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

“prescription drug plan” applies in that section

The term “prescription drug plan” has the meaning given such term in section 1395w–151(a)(14) of this title . (3) Secretary

“Secretary” applies in that section

The term “Secretary” means the Secretary of Health and Human Services. (4) System

“system” applies in that section

The term “system” means the plan complaint system developed and maintained under subsection (a).

“annual, coordinated election period” applies in that section

the term “annual, coordinated election period” means— (i) with respect to a year before 2002, the month of November before such year; (ii) with respect to 2002, 2003, 2004, and 2005, the period beginning on November 15 and ending on December 31 of the year before such year; (iii) with respect to 2006, the period beginning on November 15, 2005 , and ending on May 15, 2006 ; (iv) with respect to 2007, 2008, 2009, and 2010, the period beginning on November 15 and ending on December 31 of the year before such year; and (v) with respect to 2012 and succeeding years, the period beginning on October 15 and ending on December 7 of the year before such year.

“applicable MA plan” applies in that section

the term “applicable MA plan” means, in the case of an individual described in— (i) subparagraph (B)(i), an MA plan that is not an MA–PD plan; and (ii) subparagraph (B)(ii), an MA–PD plan. (D) Identification and notification of deemed individuals Not later than 45 days before the first day of the annual, coordinated election period under subsection (e)(3) for plan years beginning on or after January 1, 2017 , the Secretary shall identify and notify the individuals who will be subject to deemed elections under subparagraph (A) on the first day of such period.

“Medicare+Choice eligible individual” applies throughout its subchapter

the term “Medicare+Choice eligible individual” means an individual who is entitled to benefits under part A and enrolled under part B. (b) Special rules (1) Residence requirement (A) In general Except as the Secretary may otherwise provide and except as provided in subparagraph (C), an individual is eligible to elect a Medicare+Choice plan offered by a Medicare+Choice organization only if the plan serves the geographic area in which the individual resides.

“unenrolled fee-for-service individual” applies in that section

the term “unenrolled fee-for-service individual” means, with respect to a date, a Medicare Advantage eligible individual who— (I) is receiving benefits under this subchapter through enrollment in the original medicare fee-for-service program under parts A and B; (II) is not enrolled in an MA plan on such date; and (III) as of such date is not otherwise eligible to elect to enroll in an MA plan. (iii) Limitation of one change during the applicable period An individual may exercise the right under clause (i) only once during the period described in such clause.

“additional telehealth benefits” applies in that section

The term “additional telehealth benefits” means services— (I) for which benefits are available under part B, including services for which payment is not made under section 1395m(m) of this title due to the conditions for payment under such section; and (II) that are identified for such year as clinically appropriate to furnish using electronic information and telecommunications technology when a physician (as defined in section 1395x(r) of this title ) or practitioner (described in section 1395u(b)(18)(C) of this title ) providing the service is not at the same location as the plan enrollee.

“benefits under the original medicare fee-for-service program option” applies throughout its part

the term “benefits under the original medicare fee-for-service program option” means, subject to subsection (m), those items and services (other than hospice care or coverage for organ acquisitions for kidney transplants, including as covered under section 1395rr(d) of this title ) for which benefits are available under parts A and B to individuals entitled to benefits under part A and enrolled under part B, with cost-sharing for those services as required under parts A and B or, subject to clause (iii), an actuarially equivalent level of cost-sharing as determined in this part.

“chronically ill enrollee” applies in that section

the term “chronically ill enrollee” means an enrollee in an MA plan that the Secretary determines— (I) has one or more comorbid and medically complex chronic conditions that is life threatening or significantly limits the overall health or function of the enrollee; (II) has a high risk of hospitalization or other adverse health outcomes; and (III) requires intensive care coordination.

“continuing care retirement community” applies in that section

The term “continuing care retirement community” means, with respect to an enrollee in a Medicare+Choice plan, an arrangement under which housing and health-related services are provided (or arranged) through an organization for the enrollee under an agreement that is effective for the life of the enrollee or for a specified period. (m) Provision of additional telehealth benefits (1) MA plan option For plan year 2020 and subsequent plan years, subject to the requirements of paragraph (3), an MA plan may provide additional telehealth benefits (as defined in paragraph (2)) to individuals enrolled under this part.

“emergency medical condition” applies in that section

The term “emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in— (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part.

“emergency services” applies in that section

The term “emergency services” means, with respect to an individual enrolled with an organization, covered inpatient and outpatient services that— (i) are furnished by a provider that is qualified to furnish such services under this subchapter, and (ii) are needed to evaluate or stabilize an emergency medical condition (as defined in subparagraph (B)). (B) Emergency medical condition based on prudent layperson

“health care professional” applies in that section

the term “health care professional” means a physician (as defined in section 1395x(r) of this title ) or other health care professional if coverage for the professional’s services is provided under the Medicare+Choice plan for the services of the professional.

“home skilled nursing facility” applies in that section

The term “home skilled nursing facility” means, with respect to an enrollee who is entitled to receive post-hospital extended care services under a Medicare+Choice plan, any of the following skilled nursing facilities: (i) SNF residence at time of admission The skilled nursing facility in which the enrollee resided at the time of admission to the hospital preceding the receipt of such post-hospital extended care services. (ii) SNF in continuing care retirement community A skilled nursing facility that is providing such services through a continuing care retirement community (as defined in subparagraph (B)) which provided residence to the enrollee at the time of such admission.

“network area” applies in that section

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 1395w–23(b)(1)(B) of this title ) 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),

“network-based plan” applies in that section

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 1395w–21(a)(2)(A)(i) of this title ; (II) a network-based MSA plan; and (III) a reasonable cost reimbursement plan under section 1395mm of this title . (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.

“physician incentive plan” applies in that section

the term “physician incentive plan” means any compensation arrangement between a Medicare+Choice 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 under this part.

“preferred provider organization plan” applies in that section

the term “preferred provider organization plan” means an MA plan that— (I) has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan; (II) provides for reimbursement for all covered benefits regardless of whether such benefits are provided within such network of providers; and (III) is offered by an organization that is not licensed or organized under State law as a health maintenance organization.

“specified MA plan” applies in that section

the term “specified MA plan” means— (i) a network-based plan (as defined in subsection (d)(5)(C)); or (ii) a Medicare Advantage private fee-for-service plan (as defined in section 1395w–28(b)(2) of this title ) that meets the access standards under subsection (d)(4), in whole or in part, through entering into contracts or agreements as provided for under subparagraph (B) of such subsection.

“applicable amount” applies throughout its part

the term “applicable amount” means for an area— (A) for 2007— (i) if such year is not specified under subsection (c)(1)(D)(ii), an amount equal to the amount specified in subsection (c)(1)(C) for the area for 2006— (I) first adjusted by the rescaling factor for 2006 for the area (as made available by the Secretary in the announcement of the rates on April 4, 2005 , under subsection (b)(1), but excluding any national adjustment factors for coding intensity and risk adjustment budget neutrality that were included in such factor); and (II) then increased by the national per capita MA growth percentage, described in subsection (c)(6) for 2007, but not taking into account any adjustment under …

“applicable phase-out factor” applies throughout its part

the term “applicable phase-out factor” means— (i) for 2007, 0.55; (ii) for 2008, 0.40; (iii) for 2009, 0.25; and (iv) for 2010, 0.05. (D) Termination of application Subparagraph (A) shall not apply in a year if the amount estimated under subparagraph (B)(ii)(III) for the year is equal to or greater than the amount estimated under subparagraph (B)(ii)(II) for the year. (3) No revision in percent (A) In general The Secretary may not make any adjustment to the percent determined under paragraph (2)(B) for any year.

“blended benchmark amount” applies in that section

the term “blended benchmark amount” means for an area— (A) for 2012 the sum of— (i) ½ of the applicable amount for the area and year; and (ii) ½ of the amount specified in paragraph (2)(A) for the area and year; and (B) for a subsequent year the amount specified in paragraph (2)(A) for the area and year.

“consolidated metropolitan statistical area” applies in that section

the terms “metropolitan statistical area”, “consolidated metropolitan statistical area”, and “primary metropolitan statistical area” mean any area designated as such by the Secretary of Commerce. (e) Special rules for individuals electing MSA plans (1) In general If the amount of the Medicare+Choice monthly MSA premium (as defined in section 1395w–24(b)(2)(C) of this title ) for an MSA plan for a year is less than 1 ⁄ 12 of the annual Medicare+Choice capitation rate applied under this section for the area and year involved, the Secretary shall deposit an amount equal to 100 percent of such difference in a Medicare+Choice MSA established (and, if applicable, designated) by the individual …

“MA area-specific non-drug monthly benchmark amount” applies throughout its part

the term “MA area-specific non-drug monthly benchmark amount” means for a month in a year— (1) with respect to— (A) a service area that is entirely within an MA local area, subject to section 1395w–29(d)(2)(A) 2 of this title, an amount equal to 1 ⁄ 12 of the annual MA capitation rate under subsection (c)(1) for the area for the year (or, for 2007, 2008, 2009, and 2010, 1 ⁄ 12 of the applicable amount determined under subsection (k)(1) for the area for the year; for 2011, 1 ⁄ 12 of the applicable amount determined under subsection (k)(1) for the area for 2010; and, beginning with 2012, 1 ⁄ 12 of the blended benchmark amount determined under subsection (n)(1) for the area for the year), …

“MA local area” applies in that section

The term “MA local area” means a county or equivalent area specified by the Secretary. (3) Rule for ESRD beneficiaries In the case of individuals who are determined to have end stage renal disease, the Medicare+Choice payment area shall be a State or such other payment area as the Secretary specifies.

“MA payment area” applies in that section

the term “MA payment area” means— (A) with respect to an MA local plan, an MA local area (as defined in paragraph (2)); and (B) with respect to an MA regional plan, an MA region (as established under section 1395w–27a(a)(2) of this title ). (2) MA local area

“maximum cumulative adjustment percentage” applies in that section

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

“metropolitan statistical area” applies in that section

the terms “metropolitan statistical area”, “consolidated metropolitan statistical area”, and “primary metropolitan statistical area” mean any area designated as such by the Secretary of Commerce. (e) Special rules for individuals electing MSA plans (1) In general If the amount of the Medicare+Choice monthly MSA premium (as defined in section 1395w–24(b)(2)(C) of this title ) for an MSA plan for a year is less than 1 ⁄ 12 of the annual Medicare+Choice capitation rate applied under this section for the area and year involved, the Secretary shall deposit an amount equal to 100 percent of such difference in a Medicare+Choice MSA established (and, if applicable, designated) by the individual …

“new MA plan” applies in that section

The term “new MA plan” means, with respect to a year, a plan offered by an organization or sponsor that has not had a contract as a Medicare Advantage organization in the preceding 3-year period. (B) Qualifying county

“offered” applies in that section

the term “offered” means, with respect to a Medicare+Choice plan as of a date, that a Medicare+Choice eligible individual may enroll with the plan on that date, regardless of when the enrollment takes effect or when the individual obtains benefits under the plan. (j) Computation of benchmark amounts For purposes of this part, subject to subsection ( o ),

“phase-in percentage” applies in that section

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

“primary metropolitan statistical area” applies in that section

the terms “metropolitan statistical area”, “consolidated metropolitan statistical area”, and “primary metropolitan statistical area” mean any area designated as such by the Secretary of Commerce. (e) Special rules for individuals electing MSA plans (1) In general If the amount of the Medicare+Choice monthly MSA premium (as defined in section 1395w–24(b)(2)(C) of this title ) for an MSA plan for a year is less than 1 ⁄ 12 of the annual Medicare+Choice capitation rate applied under this section for the area and year involved, the Secretary shall deposit an amount equal to 100 percent of such difference in a Medicare+Choice MSA established (and, if applicable, designated) by the individual …

“qualifying county” applies in that section

The term “qualifying county” means, for a year, a county— (i) that has an MA capitation rate that, in 2004, was based on the amount specified in subsection (c)(1)(B) for a Metropolitan Statistical Area with a population of more than 250,000; (ii) for which, as of December 2009, of the Medicare Advantage eligible individuals residing in the county at least 25 percent of such individuals were enrolled in Medicare Advantage plans; and (iii) that has per capita fee-for-service spending that is lower than the national monthly per capita cost for expenditures for individuals enrolled under the original medicare fee-for-service program for the year.

“qualifying MA organization” applies in that section

the term “qualifying MA organization” means a Medicare Advantage organization that is organized as a health maintenance organization (as defined in section 300gg–91(b)(3) of this title ). (6) Meaningful EHR user attestation For purposes of this subsection and subsection (m), a qualifying MA organization shall submit an attestation, in a form and manner specified by the Secretary which may include the submission of such attestation as part of submission of the initial bid under section 1395w–24(a)(1)(A)(iv) 4 of this title, identifying— (A) whether each eligible professional described in paragraph (2), with respect to such organization is a meaningful EHR user (as defined in section 1395w–4( …

“qualifying plan” applies in that section

The term “qualifying plan” means, for a year and subject to paragraph (4), a plan that had a quality rating under paragraph (4) of 4 stars or higher based on the most recent data available for such year. (ii) Application of increases to low enrollment plans (I) 2012 For 2012,

“standardized IME cost percentage” applies in that section

The term “standardized IME cost percentage” means, for an area for a year, the per capita costs for payments under section 1395ww(d)(5)(B) of this title (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.

“MA monthly basic beneficiary premium” applies throughout its part

The term “MA monthly basic beneficiary premium” means, with respect to an MA plan— (i) described in section 1395w–23(a)(1)(B)(i) of this title (relating to plans providing rebates), zero; or (ii) described in section 1395w–23(a)(1)(B)(ii) of this title , the amount (if any) by which the unadjusted MA statutory non-drug monthly bid amount (as defined in subparagraph (E)) exceeds the applicable unadjusted MA area-specific non-drug monthly benchmark amount (as defined in section 1395w–23(j) of this title ). (B) MA monthly prescription drug beneficiary premium

“MA monthly prescription drug beneficiary premium” applies throughout its part

The term “MA monthly prescription drug beneficiary premium” means, with respect to an MA plan, the base beneficiary premium (as determined under paragraph (2) or (8) (as applicable) of section 1395w–113(a) of this title and as adjusted under section 1395w–113(a)(1)(B) of this title ), less the amount of rebate credited toward such amount under subsection (b)(1)(C)(ii)(II). (C) MA monthly supplemental beneficiary premium (i) In general

“MA monthly supplemental beneficiary premium” applies throughout its part

The term “MA monthly supplemental beneficiary premium” means, with respect to an MA plan, the portion of the aggregate monthly bid amount submitted under clause (i) of subsection (a)(6)(A) for the year that is attributable under clause (ii)(III) of such subsection to the provision of supplemental health care benefits, less the amount of rebate credited toward such portion under subsection (b)(1)(C)(ii)(I).

“Medicare+Choice monthly MSA premium” applies throughout its part

The term “Medicare+Choice monthly MSA premium” means, with respect to a Medicare+Choice plan, the amount of such premium filed under subsection (a)(3)(A) for the plan. (E) Unadjusted MA statutory non-drug monthly bid amount

“unadjusted MA statutory non-drug monthly bid amount” applies throughout its part

The term “unadjusted MA statutory non-drug monthly bid amount” means the portion of the bid amount submitted under clause (i) of subsection (a)(6)(A) for the year that is attributable under clause (ii)(I) of such subsection to the provision of benefits under the original medicare fee-for-service program option (as defined in section 1395w–22(a)(1)(B) of this title ).

“health care provider” applies in that section

the term “health care provider” means— (A) any individual who is engaged in the delivery of health care services in a State and who is required by State law or regulation to be licensed or certified by the State to engage in the delivery of such services in the State, and (B) any entity that is engaged in the delivery of health care services in a State and that, if it is required by State law or regulation to be licensed or certified by the State to engage in the delivery of such services in the State, is so licensed. (6) Regulations The Secretary shall issue regulations to carry out this subsection.

“provider-sponsored organization” applies throughout its part

the term “provider-sponsored organization” means a public or private entity— (A) that is established or organized, and operated, by a health care provider, or group of affiliated health care providers, (B) that provides a substantial proportion (as defined by the Secretary in accordance with paragraph (2)) of the health care items and services under the contract under this part directly through the provider or affiliated group of providers, and (C) with respect to which the affiliated providers share, directly or indirectly, substantial financial risk with respect to the provision of such items and services and have at least a majority financial interest in the entity.

“solvency requirements” applies in that section

the term “solvency requirements” means requirements relating to solvency and other matters covered under the standards established under section 1395w–26(a) of this title . (E) Treatment of waiver In the case of a waiver granted under this paragraph for a provider-sponsored organization with respect to a State— (i) Limitation to State The waiver shall be effective only with respect to that State and does not apply to any other State. (ii) Limitation to 36-month period The waiver shall be effective only for a 36-month period and may not be renewed.

“applicable portion” applies in that section

the term “applicable portion” means, for a fiscal year— (i) with respect to MA organizations, the Secretary’s estimate of the total proportion of expenditures under this subchapter that are attributable to expenditures made under this part (including payments under part D that are made to such organizations); or (ii) with respect to PDP sponsors, the Secretary’s estimate of the total proportion of expenditures under this subchapter that are attributable to expenditures made to such sponsors under part D.

“Medicare+Choice portion” applies in that section

the term “Medicare+Choice portion” means, for a fiscal year, the ratio, as estimated by the Secretary, of— (i) the average number of individuals enrolled in Medicare+Choice plans during the fiscal year, to (ii) the average number of individuals entitled to benefits under part A, and enrolled under part B, during the fiscal year. (F) Applicable portion defined In this paragraph,

“party in interest” applies in that section

the term “party in interest” means— (i) any director, officer, partner, or employee responsible for management or administration of a Medicare+Choice organization, any person who is directly or indirectly the beneficial owner of more than 5 percent of the equity of the organization, any person who is the beneficial owner of a mortgage, deed of trust, note, or other interest secured by, and valuing more than 5 percent of the organization, and, in the case of a Medicare+Choice organization organized as a nonprofit corporation, an incorporator or member of such corporation under applicable State corporation law; (ii) any entity in which a person described in clause (i)— (I) is an officer or …

“allowable costs” applies in that section

the term “allowable costs” means, with respect to an MA regional plan for a year, the total amount of costs described in subparagraph (B) for the plan and year, reduced by the portion of such costs attributable to administrative expenses incurred in providing the benefits described in such subparagraph. (D) Rebatable integrated benefits For purposes of this subsection,

“essential hospital” applies in that section

the term “essential hospital” means, with respect to an MA regional plan offered by an MA organization, a subsection (d) hospital (as defined in section 1395ww(d) of this title ) that the Secretary determines, based upon an application filed by the organization with the Secretary, is necessary to meet the requirements referred to in paragraph (1) for such plan.

“MA region” applies throughout its subchapter

the term “MA region” means such a region within the 50 States and the District of Columbia as established by the Secretary under this paragraph. (B) Establishment (i) Initial establishment Not later than January 1, 2005 , the Secretary shall first establish and publish MA regions. (ii) Periodic review and revision of service areas The Secretary may periodically review MA regions under this paragraph and, based on such review, may revise such regions if the Secretary determines such revision to be appropriate.

“MA region-specific non-drug monthly benchmark amount” applies in that section

the term “MA region-specific non-drug monthly benchmark amount” means, with respect to an MA region for a month in a year, the sum of the 2 components described in paragraph (2) for the region and year. The Secretary shall compute such benchmark amount for each MA region before the beginning of each annual, coordinated election period under section 1395w–21(e)(3)(B) of this title for each year (beginning with 2006).

“rebatable integrated benefits” applies in that section

the term “rebatable integrated benefits” means such non-drug supplemental benefits under subclause (I) of section 1395w–24(b)(1)(C)(ii) of this title pursuant to a rebate under such section that the Secretary determines are integrated with the benefits described in subparagraph (B)(i). (2) Adjustment of payment (A) No adjustment if allowable costs within 3 percent of target amount If the allowable costs for the plan for the year are at least 97 percent, but do not exceed 103 percent, of the target amount for the plan and year, there shall be no payment adjustment under this subsection for the plan and year.

“reference month” applies throughout its part

the term “reference month” means, with respect to a year, the most recent month during the previous year for which the Secretary determines that data are available to compute the percentage specified in subparagraph (A) and other relevant percentages under this part. (5) Determination of weighted average MA bids for a region (A) In general For purposes of paragraph (2)(B)(i), the weighted average of plan bids for an MA region and a year is the sum, for MA regional plans described in subparagraph (D) in the region and year, of the products (for each such plan) of the following: (i) Monthly MA statutory non-drug bid amount The unadjusted MA statutory non-drug monthly bid amount for the plan.

“statutory region-specific non-drug amount” applies in that section

the term “statutory region-specific non-drug amount” means, for an MA region and year, an amount equal the sum (for each MA local area within the region) of the product of— (A) MA area-specific non-drug monthly benchmark amount under section 1395w–23(j)(1)(A) of this title for that area and year; and (B) the number of MA eligible individuals residing in the local area, divided by the total number of MA eligible individuals residing in the region.

“target amount” applies in that section

the term “target amount” means, with respect to an MA regional plan offered by an organization in a year, an amount equal to— (i) the sum of— (I) the total monthly payments made to the organization for enrollees in the plan for the year that are attributable to benefits under the original medicare fee-for-service program option (as defined in section 1395w–22(a)(1)(B) of this title ); (II) the total of the MA monthly basic beneficiary premium collectable for such enrollees for the year; and (III) the total amount of the rebates under section 1395w–24(b)(1)(C)(ii) of this title that are attributable to rebatable integrated benefits; reduced by (ii) the amount of administrative expenses …

“applicable individual” applies in that section

the term “applicable individual” means an individual who— (i) is enrolled under a specialized MA plan for special needs individuals (as defined in subsection (b)(6)); and (ii) is not within the 1 or more of the classes of special needs individuals to which enrollment under the plan is restricted to. (C) Exception The Secretary shall provide for an exception to the transition described in subparagraph (A) for a limited period of time for individuals enrolled under a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii) who are no longer eligible for medical assistance under subchapter XIX.

“MA local plan” applies throughout its part

The term “MA local plan” means an MA plan that is not an MA regional plan. (6) Specialized MA plans for special needs individuals (A) In general

“MA regional plan” applies throughout its part

The term “MA regional plan” means an MA plan described in section 1395w–21(a)(2)(A)(i) of this title — (A) that has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan; (B) that provides for reimbursement for all covered benefits regardless of whether such benefits are provided within such network of providers; and (C) the service area of which is one or more entire MA regions. (5) MA local plan

“Medicare+Choice organization” applies throughout its part

The term “Medicare+Choice organization” means a public or private entity that is certified under section 1395w–26 of this title as meeting the requirements and standards of this part for such an organization. (2) Provider-sponsored organization The term “provider-sponsored organization” is defined in section 1395w–25(d)(1) of this title . (b) Definitions relating to Medicare+Choice plans (1) Medicare+Choice plan

“Medicare+Choice plan” applies throughout its part

The term “Medicare+Choice plan” means health benefits coverage offered under a policy, contract, or plan by a Medicare+Choice organization pursuant to and in accordance with a contract under section 1395w–27 of this title . (2) Medicare+Choice private fee-for-service plan

“Medicare+Choice private fee-for-service plan” applies throughout its part

The term “Medicare+Choice private fee-for-service plan” means a Medicare+Choice plan that— (A) reimburses hospitals, physicians, and other providers at a rate determined by the plan on a fee-for-service basis without placing the provider at financial risk; (B) does not vary such rates for such a provider based on utilization relating to such provider; and (C) does not restrict the selection of providers among those who are lawfully authorized to provide the covered services and agree to accept the terms and conditions of payment established by the plan.

“MSA plan” applies throughout its part

The term “MSA plan” means a Medicare+ÐChoice plan that— (i) provides reimbursement for at least the items and services described in section 1395w–22(a)(1) of this title in a year but only after the enrollee incurs countable expenses (as specified under the plan) equal to the amount of an annual deductible (described in subparagraph (B)); (ii) counts as such expenses (for purposes of such deductible) at least all amounts that would have been payable under parts A and B, and that would have been payable by the enrollee as deductibles, coinsurance, or copayments, if the enrollee had elected to receive benefits through the provisions of such parts; and (iii) provides, after such deductible is …

“special needs individual” applies throughout its part

The term “special needs individual” means an MA eligible individual who— (i) is institutionalized (as defined by the Secretary); (ii) is entitled to medical assistance under a State plan under subchapter XIX; or (iii) meets such requirements as the Secretary may determine would benefit from enrollment in such a specialized MA plan described in subparagraph (A) for individuals with severe or disabling chronic conditions who— (I) before January 1, 2022 , 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 …

“specialized MA plan for special needs individuals” applies throughout its part

The term “specialized MA plan for special needs individuals” means an MA plan that exclusively serves special needs individuals (as defined in subparagraph (B)) 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. (B) Special needs individual

“bid” applies in that section

the term “bid” means an offer to furnish an item or service for a particular price and time period that includes, where appropriate, any services that are attendant to the furnishing of the item or service. (C) Rules for mergers and acquisitions In applying subparagraph (A) to a contractor, the contractor shall include a successor entity in the case of a merger or acquisition, if the successor entity assumes such contract along with any liabilities that may have occurred thereunder.

“covered document” applies in that section

the term “covered document” means a financial, tax, or other document required to be submitted by a bidder as part of an original bid submission under a competitive acquisition program in order to meet required financial standards. Such term does not include other documents, such as the bid itself or accreditation documentation.

“applicable percentage” applies in that section

the term “applicable percentage” means— (I) subject to subclause (II), 10 percent; and (II) if applicable, in the case of a refundable single-dose container or single-use package drug described in clause (ii), a percentage specified by the Secretary pursuant to such clause. (ii) Treatment of drugs that have unique circumstances In the case of a refundable single-dose container or single-use package drug that has unique circumstances involving similar loss of product as that described in paragraph (8)(B)(ii), the Secretary, through notice and comment rulemaking, may increase the applicable percentage otherwise applicable under clause (i)(I) as determined appropriate by the Secretary.

“applicable threshold percentage” applies in that section

the term “applicable threshold percentage” means— (i) in 2005, in the case of an average sales price for a drug or biological that exceeds widely available market price or the average manufacturer price, 5 percent; and (ii) in 2006 and subsequent years, the percentage applied under this subparagraph subject to such adjustment as the Secretary may specify for the widely available market price or the average manufacturer price, or both.

“benchmark period CPI–U” applies in that section

The term “benchmark period CPI–U” means the consumer price index for all urban consumers (United States city average) for January 2021. (F) Rebate period CPI–U

“billing unit” applies in that section

the term “billing unit” means the identifiable quantity associated with a billing and payment code, as established by the Secretary. (7) Special rule Beginning with April 1, 2008 , the payment amount for— (A) each single source drug or biological described in section 1395u( o )(1)(G) of this title that is treated as a multiple source drug because of the application of subsection (c)(6)(C)(ii) is the lower of— (i) the payment amount that would be determined for such drug or biological applying such subsection; or (ii) the payment amount that would have been determined for such drug or biological if such subsection were not applied; and (B) a multiple source drug described in section 1395u( o …

“biosimilar biological product” applies in that section

The term “biosimilar biological product” means a biological product approved under an abbreviated application for a license of a biological product that relies in part on data or information in an application for another biological product licensed under section 262 of this title . (I) Reference biological product

“manufacturer” applies in that section

The term “manufacturer” means, with respect to a drug or biological, the manufacturer (as defined in section 1396r–8(k)(5) of this title ), except that, for purposes of subsection (f)(2), the Secretary may, if the Secretary determines appropriate, exclude repackagers of a drug or biological from such term. (B) Wholesale acquisition cost

“multiple source drug” applies in that section

The term “multiple source drug” means, for a calendar quarter, a drug for which there are 2 or more drug products which— (I) are rated as therapeutically equivalent (under the Food and Drug Administration’s most recent publication of “Approved Drug Products with Therapeutic Equivalence Evaluations”), (II) except as provided in subparagraph (E), are pharmaceutically equivalent and bioequivalent, as determined under subparagraph (F) and as determined by the Food and Drug Administration, and (III) are sold or marketed in the United States during the quarter.

“part B rebatable drug” applies in that section

the term “part B rebatable drug” means a single source drug or biological (as defined in subparagraph (D) of subsection (c)(6)), including a biosimilar biological product (as defined in subparagraph (H) of such subsection) but excluding a qualifying biosimilar biological product (as defined in subsection (b)(8)(B)(iii)), for which payment is made under this part, except such term shall not include such a drug or biological— (i) if, as determined by the Secretary, the average total allowed charges for such drug or biological under this part for a year per individual that uses such a drug or biological are less than, subject to subparagraph (B), $100; or (ii) that is a vaccine described in …

“payment amount benchmark quarter” applies in that section

The term “payment amount benchmark quarter” means the calendar quarter beginning July 1, 2021 . (E) Benchmark period CPI–U

“qualifying biosimilar biological product” applies in that section

the term “qualifying biosimilar biological product” means a biosimilar biological product described in paragraph (1)(C) with respect to which— (I) in the case of a product described in clause (ii)(I), the average sales price under paragraph (8)(A)(i) for a calendar quarter during the 5-year period described in such clause is not more than the average sales price under paragraph (4)(A) for such quarter for the reference biological product; and (II) in the case of a product described in clause (ii)(II), the average sales price under paragraph (8)(A)(i) for a calendar quarter during the 5-year period described in such clause is not more than the average sales price under paragraph (4)(A) for …

“rebate period CPI–U” applies in that section

The term “rebate period CPI–U” means, with respect to a calendar quarter described in subparagraph (C), the greater of the benchmark period CPI–U and the consumer price index for all urban consumers (United States city average) for the first month of the calendar quarter that is two calendar quarters prior to such described calendar quarter.

“reference biological product” applies in that section

The term “reference biological product” means the biological product licensed under such section 262 of this title that is referred to in the application described in subparagraph (H) of the biosimilar biological product. (d) Monitoring of market prices (1) In general The Inspector General of the Department of Health and Human Services shall conduct studies, which may include surveys, to determine the widely available market prices of drugs and biologicals to which this section applies, as the Inspector General, in consultation with the Secretary, determines to be appropriate.

“refundable single-dose container or single-use package drug” applies in that section

the term “refundable single-dose container or single-use package drug” means a single source drug or biological (as defined in subsection (c)(6)(D)) or a biosimilar biological product (as defined in subsection (c)(6)(H)) for which payment is made under this part and that is furnished from a single-dose container or single-use package.

“single source drug or biological” applies in that section

The term “single source drug or biological” means— (i) a biological; or (ii) a drug which is not a multiple source drug and which is produced or distributed under a new drug application approved by the Food and Drug Administration, including a drug product marketed by any cross-licensed producers or distributors operating under the new drug application.

“unit” applies in that section

the term “unit” means, with respect to each National Drug Code (including package size) associated with a drug or biological, the lowest identifiable quantity (such as a capsule or tablet, milligram of molecules, or grams) of the drug or biological that is dispensed, exclusive of any diluent without reference to volume measures pertaining to liquids. For years after 2004, the Secretary may establish the unit for a manufacturer to report and methods for counting units as the Secretary determines appropriate to implement this section.

“wholesale acquisition cost” applies in that section

The term “wholesale acquisition cost” means, with respect to a drug or biological, the manufacturer’s list price for the drug or biological to wholesalers or direct purchasers in the United States, not including prompt pay or other discounts, rebates or reductions in price, for the most recent month for which the information is available, as reported in wholesale price guides or other publications of drug or biological pricing data. (C) Multiple source drug (i) In general

“widely available market price” applies in that section

the term “widely available market price” means the price that a prudent physician or supplier would pay for the drug or biological. In determining such price, the Inspector General shall take into account the discounts, rebates, and other price concessions routinely made available to such prudent physicians or suppliers for such drugs or biologicals. (B) Considerations In determining the price under subparagraph (A), the Inspector General shall consider information from one or more of the following sources: (i) Manufacturers. (ii) Wholesalers. (iii) Distributors. (iv) Physician supply houses. (v) Specialty pharmacies. (vi) Group purchasing arrangements. (vii) Surveys of physicians.

“area” applies in that section

The terms “competitive acquisition area” and “area” mean an appropriate geographic region established by the Secretary under the program. (D) Contractor

“bid” applies in that section

the term “bid” means an offer to furnish a competitively biddable drug or biological for a particular price and time period. (3) Bidding on a national or regional basis Nothing in this section shall be construed as precluding a bidder from bidding for contracts in all areas of the United States or as requiring a bidder to submit a bid for all areas of the United States. (4) Uniformity of bids within area The amount of the bid submitted under a contract offer for any competitively biddable drug or biological for an area shall be the same for that drug or biological for all portions of that area.

“competitive acquisition area” applies in that section

The terms “competitive acquisition area” and “area” mean an appropriate geographic region established by the Secretary under the program. (D) Contractor

“competitively biddable drugs and biologicals” applies in that section

The term “competitively biddable drugs and biologicals” means a drug or biological described in section 1395u( o )(1)(C) of this title and furnished on or after January 1, 2006 . (B) Program

“contractor” applies in that section

The term “contractor” means an entity that has entered into a contract with the Secretary under this section. (3) Application of program payment methodology (A) In general With respect to competitively biddable drugs and biologicals which are supplied under the program in an area and which are prescribed by a physician who has elected this section to apply— (i) the claim for such drugs and biologicals shall be submitted by the contractor that supplied the drugs and biologicals; (ii) collection of amounts of any deductible and coinsurance applicable with respect to such drugs and biologicals shall be the responsibility of such contractor and shall not be collected unless the drug or …

“program” applies in that section

The term “program” means the competitive acquisition program under this section. (C) Competitive acquisition area; area

“selecting physician” applies in that section

the term “selecting physician” means, with respect to a contractor and category and competitive acquisition area, a physician who has elected this section to apply and has selected to apply under this section such contractor for such category and area. (b) Program requirements (1) Contract for competitively biddable drugs and biologicals The Secretary shall conduct a competition among entities for the acquisition of competitively biddable drugs and biologicals.

“adjusted historical payment basis” applies in that section

the term “adjusted historical payment basis” means, with respect to a physicians’ service furnished in a fee schedule area, the weighted average prevailing charge applied in the area for the service in 1991 (as determined by the Secretary without regard to physician specialty and as adjusted to reflect payments for services with customary charges below the prevailing charge or other payment limitations imposed by law or regulation) adjusted by the update established under subsection (d)(3) for 1992.

“applicable electronic prescribing percent” applies in that section

the term “applicable electronic prescribing percent” means— (i) for 2009 and 2010, 2.0 percent; (ii) for 2011 and 2012, 1.0 percent; and (iii) for 2013, 0.5 percent. (D) Limitation with respect to EHR incentive payments The provisions of this paragraph shall not apply to an eligible professional (or, in the case of a group practice under paragraph (3)(C), to the group practice) if, for the EHR reporting period the eligible professional (or group practice) receives an incentive payment under subsection ( o )(1)(A) with respect to a certified EHR technology (as defined in subsection ( o )(4)) that has the capability of electronic prescribing.

“applicable percent” applies in that section

the term “applicable percent” means— (I) for 2012, 99 percent; (II) for 2013, 98.5 percent; and (III) for 2014, 98 percent. (B) Significant hardship exception The Secretary may, on a case-by-case basis, exempt an eligible professional from the application of the payment adjustment under subparagraph (A) if the Secretary determines, subject to annual renewal, that compliance with the requirement for being a successful electronic prescriber would result in a significant hardship, such as in the case of an eligible professional who practices in a rural area without sufficient Internet access.

“applicable period” applies in that section

The term “applicable period” means— (i) a fiscal year, in the case of fiscal year 1998, fiscal year 1999, and fiscal year 2000; or (ii) a calendar year with respect to a year beginning with 2000; as the case may be.

“applicable practitioner” applies in that section

The term “applicable practitioner” means— (i) a physician assistant, nurse practitioner, and clinical nurse specialist (as such terms are defined in section 1395x(aa)(5) of this title ), and a certified registered nurse anesthetist (as defined in section 1395x(bb)(2) of this title ); and (ii) beginning January 1, 2019 , such other eligible professionals (as defined in subsection (k)(3)(B)) as specified by the Secretary. (10) Clarification The provisions of sections 1395aaa(b)(7) of this title and 1395aaa–1 of this title shall not apply to this subsection.

“applicable provisions” applies in that section

the term “applicable provisions” means the following provisions: (A) Subsection (q)(2)(B)(i). (B) section 13 1395 l (z)(3)(D) of this title. (6) Funding For purposes of carrying out this subsection, the Secretary shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund under section 1395t of this title , of $15,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for each of fiscal years 2015 through 2019. Amounts transferred under this paragraph shall remain available through the end of fiscal year 2022.

“applicable quality percent” applies in that section

the term “applicable quality percent” means— (i) for 2007 and 2008, 1.5 percent; (ii) for 2009 and 2010, 2.0 percent; (iii) for 2011, 1.0 percent; and (iv) for 2012, 2013, and 2014, 0.5 percent. (2) Incentive payments for electronic prescribing (A) In general Subject to subparagraph (D), for 2009 through 2013, with respect to covered professional services furnished during a reporting period by an eligible professional, if the eligible professional is a successful electronic prescriber for such reporting period, in addition to the amount otherwise paid under this part, there also shall be paid to the eligible professional (or to an employer or facility in the cases described in clause (A) of …

“applicable site of service” applies in that section

The term “applicable site of service” means a site of service other than a site where the facility rate under the fee schedule under this subsection applies and other than an office setting. (ii) Psychotherapy for crisis services The code descriptions for services described in subparagraph (B) shall be the same as the code descriptions for services identified, as of January 1, 2022 , by HCPCS codes 90839 and 90840 (and any succeeding codes), except that such new codes shall be limited to services furnished in an applicable site of service.

“base allowed charges” applies in that section

the term “base allowed charges” means, with respect to a physician’s service, the national average allowed charges for the service under this part for services furnished during 1991, as estimated by the Secretary using the most recent data available.

“category” applies in that section

the term “category” means, with respect to physicians’ services, surgical services, and all physicians’ services other than surgical services (as defined by the Secretary and including anesthesia services), primary care services (as defined in section 1395u(i)(4) of this title ), and all other physicians’ services. The Secretary shall define surgical services and publish such definition in the Federal Register no later than May 1, 1990 , after consultation with organizations representing physicians. (2) Fee schedule area Except as provided in subsection (e)(6)(D),

“certified EHR technology” applies in that section

the term “certified EHR technology” means a qualified electronic health record (as defined in section 300jj(13) of this title ) that is certified pursuant to section 300jj–11(c)(5) of this title as meeting standards adopted under section 300jj–14 of this title that are applicable to the type of record involved (as determined by the Secretary, such as an ambulatory electronic health record for office-based physicians or an inpatient hospital electronic health record for hospitals). (5) Definitions For purposes of this subsection: (A) Covered professional services

“clinical practice improvement activity” applies in that section

the term “clinical practice improvement activity” means an activity that relevant eligible professional organizations and other relevant stakeholders identify as improving clinical practice or care delivery and that the Secretary determines, when effectively executed, is likely to result in improved outcomes.

“computed radiography technology” applies in that section

the term “computed radiography technology” means cassette-based imaging which utilizes an imaging plate to create the image involved. (D) Implementation In order to implement this paragraph, the Secretary shall adopt appropriate mechanisms which may include use of modifiers.

“costs” applies in that section

The term “costs” means expenditures per individual as determined appropriate by the Secretary. In making the determination under the preceding sentence, the Secretary may take into account the amount of growth in expenditures per individual for a physician compared to the amount of such growth for other physicians. (B) Performance period

“covered professional services” applies in that section

The terms “eligible professional” and “covered professional services” have the meanings given such terms in subsection (k)(3). (ii) Physician reporting system

“EHR reporting period” applies in that section

The term “EHR reporting period” means, with respect to a year, a period (or periods) specified by the Secretary. (iii) Eligible professional

“eligible professional” applies in that section

The terms “eligible professional” and “covered professional services” have the meanings given such terms in subsection (k)(3). (ii) Physician reporting system

“eligible professional organization” applies in that section

the term “eligible professional organization” means a professional organization as defined by nationally recognized specialty boards of certification or equivalent certification boards. (iii) Requirements In selecting quality measures for inclusion in the annual final list under clause (i), the Secretary shall— (I) provide that, to the extent practicable, all quality domains (as defined in subsection (s)(1)(B)) are addressed by such measures; and (II) ensure that such selection is consistent with the process for selection of measures under subsections (k), (m), and (p)(2).

“fee schedule area” applies in that section

the term “fee schedule area” means a locality used under section 1395u(b) of this title for purposes of computing payment amounts for physicians’ services. (3) Physicians’ services

“fifth payment year” applies in that section

The terms “second payment year”, “third payment year”, “fourth payment year”, and “fifth payment year” mean, with respect to covered professional services furnished by such eligible professional, each successive year immediately following the first payment year for such professional.

“first payment year” applies in that section

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

“fourth payment year” applies in that section

The terms “second payment year”, “third payment year”, “fourth payment year”, and “fifth payment year” mean, with respect to covered professional services furnished by such eligible professional, each successive year immediately following the first payment year for such professional.

“hospital-based eligible professional” applies in that section

the term “hospital-based eligible professional” means, with respect to covered professional services furnished by an eligible professional during the EHR reporting period for a payment year, an eligible professional, such as a pathologist, anesthesiologist, or emergency physician, who furnishes substantially all of such services in a hospital inpatient or emergency room setting and through the use of the facilities and equipment, including qualified electronic health records, of the hospital.

“Maintenance of Certification Program” applies in that section

The term “Maintenance of Certification Program” means a continuous assessment program, such as qualified American Board of Medical Specialties Maintenance of Certification program or an equivalent program (as determined by the Secretary), that advances quality and the lifelong learning and self-assessment of board certified specialty physicians by focusing on the competencies of patient care, medical knowledge, practice-based learning, interpersonal and communication skills and professionalism. Such a program shall include the following: (I) The program requires the physician to maintain a valid, unrestricted medical license in the United States.

“malpractice component” applies in that section

The term “malpractice component” means the portion of the resources used in furnishing the service that reflects malpractice expenses in furnishing the service. (2) Determination of relative values (A) In general (i) Combination of units for components The Secretary shall develop a methodology for combining the work, practice expense, and malpractice relative value units, determined under subparagraph (C), for each service in a manner to produce a single relative value for that service. Such relative values are subject to adjustment under subparagraph (F)(i) and section 13515(b) of the Omnibus Budget Reconciliation Act of 1993.

“Medicare+Choice plan enrollee” applies in that section

The term “Medicare+Choice plan enrollee” means, with respect to a fiscal year, an individual enrolled under this part who has elected to receive benefits under this subchapter for the fiscal year through a Medicare+Choice plan offered under part C, and also includes an individual who is receiving benefits under this part through enrollment with an eligible organization with a risk-sharing contract under section 1395mm of this title . (C) Applicable period

“MIPS eligible professional” applies in that section

the term “MIPS eligible professional” means— (I) for the first and second years for which the MIPS applies to payments (and for the performance period for such first and second year), a physician (as defined in section 1395x(r) of this title ), a physician assistant, nurse practitioner, and clinical nurse specialist (as such terms are defined in section 1395x(aa)(5) of this title ), a certified registered nurse anesthetist (as defined in section 1395x(bb)(2) of this title ), and a group that includes such professionals; and (II) for the third year for which the MIPS applies to payments (and for the performance period for such third year) and for each succeeding year (and for the performance …

“partial qualifying APM participant” applies in that section

the term “partial qualifying APM participant” means, with respect to a year, an eligible professional for whom the Secretary determines the minimum payment percentage (or percentages), as applicable, described in paragraph (2) of section 1395 l (z) of this title for such year have not been satisfied, but who would be considered a qualifying APM participant (as defined in such paragraph) for such year if— (I) with respect to 2019 and 2020, the reference in subparagraph (A) of such paragraph to 25 percent was instead a reference to 20 percent; (II) with respect to each of 2021 through 2026 and 2028— (aa) the reference in subparagraph (B)(i) of such paragraph to 50 percent was instead a …

“payment year” applies in that section

the term “payment year” means a year beginning with 2011. (ii) First, second, etc. payment year

“performance period” applies in that section

The term “performance period” means a period specified by the Secretary. (9) Coordination with other value-based purchasing reforms The Secretary shall coordinate the value-based payment modifier established under this subsection with the Physician Feedback Program under subsection (n) and, as the Secretary determines appropriate, other similar provisions of this subchapter.

“physician” applies in that section

The term “physician” has the meaning given that term in section 1395x(r)(1) of this title . (ii) Treatment of groups Such term includes, as the Secretary determines appropriate, a group of physicians. (G) Limitations on review There shall be no administrative or judicial review under section 1395ff of this title , section 1395 oo of this title, or otherwise of the establishment of the methodology under subparagraph (C), including the determination of an episode of care under such methodology.

“physician reporting system” applies in that section

The term “physician reporting system” means the system established under subsection (k). (iii) Reporting period

“physicians’ services” applies in that section

The term “physicians’ services” includes other items and services (such as clinical diagnostic laboratory tests and radiology services), specified by the Secretary, that are commonly performed or furnished by a physician or in a physician’s office, but does not include services furnished to a Medicare+ÐChoice plan enrollee. (B) Medicare+Choice plan enrollee

“practice expense component” applies in that section

The term “practice expense component” means the portion of the resources used in furnishing the service that reflects the general categories of expenses (such as office rent and wages of personnel, but excluding malpractice expenses) comprising practice expenses. (C) “Malpractice component” defined

“practice expenses” applies in that section

The term “practice expenses” includes all expenses for furnishing physicians’ services, excluding malpractice expenses, physician compensation, and other physician fringe benefits. (k) Quality reporting system (1) In general The Secretary shall implement a system for the reporting by eligible professionals of data on quality measures specified under paragraph (2). Such data shall be submitted in a form and manner specified by the Secretary (by program instruction or otherwise), which may include submission of such data on claims under this part.

“qualified Maintenance of Certification Program practice assessment” applies in that section

The term “qualified Maintenance of Certification Program practice assessment” means an assessment of a physician’s practice that— (I) includes an initial assessment of an eligible professional’s practice that is designed to demonstrate the physician’s use of evidence-based medicine; (II) includes a survey of patient experience with care; and (III) requires a physician to implement a quality improvement intervention to address a practice weakness identified in the initial assessment under subclause (I) and then to remeasure to assess performance improvement after such intervention.

“quality domains” applies in that section

the term “quality domains” means at least the following domains: (i) Clinical care. (ii) Safety. (iii) Care coordination. (iv) Patient and caregiver experience. (v) Population health and prevention. (C) Consideration In developing the draft plan under this paragraph, the Secretary shall consider— (i) gap analyses conducted by the entity with a contract under section 1395aaa(a) of this title or other contractors or entities; (ii) whether measures are applicable across health care settings; (iii) clinical practice improvement activities submitted under subsection (q)(2)(C)(iv) for identifying possible areas for future measure development and identifying existing gaps with respect to such …

“quality reporting period” applies in that section

The term “quality reporting period” means, with respect to a year, a period specified by the Secretary. (9) Information reporting on services included in global surgical packages With respect to services for which a physician is required to report information in accordance with subsection (c)(8)(B)(i), the Secretary may through rulemaking delay payment of 5 percent of the amount that would otherwise be payable under the physician fee schedule under this section for such services until the information so required is reported.

“recognized payment amount” applies in that section

the term “recognized payment amount” means, for services furnished on or after January 1, 1992 , the fee schedule amount determined under subsection (a) (or, if payment under this part is made on a basis other than the fee schedule under this section, 95 percent of the other payment basis), and, for services furnished during 1991, the applicable percentage (as defined in section 1395u(b)(4)(A)(iv) of this title ) of the prevailing charge (or fee schedule amount) for nonparticipating physicians for that year.

“reporting period” applies in that section

The term “reporting period” means, with respect to a year, a period specified by the Secretary. (6) Special rule for teaching anesthesiologists With respect to physicians’ services furnished on or after January 1, 2010 , in the case of teaching anesthesiologists involved in the training of physician residents in a single anesthesia case or two concurrent anesthesia cases, the fee schedule amount to be applied shall be 100 percent of the fee schedule amount otherwise applicable under this section if the anesthesia services were personally performed by the teaching anesthesiologist alone and paragraph (4) shall not apply if— (A) the teaching anesthesiologist is present during all critical or …

“second payment year” applies in that section

The terms “second payment year”, “third payment year”, “fourth payment year”, and “fifth payment year” mean, with respect to covered professional services furnished by such eligible professional, each successive year immediately following the first payment year for such professional.

“third payment year” applies in that section

The terms “second payment year”, “third payment year”, “fourth payment year”, and “fifth payment year” mean, with respect to covered professional services furnished by such eligible professional, each successive year immediately following the first payment year for such professional.

“transition area” applies in that section

the term “transition area” means each of the following fee schedule areas for 2013: (i) The rest-of-State payment locality. (ii) Payment locality 3. (E) References to fee schedule areas Effective for services furnished on or after January 1, 2017 , for California, any reference in this section to a fee schedule area shall be deemed a reference to a fee schedule area established in accordance with this paragraph.

“work component” applies in that section

The term “work component” means the portion of the resources used in furnishing the service that reflects physician time and intensity in furnishing the service. Such portion shall— (i) include activities before and after direct patient contact, and (ii) be defined, with respect to surgical procedures, to reflect a global definition including pre-operative and post-operative physicians’ services. (B) “Practice expense component” defined

“eligible professional” applies in that section

The term “eligible professional” has the meaning given that term for purposes of the Physician Quality Reporting Initiative under section 1848 of the Social Security Act ( 42 U.S.C. 1395w–4 ). (2) Physician

“physician” applies in that section

The term “physician” has the meaning given that term in section 1861(r) of such Act ( 42 U.S.C. 1395x(r) ). (3) Physician Compare

“Physician Compare” applies in that section

The term “Physician Compare” means the Internet website developed under subsection (a)(1). (4) Secretary

“Secretary” applies in that section

The term “Secretary” means the Secretary of Health and Human Services.

“eligible professional” applies in that section

The terms “eligible professional”, “physician”, and “Secretary” have the meaning given such terms in section 1395w–5(i) of this title . (2) Physician compare

“physician” applies in that section

The terms “eligible professional”, “physician”, and “Secretary” have the meaning given such terms in section 1395w–5(i) of this title . (2) Physician compare

“Physician Compare” applies in that section

The term “Physician Compare” means the Physician Compare Internet website of the Centers for Medicare & Medicaid Services (or a successor website).

“Secretary” applies in that section

The terms “eligible professional”, “physician”, and “Secretary” have the meaning given such terms in section 1395w–5(i) of this title . (2) Physician compare

“a review of any current opioid prescriptions” applies in that section

the term “a review of any current opioid prescriptions” means, with respect to an individual determined to have a current prescription for opioids— (A) a review of the potential risk factors to the individual for opioid use disorder; (B) an evaluation of the individual’s severity of pain and current treatment plan; (C) the provision of information on non-opioid treatment options; and (D) a referral to a specialist, as appropriate. (xx) Cardiovascular screening blood test;

“additional preventive services” applies in that section

The term “additional preventive services” means services not described in subparagraph (A) or (C) of paragraph (3) 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.

“applicable provider” applies in that section

The term “applicable provider” means— (i) a physician; (ii) a nurse practitioner; and (iii) a physician assistant.;

“attending physician” applies throughout its subchapter

The term “attending physician” means, with respect to an individual, the physician (as defined in subsection (r)(1)), the nurse practitioner (as defined in subsection (aa)(5)), or the physician assistant (as defined in such subsection), who may be employed by a hospice program, whom the individual identifies as having the most significant role in the determination and delivery of medical care to the individual at the time the individual makes an election to receive hospice care.

“audiology services” applies in that section

The term “audiology services” means such hearing and balance assessment services furnished by a qualified audiologist as the audiologist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law), as would otherwise be covered if furnished by a physician. (4) In this subsection:;

“bona fide emergency services” applies throughout its chapter

the term “bona fide emergency services” means services provided in a hospital emergency room after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in— (I) placing the patient’s health in serious jeopardy; (II) serious impairment to bodily functions; or (III) serious dysfunction of any bodily organ or part.

“bone mass measurement” applies in that section

The term “bone mass measurement” means a radiologic or radioisotopic procedure or other procedure approved by the Food and Drug Administration performed on a qualified individual (as defined in paragraph (2)) for the purpose of identifying bone mass or detecting bone loss or determining bone quality, and includes a physician’s interpretation of the results of the procedure. (2) For purposes of this subsection,