r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE wiki — defined terms

“qualifying APM participant” applies in that section

the term “qualifying APM participant” means the following: (A) 2019 and 2020 With respect to 2019 and 2020, an eligible professional for whom the Secretary determines that at least 25 percent of payments under this part for covered professional services furnished by such professional during the most recent period for which data are available (which may be less than a year) were attributable to such services furnished under this part through an eligible alternative payment entity.

“reference average wholesale price” applies in that section

The term “reference average wholesale price” means, with respect to a specified covered outpatient drug, the average wholesale price for the drug as determined under section 1395u( o ) of this title as of May 1, 2003 . (H) Inapplicability of expenditures in determining conversion, weighting, and other adjustment factors Additional expenditures resulting from this paragraph shall not be taken into account in establishing the conversion, weighting, and other adjustment factors for 2004 and 2005 under paragraph (9), but shall be taken into account for subsequent years.

“shoes” applies throughout its subchapter

the term “shoes” includes, except for purposes of subparagraphs (A)(ii) and (B) of paragraph (2), inserts for extra-depth shoes. (p) Repealed. Pub. L. 103–432, title I, § 123(b)(2)(A)(ii) , Oct. 31, 1994 , 108 Stat. 4411 (q) Requests for payment to include information on referring physician (1) Each request for payment, or bill submitted, for an item or service furnished by an entity for which payment may be made under this part and for which the entity knows or has reason to believe there has been a referral by a referring physician (within the meaning of section 1395nn of this title ) shall include the name and unique physician identification number for the referring physician.

“sole source drug” applies in that section

The term “sole source drug” means— (I) a biological product (as defined under section 1395x(t)(1) of this title ); or (II) a single source drug (as defined in section 1396r–8(k)(7)(A)(iv) of this title ). (ii) Innovator multiple source drugs

“specified covered outpatient drug” applies in that section

the term “specified covered outpatient drug” means, subject to clause (ii), a covered outpatient drug (as defined in section 1396r–8(k)(2) of this title ) for which a separate ambulatory payment classification group (APC) has been established and that is— (I) a radiopharmaceutical; or (II) a drug or biological for which payment was made under paragraph (6) (relating to pass-through payments) on or before December 31, 2002 .

“specified percent” applies in that section

the term “specified percent” means— (A) for 2022, 80 percent; (B) for 2023 through 2026, 85 percent; and (C) for 2027 through 2029, 90 percent.

“applicable reporting provision” applies in that section

The term “applicable reporting provision” means— (i) for home health agencies, section 1395fff(b)(3)(B)(v) of this title ; (ii) for skilled nursing facilities, section 1395yy(e)(6) of this title ; (iii) for inpatient rehabilitation facilities, section 1395ww(j)(7) of this title ; and (iv) for long-term care hospitals, section 1395ww(m)(5) of this title . (D) PAC payment system

“Medicare beneficiary” applies in that section

The term “Medicare beneficiary” means an individual entitled to benefits under part A or, as appropriate, enrolled for benefits under part B. (b) Standardized patient assessment data (1) Requirement for reporting assessment data (A) In general Beginning not later than October 1, 2018 , for PAC providers described in clauses (ii), (iii), and (iv) of subsection (a)(2)(A) and January 1, 2019 , for PAC providers described in clause (i) of such subsection, the Secretary shall require PAC providers to submit to the Secretary, under the applicable reporting provisions and through the use of PAC assessment instruments, the standardized patient assessment data described in subparagraph (B).

“PAC assessment instrument” applies in that section

The term “PAC assessment instrument” means— (i) in the case of home health agencies, the instrument used for purposes of reporting and assessment with respect to the Outcome and Assessment Information Set (OASIS), as described in sections 484.55 and 484.250 of title 42, the Code of Federal Regulations, or any successor regulation, or any other instrument used with respect to home health agencies for such purposes; (ii) in the case of skilled nursing facilities, the resident’s assessment under section 1395i–3(b)(3) of this title ; (iii) in the case of inpatient rehabilitation facilities, any Medicare beneficiary assessment instrument established by the Secretary for purposes of section …

“PAC payment system” applies in that section

The term “PAC payment system” means— (i) with respect to a home health agency, the prospective payment system under section 1395fff of this title ; (ii) with respect to a skilled nursing facility, the prospective payment system under section 1395yy(e) of this title ; (iii) with respect to an inpatient rehabilitation facility, the prospective payment system under section 1395ww(j) of this title ; and (iv) with respect to a long-term care hospital, the prospective payment system under section 1395ww(m) of this title . (E) Specified application date

“PAC provider” applies in that section

The terms “post-acute care provider” and “PAC provider” mean— (i) a home health agency; (ii) a skilled nursing facility; (iii) an inpatient rehabilitation facility; and (iv) a long-term care hospital (other than a hospital classified under section 1395ww(d)(1)(B)(vi) of this title ). (B) PAC assessment instrument

“post-acute care provider” applies in that section

The terms “post-acute care provider” and “PAC provider” mean— (i) a home health agency; (ii) a skilled nursing facility; (iii) an inpatient rehabilitation facility; and (iv) a long-term care hospital (other than a hospital classified under section 1395ww(d)(1)(B)(vi) of this title ). (B) PAC assessment instrument

“specified application date” applies in that section

The term “specified application date” means the following: (i) Quality measures In the case of quality measures under subsection (c)(1)— (I) with respect to the domain described in subsection (c)(1)(A) (relating to functional status, cognitive function, and changes in function and cognitive function)— (aa) for PAC providers described in clauses (ii) and (iii) of paragraph (2)(A), October 1, 2016 ; (bb) for PAC providers described in clause (iv) of such paragraph, October 1, 2018 ; and (cc) for PAC providers described in clause (i) of such paragraph, January 1, 2019 ; (II) with respect to the domain described in subsection (c)(1)(B) (relating to skin integrity and changes in skin integrity)— …

“adjusted reasonable costs” applies in that section

the term “adjusted reasonable costs” means, with respect to any services, reasonable costs determined for such services, reduced by 10 percent. The 10-percent reduction shall not apply to services described in section 1395 l (a)(8)(B) of this title (relating to services provided by hospitals). (5) Uniform coding For claims for services submitted on or after April 1, 1998 , for which the amount of payment is determined under this subsection, the claim shall include a code (or codes) under a uniform coding system specified by the Secretary that identifies the services furnished.

“advanced diagnostic imaging services” applies in that section

the term “advanced diagnostic imaging services” includes— (i) diagnostic magnetic resonance imaging, computed tomography, and nuclear medicine (including positron emission tomography); and (ii) such other diagnostic imaging services, including services described in section 1395w–4(b)(4)(B) of this title (excluding X-ray, ultrasound, and fluoroscopy), as specified by the Secretary in consultation with physician specialty organizations and other stakeholders. (C) Supplier defined In this subsection,

“applicable computed tomography service” applies in that section

the term “applicable computed tomography service” means a service billed using diagnostic radiological imaging codes for computed tomography (identified as of January 1, 2014 , by HCPCS codes 70450–70498, 71250–71275, 72125–72133, 72191–72194, 73200–73206, 73700–73706, 74150–74178, 74261–74263, and 75571–75574 (and any succeeding codes). 6 (3) Applicable payment system defined In this subsection,

“applicable fee schedule amount” applies in that section

the term “applicable fee schedule amount” means, with respect to services furnished in a year, the amount determined under the fee schedule established under section 1395w–4 of this title for such services furnished during the year or, if there is no such fee schedule established for such services, the amount determined under the fee schedule established for such comparable services as the Secretary specifies. (4) Adjusted reasonable costs In paragraph (2),

“applicable imaging service” applies in that section

the term “applicable imaging service” means an advanced diagnostic imaging service (as defined in subsection (e)(1)(B)) for which the Secretary determines— (i) one or more applicable appropriate use criteria specified under paragraph (2) apply; (ii) there are one or more qualified clinical decision support mechanisms listed under paragraph (3)(C); and (iii) one or more of such mechanisms is available free of charge. (D) Applicable setting defined In this subsection,

“applicable payment system” applies in that section

the term “applicable payment system” means the following: (A) The technical component and the technical component of the global fee under the fee schedule established under section 1395w–4(b) of this title . (B) The prospective payment system for hospital outpatient department services under section 1395 l (t) of this title. (4) Consistency with CT equipment standard In this subsection,

“applicable percentage” applies in that section

the term “applicable percentage” means— (A) for 2016, 5 percent; and (B) for 2017 and subsequent years, 15 percent. (6) Implementation (A) Information The Secretary shall require that information be provided and attested to by a supplier and a hospital outpatient department that indicates whether an applicable computed tomography service was furnished that was not consistent with the CT equipment standard (described in paragraph (4)). Such information may be included on a claim and may be a modifier. Such information shall be verified, as appropriate, as part of the periodic accreditation of suppliers under subsection (e) and hospitals under section 1395bb(a) of this title .

“applicable percentage increase” applies in that section

the term “applicable percentage increase” means— (i) for 1991, 0 percent; (ii) for 1992 and 1993, the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the previous year; (iii) for 1994 and 1995, 0 percent; (iv) for 1996 and 1997, the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the previous year; (v) for each of the years 1998 through 2000, 1 percent; (vi) for 2001, the percentage increase in the consumer price index for all urban consumers (U.S.

“applicable period” applies in that section

the term “applicable period” means, with respect to a provider or supplier of ground ambulance services, a year specified by the Secretary not more than 2 years after the end of the period with respect to which the Secretary has made a determination under clause (i)(II) that the provider or supplier of ground ambulance services failed to sufficiently submit information under the data collection system.

“applicable setting” applies in that section

the term “applicable setting” means a physician’s office, a hospital outpatient department (including an emergency department), an ambulatory surgical center, and any other provider-led outpatient setting determined appropriate by the Secretary. (E) Ordering professional defined In this subsection,

“appropriate use criteria” applies in that section

the term “appropriate use criteria” means criteria, only developed or endorsed by national professional medical specialty societies or other provider-led entities, to assist ordering professionals and furnishing professionals in making the most appropriate treatment decision for a specific clinical condition for an individual. To the extent feasible, such criteria shall be evidence-based. (C) Applicable imaging service defined In this subsection,

“certificate of medical necessity” applies in that section

the term “certificate of medical necessity” means a form or other document containing information required by the carrier to be submitted to show that an item is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. (3) Coverage and review criteria The Secretary shall annually review the coverage and utilization of items of medical equipment and supplies to determine whether such items should be made subject to coverage and utilization review criteria, and if appropriate, shall develop and apply such criteria to such items.

“covered item” applies in that section

the term “covered item” means durable medical equipment (as defined in section 1395x(n) of this title ), including such equipment described in section 1395x(m)(5) of this title , but not including implantable items for which payment may be made under section 1395 l (t) of this title. (14) Covered item update In this subsection,

“covered item update” applies in that section

the term “covered item update” means, with respect to a year— (A) for 1991 and 1992, the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 12-month period ending with June of the previous year reduced by 1 percentage point; (B) for 1993, 1994, 1995, 1996, and 1997, the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 12-month period ending with June of the previous year; (C) for each of the years 1998 through 2000, 0 percentage points; (D) for 2001, the percentage increase in the consumer price index for all urban consumers (U.S.

“distant site” applies in that section

the term “distant site” means the site at which the physician or practitioner is located at the time the service is provided via a telecommunications system. (B) Eligible telehealth individual

“eligible home infusion supplier” applies in that section

the term “eligible home infusion supplier” means a supplier that is enrolled under this part as a pharmacy that provides external infusion pumps and external infusion pump supplies and that maintains all pharmacy licensure requirements in the State in which the applicable infusion drugs are administered. (G) Implementation Notwithstanding any other provision of law, the Secretary may implement this paragraph by program instruction or otherwise.

“eligible telehealth individual” applies in that section

The term “eligible telehealth individual” means an individual enrolled under this part who receives a telehealth service furnished at an originating site. (C) Originating site (i) In general Except as provided in clause (iii) and paragraphs (5), (6), and (7),

“furnishing professional” applies in that section

the term “furnishing professional” means a physician (as defined in section 1395x(r) of this title ) or a practitioner described in section 1395u(b)(18)(C) of this title who furnishes an applicable imaging service. (2) Establishment of applicable appropriate use criteria (A) In general Not later than November 15, 2015 , the Secretary shall through rulemaking, and in consultation with physicians, practitioners, and other stakeholders, specify applicable appropriate use criteria for applicable imaging services only from among appropriate use criteria developed or endorsed by national professional medical specialty societies or other provider-led entities.

“individual with acute kidney injury” applies in that section

the term “individual with acute kidney injury” means an individual who has acute loss of renal function and does not receive renal dialysis services for which payment is made under section 1395rr(b)(14) of this title .

“limiting charge” applies in that section

the term “limiting charge” means, with respect to a service furnished— (i) in 1989, 125 percent of the amount specified for the service in the appropriate fee schedule established under paragraph (1), (ii) in 1990, 120 percent of the amount specified for the service in the appropriate fee schedule established under paragraph (1), and (iii) after 1990, 115 percent of the amount specified for the service in the appropriate fee schedule established under paragraph (1).

“medical equipment and supplies” applies in that section

The term “medical equipment and supplies” means— (A) durable medical equipment (as defined in section 1395x(n) of this title ); (B) prosthetic devices (as described in section 1395x(s)(8) of this title ); (C) orthotics and prosthetics (as described in section 1395x(s)(9) of this title ); (D) surgical dressings (as described in section 1395x(s)(5) of this title ); (E) items and services related to the administration of intravenous immune globulin furnished on or after January 1, 2024 , as described in section 1395x(zz) of this title ; (F) lymphedema compression treatment items (as defined in section 1395x(mmm) of this title ); (G) 5 such other items as the Secretary may determine; and (G) 5 …

“not consistent with the CT equipment standard” applies in that section

the term “not consistent with the CT equipment standard” means, with respect to an applicable computed tomography service, that the service was furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) Standard XR–29–2013, entitled “Standard Attributes on CT Equipment Related to Dose Optimization and Management”. Through rulemaking, the Secretary may apply successor standards. (5) Applicable percentage defined In this subsection,

“ordering professional” applies in that section

the term “ordering professional” means a physician (as defined in section 1395x(r) of this title ) or a practitioner described in section 1395u(b)(18)(C) of this title who orders an applicable imaging service. (F) Furnishing professional defined In this subsection,

“originating site” applies in that section

the term “originating site” means only those sites described in clause (ii) at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system and only if such site is located— (I) in an area that is designated as a rural health professional shortage area under section 254e(a)(1)(A) of this title ; (II) in a county that is not included in a Metropolitan Statistical Area; or (III) from an entity that participates in a Federal telemedicine demonstration project that has been approved by (or receives funding from) the Secretary of Health and Human Services as of December 31, 2000 .

“orthotics and prosthetics” applies in that section

the term “orthotics and prosthetics” has the meaning given such term in section 1395x(s)(9) of this title (and includes shoes described in section 1395x(s)(12) of this title ), but does not include intraocular lenses or medical supplies (including catheters, catheter supplies, ostomy bags, and supplies related to ostomy care) furnished by a home health agency under section 1395x(m)(5) of this title .

“physician” applies in that section

The term “physician” has the meaning given that term in section 1395x(r) of this title . (E) Practitioner

“practitioner” applies in that section

The term “practitioner” has the meaning given that term in section 1395u(b)(18)(C) of this title and, in the case that the emergency period described in section 1320b–5(g)(1)(B) of this title ends before December 31, 2024 , for the period beginning on the first day after the end of such emergency period and ending on December 31, 2027 , shall include a qualified occupational therapist (as such term is used in section 1395x(g) of this title ), a qualified physical therapist (as such term is used in section 1395x(p) of this title ), a qualified speech-language pathologist (as defined in section 1395x( ll )(4)(A) of this title), and a qualified audiologist (as defined in section 1395x( ll …

“prosthetic devices” applies in that section

the term “prosthetic devices” has the meaning given such term in section 1395x(s)(8) of this title , except that such term does not include parenteral and enteral nutrition nutrients, supplies, and equipment and does not include an implantable item for which payment may be made under section 1395 l (t) of this title; and;

“qualified practitioner” applies in that section

the term “qualified practitioner” means a physician or other individual who— (I) is a qualified physical therapist or a qualified occupational therapist; (II) in the case of a State that provides for the licensing of orthotics and prosthetics, is licensed in orthotics or prosthetics by the State in which the item is supplied; or (III) in the case of a State that does not provide for the licensing of orthotics and prosthetics, is specifically trained and educated to provide or manage the provision of prosthetics and custom-designed or -fabricated orthotics, and is certified by the American Board for Certification in Orthotics and Prosthetics, Inc.

“qualified supplier” applies in that section

the term “qualified supplier” means any entity that is accredited by the American Board for Certification in Orthotics and Prosthetics, Inc. or by the Board for Orthotist/Prosthetist Certification, or accredited and approved by a program that the Secretary determines has accreditation and approval standards that are essentially equivalent to those of such Board.

“rural air ambulance service” applies in that section

the term “rural air ambulance service” means fixed wing and rotary wing air ambulance service in which the point of pick up of the individual occurs in a rural area (as defined in section 1395ww(d)(2)(D) of this title ) or in a rural census tract of a metropolitan statistical area (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992 (57 Fed. Reg. 6725)).

“rural area” applies in that section

the term “rural area” has the meaning given such term in section 1395ww(d)(2)(D) of this title . If feasible, the Secretary shall treat a rural census tract of a metropolitan statistical area (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992 (57 Fed. Reg. 6725) as a rural area for purposes of this paragraph. (v) Judicial review There shall be no administrative or judicial review under section 1395ff, 1395 oo of this title, or otherwise, respecting the identification of an area under this subparagraph.

“supplier” applies in that section

the term “supplier” has the meaning given such term in section 1395x(d) of this title . (2) Accreditation organizations (A) Factors for designation of accreditation organizations The Secretary shall consider the following factors in designating accreditation organizations under subparagraph (B)(i) 2 and in reviewing and modifying the list of accreditation organizations designated pursuant to subparagraph (C): (i) The ability of the organization to conduct timely reviews of accreditation applications. (ii) Whether the organization has established a process for the timely integration of new advanced diagnostic imaging services into the organization’s accreditation program.

“telecommunications system” applies in that section

the term “telecommunications system” includes store-and-forward technologies that provide for the asynchronous transmission of health care information in single or multimedia formats. (2) Payment amount (A) Distant site Subject to paragraph (8), the Secretary shall pay to a physician or practitioner located at a distant site that furnishes a telehealth service to an eligible telehealth individual an amount equal to the amount that such physician or practitioner would have been paid under this subchapter had such service been furnished without the use of a telecommunications system.

“telehealth service” applies in that section

the term “telehealth service” means professional consultations, office visits, and office psychiatry services (identified as of July 1, 2000 , by HCPCS codes 99241–99275, 99201–99215, 90804–90809, and 90862 (and as subsequently modified by the Secretary)), and any additional service specified by the Secretary. (ii) Yearly update The Secretary shall establish a process that provides, on an annual basis, for the addition or deletion of services (and HCPCS codes), as appropriate, to those specified in clause (i) for authorized payment under paragraph (1).

“telehealth services” applies in that section

the term “telehealth services” includes a rural health clinic service or Federally qualified health center service that is furnished using telehealth to the extent that payment codes corresponding to services identified by the Secretary under clause (i) or (ii) of paragraph (4)(F) are listed on the corresponding claim for such rural health clinic service or Federally qualified health center service.

“transitional home infusion drug” applies in that section

the term “transitional home infusion drug” has the meaning given to the term “home infusion drug” under section 1395x(iii)(3)(C)) 7 of this title, except that clause (ii) of such section shall not apply if a drug described in such clause is identified in clauses (i), (ii), (iii) or (iv) of subparagraph (C) as of February 9, 2018 . (B) Payment methodology For purposes of this paragraph, the Secretary shall establish a payment methodology, with respect to items and services described in subparagraph (A)(i).

“adjusted average per capita cost” applies in that section

the term “adjusted average per capita cost” means the average per capita amount that the Secretary estimates in advance (on the basis of actual experience, or retrospective actuarial equivalent based upon an adequate sample and other information and data, in a geographic area served by an eligible organization or in a similar area, with appropriate adjustments to assure actuarial equivalence) would be payable in any contract year for services covered under parts A and B, or part B only, and types of expenses otherwise reimbursable under parts A and B, or part B only (including administrative costs incurred by organizations described in sections 1395h and 1395u of this title), if the …

“eligible organization” applies in that section

the term “eligible organization” means a public or private entity (which may be a health maintenance organization or a competitive medical plan), organized under the laws of any State, which— (1) is a qualified health maintenance organization (as defined in section 300e–9(d) 1 of this title), or (2) meets the following requirements: (A) The entity provides to enrolled members at least the following health care services: (i) Physicians’ services performed by physicians (as defined in section 1395x(r)(1) of this title ). (ii) Inpatient hospital services. (iii) Laboratory, X-ray, emergency, and preventive services. (iv) Out-of-area coverage.

“physician incentive plan” applies in that section

the term “physician incentive plan” means any compensation arrangement between an eligible organization and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services provided with respect to individuals enrolled with the organization.

“reasonable cost reimbursement contract” applies in that section

the term “reasonable cost reimbursement contract” means a contract entered into under subsection (h). (B) The Secretary shall define appropriate classes of members, based on age, disability status, and such other factors as the Secretary determines to be appropriate, so as to ensure actuarial equivalence. The Secretary may add to, modify, or substitute for such classes, if such changes will improve the determination of actuarial equivalence. (C) The annual per capita rate of payment for each such class shall be equal to 95 percent of the adjusted average per capita cost (as defined in paragraph (4)) for that class.

“risk-sharing contract” applies in that section

the term “risk-sharing contract” means a contract entered into under subsection (g) and

“advanced diagnostic laboratory test” applies in that section

the term “advanced diagnostic laboratory test” means a clinical diagnostic laboratory test covered under this part that is offered and furnished only by a single laboratory and not sold for use by a laboratory other than the original developing laboratory (or a successor owner) and meets one of the following criteria: (A) The test is an analysis of multiple biomarkers of DNA, RNA, or proteins combined with a unique algorithm to yield a single patient-specific result. (B) The test is cleared or approved by the Food and Drug Administration. (C) The test meets other similar criteria established by the Secretary.

“applicable information” applies in that section

the term “applicable information” means, with respect to a laboratory test for a data collection period, the following: (i) The payment rate (as determined in accordance with paragraph (5)) that was paid by each private payor for the test during the period. (ii) The volume of such tests for each such payor for the period. (B) Exception for certain contractual arrangements Such term shall not include information with respect to a laboratory test for which payment is made on a capitated basis or other similar payment basis during the data collection period. (4) Data collection period defined (A) In general Subject to subparagraph (B), in this section,

“applicable laboratory” applies in that section

the term “applicable laboratory” means a laboratory that, with respect to its revenues under this subchapter, a majority of such revenues are from this section, section 1395 l (h) of this title, or section 1395w–4 of this title . The Secretary may establish a low volume or low expenditure threshold for excluding a laboratory from the definition of applicable laboratory under this paragraph, as the Secretary determines appropriate. (3) Applicable information defined (A) In general In this section, subject to subparagraph (B),

“applicable percent” applies in that section

the term “applicable percent” means— (i) for each of 2017 through 2020, 10 percent; (ii) for each of 2021 through 2026, 0 percent; and (iii) for each of 2027 through 2029, 15 percent. (C) No application to new tests This paragraph shall not apply to payment amounts determined under this section for either of the following. (i) A new test under subsection (c). (ii) A new advanced diagnostic test 1 (as defined in subsection (d)(5)) under subsection (d).

“data collection period” applies in that section

the term “data collection period” means a period of time, such as a previous 12 month period, specified by the Secretary. (B) Exception In the case of the reporting period described in paragraph (1)(B)(ii) with respect to clinical diagnostic laboratory tests that are not advanced diagnostic laboratory tests,

“private payor” applies in that section

the term “private payor” means the following: (A) A health insurance issuer and a group health plan (as such terms are defined in section 300gg–91 of this title ). (B) A Medicare Advantage plan under part C. (C) A medicaid managed care organization (as defined in section 1396b(m) of this title ).

“provider of services” applies in that section

the term “provider of services” shall include a clinic, rehabilitation agency, or public health agency if, in the case of a clinic or rehabilitation agency, such clinic or agency meets the requirements of section 1395x(p)(4)(A) of this title (or meets the requirements of such section through the operation of subsection (g) or ( ll )(2) of section 1395x of this title ), or if, in the case of a public health agency, such agency meets the requirements of section 1395x(p)(4)(B) of this title (or meets the requirements of such section through the operation of subsection (g) or ( ll )(2) of section 1395x of this title ), but only with respect to the furnishing of outpatient physical therapy …

“applicable hospital” applies in that section

the term “applicable hospital” means a hospital— (i) that is located in a county in which the percentage increase in the population during the most recent 5-year period (as of the date of the application under subparagraph (A)) is at least 150 percent of the percentage increase in the population growth of the State in which the hospital is located during that period, as estimated by Bureau of the Census; (ii) whose annual percent of total inpatient admissions that represent inpatient admissions under the program under subchapter XIX is equal to or greater than the average percent with respect to such admissions for all hospitals located in the county in which the hospital is located; (iii) …

“baseline number of operating rooms, procedure rooms, and beds” applies in that section

the term “baseline number of operating rooms, procedure rooms, and beds” means the number of operating rooms, procedure rooms, and beds for which the applicable hospital is licensed as of March 23, 2010 (or, in the case of a hospital that did not have a provider agreement in effect as of such date but does have such an agreement in effect on December 31, 2010 , the effective date of such provider agreement).

“compensation arrangement” applies in that section

The term “compensation arrangement” means any arrangement involving any remuneration between a physician (or an immediate family member of such physician) and an entity other than an arrangement involving only remuneration described in subparagraph (C).;

“designated health services” applies in that section

The term “designated health services” means any of the following items or services: (A) Clinical laboratory services. (B) Physical therapy services. (C) Occupational therapy services. (D) Radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services. (E) Radiation therapy services and supplies. (F) Durable medical equipment and supplies. (G) Parenteral and enteral nutrients, equipment, and supplies. (H) Prosthetics, orthotics, and prosthetic devices and supplies. (I) Home health services. (J) Outpatient prescription drugs. (K) Inpatient and outpatient hospital services. (L) Outpatient speech-language pathology services.

“fair market value” applies in that section

The term “fair market value” means the value in arms length transactions, consistent with the general market value, and, with respect to rentals or leases, the value of rental property for general commercial purposes (not taking into account its intended use) and, in the case of a lease of space, not adjusted to reflect the additional value the prospective lessee or lessor would attribute to the proximity or convenience to the lessor where the lessor is a potential source of patient referrals to the lessee. (4) Group practice (A) Definition of group practice

“group practice” applies in that section

The term “group practice” means a group of 2 or more physicians legally organized as a partnership, professional corporation, foundation, not-for-profit corporation, faculty practice plan, or similar association— (i) in which each physician who is a member of the group provides substantially the full range of services which the physician routinely provides, including medical care, consultation, diagnosis, or treatment, through the joint use of shared office space, facilities, equipment and personnel, (ii) for which substantially all of the services of the physicians who are members of the group are provided through the group and are billed under a billing number assigned to the group and …

“physician incentive plan” applies in that section

the term “physician incentive plan” means any compensation arrangement between an entity and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services provided with respect to individuals enrolled with the entity.

“physician owner or investor” applies in that section

the term “physician owner or investor” means a physician (or an immediate family member of such physician) with a direct or an indirect ownership or investment interest in the hospital. (6) Clarification Nothing in this subsection shall be construed as preventing the Secretary from revoking a hospital’s provider agreement if not in compliance with regulations implementing section 1395cc of this title .

“procedure rooms” applies in that section

the term “procedure rooms” includes rooms in which catheterizations, angiographies, angiograms, and endoscopies are performed, except such term shall not include emergency rooms or departments (exclusive of rooms in which catheterizations, angiographies, angiograms, and endoscopies are performed). (H) Publication of final decisions Not later than 60 days after receiving a complete application under this paragraph, the Secretary shall publish in the Federal Register the final decision with respect to such application.

“remuneration” applies in that section

The term “remuneration” includes any remuneration, directly or indirectly, overtly or covertly, in cash or in kind. (C) Remuneration described in this subparagraph is any remuneration consisting of any of the following: (i) The forgiveness of amounts owed for inaccurate tests or procedures, mistakenly performed tests or procedures, or the correction of minor billing errors. (ii) The provision of items, devices, or supplies that are used solely to— (I) collect, transport, process, or store specimens for the entity providing the item, device, or supply, or (II) order or communicate the results of tests or procedures for such entity.

“specialty hospital” applies in that section

the term “specialty hospital” means a subsection (d) hospital (as defined in section 1395ww(d)(1)(B) of this title ) that is primarily or exclusively engaged in the care and treatment of one of the following categories: (i) Patients with a cardiac condition. (ii) Patients with an orthopedic condition. (iii) Patients receiving a surgical procedure. (iv) Any other specialized category of services that the Secretary designates as inconsistent with the purpose of permitting physician ownership and investment interests in a hospital under this section.

“provider of services” applies in that section

the term “provider of services” includes a rural health clinic and a Federally qualified health center.

“Postal Service annuitant” applies in that section

the term “Postal Service annuitant” means an annuitant enrolled in a health benefits plan under chapter 89 of title 5, whose Government contribution is required to be paid under section 8906(g)(2) of such title.

“fiscal intermediary” applies in that section

the term “fiscal intermediary” means, with respect to a home health agency, an agency or organization with an agreement under section 1395h of this title with respect to the agency. (6) The Secretary shall monitor the proportion of denied bills submitted by home health agencies for which reconsideration is requested, and shall notify Congress if the proportion of denials reversed upon reconsideration increases significantly.

“eligible individual” applies in that section

The term “eligible individual” means an individual who is enrolled under this part B 1 and who— (i) in the case of an agreement entered into under the first sentence of paragraph (1), is within a class of individuals specified in such agreement; and (ii) in the case of an agreement entered into under the second sentence of paragraph (1), is so enrolled under this part pursuant to the special enrollment period under section 1395p( o ) of this title 2;

“joint return” applies in that section

the term “joint return” has the meaning given to such term by section 7701(a)(38) of the Internal Revenue Code of 1986. (j) Determination of premium for individuals only eligible for coverage of immunosuppressive drugs The Secretary shall, during September of each year (beginning with 2022), determine and promulgate a monthly premium rate for the succeeding calendar year for individuals enrolled only for the purpose of coverage of immunosuppressive drugs under section 1395 o (b) of this title.

“modified adjusted gross income” applies in that section

the term “modified adjusted gross income” means adjusted gross income (as defined in section 62 of the Internal Revenue Code of 1986)— (i) determined without regard to sections 135, 911, 931, and 933 of such Code; and (ii) increased by the amount of interest received or accrued during the taxable year which is exempt from tax under such Code. In the case of an individual filing a joint return, any reference in this subsection to the modified adjusted gross income of such individual shall be to such return’s modified adjusted gross income.

“part B late enrollment premium increase” applies in that section

The term “part B late enrollment premium increase” means any increase in a premium as a result of the application of subsection (b). (f) Limitation on increase in monthly premium For any calendar year after 1988, if an individual is entitled to monthly benefits under section 402 or 423 of this title or to a monthly annuity under section 3(a), 4(a), or 4(f) of the Railroad Retirement Act of 1974 [ 45 U.S.C.

“home dialysis supplies and equipment” applies throughout its subchapter

the term “home dialysis supplies and equipment” means medically necessary supplies and equipment (including supportive equipment) required by an individual suffering from end stage renal disease in connection with renal dialysis carried out in his home (as defined in regulations), including obtaining, installing, and maintaining such equipment.

“renal dialysis services” applies in that section

the term “renal dialysis services” includes— (i) items and services included in the composite rate for renal dialysis services as of December 31, 2010 ; (ii) erythropoiesis stimulating agents and any oral form of such agents that are furnished to individuals for the treatment of end stage renal disease; (iii) other drugs and biologicals that are furnished to individuals for the treatment of end stage renal disease and for which payment was (before the application of this paragraph) made separately under this subchapter, and any oral equivalent form of such drug or biological; and (iv) diagnostic laboratory tests and other items and services not described in clause (i) that are furnished to …

“self-care dialysis unit” applies throughout its subchapter

the term “self-care dialysis unit” means a renal dialysis facility or a distinct part of such facility or of a provider of services, which has been approved by the Secretary to make self-dialysis services, as defined by the Secretary in regulations, available to individuals who have been trained for self-dialysis.

“supportive equipment” applies in that section

the term “supportive equipment” includes blood pumps, heparin pumps, bubble detectors, other alarm systems, and such other items as the Secretary may determine are medically necessary. (f) Experiments, studies, and pilot projects (1) The Secretary shall initiate and carry out, at selected locations in the United States, pilot projects under which financial assistance in the purchase of new or used durable medical equipment for renal dialysis is provided to individuals suffering from end stage renal disease at the time home dialysis is begun, with provision for a trial period to assure successful adaptation to home dialysis before the actual purchase of such equipment.

“emergency declaration” applies in that section

the term “emergency declaration” means a declaration of a public health emergency under section 9604(a) of this title . (e) Environmental exposure affected individual defined (1) In general For purposes of this section,

“environmental exposure affected individual” applies in that section

the term “environmental exposure affected individual” means— (A) an individual described in paragraph (2); and (B) an individual described in paragraph (3). (2) Individual described (A) In general An individual described in this paragraph is any individual who— (i) is diagnosed with 1 or more conditions described in subparagraph (B); (ii) as demonstrated in such manner as the Secretary determines appropriate, has been present for an aggregate total of 6 months in the geographic area subject to an emergency declaration specified in subsection (b)(2)(A), during a period ending— (I) not less than 10 years prior to such diagnosis; and (II) prior to the implementation of all the remedial and …

“coordinates” applies in that section

the terms “coordinates” and “coordination” mean, with respect to a policy in relation to health benefits under this subchapter or under another health insurance policy, that the policy under its terms is secondary to, or excludes from payment, items and services to the extent available or paid for under this subchapter or under another health insurance policy. (vi) (I) An individual entitled to benefits under part A or enrolled under part B of this subchapter who is applying for a health insurance policy (other than a policy described in subclause (III)) shall be furnished a disclosure statement described in clause (vii) for the type of policy being applied for.

“coordination” applies in that section

the terms “coordinates” and “coordination” mean, with respect to a policy in relation to health benefits under this subchapter or under another health insurance policy, that the policy under its terms is secondary to, or excludes from payment, items and services to the extent available or paid for under this subchapter or under another health insurance policy. (vi) (I) An individual entitled to benefits under part A or enrolled under part B of this subchapter who is applying for a health insurance policy (other than a policy described in subclause (III)) shall be furnished a disclosure statement described in clause (vii) for the type of policy being applied for.

“family member” applies in that section

The term “family member” means with respect to an individual, any other individual who is a first-degree, second-degree, third-degree, or fourth-degree relative of such individual. (B) Genetic information (i) In general

“genetic information” applies in that section

The term “genetic information” means, with respect to any individual, information about— (I) such individual’s genetic tests, (II) the genetic tests of family members of such individual, and (III) subject to clause (iv), the manifestation of a disease or disorder in family members of such individual. (ii) Inclusion of genetic services and participation in genetic research Such term includes, with respect to any individual, any request for, or receipt of, genetic services, or participation in clinical research which includes genetic services, by such individual or any family member of such individual.

“genetic services” applies in that section

The term “genetic services” means— (i) a genetic test; (ii) genetic counseling (including obtaining, interpreting, or assessing genetic information); or (iii) genetic education. (E) Underwriting purposes

“genetic test” applies in that section

The term “genetic test” means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, that detects genotypes, mutations, or chromosomal changes. (ii) Exceptions The term “genetic test” does not mean— (I) an analysis of proteins or metabolites that does not detect genotypes, mutations, or chromosomal changes; or (II) an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition that could reasonably be detected by a health care professional with appropriate training and expertise in the field of medicine involved. (D) Genetic services

“initial part D enrollment period” applies in that section

The term “initial part D enrollment period” means the initial enrollment period described in section 1395w–101(b)(2)(A) of this title . (w) Development of new standards for medicare supplemental policies (1) In general The Secretary shall request the National Association of Insurance Commissioners to review and revise the standards for benefit packages under subsection (p)(1), taking into account the changes in benefits resulting from enactment of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and to otherwise update standards to reflect other changes in law included in such Act.

“issuer of a medicare supplemental policy” applies in that section

The term “issuer of a medicare supplemental policy” includes a third-party administrator or other person acting for or on behalf of such issuer. (4) Genetic information of a fetus or embryo Any reference in this section to genetic information concerning an individual or family member of an individual shall— (A) with respect to such an individual or family member of an individual who is a pregnant woman, include genetic information of any fetus carried by such pregnant woman; and (B) with respect to an individual or family member utilizing an assisted reproductive technology, include genetic information of any embryo legally held by the individual or family member.

“medigap Rx policy” applies in that section

The term “medigap Rx policy” means a medicare supplemental policy— (i) which has a benefit package classified as “H”, “I”, or “J” (including the benefit package classified as “J” with a high deductible feature, as described in subsection (p)(11)) under the standards established under subsection (p)(2), without regard to this subsection; and (ii) to which such standards do not apply (or to which such standards have been waived under subsection (p)(6)) but which provides benefits for prescription drugs. Such term does not include a policy with a benefit package as classified under clause (i) which has been modified under paragraph (2)(C)(i). (B) Part D enrollee

“NAIC Model Standards” applies in that section

The term “NAIC Model Standards” means the “NAIC Model Regulation to Implement the Individual Accident and Sickness Insurance Minimum Standards Act”, adopted by the National Association of Insurance Commissioners on June 6, 1979 , as it applies to medicare supplemental policies.;

“newly eligible Medicare beneficiary” applies in that section

the term “newly eligible Medicare beneficiary” means an individual who is neither of the following: (A) An individual who has attained age 65 before January 1, 2020 . (B) An individual who was entitled to benefits under part A pursuant to section 426(b) or 426–1 of this title, or deemed to be eligible for benefits under section 426(a) of this title , before January 1, 2020 .

“part D enrollee” applies in that section

The term “part D enrollee” means an individual who is enrolled in a part D plan. (C) Part D plan

“part D plan” applies in that section

The term “part D plan” means a prescription drug plan or an MA–PD plan (as defined for purposes of part D). (D) Initial part D enrollment period

“policy” applies in that section

the term “policy” includes a certificate issued under such policy. (2) For purposes of this section:;

“qualifying medicare supplemental policy” applies in that section

the term “qualifying medicare supplemental policy” means a medicare supplemental policy— (A) issued in a State which— (i) has not adopted standards equal to or more stringent than the NAIC Model Transition Regulation by January 1, 1989 , and (ii) has not adopted standards equal to or more stringent than the amended NAIC Model Regulation (or Federal model standards) by January 1, 1989 ; and (B) which has been issued in compliance with this section (as in effect on June 1, 1988 ).

“State with an approved regulatory program” applies in that section

The term “State with an approved regulatory program” means a State for which the Secretary has made a determination under subsection (b)(1). (C) The State in which a policy is issued means— (i) in the case of an individual policy, the State in which the policyholder resides; and (ii) in the case of a group policy, the State in which the holder of the master policy resides. (h) Rules and regulations The Secretary shall prescribe such regulations as may be necessary for the effective, efficient, and equitable administration of the certification procedure established under this section.

“transition deadline” applies in that section

the term “transition deadline” means 1 year after the date the Association adopts the revised NAIC Model Regulation or 1 year after the date the Secretary promulgates revised Federal model standards (as the case may be).

“underwriting purposes” applies in that section

The term “underwriting purposes” means, with respect to a medicare supplemental policy— (i) rules for, or determination of, eligibility (including enrollment and continued eligibility) for benefits under the policy; (ii) the computation of premium or contribution amounts under the policy; (iii) the application of any pre-existing condition exclusion under the policy; and (iv) other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits. (F) Issuer of a medicare supplemental policy

“applicable number of calendar days” applies in that section

The term “applicable number of calendar days” means— (I) with respect to claims received in the 12-month period beginning October 1, 1986 , 30 calendar days, (II) with respect to claims received in the 12-month period beginning October 1, 1987 , 26 calendar days (or 19 calendar days with respect to claims submitted by participating physicians), (III) with respect to claims received in the 12-month period beginning October 1, 1988 , 25 calendar days (or 18 calendar days with respect to claims submitted by participating physicians), (IV) with respect to claims received in the 12-month period beginning October 1, 1989 , and claims received in any succeeding 12-month period ending on or before …

“applicable percent” applies in that section

the term “applicable percent” means for services furnished (I) on or after January 1, 1987 , and before April 1, 1988 , 96 percent, (II) on or after April 1, 1988 , and before January 1, 1989 , 95.5 percent, and (III) on or after January 1, 1989 , 95 percent. (v) In determining the prevailing charge levels under the third and fourth sentences of paragraph (3) for physicians’ services furnished during the 3-month period beginning January 1, 1988 , the Secretary shall not set any level higher than the same level as was set for the 12-month period beginning January 1, 1987 .

“assistant at surgery” applies in that section

the term “assistant at surgery” means a physician who actively assists the physician in charge of a case in performing a surgical procedure. (iii) The Secretary shall determine appropriate methods of reimbursement of assistants at surgery where such services are reimbursable under this part.

“clean claim” applies in that section

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.;

“nonparticipating supplier or other person” applies throughout its subchapter

the term “nonparticipating supplier or other person” means a supplier or other person (excluding a provider of services) that is not a participating physician or supplier (as defined in subsection (h)(1)).;

“participating physician or supplier” applies in that section

the term “participating physician or supplier” means a physician or supplier (excluding any provider of services) who, before the beginning of any year beginning with 1984, enters into an agreement with the Secretary which provides that such physician or supplier will accept payment under this part on an assignment-related basis for all items and services furnished to individuals enrolled under this part during such year.

“percentage increase in the MEI” applies throughout its subchapter

The term “percentage increase in the MEI” means, with respect to physicians’ services furnished in a year, the percentage increase in the medicare economic index (referred to in the fourth sentence of subsection (b)(3)) applicable to such services furnished as of the first day of that year.;

“primary care services” applies throughout its subchapter

The term “primary care services” means physicians’ services which constitute office medical services, emergency department services, home medical services, skilled nursing, intermediate care, and long-term care medical services, or nursing home, boarding home, domiciliary, or custodial care medical services.

“reduced payment allowance” applies throughout its subchapter

the term “reduced payment allowance” means, with respect to an action— (I) under subsection (b)(8)(B), the inherently reasonable charge established under subsection (b)(8); (II) under subsection (b)(10)(A), (b)(11)(B), (b)(11)(C)(i), (b)(14)(A), or (b)(15)(A) or under section 1395 l ( l )(3)(B) of this title, the prevailing charge for the service after the action; or (III) under subsection (b)(11)(C)(ii), the payment allowance established under such subsection. (iv) If a physician knowingly and willfully bills in violation of clause (i) (whether or not such charge violates subparagraph (B)), the Secretary may apply sanctions against such physician in accordance with paragraph (2).

“additional payment” applies throughout its subchapter

the term “additional payment” means, with respect to a discharge for a new medical service or technology described in clause (ii)(I), an amount that exceeds the prospective payment rate otherwise applicable under this subsection to discharges involving such service or technology that would be made but for this subparagraph. (v) The requirement under clause (ii)(III) for an additional payment may be satisfied by means of a new-technology group (described in subparagraph (L)), an add-on payment, a payment adjustment, or any other similar mechanism for increasing the amount otherwise payable with respect to a discharge under this subsection.

“aggregate approved amount” applies in that section

the term “aggregate approved amount” means, for a hospital cost reporting period, the product of— (i) the hospital’s approved FTE resident amount (determined under paragraph (2)) for that period, and (ii) the weighted average number of full-time-equivalent residents (as determined under paragraph (4)) in the hospital’s approved medical residency training programs in that period. The Secretary shall reduce the aggregate approved amount to the extent payment is made under subsection (k) for residents included in the hospital’s count of full-time equivalent residents. (C) Medicare patient load As used in subparagraph (A),

“aggregate payments for all discharges” applies in that section

The term “aggregate payments for all discharges” means, for a hospital for an applicable period, the sum of the base operating DRG payment amounts for all discharges for all conditions from such hospital for such applicable period. (C) Excess readmission ratio (i) In general Subject to clause (ii),

“aggregate payments for excess readmissions” applies in that section

The term “aggregate payments for excess readmissions” means, for a hospital for an applicable period, the sum, for applicable conditions (as defined in paragraph (5)(A)), of the product, for each applicable condition, of— (i) the base operating DRG payment amount for such hospital for such applicable period for such condition; (ii) the number of admissions for such condition for such hospital for such applicable period; and (iii) the excess readmissions ratio (as defined in subparagraph (C)) for such hospital for such applicable period minus 1. (B) Aggregate payments for all discharges

“all patients” applies in that section

The term “all patients” means patients who are treated on an inpatient basis and discharged from a specified hospital (as defined in clause (ii)).;

“all-urban State” applies in that section

the term “all-urban State” means a State in which there are no rural areas (as defined in paragraph (2)(D)) or a State in which there are no hospitals classified as rural under this section. (4) (A) The Secretary shall establish a classification of inpatient hospital discharges by diagnosis-related groups and a methodology for classifying specific hospital discharges within these groups. (B) For each such diagnosis-related group the Secretary shall assign an appropriate weighting factor which reflects the relative hospital resources used with respect to discharges classified within that group compared to discharges classified within other groups.

“allogeneic hematopoietic stem cell transplant” applies throughout its subchapter

the term “allogeneic hematopoietic stem cell transplant” means, with respect to an individual, the intravenous infusion of hematopoietic cells derived from bone marrow, peripheral blood stem cells, or cord blood, but not including embryonic stem cells, of a donor to an individual that are or may be used to restore hematopoietic function in such individual having an inherited or acquired deficiency or defect.

“applicable condition” applies in that section

The term “applicable condition” means, subject to subparagraph (B), a condition or procedure selected by the Secretary among conditions and procedures for which— (i) readmissions (as defined in subparagraph (E)) that represent conditions or procedures that are high volume or high expenditures under this subchapter (or other criteria specified by the Secretary); and (ii) measures of such readmissions— (I) have been endorsed by the entity with a contract under section 1395aaa(a) of this title ; and (II) such endorsed measures have exclusions for readmissions that are unrelated to the prior discharge (such as a planned readmission or transfer to another applicable hospital).

“applicable date” applies in that section

the term “applicable date” means— (I) with respect to the initial publication of a list under clause (ii), January 5, 2023 ; and (II) with respect to the publication of an updated list under clause (ii), a date specified by the Secretary that is not more than one year prior to the date of such publication. (vi) Implementation Notwithstanding any other provision of law the Secretary may implement clauses (ii) through (v) by program instruction or otherwise. (vii) Nonapplication of Paperwork Reduction Act Chapter 35 of title 44 shall not apply to data collected under clauses (ii) through (v).

“applicable discharge” applies in that section

the term “applicable discharge” means the discharge of any individual who is enrolled under a risk-sharing contract with an eligible organization under section 1395mm of this title and who is entitled to benefits under part A or any individual who is enrolled with a Medicare+ÐChoice organization under part C. (C) Determination of amount .— The amount of the payment under this paragraph with respect to any applicable discharge shall be equal to the applicable percentage (as defined in subsection (h)(3)(D)(ii)) of the estimated average per discharge amount that would otherwise have been paid under paragraph (5)(B) if the individuals had not been enrolled as described in subparagraph (B).

“applicable hospital” applies in that section

the term “applicable hospital” means a subsection (d) hospital that meets the criteria described in subparagraph (B). (B) Criteria described (i) In general The criteria described in this subparagraph, with respect to a subsection (d) hospital, is that the subsection (d) hospital is in the top quartile of all subsection (d) hospitals, relative to the national average, of hospital acquired conditions during the applicable period, as determined by the Secretary. (ii) Risk adjustment In carrying out clause (i), the Secretary shall establish and apply an appropriate risk adjustment methodology.

“applicable percent” applies in that section

the term “applicable percent” means— (i) with respect to fiscal year 2013, 1.0 percent; (ii) with respect to fiscal year 2014, 1.25 percent; (iii) with respect to fiscal year 2015, 1.5 percent; (iv) with respect to fiscal year 2016, 1.75 percent; and (v) with respect to fiscal year 2017 and succeeding fiscal years, 2 percent. (D) Base operating DRG payment amount defined (i) In general Except as provided in clause (ii), in this subsection,

“applicable period” applies in that section

the term “applicable period” means, with respect to a fiscal year, a period specified by the Secretary. (5) Reporting to hospitals Prior to fiscal year 2015 and each subsequent fiscal year, the Secretary shall provide confidential reports to applicable hospitals with respect to hospital acquired conditions of the applicable hospital during the applicable period. (6) Reporting hospital specific information (A) In general The Secretary shall make information available to the public regarding hospital acquired conditions of each applicable hospital.

“applicable site neutral payment rate” applies in that section

the term “applicable site neutral payment rate” means— (I) for discharges in cost reporting periods beginning during fiscal years 2016 through 2019, the blended payment rate specified in clause (iii); and (II) for discharges in cost reporting periods beginning during fiscal year 2020 or a subsequent fiscal year, the site neutral payment rate (as defined in clause (ii)). (ii) Site neutral payment rate defined Subject to clause (iv), in this paragraph,

“approved medical residency training program” applies in that section

The term “approved medical residency training program” means a residency or other postgraduate medical training program participation in which may be counted toward certification in a specialty or subspecialty and includes formal postgraduate training programs in geriatric medicine approved by the Secretary. (B) Consumer price index The term “consumer price index” refers to the Consumer Price Index for All Urban Consumers (United States city average), as published by the Secretary of Commerce. (C) Direct graduate medical education costs

“base number of residents” applies in that section

the term “base number of residents” means, with respect to a qualifying entity (or its participating hospitals) operating approved medical residency training programs, the number of full-time equivalent residents in such programs (before application of weighting factors) of the entity as of the most recent residency training year ending before June 30, 1997 , or, if less, for any subsequent residency training year that ends before the date the entity makes application under this paragraph.

“base operating DRG payment amount” applies in that section

the term “base operating DRG payment amount” means, with respect to a hospital for a fiscal year— (I) the payment amount that would otherwise be made under subsection (d) (determined without regard to subsection (q)) for a discharge if this subsection did not apply; reduced by (II) any portion of such payment amount that is attributable to— (aa) payments under paragraphs (5)(A), (5)(B), (5)(F), and (12) of subsection (d); and (bb) such other payments under subsection (d) determined appropriate by the Secretary.

“capital-related costs” applies in that section

the term “capital-related costs” has the meaning given such term by the Secretary under subsection (a)(4) as of September 30, 1987 , and does not include a return on equity capital. (2) (A) The Secretary shall provide that the amount which is allowable, with respect to reasonable costs of inpatient hospital services for which payment may be made under this subchapter, for a return on equity capital for hospitals shall, for cost reporting periods beginning on or after April 20, 1983 , be equal to amounts otherwise allowable under regulations in effect on March 1, 1983 , except that the rate of return to be recognized shall be equal to the applicable percentage (described in subparagraph (B)) …

“certified EHR technology” applies in that section

The term “certified EHR technology” has the meaning given such term in section 1395w–4( o )(4) of this title. (6) Definitions For purposes of this subsection: (A) EHR reporting period

“day outlier percentage” applies in that section

the term “day outlier percentage” means, for a fiscal year, the percentage of the total additional payments made by the Secretary under this subparagraph for discharges in that fiscal year which are additional payments under clause (i).

“direct graduate medical education costs” applies in that section

The term “direct graduate medical education costs” means direct costs of approved educational activities for approved medical residency training programs. (D) Foreign medical graduate

“discharge” applies in that section

the term “discharge” means an inpatient acute care discharge of an individual regardless (except as provided in clause (i)(II) and subparagraph (D)(i)) of whether the individual is entitled to benefits under part A.

“disproportionate patient percentage” applies throughout its subchapter

the term “disproportionate patient percentage” means, with respect to a cost reporting period of a hospital, the sum of— (I) the fraction (expressed as a percentage), the numerator of which is the number of such hospital’s patient days for such period which were made up of patients who (for such days) were entitled to benefits under part A of this subchapter and were entitled to supplementary security income benefits (excluding any State supplementation) under subchapter XVI of this chapter, and the denominator of which is the number of such hospital’s patient days for such fiscal year which were made up of patients who (for such days) were entitled to benefits under part A of this …

“EHR reporting period” applies in that section

the term “EHR reporting period” means, with respect to a fiscal year, any period (or periods) as specified by the Secretary. (x) (I) The Secretary shall develop standard Internet website reports tailored to meet the needs of various stakeholders such as hospitals, patients, researchers, and policymakers. The Secretary shall seek input from such stakeholders in determining the type of information that is useful and the formats that best facilitate the use of the information. (II) The Secretary shall modify the Hospital Compare Internet website to make the use and navigation of that website readily available to individuals accessing it.

“eligible hospital” applies in that section

The term “eligible hospital” means a hospital that is a subsection (d) hospital or a subsection (d) Puerto Rico hospital. (o) Hospital value-based purchasing program (1) Establishment (A) In general Subject to the succeeding provisions of this subsection, the Secretary shall establish a hospital value-based purchasing program (in this subsection referred to as the “Program”) under which value-based incentive payments are made in a fiscal year to hospitals that meet the performance standards under paragraph (3) for the performance period for such fiscal year (as established under paragraph (4)).

“excess readmissions ratio” applies in that section

the term “excess readmissions ratio” means, with respect to an applicable condition for a hospital for an applicable period, the ratio (but not less than 1.0) of— (I) the risk adjusted readmissions based on actual readmissions, as determined consistent with a readmission measure methodology that has been endorsed under paragraph (5)(A)(ii)(I), for an applicable hospital for such condition with respect to such applicable period; to (II) the risk adjusted expected readmissions (as determined consistent with such a methodology) for such hospital for such condition with respect to such applicable period.

“first payment year” applies in that section

The term “first payment year” means, with respect to inpatient hospital services furnished by an eligible hospital, the first fiscal year for which an incentive payment is made for such services under this subsection.

“FMGEMS examination” applies in that section

The term “FMGEMS examination” means parts I and II of the Foreign Medical Graduate Examination in the Medical Sciences or any successor examination recognized by the Secretary for this purpose. (F) Initial residency period

“foreign medical graduate” applies in that section

The term “foreign medical graduate” means a resident who is not a graduate of— (i) a school of medicine accredited by the Liaison Committee on Medical Education of the American Medical Association and the Association of American Medical Colleges (or approved by such Committee as meeting the standards necessary for such accreditation), (ii) a school of osteopathy accredited by the American Osteopathic Association, or approved by such Association as meeting the standards necessary for such accreditation, or (iii) a school of dentistry or podiatry which is accredited (or meets the standards for accreditation) by an organization recognized by the Secretary for such purpose.

“fourth payment year” applies in that section

The terms “second payment year”, “third payment year”, and “fourth payment year” mean, with respect to an eligible hospital, each successive year immediately following the first payment year for that hospital.

“frontier county” applies in that section

the term “frontier county” means a county in which the population per square mile is less than 6. (IV) Limitation .— This clause shall not apply to any hospital located in a State that receives a non-labor related share adjustment under paragraph (5)(H). (iv) Floor on area wage index for hospitals in all-urban states.— (I) In general .— For discharges occurring on or after October 1, 2021 , the area wage index applicable under this subparagraph to any hospital in an all-urban State (as defined in subclause (IV)) may not be less than the minimum area wage index for the fiscal year for hospitals in that State, as established under subclause (II).

“frontier State” applies in that section

the term “frontier State” means a State in which at least 50 percent of the counties in the State are frontier counties. (III) Frontier county defined .— In this clause,

“HCPCS” applies in that section

The term “HCPCS” means, with respect to hospital items and services, the code under the Healthcare Common Procedure Coding System (HCPCS) (or a successor code) for such items and services. (B) ICD–10–PCS

“higher wage index area” applies in that section

the term “higher wage index area” means, with respect to a county, an area with a wage index that exceeds that of the county. (D) The increase in the wage index under subparagraph (A) for a qualifying county shall be equal to the percentage of the hospital employees residing in the qualifying county who are employed in any higher wage index area multiplied by the sum of the products, for each higher wage index area of— (i) the difference between— (I) the wage index for such higher wage index area, and (II) the wage index of the qualifying county; and (ii) the number of hospital employees residing in the qualifying county who are employed in such higher wage index area divided by the total …

“hospital” applies in that section

the term “hospital” means a subsection (d) hospital (as defined in subsection (d)(1)(B)). (ii) Exclusions The term “hospital” shall not include, with respect to a fiscal year, a hospital— (I) that is subject to the payment reduction under subsection (b)(3)(B)(viii)(I) for such fiscal year; (II) for which, during the performance period for such fiscal year, the Secretary has cited deficiencies that pose immediate jeopardy to the health or safety of patients; (III) for which there are not a minimum number (as determined by the Secretary) of measures that apply to the hospital for the performance period for such fiscal year; or (IV) for which there are not a minimum number (as determined by …

“hospital acquired condition” applies in that section

the term “hospital acquired condition” means a condition identified for purposes of subsection (d)(4)(D)(iv) and any other condition determined appropriate by the Secretary that an individual acquires during a stay in an applicable hospital, as determined by the Secretary. (4) Applicable period In this subsection,

“ICD–10–PCS” applies in that section

The term “ICD–10–PCS” means the International Classification of Diseases, 10th Revision, Procedure Coding System, and includes any subsequent revision of such International Classification of Diseases, Procedure Coding System.