Gus Bilirakis (R- FL). Section 102 is based on H.R. 3421, the Fair Choices for Medicare Beneficiaries Act of 2019, introduced by Representatives Jimmy Gomez and (D-CA), Vern Buchanan (R-FL), and Debbie Dingell (D-MI). Section 103 is based on H.R. 1301, the Mental Health Telemedicine Act, introduced by Representatives Suzan DelBene (D-WA), Tom Reed (R-NY), Adrian Smith (R-NE), Terri Sewell (D-AL), Mike Kelly (R-PA), David Schweikert (R-AZ), and Jackie Walorski. Section 104 is based on H.R. 3408, the Shop Rx Act of 2019, introduced by Representatives Jodey Arrington (R-TX) and Pete Olson (R-TX), and H.R. 3415, the Real Time Beneficiary Drug Cost Bill, introduced by Representatives Elissa Slotkin (D-MI). Section 105 is based on H.R. 3029, the Improving Low-Income Access to Prescription Drugs Act, introduced by Representatives Pete Olson (R-TX), John Lewis (D-GA), Nanette Diaz Barragan (D-CA), and Kenny Marchant (R-TX). Section 201 is based on H.R. 3425, the Advancing Medical Resident Training in Community Hospitals Act of 2019, introduced by Representatives Ron Kind (D-WI) and George Holding (R-NC). Section 202 is based on H.R. 3302, the Keeping Physicians Serving Patients Act of 2019, introduced by Representatives Abby Finkenauer (D-IA), Adrian Smith (R-NE), Ron Kind (D-WI), Terri Sewell (D-AL), and Darin LaHood (R-IL). Section 203 is based on H.R. 3430, To amend title XVIII of the Social Security Act to extend funding for quality measure endorsement, input, and selection under the Medicare program, introduced by Representatives Judy Chu (D-CA) and David Schweikert (R-AZ). Section 204 is based on H.R. 3406, which amends title XVIII of the Social Security Act to improve measurements under the skilled nursing facility value-based purchasing program under the Medicare program, introduced by Ways and Means Chairman Richard E. Neal (D-MA) and Ranking Member Kevin Brady (R-TX). B. Background and Need for Legislation H.R. 3417 extends four Medicare provisions set to expire at the end of fiscal or calendar year 2019. The bill additionally makes important changes for individuals suffering from mental health and substance use disorders, individuals residing in rural areas, Medicare beneficiaries, and health care providers. Expanded coverage for mental health services. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), as of 2016 more than 75 percent of all U.S. counties were considered mental health shortage areas, and half of all U.S. counties had no mental health professional.\1\ In 2016, 85 percent of Medicare beneficiaries using telehealth services had a mental health diagnosis and those diagnoses lead to higher medical costs.\2\ H.R 3417 improves access to mental health services across the board by expanding access to mental health counseling sessions. Under the BETTER Act, beneficiaries in rural and urban areas will be able to access 30-, 45-, and 60- minute mental health telehealth counseling sessions. This is particularly valuable to beneficiaries who spend part of the year in a different location and need to remain in contact with a therapist or other provider and to beneficiaries who may be of limited mobility and cannot make weekly trips for in-person sessions. --------------------------------------------------------------------------- \1\Rural Behavioral Health: Telehealth Challenges and Opportunities, 9:2 Substance Abuse and Mental Health Services Admin. at 4 (2016), https://store.samhsa.gov/sites/default/files/d7/priv/sma16- 4989.pdf. \2\Information on Medicare Telehealth, Ctrs. for Medicare & Medicaid Servs. At 2 (Nov. 15, 2018), https://www.cms.gov/About-CMS/ Agency-Information/OMH/Downloads/Information-on-Medicare-Telehealth- Report.pdf. --------------------------------------------------------------------------- Additional funding for enrollment and outreach to connect Medicare beneficiaries with needed coverage. H.R. 3417 provides funding for various beneficiary education organizations. The legislation extends funding for the State Health Insurance Assistance Program (SHIP), Beneficiary Enrollment Counselors (BEC), Area Agencies on Aging (AAA), and Aging and Disability Resource Centers (ADRC) for three years, increasing overall funding to $50 million annually. These organizations play a critical role for Medicare beneficiaries. For example, SHIPs provide information and counseling to beneficiaries through local offices, community outreach programs, and toll-free telephone services. This insurance counseling is free for Medicare beneficiaries, their families, and their caregivers. During the April 2017-March 2018 grant year, SHIPs provided one-on-one counseling and support for almost three million Medicare-eligible individuals and their families, including more than 440,000 people with disabilities. SHIPs also provided outreach and education to more than 3.5 million people across the country. Section 50207 of the Bipartisan Budget Act of 2018 extended funding for SHIPs until the end of FY 2019.\3\ --------------------------------------------------------------------------- \3\Bipartisan Budget Act of 2018 (P.L. 115-123): Brief Summary of Division E-The Advancing Chronic Care, Extenders, and Social Services (ACCESS) Act, Cong. Research Serv. At table 1, CRS-4 (Mar. 9, 2018), https://fas.org/sgp/crs/misc/R45126.pdf. --------------------------------------------------------------------------- The BETTER Act also makes critical improvements to the pre- Medicare enrollment process both for individuals approaching age 65 and those qualifying for Medicare due to disability. These individuals would receive additional and improved advance notice to ensure they understand basic Medicare enrollment rules. These changes will help ensure fewer beneficiaries are subject to a late enrollment penalty due to confusion around timing of enrollment. Improved information and coverage to ensure that Medicare beneficiaries get the right care at the right time. H.R. 3417 improves affordability by making permanent the Medicare Limited Income Newly Eligible Transition (LI NET) Program, which provides coverage under Medicare Part D for low-income beneficiaries when they first enroll to ensure they can quickly access needed medications, including retroactive payment for medicines already purchased. According to the FY2020 HHS Budget in Brief, the ``. . . current demonstration, which runs through the end of 2019, has shown the proposed approach to both save money and be less disruptive to beneficiaries.''\4\ --------------------------------------------------------------------------- \4\Putting America's Health First: FY 2020 President's Budget for HHS, Dept. Health & Human Servs. at 17 (2019), https://www.hhs.gov/ sites/default/files/fy-2020-budget-in-brief.pdf. --------------------------------------------------------------------------- The BETTER Act also requires Medicare Part D plans to use a ``real-time benefit tool'' so that Medicare beneficiaries will know the cost of a prescription drug and its alternatives when their physician is writing the prescription at their medical visit. Beneficiaries will also be able to get real-time information on out-of-pocket costs at other nearby pharmacies. Such information is critical in helping both physicians and patients understand the price of their drugs before they get to the pharmacy counter and have fewer options. Investment in quality to improve outcomes for Medicare beneficiaries. The BETTER Act includes improvements in the Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP), which today only evaluates the care provided in these facilities based on a single readmission measure. Under H.R. 3417, Medicare will be able to improve measurement of value and drive quality by adding up to 10 measures, such as those included in the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014\5\ or those related to inappropriate use of antipsychotics, sepsis, bedsores and other common quality issues that affect Medicare beneficiaries. --------------------------------------------------------------------------- \5\Improving Medicare Post-Acute Care Transformation (PACT) Act of 2014, Pub. Law No. 113-185 (Oct. 6, 2014), https://www.congress.gov/ 113/plaws/publ185/PLAW-113publ185.pdf. --------------------------------------------------------------------------- Under the BETTER Act, the National Quality Forum (NQF), the consensus-based entity that assesses, improves, and endorses quality measures, will receive $30 million for each of the next three fiscal years for all work related to quality measurement in the Medicare program. NQF publishes annual reports with recommendations to the Secretary for selection of quality measures in February of each year. Section 50206 of the Balanced Budget Act (BBA) of 2018 transferred $7.5 million from the Hospital Insurance and Supplementary Medical Insurance Trust Funds for each of Fiscal Years (FYs) 2018 and 2019 to support NQF's work. Funding for NQF expires at the end of FY 2019. Congress is still waiting to receive a report from the Government Accountability Office (GAO) on NQF activities and funding, as required under Section 50206 of the Balanced Budget Act (BBA) of 2018. C. Legislative History Background H.R. 3417 was introduced on June 21, 2019 and was referred to the Committee on Ways and Means and additionally the Committee on Energy and Commerce. Committee hearings On June 4, 2019, the Committee on Ways and Means held a full committee Member Day hearing to discuss the range of issues, concerns, and proposals among on-committee and off- committee members. During that hearing, Representatives Terri Sewell (D-AL), Adrian Smith (R-NE), Devin Nunes (R-CA), Donna Shalala (D-FL), Abigail Spanberger (D-VA), Anthony Brindisi (D- NY), Elissa Slotkin, Ben McAdams (D-UT), and TJ Cox (D-CA), discussed the need for beneficiary improvements in the Medicare program and technical barriers preventing rural hospitals from starting graduate medical education (GME) programs, the need for policies that improve drug pricing transparency (including a real-time benefit tool), the importance of making permanent a Centers for Medicare & Medicaid Services (CMS) demonstration that protects low-income Medicare beneficiaries in the Part D drug program, the need for an extension of funding for NQF, and the importance of increasing access to telehealth in Medicare. Committee action The Committee on Ways and Means marked up H.R. 3417, the ``Beneficiary Education Tools, Telehealth, and Extenders Reauthorization (BETTER) Act of 2019,'' on June 26, 2019, and ordered the bill, as amended, favorably reported (with a quorum being present) by a roll call vote of 41-0. II. EXPLANATION OF ACT A. Title I--Patient Improvements Section 101. Beneficiary Enrollment Notification and Eligibility Simplification PRESENT LAW The Social Security Administration (SSA) processes Medicare Parts A and B enrollments. Individuals who are receiving Social Security benefits prior to age 65 are automatically enrolled in Medicare Parts A and B, and coverage begins the month that the individual turns 65. Similarly, individuals who are receiving Social Security Disability Insurance (SSDI) benefits are automatically enrolled in Medicare Parts A and B at the end of their 24-month waiting period, and coverage begins the following month. These individuals may change their Medicare enrollment (for example, decline Part B) during a seven-month period (called the initial enrollment period (IEP)) surrounding their 65th birthday or the end of their Medicare waiting period. These individuals receive a Welcome to Medicare packet three months before their 65th birthday or the end of their Medicare waiting period. Medicare-eligible individuals who have not been receiving Social Security benefits prior to age 65 must proactively enroll in Medicare, during the IEP. For those who enroll in Medicare during the three months prior to the month they turn 65, coverage begins during the month they turn age 65. Coverage for those who sign up during either the month of their 65th birthday or the following three months may be delayed from one to three months after the time they enroll. Such individuals do not receive explicit notification of their upcoming initial enrollment period or of the potential for late enrollment penalties and gaps in coverage if enrollment in Medicare is delayed. When individuals first become eligible for Medicare, they may enroll in either original Medicare (Parts A and B) or a private Medicare Advantage (MA) plan (Medicare Part C). They also may choose to enroll in a Medicare Part D plan at this time. Additionally, individuals may join or switch MA and/or Part D plans during an open enrollment period, which occurs each fall from October 15 to December 7, with coverage effective January 1 of the following year. Those who do not enroll in Part B when first eligible may be subject to late enrollment premium penalties if they enroll at a subsequent date. Medicare-eligible individuals who do not enroll in Part B during their initial enrollment period can enroll during a general enrollment period that runs from January through March each year, with coverage effective that July. In certain cases, beneficiaries may delay Part B enrollment without penalty and qualify for a special enrollment period, if they or their spouse are employed and their employer-sponsored insurance remains the primary payer with Medicare as the secondary payer. REASONS FOR CHANGE There has been long-standing coordination and education issues for individuals first enrolling in Medicare. Seniors and individuals with disabilities who do not receive start receiving Social Security benefits before 65 need to proactively enroll in Medicare, but do not receive important information about Medicare, such as the Welcome to Medicare packet. This lack of information can lead to seniors making the decisions that leave them paying Medicare late enrollment penalties for the rest of their lives. Section 101 requires information to be sent to seniors approaching ages 63 to 65, and individuals with disabilities to Social Security disability beneficiaries approaching the end of their 24-month Medicare waiting period, about their Medicare coverage before they enroll. When individuals fail to timely enroll in Part B due to error, misrepresentation, or inaction by a government official, the Secretary of HHS has discretion to provide relief from the late enrollment penalty. However, individuals are not currently informed of the availability of relief. Despite the clear value of statements to the American public, the Social Security Administration (SSA) currently fails to comply with Section 1143 of the Social Security Act in two ways. First, SSA currently only mails statements to individuals age 60 and older who are not receiving Social Security benefits. Second, even among this limited group of seniors, SSA only mails statements to individuals who do not have a mySocialSecurity online account--whether or not they have recently viewed their statement online. A review by SSA's Inspector General, completed at the request of former Social Security Subcommittee Chairman Sam Johnson and Representative Vern Buchanan (R-FL), found that only about two in five individuals with a mySocialSecurity account accessed their statement online in Fiscal Year 2018. Section 101 requires HHS to reimburse SSA for the full costs of SSA's activities related to the notifications. This provision also clarifies that SSA is not relieved of its existing obligation under Section 1143 of the Social Security Act to mail an annual Social Security Statement to all individuals age 25 and older who have covered earnings and are not receiving Social Security benefits. Statements inform Americans about their Social Security benefits, help individuals to plan for their retirement, and allow workers to review and correct their earnings records. This provision also eliminates needless multi-month coverage gaps in Medicare by mandating that Part B insurance begin the first of the month following an individual's enrollment during both the later months of the beneficiary's Initial Enrollment Period (IEP) and during the General Enrollment Period (GEP). Additionally, the provision allows the federal government to create a Part B Special Enrollment Period (SEP) for exceptional circumstances like natural disasters, a provision currently used in Medicare Advantage and Part D when people are not able to sign up for Medicare due to occurrences beyond their control like, such as hurricanes and other natural disasters. Complex Medicare enrollment rules and inadequate notification cause tens of thousands of older adults and people with disabilities to face lifetime fines, coverage gaps, and other harmful consequences. With fewer people automatically enrolled in Medicare--and 10,000 Baby Boomers aging into Medicare each day--more people new to Medicare must actively enroll in the program. Individuals who miss their initial Medicare enrollment window, or who decline Part B coverage, may pay lifetime late enrollment penalties, experience lengthy gaps in outpatient health coverage, or face unaffordable and unexpected out-of-pocket health care costs. In 2018, about 760,000 people with Medicare were paying a Part B Late Enrollment Penalty (LEP) and the average LEP amounted to a nearly 28 percent increase in a beneficiary's monthly premium. According to the Medicare Payment Advisory Commission, ``up to about 20 percent of beneficiaries paying Part B late-enrollment penalties may not have known about the penalties when they turned age 65.''\6\ A bipartisan group of eight former Administrators of the Medicare program support the BENES Act and urged Congress to pass the bill: ``We all agree on the importance of treating Medicare beneficiaries fairly, efficiently, and as helpfully as possible,'' the group said, in an August 2016 letter to the Chairs and Ranking Members of the House and Senate committees of jurisdiction.\7\ --------------------------------------------------------------------------- \6\Report to the Congress: Medicare and the Health Care Delivery System, MedPAC at 4 (June 2019), http://medpac.gov/docs/default-source/ reports/jun19_ch1_medpac_reporttocongress_sec.pdf. \7\CMS Administrators Support Letter of BENES Act, Medicare Rights Center (Aug. 22, 2016), https://www.medicarerights.org/pdf/CMS-Admin- Support-Ltr-BENES-Act-S3236-HR5772-082216.pdf. --------------------------------------------------------------------------- EXPLANATION OF PROVISION Section 101 is substantively similar to H.R. 2477, Beneficiary Enrollment Notification and Eligibility Simplification (BENES) Act of 2019, introduced by Representatives Raul Ruiz (D-CA), Jackie Walorski (R-IN), Brad Schneider (D-IL), and Gus Bilirakis (R-FL). Section 101 directs the federal government to provide advance notice to individuals approaching Medicare eligibility about basic Medicare enrollment rules, mandates that Part B insurance begin the first of the month following an individual's enrollment, and creates a Part B Special Enrollment Period. Beginning in 2021, the Secretary of HHS and the Commissioner of Social Security are required to coordinate to include a Medicare notification as part of the Social Security Statement--which is required to be mailed annually to individuals not yet receiving Social Security benefits--to individuals attaining ages 63, 64 and 65, and to send a similar Medicare notification twice to all SSDI beneficiaries approaching the end of the Medicare waiting period. Going forward, the Committee intends to continue to further develop this provision to ensure that Social Security retirement and survivor beneficiaries approaching age 65 also receive a notification. The notification will include information regarding Medicare benefits, enrollment, late enrollment penalties, the availability of relief from late enrollment penalties under section 1837(h), coordination of benefits, and information for populations for whom there are special considerations. The Secretary and the Commissioner of the SSA shall develop the notice in consultation with representatives of the following groups: individuals who are 60 years of age or older; veterans; individuals with disabilities; individuals with end stage renal disease; low-income individuals and families; employers (including human resources professionals); states (including representatives of State-run Health Insurance Exchanges, Medicaid offices, and Departments of Insurance); State Health Insurance Assistance Programs; health insurers; health insurance agents and brokers; and such other groups as specified by the Secretary. The Committee anticipates that the notification will provide clear and simple information that would be contained on both sides of a single sheet of paper. The Secretary of HHS and the Commissioner of SSA are required to enter into an agreement for HHS to reimburse SSA for the full costs of SSA's activities related to the notifications. Reimbursement will cover not only the costs of developing, printing, and mailing the notifications but also costs related to increased visits to SSA's field offices and increased calls to SSA's national 1-800 number from people who have questions about the notifications. This section also clarifies that SSA is not relieved of its existing obligation under Section 1143 of the Social Security Act to physically mail an annual Social Security Statement to all individuals age 25 and older who have covered earnings and are not receiving Social Security benefits. The Committee expects that SSA will resume compliance with Section 1143 by mailing annual Statements to all individuals age 25 and older, regardless of whether or not an individual has a mySocialSecurity online account. Also beginning in 2021, the bill mandates that Part B insurance begin the first of the month following an individual's enrollment. Effective upon enactment, there will also be a SEP for ``exceptional circumstances,'' such as hurricanes and other natural disasters, to mirror authority in Medicare Advantage and Medicare Part D. EFFECTIVE DATE The provision applies for statements mailed or notices provided two years after the date of enactment; effective for changes to enrollment periods and effective date of coverage on November 1, 2021. Section 102. Extension of Funding Outreach and Assistance for Low Income Programs PRESENT LAW The Administration for Community Living administers federal grant programs that fund outreach and assistance to older adults, individuals with disabilities, and their caregivers in accessing various health and social services. Funding for these programs is provided through discretionary budget authority in annual appropriations to the following entities: SHIPs; Area Agencies on Aging (AAA); and Aging and Disability Resource Centers (ADRCs). The National Center for Benefits and Outreach Enrollment assists organizations to enroll older adults and individuals with disabilities into benefit programs that they may be eligible for, such as Medicare, Medicaid, the Supplemental Security Income program, and the Supplemental Nutrition Assistance Program, among others. In addition to discretionary funding for these programs, beginning in fiscal year (FY) 2009, Section 119 of the Medicare Improvements for Patients and Providers Act (MIPPA; P.L. 110- 275) provided mandatory funding for specific outreach and assistance activities to Medicare beneficiaries. This mandatory funding was extended multiple times, most recently in the Bipartisan Budget Act of 2018 (BBA 2018; P.L. 115-123) through FY 2019 and provided for outreach and assistance to low-income Medicare beneficiaries including those who may be eligible for the Low-Income Subsidy (LIS) program, Medicare Savings Program, and the Medicare Part D Prescription Drug Program. The Secretary of the Department of Health and Human Services (HHS) is required to transfer specified amounts for MIPPA program activities from the Medicare Hospital Insurance (HI) and Supplementary Medical Insurance (SMI) Trust Funds. REASONS FOR CHANGE The BETTER Act aims to improve existing law by extedning funding for the State Health Insurance Program (SHIP), Area Agencies on Aging (AAA), and Aging and Disability Resource Centers (ADRCs), and the National Center for Benefits and Outreach Enrollment counselors for three years, until Fiscal Year (FY) 2022, and increases that funding to $50 million a year. These counselors help Medicare beneficiaries with enrollment and appeals questions with traditional Medicare, Medicare Advantage, and Part D drug coverage. EXPLANATION OF PROVISION Section 102 is substantively similar to H.R. 3421, the Enhancing Consumer Assistance for Medicare Beneficiaries Act, introduced by Representatives Jimmy Gomez (D-CA), Vern Buchanan (R-FL), and Debbie Dingell (D-MI). Section 102 increases funding for programs that assist Medicare beneficiaries to $50,000,000 per year and extends that funding through Fiscal Year (FY) 2022. Effective FY 2020, there will be a three-year extension of the $15,000,000 per year allocated to the State Health Insurance Assistance Programs through FY 2022. In addition, there will be three years of additional funding at $15,000,000 per year to support the Area Agencies on Aging, three years of additional funding at $15,000,000 per year to support a contract with the National Center for Benefits and Outreach Enrollment, and three years of funding at $5,000,000 per year to support a contract with the Aging and Disability Resource Centers. EFFECTIVE DATE The provision applies beginning FY 2020. Section 103. Medicare Coverage of Certain Mental Health Telehealth Services PRESENT LAW In general, certain telehealth services can be provided to Medicare beneficiaries under Parts A and B, although a separate payment for telehealth services may apply in certain situations. Under current law, the term ``telehealth service'' means professional consultations, office visits, and office psychiatry services (identified as of July 1, 2000 by Healthcare Common Procedure Coding System (HCPCS) codes) and as subsequently modified by the HHS Secretary. Under Part A, telehealth services may be used to treat hospital inpatients, but there is no statutory authority for a separate payment under the Medicare hospital Inpatient Prospective Payment System (IPPS). Although no payment is involved, the CMS guidance for Part A explicitly identifies telehealth as an alternative to face-to-face encounters when a physician writes an order for home health services. Under Part B, payments for telehealth services must follow SSA Section 1834(m), which places restrictions on the location, provider, telehealth technology, and certain other parameters. The facility where the beneficiary is located is referred to as the originating site, and the site where the practitioner is located is referred to as the distant site. Medicare makes a payment to the physician or practitioner at the distant site for rendering the telehealth service, and a separate facility fee to the originating site. SSA Section 1834(m) requires that the originating site meet one of three conditions: telehealth service originating sites must be located in a rural health professional shortage area or a county not included in a Metropolitan Statistical Area (MSA), or from an entity that participates in a federal telemedicine demonstration project. Qualifying originating sites include an office of a physician or practitioner, a critical access hospital (CAH), a rural health clinic, a federally qualified health center, a hospital, a hospital- or CAH-based renal dialysis center, a skilled nursing facility, or a community mental health center. Under Part C, MA plans must provide telehealth services to the extent that they are a covered service under Medicare Part B. BBA 2018 expanded telehealth under Medicare in four ways: (1) by increasing the opportunities for certain accountable care organization (ACO) and Medicare shared savings models to receive telehealth payments, beginning January 1, 2020; (2) by eliminating the originating site restrictions for telehealth services for acute stroke evaluation, beginning January 1, 2019; (3) by allowing MA plans to provide additional telehealth benefits (minus capital and infrastructure costs), which are treated as if they are benefits required under original Medicare (Parts A and B) for payment purposes starting in plan year 2020; and (4) by permitting Medicare patients with end- stage renal disease on home dialysis to receive monthly clinical assessments at home or at freestanding dialysis facilities via telehealth, beginning January 1, 2019. Section 2001 of the SUPPORT Act (P.L.115-271) further amended SSA Section 1834(m) to eliminate the geographic originating site requirements listed above for telehealth services furnished for treating substance use disorder (SUD) and co-occurring mental health disorders. In order to receive a facility fee for SUD telehealth services, the originating site must be one of the qualifying originating sites listed above (excluding freestanding dialysis facilities). The provision also added the home of an individual as a permissible originating site for SUD telehealth services; however, facility fees do not apply to originating sites from homes. Although the provision states that the amendments in this section are to take effect beginning July 1, 2019, the HHS Secretary was given the authority to implement the modifications by interim final rule and did so. REASONS FOR CHANGE The BETTER Act expands mental health telehealth services, improving access to critical care that can help improve mental health as beneficiaries age. This provision would benefit patients in rural and urban areas alike, expanding access to a service with well-documented gaps in access to care. This provision removes certain restrictions around the provision of mental health telehealth in Medicare for specific medical billing codes, allowing reimbursement for telehealth services outside of rural geographies and demonstration pilots. The provision also requires an initial in-person assessment. Ultimately, the goal of the provision is to use telehealth to increase access to mental health services for Medicare beneficiaries. Nothing in this provision is intended to amend state laws affecting access to telemedicine services. EXPLANATION OF PROVISION Section 103 is substantively similar to H.R. 1301, The Mental Health Telemedicine Expansion Act, introduced by Representatives Suzan DelBene (D-WA), Tom Reed (R-NY), Adrian Smith (R-NE), Terri Sewell (D-AL), Mike Kelly (R-PA), David Schweikert (R-AZ), and Jackie Walorski (R-IN). Section 103 removes certain restrictions around mental health telehealth and allows payment for telehealth services regardless of its originating site. Effective January 1, 2021, Medicare will pay for certain mental health telehealth services without geographic restrictions and outside of pilot demonstrations. The section also lifts originating site restrictions, eliminates facility fees at originating sites, and makes the patient's home an originating site for mental health telehealth services. Finally, payments will be limited to services provided after an initial face-to-face assessment with occasional face-to-face reassessments. EFFECTIVE DATE The provision applies beginning on January 1, 2021 Section 104. Requiring Prescription Drug Plan Sponsors to Include Real- Time Benefit Information as Part of Such Sponsor's Electronic Prescription Program Under the Medicare Program PRESENT LAW Under Medicare Part D, private insurers and other plan sponsors enter into annual contracts with CMS to provide a defined package of outpatient drug benefits in some or all of 34 Part D regions and U.S. territories. There is no central formulary in Part D, but each plan must cover at least two drugs in each class and category and substantially all drugs in six protected classes. There is wide variation among Part D plans in regard to specific formulary drugs, prescription cost- sharing amounts, and utilization management requirements (e.g., prior authorization or quantity limits). As part of program requirements, Part D plans must support an electronic prescription (e-prescribing) program, which is defined by CMS as the use of electronic media to transmit prescription or prescription-related information between a prescriber, dispenser, pharmacy benefit manager, and/or health plan, either directly or through an intermediary, including an e-prescribing network. Technical transmission requirements for e-prescribing networks are based on standards set by the National Council for Prescription Drug Programs (NCPDP SCRIPT) and other outside organizations. E-prescribing is optional for physicians and pharmacies; however, physicians and pharmacies that choose to transmit e-prescriptions and related communications with Part D plans must comply with CMS standards. CMS also requires Part D plan sponsors and prescribers to convey electronic formulary and benefits information amongst themselves using NCPDP Formulary and Benefits Standard Implementation Guides, referred to as F&B. Part D e-prescribing standards are updated periodically to account for new technology or to respond to statutory requirements. In May 2019 CMS issued final regulations at 42 C.F.R. 423.160(b)(7) requiring Part D sponsors, no later than January 1, 2021, to implement one or more electronic real-time benefit tools (RTBT). According to CMS, the existing NCPDP SCRIPT standard allows prescribers to conduct electronic prescribing, while the F&B standard allows prescribers to see what drugs are on a plan's formulary, but neither of the standards provides patient-specific, real-time cost or coverage information, such as formulary requirements or utilization management data, at the point of prescribing. The RTBT data would be used in conjunction with existing systems to provide a more complete view of a beneficiary's prescription benefit. Specifically, the May 2019 regulations require Part D plans to have one or more RTBT systems capable of integrating with at least one prescriber's e-prescribing or electronic health record (EHR) system. Data to be provided through the RTBT regarding individual plan formularies include information on enrollee cost-sharing; clinically appropriate formulary alternatives, when available; and the utilization management requirements applicable to each drug. REASONS FOR CHANGE Currently, when health care providers prescribe drugs, they do not know how much the patient will have to pay out-of- pocket. Doctors, other prescribers, and patients want current and reliable information about patients' out-of-pocket costs so they can consider potential alternative therapies when determining a course of treatment. Title I codifies and expands the Administration's proposal for a real-time drug benefit tool, which gives doctors and Medicare beneficiaries information about how much a patient will pay for a drug while they are in the doctor's office. This section provides health care providers with real-time benefit and copay information when prescribing drugs. This type of transparency will arm patients and their health care providers with information that can lower Medicare beneficiaries' costs at the pharmacy counter. EXPLANATION OF PROVISION Section 104 is substantively similar to H.R. 3408 and H.R. 3415 introduced by Representatives Jodey Arrington (R-TX), Pete Olson (R-TX), and Elissa Slotkin (D-MI), respectively. This section codifies and expands a rule to require Part D prescription drug plans to create a real-time benefit tool that gives providers access to individual-specific formulary and benefit information under a prescription drug plan to inform patients of their actual out-of-pocket costs for a prescription. No later than January 1, 2021, prescription drug plans under the Medicare program will be required to provide for the real-time electronic transmission to prescribing health care professionals. This tool must use technology capable of integrating with providers' electronic prescribing or electronic health record systems and must be able to provide individual-specific formulary and benefit information. Information provided through this tool must include: a description of clinically appropriate alternatives, information about cost-sharing requirements (including cost variations at the pharmacy level), and information about prior authorization requirements and any alternatives within the formulary. EFFECTIVE DATE The provision applies no later than January 1, 2021 Section 105. Transitional Coverage and Retroactive Medicare Part D Coverage for Certain Low-Income Beneficiaries PRESENT LAW There is no means test for enrollment in Medicare Part D, but individuals who meet specified income and assets thresholds are eligible for the Low-Income Subsidy (LIS), which covers a greater share of out-of-pocket spending for those individuals, including premiums and prescription cost-sharing. The actual amount of LIS assistance varies based on an enrollee's assets and income and whether a beneficiary is institutionalized or is receiving community-based care. Full-subsidy LIS enrollees, including enrollees who qualify for Medicare and full Medicaid benefits (dual eligible) or Supplemental Security Income (SSI), have no deductible, minimal cost-sharing for prescription drugs, and a cap on annual out-of-pocket spending. Partial- subsidy-eligible LIS enrollees, meaning individuals with assets below set thresholds and income up to 150 percent of the federal poverty level (FPL) also receive additional Part D subsidies, but have higher prescription cost sharing than full- LIS enrollees. Under the process for obtaining LIS benefits, there must first be a determination that an individual meets the thresholds for LIS assistance. Next, the individual must be enrolled in a Part D plan. Over the years, advocates have expressed concerns about gaps in coverage for individuals who qualify for the LIS but are not yet covered by a Part D plan. To address the situation, HHS in 2010 authorized a pilot program, the Limited Income Newly Eligible Transition (LI NET), to provide immediate temporary Part D coverage for LIS individuals. LI NET provides drug coverage for up to two months until an LIS-eligible individual is covered in a Part D plan, as well as up to 36 months retroactive coverage for full- subsidy LIS and SSI-only beneficiaries, in cases where their SSI or dual eligibility is retroactive. LI NET coverage, currently provided through health insurer Humana, reimburses pharmacies for all Part D-covered drugs. CMS can automatically enroll full subsidy and SSI beneficiaries into LI NET. Individuals can also qualify for LI NET benefits by filing for coverage at a pharmacy or submitting a receipt for a past prescription that was paid out-of-pocket. For LI NET participants, enrollment in a standard Part D plan takes effect on the first day of the month after the month that follows LI NET enrollment. REASONS FOR CHANGE The legislation makes permanent a CMS demonstration that protects low-income Medicare beneficiaries in the Part D drug program. Section 105 codifies the program as it is currently administered, outlining specified purposes within which the Secretary retains discretion over LI NET Program benefit design (i.e., access to an open formulary and a prohibition on network pharmacy restrictions). The provision also grants the Secretary new authority to waive requirements of Titles XI and XVIII of the Social Security Act, as necessary, to administer the LI NET Program. EXPLANATION OF PROVISION Section 105 is substantively similar to H.R. 3029, The Improving Low-Income Access to Prescription Drugs Act of 2019, introduced by Representatives Pete Olson (R-TX), Nanette Diaz Barragan (D-CA), Kenny Marchant (R-TX), and John Lewis (D-GA). Section 105 would make the Medicare Limited Income Newly Eligible Transition (LI NET) Program a permanent part of Medicare Part D. Beginning January 1, 2021, the LI NET Program will transition into a permanent program for Medicare beneficiaries who are not currently enrolled in a prescription drug plan but who have full Medicaid benefits, receive supplemental security income (SSI), are eligible for the Medicare Savings Program, or are otherwise eligible for the Part D low-income subsidy program. Eligible beneficiaries will be automatically enrolled into LI NET, gain immediate access to coverage at the point-of- sale, or be reimbursed for out-of-pocket costs incurred during eligible periods of time. For Medicare beneficiaries receiving full Medicaid benefits or SSI, LI NET offers retroactive coverage of 30 days to 36 months. Partial duals and those eligible for the low-income subsidy (LIS) may receive retroactive coverage dating to the first day of the month when they were determined eligible. The Secretary retains discretion over the LI NET Program benefit design, including access to an open formulary and a prohibition on network pharmacy restrictions. EFFECTIVE DATE The provision applies beginning on January 1, 2021 B. Title II: Rural and Quality Improvements Section 201. Medicare GME Treatment of Hospitals Establishing New Medical Residency Training Programs After Hosting Medical Resident Rotators for Short Durations PRESENT LAW SSA Section 1886(h) requires the HHS Secretary to make Medicare Graduate Medical Education (GME) payments to hospitals for the Medicare share of direct and indirect costs of an approved medical residency training program in allopathic or osteopathic medicine, dentistry, and podiatry. Direct costs include resident stipends, supervisory physician salaries, and administrative costs. Indirect costs associated with residency programs relate to the higher patient care costs in teaching hospitals relative to non-teaching hospitals. Medicare GME payments for training residents in allopathic and osteopathic medicine are subject to a hospital-specific limit or ``cap'' on the number of full-time equivalents (FTEs). The FTE cap is based on the number of FTE residents that a hospital was training in the base year, which is the hospital's most recent cost reporting period ending on or before December 31, 1996. Medicare also limits the amount it pays for each FTE--the per resident amount (PRA)--based on a hospital's costs for a resident FTE in a base period which is FY 1984, updated by the Consumer Price Index for All Urban Consumers (CPI-U). A hospital may have a Medicare PRA and FTE cap even if it did not have an approved medical residency program during the FTE cap or PRA base periods. This can happen when a hospital hosts a rotating resident from another hospital's approved medical residency program. Medicare regulations establish the PRA based on a hospital's first cost reporting period during which residents are on duty in either a new or existing residency program; the FTE cap is established when a hospital begins training residents in a new residency program. Under these requirements, the key to ``triggering'' a PRA or FTE cap for a hospital is based on where the resident is physically located during training, not whether the hospital that the resident trains in has an approved residency program. REASON FOR CHANGE Currently, Medicare is the primary payer for GME in the United States, paying for more than two-thirds of the public funding for residency training. Medicare GME payments to hospitals are not open-ended; rather, these payments are capped based on the number of residents the hospitals trained in a base year. Hospitals that are starting new residencies establish a new cap over a period of five years. However, there is a technicality in which a hospital may still have a GME cap even if the hospital never had an approved teaching program. This situation arises when a hospital has a resident rotate through another hospital's teaching program. If a hospital had a rotator, then the hospital triggers a new cap under Medicare's rules. This provision fixes this technicality. The BETTER Act helps rural and community hospitals that have technical barriers preventing them from starting a GME program to train physicians and help reduce the physician shortage. EXPLANATION OF PROVISION Section 201 is substantively similar to H.R. 3425, the Advancing Medical Resident Training in Community Hospitals Act of 2019, introduced by Representatives Ron Kind (D-WI) and George Holding (R-NC). Section 201 establishes new rules for allocation of GME slots for hospitals that establish a new medical residency training program after hosting medical resident rotations for a short period of time. Starting with the cost reporting period beginning on or after the date of enactment, hospitals that begin a new approved medical residency training program will not have their full-time equivalent (FTE) resident amount set until the program has trained at least 1.0 FTE resident in a single cost reporting period. For hospitals that have been limited to less than one FTE resident before October 1997 or fewer than three FTE residents between October 1997 and the date of enactment of this section, they will be able to re-establish their capped resident slots through Medicare. These hospitals must begin to re-establish their caps within five years of the date of enactment. EFFECTIVE DATE The provision applies for cost reporting periods beginning on or after the date of enactment. Section 202. Extension of the Work Geographic Index Floor Under the Medicare Program PRESENT LAW Payments under the Medicare physician fee schedule (MPFS) are adjusted geographically for three factors to reflect differences in the cost of resources needed to produce physician services: physician work, practice expense, and medical malpractice insurance. The geographic adjustments are indices--known as Geographic Practice Cost Indices (GPCIs)-- that reflect how each area compares to the national average in a ``market basket'' of goods. A value of 1.00 represents the average across all areas. These indices are used in the calculation of the payment rate under the MPFS. Several laws have established a minimum value of 1.00 (floor) for the physician work GPCI for localities where the work GPCI was less than 1.00. Most recently, Section 50201 of BBA 2018 extended the physician work GPCI floor through December 31, 2019. REASON FOR CHANGE The legislation extends the floor on the Medicare Geographic Payment Cost Indices (GPCI), which protects physicians in rural areas from receiving reductions in Medicare payments. Extending this provision prevents cuts in Medicare payments for physician practices in communities under the 1.0 work GPCI floor that are paid through the Medicare Physician Fee Schedule. Such potential decreases could harm beneficiaries' access to care in these communities. The GPCI floor expires on December 31, 2019. EXPLANATION OF PROVISION Section 202 is substantively similar to H.R. 3302, the Keeping Physicians Serving Patients Act of 2019, introduced by Representatives Abby Finkenauer (D-IA), Adrian Smith (R-NE), Ron Kind (D-WI), Terri Sewell (D-AL), and Darin LaHood (R-IL). Section 202 extends the work GPCI floor of 1.00 through December 31, 2022. EFFECTIVE DATE The provision applies beginning on January 1, 2020 Section 203. Extension of Funding for Quality Measure Endorsement, Input, and Selection Under Medicare Program PRESENT LAW Under section 1890 of the Social Security Act Section, the HHS Secretary is required to have a contract with a consensus- based entity (e.g., NQF) to carry out specified duties related to performance improvement and measurement. These duties include, among others, priority setting, measure endorsement, measure maintenance, and annual reporting to Congress. SSA Section 1890A requires the Secretary to establish a pre- rulemaking process to select quality measures for use in the Medicare program, including consideration of NQF's endorsement of measures. As part of this process, the consensus-based entity with a contract gathers multi-stakeholder input and annually transmits that input to the Secretary. The Secretary makes available to the public measures under consideration for use in Medicare quality programs and broadly disseminates the quality measures that are selected to be used. Through its Measure Applications Partnership (MAP), the NQF has been convening multi-stakeholder groups to provide input into the selection of quality measures for use in Medicare and other federal programs. The MAP publishes annual reports with recommendations for selection of quality measures in February of each year, with the first report published in February 2012. REASON FOR CHANGE The legislation extends funding for NQF for three years, until FY 2022, ensuring a continuation of NQF's critical work on quality measures in the Medicare program; it also prioritizes endorsement of quality measures around maternal morbidity and mortality and allows NQF to provide input on the removal of quality measures. This is based on H.R. 3430, which amends title XVIII of the Social Security Act to extend funding for quality measure endorsement, input, and selection under the Medicare program introduced by Representatives Judy Chu (D-CA) and David Schweikert (R-AZ). NQF works with diverse stakeholders to create consensus-based measures to use in quality evaluation in the Medicare program. These measures are constantly reviewed, updated, and added as Medicare priorities and quality requirements change. Quality measures are important indicators for patients and providers to determine the extent to which care delivered to patients is appropriate and effective. In Medicare, quality measures are used for public information and feedback as well as for payment purposes. The Committee encourages CMS to seriously consider NQF's future recommendations on measure removal in the interest of streamlining quality measurement, avoiding duplication of measurement, focusing more on outcomes-based measures than process measures, and generally reducing burdens on health care providers. EXPLANATION OF PROVISION Section 203 is substantively similar to H.R. 3430, To amend title XVII of the Social Security Act to extend funding for quality measure endorsement, input, and selection under the Medicare program, introduced by Representatives Judy Chu (D-CA) and David Schweikert (R-AZ). Section 203 extends funding for quality measure endorsement through FY 2022, provides authority for the contractor to provide input on the removal of measures, and adds a prioritization of measures relating to maternal morbidity and mortality. Funding is maintained at $30,000,000 per year for FY 2020 through 2022. The contracted entity may provide input on the removal of quality and efficiency measures to the Secretary. From the time of enactment through December 31, 2023, the Secretary shall prioritize the endorsement of measures relating to maternal morbidity and mortality by the contracted entity. EFFECTIVE DATE The provision applies beginning FY 2020. Section 204. Improving Measurements Under the Skilled Nursing Facility Value-Based Purchasing Program Under the Medicare Program PRESENT LAW Most federally certified skilled nursing facilities (SNFs) are paid under a prospective payment system (PPS) for providing qualified services to Medicare beneficiaries. The Protecting Access to Medicare Act\8\ (PAMA; P.L. 113-93) amended SSA Section 1888 to require the HHS Secretary to specify two quality measures and to revise the SNF PPS by adding a value- based component to provide incentive payments for quality care provided to beneficiaries, beginning in FY 2019. --------------------------------------------------------------------------- \8\Protecting Access to Medicare Act of 2014, Pub. Law No. 113093 (Apr. 1, 2014), https://www.congress.gov/113/plaws/publ93/PLAW- 113publ93.pdf. --------------------------------------------------------------------------- Specifically, the Secretary was required to specify two SNF quality measures related to hospital readmissions: 1. A SNF all-cause, all-condition hospital readmission measure (referenced hereafter as ``Measure 1''); and 2. A SNF all-condition, risk-adjusted potentially- preventable hospital readmission measure (referenced hereafter as ``Measure 2''). The Secretary was also required to establish a SNF Value- Based Purchasing (VBP) program to adjust SNF payments for services furnished on or after October 1, 2018 as follows:Value-based payments awarded to high- performing SNFs are funded through a portion of a two percent reduction in Medicare per diem payments applied to all Medicare-covered SNF days; Subject to the Secretary's discretion, between 50 and 70 percent of the amount collected by the two percent reduction is allocated to value-based payments; and The lowest-performing 40 percent of SNFs receive a reduction in their Medicare SNF per diem payment rates (i.e., any value-based payment add-on cannot exceed the amount of the two percent reduction). For purposes of determining the value-based payment a SNF receives, the enactment of PAMA required the Secretary to use Measure 2 ``as soon as practicable.'' In lieu of adopting Measure 2, the Secretary is required to use the SNF all-cause, all-condition hospital readmission measure for ranking facilities (Measure 1). In August 2018, CMS issued a rule that finalized the SNF PPS for FY2019, including the use of Measure 1 for determining value-based payments made under the VBP program. To date, the Secretary has not yet implemented Measure 2. REASONS FOR CHANGE The legislation improves the SNF VBP by allowing the Secretary of the Department of Health and Human Services to add up to 10 additional measures to evaluate care provided to Medicare beneficiaries in SNFs. Under current law, the Secretary can only evaluate care based on readmission quality measures, which does not provide a complete picture of all value and quality in this setting. This is based on H.R. 3406, which amends title XVIII of the Social Security Act to improve measurements under the skilled nursing facility value-based purchasing program under the Medicare program, and for other purposes, introduced by Chairman Richard E. Neal (D-MA) and Ranking Member Kevin Brady (R-TX). Moreover, to improve both patient outcomes and the Medicare program, the Committee is interested in pursuing a unified prospective payment system for post-acute care services, which could include a value-based payment program. To help achieve that goal, the legislation requires the Medicare Payment Advisory Commission to complete a report no later than March 15, 2021, establishing and analyzing a prototype value-based payment program under a unified prospective payment system for post-acute care services. The Committee recognizes that adequate time is often needed for providers to adapt and implement changes in clinical practices and operations to improve care addressed by new quality measures and expects the Secretary to implement changes to this program in a manner consistent with how other value- based purchasing programs have been managed to ensure there is sufficient time to receive feedback and analysis from stakeholders on the reliability and validity of new measures. The Committee recommends that CMS align measures (to the extent that such alignment may still inspire quality improvement) with other measures used by CMS programs to maximize the incentive to achieve improvement throughout the Medicare program. The Committee has suggested ``patient experience'' as a potential measure to include. However, recognizing the cost and staff time required to administer and implement satisfaction surveys, the Committee encourages CMS to increase reliance on independent, auditable measures in the Quality Measure domain on the Nursing Home Compare website such as Medicare claims and payroll-based journal (PBJ) data. The Committee recommends that the Secretary take under consideration the longstanding goals of attaining a unified post-acute care payment system and the provisions included in the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 while implementing this legislation. In completing its report to Congress, the Committee recommends that the Medicare Payment Advisory Commission explore potential interactions between a unified post-acute care payment system (e.g., a prospective payment system for all post-acute care services) and a post-acute care value-based payment program, while recognizing that a post-acute care value-based payment program would be a component of a unified post-acute care payment system. EXPLANATION OF PROVISION Section 204 is substantively similar to H.R. 3406, the Improving Measurement Under the SNF Value-Based Purchasing Program of 2019, introduced by Chairman Richard E. Neal (D-MA) and Ranking Member Kevin Brady (R-TX). This section allows the Secretary to apply additional measures to the performance evaluation portion of the SNF VBP. Effective for payment of services furnished on or after October 1, 2022, the Secretary may add no more than 10 quality measures, including measures of functional status, patient safety, care coordination, or patient experience, to the SNF VBP for facilities with more than the required minimum number of cases. The validation of the submitted data will be supported by $5,000,000 per year from the Centers for Medicare & Medicaid Services Program Management Account for FY 2022- 2024. The Medicare Payment Advisory Commission is required to complete a report no later than March 15, 202, establishing and analyzing a prototype value-based payment program under a unified prospective payment system for post-acute care services. EFFECTIVE DATE The provision applies beginning on or after October 1, 2022. III. VOTES OF THE COMMITTEE In compliance with clause 3(b) of rule XIII of the Rules of the House of Representatives, the following statement is made concerning the vote of the Committee on Ways and Means in its consideration of H.R. 3417, the BETTER Act, on June 26, 2019. The Chairman's amendment in the nature of a substitute was adopted by a voice vote (with a quorum being present). The bill, H.R. 3417, was ordered favorably reported as amended by 41-0 roll-call vote (with a quorum being present). The vote was as follows: ---------------------------------------------------------------------------------------------------------------- Representative Yea Nay Present Representative Yea Nay Present ---------------------------------------------------------------------------------------------------------------- Mr. Neal...................... X ......... ......... Mr. Brady....... X ......... ......... Mr. Lewis..................... X ......... ......... Mr. Nunes....... X ......... ......... Mr. Doggett................... X ......... ......... Mr. Buchanan.... X ......... ......... Mr. Thompson.................. X ......... ......... Mr. Smith (NE).. X ......... ......... Mr. Larson.................... X ......... ......... Mr. Marchant.... X ......... ......... Mr. Blumenauer................ X ......... ......... Mr. Reed........ X ......... ......... Mr. Kind...................... X ......... ......... Mr. Kelly....... X ......... ......... Mr. Pascrell.................. X ......... ......... Mr. Holding..... X ......... ......... Mr. Davis..................... X ......... ......... Mr. Smith (MO).. X ......... ......... Ms. Sanchez................... X ......... ......... Mr. Rice........ X ......... ......... Mr. Higgins................... X ......... ......... Mr. Schweikert.. X ......... ......... Ms. Sewell.................... X ......... ......... Ms. Walorski.... ........ ......... ......... Ms. DelBene................... X ......... ......... Mr. LaHood...... X ......... ......... Ms. Chu....................... X ......... ......... Mr. Wenstrup.... X ......... ......... Ms. Moore..................... X ......... ......... Mr. Arrington... X ......... ......... Mr. Kildee.................... X ......... ......... Mr. Ferguson.... X ......... ......... Mr. Boyle..................... X ......... ......... Mr. Estes....... X ......... ......... Mr. Beyer..................... X ......... ......... Mr. Evans..................... X ......... ......... Mr. Schneider................. X ......... ......... Mr. Suozzi.................... X ......... ......... Mr. Panetta................... X ......... ......... Ms. Murphy.................... X ......... ......... Mr. Gomez..................... X ......... ......... Mr. Horsford.................. X ......... ......... ---------------------------------------------------------------------------------------------------------------- IV. BUDGET EFFECTS OF THE BILL A. Committee Estimate of Budgetary Effects In compliance with clause 3(d) of rule XIII of the Rules of the House of Representatives, the following statement is made concerning the effects on the budget of the bill, H.R. 3417, as reported. The Committee agrees with the estimate prepared by the Congressional Budget Office (CBO), which is included below. B. Statement Regarding New Budget Authority and Tax Expenditures Budget Authority In compliance with clause 3(c)(2) of rule XIII of the Rules of the House of Representatives, the Committee states that the bill involves no new or increased budget authority. The Committee states further that the bill involves no new or increased tax expenditures. C. Cost Estimate Prepared by the Congressional Budget Office In compliance with clause 3(c)(3) of rule XIII of the Rules of the House of Representatives, requiring a cost estimate prepared by the CBO, the following statement by CBO is provided. [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] The bill would Accelerate the starting date for coverage of some new Medicare enrollees Expand the availability of telehealth services for mental health care Allow certain hospitals to reset their graduate medical education (GME) caps Provide higher payments to Medicare physicians in rural areas Estimated budgetary effects would primarily stem from Increased costs for new Medicare enrollees Expansion of telehealth services Increased numbers of GME positions at certain hospitals Higher Medicare payments to physicians in rural areas Areas of significant uncertainty include Estimating the increased demand for telehealth mental health care services and projecting the number of providers available to meet that need Projecting the number of GME positions created under the new caps Bill summary: H.R. 3417 would accelerate the start date for coverage of certain new enrollees; expand the availability of certain telehealth services; allow certain hospitals to increase the number of residents in graduate medical education programs for which Medicare provides funding; increase Medicare payments to physicians in rural areas; and extend several expiring programs under Medicare. Estimated Federal cost: The estimated budgetary effect of H.R. 3417 is shown in Table 1. The costs of the legislation fall within budget function 570 (Medicare). TABLE 1.--ESTIMATED BUDGETARY EFFECTS OF H.R. 3417 -------------------------------------------------------------------------------------------------------------------------------------------------------- By fiscal year, millions of dollars-- ------------------------------------------------------------------------------------------- 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2020-2024 2020-2029 -------------------------------------------------------------------------------------------------------------------------------------------------------- Increases in Direct Spending Title I, Patient Improvements Section 101. Beneficiary Enrollment Notification and Eligibility Simplification Estimated Budget Authority.............................. 0 20 35 40 40 45 45 50 55 50 135 375 Estimated Outlays....................................... 0 20 35 40 40 45 45 50 55 50 135 375 Section 102. Extension of Funding Outreach and Assistance for Low-Income Programs Estimated Budget Authority.............................. 50 50 50 0 0 0 0 0 0 0 150 150 Estimated Outlays....................................... 45 50 50 5 0 0 0 0 0 0 150 150 Section 103. Medicare Coverage of Certain Mental Health Telehealth Services Estimated Budget Authority.............................. 0 5 15 30 55 105 145 185 235 250 105 1,025 Estimated Outlays....................................... 0 5 15 30 55 105 145 185 235 250 105 1,025 Title II, Rural and Quality Improvements Section 201. Medicare GME Treatment of Hospitals Establishing New Medical Residency Training Programs After Hosting Medical Resident Rotators for Short Durations Estimated Budget Authority.............................. 0 0 1 5 14 29 42 44 47 49 20 230 Estimated Outlays....................................... 0 0 1 5 14 29 42 44 47 49 20 230 Section 202. Extension of the Work Geographic Index Floor Under the Medicare Program Estimated Budget Authority.............................. 230 590 655 235 0 0 0 0 0 0 1,710 1,710 Estimated Outlays....................................... 230 590 655 235 0 0 0 0 0 0 1,710 1,710 Section 203. Extension of Funding for Quality Measure Endorsement, Input, and Selection Under Medicare Program Estimated Budget Authority.............................. 30 30 30 0 0 0 0 0 0 0 90 90 Estimated Outlays....................................... 29 30 30 1 0 0 0 0 0 0 90 90 Total Changes in Direct Spending Estimated Budget Authority.................................. 304 695 791 316 114 179 237 279 337 354 2,220 3,605 Estimated Outlays........................................... 304 695 791 316 114 179 237 279 337 354 2,220 3,605 -------------------------------------------------------------------------------------------------------------------------------------------------------- Components may not sum to totals because of rounding; GME = graduate medical education. Basis of estimate: For this estimate, CBO assumes that the bill will be enacted near the end of 2019. Direct spending: CBO estimates that enacting H.R. 3417 would increase direct spending for Medicare by $3.6 billion over the 2020-2029 period. Title I, Patient improvements. Title I would accelerate the start date for certain new enrollees, provide funding for certain agencies and programs that provide education and support to Medicare beneficiaries with low income, and expand coverage of mental health services furnished via telehealth. Section 101, Beneficiary Enrollment Notification and Eligibility Simplification. Section 101 would accelerate the start date for coverage of beneficiaries who enroll in the program during the general enrollment period (January through March of each year) or during the final three months of the initial enrollment period (when a beneficiary first becomes eligible to enroll); some of those enrollees would receive services sooner than is possible under current law. Based on historical enrollment data, CBO estimates that about 3 percent of new enrollees would receive Medicare benefits sooner than under current law. These additional months of Medicare coverage would increase direct spending by $375 million over the 2019-2029 period. Section 102, Extension of Funding Outreach and Assistance for Low-Income Programs. Section 102 would provide $50 million in annual funding for fiscal years 2020 through 2022 for certain agencies and programs that provide education and support to Medicare beneficiaries with low income. Those entities are the State Health Insurance Assistance Programs, Area Agencies on Aging, Aging and Disability Resource Centers, and the National Center for Benefits and Outreach Enrollment. CBO estimates that enacting this section would cost $150 million over the 2019-2029 period. Section 103, Medicare Coverage of Certain Mental Health Telehealth Services. Current law limits provision of covered telehealth mental health services to people in rural areas, and those beneficiaries must receive such services onsite in a medical facility. Section 103 would eliminate the geographic and originating-site requirements for providing mental health telehealth services. The bill would require an initial face-to- face assessment by a provider before telehealth psychotherapy could begin, and it would mandate periodic in-person reassessments. Under section 103, beneficiaries could receive telehealth mental health services at home. Under current law, since the use of mental health telehealth services is limited to rural areas and provided in a medical facility, the current use of these services is low. Because the provision would allow rural and urban beneficiaries to access services at home, CBO estimates that demand could increase substantially over the next five years. However, the ability to meet the demand for those services would depend on the supply of mental health practitioners. The Bureau of Labor Statistics projects growth in the mental health professions over the next few years, but CBO estimates that demand for services would still outstrip supply. Given those constraints, CBO estimates that expanding mental health telehealth to urban and rural beneficiaries at home would add an additional 150,000 visits in 2021 and Medicare would pay $73 per visit on average, depending on the length of the visit and the type of provider. CBO estimates that enacting section 103 would increase direct spending by $1 billion over the 2019-2029 period. Title II, Rural and Quality Improvements. Title II would increase the number of residents trained in GME programs for which Medicare provides funding, increase payment rates for physicians in rural areas, and extend several expiring programs. Section 201, Medicare GME Treatment of Hospitals Establishing New Medical Residency Training Programs After Hosting Medical Resident Rotators for Short Durations. After the Medicare residency caps were established in the Balanced Budget Act of 1997, some non- teaching hospitals were assigned such caps based on the presence of residents who rotated from teaching hospitals that year. But the caps also limit the number of residents in teaching programs that can be used to calculate Medicare funding for those hospitals. Section 201 would allow them to receive funding for a higher number of residents trained in GME programs. Hospitals would be eligible: if the current cap on full-time-equivalent slots for resident physicians is less than 1 (based on cost-reporting periods before October 1, 1997) or no greater than 3 (based on cost- reporting periods between October 1, 1997, and the date of the bill's enactment). Eligible hospitals would have five years from the date of enactment to begin training new residents and increase their residency caps. Based on CBO's analyses of Medicare cost- reporting data and considering the challenges hospitals would be likely to face in establishing or expanding residency programs within the period, CBO estimates that roughly 250 positions would be created during the five years after enactment. Those positions would remain in place for future calculations of Medicare GME for those hospitals. Based on a projection of costs per resident, CBO estimates that enacting this provision would increase direct spending by $230 million over the 2019-2029 period. Section 202, Extension of the Work Geographic Index Floor Under the Medicare Program. Section 202 would extend through calendar year 2022 a provision that increases Medicare's payments to rural physicians. Based on current spending for the physician fee schedule in those areas (about $450 million in 2018), CBO estimates that enacting section 202 would cost $1.7 billion over the 2019-2029 period. Section 203, Extension of Funding for Quality Measure Endorsement, Input, and Selection Under Medicare Program. For each fiscal year from 2020 through 2022, section 203 would appropriate $30 million for a contract between the Department of Health and Human Services and a consensus-based entity that would endorse standardized measures of health care performance. CBO estimates that enacting section 203 would cost $90 million over the 2019-2029 period. Spending subject to appropriation: Section 101 would require a change in the notice of Medicare eligibility that is sent to people between the ages of 63 and 65. It also would require that a notice be sent to disabled individuals in the 24-month waiting period. Those individuals do not receive such notices under current law. In addition, it would require that the updated notice be posted on the websites of the Social Security Administration and the Centers for Medicare & Medicaid Services. Because of this notice, the Social Security Administration would face increased costs for postage and mailing, staff training, and responding to additional inquiries. Based on information from the Social Security Administration, CBO estimates that implementing that provision would cost $10 million over the 2020-2024 period. Uncertainty: Section 103 would change the way telehealth services for mental health treatment are provided under Medicare. CBO cannot precisely estimate either the number of beneficiaries who would participate or whether enough providers would be available to meet the demand. Therefore, the cost of the section could be higher or lower than CBO estimates. Another source of uncertainty is the number of GME positions that would be created by hospitals that currently have caps on training programs for resident physicians. If the number of positions created is larger or smaller than estimated, the costs of section 201 could differ from CBO's estimate. Pay-As-You-Go considerations: The Statutory Pay-As-You-Go Act of 2010 establishes budget-reporting and enforcement procedures for legislation affecting direct spending or revenues. The net changes in outlays that are subject to those pay-as-you-go procedures are shown in Table 2. TABLE 2.--CBO's ESTIMATE OF THE STATUTORY PAY-AS-YOU-GO EFFECTS OF H.R. 3417 -------------------------------------------------------------------------------------------------------------------------------------------------------- By fiscal year, millions of dollars-- ------------------------------------------------------------------------------------------- 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2020-2024 2020-2029 -------------------------------------------------------------------------------------------------------------------------------------------------------- Net Increase in the Deficit Statutory Pay-As-You-Go Effect.............................. 304 695 791 316 114 179 237 279 337 354 2,220 3,605 -------------------------------------------------------------------------------------------------------------------------------------------------------- Increase in long-term deficits: CBO estimates that enacting H.R. 3417 would increase on-budget deficits by more than $5 billion in at least one of the four consecutive 10-year periods beginning in 2030. Mandates: H.R. 3417 contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act (UMRA). Participation in Medicare is voluntary for private entities. Therefore, the requirements in the bill arising from participation in Medicare would not impose private-sector mandates as defined in UMRA. Previous CBO estimate: Section 202. On September 18, 2019, CBO transmitted a cost estimate for H.R. 2328, the Reauthorizing and Extending America's Community Health Act, as ordered reported by the House Committee on Energy and Commerce on July 17, 2019. Section 202 of H.R. 3417 is the same as section 201 of H.R. 2328. Both bills would extend through calendar year 2022 a provision that increases payments to rural physicians. CBO's estimate for that provision is the same in both bills. Section 203. On September 18, 2019, CBO transmitted a cost estimate for H.R. 2328, the Reauthorizing and Extending America's Community Health Act, as ordered reported by the House Committee on Energy and Commerce on July 17, 2019. Section 203 of H.R. 3417 is similar to section 203 of H.R. 2328. Both bills would appropriate $30 million for a contract between the Department of Health and Human Services and a consensus-based entity that would endorse standardized measures of performance in health care. CBO's estimate for that provision is the same in both bills. Estimate prepared by: Federal costs: Philippa Haven, Lori Housman, Jamease Kowalczyk, Sarah Sajewski, and Rebecca Yip; Mandates: Andrew Laughlin. Estimate reviewed by: Tom Bradley, Chief, Health Systems and Medicare Cost Estimates Unit; Leo Lex, Deputy Assistant Director for Budget Analysis; Theresa Gullo, Assistant Director for Budget Analysis. V. OTHER MATTERS TO BE DISCUSSED UNDER THE RULES OF THE HOUSE A. Committee Oversight Findings and Recommendations With respect to clause 3(c)(1) of rule XIII and clause 2(b)(1) of rule X of the Rules of the House of Representatives, the Committee made findings and recommendations that are reflected in this report. B. Statement of General Performance Goals and Objectives With respect to clause 3(c)(4) of rule XIII of the Rules of the House of Representatives, the Committee advises that the bill contains no measure that authorizes funding, so no statement of general performance goals and objectives for which any measure authorizes funding is required. C. Information Relating to Unfunded Mandates This information is provided in accordance with section 423 of the Unfunded Mandates Reform Act of 1995 (Pub. L. No. 104- 4). The Committee has determined that the bill does not contain Federal mandates on the private sector. The Committee has determined that the bill does not impose a Federal intergovernmental mandate on State, local, or tribal governments. D. Congressional Earmarks, Limited Tax Benefits, and Limited Tariff Benefits With respect to clause 9 of rule XXI of the Rules of the House of Representatives, the Committee has carefully reviewed the provisions of the bill, and states that the provisions of the bill do not contain any congressional earmarks, limited tax benefits, or limited tariff benefits within the meaning of the rule. E. Duplication of Federal Programs [on a bill that establishes or reauthorizes a federal program] In compliance with clause 3(c)(5) of rule XIII of the Rules of the House of Representatives, the Committee states that no provision of the bill establishes or reauthorizes: (1) a program of the Federal Government known to be duplicative of another Federal program; (2) a program included in any report to Congress pursuant to section 21 of Public Law 111-139; or (3) a program related to a program identified in the most recent Catalog of Federal Domestic Assistance, published pursuant section 6104 of title 31, United States Code. F. Hearings In compliance with Sec.103(i) of H. Res. 6 (116th Congress) the following hearing was used to develop or consider H.R. 3417: Committee on Ways and Means ``Member Day Hearing,'' held on June 4, 2019. VI. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED In compliance with clause 3(e)(1)(B) of rule XIII of the Rules of the House of Representatives, changes in existing law proposed by the bill, as reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new matter is printed in italics, existing law in which no change is proposed is shown in roman): Changes in Existing Law Made by the Bill, as Reported In compliance with clause 3(e) of rule XIII of the Rules of the House of Representatives, changes in existing law made by the bill, as reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new matter is printed in italics, and existing law in which no change is proposed is shown in roman): SOCIAL SECURITY ACT * * * * * * * TITLE XI--GENERAL PROVISIONS, PEER REVIEW, AND ADMINISTRATIVE SIMPLIFICATION * * * * * * * Part A--General Provisions * * * * * * * social security account statements Provision Upon Request Sec. 1143. (a)(1) Beginning not later than October 1, 1990, the Commissioner of Social Security shall provide upon the request of an eligible individual a social security account statement (hereinafter referred to as the ``statement''). (2) Each statement shall contain-- (A) the amount of wages paid to and self-employment income derived by the eligible individual as shown by the records of the Commissioner at the date of the request; (B) an estimate of the aggregate of the employer, employee, and self-employment contributions of the eligible individual for old-age, survivors, and disability insurance as shown by the records of the Commissioner on the date of the request; (C) a separate estimate of the aggregate of the employer, employee, and self-employment contributions of the eligible individual for hospital insurance as shown by the records of the Commissioner on the date of the request; (D) an estimate of the potential monthly retirement, disability, survivor, and auxiliary benefits payable on the eligible individual's account together with a description of the benefits payable under the medicare program of title XVIII; and (E) in the case of an eligible individual described in paragraph (3)(C)(ii), an explanation, in language calculated to be understood by the average eligible individual, of the operation of the provisions under sections 202(k)(5) and 215(a)(7) and an explanation of the maximum potential effects of such provisions on the eligible individual's monthly retirement, survivor, and auxiliary benefits. (3) For purposes of this section, the term ``eligible individual'' means an individual-- (A) who has a social security account number, (B) who has attained age 25 or over, and (C)(i) has wages or net earnings from self- employment, or (ii) with respect to whom the Commissioner has information that the pattern of wages or self-employment income indicate a likelihood of noncovered employment. (4) Medicare eligibility information.-- (A) In general.--In the case of statements provided on or after the date that is 2 years after the date of the enactment of this paragraph to individuals who are attaining ages 63, 64, and 65, the statement shall also include a notice containing the information described in subparagraph (B). (B) Contents of notice.--The notice required under subparagraph (A) shall include a clear, simple explanation of-- (i) eligibility for benefits under the Medicare program under title XVIII, and in particular benefits under part B of such title; (ii) the reasons a late enrollment penalty for failure to timely enroll could be assessed and how such late enrollment penalty is calculated, in particular for benefits under part B; (iii) the availability of relief from the late enrollment penalty and retroactive enrollment under section 1837(h) (including as such section is applied under sections 1818(c) and 1818A(c)(3)), with examples of circumstances under which such relief may be granted and examples of circumstances under which such relief would not be granted; (iv) coordination of benefits (including primary and secondary coverage scenarios) pursuant to section 1862(b), in particular for benefits under part B of such title; and (v) information for populations, such as residents of Puerto Rico and veterans, for whom there are special considerations with respect to enrollment, eligibility, and coordination of benefits under title XVIII. (C) Development of notice.-- (i) In general.--The Secretary, in coordination with the Commissioner of Social Security, and taking into consideration information collected pursuant to clause (ii), shall, not later than 12 months after the last day of the period for the request of information described in clause (ii), develop the notice to be provided pursuant to subparagraph (A). (ii) Request for information.--Not later than 6 months after the date of the enactment of this paragraph, the Secretary shall request written information, including recommendations, from stakeholders (including the groups described in subparagraph (D)) on the information to be included in the notice. (iii) Notice improvement.--Beginning 4 years after the date of enactment of this paragraph, and not less than once every two years thereafter, the Secretary, in coordination with the Commissioner of Social Security, shall-- (I) review the content of the notice to be provided under subparagraph (A); (II) solicit recommendations on the notice through a request for information process as described in clause (ii); and (III) update and revise such notice as the Secretary deems appropriate. (D) Groups for consultation.--For purposes of subparagraph (C)(ii), the groups described in this clause include the following: (i) Individuals who are 60 years of age or older. (ii) Veterans. (iii) Individuals with disabilities. (iv) Individuals with end stage renal disease. (v) Low-income individuals and families. (vi) Employers (including human resources professionals). (vii) States (including representatives of State-run Health Insurance Exchanges, Medicaid offices, and Departments of Insurance). (viii) State Health Insurance Assistance Programs. (ix) Health insurers. (x) Health insurance agents and brokers. (xi) Such other groups as specified by the Secretary. (E) Posting of notice on websites.--The Commissioner of Social Security and the Secretary shall post the notice required under subparagraph (A) in a prominent location on the public Internet website of the Social Security Administration and on the public Internet website of the Centers for Medicare & Medicaid Services, respectively. (F) Reimbursement of costs.-- (i) In general.--Effective for fiscal years beginning in the year in which the date of enactment of this paragraph occurs, the Commissioner of Social Security and the Secretary shall enter into an agreement which shall provide funding to cover the administrative costs of the Commissioner's activities under this paragraph. Such agreement shall-- (I) provide funds to the Commissioner for the full cost of the Social Security Administration's work related to the implementation of this paragraph, including any costs incurred prior to the finalization of such agreement; (II) provide such funding quarterly in advance of the applicable quarter based on estimating methodology agreed to by the Commissioner and the Secretary; and (III) require an annual accounting and reconciliation of the actual costs incurred and funds provided under this paragraph. (ii) Limitation.--In no case shall funds from the Social Security Administration's Limitation on Administrative Expenses be used to carry out activities related to the implementation of this paragraph, except as the Commissioner determines is necessary in developing the agreement under clause (i). (G) No effect on obligation to mail statements.-- Nothing in this paragraph shall be construed to relieve the Commissioner of Social Security from any requirement under subsection (c), including the requirement to mail a statement on an annual basis to each eligible individual who is not receiving benefits under title II and for whom a mailing address can be determined through such methods as the Commissioner determines to be appropriate. Notice to Eligible Individuals (b) The Commissioner shall, to the maximum extent practicable, take such steps as are necessary to assure that eligible individuals are informed of the availability of the statement described in subsection (a). Mandatory Provision of Statements (c)(1) By not later than September 30, 1995, the Commissioner shall provide a statement to each eligible individual who has attained age 60 by October 1, 1994, and who is not receiving benefits under title II and for whom a current mailing address can be determined through such methods as the Commissioner determines to be appropriate. In fiscal years 1995 through 1999 the Commissioner shall provide a statement to each eligible individual who attains age 60 in such fiscal years and who is not receiving benefits under title II and for whom a current mailing address can be determined through such methods as the Commissioner determines to be appropriate. The Commissioner shall provide with each statement to an eligible individual notice that such statement is updated annually and is available upon request. (2) Beginning not later than October 1, 1999, the Commissioner shall provide a statement on an annual basis to each eligible individual who is not receiving benefits under title II and for whom a mailing address can be determined through such methods as the Commissioner determines to be appropriate. With respect to statements provided to eligible individuals who have not attained age 50, such statements need not include estimates of monthly retirement benefits. However, if such statements provided to eligible individuals who have not attained age 50 do not include estimates of retirement benefit amounts, such statements shall include a description of the benefits (including auxiliary benefits) that are available upon retirement. Disclosure to Governmental Employees of Effect of Noncovered Employment (d)(1) In the case of any individual commencing employment on or after January 1, 2005, in any agency or instrumentality of any State (or political subdivision thereof, as defined in section 218(b)(2)) in a position in which service performed by the individual does not constitute ``employment'' as defined in section 210, the head of the agency or instrumentality shall ensure that, prior to the date of the commencement of the individual's employment in the position, the individual is provided a written notice setting forth an explanation, in language calculated to be understood by the average individual, of the maximum effect on computations of primary insurance amounts (under section 215(a)(7)) and the effect on benefit amounts (under section 202(k)(5)) of monthly periodic payments or benefits payable based on earnings derived in such service. Such notice shall be in a form which shall be prescribed by the Commissioner of Social Security. (2) The written notice provided to an individual pursuant to paragraph (1) shall include a form which, upon completion and signature by the individual, would constitute certification by the individual of receipt of the notice. The agency or instrumentality providing the notice to the individual shall require that the form be completed and signed by the individual and submitted to the agency or instrumentality and to the pension, annuity, retirement, or similar fund or system established by the governmental entity involved responsible for paying the monthly periodic payments or benefits, before commencement of service with the agency or instrumentality. * * * * * * * MEDICARE ENROLLMENT NOTIFICATION AND ELIGIBILITY NOTICES FOR INDIVIDUALS IN MEDICARE WAITING PERIOD Sec. 1144A. (a) Notices (1) In general.--The Commissioner of Social Security shall distribute the notice to be provided pursuant to section 1143(a)(4), as may be modified under paragraph (2), to individuals in the 24-month waiting period under section 226(b). (2) Authority to modify notice.--The Secretary, in coordination with the Commissioner of Social Security, may modify the notice to be distributed under paragraph (1) as necessary to take into account the individuals described in such paragraph. (3) Posting of notice on websites.--The Commissioner of Social Security and the Secretary shall post the notice required to be distributed under paragraph (1) in a prominent location on the public Internet website of the Social Security Administration and on the public Internet website of the Centers for Medicare & Medicaid Services, respectively. (b) Timing Beginning not later than 2 years after the date of the enactment of this section, a notice required under subsection (a)(1) shall be mailed to an individual no less than two times in accordance with the following: (1) The notice shall be provided to such individual not later than 3 months prior to the date on which such individual's enrollment period begins as provided under section 1837. (2) The notice shall subsequently be provided to such individual not later than one month prior to such date. (c) Reimbursement of costs (1) In general.--Effective for fiscal years beginning in the year in which the date of enactment of this section occurs, the Commissioner of Social Security and the Secretary shall enter into an agreement which shall provide funding to cover the administrative costs of the Commissioner's activities under this section. Such agreement shall-- (A) provide funds to the Commissioner for the full cost of the Social Security Administration's work related to the implementation of this section, including any costs incurred prior to the finalization of such agreement; (B) provide such funding quarterly in advance of the applicable quarter based on estimating methodology agreed to by the Commissioner and the Secretary; and (C) require an annual accounting and reconciliation of the actual costs incurred and funds provided under this section. (2) Limitation.--In no case shall funds from the Social Security Administration's Limitation on Administrative Expenses be used to carry out activities related to the implementation of this section, except as the Commissioner determines is necessary in developing the agreement under paragraph (1). * * * * * * * TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED * * * * * * * Part B--Supplementary Medical Insurance Benefits for the Aged and Disabled * * * * * * * SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES Sec. 1834. (a) Payment for Durable Medical Equipment.-- (1) General rule for payment.-- (A) In general.--With respect to a covered item (as defined in paragraph (13)) for which payment is determined under this subsection, payment shall be made in the frequency specified in paragraphs (2) through (7) and in an amount equal to 80 percent of the payment basis described in subparagraph (B). (B) Payment basis.--Subject to subparagraph (F)(i), the payment basis described in this subparagraph is the lesser of-- (i) the actual charge for the item, or (ii) the payment amount recognized under paragraphs (2) through (7) of this subsection for the item; except that clause (i) shall not apply if the covered item is furnished by a public home health agency (or by another home health agency which demonstrates to the satisfaction of the Secretary that a significant portion of its patients are low income) free of charge or at nominal charges to the public. (C) Exclusive payment rule.--Subject to subparagraph (F)(ii), this subsection shall constitute the exclusive provision of this title for payment for covered items under this part or under part A to a home health agency. (D) Reduction in fee schedules for certain items.--With respect to a seat-lift chair or transcutaneous electrical nerve stimulator furnished on or after April 1, 1990, the Secretary shall reduce the payment amount applied under subparagraph (B)(ii) for such an item by 15 percent, and, in the case of a transcutaneous electrical nerve stimulator furnished on or after January 1, 1991, the Secretary shall further reduce such payment amount (as previously reduced) by 45 percent. (E) Clinical conditions for coverage.-- (i) In general.--The Secretary shall establish standards for clinical conditions for payment for covered items under this subsection. (ii) Requirements.--The standards established under clause (i) shall include the specification of types or classes of covered items that require, as a condition of payment under this subsection, a face-to-face examination of the individual by a physician (as defined in section 1861(r)), a physician assistant, nurse practitioner, or a clinical nurse specialist (as those terms are defined in section 1861(aa)(5)) and a prescription for the item. (iii) Priority of establishment of standards.--In establishing the standards under this subparagraph, the Secretary shall first establish standards for those covered items for which the Secretary determines there has been a proliferation of use, consistent findings of charges for covered items that are not delivered, or consistent findings of falsification of documentation to provide for payment of such covered items under this part. (iv) Standards for power wheelchairs.--Effective on the date of the enactment of this subparagraph, in the case of a covered item consisting of a motorized or power wheelchair for an individual, payment may not be made for such covered item unless a physician (as defined in section 1861(r)(1)), a physician assistant, nurse practitioner, or a clinical nurse specialist (as those terms are defined in section 1861(aa)(5)) has conducted a face-to-face examination of the individual and written a prescription for the item. (v) Limitation on payment for covered items.--Payment may not be made for a covered item under this subsection unless the item meets any standards established under this subparagraph for clinical condition of coverage. (F) Application of competitive acquisition; limitation of inherent reasonableness authority.--In the case of covered items furnished on or after January 1, 2011, subject to subparagraphs (G) and (H), that are included in a competitive acquisition program in a competitive acquisition area under section 1847(a)-- (i) the payment basis under this subsection for such items and services furnished in such area shall be the payment basis determined under such competitive acquisition program; (ii) the Secretary may (and, in the case of covered items furnished on or after January 1, 2016, subject to clause (iii), shall) use information on the payment determined under such competitive acquisition programs to adjust the payment amount otherwise recognized under subparagraph (B)(ii) for an area that is not a competitive acquisition area under section 1847 and in the case of such adjustment, paragraph (10)(B) shall not be applied; and (iii) in the case of covered items furnished on or after January 1, 2016, the Secretary shall continue to make such adjustments described in clause (ii) as, under such competitive acquisition programs, additional covered items are phased in or information is updated as contracts under section 1847 are recompeted in accordance with section 1847(b)(3)(B). (G) Use of information on competitive bid rates.--The Secretary shall specify by regulation the methodology to be used in applying the provisions of subparagraph (F)(ii) and subsection (h)(1)(H)(ii). In promulgating such regulation, the Secretary shall consider the costs of items and services in areas in which such provisions would be applied compared to the payment rates for such items and services in competitive acquisition areas.In the case of items and services furnished on or after January 1, 2019, in making any adjustments under clause (ii) or (iii) of subparagraph (F), under subsection (h)(1)(H)(ii), or under section 1842(s)(3)(B), the Secretary shall-- (i) solicit and take into account stakeholder input; and (ii) take into account the highest amount bid by a winning supplier in a competitive acquisition area and a comparison of each of the following with respect to non-competitive acquisition areas and competitive acquisition areas: (I) The average travel distance and cost associated with furnishing items and services in the area. (II) The average volume of items and services furnished by suppliers in the area. (III) The number of suppliers in the area. (H) Diabetic supplies.-- (i) In general.--On or after the date described in clause (ii), the payment amount under this part for diabetic supplies, including testing strips, that are non-mail order items (as defined by the Secretary) shall be equal to the single payment amounts established under the national mail order competition for diabetic supplies under section 1847. (ii) Date described.--The date described in this clause is the date of the implementation of the single payment amounts under the national mail order competition for diabetic supplies under section 1847. (I) Treatment of vacuum erection systems.-- Effective for items and services furnished on and after July 1, 2015, vacuum erection systems described as prosthetic devices described in section 1861(s)(8) shall be treated in the same manner as erectile dysfunction drugs are treated for purposes of section 1860D- 2(e)(2)(A). (2) Payment for inexpensive and other routinely purchased durable medical equipment.-- (A) In general.--Payment for an item of durable medical equipment (as defined in paragraph (13))-- (i) the purchase price of which does not exceed $150, (ii) which the Secretary determines is acquired at least 75 percent of the time by purchase, (iii) which is an accessory used in conjunction with a nebulizer, aspirator, or a ventilator excluded under paragraph (3)(A), or (iv) in the case of devices furnished on or after October 1, 2015, which serves as a speech generating device or which is an accessory that is needed for the individual to effectively utilize such a device, shall be made on a rental basis or in a lump- sum amount for the purchase of the item. The payment amount recognized for purchase or rental of such equipment is the amount specified in subparagraph (B) for purchase or rental, except that the total amount of payments with respect to an item may not exceed the payment amount specified in subparagraph (B) with respect to the purchase of the item. (B) Payment amount.--For purposes of subparagraph (A), the amount specified in this subparagraph, with respect to the purchase or rental of an item furnished in a carrier service area-- (i) in 1989 and in 1990 is the average reasonable charge in the area for the purchase or rental, respectively, of the item for the 12- month period ending on June 30, 1987, increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 6-month period ending with December 1987; (ii) in 1991 is the sum of (I) 67 percent of the local payment amount for the item or device computed under subparagraph (C)(i)(I) for 1991, and (II) 33 percent of the national limited payment amount for the item or device computed under subparagraph (C)(ii) for 1991; (iii) in 1992 is the sum of (I) 33 percent of the local payment amount for the item or device computed under subparagraph (C)(i)(II) for 1992, and (II) 67 percent of the national limited payment amount for the item or device computed under subparagraph (C)(ii) for 1992; and (iv) in 1993 and each subsequent year is the national limited payment amount for the item or device computed under subparagraph (C)(ii) for that year (reduced by 10 percent, in the case of a blood glucose testing strip furnished after 1997 for an individual with diabetes). (C) Computation of local payment amount and national limited payment amount.--For purposes of subparagraph (B)-- (i) the local payment amount for an item or device for a year is equal to-- (I) for 1991, the amount specified in subparagraph (B)(i) for 1990 increased by the covered item update for 1991, and (II) for 1992, 1993, and 1994 the amount determined under this clause for the preceding year increased by the covered item update for the year; and (ii) the national limited payment amount for an item or device for a year is equal to-- (I) for 1991, the local payment amount determined under clause (i) for such item or device for that year, except that the national limited payment amount may not exceed 100 percent of the weighted average of all local payment amounts determined under such clause for such item for that year and may not be less than 85 percent of the weighted average of all local payment amounts determined under such clause for such item, (II) for 1992 and 1993, the amount determined under this clause for the preceding year increased by the covered item update for such subsequent year, (III) for 1994, the local payment amount determined under clause (i) for such item or device for that year, except that the national limited payment amount may not exceed 100 percent of the median of all local payment amounts determined under such clause for such item for that year and may not be less than 85 percent of the median of all local payment amounts determined under such clause for such item or device for that year, and (IV) for each subsequent year, the amount determined under this clause for the preceding year increased by the covered item update for such subsequent year. (3) Payment for items requiring frequent and substantial servicing.-- (A) In general.--Payment for a covered item (such as IPPB machines and ventilators, excluding ventilators that are either continuous airway pressure devices or intermittent assist devices with continuous airway pressure devices) for which there must be frequent and substantial servicing in order to avoid risk to the patient's health shall be made on a monthly basis for the rental of the item and the amount recognized is the amount specified in subparagraph (B). (B) Payment amount.--For purposes of subparagraph (A), the amount specified in this subparagraph, with respect to an item or device furnished in a carrier service area-- (i) in 1989 and in 1990 is the average reasonable charge in the area for the rental of the item or device for the 12-month period ending with June 1987, increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 6-month period ending with December 1987; (ii) in 1991 is the sum of (I) 67 percent of the local payment amount for the item or device computed under subparagraph (C)(i)(I) for 1991, and (II) 33 percent of the national limited payment amount for the item or device computed under subparagraph (C)(ii) for 1991; (iii) in 1992 is the sum of (I) 33 percent of the local payment amount for the item or device computed under subparagraph (C)(i)(II) for 1992, and (II) 67 percent of the national limited payment amount for the item or device computed under subparagraph (C)(ii) for 1992; and (iv) in 1993 and each subsequent year is the national limited payment amount for the item or device computed under subparagraph (C)(ii) for that year. (C) Computation of local payment amount and national limited payment amount.--For purposes of subparagraph (B)-- (i) the local payment amount for an item or device for a year is equal to-- (I) for 1991, the amount specified in subparagraph (B)(i) for 1990 increased by the covered item update for 1991, and (II) for 1992, 1993, and 1994 the amount determined under this clause for the preceding year increased by the covered item update for the year; and (ii) the national limited payment amount for an item or device for a year is equal to-- (I) for 1991, the local payment amount determined under clause (i) for such item or device for that year, except that the national limited payment amount may not exceed 100 percent of the weighted average of all local payment amounts determined under such clause for such item for that year and may not be less than 85 percent of the weighted average of all local payment amounts determined under such clause for such item, (II) for 1992 and 1993, the amount determined under this clause for the preceding year increased by the covered item update for such subsequent year, (III) for 1994, the local payment amount determined under clause (i) for such item or device for that year, except that the national limited payment amount may not exceed 100 percent of the median of all local payment amounts determined under such clause for such item for that year and may not be less than 85 percent of the median of all local payment amounts determined under such clause for such item or device for that year, and (IV) for each subsequent year, the amount determined under this clause for the preceding year increased by the covered item update for such subsequent year. (4) Payment for certain customized items.--Payment with respect to a covered item that is uniquely constructed or substantially modified to meet the specific needs of an individual patient, and for that reason cannot be grouped with similar items for purposes of payment under this title, shall be made in a lump-sum amount (A) for the purchase of the item in a payment amount based upon the carrier's individual consideration for that item, and (B) for the reasonable and necessary maintenance and servicing for parts and labor not covered by the supplier's or manufacturer's warranty, when necessary during the period of medical need, and the amount recognized for such maintenance and servicing shall be paid on a lump-sum, as needed basis based upon the carrier's individual consideration for that item. In the case of a wheelchair furnished on or after January 1, 1992, the wheelchair shall be treated as a customized item for purposes of this paragraph if the wheelchair has been measured, fitted, or adapted in consideration of the patient's body size, disability, period of need, or intended use, and has been assembled by a supplier or ordered from a manufacturer who makes available customized features, modifications, or components for wheelchairs that are intended for an individual patient's use in accordance with instructions from the patient's physician. (5) Payment for oxygen and oxygen equipment.-- (A) In general.--Payment for oxygen and oxygen equipment shall be made on a monthly basis in the monthly payment amount recognized under paragraph (9) for oxygen and oxygen equipment (other than portable oxygen equipment), subject to subparagraphs (B), (C), (E), and (F). (B) Add-on for portable oxygen equipment.-- When portable oxygen equipment is used, but subject to subparagraph (D), the payment amount recognized under subparagraph (A) shall be increased by the monthly payment amount recognized under paragraph (9) for portable oxygen equipment. (C) Volume adjustment.--When the attending physician prescribes an oxygen flow rate-- (i) exceeding 4 liters per minute, the payment amount recognized under subparagraph (A), subject to subparagraph (D), shall be increased by 50 percent, or (ii) of less than 1 liter per minute, the payment amount recognized under subparagraph (A) shall be decreased by 50 percent. (D) Limit on adjustment.--When portable oxygen equipment is used and the attending physician prescribes an oxygen flow rate exceeding 4 liters per minute, there shall only be an increase under either subparagraph (B) or (C), whichever increase is larger, and not under both such subparagraphs. (E) Recertification for patients receiving home oxygen therapy.--In the case of a patient receiving home oxygen therapy services who, at the time such services are initiated, has an initial arterial blood gas value at or above a partial pressure of 56 or an arterial oxygen saturation at or above 89 percent (or such other values, pressures, or criteria as the Secretary may specify) no payment may be made under this part for such services after the expiration of the 90-day period that begins on the date the patient first receives such services unless the patient's attending physician certifies that, on the basis of a follow-up test of the patient's arterial blood gas value or arterial oxygen saturation conducted during the final 30 days of such 90- day period, there is a medical need for the patient to continue to receive such services. (F) Rental Cap.-- (i) In general.--Payment for oxygen equipment (including portable oxygen equipment) under this paragraph may not extend over a period of continuous use (as determined by the Secretary) of longer than 36 months. (ii) Payments and rules after rental cap.--After the 36th continuous month during which payment is made for the equipment under this paragraph-- (I) the supplier furnishing such equipment under this subsection shall continue to furnish the equipment during any period of medical need for the remainder of the reasonable useful lifetime of the equipment, as determined by the Secretary; (II) payments for oxygen shall continue to be made in the amount recognized for oxygen under paragraph (9) for the period of medical need; and (III) maintenance and servicing payments shall, if the Secretary determines such payments are reasonable and necessary, be made (for parts and labor not covered by the supplier's or manufacturer's warranty, as determined by the Secretary to be appropriate for the equipment), and such payments shall be in an amount determined to be appropriate by the Secretary. (6) Payment for other covered items (other than durable medical equipment).--Payment for other covered items (other than durable medical equipment and other covered items described in paragraph (3), (4), or (5)) shall be made in a lump-sum amount for the purchase of the item in the amount of the purchase price recognized under paragraph (8). (7) Payment for other items of durable medical equipment.-- (A) Payment.--In the case of an item of durable medical equipment not described in paragraphs (2) through (6), the following rules shall apply: (i) Rental.-- (I) In general.--Except as provided in clause (iii), payment for the item shall be made on a monthly basis for the rental of the item during the period of medical need (but payments under this clause may not extend over a period of continuous use (as determined by the Secretary) of longer than 13 months). (II) Payment amount.--Subject to subclause (III) and subparagraph (B), the amount recognized for the item, for each of the first 3 months of such period, is 10 percent of the purchase price recognized under paragraph (8) with respect to the item, and, for each of the remaining months of such period, is 7.5 percent of such purchase price. (III) Special rule for power- driven wheelchairs.--For purposes of payment for power- driven wheelchairs, subclause (II) shall be applied by substituting ``15 percent'' and ``6 percent'' for ``10 percent'' and ``7.5 percent'', respectively. (ii) Ownership after rental.--On the first day that begins after the 13th continuous month during which payment is made for the rental of an item under clause (i), the supplier of the item shall transfer title to the item to the individual. (iii) Purchase agreement option for complex, rehabilitative power-driven wheelchairs.--In the case of a complex, rehabilitative power-driven wheelchair, at the time the supplier furnishes the item, the supplier shall offer the individual the option to purchase the item, and payment for such item shall be made on a lump-sum basis if the individual exercises such option. (iv) Maintenance and servicing.-- After the supplier transfers title to the item under clause (ii) or in the case of a power-driven wheelchair for which a purchase agreement has been entered into under clause (iii), maintenance and servicing payments shall, if the Secretary determines such payments are reasonable and necessary, be made (for parts and labor not covered by the supplier's or manufacturer's warranty, as determined by the Secretary to be appropriate for the particular type of durable medical equipment), and such payments shall be in an amount determined to be appropriate by the Secretary. (B) Range for rental amounts.-- (i) For 1989.--For items furnished during 1989, the payment amount recognized under subparagraph (A)(i) shall not be more than 115 percent, and shall not be less than 85 percent, of the prevailing charge established for rental of the item in January 1987, increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 6-month period ending with December 1987. (ii) For 1990.--For items furnished during 1990, clause (i) shall apply in the same manner as it applies to items furnished during 1989. (C) Replacement of items.-- (i) Establishment of reasonable useful lifetime.--In accordance with clause (iii), the Secretary shall determine and establish a reasonable useful lifetime for items of durable medical equipment for which payment may be made under this paragraph. (ii) Payment for replacement items.-- If the reasonable lifetime of such an item, as so established, has been reached during a continuous period of medical need, or the carrier determines that the item is lost or irreparably damaged, the patient may elect to have payment for an item serving as a replacement for such item made-- (I) on a monthly basis for the rental of the replacement item in accordance with subparagraph (A); or (II) in the case of an item for which a purchase agreement has been entered into under subparagraph (A)(iii), in a lump-sum amount for the purchase of the item. (iii) Length of reasonable useful lifetime.--The reasonable useful lifetime of an item of durable medical equipment under this subparagraph shall be equal to 5 years, except that, if the Secretary determines that, on the basis of prior experience in making payments for such an item under this title, a reasonable useful lifetime of 5 years is not appropriate with respect to a particular item, the Secretary shall establish an alternative reasonable lifetime for such item. (8) Purchase price recognized for miscellaneous devices and items.--For purposes of paragraphs (6) and (7), the amount that is recognized under this paragraph as the purchase price for a covered item is the amount described in subparagraph (C) of this paragraph, determined as follows: (A) Computation of local purchase price.-- Each carrier under section 1842 shall compute a base local purchase price for the item as follows: (i) The carrier shall compute a base local purchase price, for each item described-- (I) in paragraph (6) equal to the average reasonable charge in the locality for the purchase of the item for the 12-month period ending with June 1987, or (II) in paragraph (7) equal to the average of the purchase prices on the claims submitted on an assignment-related basis for the unused item supplied during the 6-month period ending with December 1986. (ii) The carrier shall compute a local purchase price, with respect to the furnishing of each particular item-- (I) in 1989 and 1990, equal to the base local purchase price computed under clause (i) increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 6- month period ending with December 1987, (II) in 1991, equal to the local purchase price computed under this clause for the previous year, increased by the covered item update for 1991, and decreased by the percentage by which the average of the reasonable charges for claims paid for all items described in paragraph (7) is lower than the average of the purchase prices submitted for such items during the final 9 months of 1988; or (III) in 1992, 1993, and 1994 equal to the local purchase price computed under this clause for the previous year increased by the covered item update for the year. (B) Computation of national limited purchase price.--With respect to the furnishing of a particular item in a year, the Secretary shall compute a national limited purchase price-- (i) for 1991, equal to the local purchase price computed under subparagraph (A)(ii) for the item for the year, except that such national limited purchase price may not exceed 100 percent of the weighted average of all local purchase prices for the item computed under such subparagraph for the year, and may not be less than 85 percent of the weighted average of all local purchase prices for the item computed under such subparagraph for the year; (ii) for 1992 and 1993, the amount determined under this subparagraph for the preceding year increased by the covered item update for such subsequent year; (iii) for 1994, the local purchase price computed under subparagraph (A)(ii) for the item for the year, except that such national limited purchase price may not exceed 100 percent of the median of all local purchase prices computed for the item under such subparagraph for the year and may not be less than 85 percent of the median of all local purchase prices computed under such subparagraph for the item for the year; and (iv) for each subsequent year, equal to the amount determined under this subparagraph for the preceding year increased by the covered item update for such subsequent year. (C) Purchase price recognized.--For purposes of paragraphs (6) and (7), the amount that is recognized under this paragraph as the purchase price for each item furnished-- (i) in 1989 or 1990, is 100 percent of the local purchase price computed under subparagraph (A)(ii)(I); (ii) in 1991, is the sum of (I) 67 percent of the local purchase price computed under subparagraph (A)(ii)(II) for 1991, and (II) 33 percent of the national limited purchase price computed under subparagraph (B) for 1991; (iii) in 1992, is the sum of (I) 33 percent of the local purchase price computed under subparagraph (A)(ii)(III) for 1992, and (II) 67 percent of the national limited purchase price computed under subparagraph (B) for 1992; and (iv) in 1993 or a subsequent year, is the national limited purchase price computed under subparagraph (B) for that year. (9) Monthly payment amount recognized with respect to oxygen and oxygen equipment.--For purposes of paragraph (5), the amount that is recognized under this paragraph for payment for oxygen and oxygen equipment is the monthly payment amount described in subparagraph (C) of this paragraph. Such amount shall be computed separately (i) for all items of oxygen and oxygen equipment (other than portable oxygen equipment) and (ii) for portable oxygen equipment (each such group referred to in this paragraph as an ``item''). (A) Computation of local monthly payment rate.--Each carrier under this section shall compute a base local payment rate for each item as follows: (i) The carrier shall compute a base local average monthly payment rate per beneficiary as an amount equal to (I) the total reasonable charges for the item during the 12-month period ending with December 1986, divided by (II) the total number of months for all beneficiaries receiving the item in the area during the 12-month period for which the carrier made payment for the item under this title. (ii) The carrier shall compute a local average monthly payment rate for the item applicable-- (I) to 1989 and 1990, equal to 95 percent of the base local average monthly payment rate computed under clause (i) for the item increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 6-month period ending with December 1987, or (II) to 1991, 1992, 1993, and 1994 equal to the local average monthly payment rate computed under this clause for the item for the previous year increased by the covered item increase for the year. (B) Computation of national limited monthly payment rate.--With respect to the furnishing of an item in a year, the Secretary shall compute a national limited monthly payment rate equal to-- (i) for 1991, the local monthly payment rate computed under subparagraph (A)(ii)(II) for the item for the year, except that such national limited monthly payment rate may not exceed 100 percent of the weighted average of all local monthly payment rates computed for the item under such subparagraph for the year, and may not be less than 85 percent of the weighted average of all local monthly payment rates computed for the item under such subparagraph for the year; (ii) for 1992 and 1993, the amount determined under this subparagraph for the preceding year increased by the covered item update for such subsequent year; (iii) for 1994, the local monthly payment rate computed under subparagraph (A)(ii) for the item for the year, except that such national limited monthly payment rate may not exceed 100 percent of the median of all local monthly payment rates computed for the item under such subparagraph for the year and may not be less than 85 percent of the median of all local monthly payment rates computed for the item under such subparagraph for the year; (iv) for 1995, 1996, and 1997, equal to the amount determined under this subparagraph for the preceding year increased by the covered item update for such subsequent year; (v) for 1998, 75 percent of the amount determined under this subparagraph for 1997; and (vi) for 1999 and each subsequent year, 70 percent of the amount determined under this subparagraph for 1997. (C) Monthly payment amount recognized.--For purposes of paragraph (5), the amount that is recognized under this paragraph as the base monthly payment amount for each item furnished-- (i) in 1989 and in 1990, is 100 percent of the local average monthly payment rate computed under subparagraph (A)(ii) for the item; (ii) in 1991, is the sum of (I) 67 percent of the local average monthly payment rate computed under subparagraph (A)(ii)(II) for the item for 1991, and (II) 33 percent of the national limited monthly payment rate computed under subparagraph (B)(i) for the item for 1991; (iii) in 1992, is the sum of (I) 33 percent of the local average monthly payment rate computed under subparagraph (A)(ii)(II) for the item for 1992, and (II) 67 percent of the national limited monthly payment rate computed under subparagraph (B)(ii) for the item for 1992; and (iv) in a subsequent year, is the national limited monthly payment rate computed under subparagraph (B) for the item for that year. (10) Exceptions and adjustments.-- (A) Areas outside continental united states.--Exceptions to the amounts recognized under the previous provisions of this subsection shall be made to take into account the unique circumstances of covered items furnished in Alaska, Hawaii, or Puerto Rico. (B) Adjustment for inherent reasonableness.-- The Secretary is authorized to apply the provisions of paragraphs (8) and (9) of section 1842(b) to covered items and suppliers of such items and payments under this subsection in an area and with respect to covered items and services for which the Secretary does not make a payment amount adjustment under paragraph (1)(F). (C) Transcutaneous electrical nerve stimulator (tens).--In order to permit an attending physician time to determine whether the purchase of a transcutaneous electrical nerve stimulator is medically appropriate for a particular patient, the Secretary may determine an appropriate payment amount for the initial rental of such item for a period of not more than 2 months. If such item is subsequently purchased, the payment amount with respect to such purchase is the payment amount determined under paragraph (2). (11) Improper billing and requirement of physician order.-- (A) Improper billing for certain rental items.--Notwithstanding any other provision of this title, a supplier of a covered item for which payment is made under this subsection and which is furnished on a rental basis shall continue to supply the item without charge (other than a charge provided under this subsection for the maintenance and servicing of the item) after rental payments may no longer be made under this subsection. If a supplier knowingly and willfully violates the previous sentence, the Secretary may apply sanctions against the supplier under section 1842(j)(2) in the same manner such sanctions may apply with respect to a physician. (B) Requirement of physician order.-- (i) In general.--The Secretary is authorized to require, for specified covered items, that payment may be made under this subsection with respect to the item only if a physician enrolled under section 1866(j) or an eligible professional under section 1848(k)(3)(B) that is enrolled under section 1866(j) has communicated to the supplier, before delivery of the item, a written order for the item. (ii) Requirement for face to face encounter.--The Secretary shall require that such an order be written pursuant to a physician, a physician assistant, a nurse practitioner, or a clinical nurse specialist (as those terms are defined in section 1861(aa)(5)) documenting such physician, physician assistant, practitioner, or specialist has had a face-to-face encounter (including through use of telehealth under subsection (m) and other than with respect to encounters that are incident to services involved) with the individual involved during the 6-month period preceding such written order, or other reasonable timeframe as determined by the Secretary. (12) Regional carriers.--The Secretary may designate, by regulation under section 1842, one carrier for one or more entire regions to process all claims within the region for covered items under this section. (13) Covered item.--In this subsection, the term ``covered item'' means durable medical equipment (as defined in section 1861(n)), including such equipment described in section 1861(m)(5), but not including implantable items for which payment may be made under section 1833(t). (14) Covered item update.--In this subsection, the term ``covered item update'' means, with respect to a year-- (A) for 1991 and 1992, the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 12- month period ending with June of the previous year reduced by 1 percentage point; (B) for 1993, 1994, 1995, 1996, and 1997, the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 12-month period ending with June of the previous year; (C) for each of the years 1998 through 2000, 0 percentage points; (D) for 2001, the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 12-month period ending with June 2000; (E) for 2002, 0 percentage points; (F) for 2003, the percentage increase in the consumer price index for all urban consumers (U.S. urban average) for the 12-month period ending with June of 2002; (G) for 2004 through 2006-- (i) subject to clause (ii), in the case of class III medical devices described in section 513(a)(1)(C) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360(c)(1)(C)), the percentage increase described in subparagraph (B) for the year involved; and (ii) in the case of covered items not described in clause (i), 0 percentage points; (H) for 2007-- (i) subject to clause (ii), in the case of class III medical devices described in section 513(a)(1)(C) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360(c)(1)(C)), the percentage change determined by the Secretary to be appropriate taking into account recommendations contained in the report of the Comptroller General of the United States under section 302(c)(1)(B) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003; and (ii) in the case of covered items not described in clause (i), 0 percentage points; (I) for 2008-- (i) subject to clause (ii), in the case of class III medical devices described in section 513(a)(1)(C) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360(c)(1)(C)), the percentage increase described in subparagraph (B) (as applied to the payment amount for 2007 determined after the application of the percentage change under subparagraph (H)(i)); and (ii) in the case of covered items not described in clause (i), 0 percentage points; (J) for 2009-- (i) in the case of items and services furnished in any geographic area, if such items or services were selected for competitive acquisition in any area under the competitive acquisition program under section 1847(a)(1)(B)(i)(I) before July 1, 2008, including related accessories but only if furnished with such items and services selected for such competition and diabetic supplies but only if furnished through mail order, - 9.5 percent; or (ii) in the case of other items and services, the percentage increase in the consumer price index for all urban consumers (U.S. urban average) for the 12-month period ending with June 2008; (K) for 2010, the percentage increase in the consumer price index for all urban consumers (U.S. urban average) for the 12-month period ending with June of the previous year; and (L) for 2011 and each subsequent year-- (i) the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the previous year, reduced by-- (ii) the productivity adjustment described in section 1886(b)(3)(B)(xi)(II). The application of subparagraph (L)(ii) may result in the covered item update under this paragraph being less than 0.0 for a year, and may result in payment rates under this subsection for a year being less than such payment rates for the preceding year. (15) Advance determinations of coverage for certain items.-- (A) Development of lists of items by secretary.--The Secretary may develop and periodically update a list of items for which payment may be made under this subsection that the Secretary determines, on the basis of prior payment experience, are frequently subject to unnecessary utilization throughout a carrier's entire service area or a portion of such area. (B) Development of lists of suppliers by secretary.--The Secretary may develop and periodically update a list of suppliers of items for which payment may be made under this subsection with respect to whom-- (i) the Secretary has found that a substantial number of claims for payment under this part for items furnished by the supplier have been denied on the basis of the application of section 1862(a)(1); or (ii) the Secretary has identified a pattern of overutilization resulting from the business practice of the supplier. (C) Determinations of coverage in advance.--A carrier shall determine in advance of delivery of an item whether payment for the item may not be made because the item is not covered or because of the application of section 1862(a)(1) if-- (i) the item is included on the list developed by the Secretary under subparagraph (A); (ii) the item is furnished by a supplier included on the list developed by the Secretary under subparagraph (B); or (iii) the item is a customized item (other than inexpensive items specified by the Secretary) and the patient to whom the item is to be furnished or the supplier requests that such advance determination be made. (16) Disclosure of information and surety bond.--The Secretary shall not provide for the issuance (or renewal) of a provider number for a supplier of durable medical equipment, for purposes of payment under this part for durable medical equipment furnished by the supplier, unless the supplier provides the Secretary on a continuing basis-- (A) with-- (i) full and complete information as to the identity of each person with an ownership or control interest (as defined in section 1124(a)(3)) in the supplier or in any subcontractor (as defined by the Secretary in regulations) in which the supplier directly or indirectly has a 5 percent or more ownership interest; and (ii) to the extent determined to be feasible under regulations of the Secretary, the name of any disclosing entity (as defined in section 1124(a)(2)) with respect to which a person with such an ownership or control interest in the supplier is a person with such an ownership or control interest in the disclosing entity; and (B) with a surety bond in a form specified by the Secretary and in an amount that is not less than $50,000 that the Secretary determines is commensurate with the volume of the billing of the supplier. The Secretary may waive the requirement of a bond under subparagraph (B) in the case of a supplier that provides a comparable surety bond under State law. The Secretary, at the Secretary's discretion, may impose the requirements of the first sentence with respect to some or all providers of items or services under part A or some or all suppliers or other persons (other than physicians or other practitioners, as defined in section 1842(b)(18)(C)) who furnish items or services under this part. (17) Prohibition against unsolicited telephone contacts by suppliers.-- (A) In general.--A supplier of a covered item under this subsection may not contact an individual enrolled under this part by telephone regarding the furnishing of a covered item to the individual unless 1 of the following applies: (i) The individual has given written permission to the supplier to make contact by telephone regarding the furnishing of a covered item. (ii) The supplier has furnished a covered item to the individual and the supplier is contacting the individual only regarding the furnishing of such covered item. (iii) If the contact is regarding the furnishing of a covered item other than a covered item already furnished to the individual, the supplier has furnished at least 1 covered item to the individual during the 15-month period preceding the date on which the supplier makes such contact. (B) Prohibiting payment for items furnished subsequent to unsolicited contacts.--If a supplier knowingly contacts an individual in violation of subparagraph (A), no payment may be made under this part for any item subsequently furnished to the individual by the supplier. (C) Exclusion from program for suppliers engaging in pattern of unsolicited contacts.-- If a supplier knowingly contacts individuals in violation of subparagraph (A) to such an extent that the supplier's conduct establishes a pattern of contacts in violation of such subparagraph, the Secretary shall exclude the supplier from participation in the programs under this Act, in accordance with the procedures set forth in subsections (c), (f), and (g) of section 1128. (18) Refund of amounts collected for certain disallowed items.-- (A) In general.--If a nonparticipating supplier furnishes to an individual enrolled under this part a covered item for which no payment may be made under this part by reason of paragraph (17)(B), the supplier shall refund on a timely basis to the patient (and shall be liable to the patient for) any amounts collected from the patient for the item, unless-- (i) the supplier establishes that the supplier did not know and could not reasonably have been expected to know that payment may not be made for the item by reason of paragraph (17)(B), or (ii) before the item was furnished, the patient was informed that payment under this part may not be made for that item and the patient has agreed to pay for that item. (B) Sanctions.--If a supplier knowingly and willfully fails to make refunds in violation of subparagraph (A), the Secretary may apply sanctions against the supplier in accordance with section 1842(j)(2). (C) Notice.--Each carrier with a contract in effect under this part with respect to suppliers of covered items shall send any notice of denial of payment for covered items by reason of paragraph (17)(B) and for which payment is not requested on an assignment- related basis to the supplier and the patient involved. (D) Timely basis defined.--A refund under subparagraph (A) is considered to be on a timely basis only if-- (i) in the case of a supplier who does not request reconsideration or seek appeal on a timely basis, the refund is made within 30 days after the date the supplier receives a denial notice under subparagraph (C), or (ii) in the case in which such a reconsideration or appeal is taken, the refund is made within 15 days after the date the supplier receives notice of an adverse determination on reconsideration or appeal. (19) Certain upgraded items.-- (A) Individual's right to choose upgraded item.--Notwithstanding any other provision of this title, the Secretary may issue regulations under which an individual may purchase or rent from a supplier an item of upgraded durable medical equipment for which payment would be made under this subsection if the item were a standard item. (B) Payments to supplier.--In the case of the purchase or rental of an upgraded item under subparagraph (A)-- (i) the supplier shall receive payment under this subsection with respect to such item as if such item were a standard item; and (ii) the individual purchasing or renting the item shall pay the supplier an amount equal to the difference between the supplier's charge and the amount under clause (i). In no event may the supplier's charge for an upgraded item exceed the applicable fee schedule amount (if any) for such item. (C) Consumer protection safeguards.--Any regulations under subparagraph (A) shall provide for consumer protection standards with respect to the furnishing of upgraded equipment under subparagraph (A). Such regulations shall provide for-- (i) determination of fair market prices with respect to an upgraded item; (ii) full disclosure of the availability and price of standard items and proof of receipt of such disclosure information by the beneficiary before the furnishing of the upgraded item; (iii) conditions of participation for suppliers in the billing arrangement; (iv) sanctions of suppliers who are determined to engage in coercive or abusive practices, including exclusion; and (v) such other safeguards as the Secretary determines are necessary. (20) Identification of quality standards.-- (A) In general.--Subject to subparagraph (C), the Secretary shall establish and implement quality standards for suppliers of items and services described in subparagraph (D) to be applied by recognized independent accreditation organizations (as designated under subparagraph (B)) and with which such suppliers shall be required to comply in order to-- (i) furnish any such item or service for which payment is made under this part; and (ii) receive or retain a provider or supplier number used to submit claims for reimbursement for any such item or service for which payment may be made under this title. (B) Designation of independent accreditation organizations.--Not later than the date that is 1 year after the date on which the Secretary implements the quality standards under subparagraph (A), notwithstanding section 1865(a), the Secretary shall designate and approve one or more independent accreditation organizations for purposes of such subparagraph. (C) Quality standards.--The quality standards described in subparagraph (A) may not be less stringent than the quality standards that would otherwise apply if this paragraph did not apply and shall include consumer services standards. (D) Items and services described.--The items and services described in this subparagraph are the following items and services, as the Secretary determines appropriate: (i) Covered items (as defined in paragraph (13)) for which payment may otherwise be made under this subsection. (ii) Prosthetic devices and orthotics and prosthetics described in section 1834(h)(4). (iii) Items and services described in section 1842(s)(2). (E) Implementation.--The Secretary may establish by program instruction or otherwise the quality standards under this paragraph, including subparagraph (F), after consultation with representatives of relevant parties. Such standards shall be applied prospectively and shall be published on the Internet website of the Centers for Medicare & Medicaid Services. (F) Application of accreditation requirement.--In implementing quality standards under this paragraph-- (i) subject to clause (ii) and subparagraph (G), the Secretary shall require suppliers furnishing items and services described in subparagraph (D) on or after October 1, 2009, directly or as a subcontractor for another entity, to have submitted to the Secretary evidence of accreditation by an accreditation organization designated under subparagraph (B) as meeting applicable quality standards, except that the Secretary shall not require under this clause pharmacies to obtain such accreditation before January 1, 2010, except that the Secretary shall not require a pharmacy to have submitted to the Secretary such evidence of accreditation prior to January 1, 2011; and (ii) in applying such standards and the accreditation requirement of clause (i) with respect to eligible professionals (as defined in section 1848(k)(3)(B)), and including such other persons, such as orthotists and prosthetists, as specified by the Secretary, furnishing such items and services-- (I) such standards and accreditation requirement shall not apply to such professionals and persons unless the Secretary determines that the standards being applied are designed specifically to be applied to such professionals and persons; and (II) the Secretary may exempt such professionals and persons from such standards and requirement if the Secretary determines that licensing, accreditation, or other mandatory quality requirements apply to such professionals and persons with respect to the furnishing of such items and services. (G) Application of accreditation requirement to certain pharmacies.-- (i) In general.--With respect to items and services furnished on or after January 1, 2011, in implementing quality standards under this paragraph-- (I) subject to subclause (II), in applying such standards and the accreditation requirement of subparagraph (F)(i) with respect to pharmacies described in clause (ii) furnishing such items and services, such standards and accreditation requirement shall not apply to such pharmacies; and (II) the Secretary may apply to such pharmacies an alternative accreditation requirement established by the Secretary if the Secretary determines such alternative accreditation requirement is more appropriate for such pharmacies. (ii) Pharmacies described.--A pharmacy described in this clause is a pharmacy that meets each of the following criteria: (I) The total billings by the pharmacy for such items and services under this title are less than 5 percent of total pharmacy sales, as determined based on the average total pharmacy sales for the previous 3 calendar years, 3 fiscal years, or other yearly period specified by the Secretary. (II) The pharmacy has been enrolled under section 1866(j) as a supplier of durable medical equipment, prosthetics, orthotics, and supplies, has been issued (which may include the renewal of) a provider number for at least 5 years, and for which a final adverse action (as defined in section 424.57(a) of title 42, Code of Federal Regulations) has not been imposed in the past 5 years. (III) The pharmacy submits to the Secretary an attestation, in a form and manner, and at a time, specified by the Secretary, that the pharmacy meets the criteria described in subclauses (I) and (II). Such attestation shall be subject to section 1001 of title 18, United States Code. (IV) The pharmacy agrees to submit materials as requested by the Secretary, or during the course of an audit conducted on a random sample of pharmacies selected annually, to verify that the pharmacy meets the criteria described in subclauses (I) and (II). Materials submitted under the preceding sentence shall include a certification by an accountant on behalf of the pharmacy or the submission of tax returns filed by the pharmacy during the relevant periods, as requested by the Secretary. (21) Special payment rule for specified items and supplies.-- (A) In general.--Notwithstanding the preceding provisions of this subsection, for specified items and supplies (described in subparagraph (B)) furnished during 2005, the payment amount otherwise determined under this subsection for such specified items and supplies shall be reduced by the percentage difference between-- (i) the amount of payment otherwise determined for the specified item or supply under this subsection for 2002, and (ii) the amount of payment for the specified item or supply under chapter 89 of title 5, United States Code, as identified in the column entitled ``Median FEHP Price'' in the table entitled ``SUMMARY OF MEDICARE PRICES COMPARED TO VA, MEDICAID, RETAIL, AND FEHP PRICES FOR 16 ITEMS'' included in the Testimony of the Inspector General before the Senate Committee on Appropriations, June 12, 2002, or any subsequent report by the Inspector General. (B) Specified item or supply described.--For purposes of subparagraph (A), a specified item or supply means oxygen and oxygen equipment, standard wheelchairs (including standard power wheelchairs), nebulizers, diabetic supplies consisting of lancets and testing strips, hospital beds, and air mattresses, but only if the HCPCS code for the item or supply is identified in a table referred to in subparagraph (A)(ii). (C) Application of update to special payment amount.--The covered item update under paragraph (14) for specified items and supplies for 2006 and each subsequent year shall be applied to the payment amount under subparagraph (A) unless payment is made for such items and supplies under section 1847. (22) Special payment rule for diabetic supplies.-- Notwithstanding the preceding provisions of this subsection, for purposes of determining the payment amount under this subsection for diabetic supplies furnished on or after the first day of the calendar quarter during 2013 that is at least 30 days after the date of the enactment of this paragraph and before the date described in paragraph (1)(H)(ii), the Secretary shall recalculate and apply the covered item update under paragraph (14) as if subparagraph (J)(i) of such paragraph was amended by striking ``but only if furnished through mail order''. (b) Fee Schedules for Radiologist Services.-- (1) Development.--The Secretary shall develop-- (A) a relative value scale to serve as the basis for the payment for radiologist services under this part, and (B) using such scale and appropriate conversion factors and subject to subsection (c)(1)(A), fee schedules (on a regional, statewide, locality, or carrier service area basis) for payment for radiologist services under this part, to be implemented for such services furnished during 1989. (2) Consultation.--In carrying out paragraph (1), the Secretary shall regularly consult closely with the Physician Payment Review Commission, the American College of Radiology, and other organizations representing physicians or suppliers who furnish radiologist services and shall share with them the data and data analysis being used to make the determinations under paragraph (1), including data on variations in current medicare payments by geographic area, and by service and physician specialty. (3) Considerations.--In developing the relative value scale and fee schedules under paragraph (1), the Secretary-- (A) shall take into consideration variations in the cost of furnishing such services among geographic areas and among different sites where services are furnished, and (B) may also take into consideration such other factors respecting the manner in which physicians in different specialties furnish such services as may be appropriate to assure that payment amounts are equitable and designed to promote effective and efficient provision of radiologist services by physicians in the different specialties. (4) Savings.-- (A) Budget neutral fee schedules.--The Secretary shall develop preliminary fee schedules for 1989, which are designed to result in the same amount of aggregate payments (net of any coinsurance and deductibles under sections 1833(a)(1)(J) and 1833(b)) for radiologist services furnished in 1989 as would have been made if this subsection had not been enacted. (B) Initial savings.--The fee schedules established for payment purposes under this subsection for services furnished in 1989 shall be 97 percent of the amounts permitted under these preliminary fee schedules developed under subparagraph (A). (C) 1990 fee schedules.--For radiologist services (other than portable X-ray services) furnished under this part during 1990, after March 31 of such year, the conversion factors used under this subsection shall be 96 percent of the conversion factors that applied under this subsection as of December 31, 1989. (D) 1991 fee schedules.--For radiologist services (other than portable X-ray services) furnished under this part during 1991, the conversion factors used in a locality under this subsection shall, subject to clause (vii), be reduced to the adjusted conversion factor for the locality determined as follows: (i) National weighted average conversion factor.--The Secretary shall estimate the national weighted average of the conversion factors used under this subsection for services furnished during 1990 beginning on April 1, using the best available data. (ii) Reduced national weighted average.--The national weighted average estimated under clause (i) shall be reduced by 13 percent. (iii) Computation of 1990 locality index relative to national average.-- The Secretary shall establish an index which reflects, for each locality, the ratio of the conversion factor used in the locality under this subsection to the national weighted average estimated under clause (i). (iv) Adjusted conversion factor.--The adjusted conversion factor for the professional or technical component of a service in a locality is the sum of \1/2\ of the locally-adjusted amount determined under clause (v) and \1/2\ of the GPCI-adjusted amount determined under clause (vi). (v) Locally-adjusted amount.--For purposes of clause (iv), the locally adjusted amount determined under this clause is the product of (I) the national weighted average conversion factor computed under clause (ii), and (II) the index value established under clause (iii) for the locality. (vi) GPCI-adjusted amount.--For purposes of clause (iv), the GPCI- adjusted amount determined under this clause is the sum of-- (I) the product of (a) the portion of the reduced national weighted average conversion factor computed under clause (ii) which is attributable to physician work and (b) the geographic work index value for the locality (specified in Addendum C to the Model Fee Schedule for Physician Services (published on September 4, 1990, 55 Federal Register pp. 36238-36243)); and (II) the product of (a) the remaining portion of the reduced national weighted average conversion factor computed under clause (ii), and (b) the geographic practice cost index value specified in section 1842(b)(14)(C)(iv) for the locality. In applying this clause with respect to the professional component of a service, 80 percent of the conversion factor shall be considered to be attributable to physician work and with respect to the technical component of the service, 0 percent shall be considered to be attributable to physician work. (vii) Limits on conversion factor.-- The conversion factor to be applied to a locality to the professional or technical component of a service shall not be reduced under this subparagraph by more than 9.5 percent below the conversion factor applied in the locality under subparagraph (C) to such component, but in no case shall the conversion factor be less than 60 percent of the national weighted average of the conversion factors (computed under clause (i)). (E) Rule for certain scanning services.--In the case of the technical components of magnetic resonance imaging (MRI) services and computer assisted tomography (CAT) services furnished after December 31, 1990, the amount otherwise payable shall be reduced by 10 percent. (F) Subsequent updating.--For radiologist services furnished in subsequent years, the fee schedules shall be the schedules for the previous year updated by the percentage increase in the MEI (as defined in section 1842(i)(3)) for the year. (G) Nonparticipating physicians and suppliers.--Each fee schedule so established shall provide that the payment rate recognized for nonparticipating physicians and suppliers is equal to the appropriate percent (as defined in section 1842(b)(4)(A)(iv)) of the payment rate recognized for participating physicians and suppliers. (5) Limiting charges of nonparticipating physicians and suppliers.-- (A) In general.--In the case of radiologist services furnished after January 1, 1989, for which payment is made under a fee schedule under this subsection, if a nonparticipating physician or supplier furnishes the service to an individual entitled to benefits under this part, the physician or supplier may not charge the individual more than the limiting charge (as defined in subparagraph (B)). (B) Limiting charge defined.--In subparagraph (A), the term ``limiting charge'' means, with respect to a service furnished-- (i) in 1989, 125 percent of the amount specified for the service in the appropriate fee schedule established under paragraph (1), (ii) in 1990, 120 percent of the amount specified for the service in the appropriate fee schedule established under paragraph (1), and (iii) after 1990, 115 percent of the amount specified for the service in the appropriate fee schedule established under paragraph (1). (C) Enforcement.--If a physician or supplier knowingly and willfully bills in violation of subparagraph (A), the Secretary may apply sanctions against such physician or supplier in accordance with section 1842(j)(2) in the same manner as such sanctions may apply to a physician. (6) Radiologist services defined.--For the purposes of this subsection and section 1833(a)(1)(J), the term ``radiologist services'' only includes radiology services performed by, or under the direction or supervision of, a physician-- (A) who is certified, or eligible to be certified, by the American Board of Radiology, or (B) for whom radiology services account for at least 50 percent of the total amount of charges made under this part. (c) Payment and Standards for Screening Mammography.-- (1) In general.--With respect to expenses incurred for screening mammography (as defined in section 1861(jj)), payment may be made only-- (A) for screening mammography conducted consistent with the frequency permitted under paragraph (2); and (B) if the screening mammography is conducted by a facility that has a certificate (or provisional certificate) issued under section 354 of the Public Health Service Act. (2) Frequency covered.-- (A) In general.--Subject to revision by the Secretary under subparagraph (B)-- (i) no payment may be made under this part for screening mammography performed on a woman under 35 years of age; (ii) payment may be made under this part for only one screening mammography performed on a woman over 34 years of age, but under 40 years of age; and (iii) in the case of a woman over 39 years of age, payment may not be made under this part for screening mammography performed within 11 months following the month in which a previous screening mammography was performed. (B) Revision of frequency.-- (i) Review.--The Secretary, in consultation with the Director of the National Cancer Institute, shall review periodically the appropriate frequency for performing screening mammography, based on age and such other factors as the Secretary believes to be pertinent. (ii) Revision of frequency.--The Secretary, taking into consideration the review made under clause (i), may revise from time to time the frequency with which screening mammography may be paid for under this subsection. (d) Frequency Limits and Payment for Colorectal Cancer Screening Tests.-- (1) Screening fecal-occult blood tests.-- (A) Payment amount.--The payment amount for colorectal cancer screening tests consisting of screening fecal-occult blood tests is equal to the payment amount established for diagnostic fecal-occult blood tests under section 1833(h). (B) Frequency limit.--No payment may be made under this part for a colorectal cancer screening test consisting of a screening fecal- occult blood test-- (i) if the individual is under 50 years of age; or (ii) if the test is performed within the 11 months after a previous screening fecal-occult blood test. (2) Screening flexible sigmoidoscopies.-- (A) Fee schedule.--With respect to colorectal cancer screening tests consisting of screening flexible sigmoidoscopies, payment under section 1848 shall be consistent with payment under such section for similar or related services. (B) Payment limit.--In the case of screening flexible sigmoidoscopy services, payment under this part shall not exceed such amount as the Secretary specifies, based upon the rates recognized for diagnostic flexible sigmoidoscopy services. (C) Facility payment limit.-- (i) In general.--Notwithstanding subsections (i)(2)(A) and (t) of section 1833, in the case of screening flexible sigmoidoscopy services furnished on or after January 1, 1999, that-- (I) in accordance with regulations, may be performed in an ambulatory surgical center and for which the Secretary permits ambulatory surgical center payments under this part, and (II) are performed in an ambulatory surgical center or hospital outpatient department, payment under this part shall be based on the lesser of the amount under the fee schedule that would apply to such services if they were performed in a hospital outpatient department in an area or the amount under the fee schedule that would apply to such services if they were performed in an ambulatory surgical center in the same area. (ii) Limitation on coinsurance.-- Notwithstanding any other provision of this title, in the case of a beneficiary who receives the services described in clause (i)-- (I) in computing the amount of any applicable copayment, the computation of such coinsurance shall be based upon the fee schedule under which payment is made for the services, and (II) the amount of such coinsurance is equal to 25 percent of the payment amount under the fee schedule described in subclause (I). (D) Special rule for detected lesions.--If during the course of such screening flexible sigmoidoscopy, a lesion or growth is detected which results in a biopsy or removal of the lesion or growth, payment under this part shall not be made for the screening flexible sigmoidoscopy but shall be made for the procedure classified as a flexible sigmoidoscopy with such biopsy or removal. (E) Frequency limit.--No payment may be made under this part for a colorectal cancer screening test consisting of a screening flexible sigmoidoscopy-- (i) if the individual is under 50 years of age; or (ii) if the procedure is performed within the 47 months after a previous screening flexible sigmoidoscopy or, in the case of an individual who is not at high risk for colorectal cancer, if the procedure is performed within the 119 months after a previous screening colonoscopy. (3) Screening colonoscopy.-- (A) Fee schedule.--With respect to colorectal cancer screening test consisting of a screening colonoscopy, payment under section 1848 shall be consistent with payment amounts under such section for similar or related services. (B) Payment limit.--In the case of screening colonoscopy services, payment under this part shall not exceed such amount as the Secretary specifies, based upon the rates recognized for diagnostic colonoscopy services. (C) Facility payment limit.-- (i) In general.--Notwithstanding subsections (i)(2)(A) and (t) of section 1833, in the case of screening colonoscopy services furnished on or after January 1, 1999, that are performed in an ambulatory surgical center or a hospital outpatient department, payment under this part shall be based on the lesser of the amount under the fee schedule that would apply to such services if they were performed in a hospital outpatient department in an area or the amount under the fee schedule that would apply to such services if they were performed in an ambulatory surgical center in the same area. (ii) Limitation on coinsurance.-- Notwithstanding any other provision of this title, in the case of a beneficiary who receives the services described in clause (i)-- (I) in computing the amount of any applicable coinsurance, the computation of such coinsurance shall be based upon the fee schedule under which payment is made for the services, and (II) the amount of such coinsurance is equal to 25 percent of the payment amount under the fee schedule described in subclause (I). (D) Special rule for detected lesions.--If during the course of such screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the lesion or growth, payment under this part shall not be made for the screening colonoscopy but shall be made for the procedure classified as a colonoscopy with such biopsy or removal. (E) Frequency limit.--No payment may be made under this part for a colorectal cancer screening test consisting of a screening colonoscopy for individuals at high risk for colorectal cancer if the procedure is performed within the 23 months after a previous screening colonoscopy or for other individuals if the procedure is performed within the 119 months after a previous screening colonoscopy or within 47 months after a previous screening flexible sigmoidoscopy. (e) Accreditation Requirement for Advanced Diagnostic Imaging Services.-- (1) In general.-- (A) In general.--Beginning with January 1, 2012, with respect to the technical component of advanced diagnostic imaging services for which payment is made under the fee schedule established under section 1848(b) and that are furnished by a supplier, payment may only be made if such supplier is accredited by an accreditation organization designated by the Secretary under paragraph (2)(B)(i). (B) Advanced diagnostic imaging services defined.--In this subsection, the term ``advanced diagnostic imaging services'' includes-- (i) diagnostic magnetic resonance imaging, computed tomography, and nuclear medicine (including positron emission tomography); and (ii) such other diagnostic imaging services, including services described in section 1848(b)(4)(B) (excluding X- ray, ultrasound, and fluoroscopy), as specified by the Secretary in consultation with physician specialty organizations and other stakeholders. (C) Supplier defined.--In this subsection, the term ``supplier'' has the meaning given such term in section 1861(d). (2) Accreditation organizations.-- (A) Factors for designation of accreditation organizations.--The Secretary shall consider the following factors in designating accreditation organizations under subparagraph (B)(i) and in reviewing and modifying the list of accreditation organizations designated pursuant to subparagraph (C): (i) The ability of the organization to conduct timely reviews of accreditation applications. (ii) Whether the organization has established a process for the timely integration of new advanced diagnostic imaging services into the organization's accreditation program. (iii) Whether the organization uses random site visits, site audits, or other strategies for ensuring accredited suppliers maintain adherence to the criteria described in paragraph (3). (iv) The ability of the organization to take into account the capacities of suppliers located in a rural area (as defined in section 1886(d)(2)(D)). (v) Whether the organization has established reasonable fees to be charged to suppliers applying for accreditation. (vi) Such other factors as the Secretary determines appropriate. (B) Designation.--Not later than January 1, 2010, the Secretary shall designate organizations to accredit suppliers furnishing the technical component of advanced diagnostic imaging services. The list of accreditation organizations so designated may be modified pursuant to subparagraph (C). (C) Review and modification of list of accreditation organizations.-- (i) In general.--The Secretary shall review the list of accreditation organizations designated under subparagraph (B) taking into account the factors under subparagraph (A). Taking into account the results of such review, the Secretary may, by regulation, modify the list of accreditation organizations designated under subparagraph (B). (ii) Special rule for accreditations done prior to removal from list of designated accreditation organizations.--In the case where the Secretary removes an organization from the list of accreditation organizations designated under subparagraph (B), any supplier that is accredited by the organization during the period beginning on the date on which the organization is designated as an accreditation organization under subparagraph (B) and ending on the date on which the organization is removed from such list shall be considered to have been accredited by an organization designated by the Secretary under subparagraph (B) for the remaining period such accreditation is in effect. (3) Criteria for accreditation.--The Secretary shall establish procedures to ensure that the criteria used by an accreditation organization designated under paragraph (2)(B) to evaluate a supplier that furnishes the technical component of advanced diagnostic imaging services for the purpose of accreditation of such supplier is specific to each imaging modality. Such criteria shall include-- (A) standards for qualifications of medical personnel who are not physicians and who furnish the technical component of advanced diagnostic imaging services; (B) standards for qualifications and responsibilities of medical directors and supervising physicians, including standards that recognize the considerations described in paragraph (4); (C) procedures to ensure that equipment used in furnishing the technical component of advanced diagnostic imaging services meets performance specifications; (D) standards that require the supplier have procedures in place to ensure the safety of persons who furnish the technical component of advanced diagnostic imaging services and individuals to whom such services are furnished; (E) standards that require the establishment and maintenance of a quality assurance and quality control program by the supplier that is adequate and appropriate to ensure the reliability, clarity, and accuracy of the technical quality of diagnostic images produced by such supplier; and (F) any other standards or procedures the Secretary determines appropriate. (4) Recognition in standards for the evaluation of medical directors and supervising physicians.--The standards described in paragraph (3)(B) shall recognize whether a medical director or supervising physician-- (A) in a particular specialty receives training in advanced diagnostic imaging services in a residency program; (B) has attained, through experience, the necessary expertise to be a medical director or a supervising physician; (C) has completed any continuing medical education courses relating to such services; or (D) has met such other standards as the Secretary determines appropriate. (5) Rule for accreditations made prior to designation.--In the case of a supplier that is accredited before January 1, 2010, by an accreditation organization designated by the Secretary under paragraph (2)(B) as of January 1, 2010, such supplier shall be considered to have been accredited by an organization designated by the Secretary under such paragraph as of January 1, 2012, for the remaining period such accreditation is in effect. (f) Reduction in Payments for Physician Pathology Services During 1991.-- (1) In general.--For physician pathology services furnished under this part during 1991, the prevailing charges used in a locality under this part shall be 7 percent below the prevailing charges used in the locality under this part in 1990 after March 31. (2) Limitation.--The prevailing charge for the technical and professional components of an physician pathology service furnished by a physician through an independent laboratory shall not be reduced pursuant to paragraph (1) to the extent that such reduction would reduce such prevailing charge below 115 percent of the prevailing charge for the professional component of such service when furnished by a hospital-based physician in the same locality. For purposes of the preceding sentence, an independent laboratory is a laboratory that is independent of a hospital and separate from the attending or consulting physicians' office. (g) Payment for Outpatient Critical Access Hospital Services.-- (1) In general.--The amount of payment for outpatient critical access hospital services of a critical access hospital is equal to 101 percent of the reasonable costs of the hospital in providing such services, unless the hospital makes the election under paragraph (2). (2) Election of cost-based hospital outpatient service payment plus fee schedule for professional services.--A critical access hospital may elect to be paid for outpatient critical access hospital services amounts equal to the sum of the following, less the amount that such hospital may charge as described in section 1866(a)(2)(A): (A) Facility fee.--With respect to facility services, not including any services for which payment may be made under subparagraph (B), 101 percent of the reasonable costs of the critical access hospital in providing such services. (B) Fee schedule for professional services.-- With respect to professional services otherwise included within outpatient critical access hospital services, 115 percent of such amounts as would otherwise be paid under this part if such services were not included in outpatient critical access hospital services. Subsections (x) and (y) of section 1833 shall not be taken into account in determining the amounts that would otherwise be paid pursuant to the preceding sentence. The Secretary may not require, as a condition for applying subparagraph (B) with respect to a critical access hospital, that each physician or other practitioner providing professional services in the hospital must assign billing rights with respect to such services, except that such subparagraph shall not apply to those physicians and practitioners who have not assigned such billing rights. (3) Disregarding charges.--The payment amounts under this subsection shall be determined without regard to the amount of the customary or other charge. (4) Treatment of clinical diagnostic laboratory services.--No coinsurance, deductible, copayment, or other cost-sharing otherwise applicable under this part shall apply with respect to clinical diagnostic laboratory services furnished as an outpatient critical access hospital service. Nothing in this title shall be construed as providing for payment for clinical diagnostic laboratory services furnished as part of outpatient critical access hospital services, other than on the basis described in this subsection. For purposes of the preceding sentence and section 1861(mm)(3), clinical diagnostic laboratory services furnished by a critical access hospital shall be treated as being furnished as part of outpatient critical access services without regard to whether the individual with respect to whom such services are furnished is physically present in the critical access hospital, or in a skilled nursing facility or a clinic (including a rural health clinic) that is operated by a critical access hospital, at the time the specimen is collected. (5) Coverage of costs for certain emergency room on- call providers.--In determining the reasonable costs of outpatient critical access hospital services under paragraphs (1) and (2)(A), the Secretary shall recognize as allowable costs, amounts (as defined by the Secretary) for reasonable compensation and related costs for physicians, physician assistants, nurse practitioners, and clinical nurse specialists who are on-call (as defined by the Secretary) to provide emergency services but who are not present on the premises of the critical access hospital involved, and are not otherwise furnishing services covered under this title and are not on-call at any other provider or facility. (h) Payment for Prosthetic Devices and Orthotics and Prosthetics.-- (1) General rule for payment.-- (A) In general.--Payment under this subsection for prosthetic devices and orthotics and prosthetics shall be made in a lump-sum amount for the purchase of the item in an amount equal to 80 percent of the payment basis described in subparagraph (B). (B) Payment basis.--Except as provided in subparagraphs (C), (E), and (H)(i), the payment basis described in this subparagraph is the lesser of-- (i) the actual charge for the item; or (ii) the amount recognized under paragraph (2) as the purchase price for the item. (C) Exception for certain public home health agencies.--Subparagraph (B)(i) shall not apply to an item furnished by a public home health agency (or by another home health agency which demonstrates to the satisfaction of the Secretary that a significant portion of its patients are low income) free of charge or at nominal charges to the public. (D) Exclusive payment rule.--Subject to subparagraph (H)(ii), this subsection shall constitute the exclusive provision of this title for payment for prosthetic devices, orthotics, and prosthetics under this part or under part A to a home health agency. (E) Exception for certain items.--Payment for ostomy supplies, tracheostomy supplies, and urologicals shall be made in accordance with subparagraphs (B) and (C) of section 1834(a)(2). (F) Special payment rules for certain prosthetics and custom-fabricated orthotics.-- (i) In general.--No payment shall be made under this subsection for an item of custom-fabricated orthotics described in clause (ii) or for an item of prosthetics unless such item is-- (I) furnished by a qualified practitioner; and (II) fabricated by a qualified practitioner or a qualified supplier at a facility that meets such criteria as the Secretary determines appropriate. (ii) Description of custom-fabricated item.-- (I) In general.--An item described in this clause is an item of custom-fabricated orthotics that requires education, training, and experience to custom-fabricate and that is included in a list established by the Secretary in subclause (II). Such an item does not include shoes and shoe inserts. (II) List of items.--The Secretary, in consultation with appropriate experts in orthotics (including national organizations representing manufacturers of orthotics), shall establish and update as appropriate a list of items to which this subparagraph applies. No item may be included in such list unless the item is individually fabricated for the patient over a positive model of the patient. (iii) Qualified practitioner defined.--In this subparagraph, the term ``qualified practitioner'' means a physician or other individual who-- (I) is a qualified physical therapist or a qualified occupational therapist; (II) in the case of a State that provides for the licensing of orthotics and prosthetics, is licensed in orthotics or prosthetics by the State in which the item is supplied; or (III) in the case of a State that does not provide for the licensing of orthotics and prosthetics, is specifically trained and educated to provide or manage the provision of prosthetics and custom-designed or -fabricated orthotics, and is certified by the American Board for Certification in Orthotics and Prosthetics, Inc. or by the Board for Orthotist/ Prosthetist Certification, or is credentialed and approved by a program that the Secretary determines, in consultation with appropriate experts in orthotics and prosthetics, has training and education standards that are necessary to provide such prosthetics and orthotics. (iv) Qualified supplier defined.--In this subparagraph, the term ``qualified supplier'' means any entity that is accredited by the American Board for Certification in Orthotics and Prosthetics, Inc. or by the Board for Orthotist/Prosthetist Certification, or accredited and approved by a program that the Secretary determines has accreditation and approval standards that are essentially equivalent to those of such Board. (G) Replacement of prosthetic devices and parts.-- (i) In general.--Payment shall be made for the replacement of prosthetic devices which are artificial limbs, or for the replacement of any part of such devices, without regard to continuous use or useful lifetime restrictions if an ordering physician determines that the provision of a replacement device, or a replacement part of such a device, is necessary because of any of the following: (I) A change in the physiological condition of the patient. (II) An irreparable change in the condition of the device, or in a part of the device. (III) The condition of the device, or the part of the device, requires repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replaced. (ii) Confirmation may be required if device or part being replaced is less than 3 years old.--If a physician determines that a replacement device, or a replacement part, is necessary pursuant to clause (i)-- (I) such determination shall be controlling; and (II) such replacement device or part shall be deemed to be reasonable and necessary for purposes of section 1862(a)(1)(A); except that if the device, or part, being replaced is less than 3 years old (calculated from the date on which the beneficiary began to use the device or part), the Secretary may also require confirmation of necessity of the replacement device or replacement part, as the case may be. (H) Application of competitive acquisition to orthotics; limitation of inherent reasonableness authority.--In the case of orthotics described in paragraph (2)(C) of section 1847(a) furnished on or after January 1, 2009, subject to subsection (a)(1)(G), that are included in a competitive acquisition program in a competitive acquisition area under such section-- (i) the payment basis under this subsection for such orthotics furnished in such area shall be the payment basis determined under such competitive acquisition program; and (ii) subject to subsection (a)(1)(G), the Secretary may use information on the payment determined under such competitive acquisition programs to adjust the payment amount otherwise recognized under subparagraph (B)(ii) for an area that is not a competitive acquisition area under section 1847, and in the case of such adjustment, paragraphs (8) and (9) of section 1842(b) shall not be applied. (2) Purchase price recognized.--For purposes of paragraph (1), the amount that is recognized under this paragraph as the purchase price for prosthetic devices, orthotics, and prosthetics is the amount described in subparagraph (C) of this paragraph, determined as follows: (A) Computation of local purchase price.-- Each carrier under section 1842 shall compute a base local purchase price for the item as follows: (i) The carrier shall compute a base local purchase price for each item equal to the average reasonable charge in the locality for the purchase of the item for the 12-month period ending with June 1987. (ii) The carrier shall compute a local purchase price, with respect to the furnishing of each particular item-- (I) in 1989 and 1990, equal to the base local purchase price computed under clause (i) increased by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 6-month period ending with December 1987, or (II) in 1991, 1992 or 1993, equal to the local purchase price computed under this clause for the previous year increased by the applicable percentage increase for the year. (B) Computation of regional purchase price.-- With respect to the furnishing of a particular item in each region (as defined by the Secretary), the Secretary shall compute a regional purchase price-- (i) for 1992, equal to the average (weighted by relative volume of all claims among carriers) of the local purchase prices for the carriers in the region computed under subparagraph (A)(ii)(II) for the year, and (ii) for each subsequent year, equal to the regional purchase price computed under this subparagraph for the previous year increased by the applicable percentage increase for the year. (C) Purchase price recognized.--For purposes of paragraph (1) and subject to subparagraph (D), the amount that is recognized under this paragraph as the purchase price for each item furnished-- (i) in 1989, 1990, or 1991, is 100 percent of the local purchase price computed under subparagraph (A)(ii); (ii) in 1992, is the sum of (I) 75 percent of the local purchase price computed under subparagraph (A)(ii)(II) for 1992, and (II) 25 percent of the regional purchase price computed under subparagraph (B) for 1992; (iii) in 1993, is the sum of (I) 50 percent of the local purchase price computed under subparagraph (A)(ii)(II) for 1993, and (II) 50 percent of the regional purchase price computed under subparagraph (B) for 1993; and (iv) in 1994 or a subsequent year, is the regional purchase price computed under subparagraph (B) for that year. (D) Range on amount recognized.--The amount that is recognized under subparagraph (C) as the purchase price for an item furnished-- (i) in 1992, may not exceed 125 percent, and may not be lower than 85 percent, of the average of the purchase prices recognized under such subparagraph for all the carrier service areas in the United States in that year; and (ii) in a subsequent year, may not exceed 120 percent, and may not be lower than 90 percent, of the average of the purchase prices recognized under such subparagraph for all the carrier service areas in the United States in that year. (3) Applicability of certain provisions relating to durable medical equipment.--Paragraphs (12) and (17) and subparagraphs (A) and (B) of paragraph (10) and paragraph (11) of subsection (a) shall apply to prosthetic devices, orthotics, and prosthetics in the same manner as such provisions apply to covered items under such subsection. (4) Definitions.--In this subsection-- (A) the term ``applicable percentage increase'' means-- (i) for 1991, 0 percent; (ii) for 1992 and 1993, the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the previous year; (iii) for 1994 and 1995, 0 percent; (iv) for 1996 and 1997, the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the previous year; (v) for each of the years 1998 through 2000, 1 percent; (vi) for 2001, the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 12-month period ending with June 2000; (vii) for 2002, 1 percent; (viii) for 2003, the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the previous year; (ix) for 2004, 2005, and 2006, 0 percent; (x) for for each of 2007 through 2010, the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the previous year; and (xi) for 2011 and each subsequent year-- (I) the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the previous year, reduced by-- (II) the productivity adjustment described in section 1886(b)(3)(B)(xi)(II). (B) the term ``prosthetic devices'' has the meaning given such term in section 1861(s)(8), except that such term does not include parenteral and enteral nutrition nutrients, supplies, and equipment and does not include an implantable item for which payment may be made under section 1833(t); and (C) the term ``orthotics and prosthetics'' has the meaning given such term in section 1861(s)(9) (and includes shoes described in section 1861(s)(12)), but does not include intraocular lenses or medical supplies (including catheters, catheter supplies, ostomy bags, and supplies related to ostomy care) furnished by a home health agency under section 1861(m)(5). The application of subparagraph (A)(xi)(II) may result in the applicable percentage increase under subparagraph (A) being less than 0.0 for a year, and may result in payment rates under this subsection for a year being less than such payment rates for the preceding year. (5) Documentation created by orthotists and prosthetists.--For purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual's medical record to support documentation created by eligible professionals described in section 1848(k)(3)(B). (i) Payment for Surgical Dressings.-- (1) In general.--Payment under this subsection for surgical dressings (described in section 1861(s)(5)) shall be made in a lump sum amount for the purchase of the item in an amount equal to 80 percent of the lesser of-- (A) the actual charge for the item; or (B) a payment amount determined in accordance with the methodology described in subparagraphs (B) and (C) of subsection (a)(2) (except that in applying such methodology, the national limited payment amount referred to in such subparagraphs shall be initially computed based on local payment amounts using average reasonable charges for the 12-month period ending December 31, 1992, increased by the covered item updates described in such subsection for 1993 and 1994). (2) Exceptions.--Paragraph (1) shall not apply to surgical dressings that are-- (A) furnished as an incident to a physician's professional service; or (B) furnished by a home health agency. (j) Requirements for Suppliers of Medical Equipment and Supplies.-- (1) Issuance and renewal of supplier number.-- (A) Payment.--Except as provided in subparagraph (C), no payment may be made under this part after the date of the enactment of the Social Security Act Amendments of 1994 for items furnished by a supplier of medical equipment and supplies unless such supplier obtains (and renews at such intervals as the Secretary may require) a supplier number. (B) Standards for possessing a supplier number.--A supplier may not obtain a supplier number unless-- (i) for medical equipment and supplies furnished on or after the date of the enactment of the Social Security Act Amendments of 1994 and before January 1, 1996, the supplier meets standards prescribed by the Secretary in regulations issued on June 18, 1992; and (ii) for medical equipment and supplies furnished on or after January 1, 1996, the supplier meets revised standards prescribed by the Secretary (in consultation with representatives of suppliers of medical equipment and supplies, carriers, and consumers) that shall include requirements that the supplier-- (I) comply with all applicable State and Federal licensure and regulatory requirements; (II) maintain a physical facility on an appropriate site; (III) have proof of appropriate liability insurance; and (IV) meet such other requirements as the Secretary may specify. (C) Exception for items furnished as incident to a physician's service.--Subparagraph (A) shall not apply with respect to medical equipment and supplies furnished incident to a physician's service. (D) Prohibition against multiple supplier numbers.--The Secretary may not issue more than one supplier number to any supplier of medical equipment and supplies unless the issuance of more than one number is appropriate to identify subsidiary or regional entities under the supplier's ownership or control. (E) Prohibition against delegation of supplier determinations.--The Secretary may not delegate (other than by contract under section 1842) the responsibility to determine whether suppliers meet the standards necessary to obtain a supplier number. (2) Certificates of medical necessity.-- (A) Limitation on information provided by suppliers on certificates of medical necessity.-- (i) In general.--Effective 60 days after the date of the enactment of the Social Security Act Amendments of 1994, a supplier of medical equipment and supplies may distribute to physicians, or to individuals entitled to benefits under this part, a certificate of medical necessity for commercial purposes which contains no more than the following information completed by the supplier: (I) An identification of the supplier and the beneficiary to whom such medical equipment and supplies are furnished. (II) A description of such medical equipment and supplies. (III) Any product code identifying such medical equipment and supplies. (IV) Any other administrative information (other than information relating to the beneficiary's medical condition) identified by the Secretary. (ii) Information on payment amount and charges.--If a supplier distributes a certificate of medical necessity containing any of the information permitted to be supplied under clause (i), the supplier shall also list on the certificate of medical necessity the fee schedule amount and the supplier's charge for the medical equipment or supplies being furnished prior to distribution of such certificate to the physician. (iii) Penalty.--Any supplier of medical equipment and supplies who knowingly and willfully distributes a certificate of medical necessity in violation of clause (i) or fails to provide the information required under clause (ii) is subject to a civil money penalty in an amount not to exceed $1,000 for each such certificate of medical necessity so distributed. The provisions of section 1128A (other than subsections (a) and (b)) shall apply to civil money penalties under this subparagraph in the same manner as they apply to a penalty or proceeding under section 1128A(a). (B) Definition.--For purposes of this paragraph, the term ``certificate of medical necessity'' means a form or other document containing information required by the carrier to be submitted to show that an item is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. (3) Coverage and review criteria.--The Secretary shall annually review the coverage and utilization of items of medical equipment and supplies to determine whether such items should be made subject to coverage and utilization review criteria, and if appropriate, shall develop and apply such criteria to such items. (4) Limitation on patient liability.--If a supplier of medical equipment and supplies (as defined in paragraph (5))-- (A) furnishes an item or service to a beneficiary for which no payment may be made by reason of paragraph (1); (B) furnishes an item or service to a beneficiary for which payment is denied in advance under subsection (a)(15); or (C) furnishes an item or service to a beneficiary for which payment is denied under section 1862(a)(1); any expenses incurred for items and services furnished to an individual by such a supplier not on an assigned basis shall be the responsibility of such supplier. The individual shall have no financial responsibility for such expenses and the supplier shall refund on a timely basis to the individual (and shall be liable to the individual for) any amounts collected from the individual for such items or services. The provisions of subsection (a)(18) shall apply to refunds required under the previous sentence in the same manner as such provisions apply to refunds under such subsection. (5) Definition.--The term ``medical equipment and supplies'' means-- (A) durable medical equipment (as defined in section 1861(n)); (B) prosthetic devices (as described in section 1861(s)(8)); (C) orthotics and prosthetics (as described in section 1861(s)(9)); (D) surgical dressings (as described in section 1861(s)(5)); (E) such other items as the Secretary may determine; and (F) for purposes of paragraphs (1) and (3)-- (i) home dialysis supplies and equipment (as described in section 1861(s)(2)(F)), (ii) immunosuppressive drugs (as described in section 1861(s)(2)(J)), (iii) therapeutic shoes for diabetics (as described in section 1861(s)(12)), (iv) oral drugs prescribed for use as an anticancer therapeutic agent (as described in section 1861(s)(2)(Q)), and (v) self-administered erythropoetin (as described in section 1861(s)(2)(P)). (k) Payment for Outpatient Therapy Services and Comprehensive Outpatient Rehabilitation Services.-- (1) In general.--With respect to services described in section 1833(a)(8) or 1833(a)(9) for which payment is determined under this subsection, the payment basis shall be-- (A) for services furnished during 1998, the amount determined under paragraph (2); or (B) for services furnished during a subsequent year, 80 percent of the lesser of-- (i) the actual charge for the services, or (ii) the applicable fee schedule amount (as defined in paragraph (3)) for the services. (2) Payment in 1998 based upon adjusted reasonable costs.--The amount under this paragraph for services is the lesser of-- (A) the charges imposed for the services, or (B) the adjusted reasonable costs (as defined in paragraph (4)) for the services, less 20 percent of the amount of the charges imposed for such services. (3) Applicable fee schedule amount.--In this subsection, the term ``applicable fee schedule amount'' means, with respect to services furnished in a year, the amount determined under the fee schedule established under section 1848 for such services furnished during the year or, if there is no such fee schedule established for such services, the amount determined under the fee schedule established for such comparable services as the Secretary specifies. (4) Adjusted reasonable costs.--In paragraph (2), the term ``adjusted reasonable costs'' means, with respect to any services, reasonable costs determined for such services, reduced by 10 percent. The 10-percent reduction shall not apply to services described in section 1833(a)(8)(B) (relating to services provided by hospitals). (5) Uniform coding.--For claims for services submitted on or after April 1, 1998, for which the amount of payment is determined under this subsection, the claim shall include a code (or codes) under a uniform coding system specified by the Secretary that identifies the services furnished. (6) Restraint on billing.--The provisions of subparagraphs (A) and (B) of section 1842(b)(18) shall apply to therapy services for which payment is made under this subsection in the same manner as they apply to services provided by a practitioner described in section 1842(b)(18)(C). (7) Adjustment in discount for certain multiple therapy services.--In the case of therapy services furnished on or after April 1, 2013, and for which payment is made under this subsection pursuant to the applicable fee schedule amount (as defined in paragraph (3)), instead of the 25 percent multiple procedure payment reduction specified in the final rule published by the Secretary in the Federal Register on November 29, 2010, the reduction percentage shall be 50 percent. (l) Establishment of Fee Schedule for Ambulance Services.-- (1) In general.--The Secretary shall establish a fee schedule for payment for ambulance services whether provided directly by a supplier or provider or under arrangement with a provider under this part through a negotiated rulemaking process described in title 5, United States Code, and in accordance with the requirements of this subsection. (2) Considerations.--In establishing such fee schedule, the Secretary shall-- (A) establish mechanisms to control increases in expenditures for ambulance services under this part; (B) establish definitions for ambulance services which link payments to the type of services provided; (C) consider appropriate regional and operational differences; (D) consider adjustments to payment rates to account for inflation and other relevant factors; and (E) phase in the application of the payment rates under the fee schedule in an efficient and fair manner consistent with paragraph (11), except that such phase-in shall provide for full payment of any national mileage rate for ambulance services provided by suppliers that are paid by carriers in any of the 50 States where payment by a carrier for such services for all such suppliers in such State did not, prior to the implementation of the fee schedule, include a separate amount for all mileage within the county from which the beneficiary is transported. (3) Savings.--In establishing such fee schedule, the Secretary shall-- (A) ensure that the aggregate amount of payments made for ambulance services under this part during 2000 does not exceed the aggregate amount of payments which would have been made for such services under this part during such year if the amendments made by section 4531(a) of the Balanced Budget Act of 1997 continued in effect, except that in making such determination the Secretary shall assume an update in such payments for 2002 equal to percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 12-month period ending with June of the previous year reduced in the case of 2002 by 1.0 percentage points; (B) set the payment amounts provided under the fee schedule for services furnished in 2001 and each subsequent year at amounts equal to the payment amounts under the fee schedule for services furnished during the previous year, increased, subject to subparagraph (C) and the succeeding sentence of this paragraph, by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 12-month period ending with June of the previous year reduced in the case of 2002 by 1.0 percentage points; and (C) for 2011 and each subsequent year, after determining the percentage increase under subparagraph (B) for the year, reduce such percentage increase by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II). The application of subparagraph (C) may result in the percentage increase under subparagraph (B) being less than 0.0 for a year, and may result in payment rates under the fee schedule under this subsection for a year being less than such payment rates for the preceding year. (4) Consultation.--In establishing the fee schedule for ambulance services under this subsection, the Secretary shall consult with various national organizations representing individuals and entities who furnish and regulate ambulance services and share with such organizations relevant data in establishing such schedule. (5) Limitation on review.--There shall be no administrative or judicial review under section 1869 or otherwise of the amounts established under the fee schedule for ambulance services under this subsection, including matters described in paragraph (2). (6) Restraint on billing.--The provisions of subparagraphs (A) and (B) of section 1842(b)(18) shall apply to ambulance services for which payment is made under this subsection in the same manner as they apply to services provided by a practitioner described in section 1842(b)(18)(C). (7) Coding system.--The Secretary may require the claim for any services for which the amount of payment is determined under this subsection to include a code (or codes) under a uniform coding system specified by the Secretary that identifies the services furnished. (8) Services furnished by critical access hospitals.--Notwithstanding any other provision of this subsection, the Secretary shall pay 101 percent of the reasonable costs incurred in furnishing ambulance services if such services are furnished-- (A) by a critical access hospital (as defined in section 1861(mm)(1)), or (B) by an entity that is owned and operated by a critical access hospital, but only if the critical access hospital or entity is the only provider or supplier of ambulance services that is located within a 35-mile drive of such critical access hospital. (9) Transitional assistance for rural providers.--In the case of ground ambulance services furnished on or after July 1, 2001, and before January 1, 2004, for which the transportation originates in a rural area (as defined in section 1886(d)(2)(D)) or in a rural census tract of a metropolitan statistical area (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992 (57 Fed. Reg. 6725)), the fee schedule established under this subsection shall provide that, with respect to the payment rate for mileage for a trip above 17 miles, and up to 50 miles, the rate otherwise established shall be increased by not less than \1/2\ of the additional payment per mile established for the first 17 miles of such a trip originating in a rural area. (10) Phase-in providing floor using blend of fee schedule and regional fee schedules.--In carrying out the phase-in under paragraph (2)(E) for each level of ground service furnished in a year, the portion of the payment amount that is based on the fee schedule shall be the greater of the amount determined under such fee schedule (without regard to this paragraph) or the following blended rate of the fee schedule under paragraph (1) and of a regional fee schedule for the region involved: (A) For 2004 (for services furnished on or after July 1, 2004), the blended rate shall be based 20 percent on the fee schedule under paragraph (1) and 80 percent on the regional fee schedule. (B) For 2005, the blended rate shall be based 40 percent on the fee schedule under paragraph (1) and 60 percent on the regional fee schedule. (C) For 2006, the blended rate shall be based 60 percent on the fee schedule under paragraph (1) and 40 percent on the regional fee schedule. (D) For 2007, 2008, and 2009, the blended rate shall be based 80 percent on the fee schedule under paragraph (1) and 20 percent on the regional fee schedule. (E) For 2010 and each succeeding year, the blended rate shall be based 100 percent on the fee schedule under paragraph (1). For purposes of this paragraph, the Secretary shall establish a regional fee schedule for each of the nine census divisions (referred to in section 1886(d)(2)) using the methodology (used in establishing the fee schedule under paragraph (1)) to calculate a regional conversion factor and a regional mileage payment rate and using the same payment adjustments and the same relative value units as used in the fee schedule under such paragraph. (11) Adjustment in payment for certain long trips.-- In the case of ground ambulance services furnished on or after July 1, 2004, and before January 1, 2009, regardless of where the transportation originates, the fee schedule established under this subsection shall provide that, with respect to the payment rate for mileage for a trip above 50 miles the per mile rate otherwise established shall be increased by \1/4\ of the payment per mile otherwise applicable to miles in excess of 50 miles in such trip. (12) Assistance for rural providers furnishing services in low population density areas.-- (A) In general.--In the case of ground ambulance services furnished on or after July 1, 2004, and before January 1, 2023, for which the transportation originates in a qualified rural area (identified under subparagraph (B)(iii)), the Secretary shall provide for a percent increase in the base rate of the fee schedule for a trip established under this subsection. In establishing such percent increase, the Secretary shall estimate the average cost per trip for such services (not taking into account mileage) in the lowest quartile as compared to the average cost per trip for such services (not taking into account mileage) in the highest quartile of all rural county populations. (B) Identification of qualified rural areas.-- (i) Determination of population density in area.--Based upon data from the United States decennial census for the year 2000, the Secretary shall determine, for each rural area, the population density for that area. (ii) Ranking of areas.--The Secretary shall rank each such area based on such population density. (iii) Identification of qualified rural areas.--The Secretary shall identify those areas (in subparagraph (A) referred to as ``qualified rural areas'') with the lowest population densities that represent, if each such area were weighted by the population of such area (as used in computing such population densities), an aggregate total of 25 percent of the total of the population of all such areas. (iv) Rural area.--For purposes of this paragraph, the term ``rural area'' has the meaning given such term in section 1886(d)(2)(D). If feasible, the Secretary shall treat a rural census tract of a metropolitan statistical area (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992 (57 Fed. Reg. 6725) as a rural area for purposes of this paragraph. (v) Judicial review.--There shall be no administrative or judicial review under section 1869, 1878, or otherwise, respecting the identification of an area under this subparagraph. (13) Temporary increase for ground ambulance services.-- (A) In general.--After computing the rates with respect to ground ambulance services under the other applicable provisions of this subsection, in the case of such services furnished on or after July 1, 2004, and before January 1, 2007, and for such services furnished on or after July 1, 2008, and before January 1, 2023, for which the transportation originates in-- (i) a rural area described in paragraph (9) or in a rural census tract described in such paragraph, the fee schedule established under this section shall provide that the rate for the service otherwise established, after the application of any increase under paragraphs (11) and (12), shall be increased by 2 percent (or 3 percent if such service is furnished on or after July 1, 2008, and before January 1, 2023); and (ii) an area not described in clause (i), the fee schedule established under this subsection shall provide that the rate for the service otherwise established, after the application of any increase under paragraph (11), shall be increased by 1 percent (or 2 percent if such service is furnished on or after July 1, 2008, and before January 1, 2023). (B) Application of increased payments after applicable period.--The increased payments under subparagraph (A) shall not be taken into account in calculating payments for services furnished after the applicable period specified in such subparagraph. (14) Providing appropriate coverage of rural air ambulance services.-- (A) In general.--The regulations described in section 1861(s)(7) shall provide, to the extent that any ambulance services (whether ground or air) may be covered under such section, that a rural air ambulance service (as defined in subparagraph (C)) is reimbursed under this subsection at the air ambulance rate if the air ambulance service-- (i) is reasonable and necessary based on the health condition of the individual being transported at or immediately prior to the time of the transport; and (ii) complies with equipment and crew requirements established by the Secretary. (B) Satisfaction of requirement of medically necessary.--The requirement of subparagraph (A)(i) is deemed to be met for a rural air ambulance service if-- (i) subject to subparagraph (D), such service is requested by a physician or other qualified medical personnel (as specified by the Secretary) who certifies or reasonably determines that the individual's condition is such that the time needed to transport the individual by land or the instability of transportation by land poses a threat to the individual's survival or seriously endangers the individual's health; or (ii) such service is furnished pursuant to a protocol that is established by a State or regional emergency medical service (EMS) agency and recognized or approved by the Secretary under which the use of an air ambulance is recommended, if such agency does not have an ownership interest in the entity furnishing such service. (C) Rural air ambulance service defined.--For purposes of this paragraph, the term ``rural air ambulance service'' means fixed wing and rotary wing air ambulance service in which the point of pick up of the individual occurs in a rural area (as defined in section 1886(d)(2)(D)) or in a rural census tract of a metropolitan statistical area (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992 (57 Fed. Reg. 6725)). (D) Limitation.-- (i) In general.--Subparagraph (B)(i) shall not apply if there is a financial or employment relationship between the person requesting the rural air ambulance service and the entity furnishing the ambulance service, or an entity under common ownership with the entity furnishing the air ambulance service, or a financial relationship between an immediate family member of such requester and such an entity. (ii) Exception.--Where a hospital and the entity furnishing rural air ambulance services are under common ownership, clause (i) shall not apply to remuneration (through employment or other relationship) by the hospital of the requester or immediate family member if the remuneration is for provider-based physician services furnished in a hospital (as described in section 1887) which are reimbursed under part A and the amount of the remuneration is unrelated directly or indirectly to the provision of rural air ambulance services. (15) Payment adjustment for non-emergency ambulance transports for esrd beneficiaries.--The fee schedule amount otherwise applicable under the preceding provisions of this subsection shall be reduced by 10 percent for ambulance services furnished during the period beginning on October 1, 2013, and ending on September 30, 2018, and by 23 percent for such services furnished on or after October 1, 2018, consisting of non-emergency basic life support services involving transport of an individual with end-stage renal disease for renal dialysis services (as described in section 1881(b)(14)(B)) furnished other than on an emergency basis by a provider of services or a renal dialysis facility. (16) Prior authorization for repetitive scheduled non-emergent ambulance transports.-- (A) In general.--Beginning January 1, 2017, if the expansion to all States of the model of prior authorization described in paragraph (2) of section 515(a) of the Medicare Access and CHIP Reauthorization Act of 2015 meets the requirements described in paragraphs (1) through (3) of section 1115A(c), then the Secretary shall expand such model to all States. (B) Funding.--The Secretary shall use funds made available under section 1893(h)(10) to carry out this paragraph. (C) Clarification regarding budget neutrality.--Nothing in this paragraph may be construed to limit or modify the application of section 1115A(b)(3)(B) to models described in such section, including with respect to the model described in subparagraph (A) and expanded beginning on January 1, 2017, under such subparagraph. (17) Submission of cost and other information.-- (A) Development of data collection system.-- The Secretary shall develop a data collection system (which may include use of a cost survey) to collect cost, revenue, utilization, and other information determined appropriate by the Secretary with respect to providers of services (in this paragraph referred to as ``providers'') and suppliers of ground ambulance services. Such system shall be designed to collect information-- (i) needed to evaluate the extent to which reported costs relate to payment rates under this subsection; (ii) on the utilization of capital equipment and ambulance capacity, including information consistent with the type of information described in section 1121(a); and (iii) on different types of ground ambulance services furnished in different geographic locations, including rural areas and low population density areas described in paragraph (12). (B) Specification of data collection system.-- (i) In general.--The Secretary shall-- (I) not later than December 31, 2019, specify the data collection system under subparagraph (A); and (II) identify the providers and suppliers of ground ambulance services that would be required to submit information under such data collection system, including the representative sample described in clause (ii). (ii) Determination of representative sample.-- (I) In general.--Not later than December 31, 2019, with respect to the data collection for the first year under such system, and for each subsequent year through 2024, the Secretary shall determine a representative sample to submit information under the data collection system. (II) Requirements.--The sample under subclause (I) shall be representative of the different types of providers and suppliers of ground ambulance services (such as those providers and suppliers that are part of an emergency service or part of a government organization) and the geographic locations in which ground ambulance services are furnished (such as urban, rural, and low population density areas). (III) Limitation.--The Secretary shall not include an individual provider or supplier of ground ambulance services in the sample under subclause (I) in 2 consecutive years, to the extent practicable. (C) Reporting of cost information.--For each year, a provider or supplier of ground ambulance services identified by the Secretary under subparagraph (B)(i)(II) as being required to submit information under the data collection system with respect to a period for the year shall submit to the Secretary information specified under the system. Such information shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this subparagraph. (D) Payment reduction for failure to report.-- (i) In general.--Beginning January 1, 2022, subject to clause (ii), a 10 percent reduction to payments under this subsection shall be made for the applicable period (as defined in clause (ii)) to a provider or supplier of ground ambulance services that-- (I) is required to submit information under the data collection system with respect to a period under subparagraph (C); and (II) does not sufficiently submit such information, as determined by the Secretary. (ii) Applicable period defined.--For purposes of clause (i), the term ``applicable period'' means, with respect to a provider or supplier of ground ambulance services, a year specified by the Secretary not more than 2 years after the end of the period with respect to which the Secretary has made a determination under clause (i)(II) that the provider or supplier of ground ambulance services failed to sufficiently submit information under the data collection system. (iii) Hardship exemption.--The Secretary may exempt a provider or supplier from the payment reduction under clause (i) with respect to an applicable period in the event of significant hardship, such as a natural disaster, bankruptcy, or other similar situation that the Secretary determines interfered with the ability of the provider or supplier of ground ambulance services to submit such information in a timely manner for the specified period. (iv) Informal review.--The Secretary shall establish a process under which a provider or supplier of ground ambulance services may seek an informal review of a determination that the provider or supplier is subject to the payment reduction under clause (i). (E) Ongoing data collection.-- (i) Revision of data collection system.--The Secretary may, as the Secretary determines appropriate and, if available, taking into consideration the report (or reports) under subparagraph (F), revise the data collection system under subparagraph (A). (ii) Subsequent data collection.--In order to continue to evaluate the extent to which reported costs relate to payment rates under this subsection and for other purposes the Secretary deems appropriate, the Secretary shall require providers and suppliers of ground ambulance services to submit information for years after 2024 as the Secretary determines appropriate, but in no case less often than once every 3 years. (F) Ground ambulance data collection system study.-- (i) In general.--Not later than March 15, 2023, and as determined necessary by the Medicare Payment Advisory Commission thereafter, such Commission shall assess, and submit to Congress a report on, information submitted by providers and suppliers of ground ambulance services through the data collection system under subparagraph (A), the adequacy of payments for ground ambulance services under this subsection, and geographic variations in the cost of furnishing such services. (ii) Contents.--A report under clause (i) shall contain the following: (I) An analysis of information submitted through the data collection system. (II) An analysis of any burden on providers and suppliers of ground ambulance services associated with the data collection system. (III) A recommendation as to whether information should continue to be submitted through such data collection system or if such system should be revised under subparagraph (E)(i). (IV) Other information determined appropriate by the Commission. (G) Public availability.--The Secretary shall post information on the results of the data collection under this paragraph on the Internet website of the Centers for Medicare & Medicaid Services, as determined appropriate by the Secretary. (H) Implementation.--The Secretary shall implement this paragraph through notice and comment rulemaking. (I) Administration.--Chapter 35 of title 44, United States Code, shall not apply to the collection of information required under this subsection. (J) Limitations on review.--There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the data collection system or identification of respondents under this paragraph. (K) Funding for implementation.--For purposes of carrying out subparagraph (A), the Secretary shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund under section 1841, of $15,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for fiscal year 2018. Amounts transferred under this subparagraph shall remain available until expended. (m) Payment for Telehealth Services.-- (1) In general.--The Secretary shall pay for telehealth services that are furnished via a telecommunications system by a physician (as defined in section 1861(r)) or a practitioner (described in section 1842(b)(18)(C)) to an eligible telehealth individual enrolled under this part notwithstanding that the individual physician or practitioner providing the telehealth service is not at the same location as the beneficiary. For purposes of the preceding sentence, in the case of any Federal telemedicine demonstration program conducted in Alaska or Hawaii, the term ``telecommunications system'' includes store- and-forward technologies that provide for the asynchronous transmission of health care information in single or multimedia formats. (2) Payment amount.-- (A) Distant site.--The Secretary shall pay to a physician or practitioner located at a distant site that furnishes a telehealth service to an eligible telehealth individual an amount equal to the amount that such physician or practitioner would have been paid under this title had such service been furnished without the use of a telecommunications system. (B) Facility fee for originating site.-- (i) In general.--Subject to clause (ii) [and paragraph (6)(C)], paragraph (6)(C), and paragraph (8)(C), with respect to a telehealth service, subject to section 1833(a)(1)(U), there shall be paid to the originating site a facility fee equal to-- (I) for the period beginning on October 1, 2001, and ending on December 31, 2001, and for 2002, $20; and (II) for a subsequent year, the facility fee specified in subclause (I) or this subclause for the preceding year increased by the percentage increase in the MEI (as defined in section 1842(i)(3)) for such subsequent year. (ii) No facility fee if originating site is the home.--No facility fee shall be paid under this subparagraph to an originating site described in paragraph (4)(C)(ii)(X). (C) Telepresenter not required.--Nothing in this subsection shall be construed as requiring an eligible telehealth individual to be presented by a physician or practitioner at the originating site for the furnishing of a service via a telecommunications system, unless it is medically necessary (as determined by the physician or practitioner at the distant site). (3) Limitation on beneficiary charges.-- (A) Physician and practitioner.--The provisions of section 1848(g) and subparagraphs (A) and (B) of section 1842(b)(18) shall apply to a physician or practitioner receiving payment under this subsection in the same manner as they apply to physicians or practitioners under such sections. (B) Originating site.--The provisions of section 1842(b)(18) shall apply to originating sites receiving a facility fee in the same manner as they apply to practitioners under such section. (4) Definitions.--For purposes of this subsection: (A) Distant site.--The term ``distant site'' means the site at which the physician or practitioner is located at the time the service is provided via a telecommunications system. (B) Eligible telehealth individual.--The term ``eligible telehealth individual'' means an individual enrolled under this part who receives a telehealth service furnished at an originating site. (C) Originating site.-- (i) In general.--Except as provided in paragraphs (5), (6), [and (7)] (7), and (8), the term``originating site'' means only those sites described in clause (ii) at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system and only if such site is located-- (I) in an area that is designated as a rural health professional shortage area under section 332(a)(1)(A) of the Public Health Service Act (42 U.S.C. 254e(a)(1)(A)); (II) in a county that is not included in a Metropolitan Statistical Area; or (III) from an entity that participates in a Federal telemedicine demonstration project that has been approved by (or receives funding from) the Secretary of Health and Human Services as of December 31, 2000. (ii) Sites described.--The sites referred to in clause (i) are the following sites: (I) The office of a physician or practitioner. (II) A critical access hospital (as defined in section 1861(mm)(1)). (III) A rural health clinic (as defined in section 1861(aa)(2)). (IV) A Federally qualified health center (as defined in section 1861(aa)(4)). (V) A hospital (as defined in section 1861(e)). (VI) A hospital-based or critical access hospital-based renal dialysis center (including satellites). (VII) A skilled nursing facility (as defined in section 1819(a)). (VIII) A community mental health center (as defined in section 1861(ff)(3)(B)). (IX) A renal dialysis facility, but only for purposes of section 1881(b)(3)(B). (X) The home of an individual, but only for purposes of section 1881(b)(3)(B) or telehealth services described in paragraph (7). (D) Physician.--The term ``physician'' has the meaning given that term in section 1861(r). (E) Practitioner.--The term ``practitioner'' has the meaning given that term in section 1842(b)(18)(C). (F) Telehealth service.-- (i) In general.--The term ``telehealth service'' means professional consultations, office visits, and office psychiatry services (identified as of July 1, 2000, by HCPCS codes 99241-99275, 99201-99215, 90804-90809, and 90862 (and as subsequently modified by the Secretary)), services identified by CPT codes 90832, 90834, and 90837 (and as subsequently modified by the Secretary), and any additional service specified by the Secretary. (ii) Yearly update.--The Secretary shall establish a process that provides, on an annual basis, for the addition or deletion of services (and HCPCS codes), as appropriate, to those specified in clause (i) for authorized payment under paragraph (1). (5) Treatment of home dialysis monthly esrd-related visit.--The geographic requirements described in paragraph (4)(C)(i) shall not apply with respect to telehealth services furnished on or after January 1, 2019, for purposes of section 1881(b)(3)(B), at an originating site described in subclause (VI), (IX), or (X) of paragraph (4)(C)(ii). (6) Treatment of stroke telehealth services.-- (A) Non-application of originating site requirements.--The requirements described in [paragraph (4)(C)] paragraph (4)(C)(i) shall not apply with respect to telehealth services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke, as determined by the Secretary. (B) Inclusion of certain sites.--With respect to telehealth services described in subparagraph (A), the term ``originating site'' shall include any hospital (as defined in section 1861(e)) or critical access hospital (as defined in section 1861(mm)(1)), any mobile stroke unit (as defined by the Secretary), or any other site determined appropriate by the Secretary, at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system. (C) No originating site facility fee for new sites.--No facility fee shall be paid under paragraph (2)(B) to an originating site with respect to a telehealth service described in subparagraph (A) if the originating site does not otherwise meet the requirements for an originating site under paragraph (4)(C). (7) Treatment of substance use disorder services furnished through telehealth.--[The geographic requirements] Subject to paragraph (8)(D), the geographic requirements described in paragraph (4)(C)(i) shall not apply with respect to telehealth services furnished on or after July 1, 2019, to an eligible telehealth individual with a substance use disorder diagnosis for purposes of treatment of such disorder or co-occurring mental health disorder, as determined by the Secretary, at an originating site described in paragraph (4)(C)(ii) (other than an originating site described in subclause (IX) of such paragraph). (8) Treatment of mental health telehealth services.-- (A) Non-application of originating site requirements.--The requirements described in paragraph (4)(C)(i) shall not apply with respect to telehealth services furnished on or after January 1, 2021, that are mental health telehealth services. Nothing in the previous sentence shall waive any applicable State law requirements. (B) Inclusion of certain sites.--With respect to telehealth services described in subparagraph (A), the term ``originating site'' shall include the home of the eligible telehealth individual at which the individual is located at the time the service is furnished via a telecommunications system. (C) No originating site facility fee.--No facility fee shall be paid under paragraph (2)(B) to an originating site with respect to a telehealth service described in subparagraph (A) if the originating site does not otherwise meet the requirements for an originating site under paragraph (4)(C). (D) Face-to-face initial assessment; reassessments.--Payment may not be made for mental health telehealth services under this paragraph (if such payment would not otherwise be allowed under this subsection without application of this paragraph or paragraph (7)) furnished to an eligible telehealth individual unless-- (i) within the 6-month period prior to the provision of such mental health telehealth services, the individual receives a face-to-face clinical assessment, without the use of telehealth, by a physician described in subparagraph (F)(i) or a practitioner described in subparagraph (F)(ii) of the needs of such individual for such services; and (ii) the individual receives a reassessment (at a frequency specified by the Secretary) by a physician so described or a practitioner so described of the needs of such individual for such services. (E) Mental health telehealth services defined.--For purposes of this paragraph, the term ``mental health telehealth service'' means services identified by CPT codes 90832, 90834, and 90837 (and as subsequently modified by the Secretary). (F) Physician and practitioner described.-- For purposes of subparagraph (D): (i) Physician.--A physician described in this clause is a physician, as defined in section 1861(r)(1). (ii) Practitioner.--A practitioner described in this clause is a practitioner described in any of clauses (i), (iv), or (v) of section 1842(b)(18)(C). (n) Authority To Modify or Eliminate Coverage of Certain Preventive Services.--Notwithstanding any other provision of this title, effective beginning on January 1, 2010, if the Secretary determines appropriate, the Secretary may-- (1) modify-- (A) the coverage of any preventive service described in subparagraph (A) of section 1861(ddd)(3) to the extent that such modification is consistent with the recommendations of the United States Preventive Services Task Force; and (B) the services included in the initial preventive physical examination described in subparagraph (B) of such section; and (2) provide that no payment shall be made under this title for a preventive service described in subparagraph (A) of such section that has not received a grade of A, B, C, or I by such Task Force. (o) Development and Implementation of Prospective Payment System.-- (1) Development.-- (A) In general.--The Secretary shall develop a prospective payment system for payment for Federally qualified health center services furnished by Federally qualified health centers under this title. Such system shall include a process for appropriately describing the services furnished by Federally qualified health centers and shall establish payment rates for specific payment codes based on such appropriate descriptions of services. Such system shall be established to take into account the type, intensity, and duration of services furnished by Federally qualified health centers. Such system may include adjustments, including geographic adjustments, determined appropriate by the Secretary. (B) Collection of data and evaluation.--By not later than January 1, 2011, the Secretary shall require Federally qualified health centers to submit to the Secretary such information as the Secretary may require in order to develop and implement the prospective payment system under this subsection, including the reporting of services using HCPCS codes. (2) Implementation.-- (A) In general.--Notwithstanding section 1833(a)(3)(A), the Secretary shall provide, for cost reporting periods beginning on or after October 1, 2014, for payments of prospective payment rates for Federally qualified health center services furnished by Federally qualified health centers under this title in accordance with the prospective payment system developed by the Secretary under paragraph (1). (B) Payments.-- (i) Initial payments.--The Secretary shall implement such prospective payment system so that the estimated aggregate amount of prospective payment rates (determined prior to the application of section 1833(a)(1)(Z)) under this title for Federally qualified health center services in the first year that such system is implemented is equal to 100 percent of the estimated amount of reasonable costs (determined without the application of a per visit payment limit or productivity screen and prior to the application of section 1866(a)(2)(A)(ii)) that would have occurred for such services under this title in such year if the system had not been implemented. (ii) Payments in subsequent years.-- Payment rates in years after the year of implementation of such system shall be the payment rates in the previous year increased-- (I) in the first year after implementation of such system, by the percentage increase in the MEI (as defined in section 1842(i)(3)) for the year involved; and (II) in subsequent years, by the percentage increase in a market basket of Federally qualified health center goods and services as promulgated through regulations, or if such an index is not available, by the percentage increase in the MEI (as defined in section 1842(i)(3)) for the year involved. (C) Preparation for pps implementation.-- Notwithstanding any other provision of law, the Secretary may establish and implement by program instruction or otherwise the payment codes to be used under the prospective payment system under this section. (3) Additional payments for certain fqhcs with physicians or other practitioners receiving data 2000 waivers.-- (A) In general.--In the case of a Federally qualified health center with respect to which, beginning on or after January 1, 2019, Federally qualified health center services (as defined in section 1861(aa)(3)) are furnished for the treatment of opioid use disorder by a physician or practitioner who meets the requirements described in subparagraph (C), the Secretary shall, subject to availability of funds under subparagraph (D), make a payment (at such time and in such manner as specified by the Secretary) to such Federally qualified health center after receiving and approving an application submitted by such Federally qualified health center under subparagraph (B). Such a payment shall be in an amount determined by the Secretary, based on an estimate of the average costs of training for purposes of receiving a waiver described in subparagraph (C)(ii). Such a payment may be made only one time with respect to each such physician or practitioner. (B) Application.--In order to receive a payment described in subparagraph (A), a Federally qualified health center shall submit to the Secretary an application for such a payment at such time, in such manner, and containing such information as specified by the Secretary. A Federally qualified health center may apply for such a payment for each physician or practitioner described in subparagraph (A) furnishing services described in such subparagraph at such center. (C) Requirements.--For purposes of subparagraph (A), the requirements described in this subparagraph, with respect to a physician or practitioner, are the following: (i) The physician or practitioner is employed by or working under contract with a Federally qualified health center described in subparagraph (A) that submits an application under subparagraph (B). (ii) The physician or practitioner first receives a waiver under section 303(g) of the Controlled Substances Act on or after January 1, 2019. (D) Funding.--For purposes of making payments under this paragraph, there are appropriated, out of amounts in the Treasury not otherwise appropriated, $6,000,000, which shall remain available until expended. (p) Quality Incentives To Promote Patient Safety and Public Health in Computed Tomography.-- (1) Quality incentives.--In the case of an applicable computed tomography service (as defined in paragraph (2)) for which payment is made under an applicable payment system (as defined in paragraph (3)) and that is furnished on or after January 1, 2016, using equipment that is not consistent with the CT equipment standard (described in paragraph (4)), the payment amount for such service shall be reduced by the applicable percentage (as defined in paragraph (5)). (2) Applicable computed tomography services defined.--In this subsection, the term ``applicable computed tomography service'' means a service billed using diagnostic radiological imaging codes for computed tomography (identified as of January 1, 2014, by HCPCS codes 70450-70498, 71250-71275, 72125-72133, 72191-72194, 73200-73206, 73700-73706, 74150-74178, 74261-74263, and 75571-75574 (and any succeeding codes). (3) Applicable payment system defined.--In this subsection, the term ``applicable payment system'' means the following: (A) The technical component and the technical component of the global fee under the fee schedule established under section 1848(b). (B) The prospective payment system for hospital outpatient department services under section 1833(t). (4) Consistency with ct equipment standard.--In this subsection, the term ``not consistent with the CT equipment standard'' means, with respect to an applicable computed tomography service, that the service was furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013, entitled ``Standard Attributes on CT Equipment Related to Dose Optimization and Management''. Through rulemaking, the Secretary may apply successor standards. (5) Applicable percentage defined.--In this subsection, the term ``applicable percentage'' means-- (A) for 2016, 5 percent; and (B) for 2017 and subsequent years, 15 percent. (6) Implementation.-- (A) Information.--The Secretary shall require that information be provided and attested to by a supplier and a hospital outpatient department that indicates whether an applicable computed tomography service was furnished that was not consistent with the CT equipment standard (described in paragraph (4)). Such information may be included on a claim and may be a modifier. Such information shall be verified, as appropriate, as part of the periodic accreditation of suppliers under section 1834(e) and hospitals under section 1865(a). (B) Administration.--Chapter 35 of title 44, United States Code, shall not apply to information described in subparagraph (A). (q) Recognizing Appropriate Use Criteria for Certain Imaging Services.-- (1) Program established.-- (A) In general.--The Secretary shall establish a program to promote the use of appropriate use criteria (as defined in subparagraph (B)) for applicable imaging services (as defined in subparagraph (C)) furnished in an applicable setting (as defined in subparagraph (D)) by ordering professionals and furnishing professionals (as defined in subparagraphs (E) and (F), respectively). (B) Appropriate use criteria defined.--In this subsection, the term ``appropriate use criteria'' means criteria, only developed or endorsed by national professional medical specialty societies or other provider-led entities, to assist ordering professionals and furnishing professionals in making the most appropriate treatment decision for a specific clinical condition for an individual. To the extent feasible, such criteria shall be evidence-based. (C) Applicable imaging service defined.--In this subsection, the term ``applicable imaging service'' means an advanced diagnostic imaging service (as defined in subsection (e)(1)(B)) for which the Secretary determines-- (i) one or more applicable appropriate use criteria specified under paragraph (2) apply; (ii) there are one or more qualified clinical decision support mechanisms listed under paragraph (3)(C); and (iii) one or more of such mechanisms is available free of charge. (D) Applicable setting defined.--In this subsection, the term ``applicable setting'' means a physician's office, a hospital outpatient department (including an emergency department), an ambulatory surgical center, and any other provider-led outpatient setting determined appropriate by the Secretary. (E) Ordering professional defined.--In this subsection, the term ``ordering professional'' means a physician (as defined in section 1861(r)) or a practitioner described in section 1842(b)(18)(C) who orders an applicable imaging service. (F) Furnishing professional defined.--In this subsection, the term ``furnishing professional'' means a physician (as defined in section 1861(r)) or a practitioner described in section 1842(b)(18)(C) who furnishes an applicable imaging service. (2) Establishment of applicable appropriate use criteria.-- (A) In general.--Not later than November 15, 2015, the Secretary shall through rulemaking, and in consultation with physicians, practitioners, and other stakeholders, specify applicable appropriate use criteria for applicable imaging services only from among appropriate use criteria developed or endorsed by national professional medical specialty societies or other provider-led entities. (B) Considerations.--In specifying applicable appropriate use criteria under subparagraph (A), the Secretary shall take into account whether the criteria-- (i) have stakeholder consensus; (ii) are scientifically valid and evidence based; and (iii) are based on studies that are published and reviewable by stakeholders. (C) Revisions.--The Secretary shall review, on an annual basis, the specified applicable appropriate use criteria to determine if there is a need to update or revise (as appropriate) such specification of applicable appropriate use criteria and make such updates or revisions through rulemaking. (D) Treatment of multiple applicable appropriate use criteria.--In the case where the Secretary determines that more than one appropriate use criterion applies with respect to an applicable imaging service, the Secretary shall apply one or more applicable appropriate use criteria under this paragraph for the service. (3) Mechanisms for consultation with applicable appropriate use criteria.-- (A) Identification of mechanisms to consult with applicable appropriate use criteria.-- (i) In general.--The Secretary shall specify qualified clinical decision support mechanisms that could be used by ordering professionals to consult with applicable appropriate use criteria for applicable imaging services. (ii) Consultation.--The Secretary shall consult with physicians, practitioners, health care technology experts, and other stakeholders in specifying mechanisms under this paragraph. (iii) Inclusion of certain mechanisms.--Mechanisms specified under this paragraph may include any or all of the following that meet the requirements described in subparagraph (B)(ii): (I) Use of clinical decision support modules in certified EHR technology (as defined in section 1848(o)(4)). (II) Use of private sector clinical decision support mechanisms that are independent from certified EHR technology, which may include use of clinical decision support mechanisms available from medical specialty organizations. (III) Use of a clinical decision support mechanism established by the Secretary. (B) Qualified clinical decision support mechanisms.-- (i) In general.--For purposes of this subsection, a qualified clinical decision support mechanism is a mechanism that the Secretary determines meets the requirements described in clause (ii). (ii) Requirements.--The requirements described in this clause are the following: (I) The mechanism makes available to the ordering professional applicable appropriate use criteria specified under paragraph (2) and the supporting documentation for the applicable imaging service ordered. (II) In the case where there is more than one applicable appropriate use criterion specified under such paragraph for an applicable imaging service, the mechanism indicates the criteria that it uses for the service. (III) The mechanism determines the extent to which an applicable imaging service ordered is consistent with the applicable appropriate use criteria so specified. (IV) The mechanism generates and provides to the ordering professional a certification or documentation that documents that the qualified clinical decision support mechanism was consulted by the ordering professional. (V) The mechanism is updated on a timely basis to reflect revisions to the specification of applicable appropriate use criteria under such paragraph. (VI) The mechanism meets privacy and security standards under applicable provisions of law. (VII) The mechanism performs such other functions as specified by the Secretary, which may include a requirement to provide aggregate feedback to the ordering professional. (C) List of mechanisms for consultation with applicable appropriate use criteria.-- (i) Initial list.--Not later than April 1, 2016, the Secretary shall publish a list of mechanisms specified under this paragraph. (ii) Periodic updating of list.--The Secretary shall identify on an annual basis the list of qualified clinical decision support mechanisms specified under this paragraph. (4) Consultation with applicable appropriate use criteria.-- (A) Consultation by ordering professional.-- Beginning with January 1, 2017, subject to subparagraph (C), with respect to an applicable imaging service ordered by an ordering professional that would be furnished in an applicable setting and paid for under an applicable payment system (as defined in subparagraph (D)), an ordering professional shall-- (i) consult with a qualified decision support mechanism listed under paragraph (3)(C); and (ii) provide to the furnishing professional the information described in clauses (i) through (iii) of subparagraph (B). (B) Reporting by furnishing professional.-- Beginning with January 1, 2017, subject to subparagraph (C), with respect to an applicable imaging service furnished in an applicable setting and paid for under an applicable payment system (as defined in subparagraph (D)), payment for such service may only be made if the claim for the service includes the following: (i) Information about which qualified clinical decision support mechanism was consulted by the ordering professional for the service. (ii) Information regarding-- (I) whether the service ordered would adhere to the applicable appropriate use criteria specified under paragraph (2); (II) whether the service ordered would not adhere to such criteria; or (III) whether such criteria was not applicable to the service ordered. (iii) The national provider identifier of the ordering professional (if different from the furnishing professional). (C) Exceptions.--The provisions of subparagraphs (A) and (B) and paragraph (6)(A) shall not apply to the following: (i) Emergency services.--An applicable imaging service ordered for an individual with an emergency medical condition (as defined in section 1867(e)(1)). (ii) Inpatient services.--An applicable imaging service ordered for an inpatient and for which payment is made under part A. (iii) Significant hardship.--An applicable imaging service ordered by an ordering professional who the Secretary may, on a case-by-case basis, exempt from the application of such provisions if the Secretary determines, subject to annual renewal, that consultation with applicable appropriate use criteria would result in a significant hardship, such as in the case of a professional who practices in a rural area without sufficient Internet access. (D) Applicable payment system defined.--In this subsection, the term ``applicable payment system'' means the following: (i) The physician fee schedule established under section 1848(b). (ii) The prospective payment system for hospital outpatient department services under section 1833(t). (iii) The ambulatory surgical center payment systems under section 1833(i). (5) Identification of outlier ordering professionals.-- (A) In general.--With respect to applicable imaging services furnished beginning with 2017, the Secretary shall determine, on an annual basis, no more than five percent of the total number of ordering professionals who are outlier ordering professionals. (B) Outlier ordering professionals.--The determination of an outlier ordering professional shall-- (i) be based on low adherence to applicable appropriate use criteria specified under paragraph (2), which may be based on comparison to other ordering professionals; and (ii) include data for ordering professionals for whom prior authorization under paragraph (6)(A) applies. (C) Use of two years of data.--The Secretary shall use two years of data to identify outlier ordering professionals under this paragraph. (D) Process.--The Secretary shall establish a process for determining when an outlier ordering professional is no longer an outlier ordering professional. (E) Consultation with stakeholders.--The Secretary shall consult with physicians, practitioners and other stakeholders in developing methods to identify outlier ordering professionals under this paragraph. (6) Prior authorization for ordering professionals who are outliers.-- (A) In general.--Beginning January 1, 2020, subject to paragraph (4)(C), with respect to services furnished during a year, the Secretary shall, for a period determined appropriate by the Secretary, apply prior authorization for applicable imaging services that are ordered by an outlier ordering professional identified under paragraph (5). (B) Appropriate use criteria in prior authorization.--In applying prior authorization under subparagraph (A), the Secretary shall utilize only the applicable appropriate use criteria specified under this subsection. (C) Funding.--For purposes of carrying out this paragraph, the Secretary shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund under section 1841, of $5,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for each of fiscal years 2019 through 2021. Amounts transferred under the preceding sentence shall remain available until expended. (7) Construction.--Nothing in this subsection shall be construed as granting the Secretary the authority to develop or initiate the development of clinical practice guidelines or appropriate use criteria. (r) Payment for Renal Dialysis Services for Individuals With Acute Kidney Injury.-- (1) Payment rate.--In the case of renal dialysis services (as defined in subparagraph (B) of section 1881(b)(14)) furnished under this part by a renal dialysis facility or provider of services paid under such section during a year (beginning with 2017) to an individual with acute kidney injury (as defined in paragraph (2)), the amount of payment under this part for such services shall be the base rate for renal dialysis services determined for such year under such section, as adjusted by any applicable geographic adjustment factor applied under subparagraph (D)(iv)(II) of such section and may be adjusted by the Secretary (on a budget neutral basis for payments under this paragraph) by any other adjustment factor under subparagraph (D) of such section. (2) Individual with acute kidney injury defined.--In this subsection, the term ``individual with acute kidney injury'' means an individual who has acute loss of renal function and does not receive renal dialysis services for which payment is made under section 1881(b)(14). (s) Payment for Applicable Disposable Devices.-- (1) Separate payment.--The Secretary shall make a payment (separate from the payments otherwise made under section 1895) in the amount established under paragraph (3) to a home health agency for an applicable disposable device (as defined in paragraph (2)) when furnished on or after January 1, 2017, to an individual who receives home health services for which payment is made under section 1895(b). (2) Applicable disposable device.--In this subsection, the term applicable disposable device means a disposable device that, as determined by the Secretary, is-- (A) a disposable negative pressure wound therapy device that is an integrated system comprised of a non-manual vacuum pump, a receptacle for collecting exudate, and dressings for the purposes of wound therapy; and (B) a substitute for, and used in lieu of, a negative pressure wound therapy durable medical equipment item that is an integrated system of a negative pressure vacuum pump, a separate exudate collection canister, and dressings that would otherwise be covered for individuals for such wound therapy. (3) Payment amount.--The separate payment amount established under this paragraph for an applicable disposable device for a year shall be equal to the amount of the payment that would be made under section 1833(t) (relating to payment for covered OPD services) for the year for the Level I Healthcare Common Procedure Coding System (HCPCS) code for which the description for a professional service includes the furnishing of such device. (t) Site-of-Service Price Transparency.-- (1) In general.--In order to facilitate price transparency with respect to items and services for which payment may be made either to a hospital outpatient department or to an ambulatory surgical center under this title, the Secretary shall, for 2018 and each year thereafter, make available to the public via a searchable Internet website, with respect to an appropriate number of such items and services-- (A) the estimated payment amount for the item or service under the outpatient department fee schedule under subsection (t) of section 1833 and the ambulatory surgical center payment system under subsection (i) of such section; and (B) the estimated amount of beneficiary liability applicable to the item or service. (2) Calculation of estimated beneficiary liability.-- For purposes of paragraph (1)(B), the estimated amount of beneficiary liability, with respect to an item or service, is the amount for such item or service for which an individual who does not have coverage under a Medicare supplemental policy certified under section 1882 or any other supplemental insurance coverage is responsible. (3) Implementation.--In carrying out this subsection, the Secretary-- (A) shall include in the notice described in section 1804(a) a notification of the availability of the estimated amounts made available under paragraph (1); and (B) may utilize mechanisms in existence on the date of enactment of this subsection, such as the portion of the Internet website of the Centers for Medicare & Medicaid Services on which information comparing physician performance is posted (commonly referred to as the Physician Compare Internet website), to make available such estimated amounts under such paragraph. (4) Funding.--For purposes of implementing this subsection, the Secretary shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund under section 1841 to the Centers for Medicare & Medicaid Services Program Management Account, of $6,000,000 for fiscal year 2017, to remain available until expended. (u) Payment and Related Requirements for Home Infusion Therapy.-- (1) Payment.-- (A) Single payment.-- (i) In general.--Subject to clause (iii) and subparagraphs (B) and (C), the Secretary shall implement a payment system under which a single payment is made under this title to a qualified home infusion therapy supplier for items and services described in subparagraphs (A) and (B) of section 1861(iii)(2)) furnished by a qualified home infusion therapy supplier (as defined in section 1861(iii)(3)(D)) in coordination with the furnishing of home infusion drugs (as defined in section 1861(iii)(3)(C)) under this part. (ii) Unit of single payment.--A unit of single payment under the payment system implemented under this subparagraph is for each infusion drug administration calendar day in the individual's home. The Secretary shall, as appropriate, establish single payment amounts for types of infusion therapy, including to take into account variation in utilization of nursing services by therapy type. (iii) Limitation.--The single payment amount determined under this subparagraph after application of subparagraph (B) and paragraph (3) shall not exceed the amount determined under the fee schedule under section 1848 for infusion therapy services furnished in a calendar day if furnished in a physician office setting, except such single payment shall not reflect more than 5 hours of infusion for a particular therapy in a calendar day. (B) Required adjustments.--The Secretary shall adjust the single payment amount determined under subparagraph (A) for home infusion therapy services under section 1861(iii)(1) to reflect other factors such as-- (i) a geographic wage index and other costs that may vary by region; and (ii) patient acuity and complexity of drug administration. (C) Discretionary adjustments.-- (i) In general.--Subject to clause (ii), the Secretary may adjust the single payment amount determined under subparagraph (A) (after application of subparagraph (B)) to reflect outlier situations and other factors as the Secretary determines appropriate. (ii) Requirement of budget neutrality.--Any adjustment under this subparagraph shall be made in a budget neutral manner. (2) Considerations.--In developing the payment system under this subsection, the Secretary may consider the costs of furnishing infusion therapy in the home, consult with home infusion therapy suppliers, consider payment amounts for similar items and services under this part and part A, and consider payment amounts established by Medicare Advantage plans under part C and in the private insurance market for home infusion therapy (including average per treatment day payment amounts by type of home infusion therapy). (3) Annual updates.-- (A) In general.--Subject to subparagraph (B), the Secretary shall update the single payment amount under this subsection from year to year beginning in 2022 by increasing the single payment amount from the prior year by the percentage increase in the Consumer Price Index for all urban consumers (United States city average) for the 12-month period ending with June of the preceding year. (B) Adjustment.--For each year, the Secretary shall reduce the percentage increase described in subparagraph (A) by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II). The application of the preceding sentence may result in a percentage being less than 0.0 for a year, and may result in payment being less than such payment rates for the preceding year. (4) Authority to apply prior authorization.--The Secretary may, as determined appropriate by the Secretary, apply prior authorization for home infusion therapy services under section 1861(iii)(1). (5) Accreditation of qualified home infusion therapy suppliers.-- (A) Factors for designation of accreditation organizations.--The Secretary shall consider the following factors in designating accreditation organizations under subparagraph (B) and in reviewing and modifying the list of accreditation organizations designated pursuant to subparagraph (C): (i) The ability of the organization to conduct timely reviews of accreditation applications. (ii) The ability of the organization to take into account the capacities of suppliers located in a rural area (as defined in section 1886(d)(2)(D)). (iii) Whether the organization has established reasonable fees to be charged to suppliers applying for accreditation. (iv) Such other factors as the Secretary determines appropriate. (B) Designation.--Not later than January 1, 2021, the Secretary shall designate organizations to accredit suppliers furnishing home infusion therapy. The list of accreditation organizations so designated may be modified pursuant to subparagraph (C). (C) Review and modification of list of accreditation organizations.-- (i) In general.--The Secretary shall review the list of accreditation organizations designated under subparagraph (B) taking into account the factors under subparagraph (A). Taking into account the results of such review, the Secretary may, by regulation, modify the list of accreditation organizations designated under subparagraph (B). (ii) Special rule for accreditations done prior to removal from list of designated accreditation organizations.--In the case where the Secretary removes an organization from the list of accreditation organizations designated under subparagraph (B), any supplier that is accredited by the organization during the period beginning on the date on which the organization is designated as an accreditation organization under subparagraph (B) and ending on the date on which the organization is removed from such list shall be considered to have been accredited by an organization designated by the Secretary under subparagraph (B) for the remaining period such accreditation is in effect. (D) Rule for accreditations made prior to designation.--In the case of a supplier that is accredited before January 1, 2021, by an accreditation organization designated by the Secretary under subparagraph (B) as of January 1, 2019, such supplier shall be considered to have been accredited by an organization designated by the Secretary under such paragraph as of January 1, 2023, for the remaining period such accreditation is in effect. (6) Notification of infusion therapy options available prior to furnishing home infusion therapy.-- Prior to the furnishing of home infusion therapy to an individual, the physician who establishes the plan described in section 1861(iii)(1) for the individual shall provide notification (in a form, manner, and frequency determined appropriate by the Secretary) of the options available (such as home, physician's office, hospital outpatient department) for the furnishing of infusion therapy under this part. (7) Home infusion therapy services temporary transitional payment.-- (A) Temporary transitional payment.-- (i) In general.--The Secretary shall, in accordance with the payment methodology described in subparagraph (B) and subject to the provisions of this paragraph, provide a home infusion therapy services temporary transitional payment under this part to an eligible home infusion supplier (as defined in subparagraph (F)) for items and services described in subparagraphs (A) and (B) of section 1861(iii)(2)) furnished during the period specified in clause (ii) by such supplier in coordination with the furnishing of transitional home infusion drugs (as defined in clause (iii)). (ii) Period specified.--For purposes of clause (i), the period specified in this clause is the period beginning on January 1, 2019, and ending on the day before the date of the implementation of the payment system under paragraph (1)(A). (iii) Transitional home infusion drug defined.--For purposes of this paragraph, the term ``transitional home infusion drug'' has the meaning given to the term ``home infusion drug'' under section 1861(iii)(3)(C)), except that clause (ii) of such section shall not apply if a drug described in such clause is identified in clauses (i), (ii), (iii) or (iv) of subparagraph (C) as of the date of the enactment of this paragraph. (B) Payment methodology.--For purposes of this paragraph, the Secretary shall establish a payment methodology, with respect to items and services described in subparagraph (A)(i). Under such payment methodology the Secretary shall-- (i) create the three payment categories described in clauses (i), (ii), and (iii) of subparagraph (C); (ii) assign drugs to such categories, in accordance with such clauses; (iii) assign appropriate Healthcare Common Procedure Coding System (HCPCS) codes to each payment category; and (iv) establish a single payment amount for each such payment category, in accordance with subparagraph (D), for each infusion drug administration calendar day in the individual's home for drugs assigned to such category. (C) Payment categories.-- (i) Payment category 1.--The Secretary shall create a payment category 1 and assign to such category drugs which are covered under the Local Coverage Determination on External Infusion Pumps (LCD number L33794) and billed with the following HCPCS codes (as identified as of January 1, 2018, and as subsequently modified by the Secretary): J0133, J0285, J0287, J0288, J0289, J0895, J1170, J1250, J1265, J1325, J1455, J1457, J1570, J2175, J2260, J2270, J2274, J2278, J3010, or J3285. (ii) Payment category 2.--The Secretary shall create a payment category 2 and assign to such category drugs which are covered under such local coverage determination and billed with the following HCPCS codes (as identified as of January 1, 2018, and as subsequently modified by the Secretary): J1555 JB, J1559 JB, J1561 JB, J1562 JB, J1569 JB, or J1575 JB. (iii) Payment category 3.--The Secretary shall create a payment category 3 and assign to such category drugs which are covered under such local coverage determination and billed with the following HCPCS codes (as identified as of January 1, 2018, and as subsequently modified by the Secretary): J9000, J9039, J9040, J9065, J9100, J9190, J9200, J9360, or J9370. (iv) Infusion drugs not otherwise included.--With respect to drugs that are not included in payment category 1, 2, or 3 under clause (i), (ii), or (iii), respectively, the Secretary shall assign to the most appropriate of such categories, as determined by the Secretary, drugs which are-- (I) covered under such local coverage determination and billed under HCPCS codes J7799 or J7999 (as identified as of July 1, 2017, and as subsequently modified by the Secretary); or (II) billed under any code that is implemented after the date of the enactment of this paragraph and included in such local coverage determination or included in subregulatory guidance as a home infusion drug described in subparagraph (A)(i). (D) Payment amounts.-- (i) In general.--Under the payment methodology, the Secretary shall pay eligible home infusion suppliers, with respect to items and services described in subparagraph (A)(i) furnished during the period described in subparagraph (A)(ii) by such supplier to an individual, at amounts equal to the amounts determined under the physician fee schedule established under section 1848 for services furnished during the year for codes and units of such codes described in clauses (ii), (iii), and (iv) with respect to drugs included in the payment category under subparagraph (C) specified in the respective clause, determined without application of the geographic adjustment under subsection (e) of such section. (ii) Payment amount for category 1.-- For purposes of clause (i), the codes and units described in this clause, with respect to drugs included in payment category 1 described in subparagraph (C)(i), are one unit of HCPCS code 96365 plus three units of HCPCS code 96366 (as identified as of January 1, 2018, and as subsequently modified by the Secretary). (iii) Payment amount for category 2.--For purposes of clause (i), the codes and units described in this clause, with respect to drugs included in payment category 2 described in subparagraph (C)(i), are one unit of HCPCS code 96369 plus three units of HCPCS code 96370 (as identified as of January 1, 2018, and as subsequently modified by the Secretary). (iv) Payment amount for category 3.-- For purposes of clause (i), the codes and units described in this clause, with respect to drugs included in payment category 3 described in subparagraph (C)(i), are one unit of HCPCS code 96413 plus three units of HCPCS code 96415 (as identified as of January 1, 2018, and as subsequently modified by the Secretary). (E) Clarifications.-- (i) Infusion drug administration day.--For purposes of this subsection, with respect to the furnishing of transitional home infusion drugs or home infusion drugs to an individual by an eligible home infusion supplier or a qualified home infusion therapy supplier, a reference to payment to such supplier for an infusion drug administration calendar day in the individual's home shall refer to payment only for the date on which professional services (as described in section 1861(iii)(2)(A)) were furnished to administer such drugs to such individual. For purposes of the previous sentence, an infusion drug administration calendar day shall include all such drugs administered to such individual on such day. (ii) Treatment of multiple drugs administered on same infusion drug administration day.--In the case that an eligible home infusion supplier, with respect to an infusion drug administration calendar day in an individual's home, furnishes to such individual transitional home infusion drugs which are not all assigned to the same payment category under subparagraph (C), payment to such supplier for such infusion drug administration calendar day in the individual's home shall be a single payment equal to the amount of payment under this paragraph for the drug, among all such drugs so furnished to such individual during such calendar day, for which the highest payment would be made under this paragraph. (F) Eligible home infusion suppliers.--In this paragraph, the term ``eligible home infusion supplier'' means a supplier that is enrolled under this part as a pharmacy that provides external infusion pumps and external infusion pump supplies and that maintains all pharmacy licensure requirements in the State in which the applicable infusion drugs are administered. (G) Implementation.--Notwithstanding any other provision of law, the Secretary may implement this paragraph by program instruction or otherwise. (v) Payment for Outpatient Physical Therapy Services and Outpatient Occupational Therapy Services Furnished by a Therapy Assistant.-- (1) In general.--In the case of an outpatient physical therapy service or outpatient occupational therapy service furnished on or after January 1, 2022, for which payment is made under section 1848 or subsection (k), that is furnished in whole or in part by a therapy assistant (as defined by the Secretary), the amount of payment for such service shall be an amount equal to 85 percent of the amount of payment otherwise applicable for the service under this part. Nothing in the preceding sentence shall be construed to change applicable requirements with respect to such services. (2) Use of modifier.-- (A) Establishment.--Not later than January 1, 2019, the Secretary shall establish a modifier to indicate (in a form and manner specified by the Secretary), in the case of an outpatient physical therapy service or outpatient occupational therapy service furnished in whole or in part by a therapy assistant (as so defined), that the service was furnished by a therapy assistant. (B) Required use.--Each request for payment, or bill submitted, for an outpatient physical therapy service or outpatient occupational therapy service furnished in whole or in part by a therapy assistant (as so defined) on or after January 1, 2020, shall include the modifier established under subparagraph (A) for each such service. (3) Implementation.--The Secretary shall implement this subsection through notice and comment rulemaking. (w) Opioid Use Disorder Treatment Services.-- (1) In general.--The Secretary shall pay to an opioid treatment program (as defined in paragraph (2) of section 1861(jjj)) an amount that is equal to 100 percent of a bundled payment under this part for opioid use disorder treatment services (as defined in paragraph (1) of such section) that are furnished by such program to an individual during an episode of care (as defined by the Secretary) beginning on or after January 1, 2020. The Secretary shall ensure, as determined appropriate by the Secretary, that no duplicative payments are made under this part or part D for items and services furnished by an opioid treatment program. (2) Considerations.--The Secretary may implement this subsection through one or more bundles based on the type of medication provided (such as buprenorphine, methadone, naltrexone, or a new innovative drug), the frequency of services, the scope of services furnished, characteristics of the individuals furnished such services, or other factors as the Secretary determine appropriate. In developing such bundles, the Secretary may consider payment rates paid to opioid treatment programs for comparable services under State plans under title XIX or under the TRICARE program under chapter 55 of title 10 of the United States Code. (3) Annual updates.--The Secretary shall provide an update each year to the bundled payment amounts under this subsection. * * * * * * * ENROLLMENT PERIODS Sec. 1837. (a) An individual may enroll in the insurance program established by this part only in such manner and form as may be prescribed by regulations, and only during an enrollment period prescribed in or under this section. (c) In the case of individuals who first satisfy paragraph (1) or (2) of section 1836 before March 1, 1966, the initial general enrollment period shall begin on the first day of the second month which begins after the date of enactment of this title and shall end on May 31, 1966. For purposes of this subsection and subsection (d), an individual who has attained age 65 and who satisfies paragraph (1) of section 1836 but not paragraph (2) of such section shall be treated as satisfying such paragraph (1) on the first day on which he is (or on filing application would have been) entitled to hospital insurance benefits under part A. (d) In the case of an individual who first satisfies paragraph (1) or (2) of section 1836 on or after March 1, 1966, his initial enrollment period shall begin on the first day of the third month before the month in which he first satisfies such paragraphs and shall end seven months later. Where the Secretary finds that an individual who has attained age 65 failed to enroll under this part during his initial enrollment period (based on a determination by the Secretary of the month in which such individual attained age 65), because such individual (relying on documentary evidence) was mistaken as to his correct date of birth, the Secretary shall establish for such individual an initial enrollment period based on his attaining age 65 at the time shown in such documentary evidence (with a coverage period determined under section 1838 as though he had attained such age at that time). (e) There shall be a general enrollment period during the period beginning on January 1 and ending on March 31 of each year. (f) Any individual-- (1) who is eligible under section 1836 to enroll in the medical insurance program by reason of entitlement to hospital insurance benefits as described in paragraph (1) of such section, and (2) whose initial enrollment period under subsection (d) begins after March 31, 1973, and (3) who is residing in the United States, exclusive of Puerto Rico, shall be deemed to have enrolled in the medical insurance program established by this part. (g) All of the provisions of this section shall apply to individuals satisfying subsection (f), except that-- (1) in the case of an individual who satisfies subsection (f) by reason of entitlement to disability insurance benefits described in section 226(b), his initial enrollment period shall begin on the first day of the later of (A) April 1973 or (B) the third month before the 25th month of such entitlement, and shall reoccur with each continuous period of eligibility (as defined in section 1839(d)) and upon attainment of age 65; (2)(A) in the case of an individual who is entitled to monthly benefits under section 202 or 223 on the first day of his initial enrollment period or becomes entitled to monthly benefits under section 202 during the first 3 months of such period, his enrollment shall be deemed to have occurred in the third month of his initial enrollment period, and (B) in the case of an individual who is not entitled to benefits under section 202 on the first day of his initial enrollment period and does not become so entitled during the first 3 months of such period, his enrollment shall be deemed to have occurred in the month in which he files the application establishing his entitlement to hospital insurance benefits provided such filing occurs during the last 4 months of his initial enrollment period; and (3) in the case of an individual who would otherwise satisfy subsection (f) but does not establish his entitlement to hospital insurance benefits until after the last day of his initial enrollment period (as defined in subsection (d) of this section), his enrollment shall be deemed to have occurred on the first day of the earlier of the then current or immediately succeeding general enrollment period (as defined in subsection (e) of this section). (h) In any case where the Secretary finds that an individual's enrollment or nonenrollment in the insurance program established by this part or part A pursuant to section 1818 is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Federal Government, or its instrumentalities, the Secretary may take such action (including the designation for such individual of a special initial or subsequent enrollment period, with a coverage period determined on the basis thereof and with appropriate adjustments of premiums) as may be necessary to correct or eliminate the effects of such error, misrepresentation, or inaction. (i)(1) In the case of an individual who-- (A) at the time the individual first satisfies paragraph (1) or (2) of section 1836, is enrolled in a group health plan described in section 1862(b)(1)(A)(v) by reason of the individual's (or the individual's spouse's) current employment status, and (B) has elected not to enroll (or to be deemed enrolled) under this section during the individual's initial enrollment period, there shall be a special enrollment period described in paragraph (3). In the case of an individual not described in the previous sentence who has not attained the age of 65, at the time the individual first satisfies paragraph (1) of section 1836, is enrolled in a large group health plan (as that term is defined in section 1862(b)(1)(B)(iii)) by reason of the individual's current employment status (or the current employment status of a family member of the individual), and has elected not to enroll (or to be deemed enrolled) under this section during the individual's initial enrollment period, there shall be a special enrollment period described in paragraph (3)(B). (2) In the case of an individual who-- (A)(i) has enrolled (or has been deemed to have enrolled) in the medical insurance program established under this part during the individual's initial enrollment period, or (ii) is an individual described in paragraph (1)(A); (B) has enrolled in such program during any subsequent special enrollment period under this subsection during which the individual was not enrolled in a group health plan described in section 1862(b)(1)(A)(v) by reason of the individual's (or individual's spouse's) current employment status; and (C) has not terminated enrollment under this section at any time at which the individual is not enrolled in such a group health plan by reason of the individual's (or individual's spouse's) current employment status, there shall be a special enrollment period described in paragraph (3). In the case of an individual not described in the previous sentence who has not attained the age of 65, has enrolled (or has been deemed to have enrolled) in the medical insurance program established under this part during the individual's initial enrollment period, or is an individual described in the second sentence of paragraph (1), has enrolled in such program during any subsequent special enrollment period under this subsection during which the individual was not enrolled in a large group health plan (as that term is defined in section 1862(b)(1)(B)(iii)) by reason of the individual's current employment status (or the current employment status of a family member of the individual), and has not terminated enrollment under this section at any time at which the individual is not enrolled in such a large group health plan by reason of the individual's current employment status (or the current employment status of a family member of the individual), there shall be a special enrollment period described in paragraph (3)(B). (3)(A) The special enrollment period referred to in the first sentences of paragraphs (1) and (2) is the period including each month during any part of which the individual is enrolled in a group health plan described in section 1862(b)(1)(A)(v) by reason of current employment status ending with the last day of the eighth consecutive month in which the individual is at no time so enrolled. (B) The special enrollment period referred to in the second sentences of paragraphs (1) and (2) is the period including each month during any part of which the individual is enrolled in a large group health plan (as that term is defined in section 1862(b)(1)(B)(iii)) by reason of the individual's current employment status (or the current employment status of a family member of the individual) ending with the last day of the eighth consecutive month in which the individual is at no time so enrolled. (4)(A) In the case of an individual who is entitled to benefits under part A pursuant to section 226(b) and-- (i) who at the time the individual first satisfies paragraph (1) of section 1836-- (I) is enrolled in a group health plan described in section 1862(b)(1)(A)(v) by reason of the individual's current or former employment or by reason of the current or former employment status of a member of the individual's family, and (II) has elected not to enroll (or to be deemed enrolled) under this section during the individual's initial enrollment period; and (ii) whose continuous enrollment under such group health plan is involuntarily terminated at a time when the enrollment under the plan is not by reason of the individual's current employment or by reason of the current employment of a member of the individual's family, there shall be a special enrollment period described in subparagraph (B). (B) The special enrollment period referred to in subparagraph (A) is the 6-month period beginning on the first day of the month which includes the date of the enrollment termination described in subparagraph (A)(ii). (j) In applying this section in the case of an individual who is entitled to benefits under part A pursuant to the operation of section 226(h), the following special rules apply: (1) The initial enrollment period under subsection (d) shall begin on the first day of the first month in which the individual satisfies the requirement of section 1836(1). (2) In applying subsection (g)(1), the initial enrollment period shall begin on the first day of the first month of entitlement to disability insurance benefits referred to in such subsection. (k)(1) In the case of an individual who-- (A) at the time the individual first satisfies paragraph (1) or (2) of section 1836, is described in paragraph (3), and has elected not to enroll (or to be deemed enrolled) under this section during the individual's initial enrollment period; or (B) has terminated enrollment under this section during a month in which the individual is described in paragraph (3), there shall be a special enrollment period described in paragraph (2). (2) The special enrollment period described in this paragraph is the 6-month period beginning on the first day of the month which includes the date that the individual is no longer described in paragraph (3). (3) For purposes of paragraph (1), an individual described in this paragraph is an individual who-- (A) is serving as a volunteer outside of the United States through a program-- (i) that covers at least a 12-month period; and (ii) that is sponsored by an organization described in section 501(c)(3) of the Internal Revenue Code of 1986 and exempt from taxation under section 501(a) of such Code; and (B) demonstrates health insurance coverage while serving in the program. (l)(1) In the case of any individual who is a covered beneficiary (as defined in section 1072(5) of title 10, United States Code) at the time the individual is entitled to part A under section 226(b) or section 226A and who is eligible to enroll but who has elected not to enroll (or to be deemed enrolled) during the individual's initial enrollment period, there shall be a special enrollment period described in paragraph (2). (2) The special enrollment period described in this paragraph, with respect to an individual, is the 12-month period beginning on the day after the last day of the initial enrollment period of the individual or, if later, the 12-month period beginning with the month the individual is notified of enrollment under this section. (3) In the case of an individual who enrolls during the special enrollment period provided under paragraph (1), the coverage period under this part shall begin on the first day of the month in which the individual enrolls, or, at the option of the individual, the first month after the end of the individual's initial enrollment period. (4) An individual may only enroll during the special enrollment period provided under paragraph (1) one time during the individual's lifetime. (5) The Secretary shall ensure that the materials relating to coverage under this part that are provided to an individual described in paragraph (1) prior to the individual's initial enrollment period contain information concerning the impact of not enrolling under this part, including the impact on health care benefits under the TRICARE program under chapter 55 of title 10, United States Code. (6) The Secretary of Defense shall collaborate with the Secretary of Health and Human Services and the Commissioner of Social Security to provide for the accurate identification of individuals described in paragraph (1). The Secretary of Defense shall provide such individuals with notification with respect to this subsection. The Secretary of Defense shall collaborate with the Secretary of Health and Human Services and the Commissioner of Social Security to ensure appropriate follow up pursuant to any notification provided under the preceding sentence. (m) Beginning January 1, 2021, the Secretary may establish special enrollment periods in the case of individuals who meet such exceptional conditions as the Secretary may provide, such as individuals who reside in an area with an emergency or disaster as determined by the Secretary. COVERAGE PERIOD Sec. 1838. (a) The period during which an individual is entitled to benefits under the insurance program established by this part (hereinafter referred to as his ``coverage period'') shall begin on whichever of the following is the latest: (1) July 1, 1966, or (in the case of a disabled individual who has not attained age 65) July 1, 1973; or [(2)(A) in the case of an individual who enrolls pursuant to subsection (d) of section 1837 before the month in which he first satisfies paragraph (1) or (2) of section 1836, the first day of such month, or [(B) in the case of an individual who enrolls pursuant to such subsection (d) in the month in which he first satisfies such paragraph, the first day of the month following the month in which he so enrolls, or [(C) in the case of an individual who enrolls pursuant to such subsection (d) in the month following the month in which he first satisfies such paragraph, the first day of the second month following the month in which he so enrolls, or [(D) in the case of an individual who enrolls pursuant to such subsection (d) more than one month following the month in which he satisfies such paragraph, the first day of the third month following the month in which he so enrolls, or [(E) in the case of an individual who enrolls pursuant to subsection (e) of section 1837, the July 1 following the month in which he so enrolls; or [(3)(A) in the case of an individual who is deemed to have enrolled on or before the last day of the third month of his initial enrollment period, the first day of the month in which he first meets the applicable requirements of section 1836 or July 1, 1973, whichever is later, or [(B) in the case of an individual who is deemed to have enrolled on or after the first day of the fourth month of his initial enrollment period, as prescribed under subparagraphs (B), (C), (D), and (E) of paragraph (2) of this subsection.] (2)(A) in the case of an individual who enrolls pursuant to subsection (d) of section 1837 before the month in which he first satisfies paragraph (1) or (2) of section 1836, the first day of such month, (B) in the case of an individual who first satisfies such paragraph in a month beginning before January 2021 and who enrolls pursuant to such subsection (d)-- (i) in such month in which he first satisfies such paragraph, the first day of the month following the month in which he so enrolls, (ii) in the month following such month in which he first satisfies such paragraph, the first day of the second month following the month in which he so enrolls, or (iii) more than one month following such month in which he satisfies such paragraph, the first day of the third month following the month in which he so enrolls, (C) in the case of an individual who first satisfies such paragraph in a month beginning on or after January 1, 2021, and who enrolls pursuant to such subsection (d) in such month in which he first satisfies such paragraph or in any subsequent month of his initial enrollment period, the first day of the month following the month in which he so enrolls, or (D) in the case of an individual who enrolls pursuant to subsection (e) of section 1837 in a month beginning-- (i) before January 1, 2021, the July 1 following the month in which he so enrolls, or (ii) on or after January 1, 2021, the first day of the month following the month in which he so enrolls, or (3) in the case of an individual who is deemed to have enrolled-- (A) on or before the last day of the third month of his initial enrollment period, the first day of the month in which he first meets the applicable requirements of section 1836 or July 1, 1973, whichever is later, or (B) on or after the first day of the fourth month of his initial enrollment period, and where such month begins-- (i) before January 1, 2021, as prescribed under subparagraphs (B)(i), (B)(ii), (B)(iii), and (D) of paragraph (2), or (ii) on or after January 1, 2021, as prescribed under paragraph (2)(C). (b) An individual's coverage period shall continue until his enrollment has been terminated-- (1) by the filing of notice that the individual no longer wishes to participate in the insurance program established by this part, or (2) for nonpayment of premiums. The termination of a coverage period under paragraph (1) shall (except as otherwise provided in section 1843(e)) take effect at the close of the month following the month in which the notice is filed. The termination of a coverage period under paragraph (2) shall take effect on a date determined under regulations, which may be determined so as to provide a grace period in which overdue premiums may be paid and coverage continued. The grace period determined under the preceding sentence shall not exceed 90 days; except that it may be extended to not to exceed 180 days in any case where the Secretary determines that there was good cause for failure to pay the overdue premiums within such 90-day period. Where an individual who is deemed to have enrolled for medical insurance pursuant to section 1837(f) files a notice before the first day of the month in which his coverage period begins advising that he does not wish to be so enrolled, the termination of the coverage period resulting from such deemed enrollment shall take effect with the first day of the month the coverage would have been effective. Where an individual who is deemed enrolled for medical insurance benefits pursuant to section 1837(f) files a notice requesting termination of his deemed coverage in or after the month in which such coverage becomes effective, the termination of such coverage shall take effect at the close of the month following the month in which the notice is filed. (c) In the case of an individual satisfying paragraph (1) of section 1836 whose entitlement to hospital insurance benefits under part A is based on a disability rather than on his having attained the age of 65, his coverage period (and his enrollment under this part) shall be terminated as of the close of the last month for which he is entitled to hospital insurance benefits. (d) No payments may be made under this part with respect to the expenses of an individual unless such expenses were incurred by such individual during a period which, with respect to him, is a coverage period. (e) Notwithstanding subsection (a), in the case of an individual who enrolls during a special enrollment period pursuant to section 1837(i)(3) or 1837(i)(4)(B)-- (1) in any month of the special enrollment period in which the individual is at any time enrolled in a plan (specified in subparagraph (A) or (B), as applicable, of section 1837(i)(3) or specified in section 1837(i)(4)(A)(i)) or in the first month following such a month, the coverage period shall begin on the first day of the month in which the individual so enrolls (or, at the option of the individual, on the first day of any of the following three months), or (2) in any other month of the special enrollment period, the coverage period shall begin on the first day of the month following the month in which the individual so enrolls. (f) Notwithstanding subsection (a), in the case of an individual who enrolls during a special enrollment period pursuant to section 1837(k), the coverage period shall begin on the first day of the month following the month in which the individual so enrolls. (g) Notwithstanding subsection (a), in the case of an individual who enrolls during a special enrollment period pursuant to section 1837(m), the coverage period shall begin on a date the Secretary provides in a manner consistent (to the extent practicable) with protecting continuity of health benefit coverage. amounts of premiums Sec. 1839. (a)(1) The Secretary shall, during September of 1983 and of each year thereafter, determine the monthly actuarial rate for enrollees age 65 and over which shall be applicable for the succeeding calendar year. Subject to paragraphs (5) and (6), such actuarial rate shall be the amount the Secretary estimates to be necessary so that the aggregate amount for such calendar year with respect to those enrollees age 65 and older will equal one-half of the total of the benefits and administrative costs which he estimates will be payable from the Federal Supplementary Medical Insurance Trust Fund for services performed and related administrative costs incurred in such calendar year with respect to such enrollees. In calculating the monthly actuarial rate, the Secretary shall include an appropriate amount for a contingency margin. In applying this paragraph there shall not be taken into account additional payments under section 1848(o) and section 1853(l)(3) and the Government contribution under section 1844(a)(3). (2) The monthly premium of each individual enrolled under this part for each month after December 1983 shall be the amount determined under paragraph (3), adjusted as required in accordance with subsections (b), (c), (f), and (i), and to reflect any credit provided under section 1854(b)(1)(C)(ii)(III). (3) The Secretary, during September of each year, shall determine and promulgate a monthly premium rate for the succeeding calendar year that (except as provided in subsection (g)) is equal to 50 percent of the monthly actuarial rate for enrollees age 65 and over, determined according to paragraph (1), for that succeeding calendar year. Whenever the Secretary promulgates the dollar amount which shall be applicable as the monthly premium rate for any period, he shall, at the time such promulgation is announced, issue a public statement setting forth the actuarial assumptions and bases employed by him in arriving at the amount of an adequate actuarial rate for enrollees age 65 and older as provided in paragraph (1). (4) The Secretary shall also, during September of 1983 and of each year thereafter, determine the monthly actuarial rate for disabled enrollees under age 65 which shall be applicable for the succeeding calendar year. Such actuarial rate shall be the amount the Secretary estimates to be necessary so that the aggregate amount for such calendar year with respect to disabled enrollees under age 65 will equal one-half of the total of the benefits and administrative costs which he estimates will be payable from the Federal Supplementary Medical Insurance Trust Fund for services performed and related administrative costs incurred in such calendar year with respect to such enrollees. In calculating the monthly actuarial rate under this paragraph, the Secretary shall include an appropriate amount for a contingency margin. (5)(A) In applying this part (including subsection (i) and section 1833(b)), the monthly actuarial rate for enrollees age 65 and over for 2016 shall be determined as if subsection (f) did not apply. (B) Subsection (f) shall continue to be applied to paragraph (6)(A) (during a repayment month, as described in paragraph (6)(B)) and without regard to the application of subparagraph (A). (6)(A) With respect to a repayment month (as described in subparagraph (B)), the monthly premium otherwise established under paragraph (3) shall be increased by, subject to subparagraph (D), $3. (B) For purposes of this paragraph, a repayment month is a month during a year, beginning with 2016, for which a balance due amount is computed under subparagraph (C) as greater than zero. (C) For purposes of this paragraph, the balance due amount computed under this subparagraph, with respect to a month, is the amount estimated by the Chief Actuary of the Centers for Medicare & Medicaid Services to be equal to-- (i) the amount transferred under section 1844(d)(1); plus (ii) the amount that is equal to the aggregate reduction, for all individuals enrolled under this part, in the income related monthly adjustment amount as a result of the application of paragraph (5); minus (iii) the amounts payable under this part as a result of the application of this paragraph for preceding months. (D) If the balance due amount computed under subparagraph (C), without regard to this subparagraph, for December of a year would be less than zero, the Chief Actuary of the Centers for Medicare & Medicaid Services shall estimate, and the Secretary shall apply, a reduction to the dollar amount increase applied under subparagraph (A) for each month during such year in a manner such that the balance due amount for January of the subsequent year is equal to zero. (b) In the case of an individual whose coverage period began pursuant to an enrollment after his initial enrollment period (determined pursuant to subsection (c) or (d) of section 1837) and not pursuant to a special enrollment period under subsection (i)(4) [or (l)], (l), or (m) of section 1837, the monthly premium determined under subsection (a) (without regard to any adjustment under subsection (i)) shall be increased by 10 percent of the monthly premium so determined for each full 12 months (in the same continuous period of eligibility) in which he could have been but was not enrolled. For purposes of the preceding sentence, there shall be taken into account (1) the months which elapsed between the close of his initial enrollment period and the close of the enrollment period in which he enrolled, plus (in the case of an individual who reenrolls) (2) the months which elapsed between the date of termination of a previous coverage period and the close of the enrollment period in which he reenrolled, but there shall not be taken into account months for which the individual can demonstrate that the individual was enrolled in a group health plan described in section 1862(b)(1)(A)(v) by reason of the individual's (or the individual's spouse's) current employment or months during which the individual has not attained the age of 65 and for which the individual can demonstrate that the individual was enrolled in a large group health plan as an active individual (as those terms are defined in section 1862(b)(1)(B)(iii)) or months for which the individual can demonstrate that the individual was an individual described in section 1837(k)(3). Any increase in an individual's monthly premium under the first sentence of this subsection with respect to a particular continuous period of eligibility shall not be applicable with respect to any other continuous period of eligibility which such individual may have. No increase in the premium shall be effected for a month in the case of an individual who enrolls under this part during 2001, 2002, 2003, or 2004 and who demonstrates to the Secretary before December 31, 2004, that the individual is a covered beneficiary (as defined in section 1072(5) of title 10, United States Code). The Secretary of Health and Human Services shall consult with the Secretary of Defense in identifying individuals described in the previous sentence. For purposes of determining any increase under this subsection for individuals whose enrollment occurs on or after January 1, 2021, the second sentence of this subsection shall be applied by substituting ``close of the month'' for ``close of the enrollment period'' each place it appears. (c) If any monthly premium determined under the foregoing provisions of this section is not a multiple of 10 cents, such premium shall be rounded to the nearest multiple of 10 cents. (d) For purposes of subsection (b) (and section 1837(g)(1)), an individual's ``continuous period of eligibility'' is the period beginning with the first day on which he is eligible to enroll under section 1836 and ending with his death; except that any period during all of which an individual satisfied paragraph (1) of section 1836 and which terminated in or before the month preceding the month in which he attained age 65 shall be a separate ``continuous period of eligibility'' with respect to such individual (and each such period which terminates shall be deemed not to have existed for purposes of subsequently applying this section). (e)(1) Upon the request of a State (or any appropriate State or local governmental entity specified by the Secretary), the Secretary may enter into an agreement with the State (or such entity) under which the State (or such entity) agrees to pay on a quarterly or other periodic basis to the Secretary (to be deposited in the Treasury to the credit of the Federal Supplementary Medical Insurance Trust Fund) an amount equal to the amount of the part B late enrollment premium increases with respect to the premiums for eligible individuals (as defined in paragraph (3)(A)). (2) No part B late enrollment premium increase shall apply to an eligible individual for premiums for months for which the amount of such an increase is payable under an agreement under paragraph (1). (3) In this subsection: (A) The term ``eligible individual'' means an individual who is enrolled under this part B and who is within a class of individuals specified in the agreement under paragraph (1). (B) The term ``part B late enrollment premium increase'' means any increase in a premium as a result of the application of subsection (b). (f) For any calendar year after 1988, if an individual is entitled to monthly benefits under section 202 or 223 or to a monthly annuity under section 3(a), 4(a), or 4(f) of the Railroad Retirement Act of 1974 for November and December of the preceding year, if the monthly premium of the individual under this section for December and for January is deducted from those benefits under section 1840(a)(1) or section 1840(b)(1), and if the amount of the individual's premium is not adjusted for such January under subsection (i), the monthly premium otherwise determined under this section for an individual for that year shall not be increased, pursuant to this subsection, to the extent that such increase would reduce the amount of benefits payable to that individual for that December below the amount of benefits payable to that individual for that November (after the deduction of the premium under this section). For purposes of this subsection, retroactive adjustments or payments and deductions on account of work shall not be taken into account in determining the monthly benefits to which an individual is entitled under section 202 or 223 or under the Railroad Retirement Act of 1974. (g) In estimating the benefits and administrative costs which will be payable from the Federal Supplementary Medical Insurance Trust Fund for a year for purposes of determining the monthly premium rate under subsection (a)(3), the Secretary shall exclude an estimate of any benefits and administrative costs attributable to-- (1) the application of section 1861(v)(1)(L)(viii) or to the establishment under section 1861(v)(1)(L)(i)(V) of a per visit limit at 106 percent of the median (instead of 105 percent of the median), but only to the extent payment for home health services under this title is not being made under section 1895 (relating to prospective payment for home health services); and (2) the medicare prescription drug discount card and transitional assistance program under section 1860D-31. (h) Potential Application of Comparative Cost Adjustment in CCA Areas.-- (1) In general.--Certain individuals who are residing in a CCA area under section 1860C-1 who are not enrolled in an MA plan under part C may be subject to a premium adjustment under subsection (f) of such section for months in which the CCA program under such section is in effect in such area. (2) No effect on late enrollment penalty or income- related adjustment in subsidies.--Nothing in this subsection or section 1860C-1(f) shall be construed as affecting the amount of any premium adjustment under subsection (b) or (i). Subsection (f) shall be applied without regard to any premium adjustment referred to in paragraph (1). (3) Implementation.--In order to carry out a premium adjustment under this subsection and section 1860C-1(f) (insofar as it is effected through the manner of collection of premiums under section 1840(a)), the Secretary shall transmit to the Commissioner of Social Security-- (A) at the beginning of each year, the name, social security account number, and the amount of the premium adjustment (if any) for each individual enrolled under this part for each month during the year; and (B) periodically throughout the year, information to update the information previously transmitted under this paragraph for the year. (i) Reduction in Premium Subsidy Based on Income.-- (1) In general.--In the case of an individual whose modified adjusted gross income exceeds the threshold amount under paragraph (2), the monthly amount of the premium subsidy applicable to the premium under this section for a month after December 2006 shall be reduced (and the monthly premium shall be increased) by the monthly adjustment amount specified in paragraph (3). (2) Threshold amount.--For purposes of this subsection, subject to paragraph (6), the threshold amount is-- (A) except as provided in subparagraph (B), $80,000 (or, beginning with 2018, $85,000), and (B) in the case of a joint return, twice the amount applicable under subparagraph (A) for the calendar year. (3) Monthly adjustment amount.-- (A) In general.--Subject to subparagraph (B), the monthly adjustment amount specified in this paragraph for an individual for a month in a year is equal to the product of the following: (i) Sliding scale percentage.-- Subject to paragraph (6), the applicable percentage specified in the applicable table in subparagraph (C) for the individual minus 25 percentage points. (ii) Unsubsidized part b premium amount.-- (I) 200 percent of the monthly actuarial rate for enrollees age 65 and over (as determined under subsection (a)(1) for the year); plus (II) 4 times the amount of the increase in the monthly premium under subsection (a)(6) for a month in the year. (B) 3-year phase in.--The monthly adjustment amount specified in this paragraph for an individual for a month in a year before 2009 is equal to the following percentage of the monthly adjustment amount specified in subparagraph (A): (i) For 2007, 33 percent. (ii) For 2008, 67 percent. (C) Applicable percentage.-- (i) In general.-- (I) Subject to paragraphs (5) and (6), for years before 2018: If the modified adjusted gross income is: The applicable percentage is: More than $80,000 but not more than $100,000.............35 percent More than $100,000 but not more than $150,000............50 percent More than $150,000 but not more than $200,000............65 percent More than $200,000.......................................80 percent. (II) Subject to paragraph (5), for 2018: If the modified adjusted gross income is: The applicable percentage is: More than $85,000 but not more than $107,000..... 35 percent More than $107,000 but not more than $133,500.... 50 percent More than $133,500 but not more than $160,000.... 65 percent More than $160,000............................... 80 percent. (III) Subject to paragraph (5), for years beginning with 2019: If the modified adjusted gross income is:......... The applicable percentage is: More than $85,000 but not more than $107,000...... 35 percent More than $107,000 but not more than $133,500..... 50 percent More than $133,500 but not more than $160,000..... 65 percent More than $160,000 but less than $500,000......... 80 percent At least $500,000................................. 85 percent. (ii) Joint returns.--In the case of a joint return, clause (i) shall be applied by substituting dollar amounts which are twice the dollar amounts otherwise applicable under clause (i) for the calendar year except, with respect to the dollar amounts applied in the last row of the table under subclause (III) of such clause (and the second dollar amount specified in the second to last row of such table), clause (i) shall be applied by substituting dollar amounts which are 150 percent of such dollar amounts for the calendar year. (iii) Married individuals filing separate returns.--In the case of an individual who-- (I) is married as of the close of the taxable year (within the meaning of section 7703 of the Internal Revenue Code of 1986) but does not file a joint return for such year, and (II) does not live apart from such individual's spouse at all times during the taxable year, clause (i) shall be applied by reducing each of the dollar amounts otherwise applicable under such clause for the calendar year by the threshold amount for such year applicable to an unmarried individual. (4) Modified adjusted gross income.-- (A) In general.--For purposes of this subsection, the term ``modified adjusted gross income'' means adjusted gross income (as defined in section 62 of the Internal Revenue Code of 1986)-- (i) determined without regard to sections 135, 911, 931, and 933 of such Code; and (ii) increased by the amount of interest received or accrued during the taxable year which is exempt from tax under such Code. In the case of an individual filing a joint return, any reference in this subsection to the modified adjusted gross income of such individual shall be to such return's modified adjusted gross income. (B) Taxable year to be used in determining modified adjusted gross income.-- (i) In general.--In applying this subsection for an individual's premiums in a month in a year, subject to clause (ii) and subparagraph (C), the individual's modified adjusted gross income shall be such income determined for the individual's last taxable year beginning in the second calendar year preceding the year involved. (ii) Temporary use of other data.-- If, as of October 15 before a calendar year, the Secretary of the Treasury does not have adequate data for an individual in appropriate electronic form for the taxable year referred to in clause (i), the individual's modified adjusted gross income shall be determined using the data in such form from the previous taxable year. Except as provided in regulations prescribed by the Commissioner of Social Security in consultation with the Secretary, the preceding sentence shall cease to apply when adequate data in appropriate electronic form are available for the individual for the taxable year referred to in clause (i), and proper adjustments shall be made to the extent that the premium adjustments determined under the preceding sentence were inconsistent with those determined using such taxable year. (iii) Non-filers.--In the case of individuals with respect to whom the Secretary of the Treasury does not have adequate data in appropriate electronic form for either taxable year referred to in clause (i) or clause (ii), the Commissioner of Social Security, in consultation with the Secretary, shall prescribe regulations which provide for the treatment of the premium adjustment with respect to such individual under this subsection, including regulations which provide for-- (I) the application of the highest applicable percentage under paragraph (3)(C) to such individual if the Commissioner has information which indicates that such individual's modified adjusted gross income might exceed the threshold amount for the taxable year referred to in clause (i), and (II) proper adjustments in the case of the application of an applicable percentage under subclause (I) to such individual which is inconsistent with such individual's modified adjusted gross income for such taxable year. (C) Use of more recent taxable year.-- (i) In general.--The Commissioner of Social Security in consultation with the Secretary of the Treasury shall establish a procedures under which an individual's modified adjusted gross income shall, at the request of such individual, be determined under this subsection-- (I) for a more recent taxable year than the taxable year otherwise used under subparagraph (B), or (II) by such methodology as the Commissioner, in consultation with such Secretary, determines to be appropriate, which may include a methodology for aggregating or disaggregating information from tax returns in the case of marriage or divorce. (ii) Standard for granting requests.--A request under clause (i)(I) to use a more recent taxable year may be granted only if-- (I) the individual furnishes to such Commissioner with respect to such year such documentation, such as a copy of a filed Federal income tax return or an equivalent document, as the Commissioner specifies for purposes of determining the premium adjustment (if any) under this subsection; and (II) the individual's modified adjusted gross income for such year is significantly less than such income for the taxable year determined under subparagraph (B) by reason of the death of such individual's spouse, the marriage or divorce of such individual, or other major life changing events specified in regulations prescribed by the Commissioner in consultation with the Secretary. (5) Inflation adjustment.-- (A) In general.--Subject to subparagraph (C), in the case of any calendar year beginning after 2007 (other than 2018 and 2019), each dollar amount in paragraph (2) or (3) shall be increased by an amount equal to-- (i) such dollar amount, multiplied by (ii) the percentage (if any) by which the average of the Consumer Price Index for all urban consumers (United States city average) for the 12-month period ending with August of the preceding calendar year exceeds such average for the 12-month period ending with August 2006 (or, in the case of a calendar year beginning with 2020, August 2018). (B) Rounding.--If any dollar amount after being increased under subparagraph (A) or (C) is not a multiple of $1,000, such dollar amount shall be rounded to the nearest multiple of $1,000. (C) Treatment of adjustments for certain higher income individuals.-- (i) In general.--Subparagraph (A) shall not apply with respect to each dollar amount in paragraph (3) of $500,000. (ii) Adjustment beginning 2028.--In the case of any calendar year beginning after 2027, each dollar amount in paragraph (3) of $500,000 shall be increased by an amount equal to-- (I) such dollar amount, multiplied by (II) the percentage (if any) by which the average of the Consumer Price Index for all urban consumers (United States city average) for the 12-month period ending with August of the preceding calendar year exceeds such average for the 12-month period ending with August 2026. (6) Temporary adjustment to income thresholds.-- Notwithstanding any other provision of this subsection, during the period beginning on January 1, 2011, and ending on December 31, 2017-- (A) the threshold amount otherwise applicable under paragraph (2) shall be equal to such amount for 2010; and (B) the dollar amounts otherwise applicable under paragraph (3)(C)(i) shall be equal to such dollar amounts for 2010. (7) Joint return defined.--For purposes of this subsection, the term ``joint return'' has the meaning given to such term by section 7701(a)(38) of the Internal Revenue Code of 1986. * * * * * * * payment for physicians' services Sec. 1848. (a) Payment Based on Fee Schedule.-- (1) In general.--Effective for all physicians' services (as defined in subsection (j)(3)) furnished under this part during a year (beginning with 1992) for which payment is otherwise made on the basis of a reasonable charge or on the basis of a fee schedule under section 1834(b), payment under this part shall instead be based on the lesser of-- (A) the actual charge for the service, or (B) subject to the succeeding provisions of this subsection, the amount determined under the fee schedule established under subsection (b) for services furnished during that year (in this subsection referred to as the ``fee schedule amount''). (2) Transition to full fee schedule.-- (A) Limiting reductions and increases to 15 percent in 1992.-- (i) Limit on increase.--In the case of a service in a fee schedule area (as defined in subsection (j)(2)) for which the adjusted historical payment basis (as defined in subparagraph (D)) is less than 85 percent of the fee schedule amount for services furnished in 1992, there shall be substituted for the fee schedule amount an amount equal to the adjusted historical payment basis plus 15 percent of the fee schedule amount otherwise established (without regard to this paragraph). (ii) Limit in reduction.--In the case of a service in a fee schedule area for which the adjusted historical payment basis exceeds 115 percent of the fee schedule amount for services furnished in 1992, there shall be substituted for the fee schedule amount an amount equal to the adjusted historical payment basis minus 15 percent of the fee schedule amount otherwise established (without regard to this paragraph). (B) Special rule for 1993, 1994, and 1995.-- If a physicians' service in a fee schedule area is subject to the provisions of subparagraph (A) in 1992, for physicians' services furnished in the area-- (i) during 1993, there shall be substituted for the fee schedule amount an amount equal to the sum of-- (I) 75 percent of the fee schedule amount determined under subparagraph (A), adjusted by the update established under subsection (d)(3) for 1993, and (II) 25 percent of the fee schedule amount determined under paragraph (1) for 1993 without regard to this paragraph; (ii) during 1994, there shall be substituted for the fee schedule amount an amount equal to the sum of-- (I) 67 percent of the fee schedule amount determined under clause (i), adjusted by the update established under subsection (d)(3) for 1994 and as adjusted under subsection (c)(2)(F)(ii) and under section 13515(b) of the Omnibus Budget Reconciliation Act of 1993, and (II) 33 percent of the fee schedule amount determined under paragraph (1) for 1994 without regard to this paragraph; and (iii) during 1995, there shall be substituted for the fee schedule amount an amount equal to the sum of-- (I) 50 percent of the fee schedule amount determined under clause (ii) adjusted by the update established under subsection (d)(3) for 1995, and (II) 50 percent of the fee schedule amount determined under paragraph (1) for 1995 without regard to this paragraph. (C) Special rule for anesthesia and radiology services.--With respect to physicians' services which are anesthesia services, the Secretary shall provide for a transition in the same manner as a transition is provided for other services under subparagraph (B). With respect to radiology services, ``109 percent'' and ``9 percent'' shall be substituted for ``115 percent'' and ``15 percent'', respectively, in subparagraph (A)(ii). (D) Adjusted historical payment basis defined.-- (i) In general.--In this paragraph, the term ``adjusted historical payment basis'' means, with respect to a physicians' service furnished in a fee schedule area, the weighted average prevailing charge applied in the area for the service in 1991 (as determined by the Secretary without regard to physician specialty and as adjusted to reflect payments for services with customary charges below the prevailing charge or other payment limitations imposed by law or regulation) adjusted by the update established under subsection (d)(3) for 1992. (ii) Application to radiology services.--In applying clause (i) in the case of physicians' services which are radiology services (including radiologist services, as defined in section 1834(b)(6)), but excluding nuclear medicine services that are subject to section 6105(b) of the Omnibus Budget Reconciliation Act of 1989, there shall be substituted for the weighted average prevailing charge the amount provided under the fee schedule established for the service for the fee schedule area under section 1834(b). (iii) Nuclear medicine services.--In applying clause (i) in the case of physicians' services which are nuclear medicine services, there shall be substituted for the weighted average prevailing charge the amount provided under section 6105(b) of the Omnibus Budget Reconciliation Act of 1989. (3) Incentives for participating physicians and suppliers.--In applying paragraph (1)(B) in the case of a nonparticipating physician or a nonparticipating supplier or other person, the fee schedule amount shall be 95 percent of such amount otherwise applied under this subsection (without regard to this paragraph). In the case of physicians' services (including services which the Secretary excludes pursuant to subsection (j)(3)) of a nonparticipating physician, supplier, or other person for which payment is made under this part on a basis other than the fee schedule amount, the payment shall be based on 95 percent of the payment basis for such services furnished by a participating physician, supplier, or other person. (4) Special rule for medical direction.-- (A) In general.--With respect to physicians' services furnished on or after January 1, 1994, and consisting of medical direction of two, three, or four concurrent anesthesia cases, except as provided in paragraph (5), the fee schedule amount to be applied shall be equal to one-half of the amount described in subparagraph (B). (B) Amount.--The amount described in this subparagraph, for a physician's medical direction of the performance of anesthesia services, is the following percentage of the fee schedule amount otherwise applicable under this section if the anesthesia services were personally performed by the physician alone: (i) For services furnished during 1994, 120 percent. (ii) For services furnished during 1995, 115 percent. (iii) For services furnished during 1996, 110 percent. (iv) For services furnished during 1997, 105 percent. (v) For services furnished after 1997, 100 percent. (5) Incentives for electronic prescribing.-- (A) Adjustment.-- (i) In general.--Subject to subparagraph (B) and subsection (m)(2)(B), with respect to covered professional services furnished by an eligible professional during 2012, 2013 or 2014, if the eligible professional is not a successful electronic prescriber for the reporting period for the year (as determined under subsection (m)(3)(B)), the fee schedule amount for such services furnished by such professional during the year (including the fee schedule amount for purposes of determining a payment based on such amount) shall be equal to the applicable percent of the fee schedule amount that would otherwise apply to such services under this subsection (determined after application of paragraph (3) but without regard to this paragraph). (ii) Applicable percent.--For purposes of clause (i), the term ``applicable percent'' means-- (I) for 2012, 99 percent; (II) for 2013, 98.5 percent; and (III) for 2014, 98 percent. (B) Significant hardship exception.--The Secretary may, on a case-by-case basis, exempt an eligible professional from the application of the payment adjustment under subparagraph (A) if the Secretary determines, subject to annual renewal, that compliance with the requirement for being a successful electronic prescriber would result in a significant hardship, such as in the case of an eligible professional who practices in a rural area without sufficient Internet access. (C) Application.-- (i) Physician reporting system rules.--Paragraphs (5), (6), and (8) of subsection (k) shall apply for purposes of this paragraph in the same manner as they apply for purposes of such subsection. (ii) Incentive payment validation rules.--Clauses (ii) and (iii) of subsection (m)(5)(D) shall apply for purposes of this paragraph in a similar manner as they apply for purposes of such subsection. (D) Definitions.--For purposes of this paragraph: (i) Eligible professional; covered professional services.--The terms ``eligible professional'' and ``covered professional services'' have the meanings given such terms in subsection (k)(3). (ii) Physician reporting system.--The term ``physician reporting system'' means the system established under subsection (k). (iii) Reporting period.--The term ``reporting period'' means, with respect to a year, a period specified by the Secretary. (6) Special rule for teaching anesthesiologists.-- With respect to physicians' services furnished on or after January 1, 2010, in the case of teaching anesthesiologists involved in the training of physician residents in a single anesthesia case or two concurrent anesthesia cases, the fee schedule amount to be applied shall be 100 percent of the fee schedule amount otherwise applicable under this section if the anesthesia services were personally performed by the teaching anesthesiologist alone and paragraph (4) shall not apply if-- (A) the teaching anesthesiologist is present during all critical or key portions of the anesthesia service or procedure involved; and (B) the teaching anesthesiologist (or another anesthesiologist with whom the teaching anesthesiologist has entered into an arrangement) is immediately available to furnish anesthesia services during the entire procedure. (7) Incentives for meaningful use of certified ehr technology.-- (A) Adjustment.-- (i) In general.--Subject to subparagraphs (B) and (D), with respect to covered professional services furnished by an eligible professional during each of 2015 through 2018, if the eligible professional is not a meaningful EHR user (as determined under subsection (o)(2)) for an EHR reporting period for the year, the fee schedule amount for such services furnished by such professional during the year (including the fee schedule amount for purposes of determining a payment based on such amount) shall be equal to the applicable percent of the fee schedule amount that would otherwise apply to such services under this subsection (determined after application of paragraph (3) but without regard to this paragraph). (ii) Applicable percent.--Subject to clause (iii), for purposes of clause (i), the term ``applicable percent'' means-- (I) for 2015, 99 percent (or, in the case of an eligible professional who was subject to the application of the payment adjustment under section 1848(a)(5) for 2014, 98 percent); (II) for 2016, 98 percent; and (III) for 2017 and 2018, 97 percent. (iii) Authority to decrease applicable percentage for 2018.--For 2018, if the Secretary finds that the proportion of eligible professionals who are meaningful EHR users (as determined under subsection (o)(2)) is less than 75 percent, the applicable percent shall be decreased by 1 percentage point from the applicable percent in the preceding year. (B) Significant hardship exception.--The Secretary may, on a case-by-case basis (and, with respect to the payment adjustment under subparagraph (A) for 2017, for categories of eligible professionals, as established by the Secretary and posted on the Internet website of the Centers for Medicare & Medicaid Services prior to December 15, 2015, an application for which must be submitted to the Secretary by not later than March 15, 2016), exempt an eligible professional from the application of the payment adjustment under subparagraph (A) if the Secretary determines, subject to annual renewal, that compliance with the requirement for being a meaningful EHR user would result in a significant hardship, such as in the case of an eligible professional who practices in a rural area without sufficient Internet access. The Secretary shall exempt an eligible professional from the application of the payment adjustment under subparagraph (A) with respect to a year, subject to annual renewal, if the Secretary determines that compliance with the requirement for being a meaningful EHR user is not possible because the certified EHR technology used by such professional has been decertified under a program kept or recognized pursuant to section 3001(c)(5) of the Public Health Service Act. In no case may an eligible professional be granted an exemption under this subparagraph for more than 5 years. (C) Application of physician reporting system rules.--Paragraphs (5), (6), and (8) of subsection (k) shall apply for purposes of this paragraph in the same manner as they apply for purposes of such subsection. (D) Non-application to hospital-based and ambulatory surgical center-based eligible professionals.-- (i) Hospital-based.--No payment adjustment may be made under subparagraph (A) in the case of hospital-based eligible professionals (as defined in subsection (o)(1)(C)(ii)). (ii) Ambulatory surgical center- based.--Subject to clause (iv), no payment adjustment may be made under subparagraph (A) for 2017 and 2018 in the case of an eligible professional with respect to whom substantially all of the covered professional services furnished by such professional are furnished in an ambulatory surgical center. (iii) Determination.--The determination of whether an eligible professional is an eligible professional described in clause (ii) may be made on the basis of-- (I) the site of service (as defined by the Secretary); or (II) an attestation submitted by the eligible professional. Determinations made under subclauses (I) and (II) shall be made without regard to any employment or billing arrangement between the eligible professional and any other supplier or provider of services. (iv) Sunset.--Clause (ii) shall no longer apply as of the first year that begins more than 3 years after the date on which the Secretary determines, through notice and comment rulemaking, that certified EHR technology applicable to the ambulatory surgical center setting is available. (E) Definitions.--For purposes of this paragraph: (i) Covered professional services.-- The term ``covered professional services'' has the meaning given such term in subsection (k)(3). (ii) EHR reporting period.--The term ``EHR reporting period'' means, with respect to a year, a period (or periods) specified by the Secretary. (iii) Eligible professional.--The term ``eligible professional'' means a physician, as defined in section 1861(r). (8) Incentives for quality reporting.-- (A) Adjustment.-- (i) In general.--With respect to covered professional services furnished by an eligible professional during each of 2015 through 2018, if the eligible professional does not satisfactorily submit data on quality measures for covered professional services for the quality reporting period for the year (as determined under subsection (m)(3)(A)), the fee schedule amount for such services furnished by such professional during the year (including the fee schedule amount for purposes of determining a payment based on such amount) shall be equal to the applicable percent of the fee schedule amount that would otherwise apply to such services under this subsection (determined after application of paragraphs (3), (5), and (7), but without regard to this paragraph). (ii) Applicable percent.--For purposes of clause (i), the term ``applicable percent'' means-- (I) for 2015, 98.5 percent; and (II) for 2016, 2017, and 2018, 98 percent. (B) Application.-- (i) Physician reporting system rules.--Paragraphs (5), (6), and (8) of subsection (k) shall apply for purposes of this paragraph in the same manner as they apply for purposes of such subsection. (ii) Incentive payment validation rules.--Clauses (ii) and (iii) of subsection (m)(5)(D) shall apply for purposes of this paragraph in a similar manner as they apply for purposes of such subsection. (C) Definitions.--For purposes of this paragraph: (i) Eligible professional; covered professional services.--The terms ``eligible professional'' and ``covered professional services'' have the meanings given such terms in subsection (k)(3). (ii) Physician reporting system.--The term ``physician reporting system'' means the system established under subsection (k). (iii) Quality reporting period.--The term ``quality reporting period'' means, with respect to a year, a period specified by the Secretary. (9) Information reporting on services included in global surgical packages.--With respect to services for which a physician is required to report information in accordance with subsection (c)(8)(B)(i), the Secretary may through rulemaking delay payment of 5 percent of the amount that would otherwise be payable under the physician fee schedule under this section for such services until the information so required is reported. (b) Establishment of Fee Schedules.-- (1) In general.--Before November 1 of the preceding year, for each year beginning with 1998, subject to subsection (p), the Secretary shall establish, by regulation, fee schedules that establish payment amounts for all physicians' services furnished in all fee schedule areas (as defined in subsection (j)(2)) for the year. Except as provided in paragraph (2), each such payment amount for a service shall be equal to the product of-- (A) the relative value for the service (as determined in subsection (c)(2)), (B) the conversion factor (established under subsection (d)) for the year, and (C) the geographic adjustment factor (established under subsection (e)(2)) for the service for the fee schedule area. (2) Treatment of radiology services and anesthesia services.-- (A) Radiology services.--With respect to radiology services (including radiologist services, as defined in section 1834(b)(6)), the Secretary shall base the relative values on the relative value scale developed under section 1834(b)(1)(A), with appropriate modifications of the relative values to assure that the relative values established for radiology services which are similar or related to other physicians' services are consistent with the relative values established for those similar or related services. (B) Anesthesia services.--In establishing the fee schedule for anesthesia services for which a relative value guide has been established under section 4048(b) of the Omnibus Budget Reconciliation Act of 1987, the Secretary shall use, to the extent practicable, such relative value guide, with appropriate adjustment of the conversion factor, in a manner to assure that the fee schedule amounts for anesthesia services are consistent with the fee schedule amounts for other services determined by the Secretary to be of comparable value. In applying the previous sentence, the Secretary shall adjust the conversion factor by geographic adjustment factors in the same manner as such adjustment is made under paragraph (1)(C). (C) Consultation.--The Secretary shall consult with the Physician Payment Review Commission and organizations representing physicians or suppliers who furnish radiology services and anesthesia services in applying subparagraphs (A) and (B). (3) Treatment of interpretation of electrocardiograms.--The Secretary-- (A) shall make separate payment under this section for the interpretation of electrocardiograms performed or ordered to be performed as part of or in conjunction with a visit to or a consultation with a physician, and (B) shall adjust the relative values established for visits and consultations under subsection (c) so as not to include relative value units for interpretations of electrocardiograms in the relative value for visits and consultations. (4) Special rule for imaging services.-- (A) In general.--In the case of imaging services described in subparagraph (B) furnished on or after January 1, 2007, if-- (i) the technical component (including the technical component portion of a global fee) of the service established for a year under the fee schedule described in paragraph (1) without application of the geographic adjustment factor described in paragraph (1)(C), exceeds (ii) the Medicare OPD fee schedule amount established under the prospective payment system for hospital outpatient department services under paragraph (3)(D) of section 1833(t) for such service for such year, determined without regard to geographic adjustment under paragraph (2)(D) of such section, the Secretary shall substitute the amount described in clause (ii), adjusted by the geographic adjustment factor described in paragraph (1)(C), for the fee schedule amount for such technical component for such year. (B) Imaging services described.--For purposes of this paragraph, imaging services described in this subparagraph are imaging and computer- assisted imaging services, including X-ray, ultrasound (including echocardiography), nuclear medicine (including positron emission tomography), magnetic resonance imaging, computed tomography, and fluoroscopy, but excluding diagnostic and screening mammography, and for 2010, 2011, and the first 2 months of 2012, dual-energy x-ray absorptiometry services (as described in paragraph (6)). (C) Adjustment in imaging utilization rate.-- With respect to fee schedules established for 2011, 2012, and 2013, in the methodology for determining practice expense relative value units for expensive diagnostic imaging equipment under the final rule published by the Secretary in the Federal Register on November 25, 2009 (42 CFR 410 et al.), the Secretary shall use a 75 percent assumption instead of the utilization rates otherwise established in such final rule. With respect to fee schedules established for 2014 and subsequent years, in such methodology, the Secretary shall use a 90 percent utilization rate. (D) Adjustment in technical component discount on single-session imaging involving consecutive body parts.--For services furnished on or after July 1, 2010, the Secretary shall increase the reduction in payments attributable to the multiple procedure payment reduction applicable to the technical component for imaging under the final rule published by the Secretary in the Federal Register on November 21, 2005 (part 405 of title 42, Code of Federal Regulations) from 25 percent to 50 percent. (5) Treatment of intensive cardiac rehabilitation program.-- (A) In general.--In the case of an intensive cardiac rehabilitation program described in section 1861(eee)(4), the Secretary shall substitute the Medicare OPD fee schedule amount established under the prospective payment system for hospital outpatient department service under paragraph (3)(D) of section 1833(t) for cardiac rehabilitation (under HCPCS codes 93797 and 93798 for calendar year 2007, or any succeeding HCPCS codes for cardiac rehabilitation). (B) Definition of session.--Each of the services described in subparagraphs (A) through (E) of section 1861(eee)(3), when furnished for one hour, is a separate session of intensive cardiac rehabilitation. (C) Multiple sessions per day.--Payment may be made for up to 6 sessions per day of the series of 72 one-hour sessions of intensive cardiac rehabilitation services described in section 1861(eee)(4)(B). (6) Treatment of bone mass scans.--For dual-energy x- ray absorptiometry services (identified in 2006 by HCPCS codes 76075 and 76077 (and any succeeding codes)) furnished during 2010, 2011, and the first 2 months of 2012, instead of the payment amount that would otherwise be determined under this section for such years, the payment amount shall be equal to 70 percent of the product of-- (A) the relative value for the service (as determined in subsection (c)(2)) for 2006; (B) the conversion factor (established under subsection (d)) for 2006; and (C) the geographic adjustment factor (established under subsection (e)(2)) for the service for the fee schedule area for 2010, 2011, and the first 2 months of 2012, respectively. (7) Adjustment in discount for certain multiple therapy services.--In the case of therapy services furnished on or after January 1, 2011, and before April 1, 2013, and for which payment is made under fee schedules established under this section, instead of the 25 percent multiple procedure payment reduction specified in the final rule published by the Secretary in the Federal Register on November 29, 2010, the reduction percentage shall be 20 percent. In the case of such services furnished on or after April 1, 2013, and for which payment is made under such fee schedules, instead of the 25 percent multiple procedure payment reduction specified in such final rule, the reduction percentage shall be 50 percent. (8) Encouraging care management for individuals with chronic care needs.-- (A) In general.--In order to encourage the management of care for individuals with chronic care needs the Secretary shall, subject to subparagraph (B), make payment (as the Secretary determines to be appropriate) under this section for chronic care management services furnished on or after January 1, 2015, by a physician (as defined in section 1861(r)(1)), physician assistant or nurse practitioner (as defined in section 1861(aa)(5)(A)), clinical nurse specialist (as defined in section 1861(aa)(5)(B)), or certified nurse midwife (as defined in section 1861(gg)(2)). (B) Policies relating to payment.--In carrying out this paragraph, with respect to chronic care management services, the Secretary shall-- (i) make payment to only one applicable provider for such services furnished to an individual during a period; (ii) not make payment under subparagraph (A) if such payment would be duplicative of payment that is otherwise made under this title for such services; and (iii) not require that an annual wellness visit (as defined in section 1861(hhh)) or an initial preventive physical examination (as defined in section 1861(ww)) be furnished as a condition of payment for such management services. (9) Special rule to incentivize transition from traditional x-ray imaging to digital radiography.-- (A) Limitation on payment for film x-ray imaging services.--In the case of an imaging service (including the imaging portion of a service) that is an X-ray taken using film and that is furnished during 2017 or a subsequent year, the payment amount for the technical component (including the technical component portion of a global service) of such service that would otherwise be determined under this section (without application of this paragraph and before application of any other adjustment under this section) for such year shall be reduced by 20 percent. (B) Phased-in limitation on payment for computed radiography imaging services.--In the case of an imaging service (including the imaging portion of a service) that is an X-ray taken using computed radiography technology-- (i) in the case of such a service furnished during 2018, 2019, 2020, 2021, or 2022, the payment amount for the technical component (including the technical component portion of a global service) of such service that would otherwise be determined under this section (without application of this paragraph and before application of any other adjustment under this section) for such year shall be reduced by 7 percent; and (ii) in the case of such a service furnished during 2023 or a subsequent year, the payment amount for the technical component (including the technical component portion of a global service) of such service that would otherwise be determined under this section (without application of this paragraph and before application of any other adjustment under this section) for such year shall be reduced by 10 percent. (C) Computed radiography technology defined.--For purposes of this paragraph, the term ``computed radiography technology'' means cassette-based imaging which utilizes an imaging plate to create the image involved. (D) Implementation.--In order to implement this paragraph, the Secretary shall adopt appropriate mechanisms which may include use of modifiers. (10) Reduction of discount in payment for professional component of multiple imaging services.-- In the case of the professional component of imaging services furnished on or after January 1, 2017, instead of the 25 percent reduction for multiple procedures specified in the final rule published by the Secretary in the Federal Register on November 28, 2011, as amended in the final rule published by the Secretary in the Federal Register on November 16, 2012, the reduction percentage shall be 5 percent. (11) Special rule for certain radiation therapy services.--The code definitions, the work relative value units under subsection (c)(2)(C)(i), and the direct inputs for the practice expense relative value units under subsection (c)(2)(C)(ii) for radiation treatment delivery and related imaging services (identified in 2016 by HCPCS G-codes G6001 through G6015) for the fee schedule established under this subsection for services furnished in 2017, 2018, and 2019 shall be the same as such definitions, units, and inputs for such services for the fee schedule established for services furnished in 2016. (c) Determination of Relative Values for Physicians' Services.-- (1) Division of physicians' services into components.--In this section, with respect to a physicians' service: (A) Work component defined.--The term ``work component'' means the portion of the resources used in furnishing the service that reflects physician time and intensity in furnishing the service. Such portion shall-- (i) include activities before and after direct patient contact, and (ii) be defined, with respect to surgical procedures, to reflect a global definition including pre- operative and post-operative physicians' services. (B) Practice expense component defined.--The term ``practice expense component'' means the portion of the resources used in furnishing the service that reflects the general categories of expenses (such as office rent and wages of personnel, but excluding malpractice expenses) comprising practice expenses. (C) Malpractice component defined.--The term ``malpractice component'' means the portion of the resources used in furnishing the service that reflects malpractice expenses in furnishing the service. (2) Determination of relative values.-- (A) In general.-- (i) Combination of units for components.--The Secretary shall develop a methodology for combining the work, practice expense, and malpractice relative value units, determined under subparagraph (C), for each service in a manner to produce a single relative value for that service. Such relative values are subject to adjustment under subparagraph (F)(i) and section 13515(b) of the Omnibus Budget Reconciliation Act of 1993. (ii) Extrapolation.--The Secretary may use extrapolation and other techniques to determine the number of relative value units for physicians' services for which specific data are not available and shall take into account recommendations of the Physician Payment Review Commission and the results of consultations with organizations representing physicians who provide such services. (B) Periodic review and adjustments in relative values.-- (i) Periodic review.--The Secretary, not less often than every 5 years, shall review the relative values established under this paragraph for all physicians' services. (ii) Adjustments.-- (I) In general.--The Secretary shall, to the extent the Secretary determines to be necessary and subject to subclause (II) and paragraph (7), adjust the number of such units to take into account changes in medical practice, coding changes, new data on relative value components, or the addition of new procedures. The Secretary shall publish an explanation of the basis for such adjustments. (II) Limitation on annual adjustments.--Subject to clauses (iv) and (v), the adjustments under subclause (I) for a year may not cause the amount of expenditures under this part for the year to differ by more than $20,000,000 from the amount of expenditures under this part that would have been made if such adjustments had not been made. (iii) Consultation.--The Secretary, in making adjustments under clause (ii), shall consult with the Medicare Payment Advisory Commission and organizations representing physicians. (iv) Exemption of certain additional expenditures from budget neutrality.-- The additional expenditures attributable to-- (I) subparagraph (H) shall not be taken into account in applying clause (ii)(II) for 2004; (II) subparagraph (I) insofar as it relates to a physician fee schedule for 2005 or 2006 shall not be taken into account in applying clause (ii)(II) for drug administration services under the fee schedule for such year for a specialty described in subparagraph (I)(ii)(II); (III) subparagraph (J) insofar as it relates to a physician fee schedule for 2005 or 2006 shall not be taken into account in applying clause (ii)(II) for drug administration services under the fee schedule for such year; and (IV) subsection (b)(6) shall not be taken into account in applying clause (ii)(II) for 2010, 2011, or the first 2 months of 2012. (v) Exemption of certain reduced expenditures from budget-neutrality calculation.--The following reduced expenditures, as estimated by the Secretary, shall not be taken into account in applying clause (ii)(II): (I) Reduced payment for multiple imaging procedures.-- Effective for fee schedules established beginning with 2007, reduced expenditures attributable to the multiple procedure payment reduction for imaging under the final rule published by the Secretary in the Federal Register on November 21, 2005 (42 CFR 405, et al.) insofar as it relates to the physician fee schedules for 2006 and 2007. (II) OPD payment cap for imaging services.--Effective for fee schedules established beginning with 2007, reduced expenditures attributable to subsection (b)(4). (III) Change in utilization rate for certain imaging services.--Effective for fee schedules established beginning with 2011, reduced expenditures attributable to the changes in the utilization rate applicable to 2011 and 2014, as described in the first and second sentence, respectively, of subsection (b)(4)(C). (VI) Additional reduced payment for multiple imaging procedures.--Effective for fee schedules established beginning with 2010 (but not applied for services furnished prior to July 1, 2010), reduced expenditures attributable to the increase in the multiple procedure payment reduction from 25 to 50 percent (as described in subsection (b)(4)(D)). (VII) Reduced expenditures for multiple therapy services.--Effective for fee schedules established beginning with 2011, reduced expenditures attributable to the multiple procedure payment reduction for therapy services (as described in subsection (b)(7)). (VIII) Reduced expenditures attributable to application of quality incentives for computed tomography.--Effective for fee schedules established beginning with 2016, reduced expenditures attributable to the application of the quality incentives for computed tomography under section 1834(p) (IX) Reductions for misvalued services if target not met.-- Effective for fee schedules beginning with 2016, reduced expenditures attributable to the application of the target recapture amount described in subparagraph (O)(iii). (X) Reduced expenditures attributable to incentives to transition to digital radiography.--Effective for fee schedules established beginning with 2017, reduced expenditures attributable to subparagraph (A) of subsection (b)(9) and effective for fee schedules established beginning with 2018, reduced expenditures attributable to subparagraph (B) of such subsection. (XI) Discount in payment for professional component of imaging services.--Effective for fee schedules established beginning with 2017, reduced expenditures attributable to subsection (b)(10). (vi) Alternative application of budget-neutrality adjustment.-- Notwithstanding subsection (d)(9)(A), effective for fee schedules established beginning with 2009, with respect to the 5-year review of work relative value units used in fee schedules for 2007 and 2008, in lieu of continuing to apply budget-neutrality adjustments required under clause (ii) for 2007 and 2008 to work relative value units, the Secretary shall apply such budget- neutrality adjustments to the conversion factor otherwise determined for years beginning with 2009. (C) Computation of relative value units for components.--For purposes of this section for each physicians' service-- (i) Work relative value units.--The Secretary shall determine a number of work relative value units for the service or group of services based on the relative resources incorporating physician time and intensity required in furnishing the service or group of services. (ii) Practice expense relative value units.--The Secretary shall determine a number of practice expense relative value units for the service for years before 1999 equal to the product of-- (I) the base allowed charges (as defined in subparagraph (D)) for the service, and (II) the practice expense percentage for the service (as determined under paragraph (3)(C)(ii)), and for years beginning with 1999 based on the relative practice expense resources involved in furnishing the service or group of services. For 1999, such number of units shall be determined based 75 percent on such product and based 25 percent on the relative practice expense resources involved in furnishing the service. For 2000, such number of units shall be determined based 50 percent on such product and based 50 percent on such relative practice expense resources. For 2001, such number of units shall be determined based 25 percent on such product and based 75 percent on such relative practice expense resources. For a subsequent year, such number of units shall be determined based entirely on such relative practice expense resources. (iii) Malpractice relative value units.--The Secretary shall determine a number of malpractice relative value units for the service or group of services for years before 2000 equal to the product of-- (I) the base allowed charges (as defined in subparagraph (D)) for the service or group of services, and (II) the malpractice percentage for the service or group of services (as determined under paragraph (3)(C)(iii)), and for years beginning with 2000 based on the malpractice expense resources involved in furnishing the service or group of services. (D) Base allowed charges defined.--In this paragraph, the term ``base allowed charges'' means, with respect to a physician's service, the national average allowed charges for the service under this part for services furnished during 1991, as estimated by the Secretary using the most recent data available. (E) Reduction in practice expense relative value units for certain services.-- (i) In general.--Subject to clause (ii), the Secretary shall reduce the practice expense relative value units applied to services described in clause (iii) furnished in-- (I) 1994, by 25 percent of the number by which the number of practice expense relative value units (determined for 1994 without regard to this subparagraph) exceeds the number of work relative value units determined for 1994, (II) 1995, by an additional 25 percent of such excess, and (III) 1996, by an additional 25 percent of such excess. (ii) Floor on reductions.--The practice expense relative value units for a physician's service shall not be reduced under this subparagraph to a number less than 128 percent of the number of work relative value units. (iii) Services covered.--For purposes of clause (i), the services described in this clause are physicians' services that are not described in clause (iv) and for which-- (I) there are work relative value units, and (II) the number of practice expense relative value units (determined for 1994) exceeds 128 percent of the number of work relative value units (determined for such year). (iv) Excluded services.--For purposes of clause (iii), the services described in this clause are services which the Secretary determines at least 75 percent of which are provided under this title in an office setting. (F) Budget neutrality adjustments.--The Secretary-- (i) shall reduce the relative values for all services (other than anesthesia services) established under this paragraph (and in the case of anesthesia services, the conversion factor established by the Secretary for such services) by such percentage as the Secretary determines to be necessary so that, beginning in 1996, the amendment made by section 13514(a) of the Omnibus Budget Reconciliation Act of 1993 would not result in expenditures under this section that exceed the amount of such expenditures that would have been made if such amendment had not been made, and (ii) shall reduce the amounts determined under subsection (a)(2)(B)(ii)(I) by such percentage as the Secretary determines to be required to assure that, taking into account the reductions made under clause (i), the amendment made by section 13514(a) of the Omnibus Budget Reconciliation Act of 1993 would not result in expenditures under this section in 1994 that exceed the amount of such expenditures that would have been made if such amendment had not been made. (G) Adjustments in relative value units for 1998.-- (i) In general.--The Secretary shall-- (I) subject to clauses (iv) and (v), reduce the practice expense relative value units applied to any services described in clause (ii) furnished in 1998 to a number equal to 110 percent of the number of work relative value units, and (II) increase the practice expense relative value units for office visit procedure codes during 1998 by a uniform percentage which the Secretary estimates will result in an aggregate increase in payments for such services equal to the aggregate decrease in payments by reason of subclause (I). (ii) Services covered.--For purposes of clause (i), the services described in this clause are physicians' services that are not described in clause (iii) and for which-- (I) there are work relative value units, and (II) the number of practice expense relative value units (determined for 1998) exceeds 110 percent of the number of work relative value units (determined for such year). (iii) Excluded services.--For purposes of clause (ii), the services described in this clause are services which the Secretary determines at least 75 percent of which are provided under this title in an office setting. (iv) Limitation on aggregate reallocation.--If the application of clause (i)(I) would result in an aggregate amount of reductions under such clause in excess of $390,000,000, such clause shall be applied by substituting for 110 percent such greater percentage as the Secretary estimates will result in the aggregate amount of such reductions equaling $390,000,000. (v) No reduction for certain services.--Practice expense relative value units for a procedure performed in an office or in a setting out of an office shall not be reduced under clause (i) if the in-office or out-of- office practice expense relative value, respectively, for the procedure would increase under the proposed rule on resource-based practice expenses issued by the Secretary on June 18, 1997 (62 Federal Register 33158 et seq.). (H) Adjustments in practice expense relative value units for certain drug administration services beginning in 2004.-- (i) Use of survey data.--In establishing the physician fee schedule under subsection (b) with respect to payments for services furnished on or after January 1, 2004, the Secretary shall, in determining practice expense relative value units under this subsection, utilize a survey submitted to the Secretary as of January 1, 2003, by a physician specialty organization pursuant to section 212 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 if the survey-- (I) covers practice expenses for oncology drug administration services; and (II) meets criteria established by the Secretary for acceptance of such surveys. (ii) Pricing of clinical oncology nurses in practice expense methodology.--If the survey described in clause (i) includes data on wages, salaries, and compensation of clinical oncology nurses, the Secretary shall utilize such data in the methodology for determining practice expense relative value units under subsection (c). (iii) Work relative value units for certain drug administration services.-- In establishing the relative value units under this paragraph for drug administration services described in clause (iv) furnished on or after January 1, 2004, the Secretary shall establish work relative value units equal to the work relative value units for a level 1 office medical visit for an established patient. (iv) Drug administration services described.--The drug administration services described in this clause are physicians' services-- (I) which are classified as of October 1, 2003, within any of the following groups of procedures: therapeutic or diagnostic infusions (excluding chemotherapy); chemotherapy administration services; and therapeutic, prophylactic, or diagnostic injections; (II) for which there are no work relative value units assigned under this subsection as of such date; and (III) for which national relative value units have been assigned under this subsection as of such date. (I) Adjustments in practice expense relative value units for certain drug administration services beginning with 2005.-- (i) In general.--In establishing the physician fee schedule under subsection (b) with respect to payments for services furnished on or after January 1, 2005 or 2006, the Secretary shall adjust the practice expense relative value units for such year consistent with clause (ii). (ii) Use of supplemental survey data.-- (I) In general.--Subject to subclause (II), if a specialty submits to the Secretary by not later than March 1, 2004, for 2005, or March 1, 2005, for 2006, data that includes expenses for the administration of drugs and biologicals for which the payment amount is determined pursuant to section 1842(o), the Secretary shall use such supplemental survey data in carrying out this subparagraph for the years involved insofar as they are collected and provided by entities and organizations consistent with the criteria established by the Secretary pursuant to section 212(a) of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999. (II) Limitation on specialty.--Subclause (I) shall apply to a specialty only insofar as not less than 40 percent of payments for the specialty under this title in 2002 are attributable to the administration of drugs and biologicals, as determined by the Secretary. (III) Application.--This clause shall not apply with respect to a survey to which subparagraph (H)(i) applies. (J) Provisions for appropriate reporting and billing for physicians' services associated with the administration of covered outpatient drugs and biologicals.-- (i) Evaluation of codes.--The Secretary shall promptly evaluate existing drug administration codes for physicians' services to ensure accurate reporting and billing for such services, taking into account levels of complexity of the administration and resource consumption. (ii) Use of existing processes.--In carrying out clause (i), the Secretary shall use existing processes for the consideration of coding changes and, to the extent coding changes are made, shall use such processes in establishing relative values for such services. (iii) Implementation.--In carrying out clause (i), the Secretary shall consult with representatives of physician specialties affected by the implementation of section 1847A or section 1847B, and shall take such steps within the Secretary's authority to expedite such considerations under clause (ii). (iv) Subsequent, budget neutral adjustments permitted.--Nothing in subparagraph (H) or (I) or this subparagraph shall be construed as preventing the Secretary from providing for adjustments in practice expense relative value units under (and consistent with) subparagraph (B) for years after 2004, 2005, or 2006, respectively. (K) Potentially misvalued codes.-- (i) In general.--The Secretary shall-- (I) periodically identify services as being potentially misvalued using criteria specified in clause (ii); and (II) review and make appropriate adjustments to the relative values established under this paragraph for services identified as being potentially misvalued under subclause (I). (ii) Identification of potentially misvalued codes.--For purposes of identifying potentially misvalued codes pursuant to clause (i)(I), the Secretary shall examine codes (and families of codes as appropriate) based on any or all of the following criteria: (I) Codes that have experienced the fastest growth. (II) Codes that have experienced substantial changes in practice expenses. (III) Codes that describe new technologies or services within an appropriate time period (such as 3 years) after the relative values are initially established for such codes. (IV) Codes which are multiple codes that are frequently billed in conjunction with furnishing a single service. (V) Codes with low relative values, particularly those that are often billed multiple times for a single treatment. (VI) Codes that have not been subject to review since implementation of the fee schedule. (VII) Codes that account for the majority of spending under the physician fee schedule. (VIII) Codes for services that have experienced a substantial change in the hospital length of stay or procedure time. (IX) Codes for which there may be a change in the typical site of service since the code was last valued. (X) Codes for which there is a significant difference in payment for the same service between different sites of service. (XI) Codes for which there may be anomalies in relative values within a family of codes. (XII) Codes for services where there may be efficiencies when a service is furnished at the same time as other services. (XIII) Codes with high intra- service work per unit of time. (XIV) Codes with high practice expense relative value units. (XV) Codes with high cost supplies. (XVI) Codes as determined appropriate by the Secretary. (iii) Review and adjustments.-- (I) The Secretary may use existing processes to receive recommendations on the review and appropriate adjustment of potentially misvalued services described in clause (i)(II). (II) The Secretary may conduct surveys, other data collection activities, studies, or other analyses as the Secretary determines to be appropriate to facilitate the review and appropriate adjustment described in clause (i)(II). (III) The Secretary may use analytic contractors to identify and analyze services identified under clause (i)(I), conduct surveys or collect data, and make recommendations on the review and appropriate adjustment of services described in clause (i)(II). (IV) The Secretary may coordinate the review and appropriate adjustment described in clause (i)(II) with the periodic review described in subparagraph (B). (V) As part of the review and adjustment described in clause (i)(II), including with respect to codes with low relative values described in clause (ii), the Secretary may make appropriate coding revisions (including using existing processes for consideration of coding changes) which may include consolidation of individual services into bundled codes for payment under the fee schedule under subsection (b). (VI) The provisions of subparagraph (B)(ii)(II) and paragraph (7) shall apply to adjustments to relative value units made pursuant to this subparagraph in the same manner as such provisions apply to adjustments under subparagraph (B)(ii)(I). (iv) Treatment of certain radiation therapy services.--Radiation treatment delivery and related imaging services identified under subsection (b)(11) shall not be considered as potentially misvalued services for purposes of this subparagraph and subparagraph (O) for 2017, 2018, and 2019. (L) Validating relative value units.-- (i) In general.--The Secretary shall establish a process to validate relative value units under the fee schedule under subsection (b). (ii) Components and elements of work.--The process described in clause (i) may include validation of work elements (such as time, mental effort and professional judgment, technical skill and physical effort, and stress due to risk) involved with furnishing a service and may include validation of the pre-, post-, and intra-service components of work. (iii) Scope of codes.--The validation of work relative value units shall include a sampling of codes for services that is the same as the codes listed under subparagraph (K)(ii). (iv) Methods.--The Secretary may conduct the validation under this subparagraph using methods described in subclauses (I) through (V) of subparagraph (K)(iii) as the Secretary determines to be appropriate. (v) Adjustments.--The Secretary shall make appropriate adjustments to the work relative value units under the fee schedule under subsection (b). The provisions of subparagraph (B)(ii)(II) shall apply to adjustments to relative value units made pursuant to this subparagraph in the same manner as such provisions apply to adjustments under subparagraph (B)(ii)(II). (M) Authority to collect and use information on physicians' services in the determination of relative values.-- (i) Collection of information.-- Notwithstanding any other provision of law, the Secretary may collect or obtain information on the resources directly or indirectly related to furnishing services for which payment is made under the fee schedule established under subsection (b). Such information may be collected or obtained from any eligible professional or any other source. (ii) Use of information.-- Notwithstanding any other provision of law, subject to clause (v), the Secretary may (as the Secretary determines appropriate) use information collected or obtained pursuant to clause (i) in the determination of relative values for services under this section. (iii) Types of information.--The types of information described in clauses (i) and (ii) may, at the Secretary's discretion, include any or all of the following: (I) Time involved in furnishing services. (II) Amounts and types of practice expense inputs involved with furnishing services. (III) Prices (net of any discounts) for practice expense inputs, which may include paid invoice prices or other documentation or records. (IV) Overhead and accounting information for practices of physicians and other suppliers. (V) Any other element that would improve the valuation of services under this section. (iv) Information collection mechanisms.--Information may be collected or obtained pursuant to this subparagraph from any or all of the following: (I) Surveys of physicians, other suppliers, providers of services, manufacturers, and vendors. (II) Surgical logs, billing systems, or other practice or facility records. (III) Electronic health records. (IV) Any other mechanism determined appropriate by the Secretary. (v) Transparency of use of information.-- (I) In general.--Subject to subclauses (II) and (III), if the Secretary uses information collected or obtained under this subparagraph in the determination of relative values under this subsection, the Secretary shall disclose the information source and discuss the use of such information in such determination of relative values through notice and comment rulemaking. (II) Thresholds for use.--The Secretary may establish thresholds in order to use such information, including the exclusion of information collected or obtained from eligible professionals who use very high resources (as determined by the Secretary) in furnishing a service. (III) Disclosure of information.--The Secretary shall make aggregate information available under this subparagraph but shall not disclose information in a form or manner that identifies an eligible professional or a group practice, or information collected or obtained pursuant to a nondisclosure agreement. (vi) Incentive to participate.--The Secretary may provide for such payments under this part to an eligible professional that submits such solicited information under this subparagraph as the Secretary determines appropriate in order to compensate such eligible professional for such submission. Such payments shall be provided in a form and manner specified by the Secretary. (vii) Administration.--Chapter 35 of title 44, United States Code, shall not apply to information collected or obtained under this subparagraph. (viii) Definition of eligible professional.--In this subparagraph, the term ``eligible professional'' has the meaning given such term in subsection (k)(3)(B). (ix) Funding.--For purposes of carrying out this subparagraph, in addition to funds otherwise appropriated, the Secretary shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund under section 1841, of $2,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for each fiscal year beginning with fiscal year 2014. Amounts transferred under the preceding sentence for a fiscal year shall be available until expended. (N) Authority for alternative approaches to establishing practice expense relative values.--The Secretary may establish or adjust practice expense relative values under this subsection using cost, charge, or other data from suppliers or providers of services, including information collected or obtained under subparagraph (M). (O) Target for relative value adjustments for misvalued services.--With respect to fee schedules established for each of 2016 through 2018, the following shall apply: (i) Determination of net reduction in expenditures.--For each year, the Secretary shall determine the estimated net reduction in expenditures under the fee schedule under this section with respect to the year as a result of adjustments to the relative values established under this paragraph for misvalued codes. (ii) Budget neutral redistribution of funds if target met and counting overages towards the target for the succeeding year.--If the estimated net reduction in expenditures determined under clause (i) for the year is equal to or greater than the target for the year-- (I) reduced expenditures attributable to such adjustments shall be redistributed for the year in a budget neutral manner in accordance with subparagraph (B)(ii)(II); and (II) the amount by which such reduced expenditures exceeds the target for the year shall be treated as a reduction in expenditures described in clause (i) for the succeeding year, for purposes of determining whether the target has or has not been met under this subparagraph with respect to that year. (iii) Exemption from budget neutrality if target not met.--If the estimated net reduction in expenditures determined under clause (i) for the year is less than the target for the year, reduced expenditures in an amount equal to the target recapture amount shall not be taken into account in applying subparagraph (B)(ii)(II) with respect to fee schedules beginning with 2016. (iv) Target recapture amount.--For purposes of clause (iii), the target recapture amount is, with respect to a year, an amount equal to the difference between-- (I) the target for the year; and (II) the estimated net reduction in expenditures determined under clause (i) for the year. (v) Target.--For purposes of this subparagraph, with respect to a year, the target is calculated as 0.5 percent (or, for 2016, 1.0 percent) of the estimated amount of expenditures under the fee schedule under this section for the year. (3) Component percentages.--For purposes of paragraph (2), the Secretary shall determine a work percentage, a practice expense percentage, and a malpractice percentage for each physician's service as follows: (A) Division of services by specialty.--For each physician's service or class of physicians' services, the Secretary shall determine the average percentage of each such service or class of services that is performed, nationwide, under this part by physicians in each of the different physician specialties (as identified by the Secretary). (B) Division of specialty by component.--The Secretary shall determine the average percentage division of resources, among the work component, the practice expense component, and the malpractice component, used by physicians in each of such specialties in furnishing physicians' services. Such percentages shall be based on national data that describe the elements of physician practice costs and revenues, by physician specialty. The Secretary may use extrapolation and other techniques to determine practice costs and revenues for specialties for which adequate data are not available. (C) Determination of component percentages.-- (i) Work percentage.--The work percentage for a service (or class of services) is equal to the sum (for all physician specialties) of-- (I) the average percentage division for the work component for each physician specialty (determined under subparagraph (B)), multiplied by (II) the proportion (determined under subparagraph (A)) of such service (or services) performed by physicians in that specialty. (ii) Practice expense percentage.-- For years before 2002, the practice expense percentage for a service (or class of services) is equal to the sum (for all physician specialties) of-- (I) the average percentage division for the practice expense component for each physician specialty (determined under subparagraph (B)), multiplied by (II) the proportion (determined under subparagraph (A)) of such service (or services) performed by physicians in that specialty. (iii) Malpractice percentage.--For years before 1999, the malpractice percentage for a service (or class of services) is equal to the sum (for all physician specialties) of-- (I) the average percentage division for the malpractice component for each physician specialty (determined under subparagraph (B)), multiplied by (II) the proportion (determined under subparagraph (A)) of such service (or services) performed by physicians in that specialty. (D) Periodic recomputation.--The Secretary may, from time to time, provide for the recomputation of work percentages, practice expense percentages, and malpractice percentages determined under this paragraph. (4) Ancillary policies.--The Secretary may establish ancillary policies (with respect to the use of modifiers, local codes, and other matters) as may be necessary to implement this section. (5) Coding.--The Secretary shall establish a uniform procedure coding system for the coding of all physicians' services. The Secretary shall provide for an appropriate coding structure for visits and consultations. The Secretary may incorporate the use of time in the coding for visits and consultations. The Secretary, in establishing such coding system, shall consult with the Physician Payment Review Commission and other organizations representing physicians. (6) No variation for specialists.--The Secretary may not vary the conversion factor or the number of relative value units for a physicians' service based on whether the physician furnishing the service is a specialist or based on the type of specialty of the physician. (7) Phase-in of significant relative value unit (rvu) reductions.--Effective for fee schedules established beginning with 2016, for services that are not new or revised codes, if the total relative value units for a service for a year would otherwise be decreased by an estimated amount equal to or greater than 20 percent as compared to the total relative value units for the previous year, the applicable adjustments in work, practice expense, and malpractice relative value units shall be phased-in over a 2-year period. (8) Global surgical packages.-- (A) Prohibition of implementation of rule regarding global surgical packages.-- (i) In general.--The Secretary shall not implement the policy established in the final rule published on November 13, 2014 (79 Fed. Reg. 67548 et seq.), that requires the transition of all 10- day and 90-day global surgery packages to 0-day global periods. (ii) Construction.--Nothing in clause (i) shall be construed to prevent the Secretary from revaluing misvalued codes for specific surgical services or assigning values to new or revised codes for surgical services. (B) Collection of data on services included in global surgical packages.-- (i) In general.--Subject to clause (ii), the Secretary shall through rulemaking develop and implement a process to gather, from a representative sample of physicians, beginning not later than January 1, 2017, information needed to value surgical services. Such information shall include the number and level of medical visits furnished during the global period and other items and services related to the surgery and furnished during the global period, as appropriate. Such information shall be reported on claims at the end of the global period or in another manner specified by the Secretary. For purposes of carrying out this paragraph (other than clause (iii)), the Secretary shall transfer from the Federal Supplemental Medical Insurance Trust Fund under section 1841 $2,000,000 to the Center for Medicare & Medicaid Services Program Management Account for fiscal year 2015. Amounts transferred under the previous sentence shall remain available until expended. (ii) Reassessment and potential sunset.--Every 4 years, the Secretary shall reassess the value of the information collected pursuant to clause (i). Based on such a reassessment and by regulation, the Secretary may discontinue the requirement for collection of information under such clause if the Secretary determines that the Secretary has adequate information from other sources, such as qualified clinical data registries, surgical logs, billing systems or other practice or facility records, and electronic health records, in order to accurately value global surgical services under this section. (iii) Inspector general audit.--The Inspector General of the Department of Health and Human Services shall audit a sample of the information reported under clause (i) to verify the accuracy of the information so reported. (C) Improving accuracy of pricing for surgical services.--For years beginning with 2019, the Secretary shall use the information reported under subparagraph (B)(i) as appropriate and other available data for the purpose of improving the accuracy of valuation of surgical services under the physician fee schedule under this section. (d) Conversion Factors.-- (1) Establishment.-- (A) In general.--The conversion factor for each year shall be the conversion factor established under this subsection for the previous year (or, in the case of 1992, specified in subparagraph (B)) adjusted by the update (established under paragraph (3)) for the year involved (for years before 2001) and, for years beginning with 2001 and ending with 2025, multiplied by the update (established under paragraph (4) or a subsequent paragraph) for the year involved. There shall be two separate conversion factors for each year beginning with 2026, one for items and services furnished by a qualifying APM participant (as defined in section 1833(z)(2)) (referred to in this subsection as the ``qualifying APM conversion factor'') and the other for other items and services (referred to in this subsection as the ``nonqualifying APM conversion factor''), equal to the respective conversion factor for the previous year (or, in the case of 2026, equal to the single conversion factor for 2025) multiplied by the update established under paragraph (20) for such respective conversion factor for such year. (B) Special provision for 1992.--For purposes of subparagraph (A), the conversion factor specified in this subparagraph is a conversion factor (determined by the Secretary) which, if this section were to apply during 1991 using such conversion factor, would result in the same aggregate amount of payments under this part for physicians' services as the estimated aggregate amount of the payments under this part for such services in 1991. (C) Special rules for 1998.--Except as provided in subparagraph (D), the single conversion factor for 1998 under this subsection shall be the conversion factor for primary care services for 1997, increased by the Secretary's estimate of the weighted average of the three separate updates that would otherwise occur were it not for the enactment of chapter 1 of subtitle F of title IV of the Balanced Budget Act of 1997. (D) Special rules for anesthesia services.-- The separate conversion factor for anesthesia services for a year shall be equal to 46 percent of the single conversion factor (or, beginning with 2026, applicable conversion factor) established for other physicians' services, except as adjusted for changes in work, practice expense, or malpractice relative value units. (E) Publication and dissemination of information.--The Secretary shall-- (i) cause to have published in the Federal Register not later than November 1 of each year (beginning with 2000) the conversion factor which will apply to physicians' services for the succeeding year, the update determined under paragraph (4) for such succeeding year, and the allowed expenditures under such paragraph for such succeeding year; and (ii) make available to the Medicare Payment Advisory Commission and the public by March 1 of each year (beginning with 2000) an estimate of the sustainable growth rate and of the conversion factor which will apply to physicians' services for the succeeding year and data used in making such estimate. (3) Update for 1999 and 2000.-- (A) In general.--Unless otherwise provided by law, subject to subparagraph (D) and the budget-neutrality factor determined by the Secretary under subsection (c)(2)(B)(ii), the update to the single conversion factor established in paragraph (1)(C) for 1999 and 2000 is equal to the product of-- (i) 1 plus the Secretary's estimate of the percentage increase in the MEI (as defined in section 1842(i)(3)) for the year (divided by 100), and (ii) 1 plus the Secretary's estimate of the update adjustment factor for the year (divided by 100), minus 1 and multiplied by 100. (B) Update adjustment factor.--For purposes of subparagraph (A)(ii), the ``update adjustment factor'' for a year is equal (as estimated by the Secretary) to-- (i) the difference between (I) the sum of the allowed expenditures for physicians' services (as determined under subparagraph (C)) for the period beginning April 1, 1997, and ending on March 31 of the year involved, and (II) the amount of actual expenditures for physicians' services furnished during the period beginning April 1, 1997, and ending on March 31 of the preceding year; divided by (ii) the actual expenditures for physicians' services for the 12-month period ending on March 31 of the preceding year, increased by the sustainable growth rate under subsection (f) for the fiscal year which begins during such 12-month period. (C) Determination of allowed expenditures.-- For purposes of this paragraph and paragraph (4), the allowed expenditures for physicians' services for the 12-month period ending with March 31 of-- (i) 1997 is equal to the actual expenditures for physicians' services furnished during such 12-month period, as estimated by the Secretary; or (ii) a subsequent year is equal to the allowed expenditures for physicians' services for the previous year, increased by the sustainable growth rate under subsection (f) for the fiscal year which begins during such 12-month period. (D) Restriction on variation from medicare economic index.--Notwithstanding the amount of the update adjustment factor determined under subparagraph (B) for a year, the update in the conversion factor under this paragraph for the year may not be-- (i) greater than 100 times the following amount: (1.03 + (MEI percentage/100)) -1; or (ii) less than 100 times the following amount: (0.93 + (MEI percentage/100)) -1, where ``MEI percentage'' means the Secretary's estimate of the percentage increase in the MEI (as defined in section 1842(i)(3)) for the year involved. (4) Update for years beginning with 2001 and ending with 2014.-- (A) In general.--Unless otherwise provided by law, subject to the budget-neutrality factor determined by the Secretary under subsection (c)(2)(B)(ii) and subject to adjustment under subparagraph (F), the update to the single conversion factor established in paragraph (1)(C) for a year beginning with 2001 and ending with 2014 is equal to the product of-- (i) 1 plus the Secretary's estimate of the percentage increase in the MEI (as defined in section 1842(i)(3)) for the year (divided by 100); and (ii) 1 plus the Secretary's estimate of the update adjustment factor under subparagraph (B) for the year. (B) Update adjustment factor.--For purposes of subparagraph (A)(ii), subject to subparagraph (D) and the succeeding paragraphs of this subsection, the ``update adjustment factor'' for a year is equal (as estimated by the Secretary) to the sum of the following: (i) Prior year adjustment component.--An amount determined by-- (I) computing the difference (which may be positive or negative) between the amount of the allowed expenditures for physicians' services for the prior year (as determined under subparagraph (C)) and the amount of the actual expenditures for such services for that year; (II) dividing that difference by the amount of the actual expenditures for such services for that year; and (III) multiplying that quotient by 0.75. (ii) Cumulative adjustment component.--An amount determined by-- (I) computing the difference (which may be positive or negative) between the amount of the allowed expenditures for physicians' services (as determined under subparagraph (C)) from April 1, 1996, through the end of the prior year and the amount of the actual expenditures for such services during that period; (II) dividing that difference by actual expenditures for such services for the prior year as increased by the sustainable growth rate under subsection (f) for the year for which the update adjustment factor is to be determined; and (III) multiplying that quotient by 0.33. (C) Determination of allowed expenditures.-- For purposes of this paragraph: (i) Period up to april 1, 1999.--The allowed expenditures for physicians' services for a period before April 1, 1999, shall be the amount of the allowed expenditures for such period as determined under paragraph (3)(C). (ii) Transition to calendar year allowed expenditures.--Subject to subparagraph (E), the allowed expenditures for-- (I) the 9-month period beginning April 1, 1999, shall be the Secretary's estimate of the amount of the allowed expenditures that would be permitted under paragraph (3)(C) for such period; and (II) the year of 1999, shall be the Secretary's estimate of the amount of the allowed expenditures that would be permitted under paragraph (3)(C) for such year. (iii) Years beginning with 2000.--The allowed expenditures for a year (beginning with 2000) is equal to the allowed expenditures for physicians' services for the previous year, increased by the sustainable growth rate under subsection (f) for the year involved. (D) Restriction on update adjustment factor.--The update adjustment factor determined under subparagraph (B) for a year may not be less than -0.07 or greater than 0.03. (E) Recalculation of allowed expenditures for updates beginning with 2001.--For purposes of determining the update adjustment factor for a year beginning with 2001, the Secretary shall recompute the allowed expenditures for previous periods beginning on or after April 1, 1999, consistent with subsection (f)(3). (F) Transitional adjustment designed to provide for budget neutrality.--Under this subparagraph the Secretary shall provide for an adjustment to the update under subparagraph (A)-- (i) for each of 2001, 2002, 2003, and 2004, of -0.2 percent; and (ii) for 2005 of +0.8 percent. (5) Update for 2004 and 2005.--The update to the single conversion factor established in paragraph (1)(C) for each of 2004 and 2005 shall be not less than 1.5 percent. (6) Update for 2006.--The update to the single conversion factor established in paragraph (1)(C) for 2006 shall be 0 percent. (7) Conversion factor for 2007.-- (A) In general.--The conversion factor that would otherwise be applicable under this subsection for 2007 shall be the amount of such conversion factor divided by the product of-- (i) 1 plus the Secretary's estimate of the percentage increase in the MEI (as defined in section 1842(i)(3)) for 2007 (divided by 100); and (ii) 1 plus the Secretary's estimate of the update adjustment factor under paragraph (4)(B) for 2007. (B) No effect on computation of conversion factor for 2008.--The conversion factor under this subsection shall be computed under paragraph (1)(A) for 2008 as if subparagraph (A) had never applied. (8) Update for 2008.-- (A) In general.--Subject to paragraph (7)(B), in lieu of the update to the single conversion factor established in paragraph (1)(C) that would otherwise apply for 2008, the update to the single conversion factor shall be 0.5 percent. (B) No effect on computation of conversion factor for 2009.--The conversion factor under this subsection shall be computed under paragraph (1)(A) for 2009 and subsequent years as if subparagraph (A) had never applied. (9) Update for 2009.-- (A) In general.--Subject to paragraphs (7)(B) and (8)(B), in lieu of the update to the single conversion factor established in paragraph (1)(C) that would otherwise apply for 2009, the update to the single conversion factor shall be 1.1 percent. (B) No effect on computation of conversion factor for 2010 and subsequent years.--The conversion factor under this subsection shall be computed under paragraph (1)(A) for 2010 and subsequent years as if subparagraph (A) had never applied. (10) Update for January through may of 2010.-- (A) In general.--Subject to paragraphs (7)(B), (8)(B), and (9)(B), in lieu of the update to the single conversion factor established in paragraph (1)(C) that would otherwise apply for 2010 for the period beginning on January 1, 2010, and ending on May 31, 2010, the update to the single conversion factor shall be 0 percent for 2010. (B) No effect on computation of conversion factor for remaining portion of 2010 and subsequent years.--The conversion factor under this subsection shall be computed under paragraph (1)(A) for the period beginning on June 1, 2010, and ending on December 31, 2010, and for 2011 and subsequent years as if subparagraph (A) had never applied. (11) Update for june through december of 2010.-- (A) In general.--Subject to paragraphs (7)(B), (8)(B), (9)(B), and (10)(B), in lieu of the update to the single conversion factor established in paragraph (1)(C) that would otherwise apply for 2010 for the period beginning on June 1, 2010, and ending on December 31, 2010, the update to the single conversion factor shall be 2.2 percent. (B) No effect on computation of conversion factor for 2011 and subsequent years.--The conversion factor under this subsection shall be computed under paragraph (1)(A) for 2011 and subsequent years as if subparagraph (A) had never applied. (12) Update for 2011.-- (A) In general.--Subject to paragraphs (7)(B), (8)(B), (9)(B), (10)(B), and (11)(B), in lieu of the update to the single conversion factor established in paragraph (1)(C) that would otherwise apply for 2011, the update to the single conversion factor shall be 0 percent. (B) No effect on computation of conversion factor for 2012 and subsequent years.--The conversion factor under this subsection shall be computed under paragraph (1)(A) for 2012 and subsequent years as if subparagraph (A) had never applied. (13) Update for 2012.-- (A) In general.--Subject to paragraphs (7)(B), (8)(B), (9)(B), (10)(B), (11)(B), and (12)(B), in lieu of the update to the single conversion factor established in paragraph (1)(C) that would otherwise apply for 2012, the update to the single conversion factor shall be zero percent. (B) No effect on computation of conversion factor for 2013 and subsequent years.--The conversion factor under this subsection shall be computed under paragraph (1)(A) for 2013 and subsequent years as if subparagraph (A) had never applied. (14) Update for 2013.-- (A) In general.--Subject to paragraphs (7)(B), (8)(B), (9)(B), (10)(B), (11)(B), (12)(B), and (13)(B), in lieu of the update to the single conversion factor established in paragraph (1)(C) that would otherwise apply for 2013, the update to the single conversion factor for such year shall be zero percent. (B) No effect on computation of conversion factor for 2014 and subsequent years.--The conversion factor under this subsection shall be computed under paragraph (1)(A) for 2014 and subsequent years as if subparagraph (A) had never applied. (15) Update for 2014.-- (A) In general.--Subject to paragraphs (7)(B), (8)(B), (9)(B), (10)(B), (11)(B), (12)(B), (13)(B), and (14)(B), in lieu of the update to the single conversion factor established in paragraph (1)(C) that would otherwise apply for 2014, the update to the single conversion factor shall be 0.5 percent. (B) No effect on computation of conversion factor for subsequent years.--The conversion factor under this subsection shall be computed under paragraph (1)(A) for 2015 and subsequent years as if subparagraph (A) had never applied. (16) Update for january through june of 2015.-- Subject to paragraphs (7)(B), (8)(B), (9)(B), (10)(B), (11)(B), (12)(B), (13)(B), (14)(B), and (15)(B), in lieu of the update to the single conversion factor established in paragraph (1)(C) that would otherwise apply for 2015 for the period beginning on January 1, 2015, and ending on June 30, 2015, the update to the single conversion factor shall be 0.0 percent. (17) Update for july through december of 2015.--The update to the single conversion factor established in paragraph (1)(C) for the period beginning on July 1, 2015, and ending on December 31, 2015, shall be 0.5 percent. (18) Update for 2016 through 2019.--The update to the single conversion factor established in paragraph (1)(C)-- (A) for 2016 and each subsequent year through 2018 shall be 0.5 percent; and (B) for 2019 shall be 0.25 percent. (19) Update for 2020 through 2025.--The update to the single conversion factor established in paragraph (1)(C) for 2020 and each subsequent year through 2025 shall be 0.0 percent. (20) Update for 2026 and subsequent years.--For 2026 and each subsequent year, the update to the qualifying APM conversion factor established under paragraph (1)(A) is 0.75 percent, and the update to the nonqualifying APM conversion factor established under such paragraph is 0.25 percent. (e) Geographic Adjustment Factors.-- (1) Establishment of geographic indices.-- (A) In general.--Subject to subparagraphs (B), (C), (E), (G), (H), and (I), the Secretary shall establish-- (i) an index which reflects the relative costs of the mix of goods and services comprising practice expenses (other than malpractice expenses) in the different fee schedule areas compared to the national average of such costs, (ii) an index which reflects the relative costs of malpractice expenses in the different fee schedule areas compared to the national average of such costs, and (iii) an index which reflects \1/4\ of the difference between the relative value of physicians' work effort in each of the different fee schedule areas and the national average of such work effort. (B) Class-specific geographic cost-of- practice indices.--The Secretary may establish more than one index under subparagraph (A)(i) in the case of classes of physicians' services, if, because of differences in the mix of goods and services comprising practice expenses for the different classes of services, the application of a single index under such clause to different classes of such services would be substantially inequitable. (C) Periodic review and adjustments in geographic adjustment factors.--The Secretary, not less often than every 3 years, shall, in consultation with appropriate representatives of physicians, review the indices established under subparagraph (A) and the geographic index values applied under this subsection for all fee schedule areas. Based on such review, the Secretary may revise such index and adjust such index values, except that, if more than 1 year has elapsed since the date of the last previous adjustment, the adjustment to be applied in the first year of the next adjustment shall be \1/ 2\ of the adjustment that otherwise would be made. (D) Use of recent data.--In establishing indices and index values under this paragraph, the Secretary shall use the most recent data available relating to practice expenses, malpractice expenses, and physician work effort in different fee schedule areas. (E) Floor at 1.0 on work geographic index.-- After calculating the work geographic index in subparagraph (A)(iii), for purposes of payment for services furnished on or after January 1, 2004, and before January 1, [2020] 2023, the Secretary shall increase the work geographic index to 1.00 for any locality for which such work geographic index is less than 1.00. (G) Floor for practice expense, malpractice, and work geographic indices for services furnished in alaska.--For purposes of payment for services furnished in Alaska on or after January 1, 2004, and before January 1, 2006, after calculating the practice expense, malpractice, and work geographic indices in clauses (i), (ii), and (iii) of subparagraph (A) and in subparagraph (B), the Secretary shall increase any such index to 1.67 if such index would otherwise be less than 1.67. For purposes of payment for services furnished in the State described in the preceding sentence on or after January 1, 2009, after calculating the work geographic index in subparagraph (A)(iii), the Secretary shall increase the work geographic index to 1.5 if such index would otherwise be less than 1.5 (H) Practice expense geographic adjustment for 2010 and subsequent years.-- (i) For 2010.--Subject to clause (iii), for services furnished during 2010, the employee wage and rent portions of the practice expense geographic index described in subparagraph (A)(i) shall reflect \1/2\ of the difference between the relative costs of employee wages and rents in each of the different fee schedule areas and the national average of such employee wages and rents. (ii) For 2011.--Subject to clause (iii), for services furnished during 2011, the employee wage and rent portions of the practice expense geographic index described in subparagraph (A)(i) shall reflect \1/2\ of the difference between the relative costs of employee wages and rents in each of the different fee schedule areas and the national average of such employee wages and rents. (iii) Hold harmless.--The practice expense portion of the geographic adjustment factor applied in a fee schedule area for services furnished in 2010 or 2011 shall not, as a result of the application of clause (i) or (ii), be reduced below the practice expense portion of the geographic adjustment factor under subparagraph (A)(i) (as calculated prior to the application of such clause (i) or (ii), respectively) for such area for such year. (iv) Analysis.--The Secretary shall analyze current methods of establishing practice expense geographic adjustments under subparagraph (A)(i) and evaluate data that fairly and reliably establishes distinctions in the costs of operating a medical practice in the different fee schedule areas. Such analysis shall include an evaluation of the following: (I) The feasibility of using actual data or reliable survey data developed by medical organizations on the costs of operating a medical practice, including office rents and non- physician staff wages, in different fee schedule areas. (II) The office expense portion of the practice expense geographic adjustment described in subparagraph (A)(i), including the extent to which types of office expenses are determined in local markets instead of national markets. (III) The weights assigned to each of the categories within the practice expense geographic adjustment described in subparagraph (A)(i). (v) Revision for 2012 and subsequent years.--As a result of the analysis described in clause (iv), the Secretary shall, not later than January 1, 2012, make appropriate adjustments to the practice expense geographic adjustment described in subparagraph (A)(i) to ensure accurate geographic adjustments across fee schedule areas, including-- (I) basing the office rents component and its weight on office expenses that vary among fee schedule areas; and (II) considering a representative range of professional and non- professional personnel employed in a medical office based on the use of the American Community Survey data or other reliable data for wage adjustments. Such adjustments shall be made without regard to adjustments made pursuant to clauses (i) and (ii) and shall be made in a budget neutral manner. (I) Floor for practice expense index for services furnished in frontier states.-- (i) In general.--Subject to clause (ii), for purposes of payment for services furnished in a frontier State (as defined in section 1886(d)(3)(E)(iii)(II)) on or after January 1, 2011, after calculating the practice expense index in subparagraph (A)(i), the Secretary shall increase any such index to 1.00 if such index would otherwise be less that 1.00. The preceding sentence shall not be applied in a budget neutral manner. (ii) Limitation.--This subparagraph shall not apply to services furnished in a State that receives a non-labor related share adjustment under section 1886(d)(5)(H). (2) Computation of geographic adjustment factor.--For purposes of subsection (b)(1)(C), for all physicians' services for each fee schedule area the Secretary shall establish a geographic adjustment factor equal to the sum of the geographic cost-of-practice adjustment factor (specified in paragraph (3)), the geographic malpractice adjustment factor (specified in paragraph (4)), and the geographic physician work adjustment factor (specified in paragraph (5)) for the service and the area. (3) Geographic cost-of-practice adjustment factor.-- For purposes of paragraph (2), the ``geographic cost- of-practice adjustment factor'', for a service for a fee schedule area, is the product of-- (A) the proportion of the total relative value for the service that reflects the relative value units for the practice expense component, and (B) the geographic cost-of-practice index value for the area for the service, based on the index established under paragraph (1)(A)(i) or (1)(B) (as the case may be). (4) Geographic malpractice adjustment factor.--For purposes of paragraph (2), the ``geographic malpractice adjustment factor'', for a service for a fee schedule area, is the product of-- (A) the proportion of the total relative value for the service that reflects the relative value units for the malpractice component, and (B) the geographic malpractice index value for the area, based on the index established under paragraph (1)(A)(ii). (5) Geographic physician work adjustment factor.--For purposes of paragraph (2), the ``geographic physician work adjustment factor'', for a service for a fee schedule area, is the product of-- (A) the proportion of the total relative value for the service that reflects the relative value units for the work component, and (B) the geographic physician work index value for the area, based on the index established under paragraph (1)(A)(iii). (6) Use of msas as fee schedule areas in california.-- (A) In general.--Subject to the succeeding provisions of this paragraph and notwithstanding the previous provisions of this subsection, for services furnished on or after January 1, 2017, the fee schedule areas used for payment under this section applicable to California shall be the following: (i) Each Metropolitan Statistical Area (each in this paragraph referred to as an ``MSA''), as defined by the Director of the Office of Management and Budget as of December 31 of the previous year, shall be a fee schedule area. (ii) All areas not included in an MSA shall be treated as a single rest-of- State fee schedule area. (B) Transition for msas previously in rest- of-state payment locality or in locality 3.-- (i) In general.--For services furnished in California during a year beginning with 2017 and ending with 2021 in an MSA in a transition area (as defined in subparagraph (D)), subject to subparagraph (C), the geographic index values to be applied under this subsection for such year shall be equal to the sum of the following: (I) Current law component.-- The old weighting factor (described in clause (ii)) for such year multiplied by the geographic index values under this subsection for the fee schedule area that included such MSA that would have applied in such area (as estimated by the Secretary) if this paragraph did not apply. (II) MSA-based component.-- The MSA-based weighting factor (described in clause (iii)) for such year multiplied by the geographic index values computed for the fee schedule area under subparagraph (A) for the year (determined without regard to this subparagraph). (ii) Old weighting factor.--The old weighting factor described in this clause-- (I) for 2017, is \5/6\; and (II) for each succeeding year, is the old weighting factor described in this clause for the previous year minus \1/ 6\. (iii) MSA-based weighting factor.-- The MSA-based weighting factor described in this clause for a year is 1 minus the old weighting factor under clause (ii) for that year. (C) Hold harmless.--For services furnished in a transition area in California during a year beginning with 2017, the geographic index values to be applied under this subsection for such year shall not be less than the corresponding geographic index values that would have applied in such transition area (as estimated by the Secretary) if this paragraph did not apply. (D) Transition area defined.--In this paragraph, the term ``transition area'' means each of the following fee schedule areas for 2013: (i) The rest-of-State payment locality. (ii) Payment locality 3. (E) References to fee schedule areas.-- Effective for services furnished on or after January 1, 2017, for California, any reference in this section to a fee schedule area shall be deemed a reference to a fee schedule area established in accordance with this paragraph. (f) Sustainable Growth Rate.-- (1) Publication.--The Secretary shall cause to have published in the Federal Register not later than-- (A) November 1, 2000, the sustainable growth rate for 2000 and 2001; and (B) November 1 of each succeeding year through 2014 the sustainable growth rate for such succeeding year and each of the preceding 2 years. (2) Specification of growth rate.--The sustainable growth rate for all physicians' services for a fiscal year (beginning with fiscal year 1998 and ending with fiscal year 2000) and a year beginning with 2000 and ending with 2014 shall be equal to the product of-- (A) 1 plus the Secretary's estimate of the weighted average percentage increase (divided by 100) in the fees for all physicians' services in the applicable period involved, (B) 1 plus the Secretary's estimate of the percentage change (divided by 100) in the average number of individuals enrolled under this part (other than Medicare+Choice plan enrollees) from the previous applicable period to the applicable period involved, (C) 1 plus the Secretary's estimate of the annual average percentage growth in real gross domestic product per capita (divided by 100) during the 10-year period ending with the applicable period involved, and (D) 1 plus the Secretary's estimate of the percentage change (divided by 100) in expenditures for all physicians' services in the applicable period (compared with the previous applicable period) which will result from changes in law and regulations, determined without taking into account estimated changes in expenditures resulting from the update adjustment factor determined under subsection (d)(3)(B) or (d)(4)(B), as the case may be, minus 1 and multiplied by 100. (3) Data to be used.--For purposes of determining the update adjustment factor under subsection (d)(4)(B) for a year beginning with 2001, the sustainable growth rates taken into consideration in the determination under paragraph (2) shall be determined as follows: (A) For 2001.--For purposes of such calculations for 2001, the sustainable growth rates for fiscal year 2000 and the years 2000 and 2001 shall be determined on the basis of the best data available to the Secretary as of September 1, 2000. (B) For 2002.--For purposes of such calculations for 2002, the sustainable growth rates for fiscal year 2000 and for years 2000, 2001, and 2002 shall be determined on the basis of the best data available to the Secretary as of September 1, 2001. (C) For 2003 and succeeding years.--For purposes of such calculations for a year after 2002-- (i) the sustainable growth rates for that year and the preceding 2 years shall be determined on the basis of the best data available to the Secretary as of September 1 of the year preceding the year for which the calculation is made; and (ii) the sustainable growth rate for any year before a year described in clause (i) shall be the rate as most recently determined for that year under this subsection. Nothing in this paragraph shall be construed as affecting the sustainable growth rates established for fiscal year 1998 or fiscal year 1999. (4) Definitions.--In this subsection: (A) Services included in physicians' services.--The term ``physicians' services'' includes other items and services (such as clinical diagnostic laboratory tests and radiology services), specified by the Secretary, that are commonly performed or furnished by a physician or in a physician's office, but does not include services furnished to a Medicare+Choice plan enrollee. (B) Medicare+choice plan enrollee.--The term ``Medicare+Choice plan enrollee'' means, with respect to a fiscal year, an individual enrolled under this part who has elected to receive benefits under this title for the fiscal year through a Medicare+Choice plan offered under part C, and also includes an individual who is receiving benefits under this part through enrollment with an eligible organization with a risk-sharing contract under section 1876. (C) Applicable period.--The term ``applicable period'' means-- (i) a fiscal year, in the case of fiscal year 1998, fiscal year 1999, and fiscal year 2000; or (ii) a calendar year with respect to a year beginning with 2000; as the case may be. (g) Limitation on Beneficiary Liability.-- (1) Limitation on actual charges.-- (A) In general.--In the case of a nonparticipating physician or nonparticipating supplier or other person (as defined in section 1842(i)(2)) who does not accept payment on an assignment-related basis for a physician's service furnished with respect to an individual enrolled under this part, the following rules apply: (i) Application of limiting charge.-- No person may bill or collect an actual charge for the service in excess of the limiting charge described in paragraph (2) for such service. (ii) No liability for excess charges.--No person is liable for payment of any amounts billed for the service in excess of such limiting charge. (iii) Correction of excess charges.-- If such a physician, supplier, or other person bills, but does not collect, an actual charge for a service in violation of clause (i), the physician, supplier, or other person shall reduce on a timely basis the actual charge billed for the service to an amount not to exceed the limiting charge for the service. (iv) Refund of excess collections.-- If such a physician, supplier, or other person collects an actual charge for a service in violation of clause (i), the physician, supplier, or other person shall provide on a timely basis a refund to the individual charged in the amount by which the amount collected exceeded the limiting charge for the service. The amount of such a refund shall be reduced to the extent the individual has an outstanding balance owed by the individual to the physician. (B) Sanctions.--If a physician, supplier, or other person-- (i) knowingly and willfully bills or collects for services in violation of subparagraph (A)(i) on a repeated basis, or (ii) fails to comply with clause (iii) or (iv) of subparagraph (A) on a timely basis, the Secretary may apply sanctions against the physician, supplier, or other person in accordance with paragraph (2) of section 1842(j). In applying this subparagraph, paragraph (4) of such section applies in the same manner as such paragraph applies to such section and any reference in such section to a physician is deemed also to include a reference to a supplier or other person under this subparagraph. (C) Timely basis.--For purposes of this paragraph, a correction of a bill for an excess charge or refund of an amount with respect to a violation of subparagraph (A)(i) in the case of a service is considered to be provided ``on a timely basis'', if the reduction or refund is made not later than 30 days after the date the physician, supplier, or other person is notified by the carrier under this part of such violation and of the requirements of subparagraph (A). (2) Limiting charge defined.-- (A) For 1991.--For physicians' services of a physician furnished during 1991, other than radiologist services subject to section 1834(b), the ``limiting charge'' shall be the same percentage (or, if less, 25 percent) above the recognized payment amount under this part with respect to the physician (as a nonparticipating physician) as the percentage by which-- (i) the maximum allowable actual charge (as determined under section 1842(j)(1)(C) as of December 31, 1990, or, if less, the maximum actual charge otherwise permitted for the service under this part as of such date) for the service of the physician, exceeds (ii) the recognized payment amount for the service of the physician (as a nonparticipating physician) as of such date. In the case of evaluation and management services (as specified in section 1842(b)(16)(B)(ii)), the preceding sentence shall be applied by substituting ``40 percent'' for ``25 percent''. (B) For 1992.--For physicians' services furnished during 1992, other than radiologist services subject to section 1834(b), the ``limiting charge'' shall be the same percentage (or, if less, 20 percent) above the recognized payment amount under this part for nonparticipating physicians as the percentage by which-- (i) the limiting charge (as determined under subparagraph (A) as of December 31, 1991) for the service, exceeds (ii) the recognized payment amount for the service for nonparticipating physicians as of such date. (C) After 1992.--For physicians' services furnished in a year after 1992, the ``limiting charge'' shall be 115 percent of the recognized payment amount under this part for nonparticipating physicians or for nonparticipating suppliers or other persons. (D) Recognized payment amount.--In this section, the term ``recognized payment amount'' means, for services furnished on or after January 1, 1992, the fee schedule amount determined under subsection (a) (or, if payment under this part is made on a basis other than the fee schedule under this section, 95 percent of the other payment basis), and, for services furnished during 1991, the applicable percentage (as defined in section 1842(b)(4)(A)(iv)) of the prevailing charge (or fee schedule amount) for nonparticipating physicians for that year. (3) Limitation on charges for medicare beneficiaries eligible for medicaid benefits.-- (A) In general.--Payment for physicians' services furnished on or after April 1, 1990, to an individual who is enrolled under this part and eligible for any medical assistance (including as a qualified medicare beneficiary, as defined in section 1905(p)(1)) with respect to such services under a State plan approved under title XIX may only be made on an assignment-related basis and the provisions of section 1902(n)(3)(A) apply to further limit permissible charges under this section. (B) Penalty.--A person may not bill for physicians' services subject to subparagraph (A) other than on an assignment-related basis. No person is liable for payment of any amounts billed for such a service in violation of the previous sentence. If a person knowingly and willfully bills for physicians' services in violation of the first sentence, the Secretary may apply sanctions against the person in accordance with section 1842(j)(2). (4) Physician submission of claims.-- (A) In general.--For services furnished on or after September 1, 1990, within 1 year after the date of providing a service for which payment is made under this part on a reasonable charge or fee schedule basis, a physician, supplier, or other person (or an employer or facility in the cases described in section 1842(b)(6)(A))-- (i) shall complete and submit a claim for such service on a standard claim form specified by the Secretary to the carrier on behalf of a beneficiary, and (ii) may not impose any charge relating to completing and submitting such a form. (B) Penalty.--(i) With respect to an assigned claim wherever a physician, provider, supplier or other person (or an employer or facility in the cases described in section 1842(b)(6)(A)) fails to submit such a claim as required in subparagraph (A), the Secretary shall reduce by 10 percent the amount that would otherwise be paid for such claim under this part. (ii) If a physician, supplier, or other person (or an employer or facility in the cases described in section 1842(b)(6)(A)) fails to submit a claim required to be submitted under subparagraph (A) or imposes a charge in violation of such subparagraph, the Secretary shall apply the sanction with respect to such a violation in the same manner as a sanction may be imposed under section 1842(p)(3) for a violation of section 1842(p)(1). (5) Electronic billing; direct deposit.--The Secretary shall encourage and develop a system providing for expedited payment for claims submitted electronically. The Secretary shall also encourage and provide incentives allowing for direct deposit as payments for services furnished by participating physicians. The Secretary shall provide physicians with such technical information as necessary to enable such physicians to submit claims electronically. The Secretary shall submit a plan to Congress on this paragraph by May 1, 1990. (6) Monitoring of charges.-- (A) In general.--The Secretary shall monitor-- (i) the actual charges of nonparticipating physicians for physicians' services furnished on or after January 1, 1991, to individuals enrolled under this part, and (ii) changes (by specialty, type of service, and geographic area) in (I) the proportion of expenditures for physicians' services provided under this part by participating physicians, (II) the proportion of expenditures for such services for which payment is made under this part on an assignment- related basis, and (III) the amounts charged above the recognized payment amounts under this part. (B) Report.--The Secretary shall, by not later than April 15 of each year (beginning in 1992), report to the Congress information on the extent to which actual charges exceed limiting charges, the number and types of services involved, and the average amount of excess charges and information regarding the changes described in subparagraph (A)(ii). (C) Plan.--If the Secretary finds that there has been a significant decrease in the proportions described in subclauses (I) and (II) of subparagraph (A)(ii) or an increase in the amounts described in subclause (III) of that subparagraph, the Secretary shall develop a plan to address such a problem and transmit to Congress recommendations regarding the plan. The Medicare Payment Advisory Commission shall review the Secretary's plan and recommendations and transmit to Congress its comments regarding such plan and recommendations. (7) Monitoring of utilization and access.-- (A) In general.--The Secretary shall monitor-- (i) changes in the utilization of and access to services furnished under this part within geographic, population, and service related categories, (ii) possible sources of inappropriate utilization of services furnished under this part which contribute to the overall level of expenditures under this part, and (iii) factors underlying these changes and their interrelationships. (B) Report.--The Secretary shall by not later than April 15, of each year (beginning with 1991) report to the Congress on the changes described in subparagraph (A)(i) and shall include in the report an examination of the factors (including factors relating to different services and specific categories and groups of services and geographic and demographic variations in utilization) which may contribute to such changes. (C) Recommendations.--The Secretary shall include in each annual report under subparagraph (B) recommendations-- (i) addressing any identified patterns of inappropriate utilization, (ii) on utilization review, (iii) on physician education or patient education, (iv) addressing any problems of beneficiary access to care made evident by the monitoring process, and (v) on such other matters as the Secretary deems appropriate. The Medicare Payment Advisory Commission shall comment on the Secretary's recommendations and in developing its comments, the Commission shall convene and consult a panel of physician experts to evaluate the implications of medical utilization patterns for the quality of and access to patient care. (h) Sending Information to Physicians.--Before the beginning of each year (beginning with 1992), the Secretary shall send to each physician or nonparticipating supplier or other person furnishing physicians' services (as defined in section 1848(j)(3)) furnishing physicians' services under this part, for services commonly performed by the physician, supplier, or other person, information on fee schedule amounts that apply for the year in the fee schedule area for participating and non-participating physicians, and the maximum amount that may be charged consistent with subsection (g)(2). Such information shall be transmitted in conjunction with notices to physicians, suppliers, and other persons under section 1842(h) (relating to the participating physician program) for a year. (i) Miscellaneous Provisions.-- (1) Restriction on administrative and judicial review.--There shall be no administrative or judicial review under section 1869 or otherwise of-- (A) the determination of the adjusted historical payment basis (as defined in subsection (a)(2)(D)(i)), (B) the determination of relative values and relative value units under subsection (c), including adjustments under subsections (c)(2)(F), (c)(2)(H), and (c)(2)(I) and section 13515(b) of the Omnibus Budget Reconciliation Act of 1993, (C) the determination of conversion factors under subsection (d), including without limitation a prospective redetermination of the sustainable growth rates for any or all previous fiscal years, (D) the establishment of geographic adjustment factors under subsection (e), (E) the establishment of the system for the coding of physicians' services under this section, and (F) the collection and use of information in the determination of relative values under subsection (c)(2)(M). (2) Assistants-at-surgery.-- (A) In general.--Subject to subparagraph (B), in the case of a surgical service furnished by a physician, if payment is made separately under this part for the services of a physician serving as an assistant-at-surgery, the fee schedule amount shall not exceed 16 percent of the fee schedule amount otherwise determined under this section for the global surgical service involved. (B) Denial of payment in certain cases.--If the Secretary determines, based on the most recent data available, that for a surgical procedure (or class of surgical procedures) the national average percentage of such procedure performed under this part which involve the use of a physician as an assistant at surgery is less than 5 percent, no payment may be made under this part for services of an assistant at surgery involved in the procedure. (3) No comparability adjustment.--For physicians' services for which payment under this part is determined under this section-- (A) a carrier may not make any adjustment in the payment amount under section 1842(b)(3)(B) on the basis that the payment amount is higher than the charge applicable, for comparable services and under comparable circumstances, to the policyholders and subscribers of the carrier, (B) no payment adjustment may be made under section 1842(b)(8), and (C) section 1842(b)(9) shall not apply. (j) Definitions.--In this section: (1) Category.--For services furnished before January 1, 1998, the term ``category'' means, with respect to physicians' services, surgical services (as defined by the Secretary and including anesthesia services), primary care services (as defined in section 1842(i)(4)), and all other physicians' services. The Secretary shall define surgical services and publish such definitions in the Federal Register no later than May 1, 1990, after consultation with organizations representing physicians. (2) Fee schedule area.--Except as provided in subsection (e)(6)(D), the term ``fee schedule area'' means a locality used under section 1842(b) for purposes of computing payment amounts for physicians' services. (3) Physicians' services.--The term ``physicians' services'' includes items and services described in paragraphs (1), (2)(A), (2)(D), (2)(G), (2)(P) (with respect to services described in subparagraphs (A) and (C) of section 1861(oo)(2)), (2)(R) (with respect to services described in suparagraphs (B), (C), and (D) of section 1861(pp)(1)), (2)(S), (2)(W), (2)(AA), (2)(DD), (2)(EE), (2)(FF) (including administration of the health risk assessment), (3), (4), (13), (14) (with respect to services described in section 1861(nn)(2)), and (15) of section 1861(s) (other than clinical diagnostic laboratory tests and, except for purposes of subsection (a)(3), (g), and (h) such other items and services as the Secretary may specify). (4) Practice expenses.--The term ``practice expenses'' includes all expenses for furnishing physicians' services, excluding malpractice expenses, physician compensation, and other physician fringe benefits. (k) Quality Reporting System.-- (1) In general.--The Secretary shall implement a system for the reporting by eligible professionals of data on quality measures specified under paragraph (2). Such data shall be submitted in a form and manner specified by the Secretary (by program instruction or otherwise), which may include submission of such data on claims under this part. (2) Use of consensus-based quality measures.-- (A) For 2007.-- (i) In general.--For purposes of applying this subsection for the reporting of data on quality measures for covered professional services furnished during the period beginning July 1, 2007, and ending December 31, 2007, the quality measures specified under this paragraph are the measures identified as 2007 physician quality measures under the Physician Voluntary Reporting Program as published on the public website of the Centers for Medicare & Medicaid Services as of the date of the enactment of this subsection, except as may be changed by the Secretary based on the results of a consensus-based process in January of 2007, if such change is published on such website by not later than April 1, 2007. (ii) Subsequent refinements in application permitted.--The Secretary may, from time to time (but not later than July 1, 2007), publish on such website (without notice or opportunity for public comment) modifications or refinements (such as code additions, corrections, or revisions) for the application of quality measures previously published under clause (i), but may not, under this clause, change the quality measures under the reporting system. (iii) Implementation.-- Notwithstanding any other provision of law, the Secretary may implement by program instruction or otherwise this subsection for 2007. (B) For 2008 and 2009.-- (i) In general.--For purposes of reporting data on quality measures for covered professional services furnished during 2008 and 2009, the quality measures specified under this paragraph for covered professional services shall be measures that have been adopted or endorsed by a consensus organization (such as the National Quality Forum or AQA), that include measures that have been submitted by a physician specialty, and that the Secretary identifies as having used a consensus- based process for developing such measures. Such measures shall include structural measures, such as the use of electronic health records and electronic prescribing technology. (ii) Proposed set of measures.--Not later than August 15 of each of 2007 and 2008, the Secretary shall publish in the Federal Register a proposed set of quality measures that the Secretary determines are described in clause (i) and would be appropriate for eligible professionals to use to submit data to the Secretary in 2008 or 2009, as applicable. The Secretary shall provide for a period of public comment on such set of measures. (iii) Final set of measures.--Not later than November 15 of each of 2007 and 2008, the Secretary shall publish in the Federal Register a final set of quality measures that the Secretary determines are described in clause (i) and would be appropriate for eligible professionals to use to submit data to the Secretary in 2008 or 2009, as applicable. (C) For 2010 and subsequent years.-- (i) In general.--Subject to clause (ii), for purposes of reporting data on quality measures for covered professional services furnished during 2010 and each subsequent year, subject to subsection (m)(3)(C), the quality measures (including electronic prescribing quality measures) specified under this paragraph shall be such measures selected by the Secretary from measures that have been endorsed by the entity with a contract with the Secretary under section 1890(a). (ii) Exception.--In the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1890(a), the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary, such as the AQA alliance. (D) Opportunity to provide input on measures for 2009 and subsequent years.--For each quality measure (including an electronic prescribing quality measure) adopted by the Secretary under subparagraph (B) (with respect to 2009) or subparagraph (C), the Secretary shall ensure that eligible professionals have the opportunity to provide input during the development, endorsement, or selection of measures applicable to services they furnish. (3) Covered professional services and eligible professionals defined.--For purposes of this subsection: (A) Covered professional services.--The term ``covered professional services'' means services for which payment is made under, or is based on, the fee schedule established under this section and which are furnished by an eligible professional. (B) Eligible professional.--The term ``eligible professional'' means any of the following: (i) A physician. (ii) A practitioner described in section 1842(b)(18)(C). (iii) A physical or occupational therapist or a qualified speech- language pathologist. (iv) Beginning with 2009, a qualified audiologist (as defined in section 1861(ll)(3)(B)). (4) Use of registry-based reporting.--As part of the publication of proposed and final quality measures for 2008 under clauses (ii) and (iii) of paragraph (2)(B), the Secretary shall address a mechanism whereby an eligible professional may provide data on quality measures through an appropriate medical registry (such as the Society of Thoracic Surgeons National Database) or through a Maintenance of Certification program operated by a specialty body of the American Board of Medical Specialties that meets the criteria for such a registry, as identified by the Secretary. (5) Identification units.--For purposes of applying this subsection, the Secretary may identify eligible professionals through billing units, which may include the use of the Provider Identification Number, the unique physician identification number (described in section 1833(q)(1)), the taxpayer identification number, or the National Provider Identifier. For purposes of applying this subsection for 2007, the Secretary shall use the taxpayer identification number as the billing unit. (6) Education and outreach.--The Secretary shall provide for education and outreach to eligible professionals on the operation of this subsection. (7) Limitations on review.--There shall be no administrative or judicial review under section 1869, section 1878, or otherwise, of the development and implementation of the reporting system under paragraph (1), including identification of quality measures under paragraph (2) and the application of paragraphs (4) and (5). (8) Implementation.--The Secretary shall carry out this subsection acting through the Administrator of the Centers for Medicare & Medicaid Services. (9) Continued application for purposes of mips and for certain professionals volunteering to report.--The Secretary shall, in accordance with subsection (q)(1)(F), carry out the provisions of this subsection-- (A) for purposes of subsection (q); and (B) for eligible professionals who are not MIPS eligible professionals (as defined in subsection (q)(1)(C)) for the year involved. (l) Physician Assistance and Quality Initiative Fund.-- (1) Establishment.--The Secretary shall establish under this subsection a Physician Assistance and Quality Initiative Fund (in this subsection referred to as the ``Fund'') which shall be available to the Secretary for physician payment and quality improvement initiatives, which may include application of an adjustment to the update of the conversion factor under subsection (d). (2) Funding.-- (A) Amount available.-- (i) In general.--Subject to clause (ii), there shall be available to the Fund the following amounts: (I) For expenditures during 2008, an amount equal to $150,500,000. (II) For expenditures during 2009, an amount equal to $24,500,000. (ii) Limitations on expenditures.-- (I) 2008.--The amount available for expenditures during 2008 shall be reduced as provided by subparagraph (A) of section 225(c)(1) and section 524 of the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2008 (division G of the Consolidated Appropriations Act, 2008). (II) 2009.--The amount available for expenditures during 2009 shall be reduced as provided by subparagraph (B) of such section 225(c)(1). (B) Timely obligation of all available funds for services.--The Secretary shall provide for expenditures from the Fund in a manner designed to provide (to the maximum extent feasible) for the obligation of the entire amount available for expenditures, after application of subparagraph (A)(ii), during-- (i) 2008 for payment with respect to physicians' services furnished during 2008; and (ii) 2009 for payment with respect to physicians' services furnished during 2009. (C) Payment from trust fund.--The amount specified in subparagraph (A) shall be available to the Fund, as expenditures are made from the Fund, from the Federal Supplementary Medical Insurance Trust Fund under section 1841. (D) Funding limitation.--Amounts in the Fund shall be available in advance of appropriations in accordance with subparagraph (B) but only if the total amount obligated from the Fund does not exceed the amount available to the Fund under subparagraph (A). The Secretary may obligate funds from the Fund only if the Secretary determines (and the Chief Actuary of the Centers for Medicare & Medicaid Services and the appropriate budget officer certify) that there are available in the Fund sufficient amounts to cover all such obligations incurred consistent with the previous sentence. (E) Construction.--In the case that expenditures from the Fund are applied to, or otherwise affect, a conversion factor under subsection (d) for a year, the conversion factor under such subsection shall be computed for a subsequent year as if such application or effect had never occurred. (m) Incentive Payments for Quality Reporting.-- (1) Incentive payments.-- (A) In general.--For 2007 through 2014, with respect to covered professional services furnished during a reporting period by an eligible professional, if-- (i) there are any quality measures that have been established under the physician reporting system that are applicable to any such services furnished by such professional for such reporting period; (ii) the eligible professional satisfactorily submits (as determined under this subsection) to the Secretary data on such quality measures in accordance with such reporting system for such reporting period, in addition to the amount otherwise paid under this part, there also shall be paid to the eligible professional (or to an employer or facility in the cases described in clause (A) of section 1842(b)(6)) or, in the case of a group practice under paragraph (3)(C), to the group practice, from the Federal Supplementary Medical Insurance Trust Fund established under section 1841 an amount equal to the applicable quality percent of the Secretary's estimate (based on claims submitted not later than 2 months after the end of the reporting period) of the allowed charges under this part for all such covered professional services furnished by the eligible professional (or, in the case of a group practice under paragraph (3)(C), by the group practice) during the reporting period. (B) Applicable quality percent.--For purposes of subparagraph (A), the term ``applicable quality percent'' means-- (i) for 2007 and 2008, 1.5 percent; and (ii) for 2009 and 2010, 2.0 percent; (iii) for 2011, 1.0 percent; and (iv) for 2012, 2013, and 2014, 0.5 percent. (2) Incentive payments for electronic prescribing.-- (A) In general.--Subject to subparagraph (D), for 2009 through 2013, with respect to covered professional services furnished during a reporting period by an eligible professional, if the eligible professional is a successful electronic prescriber for such reporting period, in addition to the amount otherwise paid under this part, there also shall be paid to the eligible professional (or to an employer or facility in the cases described in clause (A) of section 1842(b)(6)) or, in the case of a group practice under paragraph (3)(C), to the group practice, from the Federal Supplementary Medical Insurance Trust Fund established under section 1841 an amount equal to the applicable electronic prescribing percent of the Secretary's estimate (based on claims submitted not later than 2 months after the end of the reporting period) of the allowed charges under this part for all such covered professional services furnished by the eligible professional (or, in the case of a group practice under paragraph (3)(C), by the group practice) during the reporting period. (B) Limitation with respect to electronic prescribing quality measures.--The provisions of this paragraph and subsection (a)(5) shall not apply to an eligible professional (or, in the case of a group practice under paragraph (3)(C), to the group practice) if, for the reporting period (or, for purposes of subsection (a)(5), for the reporting period for a year)-- (i) the allowed charges under this part for all covered professional services furnished by the eligible professional (or group, as applicable) for the codes to which the electronic prescribing quality measure applies (as identified by the Secretary and published on the Internet website of the Centers for Medicare & Medicaid Services as of January 1, 2008, and as subsequently modified by the Secretary) are less than 10 percent of the total of the allowed charges under this part for all such covered professional services furnished by the eligible professional (or the group, as applicable); or (ii) if determined appropriate by the Secretary, the eligible professional does not submit (including both electronically and nonelectronically) a sufficient number (as determined by the Secretary) of prescriptions under part D. If the Secretary makes the determination to apply clause (ii) for a period, then clause (i) shall not apply for such period. (C) Applicable electronic prescribing percent.--For purposes of subparagraph (A), the term ``applicable electronic prescribing percent'' means-- (i) for 2009 and 2010, 2.0 percent; (ii) for 2011 and 2012, 1.0 percent; and (iii) for 2013, 0.5 percent. (D) Limitation with respect to ehr incentive payments.--The provisions of this paragraph shall not apply to an eligible professional (or, in the case of a group practice under paragraph (3)(C), to the group practice) if, for the EHR reporting period the eligible professional (or group practice) receives an incentive payment under subsection (o)(1)(A) with respect to a certified EHR technology (as defined in subsection (o)(4)) that has the capability of electronic prescribing. (3) Satisfactory reporting and successful electronic prescriber and described.-- (A) In general.--For purposes of paragraph (1), an eligible professional shall be treated as satisfactorily submitting data on quality measures for covered professional services for a reporting period (or, for purposes of subsection (a)(8), for the quality reporting period for the year) if quality measures have been reported as follows: (i) Three or fewer quality measures applicable.--If there are no more than 3 quality measures that are provided under the physician reporting system and that are applicable to such services of such professional furnished during the period, each such quality measure has been reported under such system in at least 80 percent of the cases in which such measure is reportable under the system. (ii) Four or more quality measures applicable.--If there are 4 or more quality measures that are provided under the physician reporting system and that are applicable to such services of such professional furnishedduring the period, at least 3 such quality measures have been reported under such system in at least 80 percent of the cases in which the respective measure is reportable under the system. For years after 2008, quality measures for purposes of this subparagraph shall not include electronic prescribing quality measures. (B) Successful electronic prescriber.-- (i) In general.--For purposes of paragraph (2) and subsection (a)(5), an eligible professional shall be treated as a successful electronic prescriber for a reporting period (or, for purposes of subsection (a)(5), for the reporting period for a year) if the eligible professional meets the requirement described in clause (ii), or, if the Secretary determines appropriate, the requirement described in clause (iii). If the Secretary makes the determination under the preceding sentence to apply the requirement described in clause (iii) for a period, then the requirement described in clause (ii) shall not apply for such period. (ii) Requirement for submitting data on electronic prescribing quality measures.--The requirement described in this clause is that, with respect to covered professional services furnished by an eligible professional during a reporting period (or, for purposes of subsection (a)(5), for the reporting period for a year), if there are any electronic prescribing quality measures that have been established under the physician reporting system and are applicable to any such services furnished by such professional for the period, such professional reported each such measure under such system in at least 50 percent of the cases in which such measure is reportable by such professional under such system. (iii) Requirement for electronically prescribing under part d.--The requirement described in this clause is that the eligible professional electronically submitted a sufficient number (as determined by the Secretary) of prescriptions under part D during the reporting period (or, for purposes of subsection (a)(5), for the reporting period for a year). (iv) Use of part d data.-- Notwithstanding sections 1860D- 15(d)(2)(B) and 1860D-15(f)(2), the Secretary may use data regarding drug claims submitted for purposes of section 1860D-15 that are necessary for purposes of clause (iii), paragraph (2)(B)(ii), and paragraph (5)(G). (v) Standards for electronic prescribing.--To the extent practicable, in determining whether eligible professionals meet the requirements under clauses (ii) and (iii) for purposes of clause (i), the Secretary shall ensure that eligible professionals utilize electronic prescribing systems in compliance with standards established for such systems pursuant to the Part D Electronic Prescribing Program under section 1860D-4(e). (C) Satisfactory reporting measures for group practices.-- (i) In general.--By January 1, 2010, the Secretary shall establish and have in place a process under which eligible professionals in a group practice (as defined by the Secretary) shall be treated as satisfactorily submitting data on quality measures under subparagraph (A) and as meeting the requirement described in subparagraph (B)(ii) for covered professional services for a reporting period (or, for purposes of subsection (a)(5), for a reporting period for a year, or, for purposes of subsection (a)(8), for a quality reporting period for the year) if, in lieu of reporting measures under subsection (k)(2)(C), the group practice reports measures determined appropriate by the Secretary, such as measures that target high-cost chronic conditions and preventive care, in a form and manner, and at a time, specified by the Secretary. (ii) Statistical sampling model.--The process under clause (i) shall provide and, for 2016 and subsequent years, may provide for the use of a statistical sampling model to submit data on measures, such as the model used under the Physician Group Practice demonstration project under section 1866A. (iii) No double payments.--Payments to a group practice under this subsection by reason of the process under clause (i) shall be in lieu of the payments that would otherwise be made under this subsection to eligible professionals in the group practice for satisfactorily submitting data on quality measures. (D) Satisfactory reporting measures through participation in a qualified clinical data registry.--For 2014 and subsequent years, the Secretary shall treat an eligible professional as satisfactorily submitting data on quality measures under subparagraph (A) and, for 2016 and subsequent years, subparagraph (A) or (C) if, in lieu of reporting measures under subsection (k)(2)(C), the eligible professional is satisfactorily participating, as determined by the Secretary, in a qualified clinical data registry (as described in subparagraph (E)) for the year. (E) Qualified clinical data registry.-- (i) In general.--The Secretary shall establish requirements for an entity to be considered a qualified clinical data registry. Such requirements shall include a requirement that the entity provide the Secretary with such information, at such times, and in such manner, as the Secretary determines necessary to carry out this subsection. (ii) Considerations.--In establishing the requirements under clause (i), the Secretary shall consider whether an entity-- (I) has in place mechanisms for the transparency of data elements and specifications, risk models, and measures; (II) requires the submission of data from participants with respect to multiple payers; (III) provides timely performance reports to participants at the individual participant level; and (IV) supports quality improvement initiatives for participants. (iii) Measures.--With respect to measures used by a qualified clinical data registry-- (I) sections 1890(b)(7) and 1890A(a) shall not apply; and (II) measures endorsed by the entity with a contract with the Secretary under section 1890(a) may be used. (iv) Consultation.--In carrying out this subparagraph, the Secretary shall consult with interested parties. (v) Determination.--The Secretary shall establish a process to determine whether or not an entity meets the requirements established under clause (i). Such process may involve one or both of the following: (I) A determination by the Secretary. (II) A designation by the Secretary of one or more independent organizations to make such determination. (F) Authority to revise satisfactorily reporting data.--For years after 2009, the Secretary, in consultation with stakeholders and experts, may revise the criteria under this subsection for satisfactorily submitting data on quality measures under subparagraph (A) and the criteria for submitting data on electronic prescribing quality measures under subparagraph (B)(ii). (4) Form of payment.--The payment under this subsection shall be in the form of a single consolidated payment. (5) Application.-- (A) Physician reporting system rules.-- Paragraphs (5), (6),and (8) of subsection (k) shall apply for purposes of this subsection in the same manner as they apply for purposes of such subsection. (B) Coordination with other bonus payments.-- The provisions of this subsection shall not be taken into account in applying subsections (m) and (u) of section 1833 and any payment under such subsections shall not be taken into account in computing allowable charges under this subsection. (C) Implementation.--Notwithstanding any other provision of law, for 2007, 2008, and 2009, the Secretary may implement by program instruction or otherwise this subsection. (D) Validation.-- (i) In general.--Subject to the succeeding provisions of this subparagraph, for purposes of determining whether a measure is applicable to the covered professional services of an eligible professional under this subsection for 2007 and 288, the Secretary shall presume that if an eligible professional submits data for a measure, such measure is applicable to such professional. (ii) Method.--The Secretary may establish procedures to validate (by sampling or other means as the Secretary determines to be appropriate) whether measures applicable to covered professional services of an eligible professional have been reported. (iii) Denial of payment authority.-- If the Secretary determines that an eligible professional (or, in the case of a group practice under paragraph (3)(C), the group practice) has not reported measures applicable to covered professional services of such professional, the Secretary shall not pay the incentive payment under this subsection. If such payments for such period have already been made, the Secretary shall recoup such payments from the eligible professional (or the group practice). (E) Limitations on review.-- Except as provided in subparagraph (I), there shall be no administrative or judicial review under 1869, section 1878, or otherwise of (i) the determination of measures applicable to services furnished by eligible professionals under this subsection; (ii) the determination of satisfactory reporting under this subsection; (iii) the determination of a successful electronic prescriber under paragraph (3), the limitation under paragraph (2)(B), and the exception under subsection (a)(5)(B); and (iv) the determination of any incentive payment under this subsection and the payment adjustment under paragraphs (5)(A) and (8)(A) of subsection (a). (F) Extension.--For 2008 through reporting periods occurring in 2015, the Secretary shall establish and, for reporting periods occurring in 2016 and subsequent years, the Secretary may establish alternative criteria for satisfactorily reporting under this subsection and alternative reporting periods under paragraph (6)(C) for reporting groups of measures under subsection (k)(2)(B) and for reporting using the method specified in subsection (k)(4). (G) Posting on website.--The Secretary shall post on the Internet website of the Centers for Medicare & Medicaid Services, in an easily understandable format, a list of the names of the following: (i) The eligible professionals (or, in the case of reporting under paragraph (3)(C), the group practices) who satisfactorily submitted data on quality measures under this subsection. (ii) The eligible professionals (or, in the case of reporting under paragraph (3)(C), the group practices) who are successful electronic prescribers. (H) Feedback.--The Secretary shall provide timely feedback to eligible professionals on the performance of the eligible professional with respect to satisfactorily submitting data on quality measures under this subsection. (I) Informal appeals process.--The Secretary shall, by not later than January 1, 2011, establish and have in place an informal process for eligible professionals to seek a review of the determination that an eligible professional did not satisfactorily submit data on quality measures under this subsection. (6) Definitions.--For purposes of this subsection: (A) Eligible professional; covered professional services.--The terms ``eligible professional'' and ``covered professional services'' have the meanings given such termsin subsection (k)(3). (B) Physician reporting system.--The term ``physician reporting system'' means the system established under subsection (k). (C) Reporting period.-- (i) In general.--Subject to clauses (ii) and (iii), the term ``reporting period'' means-- (I) for 2007, the period beginning on July 1, 2007, and ending on December 31, 2007; and (II) for 2008 and subsequent years, the entire year. (ii) Authority to revise reporting period.--For years after 2009, the Secretary may revise the reporting period under clause (i) if the Secretary determines such revision is appropriate, produces valid results on measures reported, and is consistent with the goals of maximizing scientific validity and reducing administrative burden. If the Secretary revises such period pursuant to the preceding sentence, the term ``reporting period'' shall mean such revised period. (iii) Reference.--Any reference in this subsection to a reporting period with respect to the application of subsection (a)(5) (a)(8) shall be deemed a reference to the reporting period under subsection (a)(5)(D)(iii) or the quality reporting period under subsection (a)(8)(D)(iii), respectively. (7) Integration of physician quality reporting and ehr reporting.--Not later than January 1, 2012, the Secretary shall develop a plan to integrate reporting on quality measures under this subsection with reporting requirements under subsection (o) relating to the meaningful use of electronic health records. Such integration shall consist of the following: (A) The selection of measures, the reporting of which would both demonstrate-- (i) meaningful use of an electronic health record for purposes of subsection (o); and (ii) quality of care furnished to an individual. (B) Such other activities as specified by the Secretary. (8) Additional incentive payment.-- (A) In general.--For 2011 through 2014, if an eligible professional meets the requirements described in subparagraph (B), the applicable quality percent for such year, as described in clauses (iii) and (iv) of paragraph (1)(B), shall be increased by 0.5 percentage points. (B) Requirements described.--In order to qualify for the additional incentive payment described in subparagraph (A), an eligible professional shall meet the following requirements: (i) The eligible professional shall-- (I) satisfactorily submit data on quality measures for purposes of paragraph (1) for a year; and (II) have such data submitted on their behalf through a Maintenance of Certification Program (as defined in subparagraph (C)(i)) that meets-- (aa) the criteria for a registry (as described in subsection (k)(4)); or (bb) an alternative form and manner determined appropriate by the Secretary. (ii) The eligible professional, more frequently than is required to qualify for or maintain board certification status-- (I) participates in such a Maintenance of Certification program for a year; and (II) successfully completes a qualified Maintenance of Certification Program practice assessment (as defined in subparagraph (C)(ii)) for such year. (iii) A Maintenance of Certification program submits to the Secretary, on behalf of the eligible professional, information-- (I) in a form and manner specified by the Secretary, that the eligible professional has successfully met the requirements of clause (ii) (which may be in the form of a structural measure); (II) if requested by the Secretary, on the survey of patient experience with care (as described in subparagraph (C)(ii)(II)); and (III) as the Secretary may require, on the methods, measures, and data used under the Maintenance of Certification Program and the qualified Maintenance of Certification Program practice assessment. (C) Definitions.--For purposes of this paragraph: (i) The term ``Maintenance of Certification Program'' means a continuous assessment program, such as qualified American Board of Medical Specialties Maintenance of Certification program or an equivalent program (as determined by the Secretary), that advances quality and the lifelong learning and self- assessment of board certified specialty physicians by focusing on the competencies of patient care, medical knowledge, practice-based learning, interpersonal and communication skills and professionalism. Such a program shall include the following: (I) The program requires the physician to maintain a valid, unrestricted medical license in the United States. (II) The program requires a physician to participate in educational and self-assessment programs that require an assessment of what was learned. (III) The program requires a physician to demonstrate, through a formalized, secure examination, that the physician has the fundamental diagnostic skills, medical knowledge, and clinical judgment to provide quality care in their respective specialty. (IV) The program requires successful completion of a qualified Maintenance of Certification Program practice assessment as described in clause (ii). (ii) The term ``qualified Maintenance of Certification Program practice assessment'' means an assessment of a physician's practice that-- (I) includes an initial assessment of an eligible professional's practice that is designed to demonstrate the physician's use of evidence- based medicine; (II) includes a survey of patient experience with care; and (III) requires a physician to implement a quality improvement intervention to address a practice weakness identified in the initial assessment under subclause (I) and then to remeasure to assess performance improvement after such intervention. (9) Continued application for purposes of mips and for certain professionals volunteering to report.--The Secretary shall, in accordance with subsection (q)(1)(F), carry out the processes under this subsection-- (A) for purposes of subsection (q); and (B) for eligible professionals who are not MIPS eligible professionals (as defined in subsection (q)(1)(C)) for the year involved. (n) Physician Feedback Program.-- (1) Establishment.-- (A) In general.-- (i) Establishment.--The Secretary shall establish a Physician Feedback Program (in this subsection referred to as the ``Program''). (ii) Reports on resources.--The Secretary shall use claims data under this title (and may use other data) to provide confidential reports to physicians (and, as determined appropriate by the Secretary, to groups of physicians) that measure the resources involved in furnishing care to individuals under this title. (iii) Inclusion of certain information.--If determined appropriate by the Secretary, the Secretary may include information on the quality of care furnished to individuals under this title by the physician (or group of physicians) in such reports. (B) Resource use.--The resources described in subparagraph (A)(ii) may be measured-- (i) on an episode basis; (ii) on a per capita basis; or (iii) on both an episode and a per capita basis. (2) Implementation.--The Secretary shall implement the Program by not later than January 1, 2009. (3) Data for reports.--To the extent practicable, reports under the Program shall be based on the most recent data available. (4) Authority to focus initial application.--The Secretary may focus the initial application of the Program as appropriate, such as focusing the Program on-- (A) physician specialties that account for a certain percentage of all spending for physicians' services under this title; (B) physicians who treat conditions that have a high cost or a high volume, or both, under this title; (C) physicians who use a high amount of resources compared to other physicians; (D) physicians practicing in certain geographic areas; or (E) physicians who treat a minimum number of individuals under this title. (5) Authority to exclude certain information if insufficient information.--The Secretary may exclude certain information regarding a service from a report under the Program with respect to a physician (or group of physicians) if the Secretary determines that there is insufficient information relating to that service to provide a valid report on that service. (6) Adjustment of data.--To the extent practicable, the Secretary shall make appropriate adjustments to the data used in preparing reports under the Program, such as adjustments to take into account variations in health status and other patient characteristics. For adjustments for reports on utilization under paragraph (9), see subparagraph (D) of such paragraph. (7) Education and outreach.--The Secretary shall provide for education and outreach activities to physicians on the operation of, and methodologies employed under, the Program. (8) Disclosure exemption.--Reports under the Program shall be exempt from disclosure under section 552 of title 5, United States Code. (9) Reports on utilization.-- (A) Development of episode grouper.-- (i) In general.--The Secretary shall develop an episode grouper that combines separate but clinically related items and services into an episode of care for an individual, as appropriate. (ii) Timeline for development.--The episode grouper described in subparagraph (A) shall be developed by not later than January 1, 2012. (iii) Public availability.--The Secretary shall make the details of the episode grouper described in subparagraph (A) available to the public. (iv) Endorsement.--The Secretary shall seek endorsement of the episode grouper described in subparagraph (A) by the entity with a contract under section 1890(a). (B) Reports on utilization.--Effective beginning with 2012, the Secretary shall provide reports to physicians that compare, as determined appropriate by the Secretary, patterns of resource use of the individual physician to such patterns of other physicians. (C) Analysis of data.--The Secretary shall, for purposes of preparing reports under this paragraph, establish methodologies as appropriate, such as to-- (i) attribute episodes of care, in whole or in part, to physicians; (ii) identify appropriate physicians for purposes of comparison under subparagraph (B); and (iii) aggregate episodes of care attributed to a physician under clause (i) into a composite measure per individual. (D) Data adjustment.--In preparing reports under this paragraph, the Secretary shall make appropriate adjustments, including adjustments-- (i) to account for differences in socioeconomic and demographic characteristics, ethnicity, and health status of individuals (such as to recognize that less healthy individuals may require more intensive interventions); and (ii) to eliminate the effect of geographic adjustments in payment rates (as described in subsection (e)). (E) Public availability of methodology.--The Secretary shall make available to the public-- (i) the methodologies established under subparagraph (C); (ii) information regarding any adjustments made to data under subparagraph (D); and (iii) aggregate reports with respect to physicians. (F) Definition of physician.--In this paragraph: (i) In general.--The term ``physician'' has the meaning given that term in section 1861(r)(1). (ii) Treatment of groups.--Such term includes, as the Secretary determines appropriate, a group of physicians. (G) Limitations on review.--There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the establishment of the methodology under subparagraph (C), including the determination of an episode of care under such methodology. (10) Coordination with other value-based purchasing reforms.--The Secretary shall coordinate the Program with the value-based payment modifier established under subsection (p) and, as the Secretary determines appropriate, other similar provisions of this title. (11) Reports ending with 2017.--Reports under the Program shall not be provided after December 31, 2017. See subsection (q)(12) for reports under the eligible professionals Merit-based Incentive Payment System. (o) Incentives for Adoption and Meaningful Use of Certified EHR Technology.-- (1) Incentive payments.-- (A) In general.-- (i) In general.--Subject to the succeeding subparagraphs of this paragraph, with respect to covered professional services furnished by an eligible professional during a payment year (as defined in subparagraph (E)), if the eligible professional is a meaningful EHR user (as determined under paragraph (2)) for the EHR reporting period with respect to such year, in addition to the amount otherwise paid under this part, there also shall be paid to the eligible professional (or to an employer or facility in the cases described in clause (A) of section 1842(b)(6)), from the Federal Supplementary Medical Insurance Trust Fund established under section 1841 an amount equal to 75 percent of the Secretary's estimate (based on claims submitted not later than 2 months after the end of the payment year) of the allowed charges under this part for all such covered professional services furnished by the eligible professional during such year. (ii) No incentive payments with respect to years after 2016.--No incentive payments may be made under this subsection with respect to a year after 2016. (B) Limitations on amounts of incentive payments.-- (i) In general.--In no case shall the amount of the incentive payment provided under this paragraph for an eligible professional for a payment year exceed the applicable amount specified under this subparagraph with respect to such eligible professional and such year. (ii) Amount.--Subject to clauses (iii) through (v), the applicable amount specified in this subparagraph for an eligible professional is as follows: (I) For the first payment year for such professional, $15,000 (or, if the first payment year for such eligible professional is 2011 or 2012, $18,000). (II) For the second payment year for such professional, $12,000. (III) For the third payment year for such professional, $8,000. (IV) For the fourth payment year for such professional, $4,000. (V) For the fifth payment year for such professional, $2,000. (VI) For any succeeding payment year for such professional, $0. (iii) Phase down for eligible professionals first adopting ehr after 2013.--If the first payment year for an eligible professional is after 2013, then the amount specified in this subparagraph for a payment year for such professional is the same as the amount specified in clause (ii) for such payment year for an eligible professional whose first payment year is 2013. (iv) Increase for certain eligible professionals.--In the case of an eligible professional who predominantly furnishes services under this part in an area that is designated by the Secretary (under section 332(a)(1)(A) of the Public Health Service Act) as a health professional shortage area, the amount that would otherwise apply for a payment year for such professional under subclauses (I) through (V) of clause (ii) shall be increased by 10 percent. In implementing the preceding sentence, the Secretary may, as determined appropriate, apply provisions of subsections (m) and (u) of section 1833 in a similar manner as such provisions apply under such subsection. (v) No incentive payment if first adopting after 2014.--If the first payment year for an eligible professional is after 2014 then the applicable amount specified in this subparagraph for such professional for such year and any subsequent year shall be $0. (C) Non-application to hospital-based eligible professionals.-- (i) In general.--No incentive payment may be made under this paragraph in the case of a hospital-based eligible professional. (ii) Hospital-based eligible professional.--For purposes of clause (i), the term ``hospital-based eligible professional'' means, with respect to covered professional services furnished by an eligible professional during the EHR reporting period for a payment year, an eligible professional, such as a pathologist, anesthesiologist, or emergency physician, who furnishes substantially all of such services in a hospital inpatient or emergency room setting and through the use of the facilities and equipment, including qualified electronic health records, of the hospital. The determination of whether an eligible professional is a hospital-based eligible professional shall be made on the basis of the site of service (as defined by the Secretary) and without regard to any employment or billing arrangement between the eligible professional and any other provider. (D) Payment.-- (i) Form of payment.--The payment under this paragraph may be in the form of a single consolidated payment or in the form of such periodic installments as the Secretary may specify. (ii) Coordination of application of limitation for professionals in different practices.--In the case of an eligible professional furnishing covered professional services in more than one practice (as specified by the Secretary), the Secretary shall establish rules to coordinate the incentive payments, including the application of the limitation on amounts of such incentive payments under this paragraph, among such practices. (iii) Coordination with medicaid.-- The Secretary shall seek, to the maximum extent practicable, to avoid duplicative requirements from Federal and State governments to demonstrate meaningful use of certified EHR technology under this title and title XIX. The Secretary may also adjust the reporting periods under such title and such subsections in order to carry out this clause. (E) Payment year defined.-- (i) In general.--For purposes of this subsection, the term ``payment year'' means a year beginning with 2011. (ii) First, second, etc. payment year.--The term ``first payment year'' means, with respect to covered professional services furnished by an eligible professional, the first year for which an incentive payment is made for such services under this subsection. The terms ``second payment year'', ``third payment year'', ``fourth payment year'', and ``fifth payment year'' mean, with respect to covered professional services furnished by such eligible professional, each successive year immediately following the first payment year for such professional. (2) Meaningful ehr user.-- (A) In general.--An eligible professional shall be treated as a meaningful EHR user for an EHR reporting period for a payment year (or, for purposes of subsection (a)(7), for an EHR reporting period under such subsection for a year, or pursuant to subparagraph (D) for purposes of subsection (q), for a performance period under such subsection for a year) if each of the following requirements is met: (i) Meaningful use of certified ehr technology.--The eligible professional demonstrates to the satisfaction of the Secretary, in accordance with subparagraph (C)(i), that during such period the professional is using certified EHR technology in a meaningful manner, which shall include the use of electronic prescribing as determined to be appropriate by the Secretary. (ii) Information exchange.--The eligible professional demonstrates to the satisfaction of the Secretary, in accordance with subparagraph (C)(i), that during such period such certified EHR technology is connected in a manner that provides, in accordance with law and standards applicable to the exchange of information, for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination, and the professional demonstrates (through a process specified by the Secretary, such as the use of an attestation) that the professional has not knowingly and willfully taken action (such as to disable functionality) to limit or restrict the compatibility or interoperability of the certified EHR technology. (iii) Reporting on measures using ehr.--Subject to subparagraph (B)(ii) and subsection (q)(5)(B)(ii)(II) and using such certified EHR technology, the eligible professional submits information for such period, in a form and manner specified by the Secretary, on such clinical quality measures and such other measures as selected by the Secretary under subparagraph (B)(i). The Secretary may provide for the use of alternative means for meeting the requirements of clauses (i), (ii), and (iii) in the case of an eligible professional furnishing covered professional services in a group practice (as defined by the Secretary). The Secretary shall seek to improve the use of electronic health records and health care quality over time. (B) Reporting on measures.-- (i) Selection.--The Secretary shall select measures for purposes of subparagraph (A)(iii) but only consistent with the following: (I) The Secretary shall provide preference to clinical quality measures that have been endorsed by the entity with a contract with the Secretary under section 1890(a). (II) Prior to any measure being selected under this subparagraph, the Secretary shall publish in the Federal Register such measure and provide for a period of public comment on such measure. (ii) Limitation.--The Secretary may not require the electronic reporting of information on clinical quality measures under subparagraph (A)(iii) unless the Secretary has the capacity to accept the information electronically, which may be on a pilot basis. (iii) Coordination of reporting of information.--In selecting such measures, and in establishing the form and manner for reporting measures under subparagraph (A)(iii), the Secretary shall seek to avoid redundant or duplicative reporting otherwise required, including reporting under subsection (k)(2)(C). (C) Demonstration of meaningful use of certified ehr technology and information exchange.-- (i) In general.--A professional may satisfy the demonstration requirement of clauses (i) and (ii) of subparagraph (A) through means specified by the Secretary, which may include-- (I) an attestation; (II) the submission of claims with appropriate coding (such as a code indicating that a patient encounter was documented using certified EHR technology); (III) a survey response; (IV) reporting under subparagraph (A)(iii); and (V) other means specified by the Secretary. (ii) Use of part d data.-- Notwithstanding sections 1860D- 15(d)(2)(B) and 1860D-15(f)(2), the Secretary may use data regarding drug claims submitted for purposes of section 1860D-15 that are necessary for purposes of subparagraph (A). (D) Continued application for purposes of mips.--With respect to 2019 and each subsequent payment year, the Secretary shall, for purposes of subsection (q) and in accordance with paragraph (1)(F) of such subsection, determine whether an eligible professional who is a MIPS eligible professional (as defined in subsection (q)(1)(C)) for such year is a meaningful EHR user under this paragraph for the performance period under subsection (q) for such year. The provisions of subparagraphs (B) and (D) of subsection (a)(7), shall apply to assessments of MIPS eligible professionals under subsection (q) with respect to the performance category described in subsection (q)(2)(A)(iv) in an appropriate manner which may be similar to the manner in which such provisions apply with respect to payment adjustments made under subsection (a)(7)(A). (3) Application.-- (A) Physician reporting system rules.-- Paragraphs (5), (6), and (8) of subsection (k) shall apply for purposes of this subsection in the same manner as they apply for purposes of such subsection. (B) Coordination with other payments.--The provisions of this subsection shall not be taken into account in applying the provisions of subsection (m) of this section and of section 1833(m) and any payment under such provisions shall not be taken into account in computing allowable charges under this subsection. (C) Limitations on review.--There shall be no administrative or judicial review under section 1869, section 1878, or otherwise, of-- (i) the methodology and standards for determining payment amounts under this subsection and payment adjustments under subsection (a)(7)(A), including the limitation under paragraph (1)(B) and coordination under clauses (ii) and (iii) of paragraph (1)(D); (ii) the methodology and standards for determining a meaningful EHR user under paragraph (2), including selection of measures under paragraph (2)(B), specification of the means of demonstrating meaningful EHR use under paragraph (2)(C), and the hardship exception under subsection (a)(7)(B); (iii) the methodology and standards for determining a hospital-based eligible professional under paragraph (1)(C); and (iv) the specification of reporting periods under paragraph (5) and the selection of the form of payment under paragraph (1)(D)(i). (D) Posting on website.--The Secretary shall post on the Internet website of the Centers for Medicare & Medicaid Services, in an easily understandable format, a list of the names, business addresses, and business phone numbers of the eligible professionals who are meaningful EHR users and, as determined appropriate by the Secretary, of group practices receiving incentive payments under paragraph (1). (4) Certified ehr technology defined.--For purposes of this section, the term ``certified EHR technology'' means a qualified electronic health record (as defined in section 3000(13) of the Public Health Service Act) that is certified pursuant to section 3001(c)(5) of such Act as meeting standards adopted under section 3004 of such Act that are applicable to the type of record involved (as determined by the Secretary, such as an ambulatory electronic health record for office- based physicians or an inpatient hospital electronic health record for hospitals). (5) Definitions.--For purposes of this subsection: (A) Covered professional services.--The term ``covered professional services'' has the meaning given such term in subsection (k)(3). (B) EHR reporting period.--The term ``EHR reporting period'' means, with respect to a payment year, any period (or periods) as specified by the Secretary. (C) Eligible professional.--The term ``eligible professional'' means a physician, as defined in section 1861(r). (p) Establishment of Value-based Payment Modifier.-- (1) In general.--The Secretary shall establish a payment modifier that provides for differential payment to a physician or a group of physicians under the fee schedule established under subsection (b) based upon the quality of care furnished compared to cost (as determined under paragraphs (2) and (3), respectively) during a performance period. Such payment modifier shall be separate from the geographic adjustment factors established under subsection (e). (2) Quality.-- (A) In general.--For purposes of paragraph (1), quality of care shall be evaluated, to the extent practicable, based on a composite of measures of the quality of care furnished (as established by the Secretary under subparagraph (B)). (B) Measures.-- (i) The Secretary shall establish appropriate measures of the quality of care furnished by a physician or group of physicians to individuals enrolled under this part, such as measures that reflect health outcomes. Such measures shall be risk adjusted as determined appropriate by the Secretary. (ii) The Secretary shall seek endorsement of the measures established under this subparagraph by the entity with a contract under section 1890(a). (C) Continued application for purposes of mips.--The Secretary shall, in accordance with subsection (q)(1)(F), carry out subparagraph (B) for purposes of subsection (q). (3) Costs.--For purposes of paragraph (1), costs shall be evaluated, to the extent practicable, based on a composite of appropriate measures of costs established by the Secretary (such as the composite measure under the methodology established under subsection (n)(9)(C)(iii)) that eliminate the effect of geographic adjustments in payment rates (as described in subsection (e)), and take into account risk factors (such as socioeconomic and demographic characteristics, ethnicity, and health status of individuals (such as to recognize that less healthy individuals may require more intensive interventions) and other factors determined appropriate by the Secretary. With respect to 2019 and each subsequent year, the Secretary shall, in accordance with subsection (q)(1)(F), carry out this paragraph for purposes of subsection (q). (4) Implementation.-- (A) Publication of measures, dates of implementation, performance period.--Not later than January 1, 2012, the Secretary shall publish the following: (i) The measures of quality of care and costs established under paragraphs (2) and (3), respectively. (ii) The dates for implementation of the payment modifier (as determined under subparagraph (B)). (iii) The initial performance period (as specified under subparagraph (B)(ii)). (B) Deadlines for implementation.-- (i) Initial implementation.--Subject to the preceding provisions of this subparagraph, the Secretary shall begin implementing the payment modifier established under this subsection through the rulemaking process during 2013 for the physician fee schedule established under subsection (b). (ii) Initial performance period.-- (I) In general.--The Secretary shall specify an initial performance period for application of the payment modifier established under this subsection with respect to 2015. (II) Provision of information during initial performance period.--During the initial performance period, the Secretary shall, to the extent practicable, provide information to physicians and groups of physicians about the quality of care furnished by the physician or group of physicians to individuals enrolled under this part compared to cost (as determined under paragraphs (2) and (3), respectively) with respect to the performance period. (iii) Application.--The Secretary shall apply the payment modifier established under this subsection for items and services furnished on or after January 1, 2015, with respect to specific physicians and groups of physicians the Secretary determines appropriate, and for services furnished on or after January 1, 2017, with respect to all physicians and groups of physicians. Such payment modifier shall not be applied for items and services furnished on or after January 1, 2019. (C) Budget neutrality.--The payment modifier established under this subsection shall be implemented in a budget neutral manner. (5) Systems-based care.--The Secretary shall, as appropriate, apply the payment modifier established under this subsection in a manner that promotes systems-based care. (6) Consideration of special circumstances of certain providers.--In applying the payment modifier under this subsection, the Secretary shall, as appropriate, take into account the special circumstances of physicians or groups of physicians in rural areas and other underserved communities. (7) Application.--For purposes of the initial application of the payment modifier established under this subsection during the period beginning on January 1, 2015, and ending on December 31, 2016, the term ``physician'' has the meaning given such term in section 1861(r). On or after January 1, 2017, the Secretary may apply this subsection to eligible professionals (as defined in subsection (k)(3)(B)) as the Secretary determines appropriate. (8) Definitions.--For purposes of this subsection: (A) Costs.--The term ``costs'' means expenditures per individual as determined appropriate by the Secretary. In making the determination under the preceding sentence, the Secretary may take into account the amount of growth in expenditures per individual for a physician compared to the amount of such growth for other physicians. (B) Performance period.--The term ``performance period'' means a period specified by the Secretary. (9) Coordination with other value-based purchasing reforms.--The Secretary shall coordinate the value- based payment modifier established under this subsection with the Physician Feedback Program under subsection (n) and, as the Secretary determines appropriate, other similar provisions of this title. (10) Limitations on review.--There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of-- (A) the establishment of the value-based payment modifier under this subsection; (B) the evaluation of quality of care under paragraph (2), including the establishment of appropriate measures of the quality of care under paragraph (2)(B); (C) the evaluation of costs under paragraph (3), including the establishment of appropriate measures of costs under such paragraph; (D) the dates for implementation of the value-based payment modifier; (E) the specification of the initial performance period and any other performance period under paragraphs (4)(B)(ii) and (8)(B), respectively; (F) the application of the value-based payment modifier under paragraph (7); and (G) the determination of costs under paragraph (8)(A). (q) Merit-Based Incentive Payment System.-- (1) Establishment.-- (A) In general.--Subject to the succeeding provisions of this subsection, the Secretary shall establish an eligible professional Merit- based Incentive Payment System (in this subsection referred to as the ``MIPS'') under which the Secretary shall-- (i) develop a methodology for assessing the total performance of each MIPS eligible professional according to performance standards under paragraph (3) for a performance period (as established under paragraph (4)) for a year; (ii) using such methodology, provide for a composite performance score in accordance with paragraph (5) for each such professional for each performance period; and (iii) use such composite performance score of the MIPS eligible professional for a performance period for a year to determine and apply a MIPS adjustment factor (and, as applicable, an additional MIPS adjustment factor) under paragraph (6) to the professional for the year. Notwithstanding subparagraph (C)(ii), under the MIPS, the Secretary shall permit any eligible professional (as defined in subsection (k)(3)(B)) to report on applicable measures and activities described in paragraph (2)(B). (B) Program implementation.--The MIPS shall apply to payments for covered professional services (as defined in subsection (k)(3)(A)) furnished on or after January 1, 2019. (C) MIPS eligible professional defined.-- (i) In general.--For purposes of this subsection, subject to clauses (ii) and (iv), the term ``MIPS eligible professional'' means-- (I) for the first and second years for which the MIPS applies to payments (and for the performance period for such first and second year), a physician (as defined in section 1861(r)), a physician assistant, nurse practitioner, and clinical nurse specialist (as such terms are defined in section 1861(aa)(5)), a certified registered nurse anesthetist (as defined in section 1861(bb)(2)), and a group that includes such professionals; and (II) for the third year for which the MIPS applies to payments (and for the performance period for such third year) and for each succeeding year (and for the performance period for each such year), the professionals described in subclause (I), such other eligible professionals (as defined in subsection (k)(3)(B)) as specified by the Secretary, and a group that includes such professionals. (ii) Exclusions.--For purposes of clause (i), the term ``MIPS eligible professional'' does not include, with respect to a year, an eligible professional (as defined in subsection (k)(3)(B)) who-- (I) is a qualifying APM participant (as defined in section 1833(z)(2)); (II) subject to clause (vii), is a partial qualifying APM participant (as defined in clause (iii)) for the most recent period for which data are available and who, for the performance period with respect to such year, does not report on applicable measures and activities described in paragraph (2)(B) that are required to be reported by such a professional under the MIPS; or (III) for the performance period with respect to such year, does not exceed the low- volume threshold measurement selected under clause (iv). (iii) Partial qualifying apm participant.--For purposes of this subparagraph, the term ``partial qualifying APM participant'' means, with respect to a year, an eligible professional for whom the Secretary determines the minimum payment percentage (or percentages), as applicable, described in paragraph (2) of section 1833(z) for such year have not been satisfied, but who would be considered a qualifying APM participant (as defined in such paragraph) for such year if-- (I) with respect to 2019 and 2020, the reference in subparagraph (A) of such paragraph to 25 percent was instead a reference to 20 percent; (II) with respect to 2021 and 2022-- (aa) the reference in subparagraph (B)(i) of such paragraph to 50 percent was instead a reference to 40 percent; and (bb) the references in subparagraph (B)(ii) of such paragraph to 50 percent and 25 percent of such paragraph were instead references to 40 percent and 20 percent, respectively; and (III) with respect to 2023 and subsequent years-- (aa) the reference in subparagraph (C)(i) of such paragraph to 75 percent was instead a reference to 50 percent; and (bb) the references in subparagraph (C)(ii) of such paragraph to 75 percent and 25 percent of such paragraph were instead references to 50 percent and 20 percent, respectively. (iv) Selection of low-volume threshold measurement.--The Secretary shall select a low-volume threshold to apply for purposes of clause (ii)(III), which may include one or more or a combination of the following: (I) The minimum number (as determined by the Secretary) of-- (aa) for performance periods beginning before January 1, 2018, individuals enrolled under this part who are treated by the eligible professional for the performance period involved; and (bb) for performance periods beginning on or after January 1, 2018, individuals enrolled under this part who are furnished covered professional services (as defined in subsection (k)(3)(A)) by the eligible professional for the performance period involved. (II) The minimum number (as determined by the Secretary) of covered professional services (as defined in subsection (k)(3)(A)) furnished to individuals enrolled under this part by such professional for such performance period. (III) The minimum amount (as determined by the Secretary) of-- (aa) for performance periods beginning before January 1, 2018, allowed charges billed by such professional under this part for such performance period; and (bb) for performance periods beginning on or after January 1, 2018, allowed charges for covered professional services (as defined in subsection (k)(3)(A)) billed by such professional for such performance period. (v) Treatment of new medicare enrolled eligible professionals.--In the case of a professional who first becomes a Medicare enrolled eligible professional during the performance period for a year (and had not previously submitted claims under this title such as a person, an entity, or a part of a physician group or under a different billing number or tax identifier), such professional shall not be treated under this subsection as a MIPS eligible professional until the subsequent year and performance period for such subsequent year. (vi) Clarification.--In the case of items and services furnished during a year by an individual who is not a MIPS eligible professional (including pursuant to clauses (ii) and (v)) with respect to a year, in no case shall a MIPS adjustment factor (or additional MIPS adjustment factor) under paragraph (6) apply to such individual for such year. (vii) Partial qualifying apm participant clarifications.-- (I) Treatment as mips eligible professional.--In the case of an eligible professional who is a partial qualifying APM participant, with respect to a year, and who, for the performance period for such year, reports on applicable measures and activities described in paragraph (2)(B) that are required to be reported by such a professional under the MIPS, such eligible professional is considered to be a MIPS eligible professional with respect to such year. (II) Not eligible for qualifying apm participant payments.--In no case shall an eligible professional who is a partial qualifying APM participant, with respect to a year, be considered a qualifying APM participant (as defined in paragraph (2) of section 1833(z)) for such year or be eligible for the additional payment under paragraph (1) of such section for such year. (D) Application to group practices.-- (i) In general.--Under the MIPS: (I) Quality performance category.--The Secretary shall establish and apply a process that includes features of the provisions of subsection (m)(3)(C) for MIPS eligible professionals in a group practice with respect to assessing performance of such group with respect to the performance category described in clause (i) of paragraph (2)(A). (II) Other performance categories.--The Secretary may establish and apply a process that includes features of the provisions of subsection (m)(3)(C) for MIPS eligible professionals in a group practice with respect to assessing the performance of such group with respect to the performance categories described in clauses (ii) through (iv) of such paragraph. (ii) Ensuring comprehensiveness of group practice assessment.--The process established under clause (i) shall to the extent practicable reflect the range of items and services furnished by the MIPS eligible professionals in the group practice involved. (E) Use of registries.--Under the MIPS, the Secretary shall encourage the use of qualified clinical data registries pursuant to subsection (m)(3)(E) in carrying out this subsection. (F) Application of certain provisions.--In applying a provision of subsection (k), (m), (o), or (p) for purposes of this subsection, the Secretary shall-- (i) adjust the application of such provision to ensure the provision is consistent with the provisions of this subsection; and (ii) not apply such provision to the extent that the provision is duplicative with a provision of this subsection. (G) Accounting for risk factors.-- (i) Risk factors.--Taking into account the relevant studies conducted and recommendations made in reports under section 2(d) of the Improving Medicare Post-Acute Care Transformation Act of 2014, and, as appropriate, other information, including information collected before completion of such studies and recommendations, the Secretary, on an ongoing basis, shall, as the Secretary determines appropriate and based on an individual's health status and other risk factors-- (I) assess appropriate adjustments to quality measures, resource use measures, and other measures used under the MIPS; and (II) assess and implement appropriate adjustments to payment adjustments, composite performance scores, scores for performance categories, or scores for measures or activities under the MIPS. (2) Measures and activities under performance categories.-- (A) Performance categories.--Under the MIPS, the Secretary shall use the following performance categories (each of which is referred to in this subsection as a performance category) in determining the composite performance score under paragraph (5): (i) Quality. (ii) Resource use. (iii) Clinical practice improvement activities. (iv) Meaningful use of certified EHR technology. (B) Measures and activities specified for each category.--For purposes of paragraph (3)(A) and subject to subparagraph (C), measures and activities specified for a performance period (as established under paragraph (4)) for a year are as follows: (i) Quality.--For the performance category described in subparagraph (A)(i), the quality measures included in the final measures list published under subparagraph (D)(i) for such year and the list of quality measures described in subparagraph (D)(vi) used by qualified clinical data registries under subsection (m)(3)(E). (ii) Resource use.--For the performance category described in subparagraph (A)(ii), the measurement of resource use for such period under subsection (p)(3), using the methodology under subsection (r) as appropriate, and, as feasible and applicable, accounting for the cost of drugs under part D. (iii) Clinical practice improvement activities.--For the performance category described in subparagraph (A)(iii), clinical practice improvement activities (as defined in subparagraph (C)(v)(III)) under subcategories specified by the Secretary for such period, which shall include at least the following: (I) The subcategory of expanded practice access, such as same day appointments for urgent needs and after hours access to clinician advice. (II) The subcategory of population management, such as monitoring health conditions of individuals to provide timely health care interventions or participation in a qualified clinical data registry. (III) The subcategory of care coordination, such as timely communication of test results, timely exchange of clinical information to patients and other providers, and use of remote monitoring or telehealth. (IV) The subcategory of beneficiary engagement, such as the establishment of care plans for individuals with complex care needs, beneficiary self- management assessment and training, and using shared decision-making mechanisms. (V) The subcategory of patient safety and practice assessment, such as through use of clinical or surgical checklists and practice assessments related to maintaining certification. (VI) The subcategory of participation in an alternative payment model (as defined in section 1833(z)(3)(C)). In establishing activities under this clause, the Secretary shall give consideration to the circumstances of small practices (consisting of 15 or fewer professionals) and practices located in rural areas and in health professional shortage areas (as designated under section 332(a)(1)(A) of the Public Health Service Act). (iv) Meaningful ehr use.--For the performance category described in subparagraph (A)(iv), the requirements established for such period under subsection (o)(2) for determining whether an eligible professional is a meaningful EHR user. (C) Additional provisions.-- (i) Emphasizing outcome measures under the quality performance category.--In applying subparagraph (B)(i), the Secretary shall, as feasible, emphasize the application of outcome measures. (ii) Application of additional system measures.--The Secretary may use measures used for a payment system other than for physicians, such as measures for inpatient hospitals, for purposes of the performance categories described in clauses (i) and (ii) of subparagraph (A). For purposes of the previous sentence, the Secretary may not use measures for hospital outpatient departments, except in the case of items and services furnished by emergency physicians, radiologists, and anesthesiologists. (iii) Global and population-based measures.--The Secretary may use global measures, such as global outcome measures, and population-based measures for purposes of the performance category described in subparagraph (A)(i). (iv) Application of measures and activities to non-patient-facing professionals.--In carrying out this paragraph, with respect to measures and activities specified in subparagraph (B) for performance categories described in subparagraph (A), the Secretary-- (I) shall give consideration to the circumstances of professional types (or subcategories of those types determined by practice characteristics) who typically furnish services that do not involve face-to-face interaction with a patient; and (II) may, to the extent feasible and appropriate, take into account such circumstances and apply under this subsection with respect to MIPS eligible professionals of such professional types or subcategories, alternative measures or activities that fulfill the goals of the applicable performance category. In carrying out the previous sentence, the Secretary shall consult with professionals of such professional types or subcategories. (v) Clinical practice improvement activities.-- (I) Request for information.--In initially applying subparagraph (B)(iii), the Secretary shall use a request for information to solicit recommendations from stakeholders to identify activities described in such subparagraph and specifying criteria for such activities. (II) Contract authority for clinical practice improvement activities performance category.--In applying subparagraph (B)(iii), the Secretary may contract with entities to assist the Secretary in-- (aa) identifying activities described in subparagraph (B)(iii); (bb) specifying criteria for such activities; and (cc) determining whether a MIPS eligible professional meets such criteria. (III) Clinical practice improvement activities defined.--For purposes of this subsection, the term ``clinical practice improvement activity'' means an activity that relevant eligible professional organizations and other relevant stakeholders identify as improving clinical practice or care delivery and that the Secretary determines, when effectively executed, is likely to result in improved outcomes. (D) Annual list of quality measures available for mips assessment.-- (i) In general.--Under the MIPS, the Secretary, through notice and comment rulemaking and subject to the succeeding clauses of this subparagraph, shall, with respect to the performance period for a year, establish an annual final list of quality measures from which MIPS eligible professionals may choose for purposes of assessment under this subsection for such performance period. Pursuant to the previous sentence, the Secretary shall-- (I) not later than November 1 of the year prior to the first day of the first performance period under the MIPS, establish and publish in the Federal Register a final list of quality measures; and (II) not later than November 1 of the year prior to the first day of each subsequent performance period, update the final list of quality measures from the previous year (and publish such updated final list in the Federal Register), by-- (aa) removing from such list, as appropriate, quality measures, which may include the removal of measures that are no longer meaningful (such as measures that are topped out); (bb) adding to such list, as appropriate, new quality measures; and (cc) determining whether or not quality measures on such list that have undergone substantive changes should be included in the updated list. (ii) Call for quality measures.-- (I) In general.--Eligible professional organizations and other relevant stakeholders shall be requested to identify and submit quality measures to be considered for selection under this subparagraph in the annual list of quality measures published under clause (i) and to identify and submit updates to the measures on such list. For purposes of the previous sentence, measures may be submitted regardless of whether such measures were previously published in a proposed rule or endorsed by an entity with a contract under section 1890(a). (II) Eligible professional organization defined.--In this subparagraph, the term ``eligible professional organization'' means a professional organization as defined by nationally recognized specialty boards of certification or equivalent certification boards. (iii) Requirements.--In selecting quality measures for inclusion in the annual final list under clause (i), the Secretary shall-- (I) provide that, to the extent practicable, all quality domains (as defined in subsection (s)(1)(B)) are addressed by such measures; and (II) ensure that such selection is consistent with the process for selection of measures under subsections (k), (m), and (p)(2). (iv) Peer review.--Before including a new measure in the final list of measures published under clause (i) for a year, the Secretary shall submit for publication in applicable specialty- appropriate, peer-reviewed journals such measure and the method for developing and selecting such measure, including clinical and other data supporting such measure. (v) Measures for inclusion.--The final list of quality measures published under clause (i) shall include, as applicable, measures under subsections (k), (m), and (p)(2), including quality measures from among-- (I) measures endorsed by a consensus-based entity; (II) measures developed under subsection (s); and (III) measures submitted under clause (ii)(I). Any measure selected for inclusion in such list that is not endorsed by a consensus-based entity shall have a focus that is evidence-based. (vi) Exception for qualified clinical data registry measures.--Measures used by a qualified clinical data registry under subsection (m)(3)(E) shall not be subject to the requirements under clauses (i), (iv), and (v). The Secretary shall publish the list of measures used by such qualified clinical data registries on the Internet website of the Centers for Medicare & Medicaid Services. (vii) Exception for existing quality measures.--Any quality measure specified by the Secretary under subsection (k) or (m), including under subsection (m)(3)(E), and any measure of quality of care established under subsection (p)(2) for the reporting period or performance period under the respective subsection beginning before the first performance period under the MIPS-- (I) shall not be subject to the requirements under clause (i) (except under items (aa) and (cc) of subclause (II) of such clause) or to the requirement under clause (iv); and (II) shall be included in the final list of quality measures published under clause (i) unless removed under clause (i)(II)(aa). (viii) Consultation with relevant eligible professional organizations and other relevant stakeholders.--Relevant eligible professional organizations and other relevant stakeholders, including State and national medical societies, shall be consulted in carrying out this subparagraph. (ix) Optional application.--The process under section 1890A is not required to apply to the selection of measures under this subparagraph. (3) Performance standards.-- (A) Establishment.--Under the MIPS, the Secretary shall establish performance standards with respect to measures and activities specified under paragraph (2)(B) for a performance period (as established under paragraph (4)) for a year. (B) Considerations in establishing standards.--In establishing such performance standards with respect to measures and activities specified under paragraph (2)(B), the Secretary shall consider the following: (i) Historical performance standards. (ii) Improvement. (iii) The opportunity for continued improvement. (4) Performance period.--The Secretary shall establish a performance period (or periods) for a year (beginning with 2019). Such performance period (or periods) shall begin and end prior to the beginning of such year and be as close as possible to such year. In this subsection, such performance period (or periods) for a year shall be referred to as the performance period for the year. (5) Composite performance score.-- (A) In general.--Subject to the succeeding provisions of this paragraph and taking into account, as available and applicable, paragraph (1)(G), the Secretary shall develop a methodology for assessing the total performance of each MIPS eligible professional according to performance standards under paragraph (3) with respect to applicable measures and activities specified in paragraph (2)(B) with respect to each performance category applicable to such professional for a performance period (as established under paragraph (4)) for a year. Using such methodology, the Secretary shall provide for a composite assessment (using a scoring scale of 0 to 100) for each such professional for the performance period for such year. In this subsection such a composite assessment for such a professional with respect to a performance period shall be referred to as the ``composite performance score'' for such professional for such performance period. (B) Incentive to report; encouraging use of certified ehr technology for reporting quality measures.-- (i) Incentive to report.--Under the methodology established under subparagraph (A), the Secretary shall provide that in the case of a MIPS eligible professional who fails to report on an applicable measure or activity that is required to be reported by the professional, the professional shall be treated as achieving the lowest potential score applicable to such measure or activity. (ii) Encouraging use of certified ehr technology and qualified clinical data registries for reporting quality measures.--Under the methodology established under subparagraph (A), the Secretary shall-- (I) encourage MIPS eligible professionals to report on applicable measures with respect to the performance category described in paragraph (2)(A)(i) through the use of certified EHR technology and qualified clinical data registries; and (II) with respect to a performance period, with respect to a year, for which a MIPS eligible professional reports such measures through the use of such EHR technology, treat such professional as satisfying the clinical quality measures reporting requirement described in subsection (o)(2)(A)(iii) for such year. (C) Clinical practice improvement activities performance score.-- (i) Rule for certification.--A MIPS eligible professional who is in a practice that is certified as a patient-centered medical home or comparable specialty practice, as determined by the Secretary, with respect to a performance period shall be given the highest potential score for the performance category described in paragraph (2)(A)(iii) for such period. (ii) APM participation.-- Participation by a MIPS eligible professional in an alternative payment model (as defined in section 1833(z)(3)(C)) with respect to a performance period shall earn such eligible professional a minimum score of one-half of the highest potential score for the performance category described in paragraph (2)(A)(iii) for such performance period. (iii) Subcategories.--A MIPS eligible professional shall not be required to perform activities in each subcategory under paragraph (2)(B)(iii) or participate in an alternative payment model in order to achieve the highest potential score for the performance category described in paragraph (2)(A)(iii). (D) Achievement and improvement.-- (i) Taking into account improvement.--Beginning with the second year to which the MIPS applies, in addition to the achievement of a MIPS eligible professional, if data sufficient to measure improvement is available, the methodology developed under subparagraph (A)-- (I) in the case of the performance score for the performance category described in clauses (i) and (ii) of paragraph (2)(A), subject to clause (iii), shall take into account the improvement of the professional; and (II) in the case of performance scores for other performance categories, may take into account the improvement of the professional. (ii) Assigning higher weight for achievement.--Subject to clause (i), under the methodology developed under subparagraph (A), the Secretary may assign a higher scoring weight under subparagraph (F) with respect to the achievement of a MIPS eligible professional than with respect to any improvement of such professional applied under clause (i) with respect to a measure, activity, or category described in paragraph (2). (iii) Transition years.--For each of the second, third, fourth, and fifth years for which the MIPS applies to payments, the performance score for the performance category described in paragraph (2)(A)(ii) shall not take into account the improvement of the professional involved. (E) Weights for the performance categories.-- (i) In general.--Under the methodology developed under subparagraph (A), subject to subparagraph (F)(i) and clause (ii), the composite performance score shall be determined as follows: (I) Quality.-- (aa) In general.-- Subject to item (bb), thirty percent of such score shall be based on performance with respect to the category described in clause (i) of paragraph (2)(A). In applying the previous sentence, the Secretary shall, as feasible, encourage the application of outcome measures within such category. (bb) First 5 years.-- For each of the first through fifth years for which the MIPS applies to payments, the percentage applicable under item (aa) shall be increased in a manner such that the total percentage points of the increase under this item for the respective year equals the total number of percentage points by which the percentage applied under subclause (II)(bb) for the respective year is less than 30 percent. (II) Resource use.-- (aa) In general.-- Subject to item (bb), thirty percent of such score shall be based on performance with respect to the category described in clause (ii) of paragraph (2)(A). (bb) First 5 years.-- For the first year for which the MIPS applies to payments, not more than 10 percent of such score shall be based on performance with respect to the category described in clause (ii) of paragraph (2)(A). For each of the second, third, fourth, and fifth years for which the MIPS applies to payments, not less than 10 percent and not more than 30 percent of such score shall be based on performance with respect to the category described in clause (ii) of paragraph (2)(A). Nothing in the previous sentence shall be construed, with respect to a performance period for a year described in the previous sentence, as preventing the Secretary from basing 30 percent of such score for such year with respect to the category described in such clause (ii), if the Secretary determines, based on information posted under subsection (r)(2)(I) that sufficient resource use measures are ready for adoption for use under the performance category under paragraph (2)(A)(ii) for such performance period. (III) Clinical practice improvement activities.-- Fifteen percent of such score shall be based on performance with respect to the category described in clause (iii) of paragraph (2)(A). (IV) Meaningful use of certified ehr technology.-- Twenty-five percent of such score shall be based on performance with respect to the category described in clause (iv) of paragraph (2)(A). (ii) Authority to adjust percentages in case of high ehr meaningful use adoption.--In any year in which the Secretary estimates that the proportion of eligible professionals (as defined in subsection (o)(5)) who are meaningful EHR users (as determined under subsection (o)(2)) is 75 percent or greater, the Secretary may reduce the percent applicable under clause (i)(IV), but not below 15 percent. If the Secretary makes such reduction for a year, subject to subclauses (I)(bb) and (II)(bb) of clause (i), the percentages applicable under one or more of subclauses (I), (II), and (III) of clause (i) for such year shall be increased in a manner such that the total percentage points of the increase under this clause for such year equals the total number of percentage points reduced under the preceding sentence for such year. (F) Certain flexibility for weighting performance categories, measures, and activities.--Under the methodology under subparagraph (A), if there are not sufficient measures and activities (described in paragraph (2)(B)) applicable and available to each type of eligible professional involved, the Secretary shall assign different scoring weights (including a weight of 0)-- (i) which may vary from the scoring weights specified in subparagraph (E), for each performance category based on the extent to which the category is applicable to the type of eligible professional involved; and (ii) for each measure and activity specified under paragraph (2)(B) with respect to each such category based on the extent to which the measure or activity is applicable and available to the type of eligible professional involved. (G) Resource use.--Analysis of the performance category described in paragraph (2)(A)(ii) shall include results from the methodology described in subsection (r)(5), as appropriate. (H) Inclusion of quality measure data from other payers.--In applying subsections (k), (m), and (p) with respect to measures described in paragraph (2)(B)(i), analysis of the performance category described in paragraph (2)(A)(i) may include data submitted by MIPS eligible professionals with respect to items and services furnished to individuals who are not individuals entitled to benefits under part A or enrolled under part B. (I) Use of voluntary virtual groups for certain assessment purposes.-- (i) In general.--In the case of MIPS eligible professionals electing to be a virtual group under clause (ii) with respect to a performance period for a year, for purposes of applying the methodology under subparagraph (A) with respect to the performance categories described in clauses (i) and (ii) of paragraph (2)(A)-- (I) the assessment of performance provided under such methodology with respect to such performance categories that is to be applied to each such professional in such group for such performance period shall be with respect to the combined performance of all such professionals in such group for such period; and (II) with respect to the composite performance score provided under this paragraph for such performance period for each such MIPS eligible professional in such virtual group, the components of the composite performance score that assess performance with respect to such performance categories shall be based on the assessment of the combined performance under subclause (I) for such performance categories and performance period. (ii) Election of practices to be a virtual group.--The Secretary shall, in accordance with the requirements under clause (iii), establish and have in place a process to allow an individual MIPS eligible professional or a group practice consisting of not more than 10 MIPS eligible professionals to elect, with respect to a performance period for a year to be a virtual group under this subparagraph with at least one other such individual MIPS eligible professional or group practice. Such a virtual group may be based on appropriate classifications of providers, such as by geographic areas or by provider specialties defined by nationally recognized specialty boards of certification or equivalent certification boards. (iii) Requirements.--The requirements for the process under clause (ii) shall-- (I) provide that an election under such clause, with respect to a performance period, shall be made before the beginning of such performance period and may not be changed during such performance period; (II) provide that an individual MIPS eligible professional and a group practice described in clause (ii) may elect to be in no more than one virtual group for a performance period and that, in the case of such a group practice that elects to be in such virtual group for such performance period, such election applies to all MIPS eligible professionals in such group practice; (III) provide that a virtual group be a combination of tax identification numbers; (IV) provide for formal written agreements among MIPS eligible professionals electing to be a virtual group under this subparagraph; and (V) include such other requirements as the Secretary determines appropriate. (6) MIPS payments.-- (A) MIPS adjustment factor.--Taking into account paragraph (1)(G), the Secretary shall specify a MIPS adjustment factor for each MIPS eligible professional for a year. Such MIPS adjustment factor for a MIPS eligible professional for a year shall be in the form of a percent and shall be determined-- (i) by comparing the composite performance score of the eligible professional for such year to the performance threshold established under subparagraph (D)(i) for such year; (ii) in a manner such that the adjustment factors specified under this subparagraph for a year result in differential payments under this paragraph reflecting that-- (I) MIPS eligible professionals with composite performance scores for such year at or above such performance threshold for such year receive zero or positive payment adjustment factors for such year in accordance with clause (iii), with such professionals having higher composite performance scores receiving higher adjustment factors; and (II) MIPS eligible professionals with composite performance scores for such year below such performance threshold for such year receive negative payment adjustment factors for such year in accordance with clause (iv), with such professionals having lower composite performance scores receiving lower adjustment factors; (iii) in a manner such that MIPS eligible professionals with composite scores described in clause (ii)(I) for such year, subject to clauses (i) and (ii) of subparagraph (F), receive a zero or positive adjustment factor on a linear sliding scale such that an adjustment factor of 0 percent is assigned for a score at the performance threshold and an adjustment factor of the applicable percent specified in subparagraph (B) is assigned for a score of 100; and (iv) in a manner such that-- (I) subject to subclause (II), MIPS eligible professionals with composite performance scores described in clause (ii)(II) for such year receive a negative payment adjustment factor on a linear sliding scale such that an adjustment factor of 0 percent is assigned for a score at the performance threshold and an adjustment factor of the negative of the applicable percent specified in subparagraph (B) is assigned for a score of 0; and (II) MIPS eligible professionals with composite performance scores that are equal to or greater than 0, but not greater than \1/4\ of the performance threshold specified under subparagraph (D)(i) for such year, receive a negative payment adjustment factor that is equal to the negative of the applicable percent specified in subparagraph (B) for such year. (B) Applicable percent defined.--For purposes of this paragraph, the term ``applicable percent'' means-- (i) for 2019, 4 percent; (ii) for 2020, 5 percent; (iii) for 2021, 7 percent; and (iv) for 2022 and subsequent years, 9 percent. (C) Additional mips adjustment factors for exceptional performance.--For 2019 and each subsequent year through 2024, in the case of a MIPS eligible professional with a composite performance score for a year at or above the additional performance threshold under subparagraph (D)(ii) for such year, in addition to the MIPS adjustment factor under subparagraph (A) for the eligible professional for such year, subject to subparagraph (F)(iv), the Secretary shall specify an additional positive MIPS adjustment factor for such professional and year. Such additional MIPS adjustment factors shall be in the form of a percent and determined by the Secretary in a manner such that professionals having higher composite performance scores above the additional performance threshold receive higher additional MIPS adjustment factors. (D) Establishment of performance thresholds.-- (i) Performance threshold.--For each year of the MIPS, the Secretary shall compute a performance threshold with respect to which the composite performance score of MIPS eligible professionals shall be compared for purposes of determining adjustment factors under subparagraph (A) that are positive, negative, and zero. Subject to clauses (iii) and (iv), such performance threshold for a year shall be the mean or median (as selected by the Secretary) of the composite performance scores for all MIPS eligible professionals with respect to a prior period specified by the Secretary. The Secretary may reassess the selection of the mean or median under the previous sentence every 3 years. (ii) Additional performance threshold for exceptional performance.--In addition to the performance threshold under clause (i), for each year of the MIPS (beginning with 2019 and ending with 2024), the Secretary shall compute an additional performance threshold for purposes of determining the additional MIPS adjustment factors under subparagraph (C). For each such year, subject to clause (iii), the Secretary shall apply either of the following methods for computing such additional performance threshold for such a year: (I) The threshold shall be the score that is equal to the 25th percentile of the range of possible composite performance scores above the performance threshold determined under clause (i). (II) The threshold shall be the score that is equal to the 25th percentile of the actual composite performance scores for MIPS eligible professionals with composite performance scores at or above the performance threshold with respect to the prior period described in clause (i). (iii) Special rule for initial 5 years.--With respect to each of the first five years to which the MIPS applies, the Secretary shall, prior to the performance period for such years, establish a performance threshold for purposes of determining MIPS adjustment factors under subparagraph (A) and a threshold for purposes of determining additional MIPS adjustment factors under subparagraph (C). Each such performance threshold shall-- (I) be based on a period prior to such performance periods; and (II) take into account-- (aa) data available with respect to performance on measures and activities that may be used under the performance categories under subparagraph (2)(B); and (bb) other factors determined appropriate by the Secretary. (iv) Additional special rule for third, fourth and fifth years of mips.--For purposes of determining MIPS adjustment factors under subparagraph (A), in addition to the requirements specified in clause (iii), the Secretary shall increase the performance threshold with respect to each of the third, fourth, and fifth years to which the MIPS applies to ensure a gradual and incremental transition to the performance threshold described in clause (i) (as estimated by the Secretary) with respect to the sixth year to which the MIPS applies. (E) Application of mips adjustment factors.-- In the case of covered professional services (as defined in subsection (k)(3)(A)) furnished by a MIPS eligible professional during a year (beginning with 2019), the amount otherwise paid under this part with respect to such covered professional services and MIPS eligible professional for such year, shall be multiplied by-- (i) 1, plus (ii) the sum of-- (I) the MIPS adjustment factor determined under subparagraph (A) divided by 100, and (II) as applicable, the additional MIPS adjustment factor determined under subparagraph (C) divided by 100. (F) Aggregate application of mips adjustment factors.-- (i) Application of scaling factor.-- (I) In general.--With respect to positive MIPS adjustment factors under subparagraph (A)(ii)(I) for eligible professionals whose composite performance score is above the performance threshold under subparagraph (D)(i) for such year, subject to subclause (II), the Secretary shall increase or decrease such adjustment factors by a scaling factor in order to ensure that the budget neutrality requirement of clause (ii) is met. (II) Scaling factor limit.-- In no case may the scaling factor applied under this clause exceed 3.0. (ii) Budget neutrality requirement.-- (I) In general.--Subject to clause (iii), the Secretary shall ensure that the estimated amount described in subclause (II) for a year is equal to the estimated amount described in subclause (III) for such year. (II) Aggregate increases.-- The amount described in this subclause is the estimated increase in the aggregate allowed charges resulting from the application of positive MIPS adjustment factors under subparagraph (A) (after application of the scaling factor described in clause (i)) to MIPS eligible professionals whose composite performance score for a year is above the performance threshold under subparagraph (D)(i) for such year. (III) Aggregate decreases.-- The amount described in this subclause is the estimated decrease in the aggregate allowed charges resulting from the application of negative MIPS adjustment factors under subparagraph (A) to MIPS eligible professionals whose composite performance score for a year is below the performance threshold under subparagraph (D)(i) for such year. (iii) Exceptions.-- (I) In the case that all MIPS eligible professionals receive composite performance scores for a year that are below the performance threshold under subparagraph (D)(i) for such year, the negative MIPS adjustment factors under subparagraph (A) shall apply with respect to such MIPS eligible professionals and the budget neutrality requirement of clause (ii) and the additional adjustment factors under clause (iv) shall not apply for such year. (II) In the case that, with respect to a year, the application of clause (i) results in a scaling factor equal to the maximum scaling factor specified in clause (i)(II), such scaling factor shall apply and the budget neutrality requirement of clause (ii) shall not apply for such year. (iv) Additional incentive payment adjustments.-- (I) In general.--Subject to subclause (II), in specifying the MIPS additional adjustment factors under subparagraph (C) for each applicable MIPS eligible professional for a year, the Secretary shall ensure that the estimated aggregate increase in payments under this part resulting from the application of such additional adjustment factors for MIPS eligible professionals in a year shall be equal (as estimated by the Secretary) to $500,000,000 for each year beginning with 2019 and ending with 2024. (II) Limitation on additional incentive payment adjustments.--The MIPS additional adjustment factor under subparagraph (C) for a year for an applicable MIPS eligible professional whose composite performance score is above the additional performance threshold under subparagraph (D)(ii) for such year shall not exceed 10 percent. The application of the previous sentence may result in an aggregate amount of additional incentive payments that are less than the amount specified in subclause (I). (7) Announcement of result of adjustments.--Under the MIPS, the Secretary shall, not later than 30 days prior to January 1 of the year involved, make available to MIPS eligible professionals the MIPS adjustment factor (and, as applicable, the additional MIPS adjustment factor) under paragraph (6) applicable to the eligible professional for covered professional services (as defined in subsection (k)(3)(A)) furnished by the professional for such year. The Secretary may include such information in the confidential feedback under paragraph (12). (8) No effect in subsequent years.--The MIPS adjustment factors and additional MIPS adjustment factors under paragraph (6) shall apply only with respect to the year involved, and the Secretary shall not take into account such adjustment factors in making payments to a MIPS eligible professional under this part in a subsequent year. (9) Public reporting.-- (A) In general.--The Secretary shall, in an easily understandable format, make available on the Physician Compare Internet website of the Centers for Medicare & Medicaid Services the following: (i) Information regarding the performance of MIPS eligible professionals under the MIPS, which-- (I) shall include the composite score for each such MIPS eligible professional and the performance of each such MIPS eligible professional with respect to each performance category; and (II) may include the performance of each such MIPS eligible professional with respect to each measure or activity specified in paragraph (2)(B). (ii) The names of eligible professionals in eligible alternative payment models (as defined in section 1833(z)(3)(D)) and, to the extent feasible, the names of such eligible alternative payment models and performance of such models. (B) Disclosure.--The information made available under this paragraph shall indicate, where appropriate, that publicized information may not be representative of the eligible professional's entire patient population, the variety of services furnished by the eligible professional, or the health conditions of individuals treated. (C) Opportunity to review and submit corrections.--The Secretary shall provide for an opportunity for a professional described in subparagraph (A) to review, and submit corrections for, the information to be made public with respect to the professional under such subparagraph prior to such information being made public. (D) Aggregate information.--The Secretary shall periodically post on the Physician Compare Internet website aggregate information on the MIPS, including the range of composite scores for all MIPS eligible professionals and the range of the performance of all MIPS eligible professionals with respect to each performance category. (10) Consultation.--The Secretary shall consult with stakeholders in carrying out the MIPS, including for the identification of measures and activities under paragraph (2)(B) and the methodologies developed under paragraphs (5)(A) and (6) and regarding the use of qualified clinical data registries. Such consultation shall include the use of a request for information or other mechanisms determined appropriate. (11) Technical assistance to small practices and practices in health professional shortage areas.-- (A) In general.--The Secretary shall enter into contracts or agreements with appropriate entities (such as quality improvement organizations, regional extension centers (as described in section 3012(c) of the Public Health Service Act), or regional health collaboratives) to offer guidance and assistance to MIPS eligible professionals in practices of 15 or fewer professionals (with priority given to such practices located in rural areas, health professional shortage areas (as designated under in section 332(a)(1)(A) of such Act), and medically underserved areas, and practices with low composite scores) with respect to-- (i) the performance categories described in clauses (i) through (iv) of paragraph (2)(A); or (ii) how to transition to the implementation of and participation in an alternative payment model as described in section 1833(z)(3)(C). (B) Funding for technical assistance.--For purposes of implementing subparagraph (A), the Secretary shall provide for the transfer from the Federal Supplementary Medical Insurance Trust Fund established under section 1841 to the Centers for Medicare & Medicaid Services Program Management Account of $20,000,000 for each of fiscal years 2016 through 2020. Amounts transferred under this subparagraph for a fiscal year shall be available until expended. (12) Feedback and information to improve performance.-- (A) Performance feedback.-- (i) In general.--Beginning July 1, 2017, the Secretary-- (I) shall make available timely (such as quarterly) confidential feedback to MIPS eligible professionals on the performance of such professionals with respect to the performance categories under clauses (i) and (ii) of paragraph (2)(A); and (II) may make available confidential feedback to such professionals on the performance of such professionals with respect to the performance categories under clauses (iii) and (iv) of such paragraph. (ii) Mechanisms.--The Secretary may use one or more mechanisms to make feedback available under clause (i), which may include use of a web-based portal or other mechanisms determined appropriate by the Secretary. With respect to the performance category described in paragraph (2)(A)(i), feedback under this subparagraph shall, to the extent an eligible professional chooses to participate in a data registry for purposes of this subsection (including registries under subsections (k) and (m)), be provided based on performance on quality measures reported through the use of such registries. With respect to any other performance category described in paragraph (2)(A), the Secretary shall encourage provision of feedback through qualified clinical data registries as described in subsection (m)(3)(E)). (iii) Use of data.--For purposes of clause (i), the Secretary may use data, with respect to a MIPS eligible professional, from periods prior to the current performance period and may use rolling periods in order to make illustrative calculations about the performance of such professional. (iv) Disclosure exemption.--Feedback made available under this subparagraph shall be exempt from disclosure under section 552 of title 5, United States Code. (v) Receipt of information.--The Secretary may use the mechanisms established under clause (ii) to receive information from professionals, such as information with respect to this subsection. (B) Additional information.-- (i) In general.--Beginning July 1, 2018, the Secretary shall make available to MIPS eligible professionals information, with respect to individuals who are patients of such MIPS eligible professionals, about items and services for which payment is made under this title that are furnished to such individuals by other suppliers and providers of services, which may include information described in clause (ii). Such information may be made available under the previous sentence to such MIPS eligible professionals by mechanisms determined appropriate by the Secretary, which may include use of a web-based portal. Such information may be made available in accordance with the same or similar terms as data are made available to accountable care organizations participating in the shared savings program under section 1899. (ii) Type of information.--For purposes of clause (i), the information described in this clause, is the following: (I) With respect to selected items and services (as determined appropriate by the Secretary) for which payment is made under this title and that are furnished to individuals, who are patients of a MIPS eligible professional, by another supplier or provider of services during the most recent period for which data are available (such as the most recent three-month period), such as the name of such providers furnishing such items and services to such patients during such period, the types of such items and services so furnished, and the dates such items and services were so furnished. (II) Historical data, such as averages and other measures of the distribution if appropriate, of the total, and components of, allowed charges (and other figures as determined appropriate by the Secretary). (13) Review.-- (A) Targeted review.--The Secretary shall establish a process under which a MIPS eligible professional may seek an informal review of the calculation of the MIPS adjustment factor (or factors) applicable to such eligible professional under this subsection for a year. The results of a review conducted pursuant to the previous sentence shall not be taken into account for purposes of paragraph (6) with respect to a year (other than with respect to the calculation of such eligible professional's MIPS adjustment factor for such year or additional MIPS adjustment factor for such year) after the factors determined in subparagraph (A) and subparagraph (C) of such paragraph have been determined for such year. (B) Limitation.--Except as provided for in subparagraph (A), there shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the following: (i) The methodology used to determine the amount of the MIPS adjustment factor under paragraph (6)(A) and the amount of the additional MIPS adjustment factor under paragraph (6)(C) and the determination of such amounts. (ii) The establishment of the performance standards under paragraph (3) and the performance period under paragraph (4). (iii) The identification of measures and activities specified under paragraph (2)(B) and information made public or posted on the Physician Compare Internet website of the Centers for Medicare & Medicaid Services under paragraph (9). (iv) The methodology developed under paragraph (5) that is used to calculate performance scores and the calculation of such scores, including the weighting of measures and activities under such methodology. (r) Collaborating With the Physician, Practitioner, and Other Stakeholder Communities To Improve Resource Use Measurement.-- (1) In general.--In order to involve the physician, practitioner, and other stakeholder communities in enhancing the infrastructure for resource use measurement, including for purposes of the Merit-based Incentive Payment System under subsection (q) and alternative payment models under section 1833(z), the Secretary shall undertake the steps described in the succeeding provisions of this subsection. (2) Development of care episode and patient condition groups and classification codes.-- (A) In general.--In order to classify similar patients into care episode groups and patient condition groups, the Secretary shall undertake the steps described in the succeeding provisions of this paragraph. (B) Public availability of existing efforts to design an episode grouper.--Not later than 180 days after the date of the enactment of this subsection, the Secretary shall post on the Internet website of the Centers for Medicare & Medicaid Services a list of the episode groups developed pursuant to subsection (n)(9)(A) and related descriptive information. (C) Stakeholder input.--The Secretary shall accept, through the date that is 120 days after the day the Secretary posts the list pursuant to subparagraph (B), suggestions from physician specialty societies, applicable practitioner organizations, and other stakeholders for episode groups in addition to those posted pursuant to such subparagraph, and specific clinical criteria and patient characteristics to classify patients into-- (i) care episode groups; and (ii) patient condition groups. (D) Development of proposed classification codes.-- (i) In general.--Taking into account the information described in subparagraph (B) and the information received under subparagraph (C), the Secretary shall-- (I) establish care episode groups and patient condition groups, which account for a target of an estimated \1/2\ of expenditures under parts A and B (with such target increasing over time as appropriate); and (II) assign codes to such groups. (ii) Care episode groups.--In establishing the care episode groups under clause (i), the Secretary shall take into account-- (I) the patient's clinical problems at the time items and services are furnished during an episode of care, such as the clinical conditions or diagnoses, whether or not inpatient hospitalization occurs, and the principal procedures or services furnished; and (II) other factors determined appropriate by the Secretary. (iii) Patient condition groups.--In establishing the patient condition groups under clause (i), the Secretary shall take into account-- (I) the patient's clinical history at the time of a medical visit, such as the patient's combination of chronic conditions, current health status, and recent significant history (such as hospitalization and major surgery during a previous period, such as 3 months); and (II) other factors determined appropriate by the Secretary, such as eligibility status under this title (including eligibility under section 226(a), 226(b), or 226A, and dual eligibility under this title and title XIX). (E) Draft care episode and patient condition groups and classification codes.--Not later than 270 days after the end of the comment period described in subparagraph (C), the Secretary shall post on the Internet website of the Centers for Medicare & Medicaid Services a draft list of the care episode and patient condition codes established under subparagraph (D) (and the criteria and characteristics assigned to such code). (F) Solicitation of input.--The Secretary shall seek, through the date that is 120 days after the Secretary posts the list pursuant to subparagraph (E), comments from physician specialty societies, applicable practitioner organizations, and other stakeholders, including representatives of individuals entitled to benefits under part A or enrolled under this part, regarding the care episode and patient condition groups (and codes) posted under subparagraph (E). In seeking such comments, the Secretary shall use one or more mechanisms (other than notice and comment rulemaking) that may include use of open door forums, town hall meetings, or other appropriate mechanisms. (G) Operational list of care episode and patient condition groups and codes.--Not later than 270 days after the end of the comment period described in subparagraph (F), taking into account the comments received under such subparagraph, the Secretary shall post on the Internet website of the Centers for Medicare & Medicaid Services an operational list of care episode and patient condition codes (and the criteria and characteristics assigned to such code). (H) Subsequent revisions.--Not later than November 1 of each year (beginning with 2018), the Secretary shall, through rulemaking, make revisions to the operational lists of care episode and patient condition codes as the Secretary determines may be appropriate. Such revisions may be based on experience, new information developed pursuant to subsection (n)(9)(A), and input from the physician specialty societies, applicable practitioner organizations, and other stakeholders, including representatives of individuals entitled to benefits under part A or enrolled under this part. (I) Information.--The Secretary shall, not later than December 31st of each year (beginning with 2018), post on the Internet website of the Centers for Medicare & Medicaid Services information on resource use measures in use under subsection (q), resource use measures under development and the time-frame for such development, potential future resource use measure topics, a description of stakeholder engagement, and the percent of expenditures under part A and this part that are covered by resource use measures. (3) Attribution of patients to physicians or practitioners.-- (A) In general.--In order to facilitate the attribution of patients and episodes (in whole or in part) to one or more physicians or applicable practitioners furnishing items and services, the Secretary shall undertake the steps described in the succeeding provisions of this paragraph. (B) Development of patient relationship categories and codes.--The Secretary shall develop patient relationship categories and codes that define and distinguish the relationship and responsibility of a physician or applicable practitioner with a patient at the time of furnishing an item or service. Such patient relationship categories shall include different relationships of the physician or applicable practitioner to the patient (and the codes may reflect combinations of such categories), such as a physician or applicable practitioner who-- (i) considers themself to have the primary responsibility for the general and ongoing care for the patient over extended periods of time; (ii) considers themself to be the lead physician or practitioner and who furnishes items and services and coordinates care furnished by other physicians or practitioners for the patient during an acute episode; (iii) furnishes items and services to the patient on a continuing basis during an acute episode of care, but in a supportive rather than a lead role; (iv) furnishes items and services to the patient on an occasional basis, usually at the request of another physician or practitioner; or (v) furnishes items and services only as ordered by another physician or practitioner. (C) Draft list of patient relationship categories and codes.--Not later than one year after the date of the enactment of this subsection, the Secretary shall post on the Internet website of the Centers for Medicare & Medicaid Services a draft list of the patient relationship categories and codes developed under subparagraph (B). (D) Stakeholder input.--The Secretary shall seek, through the date that is 120 days after the Secretary posts the list pursuant to subparagraph (C), comments from physician specialty societies, applicable practitioner organizations, and other stakeholders, including representatives of individuals entitled to benefits under part A or enrolled under this part, regarding the patient relationship categories and codes posted under subparagraph (C). In seeking such comments, the Secretary shall use one or more mechanisms (other than notice and comment rulemaking) that may include open door forums, town hall meetings, web-based forums, or other appropriate mechanisms. (E) Operational list of patient relationship categories and codes.--Not later than 240 days after the end of the comment period described in subparagraph (D), taking into account the comments received under such subparagraph, the Secretary shall post on the Internet website of the Centers for Medicare & Medicaid Services an operational list of patient relationship categories and codes. (F) Subsequent revisions.--Not later than November 1 of each year (beginning with 2018), the Secretary shall, through rulemaking, make revisions to the operational list of patient relationship categories and codes as the Secretary determines appropriate. Such revisions may be based on experience, new information developed pursuant to subsection (n)(9)(A), and input from the physician specialty societies, applicable practitioner organizations, and other stakeholders, including representatives of individuals entitled to benefits under part A or enrolled under this part. (4) Reporting of information for resource use measurement.--Claims submitted for items and services furnished by a physician or applicable practitioner on or after January 1, 2018, shall, as determined appropriate by the Secretary, include-- (A) applicable codes established under paragraphs (2) and (3); and (B) the national provider identifier of the ordering physician or applicable practitioner (if different from the billing physician or applicable practitioner). (5) Methodology for resource use analysis.-- (A) In general.--In order to evaluate the resources used to treat patients (with respect to care episode and patient condition groups), the Secretary shall, as the Secretary determines appropriate-- (i) use the patient relationship codes reported on claims pursuant to paragraph (4) to attribute patients (in whole or in part) to one or more physicians and applicable practitioners; (ii) use the care episode and patient condition codes reported on claims pursuant to paragraph (4) as a basis to compare similar patients and care episodes and patient condition groups; and (iii) conduct an analysis of resource use (with respect to care episodes and patient condition groups of such patients). (B) Analysis of patients of physicians and practitioners.--In conducting the analysis described in subparagraph (A)(iii) with respect to patients attributed to physicians and applicable practitioners, the Secretary shall, as feasible-- (i) use the claims data experience of such patients by patient condition codes during a common period, such as 12 months; and (ii) use the claims data experience of such patients by care episode codes-- (I) in the case of episodes without a hospitalization, during periods of time (such as the number of days) determined appropriate by the Secretary; and (II) in the case of episodes with a hospitalization, during periods of time (such as the number of days) before, during, and after the hospitalization. (C) Measurement of resource use.--In measuring such resource use, the Secretary-- (i) shall use per patient total allowed charges for all services under part A and this part (and, if the Secretary determines appropriate, part D) for the analysis of patient resource use, by care episode codes and by patient condition codes; and (ii) may, as determined appropriate, use other measures of allowed charges (such as subtotals for categories of items and services) and measures of utilization of items and services (such as frequency of specific items and services and the ratio of specific items and services among attributed patients or episodes). (D) Stakeholder input.--The Secretary shall seek comments from the physician specialty societies, applicable practitioner organizations, and other stakeholders, including representatives of individuals entitled to benefits under part A or enrolled under this part, regarding the resource use methodology established pursuant to this paragraph. In seeking comments the Secretary shall use one or more mechanisms (other than notice and comment rulemaking) that may include open door forums, town hall meetings, web-based forums, or other appropriate mechanisms. (6) Implementation.--To the extent that the Secretary contracts with an entity to carry out any part of the provisions of this subsection, the Secretary may not contract with an entity or an entity with a subcontract if the entity or subcontracting entity currently makes recommendations to the Secretary on relative values for services under the fee schedule for physicians' services under this section. (7) Limitation.--There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of-- (A) care episode and patient condition groups and codes established under paragraph (2); (B) patient relationship categories and codes established under paragraph (3); and (C) measurement of, and analyses of resource use with respect to, care episode and patient condition codes and patient relationship codes pursuant to paragraph (5). (8) Administration.--Chapter 35 of title 44, United States Code, shall not apply to this section. (9) Definitions.--In this subsection: (A) Physician.--The term ``physician'' has the meaning given such term in section 1861(r)(1). (B) Applicable practitioner.--The term ``applicable practitioner'' means-- (i) a physician assistant, nurse practitioner, and clinical nurse specialist (as such terms are defined in section 1861(aa)(5)), and a certified registered nurse anesthetist (as defined in section 1861(bb)(2)); and (ii) beginning January 1, 2019, such other eligible professionals (as defined in subsection (k)(3)(B)) as specified by the Secretary. (10) Clarification.--The provisions of sections 1890(b)(7) and 1890A shall not apply to this subsection. (s) Priorities and Funding for Measure Development.-- (1) Plan identifying measure development priorities and timelines.-- (A) Draft measure development plan.--Not later than January 1, 2016, the Secretary shall develop, and post on the Internet website of the Centers for Medicare & Medicaid Services, a draft plan for the development of quality measures for application under the applicable provisions (as defined in paragraph (5)). Under such plan the Secretary shall-- (i) address how measures used by private payers and integrated delivery systems could be incorporated under title XVIII; (ii) describe how coordination, to the extent possible, will occur across organizations developing such measures; and (iii) take into account how clinical best practices and clinical practice guidelines should be used in the development of quality measures. (B) Quality domains.--For purposes of this subsection, the term ``quality domains'' means at least the following domains: (i) Clinical care. (ii) Safety. (iii) Care coordination. (iv) Patient and caregiver experience. (v) Population health and prevention. (C) Consideration.--In developing the draft plan under this paragraph, the Secretary shall consider-- (i) gap analyses conducted by the entity with a contract under section 1890(a) or other contractors or entities; (ii) whether measures are applicable across health care settings; (iii) clinical practice improvement activities submitted under subsection (q)(2)(C)(iv) for identifying possible areas for future measure development and identifying existing gaps with respect to such measures; and (iv) the quality domains applied under this subsection. (D) Priorities.--In developing the draft plan under this paragraph, the Secretary shall give priority to the following types of measures: (i) Outcome measures, including patient reported outcome and functional status measures. (ii) Patient experience measures. (iii) Care coordination measures. (iv) Measures of appropriate use of services, including measures of over use. (E) Stakeholder input.--The Secretary shall accept through March 1, 2016, comments on the draft plan posted under paragraph (1)(A) from the public, including health care providers, payers, consumers, and other stakeholders. (F) Final measure development plan.--Not later than May 1, 2016, taking into account the comments received under this subparagraph, the Secretary shall finalize the plan and post on the Internet website of the Centers for Medicare & Medicaid Services an operational plan for the development of quality measures for use under the applicable provisions. Such plan shall be updated as appropriate. (2) Contracts and other arrangements for quality measure development.-- (A) In general.--The Secretary shall enter into contracts or other arrangements with entities for the purpose of developing, improving, updating, or expanding in accordance with the plan under paragraph (1) quality measures for application under the applicable provisions. Such entities shall include organizations with quality measure development expertise. (B) Prioritization.-- (i) In general.--In entering into contracts or other arrangements under subparagraph (A), the Secretary shall give priority to the development of the types of measures described in paragraph (1)(D). (ii) Consideration.--In selecting measures for development under this subsection, the Secretary shall consider-- (I) whether such measures would be electronically specified; and (II) clinical practice guidelines to the extent that such guidelines exist. (3) Annual report by the secretary.-- (A) In general.--Not later than May 1, 2017, and annually thereafter, the Secretary shall post on the Internet website of the Centers for Medicare & Medicaid Services a report on the progress made in developing quality measures for application under the applicable provisions. (B) Requirements.--Each report submitted pursuant to subparagraph (A) shall include the following: (i) A description of the Secretary's efforts to implement this paragraph. (ii) With respect to the measures developed during the previous year-- (I) a description of the total number of quality measures developed and the types of such measures, such as an outcome or patient experience measure; (II) the name of each measure developed; (III) the name of the developer and steward of each measure; (IV) with respect to each type of measure, an estimate of the total amount expended under this title to develop all measures of such type; and (V) whether the measure would be electronically specified. (iii) With respect to measures in development at the time of the report-- (I) the information described in clause (ii), if available; and (II) a timeline for completion of the development of such measures. (iv) A description of any updates to the plan under paragraph (1) (including newly identified gaps and the status of previously identified gaps) and the inventory of measures applicable under the applicable provisions. (v) Other information the Secretary determines to be appropriate. (4) Stakeholder input.--With respect to paragraph (1), the Secretary shall seek stakeholder input with respect to-- (A) the identification of gaps where no quality measures exist, particularly with respect to the types of measures described in paragraph (1)(D); (B) prioritizing quality measure development to address such gaps; and (C) other areas related to quality measure development determined appropriate by the Secretary. (5) Definition of applicable provisions.--In this subsection, the term ``applicable provisions'' means the following provisions: (A) Subsection (q)(2)(B)(i). (B) Section 1833(z)(3)(D). (6) Funding.--For purposes of carrying out this subsection, the Secretary shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund under section 1841, of $15,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for each of fiscal years 2015 through 2019. Amounts transferred under this paragraph shall remain available through the end of fiscal year 2022. (7) Administration.--Chapter 35 of title 44, United States Code, shall not apply to the collection of information for the development of quality measures. * * * * * * * Part D--Voluntary Prescription Drug Benefit Program Subpart 1--Part D Eligible Individuals and Prescription Drug Benefits * * * * * * * beneficiary protections for qualified prescription drug coverage Sec. 1860D-4. (a) Dissemination of Information.-- (1) General information.-- (A) Application of ma information.--A PDP sponsor shall disclose, in a clear, accurate, and standardized form to each enrollee with a prescription drug plan offered by the sponsor under this part at the time of enrollment and at least annually thereafter, the information described in section 1852(c)(1) relating to such plan, insofar as the Secretary determines appropriate with respect to benefits provided under this part, and, subject to subparagraph (C), including the information described in subparagraph (B). (B) Drug specific information.--The information described in this subparagraph is information concerning the following: (i) Access to specific covered part D drugs, including access through pharmacy networks. (ii) How any formulary (including any tiered formulary structure) used by the sponsor functions, including a description of how a part D eligible individual may obtain information on the formulary consistent with paragraph (3). (iii) Beneficiary cost-sharing requirements and how a part D eligible individual may obtain information on such requirements, including tiered or other copayment level applicable to each drug (or class of drugs), consistent with paragraph (3). (iv) The medication therapy management program required under subsection (c). (v) The drug management program for at-risk beneficiaries under subsection (c)(5). (vi) For plan year 2021 and each subsequent plan year, subject to subparagraph (C), with respect to the treatment of pain-- (I) the risks associated with prolonged opioid use; and (II) coverage of nonpharmacological therapies, devices, and nonopioid medications-- (aa) in the case of an MA-PD plan under part C, under such plan; and (bb) in the case of a prescription drug plan, under such plan and under parts A and B. (C) Targeted provision of information.--A PDP sponsor of a prescription drug plan may, in lieu of disclosing the information described in subparagraph (B)(vi) to each enrollee under the plan, disclose such information through mail or electronic communications to a subset of enrollees under the plan, such as enrollees who have been prescribed an opioid in the previous 2-year period. (2) Disclosure upon request of general coverage, utilization, and grievance information.--Upon request of a part D eligible individual who is eligible to enroll in a prescription drug plan, the PDP sponsor offering such plan shall provide information similar (as determined by the Secretary) to the information described in subparagraphs (A), (B), and (C) of section 1852(c)(2) to such individual. (3) Provision of specific information.-- (A) Response to beneficiary questions.--Each PDP sponsor offering a prescription drug plan shall have a mechanism for providing specific information on a timely basis to enrollees upon request. Such mechanism shall include access to information through the use of a toll-free telephone number and, upon request, the provision of such information in writing. (B) Availability of information on changes in formulary through the internet.--A PDP sponsor offering a prescription drug plan shall make available on a timely basis through an Internet website information on specific changes in the formulary under the plan (including changes to tiered or preferred status of covered part D drugs). (4) Claims information.--A PDP sponsor offering a prescription drug plan must furnish to each enrollee in a form easily understandable to such enrollees-- (A) an explanation of benefits (in accordance with section 1806(a) or in a comparable manner); and (B) when prescription drug benefits are provided under this part, a notice of the benefits in relation to-- (i) the initial coverage limit for the current year; and (ii) the annual out-of-pocket threshold for the current year. Notices under subparagraph (B) need not be provided more often than as specified by the Secretary and notices under subparagraph (B)(ii) shall take into account the application of section 1860D-2(b)(4)(C) to the extent practicable, as specified by the Secretary. (b) Access to Covered Part D Drugs.-- (1) Assuring pharmacy access.-- (A) Participation of any willing pharmacy.--A prescription drug plan shall permit the participation of any pharmacy that meets the terms and conditions under the plan. (B) Discounts allowed for network pharmacies.--For covered part D drugs dispensed through in-network pharmacies, a prescription drug plan may, notwithstanding subparagraph (A), reduce coinsurance or copayments for part D eligible individuals enrolled in the plan below the level otherwise required. In no case shall such a reduction result in an increase in payments made by the Secretary under section 1860D-15 to a plan. (C) Convenient access for network pharmacies.-- (i) In general.--The PDP sponsor of the prescription drug plan shall secure the participation in its network of a sufficient number of pharmacies that dispense (other than by mail order) drugs directly to patients to ensure convenient access (consistent with rules established by the Secretary). (ii) Application of tricare standards.--The Secretary shall establish rules for convenient access to in-network pharmacies under this subparagraph that are no less favorable to enrollees than the rules for convenient access to pharmacies included in the statement of work of solicitation (#MDA906-03-R-0002) of the Department of Defense under the TRICARE Retail Pharmacy (TRRx) as of March 13, 2003. (iii) Adequate emergency access.-- Such rules shall include adequate emergency access for enrollees. (iv) Convenient access in long-term care facilities.--Such rules may include standards with respect to access for enrollees who are residing in long-term care facilities and for pharmacies operated by the Indian Health Service, Indian tribes and tribal organizations, and urban Indian organizations (as defined in section 4 of the Indian Health Care Improvement Act). (D) Level playing field.--Such a sponsor shall permit enrollees to receive benefits (which may include a 90-day supply of drugs or biologicals) through a pharmacy (other than a mail order pharmacy), with any differential in charge paid by such enrollees. (E) Not required to accept insurance risk.-- The terms and conditions under subparagraph (A) may not require participating pharmacies to accept insurance risk as a condition of participation. (2) Use of standardized technology.-- (A) In general.--The PDP sponsor of a prescription drug plan shall issue (and reissue, as appropriate) such a card (or other technology) that may be used by an enrollee to assure access to negotiated prices under section 1860D-2(d). (B) Standards.-- (i) In general.--The Secretary shall provide for the development, adoption, or recognition of standards relating to a standardized format for the card or other technology required under subparagraph (A). Such standards shall be compatible with part C of title XI and may be based on standards developed by an appropriate standard setting organization. (ii) Consultation.--In developing the standards under clause (i), the Secretary shall consult with the National Council for Prescription Drug Programs and other standard setting organizations determined appropriate by the Secretary. (iii) Implementation.--The Secretary shall develop, adopt, or recognize the standards under clause (i) by such date as the Secretary determines shall be sufficient to ensure that PDP sponsors utilize such standards beginning January 1, 2006. (3) Requirements on development and application of formularies.--If a PDP sponsor of a prescription drug plan uses a formulary (including the use of tiered cost-sharing), the following requirements must be met: (A) Development and revision by a pharmacy and therapeutic (p&t) committee.-- (i) In general.--The formulary must be developed and reviewed by a pharmacy and therapeutic committee. A majority of the members of such committee shall consist of individuals who are practicing physicians or practicing pharmacists (or both). (ii) Inclusion of independent experts.--Such committee shall include at least one practicing physician and at least one practicing pharmacist, each of whom-- (I) is independent and free of conflict with respect to the sponsor and plan; and (II) has expertise in the care of elderly or disabled persons. (B) Formulary development.--In developing and reviewing the formulary, the committee shall-- (i) base clinical decisions on the strength of scientific evidence and standards of practice, including assessing peer-reviewed medical literature, such as randomized clinical trials, pharmacoeconomic studies, outcomes research data, and on such other information as the committee determines to be appropriate; and (ii) take into account whether including in the formulary (or in a tier in such formulary) particular covered part D drugs has therapeutic advantages in terms of safety and efficacy. (C) Inclusion of drugs in all therapeutic categories and classes.-- (i) In general.--Subject to subparagraph (G), the formulary must include drugs within each therapeutic category and class of covered part D drugs, although not necessarily all drugs within such categories and classes. (ii) Model guidelines.--The Secretary shall request the United States Pharmacopeia to develop, in consultation with pharmaceutical benefit managers and other interested parties, a list of categories and classes that may be used by prescription drug plans under this paragraph and to revise such classification from time to time to reflect changes in therapeutic uses of covered part D drugs and the additions of new covered part D drugs. (iii) Limitation on changes in therapeutic classification.--The PDP sponsor of a prescription drug plan may not change the therapeutic categories and classes in a formulary other than at the beginning of each plan year except as the Secretary may permit to take into account new therapeutic uses and newly approved covered part D drugs. (D) Provider and patient education.--The PDP sponsor shall establish policies and procedures to educate and inform health care providers and enrollees concerning the formulary. (E) Notice before removing drug from formulary or changing preferred or tier status of drug.--Any removal of a covered part D drug from a formulary and any change in the preferred or tiered cost-sharing status of such a drug shall take effect only after appropriate notice is made available (such as under subsection (a)(3)) to the Secretary, affected enrollees, physicians, pharmacies, and pharmacists. (F) Periodic evaluation of protocols.--In connection with the formulary, the sponsor of a prescription drug plan shall provide for the periodic evaluation and analysis of treatment protocols and procedures. (G) Required inclusion of drugs in certain categories and classes.-- (i) Formulary requirements.-- (I) In general.--Subject to subclause (II), a PDP sponsor offering a prescription drug plan shall be required to include all covered part D drugs in the categories and classes identified by the Secretary under clause (ii)(I). (II) Exceptions.--The Secretary may establish exceptions that permit a PDP sponsor offering a prescription drug plan to exclude from its formulary a particular covered part D drug in a category or class that is otherwise required to be included in the formulary under subclause (I) (or to otherwise limit access to such a drug, including through prior authorization or utilization management). (ii) Identification of drugs in certain categories and classes.-- (I) In general.--Subject to clause (iv), the Secretary shall identify, as appropriate, categories and classes of drugs for which the Secretary determines are of clinical concern. (II) Criteria.--The Secretary shall use criteria established by the Secretary in making any determination under subclause (I). (iii) Implementation.--The Secretary shall establish the criteria under clause (ii)(II) and any exceptions under clause (i)(II) through the promulgation of a regulation which includes a public notice and comment period. (iv) Requirement for certain categories and classes until criteria established.--Until such time as the Secretary establishes the criteria under clause (ii)(II) the following categories and classes of drugs shall be identified under clause (ii)(I): (I) Anticonvulsants. (II) Antidepressants. (III) Antineoplastics. (IV) Antipsychotics. (V) Antiretrovirals. (VI) Immunosuppressants for the treatment of transplant rejection. (H) Use of single, uniform exceptions and appeals process.--Notwithstanding any other provision of this part, each PDP sponsor of a prescription drug plan shall-- (i) use a single, uniform exceptions and appeals process (including, to the extent the Secretary determines feasible, a single, uniform model form for use under such process) with respect to the determination of prescription drug coverage for an enrollee under the plan; and (ii) provide instant access to such process by enrollees through a toll- free telephone number and an Internet website. (c) Cost and Utilization Management; Quality Assurance; Medication Therapy Management Program.-- (1) In general.--The PDP sponsor shall have in place, directly or through appropriate arrangements, with respect to covered part D drugs, the following: (A) A cost-effective drug utilization management program, including incentives to reduce costs when medically appropriate, such as through the use of multiple source drugs (as defined in section 1927(k)(7)(A)(i)). (B) Quality assurance measures and systems to reduce medication errors and adverse drug interactions and improve medication use. (C) A medication therapy management program described in paragraph (2). (D) A program to control fraud, abuse, and waste. (E) A utilization management tool to prevent drug abuse (as described in paragraph (6)(A)). (F) With respect to plan years beginning on or after January 1, 2022, a drug management program for at-risk beneficiaries described in paragraph (5). Nothing in this section shall be construed as impairing a PDP sponsor from utilizing cost management tools (including differential payments) under all methods of operation. (2) Medication therapy management program.-- (A) Description.-- (i) In general.--A medication therapy management program described in this paragraph is a program of drug therapy management that may be furnished by a pharmacist and that is designed to assure, with respect to targeted beneficiaries described in clause (ii), that covered part D drugs under the prescription drug plan are appropriately used to optimize therapeutic outcomes through improved medication use, and to reduce the risk of adverse events, including adverse drug interactions. Such a program may distinguish between services in ambulatory and institutional settings. (ii) Targeted beneficiaries described.--Targeted beneficiaries described in this clause are the following: (I) Part D eligible individuals who-- (aa) have multiple chronic diseases (such as diabetes, asthma, hypertension, hyperlipidemia, and congestive heart failure); (bb) are taking multiple covered part D drugs; and (cc) are identified as likely to incur annual costs for covered part D drugs that exceed a level specified by the Secretary. (II) Beginning January 1, 2021, at-risk beneficiaries for prescription drug abuse (as defined in paragraph (5)(C)). (B) Elements.--Such program-- (i) may include elements that promote-- (I) enhanced enrollee understanding to promote the appropriate use of medications by enrollees and to reduce the risk of potential adverse events associated with medications, through beneficiary education, counseling, and other appropriate means; (II) increased enrollee adherence with prescription medication regimens through medication refill reminders, special packaging, and other compliance programs and other appropriate means; and (III) detection of adverse drug events and patterns of overuse and underuse of prescription drugs; and (ii) with respect to plan years beginning on or after January 1, 2021, shall provide for-- (I) the provision of information to the enrollee on the safe disposal of prescription drugs that are controlled substances that meets the criteria established under section 1852(n)(2), including information on drug takeback programs that meet such requirements determined appropriate by the Secretary and information on in-home disposal; and (II) cost-effective means by which an enrollee may so safely dispose of such drugs. (C) Required interventions.--For plan years beginning on or after the date that is 2 years after the date of the enactment of the Patient Protection and Affordable Care Act, prescription drug plan sponsors shall offer medication therapy management services to targeted beneficiaries described in subparagraph (A)(ii) that include, at a minimum, the following to increase adherence to prescription medications or other goals deemed necessary by the Secretary: (i) An annual comprehensive medication review furnished person-to- person or using telehealth technologies (as defined by the Secretary) by a licensed pharmacist or other qualified provider. The comprehensive medication review-- (I) shall include a review of the individual's medications and may result in the creation of a recommended medication action plan or other actions in consultation with the individual and with input from the prescriber to the extent necessary and practicable; and (II) shall include providing the individual with a written or printed summary of the results of the review. The Secretary, in consultation with relevant stakeholders, shall develop a standardized format for the action plan under subclause (I) and the summary under subclause (II). (ii) Follow-up interventions as warranted based on the findings of the annual medication review or the targeted medication enrollment and which may be provided person-to-person or using telehealth technologies (as defined by the Secretary). (D) Assessment.--The prescription drug plan sponsor shall have in place a process to assess, at least on a quarterly basis, the medication use of individuals who are at risk but not enrolled in the medication therapy management program, including individuals who have experienced a transition in care, if the prescription drug plan sponsor has access to that information. (E) Automatic enrollment with ability to opt- out.--The prescription drug plan sponsor shall have in place a process to-- (i) subject to clause (ii), automatically enroll targeted beneficiaries described in subparagraph (A)(ii), including beneficiaries identified under subparagraph (D), in the medication therapy management program required under this subsection; and (ii) permit such beneficiaries to opt-out of enrollment in such program. (E) Development of program in cooperation with licensed pharmacists.--Such program shall be developed in cooperation with licensed and practicing pharmacists and physicians. (F) Coordination with care management plans.--The Secretary shall establish guidelines for the coordination of any medication therapy management program under this paragraph with respect to a targeted beneficiary with any care management plan established with respect to such beneficiary under a chronic care improvement program under section 1807. (G) Considerations in pharmacy fees.--The PDP sponsor of a prescription drug plan shall take into account, in establishing fees for pharmacists and others providing services under such plan, the resources used, and time required to, implement the medication therapy management program under this paragraph. Each such sponsor shall disclose to the Secretary upon request the amount of any such management or dispensing fees. The provisions of section 1927(b)(3)(D) apply to information disclosed under this subparagraph. (3) Reducing wasteful dispensing of outpatient prescription drugs in long-term care facilities.--The Secretary shall require PDP sponsors of prescription drug plans to utilize specific, uniform dispensing techniques, as determined by the Secretary, in consultation with relevant stakeholders (including representatives of nursing facilities, residents of nursing facilities, pharmacists, the pharmacy industry (including retail and long-term care pharmacy), prescription drug plans, MA-PD plans, and any other stakeholders the Secretary determines appropriate), such as weekly, daily, or automated dose dispensing, when dispensing covered part D drugs to enrollees who reside in a long-term care facility in order to reduce waste associated with 30-day fills. (4) Requiring valid prescriber national provider identifiers on pharmacy claims.-- (A) In general.--For plan year 2016 and subsequent plan years, the Secretary shall require a claim for a covered part D drug for a part D eligible individual enrolled in a prescription drug plan under this part or an MA-PD plan under part C to include a prescriber National Provider Identifier that is determined to be valid under the procedures established under subparagraph (B)(i). (B) Procedures.-- (i) Validity of prescriber national provider identifiers.--The Secretary, in consultation with appropriate stakeholders, shall establish procedures for determining the validity of prescriber National Provider Identifiers under subparagraph (A). (ii) Informing beneficiaries of reason for denial.--The Secretary shall establish procedures to ensure that, in the case that a claim for a covered part D drug of an individual described in subparagraph (A) is denied because the claim does not meet the requirements of this paragraph, the individual is properly informed at the point of service of the reason for the denial. (C) Report.--Not later than January 1, 2018, the Inspector General of the Department of Health and Human Services shall submit to Congress a report on the effectiveness of the procedures established under subparagraph (B)(i). (D) Notification and additional requirements with respect to outlier prescribers of opioids.-- (i) Notification.--Not later than January 1, 2021, the Secretary shall, in the case of a prescriber identified by the Secretary under clause (ii) to be an outlier prescriber of opioids, provide, subject to clause (iv), an annual notification to such prescriber that such prescriber has been so identified and that includes resources on proper prescribing methods and other information as specified in accordance with clause (iii). (ii) Identification of outlier prescribers of opioids.-- (I) In general.--The Secretary shall, subject to subclause (III), using the valid prescriber National Provider Identifiers included pursuant to subparagraph (A) on claims for covered part D drugs for part D eligible individuals enrolled in prescription drug plans under this part or MA-PD plans under part C and based on the thresholds established under subclause (II), identify prescribers that are outlier opioids prescribers for a period of time specified by the Secretary. (II) Establishment of thresholds.--For purposes of subclause (I) and subject to subclause (III), the Secretary shall, after consultation with stakeholders, establish thresholds, based on prescriber specialty and geographic area, for identifying whether a prescriber in a specialty and geographic area is an outlier prescriber of opioids as compared to other prescribers of opioids within such specialty and area. (III) Exclusions.--The following shall not be included in the analysis for identifying outlier prescribers of opioids under this clause: (aa) Claims for covered part D drugs for part D eligible individuals who are receiving hospice care under this title. (bb) Claims for covered part D drugs for part D eligible individuals who are receiving oncology services under this title. (cc) Prescribers who are the subject of an investigation by the Centers for Medicare & Medicaid Services or the Inspector General of the Department of Health and Human Services. (iii) Contents of notification.--The Secretary shall include the following information in the notifications provided under clause (i): (I) Information on how such prescriber compares to other prescribers within the same specialty and geographic area. (II) Information on opioid prescribing guidelines, based on input from stakeholders, that may include the Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain and guidelines developed by physician organizations. (III) Other information determined appropriate by the Secretary. (iv) Modifications and expansions.-- (I) Frequency.--Beginning 5 years after the date of the enactment of this subparagraph, the Secretary may change the frequency of the notifications described in clause (i) based on stakeholder input and changes in opioid prescribing utilization and trends. (II) Expansion to other prescriptions.--The Secretary may expand notifications under this subparagraph to include identifications and notifications with respect to concurrent prescriptions of covered Part D drugs used in combination with opioids that are considered to have adverse side effects when so used in such combination, as determined by the Secretary. (v) Additional requirements for persistent outlier prescribers.--In the case of a prescriber who the Secretary determines is persistently identified under clause (ii) as an outlier prescriber of opioids, the following shall apply: (I) Such prescriber may be required to enroll in the program under this title under section 1866(j) if such prescriber is not otherwise required to enroll, but only after other appropriate remedies have been provided, such as the provision of education funded through section 6052 of the SUPPORT for Patients and Communities Act, for a period determined by the Secretary as sufficient to correct the prescribing patterns that lead to identification of such prescriber as a persistent outlier prescriber of opioids. The Secretary shall determine the length of the period for which such prescriber is required to maintain such enrollment, which shall be the minimum period necessary to correct such prescribing patterns. (II) Not less frequently than annually (and in a form and manner determined appropriate by the Secretary), the Secretary, consistent with clause(iv)(I), shall communicate information on such prescribers to sponsors of a prescription drug plan and Medicare Advantage organizations offering an MA-PD plan. (vi) Public availability of information.--The Secretary shall make aggregate information under this subparagraph available on the internet website of the Centers for Medicare & Medicaid Services. Such information shall be in a form and manner determined appropriate by the Secretary and shall not identify any specific prescriber. In carrying out this clause, the Secretary shall consult with interested stakeholders. (vii) Opioids defined.--For purposes of this subparagraph, the term ``opioids'' has such meaning as specified by the Secretary. (viii) Other activities.--Nothing in this subparagraph shall preclude the Secretary from conducting activities that provide prescribers with information as to how they compare to other prescribers that are in addition to the activities under this subparagraph, including activities that were being conducted as of the date of the enactment of this subparagraph. (5) Drug management program for at-risk beneficiaries.-- (A) Authority to establish.--A PDP sponsor may (and for plan years beginning on or after January 1, 2022, a PDP sponsor shall) establish a drug management program for at-risk beneficiaries under which, subject to subparagraph (B), the PDP sponsor may, in the case of an at-risk beneficiary for prescription drug abuse who is an enrollee in a prescription drug plan of such PDP sponsor, limit such beneficiary's access to coverage for frequently abused drugs under such plan to frequently abused drugs that are prescribed for such beneficiary by one or more prescribers selected under subparagraph (D), and dispensed for such beneficiary by one or more pharmacies selected under such subparagraph. (B) Requirement for notices.-- (i) In general.--A PDP sponsor may not limit the access of an at-risk beneficiary for prescription drug abuse to coverage for frequently abused drugs under a prescription drug plan until such sponsor-- (I) provides to the beneficiary an initial notice described in clause (ii) and a second notice described in clause (iii); and (II) verifies with the providers of the beneficiary that the beneficiary is an at- risk beneficiary for prescription drug abuse. (ii) Initial notice.--An initial notice described in this clause is a notice that provides to the beneficiary-- (I) notice that the PDP sponsor has identified the beneficiary as potentially being an at-risk beneficiary for prescription drug abuse; (II) information describing all State and Federal public health resources that are designed to address prescription drug abuse to which the beneficiary has access, including mental health services and other counseling services; (III) notice of, and information about, the right of the beneficiary to appeal such identification under subsection (h), including notice that if on reconsideration a PDP sponsor affirms its denial, in whole or in part, the case shall be automatically forwarded to the independent, outside entity contracted with the Secretary for review and resolution; (IV) a request for the beneficiary to submit to the PDP sponsor preferences for which prescribers and pharmacies the beneficiary would prefer the PDP sponsor to select under subparagraph (D) in the case that the beneficiary is identified as an at-risk beneficiary for prescription drug abuse as described in clause (iii)(I); (V) an explanation of the meaning and consequences of the identification of the beneficiary as potentially being an at-risk beneficiary for prescription drug abuse, including an explanation of the drug management program established by the PDP sponsor pursuant to subparagraph (A); (VI) clear instructions that explain how the beneficiary can contact the PDP sponsor in order to submit to the PDP sponsor the preferences described in subclause (IV) and any other communications relating to the drug management program for at-risk beneficiaries established by the PDP sponsor; and (VII) contact information for other organizations that can provide the beneficiary with assistance regarding such drug management program (similar to the information provided by the Secretary in other standardized notices provided to part D eligible individuals enrolled in prescription drug plans under this part). (iii) Second notice.--A second notice described in this clause is a notice that provides to the beneficiary notice-- (I) that the PDP sponsor has identified the beneficiary as an at-risk beneficiary for prescription drug abuse; (II) that such beneficiary is subject to the requirements of the drug management program for at-risk beneficiaries established by such PDP sponsor for such plan; (III) of the prescriber (or prescribers) and pharmacy (or pharmacies) selected for such individual under subparagraph (D); (IV) of, and information about, the beneficiary's right to appeal such identification under subsection (h), including notice that if on reconsideration a PDP sponsor affirms its denial, in whole or in part, the case shall be automatically forwarded to the independent, outside entity contracted with the Secretary for review and resolution; (V) that the beneficiary can, in the case that the beneficiary has not previously submitted to the PDP sponsor preferences for which prescribers and pharmacies the beneficiary would prefer the PDP sponsor select under subparagraph (D), submit such preferences to the PDP sponsor; and (VI) that includes clear instructions that explain how the beneficiary can contact the PDP sponsor. (iv) Timing of notices.-- (I) In general.--Subject to subclause (II), a second notice described in clause (iii) shall be provided to the beneficiary on a date that is not less than 30 days after an initial notice described in clause (ii) is provided to the beneficiary. (II) Exception.--In the case that the PDP sponsor, in conjunction with the Secretary, determines that concerns identified through rulemaking by the Secretary regarding the health or safety of the beneficiary or regarding significant drug diversion activities require the PDP sponsor to provide a second notice described in clause (iii) to the beneficiary on a date that is earlier than the date described in subclause (I), the PDP sponsor may provide such second notice on such earlier date. (C) At-risk beneficiary for prescription drug abuse.-- (i) In general.--Except as provided in clause (v), for purposes of this paragraph, the term ``at-risk beneficiary for prescription drug abuse'' means a part D eligible individual who is not an exempted individual described in clause (ii) and-- (I) who is identified as such an at-risk beneficiary through the use of clinical guidelines that indicate misuse or abuse of prescription drugs described in subparagraph (G) and that are developed by the Secretary in consultation with PDP sponsors and other stakeholders, including individuals entitled to benefits under part A or enrolled under part B, advocacy groups representing such individuals, physicians, pharmacists, and other clinicians, retail pharmacies, plan sponsors, entities delegated by plan sponsors, and biopharmaceutical manufacturers; or (II) with respect to whom the PDP sponsor of a prescription drug plan, upon enrolling such individual in such plan, received notice from the Secretary that such individual was identified under this paragraph to be an at-risk beneficiary for prescription drug abuse under the prescription drug plan in which such individual was most recently previously enrolled and such identification has not been terminated under subparagraph (F). (ii) Exempted individual described.-- An exempted individual described in this clause is an individual who-- (I) receives hospice care under this title; (II) is a resident of a long- term care facility, of a facility described in section 1905(d), or of another facility for which frequently abused drugs are dispensed for residents through a contract with a single pharmacy; or (III) the Secretary elects to treat as an exempted individual for purposes of clause (i). (iii) Program size.--The Secretary shall establish policies, including the guidelines developed under clause (i)(I) and the exemptions under clause (ii)(III), to ensure that the population of enrollees in a drug management program for at-risk beneficiaries operated by a prescription drug plan can be effectively managed by such plans. (iv) Clinical contact.--With respect to each at-risk beneficiary for prescription drug abuse enrolled in a prescription drug plan offered by a PDP sponsor, the PDP sponsor shall contact the beneficiary's providers who have prescribed frequently abused drugs regarding whether prescribed medications are appropriate for such beneficiary's medical conditions. (v) Treatment of enrollees with a history of opioid-related overdose.-- (I) In general.--For plan years beginning not later than January 1, 2021, a part D eligible individual who is not an exempted individual described in clause (ii) and who is identified under this clause as a part D eligible individual with a history of opioid-related overdose (as defined by the Secretary) shall be included as a potentially at-risk beneficiary for prescription drug abuse under the drug management program under this paragraph. (II) Identification and notice.--For purposes of this clause, the Secretary shall-- (aa) identify part D eligible individuals with a history of opioid-related overdose (as so defined); and (bb) notify the PDP sponsor of the prescription drug plan in which such an individual is enrolled of such identification. (D) Selection of prescribers and pharmacies.-- (i) In general.--With respect to each at-risk beneficiary for prescription drug abuse enrolled in a prescription drug plan offered by such sponsor, a PDP sponsor shall, based on the preferences submitted to the PDP sponsor by the beneficiary pursuant to clauses (ii)(IV) and (iii)(V) of subparagraph (B) (except as otherwise provided in this subparagraph) select-- (I) one, or, if the PDP sponsor reasonably determines it necessary to provide the beneficiary with reasonable access under clause (ii), more than one, individual who is authorized to prescribe frequently abused drugs (referred to in this paragraph as a ``prescriber'') who may write prescriptions for such drugs for such beneficiary; and (II) one, or, if the PDP sponsor reasonably determines it necessary to provide the beneficiary with reasonable access under clause (ii), more than one, pharmacy that may dispense such drugs to such beneficiary. For purposes of subclause (II), in the case of a pharmacy that has multiple locations that share real-time electronic data, all such locations of the pharmacy shall collectively be treated as one pharmacy. (ii) Reasonable access.--In making the selections under this subparagraph-- (I) a PDP sponsor shall ensure that the beneficiary continues to have reasonable access to frequently abused drugs (as defined in subparagraph (G)), taking into account geographic location, beneficiary preference, impact on costsharing, and reasonable travel time; and (II) a PDP sponsor shall ensure such access (including access to prescribers and pharmacies with respect to frequently abused drugs) in the case of individuals with multiple residences, in the case of natural disasters and similar situations, and in the case of the provision of emergency services. (iii) Beneficiary preferences.--If an at-risk beneficiary for prescription drug abuse submits preferences for which in-network prescribers and pharmacies the beneficiary would prefer the PDP sponsor select in response to a notice under subparagraph (B), the PDP sponsor shall-- (I) review such preferences; (II) select or change the selection of prescribers and pharmacies for the beneficiary based on such preferences; and (III) inform the beneficiary of such selection or change of selection. (iv) Exception regarding beneficiary preferences.--In the case that the PDP sponsor determines that a change to the selection of prescriber or pharmacy under clause (iii)(II) by the PDP sponsor is contributing or would contribute to prescription drug abuse or drug diversion by the beneficiary, the PDP sponsor may change the selection of prescriber or pharmacy for the beneficiary without regard to the preferences of the beneficiary described in clause (iii). If the PDP sponsor changes the selection pursuant to the preceding sentence, the PDP sponsor shall provide the beneficiary with-- (I) at least 30 days written notice of the change of selection; and (II) a rationale for the change. (v) Confirmation.--Before selecting a prescriber or pharmacy under this subparagraph, a PDP sponsor must notify the prescriber and pharmacy that the beneficiary involved has been identified for inclusion in the drug management program for at-risk beneficiaries and that the prescriber and pharmacy has been selected as the beneficiary's designated prescriber and pharmacy. (E) Terminations and appeals.--The identification of an individual as an at-risk beneficiary for prescription drug abuse under this paragraph, a coverage determination made under a drug management program for at-risk beneficiaries, the selection of prescriber or pharmacy under subparagraph (D), and information to be shared under subparagraph (I), with respect to such individual, shall be subject to reconsideration and appeal under subsection (h) and if on reconsideration a PDP sponsor affirms its denial, in whole or in part, the case shall be automatically forwarded to the independent, outside entity contracted with the Secretary for review and resolution. (F) Termination of identification.-- (i) In general.--The Secretary shall develop standards for the termination of identification of an individual as an at-risk beneficiary for prescription drug abuse under this paragraph. Under such standards such identification shall terminate as of the earlier of-- (I) the date the individual demonstrates that the individual is no longer likely, in the absence of the restrictions under this paragraph, to be an at-risk beneficiary for prescription drug abuse described in subparagraph (C)(i); and (II) the end of such maximum period of identification as the Secretary may specify. (ii) Rule of construction.--Nothing in clause (i) shall be construed as preventing a plan from identifying an individual as an at-risk beneficiary for prescription drug abuse under subparagraph (C)(i) after such termination on the basis of additional information on drug use occurring after the date of notice of such termination. (G) Frequently abused drug.--For purposes of this subsection, the term ``frequently abused drug'' means a drug that is a controlled substance that the Secretary determines to be frequently abused or diverted. (H) Data disclosure.-- (i) Data on decision to impose limitation.--In the case of an at-risk beneficiary for prescription drug abuse (or an individual who is a potentially at-risk beneficiary for prescription drug abuse) whose access to coverage for frequently abused drugs under a prescription drug plan has been limited by a PDP sponsor under this paragraph, the Secretary shall establish rules and procedures to require the PDP sponsor to disclose data, including any necessary individually identifiable health information, in a form and manner specified by the Secretary, about the decision to impose such limitations and the limitations imposed by the sponsor under this part. (ii) Data to reduce fraud, abuse, and waste.--The Secretary shall establish rules and procedures to require PDP sponsors operating a drug management program for at-risk beneficiaries under this paragraph to provide the Secretary with such data as the Secretary determines appropriate for purposes of identifying patterns of prescription drug utilization for plan enrollees that are outside normal patterns and that may indicate fraudulent, medically unnecessary, or unsafe use. (I) Sharing of information for subsequent plan enrollments.--The Secretary shall establish procedures under which PDP sponsors who offer prescription drug plans shall share information with respect to individuals who are at-risk beneficiaries for prescription drug abuse (or individuals who are potentially at- risk beneficiaries for prescription drug abuse) and enrolled in a prescription drug plan and who subsequently disenroll from such plan and enroll in another prescription drug plan offered by another PDP sponsor. (J) Privacy issues.--Prior to the implementation of the rules and procedures under this paragraph, the Secretary shall clarify privacy requirements, including requirements under the regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d-2 note), related to the sharing of data under subparagraphs (H) and (I) by PDP sponsors. Such clarification shall provide that the sharing of such data shall be considered to be protected health information in accordance with the requirements of the regulations promulgated pursuant to such section 264(c). (K) Education.--The Secretary shall provide education to enrollees in prescription drug plans of PDP sponsors and providers regarding the drug management program for at-risk beneficiaries described in this paragraph, including education-- (i) provided by Medicare administrative contractors through the improper payment outreach and education program described in section 1874A(h); and (ii) through current education efforts (such as State health insurance assistance programs described in subsection (a)(1)(A) of section 119 of the Medicare Improvements for Patients and Providers Act of 2008 (42 U.S.C. 1395b-3 note)) and materials directed toward such enrollees. (L) Application under ma-pd plans.--Pursuant to section 1860D-21(c)(1), the provisions of this paragraph apply under part D to MA organizations offering MA-PD plans to MA eligible individuals in the same manner as such provisions apply under this part to a PDP sponsor offering a prescription drug plan to a part D eligible individual. (M) CMS compliance review.--The Secretary shall ensure that existing plan sponsor compliance reviews and audit processes include the drug management programs for at-risk beneficiaries under this paragraph, including appeals processes under such programs. (6) Utilization management tool to prevent drug abuse.-- (A) In general.--A tool described in this paragraph is any of the following: (i) A utilization tool designed to prevent the abuse of frequently abused drugs by individuals and to prevent the diversion of such drugs at pharmacies. (ii) Retrospective utilization review to identify-- (I) individuals that receive frequently abused drugs at a frequency or in amounts that are not clinically appropriate; and (II) providers of services or suppliers that may facilitate the abuse or diversion of frequently abused drugs by beneficiaries. (iii) Consultation with the contractor described in subparagraph (B) to verify if an individual enrolling in a prescription drug plan offered by a PDP sponsor has been previously identified by another PDP sponsor as an individual described in clause (ii)(I). (B) Reporting.--A PDP sponsor offering a prescription drug plan (and an MA organization offering an MA-PD plan) in a State shall submit to the Secretary and the Medicare drug integrity contractor with which the Secretary has entered into a contract under section 1893 with respect to such State a report, on a monthly basis, containing information on-- (i) any provider of services or supplier described in subparagraph (A)(ii)(II) that is identified by such plan sponsor (or organization) during the 30-day period before such report is submitted; and (ii) the name and prescription records of individuals described in paragraph (5)(C). (C) CMS compliance review.--The Secretary shall ensure that plan sponsor compliance reviews and program audits biennially include a certification that utilization management tools under this paragraph are in compliance with the requirements for such tools. (6) Providing prescription drug plans with parts a and b claims data to promote the appropriate use of medications and improve health outcomes.-- (A) Process.--Subject to subparagraph (B), the Secretary shall establish a process under which a PDP sponsor of a prescription drug plan may submit a request for the Secretary to provide the sponsor, on a periodic basis and in an electronic format, beginning in plan year 2020, data described in subparagraph (D) with respect to enrollees in such plan. Such data shall be provided without regard to whether such enrollees are described in clause (ii) of paragraph (2)(A). (B) Purposes.--A PDP sponsor may use the data provided to the sponsor pursuant to subparagraph (A) for any of the following purposes: (i) To optimize therapeutic outcomes through improved medication use, as such phrase is used in clause (i) of paragraph (2)(A). (ii) To improving care coordination so as to prevent adverse health outcomes, such as preventable emergency department visits and hospital readmissions. (iii) For any other purpose determined appropriate by the Secretary. (C) Limitations on data use.--A PDP sponsor shall not use data provided to the sponsor pursuant to subparagraph (A) for any of the following purposes: (i) To inform coverage determinations under this part. (ii) To conduct retroactive reviews of medically accepted indications determinations. (iii) To facilitate enrollment changes to a different prescription drug plan or an MA-PD plan offered by the same parent organization. (iv) To inform marketing of benefits. (v) For any other purpose that the Secretary determines is necessary to include in order to protect the identity of individuals entitled to, or enrolled for, benefits under this title and to protect the security of personal health information. (D) Data described.--The data described in this clause are standardized extracts (as determined by the Secretary) of claims data under parts A and B for items and services furnished under such parts for time periods specified by the Secretary. Such data shall include data as current as practicable. (d) Consumer Satisfaction Surveys.--In order to provide for comparative information under section 1860D-1(c)(3)(A)(v), the Secretary shall conduct consumer satisfaction surveys with respect to PDP sponsors and prescription drug plans in a manner similar to the manner such surveys are conducted for MA organizations and MA plans under part C. (e) Electronic Prescription Program.-- (1) Application of standards.--As of such date as the Secretary may specify, but not later than 1 year after the date of promulgation of final standards under paragraph (4)(D), prescriptions and other information described in paragraph (2)(A) for covered part D drugs prescribed for part D eligible individuals that are transmitted electronically shall be transmitted only in accordance with such standards under an electronic prescription drug program that meets the requirements of paragraph (2). (2) Program requirements.--Consistent with uniform standards established under paragraph (3)-- (A) Provision of information to prescribing health care professional and dispensing pharmacies and pharmacists.--An electronic prescription drug program shall provide for the electronic transmittal to the prescribing health care professional and to the dispensing pharmacy and pharmacist of the prescription and information on eligibility and benefits (including the drugs included in the applicable formulary, any tiered formulary structure, and any requirements for prior authorization) and of the following information with respect to the prescribing and dispensing of a covered part D drug: (i) Information on the drug being prescribed or dispensed and other drugs listed on the medication history, including information on drug-drug interactions, warnings or cautions, and, when indicated, dosage adjustments. (ii) Information on the availability of lower cost, therapeutically appropriate alternatives (if any) for the drug prescribed. (B) Application to medical history information.--Effective on and after such date as the Secretary specifies and after the establishment of appropriate standards to carry out this subparagraph, the program shall provide for the electronic transmittal in a manner similar to the manner under subparagraph (A) of information that relates to the medical history concerning the individual and related to a covered part D drug being prescribed or dispensed, upon request of the professional or pharmacist involved. (C) Limitations.--Information shall only be disclosed under subparagraph (A) or (B) if the disclosure of such information is permitted under the Federal regulations (concerning the privacy of individually identifiable health information) promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996. (D) Timing.--[To the extent] Except as provided in subparagraph (F), to the extent feasible, the information exchanged under this paragraph shall be on an interactive, real-time basis. (E) Electronic prior authorization.-- (i) In general.--Not later than January 1, 2021, the program shall provide for the secure electronic transmission of-- (I) a prior authorization request from the prescribing health care professional for coverage of a covered part D drug for a part D eligible individual enrolled in a part D plan (as defined in section 1860D-23(a)(5)) to the PDP sponsor or Medicare Advantage organization offering such plan; and (II) a response, in accordance with this subparagraph, from such PDP sponsor or Medicare Advantage organization, respectively, to such professional. (ii) Electronic transmission.-- (I) Exclusions.--For purposes of this subparagraph, a facsimile, a proprietary payer portal that does not meet standards specified by the Secretary, or an electronic form shall not be treated as an electronic transmission described in clause (i). (II) Standards.--In order to be treated, for purposes of this subparagraph, as an electronic transmission described in clause (i), such transmission shall comply with technical standards adopted by the Secretary in consultation with the National Council for Prescription Drug Programs, other standard setting organizations determined appropriate by the Secretary, and stakeholders including PDP sponsors, Medicare Advantage organizations, health care professionals, and health information technology software vendors. (III) Application.-- Notwithstanding any other provision of law, for purposes of this subparagraph, the Secretary may require the use of such standards adopted under subclause (II) in lieu of any other applicable standards for an electronic transmission described in clause (i) for a covered part D drug for a part D eligible individual. (F) Real-time benefit information.-- (i) In general.--Not later than January 1, 2021, the program shall implement real-time benefit tools that are capable of integrating with a prescribing health care professional's electronic prescribing or electronic health record system for the transmission of formulary and benefit information in real time to prescribing health care professionals. With respect to a covered part D drug, such tools shall be capable of transmitting such information specific to an individual enrolled in a prescription drug plan. Such information shall include the following: (I) A list of any clinically- appropriate alternatives to such drug included in the formulary of such plan. (II) Cost-sharing information for such drug and such alternatives, including a description of any variance in cost sharing based on the pharmacy dispensing such drug or such alternatives. (III) Information relating to whether such drug is included in the formulary of such plan and any prior authorization or other utilization management requirements applicable to such drug and such alternatives so included. (ii) Electronic transmission.--The provisions of subclauses (I) and (II) of clause (ii) of subparagraph (E) shall apply to an electronic transmission described in clause (i) in the same manner as such provisions apply with respect to an electronic transmission described in clause (i) of such subparagraph. (iii) Special rule for 2021.--The program shall be deemed to be in compliance with clause (i) for 2021 if the program complies with the provisions of section 423.160(b)(7) of title 42, Code of Federal Regulations (or a successor regulation), for such year. (3) Standards.-- (A) In general.--The Secretary shall provide consistent with this subsection for the promulgation of uniform standards relating to the requirements for electronic prescription drug programs under paragraph (2). (B) Objectives.--Such standards shall be consistent with the objectives of improving-- (i) patient safety; (ii) the quality of care provided to patients; and (iii) efficiencies, including cost savings, in the delivery of care. (C) Design criteria.--Such standards shall-- (i) be designed so that, to the extent practicable, the standards do not impose an undue administrative burden on prescribing health care professionals and dispensing pharmacies and pharmacists; (ii) be compatible with standards established under part C of title XI, standards established under subsection (b)(2)(B)(i), and with general health information technology standards; and (iii) be designed so that they permit electronic exchange of drug labeling and drug listing information maintained by the Food and Drug Administration and the National Library of Medicine. (D) Permitting use of appropriate messaging.--Such standards shall allow for the messaging of information only if it relates to the appropriate prescribing of drugs, including quality assurance measures and systems referred to in subsection (c)(1)(B). (E) Permitting patient designation of dispensing pharmacy.-- (i) In general.--Consistent with clause (ii), such standards shall permit a part D eligible individual to designate a particular pharmacy to dispense a prescribed drug. (ii) No change in benefits.--Clause (i) shall not be construed as affecting-- (I) the access required to be provided to pharmacies by a prescription drug plan; or (II) the application of any differences in benefits or payments under such a plan based on the pharmacy dispensing a covered part D drug. (4) Development, promulgation, and modification of standards.-- (A) Initial standards.--Not later than September 1, 2005, the Secretary shall develop, adopt, recognize, or modify initial uniform standards relating to the requirements for electronic prescription drug programs described in paragraph (2) taking into consideration the recommendations (if any) from the National Committee on Vital and Health Statistics (as established under section 306(k) of the Public Health Service Act (42 U.S.C. 242k(k))) under subparagraph (B). (B) Role of ncvhs.--The National Committee on Vital and Health Statistics shall develop recommendations for uniform standards relating to such requirements in consultation with the following: (i) Standard setting organizations (as defined in section 1171(8)) (ii) Practicing physicians. (iii) Hospitals. (iv) Pharmacies. (v) Practicing pharmacists. (vi) Pharmacy benefit managers. (vii) State boards of pharmacy. (viii) State boards of medicine. (ix) Experts on electronic prescribing. (x) Other appropriate Federal agencies. (C) Pilot project to test initial standards.-- (i) In general.--During the 1-year period that begins on January 1, 2006, the Secretary shall conduct a pilot project to test the initial standards developed under subparagraph (A) prior to the promulgation of the final uniform standards under subparagraph (D) in order to provide for the efficient implementation of the requirements described in paragraph (2). (ii) Exception.--Pilot testing of standards is not required under clause (i) where there already is adequate industry experience with such standards, as determined by the Secretary after consultation with effected standard setting organizations and industry users. (iii) Voluntary participation of physicians and pharmacies.--In order to conduct the pilot project under clause (i), the Secretary shall enter into agreements with physicians, physician groups, pharmacies, hospitals, PDP sponsors, MA organizations, and other appropriate entities under which health care professionals electronically transmit prescriptions to dispensing pharmacies and pharmacists in accordance with such standards. (iv) Evaluation and report.-- (I) Evaluation.--The Secretary shall conduct an evaluation of the pilot project conducted under clause (i). (II) Report to congress.--Not later than April 1, 2007, the Secretary shall submit to Congress a report on the evaluation conducted under subclause (I). (D) Final standards.--Based upon the evaluation of the pilot project under subparagraph (C)(iv)(I) and not later than April 1, 2008, the Secretary shall promulgate uniform standards relating to the requirements described in paragraph (2). (5) Relation to state laws.--The standards promulgated under this subsection shall supersede any State law or regulation that-- (A) is contrary to the standards or restricts the ability to carry out this part; and (B) pertains to the electronic transmission of medication history and of information on eligibility, benefits, and prescriptions with respect to covered part D drugs under this part. (6) Establishment of safe harbor.--The Secretary, in consultation with the Attorney General, shall promulgate regulations that provide for a safe harbor from sanctions under paragraphs (1) and (2) of section 1128B(b) and an exception to the prohibition under subsection (a)(1) of section 1877 with respect to the provision of nonmonetary remuneration (in the form of hardware, software, or information technology and training services) necessary and used solely to receive and transmit electronic prescription information in accordance with the standards promulgated under this subsection-- (A) in the case of a hospital, by the hospital to members of its medical staff; (B) in the case of a group practice (as defined in section 1877(h)(4)), by the practice to prescribing health care professionals who are members of such practice; and (C) in the case of a PDP sponsor or MA organization, by the sponsor or organization to pharmacists and pharmacies participating in the network of such sponsor or organization, and to prescribing health care professionals. (7) Requirement of e-prescribing for controlled substances.-- (A) In general.--Subject to subparagraph (B), a prescription for a covered part D drug under a prescription drug plan (or under an MA-PD plan) for a schedule II, III, IV, or V controlled substance shall be transmitted by a health care practitioner electronically in accordance with an electronic prescription drug program that meets the requirements of paragraph (2). (B) Exception for certain circumstances.--The Secretary shall, through rulemaking, specify circumstances and processes by which the Secretary may waive the requirement under subparagraph (A), with respect to a covered part D drug, including in the case of-- (i) a prescription issued when the practitioner and dispensing pharmacy are the same entity; (ii) a prescription issued that cannot be transmitted electronically under the most recently implemented version of the National Council for Prescription Drug Programs SCRIPT Standard; (iii) a prescription issued by a practitioner who received a waiver or a renewal thereof for a period of time as determined by the Secretary, not to exceed one year, from the requirement to use electronic prescribing due to demonstrated economic hardship, technological limitations that are not reasonably within the control of the practitioner, or other exceptional circumstance demonstrated by the practitioner; (iv) a prescription issued by a practitioner under circumstances in which, notwithstanding the practitioner's ability to submit a prescription electronically as required by this subsection, such practitioner reasonably determines that it would be impractical for the individual involved to obtain substances prescribed by electronic prescription in a timely manner, and such delay would adversely impact the individual's medical condition involved; (v) a prescription issued by a practitioner prescribing a drug under a research protocol; (vi) a prescription issued by a practitioner for a drug for which the Food and Drug Administration requires a prescription to contain elements that are not able to be included in electronic prescribing, such as a drug with risk evaluation and mitigation strategies that include elements to assure safe use; (vii) a prescription issued by a practitioner-- (I) for an individual who receives hospice care under this title; and (II) that is not covered under the hospice benefit under this title; and (viii) a prescription issued by a practitioner for an individual who is-- (I) a resident of a nursing facility (as defined in section 1919(a)); and (II) dually eligible for benefits under this title and title XIX. (C) Dispensing.--(i) Nothing in this paragraph shall be construed as requiring a sponsor of a prescription drug plan under this part, MA organization offering an MA-PD plan under part C, or a pharmacist to verify that a practitioner, with respect to a prescription for a covered part D drug, has a waiver (or is otherwise exempt) under subparagraph (B) from the requirement under subparagraph (A). (ii) Nothing in this paragraph shall be construed as affecting the ability of the plan to cover or the pharmacists' ability to continue to dispense covered part D drugs from otherwise valid written, oral, or fax prescriptions that are consistent with laws and regulations. (iii) Nothing in this paragraph shall be construed as affecting the ability of an individual who is being prescribed a covered part D drug to designate a particular pharmacy to dispense the covered part D drug to the extent consistent with the requirements under subsection (b)(1) and under this paragraph. (D) Enforcement.--The Secretary shall, through rulemaking, have authority to enforce and specify appropriate penalties for non- compliance with the requirement under subparagraph (A). (f) Grievance Mechanism.--Each PDP sponsor shall provide meaningful procedures for hearing and resolving grievances between the sponsor (including any entity or individual through which the sponsor provides covered benefits) and enrollees with prescription drug plans of the sponsor under this part in accordance with section 1852(f). (g) Coverage Determinations and Reconsiderations.-- (1) Application of coverage determination and reconsideration provisions.--A PDP sponsor shall meet the requirements of paragraphs (1) through (3) of section 1852(g) with respect to covered benefits under the prescription drug plan it offers under this part in the same manner as such requirements apply to an MA organization with respect to benefits it offers under an MA plan under part C. (2) Request for a determination for the treatment of tiered formulary drug.--In the case of a prescription drug plan offered by a PDP sponsor that provides for tiered cost-sharing for drugs included within a formulary and provides lower cost-sharing for preferred drugs included within the formulary, a part D eligible individual who is enrolled in the plan may request an exception to the tiered cost-sharing structure. Under such an exception, a nonpreferred drug could be covered under the terms applicable for preferred drugs if the prescribing physician determines that the preferred drug for treatment of the same condition either would not be as effective for the individual or would have adverse effects for the individual or both. A PDP sponsor shall have an exceptions process under this paragraph consistent with guidelines established by the Secretary for making a determination with respect to such a request. Denial of such an exception shall be treated as a coverage denial for purposes of applying subsection (h). (h) Appeals.-- (1) In general.--Subject to paragraph (2), a PDP sponsor shall meet the requirements of paragraphs (4) and (5) of section 1852(g) with respect to benefits (including a determination related to the application of tiered cost-sharing described in subsection (g)(2)) in a manner similar (as determined by the Secretary) to the manner such requirements apply to an MA organization with respect to benefits under the original medicare fee-for-service program option it offers under an MA plan under part C. In applying this paragraph only the part D eligible individual shall be entitled to bring such an appeal. (2) Limitation in cases on nonformulary determinations.--A part D eligible individual who is enrolled in a prescription drug plan offered by a PDP sponsor may appeal under paragraph (1) a determination not to provide for coverage of a covered part D drug that is not on the formulary under the plan only if the prescribing physician determines that all covered part D drugs on any tier of the formulary for treatment of the same condition would not be as effective for the individual as the nonformulary drug, would have adverse effects for the individual, or both. (3) Treatment of nonformulary determinations.--If a PDP sponsor determines that a plan provides coverage for a covered part D drug that is not on the formulary of the plan, the drug shall be treated as being included on the formulary for purposes of section 1860D-2(b)(4)(C)(i). (i) Privacy, Confidentiality, and Accuracy of Enrollee Records.--The provisions of section 1852(h) shall apply to a PDP sponsor and prescription drug plan in the same manner as it applies to an MA organization and an MA plan. (j) Treatment of Accreditation.--Subparagraph (A) of section 1852(e)(4) (relating to treatment of accreditation) shall apply to a PDP sponsor under this part with respect to the following requirements, in the same manner as it applies to an MA organization with respect to the requirements in subparagraph (B) (other than clause (vii) thereof) of such section: (1) Subsection (b) of this section (relating to access to covered part D drugs). (2) Subsection (c) of this section (including quality assurance and medication therapy management). (3) Subsection (i) of this section (relating to confidentiality and accuracy of enrollee records). (k) Public Disclosure of Pharmaceutical Prices for Equivalent Drugs.-- (1) In general.--A PDP sponsor offering a prescription drug plan shall provide that each pharmacy that dispenses a covered part D drug shall inform an enrollee of any differential between the price of the drug to the enrollee and the price of the lowest priced generic covered part D drug under the plan that is therapeutically equivalent and bioequivalent and available at such pharmacy. (2) Timing of notice.-- (A) In general.--Subject to subparagraph (B), the information under paragraph (1) shall be provided at the time of purchase of the drug involved, or, in the case of dispensing by mail order, at the time of delivery of such drug. (B) Waiver.--The Secretary may waive subparagraph (A) in such circumstances as the Secretary may specify. (l) Requirements with Respect to Sales and Marketing Activities.--The following provisions shall apply to a PDP sponsor (and the agents, brokers, and other third parties representing such sponsor) in the same manner as such provisions apply to a Medicare Advantage organization (and the agents, brokers, and other third parties representing such organization): (1) The prohibition under section 1851(h)(4)(C) on conducting activities described in section 1851(j)(1). (2) The requirement under section 1851(h)(4)(D) to conduct activities described in section 1851(j)(2) in accordance with the limitations established under such subsection. (3) The inclusion of the plan type in the plan name under section 1851(h)(6). (4) The requirements regarding the appointment of agents and brokers and compliance with State information requests under subparagraphs (A) and (B), respectively, of section 1851(h)(7). (m) Prohibition on Limiting Certain Information on Drug Prices.--A PDP sponsor and a Medicare Advantage organization shall ensure that each prescription drug plan or MA-PD plan offered by the sponsor or organization does not restrict a pharmacy that dispenses a prescription drug or biological from informing, nor penalize such pharmacy for informing, an enrollee in such plan of any differential between the negotiated price of, or copayment or coinsurance for, the drug or biological to the enrollee under the plan and a lower price the individual would pay for the drug or biological if the enrollee obtained the drug without using any health insurance coverage. (m) Program Integrity Transparency Measures.--For program integrity transparency measures applied with respect to prescription drug plan and MA plans, see section 1859(i). Subpart 2--Prescription Drug Plans; PDP Sponsors; Financing * * * * * * * premium and cost-sharing subsidies for low-income individuals Sec. 1860D-14. (a) Income-Related Subsidies for Individuals With Income Up to 150 Percent of Poverty Line.-- (1) Individuals with income below 135 percent of poverty line.--In the case of a subsidy eligible individual (as defined in paragraph (3)) who is determined to have income that is below 135 percent of the poverty line applicable to a family of the size involved and who meets the resources requirement described in paragraph (3)(D) or who is covered under this paragraph under paragraph (3)(B)(i), the individual is entitled under this section to the following: (A) Full premium subsidy.--An income-related premium subsidy equal to 100 percent of the amount described in subsection (b)(1), but not to exceed the premium amount specified in subsection (b)(2)(B). (B) Elimination of deductible.--A reduction in the annual deductible applicable under section 1860D-2(b)(1) to $0. (C) Continuation of coverage above the initial coverage limit.--The continuation of coverage from the initial coverage limit (under paragraph (3) of section 1860D-2(b)) for expenditures incurred through the total amount of expenditures at which benefits are available under paragraph (4) of such section, subject to the reduced cost-sharing described in subparagraph (D). (D) Reduction in cost-sharing below out-of- pocket threshold.-- (i) Institutionalized individuals.-- In the case of an individual who is a full-benefit dual eligible individual and who is an institutionalized individual or couple (as defined in section 1902(q)(1)(B)) or, effective on a date specified by the Secretary (but in no case earlier than January 1, 2012), who would be such an institutionalized individual or couple, if the full-benefit dual eligible individual were not receiving services under a home and community-based waiver authorized for a State under section 1115 or subsection (c) or (d) of section 1915 or under a State plan amendment under subsection (i) of such section or services provided through enrollment in a medicaid managed care organization with a contract under section 1903(m) or under section 1932, the elimination of any beneficiary coinsurance described in section 1860D- 2(b)(2) (for all amounts through the total amount of expenditures at which benefits are available under section 1860D-2(b)(4)). (ii) Lowest income dual eligible individuals.--In the case of an individual not described in clause (i) who is a full-benefit dual eligible individual and whose income does not exceed 100 percent of the poverty line applicable to a family of the size involved, the substitution for the beneficiary coinsurance described in section 1860D-2(b)(2) (for all amounts through the total amount of expenditures at which benefits are available under section 1860D-2(b)(4)) of a copayment amount that does not exceed $1 for a generic drug or a preferred drug that is a multiple source drug (as defined in section 1927(k)(7)(A)(i)) and $3 for any other drug, or, if less, the copayment amount applicable to an individual under clause (iii). (iii) Other individuals.--In the case of an individual not described in clause (i) or (ii), the substitution for the beneficiary coinsurance described in section 1860D-2(b)(2) (for all amounts through the total amount of expenditures at which benefits are available under section 1860D-2(b)(4)) of a copayment amount that does not exceed the copayment amount specified under section 1860D-2(b)(4)(A)(i)(I) for the drug and year involved. (E) Elimination of cost-sharing above annual out-of-pocket threshold.--The elimination of any cost-sharing imposed under section 1860D- 2(b)(4)(A). (2) Other individuals with income below 150 percent of poverty line.--In the case of a subsidy eligible individual who is not described in paragraph (1), the individual is entitled under this section to the following: (A) Sliding scale premium subsidy.--An income-related premium subsidy determined on a linear sliding scale ranging from 100 percent of the amount described in paragraph (1)(A) for individuals with incomes at or below 135 percent of such level to 0 percent of such amount for individuals with incomes at 150 percent of such level. (B) Reduction of deductible.--A reduction in the annual deductible applicable under section 1860D-2(b)(1) to $50. (C) Continuation of coverage above the initial coverage limit.--The continuation of coverage from the initial coverage limit (under paragraph (3) of section 1860D-2(b)) for expenditures incurred through the total amount of expenditures at which benefits are available under paragraph (4) of such section, subject to the reduced coinsurance described in subparagraph (D). (D) Reduction in cost-sharing below out-of- pocket threshold.--The substitution for the beneficiary coinsurance described in section 1860D-2(b)(2) (for all amounts above the deductible under subparagraph (B) through the total amount of expenditures at which benefits are available under section 1860D-2(b)(4)) of coinsurance of ``15 percent'' instead of coinsurance of ``25 percent'' in section 1860D- 2(b)(2). (E) Reduction of cost-sharing above annual out-of-pocket threshold.--Subject to subsection (c), the substitution for the cost-sharing imposed under section 1860D-2(b)(4)(A) of a copayment or coinsurance not to exceed the copayment or coinsurance amount specified under section 1860D-2(b)(4)(A)(i)(I) for the drug and year involved. (3) Determination of eligibility.-- (A) Subsidy eligible individual defined.--For purposes of this part, subject to subparagraph (F), the term ``subsidy eligible individual'' means a part D eligible individual who-- (i) is enrolled in a prescription drug plan or MA-PD plan; (ii) has income below 150 percent of the poverty line applicable to a family of the size involved; and (iii) meets the resources requirement described in subparagraph (D) or (E). (B) Determinations.-- (i) In general.--The determination of whether a part D eligible individual residing in a State is a subsidy eligible individual and whether the individual is described in paragraph (1) shall be determined under the State plan under title XIX for the State under section 1935(a) or by the Commissioner of Social Security. There are authorized to be appropriated to the Social Security Administration such sums as may be necessary for the determination of eligibility under this subparagraph. (ii) Effective period.-- Determinations under this subparagraph shall be effective beginning with the month in which the individual applies for a determination that the individual is a subsidy eligible individual and shall remain in effect for a period specified by the Secretary, but not to exceed 1 year. (iii) Redeterminations and appeals through medicaid.--Redeterminations and appeals, with respect to eligibility determinations under clause (i) made under a State plan under title XIX, shall be made in accordance with the frequency of, and manner in which, redeterminations and appeals of eligibility are made under such plan for purposes of medical assistance under such title. (iv) Redeterminations and appeals through commissioner.--With respect to eligibility determinations under clause (i) made by the Commissioner of Social Security-- (I) redeterminations shall be made at such time or times as may be provided by the Commissioner; (II) the Commissioner shall establish procedures for appeals of such determinations that are similar to the procedures described in the third sentence of section 1631(c)(1)(A); and (III) judicial review of the final decision of the Commissioner made after a hearing shall be available to the same extent, and with the same limitations, as provided in subsections (g) and (h) of section 205. (v) Treatment of medicaid beneficiaries.--Subject to subparagraph (F), the Secretary-- (I) shall provide that part D eligible individuals who are full-benefit dual eligible individuals (as defined in section 1935(c)(6)) or who are recipients of supplemental security income benefits under title XVI shall be treated as subsidy eligible individuals described in paragraph (1); and (II) may provide that part D eligible individuals not described in subclause (I) who are determined for purposes of the State plan under title XIX to be eligible for medical assistance under clause (i), (iii), or (iv) of section 1902(a)(10)(E) are treated as being determined to be subsidy eligible individuals described in paragraph (1). Insofar as the Secretary determines that the eligibility requirements under the State plan for medical assistance referred to in subclause (II) are substantially the same as the requirements for being treated as a subsidy eligible individual described in paragraph (1), the Secretary shall provide for the treatment described in such subclause. (vi) Special rule for widows and widowers.--Notwithstanding the preceding provisions of this subparagraph, in the case of an individual whose spouse dies during the effective period for a determination or redetermination that has been made under this subparagraph, such effective period shall be extended through the date that is 1 year after the date on which the determination or redetermination would (but for the application of this clause) otherwise cease to be effective. (C) Income determinations.--For purposes of applying this section-- (i) in the case of a part D eligible individual who is not treated as a subsidy eligible individual under subparagraph (B)(v), income shall be determined in the manner described in section 1905(p)(1)(B), without regard to the application of section 1902(r)(2) and except that support and maintenance furnished in kind shall not be counted as income; and (ii) the term ``poverty line'' has the meaning given such term in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section. Nothing in clause (i) shall be construed to affect the application of section 1902(r)(2) for the determination of eligibility for medical assistance under title XIX. (D) Resource standard applied to full low- income subsidy to be based on three times ssi resource standard.--The resources requirement of this subparagraph is that an individual's resources (as determined under section 1613 for purposes of the supplemental security income program subject to the life insurance policy exclusion provided under subparagraph (G)) do not exceed-- (i) for 2006 three times the maximum amount of resources that an individual may have and obtain benefits under that program; and (ii) for a subsequent year the resource limitation established under this clause for the previous year increased by the annual percentage increase in the consumer price index (all items; U.S. city average) as of September of such previous year. Any resource limitation established under clause (ii) that is not a multiple of $10 shall be rounded to the nearest multiple of $10. (E) Alternative resource standard.-- (i) In general.--The resources requirement of this subparagraph is that an individual's resources (as determined under section 1613 for purposes of the supplemental security income program subject to the life insurance policy exclusion provided under subparagraph (G)) do not exceed-- (I) for 2006, $10,000 (or $20,000 in the case of the combined value of the individual's assets or resources and the assets or resources of the individual's spouse); and (II) for a subsequent year the dollar amounts specified in this subclause (or subclause (I)) for the previous year increased by the annual percentage increase in the consumer price index (all items; U.S. city average) as of September of such previous year. Any dollar amount established under subclause (II) that is not a multiple of $10 shall be rounded to the nearest multiple of $10. (ii) Use of simplified application form and process.--The Secretary, jointly with the Commissioner of Social Security, shall-- (I) develop a model, simplified application form and process consistent with clause (iii) for the determination and verification of a part D eligible individual's assets or resources under this subparagraph; and (II) provide such form to States. (iii) Documentation and safeguards.-- Under such process-- (I) the application form shall consist of an attestation under penalty of perjury regarding the level of assets or resources (or combined assets and resources in the case of a married part D eligible individual) and valuations of general classes of assets or resources; (II) such form shall be accompanied by copies of recent statements (if any) from financial institutions in support of the application; and (III) matters attested to in the application shall be subject to appropriate methods of verification. (iv) Methodology flexibility.--The Secretary may permit a State in making eligibility determinations for premium and cost-sharing subsidies under this section to use the same asset or resource methodologies that are used with respect to eligibility for medical assistance for medicare cost-sharing described in section 1905(p) so long as the Secretary determines that the use of such methodologies will not result in any significant differences in the number of individuals determined to be subsidy eligible individuals. (F) Treatment of territorial residents.--In the case of a part D eligible individual who is not a resident of the 50 States or the District of Columbia, the individual is not eligible to be a subsidy eligible individual under this section but may be eligible for financial assistance with prescription drug expenses under section 1935(e). (G) Life insurance policy exclusion.--In determining the resources of an individual (and the eligible spouse of the individual, if any) under section 1613 for purposes of subparagraphs (D) and (E) no part of the value of any life insurance policy shall be taken into account. (4) Indexing dollar amounts.-- (A) Copayment for lowest income dual eligible individuals.--The dollar amounts applied under paragraph (1)(D)(ii)-- (i) for 2007 shall be the dollar amounts specified in such paragraph increased by the annual percentage increase in the consumer price index (all items; U.S. city average) as of September of such previous year; or (ii) for a subsequent year shall be the dollar amounts specified in this clause (or clause (i)) for the previous year increased by the annual percentage increase in the consumer price index (all items; U.S. city average) as of September of such previous year. Any amount established under clause (i) or (ii), that is based on an increase of $1 or $3, that is not a multiple of 5 cents or 10 cents, respectively, shall be rounded to the nearest multiple of 5 cents or 10 cents, respectively. (B) Reduced deductible.--The dollar amount applied under paragraph (2)(B)-- (i) for 2007 shall be the dollar amount specified in such paragraph increased by the annual percentage increase described in section 1860D- 2(b)(6) for 2007; or (ii) for a subsequent year shall be the dollar amount specified in this clause (or clause (i)) for the previous year increased by the annual percentage increase described in section 1860D- 2(b)(6) for the year involved. Any amount established under clause (i) or (ii) that is not a multiple of $1 shall be rounded to the nearest multiple of $1. (5) Waiver of de minimis premiums.--The Secretary shall, under procedures established by the Secretary, permit a prescription drug plan or an MA-PD plan to waive the monthly beneficiary premium for a subsidy eligible individual if the amount of such premium is de minimis. If such premium is waived under the plan, the Secretary shall not reassign subsidy eligible individuals enrolled in the plan to other plans based on the fact that the monthly beneficiary premium under the plan was greater than the low-income benchmark premium amount. (b) Premium Subsidy Amount.-- (1) In general.--The premium subsidy amount described in this subsection for a subsidy eligible individual residing in a PDP region and enrolled in a prescription drug plan or MA-PD plan is the low-income benchmark premium amount (as defined in paragraph (2)) for the PDP region in which the individual resides or, if greater, the amount specified in paragraph (3). (2) Low-income benchmark premium amount defined.-- (A) In general.--For purposes of this subsection, the term ``low-income benchmark premium amount'' means, with respect to a PDP region in which-- (i) all prescription drug plans are offered by the same PDP sponsor, the weighted average of the amounts described in subparagraph (B)(i) for such plans; or (ii) there are prescription drug plans offered by more than one PDP sponsor, the weighted average of amounts described in subparagraph (B) for prescription drug plans and MA-PD plans described in section 1851(a)(2)(A)(i) offered in such region. (B) Premium amounts described.--The premium amounts described in this subparagraph are, in the case of-- (i) a prescription drug plan that is a basic prescription drug plan, the monthly beneficiary premium for such plan; (ii) a prescription drug plan that provides alternative prescription drug coverage the actuarial value of which is greater than that of standard prescription drug coverage, the portion of the monthly beneficiary premium that is attributable to basic prescription drug coverage; and (iii) an MA-PD plan, the portion of the MA monthly prescription drug beneficiary premium that is attributable to basic prescription drug benefits (described in section 1852(a)(6)(B)(ii)) and determined before the application of the monthly rebate computed under section 1854(b)(1)(C)(i) for that plan and year involved and, in the case of a qualifying plan, before the application of the increase under section 1853(o) for that plan and year involved. The premium amounts described in this subparagraph do not include any amounts attributable to late enrollment penalties under section 1860D-13(b). (3) Access to 0 premium plan.--In no case shall the premium subsidy amount under this subsection for a PDP region be less than the lowest monthly beneficiary premium for a prescription drug plan that offers basic prescription drug coverage in the region. (c) Administration of Subsidy Program.-- (1) In general.--The Secretary shall provide a process whereby, in the case of a part D eligible individual who is determined to be a subsidy eligible individual and who is enrolled in a prescription drug plan or is enrolled in an MA-PD plan-- (A) the Secretary provides for a notification of the PDP sponsor or the MA organization offering the plan involved that the individual is eligible for a subsidy and the amount of the subsidy under subsection (a); (B) the sponsor or organization involved reduces the premiums or cost-sharing otherwise imposed by the amount of the applicable subsidy and submits to the Secretary information on the amount of such reduction; (C) the Secretary periodically and on a timely basis reimburses the sponsor or organization for the amount of such reductions; and (D) the Secretary ensures the confidentiality of individually identifiable information. In applying subparagraph (C), the Secretary shall compute reductions based upon imposition under subsections (a)(1)(D) and (a)(2)(E) of unreduced copayment amounts applied under such subsections. (2) Use of capitated form of payment.--The reimbursement under this section with respect to cost- sharing subsidies may be computed on a capitated basis, taking into account the actuarial value of the subsidies and with appropriate adjustments to reflect differences in the risks actually involved. (d) Facilitation of Reassignments.--Beginning not later than January 1, 2011, the Secretary shall, in the case of a subsidy eligible individual who is enrolled in one prescription drug plan and is subsequently reassigned by the Secretary to a new prescription drug plan, provide the individual, within 30 days of such reassignment, with-- (1) information on formulary differences between the individual's former plan and the plan to which the individual is reassigned with respect to the individual's drug regimens; and (2) a description of the individual's right to request a coverage determination, exception, or reconsideration under section 1860D-4(g), bring an appeal under section 1860D-4(h), or resolve a grievance under section 1860D-4(f). (e) Limited Income Newly Eligible Transition Program.-- (1) In general.--Beginning not later than January 1, 2021, the Secretary shall carry out a program to provide transitional coverage for covered part D drugs for LI NET eligible individuals in accordance with this subsection. (2) LI net eligible individual defined.--For purposes of this subsection, the term ``LI NET eligible individual'' means a part D eligible individual who-- (A) meets the requirements of clauses (ii) and (iii) of subsection (a)(3)(A); and (B) has not yet enrolled in a prescription drug plan or an MA-PD plan, or, who has so enrolled, but with respect to whom coverage under such plan has not yet taken effect. (3) Transitional coverage.--For purposes of this subsection, the term ``transitional coverage'' means with respect to an LI NET eligible individual-- (A) immediate access to covered part D drugs at the point of sale during the period that begins on the first day of the month such individual is determined to meet the requirements of clauses (ii) and (iii) of subsection (a)(3)(A) and ends on the date that coverage under a prescription drug plan or MA- PD plan takes effect with respect to such individual; and (B) in the case of an LI NET eligible individual who is a full-benefit dual eligible individual (as defined in section 1935(c)(6)) or a recipient of supplemental security income benefits under title XVI, retroactive coverage (in the form of reimbursement of the amounts that would have been paid under this part had such individual been enrolled in a prescription drug plan or MA-PD plan) of covered part D drugs purchased by such individual during the period that begins on the date that is the later of-- (i) the date that such individual was first eligible for a low-income subsidy under this part; or (ii) the date that is 36 months prior to the date such individual enrolls in a prescription drug plan or MA-PD plan, and ends on the date that coverage under such plan takes effect. (4) Program administration.-- (A) Single point of contact.--The Secretary shall, to the extent feasible, administer the program under this subsection through a contract with a single program administrator. (B) Benefit design.--The Secretary shall ensure that the transitional coverage provided to LI NET eligible individuals under this subsection-- (i) provides access to all covered part D drugs under an open formulary; (ii) permits all pharmacies determined by the Secretary to be in good standing to process claims under the program; (iii) is consistent with such requirements as the Secretary considers necessary to improve patient safety and ensure appropriate dispensing of medication; and (iv) meets such other requirements as the Secretary may establish. (5) Relationship to other provisions of this title; waiver authority.-- (A) In general.--The following provisions shall not apply with respect to the program under this subsection: (i) Paragraphs (1) and (3)(B) of section 1860D-4(a) (relating to dissemination of general information; availability of information on changes in formulary through the internet). (ii) Subparagraphs (A) and (B) of section 1860D-4(b)(3) (relating to requirements on development and application of formularies; formulary development). (iii) Paragraphs (1)(C) and (2) of section 1860D-4(c) (relating to medication therapy management program). (B) Waiver authority.--The Secretary may waive such other requirements of title XI and this title as may be necessary to carry out the purposes of the program established under this subsection. [(e)] (f) Relation to Medicaid Program.--For special provisions under the medicaid program relating to medicare prescription drug benefits, see section 1935. * * * * * * * Part E--Miscellaneous Provisions * * * * * * * payment to hospitals for inpatient hospital services Sec. 1886. (a)(1)(A)(i) The Secretary, in determining the amount of the payments that may be made under this title with respect to operating costs of inpatient hospital services (as defined in paragraph (4)) shall not recognize as reasonable (in the efficient delivery of health services) costs for the provision of such services by a hospital for a cost reporting period to the extent such costs exceed the applicable percentage (as determined under clause (ii)) of the average of such costs for all hospitals in the same grouping as such hospital for comparable time periods. (ii) For purposes of clause (i), the applicable percentage for hospital cost reporting periods beginning-- (I) on or after October 1, 1982, and before October 1, 1983, is 120 percent; (II) on or after October 1, 1983, and before October 1, 1984, is 115 percent; and (III) on or after October 1, 1984, is 110 percent. (B)(i) For purposes of subparagraph (A) the Secretary shall establish case mix indexes for all short- term hospitals, and shall set limits for each hospital based upon the general mix of types of medical cases with respect to which such hospital provides services for which payment may be made under this title. (ii) The Secretary shall set such limits for a cost reporting period of a hospital-- (I) by updating available data for a previous period to the immediate preceding cost reporting period by the estimated average rate of change of hospital costs industry-wide, and (II) by projecting for the cost reporting period by the applicable percentage increase (as defined in subsection (b)(3)(B)). (C) The limitation established under subparagraph (A) for any hospital shall in no event be lower than the allowable operating costs of inpatient hospital services (as defined in paragraph (4)) recognized under this title for such hospital for such hospital's last cost reporting period prior to the hospital's first cost reporting period for which this section is in effect. (D) Subparagraph (A) shall not apply to cost reporting periods beginning on or after October 1, 1983. (2) The Secretary shall provide for such exemptions from, and exceptions and adjustments to, the limitation established under paragraph (1)(A) as he deems appropriate, including those which he deems necessary to take into account-- (A) the special needs of sole community hospitals, of new hospitals, of risk based health maintenance organizations, and of hospitals which provide atypical services or essential community services, and to take into account extraordinary circumstances beyond the hospital's control, medical and paramedical education costs, significantly fluctuating population in the service area of the hospital, and unusual labor costs, (B) the special needs of psychiatric hospitals and of public or other hospitals that serve a significantly disproportionate number of patients who have low income or are entitled to benefits under part A of this title, and (C) a decrease in the inpatient hospital services that a hospital provides and that are customarily provided directly by similar hospitals which results in a significant distortion in the operating costs of inpatient hospital services. (3) The limitation established under paragraph (1)(A) shall not apply with respect to any hospital which-- (A) is located outside of a standard metropolitan statistical area, and (B)(i) has less than 50 beds, and (ii) was in operation and had less than 50 beds on the date of the enactment of this section. (4) For purposes of this section, the term ``operating costs of inpatient hospital services'' includes all routine operating costs, ancillary service operating costs, and special care unit operating costs with respect to inpatient hospital services as such costs are determined on an average per admission or per discharge basis (as determined by the Secretary), and includes the costs of all services for which payment may be made under this title that are provided by the hospital (or by an entity wholly owned or operated by the hospital) to the patient during the 3 days (or, in the case of a hospital that is not a subsection (d) hospital, during the 1 day) immediately preceding the date of the patient's admission if such services are diagnostic services (including clinical diagnostic laboratory tests) or are other services related to the admission (as defined by the Secretary). Such term does not include costs of approved educational activities, a return on equity capital, other capital-related costs (as defined by the Secretary for periods before October 1, 1987), or costs with respect to administering blood clotting factors to individuals with hemophilia. In applying the first sentence of this paragraph, the term ``other services related to the admission'' includes all services that are not diagnostic services (other than ambulance and maintenance renal dialysis services) for which payment may be made under this title that are provided by a hospital (or an entity wholly owned or operated by the hospital) to a patient-- (A) on the date of the patient's inpatient admission; or (B) during the 3 days (or, in the case of a hospital that is not a subsection (d) hospital, during the 1 day) immediately preceding the date of such admission unless the hospital demonstrates (in a form and manner, and at a time, specified by the Secretary) that such services are not related (as determined by the Secretary) to such admission. (b)(1) Notwithstanding section 1814(b) but subject to the provisions of section 1813, if the operating costs of inpatient hospital services (as defined in subsection (a)(4)) of a hospital (other than a subsection (d) hospital, as defined in subsection (d)(1)(B) and other than a rehabilitation facility described in subsection (j)(1)) for a cost reporting period subject to this paragraph-- (A) are less than or equal to the target amount (as defined in paragraph (3)) for that hospital for that period, the amount of the payment with respect to such operating costs payable under part A on a per discharge or per admission basis (as the case may be) shall be equal to the amount of such operating costs, plus-- (i) 15 percent of the amount by which the target amount exceeds the amount of the operating costs, or (ii) 2 percent of the target amount, whichever is less; (B) are greater than the target amount but do not exceed 110 percent of the target amount, the amount of the payment with respect to those operating costs payable under part A on a per discharge basis shall equal the target amount; or (C) are greater than 110 percent of the target amount, the amount of the payment with respect to such operating costs payable under part A on a per discharge or per admission basis (as the case may be) shall be equal to (i) the target amount, plus (ii) in the case of cost reporting periods beginning on or after October 1, 1991, an additional amount equal to 50 percent of the amount by which the operating costs exceed 110 percent of the target amount (except that such additional amount may not exceed 10 percent of the target amount) after any exceptions or adjustments are made to such target amount for the cost reporting period; plus the amount, if any, provided under paragraph (2), except that in no case may the amount payable under this title (other than on the basis of a DRG prospective payment rate determined under subsection (d)) with respect to operating costs of inpatient hospital services exceed the maximum amount payable with respect to such costs pursuant to subsection (a). (2)(A) Except as provided in subparagraph (E), in addition to the payment computed under paragraph (1), in the case of an eligible hospital (described in subparagraph (B)) for a cost reporting period beginning on or after October 1, 1997, the amount of payment on a per discharge basis under paragraph (1) shall be increased by the lesser of-- (i) 50 percent of the amount by which the operating costs are less than the expected costs (as defined in subparagraph (D)) for the period; or (ii) 1 percent of the target amount for the period. (B) For purposes of this paragraph, an ``eligible hospital'' means with respect to a cost reporting period, a hospital-- (i) that has received payments under this subsection for at least 3 full cost reporting periods before that cost reporting period, and (ii) whose operating costs for the period are less than the least of its target amount, its trended costs (as defined in subparagraph (C)), or its expected costs (as defined in subparagraph (D)) for the period. (C) For purposes of subparagraph (B)(ii), the term ``trended costs'' means for a hospital cost reporting period ending in a fiscal year-- (i) in the case of a hospital for which its cost reporting period ending in fiscal year 1996 was its third or subsequent full cost reporting period for which it receives payments under this subsection, the lesser of the operating costs or target amount for that hospital for its cost reporting period ending in fiscal year 1996, or (ii) in the case of any other hospital, the operating costs for that hospital for its third full cost reporting period for which it receives payments under this subsection, increased (in a compounded manner) for each succeeding fiscal year (through the fiscal year involved) by the market basket percentage increase for the fiscal year. (D) For purposes of this paragraph, the term ``expected costs'', with respect to the cost reporting period ending in a fiscal year, means the lesser of the operating costs of inpatient hospital services or target amount per discharge for the previous cost reporting period updated by the market basket percentage increase (as defined in paragraph (3)(B)(iii)) for the fiscal year. (E)(i) In the case of an eligible hospital that is a hospital or unit that is within a class of hospital described in clause (ii) with a 12-month cost reporting period beginning before the enactment of this subparagraph, in determining the amount of the increase under subparagraph (A), the Secretary shall substitute for the percentage of the target amount applicable under subparagraph (A)(ii)-- (I) for a cost reporting period beginning on or after October 1, 2000, and before September 30, 2001, 1.5 percent; and (II) for a cost reporting period beginning on or after October 1, 2001, and before September 30, 2002, 2 percent. (ii) For purposes of clause (i), each of the following shall be treated as a separate class of hospital: (I) Hospitals described in clause (i) of subsection (d)(1)(B) and psychiatric units described in the matter following clause (v) of such subsection. (II) Hospitals described in clause (iv) of such subsection. (3)(A) Except as provided in subparagraph (C) and succeeding subparagraphs and in paragraph (7)(A)(ii), for purposes of this subsection, the term ``target amount'' means, with respect to a hospital for a particular 12-month cost reporting period-- (i) in the case of the first such reporting period for which this subsection is in effect, the allowable operating costs of inpatient hospital services (as defined in subsection (a)(4)) recognized under this title for such hospital for the preceding 12-month cost reporting period, and (ii) in the case of a later reporting period, the target amount for the preceding 12-month cost reporting period, increased by the applicable percentage increase under subparagraph (B) for that particular cost reporting period. (B)(i) For purposes of subsection (d) and subsection (j) for discharges occurring during a fiscal year, the ``applicable percentage increase'' shall be-- (I) for fiscal year 1986, \1/2\ percent, (II) for fiscal year 1987, 1.15 percent, (III) for fiscal year 1988, 3.0 percent for hospitals located in a rural area, 1.5 percent for hospitals located in a large urban area (as defined in subsection (d)(2)(D)), and 1.0 percent for hospitals located in other urban areas, (IV) for fiscal year 1989, the market basket percentage increase minus 1.5 percentage points for hospitals located in a rural area, the market basket percentage increase minus 2.0 percentage points for hospitals located in a large urban area, and the market basket percentage increase minus 2.5 percentage points for hospitals located in other urban areas, (V) for fiscal year 1990, the market basket percentage increase plus 4.22 percentage points for hospitals located in a rural area, the market basket percentage increase plus 0.12 percentage points for hospitals located in a large urban area, and the market basket percentage increase minus 0.53 percentage points for hospitals located in other urban areas, (VI) for fiscal year 1991, the market basket percentage increase minus 2.0 percentage points for hospitals in a large urban or other urban area, and the market basket percentage increase minus 0.7 percentage point for hospitals located in a rural area, (VII) for fiscal year 1992, the market basket percentage increase minus 1.6 percentage points for hospitals in a large urban or other urban area, and the market basket percentage increase minus 0.6 percentage point for hospitals located in a rural area, (VIII) for fiscal year 1993, the market basket percentage increase minus 1.55 percentage point for hospitals in a large urban or other urban area, and the market basket percentage increase minus 0.55 for hospitals located in a rural area, (IX) for fiscal year 1994, the market basket percentage increase minus 2.5 percentage points for hospitals located in a large urban or other urban area, and the market basket percentage increase minus 1.0 percentage point for hospitals located in a rural area, (X) for fiscal year 1995, the market basket percentage increase minus 2.5 percentage points for hospitals located in a large urban or other urban area, and such percentage increase for hospitals located in a rural area as will provide for the average standardized amount determined under subsection (d)(3)(A) for hospitals located in a rural area being equal to such average standardized amount for hospitals located in an urban area (other than a large urban area), (XI) for fiscal year 1996, the market basket percentage increase minus 2.0 percentage points for hospitals in all areas, (XII) for fiscal year 1997, the market basket percentage increase minus 0.5 percentage point for hospitals in all areas, (XIII) for fiscal year 1998, 0 percent, (XIV) for fiscal year 1999, the market basket percentage increase minus 1.9 percentage points for hospitals in all areas, (XV) for fiscal year 2000, the market basket percentage increase minus 1.8 percentage points for hospitals in all areas, (XVI) for fiscal year 2001, the market basket percentage increase for hospitals in all areas, (XVII) for fiscal year 2002, the market basket percentage increase minus 0.55 percentage points for hospitals in all areas, (XVIII) for fiscal year 2003, the market basket percentage increase minus 0.55 percentage points for hospitals in all areas, (XIX) for each of fiscal years 2004 through 2006, subject to clause (vii), the market basket percentage increase for hospitals in all areas; and (XX) for each subsequent fiscal year, subject to clauses (viii), (ix), (xi), and (xii), the market basket percentage increase for hospitals in all areas. (ii) For purposes of subparagraphs (A) and (E), the ``applicable percentage increase'' for 12-month cost reporting periods beginning during-- (I) fiscal year 1986, is 0.5 percent, (II) fiscal year 1987, is 1.15 percent, (III) fiscal year 1988, is the market basket percentage increase minus 2.0 percentage points, (IV) a subsequent fiscal year ending on or before September 30, 1993, is the market basket percentage increase, (V) fiscal years 1994 through 1997, is the market basket percentage increase minus the applicable reduction (as defined in clause (v)(II)), or in the case of a hospital for a fiscal year for which the hospital's update adjustment percentage (as defined in clause (v)(I)) is at least 10 percent, the market basket percentage increase, (VI) for fiscal year 1998, is 0 percent, (VII) for fiscal years 1999 through 2002, is the applicable update factor specified under clause (vi) for the fiscal year, and (VIII) subsequent fiscal years is the market basket percentage increase. (iii) For purposes of this subparagraph, the term ``market basket percentage increase'' means, with respect to cost reporting periods and discharges occurring in a fiscal year, the percentage, estimated by the Secretary before the beginning of the period or fiscal year, by which the cost of the mix of goods and services (including personnel costs but excluding nonoperating costs) comprising routine, ancillary, and special care unit inpatient hospital services, based on an index of appropriately weighted indicators of changes in wages and prices which are representative of the mix of goods and services included in such inpatient hospital services, for the period or fiscal year will exceed the cost of such mix of goods and services for the preceding 12-month cost reporting period or fiscal year. (iv) For purposes of subparagraphs (C) and (D), the ``applicable percentage increase'' is-- (I) for 12-month cost reporting periods beginning during fiscal years 1986 through 1993, the applicable percentage increase specified in clause (ii), (II) for fiscal year 1994, the market basket percentage increase minus 2.3 percentage points (adjusted to exclude any portion of a cost reporting period beginning during fiscal year 1993 for which the applicable percentage increase is determined under subparagraph (I)), (III) for fiscal year 1995, the market basket percentage increase minus 2.2 percentage points, and (IV) for fiscal year 1996 and each subsequent fiscal year, the applicable percentage increase under clause (i). (v) For purposes of clause (ii)(V)-- (I) a hospital's ``update adjustment percentage'' for a fiscal year is the percentage by which the hospital's allowable operating costs of inpatient hospital services recognized under this title for the cost reporting period beginning in fiscal year 1990 exceeds the hospital's target amount (as determined under subparagraph (A)) for such cost reporting period, increased for each fiscal year (beginning with fiscal year 1994) by the sum of any of the hospital's applicable reductions under subclause (V) for previous fiscal years; and (II) the ``applicable reduction'' with respect to a hospital for a fiscal year is the lesser of 1 percentage point or the percentage point difference between 10 percent and the hospital's update adjustment percentage for the fiscal year. (vi) For purposes of clause (ii)(VII) for a fiscal year, if a hospital's allowable operating costs of inpatient hospital services recognized under this title for the most recent cost reporting period for which information is available-- (I) is equal to, or exceeds, 110 percent of the hospital's target amount (as determined under subparagraph (A)) for such cost reporting period, the applicable update factor specified under this clause is the market basket percentage; (II) exceeds 100 percent, but is less than 110 percent, of such target amount for the hospital, the applicable update factor specified under this clause is 0 percent or, if greater, the market basket percentage minus 0.25 percentage points for each percentage point by which such allowable operating costs (expressed as a percentage of such target amount) is less than 110 percent of such target amount; (III) is equal to, or less than 100 percent, but exceeds \2/3\ of such target amount for the hospital, the applicable update factor specified under this clause is 0 percent or, if greater, the market basket percentage minus 2.5 percentage points; or (IV) does not exceed \2/3\ of such target amount for the hospital, the applicable update factor specified under this clause is 0 percent. (vii)(I) For purposes of clause (i)(XIX) for fiscal years 2005 and 2006, in a case of a subsection (d) hospital that does not submit data to the Secretary in accordance with subclause (II) with respect to such a fiscal year, the applicable percentage increase under such clause for such fiscal year shall be reduced by 0.4 percentage points. Such reduction shall apply only with respect to the fiscal year involved, and the Secretary shall not take into account such reduction in computing the applicable percentage increase under clause (i)(XIX) for a subsequent fiscal year. (II) For fiscal years 2005 and 2006, each subsection (d) hospital shall submit to the Secretary quality data (for a set of 10 indicators established by the Secretary as of November 1, 2003) that relate to the quality of care furnished by the hospital in inpatient settings in a form and manner, and at a time, specified by the Secretary for purposes of this clause, but with respect to fiscal year 2005, the Secretary shall provide for a 30-day grace period for the submission of data by a hospital. (viii)(I) For purposes of clause (i) for fiscal year 2007 and each subsequent fiscal year, in the case of a subsection (d) hospital that does not submit, to the Secretary in accordance with this clause, data required to be submitted on measures selected under this clause with respect to such a fiscal year, the applicable percentage increase under clause (i) for such fiscal year shall be reduced by 2.0 percentage points (or, beginning with fiscal year 2015, by one-quarter of such applicable percentage increase (determined without regard to clause (ix), (xi), or (xii))). Such reduction shall apply only with respect to the fiscal year involved and the Secretary shall not take into account such reduction in computing the applicable percentage increase under clause (i) for a subsequent fiscal year, and the Secretary and the Medicare Payment Advisory Commission shall carry out the requirements under section 5001(b) of the Deficit Reduction Act of 2005. (II) Each subsection (d) hospital shall submit data on measures selected under this clause to the Secretary in a form and manner, and at a time, specified by the Secretary for purposes of this clause. The Secretary may require hospitals to submit data on measures that are not used for the determination of value-based incentive payments under subsection (o). (III) The Secretary shall expand, beyond the measures specified under clause (vii)(II) and consistent with the succeeding subclauses, the set of measures that the Secretary determines to be appropriate for the measurement of the quality of care (including medication errors) furnished by hospitals in inpatient settings. (IV) Effective for payments beginning with fiscal year 2007, in expanding the number of measures under subclause (III), the Secretary shall begin to adopt the baseline set of performance measures as set forth in the November 2005 report by the Institute of Medicine of the National Academy of Sciences under section 238(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. (V) Effective for payments for fiscal years 2008 through 2012, the Secretary shall add other measures that reflect consensus among affected parties and, to the extent feasible and practicable, shall include measures set forth by one or more national consensus building entities. (VI) For purposes of this clause and clause (vii), the Secretary may replace any measures or indicators in appropriate cases, such as where all hospitals are effectively in compliance or the measures or indicators have been subsequently shown not to represent the best clinical practice. (VII) The Secretary shall establish procedures for making information regarding measures submitted under this clause available to the public. Such procedures shall ensure that a hospital has the opportunity to review the data that are to be made public with respect to the hospital prior to such data being made public. The Secretary shall report quality measures of process, structure, outcome, patients' perspectives on care, efficiency, and costs of care that relate to services furnished in inpatient settings in hospitals on the Internet website of the Centers for Medicare & Medicaid Services. (VIII) Effective for payments beginning with fiscal year 2013, with respect to quality measures for outcomes of care, the Secretary shall provide for such risk adjustment as the Secretary determines to be appropriate to maintain incentives for hospitals to treat patients with severe illnesses or conditions. (IX)(aa) Subject to item (bb), effective for payments beginning with fiscal year 2013, each measure specified by the Secretary under this clause shall be endorsed by the entity with a contract under section 1890(a). (bb) In the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1890(a), the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary. (X) To the extent practicable, the Secretary shall, with input from consensus organizations and other stakeholders, take steps to ensure that the measures specified by the Secretary under this clause are coordinated and aligned with quality measures applicable to-- (aa) physicians under section 1848(k); and (bb) other providers of services and suppliers under this title. (XI) The Secretary shall establish a process to validate measures specified under this clause as appropriate. Such process shall include the auditing of a number of randomly selected hospitals sufficient to ensure validity of the reporting program under this clause as a whole and shall provide a hospital with an opportunity to appeal the validation of measures reported by such hospital. (XII)(aa) With respect to a Hospital Consumer Assessment of Healthcare Providers and Systems survey (or a successor survey) conducted on or after January 1, 2020, such survey may not include questions about communication by hospital staff with an individual about such individual's pain unless such questions take into account, as applicable, whether an individual experiencing pain was informed about risks associated with the use of opioids and about non-opioid alternatives for the treatment of pain. (bb) The Secretary shall not include on the Hospital Compare internet website any measures based on the questions appearing on the Hospital Consumer Assessment of Healthcare Providers and Systems survey in 2018 or 2019 about communication by hospital staff with an individual about such individual's pain. (ix)(I) For purposes of clause (i) for fiscal year 2015 and each subsequent fiscal year, in the case of an eligible hospital (as defined in subsection (n)(6)(B)) that is not a meaningful EHR user (as defined in subsection (n)(3)) for an EHR reporting period for such fiscal year, three-quarters of the applicable percentage increase otherwise applicable under clause (i) (determined without regard to clause (viii), (xi), or (xii)) for such fiscal year shall be reduced by 33\1/3\ percent for fiscal year 2015, 66\2/3\ percent for fiscal year 2016, and 100 percent for fiscal year 2017 and each subsequent fiscal year. Such reduction shall apply only with respect to the fiscal year involved and the Secretary shall not take into account such reduction in computing the applicable percentage increase under clause (i) for a subsequent fiscal year. (II) The Secretary may, on a case-by-case basis (and, with respect to the application of subclause (I) for fiscal year 2017, for categories of subsection (d) hospitals, as established by the Secretary and posted on the Internet website of the Centers for Medicare & Medicaid Services prior to December 15, 2015, an application for which must be submitted to the Secretary by not later than April 1, 2016), exempt an eligible hospital from the application of subclause (I) with respect to a fiscal year if the Secretary determines, subject to annual renewal, that requiring such hospital to be a meaningful EHR user during such fiscal year would result in a significant hardship, such as in the case of a hospital in a rural area without sufficient Internet access. The Secretary shall exempt an eligible hospital from the application of the payment adjustment under subclause (I) with respect to a fiscal year, subject to annual renewal, if the Secretary determines that compliance with the requirement for being a meaningful EHR user is not possible because the certified EHR technology used by such hospital is decertified under a program kept or recognized pursuant to section 3001(c)(5) of the Public Health Service Act. In no case may a hospital be granted an exemption under this subclause for more than 5 years. (III) For fiscal year 2015 and each subsequent fiscal year, a State in which hospitals are paid for services under section 1814(b)(3) shall adjust the payments to each subsection (d) hospital in the State that is not a meaningful EHR user (as defined in subsection (n)(3)) in a manner that is designed to result in an aggregate reduction in payments to hospitals in the State that is equivalent to the aggregate reduction that would have occurred if payments had been reduced to each subsection (d) hospital in the State in a manner comparable to the reduction under the previous provisions of this clause. The State shall report to the Secretary the methodology it will use to make the payment adjustment under the previous sentence. (IV) For purposes of this clause, the term ``EHR reporting period'' means, with respect to a fiscal year, any period (or periods) as specified by the Secretary. (x)(I) The Secretary shall develop standard Internet website reports tailored to meet the needs of various stakeholders such as hospitals, patients, researchers, and policymakers. The Secretary shall seek input from such stakeholders in determining the type of information that is useful and the formats that best facilitate the use of the information. (II) The Secretary shall modify the Hospital Compare Internet website to make the use and navigation of that website readily available to individuals accessing it. (xi)(I) For 2012 and each subsequent fiscal year, after determining the applicable percentage increase described in clause (i) and after application of clauses (viii) and (ix), such percentage increase shall be reduced by the productivity adjustment described in subclause (II). (II) The productivity adjustment described in this subclause, with respect to a percentage, factor, or update for a fiscal year, year, cost reporting period, or other annual period, is a productivity adjustment equal to the 10-year moving average of changes in annual economy-wide private nonfarm business multi- factor productivity (as projected by the Secretary for the 10- year period ending with the applicable fiscal year, year, cost reporting period, or other annual period). (III) The application of subclause (I) may result in the applicable percentage increase described in clause (i) being less than 0.0 for a fiscal year, and may result in payment rates under this section for a fiscal year being less than such payment rates for the preceding fiscal year. (xii) After determining the applicable percentage increase described in clause (i), and after application of clauses (viii), (ix), and (xi), the Secretary shall reduce such applicable percentage increase-- (I) for each of fiscal years 2010 and 2011, by 0.25 percentage point; (II) for each of fiscal years 2012 and 2013, by 0.1 percentage point; (III) for fiscal year 2014, by 0.3 percentage point; (IV) for each of fiscal years 2015 and 2016, by 0.2 percentage point; and (V) for each of fiscal years 2017, 2018, and 2019, by 0.75 percentage point. The application of this clause may result in the applicable percentage increase described in clause (i) being less than 0.0 for a fiscal year, and may result in payment rates under this section for a fiscal year being less than such payment rates for the preceding fiscal year. (C) In the case of a hospital that is a sole community hospital (as defined in subsection (d)(5)(D)(iii)), subject to subparagraphs (I) and (L), the term ``target amount'' means-- (i) with respect to the first 12-month cost reporting period in which this subparagraph is applied to the hospital-- (I) the allowable operating costs of inpatient hospital services (as defined in subsection (a)(4)) recognized under this title for the hospital for the 12-month cost reporting period (in this subparagraph referred to as the ``base cost reporting period'') preceding the first cost reporting period for which this subsection was in effect with respect to such hospital, increased (in a compounded manner) by-- (II) the applicable percentage increases applied to such hospital under this paragraph for cost reporting periods after the base cost reporting period and up to and including such first 12-month cost reporting period, (ii) with respect to a later cost reporting period beginning before fiscal year 1994, the target amount for the preceding 12-month cost reporting period, increased by the applicable percentage increase under subparagraph (B)(iv) for discharges occurring in the fiscal year in which that later cost reporting period begins, (iii) with respect to discharges occurring in fiscal year 1994, the target amount for the cost reporting period beginning in fiscal year 1993 increased by the applicable percentage increase under subparagraph (B)(iv), or (iv) with respect to discharges occurring in fiscal year 1995 and each subsequent fiscal year, the target amount for the preceding year increased by the applicable percentage increase under subparagraph (B)(iv). There shall be substituted for the base cost reporting period described in clause (i) a hospital's cost reporting period (if any) beginning during fiscal year 1987 if such substitution results in an increase in the target amount for the hospital. (D) For cost reporting periods ending on or before September 30, 1994, and for cost reporting periods occurring on or after October 1, 1997, and before October 1, 2022, in the case of a hospital that is a medicare-dependent, small rural hospital (as defined in subsection (d)(5)(G)), subject to subparagraph (K), the term ``target amount'' means-- (i) with respect to the first 12-month cost reporting period in which this subparagraph is applied to the hospital-- (I) the allowable operating costs of inpatient hospital services (as defined in subsection (a)(4)) recognized under this title for the hospital for the 12-month cost reporting period (in this subparagraph referred to as the ``base cost reporting period'') preceding the first cost reporting period for which this subsection was in effect with respect to such hospital, increased (in a compounded manner) by-- (II) the applicable percentage increases applied to such hospital under this paragraph for cost reporting periods after the base cost reporting period and up to and including such first 12-month cost reporting period, or (ii) with respect to a later cost reporting period beginning before fiscal year 1994, the target amount for the preceding 12-month cost reporting period, increased by the applicable percentage increase under subparagraph (B)(iv) for discharges occurring in the fiscal year in which that later cost reporting period begins, (iii) with respect to discharges occurring in fiscal year 1994, the target amount for the cost reporting period beginning in fiscal year 1993 increased by the applicable percentage increase under subparagraph (B)(iv), and (iv) with respect to discharges occurring during fiscal year 1998 through fiscal year 2022, the target amount for the preceding year increased by the applicable percentage increase under subparagraph (B)(iv). There shall be substituted for the base cost reporting period described in clause (i) a hospital's cost reporting period (if any) beginning during fiscal year 1987 if such substitution results in an increase in the target amount for the hospital. (E) In the case of a hospital described in clause (v) of subsection (d)(1)(B), the term ``target amount'' means-- (i) with respect to the first 12-month cost reporting period in which this subparagraph is applied to the hospital-- (I) the allowable operating costs of inpatient hospital services (as defined in subsection (a)(4)) recognized under this title for the hospital for the 12-month cost reporting period (in this subparagraph referred to as the ``base cost reporting period'') preceding the first cost reporting period for which this subsection was in effect with respect to such hospital, increased (in a compounded manner) by-- (II) the sum of the applicable percentage increases applied to such hospital under this paragraph for cost reporting periods after the base cost reporting period and up to and including such first 12-month cost reporting period, or (ii) with respect to a later cost reporting period, the target amount for the preceding 12-month cost reporting period, increased by the applicable percentage increase under subparagraph (B)(ii) for that later cost reporting period. There shall be substituted for the base cost reporting period described in clause (i) a hospital's cost reporting period (if any) beginning during fiscal year 1987 if such substitution results in an increase in the target amount for the hospital. (F)(i) In the case of a hospital (or unit described in the matter following clause (v) of subsection (d)(1)(B)) that received payment under this subsection for inpatient hospital services furnished during cost reporting periods beginning before October 1, 1990, that is within a class of hospital described in clause (iii), and that elects (in a form and manner determined by the Secretary) this subparagraph to apply to the hospital, the target amount for the hospital's 12-month cost reporting period beginning during fiscal year 1998 is equal to the average described in clause (ii). (ii) The average described in this clause for a hospital or unit shall be determined by the Secretary as follows: (I) The Secretary shall determine the allowable operating costs for inpatient hospital services for the hospital or unit for each of the 5 cost reporting periods for which the Secretary has the most recent settled cost reports as of the date of the enactment of this subparagraph. (II) The Secretary shall increase the amount determined under subclause (I) for each cost reporting period by the applicable percentage increase under subparagraph (B)(ii) for each subsequent cost reporting period up to the cost reporting period described in clause (i). (III) The Secretary shall identify among such 5 cost reporting periods the cost reporting periods for which the amount determined under subclause (II) is the highest, and the lowest. (IV) The Secretary shall compute the averages of the amounts determined under subclause (II) for the 3 cost reporting periods not identified under subclause (III). (iii) For purposes of this subparagraph, each of the following shall be treated as a separate class of hospital: (I) Hospitals described in clause (i) of subsection (d)(1)(B) and psychiatric units described in the matter following clause (v) of such subsection. (II) Hospitals described in clause (ii) of such subsection and rehabilitation units described in the matter following clause (v) of such subsection. (III) Hospitals described in clause (iii) of such subsection. (IV) Hospitals described in clause (iv) of such subsection. (V) Hospitals described in clause (v) of such subsection. (G)(i) In the case of a qualified long-term care hospital (as defined in clause (ii)) that elects (in a form and manner determined by the Secretary) this subparagraph to apply to the hospital, the target amount for the hospital's 12-month cost reporting period beginning during fiscal year 1998 is equal to the allowable operating costs of inpatient hospital services (as defined in subsection (a)(4)) recognized under this title for the hospital for the 12-month cost reporting period beginning during fiscal year 1996, increased by the applicable percentage increase for the cost reporting period beginning during fiscal year 1997. (ii) In clause (i), a ``qualified long-term care hospital'' means, with respect to a cost reporting period, a hospital described in clause (iv) of subsection (d)(1)(B) during each of the 2 cost reporting periods for which the Secretary has the most recent settled cost reports as of the date of the enactment of this subparagraph for each of which-- (I) the hospital's allowable operating costs of inpatient hospital services recognized under this title exceeded 115 percent of the hospital's target amount, and (II) the hospital would have a disproportionate patient percentage of at least 70 percent (as determined by the Secretary under subsection (d)(5)(F)(vi)) if the hospital were a subsection (d) hospital. (H)(i) In the case of a hospital or unit that is within a class of hospital described in clause (iv), for a cost reporting period beginning during fiscal years 1998 through 2002, the target amount for such a hospital or unit may not exceed the amount as updated up to or for such cost reporting period under clause (ii). (ii)(I) In the case of a hospital or unit that is within a class of hospital described in clause (iv), the Secretary shall estimate the 75th percentile of the target amounts for such hospitals within such class for cost reporting periods ending during fiscal year 1996, as adjusted under clause (iii). (II) The Secretary shall update the amount determined under subclause (I), for each cost reporting period after the cost reporting period described in such subclause and up to the first cost reporting period beginning on or after October 1, 1997, by a factor equal to the market basket percentage increase. (III) For cost reporting periods beginning during each of fiscal years 1999 through 2002, subject to subparagraph (J), the Secretary shall update such amount by a factor equal to the market basket percentage increase. (iii) In applying clause (ii)(I) in the case of a hospital or unit, the Secretary shall provide for an appropriate adjustment to the labor-related portion of the amount determined under such subparagraph to take into account differences between average wage-related costs in the area of the hospital and the national average of such costs within the same class of hospital. (iv) For purposes of this subparagraph, each of the following shall be treated as a separate class of hospital: (I) Hospitals described in clause (i) of subsection (d)(1)(B) and psychiatric units described in the matter following clause (v) of such subsection. (II) Hospitals described in clause (ii) of such subsection and rehabilitation units described in the matter following clause (v) of such subsection. (III) Hospitals described in clause (iv) of such subsection. (I)(i) Subject to subparagraph (L), for cost reporting periods beginning on or after October 1, 2000, in the case of a sole community hospital there shall be substituted for the amount otherwise determined under subsection (d)(5)(D)(i), if such substitution results in a greater amount of payment under this section for the hospital-- (I) with respect to discharges occurring in fiscal year 2001, 75 percent of the amount otherwise applicable to the hospital under subsection (d)(5)(D)(i) (referred to in this clause as the ``subsection (d)(5)(D)(i) amount'') and 25 percent of the rebased target amount (as defined in clause (ii)); (II) with respect to discharges occurring in fiscal year 2002, 50 percent of the subsection (d)(5)(D)(i) amount and 50 percent of the rebased target amount; (III) with respect to discharges occurring in fiscal year 2003, 25 percent of the subsection (d)(5)(D)(i) amount and 75 percent of the rebased target amount; and (IV) with respect to discharges occurring after fiscal year 2003, 100 percent of the rebased target amount. (ii) For purposes of this subparagraph, the ``rebased target amount'' has the meaning given the term ``target amount'' in subparagraph (C) except that-- (I) there shall be substituted for the base cost reporting period the 12-month cost reporting period beginning during fiscal year 1996; (II) any reference in subparagraph (C)(i) to the ``first cost reporting period'' described in such subparagraph is deemed a reference to the first cost reporting period beginning on or after October 1, 2000; and (III) applicable increase percentage shall only be applied under subparagraph (C)(iv) for discharges occurring in fiscal years beginning with fiscal year 2002. (iii) In no case shall a hospital be denied treatment as a sole community hospital or payment (on the basis of a target rate as such as a hospital) because data are unavailable for any cost reporting period due to changes in ownership, changes in fiscal intermediaries, or other extraordinary circumstances, so long as data for at least one applicable base cost reporting period is available. (J) For cost reporting periods beginning during fiscal year 2001, for a hospital described in subsection (d)(1)(B)(iv)-- (i) the limiting or cap amount otherwise determined under subparagraph (H) shall be increased by 2 percent; and (ii) the target amount otherwise determined under subparagraph (A) shall be increased by 25 percent (subject to the limiting or cap amount determined under subparagraph (H), as increased by clause (i)). (K)(i) With respect to discharges occurring on or after October 1, 2006, in the case of a medicare-dependent, small rural hospital, for purposes of applying subparagraph (D)-- (I) there shall be substituted for the base cost reporting period described in subparagraph (D)(i) the 12-month cost reporting period beginning during fiscal year 2002; and (II) any reference in such subparagraph to the ``first cost reporting period'' described in such subparagraph is deemed a reference to the first cost reporting period beginning on or after October 1, 2006. (ii) This subparagraph shall only apply to a hospital if the substitution described in clause (i)(I) results in an increase in the target amount under subparagraph (D) for the hospital. (L)(i) For cost reporting periods beginning on or after January 1, 2009, in the case of a sole community hospital there shall be substituted for the amount otherwise determined under subsection (d)(5)(D)(i) of this section, if such substitution results in a greater amount of payment under this section for the hospital, the subparagraph (L) rebased target amount. (ii) For purposes of this subparagraph, the term ``subparagraph (L) rebased target amount'' has the meaning given the term ``target amount'' in subparagraph (C), except that-- (I) there shall be substituted for the base cost reporting period the 12-month cost reporting period beginning during fiscal year 2006; (II) any reference in subparagraph (C)(i) to the ``first cost reporting period'' described in such subparagraph is deemed a reference to the first cost reporting period beginning on or after January 1, 2009; and (III) the applicable percentage increase shall only be applied under subparagraph (C)(iv) for discharges occurring on or after January 1, 2009. (4)(A)(i) The Secretary shall provide for an exception and adjustment to (and in the case of a hospital described in subsection (d)(1)(B)(iii), may provide an exemption from) the method under this subsection for determining the amount of payment to a hospital where events beyond the hospital's control or extraordinary circumstances, including changes in the case mix of such hospital, create a distortion in the increase in costs for a cost reporting period (including any distortion in the costs for the base period against which such increase is measured). The Secretary may provide for such other exemptions from, and exceptions and adjustments to, such method as the Secretary deems appropriate, including the assignment of a new base period which is more representative, as determined by the Secretary, of the reasonable and necessary cost of inpatient services and including those which he deems necessary to take into account a decrease in the inpatient hospital services that a hospital provides and that are customarily provided directly by similar hospitals which results in a significant distortion in the operating costs of inpatient hospital services. The Secretary shall announce a decision on any request for an exemption, exception, or adjustment under this paragraph not later than 180 days after receiving a completed application from the intermediary for such exemption, exception, or adjustment, and shall include in such decision a detailed explanation of the grounds on which such request was approved or denied. (ii) The payment reductions under paragraph (3)(B)(ii)(V) shall not be considered by the Secretary in making adjustments pursuant to clause (i). In making such reductions, the Secretary shall treat the applicable update factor described in paragraph (3)(B)(vi) for a fiscal year as being equal to the market basket percentage for that year. (B) In determining under subparagraph (A) whether to assign a new base period which is more representative of the reasonable and necessary cost to a hospital of providing inpatient services, the Secretary shall take into consideration-- (i) changes in applicable technologies and medical practices, or differences in the severity of illness among patients, that increase the hospital's costs; (ii) whether increases in wages and wage-related costs for hospitals located in the geographic area in which the hospital is located exceed the average of the increases in such costs paid by hospitals in the United States; and (iii) such other factors as the Secretary considers appropriate in determining increases in the hospital's costs of providing inpatient services. (C) Paragraph (1) shall not apply to payment of hospitals which is otherwise determined under paragraph (3) of section 1814(b). (5) In the case of any hospital having any cost reporting period of other than a 12-month period, the Secretary shall determine the 12-month period which shall be used for purposes of this section. (6) In the case of any hospital which becomes subject to the taxes under section 3111 of the Internal Revenue Code of 1954, with respect to any or all of its employees, for part or all of a cost reporting period, and was not subject to such taxes with respect to any or all of its employees for all or part of the 12-month base cost reporting period referred to in subsection (b)(3)(A)(i), the Secretary shall provide for an adjustment by increasing the base period amount described in such subsection for such hospital by an amount equal to the amount of such taxes which would have been paid or accrued by such hospital for such base period if such hospital had been subject to such taxes for all of such base period with respect to all its employees, minus the amount of any such taxes actually paid or accrued for such base period. (7)(A) Notwithstanding paragraph (1), in the case of a hospital or unit that is within a class of hospital described in subparagraph (B) which first receives payments under this section on or after October 1, 1997-- (i) for each of the first 2 cost reporting periods for which the hospital has a settled cost report, the amount of the payment with respect to operating costs described in paragraph (1) under part A on a per discharge or per admission basis (as the case may be) is equal to the lesser of-- (I) the amount of operating costs for such respective period, or (II) 110 percent of the national median (as estimated by the Secretary) of the target amount for hospitals in the same class as the hospital for cost reporting periods ending during fiscal year 1996, updated by the hospital market basket increase percentage to the fiscal year in which the hospital first received payments under this section, as adjusted under subparagraph (C); and (ii) for purposes of computing the target amount for the subsequent cost reporting period, the target amount for the preceding cost reporting period is equal to the amount determined under clause (i) for such preceding period. (B) For purposes of this paragraph, each of the following shall be treated as a separate class of hospital: (i) Hospitals described in clause (i) of subsection (d)(1)(B) and psychiatric units described in the matter following clause (v) of such subsection. (ii) Hospitals described in clause (ii) of such subsection and rehabilitation units described in the matter following clause (v) of such subsection. (iii) Hospitals described in clause (iv) of such subsection. (C) In applying subparagraph (A)(i)(II) in the case of a hospital or unit, the Secretary shall provide for an appropriate adjustment to the labor-related portion of the amount determined under such subparagraph to take into account differences between average wage-related costs in the area of the hospital and the national average of such costs within the same class of hospital. (c)(1) The Secretary may provide, in his discretion, that payment with respect to services provided by a hospital in a State may be made in accordance with a hospital reimbursement control system in a State, rather than in accordance with the other provisions of this title, if the chief executive officer of the State requests such treatment and if-- (A) the Secretary determines that the system, if approved under this subsection, will apply (i) to substantially all non- Federal acute care hospitals (as defined by the Secretary) in the State and (ii) to the review of at least 75 percent of all revenues or expenses in the State for inpatient hospital services and of revenues or expenses for inpatient hospital services provided under the State's plan approved under title XIX; (B) the Secretary has been provided satisfactory assurances as to the equitable treatment under the system of all entities (including Federal and State programs) that pay hospitals for inpatient hospital services, of hospital employees, and of hospital patients; (C) the Secretary has been provided satisfactory assurances that under the system, over 36-month periods (the first such period beginning with the first month in which this subsection applies to that system in the State), the amount of payments made under this title under such system will not exceed the amount of payments which would otherwise have been made under this title not using such system; (D) the Secretary determines that the system will not preclude an eligible organization (as defined in section 1876(b)) from negotiating directly with hospitals with respect to the organization's rate of payment for inpatient hospital services; and (E) the Secretary determines that the system requires hospitals to meet the requirement of section 1866(a)(1)(G) and the system provides for the exclusion of certain costs in accordance with section 1862(a)(14) (except for such waivers thereof as the Secretary provides by regulation). The Secretary cannot deny the application of a State under this subsection on the ground that the State's hospital reimbursement control system is based on a payment methodology other than on the basis of a diagnosis-related group or on the ground that the amount of payments made under this title under such system must be less than the amount of payments which would otherwise have been made under this title not using such system. If the Secretary determines that the conditions described in subparagraph (C) are based on maintaining payment amounts at no more than a specified percentage increase above the payment amounts in a base period, the State has the option of applying such test (for inpatient hospital services under part A) on an aggregate payment basis or on the basis of the amount of payment per inpatient discharge or admission. If the Secretary determines that the conditions described in subparagraph (C) are based on maintaining aggregate payment amounts below a national average percentage increase in total payments under part A for inpatient hospital services, the Secretary cannot deny the application of a State under this subsection on the ground that the State's rate of increase in such payments for such services must be less than such national average rate of increase. (2) In determining under paragraph (1)(C) the amount of payment which would otherwise have been made under this title for a State, the Secretary may provide for appropriate adjustment of such amount to take into account previous reductions effected in the amount of payments made under this title in the State due to the operation of the hospital reimbursement control system in the State if the system has resulted in an aggregate rate of increase in operating costs of inpatient hospital services (as defined in subsection (a)(4)) under this title for hospitals in the State which is less than the aggregate rate of increase in such costs under this title for hospitals in the United States. (3) The Secretary shall discontinue payments under a system described in paragraph (1) if the Secretary-- (A) determines that the system no longer meets the requirements of subparagraphs (A), (D), and (E) of paragraph (1) and, if applicable, the requirements of paragraph (5), or (B) has reason to believe that the assurances described in subparagraph (B) or (C) of paragraph (1) (or, if applicable, in paragraph (5)) are not being (or will not be) met. (4) The Secretary shall approve the request of a State under paragraph (1) with respect to a hospital reimbursement control system if-- (A) the requirements of subparagraphs (A), (B), (C), (D), and (E) of paragraph (1) have been met with respect to the system, and (B) with respect to that system a waiver of certain requirements of title XVIII of the Social Security Act has been approved on or before (and which is in effect as of) the date of the enactment of the Social Security Amendments of 1983, pursuant to section 402(a) of the Social Security Amendments of 1967 or section 222(a) of the Social Security Amendments of 1972. With respect to a State system described in this paragraph, the Secretary shall judge the effectiveness of such system on the basis of its rate of increase or inflation in inpatient hospital payments for individuals under this title, as compared to the national rate of increase or inflation for such payments, with the State retaining the option to have the test applied on the basis of the aggregate payments under the State system as compared to aggregate payments which would have been made under the national system since October 1, 1984, to the most recent date for which annual data are available. (5) The Secretary shall approve the request of a State under paragraph (1) with respect to a hospital reimbursement control system if-- (A) the requirements of subparagraphs (A), (B), (C), (D), and (E) of paragraph (1) have been met with respect to the system; (B) the Secretary determines that the system-- (i) is operated directly by the State or by an entity designated pursuant to State law, (ii) provides for payment of hospitals covered under the system under a methodology (which sets forth exceptions and adjustments, as well as any method for changes in the methodology) by which rates or amounts to be paid for hospital services during a specified period are established under the system prior to the defined rate period, and (iii) hospitals covered under the system will make such reports (in lieu of cost and other reports, identified by the Secretary, otherwise required under this title) as the Secretary may require in order to properly monitor assurances provided under this subsection; (C) the State has provided the Secretary with satisfactory assurances that operation of the system will not result in any change in hospital admission practices which result in-- (i) a significant reduction in the proportion of patients (receiving hospital services covered under the system) who have no third- party coverage and who are unable to pay for hospital services, (ii) a significant reduction in the proportion of individuals admitted to hospitals for inpatient hospital services for which payment is (or is likely to be) less than the anticipated charges for or costs of such services, (iii) the refusal to admit patients who would be expected to require unusually costly or prolonged treatment for reasons other than those related to the appropriateness of the care available at the hospital, or (iv) the refusal to provide emergency services to any person who is in need of emergency services if the hospital provides such services; (D) any change by the State in the system which has the effect of materially reducing payments to hospitals can only take effect upon 60 days notice to the Secretary and to the hospitals the payment to which is likely to be materially affected by the change; and (E) the State has provided the Secretary with satisfactory assurances that in the development of the system the State has consulted with local governmental officials concerning the impact of the system on public hospitals. The Secretary shall respond to requests of States under this paragraph within 60 days of the date the request is submitted to the Secretary. (6) If the Secretary determines that the assurances described in paragraph (1)(C) have not been met with respect to any 36- month period, the Secretary may reduce payments under this title to hospitals under the system in an amount equal to the amount by which the payment under this title under such system for such period exceeded the amount of payments which would otherwise have been made under this title not using such system. (7) In the case of a State which made a request under paragraph (5) before December 31, 1984, for the approval of a State hospital reimbursement control system and which request was approved-- (A) in applying paragraphs (1)(C) and (6), a reference to a ``36-month period'' is deemed a reference to a ``48-month period'', and (B) in order to allow the State the opportunity to provide the assurances described in paragraph (1)(C) for a 48-month period, the Secretary may not discontinue payments under the system, under the authority of paragraph (3)(A) because the Secretary has reason to believe that such assurances are not being (or will not be) met, before July 1, 1986. (d)(1)(A) Notwithstanding section 1814(b) but subject to the provisions of section 1813, the amount of the payment with respect to the operating costs of inpatient hospital services (as defined in subsection (a)(4)) of a subsection (d) hospital (as defined in subparagraph (B)) for inpatient hospital discharges in a cost reporting period or in a fiscal year-- (i) beginning on or after October 1, 1983, and before October 1, 1984, is equal to the sum of-- (I) the target percentage (as defined in subparagraph (C)) of the hospital's target amount for the cost reporting period (as defined in subsection (b)(3)(A), but determined without the application of subsection (a)), and (II) the DRG percentage (as defined in subparagraph (C)) of the regional adjusted DRG prospective payment rate determined under paragraph (2) for such discharges; (ii) beginning on or after October 1, 1984, and before October 1, 1987, is equal to the sum of-- (I) the target percentage (as defined in subparagraph (C)) of the hospital's target amount for the cost reporting period (as defined in subsection (b)(3)(A), but determined without the application of subsection (a)), and (II) the DRG percentage (as defined in subparagraph (C)) of the applicable combined adjusted DRG prospective payment rate determined under subparagraph (D) for such discharges; or (iii) beginning on or after April 1, 1988, is equal to (I) the national adjusted DRG prospective payment rate determined under paragraph (3) for such discharges, or (II) for discharges occurring during a fiscal year ending on or before September 30, 1996, the sum of 85 percent of the national adjusted DRG prospective payment rate determined under paragraph (3) for such discharges and 15 percent of the regional adjusted DRG prospective payment rate determined under such paragraph, but only if the average standardized amount (described in clause (i)(I) or clause (ii)(I) of paragraph (3)(D)) for hospitals within the region of, and in the same large urban or other area (or, for discharges occurring during a fiscal year ending on or before September 30, 1994, the same rural, large urban, or other urban area) as, the hospital is greater than the average standardized amount (described in the respective clause) for hospitals within the United States in that type of area for discharges occurring during such fiscal year. (B) As used in this section, the term ``subsection (d) hospital'' means a hospital located in one of the fifty States or the District of Columbia other than-- (i) a psychiatric hospital (as defined in section 1861(f)), (ii) a rehabilitation hospital (as defined by the Secretary), (iii) a hospital whose inpatients are predominantly individuals under 18 years of age, (iv) a hospital which has an average inpatient length of stay (as determined by the Secretary) of greater than 25 days, (v)(I) a hospital that the Secretary has classified, at any time on or before December 31, 1990, (or, in the case of a hospital that, as of the date of the enactment of this clause, is located in a State operating a demonstration project under section 1814(b), on or before December 31, 1991) for purposes of applying exceptions and adjustments to payment amounts under this subsection, as a hospital involved extensively in treatment for or research on cancer, (II) a hospital that was recognized as a comprehensive cancer center or clinical cancer research center by the National Cancer Institute of the National Institutes of Health as of April 20, 1983, that is located in a State which, as of December 19, 1989, was not operating a demonstration project under section 1814(b), that applied and was denied, on or before December 31, 1990, for classification as a hospital involved extensively in treatment for or research on cancer under this clause (as in effect on the day before the date of the enactment of this subclause), that as of the date of the enactment of this subclause, is licensed for less than 50 acute care beds, and that demonstrates for the 4-year period ending on December 31, 1996, that at least 50 percent of its total discharges have a principal finding of neoplastic disease, as defined in subparagraph (E), or (III) a hospital that was recognized as a clinical cancer research center by the National Cancer Institute of the National Institutes of Health as of February 18, 1998, that has never been reimbursed for inpatient hospital services pursuant to a reimbursement system under a demonstration project under section 1814(b), that is a freestanding facility organized primarily for treatment of and research on cancer and is not a unit of another hospital, that as of the date of the enactment of this subclause, is licensed for 162 acute care beds, and that demonstrates for the 4-year period ending on June 30, 1999, that at least 50 percent of its total discharges have a principal finding of neoplastic disease, as defined in subparagraph (E), or (vi) a hospital that first received payment under this subsection in 1986 which has an average inpatient length of stay (as determined by the Secretary) of greater than 20 days and that has 80 percent or more of its annual medicare inpatient discharges with a principal diagnosis that reflects a finding of neoplastic disease in the 12-month cost reporting period ending in fiscal year 1997; and, in accordance with regulations of the Secretary, does not include a psychiatric or rehabilitation unit of the hospital which is a distinct part of the hospital (as defined by the Secretary). A hospital that was classified by the Secretary on or before September 30, 1995, as a hospital described in clause (iv) (as in effect as of such date) shall continue to be so classified (or, in the case of a hospital described in clause (iv)(II), as so in effect, shall be classified under clause (vi) on and after the effective date of such clause (vi) and for cost reporting periods beginning on or after January 1, 2015, shall not be subject to subsection (m) as of the date of such classification) notwithstanding that it is located in the same building as, or on the same campus as, another hospital. (C) For purposes of this subsection, for cost reporting periods beginning-- (i) on or after October 1, 1983, and before October 1, 1984, the ``target percentage'' is 75 percent and the ``DRG percentage'' is 25 percent; (ii) on or after October 1, 1984, and before October 1, 1985, the ``target percentage'' is 50 percent and the ``DRG percentage'' is 50 percent; (iii) on or after October 1, 1985, and before October 1, 1986, the ``target percentage'' is 45 percent and the ``DRG percentage'' is 55 percent; and (iv) on or after October 1, 1986, and before October 1, 1987, the ``target percentage'' is 25 percent and the ``DRG percentage'' is 75 percent. (D) For purposes of subparagraph (A)(ii)(II), the ``applicable combined adjusted DRG prospective payment rate'' for discharges occurring-- (i) on or after October 1, 1984, and before October 1, 1986, is a combined rate consisting of 25 percent of the national adjusted DRG prospective payment rate, and 75 percent of the regional adjusted DRG prospective payment rate, determined under paragraph (3) for such discharges; and (ii) on or after October 1, 1986, and before October 1, 1987, is a combined rate consisting of 50 percent of the national adjusted DRG prospective payment rate, and 50 percent of the regional adjusted DRG prospective payment rate, determined under paragraph (3) for such discharges. (E) For purposes of subclauses (II) and (III) of subparagraph (B)(v) only, the term ``principal finding of neoplastic disease'' means the condition established after study to be chiefly responsible for occasioning the admission of a patient to a hospital, except that only discharges with ICD-9-CM principal diagnosis codes of 140 through 239, V58.0, V58.1, V66.1, V66.2, or 990 will be considered to reflect such a principal diagnosis. (2) The Secretary shall determine a national adjusted DRG prospective payment rate, for each inpatient hospital discharge in fiscal year 1984 involving inpatient hospital services of a subsection (d) hospital in the United States, and shall determine a regional adjusted DRG prospective payment rate for such discharges in each region, for which payment may be made under part A of this title. Each such rate shall be determined for hospitals located in urban or rural areas within the United States or within each such region, respectively, as follows: (A) Determining allowable individual hospital costs for base period.--The Secretary shall determine the allowable operating costs per discharge of inpatient hospital services for the hospital for the most recent cost reporting period for which data are available. (B) Updating for fiscal year 1984.--The Secretary shall update each amount determined under subparagraph (A) for fiscal year 1984 by-- (i) updating for fiscal year 1983 by the estimated average rate of change of hospital costs industry-wide between the cost reporting period used under such subparagraph and fiscal year 1983 and the most recent case-mix data available, and (ii) projecting for fiscal year 1984 by the applicable percentage increase (as defined in subsection (b)(3)(B)) for fiscal year 1984. (C) Standardizing amounts.--The Secretary shall standardize the amount updated under subparagraph (B) for each hospital by-- (i) excluding an estimate of indirect medical education costs (taking into account, for discharges occurring after September 30, 1986, the amendments made by section 9104(a) of the Medicare and Medicaid Budget Reconciliation Amendments of 1985), except that the Secretary shall not take into account any reduction in the amount of additional payments under paragraph (5)(B)(ii) resulting from the amendment made by section 4621(a)(1) of the Balanced Budget Act of 1997 or any additional payments under such paragraph resulting from the application of section 111 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, of section 302 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, or the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, (ii) adjusting for variations among hospitals by area in the average hospital wage level, (iii) adjusting for variations in case mix among hospitals, and (iv) for discharges occurring on or after October 1, 1986, excluding an estimate of the additional payments to certain hospitals to be made under paragraph (5)(F), except that the Secretary shall not exclude additional payments under such paragraph made as a result of the enactment of section 6003(c) of the Omnibus Budget Reconciliation Act of 1989, the enactment of section 4002(b) of the Omnibus Budget Reconciliation Act of 1990, the enactment of section 303 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, or the enactment of section 402(a)(1) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. (D) Computing urban and rural averages.--The Secretary shall compute an average of the standardized amounts determined under subparagraph (C) for the United States and for each region-- (i) for all subsection (d) hospitals located in an urban area within the United States or that region, respectively, and (ii) for all subsection (d) hospitals located in a rural area within the United States or that region, respectively. For purposes of this subsection, the term ``region'' means one of the nine census divisions, comprising the fifty States and the District of Columbia, established by the Bureau of the Census for statistical and reporting purposes; the term ``urban area'' means an area within a Metropolitan Statistical Area (as defined by the Office of Management and Budget) or within such similar area as the Secretary has recognized under subsection (a) by regulation; the term ``large urban area'' means, with respect to a fiscal year, such an urban area which the Secretary determines (in the publications described in subsection (e)(5) before the fiscal year) has a population of more than 1,000,000 (as determined by the Secretary based on the most recent available population data published by the Bureau of the Census); and the term ``rural area'' means any area outside such an area or similar area. A hospital located in a Metropolitan Statistical Area shall be deemed to be located in the region in which the largest number of the hospitals in the same Metropolitan Statistical Area are located, or, at the option of the Secretary, the region in which the majority of the inpatient discharges (with respect to which payments are made under this title) from hospitals in the same Metropolitan Statistical Area are made. (E) Reducing for value of outlier payments.--The Secretary shall reduce each of the average standardized amounts determined under subparagraph (D) by a proportion equal to the proportion (estimated by the Secretary) of the amount of payments under this subsection based on DRG prospective payment rates which are additional payments described in paragraph (5)(A) (relating to outlier payments). (F) Maintaining budget neutrality.--The Secretary shall adjust each of such average standardized amounts as may be required under subsection (e)(1)(B) for that fiscal year. (G) Computing drg-specific rates for urban and rural hospitals in the united states and in each region.--For each discharge classified within a diagnosis-related group, the Secretary shall establish a national DRG prospective payment rate and shall establish a regional DRG prospective payment rate for each region, each of which is equal-- (i) for hospitals located in an urban area in the United States or that region (respectively), to the product of-- (I) the average standardized amount (computed under subparagraph (D), reduced under subparagraph (E), and adjusted under subparagraph (F)) for hospitals located in an urban area in the United States or that region, and (II) the weighting factor (determined under paragraph (4)(B)) for that diagnosis-related group; and (ii) for hospitals located in a rural area in the United States or that region (respectively), to the product of-- (I) the average standardized amount (computed under subparagraph (D), reduced under subparagraph (E), and adjusted under subparagraph (F)) for hospitals located in a rural area in the United States or that region, and (II) the weighting factor (determined under paragraph (4)(B)) for that diagnosis-related group. (H) Adjusting for different area wage levels.--The Secretary shall adjust the proportion, (as estimated by the Secretary from time to time) of hospitals' costs which are attributable to wages and wage-related costs, of the national and regional DRG prospective payment rates computed under subparagraph (G) for area differences in hospital wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level. (3) The Secretary shall determine a national adjusted DRG prospective payment rate, for each inpatient hospital discharge in a fiscal year after fiscal year 1984 involving inpatient hospital services of a subsection (d) hospital in the United States, and shall determine, for fiscal years before fiscal year 1997, a regional adjusted DRG prospective payment rate for such discharges in each region for which payment may be made under part A of this title. Each such rate shall be determined for hospitals located in large urban, other urban, or rural areas within the United States and within each such region, respectively, as follows: (A) Updating previous standardized amounts.--(i) For discharges occurring in a fiscal year beginning before October 1, 1987, the Secretary shall compute an average standardized amount for hospitals located in an urban area and for hospitals located in a rural area within the United States and for hospitals located in an urban area and for hospitals located in a rural area within each region, equal to the respective average standardized amount computed for the previous fiscal year under paragraph (2)(D) or under this subparagraph, increased for the fiscal year involved by the applicable percentage increase under subsection (b)(3)(B). With respect to discharges occurring on or after October 1, 1987, the Secretary shall compute urban and rural averages on the basis of discharge weighting rather than hospital weighting, making appropriate adjustments to ensure that computation on such basis does not result in total payments under this section that are greater or less than the total payments that would have been made under this section but for this sentence, and making appropriate changes in the manner of determining the reductions under subparagraph (C)(ii). (ii) For discharges occurring in a fiscal year beginning on or after October 1, 1987, and ending on or before September 30, 1994, the Secretary shall compute an average standardized amount for hospitals located in a large urban area, for hospitals located in a rural area, and for hospitals located in other urban areas, within the United States and within each region, equal to the respective average standardized amount computed for the previous fiscal year under this subparagraph increased by the applicable percentage increase under subsection (b)(3)(B)(i) with respect to hospitals located in the respective areas for the fiscal year involved. (iii) For discharges occurring in the fiscal year beginning on October 1, 1994, the average standardized amount for hospitals located in a rural area shall be equal to the average standardized amount for hospitals located in an urban area. For discharges occurring on or after October 1, 1994, the Secretary shall adjust the ratio of the labor portion to non-labor portion of each average standardized amount to equal such ratio for the national average of all standardized amounts. (iv)(I) Subject to subclause (II), for discharges occurring in a fiscal year beginning on or after October 1, 1995, the Secretary shall compute an average standardized amount for hospitals located in a large urban area and for hospitals located in other areas within the United States and within each region equal to the respective average standardized amount computed for the previous fiscal year under this subparagraph increased by the applicable percentage increase under subsection (b)(3)(B)(i) with respect to hospitals located in the respective areas for the fiscal year involved. (II) For discharges occurring in a fiscal year (beginning with fiscal year 2004), the Secretary shall compute a standardized amount for hospitals located in any area within the United States and within each region equal to the standardized amount computed for the previous fiscal year under this subparagraph for hospitals located in a large urban area (or, beginning with fiscal year 2005, for all hospitals in the previous fiscal year) increased by the applicable percentage increase under subsection (b)(3)(B)(i) for the fiscal year involved. (v) Average standardized amounts computed under this paragraph shall be adjusted to reflect the most recent case-mix data available. (vi) Insofar as the Secretary determines that the adjustments under paragraph (4)(C)(i) for a previous fiscal year (or estimates that such adjustments for a future fiscal year) did (or are likely to) result in a change in aggregate payments under this subsection during the fiscal year that are a result of changes in the coding or classification of discharges that do not reflect real changes in case mix, the Secretary may adjust the average standardized amounts computed under this paragraph for subsequent fiscal years so as to eliminate the effect of such coding or classification changes. (B) Reducing for value of outlier payments.--The Secretary shall reduce each of the average standardized amounts determined under subparagraph (A) by a factor equal to the proportion of payments under this subsection (as estimated by the Secretary) based on DRG prospective payment amounts which are additional payments described in paragraph (5)(A) (relating to outlier payments). (C)(i) Maintaining budget neutrality for fiscal year 1985.--For discharges occurring in fiscal year 1985, the Secretary shall adjust each of such average standardized amounts as may be required under subsection (e)(1)(B) for that fiscal year. (ii) Reducing for savings from amendment to indirect teaching adjustment for discharges after September 30, 1986.--For discharges occurring after September 30, 1986, the Secretary shall further reduce each of the average standardized amounts (in a proportion which takes into account the differing effects of the standardization effected under paragraph (2)(C)(i)) so as to provide for a reduction in the total of the payments (attributable to this paragraph) made for discharges occurring on or after October 1, 1986, of an amount equal to the estimated reduction in the payment amounts under paragraph (5)(B) that would have resulted from the enactment of the amendments made by section 9104 of the Medicare and Medicaid Budget Reconciliation Amendments of 1985 and by section 4003(a)(1) of the Omnibus Budget Reconciliation Act of 1987 if the factor described in clause (ii)(II) of paragraph (5)(B) (determined without regard to amendments made by the Omnibus Budget Reconciliation Act of 1990) were applied for discharges occurring on or after such date instead of the factor described in clause (ii) of that paragraph. (D) Computing drg-specific rates for hospitals.--For each discharge classified within a diagnosis-related group, the Secretary shall establish for the fiscal year a national DRG prospective payment rate and shall establish, for fiscal years before fiscal year 1997, a regional DRG prospective payment rate for each region which is equal-- (i) for fiscal years before fiscal year 2004, for hospitals located in a large urban area in the United States or that region (respectively), to the product of-- (I) the average standardized amount (computed under subparagraph (A), reduced under subparagraph (B), and adjusted or reduced under subparagraph (C)) for the fiscal year for hospitals located in such a large urban area in the United States or that region, and (II) the weighting factor (determined under paragraph (4)(B)) for that diagnosis-related group; (ii) for fiscal years before fiscal year 2004, for hospitals located in other areas in the United States or that region (respectively), to the product of-- (I) the average standardized amount (computed under subparagraph (A), reduced under subparagraph (B), and adjusted or reduced under subparagraph (C)) for the fiscal year for hospitals located in other areas in the United States or that region, and (II) the weighting factor (determined under paragraph (4)(B)) for that diagnosis-related group; and (iii) for a fiscal year beginning after fiscal year 2003, for hospitals located in all areas, to the product of-- (I) the applicable standardized amount (computed under subparagraph (A)), reduced under subparagraph (B), and adjusted or reduced under subparagraph (C) for the fiscal year; and (II) the weighting factor (determined under paragraph (4)(B)) for that diagnosis-related group. (E) Adjusting for different area wage levels.-- (i) In general.--Except as provided in clause (ii) or (iii), the Secretary shall adjust the proportion, (as estimated by the Secretary from time to time) of hospitals' costs which are attributable to wages and wage-related costs, of the DRG prospective payment rates computed under subparagraph (D) for area differences in hospital wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level. Not later than October 1, 1990, and October 1, 1993 (and at least every 12 months thereafter), the Secretary shall update the factor under the preceding sentence on the basis of a survey conducted by the Secretary (and updated as appropriate) of the wages and wage-related costs of subsection (d) hospitals in the United States. Not less often than once every 3 years the Secretary (through such survey or otherwise) shall measure the earnings and paid hours of employment by occupational category and shall exclude data with respect to the wages and wage-related costs incurred in furnishing skilled nursing facility services. Any adjustments or updates made under this subparagraph for a fiscal year (beginning with fiscal year 1991) shall be made in a manner that assures that the aggregate payments under this subsection in the fiscal year are not greater or less than those that would have been made in the year without such adjustment. The Secretary shall apply the previous sentence for any period as if the amendments made by section 403(a)(1) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and the amendments made by section 10324(a)(1) of the Patient Protection and Affordable Care Act had not been enacted. (ii) Alternative proportion to be adjusted beginning in fiscal year 2005.--For discharges occurring on or after October 1, 2004, the Secretary shall substitute ``62 percent'' for the proportion described in the first sentence of clause (i), unless the application of this clause would result in lower payments to a hospital than would otherwise be made. (iii) Floor on area wage index for hospitals in frontier states.-- (I) In general.--Subject to subclause (IV), for discharges occurring on or after October 1, 2010, the area wage index applicable under this subparagraph to any hospital which is located in a frontier State (as defined in subclause (II)) may not be less than 1.00. (II) Frontier state defined.--In this clause, the term ``frontier State'' means a State in which at least 50 percent of the counties in the State are frontier counties. (III) Frontier county defined.--In this clause, the term ``frontier county'' means a county in which the population per square mile is less than 6. (IV) Limitation.--This clause shall not apply to any hospital located in a State that receives a non-labor related share adjustment under paragraph (5)(H). (4)(A) The Secretary shall establish a classification of inpatient hospital discharges by diagnosis-related groups and a methodology for classifying specific hospital discharges within these groups. (B) For each such diagnosis-related group the Secretary shall assign an appropriate weighting factor which reflects the relative hospital resources used with respect to discharges classified within that group compared to discharges classified within other groups. (C)(i) The Secretary shall adjust the classifications and weighting factors established under subparagraphs (A) and (B), for discharges in fiscal year 1988 and at least annually thereafter, to reflect changes in treatment patterns, technology (including a new medical service or technology under paragraph (5)(K)), and other factors which may change the relative use of hospital resources. (ii) For discharges in fiscal year 1990, the Secretary shall reduce the weighting factor for each diagnosis-related group by 1.22 percent. (iii) Any such adjustment under clause (i) for discharges in a fiscal year (beginning with fiscal year 1991) shall be made in a manner that assures that the aggregate payments under this subsection for discharges in the fiscal year are not greater or less than those that would have been made for discharges in the year without such adjustment. (D)(i) For discharges occurring on or after October 1, 2008, the diagnosis-related group to be assigned under this paragraph for a discharge described in clause (ii) shall be a diagnosis- related group that does not result in higher payment based on the presence of a secondary diagnosis code described in clause (iv). (ii) A discharge described in this clause is a discharge which meets the following requirements: (I) The discharge includes a condition identified by a diagnosis code selected under clause (iv) as a secondary diagnosis. (II) But for clause (i), the discharge would have been classified to a diagnosis-related group that results in a higher payment based on the presence of a secondary diagnosis code selected under clause (iv). (III) At the time of admission, no code selected under clause (iv) was present. (iii) As part of the information required to be reported by a hospital with respect to a discharge of an individual in order for payment to be made under this subsection, for discharges occurring on or after October 1, 2007, the information shall include the secondary diagnosis of the individual at admission. (iv) By not later than October 1, 2007, the Secretary shall select diagnosis codes associated with at least two conditions, each of which codes meets all of the following requirements (as determined by the Secretary): (I) Cases described by such code have a high cost or high volume, or both, under this title. (II) The code results in the assignment of a case to a diagnosis-related group that has a higher payment when the code is present as a secondary diagnosis. (III) The code describes such conditions that could reasonably have been prevented through the application of evidence-based guidelines. The Secretary may from time to time revise (through addition or deletion of codes) the diagnosis codes selected under this clause so long as there are diagnosis codes associated with at least two conditions selected for discharges occurring during any fiscal year. (v) In selecting and revising diagnosis codes under clause (iv), the Secretary shall consult with the Centers for Disease Control and Prevention and other appropriate entities. (vi) Any change resulting from the application of this subparagraph shall not be taken into account in adjusting the weighting factors under subparagraph (C)(i) or in applying budget neutrality under subparagraph (C)(iii). (5)(A)(i) For discharges occurring during fiscal years ending on or before September 30, 1997, the Secretary shall provide for an additional payment for a subsection (d) hospital for any discharge in a diagnosis-related group, the length of stay of which exceeds the mean length of stay for discharges within that group by a fixed number of days, or exceeds such mean length of stay by some fixed number of standard deviations, whichever is the fewer number of days. (ii) For cases which are not included in clause (i), a subsection (d) hospital may request additional payments in any case where charges, adjusted to cost, exceed a fixed multiple of the applicable DRG prospective payment rate, or exceed such other fixed dollar amount, whichever is greater, or for discharges in fiscal years beginning on or after October 1, 1994, exceed the sum of the applicable DRG prospective payment rate plus any amounts payable under subparagraphs (B) and (F) plus a fixed dollar amount determined by the Secretary. (iii) The amount of such additional payment under clauses (i) and (ii) shall be determined by the Secretary and shall (except as payments under clause (i) are required to be reduced to take into account the requirements of clause (v)) approximate the marginal cost of care beyond the cutoff point applicable under clause (i) or (ii). (iv) The total amount of the additional payments made under this subparagraph for discharges in a fiscal year may not be less than 5 percent nor more than 6 percent of the total payments projected or estimated to be made based on DRG prospective payment rates for discharges in that year. (v) The Secretary shall provide that-- (I) the day outlier percentage for fiscal year 1995 shall be 75 percent of the day outlier percentage for fiscal year 1994; (II) the day outlier percentage for fiscal year 1996 shall be 50 percent of the day outlier percentage for fiscal year 1994; and (III) the day outlier percentage for fiscal year 1997 shall be 25 percent of the day outlier percentage for fiscal year 1994. (vi) For purposes of this subparagraph the term ``day outlier percentage'' means, for a fiscal year, the percentage of the total additional payments made by the Secretary under this subparagraph for discharges in that fiscal year which are additional payments under clause (i). (B) The Secretary shall provide for an additional payment amount for subsection (d) hospitals with indirect costs of medical education, in an amount computed in the same manner as the adjustment for such costs under regulations (in effect as of January 1, 1983) under subsection (a)(2), except as follows: (i) The amount of such additional payment shall be determined by multiplying (I) the sum of the amount determined under paragraph (1)(A)(ii)(II) (or, if applicable, the amount determined under paragraph (1)(A)(iii)) and, for cases qualifying for additional payment under subparagraph (A)(i), the amount paid to the hospital under subparagraph (A), by (II) the indirect teaching adjustment factor described in clause (ii). (ii) For purposes of clause (i)(II), the indirect teaching adjustment factor is equal to c (((1+r) to the nth power) - 1), where ``r'' is the ratio of the hospital's full-time equivalent interns and residents to beds and ``n'' equals .405. Subject to clause (ix), for discharges occurring-- (I) on or after October 1, 1988, and before October 1, 1997, ``c'' is equal to 1.89; (II) during fiscal year 1998, ``c'' is equal to 1.72; (III) during fiscal year 1999, ``c'' is equal to 1.6; (IV) during fiscal year 2000, ``c'' is equal to 1.47; (V) during fiscal year 2001, ``c'' is equal to 1.54; (VI) during fiscal year 2002, ``c'' is equal to 1.6; (VII) on or after October 1, 2002, and before April 1, 2004, ``c'' is equal to 1.35; (VIII) on or after April 1, 2004, and before October 1, 2004, ``c'' is equal to 1.47; (IX) during fiscal year 2005, ``c'' is equal to 1.42; (X) during fiscal year 2006, ``c'' is equal to 1.37; (XI) during fiscal year 2007, ``c'' is equal to 1.32; and (XII) on or after October 1, 2007, ``c'' is equal to 1.35. (iii) In determining such adjustment the Secretary shall not distinguish between those interns and residents who are employees of a hospital and those interns and residents who furnish services to a hospital but are not employees of such hospital. (iv)(I) Effective for discharges occurring on or after October 1, 1997, and before July 1, 2010, all the time spent by an intern or resident in patient care activities under an approved medical residency training program at an entity in a nonhospital setting shall be counted towards the determination of full-time equivalency if the hospital incurs all, or substantially all, of the costs for the training program in that setting. (II) Effective for discharges occurring on or after July 1, 2010, all the time spent by an intern or resident in patient care activities in a nonprovider setting shall be counted towards the determination of full-time equivalency if a hospital incurs the costs of the stipends and fringe benefits of the intern or resident during the time the intern or resident spends in that setting. If more than one hospital incurs these costs, either directly or through a third party, such hospitals shall count a proportional share of the time, as determined by written agreement between the hospitals, that a resident spends training in that setting. (v) In determining the adjustment with respect to a hospital for discharges occurring on or after October 1, 1997, the total number of full-time equivalent interns and residents in the fields of allopathic and osteopathic medicine in either a hospital or nonhospital setting may not exceed the number (or, 130 percent of such number in the case of a hospital located in a rural area) of such full-time equivalent interns and residents in the hospital with respect to the hospital's most recent cost reporting period ending on or before December 31, 1996. Rules similar to the rules of subsection (h)(4)(F)(ii) shall apply for purposes of this clause. The provisions of subsections (h)(4)(H)(vi), (h)(7), and (h)(8) shall apply with respect to the first sentence of this clause in the same manner as they apply with respect to subsection (h)(4)(F)(i). (vi) For purposes of clause (ii)-- (I) ``r'' may not exceed the ratio of the number of interns and residents, subject to the limit under clause (v), with respect to the hospital for its most recent cost reporting period to the hospital's available beds (as defined by the Secretary) during that cost reporting period, and (II) for the hospital's cost reporting periods beginning on or after October 1, 1997, subject to the limits described in clauses (iv) and (v), the total number of full-time equivalent residents for payment purposes shall equal the average of the actual full-time equivalent resident count for the cost reporting period and the preceding two cost reporting periods. In the case of the first cost reporting period beginning on or after October 1, 1997, subclause (II) shall be applied by using the average for such period and the preceding cost reporting period. (vii) If any cost reporting period beginning on or after October 1, 1997, is not equal to twelve months, the Secretary shall make appropriate modifications to ensure that the average full-time equivalent residency count pursuant to subclause (II) of clause (vi) is based on the equivalent of full twelve-month cost reporting periods. (viii) Rules similar to the rules of [subsection (h)(4)(H)] paragraphs (2)(F)(iv) and (4)(H) of subsection (h) shall apply for purposes of clauses (v) and (vi). (ix) For discharges occurring on or after July 1, 2005, insofar as an additional payment amount under this subparagraph is attributable to resident positions redistributed to a hospital under subsection (h)(7)(B), in computing the indirect teaching adjustment factor under clause (ii) the adjustment shall be computed in a manner as if ``c'' were equal to 0.66 with respect to such resident positions. (x) For discharges occurring on or after July 1, 2011, insofar as an additional payment amount under this subparagraph is attributable to resident positions distributed to a hospital under subsection (h)(8)(B), the indirect teaching adjustment factor shall be computed in the same manner as provided under clause (ii) with respect to such resident positions. (x)(I) The provisions of subparagraph (K) of subsection (h)(4) shall apply under this subparagraph in the same manner as they apply under such subsection. (II) In determining the hospital's number of full-time equivalent residents for purposes of this subparagraph, all the time spent by an intern or resident in an approved medical residency training program in non-patient care activities, such as didactic conferences and seminars, as such time and activities are defined by the Secretary, that occurs in the hospital shall be counted toward the determination of full-time equivalency if the hospital-- (aa) is recognized as a subsection (d) hospital; (bb) is recognized as a subsection (d) Puerto Rico hospital; (cc) is reimbursed under a reimbursement system authorized under section 1814(b)(3); or (dd) is a provider-based hospital outpatient department. (III) In determining the hospital's number of full-time equivalent residents for purposes of this subparagraph, all the time spent by an intern or resident in an approved medical residency training program in research activities that are not associated with the treatment or diagnosis of a particular patient, as such time and activities are defined by the Secretary, shall not be counted toward the determination of full-time equivalency. (C)(i) The Secretary shall provide for such exceptions and adjustments to the payment amounts established under this subsection (other than under paragraph (9)) as the Secretary deems appropriate to take into account the special needs of regional and national referral centers (including those hospitals of 275 or more beds located in rural areas). A hospital which is classified as a rural hospital may appeal to the Secretary to be classified as a rural referral center under this clause on the basis of criteria (established by the Secretary) which shall allow the hospital to demonstrate that it should be so reclassified by reason of certain of its operating characteristics being similar to those of a typical urban hospital located in the same census region and which shall not require a rural osteopathic hospital to have more than 3,000 discharges in a year in order to be classified as a rural referral center. Such characteristics may include wages, scope of services, service area, and the mix of medical specialties. The Secretary shall publish the criteria not later than August 17, 1984, for implementation by October 1, 1984. An appeal allowed under this clause must be submitted to the Secretary (in such form and manner as the Secretary may prescribe) during the quarter before the first quarter of the hospital's cost reporting period (or, in the case of a cost reporting period beginning during October 1984, during the first quarter of that period), and the Secretary must make a final determination with respect to such appeal within 60 days after the date the appeal was submitted. Any payment adjustments necessitated by a reclassification based upon the appeal shall be effective at the beginning of such cost reporting period. (ii) The Secretary shall provide, under clause (i), for the classification of a rural hospital as a regional referral center if the hospital has a case mix index equal to or greater than the median case mix index for hospitals (other than hospitals with approved teaching programs) located in an urban area in the same region (as defined in paragraph (2)(D)), has at least 5,000 discharges a year or, if less, the median number of discharges in urban hospitals in the region in which the hospital is located (or, in the case of a rural osteopathic hospital, meets the criterion established by the Secretary under clause (i) with respect to the annual number of discharges for such hospitals), and meets any other criteria established by the Secretary under clause (i). (D)(i) For any cost reporting period beginning on or after April 1, 1990, with respect to a subsection (d) hospital which is a sole community hospital, payment under paragraph (1)(A) shall be-- (I) an amount based on 100 percent of the hospital's target amount for the cost reporting period, as defined in subsection (b)(3)(C), or (II) the amount determined under paragraph (1)(A)(iii), whichever results in greater payment to the hospital. (ii) In the case of a sole community hospital that experiences, in a cost reporting period compared to the previous cost reporting period, a decrease of more than 5 percent in its total number of inpatient cases due to circumstances beyond its control, the Secretary shall provide for such adjustment to the payment amounts under this subsection (other than under paragraph (9)) as may be necessary to fully compensate the hospital for the fixed costs it incurs in the period in providing inpatient hospital services, including the reasonable cost of maintaining necessary core staff and services. (iii) For purposes of this title, the term ``sole community hospital'' means any hospital-- (I) that the Secretary determines is located more than 35 road miles from another hospital, (II) that, by reason of factors such as the time required for an individual to travel to the nearest alternative source of appropriate inpatient care (in accordance with standards promulgated by the Secretary), location, weather conditions, travel conditions, or absence of other like hospitals (as determined by the Secretary), is the sole source of inpatient hospital services reasonably available to individuals in a geographic area who are entitled to benefits under part A, or (III) that is located in a rural area and designated by the Secretary as an essential access community hospital under section 1820(i)(1) as in effect on September 30, 1997. (iv) The Secretary shall promulgate a standard for determining whether a hospital meets the criteria for classification as a sole community hospital under clause (iii)(II) because of the time required for an individual to travel to the nearest alternative source of appropriate inpatient care. (v) If the Secretary determines that, in the case of a hospital located in a rural area and designated by the Secretary as an essential access community hospital under section 1820(i)(1) as in effect on September 30, 1997, the hospital has incurred increases in reasonable costs during a cost reporting period as a result of becoming a member of a rural health network (as defined in section 1820(d)) in the State in which it is located, and in incurring such increases, the hospital will increase its costs for subsequent cost reporting periods, the Secretary shall increase the hospital's target amount under subsection (b)(3)(C) to account for such incurred increases. (E)(i) The Secretary shall estimate the amount of reimbursement made for services described in section 1862(a)(14) with respect to which payment was made under part B in the base reporting periods referred to in paragraph (2)(A) and with respect to which payment is no longer being made. (ii) The Secretary shall provide for an adjustment to the payment for subsection (d) hospitals in each fiscal year so as appropriately to reflect the net amount described in clause (i). (F)(i) Subject to subsection (r), for discharges occurring on or after May 1, 1986, the Secretary shall provide, in accordance with this subparagraph, for an additional payment amount for each subsection (d) hospital which-- (I) serves a significantly disproportionate number of low-income patients (as defined in clause (v)), or (II) is located in an urban area, has 100 or more beds, and can demonstrate that its net inpatient care revenues (excluding any of such revenues attributable to this title or State plans approved under title XIX), during the cost reporting period in which the discharges occur, for indigent care from State and local government sources exceed 30 percent of its total of such net inpatient care revenues during the period. (ii) Subject to clause (ix), the amount of such payment for each discharge shall be determined by multiplying (I) the sum of the amount determined under paragraph (1)(A)(ii)(II) (or, if applicable, the amount determined under paragraph (1)(A)(iii)) and, for cases qualifying for additional payment under subparagraph (A)(i), the amount paid to the hospital under subparagraph (A) for that discharge, by (II) the disproportionate share adjustment percentage established under clause (iii) or (iv) for the cost reporting period in which the discharge occurs. (iii) The disproportionate share adjustment percentage for a cost reporting period for a hospital described in clause (i)(II) is equal to 35 percent. (iv) The disproportionate share adjustment percentage for a cost reporting period for a hospital that is not described in clause (i)(II) and that-- (I) is located in an urban area and has 100 or more beds or is described in the second sentence of clause (v), is equal to the percent determined in accordance with the applicable formula described in clause (vii); (II) is located in an urban area and has less than 100 beds, is equal to 5 percent or, subject to clause (xiv) and for discharges occurring on or after April 1, 2001, is equal to the percent determined in accordance with clause (xiii); (III) is located in a rural area and is not described in subclause (IV) or (V) or in the second sentence of clause (v), is equal to 4 percent or, subject to clause (xiv) and for discharges occurring on or after April 1, 2001, is equal to the percent determined in accordance with clause (xii); (IV) is located in a rural area, is classified as a rural referral center under subparagraph (C), and is classified as a sole community hospital under subparagraph (D), is equal to 10 percent or, if greater, the percent determined in accordance with the applicable formula described in clause (viii) or, subject to clause (xiv) and for discharges occurring on or after April 1, 2001, the greater of the percentages determined under clause (x) or (xi); (V) is located in a rural area, is classified as a rural referral center under subparagraph (C), and is not classified as a sole community hospital under subparagraph (D), is equal to the percent determined in accordance with the applicable formula described in clause (viii) or, subject to clause (xiv) and for discharges occurring on or after April 1, 2001, is equal to the percent determined in accordance with clause (xi); or (VI) is located in a rural area, is classified as a sole community hospital under subparagraph (D), and is not classified as a rural referral center under subparagraph (C), is 10 percent or, subject to clause (xiv) and for discharges occurring on or after April 1, 2001, is equal to the percent determined in accordance with clause (x). (v) In this subparagraph, a hospital ``serves a significantly disproportionate number of low income patients'' for a cost reporting period if the hospital has a disproportionate patient percentage (as defined in clause (vi)) for that period which equals, or exceeds-- (I) 15 percent, if the hospital is located in an urban area and has 100 or more beds, (II) 30 percent (or 15 percent, for discharges occurring on or after April 1, 2001), if the hospital is located in a rural area and has more than 100 beds, or is located in a rural area and is classified as a sole community hospital under subparagraph (D), (III) 40 percent (or 15 percent, for discharges occurring on or after April 1, 2001), if the hospital is located in an urban area and has less than 100 beds, or (IV) 45 percent (or 15 percent, for discharges occurring on or after April 1, 2001), if the hospital is located in a rural area and is not described in subclause (II). A hospital located in a rural area and with 500 or more beds also ``serves a significantly disproportionate number of low income patients'' for a cost reporting period if the hospital has a disproportionate patient percentage (as defined in clause (vi)) for that period which equals or exceeds a percentage specified by the Secretary. (vi) In this subparagraph, the term ``disproportionate patient percentage'' means, with respect to a cost reporting period of a hospital, the sum of-- (I) the fraction (expressed as a percentage), the numerator of which is the number of such hospital's patient days for such period which were made up of patients who (for such days) were entitled to benefits under part A of this title and were entitled to supplementary security income benefits (excluding any State supplementation) under title XVI of this Act, and the denominator of which is the number of such hospital's patient days for such fiscal year which were made up of patients who (for such days) were entitled to benefits under part A of this title, and (II) the fraction (expressed as a percentage), the numerator of which is the number of the hospital's patient days for such period which consist of patients who (for such days) were eligible for medical assistance under a State plan approved under title XIX, but who were not entitled to benefits under part A of this title, and the denominator of which is the total number of the hospital's patient days for such period. In determining under subclause (II) the number of the hospital's patient days for such period which consist of patients who (for such days) were eligible for medical assistance under a State plan approved under title XIX, the Secretary may, to the extent and for the period the Secretary determines appropriate, include patient days of patients not so eligible but who are regarded as such because they receive benefits under a demonstration project approved under title XI. (vii) The formula used to determine the disproportionate share adjustment percentage for a cost reporting period for a hospital described in clause (iv)(I) is-- (I) in the case of such a hospital with a disproportionate patient percentage (as defined in clause (vi)) greater than 20.2-- (a) for discharges occurring on or after April 1, 1990, and on or before December 31, 1990, (P-20.2)(.65) + 5.62, (b) for discharges occurring on or after January 1, 1991, and on or before September 30, 1993, (P-20.2)(.7) + 5.62, (c) for discharges occurring on or after October 1, 1993, and on or before September 30, 1994, (P-20.2)(.8) + 5.88, and (d) for discharges occurring on or after October 1, 1994, (P-20.2)(.825) + 5.88; or (II) in the case of any other such hospital-- (a) for discharges occurring on or after April 1, 1990, and on or before December 31, 1990, (P-15)(.6) + 2.5, (b) for discharges occurring on or after January 1, 1991, and on or before September 30, 1993, (P-15)(.6) + 2.5, (c) for discharges occurring on or after October 1, 1993, (P-15)(.65) + 2.5, where ``P'' is the hospital's disproportionate patient percentage (as defined in clause (vi)). (viii) Subject to clause (xiv), the formula used to determine the disproportionate share adjustment percentage for a cost reporting period for a hospital described in clause (iv)(IV) or (iv)(V) is the percentage determined in accordance with the following formula:(P-30)(.6) + 4.0, where ``P'' is the hospital's disproportionate patient percentage (as defined in clause (vi)). (ix) In the case of discharges occurring-- (I) during fiscal year 1998, the additional payment amount otherwise determined under clause (ii) shall be reduced by 1 percent; (II) during fiscal year 1999, such additional payment amount shall be reduced by 2 percent; (III) during fiscal years 2000 and 2001, such additional payment amount shall be reduced by 3 percent and 2 percent, respectively; (IV) during fiscal year 2002, such additional payment amount shall be reduced by 3 percent; and (V) during fiscal year 2003 and each subsequent fiscal year, such additional payment amount shall be reduced by 0 percent. (x) Subject to clause (xiv), for purposes of clause (iv)(VI) (relating to sole community hospitals), in the case of a hospital for a cost reporting period with a disproportionate patient percentage (as defined in clause (vi)) that-- (I) is less than 19.3, the disproportionate share adjustment percentage is determined in accordance with the following formula: (P-15)(.65) + 2.5; (II) is equal to or exceeds 19.3, but is less than 30.0, such adjustment percentage is equal to 5.25 percent; or (III) is equal to or exceeds 30, such adjustment percentage is equal to 10 percent, where ``P'' is the hospital's disproportionate patient percentage (as defined in clause (vi)). (xi) Subject to clause (xiv), for purposes of clause (iv)(V) (relating to rural referral centers), in the case of a hospital for a cost reporting period with a disproportionate patient percentage (as defined in clause (vi)) that-- (I) is less than 19.3, the disproportionate share adjustment percentage is determined in accordance with the following formula: (P-15)(.65) + 2.5; (II) is equal to or exceeds 19.3, but is less than 30.0, such adjustment percentage is equal to 5.25 percent; or (III) is equal to or exceeds 30, such adjustment percentage is determined in accordance with the following formula: (P-30)(.6) + 5.25, where ``P'' is the hospital's disproportionate patient percentage (as defined in clause (vi)). (xii) Subject to clause (xiv), for purposes of clause (iv)(III) (relating to small rural hospitals generally), in the case of a hospital for a cost reporting period with a disproportionate patient percentage (as defined in clause (vi)) that-- (I) is less than 19.3, the disproportionate share adjustment percentage is determined in accordance with the following formula: (P-15)(.65) + 2.5; or (II) is equal to or exceeds 19.3, such adjustment percentage is equal to 5.25 percent, where ``P'' is the hospital's disproportionate patient percentage (as defined in clause (vi)). (xiii) Subject to clause (xiv), for purposes of clause (iv)(II) (relating to urban hospitals with less than 100 beds), in the case of a hospital for a cost reporting period with a disproportionate patient percentage (as defined in clause (vi)) that-- (I) is less than 19.3, the disproportionate share adjustment percentage is determined in accordance with the following formula: (P-15)(.65) + 2.5; or (II) is equal to or exceeds 19.3, such adjustment percentage is equal to 5.25 percent, where ``P'' is the hospital's disproportionate patient percentage (as defined in clause (vi)). (xiv)(I) In the case of discharges occurring on or after April 1, 2004, subject to subclause (II), there shall be substituted for the disproportionate share adjustment percentage otherwise determined under clause (iv) (other than subclause (I)) or under clause (viii), (x), (xi), (xii), or (xiii), the disproportionate share adjustment percentage determined under clause (vii) (relating to large, urban hospitals). (II) Under subclause (I), the disproportionate share adjustment percentage shall not exceed 12 percent for a hospital that is not classified as a rural referral center under subparagraph (C) or, in the case of discharges occurring on or after October 1, 2006, as a medicare-dependent, small rural hospital under subparagraph (G)(iv). (G)(i) For any cost reporting period beginning on or after April 1, 1990, and before October 1, 1994, or discharges occurring on or after October 1, 1997, and before October 1, 2022, in the case of a subsection (d) hospital which is a medicare-dependent, small rural hospital, payment under paragraph (1)(A) shall be equal to the sum of the amount determined under clause (ii) and the amount determined under paragraph (1)(A)(iii). (ii) The amount determined under this clause is-- (I) for discharges occurring during the 36-month period beginning with the first day of the cost reporting period that begins on or after April 1, 1990, the amount by which the hospital's target amount for the cost reporting period (as defined in subsection (b)(3)(D)) exceeds the amount determined under paragraph (1)(A)(iii); and (II) for discharges occurring during any subsequent cost reporting period (or portion thereof) and before October 1, 1994, or discharges occurring on or after October 1, 1997, and before October 1, 2022, 50 percent (or 75 percent in the case of discharges occurring on or after October 1, 2006) of the amount by which the hospital's target amount for the cost reporting period or for discharges in the fiscal year (as defined in subsection (b)(3)(D)) exceeds the amount determined under paragraph (1)(A)(iii). (iii) In the case of a medicare dependent, small rural hospital that experiences, in a cost reporting period compared to the previous cost reporting period, a decrease of more than 5 percent in its total number of inpatient cases due to circumstances beyond its control, the Secretary shall provide for such adjustment to the payment amounts under this subsection (other than under paragraph (9)) as may be necessary to fully compensate the hospital for the fixed costs it incurs in the period in providing inpatient hospital services, including the reasonable cost of maintaining necessary core staff and services. (iv) The term ``medicare-dependent, small rural hospital'' means, with respect to any cost reporting period to which clause (i) applies, any hospital-- (I) that is located in-- (aa) a rural area; or (bb) a State with no rural area (as defined in paragraph (2)(D)) and satisfies any of the criteria in subclause (I), (II), or (III) of paragraph (8)(E)(ii), (II) that has not more than 100 beds, (III) that is not classified as a sole community hospital under subparagraph (D), and (IV) for which not less than 60 percent of its inpatient days or discharges during the cost reporting period beginning in fiscal year 1987, or two of the three most recently audited cost reporting periods for which the Secretary has a settled cost report, were attributable to inpatients entitled to benefits under part A. Subclause (I)(bb) shall apply for purposes of payment under clause (ii) only for discharges of a hospital occurring on or after the effective date of a determination of medicare- dependent small rural hospital status made by the Secretary with respect to the hospital after the date of the enactment of this sentence. For purposes of applying subclause (II) of paragraph (8)(E)(ii) under subclause (I)(bb), such subclause (II) shall be applied by inserting ``as of January 1, 2018,'' after ``such State'' each place it appears. (H) The Secretary may provide for such adjustments to the payment amounts under this subsection as the Secretary deems appropriate to take into account the unique circumstances of hospitals located in Alaska and Hawaii. (I)(i) The Secretary shall provide by regulation for such other exceptions and adjustments to such payment amounts under this subsection as the Secretary deems appropriate. (ii) In making adjustments under clause (i) for transfer cases (as defined by the Secretary) in a fiscal year, not taking in account the effect of subparagraph (J), the Secretary may make adjustments to each of the average standardized amounts determined under paragraph (3) to assure that the aggregate payments made under this subsection for such fiscal year are not greater or lesser than those that would have otherwise been made in such fiscal year. (J)(i) The Secretary shall treat the term ``transfer case'' (as defined in subparagraph (I)(ii)) as including the case of a qualified discharge (as defined in clause (ii)), which is classified within a diagnosis-related group described in clause (iii), and which occurs on or after October 1, 1998. In the case of a qualified discharge for which a substantial portion of the costs of care are incurred in the early days of the inpatient stay (as defined by the Secretary), in no case may the payment amount otherwise provided under this subsection exceed an amount equal to the sum of-- (I) 50 percent of the amount of payment under this subsection for transfer cases (as established under subparagraph (I)(i)), and (II) 50 percent of the amount of payment which would have been made under this subsection with respect to the qualified discharge if no transfer were involved. (ii) For purposes of clause (i), subject to clause (iii), the term ``qualified discharge'' means a discharge classified with a diagnosis-related group (described in clause (iii)) of an individual from a subsection (d) hospital, if upon such discharge the individual-- (I) is admitted as an inpatient to a hospital or hospital unit that is not a subsection (d) hospital for the provision of inpatient hospital services; (II) is admitted to a skilled nursing facility; (III) is provided home health services from a home health agency, if such services relate to the condition or diagnosis for which such individual received inpatient hospital services from the subsection (d) hospital, and if such services are provided within an appropriate period (as determined by the Secretary); (IV) for discharges occurring on or after October 1, 2018, is provided hospice care by a hospice program; or (V) for discharges occurring on or after October 1, 2000, the individual receives post discharge services described in clause (iv)(I). (iii) Subject to clause (iv), a diagnosis-related group described in this clause is-- (I) 1 of 10 diagnosis-related groups selected by the Secretary based upon a high volume of discharges classified within such groups and a disproportionate use of post discharge services described in clause (ii); and (II) a diagnosis-related group specified by the Secretary under clause (iv)(II). (iv) The Secretary shall include in the proposed rule published under subsection (e)(5)(A) for fiscal year 2001, a description of the effect of this subparagraph. The Secretary shall include in the proposed rule published for fiscal year 2019, a description of the effect of clause (ii)(IV). The Secretary may include in the proposed rule (and in the final rule published under paragraph (6)) for fiscal year 2001 or a subsequent fiscal year, a description of-- (I) post-discharge services not described in subclauses (I), (II), (III), and, in the case of proposed and final rules for fiscal year 2019 and subsequent fiscal years, (IV) of clause (ii), the receipt of which results in a qualified discharge; and (II) diagnosis-related groups described in clause (iii)(I) in addition to the 10 selected under such clause. (K)(i) Effective for discharges beginning on or after October 1, 2001, the Secretary shall establish a mechanism to recognize the costs of new medical services and technologies under the payment system established under this subsection. Such mechanism shall be established after notice and opportunity for public comment (in the publications required by subsection (e)(5) for a fiscal year or otherwise). Such mechanism shall be modified to meet the requirements of clause (viii). (ii) The mechanism established pursuant to clause (i) shall-- (I) apply to a new medical service or technology if, based on the estimated costs incurred with respect to discharges involving such service or technology, the DRG prospective payment rate otherwise applicable to such discharges under this subsection is inadequate (applying a threshold specified by the Secretary that is the lesser of 75 percent of the standardized amount (increased to reflect the difference between cost and charges) or 75 percent of one standard deviation for the diagnosis-related group involved); (II) provide for the collection of data with respect to the costs of a new medical service or technology described in subclause (I) for a period of not less than two years and not more than three years beginning on the date on which an inpatient hospital code is issued with respect to the service or technology; (III) provide for additional payment to be made under this subsection with respect to discharges involving a new medical service or technology described in subclause (I) that occur during the period described in subclause (II) in an amount that adequately reflects the estimated average cost of such service or technology; and (IV) provide that discharges involving such a service or technology that occur after the close of the period described in subclause (II) will be classified within a new or existing diagnosis-related group with a weighting factor under paragraph (4)(B) that is derived from cost data collected with respect to discharges occurring during such period. (iii) For purposes of clause (ii)(II), the term ``inpatient hospital code'' means any code that is used with respect to inpatient hospital services for which payment may be made under this subsection and includes an alphanumeric code issued under the International Classification of Diseases, 9th Revision, Clinical Modification (``ICD-9-CM'') and its subsequent revisions. (iv) For purposes of clause (ii)(III), the term ``additional payment'' means, with respect to a discharge for a new medical service or technology described in clause (ii)(I), an amount that exceeds the prospective payment rate otherwise applicable under this subsection to discharges involving such service or technology that would be made but for this subparagraph. (v) The requirement under clause (ii)(III) for an additional payment may be satisfied by means of a new-technology group (described in subparagraph (L)), an add-on payment, a payment adjustment, or any other similar mechanism for increasing the amount otherwise payable with respect to a discharge under this subsection. The Secretary may not establish a separate fee schedule for such additional payment for such services and technologies, by utilizing a methodology established under subsection (a) or (h) of section 1834 to determine the amount of such additional payment, or by other similar mechanisms or methodologies. (vi) For purposes of this subparagraph and subparagraph (L), a medical service or technology will be considered a ``new medical service or technology'' if the service or technology meets criteria established by the Secretary after notice and an opportunity for public comment. (vii) Under the mechanism under this subparagraph, the Secretary shall provide for the addition of new diagnosis and procedure codes in April 1 of each year, but the addition of such codes shall not require the Secretary to adjust the payment (or diagnosis-related group classification) under this subsection until the fiscal year that begins after such date. (viii) The mechanism established pursuant to clause (i) shall be adjusted to provide, before publication of a proposed rule, for public input regarding whether a new service or technology represents an advance in medical technology that substantially improves the diagnosis or treatment of individuals entitled to benefits under part A as follows: (I) The Secretary shall make public and periodically update a list of all the services and technologies for which an application for additional payment under this subparagraph is pending. (II) The Secretary shall accept comments, recommendations, and data from the public regarding whether the service or technology represents a substantial improvement. (III) The Secretary shall provide for a meeting at which organizations representing hospitals, physicians, such individuals, manufacturers, and any other interested party may present comments, recommendations, and data to the clinical staff of the Centers for Medicare & Medicaid Services before publication of a notice of proposed rulemaking regarding whether service or technology represents a substantial improvement. (ix) Before establishing any add-on payment under this subparagraph with respect to a new technology, the Secretary shall seek to identify one or more diagnosis-related groups associated with such technology, based on similar clinical or anatomical characteristics and the cost of the technology. Within such groups the Secretary shall assign an eligible new technology into a diagnosis-related group where the average costs of care most closely approximate the costs of care of using the new technology. No add-on payment under this subparagraph shall be made with respect to such new technology and this clause shall not affect the application of paragraph (4)(C)(iii). (L)(i) In establishing the mechanism under subparagraph (K), the Secretary may establish new-technology groups into which a new medical service or technology will be classified if, based on the estimated average costs incurred with respect to discharges involving such service or technology, the DRG prospective payment rate otherwise applicable to such discharges under this subsection is inadequate. (ii) Such groups-- (I) shall not be based on the costs associated with a specific new medical service or technology; but (II) shall, in combination with the applicable standardized amounts and the weighting factors assigned to such groups under paragraph (4)(B), reflect such cost cohorts as the Secretary determines are appropriate for all new medical services and technologies that are likely to be provided as inpatient hospital services in a fiscal year. (iii) The methodology for classifying specific hospital discharges within a diagnosis-related group under paragraph (4)(A) or a new-technology group shall provide that a specific hospital discharge may not be classified within both a diagnosis-related group and a new-technology group. (6) The Secretary shall provide for publication in the Federal Register, on or before the August 1 before each fiscal year (beginning with fiscal year 1984), of a description of the methodology and data used in computing the adjusted DRG prospective payment rates under this subsection, including any adjustments required under subsection (e)(1)(B). (7) There shall be no administrative or judicial review under section 1878 or otherwise of-- (A) the determination of the requirement, or the proportional amount, of any adjustment effected pursuant to subsection (e)(1) or the determination of the applicable percentage increase under paragraph (12)(A)(ii), (B) the establishment of diagnosis-related groups, of the methodology for the classification of discharges within such groups, and of the appropriate weighting factors thereof under paragraph (4), including the selection and revision of codes under paragraph (4)(D), and (C) the determination of whether services provided prior to a patient's inpatient admission are related to the admission (as described in subsection (a)(4)). (8)(A) In the case of any hospital which is located in an area which is, at any time after April 20, 1983, reclassified from an urban to a rural area, payments to such hospital for the first two cost reporting periods for which such reclassification is effective shall be made as follows: (i) For the first such cost reporting period, payment shall be equal to the amount payable to such hospital for such reporting period on the basis of the rural classification, plus an amount equal to two-thirds of the amount (if any) by which-- (I) the amount which would have been payable to such hospital for such reporting period on the basis of an urban classification, exceeds (II) the amount payable to such hospital for such reporting period on the basis of the rural classification. (ii) For the second such cost reporting period, payment shall be equal to the amount payable to such hospital for such reporting period on the basis of the rural classification, plus an amount equal to one-third of the amount (if any) by which-- (I) the amount which would have been payable to such hospital for such reporting period on the basis of an urban classification, exceeds (II) the amount payable to such hospital for such reporting period on the basis of the rural classification. (B)(i) For purposes of this subsection, the Secretary shall treat a hospital located in a rural county adjacent to one or more urban areas as being located in the urban metropolitan statistical area to which the greatest number of workers in the county commute, if the rural county would otherwise be considered part of an urban area, under the standards for designating Metropolitan Statistical Areas (and for designating New England County Metropolitan Areas) described in clause (ii), if the commuting rates used in determining outlying counties (or, for New England, similar recognized areas) were determined on the basis of the aggregate number of resident workers who commute to (and, if applicable under the standards, from) the central county or counties of all contiguous Metropolitan Statistical Areas (or New England County Metropolitan Areas). (ii) The standards described in this clause for cost reporting periods beginning in a fiscal year-- (I) before fiscal year 2003, are the standards published in the Federal Register on January 3, 1980, or, at the election of the hospital with respect to fiscal years 2001 and 2002, standards so published on March 30, 1990; and (II) after fiscal year 2002, are the standards published in the Federal Register by the Director of the Office of Management and Budget based on the most recent available decennial population data. Subparagraphs (C) and (D) shall not apply with respect to the application of subclause (I). (C)(i) If the application of subparagraph (B) or a decision of the Medicare Geographic Classification Review Board or the Secretary under paragraph (10), by treating hospitals located in a rural county or counties as being located in an urban area, or by treating hospitals located in one urban area as being located in another urban area-- (I) reduces the wage index for that urban area (as applied under this subsection) by 1 percentage point or less, the Secretary, in calculating such wage index under this subsection, shall exclude those hospitals so treated, or (II) reduces the wage index for that urban area by more than 1 percentage point (as applied under this subsection), the Secretary shall calculate and apply such wage index under this subsection separately to hospitals located in such urban area (excluding all the hospitals so treated) and to the hospitals so treated (as if such hospitals were located in such urban area). (ii) If the application of subparagraph (B) or a decision of the Medicare Geographic Classification Review Board or the Secretary under paragraph (10), by treating hospitals located in a rural county or counties as not being located in the rural area in a State, reduces the wage index for that rural area (as applied under this subsection), the Secretary shall calculate and apply such wage index under this subsection as if the hospitals so treated had not been excluded from calculation of the wage index for that rural area. (iii) The application of subparagraph (B) or a decision of the Medicare Geographic Classification Review Board or the Secretary under paragraph (10) may not result in the reduction of any county's wage index to a level below the wage index for rural areas in the State in which the county is located. (iv) The application of subparagraph (B) or a decision of the Medicare Geographic Classification Review Board or of the Secretary under paragraph (10) may not result in a reduction in an urban area's wage index if-- (I) the urban area has a wage index below the wage index for rural areas in the State in which it is located; or (II) the urban area is located in a State that is composed of a single urban area. (v) This subparagraph shall apply with respect to discharges occurring in a fiscal year only if the Secretary uses a method for making adjustments to the DRG prospective payment rate for area differences in hospital wage levels under paragraph (3)(E) for the fiscal year that is based on the use of Metropolitan Statistical Area classifications. (D) The Secretary shall make a proportional adjustment in the standardized amounts determined under paragraph (3) to assure that the provisions of subparagraphs (B) and (C) or a decision of the Medicare Geographic Classification Review Board or the Secretary under paragraph (10) do not result in aggregate payments under this section that are greater or less than those that would otherwise be made. (E)(i) For purposes of this subsection, not later than 60 days after the receipt of an application (in a form and manner determined by the Secretary) from a subsection (d) hospital described in clause (ii), the Secretary shall treat the hospital as being located in the rural area (as defined in paragraph (2)(D)) of the State in which the hospital is located. (ii) For purposes of clause (i), a subsection (d) hospital described in this clause is a subsection (d) hospital that is located in an urban area (as defined in paragraph (2)(D)) and satisfies any of the following criteria: (I) The hospital is located in a rural census tract of a metropolitan statistical area (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992 (57 Fed. Reg. 6725)). (II) The hospital is located in an area designated by any law or regulation of such State as a rural area (or is designated by such State as a rural hospital). (III) The hospital would qualify as a rural, regional, or national referral center under paragraph (5)(C) or as a sole community hospital under paragraph (5)(D) if the hospital were located in a rural area. (IV) The hospital meets such other criteria as the Secretary may specify. (9)(A) Notwithstanding section 1814(b) but subject to the provisions of section 1813, the amount of the payment with respect to the operating costs of inpatient hospital services of a subsection (d) Puerto Rico hospital for inpatient hospital discharges is equal to the sum of-- (i) the applicable Puerto Rico percentage (specified in subparagraph (E)) of the Puerto Rico adjusted DRG prospective payment rate (determined under subparagraph (B) or (C)) for such discharges, (ii) the applicable Federal percentage (specified in subparagraph (E)) of-- (I) for discharges beginning in a fiscal year beginning on or after October 1, 1997, and before October 1, 2003, the discharge-weighted average of-- (aa) the national adjusted DRG prospective payment rate (determined under paragraph (3)(D)) for hospitals located in a large urban area, (bb) such rate for hospitals located in other urban areas, and (cc) such rate for hospitals located in a rural area, for such discharges, adjusted in the manner provided in paragraph (3)(E) for different area wage levels; and (II) for discharges in a fiscal year beginning on or after October 1, 2003, the national DRG prospective payment rate determined under paragraph (3)(D)(iii) for hospitals located in any area for such discharges, adjusted in the manner provided in paragraph (3)(E) for different area wage levels. As used in this section, the term ``subsection (d) Puerto Rico hospital'' means a hospital that is located in Puerto Rico and that would be a subsection (d) hospital (as defined in paragraph (1)(B)) if it were located in one of the 50 States. (B) The Secretary shall determine a Puerto Rico adjusted DRG prospective payment rate, for each inpatient hospital discharge in fiscal year 1988 involving inpatient hospital services of a subsection (d) Puerto Rico hospital for which payment may be made under part A of this title. Such rate shall be determined for such hospitals located in urban or rural areas within Puerto Rico, as follows: (i) The Secretary shall determine the target amount (as defined in subsection (b)(3)(A)) for the hospital for the cost reporting period beginning in fiscal year 1987 and increase such amount by prorating the applicable percentage increase (as defined in subsection (b)(3)(B)) to update the amount to the midpoint in fiscal year 1988. (ii) The Secretary shall standardize the amount determined under clause (i) for each hospital by-- (I) excluding an estimate of indirect medical education costs, (II) adjusting for variations among hospitals by area in the average hospital wage level, (III) adjusting for variations in case mix among hospitals, and (IV) excluding an estimate of the additional payments to certain subsection (d) Puerto Rico hospitals to be made under subparagraph (D)(iii) (relating to disproportionate share payments). (iii) The Secretary shall compute a discharge weighted average of the standardized amounts determined under clause (ii) for all hospitals located in an urban area and for all hospitals located in a rural area (as such terms are defined in paragraph (2)(D)). (iv) The Secretary shall reduce the average standardized amount by a proportion equal to the proportion (estimated by the Secretary) of the amount of payments under this paragraph which are additional payments described in subparagraph (D)(i) (relating to outlier payments). (v) For each discharge classified within a diagnosis- related group for hospitals located in an urban or rural area, respectively, the Secretary shall establish a Puerto Rico DRG prospective payment rate equal to the product of-- (I) the average standardized amount (computed under clause (iii) and reduced under clause (iv)) for hospitals located in an urban or rural area, respectively, and (II) the weighting factor (determined under paragraph (4)(B)) for that diagnosis-related group. (vi) The Secretary shall adjust the proportion (as estimated by the Secretary from time to time) of hospitals' costs which are attributable to wages and wage-related costs, of the Puerto Rico DRG prospective payment rate computed under clause (v) for area differences in hospital wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the hospital compared to the Puerto Rican average hospital wage level. (C) The Secretary shall determine a Puerto Rico adjusted DRG prospective payment rate, for each inpatient hospital discharge after fiscal year 1988 involving inpatient hospital services of a subsection (d) Puerto Rico hospital for which payment may be made under part A of this title. Such rate shall be determined for hospitals located in urban or rural areas within Puerto Rico as follows: (i)(I) For discharges in a fiscal year after fiscal year 1988 and before fiscal year 2004, the Secretary shall compute an average standardized amount for hospitals located in an urban area and for hospitals located in a rural area equal to the respective average standardized amount computed for the previous fiscal year under subparagraph (B)(iii) or under this clause, increased for fiscal year 1989 by the applicable percentage increase under subsection (b)(3)(B), and adjusted for subsequent fiscal years in accordance with the final determination of the Secretary under subsection (e)(4), and adjusted to reflect the most recent case-mix data available. (II) For discharges occurring in a fiscal year (beginning with fiscal year 2004), the Secretary shall compute an average standardized amount for hospitals located in any area of Puerto Rico that is equal to the average standardized amount computed under subclause (I) for fiscal year 2003 for hospitals in a large urban area (or, beginning with fiscal year 2005, for all hospitals in the previous fiscal year) increased by the applicable percentage increase under subsection (b)(3)(B) for the fiscal year involved. (ii) The Secretary shall reduce each of the average standardized amounts (or for fiscal year 2004 and thereafter, the average standardized amount) by a proportion equal to the proportion (estimated by the Secretary) of the amount of payments under this paragraph which are additional payments described in subparagraph (D)(i) (relating to outlier payments). (iii) For each discharge classified within a diagnosis-related group for hospitals located in an urban or rural area, respectively, the Secretary shall establish a Puerto Rico DRG prospective payment rate equal to the product of-- (I) the average standardized amount (computed under clause (i) and reduced under clause (ii)), and (II) the weighting factor (determined under paragraph (4)(B)) for that diagnosis-related group. (iv)(I) The Secretary shall adjust the proportion (as estimated by the Secretary from time to time) of hospitals' costs which are attributable to wages and wage-related costs, of the Puerto Rico DRG prospective payment rate computed under clause (iii) for area differences in hospital wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the hospital compared to the Puerto Rico average hospital wage level. The second and third sentences of paragraph (3)(E)(i) shall apply to subsection (d) Puerto Rico hospitals under this clause in the same manner as they apply to subsection (d) hospitals under such paragraph and, for purposes of this clause, any reference in such paragraph to a subsection (d) hospital is deemed a reference to a subsection (d) Puerto Rico hospital. (II) For discharges occurring on or after October 1, 2004, the Secretary shall substitute ``62 percent'' for the proportion described in the first sentence of clause (i), unless the application of this subclause would result in lower payments to a hospital than would otherwise be made. (D) The following provisions of paragraph (5) shall apply to subsection (d) Puerto Rico hospitals receiving payment under this paragraph in the same manner and to the extent as they apply to subsection (d) hospitals receiving payment under this subsection: (i) Subparagraph (A) (relating to outlier payments). (ii) Subparagraph (B) (relating to payments for indirect medical education costs), except that for this purpose the sum of the amount determined under subparagraph (A) of this paragraph and the amount paid to the hospital under clause (i) of this subparagraph shall be substituted for the sum referred to in paragraph (5)(B)(i)(I). (iii) Subparagraph (F) (relating to disproportionate share payments), except that for this purpose the sum described in clause (ii) of this subparagraph shall be substituted for the sum referred to in paragraph (5)(F)(ii)(I). (iv) Subparagraph (H) (relating to exceptions and adjustments). (E) For purposes of subparagraph (A), for discharges occurring-- (i) on or after October 1, 1987, and before October 1, 1997, the applicable Puerto Rico percentage is 75 percent and the applicable Federal percentage is 25 percent; (ii) on or after October 1, 1997, and before April 1, 2004, the applicable Puerto Rico percentage is 50 percent and the applicable Federal percentage is 50 percent; (iii) on or after April 1, 2004, and before October 1, 2004, the applicable Puerto Rico percentage is 37.5 percent and the applicable Federal percentage is 62.5 percent; (iv) on or after October 1, 2004, and before January 1, 2016, the applicable Puerto Rico percentage is 25 percent and the applicable Federal percentage is 75 percent; and (v) on or after January 1, 2016, the applicable Puerto Rico percentage is 0 percent and the applicable Federal percentage is 100 percent. (10)(A) There is hereby established the Medicare Geographic Classification Review Board (hereinafter in this paragraph referred to as the ``Board''). (B)(i) The Board shall be composed of 5 members appointed by the Secretary without regard to the provisions of title 5, United States Code, governing appointments in the competitive service. Two of such members shall be representative of subsection (d) hospitals located in a rural area under paragraph (2)(D). At least 1 member shall be knowledgeable in the field of analyzing costs with respect to the provision of inpatient hospital services. (ii) The Secretary shall make initial appointments to the Board as provided in this paragraph within 180 days after the date of the enactment of this paragraph. (C)(i) The Board shall consider the application of any subsection (d) hospital requesting that the Secretary change the hospital's geographic classification for purposes of determining for a fiscal year-- (I) the hospital's average standardized amount under paragraph (2)(D), or (II) the factor used to adjust the DRG prospective payment rate for area differences in hospital wage levels that applies to such hospital under paragraph (3)(E). (ii) A hospital requesting a change in geographic classification under clause (i) for a fiscal year shall submit its application to the Board not later than the first day of the 13-month period ending on September 30 of the preceding fiscal year. (iii)(I) The Board shall render a decision on an application submitted under clause (i) not later than 180 days after the deadline referred to in clause (ii). (II) Appeal of decisions of the Board shall be subject to the provisions of section 557b of title 5, United States Code. The Secretary shall issue a decision on such an appeal not later than 90 days after the date on which the appeal is filed. The decision of the Secretary shall be final and shall not be subject to judicial review. (D)(i) The Secretary shall publish guidelines to be utilized by the Board in rendering decisions on applications submitted under this paragraph, and shall include in such guidelines the following: (I) Guidelines for comparing wages, taking into account (to the extent the Secretary determines appropriate) occupational mix, in the area in which the hospital is classified and the area in which the hospital is applying to be classified. (II) Guidelines for determining whether the county in which the hospital is located should be treated as being a part of a particular Metropolitan Statistical Area. (III) Guidelines for considering information provided by an applicant with respect to the effects of the hospital's geographic classification on access to inpatient hospital services by medicare beneficiaries. (IV) Guidelines for considering the appropriateness of the criteria used to define New England County Metropolitan Areas. (ii) Notwithstanding clause (i), if the Secretary uses a method for making adjustments to the DRG prospective payment rate for area differences in hospital wage levels under paragraph (3)(E) that is not based on the use of Metropolitan Statistical Area classifications, the Secretary may revise the guidelines published under clause (i) to the extent such guidelines are used to determine the appropriateness of the geographic area in which the hospital is determined to be located for purposes of making such adjustments. (iii) Under the guidelines published by the Secretary under clause (i), in the case of a hospital which has ever been classified by the Secretary as a rural referral center under paragraph (5)(C), the Board may not reject the application of the hospital under this paragraph on the basis of any comparison between the average hourly wage of the hospital and the average hourly wage of hospitals in the area in which it is located. (iv) The Secretary shall publish the guidelines described in clause (i) by July 1, 1990. (v) Any decision of the Board to reclassify a subsection (d) hospital for purposes of the adjustment factor described in subparagraph (C)(i)(II) for fiscal year 2001 or any fiscal year thereafter shall be effective for a period of 3 fiscal years, except that the Secretary shall establish procedures under which a subsection (d) hospital may elect to terminate such reclassification before the end of such period. (vi) Such guidelines shall provide that, in making decisions on applications for reclassification for the purposes described in clause (v) for fiscal year 2003 and any succeeding fiscal year, the Board shall base any comparison of the average hourly wage for the hospital with the average hourly wage for hospitals in an area on-- (I) an average of the average hourly wage amount for the hospital from the most recently published hospital wage survey data of the Secretary (as of the date on which the hospital applies for reclassification) and such amount from each of the two immediately preceding surveys; and (II) an average of the average hourly wage amount for hospitals in such area from the most recently published hospital wage survey data of the Secretary (as of the date on which the hospital applies for reclassification) and such amount from each of the two immediately preceding surveys. (E)(i) The Board shall have full power and authority to make rules and establish procedures, not inconsistent with the provisions of this title or regulations of the Secretary, which are necessary or appropriate to carry out the provisions of this paragraph. In the course of any hearing the Board may administer oaths and affirmations. The provisions of subsections (d) and (e) of section 205 with respect to subpenas shall apply to the Board to the same extent as such provisions apply to the Secretary with respect to title II. (ii) The Board is authorized to engage such technical assistance and to receive such information as may be required to carry out its functions, and the Secretary shall, in addition, make available to the Board such secretarial, clerical, and other assistance as the Board may require to carry out its functions. (F)(i) Each member of the Board who is not an officer or employee of the Federal Government shall be compensated at a rate equal to the daily equivalent of the annual rate of basic pay prescribed for grade GS-18 of the General Schedule under section 5332 of title 5, United States Code, for each day (including travel time) during which such member is engaged in the performance of the duties of the Board. Each member of the Board who is an officer or employee of the United States shall serve without compensation in addition to that received for service as an officer or employee of the United States. (ii) Members of the Board shall be allowed travel expenses, including per diem in lieu of subsistence, at rates authorized for employees of agencies under subchapter I of chapter 57 of title 5, United States Code, while away from their homes or regular places of business in the performance of services for the Board. (11) Additional payments for managed care enrollees.-- (A) In general.--For portions of cost reporting periods occurring on or after January 1, 1998, the Secretary shall provide for an additional payment amount for each applicable discharge of any subsection (d) hospital that has an approved medical residency training program. (B) Applicable discharge.--For purposes of this paragraph, the term ``applicable discharge'' means the discharge of any individual who is enrolled under a risk-sharing contract with an eligible organization under section 1876 and who is entitled to benefits under part A or any individual who is enrolled with a Medicare+Choice organization under part C. (C) Determination of amount.--The amount of the payment under this paragraph with respect to any applicable discharge shall be equal to the applicable percentage (as defined in subsection (h)(3)(D)(ii)) of the estimated average per discharge amount that would otherwise have been paid under paragraph (5)(B) if the individuals had not been enrolled as described in subparagraph (B). (D) Special rule for hospitals under reimbursement system.--The Secretary shall establish rules for the application of this paragraph to a hospital reimbursed under a reimbursement system authorized under section 1814(b)(3) in the same manner as it would apply to the hospital if it were not reimbursed under such section. (12) Payment adjustment for low-volume hospitals.-- (A) In general.--In addition to any payments calculated under this section for a subsection (d) hospital, for discharges occurring during a fiscal year (beginning with fiscal year 2005), the Secretary shall provide for an additional payment amount to each low-volume hospital (as defined in subparagraph (C)(i)) for discharges occurring during that fiscal year that is equal to the applicable percentage increase (determined under subparagraph (B) or (D) for the hospital involved) in the amount paid to such hospital under this section for such discharges (determined without regard to this paragraph). (B) Applicable percentage increase.--For discharges occurring in fiscal years 2005 through 2010 and for discharges occurring in fiscal year 2023 and subsequent fiscal years, the Secretary shall determine an applicable percentage increase for purposes of subparagraph (A) as follows: (i) The Secretary shall determine the empirical relationship for subsection (d) hospitals between the standardized cost-per-case for such hospitals and the total number of discharges of such hospitals and the amount of the additional incremental costs (if any) that are associated with such number of discharges. (ii) The applicable percentage increase shall be determined based upon such relationship in a manner that reflects, based upon the number of such discharges for a subsection (d) hospital, such additional incremental costs. (iii) In no case shall the applicable percentage increase exceed 25 percent. (C) Definitions.-- (i) Low-volume hospital.--For purposes of this paragraph, the term ``low-volume hospital'' means, for a fiscal year, a subsection (d) hospital (as defined in paragraph (1)(B)) that the Secretary determines is located more than 25 road miles (or, with respect to fiscal years 2011 through 2022, 15 road miles) from another subsection (d) hospital and has-- (I) with respect to each of fiscal years 2005 through 2010, less than 800 discharges during the fiscal year; (II) with respect to each of fiscal years 2011 through 2018, less than 1,600 discharges of individuals entitled to, or enrolled for, benefits under part A during the fiscal year or portion of fiscal year; (III) with respect to each of fiscal years 2019 through 2022, less than 3,800 discharges during the fiscal year; and (IV) with respect to fiscal year 2023 and each subsequent fiscal year, less than 800 discharges during the fiscal year. (ii) Discharge.--For purposes of subparagraphs (B) and (D) and clause (i), the term ``discharge'' means an inpatient acute care discharge of an individual regardless (except as provided in clause (i)(II) and subparagraph (D)(i)) of whether the individual is entitled to benefits under part A. (iii) Treatment of indian health service and non-indian health service facilities.--For purposes of determining whether-- (I) a subsection (d) hospital of the Indian Health Service (whether operated by such Service or by an Indian tribe or tribal organization (as those terms are defined in section 4 of the Indian Health Care Improvement Act)), or (II) a subsection (d) hospital other than a hospital of the Indian Health Service meets the mileage criterion under clause (i) with respect to fiscal year 2011 or a succeeding fiscal year, the Secretary shall apply the policy described in the regulation at part 412.101(e) of title 42, Code of Federal Regulations (as in effect on the date of enactment of this clause). (D) Temporary applicable percentage increase.--For discharges occurring in fiscal years 2011 through 2022, the Secretary shall determine an applicable percentage increase for purposes of subparagraph (A) using a continuous linear sliding scale ranging from 25 percent for low-volume hospitals-- (i) with respect to each of fiscal years 2011 through 2018, with 200 or fewer discharges of individuals entitled to, or enrolled for, benefits under part A in the fiscal year or the portion of fiscal year to 0 percent for low-volume hospitals with greater than 1,600 discharges of such individuals in the fiscal yearor portion of fiscal year; and (ii) with respect to each of fiscal years 2019 through 2022, with 500 or fewer discharges in the fiscal year to 0 percent for low-volume hospitals with greater than 3,800 discharges in the fiscal year. (13)(A) In order to recognize commuting patterns among geographic areas, the Secretary shall establish a process through application or otherwise for an increase of the wage index applied under paragraph (3)(E) for subsection (d) hospitals located in a qualifying county described in subparagraph (B) in the amount computed under subparagraph (D) based on out-migration of hospital employees who reside in that county to any higher wage index area. (B) The Secretary shall establish criteria for a qualifying county under this subparagraph based on the out-migration referred to in subparagraph (A) and differences in the area wage indices. Under such criteria the Secretary shall, utilizing such data as the Secretary determines to be appropriate, establish-- (i) a threshold percentage, established by the Secretary, of the weighted average of the area wage index or indices for the higher wage index areas involved; (ii) a threshold (of not less than 10 percent) for minimum out-migration to a higher wage index area or areas; and (iii) a requirement that the average hourly wage of the hospitals in the qualifying county equals or exceeds the average hourly wage of all the hospitals in the area in which the qualifying county is located. (C) For purposes of this paragraph, the term ``higher wage index area'' means, with respect to a county, an area with a wage index that exceeds that of the county. (D) The increase in the wage index under subparagraph (A) for a qualifying county shall be equal to the percentage of the hospital employees residing in the qualifying county who are employed in any higher wage index area multiplied by the sum of the products, for each higher wage index area of-- (i) the difference between-- (I) the wage index for such higher wage index area, and (II) the wage index of the qualifying county; and (ii) the number of hospital employees residing in the qualifying county who are employed in such higher wage index area divided by the total number of hospital employees residing in the qualifying county who are employed in any higher wage index area. (E) The process under this paragraph may be based upon the process used by the Medicare Geographic Classification Review Board under paragraph (10). As the Secretary determines to be appropriate to carry out such process, the Secretary may require hospitals (including subsection (d) hospitals and other hospitals) and critical access hospitals, as required under section 1866(a)(1)(T), to submit data regarding the location of residence, or the Secretary may use data from other sources. (F) A wage index increase under this paragraph shall be effective for a period of 3 fiscal years, except that the Secretary shall establish procedures under which a subsection (d) hospital may elect to waive the application of such wage index increase. (G) A hospital in a county that has a wage index increase under this paragraph for a period and that has not waived the application of such an increase under subparagraph (F) is not eligible for reclassification under paragraph (8) or (10) during that period. (H) Any increase in a wage index under this paragraph for a county shall not be taken into account for purposes of-- (i) computing the wage index for portions of the wage index area (not including the county) in which the county is located; or (ii) applying any budget neutrality adjustment with respect to such index under paragraph (8)(D). (I) The thresholds described in subparagraph (B), data on hospital employees used under this paragraph, and any determination of the Secretary under the process described in subparagraph (E) shall be final and shall not be subject to judicial review. (e)(1)(A) For cost reporting periods of hospitals beginning in fiscal year 1984 or fiscal year 1985, the Secretary shall provide for such proportional adjustment in the applicable percentage increase (otherwise applicable to the periods under subsection (b)(3)(B)) as may be necessary to assure that-- (i) the aggregate payment amounts otherwise provided under subsection (d)(1)(A)(i)(I) for that fiscal year for operating costs of inpatient hospital services of hospitals (excluding payments made under section 1866(a)(1)(F)), are not greater or less than-- (ii) the target percentage (as defined in subsection (d)(1)(C)) of the payment amounts which would have been payable for such services for those same hospitals for that fiscal year under this section under the law as in effect before the date of the enactment of the Social Security Amendments of 1983 (excluding payments made under section 1866(a)(1)(F)); except that the adjustment made under this subparagraph shall apply only to subsection (d) hospitals and shall not apply for purposes of making computations under subsection (d)(2)(B)(ii) or subsection (d)(3)(A). (B) For discharges occurring in fiscal year 1984 or fiscal year 1985, the Secretary shall provide under subsections (d)(2)(F) and (d)(3)(C) for such equal proportional adjustment in each of the average standardized amounts otherwise computed for that fiscal year as may be necessary to assure that-- (i) the aggregate payment amounts otherwise provided under subsection (d)(1)(A)(i)(II) and (d)(5) for that fiscal year for operating costs of inpatient hospital services of hospitals (excluding payments made under section 1866(a)(1)(F)), are not greater or less than-- (ii) the DRG percentage (as defined in subsection (d)(1)(C)) of the payment amounts which would have been payable for such services for those same hospitals for that fiscal year under this section under the law as in effect before the date of the enactment of the Social Security Amendments of 1983 (excluding payments made under section 1866(a)(1)(F)). (C) For discharges occurring in fiscal year 1988, the Secretary shall provide for such equal proportional adjustment in each of the average standardized amounts otherwise computed under subsection (d)(3) for that fiscal year as may be necessary to assure that-- (i) the aggregate payment amounts otherwise provided under subsections (d)(1)(A)(iii), (d)(5), and (d)(9) for that fiscal year for operating costs of inpatient hospital services of subsection (d) hospitals and subsection (d) Puerto Rico hospitals, are not greater or less than-- (ii) the payment amounts that would have been payable for such services for those same hospitals for that fiscal year but for the enactment of the amendments made by section 9304 of the Omnibus Budget Reconciliation Act of 1986. (4)(A) Taking into consideration the recommendations of the Commission, the Secretary shall recommend for each fiscal year (beginning with fiscal year 1988) an appropriate change factor for inpatient hospital services for discharges in that fiscal year which will take into account amounts necessary for the efficient and effective delivery of medically appropriate and necessary care of high quality. The appropriate change factor may be different for all large urban subsection (d) hospitals, other urban subsection (d) hospitals, urban subsection (d) Puerto Rico hospitals, rural subsection (d) hospitals, and rural subsection (d) Puerto Rico hospitals, and all other hospitals and units not paid under subsection (d), and may vary among such other hospitals and units. (B) In addition to the recommendation made under subparagraph (A), the Secretary shall, taking into consideration the recommendations of the Commission under paragraph (2)(B), recommend for each fiscal year (beginning with fiscal year 1992) other appropriate changes in each existing reimbursement policy under this title under which payments to an institution are based upon prospectively determined rates. (5) The Secretary shall cause to have published in the Federal Register, not later than-- (A) the April 1 before each fiscal year (beginning with fiscal year 1986), the Secretary's proposed recommendations under paragraph (4) for that fiscal year for public comment, and (B) the August 1 before such fiscal year after such consideration of public comment on the proposal as is feasible in the time available, the Secretary's final recommendations under such paragraph for that year. The Secretary shall include in the publication referred to in subparagraph (A) for a fiscal year the report of the Commission's recommendations submitted under paragraph (3) for that fiscal year. To the extent that the Secretary's recommendations under paragraph (4) differ from the Commission's recommendations for that fiscal year, the Secretary shall include in the publication referred to in subparagraph (A) an explanation of the Secretary's grounds for not following the Commission's recommendations. (f)(1)(A) The Secretary shall maintain a system for the reporting of costs of hospitals receiving payments computed under subsection (d). (B)(i) Subject to clause (ii), the Secretary shall place into effect a standardized electronic cost reporting format for hospitals under this title. (ii) The Secretary may delay or waive the implementation of such format in particular instances where such implementation would result in financial hardship (in particular with respect to hospitals with a small percentage of inpatients entitled to benefits under this title). (2) If the Secretary determines, based upon information supplied by a quality improvement organization under part B of title XI, that a hospital, in order to circumvent the payment method established under subsection (b) or (d) of this section, has taken an action that results in the admission of individuals entitled to benefits under part A unnecessarily, unnecessary multiple admissions of the same such individuals, or other inappropriate medical or other practices with respect to such individuals, the Secretary may-- (A) deny payment (in whole or in part) under part A with respect to inpatient hospital services provided with respect to such an unnecessary admission (or subsequent admission of the same individual), or (B) require the hospital to take other corrective action necessary to prevent or correct the inappropriate practice. (3) The provisions of subsections (c) through (g) of section 1128 shall apply to determinations made under paragraph (2) in the same manner as they apply to exclusions effected under section 1128(b)(13). (g)(1)(A) Notwithstanding section 1861(v), instead of any amounts that are otherwise payable under this title with respect to the reasonable costs of subsection (d) hospitals and subsection (d) Puerto Rico hospitals for capital-related costs of inpatient hospital services, the Secretary shall, for hospital cost reporting periods beginning on or after October 1, 1991, provide for payments for such costs in accordance with a prospective payment system established by the Secretary. Aggregate payments made under subsection (d) and this subsection during fiscal years 1992 through 1995 shall be reduced in a manner that results in a reduction (as estimated by the Secretary) in the amount of such payments equal to a 10 percent reduction in the amount of payments attributable to capital-related costs that would otherwise have been made during such fiscal year had the amount of such payments been based on reasonable costs (as defined in section 1861(v)). For discharges occurring after September 30, 1993, the Secretary shall reduce by 7.4 percent the unadjusted standard Federal capital payment rate (as described in 42 CFR 412.308(c), as in effect on the date of the enactment of the Omnibus Budget Reconciliation Act of 1993) and shall (for hospital cost reporting periods beginning on or after October 1, 1993) redetermine which payment methodology is applied to the hospital under such system to take into account such reduction. In addition to the reduction described in the preceding sentence, for discharges occurring on or after October 1, 1997, the Secretary shall apply the budget neutrality adjustment factor used to determine the Federal capital payment rate in effect on September 30, 1995 (as described in section 412.352 of title 42 of the Code of Federal Regulations), to (i) the unadjusted standard Federal capital payment rate (as described in section 412.308(c) of that title, as in effect on September 30, 1997), and (ii) the unadjusted hospital-specific rate (as described in section 412.328(e)(1) of that title, as in effect on September 30, 1997), and, for discharges occurring on or after October 1, 1997, and before October 1, 2002, reduce the rates described in clauses (i) and (ii) by 2.1 percent. (B) Such system-- (i) shall provide for (I) a payment on a per discharge basis, and (II) an appropriate weighting of such payment amount as relates to the classification of the discharge; (ii) may provide for an adjustment to take into account variations in the relative costs of capital and construction for the different types of facilities or areas in which they are located; (iii) may provide for such exceptions (including appropriate exceptions to reflect capital obligations) as the Secretary determines to be appropriate, and (iv) may provide for suitable adjustment to reflect hospital occupancy rate. (C) In this paragraph, the term ``capital-related costs'' has the meaning given such term by the Secretary under subsection (a)(4) as of September 30, 1987, and does not include a return on equity capital. (2)(A) The Secretary shall provide that the amount which is allowable, with respect to reasonable costs of inpatient hospital services for which payment may be made under this title, for a return on equity capital for hospitals shall, for cost reporting periods beginning on or after the date of the enactment of this subsection, be equal to amounts otherwise allowable under regulations in effect on March 1, 1983, except that the rate of return to be recognized shall be equal to the applicable percentage (described in subparagraph (B)) of the average of the rates of interest, for each of the months any part of which is included in the reporting period, on obligations issued for purchase by the Federal Hospital Insurance Trust Fund. (B) In this paragraph, the ``applicable percentage'' is-- (i) 75 percent, for cost reporting periods beginning during fiscal year 1987, (ii) 50 percent, for cost reporting periods beginning during fiscal year 1988, (iii) 25 percent, for cost reporting periods beginning during fiscal year 1989, and (iv) 0 percent, for cost reporting periods beginning on or after October 1, 1989. (3)(A) Except as provided in subparagraph (B), in determining the amount of the payments that may be made under this title with respect to all the capital-related costs of inpatient hospital services of a subsection (d) hospital and a subsection (d) Puerto Rico hospital, the Secretary shall reduce the amounts of such payments otherwise established under this title by-- (i) 3.5 percent for payments attributable to portions of cost reporting periods occurring during fiscal year 1987, (ii) 7 percent for payments attributable to portions of cost reporting periods or discharges (as the case may be) occurring during fiscal year 1988 on or after October 1, 1987, and before January 1, 1988, (iii) 12 percent for payments attributable to portions of cost reporting periods or discharges (as the case may be) in fiscal year 1988, occurring on or after January 1, 1988, (iv) 15 percent for payments attributable to portions of cost reporting periods or discharges (as the case may be) occurring during fiscal year 1989, and (v) 15 percent for payments attributable to portions of cost reporting periods or discharges (as the case may be) occurring during the period beginning January 1, 1990, and ending September 30, 1991. (B) Subparagraph (A) shall not apply to payments with respect to the capital-related costs of any hospital that is a sole community hospital (as defined in subsection (d)(5)(D)(iii)) or a critical access hospital (as defined in section 1861(mm)(1)). (4) In determining the amount of the payments that are attributable to portions of cost reporting periods occurring during fiscal years 1998 through 2002 and that may be made under this title with respect to capital-related costs of inpatient hospital services of a hospital which is described in clause (i), (ii), or (iv) of subsection (d)(1)(B) or a unit described in the matter after clause (v) of such subsection, the Secretary shall reduce the amounts of such payments otherwise determined under this title by 15 percent. (h) Payments for Direct Graduate Medical Education Costs.-- (1) Substitution of special payment rules.-- Notwithstanding section 1861(v), instead of any amounts that are otherwise payable under this title with respect to the reasonable costs of hospitals for direct graduate medical education costs, the Secretary shall provide for payments for such costs in accordance with paragraph (3) of this subsection. In providing for such payments, the Secretary shall provide for an allocation of such payments between part A and part B (and the trust funds established under the respective parts) as reasonably reflects the proportion of direct graduate medical education costs of hospitals associated with the provision of services under each respective part. (2) Determination of hospital-specific approved fte resident amounts.--The Secretary shall determine, for each hospital with an approved medical residency training program, an approved FTE resident amount for each cost reporting period beginning on or after July 1, 1985, as follows: (A) Determining allowable average cost per fte resident in a hospital's base period.--The Secretary shall determine, for the hospital's cost reporting period that began during fiscal year 1984, the average amount recognized as reasonable under this title for direct graduate medical education costs of the hospital for each full-time-equivalent resident. (B) Updating to the first cost reporting period.-- (i) In general.--The Secretary shall update each average amount determined under subparagraph (A) by the percentage increase in the consumer price index during the 12-month cost reporting period described in such subparagraph. (ii) Exception.--The Secretary shall not perform an update under clause (i) in the case of a hospital if the hospital's reporting period, described in subparagraph (A), began on or after July 1, 1984, and before October 1, 1984. (C) Amount for first cost reporting period.-- For the first cost reporting period of the hospital beginning on or after July 1, 1985, the approved FTE resident amount for the hospital is equal to the amount determined under subparagraph (B) increased by 1 percent. (D) Amount for subsequent cost reporting periods.-- (i) In general.--Except as provided in a subsequent clause, for each subsequent cost reporting period, the approved FTE resident amount for the hospital is equal to the approved FTE resident amount determined under this paragraph for the previous cost reporting period updated, through the midpoint of the period, by projecting the estimated percentage change in the consumer price index during the 12- month period ending at that midpoint, with appropriate adjustments to reflect previous under-or over-estimations under this subparagraph in the projected percentage change in the consumer price index. (ii) Freeze in update for fiscal years 1994 and 1995.--For cost reporting periods beginning during fiscal year 1994 or fiscal year 1995, the approved FTE resident amount for a hospital shall not be updated under clause (i) for a resident who is not a primary care resident (as defined in paragraph (5)(H)) or a resident enrolled in an approved medical residency training program in obstetrics and gynecology. (iii) Floor for locality adjusted national average per resident amount.-- The approved FTE resident amount for a hospital for the cost reporting period beginning during fiscal year 2001 shall not be less than 70 percent, and for the cost reporting period beginning during fiscal year 2002 shall not be less than 85 percent, of the locality adjusted national average per resident amount computed under subparagraph (E) for the hospital and period. (iv) Adjustment in rate of increase for hospitals with fte approved amount above 140 percent of locality adjusted national average per resident amount.-- (I) Freeze for fiscal years 2001 and 2002 and 2004 through 2013.--For a cost reporting period beginning during fiscal year 2001 or fiscal year 2002 or during the period beginning with fiscal year 2004 and ending with fiscal year 2013, if the approved FTE resident amount for a hospital for the preceding cost reporting period exceeds 140 percent of the locality adjusted national average per resident amount computed under subparagraph (E) for that hospital and period, subject to subclause (III), the approved FTE resident amount for the period involved shall be the same as the approved FTE resident amount for the hospital for such preceding cost reporting period. (II) 2 percent decrease in update for fiscal years 2003, 2004, and 2005.--For the cost reporting period beginning during fiscal year 2003, if the approved FTE resident amount for a hospital for the preceding cost reporting period exceeds 140 percent of the locality adjusted national average per resident amount computed under subparagraph (E) for that hospital and preceding period, the approved FTE resident amount for the period involved shall be updated in the manner described in subparagraph (D)(i) except that, subject to subclause (III), the consumer price index applied for a 12-month period shall be reduced (but not below zero) by 2 percentage points. (III) No adjustment below 140 percent.--In no case shall subclause (I) or (II) reduce an approved FTE resident amount for a hospital for a cost reporting period below 140 percent of the locality adjusted national average per resident amount computed under subparagraph (E) for such hospital and period. (E) Determination of locality adjusted national average per resident amount.--The Secretary shall determine a locality adjusted national average per resident amount with respect to a cost reporting period of a hospital beginning during a fiscal year as follows: (i) Determining hospital single per resident amount.--The Secretary shall compute for each hospital operating an approved graduate medical education program a single per resident amount equal to the average (weighted by number of full-time equivalent residents, as determined under paragraph (4)) of the primary care per resident amount and the non-primary care per resident amount computed under paragraph (2) for cost reporting periods ending during fiscal year 1997. (ii) Standardizing per resident amounts.--The Secretary shall compute a standardized per resident amount for each such hospital by dividing the single per resident amount computed under clause (i) by an average of the 3 geographic index values (weighted by the national average weight for each of the work, practice expense, and malpractice components) as applied under section 1848(e) for 1999 for the fee schedule area in which the hospital is located. (iii) Computing of weighted average.--The Secretary shall compute the average of the standardized per resident amounts computed under clause (ii) for such hospitals, with the amount for each hospital weighted by the average number of full-time equivalent residents at such hospital (as determined under paragraph (4)). (iv) Computing national average per resident amount.--The Secretary shall compute the national average per resident amount, for a hospital's cost reporting period that begins during fiscal year 2001, equal to the weighted average computed under clause (iii) increased by the estimated percentage increase in the consumer price index for all urban consumers during the period beginning with the month that represents the midpoint of the cost reporting periods described in clause (i) and ending with the midpoint of the hospital's cost reporting period that begins during fiscal year 2001. (v) Adjusting for locality.--The Secretary shall compute the product of-- (I) the national average per resident amount computed under clause (iv) for the hospital, and (II) the geographic index value average (described and applied under clause (ii)) for the fee schedule area in which the hospital is located. (vi) Computing locality adjusted amount.--The locality adjusted national per resident amount for a hospital for-- (I) the cost reporting period beginning during fiscal year 2001 is the product computed under clause (v); or (II) each subsequent cost reporting period is equal to the locality adjusted national per resident amount for the hospital for the previous cost reporting period (as determined under this clause) updated, through the midpoint of the period, by projecting the estimated percentage change in the consumer price index for all urban consumers during the 12-month period ending at that midpoint. (F) Treatment of certain hospitals.--(i) In the case of a hospital that did not have an approved medical residency training program or was not participating in the program under this title for a cost reporting period beginning during fiscal year 1984, the Secretary shall, for the first such period for which it has such a residency training program and is participating under this title, provide for such approved FTE resident amount as the Secretary determines to be appropriate, based on approved FTE resident amounts for comparable programs. (ii) In applying this subparagraph in the case of a hospital that trains residents and has not entered into a GME affiliation agreement (as defined by the Secretary for purposes of paragraph (4)(H)(ii)), on or after the date of the enactment of this clause, the Secretary shall not establish an FTE resident amount until such time as the Secretary determines that the hospital has trained at least 1.0 full-time-equivalent resident in an approved medical residency training program in a cost reporting period. (iii) In applying this subparagraph for cost reporting periods beginning on or after the date of enactment of this clause, in the case of a hospital that, as of such date of enactment, has an approved FTE resident amount based on the training in an approved medical residency program or programs of-- (I) less than 1.0 full-time- equivalent resident in any cost reporting period beginning before October 1, 1997, as determined by the Secretary; or (II) no more than 3.0 full-time- equivalent residents in any cost reporting period beginning on or after October 1, 1997, and before the date of the enactment of this clause, as determined by the Secretary, in lieu of such FTE resident amount the Secretary shall, in accordance with the methodology described in section 413.77(e) of title 42 of the Code of Federal Regulations (or any successor regulation), establish a new FTE resident amount if the hospital trains at least 1.0 full-time-equivalent resident (in the case of a hospital described in subclause (I)) or more than 3.0 full-time-equivalent residents (in the case of a hospital described in subclause (II)) in a cost reporting period beginning on or after such date of enactment and before the date that is 5 years after such date of enactment. (iv) For purposes of carrying out this subparagraph for cost reporting periods beginning on or after the date of the enactment of this clause, a hospital shall report full- time-equivalent residents on its cost report for a cost reporting period if the hospital trains at least 1.0 full-time-equivalent residents in an approved medical residency training program or programs in such period. (v) As appropriate, the Secretary may consider information from any cost reporting period necessary to establish a new FTE resident amount as described in clause (iii). (3) Hospital payment amount per resident.-- (A) In general.--The payment amount, for a hospital cost reporting period beginning on or after July 1, 1985, is equal to the product of-- (i) the aggregate approved amount (as defined in subparagraph (B)) for that period, and (ii) the hospital's medicare patient load (as defined in subparagraph (C)) for that period. (B) Aggregate approved amount.--As used in subparagraph (A), the term ``aggregate approved amount'' means, for a hospital cost reporting period, the product of-- (i) the hospital's approved FTE resident amount (determined under paragraph (2)) for that period, and (ii) the weighted average number of full-time-equivalent residents (as determined under paragraph (4)) in the hospital's approved medical residency training programs in that period. The Secretary shall reduce the aggregate approved amount to the extent payment is made under subsection (k) for residents included in the hospital's count of full-time equivalent residents. (C) Medicare patient load.--As used in subparagraph (A), the term ``medicare patient load'' means, with respect to a hospital's cost reporting period, the fraction of the total number of inpatient-bed-days (as established by the Secretary) during the period which are attributable to patients with respect to whom payment may be made under part A. (D) Payment for managed care enrollees.-- (i) In general.--For portions of cost reporting periods occurring on or after January 1, 1998, the Secretary shall provide for an additional payment amount under this subsection for services furnished to individuals who are enrolled under a risk-sharing contract with an eligible organization under section 1876 and who are entitled to part A or with a Medicare+Choice organization under part C. The amount of such a payment shall equal, subject to clause (iii), the applicable percentage of the product of-- (I) the aggregate approved amount (as defined in subparagraph (B)) for that period; and (II) the fraction of the total number of inpatient-bed days (as established by the Secretary) during the period which are attributable to such enrolled individuals. (ii) Applicable percentage.--For purposes of clause (i), the applicable percentage is-- (I) 20 percent in 1998, (II) 40 percent in 1999, (III) 60 percent in 2000, (IV) 80 percent in 2001, and (V) 100 percent in 2002 and subsequent years. (iii) Proportional reduction for nursing and allied health education.-- The Secretary shall estimate a proportional adjustment in payments to all hospitals determined under clauses (i) and (ii) for portions of cost reporting periods beginning in a year (beginning with 2000) such that the proportional adjustment reduces payments in an amount for such year equal to the total additional payment amounts for nursing and allied health education determined under subsection (l) for portions of cost reporting periods occurring in that year. (iv) Special rule for hospitals under reimbursement system.--The Secretary shall establish rules for the application of this subparagraph to a hospital reimbursed under a reimbursement system authorized under section 1814(b)(3) in the same manner as it would apply to the hospital if it were not reimbursed under such section. (4) Determination of full-time-equivalent residents.-- (A) Rules.--The Secretary shall establish rules consistent with this paragraph for the computation of the number of full-time- equivalent residents in an approved medical residency training program. (B) Adjustment for part-year or part-time residents.--Such rules shall take into account individuals who serve as residents for only a portion of a period with a hospital or simultaneously with more than one hospital. (C) Weighting factors for certain residents.--Subject to subparagraph (D), such rules shall provide, in calculating the number of full-time-equivalent residents in an approved residency program-- (i) before July 1, 1986, for each resident the weighting factor is 1.00, (ii) on or after July 1, 1986, for a resident who is in the resident's initial residency period (as defined in paragraph (5)(F)), the weighting factor is 1.00, (iii) on or after July 1, 1986, and before July 1, 1987, for a resident who is not in the resident's initial residency period (as defined in paragraph (5)(F)), the weighting factor is .75, and (iv) on or after July 1, 1987, for a resident who is not in the resident's initial residency period (as defined in paragraph (5)(F)), the weighting factor is .50. (D) Foreign medical graduates required to pass fmgems examination.-- (i) In general.--Except as provided in clause (ii), such rules shall provide that, in the case of an individual who is a foreign medical graduate (as defined in paragraph (5)(D)), the individual shall not be counted as a resident on or after July 1, 1986, unless-- (I) the individual has passed the FMGEMS examination (as defined in paragraph (5)(E)), or (II) the individual has previously received certification from, or has previously passed the examination of, the Educational Commission for Foreign Medical Graduates. (ii) Transition for current fmgs.--On or after July 1, 1986, but before July 1, 1987, in the case of a foreign medical graduate who-- (I) has served as a resident before July 1, 1986, and is serving as a resident after that date, but (II) has not passed the FMGEMS examination or a previous examination of the Educational Commission for Foreign Medical Graduates before July 1, 1986, the individual shall be counted as a resident at a rate equal to one-half of the rate at which the individual would otherwise be counted. (E) Counting time spent in outpatient settings.--Subject to subparagraphs (J) and (K), such rules shall provide that only time spent in activities relating to patient care shall be counted and that-- (i) effective for cost reporting periods beginning before July 1, 2010, all the time; (ii) effective for cost reporting periods beginning on or after July 1, 2010, all the time so spent by a resident shall be counted towards the determination of full-time equivalency, without regard to the setting in which the activities are performed, if a hospital incurs the costs of the stipends and fringe benefits of the resident during the time the resident spends in that setting. If more than one hospital incurs these costs, either directly or through a third party, such hospitals shall count a proportional share of the time, as determined by written agreement between the hospitals, that a resident spends training in that setting. so spent by a resident under an approved medical residency training program shall be counted towards the determination of full-time equivalency, without regard to the setting in which the activities are performed, if the hospital incurs all, or substantially all, of the costs for the training program in that setting. Any hospital claiming under this subparagraph for time spent in a nonprovider setting shall maintain and make available to the Secretary records regarding the amount of such time and such amount in comparison with amounts of such time in such base year as the Secretary shall specify. (F) Limitation on number of residents in allopathic and osteopathic medicine.-- (i) In general.--Such rules shall provide that for purposes of a cost reporting period beginning on or after October 1, 1997, subject to paragraphs (7) and (8), the total number of full- time equivalent residents before application of weighting factors (as determined under this paragraph) with respect to a hospital's approved medical residency training program in the fields of allopathic medicine and osteopathic medicine may not exceed the number (or, 130 percent of such number in the case of a hospital located in a rural area) of such full-time equivalent residents for the hospital's most recent cost reporting period ending on or before December 31, 1996. (ii) Counting primary care residents on certain approved leaves of absence in base year fte count.-- (I) In general.--In determining the number of such full-time equivalent residents for a hospital's most recent cost reporting period ending on or before December 31, 1996, for purposes of clause (i), the Secretary shall count an individual to the extent that the individual would have been counted as a primary care resident for such period but for the fact that the individual, as determined by the Secretary, was on maternity or disability leave or a similar approved leave of absence. (II) Limitation to 3 fte residents for any hospital.-- The total number of individuals counted under subclause (I) for a hospital may not exceed 3 full-time equivalent residents. (G) Counting interns and residents for fy 1998 and subsequent years.-- (i) In general.--For cost reporting periods beginning during fiscal years beginning on or after October 1, 1997, subject to the limit described in subparagraph (F), the total number of full-time equivalent residents for determining a hospital's graduate medical education payment shall equal the average of the actual full-time equivalent resident counts for the cost reporting period and the preceding two cost reporting periods. (ii) Adjustment for short periods.-- If any cost reporting period beginning on or after October 1, 1997, is not equal to twelve months, the Secretary shall make appropriate modifications to ensure that the average full-time equivalent resident counts pursuant to clause (i) are based on the equivalent of full twelve-month cost reporting periods. (iii) Transition rule for 1998.--In the case of a hospital's first cost reporting period beginning on or after October 1, 1997, clause (i) shall be applied by using the average for such period and the preceding cost reporting period. (H) Special rules for application of subparagraphs (f) and (g).-- (i) New facilities.--(I) The Secretary shall, consistent with the principles of subparagraphs (F) and (G) and subject to paragraphs (7) and (8), prescribe rules for the application of such subparagraphs in the case of medical residency training programs established on or after January 1, 1995. In promulgating such rules for purposes of subparagraph (F), the Secretary shall give special consideration to facilities that meet the needs of underserved rural areas. (II) In applying this clause in the case of a hospital that, on or after the date of the enactment of this subclause, begins training residents in a new approved medical residency training program or programs (as defined by the Secretary), the Secretary shall not determine a limitation applicable to the hospital under subparagraph (F) until such time as the Secretary determines that the hospital has trained at least 1.0 full- time-equivalent resident in such new approved medical residency training program or programs in a cost reporting period. (III) In applying this clause in the case of a hospital that, as of the date of the enactment of this subclause, has a limitation under subparagraph (F), based on a cost reporting period beginning before October 1, 1997, of less than 1.0 full-time-equivalent resident, the Secretary shall adjust the limitation in the manner applicable to a new approved medical residency training program if the Secretary determines the hospital begins training at least 1.0 full-time-equivalent residents in a program year beginning on or after such date of enactment and before the date that is 5 years after such date of enactment. (IV) In applying this clause in the case of a hospital that, as of the date of the enactment of this subclause, has a limitation under subparagraph (F), based on a cost reporting period beginning on or after October 1, 1997, and before such date of enactment, of no more than 3.0 full-time-equivalent residents, the Secretary shall adjust the limitation in the manner applicable to a new approved medical residency training program if the Secretary determines the hospital begins training more than 3.0 full-time-equivalent residents in a program year beginning on or after such date of enactment and before the date that is 5 years after such date of enactment. (V) An adjustment to the limitation applicable to a hospital made pursuant to subclause (III) or (IV) shall be made in a manner consistent with the methodology, as appropriate, in section 413.79(e) of title 42, Code of Federal Regulations (or any successor regulation). As appropriate, the Secretary may consider information from any cost reporting periods necessary to make such an adjustment to the limitation. (ii) Aggregation.--The Secretary may prescribe rules which allow institutions which are members of the same affiliated group (as defined by the Secretary) to elect to apply the limitation of subparagraph (F) on an aggregate basis. (iii) Data collection.--The Secretary may require any entity that operates a medical residency training program and to which subparagraphs (F) and (G) apply to submit to the Secretary such additional information as the Secretary considers necessary to carry out such subparagraphs. (iv) Nonrural hospitals operating training programs in rural areas.--In the case of a hospital that is not located in a rural area but establishes separately accredited approved medical residency training programs (or rural tracks) in [an rural area] a rural area or has an accredited training program with an integrated rural track, the Secretary shall adjust the limitation under subparagraph (F) in an appropriate manner insofar as it applies to such programs in such rural areas in order to encourage the training of physicians in rural areas. (v) Special provider agreement.--If an entity enters into a provider agreement pursuant to section 1866(a) to provide hospital services on the same physical site previously used by Medicare Provider No. 05-0578-- (I) the limitation on the number of total full time equivalent residents under subparagraph (F) and clauses (v) and (vi)(I) of subsection (d)(5)(B) applicable to such provider shall be equal to the limitation applicable under such provisions to Provider No. 05-0578 for its cost reporting period ending on June 30, 2006; and (II) the provisions of subparagraph (G) and subsection (d)(5)(B)(vi)(II) shall not be applicable to such provider for the first three cost reporting years in which such provider trains residents under any approved medical residency training program. (vi) Redistribution of residency slots after a hospital closes.-- (I) In general.--Subject to the succeeding provisions of this clause, the Secretary shall, by regulation, establish a process under which, in the case where a hospital (other than a hospital described in clause (v)) with an approved medical residency program closes on or after a date that is 2 years before the date of enactment of this clause, the Secretary shall increase the otherwise applicable resident limit under this paragraph for other hospitals in accordance with this clause. (II) Priority for hospitals in certain areas.--Subject to the succeeding provisions of this clause, in determining for which hospitals the increase in the otherwise applicable resident limit is provided under such process, the Secretary shall distribute the increase to hospitals in the following priority order (with preference given within each category to hospitals that are members of the same affiliated group (as defined by the Secretary under clause (ii)) as the closed hospital): (aa) First, to hospitals located in the same core-based statistical area as, or a core-based statistical area contiguous to, the hospital that closed. (bb) Second, to hospitals located in the same State as the hospital that closed. (cc) Third, to hospitals located in the same region of the country as the hospital that closed. (dd) Fourth, only if the Secretary is not able to distribute the increase to hospitals described in item (cc), to qualifying hospitals in accordance with the provisions of paragraph (8). (III) Requirement hospital likely to fill position within certain time period.--The Secretary may only increase the otherwise applicable resident limit of a hospital under such process if the Secretary determines the hospital has demonstrated a likelihood of filling the positions made available under this clause within 3 years. (IV) Limitation.--The aggregate number of increases in the otherwise applicable resident limits for hospitals under this clause shall be equal to the number of resident positions in the approved medical residency programs that closed on or after the date described in subclause (I). (V) Administration.--Chapter 35 of title 44, United States Code, shall not apply to the implementation of this clause. (J) Treatment of certain nonprovider and didactic activities.--Such rules shall provide that all time spent by an intern or resident in an approved medical residency training program in a nonprovider setting that is primarily engaged in furnishing patient care (as defined in paragraph (5)(K)) in non-patient care activities, such as didactic conferences and seminars, but not including research not associated with the treatment or diagnosis of a particular patient, as such time and activities are defined by the Secretary, shall be counted toward the determination of full-time equivalency. (K) Treatment of certain other activities.-- In determining the hospital's number of full- time equivalent residents for purposes of this subsection, all the time that is spent by an intern or resident in an approved medical residency training program on vacation, sick leave, or other approved leave, as such time is defined by the Secretary, and that does not prolong the total time the resident is participating in the approved program beyond the normal duration of the program shall be counted toward the determination of full-time equivalency. (5) Definitions and special rules.--As used in this subsection: (A) Approved medical residency training program.--The term ``approved medical residency training program'' means a residency or other postgraduate medical training program participation in which may be counted toward certification in a specialty or subspecialty and includes formal postgraduate training programs in geriatric medicine approved by the Secretary. (B) Consumer price index.--The term ``consumer price index'' refers to the Consumer Price Index for All Urban Consumers (United States city average), as published by the Secretary of Commerce. (C) Direct graduate medical education costs.--The term ``direct graduate medical education costs'' means direct costs of approved educational activities for approved medical residency training programs. (D) Foreign medical graduate.--The term ``foreign medical graduate'' means a resident who is not a graduate of-- (i) a school of medicine accredited by the Liaison Committee on Medical Education of the American Medical Association and the Association of American Medical Colleges (or approved by such Committee as meeting the standards necessary for such accreditation), (ii) a school of osteopathy accredited by the American Osteopathic Association, or approved by such Association as meeting the standards necessary for such accreditation, or (iii) a school of dentistry or podiatry which is accredited (or meets the standards for accreditation) by an organization recognized by the Secretary for such purpose. (E) FMGEMS examination.--The term ``FMGEMS examination'' means parts I and II of the Foreign Medical Graduate Examination in the Medical Sciences or any successor examination recognized by the Secretary for this purpose. (F) Initial residency period.--The term ``initial residency period'' means the period of board eligibility, except that-- (i) except as provided in clause (ii), in no case shall the initial period of residency exceed an aggregate period of formal training of more than five years for any individual, and (ii) a period, of not more than two years, during which an individual is in a geriatric residency or fellowship program or a preventive medicine residency or fellowship program which meets such criteria as the Secretary may establish, shall be treated as part of the initial residency period, but shall not be counted against any limitation on the initial residency period. Subject to subparagraph (G)(v), the initial residency period shall be determined, with respect to a resident, as of the time the resident enters the residency training program. (G) Period of board eligibility.-- (i) General rule.--Subject to clauses (ii), (iii), (iv), and (v), the term ``period of board eligibility'' means, for a resident, the minimum number of years of formal training necessary to satisfy the requirements for initial board eligibility in the particular specialty for which the resident is training. (ii) Application of 1985-1986 directory.--Except as provided in clause (iii), the period of board eligibility shall be such period specified in the 1985-1986 Directory of Residency Training Programs published by the Accreditation Council on Graduate Medical Education. (iii) Changes in period of board eligibility.--On or after July 1, 1989, if the Accreditation Council on Graduate Medical Education, in its Directory of Residency Training Programs-- (I) increases the minimum number of years of formal training necessary to satisfy the requirements for a specialty, above the period specified in its 1985-1986 Directory, the Secretary may increase the period of board eligibility for that specialty, but not to exceed the period of board eligibility specified in that later Directory, or (II) decreases the minimum number of years of formal training necessary to satisfy the requirements for a specialty, below the period specified in its 1985-1986 Directory, the Secretary may decrease the period of board eligibility for that specialty, but not below the period of board eligibility specified in that later Directory. (iv) Special rule for certain primary care combined residency programs.--(I) In the case of a resident enrolled in a combined medical residency training program in which all of the individual programs (that are combined) are for training a primary care resident (as defined in subparagraph (H)), the period of board eligibility shall be the minimum number of years of formal training required to satisfy the requirements for initial board eligibility in the longest of the individual programs plus one additional year. (II) A resident enrolled in a combined medical residency training program that includes an obstetrics and gynecology program shall qualify for the period of board eligibility under subclause (I) if the other programs such resident combines with such obstetrics and gynecology program are for training a primary care resident. (v) Child neurology training programs.--In the case of a resident enrolled in a child neurology residency training program, the period of board eligibility and the initial residency period shall be the period of board eligibility for pediatrics plus 2 years. (H) Primary care resident.--The term ``primary care resident'' means a resident enrolled in an approved medical residency training program in family medicine, general internal medicine, general pediatrics, preventive medicine, geriatric medicine, or osteopathic general practice. (I) Resident.--The term ``resident'' includes an intern or other participant in an approved medical residency training program. (J) Adjustments for certain family practice residency programs.-- (i) In general.--In the case of an approved medical residency training program (meeting the requirements of clause (ii)) of a hospital which received funds from the United States, a State, or a political subdivision of a State or an instrumentality of such a State or political subdivision (other than payments under this title or a State plan under title XIX) for the program during the cost reporting period that began during fiscal year 1984, the Secretary shall-- (I) provide for an average amount under paragraph (2)(A) that takes into account the Secretary's estimate of the amount that would have been recognized as reasonable under this title if the hospital had not received such funds, and (II) reduce the payment amount otherwise provided under this subsection in an amount equal to the proportion of such program funds received during the cost reporting period involved that is allocable to this title. (ii) Additional requirements.--A hospital's approved medical residency program meets the requirements of this clause if-- (I) the program is limited to training for family and community medicine; (II) the program is the only approved medical residency program of the hospital; and (III) the average amount determined under paragraph (2)(A) for the hospital (as determined without regard to the increase in such amount described in clause (i)(I)) does not exceed $10,000. (K) Nonprovider setting that is primarily engaged in furnishing patient care.--The term ``nonprovider setting that is primarily engaged in furnishing patient care'' means a nonprovider setting in which the primary activity is the care and treatment of patients, as defined by the Secretary. (6) Incentive payment under plans for voluntary reduction in number of residents.-- (A) In general.--In the case of a voluntary residency reduction plan for which an application is approved under subparagraph (B), subject to subparagraph (F), each hospital which is part of the qualifying entity submitting the plan shall be paid an applicable hold harmless percentage (as specified in subparagraph (E)) of the sum of-- (i) the amount (if any) by which-- (I) the amount of payment which would have been made under this subsection if there had been a 5-percent reduction in the number of full-time equivalent residents in the approved medical education training programs of the hospital as of June 30, 1997, exceeds (II) the amount of payment which is made under this subsection, taking into account the reduction in such number effected under the reduction plan; and (ii) the amount of the reduction in payment under subsection (d)(5)(B) for the hospital that is attributable to the reduction in number of residents effected under the plan below 95 percent of the number of full-time equivalent residents in such programs of the hospital as of June 30, 1997. The determination of the amounts under clauses (i) and (ii) for any year shall be made on the basis of the provisions of this title in effect on the application deadline date for the first calendar year to which the reduction plan applies. (B) Approval of plan applications.--The Secretary may not approve the application of an qualifying entity unless-- (i) the application is submitted in a form and manner specified by the Secretary and by not later than November 1, 1999, (ii) the application provides for the operation of a plan for the reduction in the number of full-time equivalent residents in the approved medical residency training programs of the entity consistent with the requirements of subparagraph (D); (iii) the entity elects in the application the period of residency training years (not greater than 5) over which the reduction will occur; (iv) the entity will not reduce the proportion of its residents in primary care (to the total number of residents) below such proportion as in effect as of the applicable time described in subparagraph (D)(v); and (v) the Secretary determines that the application and the entity and such plan meet such other requirements as the Secretary specifies in regulations. (C) Qualifying entity.--For purposes of this paragraph, any of the following may be a qualifying entity: (i) Individual hospitals operating one or more approved medical residency training programs. (ii) Two or more hospitals that operate such programs and apply for treatment under this paragraph as a single qualifying entity. (iii) A qualifying consortium (as described in section 4628 of the Balanced Budget Act of 1997). (D) Residency reduction requirements.-- (i) Individual hospital applicants.-- In the case of a qualifying entity described in subparagraph (C)(i), the number of full-time equivalent residents in all the approved medical residency training programs operated by or through the entity shall be reduced as follows: (I) If the base number of residents exceeds 750 residents, by a number equal to at least 20 percent of such base number. (II) Subject to subclause (IV), if the base number of residents exceeds 600 but is less than 750 residents, by 150 residents. (III) Subject to subclause (IV), if the base number of residents does not exceed 600 residents, by a number equal to at least 25 percent of such base number. (IV) In the case of a qualifying entity which is described in clause (v) and which elects treatment under this subclause, by a number equal to at least 20 percent of the base number. (ii) Joint applicants.--In the case of a qualifying entity described in subparagraph (C)(ii), the number of full-time equivalent residents in the aggregate for all the approved medical residency training programs operated by or through the entity shall be reduced as follows: (I) Subject to subclause (II), by a number equal to at least 25 percent of the base number. (II) In the case of such a qualifying entity which is described in clause (v) and which elects treatment under this subclause, by a number equal to at least 20 percent of the base number. (iii) Consortia.--In the case of a qualifying entity described in subparagraph (C)(iii), the number of full-time equivalent residents in the aggregate for all the approved medical residency training programs operated by or through the entity shall be reduced by a number equal to at least 20 percent of the base number. (iv) Manner of reduction.--The reductions specified under the preceding provisions of this subparagraph for a qualifying entity shall be below the base number of residents for that entity and shall be fully effective not later than the 5th residency training year in which the application under subparagraph (B) is effective. (v) Entities providing assurance of increase in primary care residents.--An entity is described in this clause if-- (I) the base number of residents for the entity is less than 750 or the entity is described in subparagraph (C)(ii); and (II) the entity represents in its application under subparagraph (B) that it will increase the number of full- time equivalent residents in primary care by at least 20 percent (from such number included in the base number of residents) by not later than the 5th residency training year in which the application under subparagraph (B) is effective. If a qualifying entity fails to comply with the representation described in subclause (II) by the end of such 5th residency training year, the entity shall be subject to repayment of all amounts paid under this paragraph, in accordance with procedures established to carry out subparagraph (F). (vi) Base number of residents defined.--For purposes of this paragraph, the term ``base number of residents'' means, with respect to a qualifying entity (or its participating hospitals) operating approved medical residency training programs, the number of full-time equivalent residents in such programs (before application of weighting factors) of the entity as of the most recent residency training year ending before June 30, 1997, or, if less, for any subsequent residency training year that ends before the date the entity makes application under this paragraph. (E) Applicable hold harmless percentage.--For purposes of subparagraph (A), the ``applicable hold harmless percentage'' for the-- (i) first and second residency training years in which the reduction plan is in effect, 100 percent, (ii) third such year, 75 percent, (iii) fourth such year, 50 percent, and (iv) fifth such year, 25 percent. (F) Penalty for noncompliance.-- (i) In general.--No payment may be made under this paragraph to a hospital for a residency training year if the hospital has failed to reduce the number of full-time equivalent residents (in the manner required under subparagraph (D)) to the number agreed to by the Secretary and the qualifying entity in approving the application under this paragraph with respect to such year. (ii) Increase in number of residents in subsequent years.--If payments are made under this paragraph to a hospital, and if the hospital increases the number of full-time equivalent residents above the number of such residents permitted under the reduction plan as of the completion of the plan, then, as specified by the Secretary, the entity is liable for repayment to the Secretary of the total amounts paid under this paragraph to the entity. (G) Treatment of rotating residents.--In applying this paragraph, the Secretary shall establish rules regarding the counting of residents who are assigned to institutions the medical residency training programs in which are not covered under approved applications under this paragraph. (7) Redistribution of unused resident positions.-- (A) Reduction in limit based on unused positions.-- (i) Programs subject to reduction.-- (I) In general.--Except as provided in subclause (II), if a hospital's reference resident level (specified in clause (ii)) is less than the otherwise applicable resident limit (as defined in subparagraph (C)(ii)), effective for portions of cost reporting periods occurring on or after July 1, 2005, the otherwise applicable resident limit shall be reduced by 75 percent of the difference between such otherwise applicable resident limit and such reference resident level. (II) Exception for small rural hospitals.--This subparagraph shall not apply to a hospital located in a rural area (as defined in subsection (d)(2)(D)(ii)) with fewer than 250 acute care inpatient beds. (ii) Reference resident level.-- (I) In general.--Except as otherwise provided in subclauses (II) and (III), the reference resident level specified in this clause for a hospital is the resident level for the most recent cost reporting period of the hospital ending on or before September 30, 2002, for which a cost report has been settled (or, if not, submitted (subject to audit)), as determined by the Secretary. (II) Use of most recent accounting period to recognize expansion of existing programs.--If a hospital submits a timely request to increase its resident level due to an expansion of an existing residency training program that is not reflected on the most recent settled cost report, after audit and subject to the discretion of the Secretary, the reference resident level for such hospital is the resident level for the cost reporting period that includes July 1, 2003, as determined by the Secretary. (III) Expansions under newly approved programs.--Upon the timely request of a hospital, the Secretary shall adjust the reference resident level specified under subclause (I) or (II) to include the number of medical residents that were approved in an application for a medical residency training program that was approved by an appropriate accrediting organization (as determined by the Secretary) before January 1, 2002, but which was not in operation during the cost reporting period used under subclause (I) or (II), as the case may be, as determined by the Secretary. (iii) Affiliation.--The provisions of clause (i) shall be applied to hospitals which are members of the same affiliated group (as defined by the Secretary under paragraph (4)(H)(ii)) as of July 1, 2003. (B) Redistribution.-- (i) In general.--The Secretary is authorized to increase the otherwise applicable resident limit for each qualifying hospital that submits a timely application under this subparagraph by such number as the Secretary may approve for portions of cost reporting periods occurring on or after July 1, 2005. The aggregate number of increases in the otherwise applicable resident limits under this subparagraph may not exceed the Secretary's estimate of the aggregate reduction in such limits attributable to subparagraph (A). (ii) Considerations in redistribution.--In determining for which hospitals the increase in the otherwise applicable resident limit is provided under clause (i), the Secretary shall take into account the demonstrated likelihood of the hospital filling the positions within the first 3 cost reporting periods beginning on or after July 1, 2005, made available under this subparagraph, as determined by the Secretary. (iii) Priority for rural and small urban areas.--In determining for which hospitals and residency training programs an increase in the otherwise applicable resident limit is provided under clause (i), the Secretary shall distribute the increase to programs of hospitals located in the following priority order: (I) First, to hospitals located in rural areas (as defined in subsection (d)(2)(D)(ii)). (II) Second, to hospitals located in urban areas that are not large urban areas (as defined for purposes of subsection (d)). (III) Third, to other hospitals in a State if the residency training program involved is in a specialty for which there are not other residency training programs in the State. Increases of residency limits within the same priority category under this clause shall be determined by the Secretary. (iv) Limitation.--In no case shall more than 25 full-time equivalent additional residency positions be made available under this subparagraph with respect to any hospital. (v) Application of locality adjusted national average per resident amount.-- With respect to additional residency positions in a hospital attributable to the increase provided under this subparagraph, notwithstanding any other provision of this subsection, the approved FTE resident amount is deemed to be equal to the locality adjusted national average per resident amount computed under paragraph (4)(E) for that hospital. (vi) Construction.--Nothing in this subparagraph shall be construed as permitting the redistribution of reductions in residency positions attributable to voluntary reduction programs under paragraph (6), under a demonstration project approved as of October 31, 2003, under the authority of section 402 of Public Law 90-248, or as affecting the ability of a hospital to establish new medical residency training programs under paragraph (4)(H). (C) Resident level and limit defined.--In this paragraph: (i) Resident level.--The term ``resident level'' means, with respect to a hospital, the total number of full-time equivalent residents, before the application of weighting factors (as determined under paragraph (4)), in the fields of allopathic and osteopathic medicine for the hospital. (ii) Otherwise applicable resident limit.--The term ``otherwise applicable resident limit'' means, with respect to a hospital, the limit otherwise applicable under subparagraphs (F)(i) and (H) of paragraph (4) on the resident level for the hospital determined without regard to this paragraph. (D) Adjustment based on settled cost report.--In the case of a hospital with a dual accredited osteopathic and allopathic family practice program for which-- (i) the otherwise applicable resident limit was reduced under subparagraph (A)(i)(I); and (ii) such reduction was based on a reference resident level that was determined using a cost report and where a revised or corrected notice of program reimbursement was issued for such cost report between September 1, 2006 and September 15, 2006, whether as a result of an appeal or otherwise, and the reference resident level under such settled cost report is higher than the level used for the reduction under subparagraph (A)(i)(I); the Secretary shall apply subparagraph (A)(i)(I) using the higher resident reference level and make any necessary adjustments to such reduction. Any such necessary adjustments shall be effective for portions of cost reporting periods occurring on or after July 1, 2005. (E) Judicial review.--There shall be no administrative or judicial review under section 1869, 1878, or otherwise, with respect to determinations made [under this this paragraph, paragraph (8), or paragraph (4)(H)(vi).] under this paragraph, paragraph (8), clause (i), (ii), (iii), or (v) of paragraph (2)(F), or clause (i) or (vi) of paragraph (4)(H). (8) Distribution of additional residency positions.-- (A) Reductions in limit based on unused positions.-- (i) In general.--Except as provided in clause (ii), if a hospital's reference resident level (as defined in subparagraph (H)(i)) is less than the otherwise applicable resident limit (as defined in subparagraph (H)(iii)), effective for portions of cost reporting periods occurring on or after July 1, 2011, the otherwise applicable resident limit shall be reduced by 65 percent of the difference between such otherwise applicable resident limit and such reference resident level. (ii) Exceptions.--This subparagraph shall not apply to-- (I) a hospital located in a rural area (as defined in subsection (d)(2)(D)(ii)) with fewer than 250 acute care inpatient beds; (II) a hospital that was part of a qualifying entity which had a voluntary residency reduction plan approved under paragraph (6)(B) or under the authority of section 402 of Public Law 90-248, if the hospital demonstrates to the Secretary that it has a specified plan in place for filling the unused positions by not later than 2 years after the date of enactment of this paragraph; or (III) a hospital described in paragraph (4)(H)(v). (B) Distribution.-- (i) In general.--The Secretary shall increase the otherwise applicable resident limit for each qualifying hospital that submits an application under this subparagraph by such number as the Secretary may approve for portions of cost reporting periods occurring on or after July 1, 2011. The aggregate number of increases in the otherwise applicable resident limit under this subparagraph shall be equal to the aggregate reduction in such limits attributable to subparagraph (A) (as estimated by the Secretary). (ii) Requirements.--Subject to clause (iii), a hospital that receives an increase in the otherwise applicable resident limit under this subparagraph shall ensure, during the 5-year period beginning on the date of such increase, that-- (I) the number of full-time equivalent primary care residents, as defined in paragraph (5)(H) (as determined by the Secretary), excluding any additional positions under subclause (II), is not less than the average number of full-time equivalent primary care residents (as so determined) during the 3 most recent cost reporting periods ending prior to the date of enactment of this paragraph; and (II) not less than 75 percent of the positions attributable to such increase are in a primary care or general surgery residency (as determined by the Secretary). The Secretary may determine whether a hospital has met the requirements under this clause during such 5-year period in such manner and at such time as the Secretary determines appropriate, including at the end of such 5-year period. (iii) Redistribution of positions if hospital no longer meets certain requirements.--In the case where the Secretary determines that a hospital described in clause (ii) does not meet either of the requirements under subclause (I) or (II) of such clause, the Secretary shall-- (I) reduce the otherwise applicable resident limit of the hospital by the amount by which such limit was increased under this paragraph; and (II) provide for the distribution of positions attributable to such reduction in accordance with the requirements of this paragraph. (C) Considerations in redistribution.--In determining for which hospitals the increase in the otherwise applicable resident limit is provided under subparagraph (B), the Secretary shall take into account-- (i) the demonstration likelihood of the hospital filling the positions made available under this paragraph within the first 3 cost reporting periods beginning on or after July 1, 2011, as determined by the Secretary; and (ii) whether the hospital has an accredited rural training track (as described in paragraph (4)(H)(iv)). (D) Priority for certain areas.--In determining for which hospitals the increase in the otherwise applicable resident limit is provided under subparagraph (B), subject to subparagraph (E), the Secretary shall distribute the increase to hospitals based on the following factors: (i) Whether the hospital is located in a State with a resident-to- population ratio in the lowest quartile (as determined by the Secretary). (ii) Whether the hospital is located in a State, a territory of the United States, or the District of Columbia that is among the top 10 States, territories, or Districts in terms of the ratio of-- (I) the total population of the State, territory, or District living in an area designated (under such section 332(a)(1)(A)) as a health professional shortage area (as of the date of enactment of this paragraph); to (II) the total population of the State, territory, or District (as determined by the Secretary based on the most recent available population data published by the Bureau of the Census). (iii) Whether the hospital is located in a rural area (as defined in subsection (d)(2)(D)(ii)). (E) Reservation of positions for certain hospitals.-- (i) In general.--Subject to clause (ii), the Secretary shall reserve the positions available for distribution under this paragraph as follows: (I) 70 percent of such positions for distribution to hospitals described in clause (i) of subparagraph (D). (II) 30 percent of such positions for distribution to hospitals described in clause (ii) and (iii) of such subparagraph. (ii) Exception if positions not redistributed by july 1, 2011.--In the case where the Secretary does not distribute positions to hospitals in accordance with clause (i) by July 1, 2011, the Secretary shall distribute such positions to other hospitals in accordance with the considerations described in subparagraph (C) and the priority described in subparagraph (D). (F) Limitation.--A hospital may not receive more than 75 full-time equivalent additional residency positions under this paragraph. (G) Application of per resident amounts for primary care and nonprimary care.--With respect to additional residency positions in a hospital attributable to the increase provided under this paragraph, the approved FTE per resident amounts are deemed to be equal to the hospital per resident amounts for primary care and nonprimary care computed under paragraph (2)(D) for that hospital. (H) Definitions.--In this paragraph: (i) Reference resident level.--The term ``reference resident level'' means, with respect to a hospital, the highest resident level for any of the 3 most recent cost reporting periods (ending before the date of the enactment of this paragraph) of the hospital for which a cost report has been settled (or, if not, submitted (subject to audit)), as determined by the Secretary. (ii) Resident level.--The term ``resident level'' has the meaning given such term in paragraph (7)(C)(i). (iii) Otherwise applicable resident limit.--The term ``otherwise applicable resident limit'' means, with respect to a hospital, the limit otherwise applicable under subparagraphs (F)(i) and (H) of paragraph (4) on the resident level for the hospital determined without regard to this paragraph but taking into account paragraph (7)(A). (I) Affiliation.--The provisions of this paragraph shall be applied to hospitals which are members of the same affiliated group (as defined by the Secretary under paragraph (4)(H)(ii)) and the reference resident level for each such hospital shall be the reference resident level with respect to the cost reporting period that results in the smallest difference between the reference resident level and the otherwise applicable resident limit. (i) Avoiding Duplicative Payments to Hospitals Participating in Rural Demonstration Programs.--The Secretary shall reduce any payment amounts otherwise determined under this section to the extent necessary to avoid duplication of any payment made under section 4005(e) of the Omnibus Budget Reconciliation Act of 1987. (j) Prospective Payment for Inpatient Rehabilitation Services.-- (1) Payment during transition period.-- (A) In general.--Notwithstanding section 1814(b), but subject to the provisions of section 1813, the amount of the payment with respect to the operating and capital costs of inpatient hospital services of a rehabilitation hospital or a rehabilitation unit (in this subsection referred to as a ``rehabilitation facility''), other than a facility making an election under subparagraph (F) in a cost reporting period beginning on or after October 1, 2000, and before October 1, 2002, is equal to the sum of-- (i) the TEFRA percentage (as defined in subparagraph (C)) of the amount that would have been paid under part A with respect to such costs if this subsection did not apply, and (ii) the prospective payment percentage (as defined in subparagraph (C)) of the product of (I) the per unit payment rate established under this subsection for the fiscal year in which the payment unit of service occurs, and (II) the number of such payment units occurring in the cost reporting period. (B) Fully implemented system.-- Notwithstanding section 1814(b), but subject to the provisions of section 1813, the amount of the payment with respect to the operating and capital costs of inpatient hospital services of a rehabilitation facility for a payment unit in a cost reporting period beginning on or after October 1, 2002, or, in the case of a facility making an election under subparagraph (F), for any cost reporting period described in such subparagraph, is equal to the per unit payment rate established under this subsection for the fiscal year in which the payment unit of service occurs. (C) TEFRA and prospective payment percentages specified.--For purposes of subparagraph (A), for a cost reporting period beginning-- (i) on or after October 1, 2000, and before October 1, 2001, the ``TEFRA percentage'' is 66\2/3\ percent and the ``prospective payment percentage'' is 33\1/3\ percent; and (ii) on or after October 1, 2001, and before October 1, 2002, the ``TEFRA percentage'' is 33\1/3\ percent and the ``prospective payment percentage'' is 66\2/3\ percent. (D) Payment unit.--For purposes of this subsection, the term ``payment unit'' means a discharge. (E) Construction relating to transfer authority.--Nothing in this subsection shall be construed as preventing the Secretary from providing for an adjustment to payments to take into account the early transfer of a patient from a rehabilitation facility to another site of care. (F) Election to apply full prospective payment system.--A rehabilitation facility may elect, not later than 30 days before its first cost reporting period for which the payment methodology under this subsection applies to the facility, to have payment made to the facility under this subsection under the provisions of subparagraph (B) (rather than subparagraph (A)) for each cost reporting period to which such payment methodology applies. (2) Patient case mix groups.-- (A) Establishment.--The Secretary shall establish-- (i) classes of patient discharges of rehabilitation facilities by functional-related groups (each in this subsection referred to as a ``case mix group''), based on impairment, age, comorbidities, and functional capability of the patient and such other factors as the Secretary deems appropriate to improve the explanatory power of functional independence measure-function related groups; and (ii) a method of classifying specific patients in rehabilitation facilities within these groups. (B) Weighting factors.--For each case mix group the Secretary shall assign an appropriate weighting which reflects the relative facility resources used with respect to patients classified within that group compared to patients classified within other groups. (C) Adjustments for case mix.-- (i) In general.--The Secretary shall from time to time adjust the classifications and weighting factors established under this paragraph as appropriate to reflect changes in treatment patterns, technology, case mix, number of payment units for which payment is made under this title, and other factors which may affect the relative use of resources. Such adjustments shall be made in a manner so that changes in aggregate payments under the classification system are a result of real changes and are not a result of changes in coding that are unrelated to real changes in case mix. (ii) Adjustment.--Insofar as the Secretary determines that such adjustments for a previous fiscal year (or estimates that such adjustments for a future fiscal year) did (or are likely to) result in a change in aggregate payments under the classification system during the fiscal year that are a result of changes in the coding or classification of patients that do not reflect real changes in case mix, the Secretary shall adjust the per payment unit payment rate for subsequent years so as to eliminate the effect of such coding or classification changes. (D) Data collection.--The Secretary is authorized to require rehabilitation facilities that provide inpatient hospital services to submit such data as the Secretary deems necessary to establish and administer the prospective payment system under this subsection. (3) Payment rate.-- (A) In general.--The Secretary shall determine a prospective payment rate for each payment unit for which such rehabilitation facility is entitled to receive payment under this title. Subject to subparagraph (B), such rate for payment units occurring during a fiscal year shall be based on the average payment per payment unit under this title for inpatient operating and capital costs of rehabilitation facilities using the most recent data available (as estimated by the Secretary as of the date of establishment of the system) adjusted-- (i) by updating such per-payment-unit amount to the fiscal year involved by the weighted average of the applicable percentage increases provided under subsection (b)(3)(B)(ii) (for cost reporting periods beginning during the fiscal year) covering the period from the midpoint of the period for such data through the midpoint of fiscal year 2000 and by an increase factor (described in subparagraph (C)) specified by the Secretary for subsequent fiscal years up to the fiscal year involved; (ii) by reducing such rates by a factor equal to the proportion of payments under this subsection (as estimated by the Secretary) based on prospective payment amounts which are additional payments described in paragraph (4) (relating to outlier and related payments); (iii) for variations among rehabilitation facilities by area under paragraph (6); (iv) by the weighting factors established under paragraph (2)(B); and (v) by such other factors as the Secretary determines are necessary to properly reflect variations in necessary costs of treatment among rehabilitation facilities. (B) Budget neutral rates.--The Secretary shall establish the prospective payment amounts under this subsection for payment units during fiscal years 2001 and 2002 at levels such that, in the Secretary's estimation, the amount of total payments under this subsection for such fiscal years (including any payment adjustments pursuant to paragraphs (4) and (6) but not taking into account any payment adjustment resulting from an election permitted under paragraph (1)(F)) shall be equal to 98 percent for fiscal year 2001 and 100 percent for fiscal year 2002 of the amount of payments that would have been made under this title during the fiscal years for operating and capital costs of rehabilitation facilities had this subsection not been enacted. In establishing such payment amounts, the Secretary shall consider the effects of the prospective payment system established under this subsection on the total number of payment units from rehabilitation facilities and other factors described in subparagraph (A). (C) Increase factor.-- (i) In general.--For purposes of this subsection for payment units in each fiscal year (beginning with fiscal year 2001), the Secretary shall establish an increase factor subject to clauses (ii) and (iii). Such factor shall be based on an appropriate percentage increase in a market basket of goods and services comprising services for which payment is made under this subsection, which may be the market basket percentage increase described in subsection (b)(3)(B)(iii). The increase factor to be applied under this subparagraph for each of fiscal years 2008 and 2009 shall be 0 percent. (ii) Productivity and other adjustment.--Subject to clause (iii), after establishing the increase factor described in clause (i) for a fiscal year, the Secretary shall reduce such increase factor-- (I) for fiscal year 2012 and each subsequent fiscal year, by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II); and (II) for each of fiscal years 2010 through 2019, by the other adjustment described in subparagraph (D). The application of this clause may result in the increase factor under this subparagraph being less than 0.0 for a fiscal year, and may result in payment rates under this subsection for a fiscal year being less than such payment rates for the preceding fiscal year. (iii) Special rule for fiscal year 2018.--The increase factor to be applied under this subparagraph for fiscal year 2018, after the application of clause (ii), shall be 1 percent. (D) Other adjustment.--For purposes of subparagraph (C)(ii)(II), the other adjustment described in this subparagraph is-- (i) for each of fiscal years 2010 and 2011, 0.25 percentage point; (ii) for each of fiscal years 2012 and 2013, 0.1 percentage point; (iii) for fiscal year 2014, 0.3 percentage point; (iv) for each of fiscal years 2015 and 2016, 0.2 percentage point; and (v) for each of fiscal years 2017, 2018, and 2019, 0.75 percentage point. (4) Outlier and special payments.-- (A) Outliers.-- (i) In general.--The Secretary may provide for an additional payment to a rehabilitation facility for patients in a case mix group, based upon the patient being classified as an outlier based on an unusual length of stay, costs, or other factors specified by the Secretary. (ii) Payment based on marginal cost of care.--The amount of such additional payment under clause (i) shall be determined by the Secretary and shall approximate the marginal cost of care beyond the cutoff point applicable under clause (i). (iii) Total payments.--The total amount of the additional payments made under this subparagraph for payment units in a fiscal year may not exceed 5 percent of the total payments projected or estimated to be made based on prospective payment rates for payment units in that year. (B) Adjustment.--The Secretary may provide for such adjustments to the payment amounts under this subsection as the Secretary deems appropriate to take into account the unique circumstances of rehabilitation facilities located in Alaska and Hawaii. (5) Publication.--The Secretary shall provide for publication in the Federal Register, on or before August 1 before each fiscal year (beginning with fiscal year 2001), of the classification and weighting factors for case mix groups under paragraph (2) for such fiscal year and a description of the methodology and data used in computing the prospective payment rates under this subsection for that fiscal year. (6) Area wage adjustment.--The Secretary shall adjust the proportion (as estimated by the Secretary from time to time) of rehabilitation facilities' costs which are attributable to wages and wage-related costs, of the prospective payment rates computed under paragraph (3) for area differences in wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the rehabilitation facility compared to the national average wage level for such facilities. Not later than October 1, 2001 (and at least every 36 months thereafter), the Secretary shall update the factor under the preceding sentence on the basis of information available to the Secretary (and updated as appropriate) of the wages and wage-related costs incurred in furnishing rehabilitation services. Any adjustments or updates made under this paragraph for a fiscal year shall be made in a manner that assures that the aggregated payments under this subsection in the fiscal year are not greater or less than those that would have been made in the year without such adjustment. (7) Quality reporting.-- (A) Reduction in update for failure to report.-- (i) In general.--For purposes of fiscal year 2014 and each subsequent fiscal year, in the case of a rehabilitation facility that does not submit data to the Secretary in accordance with subparagraphs (C) and (F) with respect to such a fiscal year, after determining the increase factor described in paragraph (3)(C), and after application of subparagraphs (C)(iii) and (D) of paragraph (3), the Secretary shall reduce such increase factor for payments for discharges occurring during such fiscal year by 2 percentage points. (ii) Special rule.--The application of this subparagraph may result in the increase factor described in paragraph (3)(C) being less than 0.0 for a fiscal year, and may result in payment rates under this subsection for a fiscal year being less than such payment rates for the preceding fiscal year. (B) Noncumulative application.--Any reduction under subparagraph (A) shall apply only with respect to the fiscal year involved and the Secretary shall not take into account such reduction in computing the payment amount under this subsection for a subsequent fiscal year. (C) Submission of quality data.--Subject to subparagraph (G), for fiscal year 2014 and each subsequent fiscal year, each rehabilitation facility shall submit to the Secretary data on quality measures specified under subparagraph (D). Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this subparagraph. (D) Quality measures.-- (i) In general.--Subject to clause (ii), any measure specified by the Secretary under this subparagraph must have been endorsed by the entity with a contract under section 1890(a). (ii) Exception.--In the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1890(a), the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary. (iii) Time frame.--Not later than October 1, 2012, the Secretary shall publish the measures selected under this subparagraph that will be applicable with respect to fiscal year 2014. (E) Public availability of data submitted.-- The Secretary shall establish procedures for making data submitted under subparagraph (C) and subparagraph (F)(i) available to the public. Such procedures shall ensure that a rehabilitation facility has the opportunity to review the data that is to be made public with respect to the facility prior to such data being made public. The Secretary shall report quality measures that relate to services furnished in inpatient settings in rehabilitation facilities on the Internet website of the Centers for Medicare & Medicaid Services. (F) Submission of additional data.-- (i) In general.--For the fiscal year beginning on the specified application date (as defined in subsection (a)(2)(E) of section 1899B), as applicable with respect to inpatient rehabilitation facilities and quality measures under subsection (c)(1) of such section and measures under subsection (d)(1) of such section, and each subsequent fiscal year, in addition to such data on the quality measures described in subparagraph (C), each rehabilitation facility shall submit to the Secretary data on the quality measures under such subsection (c)(1) and any necessary data specified by the Secretary under such subsection (d)(1). (ii) Standardized patient assessment data.--For fiscal year 2019 and each subsequent fiscal year, in addition to such data described in clause (i), each rehabilitation facility shall submit to the Secretary standardized patient assessment data required under subsection (b)(1) of section 1899B. (iii) Submission.--Such data shall be submitted in the form and manner, and at the time, specified by the Secretary for purposes of this subparagraph. (G) Non-duplication.--To the extent data submitted under subparagraph (F) duplicates other data required to be submitted under subparagraph (C), the submission of such data under subparagraph (F) shall be in lieu of the submission of such data under subparagraph (C). The previous sentence shall not apply insofar as the Secretary determines it is necessary to avoid a delay in the implementation of section 1899B, taking into account the different specified application dates under subsection (a)(2)(E) of such section. (8) Limitation on review.--There shall be no administrative or judicial review under section 1869, 1878, or otherwise of the establishment of-- (A) case mix groups, of the methodology for the classification of patients within such groups, and of the appropriate weighting factors thereof under paragraph (2), (B) the prospective payment rates under paragraph (3), (C) outlier and special payments under paragraph (4), and (D) area wage adjustments under paragraph (6). (k) Payment to Nonhospital Providers.-- (1) In general.--For cost reporting periods beginning on or after October 1, 1997, the Secretary may establish rules for payment to qualified nonhospital providers for their direct costs of medical education, if those costs are incurred in the operation of an approved medical residency training program described in subsection (h). Such rules shall specify the amounts, form, and manner in which such payments will be made and the portion of such payments that will be made from each of the trust funds under this title. (2) Qualified nonhospital providers.--For purposes of this subsection, the term ``qualified nonhospital providers'' means-- (A) a Federally qualified health center, as defined in section 1861(aa)(4); (B) a rural health clinic, as defined in section 1861(aa)(2); (C) Medicare+Choice organizations; and (D) such other providers (other than hospitals) as the Secretary determines to be appropriate. (l) Payment for Nursing and Allied Health Education for Managed Care Enrollees.-- (1) In general.--For portions of cost reporting periods occurring in a year (beginning with 2000), the Secretary shall provide for an additional payment amount for any hospital that receives payments for the costs of approved educational activities for nurse and allied health professional training under section 1861(v)(1). (2) Payment amount.--The additional payment amount under this subsection for each hospital for portions of cost reporting periods occurring in a year shall be an amount specified by the Secretary in a manner consistent with the following: (A) Determination of managed care enrollee payment ratio for graduate medical education payments.--The Secretary shall estimate the ratio of payments for all hospitals for portions of cost reporting periods occurring in the year under subsection (h)(3)(D) to total direct graduate medical education payments estimated for such portions of periods under subsection (h)(3). (B) Application to fee-for-service nursing and allied health education payments.--Such ratio shall be applied to the Secretary's estimate of total payments for nursing and allied health education determined under section 1861(v) for portions of cost reporting periods occurring in the year to determine a total amount of additional payments for nursing and allied health education to be distributed to hospitals under this subsection for portions of cost reporting periods occurring in the year; except that in no case shall such total amount exceed $60,000,000 in any year. (C) Application to hospital.--The amount of payment under this subsection to a hospital for portions of cost reporting periods occurring in a year is equal to the total amount of payments determined under subparagraph (B) for the year multiplied by the ratio of-- (i) the product of (I) the Secretary's estimate of the ratio of the amount of payments made under section 1861(v) to the hospital for nursing and allied health education activities for the hospital's cost reporting period ending in the second preceding fiscal year, to the hospital's total inpatient days for such period, and (II) the total number of inpatient days (as established by the Secretary) for such period which are attributable to services furnished to individuals who are enrolled under a risk sharing contract with an eligible organization under section 1876 and who are entitled to benefits under part A or who are enrolled with a Medicare+Choice organization under part C; to (ii) the sum of the products determined under clause (i) for such cost reporting periods. (m) Prospective Payment for Long-Term Care Hospitals.-- (1) Reference to establishment and implementation of system.--For provisions related to the establishment and implementation of a prospective payment system for payments under this title for inpatient hospital services furnished by a long-term care hospital described in subsection (d)(1)(B)(iv), see section 123 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 and section 307(b) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000. (2) Update for rate year 2008.--In implementing the system described in paragraph (1) for discharges occurring during the rate year ending in 2008 for a hospital, the base rate for such discharges for the hospital shall be the same as the base rate for discharges for the hospital occurring during the rate year ending in 2007. (3) Implementation for rate year 2010 and subsequent years.-- (A) In general.--Subject to subparagraph (C), in implementing the system described in paragraph (1) for rate year 2010 and each subsequent rate year, any annual update to a standard Federal rate for discharges for the hospital during the rate year, shall be reduced-- (i) for rate year 2012 and each subsequent rate year, by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II); and (ii) for each of rate years 2010 through 2019, by the other adjustment described in paragraph (4). (B) Special rule.--The application of this paragraph may result in such annual update being less than 0.0 for a rate year, and may result in payment rates under the system described in paragraph (1) for a rate year being less than such payment rates for the preceding rate year. (C) Additional special rule.--For fiscal year 2018, the annual update under subparagraph (A) for the fiscal year, after application of clauses (i) and (ii) of subparagraph (A), shall be 1 percent. (4) Other adjustment.--For purposes of paragraph (3)(A)(ii), the other adjustment described in this paragraph is-- (A) for rate year 2010, 0.25 percentage point; (B) for rate year 2011, 0.50 percentage point; (C) for each of the rate years beginning in 2012 and 2013, 0.1 percentage point; (D) for rate year 2014, 0.3 percentage point; (E) for each of rate years 2015 and 2016, 0.2 percentage point; and (F) for each of rate years 2017, 2018, and 2019, 0.75 percentage point. (5) Quality reporting.-- (A) Reduction in update for failure to report.-- (i) In general.--Under the system described in paragraph (1), for rate year 2014 and each subsequent rate year, in the case of a long-term care hospital that does not submit data to the Secretary in accordance with subparagraphs (C) and (F) with respect to such a rate year, any annual update to a standard Federal rate for discharges for the hospital during the rate year, and after application of paragraph (3), shall be reduced by 2 percentage points. (ii) Special rule.--The application of this subparagraph may result in such annual update being less than 0.0 for a rate year, and may result in payment rates under the system described in paragraph (1) for a rate year being less than such payment rates for the preceding rate year. (B) Noncumulative application.--Any reduction under subparagraph (A) shall apply only with respect to the rate year involved and the Secretary shall not take into account such reduction in computing the payment amount under the system described in paragraph (1) for a subsequent rate year. (C) Submission of quality data.--Subject to subparagraph (G), for rate year 2014 and each subsequent rate year, each long-term care hospital shall submit to the Secretary data on quality measures specified under subparagraph (D). Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this subparagraph. (D) Quality measures.-- (i) In general.--Subject to clause (ii), any measure specified by the Secretary under this subparagraph must have been endorsed by the entity with a contract under section 1890(a). (ii) Exception.--In the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1890(a), the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary. (iii) Time frame.--Not later than October 1, 2012, the Secretary shall publish the measures selected under this subparagraph that will be applicable with respect to rate year 2014. (iv) Additional quality measures.-- Not later than October 1, 2015, the Secretary shall establish a functional status quality measure for change in mobility among inpatients requiring ventilator support. (E) Public availability of data submitted.-- The Secretary shall establish procedures for making data submitted under subparagraph (C) and subparagraph (F)(i) available to the public. Such procedures shall ensure that a long-term care hospital has the opportunity to review the data that is to be made public with respect to the hospital prior to such data being made public. The Secretary shall report quality measures that relate to services furnished in inpatient settings in long-term care hospitals on the Internet website of the Centers for Medicare & Medicaid Services. (F) Submission of additional data.-- (i) In general.--For the rate year beginning on the specified application date (as defined in subsection (a)(2)(E) of section 1899B), as applicable with respect to long-term care hospitals and quality measures under subsection (c)(1) of such section and measures under subsection (d)(1) of such section, and each subsequent rate year, in addition to the data on the quality measures described in subparagraph (C), each long-term care hospital (other than a hospital classified under subsection (d)(1)(B)(vi)) shall submit to the Secretary data on the quality measures under such subsection (c)(1) and any necessary data specified by the Secretary under such subsection (d)(1). (ii) Standardized patient assessment data.--For rate year 2019 and each subsequent rate year, in addition to such data described in clause (i), each long-term care hospital (other than a hospital classified under subsection (d)(1)(B)(vi)) shall submit to the Secretary standardized patient assessment data required under subsection (b)(1) of section 1899B. (iii) Submission.--Such data shall be submitted in the form and manner, and at the time, specified by the Secretary for purposes of this subparagraph. (G) Non-duplication.--To the extent data submitted under subparagraph (F) duplicates other data required to be submitted under subparagraph (C), the submission of such data under subparagraph (F) shall be in lieu of the submission of such data under subparagraph (C). The previous sentence shall not apply insofar as the Secretary determines it is necessary to avoid a delay in the implementation of section 1899B, taking into account the different specified application dates under subsection (a)(2)(E) of such section. (6) Application of site neutral ipps payment rate in certain cases.-- (A) General application of site neutral ipps payment amount for discharges failing to meet applicable criteria.-- (i) In general.--For a discharge in cost reporting periods beginning on or after October 1, 2015, except as provided in clause (ii) and subparagraphs (C), (E), (F), and (G), payment under this title to a long-term care hospital for inpatient hospital services shall be made at the applicable site neutral payment rate (as defined in subparagraph (B)). (ii) Exception for certain discharges meeting criteria.--Clause (i) shall not apply (and payment shall be made to a long-term care hospital without regard to this paragraph) for a discharge if-- (I) the discharge meets the ICU criterion under clause (iii) or the ventilator criterion under clause (iv); and (II) the discharge does not have a principal diagnosis relating to a psychiatric diagnosis or to rehabilitation. (iii) Intensive care unit (icu) criterion.-- (I) In general.--The criterion specified in this clause (in this paragraph referred to as the ``ICU criterion''), for a discharge from a long-term care hospital, is that the stay in the long- term care hospital ending with such discharge was immediately preceded by a discharge from a stay in a subsection (d) hospital that included at least 3 days in an intensive care unit (ICU), as determined by the Secretary. (II) Determining icu days.-- In determining intensive care unit days under subclause (I), the Secretary shall use data from revenue center codes 020x or 021x (or such successor codes as the Secretary may establish). (iv) Ventilator criterion.--The criterion specified in this clause (in this paragraph referred to as the ``ventilator criterion''), for a discharge from a long-term care hospital, is that-- (I) the stay in the long-term care hospital ending with such discharge was immediately preceded by a discharge from a stay in a subsection (d) hospital; and (II) the individual discharged was assigned to a Medicare-Severity-Long-Term- Care-Diagnosis-Related-Group (MS-LTC-DRG) based on the receipt of ventilator services of at least 96 hours. (B) Applicable site neutral payment rate defined.-- (i) In general.--In this paragraph, the term ``applicable site neutral payment rate'' means-- (I) for discharges in cost reporting periods beginning during fiscal years 2016 through 2019, the blended payment rate specified in clause (iii); and (II) for discharges in cost reporting periods beginning during fiscal year 2020 or a subsequent fiscal year, the site neutral payment rate (as defined in clause (ii)). (ii) Site neutral payment rate defined.--Subject to clause (iv), in this paragraph, the term ``site neutral payment rate'' means the lower of-- (I) the IPPS comparable per diem amount determined under paragraph (d)(4) of section 412.529 of title 42, Code of Federal Regulations, including any applicable outlier payments under section 412.525 of such title; or (II) 100 percent of the estimated cost for the services involved. (iii) Blended payment rate.--The blended payment rate specified in this clause, for a long-term care hospital for inpatient hospital services for a discharge, is comprised of-- (I) half of the site neutral payment rate (as defined in clause (ii)) for the discharge; and (II) half of the payment rate that would otherwise be applicable to such discharge without regard to this paragraph, as determined by the Secretary. (iv) Adjustment.--For each of fiscal years 2018 through 2026, the amount that would otherwise apply under clause (ii)(I) for the year (determined without regard to this clause) shall be reduced by 4.6 percent. (C) Limiting payment for all hospital discharges to site neutral payment rate for hospitals failing to meet applicable ltch discharge thresholds.-- (i) Notice of ltch discharge payment percentage.--For cost reporting periods beginning during or after fiscal year 2016, the Secretary shall inform each long-term care hospital of its LTCH discharge payment percentage (as defined in clause (iv)) for such period. (ii) Limitation.--For cost reporting periods beginning during or after fiscal year 2020, if the Secretary determines for a long-term care hospital that its LTCH discharge payment percentage for the period is not at least 50 percent-- (I) the Secretary shall inform the hospital of such fact; and (II) subject to clause (iii), for all discharges in the hospital in each succeeding cost reporting period, the payment amount under this subsection shall be the payment amount that would apply under subsection (d) for the discharge if the hospital were a subsection (d) hospital. (iii) Process for reinstatement.--The Secretary shall establish a process whereby a long-term care hospital may seek to and have the provisions of subclause (II) of clause (ii) discontinued with respect to that hospital. (iv) LTCH discharge payment percentage.--In this subparagraph, the term ``LTCH discharge payment percentage'' means, with respect to a long-term care hospital for a cost reporting period beginning during or after fiscal year 2020, the ratio (expressed as a percentage) of-- (I) the number of Medicare fee-for-service discharges for such hospital and period for which payment is not made at the site neutral payment rate, to (II) the total number of Medicare fee-for-service discharges for such hospital and period. (D) Inclusion of subsection (d) puerto rico hospitals.--In this paragraph, any reference in this paragraph to a subsection (d) hospital shall be deemed to include a reference to a subsection (d) Puerto Rico hospital. (E) Temporary exception for certain severe wound discharges from certain long-term care hospitals.-- (i) In general.--In the case of a discharge occurring prior to January 1, 2017, subparagraph (A)(i) shall not apply (and payment shall be made to a long-term care hospital without regard to this paragraph) if such discharge-- (I) is from a long-term care hospital that is-- (aa) identified by the last sentence of subsection (d)(1)(B); and (bb) located in a rural area (as defined in subsection (d)(2)(D)) or treated as being so located pursuant to subsection (d)(8)(E); and (II) the individual discharged has a severe wound. (ii) Severe wound defined.--In this subparagraph, the term ``severe wound'' means a stage 3 wound, stage 4 wound, unstageable wound, non-healing surgical wound, infected wound, fistula, osteomyelitis, or wound with morbid obesity, as identified in the claim from the long-term care hospital. (F) Temporary exception for certain spinal cord specialty hospitals.--For discharges in cost reporting periods beginning during fiscal years 2018 and 2019, subparagraph (A)(i) shall not apply (and payment shall be made to a long- term care hospital without regard to this paragraph) if such discharge is from a long- term care hospital that meets each of the following requirements: (i) Not-for-profit.--The long-term care hospital was a not-for-profit long-term care hospital on June 1, 2014, as determined by cost report data. (ii) Primarily providing treatment for catastrophic spinal cord or acquired brain injuries or other paralyzing neuromuscular conditions.-- Of the discharges in calendar year 2013 from the long-term care hospital for which payment was made under this section, at least 50 percent were classified under MS-LTCH-DRGs 28, 29, 52, 57, 551, 573, and 963. (iii) Significant out-of-state admissions.-- (I) In general.--The long- term care hospital discharged inpatients (including both individuals entitled to, or enrolled for, benefits under this title and individuals not so entitled or enrolled) during fiscal year 2014 who had been admitted from at least 20 of the 50 States, determined by the States of residency of such inpatients and based on such data submitted by the hospital to the Secretary as the Secretary may require. (II) Implementation.-- Notwithstanding any other provision of law, the Secretary may implement subclause (I) by program instruction or otherwise. (III) Non-application of paperwork reduction act.-- Chapter 35 of title 44, United States Code, shall not apply to data collected under this clause. (G) Additional temporary exception for certain severe wound discharges from certain long-term care hospitals.-- (i) In general.--For a discharge occurring in a cost reporting period beginning during fiscal year 2018, subparagraph (A)(i) shall not apply (and payment shall be made to a long- term care hospital without regard to this paragraph) if such discharge-- (I) is from a long-term care hospital identified by the last sentence of subsection (d)(1)(B); (II) is classified under MS- LTCH-DRG 602, 603, 539, or 540; and (III) is with respect to an individual treated by a long- term care hospital for a severe wound. (ii) Severe wound defined.--In this subparagraph, the term ``severe wound'' means a wound which is a stage 3 wound, stage 4 wound, unstageable wound, non- healing surgical wound, or fistula as identified in the claim from the long- term care hospital. (iii) Wound defined.--In this subparagraph, the term ``wound'' means an injury involving division of tissue or rupture of the integument or mucous membrane with exposure to the external environment. (7) Treatment of high cost outlier payments.-- (A) Adjustment to the standard federal payment rate for estimated high cost outlier payments.--Under the system described in paragraph (1), for fiscal years beginning on or after October 1, 2017, the Secretary shall reduce the standard Federal payment rate as if the estimated aggregate amount of high cost outlier payments for standard Federal payment rate discharges for each such fiscal year would be equal to 8 percent of estimated aggregate payments for standard Federal payment rate discharges for each such fiscal year. (B) Limitation on high cost outlier payment amounts.--Notwithstanding subparagraph (A), the Secretary shall set the fixed loss amount for high cost outlier payments such that the estimated aggregate amount of high cost outlier payments made for standard Federal payment rate discharges for fiscal years beginning on or after October 1, 2017, shall be equal to 99.6875 percent of 8 percent of estimated aggregate payments for standard Federal payment rate discharges for each such fiscal year. (C) Waiver of budget neutrality.--Any reduction in payments resulting from the application of subparagraph (B) shall not be taken into account in applying any budget neutrality provision under such system. (D) No effect on site neutral high cost outlier payment rate.--This paragraph shall not apply with respect to the computation of the applicable site neutral payment rate under paragraph (6). (n) Incentives for Adoption and Meaningful Use of Certified EHR Technology.-- (1) In general.--Subject to the succeeding provisions of this subsection, with respect to inpatient hospital services furnished by an eligible hospital during a payment year (as defined in paragraph (2)(G)), if the eligible hospital is a meaningful EHR user (as determined under paragraph (3)) for the EHR reporting period with respect to such year, in addition to the amount otherwise paid under this section, there also shall be paid to the eligible hospital, from the Federal Hospital Insurance Trust Fund established under section 1817, an amount equal to the applicable amount specified in paragraph (2)(A) for the hospital for such payment year. (2) Payment amount.-- (A) In general.--Subject to the succeeding subparagraphs of this paragraph, the applicable amount specified in this subparagraph for an eligible hospital for a payment year is equal to the product of the following: (i) Initial amount.--The sum of-- (I) the base amount specified in subparagraph (B); plus (II) the discharge related amount specified in subparagraph (C) for a 12-month period selected by the Secretary with respect to such payment year. (ii) Medicare share.--The Medicare share as specified in subparagraph (D) for the eligible hospital for a period selected by the Secretary with respect to such payment year. (iii) Transition factor.--The transition factor specified in subparagraph (E) for the eligible hospital for the payment year. (B) Base amount.--The base amount specified in this subparagraph is $2,000,000. (C) Discharge related amount.--The discharge related amount specified in this subparagraph for a 12-month period selected by the Secretary shall be determined as the sum of the amount, estimated based upon total discharges for the eligible hospital (regardless of any source of payment) for the period, for each discharge up to the 23,000th discharge as follows: (i) For the first through 1,149th discharge, $0. (ii) For the 1,150th through the 23,000th discharge, $200. (iii) For any discharge greater than the 23,000th, $0. (D) Medicare share.--The Medicare share specified under this subparagraph for an eligible hospital for a period selected by the Secretary for a payment year is equal to the fraction-- (i) the numerator of which is the sum (for such period and with respect to the eligible hospital) of-- (I) the estimated number of inpatient-bed-days (as established by the Secretary) which are attributable to individuals with respect to whom payment may be made under part A; and (II) the estimated number of inpatient-bed-days (as so established) which are attributable to individuals who are enrolled with a Medicare Advantage organization under part C; and (ii) the denominator of which is the product of-- (I) the estimated total number of inpatient-bed-days with respect to the eligible hospital during such period; and (II) the estimated total amount of the eligible hospital's charges during such period, not including any charges that are attributable to charity care (as such term is used for purposes of hospital cost reporting under this title), divided by the estimated total amount of the hospital's charges during such period. Insofar as the Secretary determines that data are not available on charity care necessary to calculate the portion of the formula specified in clause (ii)(II), the Secretary shall use data on uncompensated care and may adjust such data so as to be an appropriate proxy for charity care including a downward adjustment to eliminate bad debt data from uncompensated care data. In the absence of the data necessary, with respect to a hospital, for the Secretary to compute the amount described in clause (ii)(II), the amount under such clause shall be deemed to be 1. In the absence of data, with respect to a hospital, necessary to compute the amount described in clause (i)(II), the amount under such clause shall be deemed to be 0. (E) Transition factor specified.-- (i) In general.--Subject to clause (ii), the transition factor specified in this subparagraph for an eligible hospital for a payment year is as follows: (I) For the first payment year for such hospital, 1. (II) For the second payment year for such hospital, \3/4\. (III) For the third payment year for such hospital, \1/2\. (IV) For the fourth payment year for such hospital, \1/4\. (V) For any succeeding payment year for such hospital, 0. (ii) Phase down for eligible hospitals first adopting ehr after 2013.--If the first payment year for an eligible hospital is after 2013, then the transition factor specified in this subparagraph for a payment year for such hospital is the same as the amount specified in clause (i) for such payment year for an eligible hospital for which the first payment year is 2013. If the first payment year for an eligible hospital is after 2015 then the transition factor specified in this subparagraph for such hospital and for such year and any subsequent year shall be 0. (F) Form of payment.--The payment under this subsection for a payment year may be in the form of a single consolidated payment or in the form of such periodic installments as the Secretary may specify. (G) Payment year defined.-- (i) In general.--For purposes of this subsection, the term ``payment year'' means a fiscal year beginning with fiscal year 2011. (ii) First, second, etc. payment year.--The term ``first payment year'' means, with respect to inpatient hospital services furnished by an eligible hospital, the first fiscal year for which an incentive payment is made for such services under this subsection. The terms ``second payment year'', ``third payment year'', and ``fourth payment year'' mean, with respect to an eligible hospital, each successive year immediately following the first payment year for that hospital. (3) Meaningful ehr user.-- (A) In general.--For purposes of paragraph (1), an eligible hospital shall be treated as a meaningful EHR user for an EHR reporting period for a payment year (or, for purposes of subsection (b)(3)(B)(ix), for an EHR reporting period under such subsection for a fiscal year) if each of the following requirements are met: (i) Meaningful use of certified ehr technology.--The eligible hospital demonstrates to the satisfaction of the Secretary, in accordance with subparagraph (C)(i), that during such period the hospital is using certified EHR technology in a meaningful manner. (ii) Information exchange.--The eligible hospital demonstrates to the satisfaction of the Secretary, in accordance with subparagraph (C)(i), that during such period such certified EHR technology is connected in a manner that provides, in accordance with law and standards applicable to the exchange of information, for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination, and the hospital demonstrates (through a process specified by the Secretary, such as the use of an attestation) that the hospital has not knowingly and willfully taken action (such as to disable functionality) to limit or restrict the compatibility or interoperability of the certified EHR technology. (iii) Reporting on measures using ehr.--Subject to subparagraph (B)(ii) and using such certified EHR technology, the eligible hospital submits information for such period, in a form and manner specified by the Secretary, on such clinical quality measures and such other measures as selected by the Secretary under subparagraph (B)(i). The Secretary shall seek to improve the use of electronic health records and health care quality over time. (B) Reporting on measures.-- (i) Selection.--The Secretary shall select measures for purposes of subparagraph (A)(iii) but only consistent with the following: (I) The Secretary shall provide preference to clinical quality measures that have been selected for purposes of applying subsection (b)(3)(B)(viii) or that have been endorsed by the entity with a contract with the Secretary under section 1890(a). (II) Prior to any measure (other than a clinical quality measure that has been selected for purposes of applying subsection (b)(3)(B)(viii)) being selected under this subparagraph, the Secretary shall publish in the Federal Register such measure and provide for a period of public comment on such measure. (ii) Limitations.--The Secretary may not require the electronic reporting of information on clinical quality measures under subparagraph (A)(iii) unless the Secretary has the capacity to accept the information electronically, which may be on a pilot basis. (iii) Coordination of reporting of information.--In selecting such measures, and in establishing the form and manner for reporting measures under subparagraph (A)(iii), the Secretary shall seek to avoid redundant or duplicative reporting with reporting otherwise required, including reporting under subsection (b)(3)(B)(viii). (C) Demonstration of meaningful use of certified ehr technology and information exchange.-- (i) In general.--An eligible hospital may satisfy the demonstration requirement of clauses (i) and (ii) of subparagraph (A) through means specified by the Secretary, which may include-- (I) an attestation; (II) the submission of claims with appropriate coding (such as a code indicating that inpatient care was documented using certified EHR technology); (III) a survey response; (IV) reporting under subparagraph (A)(iii); and (V) other means specified by the Secretary. (ii) Use of part d data.-- Notwithstanding sections 1860D- 15(d)(2)(B) and 1860D-15(f)(2), the Secretary may use data regarding drug claims submitted for purposes of section 1860D-15 that are necessary for purposes of subparagraph (A). (4) Application.-- (A) Limitations on review.--There shall be no administrative or judicial review under section 1869, section 1878, or otherwise, of-- (i) the methodology and standards for determining payment amounts under this subsection and payment adjustments under subsection (b)(3)(B)(ix), including selection of periods under paragraph (2) for determining, and making estimates or using proxies of, discharges under paragraph (2)(C) and inpatient-bed-days, hospital charges, charity charges, and Medicare share under paragraph (2)(D); (ii) the methodology and standards for determining a meaningful EHR user under paragraph (3), including selection of measures under paragraph (3)(B), specification of the means of demonstrating meaningful EHR use under paragraph (3)(C), and the hardship exception under subsection (b)(3)(B)(ix)(II); and (iii) the specification of EHR reporting periods under paragraph (6)(B) and the selection of the form of payment under paragraph (2)(F). (B) Posting on website.--The Secretary shall post on the Internet website of the Centers for Medicare & Medicaid Services, in an easily understandable format, a list of the names of the eligible hospitals that are meaningful EHR users under this subsection or subsection (b)(3)(B)(ix) (and a list of the names of critical access hospitals to which paragraph (3) or (4) of section 1814(l) applies), and other relevant data as determined appropriate by the Secretary. The Secretary shall ensure that an eligible hospital (or critical access hospital) has the opportunity to review the other relevant data that are to be made public with respect to the hospital (or critical access hospital) prior to such data being made public. (5) Certified ehr technology defined.--The term ``certified EHR technology'' has the meaning given such term in section 1848(o)(4). (6) Definitions.--For purposes of this subsection: (A) EHR reporting period.--The term ``EHR reporting period'' means, with respect to a payment year, any period (or periods) as specified by the Secretary. (B) Eligible hospital.--The term ``eligible hospital'' means a hospital that is a subsection (d) hospital or a subsection (d) Puerto Rico hospital. (o) Hospital Value-Based Purchasing Program.-- (1) Establishment.-- (A) In general.--Subject to the succeeding provisions of this subsection, the Secretary shall establish a hospital value-based purchasing program (in this subsection referred to as the ``Program'') under which value-based incentive payments are made in a fiscal year to hospitals that meet the performance standards under paragraph (3) for the performance period for such fiscal year (as established under paragraph (4)). (B) Program to begin in fiscal year 2013.-- The Program shall apply to payments for discharges occurring on or after October 1, 2012. (C) Applicability of program to hospitals.-- (i) In general.--For purposes of this subsection, subject to clause (ii), the term ``hospital'' means a subsection (d) hospital (as defined in subsection (d)(1)(B)). (ii) Exclusions.--The term ``hospital'' shall not include, with respect to a fiscal year, a hospital-- (I) that is subject to the payment reduction under subsection (b)(3)(B)(viii)(I) for such fiscal year; (II) for which, during the performance period for such fiscal year, the Secretary has cited deficiencies that pose immediate jeopardy to the health or safety of patients; (III) for which there are not a minimum number (as determined by the Secretary) of measures that apply to the hospital for the performance period for such fiscal year; or (IV) for which there are not a minimum number (as determined by the Secretary) of cases for the measures that apply to the hospital for the performance period for such fiscal year. (iii) Independent analysis.--For purposes of determining the minimum numbers under subclauses (III) and (IV) of clause (ii), the Secretary shall have conducted an independent analysis of what numbers are appropriate. (iv) Exemption.--In the case of a hospital that is paid under section 1814(b)(3), the Secretary may exempt such hospital from the application of this subsection if the State which is paid under such section submits an annual report to the Secretary describing how a similar program in the State for a participating hospital or hospitals achieves or surpasses the measured results in terms of patient health outcomes and cost savings established under this subsection. (2) Measures.-- (A) In general.--The Secretary shall select measures, other than measures of readmissions, for purposes of the Program. Such measures shall be selected from the measures specified under subsection (b)(3)(B)(viii). (B) Requirements.-- (i) For fiscal year 2013.--For value- based incentive payments made with respect to discharges occurring during fiscal year 2013, the Secretary shall ensure the following: (I) Conditions or procedures.--Measures are selected under subparagraph (A) that cover at least the following 5 specific conditions or procedures: (aa) Acute myocardial infarction (AMI). (bb) Heart failure. (cc) Pneumonia. (dd) Surgeries, as measured by the Surgical Care Improvement Project (formerly referred to as ``Surgical Infection Prevention'' for discharges occurring before July 2006). (ee) Healthcare- associated infections, as measured by the prevention metrics and targets established in the HHS Action Plan to Prevent Healthcare- Associated Infections (or any successor plan) of the Department of Health and Human Services. (II) HCAHPS.--Measures selected under subparagraph (A) shall be related to the Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS). (ii) Inclusion of efficiency measures.--For value-based incentive payments made with respect to discharges occurring during fiscal year 2014 or a subsequent fiscal year, the Secretary shall ensure that measures selected under subparagraph (A) include efficiency measures, including measures of ``Medicare spending per beneficiary''. Such measures shall be adjusted for factors such as age, sex, race, severity of illness, and other factors that the Secretary determines appropriate. (iii) HCAHPS pain questions.--The Secretary may not include under subparagraph (A) a measure that is based on the questions appearing on the Hospital Consumer Assessment of Healthcare Providers and Systems survey in 2018 or 2019 about communication by hospital staff with an individual about the individual's pain. (C) Limitations.-- (i) Time requirement for prior reporting and notice.--The Secretary may not select a measure under subparagraph (A) for use under the Program with respect to a performance period for a fiscal year (as established under paragraph (4)) unless such measure has been specified under subsection (b)(3)(B)(viii) and included on the Hospital Compare Internet website for at least 1 year prior to the beginning of such performance period. (ii) Measure not applicable unless hospital furnishes services appropriate to the measure.--A measure selected under subparagraph (A) shall not apply to a hospital if such hospital does not furnish services appropriate to such measure. (D) Replacing measures.--Subclause (VI) of subsection (b)(3)(B)(viii) shall apply to measures selected under subparagraph (A) in the same manner as such subclause applies to measures selected under such subsection. (3) Performance standards.-- (A) Establishment.--The Secretary shall establish performance standards with respect to measures selected under paragraph (2) for a performance period for a fiscal year (as established under paragraph (4)). (B) Achievement and improvement.--The performance standards established under subparagraph (A) shall include levels of achievement and improvement. (C) Timing.--The Secretary shall establish and announce the performance standards under subparagraph (A) not later than 60 days prior to the beginning of the performance period for the fiscal year involved. (D) Considerations in establishing standards.--In establishing performance standards with respect to measures under this paragraph, the Secretary shall take into account appropriate factors, such as-- (i) practical experience with the measures involved, including whether a significant proportion of hospitals failed to meet the performance standard during previous performance periods; (ii) historical performance standards; (iii) improvement rates; and (iv) the opportunity for continued improvement. (4) Performance period.--For purposes of the Program, the Secretary shall establish the performance period for a fiscal year. Such performance period shall begin and end prior to the beginning of such fiscal year. (5) Hospital performance score.-- (A) In general.--Subject to subparagraph (B), the Secretary shall develop a methodology for assessing the total performance of each hospital based on performance standards with respect to the measures selected under paragraph (2) for a performance period (as established under paragraph (4)). Using such methodology, the Secretary shall provide for an assessment (in this subsection referred to as the ``hospital performance score'') for each hospital for each performance period. (B) Application.-- (i) Appropriate distribution.--The Secretary shall ensure that the application of the methodology developed under subparagraph (A) results in an appropriate distribution of value-based incentive payments under paragraph (6) among hospitals achieving different levels of hospital performance scores, with hospitals achieving the highest hospital performance scores receiving the largest value-based incentive payments. (ii) Higher of achievement or improvement.--The methodology developed under subparagraph (A) shall provide that the hospital performance score is determined using the higher of its achievement or improvement score for each measure. (iii) Weights.--The methodology developed under subparagraph (A) shall provide for the assignment of weights for categories of measures as the Secretary determines appropriate. (iv) No minimum performance standard.--The Secretary shall not set a minimum performance standard in determining the hospital performance score for any hospital. (v) Reflection of measures applicable to the hospital.--The hospital performance score for a hospital shall reflect the measures that apply to the hospital. (6) Calculation of value-based incentive payments.-- (A) In general.--In the case of a hospital that the Secretary determines meets (or exceeds) the performance standards under paragraph (3) for the performance period for a fiscal year (as established under paragraph (4)), the Secretary shall increase the base operating DRG payment amount (as defined in paragraph (7)(D)), as determined after application of paragraph (7)(B)(i), for a hospital for each discharge occurring in such fiscal year by the value-based incentive payment amount. (B) Value-based incentive payment amount.-- The value-based incentive payment amount for each discharge of a hospital in a fiscal year shall be equal to the product of-- (i) the base operating DRG payment amount (as defined in paragraph (7)(D)) for the discharge for the hospital for such fiscal year; and (ii) the value-based incentive payment percentage specified under subparagraph (C) for the hospital for such fiscal year. (C) Value-based incentive payment percentage.-- (i) In general.--The Secretary shall specify a value-based incentive payment percentage for a hospital for a fiscal year. (ii) Requirements.--In specifying the value-based incentive payment percentage for each hospital for a fiscal year under clause (i), the Secretary shall ensure that-- (I) such percentage is based on the hospital performance score of the hospital under paragraph (5); and (II) the total amount of value-based incentive payments under this paragraph to all hospitals in such fiscal year is equal to the total amount available for value-based incentive payments for such fiscal year under paragraph (7)(A), as estimated by the Secretary. (7) Funding for value-based incentive payments.-- (A) Amount.--The total amount available for value-based incentive payments under paragraph (6) for all hospitals for a fiscal year shall be equal to the total amount of reduced payments for all hospitals under subparagraph (B) for such fiscal year, as estimated by the Secretary. (B) Adjustment to payments.-- (i) In general.--The Secretary shall reduce the base operating DRG payment amount (as defined in subparagraph (D)) for a hospital for each discharge in a fiscal year (beginning with fiscal year 2013) by an amount equal to the applicable percent (as defined in subparagraph (C)) of the base operating DRG payment amount for the discharge for the hospital for such fiscal year. The Secretary shall make such reductions for all hospitals in the fiscal year involved, regardless of whether or not the hospital has been determined by the Secretary to have earned a value-based incentive payment under paragraph (6) for such fiscal year. (ii) No effect on other payments.-- Payments described in items (aa) and (bb) of subparagraph (D)(i)(II) for a hospital shall be determined as if this subsection had not been enacted. (C) Applicable percent defined.--For purposes of subparagraph (B), the term ``applicable percent'' means-- (i) with respect to fiscal year 2013, 1.0 percent; (ii) with respect to fiscal year 2014, 1.25 percent; (iii) with respect to fiscal year 2015, 1.5 percent; (iv) with respect to fiscal year 2016, 1.75 percent; and (v) with respect to fiscal year 2017 and succeeding fiscal years, 2 percent. (D) Base operating drg payment amount defined.-- (i) In general.--Except as provided in clause (ii), in this subsection, the term ``base operating DRG payment amount'' means, with respect to a hospital for a fiscal year-- (I) the payment amount that would otherwise be made under subsection (d) (determined without regard to subsection (q)) for a discharge if this subsection did not apply; reduced by (II) any portion of such payment amount that is attributable to-- (aa) payments under paragraphs (5)(A), (5)(B), (5)(F), and (12) of subsection (d); and (bb) such other payments under subsection (d) determined appropriate by the Secretary. (ii) Special rules for certain hospitals.-- (I) Sole community hospitals and medicare-dependent, small rural hospitals.--In the case of a medicare-dependent, small rural hospital (with respect to discharges occurring during fiscal year 2012 and 2013) or a sole community hospital, in applying subparagraph (A)(i), the payment amount that would otherwise be made under subsection (d) shall be determined without regard to subparagraphs (I) and (L) of subsection (b)(3) and subparagraphs (D) and (G) of subsection (d)(5). (II) Hospitals paid under section 1814.--In the case of a hospital that is paid under section 1814(b)(3), the term ``base operating DRG payment amount'' means the payment amount under such section. (8) Announcement of net result of adjustments.--Under the Program, the Secretary shall, not later than 60 days prior to the fiscal year involved, inform each hospital of the adjustments to payments to the hospital for discharges occurring in such fiscal year under paragraphs (6) and (7)(B)(i). (9) No effect in subsequent fiscal years.--The value- based incentive payment under paragraph (6) and the payment reduction under paragraph (7)(B)(i) shall each apply only with respect to the fiscal year involved, and the Secretary shall not take into account such value-based incentive payment or payment reduction in making payments to a hospital under this section in a subsequent fiscal year. (10) Public reporting.-- (A) Hospital specific information.-- (i) In general.--The Secretary shall make information available to the public regarding the performance of individual hospitals under the Program, including-- (I) the performance of the hospital with respect to each measure that applies to the hospital; (II) the performance of the hospital with respect to each condition or procedure; and (III) the hospital performance score assessing the total performance of the hospital. (ii) Opportunity to review and submit corrections.--The Secretary shall ensure that a hospital has the opportunity to review, and submit corrections for, the information to be made public with respect to the hospital under clause (i) prior to such information being made public. (iii) Website.--Such information shall be posted on the Hospital Compare Internet website in an easily understandable format. (B) Aggregate information.--The Secretary shall periodically post on the Hospital Compare Internet website aggregate information on the Program, including-- (i) the number of hospitals receiving value-based incentive payments under paragraph (6) and the range and total amount of such value-based incentive payments; and (ii) the number of hospitals receiving less than the maximum value- based incentive payment available to the hospital for the fiscal year involved and the range and amount of such payments. (11) Implementation.-- (A) Appeals.--The Secretary shall establish a process by which hospitals may appeal the calculation of a hospital's performance assessment with respect to the performance standards established under paragraph (3)(A) and the hospital performance score under paragraph (5). The Secretary shall ensure that such process provides for resolution of such appeals in a timely manner. (B) Limitation on review.--Except as provided in subparagraph (A), there shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the following: (i) The methodology used to determine the amount of the value-based incentive payment under paragraph (6) and the determination of such amount. (ii) The determination of the amount of funding available for such value- based incentive payments under paragraph (7)(A) and the payment reduction under paragraph (7)(B)(i). (iii) The establishment of the performance standards under paragraph (3) and the performance period under paragraph (4). (iv) The measures specified under subsection (b)(3)(B)(viii) and the measures selected under paragraph (2). (v) The methodology developed under paragraph (5) that is used to calculate hospital performance scores and the calculation of such scores. (vi) The validation methodology specified in subsection (b)(3)(B)(viii)(XI). (C) Consultation with small hospitals.--The Secretary shall consult with small rural and urban hospitals on the application of the Program to such hospitals. (12) Promulgation of regulations.--The Secretary shall promulgate regulations to carry out the Program, including the selection of measures under paragraph (2), the methodology developed under paragraph (5) that is used to calculate hospital performance scores, and the methodology used to determine the amount of value- based incentive payments under paragraph (6). (p) Adjustment to Hospital Payments for Hospital Acquired Conditions.-- (1) In general.--In order to provide an incentive for applicable hospitals to reduce hospital acquired conditions under this title, with respect to discharges from an applicable hospital occurring during fiscal year 2015 or a subsequent fiscal year, the amount of payment under this section or section 1814(b)(3), as applicable, for such discharges during the fiscal year shall be equal to 99 percent of the amount of payment that would otherwise apply to such discharges under this section or section 1814(b)(3) (determined after the application of subsections (o) and (q) and section 1814(l)(4) but without regard to this subsection). (2) Applicable hospitals.-- (A) In general.--For purposes of this subsection, the term ``applicable hospital'' means a subsection (d) hospital that meets the criteria described in subparagraph (B). (B) Criteria described.-- (i) In general.--The criteria described in this subparagraph, with respect to a subsection (d) hospital, is that the subsection (d) hospital is in the top quartile of all subsection (d) hospitals, relative to the national average, of hospital acquired conditions during the applicable period, as determined by the Secretary. (ii) Risk adjustment.--In carrying out clause (i), the Secretary shall establish and apply an appropriate risk adjustment methodology. (C) Exemption.--In the case of a hospital that is paid under section 1814(b)(3), the Secretary may exempt such hospital from the application of this subsection if the State which is paid under such section submits an annual report to the Secretary describing how a similar program in the State for a participating hospital or hospitals achieves or surpasses the measured results in terms of patient health outcomes and cost savings established under this subsection. (3) Hospital acquired conditions.--For purposes of this subsection, the term ``hospital acquired condition'' means a condition identified for purposes of subsection (d)(4)(D)(iv) and any other condition determined appropriate by the Secretary that an individual acquires during a stay in an applicable hospital, as determined by the Secretary. (4) Applicable period.--In this subsection, the term ``applicable period'' means, with respect to a fiscal year, a period specified by the Secretary. (5) Reporting to hospitals.--Prior to fiscal year 2015 and each subsequent fiscal year, the Secretary shall provide confidential reports to applicable hospitals with respect to hospital acquired conditions of the applicable hospital during the applicable period. (6) Reporting hospital specific information.-- (A) In general.--The Secretary shall make information available to the public regarding hospital acquired conditions of each applicable hospital. (B) Opportunity to review and submit corrections.--The Secretary shall ensure that an applicable hospital has the opportunity to review, and submit corrections for, the information to be made public with respect to the hospital under subparagraph (A) prior to such information being made public. (C) Website.--Such information shall be posted on the Hospital Compare Internet website in an easily understandable format. (7) Limitations on review.--There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the following: (A) The criteria described in paragraph (2)(A). (B) The specification of hospital acquired conditions under paragraph (3). (C) The specification of the applicable period under paragraph (4). (D) The provision of reports to applicable hospitals under paragraph (5) and the information made available to the public under paragraph (6). (q) Hospital Readmissions Reduction Program.-- (1) In general.--With respect to payment for discharges from an applicable hospital (as defined in paragraph (5)(C)) occurring during a fiscal year beginning on or after October 1, 2012, in order to account for excess readmissions in the hospital, the Secretary shall make payments (in addition to the payments described in paragraph (2)(A)(ii)) for such a discharge to such hospital under subsection (d) (or section 1814(b)(3), as the case may be) in an amount equal to the product of-- (A) the base operating DRG payment amount (as defined in paragraph (2)) for the discharge; and (B) the adjustment factor (described in paragraph (3)(A)) for the hospital for the fiscal year. (2) Base operating drg payment amount defined.-- (A) In general.--Except as provided in subparagraph (B), in this subsection, the term ``base operating DRG payment amount'' means, with respect to a hospital for a fiscal year-- (i) the payment amount that would otherwise be made under subsection (d) (determined without regard to subsection (o)) for a discharge if this subsection did not apply; reduced by (ii) any portion of such payment amount that is attributable to payments under paragraphs (5)(A), (5)(B), (5)(F), and (12) of subsection (d). (B) Special rules for certain hospitals.-- (i) Sole community hospitals and medicare-dependent, small rural hospitals.--In the case of a medicare- dependent, small rural hospital (with respect to discharges occurring during fiscal years 2012 and 2013) or a sole community hospital, in applying subparagraph (A)(i), the payment amount that would otherwise be made under subsection (d) shall be determined without regard to subparagraphs (I) and (L) of subsection (b)(3) and subparagraphs (D) and (G) of subsection (d)(5). (ii) Hospitals paid under section 1814.--In the case of a hospital that is paid under section 1814(b)(3), the Secretary may exempt such hospitals provided that States paid under such section submit an annual report to the Secretary describing how a similar program in the State for a participating hospital or hospitals achieves or surpasses the measured results in terms of patient health outcomes and cost savings established herein with respect to this section. (3) Adjustment factor.-- (A) In general.--For purposes of paragraph (1), subject to subparagraph (D), the adjustment factor under this paragraph for an applicable hospital for a fiscal year is equal to the greater of-- (i) the ratio described in subparagraph (B) for the hospital for the applicable period (as defined in paragraph (5)(D)) for such fiscal year; or (ii) the floor adjustment factor specified in subparagraph (C). (B) Ratio.--The ratio described in this subparagraph for a hospital for an applicable period is equal to 1 minus the ratio of-- (i) the aggregate payments for excess readmissions (as defined in paragraph (4)(A)) with respect to an applicable hospital for the applicable period; and (ii) the aggregate payments for all discharges (as defined in paragraph (4)(B)) with respect to such applicable hospital for such applicable period. (C) Floor adjustment factor.--For purposes of subparagraph (A), the floor adjustment factor specified in this subparagraph for-- (i) fiscal year 2013 is 0.99; (ii) fiscal year 2014 is 0.98; or (iii) fiscal year 2015 and subsequent fiscal years is 0.97. (D) Transitional adjustment for dual eligibles.-- (i) In general.--In determining a hospital's adjustment factor under this paragraph for purposes of making payments for discharges occurring during and after fiscal year 2019, and before the application of clause (i) of subparagraph (E), the Secretary shall assign hospitals to groups (as defined by the Secretary under clause (ii)) and apply the applicable provisions of this subsection using a methodology in a manner that allows for separate comparison of hospitals within each such group, as determined by the Secretary. (ii) Defining groups.--For purposes of this subparagraph, the Secretary shall define groups of hospitals, based on their overall proportion, of the inpatients who are entitled to, or enrolled for, benefits under part A, and who are full-benefit dual eligible individuals (as defined in section 1935(c)(6)). In defining groups, the Secretary shall consult the Medicare Payment Advisory Commission and may consider the analysis done by such Commission in preparing the portion of its report submitted to Congress in June 2013 relating to readmissions. (iii) Minimizing reporting burden on hospitals.--In carrying out this subparagraph, the Secretary shall not impose any additional reporting requirements on hospitals. (iv) Budget neutral design methodology.--The Secretary shall design the methodology to implement this subparagraph so that the estimated total amount of reductions in payments under this subsection equals the estimated total amount of reductions in payments that would otherwise occur under this subsection if this subparagraph did not apply. (E) Changes in risk adjustment.-- (i) Consideration of recommendations in impact reports.--The Secretary may take into account the studies conducted and the recommendations made by the Secretary under section 2(d)(1) of the IMPACT Act of 2014 (Public Law 113-185; 42 U.S.C. 1395lll note) with respect to the application under this subsection of risk adjustment methodologies. Nothing in this clause shall be construed as precluding consideration of the use of groupings of hospitals. (ii) Consideration of exclusion of patient cases based on v or other appropriate codes.--In promulgating regulations to carry out this subsection with respect to discharges occurring after fiscal year 2018, the Secretary may consider the use of V or other ICD-related codes for removal of a readmission. The Secretary may consider modifying measures under this subsection to incorporate V or other ICD-related codes at the same time as other changes are being made under this subparagraph. (iii) Removal of certain readmissions.--In promulgating regulations to carry out this subsection, with respect to discharges occurring after fiscal year 2018, the Secretary may consider removal as a readmission of an admission that is classified within one or more of the following: transplants, end-stage renal disease, burns, trauma, psychosis, or substance abuse. The Secretary may consider modifying measures under this subsection to remove readmissions at the same time as other changes are being made under this subparagraph. (4) Aggregate payments, excess readmission ratio defined.--For purposes of this subsection: (A) Aggregate payments for excess readmissions.--The term ``aggregate payments for excess readmissions'' means, for a hospital for an applicable period, the sum, for applicable conditions (as defined in paragraph (5)(A)), of the product, for each applicable condition, of-- (i) the base operating DRG payment amount for such hospital for such applicable period for such condition; (ii) the number of admissions for such condition for such hospital for such applicable period; and (iii) the excess readmissions ratio (as defined in subparagraph (C)) for such hospital for such applicable period minus 1. (B) Aggregate payments for all discharges.-- The term ``aggregate payments for all discharges'' means, for a hospital for an applicable period, the sum of the base operating DRG payment amounts for all discharges for all conditions from such hospital for such applicable period. (C) Excess readmission ratio.-- (i) In general.--Subject to clause (ii), the term ``excess readmissions ratio'' means, with respect to an applicable condition for a hospital for an applicable period, the ratio (but not less than 1.0) of-- (I) the risk adjusted readmissions based on actual readmissions, as determined consistent with a readmission measure methodology that has been endorsed under paragraph (5)(A)(ii)(I), for an applicable hospital for such condition with respect to such applicable period; to (II) the risk adjusted expected readmissions (as determined consistent with such a methodology) for such hospital for such condition with respect to such applicable period. (ii) Exclusion of certain readmissions.--For purposes of clause (i), with respect to a hospital, excess readmissions shall not include readmissions for an applicable condition for which there are fewer than a minimum number (as determined by the Secretary) of discharges for such applicable condition for the applicable period and such hospital. (5) Definitions.--For purposes of this subsection: (A) Applicable condition.--The term ``applicable condition'' means, subject to subparagraph (B), a condition or procedure selected by the Secretary among conditions and procedures for which-- (i) readmissions (as defined in subparagraph (E)) that represent conditions or procedures that are high volume or high expenditures under this title (or other criteria specified by the Secretary); and (ii) measures of such readmissions-- (I) have been endorsed by the entity with a contract under section 1890(a); and (II) such endorsed measures have exclusions for readmissions that are unrelated to the prior discharge (such as a planned readmission or transfer to another applicable hospital). (B) Expansion of applicable conditions.-- Beginning with fiscal year 2015, the Secretary shall, to the extent practicable, expand the applicable conditions beyond the 3 conditions for which measures have been endorsed as described in subparagraph (A)(ii)(I) as of the date of the enactment of this subsection to the additional 4 conditions that have been identified by the Medicare Payment Advisory Commission in its report to Congress in June 2007 and to other conditions and procedures as determined appropriate by the Secretary. In expanding such applicable conditions, the Secretary shall seek the endorsement described in subparagraph (A)(ii)(I) but may apply such measures without such an endorsement in the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1890(a) as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary. (C) Applicable hospital.--The term ``applicable hospital'' means a subsection (d) hospital or a hospital that is paid under section 1814(b)(3), as the case may be. (D) Applicable period.--The term ``applicable period'' means, with respect to a fiscal year, such period as the Secretary shall specify. (E) Readmission.--The term ``readmission'' means, in the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same or another applicable hospital within a time period specified by the Secretary from the date of such discharge. Insofar as the discharge relates to an applicable condition for which there is an endorsed measure described in subparagraph (A)(ii)(I), such time period (such as 30 days) shall be consistent with the time period specified for such measure. (6) Reporting hospital specific information.-- (A) In general.--The Secretary shall make information available to the public regarding readmission rates of each subsection (d) hospital under the program. (B) Opportunity to review and submit corrections.--The Secretary shall ensure that a subsection (d) hospital has the opportunity to review, and submit corrections for, the information to be made public with respect to the hospital under subparagraph (A) prior to such information being made public. (C) Website.--Such information shall be posted on the Hospital Compare Internet website in an easily understandable format. (7) Limitations on review.--There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the following: (A) The determination of base operating DRG payment amounts. (B) The methodology for determining the adjustment factor under paragraph (3), including excess readmissions ratio under paragraph (4)(C), aggregate payments for excess readmissions under paragraph (4)(A), and aggregate payments for all discharges under paragraph (4)(B), and applicable periods and applicable conditions under paragraph (5). (C) The measures of readmissions as described in paragraph (5)(A)(ii). (8) Readmission rates for all patients.-- (A) Calculation of readmission.--The Secretary shall calculate readmission rates for all patients (as defined in subparagraph (D)) for a specified hospital (as defined in subparagraph (D)(ii)) for an applicable condition (as defined in paragraph (5)(B)) and other conditions deemed appropriate by the Secretary for an applicable period (as defined in paragraph (5)(D)) in the same manner as used to calculate such readmission rates for hospitals with respect to this title and posted on the CMS Hospital Compare website. (B) Posting of hospital specific all patient readmission rates.--The Secretary shall make information on all patient readmission rates calculated under subparagraph (A) available on the CMS Hospital Compare website in a form and manner determined appropriate by the Secretary. The Secretary may also make other information determined appropriate by the Secretary available on such website. (C) Hospital submission of all patient data.-- (i) Except as provided for in clause (ii), each specified hospital (as defined in subparagraph (D)(ii)) shall submit to the Secretary, in a form, manner and time specified by the Secretary, data and information determined necessary by the Secretary for the Secretary to calculate the all patient readmission rates described in subparagraph (A). (ii) Instead of a specified hospital submitting to the Secretary the data and information described in clause (i), such data and information may be submitted to the Secretary, on behalf of such a specified hospital, by a state or an entity determined appropriate by the Secretary. (D) Definitions.--For purposes of this paragraph: (i) The term ``all patients'' means patients who are treated on an inpatient basis and discharged from a specified hospital (as defined in clause (ii)). (ii) The term ``specified hospital'' means a subsection (d) hospital, hospitals described in clauses (i) through (v) of subsection (d)(1)(B) and, as determined feasible and appropriate by the Secretary, other hospitals not otherwise described in this subparagraph. (r) Adjustments to Medicare DSH Payments.-- (1) Empirically justified dsh payments.--For fiscal year 2014 and each subsequent fiscal year, instead of the amount of disproportionate share hospital payment that would otherwise be made under subsection (d)(5)(F) to a subsection (d) hospital for the fiscal year, the Secretary shall pay to the subsection (d) hospital 25 percent of such amount (which represents the empirically justified amount for such payment, as determined by the Medicare Payment Advisory Commission in its March 2007 Report to the Congress). (2) Additional payment.--In addition to the payment made to a subsection (d) hospital under paragraph (1), for fiscal year 2014 and each subsequent fiscal year, the Secretary shall pay to such subsection (d) hospitals an additional amount equal to the product of the following factors: (A) Factor one.--A factor equal to the difference between-- (i) the aggregate amount of payments that would be made to subsection (d) hospitals under subsection (d)(5)(F) if this subsection did not apply for such fiscal year (as estimated by the Secretary); and (ii) the aggregate amount of payments that are made to subsection (d) hospitals under paragraph (1) for such fiscal year (as so estimated). (B) Factor two.-- (i) Fiscal years 2014, 2015, 2016, and 2017.--For each of fiscal years 2014, 2015, 2016, and 2017, a factor equal to 1 minus the percent change in the percent of individuals under the age of 65 who are uninsured, as determined by comparing the percent of such individuals-- (I) who are uninsured in 2013, the last year before coverage expansion under the Patient Protection and Affordable Care Act (as calculated by the Secretary based on the most recent estimates available from the Director of the Congressional Budget Office before a vote in either House on the Health Care and Education Reconciliation Act of 2010 that, if determined in the affirmative, would clear such Act for enrollment); and (II) who are uninsured in the most recent period for which data is available (as so calculated), minus 0.1 percentage points for fiscal year 2014 and minus 0.2 percentage points for each of fiscal years 2015, 2016, and 2017. (ii) 2018 and subsequent years.--For fiscal year 2018 and each subsequent fiscal year, a factor equal to 1 minus the percent change in the percent of individuals who are uninsured, as determined by comparing the percent of individuals-- (I) who are uninsured in 2013 (as estimated by the Secretary, based on data from the Census Bureau or other sources the Secretary determines appropriate, and certified by the Chief Actuary of the Centers for Medicare & Medicaid Services); and (II) who are uninsured in the most recent period for which data is available (as so estimated and certified), minus 0.2 percentage points for each of fiscal years 2018 and 2019. (C) Factor three.--A factor equal to the percent, for each subsection (d) hospital, that represents the quotient of-- (i) the amount of uncompensated care for such hospital for a period selected by the Secretary (as estimated by the Secretary, based on appropriate data (including, in the case where the Secretary determines that alternative data is available which is a better proxy for the costs of subsection (d) hospitals for treating the uninsured, the use of such alternative data)); and (ii) the aggregate amount of uncompensated care for all subsection (d) hospitals that receive a payment under this subsection for such period (as so estimated, based on such data). (3) Limitations on review.--There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the following: (A) Any estimate of the Secretary for purposes of determining the factors described in paragraph (2). (B) Any period selected by the Secretary for such purposes. (s) Prospective Payment for Psychiatric Hospitals.-- (1) Reference to establishment and implementation of system.--For provisions related to the establishment and implementation of a prospective payment system for payments under this title for inpatient hospital services furnished by psychiatric hospitals (as described in clause (i) of subsection (d)(1)(B)) and psychiatric units (as described in the matter following clause (v) of such subsection), see section 124 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999. (2) Implementation for rate year beginning in 2010 and subsequent rate years.-- (A) In general.--In implementing the system described in paragraph (1) for the rate year beginning in 2010 and any subsequent rate year, any update to a base rate for days during the rate year for a psychiatric hospital or unit, respectively, shall be reduced-- (i) for the rate year beginning in 2012 and each subsequent rate year, by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II); and (ii) for each of the rate years beginning in 2010 through 2019, by the other adjustment described in paragraph (3). (B) Special rule.--The application of this paragraph may result in such update being less than 0.0 for a rate year, and may result in payment rates under the system described in paragraph (1) for a rate year being less than such payment rates for the preceding rate year. (3) Other adjustment.--For purposes of paragraph (2)(A)(ii), the other adjustment described in this paragraph is-- (A) for each of the rate years beginning in 2010 and 2011, 0.25 percentage point; (B) for each of the rate years beginning in 2012 and 2013, 0.1 percentage point; (C) for the rate year beginning in 2014, 0.3 percentage point; (D) for each of the rate years beginning in 2015 and 2016, 0.2 percentage point; and (E) for each of the rate years beginning in 2017, 2018, and 2019, 0.75 percentage point. (4) Quality reporting.-- (A) Reduction in update for failure to report.-- (i) In general.--Under the system described in paragraph (1), for rate year 2014 and each subsequent rate year, in the case of a psychiatric hospital or psychiatric unit that does not submit data to the Secretary in accordance with subparagraph (C) with respect to such a rate year, any annual update to a standard Federal rate for discharges for the hospital during the rate year, and after application of paragraph (2), shall be reduced by 2 percentage points. (ii) Special rule.--The application of this subparagraph may result in such annual update being less than 0.0 for a rate year, and may result in payment rates under the system described in paragraph (1) for a rate year being less than such payment rates for the preceding rate year. (B) Noncumulative application.--Any reduction under subparagraph (A) shall apply only with respect to the rate year involved and the Secretary shall not take into account such reduction in computing the payment amount under the system described in paragraph (1) for a subsequent rate year. (C) Submission of quality data.--For rate year 2014 and each subsequent rate year, each psychiatric hospital and psychiatric unit shall submit to the Secretary data on quality measures specified under subparagraph (D). Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this subparagraph. (D) Quality measures.-- (i) In general.--Subject to clause (ii), any measure specified by the Secretary under this subparagraph must have been endorsed by the entity with a contract under section 1890(a). (ii) Exception.--In the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1890(a), the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary. (iii) Time frame.--Not later than October 1, 2012, the Secretary shall publish the measures selected under this subparagraph that will be applicable with respect to rate year 2014. (E) Public availability of data submitted.-- The Secretary shall establish procedures for making data submitted under subparagraph (C) available to the public. Such procedures shall ensure that a psychiatric hospital and a psychiatric unit has the opportunity to review the data that is to be made public with respect to the hospital or unit prior to such data being made public. The Secretary shall report quality measures that relate to services furnished in inpatient settings in psychiatric hospitals and psychiatric units on the Internet website of the Centers for Medicare & Medicaid Services. (t) Relating Similar Inpatient and Outpatient Hospital Services.-- (1) Development of hcpcs version of ms-drg codes.-- Not later than January 1, 2018, the Secretary shall develop HCPCS versions for MS-DRGs that are similar to the ICD-10-PCS for such MS-DRGs such that, to the extent possible, the MS-DRG assignment shall be similar for a claim coded with the HCPCS version as an identical claim coded with a ICD-10-PCS code. (2) Coverage of surgical ms-drgs.--In carrying out paragraph (1), the Secretary shall develop HCPCS versions of MS-DRG codes for not fewer than 10 surgical MS-DRGs. (3) Publication and dissemination of the hcpcs versions of ms-drgs.-- (A) In general.--The Secretary shall develop a HCPCS MS-DRG definitions manual and software that is similar to the definitions manual and software for ICD-10-PCS codes for such MS-DRGs. The Secretary shall post the HCPCS MS-DRG definitions manual and software on the Internet website of the Centers for Medicare & Medicaid Services. The HCPCS MS-DRG definitions manual and software shall be in the public domain and available for use and redistribution without charge. (B) Use of previous analysis done by medpac.--In developing the HCPCS MS-DRG definitions manual and software under subparagraph (A), the Secretary shall consult with the Medicare Payment Advisory Commission and shall consider the analysis done by such Commission in translating outpatient surgical claims into inpatient surgical MS-DRGs in preparing chapter 7 (relating to hospital short-stay policy issues) of its ``Medicare and the Health Care Delivery System'' report submitted to Congress in June 2015. (4) Definition and reference.--In this subsection: (A) HCPCS.--The term ``HCPCS'' means, with respect to hospital items and services, the code under the Healthcare Common Procedure Coding System (HCPCS) (or a successor code) for such items and services. (B) ICD-10-pcs.--The term ``ICD-10-PCS'' means the International Classification of Diseases, 10th Revision, Procedure Coding System, and includes any subsequent revision of such International Classification of Diseases, Procedure Coding System. * * * * * * * payment to skilled nursing facilities for routine service costs Sec. 1888. (a) The Secretary, in determining the amount of the payments which may be made under this title with respect to routine service costs of extended care services shall not recognize as reasonable (in the efficient delivery of health services) per diem costs of such services to the extent that such per diem costs exceed the following per diem limits, except as otherwise provided in this section: (1) With respect to freestanding skilled nursing facilities located in urban areas, the limit shall be equal to 112 percent of the mean per diem routine service costs for freestanding skilled nursing facilities located in urban areas. (2) With respect to freestanding skilled nursing facilities located in rural areas, the limit shall be equal to 112 percent of the mean per diem routine service costs for freestanding skilled nursing facilities located in rural areas. (3) With respect to hospital-based skilled nursing facilities located in urban areas, the limit shall be equal to the sum of the limit for freestanding skilled nursing facilities located in urban areas, plus 50 percent of the amount by which 112 percent of the mean per diem routine service costs for hospital-based skilled nursing facilities located in urban areas exceeds the limit for freestanding skilled nursing facilities located in urban areas. (4) With respect to hospital-based skilled nursing facilities located in rural areas, the limit shall be equal to the sum of the limit for freestanding skilled nursing facilities located in rural areas, plus 50 percent of the amount by which 112 percent of the mean per diem routine service costs for hospital-based skilled nursing facilities located in rural areas exceeds the limit for freestanding skilled nursing facilities located in rural areas. In applying this subsection the Secretary shall make appropriate adjustments to the labor related portion of the costs based upon an appropriate wage index, and shall, for cost reporting periods beginning on or after October 1, 1992, on or after October 1, 1995, and every 2 years thereafter, provide for an update to the per diem cost limits described in this subsection, except that the limits effective for cost reporting periods beginning on or after October 1, 1997, shall be based on the limits effective for cost reporting periods beginning on or after October 1, 1996. (b) With respect to a hospital-based skilled nursing facility, the Secretary may not recognize as reasonable the portion of the cost differences between hospital-based and freestanding skilled nursing facilities attributable to excess overhead allocations. (c) The Secretary may make adjustments in the limits set forth in subsection (a) with respect to any skilled nursing facility to the extent the Secretary deems appropriate, based upon case mix or circumstances beyond the control of the facility. The Secretary shall publish the data and criteria to be used for purposes of this subsection on an annual basis. (d)(1) Subject to subsection (e), any skilled nursing facility may choose to be paid under this subsection on the basis of a prospective payment for all routine service costs (including the costs of services required to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident eligible for benefits under this title) and capital-related costs of extended care services provided in a cost reporting period if such facility had, in the preceding cost reporting period, fewer than 1,500 patient days with respect to which payments were made under this title. Such prospective payment shall be in lieu of payments which would otherwise be made for routine service costs pursuant to section 1861(v) and subsections (a) through (c) of this section and capital-related costs pursuant to section 1861(v). This subsection shall not apply to a facility for any cost reporting period immediately following a cost reporting period in which such facility had 1,500 or more patient days with respect to which payments were made under this title, without regard to whether payments were made under this subsection during such preceding cost reporting period. (2)(A) The amount of the payment under this section shall be determined on a per diem basis. (B) Subject to the limitations of subparagraph (C), for skilled nursing facilities located-- (i) in an urban area, the amount shall be equal to 105 percent of the mean of the per diem reasonable routine service and capital-related costs of extended care services for skilled nursing facilities in urban areas within the same region, determined without regard to the limitations of subsection (a) and adjusted for different area wage levels, and (ii) in a rural area the amount shall be equal to 105 percent of the mean of the per diem reasonable routine service and capital-related costs of extended care services for skilled nursing facilities in rural areas within the same region, determined without regard to the limitations of subsection (a) and adjusted for different area wage levels. (C) The per diem amounts determined under subparagraph (B) shall not exceed the limit on routine service costs determined under subsection (a) with respect to the facility, adjusted to take into account average capital-related costs with respect to the type and location of the facility. (3) For purposes of this subsection, urban and rural areas shall be determined in the same manner as for purposes of subsection (a), and the term ``region'' shall have the same meaning as under section 1886(d)(2)(D). (4) The Secretary shall establish the prospective payment amounts for cost reporting periods beginning in a fiscal year at least 90 days prior to the beginning of such fiscal year, on the basis of the most recent data available for a 12-month period. A skilled nursing facility must notify the Secretary of its intention to be paid pursuant to this subsection for a cost reporting period no later than 30 days before the beginning of that period. (5) The Secretary shall provide for a simplified cost report to be filed by facilities being paid pursuant to this subsection, which shall require only the cost information necessary for determining prospective payment amounts pursuant to paragraph (2) and reasonable costs of ancillary services. (6) In lieu of payment on a cost basis for ancillary services provided by a facility which is being paid pursuant to this subsection, the Secretary may pay for such ancillary services on a reasonable charge basis if the Secretary determines that such payment basis will provide an equitable level of reimbursement and will ease the reporting burden of the facility. (7) In computing the rates of payment to be made under this subsection, there shall be taken into account the costs described in the last sentence of section 1861(v)(1)(E) (relating to compliance with nursing facility requirements and of conducting nurse aide training and competency evaluation programs and competency evaluation programs). (e) Prospective Payment.-- (1) Payment provision.--Notwithstanding any other provision of this title, subject to paragraphs (7), (11), and (12), the amount of the payment for all costs (as defined in paragraph (2)(B)) of covered skilled nursing facility services (as defined in paragraph (2)(A)) for each day of such services furnished-- (A) in a cost reporting period during the transition period (as defined in paragraph (2)(E)), is equal to the sum of-- (i) the non-Federal percentage of the facility-specific per diem rate (computed under paragraph (3)), and (ii) the Federal percentage of the adjusted Federal per diem rate (determined under paragraph (4)) applicable to the facility; and (B) after the transition period is equal to the adjusted Federal per diem rate applicable to the facility. (2) Definitions.--For purposes of this subsection: (A) Covered skilled nursing facility services.-- (i) In general.--The term ``covered skilled nursing facility services''-- (I) means post-hospital extended care services as defined in section 1861(i) for which benefits are provided under part A; and (II) includes all items and services (other than items and services described in clauses (ii), (iii), and (iv)) for which payment may be made under part B and which are furnished to an individual who is a resident of a skilled nursing facility during the period in which the individual is provided covered post-hospital extended care services. (ii) Services excluded.--Services described in this clause are physicians' services, services described by clauses (i) and (ii) of section 1861(s)(2)(K), certified nurse- midwife services, qualified psychologist services, services of a certified registered nurse anesthetist, items and services described in subparagraphs (F) and (O) of section 1861(s)(2), telehealth services furnished under section 1834(m)(4)(C)(ii)(VII), and, only with respect to services furnished during 1998, the transportation costs of electrocardiogram equipment for electrocardiogram test services (HCPCS Code R0076). Services described in this clause do not include any physical, occupational, or speech-language therapy services regardless of whether or not the services are furnished by, or under the supervision of, a physician or other health care professional. (iii) Exclusion of certain additional items and services.--Items and services described in this clause are the following: (I) Ambulance services furnished to an individual in conjunction with renal dialysis services described in section 1861(s)(2)(F). (II) Chemotherapy items (identified as of July 1, 1999, by HCPCS codes J9000-J9020; J9040-J9151; J9170-J9185; J9200-J9201; J9206-J9208; J9211; J9230-J9245; and J9265- J9600 (and as subsequently modified by the Secretary)) and any additional chemotherapy items identified by the Secretary. (III) Chemotherapy administration services (identified as of July 1, 1999, by HCPCS codes 36260-36262; 36489; 36530-36535; 36640; 36823; and 96405-96542 (and as subsequently modified by the Secretary)) and any additional chemotherapy administration services identified by the Secretary. (IV) Radioisotope services (identified as of July 1, 1999, by HCPCS codes 79030-79440 (and as subsequently modified by the Secretary)) and any additional radioisotope services identified by the Secretary. (V) Customized prosthetic devices (commonly known as artificial limbs or components of artificial limbs) under the following HCPCS codes (as of July 1, 1999 (and as subsequently modified by the Secretary)), and any additional customized prosthetic devices identified by the Secretary, if delivered to an inpatient for use during the stay in the skilled nursing facility and intended to be used by the individual after discharge from the facility: L5050-L5340; L5500-L5611; L5613-L5986; L5988; L6050-L6370; L6400- L6880; L6920-L7274; and L7362- 7366. (iv) Exclusion of certain rural health clinic and federally qualified health center services.--Services described in this clause are-- (I) rural health clinic services (as defined in paragraph (1) of section 1861(aa)); and (II) federally qualified health center services (as defined in paragraph (3) of such section); that would be described in clause (ii) if such services were furnished by an individual not affiliated with a rural health clinic or a federally qualified health center. (B) All costs.--The term ``all costs'' means routine service costs, ancillary costs, and capital-related costs of covered skilled nursing facility services, but does not include costs associated with approved educational activities. (C) Non-federal percentage; federal percentage.--For-- (i) the first cost reporting period (as defined in subparagraph (D)) of a facility, the ``non-Federal percentage'' is 75 percent and the ``Federal percentage'' is 25 percent; (ii) the next cost reporting period of such facility, the ``non-Federal percentage'' is 50 percent and the ``Federal percentage'' is 50 percent; and (iii) the subsequent cost reporting period of such facility, the ``non- Federal percentage'' is 25 percent and the ``Federal percentage'' is 75 percent. (D) First cost reporting period.--The term ``first cost reporting period'' means, with respect to a skilled nursing facility, the first cost reporting period of the facility beginning on or after July 1, 1998. (E) Transition period.-- (i) In general.--The term ``transition period'' means, with respect to a skilled nursing facility, the 3 cost reporting periods of the facility beginning with the first cost reporting period. (ii) Treatment of new skilled nursing facilities.--In the case of a skilled nursing facility that first received payment for services under this title on or after October 1, 1995, payment for such services shall be made under this subsection as if all services were furnished after the transition period. (3) Determination of facility specific per diem rates.--The Secretary shall determine a facility- specific per diem rate for each skilled nursing facility not described in paragraph (2)(E)(ii) for a cost reporting period as follows: (A) Determining base payments.--The Secretary shall determine, on a per diem basis, the total of-- (i) the allowable costs of extended care services for the facility for cost reporting periods beginning in fiscal year 1995, including costs associated with facilities described in subsection (d), with appropriate adjustments (as determined by the Secretary) to non- settled cost reports or, in the case of a facility participating in the Nursing Home Case-Mix and Quality Demonstration (RUGS-III), the RUGS-III rate received by the facility during the cost reporting period beginning in 1997, and (ii) an estimate of the amounts that would be payable under part B (disregarding any applicable deductibles, coinsurance, and copayments) for covered skilled nursing facility services described in paragraph (2)(A)(i)(II) furnished during the applicable cost reporting period described in clause (i) to an individual who is a resident of the facility, regardless of whether or not the payment was made to the facility or to another entity. In making appropriate adjustments under clause (i), the Secretary shall take into account exceptions and shall take into account exemptions but, with respect to exemptions, only to the extent that routine costs do not exceed 150 percent of the routine cost limits otherwise applicable but for the exemption. (B) Update to first cost reporting period.-- The Secretary shall update the amount determined under subparagraph (A), for each cost reporting period after the applicable cost reporting period described in subparagraph (A)(i) and up to the first cost reporting period by a factor equal to the skilled nursing facility market basket percentage increase minus 1.0 percentage point. (C) Updating to applicable cost reporting period.--The Secretary shall update the amount determined under subparagraph (B) for each cost reporting period beginning with the first cost reporting period and up to and including the cost reporting period involved by a factor equal to the facility-specific update factor. (D) Facility-specific update factor.--For purposes of this paragraph, the ``facility- specific update factor'' for cost reporting periods beginning during-- (i) during each of fiscal years 1998 and 1999, is equal to the skilled nursing facility market basket percentage increase for such fiscal year minus 1 percentage point, and (ii) during each subsequent fiscal year is equal to the skilled nursing facility market basket percentage increase for such fiscal year. (4) Federal per diem rate.-- (A) Determination of historical per diem for facilities.--For each skilled nursing facility that received payments for post-hospital extended care services during a cost reporting period beginning in fiscal year 1995 and that was subject to (and not exempted from) the per diem limits referred to in paragraph (1) or (2) of subsection (a) (and facilities described in subsection (d)), the Secretary shall estimate, on a per diem basis for such cost reporting period, the total of-- (i) the allowable costs of extended care services (excluding exceptions payments) for the facility for cost reporting periods beginning in 1995 with appropriate adjustments (as determined by the Secretary) to non- settled cost reports, and (ii) an estimate of the amounts that would be payable under part B (disregarding any applicable deductibles, coinsurance, and copayments) for covered skilled nursing facility services described in paragraph (2)(A)(i)(II) furnished during such period to an individual who is a resident of the facility, regardless of whether or not the payment was made to the facility or to another entity. (B) Update to first fiscal year.--The Secretary shall update the amount determined under subparagraph (A), for each cost reporting period after the cost reporting period described in subparagraph (A)(i) and up to the first cost reporting period by a factor equal to the skilled nursing facility market basket percentage increase reduced (on an annualized basis) by 1 percentage point. (C) Computation of standardized per diem rate.--The Secretary shall standardize the amount updated under subparagraph (B) for each facility by-- (i) adjusting for variations among facilities by area in the average facility wage level per diem, and (ii) adjusting for variations in case mix per diem among facilities. (D) Computation of weighted average per diem rates.-- (i) All facilities.--The Secretary shall compute a weighted average per diem rate for all facilities by computing an average of the standardized amounts computed under subparagraph (C), weighted for each facility by the number of days of extended care services furnished during the cost reporting period referred to in subparagraph (A). (ii) Freestanding facilities.--The Secretary shall compute a weighted average per diem rate for freestanding facilities by computing an average of the standardized amounts computed under subparagraph (C) only for such facilities, weighted for each facility by the number of days of extended care services furnished during the cost reporting period referred to in subparagraph (A). (iii) Separate computation.--The Secretary may compute and apply such averages separately for facilities located in urban and rural areas (as defined in section 1886(d)(2)(D)). (E) Updating.-- (i) Initial period.--For the initial period beginning on July 1, 1998, and ending on September 30, 1999, the Secretary shall compute for skilled nursing facilities an unadjusted Federal per diem rate equal to the average of the weighted average per diem rates computed under clauses (i) and (ii) of subparagraph (D), increased by skilled nursing facility market basket percentage change for such period minus 1 percentage point. (ii) Subsequent fiscal years.--The Secretary shall compute an unadjusted Federal per diem rate equal to the Federal per diem rate computed under this subparagraph-- (I) for fiscal year 2000, the rate computed for the initial period described in clause (i), increased by the skilled nursing facility market basket percentage change for the initial period minus 1 percentage point; (II) for fiscal year 2001, the rate computed for the previous fiscal year increased by the skilled nursing facility market basket percentage change for the fiscal year; (III) for each of fiscal years 2002 and 2003, the rate computed for the previous fiscal year increased by the skilled nursing facility market basket percentage change for the fiscal year involved minus 0.5 percentage points; and (IV) for each subsequent fiscal year, the rate computed for the previous fiscal year increased by the skilled nursing facility market basket percentage change for the fiscal year involved. (F) Adjustment for case mix creep.--Insofar as the Secretary determines that the adjustments under subparagraph (G)(i) for a previous fiscal year (or estimates that such adjustments for a future fiscal year) did (or are likely to) result in a change in aggregate payments under this subsection during the fiscal year that are a result of changes in the coding or classification of residents that do not reflect real changes in case mix, the Secretary may adjust unadjusted Federal per diem rates for subsequent fiscal years so as to eliminate the effect of such coding or classification changes. (G) Determination of federal rate.--The Secretary shall compute for each skilled nursing facility for each fiscal year (beginning with the initial period described in subparagraph (E)(i)) an adjusted Federal per diem rate equal to the unadjusted Federal per diem rate determined under subparagraph (E), as adjusted under subparagraph (F), and as further adjusted as follows: (i) Adjustment for case mix.--The Secretary shall provide for an appropriate adjustment to account for case mix. Such adjustment shall be based on a resident classification system, established by the Secretary, that accounts for the relative resource utilization of different patient types. The case mix adjustment shall be based on resident assessment data and other data that the Secretary considers appropriate. (ii) Adjustment for geographic variations in labor costs.--The Secretary shall adjust the portion of such per diem rate attributable to wages and wage-related costs for the area in which the facility is located compared to the national average of such costs using an appropriate wage index as determined by the Secretary. Such adjustment shall be done in a manner that does not result in aggregate payments under this subsection that are greater or less than those that would otherwise be made if such adjustment had not been made. (iii) Adjustment for exclusion of certain additional items and services.--The Secretary shall provide for an appropriate proportional reduction in payments so that beginning with fiscal year 2001, the aggregate amount of such reductions is equal to the aggregate increase in payments attributable to the exclusion effected under clause (iii) of paragraph (2)(A). (H) Publication of information on per diem rates.--The Secretary shall provide for publication in the Federal Register, before May 1, 1998 (with respect to fiscal period described in subparagraph (E)(i)) and before the August 1 preceding each succeeding fiscal year (with respect to that succeeding fiscal year), of-- (i) the unadjusted Federal per diem rates to be applied to days of covered skilled nursing facility services furnished during the fiscal year, (ii) the case mix classification system to be applied under subparagraph (G)(i) with respect to such services during the fiscal year, and (iii) the factors to be applied in making the area wage adjustment under subparagraph (G)(ii) with respect to such services. (5) Skilled nursing facility market basket index and percentage.--For purposes of this subsection: (A) Skilled nursing facility market basket index.--The Secretary shall establish a skilled nursing facility market basket index that reflects changes over time in the prices of an appropriate mix of goods and services included in covered skilled nursing facility services. (B) Skilled nursing facility market basket percentage.-- (i) In general.--Subject to clauses (ii), (iii), and (iv), the term ``skilled nursing facility market basket percentage'' means, for a fiscal year or other annual period and as calculated by the Secretary, the percentage change in the skilled nursing facility market basket index (established under subparagraph (A)) from the midpoint of the prior fiscal year (or period) to the midpoint of the fiscal year (or other period) involved. (ii) Adjustment.--For fiscal year 2012 and each subsequent fiscal year, subject to clauses (iii) and (iv), after determining the percentage described in clause (i), the Secretary shall reduce such percentage by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II). The application of the preceding sentence may result in such percentage being less than 0.0 for a fiscal year, and may result in payment rates under this subsection for a fiscal year being less than such payment rates for the preceding fiscal year. (iii) Special rule for fiscal year 2018.--For fiscal year 2018 (or other similar annual period specified in clause (i)), the skilled nursing facility market basket percentage, after application of clause (ii), is equal to 1 percent. (iv) Special rule for fiscal year 2019.--For fiscal year 2019 (or other similar annual period specified in clause (i)), the skilled nursing facility market basket percentage, after application of clause (ii), is equal to 2.4 percent. (6) Reporting of assessment and quality data.-- (A) Reduction in update for failure to report.-- (i) In general.--For fiscal years beginning with fiscal year 2018, in the case of a skilled nursing facility that does not submit data, as applicable, in accordance with subclauses (II) and (III) of subparagraph (B)(i) with respect to such a fiscal year, after determining the percentage described in paragraph (5)(B)(i), and after application of clauses (ii) and (iii) of paragraph (5)(B), the Secretary shall reduce such percentage for payment rates during such fiscal year by 2 percentage points. (ii) Special rule.--The application of this subparagraph may result in the percentage described in paragraph (5)(B)(i), after application of clauses (ii) and (iii) of paragraph (5)(B), being less than 0.0 for a fiscal year, and may result in payment rates under this subsection for a fiscal year being less than such payment rates for the preceding fiscal year. (iii) Noncumulative application.--Any reduction under clause (i) shall apply only with respect to the fiscal year involved and the Secretary shall not take into account such reduction in computing the payment amount under this subsection for a subsequent fiscal year. (B) Assessment and measure data.-- (i) In general.--A skilled nursing facility, or a facility (other than a critical access hospital) described in paragraph (7)(B), shall submit to the Secretary, in a manner and within the timeframes prescribed by the Secretary-- (I) subject to clause (iii), the resident assessment data necessary to develop and implement the rates under this subsection; (II) for fiscal years beginning on or after the specified application date (as defined in subsection (a)(2)(E) of section 1899B), as applicable with respect to skilled nursing facilities and quality measures under subsection (c)(1) of such section and measures under subsection (d)(1) of such section, data on such quality measures under such subsection (c)(1) and any necessary data specified by the Secretary under such subsection (d)(1); and (III) for fiscal years beginning on or after October 1, 2018, standardized patient assessment data required under subsection (b)(1) of section 1899B. (ii) Use of standard instrument.--For purposes of meeting the requirement under clause (i), a skilled nursing facility, or a facility (other than a critical access hospital) described in paragraph (7)(B), may submit the resident assessment data required under section 1819(b)(3), using the standard instrument designated by the State under section 1819(e)(5). (iii) Non-duplication.--To the extent data submitted under subclause (II) or (III) of clause (i) duplicates other data required to be submitted under clause (i)(I), the submission of such data under such a subclause shall be in lieu of the submission of such data under clause (i)(I). The previous sentence shall not apply insofar as the Secretary determines it is necessary to avoid a delay in the implementation of section 1899B, taking into account the different specified application dates under subsection (a)(2)(E) of such section. (7) Treatment of medicare swing bed hospitals.-- (A) Transition.--Subject to subparagraph (C), the Secretary shall determine an appropriate manner in which to apply this subsection to the facilities described in subparagraph (B) (other than critical access hospitals), taking into account the purposes of this subsection, and shall provide that at the end of the transition period (as defined in paragraph (2)(E)) such facilities shall be paid only under this subsection. Payment shall not be made under this subsection to such facilities for cost reporting periods beginning before such date (not earlier than July 1, 1999) as the Secretary specifies. (B) Facilities described.--The facilities described in this subparagraph are facilities that have in effect an agreement described in section 1883. (C) Exemption from pps of swing-bed services furnished in critical access hospitals.--The prospective payment system established under this subsection shall not apply to services furnished by a critical access hospital pursuant to an agreement under section 1883. (8) Limitation on review.--There shall be no administrative or judicial review under section 1869, 1878, or otherwise of-- (A) the establishment of Federal per diem rates under paragraph (4), including the computation of the standardized per diem rates under paragraph (4)(C), adjustments and corrections for case mix under paragraphs (4)(F) and (4)(G)(i), adjustments for variations in labor-related costs under paragraph (4)(G)(ii), and adjustments under paragraph (4)(G)(iii); (B) the establishment of facility specific rates before July 1, 1999 (except any determination of costs paid under part A of this title); and (C) the establishment of transitional amounts under paragraph (7). (9) Payment for certain services.--In the case of an item or service furnished to a resident of a skilled nursing facility or a part of a facility that includes a skilled nursing facility (as determined under regulations) for which payment would (but for this paragraph) be made under part B in an amount determined in accordance with section 1833(a)(2)(B), the amount of the payment under such part shall be the amount provided under the fee schedule for such item or service. In the case of an item or service described in clause (iii) of paragraph (2)(A) that would be payable under part A but for the exclusion of such item or service under such clause, payment shall be made for the item or service, in an amount otherwise determined under part B of this title for such item or service, from the Federal Hospital Insurance Trust Fund under section 1817 (rather than from the Federal Supplementary Medical Insurance Trust Fund under section 1841). (10) Required coding.--No payment may be made under part B for items and services (other than services described in paragraph (2)(A)(ii)) furnished to an individual who is a resident of a skilled nursing facility or of a part of a facility that includes a skilled nursing facility (as determined under regulations), unless the claim for such payment includes a code (or codes) under a uniform coding system specified by the Secretary that identifies the items or services furnished. (11) Permitting facilities to waive 3-year transition.--Notwithstanding paragraph (1)(A), a facility may elect to have the amount of the payment for all costs of covered skilled nursing facility services for each day of such services furnished in cost reporting periods beginning no earlier than 30 days before the date of such election determined pursuant to paragraph (1)(B). (12) Adjustment for residents with aids.-- (A) In general.--Subject to subparagraph (B), in the case of a resident of a skilled nursing facility who is afflicted with acquired immune deficiency syndrome (AIDS), the per diem amount of payment otherwise applicable (determined without regard to any increase under section 101 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, or under section 314(a) of Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000), shall be increased by 128 percent to reflect increased costs associated with such residents. (B) Sunset.--Subparagraph (A) shall not apply on and after such date as the Secretary certifies that there is an appropriate adjustment in the case mix under paragraph (4)(G)(i) to compensate for the increased costs associated with residents described in such subparagraph. (f) Reporting of Direct Care Expenditures.-- (1) In general.--For cost reports submitted under this title for cost reporting periods beginning on or after the date that is 2 years after the date of the enactment of this subsection, skilled nursing facilities shall separately report expenditures for wages and benefits for direct care staff (breaking out (at a minimum) registered nurses, licensed professional nurses, certified nurse assistants, and other medical and therapy staff). (2) Modification of form.--The Secretary, in consultation with private sector accountants experienced with Medicare and Medicaid nursing facility home cost reports, shall redesign such reports to meet the requirement of paragraph (1) not later than 1 year after the date of the enactment of this subsection. (3) Categorization by functional accounts.--Not later than 30 months after the date of the enactment of this subsection, the Secretary, working in consultation with the Medicare Payment Advisory Commission, the Medicaid and CHIP Payment and Access Commission, the Inspector General of the Department of Health and Human Services, and other expert parties the Secretary determines appropriate, shall take the expenditures listed on cost reports, as modified under paragraph (1), submitted by skilled nursing facilities and categorize such expenditures, regardless of any source of payment for such expenditures, for each skilled nursing facility into the following functional accounts on an annual basis: (A) Spending on direct care services (including nursing, therapy, and medical services). (B) Spending on indirect care (including housekeeping and dietary services). (C) Capital assets (including building and land costs). (D) Administrative services costs. (4) Availability of information submitted.--The Secretary shall establish procedures to make information on expenditures submitted under this subsection readily available to interested parties upon request, subject to such requirements as the Secretary may specify under the procedures established under this paragraph. (g) Skilled Nursing Facility Readmission Measure.-- (1) Readmission measure.--Not later than October 1, 2015, the Secretary shall specify a skilled nursing facility all-cause all-condition hospital readmission measure (or any successor to such a measure). (2) Resource use measure.--Not later than October 1, 2016, the Secretary shall specify a measure to reflect an all-condition risk-adjusted potentially preventable hospital readmission rate for skilled nursing facilities. (3) Measure adjustments.--When specifying the measures under paragraphs (1) and (2), the Secretary shall devise a methodology to achieve a high level of reliability and validity, especially for skilled nursing facilities with a low volume of readmissions. (4) Pre-rulemaking process (measure application partnership process).--The application of the provisions of section 1890A shall be optional in the case of a measure specified under paragraph (1) and a measure specified under paragraph (2). (5) Feedback reports to skilled nursing facilities.--Beginning October 1, 2016, and every quarter thereafter, the Secretary shall provide confidential feedback reports to skilled nursing facilities on the performance of such facilities with respect to a measure specified under paragraph (1) or (2). (6) Public reporting of skilled nursing facilities.-- (A) In general.--Subject to subparagraphs (B) and (C), the Secretary shall establish procedures for making available to the public by posting on the Nursing Home Compare Medicare website (or a successor website) described in section 1819(i) information on the performance of skilled nursing facilities with respect to a measure specified under paragraph (1) and a measure specified under paragraph (2). (B) Opportunity to review.--The procedures under subparagraph (A) shall ensure that a skilled nursing facility has the opportunity to review and submit corrections to the information that is to be made public with respect to the facility prior to such information being made public. (C) Timing.--Such procedures shall provide that the information described in subparagraph (A) is made publicly available beginning not later than October 1, 2017. (7) Non-application of paperwork reduction act.-- Chapter 35 of title 44, United States Code (commonly referred to as the `Paperwork Reduction Act of 1995') shall not apply to this subsection. (h) Skilled Nursing Facility Value-Based Purchasing Program.-- (1) Establishment.-- (A) In general.--Subject to the succeeding provisions of this subsection, the Secretary shall establish a skilled nursing facility value-based purchasing program (in this subsection referred to as the ``SNF VBP Program'') under which value-based incentive payments are made in a fiscal year to skilled nursing facilities. (B) Program to begin in fiscal year 2019.-- The SNF VBP Program shall apply to payments for services furnished on or after October 1, 2018. (C) Exclusions.--With respect to payments for services furnished on or after October 1, 2021, this subsection shall not apply to a facility for which there are not a minimum number (as determined by the Secretary) of-- (i) cases for the measures that apply to the facility for the performance period for the applicable fiscal year; or (ii) measures that apply to the facility for the performance period for the applicable fiscal year. (2) Application of measures.-- (A) In general.--[The Secretary shall apply] The Secretary-- (i) shall apply the measure specified under subsection (g)(1) for purposes of the SNF VBP Program[.]; and (ii) may, with respect to payments for services furnished on or after October 1, 2022, apply additional measures determined appropriate by the Secretary, which may include measures of functional status, patient safety, care coordination, or patient experience. Subject to the succeeding sentence, in the case that the Secretary applies additional measures under clause (ii), the Secretary shall consider and apply, as appropriate, quality measures specified under section 1899B(c)(1). In no case may the Secretary apply more than 10 measures under this subparagraph. (B) Replacement.--For purposes of the SNF VBP Program, the Secretary shall apply the measure specified under (g)(2) instead of the measure specified under (g)(1) as soon as practicable. (3) Performance standards.-- (A) Establishment.--The Secretary shall establish performance standards with respect to the [measure] measures applied under paragraph (2) for a performance period for a fiscal year. (B) Higher of achievement and improvement.-- The performance standards established under subparagraph (A) shall include levels of achievement and improvement. In calculating the SNF performance score under paragraph (4), the Secretary shall use the higher of either improvement or achievement. (C) Timing.--The Secretary shall establish and announce the performance standards established under subparagraph (A) not later than 60 days prior to the beginning of the performance period for the fiscal year involved. (4) SNF performance score.-- (A) In general.--The Secretary shall develop a methodology for assessing the total performance of each skilled nursing facility based on performance standards established under paragraph (3) with respect to the [measure] measures applied under paragraph (2). Using such methodology, the Secretary shall provide for an assessment (in this subsection referred to as the ``SNF performance score'') for each skilled nursing facility for each such performance period. (B) Ranking of snf performance scores.--The Secretary shall, for the performance period for each fiscal year, rank the SNF performance scores determined under subparagraph (A) from low to high. (5) Calculation of value-based incentive payments.-- (A) In general.--With respect to a skilled nursing facility, based on the ranking under paragraph (4)(B) for a performance period for a fiscal year, the Secretary shall increase the adjusted Federal per diem rate determined under subsection (e)(4)(G) otherwise applicable to such skilled nursing facility (and after application of paragraph (6)) for services furnished by such facility during such fiscal year by the value-based incentive payment amount under subparagraph (B). (B) Value-based incentive payment amount.-- The value-based incentive payment amount for services furnished by a skilled nursing facility in a fiscal year shall be equal to the product of-- (i) the adjusted Federal per diem rate determined under subsection (e)(4)(G) otherwise applicable to such skilled nursing facility for such services furnished by the skilled nursing facility during such fiscal year; and (ii) the value-based incentive payment percentage specified under subparagraph (C) for the skilled nursing facility for such fiscal year. (C) Value-based incentive payment percentage.-- (i) In general.--The Secretary shall specify a value-based incentive payment percentage for a skilled nursing facility for a fiscal year which may include a zero percentage. (ii) Requirements.--In specifying the value-based incentive payment percentage for each skilled nursing facility for a fiscal year under clause (i), the Secretary shall ensure that-- (I) such percentage is based on the SNF performance score of the skilled nursing facility provided under paragraph (4) for the performance period for such fiscal year; (II) the application of all such percentages in such fiscal year results in an appropriate distribution of value-based incentive payments under subparagraph (B) such that-- (aa) skilled nursing facilities with the highest rankings under paragraph (4)(B) receive the highest value-based incentive payment amounts under subparagraph (B); (bb) skilled nursing facilities with the lowest rankings under paragraph (4)(B) receive the lowest value-based incentive payment amounts under subparagraph (B); and (cc) in the case of skilled nursing facilities in the lowest 40 percent of the ranking under paragraph (4)(B), the payment rate under subparagraph (A) for services furnished by such facility during such fiscal year shall be less than the payment rate for such services for such fiscal year that would otherwise apply under subsection (e)(4)(G) without application of this subsection; and (III) the total amount of value-based incentive payments under this paragraph for all skilled nursing facilities in such fiscal year shall be greater than or equal to 50 percent, but not greater than 70 percent, of the total amount of the reductions to payments for such fiscal year under paragraph (6), as estimated by the Secretary. (6) Funding for value-based incentive payments.-- (A) In general.--The Secretary shall reduce the adjusted Federal per diem rate determined under subsection (e)(4)(G) otherwise applicable to a skilled nursing facility for services furnished by such facility during a fiscal year (beginning with fiscal year 2019) by the applicable percent (as defined in subparagraph (B)). The Secretary shall make such reductions for all skilled nursing facilities in the fiscal year involved, regardless of whether or not the skilled nursing facility has been determined by the Secretary to have earned a value-based incentive payment under paragraph (5) for such fiscal year. (B) Applicable percent.--For purposes of subparagraph (A), the term ``applicable percent'' means, with respect to fiscal year 2019 and succeeding fiscal years, 2 percent. (7) Announcement of net result of adjustments.--Under the SNF VBP Program, the Secretary shall, not later than 60 days prior to the fiscal year involved, inform each skilled nursing facility of the adjustments to payments to the skilled nursing facility for services furnished by such facility during the fiscal year under paragraphs (5) and (6). (8) No effect in subsequent fiscal years.--The value- based incentive payment under paragraph (5) and the payment reduction under paragraph (6) shall each apply only with respect to the fiscal year involved, and the Secretary shall not take into account such value-based incentive payment or payment reduction in making payments to a skilled nursing facility under this section in a subsequent fiscal year. (9) Public reporting.-- (A) SNF specific information.--The Secretary shall make available to the public, by posting on the Nursing Home Compare Medicare website (or a successor website) described in section 1819(i) in an easily understandable format, information regarding the performance of individual skilled nursing facilities under the SNF VBP Program, with respect to a fiscal year, including-- (i) the SNF performance score of the skilled nursing facility for such fiscal year; and (ii) the ranking of the skilled nursing facility under paragraph (4)(B) for the performance period for such fiscal year. (B) Aggregate information.--The Secretary shall periodically post on the Nursing Home Compare Medicare website (or a successor website) described in section 1819(i) aggregate information on the SNF VBP Program, including-- (i) the range of SNF performance scores provided under paragraph (4)(A); and (ii) the number of skilled nursing facilities receiving value-based incentive payments under paragraph (5) and the range and total amount of such value-based incentive payments. (10) Limitation on review.--There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the following: (A) The methodology used to determine the value-based incentive payment percentage and the amount of the value-based incentive payment under paragraph (5). (B) The determination of the amount of funding available for such value-based incentive payments under paragraph (5)(C)(ii)(III) and the payment reduction under paragraph (6). (C) The establishment of the performance standards under paragraph (3) and the performance period. (D) The methodology developed under paragraph (4) that is used to calculate SNF performance scores and the calculation of such scores. (E) The ranking determinations under paragraph (4)(B). (11) Funding for program management.--The Secretary shall provide for the one time transfer from the Federal Hospital Insurance Trust Fund established under section 1817 to the Centers for Medicare & Medicaid Services Program Management Account of-- (A) for purposes of subsection (g)(2), $2,000,000; and (B) for purposes of implementing this subsection, $10,000,000. Such funds shall remain available until expended. (12) Validation.-- (A) In general.--The Secretary shall apply to the measures applied under this subsection and the data submitted under subsection (e)(6) a process to validate such measures and data, as appropriate, which may be similar to the process specified in section 1886(b)(3)(B)(viii)(XI) for validating inpatient hospital measures. (B) Funding.--For purposes of carrying out this paragraph, the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund established under section 1817, of $5,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for each of fiscal years 2022 through 2024. * * * * * * * contract with a consensus-based entity regarding performance measurement Sec. 1890. (a) Contract.-- (1) In general.--For purposes of activities conducted under this Act, the Secretary shall identify and have in effect a contract with a consensus-based entity, such as the National Quality Forum, that meets the requirements described in subsection (c). Such contract shall provide that the entity will perform the duties described in subsection (b). (2) Timing for first contract.--As soon as practicable after the date of the enactment of this subsection, the Secretary shall enter into the first contract under paragraph (1). (3) Period of contract.--A contract under paragraph (1) shall be for a period of 4 years (except as may be renewed after a subsequent bidding process). (4) Competitive procedures.--Competitive procedures (as defined in section 4(5) of the Office of Federal Procurement Policy Act (41 U.S.C. 403(5))) shall be used to enter into a contract under paragraph (1). (b) Duties.--The duties described in this subsection are the following: (1) Priority setting process.--The entity shall synthesize evidence and convene key stakeholders to make recommendations, with respect to activities conducted under this Act, on an integrated national strategy and priorities for health care performance measurement in all applicable settings. In making such recommendations, the entity shall-- (A) ensure that priority is given to measures-- (i) that address the health care provided to patients with prevalent, high-cost chronic diseases; (ii) with the greatest potential for improving the quality, efficiency, and patient-centeredness of health care; and (iii) that may be implemented rapidly due to existing evidence, standards of care, or other reasons; and (B) take into account measures that-- (i) may assist consumers and patients in making informed health care decisions; (ii) address health disparities across groups and areas; and (iii) address the continuum of care a patient receives, including services furnished by multiple health care providers or practitioners and across multiple settings. (2) Endorsement of measures.--The entity shall provide for the endorsement of standardized health care performance measures. The endorsement process under the preceding sentence shall consider whether a measure-- (A) is evidence-based, reliable, valid, verifiable, relevant to enhanced health outcomes, actionable at the caregiver level, feasible to collect and report, and responsive to variations in patient characteristics, such as health status, language capabilities, race or ethnicity, and income level; and (B) is consistent across types of health care providers, including hospitals and physicians. (3) Maintenance of measures.--The entity shall establish and implement a process to ensure that measures endorsed under paragraph (2) are updated (or retired if obsolete) as new evidence is developed. (4) Removal of measures.--The entity may provide input to the Secretary on quality and efficiency measures described in paragraph (7)(B) that could be considered for removal. (5) Annual report to congress and the secretary; secretarial publication and comment.-- (A) Annual report.--By not later than March 1 of each year (beginning with 2009), the entity shall submit to Congress and the Secretary a report containing the following: (i) A description of-- (I) the implementation of quality measurement initiatives under this Act and the coordination of such initiatives with quality initiatives implemented by other payers; (II) the recommendations made under paragraph (1); (III) the performance by the entity of the duties required under the contract entered into with the Secretary under subsection (a); (IV) gaps in endorsed quality measures, which shall include measures that are within priority areas identified by the Secretary under the national strategy established under section 399HH of the Public Health Service Act, and where quality measures are unavailable or inadequate to identify or address such gaps; (V) areas in which evidence is insufficient to support endorsement of quality measures in priority areas identified by the Secretary under the national strategy established under section 399HH of the Public Health Service Act and where targeted research may address such gaps; and (VI) the matters described in clauses (i) and (ii) of paragraph (7)(A). (ii) An itemization of financial information for the fiscal year ending September 30 of the preceding year, including-- (I) annual revenues of the entity (including any government funding, private sector contributions, grants, membership revenues, and investment revenue); (II) annual expenses of the entity (including grants paid, benefits paid, salaries or other compensation, fundraising expenses, and overhead costs); and (III) a breakdown of the amount awarded per contracted task order and the specific projects funded in each task order assigned to the entity. (iii) Any updates or modifications of internal policies and procedures of the entity as they relate to the duties of the entity under this section, including-- (I) specifically identifying any modifications to the disclosure of interests and conflicts of interests for committees, work groups, task forces, and advisory panels of the entity; and (II) information on external stakeholder participation in the duties of the entity under this section (including complete rosters for all committees, work groups, task forces, and advisory panels funded through government contracts, descriptions of relevant interests and any conflicts of interest for members of all committees, work groups, task forces, and advisory panels, and the total percentage by health care sector of all convened committees, work groups, task forces, and advisory panels. (B) Secretarial review and publication of annual report.--Not later than 6 months after receiving a report under subparagraph (A) for a year, the Secretary shall-- (i) review such report; and (ii) publish such report in the Federal Register, together with any comments of the Secretary on such report. (6) Review and endorsement of episode grouper under the physician feedback program.--The entity shall provide for the review and, as appropriate, the endorsement of the episode grouper developed by the Secretary under section 1848(n)(9)(A). Such review shall be conducted on an expedited basis. (7) Convening multi-stakeholder groups.-- (A) In general.--The entity shall convene multi-stakeholder groups to provide input on-- (i) the selection of quality and efficiency measures described in subparagraph (B), from among-- (I) such measures that have been endorsed by the entity; and (II) such measures that have not been considered for endorsement by such entity but are used or proposed to be used by the Secretary for the collection or reporting of quality and efficiency measures; and (ii) national priorities (as identified under section 399HH of the Public Health Service Act) for improvement in population health and in the delivery of health care services for consideration under the national strategy established under section 399HH of the Public Health Service Act. (B) Quality measures.-- (i) In general.--Subject to clause (ii), the quality and efficiency measures described in this subparagraph are quality and efficiency measures-- (I) for use pursuant to sections 1814(i)(5)(D), 1833(i)(7), 1833(t)(17), 1848(k)(2)(C), 1866(k)(3), 1881(h)(2)(A)(iii), 1886(b)(3)(B)(viii), 1886(j)(7)(D), 1886(m)(5)(D), 1886(o)(2), 1886(s)(4)(D), and 1895(b)(3)(B)(v); (II) for use in reporting performance information to the public; and (III) for use in health care programs other than for use under this Act. (ii) Exclusion.--Data sets (such as the outcome and assessment information set for home health services and the minimum data set for skilled nursing facility services) that are used for purposes of classification systems used in establishing payment rates under this title shall not be quality and efficiency measures described in this subparagraph. (C) Requirement for transparency in process.-- (i) In general.--In convening multi- stakeholder groups under subparagraph (A) with respect to the selection of quality and efficiency measures, the entity shall provide for an open and transparent process for the activities conducted pursuant to such convening. (ii) Selection of organizations participating in multi-stakeholder groups.--The process described in clause (i) shall ensure that the selection of representatives comprising such groups provides for public nominations for, and the opportunity for public comment on, such selection. (D) Multi-stakeholder group defined.--In this paragraph, the term ``multi-stakeholder group'' means, with respect to a quality and efficiency measure, a voluntary collaborative of organizations representing a broad group of stakeholders interested in or affected by the use of such quality and efficiency measure. (8) Transmission of multi-stakeholder input.--Not later than February 1 of each year (beginning with 2012), the entity shall transmit to the Secretary the input of multi-stakeholder groups provided under paragraph (7). (9) Prioritization of measure endorsement.--The entity-- (A) during the period beginning on the date of the enactment of this paragraph and ending on December 31, 2023, shall prioritize the endorsement of measures relating to maternal morbidity and mortality by the entity with a contract under subsection (a) in connection with endorsement of measures described in paragraph (2); and (B) on and after January 1, 2024, may prioritize the endorsement of such measures by such entity. (c) Requirements Described.--The requirements described in this subsection are the following: (1) Private nonprofit.--The entity is a private nonprofit entity governed by a board. (2) Board membership.--The members of the board of the entity include-- (A) representatives of health plans and health care providers and practitioners or representatives of groups representing such health plans and health care providers and practitioners; (B) health care consumers or representatives of groups representing health care consumers; and (C) representatives of purchasers and employers or representatives of groups representing purchasers or employers. (3) Entity membership.--The membership of the entity includes persons who have experience with-- (A) urban health care issues; (B) safety net health care issues; (C) rural and frontier health care issues; and (D) health care quality and safety issues. (4) Open and transparent.--With respect to matters related to the contract with the Secretary under subsection (a), the entity conducts its business in an open and transparent manner and provides the opportunity for public comment on its activities. (5) Voluntary consensus standards setting organization.--The entity operates as a voluntary consensus standards setting organization as defined for purposes of section 12(d) of the National Technology Transfer and Advancement Act of 1995 (Public Law 104- 113) and Office of Management and Budget Revised Circular A-119 (published in the Federal Register on February 10, 1998). (6) Experience.--The entity has at least 4 years of experience in establishing national consensus standards. (7) Membership fees.--If the entity requires a membership fee for participation in the functions of the entity, such fees shall be reasonable and adjusted based on the capacity of the potential member to pay the fee. In no case shall membership fees pose a barrier to the participation of individuals or groups with low or nominal resources to participate in the functions of the entity. (d) Funding.--(1) For purposes of carrying out this section, the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 and the Federal Supplementary Medical Insurance Trust Fund under section 1841 (in such proportion as the Secretary determines appropriate), of $10,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for each of fiscal years 2009 through 2013. Amounts transferred under the preceding sentence shall remain available until expended. (2) For purposes of carrying out this section and section 1890A (other than subsections (e) and (f)), the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 and the Federal Supplementary Medical Insurance Trust Fund under section 1841, in such proportion as the Secretary determines appropriate, to the Centers for Medicare & Medicaid Services Program Management Account of $5,000,000 for fiscal year 2014, $30,000,000 for each of fiscal years 2015 through 2017, [and $7,500,000] $7,500,000 for each of fiscal years 2018 [and 2019.] and 2019, and $30,000,000 for each of fiscal years 2020 through 2022. Amounts transferred under the preceding sentence shall remain available until expended. Amounts transferred for each of fiscal years 2018 and 2019 shall be in addition to any unobligated funds transferred for a preceding fiscal year that are available under the preceding sentence. (e) Annual Report by Secretary to Congress.--By not later than March 1 of each year (beginning with 2019), the Secretary shall submit to Congress a report containing the following: (1) A comprehensive plan that identifies the quality measurement needs of programs and initiatives of the Secretary and provides a strategy for using the entity with a contract under subsection (a) and any other entity the Secretary has contracted with or may contract with to perform work associated with section 1890A to help meet those needs, specifically with respect to the programs under this title and title XIX. In years after the first plan under this paragraph is submitted, the requirements of this paragraph may be met by providing an update to the plan. (2) The amount of funding provided under subsection (d) for purposes of carrying out this section and section 1890A that has been obligated by the Secretary, the amount of funding provided that has been expended, and the amount of funding provided that remains unobligated. (3) With respect to the activities described under this section or section 1890A, a description of how the funds described in paragraph (2) have been obligated or expended, including how much of that funding has been obligated or expended for work performed by the Secretary, the entity with a contract under subsection (a), and any other entity the Secretary has contracted with to perform work. (4) A description of the activities for which the funds described in paragraph (2) were used, including task orders and activities assigned to the entity with a contract under subsection (a), activities performed by the Secretary, and task orders and activities assigned to any other entity the Secretary has contracted with to perform work related to carrying out section 1890A. (5) The amount of funding described in paragraph (2) that has been obligated or expended for each of the activities described in paragraph (4). (6) Estimates for, and descriptions of, obligations and expenditures that the Secretary anticipates will be needed in the succeeding two year period to carry out each of the quality measurement activities required under this section and section 1890A, including any obligations that will require funds to be expended in a future year. * * * * * * * ---------- MEDICARE IMPROVEMENTS FOR PATIENTS AND PROVIDERS ACT OF 2008 * * * * * * * TITLE I--MEDICARE Subtitle A--Beneficiary Improvements * * * * * * * PART II--LOW-INCOME PROGRAMS * * * * * * * SEC. 119. MEDICARE ENROLLMENT ASSISTANCE. (a) Additional Funding for State Health Insurance Assistance Programs.-- (1) Grants.-- (A) In general.--The Secretary of Health and Human Services (in this section referred to as the ``Secretary'') shall use amounts made available under subparagraph (B) to make grants to States for State health insurance assistance programs receiving assistance under section 4360 of the Omnibus Budget Reconciliation Act of 1990. (B) Funding.--For purposes of making grants under this subsection, the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 of the Social Security Act (42 U.S.C. 1395i) and the Federal Supplementary Medical Insurance Trust Fund under section 1841 of such Act (42 U.S.C. 1395t), in the same proportion as the Secretary determines under section 1853(f) of such Act (42 U.S.C. 1395w-23(f)), to the Centers for Medicare & Medicaid Services Program Management Account-- (i) for fiscal year 2009, of $7,500,000; (ii) for the period of fiscal years 2010 through 2012, of $15,000,000; (iii) for fiscal year 2013, of $7,500,000; (iv) for fiscal year 2014, of $7,500,000; (v) for fiscal year 2015, of $7,500,000; (vi) for fiscal year 2016, of $13,000,000; (vii) for fiscal year 2017, of $13,000,000; [and] (viii) for fiscal year 2018, of $13,000,000; [and] (ix) for fiscal year 2019, of $13,000,000[.]; and (x) for each of fiscal years 2020 through 2022, of $15,000,000. Amounts appropriated under this subparagraph shall remain available until expended. (2) Amount of grants.--The amount of a grant to a State under this subsection from the total amount made available under paragraph (1) shall be equal to the sum of the amount allocated to the State under paragraph (3)(A) and the amount allocated to the State under subparagraph (3)(B). (3) Allocation to states.-- (A) Allocation based on percentage of low- income beneficiaries.--The amount allocated to a State under this subparagraph from \2/3\ of the total amount made available under paragraph (1) shall be based on the number of individuals who meet the requirement under subsection (a)(3)(A)(ii) of section 1860D-14 of the Social Security Act (42 U.S.C. 1395w-114) but who have not enrolled to receive a subsidy under such section 1860D-14 relative to the total number of individuals who meet the requirement under such subsection (a)(3)(A)(ii) in each State, as estimated by the Secretary. (B) Allocation based on percentage of rural beneficiaries.--The amount allocated to a State under this subparagraph from \1/3\ of the total amount made available under paragraph (1) shall be based on the number of part D eligible individuals (as defined in section 1860D- 1(a)(3)(A) of such Act (42 U.S.C. 1395w- 101(a)(3)(A))) residing in a rural area relative to the total number of such individuals in each State, as estimated by the Secretary. (4) Portion of grant based on percentage of low- income beneficiaries to be used to provide outreach to individuals who may be subsidy eligible individuals or eligible for the medicare savings program.--Each grant awarded under this subsection with respect to amounts allocated under paragraph (3)(A) shall be used to provide outreach to individuals who may be subsidy eligible individuals (as defined in section 1860D- 14(a)(3)(A) of the Social Security Act (42 U.S.C. 1395w-114(a)(3)(A)) or eligible for the Medicare Savings Program (as defined in subsection (f)). (b) Additional Funding for Area Agencies on Aging.-- (1) Grants.-- (A) In general.--The Secretary, acting through the Assistant Secretary for Aging, shall make grants to States for area agencies on aging (as defined in section 102 of the Older Americans Act of 1965 (42 U.S.C. 3002)) and Native American programs carried out under the Older Americans Act of 1965 (42 U.S.C. 3001 et seq.). (B) Funding.--For purposes of making grants under this subsection, the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 of the Social Security Act (42 U.S.C. 1395i) and the Federal Supplementary Medical Insurance Trust Fund under section 1841 of such Act (42 U.S.C. 1395t), in the same proportion as the Secretary determines under section 1853(f) of such Act (42 U.S.C. 1395w-23(f)), to the Administration on Aging-- (i) for fiscal year 2009, of $7,500,000; (ii) for the period of fiscal years 2010 through 2012, of $15,000,000; (iii) for fiscal year 2013, of $7,500,000; (iv) for fiscal year 2014, of $7,500,000; (v) for fiscal year 2015, of $7,500,000; (vi) for fiscal year 2016, of $7,500,000; (vii) for fiscal year 2017, of $7,500,000; [and] (viii) for fiscal year 2018, of $7,500,000; [and] (ix) for fiscal year 2019, of $7,500,000[.]; and (x) for each of fiscal years 2020 through 2022, of $15,000,000. Amounts appropriated under this subparagraph shall remain available until expended. (2) Amount of grant and allocation to states based on percentage of low-income and rural beneficiaries.--The amount of a grant to a State under this subsection from the total amount made available under paragraph (1) shall be determined in the same manner as the amount of a grant to a State under subsection (a), from the total amount made available under paragraph (1) of such subsection, is determined under paragraph (2) and subparagraphs (A) and (B) of paragraph (3) of such subsection. (3) Required use of funds.-- (A) All funds.--Subject to subparagraph (B), each grant awarded under this subsection shall be used to provide outreach to eligible Medicare beneficiaries regarding the benefits available under title XVIII of the Social Security Act. (B) Outreach to individuals who may be subsidy eligible individuals or eligible for the medicare savings program.--Subsection (a)(4) shall apply to each grant awarded under this subsection in the same manner as it applies to a grant under subsection (a). (c) Additional Funding for Aging and Disability Resource Centers.-- (1) Grants.-- (A) In general.--The Secretary shall make grants to Aging and Disability Resource Centers under the Aging and Disability Resource Center grant program that are established centers under such program on the date of the enactment of this Act. (B) Funding.--For purposes of making grants under this subsection, the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 of the Social Security Act (42 U.S.C. 1395i) and the Federal Supplementary Medical Insurance Trust Fund under section 1841 of such Act (42 U.S.C. 1395t), in the same proportion as the Secretary determines under section 1853(f) of such Act (42 U.S.C. 1395w-23(f)), to the Administration on Aging-- (i) for fiscal year 2009, of $5,000,000; (ii) for the period of fiscal years 2010 through 2012, of $10,000,000; (iii) for fiscal year 2013, of $5,000,000; (iv) for fiscal year 2014, of $5,000,000; (v) for fiscal year 2015, of $5,000,000; (vi) for fiscal year 2016, of $5,000,000; (vii) for fiscal year 2017, of $5,000,000; [and] (viii) for fiscal year 2018, of $5,000,000; [and] (ix) for fiscal year 2019, of $5,000,000[.]; and (x) for each of fiscal years 2020 through 2022, of $5,000,000. Amounts appropriated under this subparagraph shall remain available until expended. (2) Required use of funds.--Each grant awarded under this subsection shall be used to provide outreach to individuals regarding the benefits available under the Medicare prescription drug benefit under part D of title XVIII of the Social Security Act and under the Medicare Savings Program. (d) Coordination of Efforts To Inform Older Americans About Benefits Available Under Federal and State Programs.-- (1) In general.--The Secretary, acting through the Assistant Secretary for Aging, in cooperation with related Federal agency partners, shall make a grant to, or enter into a contract with, a qualified, experienced entity under which the entity shall-- (A) maintain and update web-based decision support tools, and integrated, person-centered systems, designed to inform older individuals (as defined in section 102 of the Older Americans Act of 1965 (42 U.S.C. 3002)) about the full range of benefits for which the individuals may be eligible under Federal and State programs; (B) utilize cost-effective strategies to find older individuals with the greatest economic need (as defined in such section 102) and inform the individuals of the programs; (C) develop and maintain an information clearinghouse on best practices and the most cost-effective methods for finding older individuals with greatest economic need and informing the individuals of the programs; and (D) provide, in collaboration with related Federal agency partners administering the Federal programs, training and technical assistance on the most effective outreach, screening, and follow-up strategies for the Federal and State programs. (2) Funding.--For purposes of making a grant or entering into a contract under paragraph (1), the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 of the Social Security Act (42 U.S.C. 1395i) and the Federal Supplementary Medical Insurance Trust Fund under section 1841 of such Act (42 U.S.C. 1395t), in the same proportion as the Secretary determines under section 1853(f) of such Act (42 U.S.C. 1395w-23(f)), to the Administration on Aging-- (i) for fiscal year 2009, of $5,000,000; (ii) for the period of fiscal years 2010 through 2012, of $5,000,000; (iii) for fiscal year 2013, of $5,000,000; (iv) for fiscal year 2014, of $5,000,000; (v) for fiscal year 2015, of $5,000,000; (vi) for fiscal year 2016, of $12,000,000; (vii) for fiscal year 2017, of $12,000,000; [and] (viii) for fiscal year 2018, of $12,000,000; [and] (ix) for fiscal year 2019, of $12,000,000[.]; and (x) for each of fiscal years 2020 through 2022, of $15,000,000. Amounts appropriated under this subparagraph shall remain available until expended. (e) Reprogramming Funds From Medicare, Medicaid, and SCHIP Extension Act of 2007.--The Secretary shall only use the $5,000,000 in funds allocated to make grants to States for Area Agencies on Aging and Aging Disability and Resource Centers for the period of fiscal years 2008 through 2009 under section 118 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173) for the sole purpose of providing outreach to individuals regarding the benefits available under the Medicare prescription drug benefit under part D of title XVIII of the Social Security Act. The Secretary shall republish the request for proposals issued on April 17, 2008, in order to comply with the preceding sentence. (f) Medicare Savings Program Defined.--For purposes of this section, the term ``Medicare Savings Program'' means the program of medical assistance for payment of the cost of medicare cost-sharing under the Medicaid program pursuant to sections 1902(a)(10)(E) and 1933 of the Social Security Act (42 U.S.C. 1396a(a)(10)(E), 1396u-3). (g) Secretarial Authority To Enlist Support in Conducting Certain Outreach Activities.--The Secretary may request that an entity awarded a grant under this section support the conduct of outreach activities aimed at preventing disease and promoting wellness. Notwithstanding any other provision of this section, an entity may use a grant awarded under this subsection to support the conduct of activities described in the preceding sentence. * * * * * * * [all]