[Congressional Bills 110th Congress]
[From the U.S. Government Printing Office]
[H.R. 6331 Enrolled Bill (ENR)]
H.R.6331
One Hundred Tenth Congress
of the
United States of America
AT THE SECOND SESSION
Begun and held at the City of Washington on Thursday,
the third day of January, two thousand and eight
An Act
To amend titles XVIII and XIX of the Social Security Act to extend
expiring provisions under the Medicare Program, to improve beneficiary
access to preventive and mental health services, to enhance low-income
benefit programs, and to maintain access to care in rural areas,
including pharmacy access, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,

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(a) Short Title.--This Act may be cited as the ``Medicare
Improvements for Patients and Providers Act of 2008''.
(b) Table of Contents.--The table of contents of this Act is as
follows:

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Subtitle A--Beneficiary Improvements
Part I--Prevention, Mental Health, and Marketing

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TITLE I

-MEDICARE

activities under Medicare Advantage plans and prescription
drug plans.

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Security under the Medicare part D low-income subsidy program.

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Subtitle B--Provisions Relating to Part A

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Commission.
Subtitle C--Provisions Relating to Part B
Part I--Physicians' Services

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under the Medicare physician fee schedule.

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Part II--Other Payment and Coverage Improvements

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obstructive pulmonary disease and other conditions.

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provision under the prospective payment system for hospital
outpatient department (HOPD) services for certain hospitals.

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program.
Subtitle D--Provisions Relating to Part C

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qualified medicare beneficiaries enrolled in a specialized
Medicare Advantage plan for special needs individuals.

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Subtitle E--Provisions Relating to Part D
Part I--Improving Pharmacy Access

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classes of drugs.
Subtitle F--Other Provisions

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enforcement of national standards on culturally and
linguistically appropriate services (CLAS) in Medicare.

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Payment Levy and Administrative Offset Program.

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TITLE II

-MEDICAID

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TITLE III

-MISCELLANEOUS

reviews of clinical effectiveness research and for developing
clinical protocols.
Subtitle A--Beneficiary Improvements
PART I--PREVENTION, MENTAL HEALTH, AND MARKETING

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(a) Coverage of Additional Preventive Services.--
(1) Coverage.--Section 1861 of the Social Security Act (42
U.S.C. 1395x), as amended by section 114 of the Medicare, Medicaid,
and SCHIP Extension Act of 2007 (Public Law 110-173), is amended--
(A) in subsection (s)(2)--
(i) in subparagraph (Z), by striking ``and'' after the
semicolon at the end;
(ii) in subparagraph (AA), by adding ``and'' after the
semicolon at the end; and
(iii) by adding at the end the following new
subparagraph:
``(BB) additional preventive services (described in subsection
(ddd)(1));''; and
(B) by adding at the end the following new subsection:
``Additional Preventive Services
``(ddd)(1) The term `additional preventive services' means services
not otherwise described in this title that identify medical conditions
or risk factors and that the Secretary determines are--
``(A) reasonable and necessary for the prevention or early
detection of an illness or disability;
``(B) recommended with a grade of A or B by the United States
Preventive Services Task Force; and
``(C) appropriate for individuals entitled to benefits under
part A or enrolled under part B.
``(2) In making determinations under paragraph (1) regarding the
coverage of a new service, the Secretary shall use the process for
making national coverage determinations (as defined in section
1869(f)(1)(B)) under this title. As part of the use of such process,
the Secretary may conduct an assessment of the relation between
predicted outcomes and the expenditures for such service and may take
into account the results of such assessment in making such
determination.''.
(2) Payment and coinsurance for additional preventive
services.--Section 1833(a)(1) of the Social Security Act (42 U.S.C.
1395l(a)(1)) is amended--
(A) by striking ``and'' before ``(V)''; and
(B) by inserting before the semicolon at the end the
following: ``, and (W) with respect to additional preventive
services (as defined in section 1861(ddd)(1)), the amount paid
shall be (i) in the case of such services which are clinical
diagnostic laboratory tests, the amount determined under
subparagraph (D), and (ii) in the case of all other such
services, 80 percent of the lesser of the actual charge for the
service or the amount determined under a fee schedule
established by the Secretary for purposes of this
subparagraph''.
(3) Conforming amendment regarding coverage.--Section
1862(a)(1)(A) of the Social Security Act (42 U.S.C. 1395y(a)(1)(A))
is amended by inserting ``or additional preventive services (as
described in section 1861(ddd)(1))'' after ``succeeding
subparagraph''.
(4) Rule of construction.--Nothing in the provisions of, or
amendments made by, this subsection shall be construed to provide
coverage under title XVIII of the Social Security Act of items and
services for the treatment of a medical condition that is not
otherwise covered under such title.
(b) Revisions to Initial Preventive Physical Examination.--
(1) In general.--Section 1861(ww) of the Social Security Act
(42 U.S.C. 1395x(ww)) is amended--
(A) in paragraph (1)--
(i) by inserting ``body mass index,'' after ``weight'';
(ii) by striking ``, and an electrocardiogram''; and
(iii) by inserting ``and end-of-life planning (as
defined in paragraph (3)) upon the agreement with the
individual'' after ``paragraph (2)'';
(B) in paragraph (2), by adding at the end the following
new subparagraphs:
``(M) An electrocardiogram.
``(N) Additional preventive services (as defined in subsection
(ddd)(1)).''; and
(C) by adding at the end the following new paragraph:
``(3) For purposes of paragraph (1), the term `end-of-life
planning' means verbal or written information regarding--
``(A) an individual's ability to prepare an advance directive
in the case that an injury or illness causes the individual to be
unable to make health care decisions; and
``(B) whether or not the physician is willing to follow the
individual's wishes as expressed in an advance directive.''.
(2) Waiver of application of deductible.--The first sentence of
section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)) is
amended--
(A) by striking ``and'' before ``(8)''; and
(B) by inserting ``, and (9) such deductible shall not
apply with respect to an initial preventive physical
examination (as defined in section 1861(ww))'' before the
period at the end.
(3) Extension of eligibility period from six months to one
year.--Section 1862(a)(1)(K) of the Social Security Act (42 U.S.C.
1395y(a)(1)(K)) is amended by striking ``6 months'' and inserting
``1 year''.
(4) Technical correction.--Section 1862(a)(1)(K) of the Social
Security Act (42 U.S.C. 1395y(a)(1)(K)) is amended by striking
``not later'' and inserting ``more''.
(c) Effective Date.--The amendments made by this section shall
apply to services furnished on or after January 1, 2009.

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MEDICARE OUTPATIENT PSYCHIATRIC SERVICES.
Section 1833(c) of the Social Security Act (42 U.S.C. 1395l(c)) is
amended to read as follows:
``(c)(1) Notwithstanding any other provision of this part, with
respect to expenses incurred in a calendar year in connection with the
treatment of mental, psychoneurotic, and personality disorders of an
individual who is not an inpatient of a hospital at the time such
expenses are incurred, there shall be considered as incurred expenses
for purposes of subsections (a) and (b)--
``(A) for expenses incurred in years prior to 2010, only 62\1/
2\ percent of such expenses;
``(B) for expenses incurred in 2010 or 2011, only 68\3/4\
percent of such expenses;
``(C) for expenses incurred in 2012, only 75 percent of such
expenses;
``(D) for expenses incurred in 2013, only 81\1/4\ percent of
such expenses; and
``(E) for expenses incurred in 2014 or any subsequent calendar
year, 100 percent of such expenses.
``(2) For purposes of subparagraphs (A) through (D) of paragraph
(1), the term `treatment' does not include brief office visits (as
defined by the Secretary) for the sole purpose of monitoring or
changing drug prescriptions used in the treatment of such disorders or
partial hospitalization services that are not directly provided by a
physician.''.

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MARKETING ACTIVITIES UNDER MEDICARE ADVANTAGE PLANS AND
PRESCRIPTION DRUG PLANS.
(a) Prohibitions.--
(1) Medicare advantage program.--
(A) In general.--Section 1851 of the Social Security Act
(42 U.S.C. 1395w-21) is amended--
(i) in subsection (h)(4)--
(I) in subparagraph (A)--
(aa) by striking ``cash or other monetary
rebates'' and inserting ``, subject to subsection
(j)(2)(C), cash, gifts, prizes, or other monetary
rebates''; and
(bb) by striking ``, and'' at the end and
inserting a semicolon;
(II) in subparagraph (B), by striking the period at
the end and inserting a semicolon; and
(III) by adding at the end the following new
subparagraph:
``(C) shall not permit a Medicare Advantage organization
(or the agents, brokers, and other third parties representing
such organization) to conduct the prohibited activities
described in subsection (j)(1); and''; and
(ii) by adding at the end the following new subsection:
``(j) Prohibited Activities Described and Limitations on the
Conduct of Certain Other Activities.--
``(1) Prohibited activities described.--The following
prohibited activities are described in this paragraph:
``(A) Unsolicited means of direct contact.--Any unsolicited
means of direct contact of prospective enrollees, including
soliciting door-to-door or any outbound telemarketing without
the prospective enrollee initiating contact.
``(B) Cross-selling.--The sale of other non-health related
products (such as annuities and life insurance) during any
sales or marketing activity or presentation conducted with
respect to a Medicare Advantage plan.
``(C) Meals.--The provision of meals of any sort,
regardless of value, to prospective enrollees at promotional
and sales activities.
``(D) Sales and marketing in health care settings and at
educational events.--Sales and marketing activities for the
enrollment of individuals in Medicare Advantage plans that are
conducted--
``(i) in health care settings in areas where health
care is delivered to individuals (such as physician offices
and pharmacies), except in the case where such activities
are conducted in common areas in health care settings; and
``(ii) at educational events.''.
(2) Medicare prescription drug program.--Section 1860D-4 of the
Social Security Act (42 U.S.C. 1395w-104) is amended by adding at
the end the following new subsection:
``(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).''.
(3) Effective date.--The amendments made by this subsection
shall apply to plan years beginning on or after January 1, 2009.
(b) Limitations.--
(1) Medicare advantage program.--Section 1851 of the Social
Security Act (42 U.S.C. 1395w-21), as amended by subsection (a)(1),
is amended--
(A) in subsection (h)(4), by adding at the end the
following new subparagraph:
``(D) shall only permit a Medicare Advantage organization
(and the agents, brokers, and other third parties representing
such organization) to conduct the activities described in
subsection (j)(2) in accordance with the limitations
established under such subsection.''; and
(B) in subsection (j), by adding at the end the following
new paragraph:
``(2) Limitations.--The Secretary shall establish limitations
with respect to at least the following:
``(A) Scope of marketing appointments.--The scope of any
appointment with respect to the marketing of a Medicare
Advantage plan. Such limitation shall require advance agreement
with a prospective enrollee on the scope of the marketing
appointment and documentation of such agreement by the Medicare
Advantage organization. In the case where the marketing
appointment is in person, such documentation shall be in
writing.
``(B) Co-branding.--The use of the name or logo of a co-
branded network provider on Medicare Advantage plan membership
and marketing materials.
``(C) Limitation of gifts to nominal dollar value.--The
offering of gifts and other promotional items other than those
that are of nominal value (as determined by the Secretary) to
prospective enrollees at promotional activities.
``(D) Compensation.--The use of compensation other than as
provided under guidelines established by the Secretary. Such
guidelines shall ensure that the use of compensation creates
incentives for agents and brokers to enroll individuals in the
Medicare Advantage plan that is intended to best meet their
health care needs.
``(E) Required training, annual retraining, and testing of
agents, brokers, and other third parties.--The use by a
Medicare Advantage organization of any individual as an agent,
broker, or other third party representing the organization that
has not completed an initial training and testing program and
does not complete an annual retraining and testing program.''.
(2) Medicare prescription drug program.--Section 1860D-4(l) of
the Social Security Act, as added by subsection (a)(2), is amended
by adding at the end the following new paragraph:
``(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) Effective date.--The amendments made by this subsection
shall take effect on a date specified by the Secretary (but in no
case later than November 15, 2008).
(c) Required Inclusion of Plan Type in Plan Name.--
(1) Medicare advantage program.--Section 1851(h) of the Social
Security Act (42 U.S.C. 1395w-21(h)) is amended by adding at the
end following new paragraph:
``(6) Required inclusion of plan type in plan name.--For plan
years beginning on or after January 1, 2010, a Medicare Advantage
organization must ensure that the name of each Medicare Advantage
plan offered by the Medicare Advantage organization includes the
plan type of the plan (using standard terminology developed by the
Secretary).''.
(2) Prescription drug plans.--Section 1860D-4(l) of the Social
Security Act, as added by subsection (a)(2) and amended by
subsection (b)(2), is amended by adding at the end the following
new paragraph:
``(3) The inclusion of the plan type in the plan name under
section 1851(h)(6).''.
(d) Strengthening the Ability of States to Act in Collaboration
With the Secretary to Address Fraudulent or Inappropriate Marketing
Practices.--
(1) Medicare advantage program.--Section 1851(h) of the Social
Security Act (42 U.S.C. 1395w-21(h), as amended by subsection
(c)(1), is amended by adding at the end the following new
paragraph:
``(7) Strengthening the ability of states to act in
collaboration with the secretary to address fraudulent or
inappropriate marketing practices.--
``(A) Appointment of agents and brokers.--Each Medicare
Advantage organization shall--
``(i) only use agents and brokers who have been
licensed under State law to sell Medicare Advantage plans
offered by the Medicare Advantage organization;
``(ii) in the case where a State has a State
appointment law, abide by such law; and
``(iii) report to the applicable State the termination
of any such agent or broker, including the reasons for such
termination (as required under applicable State law).
``(B) Compliance with state information requests.--Each
Medicare Advantage organization shall comply in a timely manner
with any request by a State for information regarding the
performance of a licensed agent, broker, or other third party
representing the Medicare Advantage organization as part of an
investigation by the State into the conduct of the agent,
broker, or other third party.''.
(2) Prescription drug plans.--Section 1860D-4(l) of the Social
Security Act, as amended by subsection (c)(2), is amended by adding
at the end the following new paragraph:
``(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).''.
(3) Effective date.--The amendments made by this subsection
shall apply to plan years beginning on or after January 1, 2009.

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(a) Implementation of NAIC Recommendations.--
(1) In general.--The Secretary of Health and Human Services (in
this section referred to as the ``Secretary'') shall provide for
implementation of the changes in the NAIC model law and regulations
approved by the National Association of Insurance Commissioners in
its Model #651 (``Model Regulation to Implement the NAIC Medicare
Supplement Insurance Minimum Standards Model Act'') on March 11,
2007, as modified to reflect the changes made under this Act and
the Genetic Information Nondiscrimination Act of 2008 (Public Law
110-233).
(2) Implementation dates.--
(A) In general.--The modifications to Model #651 required
under paragraph (1) shall be completed by the National
Association of Insurance Commissioners not later than October
31, 2008. Except as provided in subparagraph (B), each State
shall have 1 year from the date the National Association of
Insurance Commissioners adopts the revised NAIC model law and
regulations (as changed by Model #651, as so modified) to
conform the regulatory program established by the State to such
revised NAIC model law and regulations.
(B) Extension of effective date for state law amendment.--
In the case of a State which the Secretary determines requires
State legislation in order to conform the regulatory program
established by the State to such revised NAIC model law and
regulations, the State shall not be regarded as failing to
comply with the requirements of this section solely on the
basis of its failure to meet such requirements before the first
day of the first calendar quarter beginning after the close of
the first regular session of the State legislature that begins
after the date of the enactment of this Act. For purposes of
the previous sentence, in the case of a State that has a 2-year
legislative session, each year of the session is considered to
be a separate regular session of the State legislature.
(C) Transition dates.--No carrier may issue a new or
revised medicare supplemental policy or certificate under
section 1882 of the Social Security Act (42 U.S.C. 1395ss) that
meets the requirements of such revised NAIC model law and
regulations for coverage effective prior to June 1, 2010. A
carrier may continue to offer or issue a medicare supplemental
policy under such section that meets the requirements of the
NAIC model law and regulations and State law (as in effect
prior to the adoption of such revised NAIC model law and
regulations) prior to June 1, 2010. Nothing shall preclude
carriers from marketing new or revised medicare supplemental
policies or certificates that meet the requirements of such
revised NAIC model law and regulations on or after the date on
which the State conforms the regulatory program established by
the State to such revised NAIC model law and regulations.
(b) Required Offering of a Range of Policies.--Section 1882(o) of
the Social Security Act (42 U.S.C. 1395s(o)), as amended by section
104(b)(3) of the Genetic Information Nondiscrimination Act of 2008
(Public Law 110-233), is amended by adding at the end the following new
paragraph:
``(5) In addition to the requirement under paragraph (2), the
issuer of the policy must make available to the individual at least
Medicare supplemental policies with benefit packages classified as
`C' or `F'.''.
(c) Clarification.--Any health insurance policy that provides
reimbursement for expenses incurred for items and services for which
payment may be made under title XVIII of the Social Security Act but
which are not reimbursable by reason of the applicability of
deductibles, coinsurance, copayments or other limitations imposed by a
Medicare Advantage plan (including a Medicare Advantage private fee-
for-service plan) under part C of such title shall comply with the
requirements of section 1882(o) of the such Act (42 U.S.C. 1395ss(o)).
PART II--LOW-INCOME PROGRAMS

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(a) Extension.--Section 1902(a)(10)(E)(iv) of the Social Security
Act (42 U.S.C. 1396a(a)(10)(E)(iv)) is amended by striking ``June
2008'' and inserting ``December 2009''.
(b) Extending Total Amount Available for Allocation.--Section
1933(g) of such Act (42 U.S.C. 1396u-3(g)) is amended--
(1) in paragraph (2)--
(A) by striking ``and'' at the end of subparagraph (H);
(B) in subparagraph (I)--
(i) by striking ``June 30'' and inserting ``September
30'';
(ii) by striking ``$200,000,000'' and inserting
``$300,000,000''; and
(iii) by striking the period at the end and inserting a
semicolon; and
(C) by adding at the end the following new subparagraphs:
``(J) for the period that begins on October 1, 2008, and
ends on December 31, 2008, the total allocation amount is
$100,000,000;
``(K) for the period that begins on January 1, 2009, and
ends on September 30, 2009, the total allocation amount is
$350,000,000; and
``(L) for the period that begins on October 1, 2009, and
ends on December 31, 2009, the total allocation amount is
$150,000,000.''; and
(2) in paragraph (3), in the matter preceding subparagraph (A),
by striking ``or (H)'' and inserting ``(H), (J), or (L)''.

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MEDICARE SAVINGS PROGRAM.
Section 1905(p)(1)(C) of such Act (42 U.S.C. 1396d(p)(1)(C)) is
amended by inserting before the period at the end the following: ``or,
effective beginning with January 1, 2010, whose resources (as so
determined) do not exceed the maximum resource level applied for the
year under subparagraph (D) of section 1860D-14(a)(3) (determined
without regard to the life insurance policy exclusion provided under
subparagraph (G) of such section) applicable to an individual or to the
individual and the individual's spouse (as the case may be)''.

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(a) SSA Assistance With Medicare Savings Program and Low-Income
Subsidy Program Applications.--Section 1144 of such Act (42 U.S.C.
1320b-14) is amended by adding at the end the following new subsection:
``(c) Assistance With Medicare Savings Program and Low-Income
Subsidy Program Applications.--
``(1) Distribution of applications and information to
individuals who are potentially eligible for low-income subsidy
program.--For each individual who submits an application for low-
income subsidies under section 1860D-14, requests an application
for such subsidies, or is otherwise identified as an individual who
is potentially eligible for such subsidies, the Commissioner shall
do the following:
``(A) Provide information describing the low-income subsidy
program under section 1860D-14 and the Medicare Savings Program
(as defined in paragraph (7)).
``(B) Provide an application for enrollment under such low-
income subsidy program (if not already received by the
Commissioner).
``(C) In accordance with paragraph (3), transmit data from
such an application for purposes of initiating an application
for benefits under the Medicare Savings Program.
``(D) Provide information on how the individual may obtain
assistance in completing such application and an application
under the Medicare Savings Program, including information on
how the individual may contact the State health insurance
assistance program (SHIP).
``(E) Make the application described in subparagraph (B)
and the information described in subparagraphs (A) and (D)
available at local offices of the Social Security
Administration.
``(2) Training personnel in explaining benefit programs and
assisting in completing lis application.--The Commissioner shall
provide training to those employees of the Social Security
Administration who are involved in receiving applications for
benefits described in paragraph (1)(B) in order that they may
promote beneficiary understanding of the low-income subsidy program
and the Medicare Savings Program in order to increase participation
in these programs. Such employees shall provide assistance in
completing an application described in paragraph (1)(B) upon
request.
``(3) Transmittal of data to states.--Beginning on January 1,
2010, with the consent of an individual completing an application
for benefits described in paragraph (1)(B), the Commissioner shall
electronically transmit to the appropriate State Medicaid agency
data from such application, as determined by the Commissioner,
which transmittal shall initiate an application of the individual
for benefits under the Medicare Savings Program with the State
Medicaid agency. In order to ensure that such data transmittal
provides effective assistance for purposes of State adjudication of
applications for benefits under the Medicare Savings Program, the
Commissioner shall consult with the Secretary, after the Secretary
has consulted with the States, regarding the content, form,
frequency, and manner in which data (on a uniform basis for all
States) shall be transmitted under this subparagraph.
``(4) Coordination with outreach.--The Commissioner shall
coordinate outreach activities under this subsection in connection
with the low-income subsidy program and the Medicare Savings
Program.
``(5) Reimbursement of social security administration
administrative costs.--
``(A) Initial medicare savings program costs; additional
low-income subsidy costs.--
``(i) Initial medicare savings program costs.--There
are hereby appropriated to the Commissioner to carry out
this subsection, out of any funds in the Treasury not
otherwise appropriated, $24,100,000. The amount
appropriated under ths clause shall be available on October
1, 2008, and shall remain available until expended.
``(ii) Additional amount for low-income subsidy
activities.--There are hereby appropriated to the
Commissioner, out of any funds in the Treasury not
otherwise appropriated, $24,800,000 for fiscal year 2009 to
carry out low-income subsidy activities under section
1860D-14 and the Medicare Savings Program (in accordance
with this subsection), to remain available until expended.
Such funds shall be in addition to the Social Security
Administration's Limitation on Administrative Expenditure
appropriations for such fiscal year.
``(B) Subsequent funding under agreements.--
``(i) In general.--Effective for fiscal years beginning
on or after October 1, 2010, the Commissioner and the
Secretary shall enter into an agreement which shall provide
funding (subject to the amount appropriated under clause
(ii)) to cover the administrative costs of the
Commissioner's activities under this subsection. Such
agreement shall--
``(I) provide funds to the Commissioner for the
full cost of the Social Security Administration's work
related to the Medicare Savings Program required under
this section;
``(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 subsection.
``(ii) Appropriation.--There are hereby appropriated to
the Secretary solely for the purpose of providing payments
to the Commissioner pursuant to an agreement specified in
clause (i) that is in effect, out of any funds in the
Treasury not otherwise appropriated, not more than
$3,000,000 for fiscal year 2011 and each fiscal year
thereafter.
``(C) 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 Medicare Savings
Program. For fiscal years beginning on or after October 1,
2010, no such activities shall be undertaken by the Social
Security Administration unless the agreement specified in
subparagraph (B) is in effect and full funding has been
provided to the Commissioner as specified in such subparagraph.
``(6) GAO analysis and report.--
``(A) Analysis.--The Comptroller General of the United
States shall prepare an analysis of the impact of this
subsection--
``(i) in increasing participation in the Medicare
Savings Program, and
``(ii) on States and the Social Security
Administration.
``(B) Report.--Not later than January 1, 2012, the
Comptroller General shall submit to Congress, the Commissioner,
and the Secretary a report on the analysis conducted under
subparagraph (A).
``(7) Medicare savings program defined.--For purposes of this
subsection, 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.''.
(b) Medicaid Agency Consideration of Data Transmittal.--
(1) In general.--Section 1935(a) of such Act (42 U.S.C. 1396u-
5(a)) is amended by adding at the end the following new paragraph:
``(4) Consideration of data transmitted by the social security
administration for purposes of medicare savings program.--The State
shall accept data transmitted under section 1144(c)(3) and act on
such data in the same manner and in accordance with the same
deadlines as if the data constituted an initiation of an
application for benefits under the Medicare Savings Program (as
defined for purposes of such section) that had been submitted
directly by the applicant. The date of the individual's application
for the low income subsidy program from which the data have been
derived shall constitute the date of filing of such application for
benefits under the Medicare Savings Program.''.
(2) Conforming amendments.--Section 1935(a) of such Act (42
U.S.C. 1396u-5(a)) is amended in the subsection heading by striking
``and'' and by inserting ``, and Medicare Cost-Sharing'' after
``Assistance''.
(c) Effective Date.--Except as otherwise provided, the amendments
made by this section shall take effect on January 1, 2010.

f99ddaec98e3ecc26de2a3fc64e5c3e097de84d7d300f3809b28519a38bb5317

PAID BY SUBSIDY ELIGIBLE INDIVIDUALS.
(a) Waiver of Late Enrollment Penalty.--
(1) In general.--Section 1860D-13(b) of the Social Security Act
(42 U.S.C. 1395w-113(b)) is amended by adding at the end the
following new paragraph:
``(8) Waiver of penalty for subsidy-eligible individuals.--In
no case shall a part D eligible individual who is determined to be
a subsidy eligible individual (as defined in section 1860D-
14(a)(3)) be subject to an increase in the monthly beneficiary
premium established under subsection (a).''.
(2) Conforming amendment.--Section 1860D-14(a)(1)(A) of the
Social Security Act (42 U.S.C. 1395w-114(a)(1)(A)) is amended by
striking ``equal to'' and all that follows through the period and
inserting ``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) Effective Date.--The amendments made by this section shall
apply to subsidies for months beginning with January 2009.

55ef209457f232eec6bfc334baef517721690ae2b2a49640ccbdf9ee61d82e41

(a) In General.--Section 1917(b)(1)(B)(ii) of the Social Security
Act (42 U.S.C. 1396p(b)(1)(B)(ii)) is amended by inserting ``(but not
including medical assistance for medicare cost-sharing or for benefits
described in section 1902(a)(10)(E))'' before the period at the end.
(b) Effective Date.--The amendment made by subsection (a) shall
take effect as of January 1, 2010.

45b8de62178ca64f539a8f36359aeac4f01f99cd0aa59fef2303e85dbe9e5ff8

ELIGIBILITY FOR LOW-INCOME SUBSIDY.
(a) In General.--Section 1860D-14(a)(3) of the Social Security Act
(42 U.S.C. 1395w-114(a)(3)) is amended--
(1) in subparagraph (C)(i), by inserting ``and except that
support and maintenance furnished in kind shall not be counted as
income'' after ``section 1902(r)(2)'';
(2) in subparagraph (D), in the matter before clause (i), by
inserting ``subject to the life insurance policy exclusion provided
under subparagraph (G)'' before ``)'';
(3) in subparagraph (E)(i), in the matter before subclause (I),
by inserting ``subject to the life insurance policy exclusion
provided under subparagraph (G)'' before ``)''; and
(4) by adding at the end the following new subparagraph:
``(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.''.
(b) Effective Date.--The amendments made by this section shall take
effect with respect to applications filed on or after January 1, 2010.

1c3faeb1b47741aa3c5b8fd471f98825c8586e78567c005504649384fdf1fe15

SOCIAL SECURITY UNDER THE MEDICARE PART D LOW-INCOME SUBSIDY
PROGRAM.
(a) In General.--Section 1860D-14(a)(3)(B)(iv) of the Social
Security Act (42 U.S.C. 1395w-114(a)(3)(B)(iv)) is amended--
(1) in subclause (I), by striking ``and'' at the end;
(2) in subclause (II), by striking the period at the end and
inserting ``; and''; and
(3) by adding at the end the following new subclause:
``(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.''.
(b) Effective Date.--The amendments made by subsection (a) shall
take effect as if included in the enactment of section 101 of the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

e1f82b21bf4bd8ed8828cbf74a85a8faf0bb8e79044521d4ed9ee611f7aabd7d

(a) In General.--Section 1905(p)(5)(A) of the Social Security Act
(42 U.S.C. 1396d(p)(5)(A)) is amended by adding at the end the
following: ``The Secretary shall provide for the translation of such
application form into at least the 10 languages (other than English)
that are most often used by individuals applying for hospital insurance
benefits under section 226 or 226A and shall make the translated forms
available to the States and to the Commissioner of Social Security.''.
(b) Effective Date.--The amendment made by subsection (a) shall
take effect on January 1, 2010.

5014052bfb728a7e8f432953994dd7c91dad99ff418dc099f5288ba5874c4139

(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)), of $7,500,000 to the Centers for Medicare
& Medicaid Services Program Management Account for fiscal year
2009, to 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)), of $7,500,000 to the Administration on
Aging for fiscal year 2009, to 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)), of $5,000,000 to the Administration on
Aging for fiscal year 2009, to 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)), of $5,000,000 to the Administration on Aging for
fiscal year 2009, to 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).
Subtitle B--Provisions Relating to Part A

8494cd53c185083da9c39a1020cd3f3f6155bd5846faabe4bb982a857e5c87f2

FLEXIBILITY PROGRAM.
(a) In General.--Section 1820(g) of the Social Security Act (42
U.S.C. 1395i-4(g)) is amended by adding at the end the following new
paragraph:
``(6) Providing mental health services and other health
services to veterans and other residents of rural areas.--
``(A) Grants to states.--The Secretary may award grants to
States that have submitted applications in accordance with
subparagraph (B) for increasing the delivery of mental health
services or other health care services deemed necessary to meet
the needs of veterans of Operation Iraqi Freedom and Operation
Enduring Freedom living in rural areas (as defined for purposes
of section 1886(d) and including areas that are rural census
tracks, as defined by the Administrator of the Health Resources
and Services Administration), including for the provision of
crisis intervention services and the detection of post-
traumatic stress disorder, traumatic brain injury, and other
signature injuries of veterans of Operation Iraqi Freedom and
Operation Enduring Freedom, and for referral of such veterans
to medical facilities operated by the Department of Veterans
Affairs, and for the delivery of such services to other
residents of such rural areas.
``(B) Application.--
``(i) In general.--An application is in accordance with
this subparagraph if the State submits to the Secretary at
such time and in such form as the Secretary may require an
application containing the assurances described in
subparagraphs (A)(ii) and (A)(iii) of subsection (b)(1).
``(ii) Consideration of regional approaches, networks,
or technology.--The Secretary may, as appropriate in
awarding grants to States under subparagraph (A), consider
whether the application submitted by a State under this
subparagraph includes 1 or more proposals that utilize
regional approaches, networks, health information
technology, telehealth, or telemedicine to deliver services
described in subparagraph (A) to individuals described in
that subparagraph. For purposes of this clause, a network
may, as the Secretary determines appropriate, include
Federally qualified health centers (as defined in section
1861(aa)(4)), rural health clinics (as defined in section
1861(aa)(2)), home health agencies (as defined in section
1861(o)), community mental health centers (as defined in
section 1861(ff)(3)(B)) and other providers of mental
health services, pharmacists, local government, and other
providers deemed necessary to meet the needs of veterans.
``(iii) Coordination at local level.--The Secretary
shall require, as appropriate, a State to demonstrate
consultation with the hospital association of such State,
rural hospitals located in such State, providers of mental
health services, or other appropriate stakeholders for the
provision of services under a grant awarded under this
paragraph.
``(iv) Special consideration of certain applications.--
In awarding grants to States under subparagraph (A), the
Secretary shall give special consideration to applications
submitted by States in which veterans make up a high
percentage (as determined by the Secretary) of the total
population of the State. Such consideration shall be given
without regard to the number of veterans of Operation Iraqi
Freedom and Operation Enduring Freedom living in the areas
in which mental health services and other health care
services would be delivered under the application.
``(C) Coordination with va.--The Secretary shall, as
appropriate, consult with the Director of the Office of Rural
Health of the Department of Veterans Affairs in awarding and
administering grants to States under subparagraph (A).
``(D) Use of funds.--A State awarded a grant under this
paragraph may, as appropriate, use the funds to reimburse
providers of services described in subparagraph (A) to
individuals described in that subparagraph.
``(E) Limitation on use of grant funds for administrative
expenses.--A State awarded a grant under this paragraph may not
expend more than 15 percent of the amount of the grant for
administrative expenses.
``(F) Independent evaluation and final report.--The
Secretary shall provide for an independent evaluation of the
grants awarded under subparagraph (A). Not later than 1 year
after the date on which the last grant is awarded to a State
under such subparagraph, the Secretary shall submit a report to
Congress on such evaluation. Such report shall include an
assessment of the impact of such grants on increasing the
delivery of mental health services and other health services to
veterans of the United States Armed Forces living in rural
areas (as so defined and including such areas that are rural
census tracks), with particular emphasis on the impact of such
grants on the delivery of such services to veterans of
Operation Enduring Freedom and Operation Iraqi Freedom, and to
other individuals living in such rural areas.''.
(b) Use of Funds for Federal Administrative Expenses.--Section
1820(g)(5) of the Social Security Act (42 U.S.C. 1395i-4(g)(5)) is
amended--
(1) by striking ``beginning with fiscal year 2005'' and
inserting ``for each of fiscal years 2005 through 2008''; and
(2) by inserting ``and, of the total amount appropriated for
grants under paragraphs (1), (2), and (6) for a fiscal year
(beginning with fiscal year 2009)'' after ``2005)''.
(c) Extension of Authorization for FLEX Grants.--Section 1820(j) of
the Social Security Act (42 U.S.C. 1395i-4(j)) is amended--
(1) by striking ``and for'' and inserting ``for''; and
(2) by inserting ``, for making grants to all States under
paragraphs (1) and (2) of subsection (g), $55,000,000 in each of
fiscal years 2009 and 2010, and for making grants to all States
under paragraph (6) of subsection (g), $50,000,000 in each of
fiscal years 2009 and 2010, to remain available until expended''
before the period at the end.
(d) Medicare Rural Hospital Flexibility Program.--Section
1820(g)(1) of the Social Security Act (42 U.S.C. 1395i-4(g)(1)) is
amended--
(1) in subparagraph (B), by striking ``and'' at the end;
(2) in subparagraph (C), by striking the period at the end and
inserting ``; and''; and
(3) by adding at the end the following new subparagraph:
``(D) providing support for critical access hospitals for
quality improvement, quality reporting, performance
improvements, and benchmarking.''.
(e) Assistance to Small Critical Access Hospitals Transitioning to
Skilled Nursing Facilities and Assisted Living Facilities.--Section
1820(g) of the Social Security Act (42 U.S.C. 1395i-4(g)), as amended
by subsection (a), is amended by adding at the end the following new
paragraph:
``(7) Critical access hospitals transitioning to skilled
nursing facilities and assisted living facilities.--
``(A) Grants.--The Secretary may award grants to eligible
critical access hospitals that have submitted applications in
accordance with subparagraph (B) for assisting such hospitals
in the transition to skilled nursing facilities and assisted
living facilities.
``(B) Application.--An applicable critical access hospital
seeking a grant under this paragraph shall submit an
application to the Secretary on or before such date and in such
form and manner as the Secretary specifies.
``(C) Additional requirements.--The Secretary may not award
a grant under this paragraph to an eligible critical access
hospital unless--
``(i) local organizations or the State in which the
hospital is located provides matching funds; and
``(ii) the hospital provides assurances that it will
surrender critical access hospital status under this title
within 180 days of receiving the grant.
``(D) Amount of grant.--A grant to an eligible critical
access hospital under this paragraph may not exceed $1,000,000.
``(E) Funding.--There are appropriated from the Federal
Hospital Insurance Trust Fund under section 1817 for making
grants under this paragraph, $5,000,000 for fiscal year 2008.
``(F) Eligible critical access hospital defined.--For
purposes of this paragraph, the term `eligible critical access
hospital' means a critical access hospital that has an average
daily acute census of less than 0.5 and an average daily swing
bed census of greater than 10.0.''.

c6d915a64157a7631a8100e88abc02abf73106100a252a141b85fa5dbac37886

(a) Rebasing Permitted.--Section 1886(b)(3) of the Social Security
Act (42 U.S.C. 1395ww(b)(3)) is amended by adding at the end the
following new subparagraph:
``(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.''.
(b) Conforming Amendments.--Section 1886(b)(3) of the Social
Security Act (42 U.S.C. 1395ww(b)(3)) is amended--
(1) in subparagraph (C), in the matter preceding clause (i), by
striking ``subparagraph (I)'' and inserting ``subparagraphs (I) and
(L)''; and
(2) in subparagraph (I)(i), in the matter preceding subclause
(I), by striking ``For'' and inserting ``Subject to subparagraph
(L), for''.

a1760823d4b37f791aa279857cd8f3dd7bf188649114aacae052fa3f06c82d1e

MODELS IN CERTAIN RURAL COUNTIES.
(a) In General.--The Secretary shall establish a demonstration
project to allow eligible entities to develop and test new models for
the delivery of health care services in eligible counties for the
purpose of improving access to, and better integrating the delivery of,
acute care, extended care, and other essential health care services to
Medicare beneficiaries.
(b) Purpose.--The purpose of the demonstration project under this
section is to--
(1) explore ways to increase access to, and improve the
adequacy of, payments for acute care, extended care, and other
essential health care services provided under the Medicare and
Medicaid programs in eligible counties; and
(2) evaluate regulatory challenges facing such providers and
the communities they serve.
(c) Requirements.--The following requirements shall apply under the
demonstration project:
(1) Health care providers in eligible counties selected to
participate in the demonstration project under subsection (d)(3)
shall (when determined appropriate by the Secretary), instead of
the payment rates otherwise applicable under the Medicare program,
be reimbursed at a rate that covers at least the reasonable costs
of the provider in furnishing acute care, extended care, and other
essential health care services to Medicare beneficiaries.
(2) Methods to coordinate the survey and certification process
under the Medicare program and the Medicaid program across all
health service categories included in the demonstration project
shall be tested with the goal of assuring quality and safety while
reducing administrative burdens, as appropriate, related to
completing such survey and certification process.
(3) Health care providers in eligible counties selected to
participate in the demonstration project under subsection (d)(3)
and the Secretary shall work with the State to explore ways to
revise reimbursement policies under the Medicaid program to improve
access to the range of health care services available in such
eligible counties.
(4) The Secretary shall identify regulatory requirements that
may be revised appropriately to improve access to care in eligible
counties.
(5) Other essential health care services necessary to ensure
access to the range of health care services in eligible counties
selected to participate in the demonstration project under
subsection (d)(3) shall be identified. Ways to ensure adequate
funding for such services shall also be explored.
(d) Application Process.--
(1) Eligibility.--
(A) In general.--Eligibility to participate in the
demonstration project under this section shall be limited to
eligible entities.
(B) Eligible entity defined.--In this section, the term
``eligible entity'' means an entity that--
(i) is a Rural Hospital Flexibility Program grantee
under section 1820(g) of the Social Security Act (42 U.S.C.
1395i-4(g)); and
(ii) is located in a State in which at least 65 percent
of the counties in the State are counties that have 6 or
less residents per square mile.
(2) Application.--
(A) In general.--An eligible entity seeking to participate
in the demonstration project under this section shall submit an
application to the Secretary at such time, in such manner, and
containing such information as the Secretary may require.
(B) Limitation.--The Secretary shall select eligible
entities located in not more than 4 States to participate in
the demonstration project under this section.
(3) Selection of eligible counties.--An eligible entity
selected by the Secretary to participate in the demonstration
project under this section shall select not more than 6 eligible
counties in the State in which the entity is located in which to
conduct the demonstration project.
(4) Eligible county defined.--In this section, the term
``eligible county'' means a county that meets the following
requirements:
(A) The county has 6 or less residents per square mile.
(B) As of the date of the enactment of this Act, a facility
designated as a critical access hospital which meets the
following requirements was located in the county:
(i) As of the date of the enactment of this Act, the
critical access hospital furnished 1 or more of the
following:
(I) Home health services.
(II) Hospice care.
(III) Rural health clinic services.
(ii) As of the date of the enactment of this Act, the
critical access hospital has an average daily inpatient
census of 5 or less.
(C) As of the date of the enactment of this Act, skilled
nursing facility services were available in the county in--
(i) a critical access hospital using swing beds; or
(ii) a local nursing home.
(e) Administration.--
(1) In general.--The demonstration project under this section
shall be administered jointly by the Administrator of the Office of
Rural Health Policy of the Health Resources and Services
Administration and the Administrator of the Centers for Medicare &
Medicaid Services, in accordance with paragraphs (2) and (3).
(2) HRSA duties.--In administering the demonstration project
under this section, the Administrator of the Office of Rural Health
Policy of the Health Resources and Services Administration shall--
(A) award grants to the eligible entities selected to
participate in the demonstration project; and
(B) work with such entities to provide technical assistance
related to the requirements under the project.
(3) CMS duties.--In administering the demonstration project
under this section, the Administrator of the Centers for Medicare &
Medicaid Services shall determine which provisions of titles XVIII
and XIX of the Social Security Act (42 U.S.C. 1395 et seq.; 1396 et
seq.) the Secretary should waive under the waiver authority under
subsection (i) that are relevant to the development of alternative
reimbursement methodologies, which may include, as appropriate,
covering at least the reasonable costs of the provider in
furnishing acute care, extended care, and other essential health
care services to Medicare beneficiaries and coordinating the survey
and certification process under the Medicare and Medicaid programs,
as appropriate, across all service categories included in the
demonstration project.
(f) Duration.--
(1) In general.--The demonstration project under this section
shall be conducted for a 3-year period beginning on October 1,
2009.
(2) Beginning date of demonstration project.--The demonstration
project under this section shall be considered to have begun in a
State on the date on which the eligible counties selected to
participate in the demonstration project under subsection (d)(3)
begin operations in accordance with the requirements under the
demonstration project.
(g) Funding.--
(1) CMS.--
(A) In general.--The Secretary shall provide for the
transfer, in appropriate part from the Federal Hospital
Insurance Trust Fund established under section 1817 of the
Social Security Act (42 U.S.C. 1395i) and the Federal
Supplementary Medical Insurance Trust Fund established under
section 1841 of such Act (42 U.S.C. 1395t), of such sums as are
necessary for the costs to the Centers for Medicare & Medicaid
Services of carrying out its duties under the demonstration
project under this section.
(B) Budget neutrality.--In conducting the demonstration
project under this section, the Secretary shall ensure that the
aggregate payments made by the Secretary do not exceed the
amount which the Secretary estimates would have been paid if
the demonstration project under this section was not
implemented.
(2) HRSA.--There are authorized to be appropriated to the
Office of Rural Health Policy of the Health Resources and Services
Administration $800,000 for each of fiscal years 2010, 2011, and
2012 for the purpose of carrying out the duties of such Office
under the demonstration project under this section, to remain
available for the duration of the demonstration project.
(h) Report.--
(1) Interim report.--Not later than the date that is 2 years
after the date on which the demonstration project under this
section is implemented, the Administrator of the Office of Rural
Health Policy of the Health Resources and Services Administration,
in coordination with the Administrator of the Centers for Medicare
& Medicaid Services, shall submit a report to Congress on the
status of the demonstration project that includes initial
recommendations on ways to improve access to, and the availability
of, health care services in eligible counties based on the findings
of the demonstration project.
(2) Final report.--Not later than 1 year after the completion
of the demonstration project, the Administrator of the Office of
Rural Health Policy of the Health Resources and Services
Administration, in coordination with the Administrator of the
Centers for Medicare & Medicaid Services, shall submit a report to
Congress on such project, together with recommendations for such
legislation and administrative action as the Secretary determines
appropriate.
(i) Waiver Authority.--The Secretary may waive such requirements of
titles XVIII and XIX of the Social Security Act (42 U.S.C. 1395 et
seq.; 1396 et seq.) as may be necessary and appropriate for the purpose
of carrying out the demonstration project under this section.
(j) Definitions.--In this section:
(1) Extended care services.--The term ``extended care
services'' means the following:
(A) Home health services.
(B) Covered skilled nursing facility services.
(C) Hospice care.
(2) Covered skilled nursing facility services.--The term
``covered skilled nursing facility services'' has the meaning given
such term in section 1888(e)(2)(A) of the Social Security Act (42
U.S.C. 1395yy(e)(2)(A)).
(3) Critical access hospital.--The term ``critical access
hospital'' means a facility designated as a critical access
hospital under section 1820(c) of such Act (42 U.S.C. 1395i-4(c)).
(4) Home health services.--The term ``home health services''
has the meaning given such term in section 1861(m) of such Act (42
U.S.C. 1395x(m)).
(5) Hospice care.--The term ``hospice care'' has the meaning
given such term in section 1861(dd) of such Act (42 U.S.C.
1395x(dd)).
(6) Medicaid program.--The term ``Medicaid program'' means the
program under title XIX of such Act (42 U.S.C. 1396 et seq.).
(7) Medicare program.--The term ``Medicare program'' means the
program under title XVIII of such Act (42 U.S.C. 1395 et seq.).
(8) Other essential health care services.--The term ``other
essential health care services'' means the following:
(A) Ambulance services (as described in section 1861(s)(7)
of the Social Security Act (42 U.S.C. 1395x(s)(7))).
(B) Rural health clinic services.
(C) Public health services (as defined by the Secretary).
(D) Other health care services determined appropriate by
the Secretary.
(9) Rural health clinic services.--The term ``rural health
clinic services'' has the meaning given such term in section
1861(aa)(1) of such Act (42 U.S.C. 1395x(aa)(1)).
(10) Secretary.--The term ``Secretary'' means the Secretary of
Health and Human Services.

f9832b3f4ac4246ab157f1b0895caca67aba684da0962706131dbf76772301a0

(a) 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), is amended by striking ``September
30, 2008'' and inserting ``September 30, 2009''.
(b) Special Exception Reclassifications.--Section 117(a)(2) of the
Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-
173)) is amended by striking ``September 30, 2008'' and inserting ``the
last date of the extension of reclassifications under section 106(a) of
the Medicare Improvement and Extension Act of 2006 (division B of
Public Law 109-432)''.
(c) Disregarding Section 508 Hospital Reclassifications for
Purposes of Group Reclassifications.--Section 508(g) of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003 (Public
Law 108-173, 42 U.S.C. 1395ww note), as added by section 117(b) of the
Medicare, Medicaid, and SCHIP Extension Act of 2008 (Public Law 110-
173)), is amended by striking ``during fiscal year 2008'' and inserting
``beginning on October 1, 2007, and ending on the last date of the
extension of reclassifications under section 106(a) of the Medicare
Improvement and Extension Act of 2006 (division B of Public Law 109-
432)''.

67f0b6f4a84b854430657f18fe6e7b0b44e33debbded6f73424991b730bd3c36

COMMISSION.
(a) Revocation.--Section 1865 of the Social Security Act (42 U.S.C.
1395bb) is amended--
(1) by striking subsection (a); and
(2) by redesignating subsections (b), (c), (d), and (e) as
subsections (a), (b), (c), and (d), respectively.
(b) Conforming Amendments.--(1) Section 1865 of the Social Security
Act (42 U.S.C. 1395bb) is amended--
(A) in subsection (a)(1), as redesignated by subsection (a)(2),
by striking ``In addition, if'' and inserting ``If'';
(B) in subsection (b), as so redesignated--
(i) by striking ``released to him by the Joint Commission
on Accreditation of Hospitals,'' and inserting ``released to
the Secretary by''; and
(ii) by striking the comma after ``Association'';
(C) in subsection (c), as so redesignated, by striking
``pursuant to subsection (a) or (b)(1)'' and inserting ``pursuant
to subsection (a)(1)''; and
(D) in subsection (d), as so redesignated, by striking
``pursuant to subsection (a) or (b)(1)'' and inserting ``pursuant
to subsection (a)(1)''.
(2) Section 1861(e) of the Social Security Act (42 U.S.C. 1395x(e))
is amended in the fourth sentence by striking ``and (ii) is accredited
by the Joint Commission on Accreditation of Hospitals, or is accredited
by or approved by a program of the country in which such institution is
located if the Secretary finds the accreditation or comparable approval
standards of such program to be essentially equivalent to those of the
Joint Commission on Accreditation of Hospitals'' and inserting ``and
(ii) is accredited by a national accreditation body recognized by the
Secretary under section 1865(a), or is accredited by or approved by a
program of the country in which such institution is located if the
Secretary finds the accreditation or comparable approval standards of
such program to be essentially equivalent to those of such a national
accreditation body.''.
(3) Section 1864(c) of the Social Security Act (42 U.S.C.
1395aa(c)) is amended by striking ``pursuant to subsection (a) or
(b)(1) of section 1865'' and inserting ``pursuant to section
1865(a)(1)''.
(4) Section 1875(b) of the Social Security Act (42 U.S.C.
1395ll(b)) is amended by striking ``the Joint Commission on
Accreditation of Hospitals,'' and inserting ``national accreditation
bodies under section 1865(a)''.
(5) Section 1834(a)(20)(B) of the Social Security Act (42 U.S.C.
1395m(a)(20)(B)) is amended by striking ``section 1865(b)'' and
inserting ``section 1865(a)''.
(6) Section 1852(e)(4)(C) of the Social Security Act (42 U.S.C.
1395w-22(e)(4)(C)) is amended by striking ``section 1865(b)(2)'' and
inserting ``section 1865(a)(2)''.
(c) Authority To Recognize the Joint Commission as a National
Accreditation Body.--The Secretary of Health and Human Services may
recognize the Joint Commission as a national accreditation body under
section 1865 of the Social Security Act (42 U.S.C. 1395bb), as amended
by this section, upon such terms and conditions, and upon submission of
such information, as the Secretary may require.
(d) Effective Date; Transition Rule.--(1) Subject to paragraph (2),
the amendments made by this section shall apply with respect to
accreditations of hospitals granted on or after the date that is 24
months after the date of the enactment of this Act.
(2) For purposes of title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.), the amendments made by this section shall not
effect the accreditation of a hospital by the Joint Commission, or
under accreditation or comparable approval standards found to be
essentially equivalent to accreditation or approval standards of the
Joint Commission, for the period of time applicable under such
accreditation.
Subtitle C--Provisions Relating to Part B
PART I--PHYSICIANS' SERVICES

dd1d5c46432f5b332cbfba4dc818b1cda420f0833dccc23fbb6dc685066bcd37

(a) In General.--
(1) Increase in update for the second half of 2008 and for
2009.--
(A) For the second half of 2008.--Section 1848(d)(8) of the
Social Security Act (42 U.S.C. 1395w-4(d)(8)), as added by
section 101 of the Medicare, Medicaid, and SCHIP Extension Act
of 2007 (Public Law 110-173), is amended--
(i) in the heading, by striking ``a portion of'';
(ii) in subparagraph (A), by striking ``for the period
beginning on January 1, 2008, and ending on June 30,
2008,''; and
(iii) in subparagraph (B)--
(I) in the heading, by striking ``the remaining
portion of 2008 and''; and
(II) by striking ``for the period beginning on July
1, 2008, and ending on December 31, 2008, and''.
(B) For 2009.--Section 1848(d) of the Social Security Act
(42 U.S.C. 1395w-4(d)), as amended by section 101 of the
Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law
110-173), is amended by adding at the end the following new
paragraph:
``(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.''.
(3) Revision of the physician assistance and quality initiative
fund.--
(A) In general.--Subject to subparagraph (B), section
1848(l)(2) of the Social Security Act (42 U.S.C. 1395w-
4(l)(2)), as amended by section 101(a)(2) of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173),
is amended--
(i) in subparagraph (A)--
(I) by striking clause (i)(III); and
(II) by striking clause (ii)(III); and
(ii) in subparagraph (B)--
(I) in clause (i), by adding ``and'' at the end;
(II) in clause (ii), by striking ``; and'' and
inserting a period; and
(III) by striking clause (iii).
(B) Contingency.--If there is enacted, before, on, or after
the date of the enactment of this Act, a Supplemental
Appropriations Act, 2008 that includes a provision amending
section 1848(l) of the Social Security Act, the alternative
amendment described in subparagraph (C)--
(i) shall apply instead of the amendments made by
subparagraph (A); and
(ii) shall be executed after such provision in such
Supplemental Appropriations Act.
(C) Alternative amendment described.--The alternative
amendment described in this subparagraph is as follows: Section
1848(l)(2) of the Social Security Act (42 U.S.C. 1395w-
4(l)(2)), as amended by section 101(a)(2) of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173)
and by the Supplemental Appropriations Act, 2008, is amended--
(i) in subparagraph (A)--
(I) by striking subclauses (III) and (IV) of clause
(i); and
(II) by striking subclauses (III) and (IV) of
clause (ii); and
(ii) in subparagraph (B)--
(I) in clause (i), by adding ``and'' at the end;
(II) in clause (ii), by striking the semicolon at
the end and inserting a period; and
(III) by striking clauses (iii) and (iv).
(b) Extension and Improvement of the Quality Reporting System.--
(1) System.--Section 1848(k)(2) of the Social Security Act (42
U.S.C. 1395w-4(k)(2)), as amended by section 101(b)(1) of the
Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law
110-173), is amended by adding at the end the following new
subparagraphs:
``(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.''.
(2) Redesignation of reporting system.--Subsection (c) of
section 101 of division B of the Tax Relief and Health Care Act of
2006 (42 U.S.C. 1395w-4 note), as amended by section 101(b)(2) of
the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law
110-173), is redesignated as subsection (m) of section 1848 of the
Social Security Act.
(3) Incentive payments under reporting system.--Section 1848(m)
of the Social Security Act, as redesignated by paragraph (2), is
amended--
(A) by amending the heading to read as follows: ``Incentive
Payments for Quality Reporting'';
(B) by striking paragraph (1) and inserting the following:
``(1) Incentive payments.--
``(A) In general.--For 2007 through 2010, 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; and
``(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.'';
(C) by striking paragraph (3) and redesignating paragraph
(2) as paragraph (3);
(D) in paragraph (3), as so redesignated--
(i) in the matter preceding subparagraph (A), by
striking ``For purposes'' and inserting the following:
``(A) In general.--For purposes'';
(ii) by redesignating subparagraphs (A) and (B) as
clauses (i) and (ii), respectively, and moving the
indentation of such clauses 2 ems to the right;
(iii) in subparagraph (A), as added by clause (i), by
adding at the end the following flush sentence:
``For years after 2008, quality measures for purposes of this
subparagraph shall not include electronic prescribing quality
measures.''; and
(iv) by adding at the end the following new
subparagraphs:
``(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) 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 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) 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).'';
(E) in paragraph (5)--
(i) in subparagraph (C), by inserting ``for 2007, 2008,
and 2009,'' after ``provision of law,'';
(ii) in subparagraph (D)--
(I) in clause (i)--
(aa) by inserting ``for 2007 and 2008'' after
``under this subsection''; and
(bb) by striking ``paragraph (2)'' and
inserting ``this subsection'';
(II) in clause (ii), by striking ``shall'' and
inserting ``may establish procedures to''; and
(III) in clause (iii)--
(aa) by inserting ``(or, in the case of a group
practice under paragraph (3)(C), the group
practice)'' after ``an eligible professional'';
(bb) by striking ``bonus incentive payment''
and inserting ``incentive payment under this
subsection''; and
(cc) by adding at the end the following new
sentence: ``If such payments for such period have
already been made, the Secretary shall recoup such
payments from the eligible professional (or the
group practice).'';
(iii) in subparagraph (E)--
(I) by striking ``(i) in general.--'';
(II) by striking clause (ii);
(III) by redesignating subclauses (I) through (IV)
as clauses (i) through (iv), respectively, and moving
the indentation of such clauses 2 ems to the left;
(IV) in clause (ii), as so redesignated, by
striking ``paragraph (2)'' and inserting ``this
subsection''; and
(V) in clause (iv), as so redesignated--
(aa) by striking ``the bonus'' and inserting
``any''; and
(bb) by inserting ``and the payment adjustment
under subsection (a)(5)(A)'' before the period at
the end;
(iv) in subparagraph (F)--
(I) by striking ``2009, paragraph (3) shall not
apply, and'' and inserting ``subsequent years,''; and
(II) by striking ``paragraph (2)'' and inserting
``this subsection''; and
(v) by adding at the end the following new
subparagraph:
``(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.''; and
(F) in paragraph (6), by striking subparagraph (C) and
inserting the following:
``(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, 2009, 2010, and 2011, 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) shall be deemed a reference to the
reporting period under subparagraph (D)(iii) of such
subsection.''.
(4) Inclusion of qualified audiologists as eligible
professionals.--
(A) In general.--Section 1848(k)(3)(B) of the Social
Security Act (42 U.S.C. 1395w-4(k)(3)(B)), is amended by adding
at the end the following new clause:
``(iv) Beginning with 2009, a qualified audiologist (as
defined in section 1861(ll)(3)(B)).''.
(B) No change in billing.--Nothing in the amendment made by
subparagraph (A) shall be construed to change the way in which
billing for audiology services (as defined in section
1861(ll)(2) of the Social Security Act (42 U.S.C.
1395x(ll)(2))) occurs under title XVIII of such Act as of July
1, 2008.
(5) Conforming amendments.--Section 1848(m) of the Social
Security Act, as added and amended by paragraphs (2) and (3), is
amended--
(A) in paragraph (5)--
(i) in subparagraph (A)--
(I) by striking ``section 1848(k) of the Social
Security Act, as added by subsection (b),'' and
inserting ``subsection (k)''; and
(II) by striking ``such section'' and inserting
``such subsection'';
(ii) in subparagraph (B), by striking ``of the Social
Security Act (42 U.S.C. 1395l)'';
(iii) in subparagraph (E), in the matter preceding
clause (i), by striking ``1869 or 1878 of the Social
Security Act or otherwise'' and inserting ``1869, section
1878, or otherwise''; and
(iv) in subparagraph (F)--
(I) by striking ``paragraph (2)(B) of section
1848(k) of the Social Security Act (42 U.S.C. 1395w-
4(k))'' and inserting ``subsection (k)(2)(B)''; and
(II) by striking ``paragraph (4) of such section''
and inserting ``subsection (k)(4)'';
(B) in paragraph (6)--
(i) in subparagraph (A), by striking ``section
1848(k)(3) of the Social Security Act, as added by
subsection (b)'' and inserting ``subsection (k)(3)''; and
(ii) in subparagraph (B), by striking ``section 1848(k)
of the Social Security Act, as added by subsection (b)''
and inserting ``subsection (k)''; and
(C) by striking paragraph (6)(D).
(6) No affect on incentive payments for 2007 or 2008.--Nothing
in the amendments made by this subsection or section 132 shall
affect the operation of the provisions of section 1848(m) of the
Social Security Act, as redesignated and amended by such subsection
and section, with respect to 2007 or 2008.
(c) Physician Feedback Program To Improve Efficiency and Control
Costs.--
(1) In general.--Section 1848 of the Social Security Act (42
U.S.C. 1395w-4), as amended by subsection (b), is amended by adding
at the end the following new subsection:
``(n) Physician Feedback Program.--
``(1) Establishment.--
``(A) In general.--The Secretary shall establish a
Physician Feedback Program (in this subsection referred to as
the `Program') under which 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. 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) 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 application.--The Secretary may focus
the 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.
``(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.''.
(2) GAO study and report on the physician feedback program.--
(A) Study.--The Comptroller General of the United States
shall conduct a study of the Physician Feedback Program
conducted under section 1848(n) of the Social Security Act, as
added by paragraph (1), including the implementation of the
Program.
(B) Report.--Not later than March 1, 2011, the Comptroller
General of the United States shall submit a report to Congress
containing the results of the study conducted under
subparagraph (A), together with recommendations for such
legislation and administrative action as the Comptroller
General determines appropriate.
(d) Plan for Transition to Value-Based Purchasing Program for
Physicians and Other Practitioners.--
(1) In general.--The Secretary of Health and Human Services
shall develop a plan to transition to a value-based purchasing
program for payment under the Medicare program for covered
professional services (as defined in section 1848(k)(3)(A) of the
Social Security Act (42 U.S.C. 1395w-4(k)(3)(A))).
(2) Report.--Not later than May 1, 2010, the Secretary of
Health and Human Services shall submit a report to Congress
containing the plan developed under paragraph (1), together with
recommendations for such legislation and administrative action as
the Secretary determines appropriate.

bd79fc443880ace15b34788ff46377708eb9b81cf2aa5946446a7960513f21da

(a) Incentive Payments.--Section 1848(m) of the Social Security
Act, as added and amended by section 131(b), is amended--
(1) by inserting after paragraph (1), the following new
paragraph:
``(2) Incentive payments for electronic prescribing.--
``(A) In general.--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.'';
(2) in paragraph (3), as redesignated by section 131(b)--
(A) in the heading, by inserting ``and successful
electronic prescriber'' after ``reporting''; and
(B) by inserting after subparagraph (A) the following new
subparagraph:
``(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).'';
and
(3) in paragraph (5)(E), by striking clause (iii) and inserting
the following new clause:
``(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''.
(b) Incentive Payment Adjustment.--Section 1848(a) of the Social
Security Act (42 U.S.C. 1395w-4(a)) is amended by adding at the end the
following new paragraph:
``(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
or any subsequent year, 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 and each subsequent year, 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.''.
(c) GAO Report on Electronic Prescribing.--Not later than September
1, 2012, the Comptroller General of the United States shall submit to
Congress a report on the implementation of the incentives for
electronic prescribing established under the provisions of, and
amendments made by, this section. Such report shall include information
regarding the following:
(1) The percentage of eligible professionals (as defined in
section 1848(k)(3) of the Social Security Act (42 U.S.C. 1395w-
4(k)(3)) that are using electronic prescribing systems, including a
determination of whether less than 50 percent of eligible
professionals are using electronic prescribing systems.
(2) If less than 50 percent of eligible professionals are using
electronic prescribing systems, recommendations for increasing the
use of electronic prescribing systems by eligible professionals,
such as changes to the incentive payment adjustments established
under section 1848(a)(5) of such Act, as added by subsection (b).
(3) The estimated savings to the Medicare program under title
XVIII of such Act resulting from the use of electronic prescribing
systems.
(4) Reductions in avoidable medical errors resulting from the
use of electronic prescribing systems.
(5) The extent to which the privacy and security of the
personal health information of Medicare beneficiaries is protected
when such beneficiaries' prescription drug data and usage
information is used for purposes other than their direct clinical
care, including--
(A) whether information identifying the beneficiary is, and
remains, removed from data regarding the beneficiary's
prescription drug utilization; and
(B) the extent to which current law requires sufficient and
appropriate oversight and audit capabilities to monitor the
practice of prescription drug data mining.
(6) Such other recommendations and administrative action as the
Comptroller General determines to be appropriate.

75a2d8da6503446e53b6ee1189757fa8d90c787e267e44d6fe66c526cfa18398

(a) Revisions to the Medicare Medical Home Demonstration Project.--
(1) Authority to expand.--Section 204(b) of division B of the
Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395b-1 note) is
amended--
(A) in paragraph (1), by striking ``The project'' and
inserting ``Subject to paragraph (3), the project''; and
(B) by adding at the end the following new paragraph:
``(3) Expansion.--The Secretary may expand the duration and the
scope of the project under paragraph (1), to an extent determined
appropriate by the Secretary, if the Secretary determines that such
expansion will result in any of the following conditions being met:
``(A) The expansion of the project is expected to improve
the quality of patient care without increasing spending under
the Medicare program (not taking into account amounts available
under subsection (g)).
``(B) The expansion of the project is expected to reduce
spending under the Medicare program (not taking into account
amounts available under subsection (g)) without reducing the
quality of patient care.''.
(2) Funding and application.--Section 204 of division B of the
Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395b-1 note) is
amended by adding at the end the following new subsections:
``(g) Funding From SMI Trust Fund.--There shall be available, from
the Federal Supplementary Medical Insurance Trust Fund (under section
1841 of the Social Security Act (42 U.S.C. 1395t)), the amount of
$100,000,000 to carry out the project.
``(h) Application.--Chapter 35 of title 44, United States Code,
shall not apply to the conduct of the project.''.
(b) Application of Budget-Neutrality Adjustor to Conversion
Factor.--Section 1848(c)(2)(B) of the Social Security Act (42 U.S.C.
1395w-4(c)(2)(B)) is amended by adding at the end the following new
clause:
``(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.''.

1dabe0e2fcb24633b1c51d5ae38a88c030ab3edcac54e1318793738030f5ccb3

UNDER THE MEDICARE PHYSICIAN FEE SCHEDULE.
(a) In General.--Section 1848(e)(1)(E) of the Social Security Act
(42 U.S.C. 1395w-4(e)(1)(E)), as amended by section 103 of the
Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-
173), is amended by striking ``before July 1, 2008'' and inserting
``before January 1, 2010''.
(b) Treatment of Physicians' Services Furnished in Certain Areas.--
Section 1848(e)(1)(G) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)(G)) is amended by adding at the end the following new sentence:
``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''.
(c) Technical Correction.--Section 602(1) of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003 (Public
Law 108-173; 117 Stat. 2301) is amended to read as follows:
``(1) in subparagraph (A), by striking `subparagraphs (B), (C),
and (E)' and inserting `subparagraphs (B), (C), (E), and (G)';
and''.

5dd957595d334b9b49f39da078c8ac5a6fae377e333b257ab077ba230b43bae2

840a27cdbfbae98605da05fb320bc0a71f00f04d62dc09a2974f109e7f5c2a04

SERVICES UNDER MEDICARE.
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), and section 104
of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law
110-173), is amended by striking ``2007, and the first 6 months of
2008'' and inserting ``2007, 2008, and 2009''.

0e96d5f08da24582371bc044ddf4c4f84a87bb80f3711eea713b4056ddae4a38

ARMED SERVICES.
Section 1842(b)(6)(D)(iii) of the Social Security Act (42 U.S.C.
1395u(b)(6)(D)(iii)), as amended by section 116 of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173), is
amended by striking ``(before July 1, 2008)''.

36b88b8c20bf95e6ea30cc7e955db699870cd99c6a7ca78ddd62942313bade5f

(a) Payment Adjustment.--
(1) In general.--For purposes of payment for services furnished
under the physician fee schedule under section 1848 of the Social
Security Act (42 U.S.C. 1395w-4) during the period beginning on
July 1, 2008, and ending on December 31, 2009, the Secretary of
Health and Human Services shall increase the fee schedule otherwise
applicable for specified services by 5 percent.
(2) Nonapplication of budget-neutrality.--The budget-neutrality
provision of section 1848(c)(2)(B)(ii) of the Social Security Act
(42 U.S.C. 1395w-4(c)(2)(B)(ii)) shall not apply to the adjustments
described in paragraph (1).
(b) Definition of Specified Services.--In this section, the term
``specified services'' means procedure codes for services in the
categories of the Health Care Common Procedure Coding System,
established by the Secretary of Health and Human Services under section
1848(c)(5) of the Social Security Act (42 U.S.C. 1395w-4(c)(5)), as of
July 1, 2007, and as subsequently modified by the Secretary, consisting
of psychiatric therapeutic procedures furnished in office or other
outpatient facility settings or in inpatient hospital, partial
hospital, or residential care facility settings, but only with respect
to such services in such categories that are in the subcategories of
services which are--
(1) insight oriented, behavior modifying, or supportive
psychotherapy; or
(2) interactive psychotherapy.
(c) Implementation.--Notwithstanding any other provision of law,
the Secretary may implement this section by program instruction or
otherwise.

e0541b2523c253c897de37628c485911d18a3ee92e6e3be3cd037d58fa5144fb

(a) Special Payment Rule for Teaching Anesthesiologists.--Section
1848(a) of the Social Security Act (42 U.S.C. 1395w-4(a)), as amended
by section 132(b), is amended--
(1) in paragraph (4)(A), by inserting ``except as provided in
paragraph (5),'' after ``anesthesia cases,''; and
(2) by adding at the end the following new paragraph:
``(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.''.
(b) Treatment of Certified Registered Nurse Anesthetists.--With
respect to items and services furnished on or after January 1, 2010,
the Secretary of Health and Human Services shall make appropriate
adjustments to payments under the Medicare program under title XVIII of
the Social Security Act for teaching certified registered nurse
anesthetists to implement a policy with respect to teaching certified
registered nurse anesthetists that--
(1) is consistent with the adjustments made by the special rule
for teaching anesthesiologists under section 1848(a)(6) of the
Social Security Act, as added by subsection (a); and
(2) maintains the existing payment differences between teaching
anesthesiologists and teaching certified registered nurse
anesthetists.
PART II--OTHER PAYMENT AND COVERAGE IMPROVEMENTS

cb5d18beabb8778cbbca7d4ee75e6a125f43338ff1390b8c204c21972e47db5f

CAPS.
Section 1833(g)(5) of the Social Security Act (42 U.S.C.
1395l(g)(5)), as amended by section 105 of the Medicare, Medicaid, and
SCHIP Extension Act of 2007 (Public Law 110-173), is amended by
striking ``June 30, 2008'' and inserting ``December 31, 2009''.

f59cb5179fc6b080cfb96df4e9e4b8ee57c21c54af4e1d0b429641eecef1bf46

THERAPEUTIC RADIOPHARMACEUTICALS.
Section 1833(t)(16)(C) of the Social Security Act (42 U.S.C.
1395l(t)(16)(C)), as amended by section 106 of the Medicare, Medicaid,
and SCHIP Extension Act of 2007 (Public Law 110-173), is amended by
striking ``July 1, 2008'' each place it appears and inserting ``January
1, 2010''.

1a73a44fd2668e75865d845928559807b94cd25798f9571af4d36ebfe2847b35

(a) In General.--Section 1861(ll) of the Social Security Act (42
U.S.C. 1395x(ll)) is amended--
(1) by redesignating paragraphs (2) and (3) as paragraphs (3)
and (4), respectively; and
(2) by inserting after paragraph (1) the following new
paragraph:
``(2) The term `outpatient speech-language pathology services' has
the meaning given the term `outpatient physical therapy services' in
subsection (p), except that in applying such subsection--
``(A) `speech-language pathology' shall be substituted for
`physical therapy' each place it appears; and
``(B) `speech-language pathologist' shall be substituted for
`physical therapist' each place it appears.''.
(b) Conforming Amendments.--
(1) Section 1832(a)(2)(C) of the Social Security Act (42 U.S.C.
1395k(a)(2)(C)) is amended--
(A) by striking ``and outpatient'' and inserting ``,
outpatient''; and
(B) by inserting before the semicolon at the end the
following: ``, and outpatient speech-language pathology
services (other than services to which the second sentence of
section 1861(p) applies through the application of section
1861(ll)(2))''.
(2) Subparagraphs (A) and (B) of section 1833(a)(8) of the
Social Security Act (42 U.S.C. 1395l(a)(8)) are each amended by
striking ``(which includes outpatient speech-language pathology
services)'' and inserting ``, outpatient speech-language pathology
services,''.
(3) Section 1833(g)(1) of the Social Security Act (42 U.S.C.
1395l(g)(1)) is amended--
(A) by inserting ``and speech-language pathology services
of the type described in such section through the application
of section 1861(ll)(2)'' after ``1861(p)''; and
(B) by inserting ``and speech-language pathology services''
after ``and physical therapy services''.
(4) The second sentence of section 1835(a) of the Social
Security Act (42 U.S.C. 1395n(a)) is amended--
(A) by striking ``section 1861(g)'' and inserting
``subsection (g) or (ll)(2) of section 1861'' each place it
appears; and
(B) by inserting ``or outpatient speech-language pathology
services, respectively'' after ``occupational therapy
services''.
(5) Section 1861(p) of the Social Security Act (42 U.S.C.
1395x(p)) is amended by striking the fourth sentence.
(6) Section 1861(s)(2)(D) of the Social Security Act (42 U.S.C.
1395x(s)(2)(D)) is amended by inserting ``, outpatient speech-
language pathology services,'' after ``physical therapy services''.
(7) Section 1862(a)(20) of the Social Security Act (42 U.S.C.
1395y(a)(20)) is amended--
(A) by striking ``outpatient occupational therapy services
or outpatient physical therapy services'' and inserting
``outpatient physical therapy services, outpatient speech-
language pathology services, or outpatient occupational therapy
services''; and
(B) by striking ``section 1861(g)'' and inserting
``subsection (g) or (ll)(2) of section 1861''.
(8) Section 1866(e)(1) of the Social Security Act (42 U.S.C.
1395cc(e)(1)) is amended--
(A) by striking ``section 1861(g)'' and inserting
``subsection (g) or (ll)(2) of section 1861'' the first two
places it appears;
(B) by striking ``defined) or'' and inserting
``defined),''; and
(C) by inserting before the semicolon at the end the
following: ``, or (through the operation of section
1861(ll)(2)) with respect to the furnishing of outpatient
speech-language pathology''.
(9) Section 1877(h)(6) of the Social Security Act (42 U.S.C.
1395nn(h)(6)) is amended by adding at the end the following new
subparagraph:
``(L) Outpatient speech-language pathology services.''.
(c) Effective Date.--The amendments made by this section shall
apply to services furnished on or after July 1, 2009.
(d) Construction.--Nothing in this section shall be construed to
affect existing regulations and policies of the Centers for Medicare &
Medicaid Services that require physician oversight of care as a
condition of payment for speech-language pathology services under part
B of the Medicare program.

3b682188cde186a99cdba83ffbd4eee8d34b819e22e9b166594b89ce0d4023b7

CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND OTHER CONDITIONS.
(a) Coverage of Pulmonary and Cardiac Rehabilitation.--
(1) In general.--Section 1861 of the Social Security Act (42
U.S.C. 1395x), as amended by section 101(a), is amended--
(A) in subsection (s)(2)--
(i) in subparagraph (AA), by striking ``and'' at the
end;
(ii) by adding at the end the following new
subparagraphs:
``(CC) items and services furnished under a cardiac
rehabilitation program (as defined in subsection (eee)(1)) or
under a pulmonary rehabilitation program (as defined in
subsection (fff)(1)); and
``(DD) items and services furnished under an intensive
cardiac rehabilitation program (as defined in subsection
(eee)(4));''; and
(B) by adding at the end the following new subsections:
``Cardiac Rehabilitation Program; Intensive Cardiac Rehabilitation
Program
``(eee)(1) The term `cardiac rehabilitation program' means a
physician-supervised program (as described in paragraph (2)) that
furnishes the items and services described in paragraph (3).
``(2) A program described in this paragraph is a program under
which--
``(A) items and services under the program are delivered--
``(i) in a physician's office;
``(ii) in a hospital on an outpatient basis; or
``(iii) in other settings determined appropriate by the
Secretary.
``(B) a physician is immediately available and accessible for
medical consultation and medical emergencies at all times items and
services are being furnished under the program, except that, in the
case of items and services furnished under such a program in a
hospital, such availability shall be presumed; and
``(C) individualized treatment is furnished under a written
plan established, reviewed, and signed by a physician every 30 days
that describes--
``(i) the individual's diagnosis;
``(ii) the type, amount, frequency, and duration of the
items and services furnished under the plan; and
``(iii) the goals set for the individual under the plan.
``(3) The items and services described in this paragraph are--
``(A) physician-prescribed exercise;
``(B) cardiac risk factor modification, including education,
counseling, and behavioral intervention (to the extent such
education, counseling, and behavioral intervention is closely
related to the individual's care and treatment and is tailored to
the individual's needs);
``(C) psychosocial assessment;
``(D) outcomes assessment; and
``(E) such other items and services as the Secretary may
determine, but only if such items and services are--
``(i) reasonable and necessary for the diagnosis or active
treatment of the individual's condition;
``(ii) reasonably expected to improve or maintain the
individual's condition and functional level; and
``(iii) furnished under such guidelines relating to the
frequency and duration of such items and services as the
Secretary shall establish, taking into account accepted norms
of medical practice and the reasonable expectation of
improvement of the individual.
``(4)(A) The term `intensive cardiac rehabilitation program' means
a physician-supervised program (as described in paragraph (2)) that
furnishes the items and services described in paragraph (3) and has
shown, in peer-reviewed published research, that it accomplished--
``(i) one or more of the following:
``(I) positively affected the progression of coronary heart
disease; or
``(II) reduced the need for coronary bypass surgery; or
``(III) reduced the need for percutaneous coronary
interventions; and
``(ii) a statistically significant reduction in 5 or more of
the following measures from their level before receipt of cardiac
rehabilitation services to their level after receipt of such
services:
``(I) low density lipoprotein;
``(II) triglycerides;
``(III) body mass index;
``(IV) systolic blood pressure;
``(V) diastolic blood pressure; or
``(VI) the need for cholesterol, blood pressure, and
diabetes medications.
``(B) To be eligible for an intensive cardiac rehabilitation
program, an individual must have--
``(i) had an acute myocardial infarction within the preceding
12 months;
``(ii) had coronary bypass surgery;
``(iii) stable angina pectoris;
``(iv) had heart valve repair or replacement;
``(v) had percutaneous transluminal coronary angioplasty (PTCA)
or coronary stenting; or
``(vi) had a heart or heart-lung transplant.
``(C) An intensive cardiac rehabilitation program may be provided
in a series of 72 one-hour sessions (as defined in section 1848(b)(5)),
up to 6 sessions per day, over a period of up to 18 weeks.
``(5) The Secretary shall establish standards to ensure that a
physician with expertise in the management of individuals with cardiac
pathophysiology who is licensed to practice medicine in the State in
which a cardiac rehabilitation program (or the intensive cardiac
rehabilitation program, as the case may be) is offered--
``(A) is responsible for such program; and
``(B) in consultation with appropriate staff, is involved
substantially in directing the progress of individual in the
program.
``Pulmonary Rehabilitation Program
``(fff)(1) The term `pulmonary rehabilitation program' means a
physician-supervised program (as described in subsection (eee)(2) with
respect to a program under this subsection) that furnishes the items
and services described in paragraph (2).
``(2) The items and services described in this paragraph are--
``(A) physician-prescribed exercise;
``(B) education or training (to the extent the education or
training is closely and clearly related to the individual's care
and treatment and is tailored to such individual's needs);
``(C) psychosocial assessment;
``(D) outcomes assessment; and
``(E) such other items and services as the Secretary may
determine, but only if such items and services are--
``(i) reasonable and necessary for the diagnosis or active
treatment of the individual's condition;
``(ii) reasonably expected to improve or maintain the
individual's condition and functional level; and
``(iii) furnished under such guidelines relating to the
frequency and duration of such items and services as the
Secretary shall establish, taking into account accepted norms
of medical practice and the reasonable expectation of
improvement of the individual.
``(3) The Secretary shall establish standards to ensure that a
physician with expertise in the management of individuals with
respiratory pathophysiology who is licensed to practice medicine in the
State in which a pulmonary rehabilitation program is offered--
``(A) is responsible for such program; and
``(B) in consultation with appropriate staff, is involved
substantially in directing the progress of individual in the
program.''.
(2) Payment for intensive cardiac rehabilitation programs.--
(A) Inclusion in physician fee schedule.--Section
1848(j)(3) of the Social Security Act (42 U.S.C. 1395w-4(j)(3))
is amended by inserting ``(2)(DD),'' after ``(2)(AA),''.
(B) Conforming amendment.--Section 1848(b) of the Social
Security Act (42 U.S.C. 1395w-4(b)) is amended by adding at the
end the following new paragraph:
``(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).''.
(3) Effective date.--The amendments made by this subsection
shall apply to items and services furnished on or after January 1,
2010.
(b) Repeal of Transfer of Ownership of Oxygen Equipment.--
(1) In general.--Section 1834(a)(5)(F) of the Social Security
Act (42 U.S.C. 1395m(a)(5)(F)) is amended--
(A) in the heading, by striking ``OWNERSHIP of equipment''
and inserting ``RENTAL cap''; and
(B) by striking clause (ii) and inserting the following:
``(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.''.
(2) Effective date.--The amendments made by paragraph (1) shall
take effect on January 1, 2009.

c1ba829e6e03f357ebd5808f63a48e2434c1bb542faa9a0376d78f96032cea2b

(a) Repeal of Medicare Competitive Bidding Demonstration Project
for Clinical Laboratory Services.--
(1) In general.--Section 1847 of the Social Security Act (42
U.S.C. 1395w-3) is amended by striking subsection (e).
(2) Conforming amendments.--Section 1833(a)(1)(D) of the Social
Security Act (42 U.S.C. 1395l(a)(1)(D)) is amended--
(A) by inserting ``or'' before ``(ii)''; and
(B) by striking ``or (iii) on the basis'' and all that
follows before the comma at the end.
(3) Effective date.--The amendments made by this subsection
shall take effect on the date of the enactment of this Act.
(b) Clinical Laboratory Test Fee Schedule Update Adjustment.--
Section 1833(h)(2)(A)(i) of the Social Security Act (42 U.S.C.
1395l(h)(2)(A)(ii)) is amended by inserting ``minus, for each of the
years 2009 through 2013, 0.5 percentage points'' after ``city
average)''.

07c5571e6fcc0be5143bbd279b1b056f7fdde79662534cf3fe4f1314a14bbc6e

(a) Extension of Increased Medicare Payments for Ground Ambulance
Services.--Section 1834(l)(13) of the Social Security Act (42 U.S.C.
1395m(l)(13)) is amended--
(1) in subparagraph (A)--
(A) in the matter preceding clause (i), by inserting ``and
for such services furnished on or after July 1, 2008, and
before January 1, 2010'' after ``2007,'';
(B) in clause (i), by inserting ``(or 3 percent if such
service is furnished on or after July 1, 2008, and before
January 1, 2010)'' after ``2 percent''; and
(C) in clause (ii), by inserting ``(or 2 percent if such
service is furnished on or after July 1, 2008, and before
January 1, 2010)'' after ``1 percent''; and
(2) in subparagraph (B)--
(A) in the heading, by striking ``2006'' and inserting
``applicable period''; and
(B) by inserting ``applicable'' before ``period''.
(b) Air Ambulance Payment Improvements.--
(1) Treatment of certain areas for payment for air ambulance
services under the ambulance fee schedule.--Notwithstanding any
other provision of law, for purposes of making payments under
section 1834(l) of the Social Security Act (42 U.S.C. 1395m(l)) for
air ambulance services furnished during the period beginning on
July 1, 2008, and ending on December 31, 2009, any area that was
designated as a rural area for purposes of making payments under
such section for air ambulance services furnished on December 31,
2006, shall be treated as a rural area for purposes of making
payments under such section for air ambulance services furnished
during such period.
(2) Clarification regarding satisfaction of requirement of
medically necessary.--
(A) In general.--Section 1834(l)(14)(B)(i) of the Social
Security Act (42 U.S.C. 1395m(l)(14)(B)(i)) is amended by
striking ``reasonably determines or certifies'' and inserting
``certifies or reasonably determines''.
(B) Effective date.--The amendment made by subparagraph (A)
shall apply to services furnished on or after the date of the
enactment of this Act.

3be411ef8ebfc4f707d41d20c606cc6f39aeadcd47ce4edc29df13a40e10a568

PROVISION UNDER THE PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL
OUTPATIENT DEPARTMENT (HOPD) SERVICES FOR CERTAIN HOSPITALS.
Section 1833(t)(7)(D)(i) of the Social Security Act (42 U.S.C.
1395l(t)(7)(D)(i)) is amended--
(1) in subclause (II)--
(A) in the first sentence, by striking ``2009'' and
inserting ``2010''; and
(B) by striking the second sentence and inserting the
following new sentence: ``For purposes of the preceding
sentence, the applicable percentage shall be 95 percent with
respect to covered OPD services furnished in 2006, 90 percent
with respect to such services furnished in 2007, and 85 percent
with respect to such services furnished in 2008 or 2009.''; and
(2) by adding at the end the following new subclause:
``(III) In the case of a sole community hospital (as
defined in section 1886(d)(5)(D)(iii)) that has not more
than 100 beds, for covered OPD services furnished on or
after January 1, 2009, and before January 1, 2010, for
which the PPS amount is less than the pre-BBA amount, the
amount of payment under this subsection shall be increased
by 85 percent of the amount of such difference.''.

f9861313c23cbd09310c3f177ceb6df1837838127811d9fc336d06976704d7b0

FURNISHED BY CRITICAL ACCESS HOSPITALS.
(a) In General.--Section 1834(g)(4) of the Social Security Act (42
U.S.C. 1395m(g)(4)) is amended--
(1) in the heading, by striking ``no beneficiary cost-sharing
for'' and inserting ``treatment of''; and
(2) by adding at the end the following new sentence: ``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.''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to services furnished on or after July 1, 2009.

9a9b841f3ffa5829466cbe0d24678a536afe7a14a4e94e1719bfc1b029e431ad

OF TELEHEALTH SERVICES.
(a) In General.--Section 1834(m)(4)(C)(ii) of the Social Security
Act (42 U.S.C. 1395m(m)(4)(C)(ii)) is amended by adding at the end the
following new subclauses:
``(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)).''.
(b) Conforming Amendment.--Section 1888(e)(2)(A)(ii) of the Social
Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting
``telehealth services furnished under section 1834(m)(4)(C)(ii)(VII),''
after ``section 1861(s)(2),''.
(c) Effective Date.--The amendments made by this section shall
apply to services furnished on or after January 1, 2009.

cb0478ba0775ffdcb9f1330bfa3bba7045b7ed585dc9356a7465e56b57cbca4b

DEMONSTRATION PROGRAMS.
(a) Study.--The Medicare Payment Advisory Commission (in this
section referred to as the ``Commission'') shall conduct a study on the
feasability and advisability of establishing a Medicare Chronic Care
Practice Research Network that would serve as a standing network of
providers testing new models of care coordination and other care
approaches for chronically ill beneficiaries, including the initiation,
operation, evaluation, and, if appropriate, expansion of such models to
the broader Medicare patient population. In conducting such study, the
Commission shall take into account the structure, implementation, and
results of prior and existing care coordination and disease management
demonstrations and pilots, including the Medicare Coordinated Care
Demonstration Project under section 4016 of the Balanced Budget Act of
1997 (42 U.S.C. 1395b-1 note) and the chronic care improvement programs
under section 1807 of the Social Security Act (42 U.S.C. 1395b-8),
commonly known to as ``Medicare Health Support''.
(b) Report.--Not later than June 15, 2009, the Commission shall
submit to Congress a report containing the results of the study
conducted under subsection (a).

c6e52952f6d6219a6893bfee27762cb9c6d6dab0ad9a3aa2e64be1248adc2876

(a) In General.--Section 1833 of the Social Security Act (42 U.S.C.
1395l) is amended by adding at the end the following new subsection:
``(v) Increase of FQHC Payment Limits.--In the case of services
furnished by Federally qualified health centers (as defined in section
1861(aa)(4)), the Secretary shall establish payment limits with respect
to such services under this part for services furnished--
``(1) in 2010, at the limits otherwise established under this
part for such year increased by $5; and
``(2) in a subsequent year, at the limits established under
this subsection for the previous year increased by the percentage
increase in the MEI (as defined in section 1842(i)(3)) for such
subsequent year.''.
(b) Study and Report on the Effects and Adequacy of the Medicare
Federally Qualified Health Center Payment Structure.--
(1) Study.--The Comptroller General of the United States shall
conduct a study to determine whether the structure for payments for
services furnished by Federally qualified health centers (as
defined in section 1861(aa)(4) of the Social Security Act (42
U.S.C. 1395x(aa)(4)) under part B of title XVIII of the Social
Security Act (42 U.S.C. 1395j et seq.) adequately reimburses
Federally qualified health centers for the care furnished to
Medicare beneficiaries. In conducting such study, the Comptroller
General shall--
(A) use the most current cost report data available;
(B) examine the effects of the payment limits established
with respect to such services under such part B on the ability
of Federally qualified health centers to furnish care to
Medicare beneficiaries; and
(C) examine the cost of furnishing services covered under
the Medicare program as of the date of the enactment of this
Act that were not covered under such program as of the date on
which the Secretary determined the payment rate for Federally
qualified health centers in 1991.
(2) Report.--Not later than 15 months after the date of the
enactment of this Act, the Comptroller General of the United States
shall submit to Congress a report on the study conducted under
paragraph (1), together with recommendations for such legislation
and administrative action the Comptroller General determines
appropriate, taking into consideration the structure and adequacy
of the prospective payment methodology used to make payments to
Federally qualified health centers under the Medicaid program under
title XIX of the Social Security Act (42 U.S.C. 1396 et seq.).

229c081ef0a784a8ce4276613c4de1c91f636e419ab8cae0e234bbed189475a1

(a) Chronic Kidney Disease Initiatives.--Part P of title III of the
Public Health Service Act (42 U.S.C. 280g et seq.) is amended by adding
at the end the following new section:
``SEC. 399R. CHRONIC KIDNEY DISEASE INITIATIVES.
``(a) In General.--The Secretary shall establish pilot projects
to--
``(1) increase public and medical community awareness
(particularly of those who treat patients with diabetes and
hypertension) regarding chronic kidney disease, focusing on
prevention;
``(2) increase screening for chronic kidney disease, focusing
on Medicare beneficiaries at risk of chronic kidney disease; and
``(3) enhance surveillance systems to better assess the
prevalence and incidence of chronic kidney disease.
``(b) Scope and Duration.--
``(1) Scope.--The Secretary shall select at least 3 States in
which to conduct pilot projects under this section.
``(2) Duration.--The pilot projects under this section shall be
conducted for a period that is not longer than 5 years and shall
begin on January 1, 2009.
``(c) Evaluation and Report.--The Comptroller General of the United
States shall conduct an evaluation of the pilot projects conducted
under this section. Not later than 12 months after the date on which
the pilot projects are completed, the Comptroller General shall submit
to Congress a report on the evaluation.
``(d) Authorization of Appropriations.--There are authorized to be
appropriated such sums as may be necessary for the purpose of carrying
out this section.''.
(b) Medicare Coverage of Kidney Disease Patient Education
Services.--
(1) Coverage of kidney disease education services.--
(A) Coverage.--Section 1861(s)(2) of the Social Security
Act (42 U.S.C. 1395x(s)(2)), as amended by section 144(a), is
amended--
(i) in subparagraph (CC), by striking ``and'' after the
semicolon at the end;
(ii) in subparagraph (DD), by adding ``and'' after the
semicolon at the end; and
(iii) by adding at the end the following new
subparagraph:
``(EE) kidney disease education services (as defined in
subsection (ggg));''.
(B) Services described.--Section 1861 of the Social
Security Act (42 U.S.C. 1395x), as amended by section 144(a),
is amended by adding at the end the following new subsection:
``Kidney Disease Education Services
``(ggg)(1) The term `kidney disease education services' means
educational services that are--
``(A) furnished to an individual with stage IV chronic kidney
disease who, according to accepted clinical guidelines identified
by the Secretary, will require dialysis or a kidney transplant;
``(B) furnished, upon the referral of the physician managing
the individual's kidney condition, by a qualified person (as
defined in paragraph (2)); and
``(C) designed--
``(i) to provide comprehensive information (consistent with
the standards set under paragraph (3)) regarding--
``(I) the management of comorbidities, including for
purposes of delaying the need for dialysis;
``(II) the prevention of uremic complications; and
``(III) each option for renal replacement therapy
(including hemodialysis and peritoneal dialysis at home and
in-center as well as vascular access options and
transplantation);
``(ii) to ensure that the individual has the opportunity to
actively participate in the choice of therapy; and
``(iii) to be tailored to meet the needs of the individual
involved.
``(2)(A) The term `qualified person' means--
``(i) a physician (as defined in section 1861(r)(1)) or a
physician assistant, nurse practitioner, or clinical nurse
specialist (as defined in section 1861(aa)(5)), who furnishes
services for which payment may be made under the fee schedule
established under section 1848; and
``(ii) a provider of services located in a rural area (as
defined in section 1886(d)(2)(D)).
``(B) Such term does not include a provider of services (other than
a provider of services described in subparagraph (A)(ii)) or a renal
dialysis facility.
``(3) The Secretary shall set standards for the content of such
information to be provided under paragraph (1)(C)(i) after consulting
with physicians, other health professionals, health educators,
professional organizations, accrediting organizations, kidney patient
organizations, dialysis facilities, transplant centers, network
organizations described in section 1881(c)(2), and other knowledgeable
persons. To the extent possible the Secretary shall consult with
persons or entities described in the previous sentence, other than a
dialysis facility, that has not received industry funding from a drug
or biological manufacturer or dialysis facility.
``(4) No individual shall be furnished more than 6 sessions of
kidney disease education services under this title.''.
(C) Payment under the physician fee schedule.--Section
1848(j)(3) of the Social Security Act (42 U.S.C. 1395w-
4(j)(3)), as amended by section 144(b), is amended by inserting
``(2)(EE),'' after ``(2)(DD),''.
(D) Limitation on number of sessions.--Section 1862(a)(1)
of the Social Security Act (42 U.S.C. 1395y(a)(1)) is amended--
(i) in subparagraph (M), by striking ``and'' at the
end;
(ii) in subparagraph (N), by striking the semicolon at
the end and inserting ``, and''; and
(iii) by adding at the end the following new
subparagraph:
``(O) in the case of kidney disease education services (as
defined in paragraph (1) of section 1861(ggg)), which are furnished
in excess of the number of sessions covered under paragraph (4) of
such section;''.
(2) Effective date.--The amendments made by this subsection
shall apply to services furnished on or after January 1, 2010.

c3dac2c17033f0e0d10027cc0f419f05ca6c6a4e5a6768c68d5cb3a1cc79cc8d

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37567958483a59368f741a184307ffac91b054927fe3683c1fc33d74eb39f67d

(a) In General.--Section 1853(k) of the Social Security Act (42
U.S.C. 1395w-23(k)) is amended--
(1) in paragraph (1), in the matter preceding subparagraph (A),
by striking ``paragraph (2)'' and inserting ``paragraphs (2) and
(4)''; and
(2) by adding at the end the following new paragraph:
``(4) Phase-out of the indirect costs of medical education from
capitation rates.--
``(A) In general.--After determining the applicable amount
for an area for a year under paragraph (1) (beginning with
2010), the Secretary shall adjust such applicable amount to
exclude from such applicable amount the phase-in percentage (as
defined in subparagraph (B)(i)) for the year of the Secretary's
estimate of the standardized costs for payments under section
1886(d)(5)(B) in the area for the year. Any adjustment under
the preceding sentence shall be made prior to the application
of paragraph (2).
``(B) Percentages defined.--For purposes of this paragraph:
``(i) Phase-in percentage.--The term `phase-in
percentage' means, for an area for a year, the ratio
(expressed as a percentage, but in no case greater than 100
percent) of--
``(I) the maximum cumulative adjustment percentage
for the year (as defined in clause (ii)); to
``(II) the standardized IME cost percentage (as
defined in clause (iii)) for the area and year.
``(ii) Maximum cumulative adjustment percentage.--The
term `maximum cumulative adjustment percentage' means,
for--
``(I) 2010, 0.60 percent; and
``(II) a subsequent year, the maximum cumulative
adjustment percentage for the previous year increased
by 0.60 percentage points.
``(iii) Standardized ime cost percentage.--The term
`standardized IME cost percentage' means, for an area for a
year, the per capita costs for payments under section
1886(d)(5)(B) (expressed as a percentage of the fee-for-
service amount specified in subparagraph (C)) for the area
and the year.
``(C) Fee-for-service amount.--The fee-for-service amount
specified in this subparagraph for an area for a year is the
amount specified under subsection (c)(1)(D) for the area and
the year.''.
(b) Excluding Adjustment From the Update.--Section 1853(k)(1)(B)(i)
of the Social Security Act (42 U.S.C. 1395w-23(k)(1)(B)(i)) is amended
by striking ``paragraph (2)'' and inserting ``paragraphs (2) and (4)''.
(c) Hold Harmless for PACE Program Payments.--Section 1894(d) of
the Social Security Act (42 U.S.C. 1395eee(d)) is amended by adding at
the end the following new paragraph:
``(3) Capitation rates determined without regard to the phase-
out of the indirect costs of medical education from the annual
medicare advantage capitation rate.--Capitation amounts under this
subsection shall be determined without regard to the application of
section 1853(k)(4).''.

b29a357e7a9ee5f175db5a076fb233dd56879835cadee10da6e61656181b1802

FEE-FOR-SERVICE PLANS.
(a) Requirements To Assure Access to Network Coverage.--
(1) Individual market.--Section 1852(d) of the Social Security
Act (42 U.S.C. 1395w-22(d)) is amended--
(A) in paragraph (4), in the second sentence, by striking
``The Secretary'' and inserting ``Subject to paragraph (5), the
Secretary''; and
(B) by adding at the end the following new paragraph:
``(5) Requirement of certain nonemployer medicare advantage
private fee-for-service plans to use contracts with providers.--
``(A) In general.--For plan year 2011 and subsequent plan
years, in the case of a Medicare Advantage private fee-for-
service plan not described in paragraph (1) or (2) of section
1857(i) operating in a network area (as defined in subparagraph
(B)), the plan shall meet the access standards under paragraph
(4) in that area only through entering into written contracts
as provided for under subparagraph (B) of such paragraph and
not, in whole or in part, through the establishment of payment
rates meeting the requirements under subparagraph (A) of such
paragraph.
``(B) Network area defined.--For purposes of subparagraph
(A), the term `network area' means, for a plan year, an area
which the Secretary identifies (in the Secretary's announcement
of the proposed payment rates for the previous plan year under
section 1853(b)(1)(B)) as having at least 2 network-based plans
(as defined in subparagraph (C)) with enrollment under this
part as of the first day of the year in which such announcement
is made.
``(C) Network-based plan defined.--
``(i) In general.--For purposes of subparagraph (B),
the term `network-based plan' means--
``(I) except as provided in clause (ii), a Medicare
Advantage plan that is a coordinated care plan
described in section 1851(a)(2)(A)(i);
``(II) a network-based MSA plan; and
``(III) a reasonable cost reimbursement plan under
section 1876.
``(ii) Exclusion of non-network regional ppos.--The
term `network-based plan' shall not include an MA regional
plan that, with respect to the area, meets access adequacy
standards under this part substantially through the
authority of section 422.112(a)(1)(ii) of title 42, Code of
Federal Regulations, rather than through written
contracts.''.
(2) Employer plans.--Section 1852(d) of the Social Security Act
(42 U.S.C. 1395w-22(d)), as amended by paragraph (1), is amended--
(A) in paragraph (4), in the second sentence, by striking
``paragraph (5)'' and inserting ``paragraphs (5) and (6)''; and
(B) by adding at the end the following new paragraph:
``(6) Requirement of all employer medicare advantage private
fee-for-service plans to use contracts with providers.--For plan
year 2011 and subsequent plan years, in the case of a Medicare
Advantage private fee-for-service plan that is described in
paragraph (1) or (2) of section 1857(i), the plan shall meet the
access standards under paragraph (4) only through entering into
written contracts as provided for under subparagraph (B) of such
paragraph and not, in whole or in part, through the establishment
of payment rates meeting the requirements under subparagraph (A) of
such paragraph.''.
(3) Access requirements.--
(A) In general.--Section 1852(d)(4)(B) of the Social
Security Act (42 U.S.C. 1395w-22(d)(4)(B)) is amended by
striking ``a sufficient number'' through ``terms of the plan''
and inserting ``a sufficient number and range of providers
within such category to meet the access standards in
subparagraphs (A) through (E) of paragraph (1)''.
(B) Effective date.--The amendment made by subparagraph (A)
shall apply to plan year 2010 and subsequent plan years.
(b) Clarification Regarding Utilization.--Section 1859(b)(2) of the
Social Security Act (42 U.S.C. 1395w-28(b)(2)) is amended by adding at
the end the following flush sentence:
``Nothing in subparagraph (B) shall be construed to preclude a plan
from varying rates for such a provider based on the specialty of
the provider, the location of the provider, or other factors
related to such provider that are not related to utilization, or to
preclude a plan from increasing rates for such a provider based on
increased utilization of specified preventive or screening
services.''.

c8d25bef51d7730b8b3fbfa0c3551d7c352962acfc515fb5a6f7e007dd4b8051

(a) Requirement for MA Private Fee-for-Service and MSA Plans To
Have a Quality Improvement Program.--Section 1852(e)(1) of the Social
Security Act (42 U.S.C. 1395w-22(e)(1)) is amended by striking ``(other
than an MA private fee-for-service plan or an MSA plan)''.
(b) Data Collection Requirements for MA Regional Plans, MA Private
Fee-for-Service Plans, and MSA Plans.--Section 1852(e)(3)(A) of the
Social Security Act (42 U.S.C. 1395w-22(e)(3)(A)) is amended--
(1) in clause (i), by adding at the end the following new
sentence: ``With respect to MA private fee-for-service plans and
MSA plans, the requirements under the preceding sentence may not
exceed the requirements under this subparagraph with respect to MA
local plans that are preferred provider organization plans, except
that, for plan year 2010, the limitation under clause (iii) shall
not apply and such requirements shall apply only with respect to
administrative claims data.''
(2) by striking clause (ii); and
(3) in clause (iii)--
(A) in the heading--
(i) by inserting ``local'' after ``to''; and
(ii) by inserting ``and ma regional plans'' after
``organizations''; and
(B) by inserting ``and to MA regional plans'' after
``organization plans''.
(c) Effective Date.--The amendments made by this section shall
apply to plan years beginning on or after January 1, 2010.

4cc417d590326776dd20f3943e57436b98b9269f6f5c0dcaea1653564923273f

PLANS FOR SPECIAL NEEDS INDIVIDUALS.
(a) Extension of Authority To Restrict Enrollment.--Section 1859(f)
of the Social Security Act (42 U.S.C. 1395w-28(f)), as amended by
section 108(a) of the Medicare, Medicaid, and SCHIP Extension Act of
2007 (Public Law 110-173) is amended by striking ``2010'' and inserting
``2011''.
(b) Moratorium on Authority To Designate Other Plans as Specialized
MA Plans.--During the period beginning on January 1, 2010, and ending
on December 31, 2010, the Secretary of Health and Human Services may
not exercise the authority provided under section 231(d) of the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003
(42 U.S.C. 1395w-21 note) to designate other plans as specialized MA
plans for special needs individuals.
(c) Requirements for Enrollment.--
(1) In general.--Section 1859 of the Social Security Act (42
U.S.C. 1395w-28) is amended--
(A) in subsection (b)(6)(A), by inserting ``and that, as of
January 1, 2010, meets the applicable requirements of paragraph
(2), (3), or (4) of subsection (f), as the case may be'' before
the period at the end; and
(B) in subsection (f)--
(i) by amending the heading to read as follows:
``Requirements Regarding Enrollment in Specialized MA Plans
for Special Needs Individuals'';
(ii) by designating the sentence beginning ``In the
case of'' as paragraph (1) with the heading ``Requirements
for enrollment.--'' and with appropriate indentation; and
(iii) by adding at the end the following new
paragraphs:
``(2) Additional requirements for institutional snps.--In the
case of a specialized MA plan for special needs individuals
described in subsection (b)(6)(B)(i), the applicable requirements
described in this paragraph are as follows:
``(A) Each individual that enrolls in the plan on or after
January 1, 2010, is a special needs individuals described in
subsection (b)(6)(B)(i). In the case of an individual who is
living in the community but requires an institutional level of
care, such individual shall not be considered a special needs
individual described in subsection (b)(6)(B)(i) unless the
determination that the individual requires an institutional
level of care was made--
``(i) using a State assessment tool of the State in
which the individual resides; and
``(ii) by an entity other than the organization
offering the plan.
``(B) The plan meets the requirements described in
paragraph (5).
``(3) Additional requirements for dual snps.--In the case of a
specialized MA plan for special needs individuals described in
subsection (b)(6)(B)(ii), the applicable requirements described in
this paragraph are as follows:
``(A) Each individual that enrolls in the plan on or after
January 1, 2010, is a special needs individuals described in
subsection (b)(6)(B)(ii).
``(B) The plan meets the requirements described in
paragraph (5).
``(C) The plan provides each prospective enrollee, prior to
enrollment, with a comprehensive written statement (using
standardized content and format established by the Secretary)
that describes--
``(i) the benefits and cost-sharing protections that
the individual is entitled to under the State Medicaid
program under title XIX; and
``(ii) which of such benefits and cost-sharing
protections are covered under the plan.
Such statement shall be included with any description of
benefits offered by the plan.
``(D) The plan has a contract with the State Medicaid
agency to provide benefits, or arrange for benefits to be
provided, for which such individual is entitled to receive as
medical assistance under title XIX. Such benefits may include
long-term care services consistent with State policy.
``(4) Additional requirements for severe or disabling chronic
condition snps.--In the case of a specialized MA plan for special
needs individuals described in subsection (b)(6)(B)(iii), the
applicable requirements described in this paragraph are as follows:
``(A) Each individual that enrolls in the plan on or after
January 1, 2010, is a special needs individual described in
subsection (b)(6)(B)(iii).
``(B) The plan meets the requirements described in
paragraph (5).''.
(2) Authority to operate but no service area expansion for dual
snps that do not meet certain requirements.--Notwithstanding
subsection (f) of section 1859 of the Social Security Act (42
U.S.C. 1395w-28), during the period beginning on January 1, 2010,
and ending on December 31, 2010, in the case of a specialized
Medicare Advantage plan for special needs individuals described in
subsection (b)(6)(B)(ii) of such section, as amended by this
section, that does not meet the requirement described in subsection
(f)(3)(D) of such section, the Secretary of Health and Human
Services--
(A) shall permit such plan to be offered under part C of
title XVIII of such Act; and
(B) shall not permit an expansion of the service area of
the plan under such part C.
(3) Resources for state medicaid agencies.--The Secretary of
Health and Human Services shall provide for the designation of
appropriate staff and resources that can address State inquiries
with respect to the coordination of State and Federal policies for
specialized MA plans for special needs individuals described in
section 1859(b)(6)(B)(ii) of the Social Security Act (42 U.S.C.
1395w-28(b)(6)(B)(ii)), as amended by this section.
(4) No requirement for contract.--Nothing in the provisions of,
or amendments made by, this subsection shall require a State to
enter into a contract with a Medicare Advantage organization with
respect to a specialized MA plan for special needs individuals
described in section 1859(b)(6)(B)(ii) of the Social Security Act
(42 U.S.C. 1395w-28(b)(6)(B)(ii)), as amended by this section.
(d) Care Management Requirements for All SNPs.--
(1) Requirements.--Section 1859(f) of the Social Security Act
(42 U.S.C. 1395w-28(f)), as amended by subsection (c)(1), is
amended by adding at the end the following new paragraph:
``(5) Care management requirements for all snps.--The
requirements described in this paragraph are that the organization
offering a specialized MA plan for special needs individuals
described in subsection (b)(6)(B)(i)--
``(A) have in place an evidenced-based model of care with
appropriate networks of providers and specialists; and
``(B) with respect to each individual enrolled in the
plan--
``(i) conduct an initial assessment and an annual
reassessment of the individual's physical, psychosocial,
and functional needs;
``(ii) develop a plan, in consultation with the
individual as feasible, that identifies goals and
objectives, including measurable outcomes as well as
specific services and benefits to be provided; and
``(iii) use an interdisciplinary team in the management
of care.''.
(2) Review to ensure compliance with care management
requirements.--Section 1857(d) of the Social Security Act (42
U.S.C. 1395w-27(d)) is amended by adding at the end the following
new paragraph:
``(6) Review to ensure compliance with care management
requirements for specialized medicare advantage plans for special
needs individuals.--In conjunction with the periodic audit of a
specialized Medicare Advantage plan for special needs individuals
under paragraph (1), the Secretary shall conduct a review to ensure
that such organization offering the plan meets the requirements
described in section 1859(f)(5).''.
(e) Clarification of the Definition of a Severe or Disabling
Chronic Conditions Specialized Needs Individual.--
(1) In general.--Section 1859(b)(6)(B)(iii) of the Social
Security Act (42 U.S.C. 1395w-28(b)(6)(B)(iii)) is amended by
inserting ``who have one or more comorbid and medically complex
chronic conditions that are substantially disabling or life
threatening, have a high risk of hospitalization or other
significant adverse health outcomes, and require specialized
delivery systems across domains of care'' before the period at the
end.
(2) Panel.--The Secretary of Health and Human Services shall
convene a panel of clinical advisors to determine the conditions
that meet the definition of severe and disabling chronic conditions
under section 1859(b)(6)(B)(iii) of the Social Security Act (42
U.S.C. 1395w-28(b)(6)(B)(iii)), as amended by paragraph (1). The
panel shall include the Director of the Agency for Healthcare
Research and Quality (or the Director's designee).
(f) Special Requirements Regarding Quality Reporting for
Specialized MA Plans for Special Needs Individuals.--
(1) In general.--Section 1852(e)(3)(A) of the Social Security
Act (42 U.S.C. 1395w-22(e)(3)(A)), as amended by section 163, is
amended by inserting after clause (i) the following new clause:
``(ii) Special requirements for specialized ma plans
for special needs individuals.--In addition to the data
required to be collected, analyzed, and reported under
clause (i) and notwithstanding the limitations under
subparagraph (B), as part of the quality improvement
program under paragraph (1), each MA organization offering
a specialized Medicare Advantage plan for special needs
individuals shall provide for the collection, analysis, and
reporting of data that permits the measurement of health
outcomes and other indices of quality with respect to the
requirements described in paragraphs (2) through (5) of
subsection (f). Such data may be based on claims data and
shall be at the plan level.''.
(2) Effective date.--The amendment made by paragraph (1) shall
take effect on a date specified by the Secretary of Health and
Human Services (but in no case later than January 1, 2010), and
shall apply to all specialized Medicare Advantage plans for special
needs individuals regardless of when the plan first entered the
Medicare Advantage program under part C of title XVIII of the
Social Security Act.
(g) Effective Date and Application.--The amendments made by
subsections (c)(1), (d), and (e)(1) shall apply to plan years beginning
on or after January 1, 2010, and shall apply to all specialized
Medicare Advantage plans for special needs individuals regardless of
when the plan first entered the Medicare Advantage program under part C
of title XVIII of the Social Security Act.
(h) No Affect on Medicaid Benefits for Duals.--Nothing in the
provisions of, or amendments made by, this section shall affect the
benefits available under the Medicaid program under title XIX of the
Social Security Act for special needs individuals described in section
1859(b)(6)(B)(ii) of such Act (42 U.S.C. 1395w-28(b)(6)(B)(ii)).

161f919319ff603fb598cca70891b9d35501a89ec23354ee7b84a1404cb20a54

QUALIFIED MEDICARE BENEFICIARIES ENROLLED IN A SPECIALIZED
MEDICARE ADVANTAGE PLAN FOR SPECIAL NEEDS INDIVIDUALS.
(a) In General.--Section 1852(a) of the Social Security Act (42
U.S.C. 1395w-22(a)) is amended by adding at the end the following new
paragraph:
``(7) Limitation on cost-sharing for dual eligibles and
qualified medicare beneficiaries.--In the case of an individual who
is a full-benefit dual eligible individual (as defined in section
1935(c)(6)) or a qualified medicare beneficiary (as defined in
section 1905(p)(1)) and who is enrolled in a specialized Medicare
Advantage plan for special needs individuals described in section
1859(b)(6)(B)(ii), the plan may not impose cost-sharing that
exceeds the amount of cost-sharing that would be permitted with
respect to the individual under title XIX if the individual were
not enrolled in such plan.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to plan years beginning on or after January 1, 2010.

fcbf47f0ca5a35d912a2dbea04a1f208b13d84c4dc7ccf7c57078e169259c588

Section 1858(e)(2)(A)(i) of the Social Security Act (42 U.S.C.
1395w-27a(e)(2)(A)(i)), as amended by section 110 of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173), is
amended--
(1) by striking ``2013'' and inserting ``2014''; and
(2) by striking ``$1,790,000,000'' and inserting ``$1''.

c2149b604142ff81f642a17fad9cd4cae46157a697cb194d7beccf85090c2b91

(a) Extension of Reasonable Cost Contracts.--Section
1876(h)(5)(C)(ii) of the Social Security Act (42 U.S.C.
1395mm(h)(5)(C)(ii)), as amended by section 109 of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173), is
amended by striking ``January 1, 2009'' and inserting ``January 1,
2010'' in the matter preceding subclause (I).
(b) Requirement for at Least Two Medicare Advantage Organizations
To Be Offering a Plan in an Area for the Prohibition To Be
Applicable.--Subclauses (I) and (II) of section 1876(h)(5)(C)(ii) of
the Social Security Act (42 U.S.C. 1395mm(h)(5)(C)(ii)) are each
amended by inserting ``, provided that all such plans are not offered
by the same Medicare Advantage organization'' after ``clause (iii)''.
(c) Revision of Requirements for a Plan That Are Used To Determine
if Prohibition Is Applicable.--
(1) In general.--Section 1876(h)(5)(C)(iii)(I) of the Social
Security Act (42 U.S.C. 1395mm(h)(5)(C)(iii)(I)) is amended by
inserting ``that are not in another Metropolitan Statistical Area
with a population of more than 250,000'' after ``such Metropolitan
Statistical Area''.
(2) Clarification.--Section 1876(h)(5)(C)(iii)(I) of the Social
Security Act (42 U.S.C. 1395mm(h)(5)(C)(iii)(I)) is amended by
adding at the end the following new sentence: ``If the service area
includes a portion in more than 1 Metropolitan Statistical Area
with a population of more than 250,000, the minimum enrollment
determination under the preceding sentence shall be made with
respect to each such Metropolitan Statistical Area (and such
applicable contiguous counties to such Metropolitan Statistical
Area).''.
(d) GAO Study and Report.--
(1) Study.--The Comptroller General of the United States shall
conduct a study of the reasons (if any) why reasonable cost
contracts under section 1876(h) of the Social Security Act (42
U.S.C. 1395mm(h)) are unable to become Medicare Advantage plans
under part C of title XVIII of such Act.
(2) Report.--Not later than December 31, 2009, the Comptroller
General of the United States shall submit to Congress a report
containing the results of the study conducted under paragraph (1),
together with recommendations for such legislation and
administrative action as the Comptroller General determines
appropriate.

ea8f1e4335d6a3c23d831d08d06f027060ea95e159c3b2c20876c4da66242024

(a) Study.--The Medicare Payment Advisory Commission shall conduct
a study on how comparable measures of performance and patient
experience can be collected and reported by 2011 for the Medicare
Advantage program under part C of title XVIII of the Social Security
Act and the original Medicare fee-for-service program under parts A and
B of such title. Such study shall address technical issues, such as
data requirements, in addition to issues relating to appropriate
quality benchmarks that--
(1) compare the quality of care Medicare beneficiaries receive
across Medicare Advantage plans; and
(2) compare the quality of care Medicare beneficiaries receive
under Medicare Advantage plans and under the original Medicare fee-
for-service program.
(b) Report.--Not later than March 31, 2010, the Medicare Payment
Advisory Commission 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
Medicare Payment Advisory Commission determines appropriate.

31c1d0a357b026ec1e224b6858d8a96be22d3d782043f001ed7e7905fa1419e1

(a) Study.--The Medicare Payment Advisory Commission (in this
section referred to as the ``Commission'') shall conduct a study of the
following:
(1) The correlation between--
(A) the costs that Medicare Advantage organizations with
respect to Medicare Advantage plans incur in providing coverage
under the plan for items and services covered under the
original Medicare fee-for-service program under parts A and B
of title XVIII of the Social Security Act, as reflected in plan
bids; and
(B) county-level spending under such original Medicare fee-
for-service program on a per capita basis, as calculated by the
Chief Actuary of the Centers for Medicare & Medicaid Services.
The study with respect to the issue described in the preceding
sentence shall include differences in correlation statistics by
plan type and geographic area.
(2) Based on these results of the study with respect to the
issue described in paragraph (1), and other data the Commission
determines appropriate--
(A) alternate approaches to payment with respect to a
Medicare beneficiary enrolled in a Medicare Advantage plan
other than through county-level payment area equivalents.
(B) the accuracy and completeness of county-level estimates
of per capita spending under such original Medicare fee-for-
service program (including counties in Puerto Rico), as used to
determine the annual Medicare Advantage capitation rate under
section 1853 of the Social Security Act (42 U.S.C. 1395w-23),
and whether such estimates include--
(i) expenditures with respect to Medicare beneficiaries
at facilities of the Department of Veterans Affairs; and
(ii) all appropriate administrative expenses, including
claims processing.
(3) Ways to improve the accuracy and completeness of county-
level estimates of per capita spending described in paragraph
(2)(B).
(b) Report.--Not later than March 31, 2010, the Commission 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 Commission determines
appropriate.
Subtitle E--Provisions Relating to Part D
PART I--IMPROVING PHARMACY ACCESS

c1da1564fc4851aa75a25c9d39156800cfe6d01e338481899174275ba763d37b

UNDER PART D.
(a) Prompt Payment by Prescription Drug Plans.--Section 1860D-12(b)
of the Social Security Act (42 U.S.C. 1395w-112(b)) is amended by
adding at the end the following new paragraph:
``(4) Prompt payment of clean claims.--
``(A) Prompt payment.--
``(i) In general.--Each contract entered into with a
PDP sponsor under this part with respect to a prescription
drug plan offered by such sponsor shall provide that
payment shall be issued, mailed, or otherwise transmitted
with respect to all clean claims submitted by pharmacies
(other than pharmacies that dispense drugs by mail order
only or are located in, or contract with, a long-term care
facility) under this part within the applicable number of
calendar days after the date on which the claim is
received.
``(ii) Clean claim defined.--In this paragraph, the
term `clean claim' means a claim that has no defect or
impropriety (including any lack of any required
substantiating documentation) or particular circumstance
requiring special treatment that prevents timely payment
from being made on the claim under this part.
``(iii) Date of receipt of claim.--In this paragraph, a
claim is considered to have been received--
``(I) with respect to claims submitted
electronically, on the date on which the claim is
transferred; and
``(II) with respect to claims submitted otherwise,
on the 5th day after the postmark date of the claim or
the date specified in the time stamp of the
transmission.
``(B) Applicable number of calendar days defined.--In this
paragraph, the term `applicable number of calendar days'
means--
``(i) with respect to claims submitted electronically,
14 days; and
``(ii) with respect to claims submitted otherwise, 30
days.
``(C) Interest payment.--
``(i) In general.--Subject to clause (ii), if payment
is not issued, mailed, or otherwise transmitted within the
applicable number of calendar days (as defined in
subparagraph (B)) after a clean claim is received, the PDP
sponsor shall pay interest to the pharmacy that submitted
the claim at a rate equal to the weighted average of
interest on 3-month marketable Treasury securities
determined for such period, increased by 0.1 percentage
point for the period beginning on the day after the
required payment date and ending on the date on which
payment is made (as determined under subparagraph (D)(iv)).
Interest amounts paid under this subparagraph shall not be
counted against the administrative costs of a prescription
drug plan or treated as allowable risk corridor costs under
section 1860D-15(e).
``(ii) Authority not to charge interest.--The Secretary
may provide that a PDP sponsor is not charged interest
under clause (i) in the case where there are exigent
circumstances, including natural disasters and other unique
and unexpected events, that prevent the timely processing
of claims.
``(D) Procedures involving claims.--
``(i) Claim deemed to be clean.--A claim is deemed to
be a clean claim if the PDP sponsor involved does not
provide notice to the claimant of any deficiency in the
claim--
``(I) with respect to claims submitted
electronically, within 10 days after the date on which
the claim is received; and
``(II) with respect to claims submitted otherwise,
within 15 days after the date on which the claim is
received.
``(ii) Claim determined to not be a clean claim.--
``(I) In general.--If a PDP sponsor determines that
a submitted claim is not a clean claim, the PDP sponsor
shall, not later than the end of the period described
in clause (i), notify the claimant of such
determination. Such notification shall specify all
defects or improprieties in the claim and shall list
all additional information or documents necessary for
the proper processing and payment of the claim.
``(II) Determination after submission of additional
information.--A claim is deemed to be a clean claim
under this paragraph if the PDP sponsor involved does
not provide notice to the claimant of any defect or
impropriety in the claim within 10 days of the date on
which additional information is received under
subclause (I).
``(iii) Obligation to pay.--A claim submitted to a PDP
sponsor that is not paid or contested by the sponsor within
the applicable number of days (as defined in subparagraph
(B)) after the date on which the claim is received shall be
deemed to be a clean claim and shall be paid by the PDP
sponsor in accordance with subparagraph (A).
``(iv) Date of payment of claim.--Payment of a clean
claim under such subparagraph is considered to have been
made on the date on which--
``(I) with respect to claims paid electronically,
the payment is transferred; and
``(II) with respect to claims paid otherwise, the
payment is submitted to the United States Postal
Service or common carrier for delivery.
``(E) Electronic transfer of funds.--A PDP sponsor shall
pay all clean claims submitted electronically by electronic
transfer of funds if the pharmacy so requests or has so
requested previously. In the case where such payment is made
electronically, remittance may be made by the PDP sponsor
electronically as well.
``(F) Protecting the rights of claimants.--
``(i) In general.--Nothing in this paragraph shall be
construed to prohibit or limit a claim or action not
covered by the subject matter of this section that any
individual or organization has against a provider or a PDP
sponsor.
``(ii) Anti-retaliation.--Consistent with applicable
Federal or State law, a PDP sponsor shall not retaliate
against an individual or provider for exercising a right of
action under this subparagraph.
``(G) Rule of construction.--A determination under this
paragraph that a claim submitted by a pharmacy is a clean claim
shall not be construed as a positive determination regarding
eligibility for payment under this title, nor is it an
indication of government approval of, or acquiescence
regarding, the claim submitted. The determination shall not
relieve any party of civil or criminal liability with respect
to the claim, nor does it offer a defense to any
administrative, civil, or criminal action with respect to the
claim.''.
(b) Prompt Payment by MA-PD Plans.--Section 1857(f) of the Social
Security Act (42 U.S.C. 1395w-27) is amended by adding at the end the
following new paragraph:
``(3) Incorporation of certain prescription drug plan contract
requirements.--The following provisions shall apply to contracts
with a Medicare Advantage organization offering an MA-PD plan in
the same manner as they apply to contracts with a PDP sponsor
offering a prescription drug plan under part D:
``(A) Prompt payment.--Section 1860D-12(b)(4).''.
(c) Effective Date.--The amendments made by this section shall
apply to plan years beginning on or after January 1, 2010.

c5db54f19be0e07fc8b655bb2f3e55cb1a83b93f60aa1e46855f35f75e23bc94

CONTRACTING WITH LONG-TERM CARE FACILITIES.
(a) Submission of Claims by Pharmacies Located in or Contracting
With Long-Term Care Facilities.--
(1) Submission of claims to prescription drug plans.--Section
1860D-12(b) of the Social Security Act (42 U.S.C. 1395w-112(b)), as
amended by section 171(a), is amended by adding at the end the
following new paragraph:
``(5) Submission of claims by pharmacies located in or
contracting with long-term care facilities.--Each contract entered
into with a PDP sponsor under this part with respect to a
prescription drug plan offered by such sponsor shall provide that a
pharmacy located in, or having a contract with, a long-term care
facility shall have not less than 30 days (but not more than 90
days) to submit claims to the sponsor for reimbursement under the
plan.''.
(2) Submission of claims to ma-pd plans.--Section 1857(f)(3) of
the Social Security Act, as added by section 171(b), is amended by
adding at the end the following new subparagraph:
``(B) Submission of claims by pharmacies located in or
contracting with long-term care facilities.--Section 1860D-
12(b)(5).''.
(b) Effective Date.--The amendments made by this section shall
apply to plan years beginning on or after January 1, 2010.

9be4b591ccbb76b809e7299f05cc1077d5b4577cae1072281030ea64a469d283

(a) Requirement for Prescription Drug Plans.--Section 1860D-12(b)
of the Social Security Act (42 U.S.C. 1395w-112(b)), as amended by
section 172(a)(1), is amended by adding at the end the following new
paragraph:
``(6) Regular update of prescription drug pricing standard.--If
the PDP sponsor of a prescription drug plan uses a standard for
reimbursement of pharmacies based on the cost of a drug, each
contract entered into with such sponsor under this part with
respect to the plan shall provide that the sponsor shall update
such standard not less frequently than once every 7 days, beginning
with an initial update on January 1 of each year, to accurately
reflect the market price of acquiring the drug.''.
(b) Requirement for MA-PD Plans.--Section 1857(f)(3) of the Social
Security Act, as amended by section 172(a)(2), is amended by adding at
the end the following new subparagraph:
``(C) Regular update of prescription drug pricing
standard.--Section 1860D-12(b)(6).''.
(c) Effective Date.--The amendments made by this section shall
apply to plan years beginning on or after January 1, 2009.
PART II--OTHER PROVISIONS

6ae72c044ffef5c0fe5631e2b2e6c33f7d49aa5614a87f12fa6a5228cf87b01e

PART D DRUGS.
(a) In General.--Section 1860D-2(e)(2)(A) of the Social Security
Act (42 U.S.C. 1395w-102(e)(2)(A)) is amended by inserting after
``agents),'' the following ``other than subparagraph (I) of such
section (relating to barbiturates) if the barbiturate is used in the
treatment of epilepsy, cancer, or a chronic mental health disorder, and
other than subparagraph (J) of such section (relating to
benzodiazepines),''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to prescriptions dispensed on or after January 1, 2013.

5da13792742a21554e1bb33c3f7012a0a5abd766b008fb236841e0a5591d8c18

OR CLASSES OF DRUGS.
Section 1860D-4(b)(3) of the Social Security Act (42 U.S.C. 1395w-
104(b)(3)) is amended--
(1) in subparagraph (C)(i), by striking ``The formulary'' and
inserting ``Subject to subparagraph (G), the formulary''; and
(2) by inserting after subparagraph (F) the following new
subparagraph:
``(G) Required inclusion of drugs in certain categories and
classes.--
``(i) Identification of drugs in certain categories and
classes.--Beginning with plan year 2010, the Secretary
shall identify, as appropriate, categories and classes of
drugs for which both of the following criteria are met:
``(I) Restricted access to drugs in the category or
class would have major or life threatening clinical
consequences for individuals who have a disease or
disorder treated by the drugs in such category or
class.
``(II) There is significant clinical need for such
individuals to have access to multiple drugs within a
category or class due to unique chemical actions and
pharmacological effects of the drugs within the
category or class, such as drugs used in the treatment
of cancer.
``(ii) Formulary requirements.--Subject to clause
(iii), PDP sponsors offering prescription drug plans shall
be required to include all covered part D drugs in the
categories and classes identified by the Secretary under
clause (i).
``(iii) Exceptions.--The Secretary may establish
exceptions that permits a PDP sponsor of 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
clause (ii) (or to otherwise limit access to such a drug,
including through prior authorization or utilization
management). Any exceptions established under the preceding
sentence shall be provided under a process that--
``(I) ensures that any exception to such
requirement is based upon scientific evidence and
medical standards of practice (and, in the case of
antiretroviral medications, is consistent with the
Department of Health and Human Services Guidelines for
the Use of Antiretroviral Agents in HIV-1-Infected
Adults and Adolescents); and
``(II) includes a public notice and comment
period.''.
Subtitle F--Other Provisions

da1cdbb4e88077a70280d36b22d5df9f88f26f848b02cc6b320af7f79a8c68f4

Section 1860D-12(b)(3)(D) of the Social Security Act (42 U.S.C.
1395w-112(b)(3)(D)) is amended by adding at the end the following
sentence: ``Notwithstanding any other provision of law, information
provided to the Secretary under the application of section 1857(e)(1)
to contracts under this section under the preceding sentence--
``(i) may be used for the purposes of carrying out this
part, improving public health through research on the
utilization, safety, effectiveness, quality, and efficiency
of health care services (as the Secretary determines
appropriate); and
``(ii) shall be made available to Congressional support
agencies (in accordance with their obligations to support
Congress as set out in their authorizing statutes) for the
purposes of conducting Congressional oversight, monitoring,
making recommendations, and analysis of the program under
this title.''.

3e2b4c3810acde29bad48798efc600212eea284ef06a9574423871c7fec68950

FOR DRUGS.
(a) Revision of Definition for Part D Drugs.--
(1) In general.--Section 1860D-2(e)(1) of the Social Security
Act (42 U.S.C. 1395w-102(e)(1)) is amended, in the matter following
subparagraph (B)--
(A) by striking ``(as defined in section 1927(k)(6))'' and
inserting ``(as defined in paragraph (4))''; and
(B) by adding at the end the following new paragraph:
``(4) Medically accepted indication defined.--
``(A) In general.--For purposes of paragraph (1), the term
`medically accepted indication' has the meaning given that
term--
``(i) in the case of a covered part D drug used in an
anticancer chemotherapeutic regimen, in section
1861(t)(2)(B), except that in applying such section--
``(I) `prescription drug plan or MA-PD plan' shall
be substituted for `carrier' each place it appears; and
``(II) subject to subparagraph (B), the compendia
described in section 1927(g)(1)(B)(i)(III) shall be
included in the list of compendia described in clause
(ii)(I) section 1861(t)(2)(B); and
``(ii) in the case of any other covered part D drug, in
section 1927(k)(6).
``(B) Conflict of interest.--On and after January 1, 2010,
subparagraph (A)(i)(II) shall not apply unless the compendia
described in section 1927(g)(1)(B)(i)(III) meets the
requirement in the third sentence of section 1861(t)(2)(B).
``(C) Update.--For purposes of applying subparagraph
(A)(ii), the Secretary shall revise the list of compendia
described in section 1927(g)(1)(B)(i) as is appropriate for
identifying medically accepted indications for drugs. Any such
revision shall be done in a manner consistent with the process
for revising compendia under section 1861(t)(2)(B).''.
(2) Effective date.--The amendments made by this subsection
shall apply to plan years beginning on or after January 1, 2009.
(b) Conflicts of Interest.--Section 1861(t)(2)(B) of the Social
Security Act (42 U.S.C. 1395x(t)(2)(B)) is amended by adding at the end
the following new sentence: ``On and after January 1, 2010, no
compendia may be included on the list of compendia under this
subparagraph unless the compendia has a publicly transparent process
for evaluating therapies and for identifying potential conflicts of
interests.''.

d4053d96b950c75f4487856a0f65054b7609fb73a3db38bdd368d8f5fffae845

PERFORMANCE MEASUREMENT.
(a) Contract.--
(1) In general.--Part E of title XVIII of the Social Security
Act (42 U.S.C. 1395x et seq.) is amended by inserting after section
1889 the following new section:
``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) Promotion of the development of electronic health
records.--The entity shall promote the development and use of
electronic health records that contain the functionality for
automated collection, aggregation, and transmission of performance
measurement information.
``(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 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);
and
``(iii) the performance by the entity of the duties
required under the contract entered into with the Secretary
under subsection (a).
``(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.
``(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.--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 2012.''.
(2) Sense of the senate.--It is the Sense of the Senate that
the selection by the Secretary of Health and Human Services of an
entity to contract with under section 1890(a) of the Social
Security Act, as added by paragraph (1), should not be construed as
diminishing the significant contributions of the Boards of
Medicine, the quality alliances, and other clinical and technical
experts to efforts to measure and improve the quality of health
care services.
(b) GAO Study and Reports on the Performance and Costs of the
Consensus-Based Entity Under the Contract.--
(1) In general.--The Comptroller General of the United States
shall conduct a study on--
(A) the performance of the entity with a contract with the
Secretary of Health and Human Services under section 1890(a) of
the Social Security Act, as added by subsection (a), of its
duties under such contract; and
(B) the costs incurred by such entity in performing such
duties.
(2) Reports.--Not later than 18 months and 36 months after the
effective date of the first contract entered into under such
section 1890(a), the Comptroller General of the United States shall
submit to Congress a report containing the results of the study
conducted under paragraph (1), together with recommendations for
such legislation and administrative action as the Comptroller
General determines appropriate.

bacabd5f657173cd639628fc8ad400f8d68fd8642384d1a813dfbb70801477b3

Section 1833 of the Social Security Act (42 U.S.C. 1395l), as
amended by section 151(a), is amended by adding at the end the
following new subsection:
``(w) Methods of Payment.--The Secretary may develop alternative
methods of payment for items and services provided under clinical
trials and comparative effectiveness studies sponsored or supported by
an agency of the Department of Health and Human Services, as determined
by the Secretary, to those that would otherwise apply under this
section, to the extent such alternative methods are necessary to
preserve the scientific validity of such trials or studies, such as in
the case where masking the identity of interventions from patients and
investigators is necessary to comply with the particular trial or study
design.''.

f1ec96259c00b539b755f3be2c548f65f9951e1136f5c1aa641a6dd590c3e664

Medicare Improvements for Patients and Providers Act of 2008 — HR. 6331

Other Sections

TITLE I

TITLE II

TITLE III

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