US Laws - Affordable Health Care Act (HR3950F)
TITLE III--IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE
Subtitle B--Improving Medicare for Patients and Providers

Subtitle B--Improving Medicare for Patients and Providers (4494)(1-click HTML)

PART I--ENSURING BENEFICIARY ACCESS TO PHYSICIAN CARE AND OTHER SERVICES (4495)(1-click HTML)

SEC. 3101. INCREASE IN THE PHYSICIAN PAYMENT UPDATE. (4496)(1-click HTML)

Section 1848(d) of the Social Security Act (42 U.S.C. 1395w-4(d)) is amended by adding at the end the following new paragraph: (4497)

"(10) UPDATE FOR 2010- (4498)

"(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, the update to the single conversion factor shall be 0.5 percent. (4499)

"(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.". (4500)

SEC. 3102. EXTENSION OF THE WORK GEOGRAPHIC INDEX FLOOR AND REVISIONS TO THE PRACTICE EXPENSE GEOGRAPHIC ADJUSTMENT UNDER THE MEDICARE PHYSICIAN FEE SCHEDULE. (4501)(1-click HTML)

(a) Extension of Work GPCI Floor- Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-4(e)(1)(E)) is amended by striking "before January 1, 2010" and inserting "before January 1, 2011". (4502)

(b) Practice Expense Geographic Adjustment for 2010 and Subsequent Years- Section 1848(e)(1) of the Social Security Act (42 U.S.C. 1395w4(e)(1)) is amended-- (4503)

(1) in subparagraph (A), by striking "and (G)" and inserting "(G), and (H)"; and (4504)

(2) by adding at the end the following new subparagraph: (4505)

"(H) PRACTICE EXPENSE GEOGRAPHIC ADJUSTMENT FOR 2010 AND SUBSEQUENT YEARS- (4506)

"(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 3/4 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. (4507)

"(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. (4508)

"(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. (4509)

"(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: (4510)

"(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. (4511)

"(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. (4512)

"(III) The weights assigned to each of the categories within the practice expense geographic adjustment described in subparagraph (A)(i). (4513)

"(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-- (4514)

"(I) basing the office rents component and its weight on office expenses that vary among fee schedule areas; and (4515)

"(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. (4516)

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.". (4517)

SEC. 3103. EXTENSION OF EXCEPTIONS PROCESS FOR MEDICARE THERAPY CAPS. (4518)(1-click HTML)

Section 1833(g)(5) of the Social Security Act (42 U.S.C. 1395l(g)(5)) is amended by striking "December 31, 2009" and inserting "December 31, 2010". (4519)

SEC. 3104. EXTENSION OF PAYMENT FOR TECHNICAL COMPONENT OF CERTAIN PHYSICIAN PATHOLOGY SERVICES. (4520)(1-click HTML)

Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (as enacted into law by section 1(a)(6) of Public Law 106-554), as amended by section 732 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 U.S.C. 1395w-4 note), section 104 of division B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395w-4 note), section 104 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173), and section 136 of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275), is amended by striking "and 2009" and inserting "2009, and 2010". (4521)

SEC. 3105. EXTENSION OF AMBULANCE ADD-ONS. (4522)(1-click HTML)

(a) Ground Ambulance- Section 1834(l)(13)(A) of the Social Security Act (42 U.S.C. 1395m(l)(13)(A)) is amended-- (4523)

(1) in the matter preceding clause (i)-- (4524)

(A) by striking "2007, and for" and inserting "2007, for"; and (4525)

(B) by striking "2010" and inserting "2010, and for such services furnished on or after April 1, 2010, and before January 1, 2011,"; and (4526)

(2) in each of clauses (i) and (ii), by inserting ", and on or after April 1, 2010, and before January 1, 2011" after "January 1, 2010" each place it appears. (4527)

(b) Air Ambulance- Section 146(b)(1) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275) is amended by striking "December 31, 2009" and inserting "December 31, 2009, and during the period beginning on April 1, 2010, and ending on January 1, 2011". (4528)

(c) Super Rural Ambulance- Section 1834(l)(12)(A) of the Social Security Act (42 U.S.C. 1395m(l)(12)(A)) is amended by striking "2010" and inserting "2010, and on or after April 1, 2010, and before January 1, 2011". (4529)

SEC. 3106. EXTENSION OF CERTAIN PAYMENT RULES FOR LONG-TERM CARE HOSPITAL SERVICES AND OF MORATORIUM ON THE ESTABLISHMENT OF CERTAIN HOSPITALS AND FACILITIES. (4530)(1-click HTML)

(a) Extension of Certain Payment Rules- Section 114(c) of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395ww note), as amended by section 4302(a) of the American Recovery and Reinvestment Act (Public Law 111-5), is further amended by striking "3-year period" each place it appears and inserting "4-year period". (4531)

(b) Extension of Moratorium- Section 114(d)(1) of such Act (42 U.S.C. 1395ww note), in the matter preceding subparagraph (A), is amended by striking "3-year period" and inserting "4-year period". (4532)

SEC. 3107. EXTENSION OF PHYSICIAN FEE SCHEDULE MENTAL HEALTH ADD-ON. (4533)(1-click HTML)

Section 138(a)(1) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275) is amended by striking "December 31, 2009" and inserting "December 31, 2010". (4534)

SEC. 3108. PERMITTING PHYSICIAN ASSISTANTS TO ORDER POST-HOSPITAL EXTENDED CARE SERVICES. (4535)(1-click HTML)

(a) Ordering Post-Hospital Extended Care Services- (4536)

(1) IN GENERAL- Section 1814(a)(2) of the Social Security Act (42 U.S.C. 1395f(a)(2)), in the matter preceding subparagraph (A), is amended by striking "or clinical nurse specialist" and inserting ", a clinical nurse specialist, or a physician assistant (as those terms are defined in section 1861(aa)(5))" after "nurse practitioner". (4537)

(2) CONFORMING AMENDMENT- Section 1814(a) of the Social Security Act (42 U.S.C. 1395f(a)) is amended, in the second sentence, by striking "or clinical nurse specialist" and inserting "clinical nurse specialist, or physician assistant" after "nurse practitioner,". (4538)

(b) Effective Date- The amendments made by this section shall apply to items and services furnished on or after January 1, 2011. (4539)

SEC. 3109. EXEMPTION OF CERTAIN PHARMACIES FROM ACCREDITATION REQUIREMENTS. (4540)(1-click HTML)

(a) In General- Section 1834(a)(20) of the Social Security Act (42 U.S.C. 1395m(a)(20)), as added by section 154(b)(1)(A) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 100-275), is amended-- (4541)

(1) in subparagraph (F)(i)-- (4542)

(A) by inserting "and subparagraph (G)" after "clause (ii)"; and (4543)

(B) by inserting ", except that the Secretary shall not require a pharmacy to have submitted to the Secretary such evidence of accreditation prior to January 1, 2011" before the semicolon at the end; and (4544)

(2) by adding at the end the following new subparagraph: (4545)

"(G) APPLICATION OF ACCREDITATION REQUIREMENT TO CERTAIN PHARMACIES- (4546)

"(i) IN GENERAL- With respect to items and services furnished on or after January 1, 2011, in implementing quality standards under this paragraph-- (4547)

"(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 (4548)

"(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. (4549)

"(ii) PHARMACIES DESCRIBED- A pharmacy described in this clause is a pharmacy that meets each of the following criteria: (4550)

"(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. (4551)

"(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. (4552)

"(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. (4553)

"(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.". (4554)

(b) Administration- Notwithstanding any other provision of law, the Secretary may implement the amendments made by subsection (a) by program instruction or otherwise. (4555)

(c) Rule of Construction- Nothing in the provisions of or amendments made by this section shall be construed as affecting the application of an accreditation requirement for pharmacies to qualify for bidding in a competitive acquisition area under section 1847 of the Social Security Act (42 U.S.C. 1395w-3). (4556)

SEC. 3110. PART B SPECIAL ENROLLMENT PERIOD FOR DISABLED TRICARE BENEFICIARIES. (4557)(1-click HTML)

(a) In General- (4558)

(1) IN GENERAL- Section 1837 of the Social Security Act (42 U.S.C. 1395p) is amended by adding at the end the following new subsection: (4559)

"(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). (4560)

"(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. (4561)

"(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. (4562)

"(4) An individual may only enroll during the special enrollment period provided under paragraph (1) one time during the individual"s lifetime. (4563)

"(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. (4564)

"(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.". (4565)

(2) EFFECTIVE DATE- The amendment made by paragraph (1) shall apply to elections made with respect to initial enrollment periods that end after the date of the enactment of this Act. (4566)

(b) Waiver of Increase of Premium- Section 1839(b) of the Social Security Act (42 U.S.C. 1395r(b)) is amended by striking "section 1837(i)(4)" and inserting "subsection (i)(4) or (l) of section 1837". (4567)

SEC. 3111. PAYMENT FOR BONE DENSITY TESTS. (4568)(1-click HTML)

(a) Payment- (4569)

(1) IN GENERAL- Section 1848 of the Social Security Act (42 U.S.C. 1395w-4) is amended-- (4570)

(A) in subsection (b)-- (4571)

(i) in paragraph (4)(B), by inserting ", and for 2010 and 2011, dual-energy x-ray absorptiometry services (as described in paragraph (6))" before the period at the end; and (4572)

(ii) by adding at the end the following new paragraph: (4573)

"(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 and 2011, 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-- (4574)

"(A) the relative value for the service (as determined in subsection (c)(2)) for 2006; (4575)

"(B) the conversion factor (established under subsection (d)) for 2006; and (4576)

"(C) the geographic adjustment factor (established under subsection (e)(2)) for the service for the fee schedule area for 2010 and 2011, respectively."; and (4577)

(B) in subsection (c)(2)(B)(iv)-- (4578)

(i) in subclause (II), by striking "and" at the end; (4579)

(ii) in subclause (III), by striking the period at the end and inserting "; and"; and (4580)

(iii) by adding at the end the following new subclause: (4581)

"(IV) subsection (b)(6) shall not be taken into account in applying clause (ii)(II) for 2010 or 2011.". (4582)

(2) IMPLEMENTATION- Notwithstanding any other provision of law, the Secretary may implement the amendments made by paragraph (1) by program instruction or otherwise. (4583)

(b) Study and Report by the Institute of Medicine- (4584)

(1) IN GENERAL- The Secretary of Health and Human Services is authorized to enter into an agreement with the Institute of Medicine of the National Academies to conduct a study on the ramifications of Medicare payment reductions for dual-energy x-ray absorptiometry (as described in section 1848(b)(6) of the Social Security Act, as added by subsection (a)(1)) during 2007, 2008, and 2009 on beneficiary access to bone mass density tests. (4585)

(2) REPORT- An agreement entered into under paragraph (1) shall provide for the Institute of Medicine to submit to the Secretary and to Congress a report containing the results of the study conducted under such paragraph. (4586)

SEC. 3112. REVISION TO THE MEDICARE IMPROVEMENT FUND. (4587)(1-click HTML)

Section 1898(b)(1)(A) of the Social Security Act (42 U.S.C. 1395iii) is amended by striking "$22,290,000,000" and inserting "$0". (4588)

SEC. 3113. TREATMENT OF CERTAIN COMPLEX DIAGNOSTIC LABORATORY TESTS. (4589)(1-click HTML)

(a) Demonstration Project- (4590)

(1) IN GENERAL- The Secretary of Health and Human Services (in this section referred to as the "Secretary") shall conduct a demonstration project under part B title XVIII of the Social Security Act under which separate payments are made under such part for complex diagnostic laboratory tests provided to individuals under such part. Under the demonstration project, the Secretary shall establish appropriate payment rates for such tests. (4591)

(2) COVERED COMPLEX DIAGNOSTIC LABORATORY TEST DEFINED- In this section, the term "complex diagnostic laboratory test" means a diagnostic laboratory test-- (4592)

(A) that is an analysis of gene protein expression, topographic genotyping, or a cancer chemotherapy sensitivity assay; (4593)

(B) that is determined by the Secretary to be a laboratory test for which there is not an alternative test having equivalent performance characteristics; (4594)

(C) which is billed using a Health Care Procedure Coding System (HCPCS) code other than a not otherwise classified code under such Coding System; (4595)

(D) which is approved or cleared by the Food and Drug Administration or is covered under title XVIII of the Social Security Act; and (4596)

(E) is described in section 1861(s)(3) of the Social Security Act (42 U.S.C. 1395x(s)(3)). (4597)

(3) SEPARATE PAYMENT DEFINED- In this section, the term "separate payment" means direct payment to a laboratory (including a hospital-based or independent laboratory) that performs a complex diagnostic laboratory test with respect to a specimen collected from an individual during a period in which the individual is a patient of a hospital if the test is performed after such period of hospitalization and if separate payment would not otherwise be made under title XVIII of the Social Security Act by reason of sections 1862(a)(14) and 1866(a)(1)(H)(i) of the such Act (42 U.S.C. 1395y(a)(14); 42 U.S.C. 1395cc(a)(1)(H)(i)). (4598)

(b) Duration- Subject to subsection (c)(2), the Secretary shall conduct the demonstration project under this section for the 2-year period beginning on July 1, 2011. (4599)

(c) Payments and Limitation- Payments under the demonstration project under this section shall-- (4600)

(1) be made from the Federal Supplemental Medical Insurance Trust Fund under section 1841 of the Social Security Act (42 U.S.C. 1395t); and (4601)

(2) may not exceed $100,000,000. (4602)

(d) Report- Not later than 2 years after the completion of the demonstration project under this section, the Secretary shall submit to Congress a report on the project. Such report shall include-- (4603)

(1) an assessment of the impact of the demonstration project on access to care, quality of care, health outcomes, and expenditures under title XVIII of the Social Security Act (including any savings under such title); and (4604)

(2) such recommendations as the Secretary determines appropriate. (4605)

(e) Implementation Funding- For purposes of administering this section (including preparing and submitting the report under subsection (d)), the Secretary shall provide for the transfer, from the Federal Supplemental Medical Insurance Trust Fund under section 1841 of the Social Security Act (42 U.S.C. 1395t), to the Centers for Medicare & Medicaid Services Program Management Account, of $5,000,000. Amounts transferred under the preceding sentence shall remain available until expended. (4606)

SEC. 3114. IMPROVED ACCESS FOR CERTIFIED NURSE-MIDWIFE SERVICES. (4607)(1-click HTML)

Section 1833(a)(1)(K) of the Social Security Act (42 U.S.C. 1395l(a)(1)(K)) is amended by inserting "(or 100 percent for services furnished on or after January 1, 2011)" after "1992, 65 percent". (4608)

PART II--RURAL PROTECTIONS (4609)(1-click HTML)

SEC. 3121. EXTENSION OF OUTPATIENT HOLD HARMLESS PROVISION. (4610)(1-click HTML)

(a) In General- Section 1833(t)(7)(D)(i) of the Social Security Act (42 U.S.C. 1395l(t)(7)(D)(i)) is amended-- (4611)

(1) in subclause (II)-- (4612)

(A) in the first sentence, by striking "2010"and inserting "2011"; and (4613)

(B) in the second sentence, by striking "or 2009" and inserting ", 2009, or 2010"; and (4614)

(2) in subclause (III), by striking "January 1, 2010" and inserting "January 1, 2011". (4615)

(b) Permitting All Sole Community Hospitals To Be Eligible for Hold Harmless- Section 1833(t)(7)(D)(i)(III) of the Social Security Act (42 U.S.C. 1395l(t)(7)(D)(i)(III)) is amended by adding at the end the following new sentence: "In the case of covered OPD services furnished on or after January 1, 2010, and before January 1, 2011, the preceding sentence shall be applied without regard to the 100-bed limitation.". (4616)

SEC. 3122. EXTENSION OF MEDICARE REASONABLE COSTS PAYMENTS FOR CERTAIN CLINICAL DIAGNOSTIC LABORATORY TESTS FURNISHED TO HOSPITAL PATIENTS IN CERTAIN RURAL AREAS. (4617)(1-click HTML)

Section 416(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 U.S.C. 1395l-4), as amended by section 105 of division B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395l note) and section 107 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395l note), is amended by inserting "or during the 1-year period beginning on July 1, 2010" before the period at the end. (4618)

SEC. 3123. EXTENSION OF THE RURAL COMMUNITY HOSPITAL DEMONSTRATION PROGRAM. (4619)(1-click HTML)

(a) One-year Extension- Section 410A of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2272) is amended by adding at the end the following new subsection: (4620)

"(g) One-Year Extension of Demonstration Program- (4621)

"(1) IN GENERAL- Subject to the succeeding provisions of this subsection, the Secretary shall conduct the demonstration program under this section for an additional 1-year period (in this section referred to as the "1-year extension period") that begins on the date immediately following the last day of the initial 5-year period under subsection (a)(5). (4622)

"(2) EXPANSION OF DEMONSTRATION STATES- Notwithstanding subsection (a)(2), during the 1-year extension period, the Secretary shall expand the number of States with low population densities determined by the Secretary under such subsection to 20. In determining which States to include in such expansion, the Secretary shall use the same criteria and data that the Secretary used to determine the States under such subsection for purposes of the initial 5-year period. (4623)

"(3) INCREASE IN MAXIMUM NUMBER OF HOSPITALS PARTICIPATING IN THE DEMONSTRATION PROGRAM- Notwithstanding subsection (a)(4), during the 1-year extension period, not more than 30 rural community hospitals may participate in the demonstration program under this section. (4624)

"(4) NO AFFECT ON HOSPITALS IN DEMONSTRATION PROGRAM ON DATE OF ENACTMENT- In the case of a rural community hospital that is participating in the demonstration program under this section as of the last day of the initial 5-year period, the Secretary shall provide for the continued participation of such rural community hospital in the demonstration program during the 1-year extension period unless the rural community hospital makes an election, in such form and manner as the Secretary may specify, to discontinue such participation.". (4625)

(b) Conforming Amendments- Subsection (a)(5) of section 410A of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2272) is amended by inserting "(in this section referred to as the "initial 5-year period") and, as provided in subsection (g), for the 1-year extension period" after "5-year period". (4626)

(c) Technical Amendments- (4627)

(1) Subsection (b) of section 410A of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2272) is amended-- (4628)

(A) in paragraph (1)(B)(ii), by striking "2)" and inserting "2))"; and (4629)

(B) in paragraph (2), by inserting "cost" before "reporting period" the first place such term appears in each of subparagraphs (A) and (B). (4630)

(2) Subsection (f)(1) of section 410A of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2272) is amended-- (4631)

(A) in subparagraph (A)(ii), by striking "paragraph (2)" and inserting "subparagraph (B)"; and (4632)

(B) in subparagraph (B), by striking "paragraph (1)(B)" and inserting "subparagraph (A)(ii)". (4633)

SEC. 3124. EXTENSION OF THE MEDICARE-DEPENDENT HOSPITAL (MDH) PROGRAM. (4634)(1-click HTML)

(a) Extension of Payment Methodology- Section 1886(d)(5)(G) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(G)) is amended-- (4635)

(1) in clause (i), by striking "October 1, 2011" and inserting "October 1, 2012"; and (4636)

(2) in clause (ii)(II), by striking "October 1, 2011" and inserting "October 1, 2012". (4637)

(b) Conforming Amendments- (4638)

(1) EXTENSION OF TARGET AMOUNT- Section 1886(b)(3)(D) of the Social Security Act (42 U.S.C. 1395ww(b)(3)(D)) is amended-- (4639)

(A) in the matter preceding clause (i), by striking "October 1, 2011" and inserting "October 1, 2012"; and (4640)

(B) in clause (iv), by striking "through fiscal year 2011" and inserting "through fiscal year 2012". (4641)

(2) PERMITTING HOSPITALS TO DECLINE RECLASSIFICATION- Section 13501(e)(2) of the Omnibus Budget Reconciliation Act of 1993 (42 U.S.C. 1395ww note) is amended by striking "through fiscal year 2011" and inserting "through fiscal year 2012". (4642)

SEC. 3125. TEMPORARY IMPROVEMENTS TO THE MEDICARE INPATIENT HOSPITAL PAYMENT ADJUSTMENT FOR LOW-VOLUME HOSPITALS. (4643)(1-click HTML)

Section 1886(d)(12) of the Social Security Act (42 U.S.C. 1395ww(d)(12)) is amended-- (4644)

(1) in subparagraph (A), by inserting "or (D)" after "subparagraph (B)"; (4645)

(2) in subparagraph (B), in the matter preceding clause (i), by striking "The Secretary" and inserting "For discharges occurring in fiscal years 2005 through 2010 and for discharges occurring in fiscal year 2013 and subsequent fiscal years, the Secretary"; (4646)

(3) in subparagraph (C)(i)-- (4647)

(A) by inserting "(or, with respect to fiscal years 2011 and 2012, 15 road miles)" after "25 road miles"; and (4648)

(B) by inserting "(or, with respect to fiscal years 2011 and 2012, 1,500 discharges of individuals entitled to, or enrolled for, benefits under part A)" after "800 discharges"; and (4649)

(4) by adding at the end the following new subparagraph: (4650)

"(D) TEMPORARY APPLICABLE PERCENTAGE INCREASE- For discharges occurring in fiscal years 2011 and 2012, 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 with 200 or fewer discharges of individuals entitled to, or enrolled for, benefits under part A in the fiscal year to 0 percent for low-volume hospitals with greater than 1,500 discharges of such individuals in the fiscal year.". (4651)

SEC. 3126. IMPROVEMENTS TO THE DEMONSTRATION PROJECT ON COMMUNITY HEALTH INTEGRATION MODELS IN CERTAIN RURAL COUNTIES. (4652)(1-click HTML)

(a) Removal of Limitation on Number of Eligible Counties Selected- Subsection (d)(3) of section 123 of the Medicare Improvements for Patients and Providers Act of 2008 (42 U.S.C. 1395i-4 note) is amended by striking "not more than 6". (4653)

(b) Removal of References to Rural Health Clinic Services and Inclusion of Physicians" Services in Scope of Demonstration Project- Such section 123 is amended-- (4654)

(1) in subsection (d)(4)(B)(i)(3), by striking subclause (III); and (4655)

(2) in subsection (j)-- (4656)

(A) in paragraph (8), by striking subparagraph (B) and inserting the following: (4657)

"(B) Physicians" services (as defined in section 1861(q) of the Social Security Act (42 U.S.C. 1395x(q))."; (4658)

(B) by striking paragraph (9); and (4659)

(C) by redesignating paragraph (10) as paragraph (9). (4660)

SEC. 3127. MEDPAC STUDY ON ADEQUACY OF MEDICARE PAYMENTS FOR HEALTH CARE PROVIDERS SERVING IN RURAL AREAS. (4661)(1-click HTML)

(a) Study- The Medicare Payment Advisory Commission shall conduct a study on the adequacy of payments for items and services furnished by providers of services and suppliers in rural areas under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.). Such study shall include an analysis of-- (4662)

(1) any adjustments in payments to providers of services and suppliers that furnish items and services in rural areas; (4663)

(2) access by Medicare beneficiaries to items and services in rural areas; (4664)

(3) the adequacy of payments to providers of services and suppliers that furnish items and services in rural areas; and (4665)

(4) the quality of care furnished in rural areas. (4666)

(b) Report- Not later than January 1, 2011, the Medicare Payment Advisory Commission shall submit to Congress a report containing the results of the study conducted under subsection (a). Such report shall include recommendations on appropriate modifications to any adjustments in payments to providers of services and suppliers that furnish items and services in rural areas, together with recommendations for such legislation and administrative action as the Medicare Payment Advisory Commission determines appropriate. (4667)

SEC. 3128. TECHNICAL CORRECTION RELATED TO CRITICAL ACCESS HOSPITAL SERVICES. (4668)(1-click HTML)

(a) In General- Subsections (g)(2)(A) and (l)(8) of section 1834 of the Social Security Act (42 U.S.C. 1395m) are each amended by inserting "101 percent of" before "the reasonable costs". (4669)

(b) Effective Date- The amendments made by subsection (a) shall take effect as if included in the enactment of section 405(a) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2266). (4670)

SEC. 3129. EXTENSION OF AND REVISIONS TO MEDICARE RURAL HOSPITAL FLEXIBILITY PROGRAM. (4671)(1-click HTML)

(a) Authorization- Section 1820(j) of the Social Security Act (42 U.S.C. 1395i-4(j)) is amended-- (4672)

(1) by striking "2010, and for" and inserting "2010, for"; and (4673)

(2) by inserting "and for making grants to all States under subsection (g), such sums as may be necessary in each of fiscal years 2011 and 2012, to remain available until expended" before the period at the end. (4674)

(b) Use of Funds- Section 1820(g)(3) of the Social Security Act (42 U.S.C. 1395i-4(g)(3)) is amended-- (4675)

(1) in subparagraph (A), by inserting "and to assist such hospitals in participating in delivery system reforms under the provisions of and amendments made by the Patient Protection and Affordable Care Act, such as value-based purchasing programs, accountable care organizations under section 1899, the National pilot program on payment bundling under section 1866D, and other delivery system reform programs determined appropriate by the Secretary" before the period at the end; and (4676)

(2) in subparagraph (E)-- (4677)

(A) by striking ", and to offset" and inserting ", to offset"; and (4678)

(B) by inserting "and to participate in delivery system reforms under the provisions of and amendments made by the Patient Protection and Affordable Care Act, such as value-based purchasing programs, accountable care organizations under section 1899, the National pilot program on payment bundling under section 1866D, and other delivery system reform programs determined appropriate by the Secretary" before the period at the end. (4679)

(c) Effective Date- The amendments made by this section shall apply to grants made on or after January 1, 2010. (4680)

PART III--IMPROVING PAYMENT ACCURACY (4681)(1-click HTML)

SEC. 3131. PAYMENT ADJUSTMENTS FOR HOME HEALTH CARE. (4682)(1-click HTML)

(a) Rebasing Home Health Prospective Payment Amount- (4683)

(1) IN GENERAL- Section 1895(b)(3)(A) of the Social Security Act (42 U.S.C. 1395fff(b)(3)(A)) is amended-- (4684)

(A) in clause (i)(III), by striking "For periods" and inserting "Subject to clause (iii), for periods"; and (4685)

(B) by adding at the end the following new clause: (4686)

"(iii) ADJUSTMENT FOR 2013 AND SUBSEQUENT YEARS- (4687)

"(I) IN GENERAL- Subject to subclause (II), for 2013 and subsequent years, the amount (or amounts) that would otherwise be applicable under clause (i)(III) shall be adjusted by a percentage determined appropriate by the Secretary to reflect such factors as changes in the number of visits in an episode, the mix of services in an episode, the level of intensity of services in an episode, the average cost of providing care per episode, and other factors that the Secretary considers to be relevant. In conducting the analysis under the preceding sentence, the Secretary may consider differences between hospital-based and freestanding agencies, between for-profit and nonprofit agencies, and between the resource costs of urban and rural agencies. Such adjustment shall be made before the update under subparagraph (B) is applied for the year. (4688)

"(II) TRANSITION- The Secretary shall provide for a 4-year phase-in (in equal increments) of the adjustment under subclause (I), with such adjustment being fully implemented for 2016. During each year of such phase-in, the amount of any adjustment under subclause (I) for the year may not exceed 3.5 percent of the amount (or amounts) applicable under clause (i)(III) as of the date of enactment of the Patient Protection and Affordable Care Act.". (4689)

(2) MEDPAC STUDY AND REPORT- (4690)

(A) STUDY- The Medicare Payment Advisory Commission shall conduct a study on the implementation of the amendments made by paragraph (1). Such study shall include an analysis of the impact of such amendments on-- (4691)

(i) access to care; (4692)

(ii) quality outcomes; (4693)

(iii) the number of home health agencies; and (4694)

(iv) rural agencies, urban agencies, for-profit agencies, and nonprofit agencies. (4695)

(B) REPORT- Not later than January 1, 2015, the Medicare Payment Advisory Commission shall submit to Congress a report on the study conducted under subparagraph (A), together with recommendations for such legislation and administrative action as the Commission determines appropriate. (4696)

(b) Program-specific Outlier Cap- Section 1895(b) of the Social Security Act (42 U.S.C. 1395fff(b)) is amended-- (4697)

(1) in paragraph (3)(C), by striking "the aggregate" and all that follows through the period at the end and inserting "5 percent of the total payments estimated to be made based on the prospective payment system under this subsection for the period."; and (4698)

(2) in paragraph (5)-- (4699)

(A) by striking "OUTLIERS- The Secretary" and inserting the following: "OUTLIERS- (4700)

"(A) IN GENERAL- Subject to subparagraph (B), the Secretary"; (4701)

(B) in subparagraph (A), as added by subparagraph (A), by striking "5 percent" and inserting "2.5 percent"; and (4702)

(C) by adding at the end the following new subparagraph: (4703)

"(B) PROGRAM SPECIFIC OUTLIER CAP- The estimated total amount of additional payments or payment adjustments made under subparagraph (A) with respect to a home health agency for a year (beginning with 2011) may not exceed an amount equal to 10 percent of the estimated total amount of payments made under this section (without regard to this paragraph) with respect to the home health agency for the year.". (4704)

(c) Application of the Medicare Rural Home Health Add-on Policy- Section 421 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2283), as amended by section 5201(b) of the Deficit Reduction Act of 2005 (Public Law 109-171; 120 Stat. 46), is amended-- (4705)

(1) in the section heading, by striking "one-year" and inserting "temporary"; and (4706)

(2) in subsection (a)-- (4707)

(A) by striking ", and episodes" and inserting ", episodes"; (4708)

(B) by inserting "and episodes and visits ending on or after April 1, 2010, and before January 1, 2016," after "January 1, 2007,"; and (4709)

(C) by inserting "(or, in the case of episodes and visits ending on or after April 1, 2010, and before January 1, 2016, 3 percent)" before the period at the end. (4710)

(d) Study and Report on the Development of Home Health Payment Reforms in Order To Ensure Access to Care and Quality Services- (4711)

(1) IN GENERAL- The Secretary of Health and Human Services (in this section referred to as the "Secretary") shall conduct a study to evaluate the costs and quality of care among efficient home health agencies relative to other such agencies in providing ongoing access to care and in treating Medicare beneficiaries with varying severity levels of illness. Such study shall include an analysis of the following: (4712)

(A) Methods to revise the home health prospective payment system under section 1895 of the Social Security Act (42 U.S.C. 1395fff) to more accurately account for the costs related to patient severity of illness or to improving beneficiary access to care, including-- (4713)

(i) payment adjustments for services that may be under- or over-valued; (4714)

(ii) necessary changes to reflect the resource use relative to providing home health services to low-income Medicare beneficiaries or Medicare beneficiaries living in medically underserved areas; (4715)

(iii) ways the outlier payment may be improved to more accurately reflect the cost of treating Medicare beneficiaries with high severity levels of illness; (4716)

(iv) the role of quality of care incentives and penalties in driving provider and patient behavior; (4717)

(v) improvements in the application of a wage index; and (4718)

(vi) other areas determined appropriate by the Secretary. (4719)

(B) The validity and reliability of responses on the OASIS instrument with particular emphasis on questions that relate to higher payment under the home health prospective payment system and higher outcome scores under Home Care Compare. (4720)

(C) Additional research or payment revisions under the home health prospective payment system that may be necessary to set the payment rates for home health services based on costs of high-quality and efficient home health agencies or to improve Medicare beneficiary access to care. (4721)

(D) A timetable for implementation of any appropriate changes based on the analysis of the matters described in subparagraphs (A), (B), and (C). (4722)

(E) Other areas determined appropriate by the Secretary. (4723)

(2) CONSIDERATIONS- In conducting the study under paragraph (1), the Secretary shall consider whether certain factors should be used to measure patient severity of illness and access to care, such as-- (4724)

(A) population density and relative patient access to care; (4725)

(B) variations in service costs for providing care to individuals who are dually eligible under the Medicare and Medicaid programs; (4726)

(C) the presence of severe or chronic diseases, as evidenced by multiple, discontinuous home health episodes; (4727)

(D) poverty status, as evidenced by the receipt of Supplemental Security Income under title XVI of the Social Security Act; (4728)

(E) the absence of caregivers; (4729)

(F) language barriers; (4730)

(G) atypical transportation costs; (4731)

(H) security costs; and (4732)

(I) other factors determined appropriate by the Secretary. (4733)

(3) REPORT- Not later than March 1, 2011, the Secretary shall submit to Congress a report on the study conducted under paragraph (1), together with recommendations for such legislation and administrative action as the Secretary determines appropriate. (4734)

(4) CONSULTATIONS- In conducting the study under paragraph (1) and preparing the report under paragraph (3), the Secretary shall consult with-- (4735)

(A) stakeholders representing home health agencies; (4736)

(B) groups representing Medicare beneficiaries; (4737)

(C) the Medicare Payment Advisory Commission; (4738)

(D) the Inspector General of the Department of Health and Human Services; and (4739)

(E) the Comptroller General of the United States. (4740)

SEC. 3132. HOSPICE REFORM. (4741)(1-click HTML)

(a) Hospice Care Payment Reforms- (4742)

(1) IN GENERAL- Section 1814(i) of the Social Security Act (42 U.S.C. 1395f(i)), as amended by section 3004(c), is amended-- (4743)

(A) by redesignating paragraph (6) as paragraph (7); and (4744)

(B) by inserting after paragraph (5) the following new paragraph: (4745)

"(6)(A) The Secretary shall collect additional data and information as the Secretary determines appropriate to revise payments for hospice care under this subsection pursuant to subparagraph (D) and for other purposes as determined appropriate by the Secretary. The Secretary shall begin to collect such data by not later than January 1, 2011. (4746)

"(B) The additional data and information to be collected under subparagraph (A) may include data and information on-- (4747)

"(i) charges and payments; (4748)

"(ii) the number of days of hospice care which are attributable to individuals who are entitled to, or enrolled for, benefits under part A; and (4749)

"(iii) with respect to each type of service included in hospice care-- (4750)

"(I) the number of days of hospice care attributable to the type of service; (4751)

"(II) the cost of the type of service; and (4752)

"(III) the amount of payment for the type of service; (4753)

"(iv) charitable contributions and other revenue of the hospice program; (4754)

"(v) the number of hospice visits; (4755)

"(vi) the type of practitioner providing the visit; and (4756)

"(vii) the length of the visit and other basic information with respect to the visit. (4757)

"(C) The Secretary may collect the additional data and information under subparagraph (A) on cost reports, claims, or other mechanisms as the Secretary determines to be appropriate. (4758)

"(D)(i) Notwithstanding the preceding paragraphs of this subsection, not earlier than October 1, 2013, the Secretary shall, by regulation, implement revisions to the methodology for determining the payment rates for routine home care and other services included in hospice care under this part, as the Secretary determines to be appropriate. Such revisions may be based on an analysis of data and information collected under subparagraph (A). Such revisions may include adjustments to per diem payments that reflect changes in resource intensity in providing such care and services during the course of the entire episode of hospice care. (4759)

"(ii) Revisions in payment implemented pursuant to clause (i) shall result in the same estimated amount of aggregate expenditures under this title for hospice care furnished in the fiscal year in which such revisions in payment are implemented as would have been made under this title for such care in such fiscal year if such revisions had not been implemented. (4760)

"(E) The Secretary shall consult with hospice programs and the Medicare Payment Advisory Commission regarding the additional data and information to be collected under subparagraph (A) and the payment revisions under subparagraph (D).". (4761)

(2) CONFORMING AMENDMENTS- Section 1814(i)(1)(C) of the Social Security Act (42 U.S.C. 1395f(i)(1)(C)) is amended-- (4762)

(A) in clause (ii)-- (4763)

(i) in the matter preceding subclause (I), by inserting "(before the first fiscal year in which the payment revisions described in paragraph (6)(D) are implemented)" after "subsequent fiscal year"; and (4764)

(ii) in subclause (VII), by inserting "(before the first fiscal year in which the payment revisions described in paragraph (6)(D) are implemented), subject to clause (iv)," after "subsequent fiscal year"; and (4765)

(B) by adding at the end the following new clause: (4766)

"(iii) With respect to routine home care and other services included in hospice care furnished during fiscal years subsequent to the first fiscal year in which payment revisions described in paragraph (6)(D) are implemented, the payment rates for such care and services shall be the payment rates in effect under this clause during the preceding fiscal year increased by, subject to clause (iv), the market basket percentage increase (as defined in section 1886(b)(3)(B)(iii)) for the fiscal year.". (4767)

(b) Adoption of MedPAC Hospice Program Eligibility Recertification Recommendations- Section 1814(a)(7) of the Social Security Act (42 U.S.C. 1395f(a)(7)) is amended-- (4768)

(1) in subparagraph (B), by striking "and" at the end; and (4769)

(2) by adding at the end the following new subparagraph: (4770)

"(D) on and after January 1, 2011-- (4771)

"(i) a hospice physician or nurse practitioner has a face-to-face encounter with the individual to determine continued eligibility of the individual for hospice care prior to the 180th-day recertification and each subsequent recertification under subparagraph (A)(ii) and attests that such visit took place (in accordance with procedures established by the Secretary); and (4772)

"(ii) in the case of hospice care provided an individual for more than 180 days by a hospice program for which the number of such cases for such program comprises more than a percent (specified by the Secretary) of the total number of such cases for all programs under this title, the hospice care provided to such individual is medically reviewed (in accordance with procedures established by the Secretary); and". (4773)

SEC. 3133. IMPROVEMENT TO MEDICARE DISPROPORTIONATE SHARE HOSPITAL (DSH) PAYMENTS. (4774)(1-click HTML)

Section 1886 of the Social Security Act (42 U.S.C. 1395ww), as amended by sections 3001, 3008, and 3025, is amended-- (4775)

(1) in subsection (d)(5)(F)(i), by striking "For" and inserting "Subject to subsection (r), for"; and (4776)

(2) by adding at the end the following new subsection: (4777)

"(r) Adjustments to Medicare DSH Payments- (4778)

"(1) EMPIRICALLY JUSTIFIED DSH PAYMENTS- For fiscal year 2015 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). (4779)

"(2) ADDITIONAL PAYMENT- In addition to the payment made to a subsection (d) hospital under paragraph (1), for fiscal year 2015 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: (4780)

"(A) FACTOR ONE- A factor equal to the difference between-- (4781)

"(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 (4782)

"(ii) the aggregate amount of payments that are made to subsection (d) hospitals under paragraph (1) for such fiscal year (as so estimated). (4783)

"(B) FACTOR TWO- (4784)

"(i) FISCAL YEARS 2015, 2016, AND 2017- For each of fiscal years 2015, 2016, and 2017, a factor equal to 1 minus the percent change (divided by 100) in the percent of individuals under the age of 65 who are uninsured, as determined by comparing the percent of such individuals-- (4785)

"(I) who are uninsured in 2012, 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 such Act that, if determined in the affirmative, would clear such Act for enrollment); and (4786)

"(II) who are uninsured in the most recent period for which data is available (as so calculated). (4787)

"(ii) 2018 AND SUBSEQUENT YEARS- For fiscal year 2018 and each subsequent fiscal year, a factor equal to 1 minus the percent change (divided by 100) in the percent of individuals who are uninsured, as determined by comparing the percent of individuals-- (4788)

"(I) who are uninsured in 2012 (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 (4789)

"(II) who are uninsured in the most recent period for which data is available (as so estimated and certified). (4790)

"(C) FACTOR THREE- A factor equal to the percent, for each subsection (d) hospital, that represents the quotient of-- (4791)

"(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 (4792)

"(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). (4793)

"(3) LIMITATIONS ON REVIEW- There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the following: (4794)

"(A) Any estimate of the Secretary for purposes of determining the factors described in paragraph (2). (4795)

"(B) Any period selected by the Secretary for such purposes.". (4796)

SEC. 3134. MISVALUED CODES UNDER THE PHYSICIAN FEE SCHEDULE. (4797)(1-click HTML)

(a) In General- Section 1848(c)(2) of the Social Security Act (42 U.S.C. 1395w-4(c)(2)) is amended by adding at the end the following new subparagraphs: (4798)

"(K) POTENTIALLY MISVALUED CODES- (4799)

"(i) IN GENERAL- The Secretary shall-- (4800)

"(I) periodically identify services as being potentially misvalued using criteria specified in clause (ii); and (4801)

"(II) review and make appropriate adjustments to the relative values established under this paragraph for services identified as being potentially misvalued under subclause (I). (4802)

"(ii) IDENTIFICATION OF POTENTIALLY MISVALUED CODES- For purposes of identifying potentially misvalued services pursuant to clause (i)(I), the Secretary shall examine (as the Secretary determines to be appropriate) codes (and families of codes as appropriate) for which there has been the fastest growth; codes (and families of codes as appropriate) that have experienced substantial changes in practice expenses; codes for new technologies or services within an appropriate period (such as 3 years) after the relative values are initially established for such codes; multiple codes that are frequently billed in conjunction with furnishing a single service; codes with low relative values, particularly those that are often billed multiple times for a single treatment; codes which have not been subject to review since the implementation of the RBRVS (the so-called "Harvard-valued codes"); and such other codes determined to be appropriate by the Secretary. (4803)

"(iii) REVIEW AND ADJUSTMENTS- (4804)

"(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). (4805)

"(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). (4806)

"(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). (4807)

"(IV) The Secretary may coordinate the review and appropriate adjustment described in clause (i)(II) with the periodic review described in subparagraph (B). (4808)

"(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). (4809)

"(VI) 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). (4810)

"(L) VALIDATING RELATIVE VALUE UNITS- (4811)

"(i) IN GENERAL- The Secretary shall establish a process to validate relative value units under the fee schedule under subsection (b). (4812)

"(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. (4813)

"(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). (4814)

"(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. (4815)

"(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).". (4816)

(b) Implementation- (4817)

(1) ADMINISTRATION- (4818)

(A) Chapter 35 of title 44, United States Code and the provisions of the Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to this section or the amendment made by this section. (4819)

(B) Notwithstanding any other provision of law, the Secretary may implement subparagraphs (K) and (L) of 1848(c)(2) of the Social Security Act, as added by subsection (a), by program instruction or otherwise. (4820)

(C) Section 4505(d) of the Balanced Budget Act of 1997 is repealed. (4821)

(D) Except for provisions related to confidentiality of information, the provisions of the Federal Acquisition Regulation shall not apply to this section or the amendment made by this section. (4822)

(2) FOCUSING CMS RESOURCES ON POTENTIALLY OVERVALUED CODES- Section 1868(a) of the Social Security Act (42 U.S.C. 1395ee(a)) is repealed. (4823)

SEC. 3135. MODIFICATION OF EQUIPMENT UTILIZATION FACTOR FOR ADVANCED IMAGING SERVICES. (4824)(1-click HTML)

(a) Adjustment in Practice Expense To Reflect Higher Presumed Utilization- Section 1848 of the Social Security Act (42 U.S.C. 1395w-4) is amended-- (4825)

(1) in subsection (b)(4)-- (4826)

(A) in subparagraph (B), by striking "subparagraph (A)" and inserting "this paragraph"; and (4827)

(B) by adding at the end the following new subparagraph: (4828)

"(C) ADJUSTMENT IN PRACTICE EXPENSE TO REFLECT HIGHER PRESUMED UTILIZATION- Consistent with the methodology for computing the number of practice expense relative value units under subsection (c)(2)(C)(ii) with respect to advanced diagnostic imaging services (as defined in section 1834(e)(1)(B)) furnished on or after January 1, 2010, the Secretary shall adjust such number of units so it reflects-- (4829)

"(i) in the case of services furnished on or after January 1, 2010, and before January 1, 2013, a 65 percent (rather than 50 percent) presumed rate of utilization of imaging equipment; (4830)

"(ii) in the case of services furnished on or after January 1, 2013, and before January 1, 2014, a 70 percent (rather than 50 percent) presumed rate of utilization of imaging equipment; and (4831)

"(iii) in the case of services furnished on or after January 1, 2014, a 75 percent (rather than 50 percent) presumed rate of utilization of imaging equipment."; and (4832)

(2) in subsection (c)(2)(B)(v), by adding at the end the following new subclauses: (4833)

"(III) CHANGE IN PRESUMED UTILIZATION LEVEL OF CERTAIN ADVANCED DIAGNOSTIC IMAGING SERVICES FOR 2010 THROUGH 2012- Effective for fee schedules established beginning with 2010 and ending with 2012, reduced expenditures attributable to the presumed rate of utilization of imaging equipment of 65 percent under subsection (b)(4)(C)(i) instead of a presumed rate of utilization of such equipment of 50 percent. (4834)

"(IV) CHANGE IN PRESUMED UTILIZATION LEVEL OF CERTAIN ADVANCED DIAGNOSTIC IMAGING SERVICES FOR 2013- Effective for fee schedules established for 2013, reduced expenditures attributable to the presumed rate of utilization of imaging equipment of 70 percent under subsection (b)(4)(C)(ii) instead of a presumed rate of utilization of such equipment of 50 percent. (4835)

"(V) CHANGE IN PRESUMED UTILIZATION LEVEL OF CERTAIN ADVANCED DIAGNOSTIC IMAGING SERVICES FOR 2014 AND SUBSEQUENT YEARS- Effective for fee schedules established beginning with 2014, reduced expenditures attributable to the presumed rate of utilization of imaging equipment of 75 percent under subsection (b)(4)(C)(iii) instead of a presumed rate of utilization of such equipment of 50 percent.". (4836)

(b) Adjustment in Technical Component "discount" on Single-session Imaging to Consecutive Body Parts- Section 1848 of the Social Security Act (42 U.S.C. 1395w-4), as amended by subsection (a), is amended-- (4837)

(1) in subsection (b)(4), by adding at the end the following new subparagraph: (4838)

"(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."; and (4839)

(2) in subsection (c)(2)(B)(v), by adding at the end the following new subclause: (4840)

"(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)).". (4841)

(c) Analysis by the Chief Actuary of the Centers for Medicare & Medicaid Services- Not later than January 1, 2013, the Chief Actuary of the Centers for Medicare & Medicaid Services shall make publicly available an analysis of whether, for the period of 2010 through 2019, the cumulative expenditure reductions under title XVIII of the Social Security Act that are attributable to the adjustments under the amendments made by this section are projected to exceed $3,000,000,000. (4842)

SEC. 3136. REVISION OF PAYMENT FOR POWER-DRIVEN WHEELCHAIRS. (4843)(1-click HTML)

(a) In General- Section 1834(a)(7)(A) of the Social Security Act (42 U.S.C. 1395m(a)(7)(A)) is amended-- (4844)

(1) in clause (i)-- (4845)

(A) in subclause (II), by inserting "subclause (III) and" after "Subject to"; and (4846)

(B) by adding at the end the following new subclause: (4847)

"(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."; and (4848)

(2) in clause (iii)-- (4849)

(A) in the heading, by inserting "COMPLEX, REHABILITATIVE" before "POWER-DRIVEN"; and (4850)

(B) by inserting "complex, rehabilitative" before "power-driven". (4851)

(b) Technical Amendment- Section 1834(a)(7)(C)(ii)(II) of the Social Security Act (42 U.S.C. 1395m(a)(7)(C)(ii)(II)) is amended by striking "(A)(ii) or". (4852)

(c) Effective Date- (4853)

(1) IN GENERAL- Subject to paragraph (2), the amendments made by subsection (a) shall take effect on January 1, 2011, and shall apply to power-driven wheelchairs furnished on or after such date. (4854)

(2) APPLICATION TO COMPETITIVE BIDDING- The amendments made by subsection (a) shall not apply to payment made for items and services furnished pursuant to contracts entered into under section 1847 of the Social Security Act (42 U.S.C. 1395w-3) prior to January 1, 2011, pursuant to the implementation of subsection (a)(1)(B)(i)(I) of such section 1847. (4855)

SEC. 3137. HOSPITAL WAGE INDEX IMPROVEMENT. (4856)(1-click HTML)

(a) Extension of Section 508 Hospital Reclassifications- (4857)

(1) IN GENERAL- Subsection (a) of section 106 of division B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395 note), as amended by section 117 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173) and section 124 of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275), is amended by striking "September 30, 2009" and inserting "September 30, 2010". (4858)

(2) USE OF PARTICULAR WAGE INDEX IN FISCAL YEAR 2010- For purposes of implementation of the amendment made by this subsection during fiscal year 2010, the Secretary shall use the hospital wage index that was promulgated by the Secretary in the Federal Register on August 27, 2009 (74 Fed. Reg. 43754), and any subsequent corrections. (4859)

(b) Plan for Reforming the Medicare Hospital Wage Index System- (4860)

(1) IN GENERAL- Not later than December 31, 2011, the Secretary of Health and Human Services (in this section referred to as the "Secretary") shall submit to Congress a report that includes a plan to reform the hospital wage index system under section 1886 of the Social Security Act. (4861)

(2) DETAILS- In developing the plan under paragraph (1), the Secretary shall take into account the goals for reforming such system set forth in the Medicare Payment Advisory Commission June 2007 report entitled "Report to Congress: Promoting Greater Efficiency in Medicare", including establishing a new hospital compensation index system that-- (4862)

(A) uses Bureau of Labor Statistics data, or other data or methodologies, to calculate relative wages for each geographic area involved; (4863)

(B) minimizes wage index adjustments between and within metropolitan statistical areas and statewide rural areas; (4864)

(C) includes methods to minimize the volatility of wage index adjustments that result from implementation of policy, while maintaining budget neutrality in applying such adjustments; (4865)

(D) takes into account the effect that implementation of the system would have on health care providers and on each region of the country; (4866)

(E) addresses issues related to occupational mix, such as staffing practices and ratios, and any evidence on the effect on quality of care or patient safety as a result of the implementation of the system; and (4867)

(F) provides for a transition. (4868)

(3) CONSULTATION- In developing the plan under paragraph (1), the Secretary shall consult with relevant affected parties. (4869)

(c) Use of Particular Criteria for Determining Reclassifications- Notwithstanding any other provision of law, in making decisions on applications for reclassification of a subsection (d) hospital (as defined in paragraph (1)(B) of section 1886(d) of the Social Security Act (42 U.S.C. 1395ww(d)) for the purposes described in paragraph (10)(D)(v) of such section for fiscal year 2011 and each subsequent fiscal year (until the first fiscal year beginning on or after the date that is 1 year after the Secretary of Health and Human Services submits the report to Congress under subsection (b)), the Geographic Classification Review Board established under paragraph (10) of such section shall use the average hourly wage comparison criteria used in making such decisions as of September 30, 2008. The preceding sentence shall be effected in a budget neutral manner. (4870)

SEC. 3138. TREATMENT OF CERTAIN CANCER HOSPITALS. (4871)(1-click HTML)

Section 1833(t) of the Social Security Act (42 U.S.C. 1395l(t)) is amended by adding at the end the following new paragraph: (4872)

"(18) AUTHORIZATION OF ADJUSTMENT FOR CANCER HOSPITALS- (4873)

"(A) STUDY- The Secretary shall conduct a study to determine if, under the system under this subsection, costs incurred by hospitals described in section 1886(d)(1)(B)(v) with respect to ambulatory payment classification groups exceed those costs incurred by other hospitals furnishing services under this subsection (as determined appropriate by the Secretary). In conducting the study under this subparagraph, the Secretary shall take into consideration the cost of drugs and biologicals incurred by such hospitals. (4874)

"(B) AUTHORIZATION OF ADJUSTMENT- Insofar as the Secretary determines under subparagraph (A) that costs incurred by hospitals described in section 1886(d)(1)(B)(v) exceed those costs incurred by other hospitals furnishing services under this subsection, the Secretary shall provide for an appropriate adjustment under paragraph (2)(E) to reflect those higher costs effective for services furnished on or after January 1, 2011.". (4875)

SEC. 3139. PAYMENT FOR BIOSIMILAR BIOLOGICAL PRODUCTS. (4876)(1-click HTML)

(a) In General- Section 1847A of the Social Security Act (42 U.S.C. 1395w-3a) is amended-- (4877)

(1) in subsection (b)-- (4878)

(A) in paragraph (1)-- (4879)

(i) in subparagraph (A), by striking "or" at the end; (4880)

(ii) in subparagraph (B), by striking the period at the end and inserting "; or"; and (4881)

(iii) by adding at the end the following new subparagraph: (4882)

"(C) in the case of a biosimilar biological product (as defined in subsection (c)(6)(H)), the amount determined under paragraph (8)."; and (4883)

(B) by adding at the end the following new paragraph: (4884)

"(8) BIOSIMILAR BIOLOGICAL PRODUCT- The amount specified in this paragraph for a biosimilar biological product described in paragraph (1)(C) is the sum of-- (4885)

"(A) the average sales price as determined using the methodology described under paragraph (6) applied to a biosimilar biological product for all National Drug Codes assigned to such product in the same manner as such paragraph is applied to drugs described in such paragraph; and (4886)

"(B) 6 percent of the amount determined under paragraph (4) for the reference biological product (as defined in subsection (c)(6)(I))."; and (4887)

(2) in subsection (c)(6), by adding at the end the following new subparagraph: (4888)

"(H) BIOSIMILAR BIOLOGICAL PRODUCT- The term "biosimilar biological product" means a biological product approved under an abbreviated application for a license of a biological product that relies in part on data or information in an application for another biological product licensed under section 351 of the Public Health Service Act. (4889)

"(I) REFERENCE BIOLOGICAL PRODUCT- The term "reference biological product" means the biological product licensed under such section 351 that is referred to in the application described in subparagraph (H) of the biosimilar biological product.". (4890)

(b) Effective Date- The amendments made by subsection (a) shall apply to payments for biosimilar biological products beginning with the first day of the second calendar quarter after enactment of legislation providing for a biosimilar pathway (as determined by the Secretary). (4891)

SEC. 3140. MEDICARE HOSPICE CONCURRENT CARE DEMONSTRATION PROGRAM. (4892)(1-click HTML)

(a) Establishment- (4893)

(1) IN GENERAL- The Secretary of Health and Human Services (in this section referred to as the "Secretary") shall establish a Medicare Hospice Concurrent Care demonstration program at participating hospice programs under which Medicare beneficiaries are furnished, during the same period, hospice care and any other items or services covered under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) from funds otherwise paid under such title to such hospice programs. (4894)

(2) DURATION- The demonstration program under this section shall be conducted for a 3-year period. (4895)

(3) SITES- The Secretary shall select not more than 15 hospice programs at which the demonstration program under this section shall be conducted. Such hospice programs shall be located in urban and rural areas. (4896)

(b) Independent Evaluation and Reports- (4897)

(1) INDEPENDENT EVALUATION- The Secretary shall provide for the conduct of an independent evaluation of the demonstration program under this section. Such independent evaluation shall determine whether the demonstration program has improved patient care, quality of life, and cost-effectiveness for Medicare beneficiaries participating in the demonstration program. (4898)

(2) REPORTS- The Secretary shall submit to Congress a report containing the results of the evaluation conducted under paragraph (1), together with such recommendations as the Secretary determines appropriate. (4899)

(c) Budget Neutrality- With respect to the 3-year period of the demonstration program under this section, the Secretary shall ensure that the aggregate expenditures under title XVIII for such period shall not exceed the aggregate expenditures that would have been expended under such title if the demonstration program under this section had not been implemented. (4900)

SEC. 3141. APPLICATION OF BUDGET NEUTRALITY ON A NATIONAL BASIS IN THE CALCULATION OF THE MEDICARE HOSPITAL WAGE INDEX FLOOR. (4901)(1-click HTML)

In the case of discharges occurring on or after October 1, 2010, for purposes of applying section 4410 of the Balanced Budget Act of 1997 (42 U.S.C. 1395ww note) and paragraph (h)(4) of section 412.64 of title 42, Code of Federal Regulations, the Secretary of Health and Human Services shall administer subsection (b) of such section 4410 and paragraph (e) of such section 412.64 in the same manner as the Secretary administered such subsection (b) and paragraph (e) for discharges occurring during fiscal year 2008 (through a uniform, national adjustment to the area wage index). (4902)

SEC. 3142. HHS STUDY ON URBAN MEDICARE-DEPENDENT HOSPITALS. (4903)(1-click HTML)

(a) Study- (4904)

(1) IN GENERAL- The Secretary of Health and Human Services (in this section referred to as the "Secretary") shall conduct a study on the need for an additional payment for urban Medicare-dependent hospitals for inpatient hospital services under section 1886 of the Social Security Act (42 U.S.C. 1395ww). Such study shall include an analysis of-- (4905)

(A) the Medicare inpatient margins of urban Medicare-dependent hospitals, as compared to other hospitals which receive 1 or more additional payments or adjustments under such section (including those payments or adjustments described in paragraph (2)(A)); and (4906)

(B) whether payments to medicare-dependent, small rural hospitals under subsection (d)(5)(G) of such section should be applied to urban Medicare-dependent hospitals. (4907)

(2) URBAN MEDICARE-DEPENDENT HOSPITAL DEFINED- For purposes of this section, the term "urban Medicare-dependent hospital" means a subsection (d) hospital (as defined in subsection (d)(1)(B) of such section) that-- (4908)

(A) does not receive any additional payment or adjustment under such section, such as payments for indirect medical education costs under subsection (d)(5)(B) of such section, disproportionate share payments under subsection (d)(5)(A) of such section, payments to a rural referral center under subsection (d)(5)(C) of such section, payments to a critical access hospital under section 1814(l) of such Act (42 U.S.C. 1395f(l)), payments to a sole community hospital under subsection (d)(5)(D) of such section 1886, or payments to a medicare-dependent, small rural hospital under subsection (d)(5)(G) of such section 1886; and (4909)

(B) for which more than 60 percent of its inpatient days or discharges during 2 of the 3 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 of title XVIII of such Act. (4910)

(b) Report- Not later than 9 months after the date of enactment of this Act, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate. (4911)

SEC. 3143. PROTECTING HOME HEALTH BENEFITS. (4912)(1-click HTML)

Nothing in the provisions of, or amendments made by, this Act shall result in the reduction of guaranteed home health benefits under title XVIII of the Social Security Act. (4913)

  

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