P.L. 114–010, Approved April 16, 2015 (129Stat. 87)

Medicare Access and CHIP Reauthorization Act of 2015

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 [42U.S.C. 1305 note]  To amend title XVIII of the Social Security Act to repeal the Medicare sustainable growth rate and strengthen Medicare access by improving physician payments and making other improvements, to reauthorize the Children's Health Insurance Program, and for other purposes. This Act may be cited as the “Medicare Access and CHIP Reauthorization Act of 2015”.

SECTION 101. REPEALING THE SUSTAINABLE GROWTH RATE (SGR) AND IMPROVING MEDICARE PAYMENT FOR PHYSICIANS' SERVICES

(a) Stabilizing Fee Updates.—

(1)  Repeal of sgr payment methodology.—Section 1848 of the Social Security Act (42 U.S.C. 1395w-4) is amended —

(A)  in subsection (d) —

(i)  in paragraph (1)(A) —

(I)  by inserting “and ending with 2025” after “beginning with 2001”; and

(II)  by inserting “or a subsequent paragraph” after “paragraph (4)”; and

(ii)  in paragraph (4) —

(I)  in the heading, by inserting “and ending with 2014” after “years beginning with 2001”; and

(II)  in subparagraph (A), by inserting “and ending with 2014” after “a year beginning with 2001”; and

(B)  in subsection (f) —

(i)  in paragraph (1)(B), by inserting “through 2014” after “of each succeeding year”; and

(ii)  in paragraph (2), in the matter preceding subparagraph (A), by inserting “and ending with 2014” after “beginning with 2000”.

(2)  Update of rates for 2015 and subsequent years.—Subsection (d) of section 1848 of the Social Security Act (42 U.S.C. 1395w-4) is amended —

(A)  in paragraph (1)(A), by adding at the end the following: “There shall be two separate conversion factors for each year beginning with 2026, one for items and services furnished by a qualifying APM participant (as defined in section 1833(z)(2)) (referred to in this subsection as the `qualifying APM conversion factor') and the other for other items and services (referred to in this subsection as the `nonqualifying APM conversion factor'), equal to the respective conversion factor for the previous year (or, in the case of 2026, equal to the single conversion factor for 2025) multiplied by the update established under paragraph (20) for such respective conversion factor for such year.”;

(B)  in paragraph (1)(D), by inserting “(or, beginning with 2026, applicable conversion factor)” after “single conversion factor”; and

(C)  by striking paragraph (16) and inserting the following new paragraphs:

“(16) Update for january through june of 2015. — Subject to paragraphs (7)(B), (8)(B), (9)(B), (10)(B), (11)(B), (12)(B), (13)(B), (14)(B), and (15)(B), in lieu of the update to the single conversion factor established in paragraph (1)(C) that would otherwise apply for 2015 for the period beginning on January 1, 2015, and ending on June 30, 2015, the update to the single conversion factor shall be 0.0 percent.

“(17) Update for july through december of 2015. — The update to the single conversion factor established in paragraph (1)(C) for the period beginning on July 1, 2015, and ending on December 31, 2015, shall be 0.5 percent.

“(18) Update for 2016 through 2019. — The update to the single conversion factor established in paragraph (1)(C) for 2016 and each subsequent year through 2019 shall be 0.5 percent.

“(19) Update for 2020 through 2025. — The update to the single conversion factor established in paragraph (1)(C) for 2020 and each subsequent year through 2025 shall be 0.0 percent.

“(20) Update for 2026 and subsequent years. — For 2026 and each subsequent year, the update to the qualifying APM conversion factor established under paragraph (1)(A) is 0.75 percent, and the update to the nonqualifying APM conversion factor established under such paragraph is 0.25 percent.”.

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(b) Consolidation of Certain Current Law Performance Programs With New Merit-Based Incentive Payment System.—

(1) EHR meaningful use incentive program.—

(A)  Sunsetting separate meaningful use payment adjustments.—Section 1848(a)(7)(A) of the Social Security Act (42 U.S.C. 1395w-4(a)(7)(A)) is amended —

(i)  in clause (i), by striking “2015 or any subsequent payment year” and inserting “each of 2015 through 2018”;

(ii)  in clause (ii)(III), by striking “each subsequent year” and inserting “2018”; and

(iii)  in clause (iii) —

(I)  in the heading, by striking “and subsequent years”;

(II)  by striking “and each subsequent year”; and

(III)  by striking “, but in no case shall the applicable percent be less than 95 percent”.

(B)  Continuation of meaningful use determinations for mips.—Section 1848(o)(2) of the Social Security Act (42 U.S.C. 1395w-4(o)(2)) is amended —

(i)  in subparagraph (A), in the matter preceding clause (i) —

(I)  by striking “For purposes of paragraph (1), an” and inserting “An”; and

(II)  by inserting “, or pursuant to subparagraph (D) for purposes of subsection (q), for a performance period under such subsection for a year” after “under such subsection for a year”; and

(ii)  by adding at the end the following new subparagraph:

“(D) Continued application for purposes of mips. — With respect to 2019 and each subsequent payment year, the Secretary shall, for purposes of subsection (q) and in accordance with paragraph (1)(F) of such subsection, determine whether an eligible professional who is a MIPS eligible professional (as defined in subsection (q)(1)(C)) for such year is a meaningful EHR user under this paragraph for the performance period under subsection (q) for such year.”.

(2) Quality reporting.—

(A)  Sunsetting separate quality reporting incentives.—Section 1848(a)(8)(A) of the Social Security Act (42 U.S.C. 1395w-4(a)(8)(A)) is amended —

(i)  in clause (i), by striking “2015 or any subsequent year” and inserting “each of 2015 through 2018”; and

(ii)  in clause (ii)(II), by striking “and each subsequent year” and inserting “, 2017, and 2018”.

(B)  Continuation of quality measures and processes for mips.—Section 1848 of the Social Security Act (42 U.S.C. 1395w-4) is amended —

(i)  in subsection (k), by adding at the end the following new paragraph:

“(9) Continued application for purposes of mips and for certain professionals volunteering to report. — The Secretary shall, in accordance with subsection (q)(1)(F), carry out the provisions of this subsection

“(A) for purposes of subsection (q); and

“(B) for eligible professionals who are not MIPS eligible professionals (as defined in subsection (q)(1)(C)) for the year involved.”; and

(ii)  in subsection (m) —

(I)  by redesignating paragraph (7) added by section 10327(a) of Public Law 111-148 as paragraph (8); and

(II)  by adding at the end the following new paragraph:

“(9) Continued application for purposes of mips and for certain professionals volunteering to report. — The Secretary shall, in accordance with subsection (q)(1)(F), carry out the processes under this subsection —

“(A) for purposes of subsection (q); and

“(B) for eligible professionals who are not MIPS eligible professionals (as defined in subsection (q)(1)(C)) for the year involved.”.

(3) Value-based payments.—

(A)  Sunsetting separate value-based payments.—Clause (iii) of section 1848(p)(4)(B) of the Social Security Act (42 U.S.C. 1395w-4(p)(4)(B)) is amended to read as follows:

“(iii) Application. — The Secretary shall apply the payment modifier established under this subsection for items and services furnished on or after January 1, 2015, with respect to specific physicians and groups of physicians the Secretary determines appropriate, and for services furnished on or after January 1, 2017, with respect to all physicians and groups of physicians. Such payment modifier shall not be applied for items and services furnished on or after January 1, 2019.”.

(B)  Continuation of value-based payment modifier measures for mips.—Section 1848(p) of the Social Security Act (42 U.S.C. 1395w-4(p)) is amended —

(i)  in paragraph (2), by adding at the end the following new subparagraph:

“(C) Continued application for purposes of mips. — The Secretary shall, in accordance with subsection (q)(1)(F), carry out subparagraph (B) for purposes of subsection (q).”; and

(ii)  in paragraph (3), by adding at the end the following:

“With respect to 2019 and each subsequent year, the Secretary shall, in accordance with subsection (q)(1)(F), carry out this paragraph for purposes of subsection (q).”.

(c) Merit-Based Incentive Payment System.—

(1)  In general.—Section 1848 of the Social Security Act (42 U.S.C. 1395w-4) is amended by adding at the end the following new subsection:

“(q) Merit-Based Incentive Payment System. —

“(1) Establishment. —

“(A) In general. —

Subject to the succeeding provisions of this subsection, the Secretary shall establish an eligible professional Merit-based Incentive Payment System (in this subsection referred to as the `MIPS') under which the Secretary shall —

“(i) develop a methodology for assessing the total performance of each MIPS eligible professional according to performance standards under paragraph (3) for a performance period (as established under paragraph (4)) for a year;

“(ii) using such methodology, provide for a composite performance score in accordance with paragraph (5) for each such professional for each performance period; and

“(iii) use such composite performance score of the MIPS eligible professional for a performance period for a year to determine and apply a MIPS adjustment factor (and, as applicable, an additional MIPS adjustment factor) under paragraph (6) to the professional for the year. Notwithstanding subparagraph (C)(ii), under the MIPS, the Secretary shall permit any eligible professional (as defined in subsection (k)(3)(B)) to report on applicable measures and activities described in paragraph (2)(B).

“(B) Program implementation. — The MIPS shall apply to payments for items and services furnished on or after January 1, 2019.

“(C) MIPS eligible professional defined. —

“(i) In general. — For purposes of this subsection, subject to clauses (ii) and (iv), the term `MIPS eligible professional' means —

“(I) for the first and second years for which the MIPS applies to payments (and for the performance period for such first and second year), a physician (as defined in section 1861(r)), a physician assistant, nurse practitioner, and clinical nurse specialist (as such terms are defined in section 1861(aa)(5)), a certified registered nurse anesthetist (as defined in section 1861(bb)(2)), and a group that includes such professionals; and

“(II) for the third year for which the MIPS applies to payments (and for the performance period for such third year) and for each succeeding year (and for the performance period for each such year), the professionals described in subclause (I), such other eligible professionals (as defined in subsection (k)(3)(B)) as specified by the Secretary, and a group that includes such professionals.

“(ii) Exclusions. — For purposes of clause (i), the term `MIPS eligible professional' does not include, with respect to a year, an eligible professional (as defined in subsection (k)(3)(B)) who —

“(I) is a qualifying APM participant (as defined in section 1833(z)(2));

“(II) subject to clause (vii), is a partial qualifying APM participant (as defined in clause (iii)) for the most recent period for which data are available and who, for the performance period with respect to such year, does not report on applicable measures and activities described in paragraph (2)(B) that are required to be reported by such a professional under the MIPS; or “(III) for the performance period with respect to such year, does not exceed the low-volume threshold measurement selected under clause (iv).

“(iii) Partial qualifying apm participant. — For purposes of this subparagraph, the term `partial qualifying APM participant' means, with respect to a year, an eligible professional for whom the Secretary determines the minimum payment percentage (or percentages), as applicable, described in paragraph (2) of section 1833(z) for such year have not been satisfied, but who would be considered a qualifying APM participant (as defined in such paragraph) for such year if —

“(I) with respect to 2019 and 2020, the reference in subparagraph (A) of such paragraph to 25 percent was instead a reference to 20 percent;

“(II) with respect to 2021 and 2022 —

“(aa) the reference in subparagraph (B)(i) of such paragraph to 50 percent was instead a reference to 40 percent; and

“(bb) the references in subparagraph (B)(ii) of such paragraph to 50 percent and 25 percent of such paragraph were instead references to 40 percent and 20 percent, respectively; and

“(III) with respect to 2023 and subsequent years —

“(aa) the reference in subparagraph (C)(i) of such paragraph to 75 percent was instead a reference to 50 percent; and

“(bb) the references in subparagraph (C)(ii) of such paragraph to 75 percent and 25 percent of such paragraph were instead references to 50 percent and 20 percent, respectively.

“(iv) Selection of low-volume threshold measurement. — The Secretary shall select a low- volume threshold to apply for purposes of clause (ii)(III), which may include one or more or a combination of the following:

“(I) The minimum number (as determined by the Secretary) of individuals enrolled under this part who are treated by the eligible professional for the performance period involved.

“(II) The minimum number (as determined by the Secretary) of items and services furnished to individuals enrolled under this part by such professional for such performance period.

“(III) The minimum amount (as determined by the Secretary) of allowed charges billed by such professional under this part for such performance period.

“(v) Treatment of new medicare enrolled eligible professionals. — In the case of a professional who first becomes a Medicare enrolled eligible professional during the performance period for a year (and had not previously submitted claims under this title such as a person, an entity, or a part of a physician group or under a different billing number or tax identifier), such professional shall not be treated under this subsection as a MIPS eligible professional until the subsequent year and performance period for such subsequent year.

“(vi) Clarification. — In the case of items and services furnished during a year by an individual who is not a MIPS eligible professional (including pursuant to clauses (ii) and (v)) with respect to a year, in no case shall a MIPS adjustment factor (or additional MIPS adjustment factor) under paragraph (6) apply to such individual for such year.

“(vii) Partial qualifying apm participant clarifications. —

“(I) Treatment as mips eligible professional. — In the case of an eligible professional who is a partial qualifying APM participant, with respect to a year, and who, for the performance period for such year, reports on applicable measures and activities described in paragraph (2)(B) that are required to be reported by such a professional under the MIPS, such eligible professional is considered to be a MIPS eligible professional with respect to such year.

“(II) Not eligible for qualifying apm participant payments. — In no case shall an eligible professional who is a partial qualifying APM participant, with respect to a year, be considered a qualifying APM participant (as defined in paragraph (2) of section 1833(z)) for such year or be eligible for the additional payment under paragraph (1) of such section for such year.

“(D) Application to group practices. —

“(i) In general. —

(1)Under the MIPS:

“(I) Quality performance category. — The Secretary shall establish and apply a process that includes features of the provisions of subsection (m)(3)(C) for MIPS eligible professionals in a group practice with respect to assessing performance of such group with respect to the performance category described in clause (i) of paragraph (2)(A).

“(II) Other performance categories. — The Secretary may establish and apply a process that includes features of the provisions of subsection (m)(3)(C) for MIPS eligible professionals in a group practice with respect to assessing the performance of such group with respect to the performance categories described in clauses (ii) through (iv) of such paragraph.

“(ii) Ensuring comprehensiveness of group practice assessment. — The process established under clause (i) shall to the extent practicable reflect the range of items and services furnished by the MIPS eligible professionals in the group practice involved.

“(E) Use of registries. — Under the MIPS, the Secretary shall encourage the use of qualified clinical data registries pursuant to subsection (m)(3)(E) in carrying out this subsection.

“(F) Application of certain provisions. — In applying a provision of subsection (k), (m), (o), or (p) for purposes of this subsection, the Secretary shall —

“(i) adjust the application of such provision to ensure the provision is consistent with the provisions of this subsection; and

“(ii) not apply such provision to the extent that the provision is duplicative with a provision of this subsection.

“(G) Accounting for risk factors. —

“(i) Risk factors. — Taking into account the relevant studies conducted and recommendations made in reports under section 2(d) of the Improving Medicare Post-Acute Care Transformation Act of 2014, and, as appropriate, other information, including information collected before completion of such studies and recommendations, the Secretary, on an ongoing basis, shall, as the Secretary determines appropriate and based on an individual's health status and other risk factors —

“(I) assess appropriate adjustments to quality measures, resource use measures, and other measures used under the MIPS; and

“(II) assess and implement appropriate adjustments to payment adjustments, composite performance scores, scores for performance categories, or scores for measures or activities under the MIPS.

“(2) Measures and activities under performance categories.—

“(A)  Performance categories.—Under the MIPS, the Secretary shall use the following performance categories (each of which is referred to in this subsection as a performance category) in determining the composite performance score under paragraph (5):

“(i) Quality.

“(ii) Resource use.

“(iii) Clinical practice improvement activities.

“(iv) Meaningful use of certified EHR technology.

“(B)  Measures and activities specified for each category.—For purposes of paragraph (3)(A) and subject to subparagraph (C), measures and activities specified for a performance period (as established under paragraph (4)) for a year are as follows:

“(i) Quality. — For the performance category described in subparagraph (A)(i), the quality measures included in the final measures list published under subparagraph (D)(i) for such year and the list of quality measures described in subparagraph (D)(vi) used by qualified clinical data registries under subsection (m)(3)(E).

“(ii) Resource use. — For the performance category described in subparagraph (A)(ii), the measurement of resource use for such period under subsection (p)(3), using the methodology under subsection (r) as appropriate, and, as feasible and applicable, accounting for the cost of drugs under part D.

“(iii) Clinical practice improvement activities. — For the performance category described in subparagraph (A)(iii), clinical practice improvement activities (as defined in subparagraph (C)(v)(III)) under subcategories specified by the Secretary for such period, which shall include at least the following:

“(I) The subcategory of expanded practice access, such as same day appointments for urgent needs and after hours access to clinician advice.

“(II) The subcategory of population management, such as monitoring health conditions of individuals to provide timely health care interventions or participation in a qualified clinical data registry.

“(III) The subcategory of care coordination, such as timely communication of test results, timely exchange of clinical information to patients and other providers, and use of remote monitoring or telehealth.

“(IV) The subcategory of beneficiary engagement, such as the establishment of care plans for individuals with complex care needs, beneficiary self-management assessment and training, and using shared decision- making mechanisms.

“(V) The subcategory of patient safety and practice assessment, such as through use of clinical or surgical checklists and practice assessments related to maintaining certification.

“(VI) The subcategory of participation in an alternative payment model (as defined in section 1833(z)(3)(C)). In establishing activities under this clause, the Secretary shall give consideration to the circumstances of small practices (consisting of 15 or fewer professionals) and practices located in rural areas and in health professional shortage areas (as designated under section 332(a)(1)(A) of the Public Health Service Act).

“(iv) Meaningful ehr use. — For the performance category described in subparagraph (A)(iv), the requirements established for such period under subsection (o)(2) for determining whether an eligible professional is a meaningful EHR user.

“(C)  Additional provisions.—

“(i) Emphasizing outcome measures under the quality performance category. — In applying subparagraph (B)(i), the Secretary shall, as feasible, emphasize the application of outcome measures.

“(ii) Application of additional system measures. — The Secretary may use measures used for a payment system other than for physicians, such as measures for inpatient hospitals, for purposes of the performance categories described in clauses (i) and (ii) of subparagraph (A). For purposes of the previous sentence, the Secretary may not use measures for hospital outpatient departments, except in the case of items and services furnished by emergency physicians, radiologists, and anesthesiologists.

“(iii) Global and population-based measures. — The Secretary may use global measures, such as global outcome measures, and population- based measures for purposes of the performance category described in subparagraph (A)(i).

“(iv) Application of measures and activities to non-patient-facing professionals. — In carrying out this paragraph, with respect to measures and activities specified in subparagraph (B) for performance categories described in subparagraph (A), the Secretary —

“(I) shall give consideration to the circumstances of professional types (or subcategories of those types determined by practice characteristics) who typically furnish services that do not involve face-to-face interaction with a patient; and

“(II) may, to the extent feasible and appropriate, take into account such circumstances and apply under this subsection with respect to MIPS eligible professionals of such professional types or subcategories, alternative measures or activities that fulfill the goals of the applicable performance category. In carrying out the previous sentence, the Secretary shall consult with professionals of such professional types or subcategories.

“(v) Clinical practice improvement activities. —

“(I) Request for information. — In initially applying subparagraph (B)(iii), the Secretary shall use a request for information to solicit recommendations from stakeholders to identify activities described in such subparagraph and specifying criteria for such activities.

“(II) Contract authority for clinical practice improvement activities performance category. — In applying subparagraph (B)(iii), the Secretary may contract with entities to assist the Secretary in —

“(aa) identifying activities described in subparagraph (B)(iii);

“(bb) specifying criteria for such activities; and

“(cc) determining whether a MIPS eligible professional meets such criteria.

“(III) Clinical practice improvement activities defined. — For purposes of this subsection, the term `clinical practice improvement activity' means an activity that relevant eligible professional organizations and other relevant stakeholders identify as improving clinical practice or care delivery and that the Secretary determines, when effectively executed, is likely to result in improved outcomes.

“(D) Annual list of quality measures available for mips assessment.—

“(i) In general. — Under the MIPS, the Secretary, through notice and comment rulemaking and subject to the succeeding clauses of this subparagraph, shall, with respect to the performance period for a year, establish an annual final list of quality measures from which MIPS eligible professionals may choose for purposes of assessment under this subsection for such performance period. Pursuant to the previous sentence, the Secretary shall —

“(I) not later than November 1 of the year prior to the first day of the first performance period under the MIPS, establish and publish in the Federal Register a final list of quality measures; and

“(II) not later than November 1 of the year prior to the first day of each subsequent performance period, update the final list of quality measures from the previous year (and publish such updated final list in the Federal Register), by —

“(aa) removing from such list, as appropriate, quality measures, which may include the removal of measures that are no longer meaningful (such as measures that are topped out);

“(bb) adding to such list, as appropriate, new quality measures; and

“(cc) determining whether or not quality measures on such list that have undergone substantive changes should be included in the updated list.

“(ii) Call for quality measures. —

“(I) In general. — Eligible professional organizations and other relevant stakeholders shall be requested to identify and submit quality measures to be considered for selection under this subparagraph in the annual list of quality measures published under clause (i) and to identify and submit updates to the measures on such list. For purposes of the previous sentence, measures may be submitted regardless of whether such measures were previously published in a proposed rule or endorsed by an entity with a contract under section 1890(a).

“(II) Eligible professional organization defined. — In this subparagraph, the term `eligible professional organization' means a professional organization as defined by nationally recognized specialty boards of certification or equivalent certification boards.

“(iii) Requirements. — In selecting quality measures for inclusion in the annual final list under clause (i), the Secretary shall —

“(I) provide that, to the extent practicable, all quality domains (as defined in subsection (s)(1)(B)) are addressed by such measures; and

“(II) ensure that such selection is consistent with the process for selection of measures under subsections (k), (m), and (p)(2).

“(iv) Peer review. — Before including a new measure in the final list of measures published under clause (i) for a year, the Secretary shall submit for publication in applicable specialty-appropriate, peer-reviewed journals such measure and the method for developing and selecting such measure, including clinical and other data supporting such measure.

“(v) Measures for inclusion. — The final list of quality measures published under clause (i) shall include, as applicable, measures under subsections (k), (m), and (p)(2), including quality measures from among —

“(I) measures endorsed by a consensus-based entity;

“(II) measures developed under subsection (s); and

“(III) measures submitted under clause (ii)(I). Any measure selected for inclusion in such list that is not endorsed by a consensus-based entity shall have a focus that is evidence-based.

“(vi) Exception for qualified clinical data registry measures. — Measures used by a qualified clinical data registry under subsection (m)(3)(E) shall not be subject to the requirements under clauses (i), (iv), and (v). The Secretary shall publish the list of measures used by such qualified clinical data registries on the Internet website of the Centers for Medicare & Medicaid Services.

“(vii) Exception for existing quality measures. — Any quality measure specified by the Secretary under subsection (k) or (m), including under subsection (m)(3)(E), and any measure of quality of care established under subsection (p)(2) for the reporting period or performance period under the respective subsection beginning before the first performance period under the MIPS —

“(I) shall not be subject to the requirements under clause (i) (except under items (aa) and (cc) of subclause (II) of such clause) or to the requirement under clause (iv); and

“(II) shall be included in the final list of quality measures published under clause (i) unless removed under clause (i)(II)(aa).

“(viii) Consultation with relevant eligible professional organizations and other relevant stakeholders. — Relevant eligible professional organizations and other relevant stakeholders, including State and national medical societies, shall be consulted in carrying out this subparagraph.

“(ix) Optional application. — The process under section 1890A is not required to apply to the selection of measures under this subparagraph.

“(3) Performance standards.—

“(A)  Establishment.—Under the MIPS, the Secretary shall establish performance standards with respect to measures and activities specified under paragraph (2)(B) for a performance period (as established under paragraph (4)) for a year.

“(B)  Considerations in establishing standards.—In establishing such performance standards with respect to measures and activities specified under paragraph (2)(B), the Secretary shall consider the following:

“(i) Historical performance standards.

“(ii) Improvement.

“(iii) The opportunity for continued improvement.

“(4)  Performance period.—The Secretary shall establish a performance period (or periods) for a year (beginning with 2019). Such performance period (or periods) shall begin and end prior to the beginning of such year and be as close as possible to such year. In this subsection, such performance period (or periods) for a year shall be referred to as the performance period for the year.

“(5) Composite performance score.—

“(A)  In general.—Subject to the succeeding provisions of this paragraph and taking into account, as available and applicable, paragraph (1)(G), the Secretary shall develop a methodology for assessing the total performance of each MIPS eligible professional according to performance standards under paragraph (3) with respect to applicable measures and activities specified in paragraph (2)(B) with respect to each performance category applicable to such professional for a performance period (as established under paragraph (4)) for a year. Using such methodology, the Secretary shall provide for a composite assessment (using a scoring scale of 0 to 100) for each such professional for the performance period for such year. In this subsection such a composite assessment for such a professional with respect to a performance period shall be referred to as the `composite performance score' for such professional for such performance period.

“(B) Incentive to report; encouraging use of certified ehr technology for reporting quality measures.—

“(i) Incentive to report. — Under the methodology established under subparagraph (A), the Secretary shall provide that in the case of a MIPS eligible professional who fails to report on an applicable measure or activity that is required to be reported by the professional, the professional shall be treated as achieving the lowest potential score applicable to such measure or activity.

“(ii) Encouraging use of certified ehr technology and qualified clinical data registries for reporting quality measures. — Under the methodology established under subparagraph (A), the Secretary shall —

“(I) encourage MIPS eligible professionals to report on applicable measures with respect to the performance category described in paragraph (2)(A)(i) through the use of certified EHR technology and qualified clinical data registries; and

“(II) with respect to a performance period, with respect to a year, for which a MIPS eligible professional reports such measures through the use of such EHR technology, treat such professional as satisfying the clinical quality measures reporting requirement described in subsection (o)(2)(A)(iii) for such year.

“(C) Clinical practice improvement activities performance score.—

“(i) Rule for certification. — A MIPS eligible professional who is in a practice that is certified as a patient-centered medical home or comparable specialty practice, as determined by the Secretary, with respect to a performance period shall be given the highest potential score for the performance category described in paragraph (2)(A)(iii) for such period.

“(ii) APM participation. — Participation by a MIPS eligible professional in an alternative payment model (as defined in section 1833(z)(3)(C)) with respect to a performance period shall earn such eligible professional a minimum score of one-half of the highest potential score for the performance category described in paragraph (2)(A)(iii) for such performance period.

“(iii) Subcategories. — A MIPS eligible professional shall not be required to perform activities in each subcategory under paragraph (2)(B)(iii) or participate in an alternative payment model in order to achieve the highest potential score for the performance category described in paragraph (2)(A)(iii).

“(D) Achievement and improvement.—

“(i) Taking into account improvement. — Beginning with the second year to which the MIPS applies, in addition to the achievement of a MIPS eligible professional, if data sufficient to measure improvement is available, the methodology developed under subparagraph (A) —

“(I) in the case of the performance score for the performance category described in clauses (i) and (ii) of paragraph (2)(A), shall take into account the improvement of the professional; and

“(II) in the case of performance scores for other performance categories, may take into account the improvement of the professional.

“(ii) Assigning higher weight for achievement. — Subject to clause (i), under the methodology developed under subparagraph (A), the Secretary may assign a higher scoring weight under subparagraph (F) with respect to the achievement of a MIPS eligible professional than with respect to any improvement of such professional applied under clause (i) with respect to a measure, activity, or category described in paragraph (2).

“(E) Weights for the performance categories.—

“(i) In general. — Under the methodology developed under subparagraph (A), subject to subparagraph (F)(i) and clause (ii), the composite performance score shall be determined as follows:

“(I) Quality. —

“(aa) In general. — Subject to item (bb), thirty percent of such score shall be based on performance with respect to the category described in clause (i) of paragraph (2)(A). In applying the previous sentence, the Secretary shall, as feasible, encourage the application of outcome measures within such category.

“(bb) First 2 years. — For the first and second years for which the MIPS applies to payments, the percentage applicable under item (aa) shall be increased in a manner such that the total percentage points of the increase under this item for the respective year equals the total number of percentage points by which the percentage applied under subclause (II)(bb) for the respective year is less than 30 percent.

“(II) Resource use. —

“(aa) In general. — Subject to item (bb), thirty percent of such score shall be based on performance with respect to the category described in clause (ii) of paragraph (2)(A).

“(bb) First 2 years. — For the first year for which the MIPS applies to payments, not more than 10 percent of such score shall be based on performance with respect to the category described in clause (ii) of paragraph (2)(A). For the second year for which the MIPS applies to payments, not more than 15 percent of such score shall be based on performance with respect to the category described in clause (ii) of paragraph (2)(A).

“(III) Clinical practice improvement activities. — Fifteen percent of such score shall be based on performance with respect to the category described in clause (iii) of paragraph (2)(A). “(IV) Meaningful use of certified ehr technology. — Twenty-five percent of such score shall be based on performance with respect to the category described in clause (iv) of paragraph (2)(A).

“(ii) Authority to adjust percentages in case of high ehr meaningful use adoption. — In any year in which the Secretary estimates that the proportion of eligible professionals (as defined in subsection (o)(5)) who are meaningful EHR users (as determined under subsection (o)(2)) is 75 percent or greater, the Secretary may reduce the percent applicable under clause (i)(IV), but not below 15 percent. If the Secretary makes such reduction for a year, subject to subclauses (I)(bb) and (II)(bb) of clause (i), the percentages applicable under one or more of subclauses (I), (II), and (III) of clause (i) for such year shall be increased in a manner such that the total percentage points of the increase under this clause for such year equals the total number of percentage points reduced under the preceding sentence for such year.

“(F)  Certain flexibility for weighting performance categories, measures, and activities.—Under the methodology under subparagraph (A), if there are not sufficient measures and activities (described in paragraph (2)(B)) applicable and available to each type of eligible professional involved, the Secretary shall assign different scoring weights (including a weight of 0) —

“(i) which may vary from the scoring weights specified in subparagraph (E), for each performance category based on the extent to which the category is applicable to the type of eligible professional involved; and

“(ii) for each measure and activity specified under paragraph (2)(B) with respect to each such category based on the extent to which the measure or activity is applicable and available to the type of eligible professional involved.

“(G)  Resource use.—Analysis of the performance category described in paragraph (2)(A)(ii) shall include results from the methodology described in subsection (r)(5), as appropriate.

“(H)  Inclusion of quality measure data from other payers.—In applying subsections (k), (m), and (p) with respect to measures described in paragraph (2)(B)(i), analysis of the performance category described in paragraph (2)(A)(i) may include data submitted by MIPS eligible professionals with respect to items and services furnished to individuals who are not individuals entitled to benefits under part A or enrolled under part B. “(I) Use of voluntary virtual groups for certain assessment purposes. —

“(i) In general. — In the case of MIPS eligible professionals electing to be a virtual group under clause (ii) with respect to a performance period for a year, for purposes of applying the methodology under subparagraph (A) with respect to the performance categories described in clauses (i) and (ii) of paragraph (2)(A) —

“(I) the assessment of performance provided under such methodology with respect to such performance categories that is to be applied to each such professional in such group for such performance period shall be with respect to the combined performance of all such professionals in such group for such period; and

“(II) with respect to the composite performance score provided under this paragraph for such performance period for each such MIPS eligible professional in such virtual group, the components of the composite performance score that assess performance with respect to such performance categories shall be based on the assessment of the combined performance under subclause (I) for such performance categories and performance period.

“(ii) Election of practices to be a virtual group. — The Secretary shall, in accordance with the requirements under clause (iii), establish and have in place a process to allow an individual MIPS eligible professional or a group practice consisting of not more than 10 MIPS eligible professionals to elect, with respect to a performance period for a year to be a virtual group under this subparagraph with at least one other such individual MIPS eligible professional or group practice. Such a virtual group may be based on appropriate classifications of providers, such as by geographic areas or by provider specialties defined by nationally recognized specialty boards of certification or equivalent certification boards.

“(iii) Requirements. — The requirements for the process under clause (ii) shall —

“(I) provide that an election under such clause, with respect to a performance period, shall be made before the beginning of such performance period and may not be changed during such performance period;

“(II) provide that an individual MIPS eligible professional and a group practice described in clause (ii) may elect to be in no more than one virtual group for a performance period and that, in the case of such a group practice that elects to be in such virtual group for such performance period, such election applies to all MIPS eligible professionals in such group practice;

“(III) provide that a virtual group be a combination of tax identification numbers;

“(IV) provide for formal written agreements among MIPS eligible professionals electing to be a virtual group under this subparagraph; and

“(V) include such other requirements as the Secretary determines appropriate.

“(6) MIPS payments.—

“(A)  MIPS adjustment factor.—Taking into account paragraph (1)(G), the Secretary shall specify a MIPS adjustment factor for each MIPS eligible professional for a year. Such MIPS adjustment factor for a MIPS eligible professional for a year shall be in the form of a percent and shall be determined —

“(i) by comparing the composite performance score of the eligible professional for such year to the performance threshold established under subparagraph (D)(i) for such year;

“(ii) in a manner such that the adjustment factors specified under this subparagraph for a year result in differential payments under this paragraph reflecting that —

“(I) MIPS eligible professionals with composite performance scores for such year at or above such performance threshold for such year receive zero or positive payment adjustment factors for such year in accordance with clause (iii), with such professionals having higher composite performance scores receiving higher adjustment factors; and

“(II) MIPS eligible professionals with composite performance scores for such year below such performance threshold for such year receive negative payment adjustment factors for such year in accordance with clause (iv), with such professionals having lower composite performance scores receiving lower adjustment factors;

“(iii) in a manner such that MIPS eligible professionals with composite scores described in clause (ii)(I) for such year, subject to clauses (i) and (ii) of subparagraph (F), receive a zero or positive adjustment factor on a linear sliding scale such that an adjustment factor of 0 percent is assigned for a score at the performance threshold and an adjustment factor of the applicable percent specified in subparagraph (B) is assigned for a score of 100; and

“(iv) in a manner such that —

“(I) subject to subclause (II), MIPS eligible professionals with composite performance scores described in clause (ii)(II) for such year receive a negative payment adjustment factor on a linear sliding scale such that an adjustment factor of 0 percent is assigned for a score at the performance threshold and an adjustment factor of the negative of the applicable percent specified in subparagraph (B) is assigned for a score of 0; and

“(II) MIPS eligible professionals with composite performance scores that are equal to or greater than 0, but not greater than \1/4\ of the performance threshold specified under subparagraph (D)(i) for such year, receive a negative payment adjustment factor that is equal to the negative of the applicable percent specified in subparagraph (B) for such year.

“(B)  Applicable percent defined.—For purposes of this paragraph, the term `applicable percent' means —

“(i) for 2019, 4 percent;

“(ii) for 2020, 5 percent;

“(iii) for 2021, 7 percent; and “(iv) for 2022 and subsequent years, 9 percent.

“(C)  Additional mips adjustment factors for exceptional performance.—For 2019 and each subsequent year through 2024, in the case of a MIPS eligible professional with a composite performance score for a year at or above the additional performance threshold under subparagraph (D)(ii) for such year, in addition to the MIPS adjustment factor under subparagraph (A) for the eligible professional for such year, subject to subparagraph (F)(iv), the Secretary shall specify an additional positive MIPS adjustment factor for such professional and year. Such additional MIPS adjustment factors shall be in the form of a percent and determined by the Secretary in a manner such that professionals having higher composite performance scores above the additional performance threshold receive higher additional MIPS adjustment factors.

“(D) Establishment of performance thresholds.—

“(i) Performance threshold. — For each year of the MIPS, the Secretary shall compute a performance threshold with respect to which the composite performance score of MIPS eligible professionals shall be compared for purposes of determining adjustment factors under subparagraph (A) that are positive, negative, and zero. Such performance threshold for a year shall be the mean or median (as selected by the Secretary) of the composite performance scores for all MIPS eligible professionals with respect to a prior period specified by the Secretary. The Secretary may reassess the selection of the mean or median under the previous sentence every 3 years.

“(ii) Additional performance threshold for exceptional performance. — In addition to the performance threshold under clause (i), for each year of the MIPS, the Secretary shall compute an additional performance threshold for purposes of determining the additional MIPS adjustment factors under subparagraph (C). For each such year, the Secretary shall apply either of the following methods for computing such additional performance threshold for such a year:

“(I) The threshold shall be the score that is equal to the 25th percentile of the range of possible composite performance scores above the performance threshold determined under clause (i).

“(II) The threshold shall be the score that is equal to the 25th percentile of the actual composite performance scores for MIPS eligible professionals with composite performance scores at or above the performance threshold with respect to the prior period described in clause (i).

“(iii) Special rule for initial 2 years. — With respect to each of the first two years to which the MIPS applies, the Secretary shall, prior to the performance period for such years, establish a performance threshold for purposes of determining MIPS adjustment factors under subparagraph (A) and a threshold for purposes of determining additional MIPS adjustment factors under subparagraph (C). Each such performance threshold shall —

“(I) be based on a period prior to such performance periods; and

“(II) take into account —

“(aa) data available with respect to performance on measures and activities that may be used under the performance categories under subparagraph (2)(B); and

“(bb) other factors determined appropriate by the Secretary.

“(E)  Application of mips adjustment factors.—In the case of items and services furnished by a MIPS eligible professional during a year (beginning with 2019), the amount otherwise paid under this part with respect to such items and services and MIPS eligible professional for such year, shall be multiplied by —

“(i) 1, plus

“(ii) the sum of —

“(I) the MIPS adjustment factor determined under subparagraph (A) divided by 100, and

“(II) as applicable, the additional MIPS adjustment factor determined under subparagraph (C) divided by 100.

“(F) Aggregate application of mips adjustment factors.—

“(i) Application of scaling factor. —

“(I) In general. — With respect to positive MIPS adjustment factors under subparagraph (A)(ii)(I) for eligible professionals whose composite performance score is above the performance threshold under subparagraph (D)(i) for such year, subject to subclause (II), the Secretary shall increase or decrease such adjustment factors by a scaling factor in order to ensure that the budget neutrality requirement of clause (ii) is met.

“(II) Scaling factor limit. — In no case may the scaling factor applied under this clause exceed 3.0.

“(ii) Budget neutrality requirement. —

“(I) In general. — Subject to clause (iii), the Secretary shall ensure that the estimated amount described in subclause (II) for a year is equal to the estimated amount described in subclause (III) for such year.

“(II) Aggregate increases. — The amount described in this subclause is the estimated increase in the aggregate allowed charges resulting from the application of positive MIPS adjustment factors under subparagraph (A) (after application of the scaling factor described in clause (i)) to MIPS eligible professionals whose composite performance score for a year is above the performance threshold under subparagraph (D)(i) for such year.

“(III) Aggregate decreases. — The amount described in this subclause is the estimated decrease in the aggregate allowed charges resulting from the application of negative MIPS adjustment factors under subparagraph (A) to MIPS eligible professionals whose composite performance score for a year is below the performance threshold under subparagraph (D)(i) for such year.

“(iii) Exceptions. —

“(I) In the case that all MIPS eligible professionals receive composite performance scores for a year that are below the performance threshold under subparagraph (D)(i) for such year, the negative MIPS adjustment factors under subparagraph (A) shall apply with respect to such MIPS eligible professionals and the budget neutrality requirement of clause (ii) and the additional adjustment factors under clause (iv) shall not apply for such year.

“(II) In the case that, with respect to a year, the application of clause (i) results in a scaling factor equal to the maximum scaling factor specified in clause (i)(II), such scaling factor shall apply and the budget neutrality requirement of clause (ii) shall not apply for such year.

“(iv) Additional incentive payment adjustments. —

“(I) In general. — Subject to subclause (II), in specifying the MIPS additional adjustment factors under subparagraph (C) for each applicable MIPS eligible professional for a year, the Secretary shall ensure that the estimated aggregate increase in payments under this part resulting from the application of such additional adjustment factors for MIPS eligible professionals in a year shall be equal (as estimated by the Secretary) to $500,000,000 for each year beginning with 2019 and ending with 2024.

“(II) Limitation on additional incentive payment adjustments. — The MIPS additional adjustment factor under subparagraph (C) for a year for an applicable MIPS eligible professional whose composite performance score is above the additional performance threshold under subparagraph (D)(ii) for such year shall not exceed 10 percent. The application of the previous sentence may result in an aggregate amount of additional incentive payments that are less than the amount specified in subclause (I).

“(7)   Announcement of result of adjustments.—Under the MIPS, the Secretary shall, not later than 30 days prior to January 1 of the year involved, make available to MIPS eligible professionals the MIPS adjustment factor (and, as applicable, the additional MIPS adjustment factor) under paragraph (6) applicable to the eligible professional for items and services furnished by the professional for such year. The Secretary may include such information in the confidential feedback under paragraph (12).

“(8)   No effect in subsequent years.—The MIPS adjustment factors and additional MIPS adjustment factors under paragraph (6) shall apply only with respect to the year involved, and the Secretary shall not take into account such adjustment factors in making payments to a MIPS eligible professional under this part in a subsequent year.

“(9) Public reporting.—

“(A)  In general.—The Secretary shall, in an easily understandable format, make available on the Physician Compare Internet website of the Centers for Medicare & Medicaid Services the following:

“(i) Information regarding the performance of MIPS eligible professionals under the MIPS, which —

“(I) shall include the composite score for each such MIPS eligible professional and the performance of each such MIPS eligible professional with respect to each performance category; and

“(II) may include the performance of each such MIPS eligible professional with respect to each measure or activity specified in paragraph (2)(B).

“(ii) The names of eligible professionals in eligible alternative payment models (as defined in section 1833(z)(3)(D)) and, to the extent feasible, the names of such eligible alternative payment models and performance of such models.

“(B)  Disclosure.—The information made available under this paragraph shall indicate, where appropriate, that publicized information may not be representative of the eligible professional's entire patient population, the variety of services furnished by the eligible professional, or the health conditions of individuals treated.

“(C)  Opportunity to review and submit corrections.—The Secretary shall provide for an opportunity for a professional described in subparagraph (A) to review, and submit corrections for, the information to be made public with respect to the professional under such subparagraph prior to such information being made public.

“(D)  Aggregate information.—The Secretary shall periodically post on the Physician Compare Internet website aggregate information on the MIPS, including the range of composite scores for all MIPS eligible professionals and the range of the performance of all MIPS eligible professionals with respect to each performance category.

“(10)  Consultation.—The Secretary shall consult with stakeholders in carrying out the MIPS, including for the identification of measures and activities under paragraph (2)(B) and the methodologies developed under paragraphs (5)(A) and (6) and regarding the use of qualified clinical data registries. Such consultation shall include the use of a request for information or other mechanisms determined appropriate.

“(11) Technical assistance to small practices and practices in health professional shortage areas.—

“(A)  In general.—The Secretary shall enter into contracts or agreements with appropriate entities (such as quality improvement organizations, regional extension centers (as described in section 3012(c) of the Public Health Service Act), or regional health collaboratives) to offer guidance and assistance to MIPS eligible professionals in practices of 15 or fewer professionals (with priority given to such practices located in rural areas, health professional shortage areas (as designated under in section 332(a)(1)(A) of such Act), and medically underserved areas, and practices with low composite scores) with respect to —

“(i) the performance categories described in clauses (i) through (iv) of paragraph (2)(A); or

“(ii) how to transition to the implementation of and participation in an alternative payment model as described in section 1833(z)(3)(C).

“(B)  Funding for technical assistance.—For purposes of implementing subparagraph (A), the Secretary shall provide for the transfer from the Federal Supplementary Medical Insurance Trust Fund established under section 1841 to the Centers for Medicare & Medicaid Services Program Management Account of $20,000,000 for each of fiscal years 2016 through 2020. Amounts transferred under this subparagraph for a fiscal year shall be available until expended.

“(12) Feedback and information to improve performance.—

“(A) Performance feedback.—

“(i) In general. — Beginning July 1, 2017, the Secretary —

“(I) shall make available timely (such as quarterly) confidential feedback to MIPS eligible professionals on the performance of such professionals with respect to the performance categories under clauses (i) and (ii) of paragraph (2)(A); and

“(II) may make available confidential feedback to such professionals on the performance of such professionals with respect to the performance categories under clauses (iii) and (iv) of such paragraph.

“(ii) Mechanisms. — The Secretary may use one or more mechanisms to make feedback available under clause (i), which may include use of a web- based portal or other mechanisms determined appropriate by the Secretary. With respect to the performance category described in paragraph (2)(A)(i), feedback under this subparagraph shall, to the extent an eligible professional chooses to participate in a data registry for purposes of this subsection (including registries under subsections (k) and (m)), be provided based on performance on quality measures reported through the use of such registries. With respect to any other performance category described in paragraph (2)(A), the Secretary shall encourage provision of feedback through qualified clinical data registries as described in subsection (m)(3)(E)).

“(iii) Use of data. — For purposes of clause (i), the Secretary may use data, with respect to a MIPS eligible professional, from periods prior to the current performance period and may use rolling periods in order to make illustrative calculations about the performance of such professional.

“(iv) Disclosure exemption. — Feedback made available under this subparagraph shall be exempt from disclosure under section 552 of title 5, United States Code.

“(v) Receipt of information. — The Secretary may use the mechanisms established under clause (ii) to receive information from professionals, such as information with respect to this subsection.

“(B) Additional information.—

“(i) In general. — Beginning July 1, 2018, the Secretary shall make available to MIPS eligible professionals information, with respect to individuals who are patients of such MIPS eligible professionals, about items and services for which payment is made under this title that are furnished to such individuals by other suppliers and providers of services, which may include information described in clause (ii). Such information may be made available under the previous sentence to such MIPS eligible professionals by mechanisms determined appropriate by the Secretary, which may include use of a web-based portal. Such information may be made available in accordance with the same or similar terms as data are made available to accountable care organizations participating in the shared savings program under section 1899.

“(ii) Type of information. — For purposes of clause (i), the information described in this clause, is the following:

“(I) With respect to selected items and services (as determined appropriate by the Secretary) for which payment is made under this title and that are furnished to individuals, who are patients of a MIPS eligible professional, by another supplier or provider of services during the most recent period for which data are available (such as the most recent three-month period), such as the name of such providers furnishing such items and services to such patients during such period, the types of such items and services so furnished, and the dates such items and services were so furnished.

“(II) Historical data, such as averages and other measures of the distribution if appropriate, of the total, and components of, allowed charges (and other figures as determined appropriate by the Secretary).

“(A)  Targeted review.—The Secretary shall establish a process under which a MIPS eligible professional may seek an informal review of the calculation of the MIPS adjustment factor (or factors) applicable to such eligible professional under this subsection for a year. The results of a review conducted pursuant to the previous sentence shall not be taken into account for purposes of paragraph (6) with respect to a year (other than with respect to the calculation of such eligible professional's MIPS adjustment factor for such year or additional MIPS adjustment factor for such year) after the factors determined in subparagraph (A) and subparagraph (C) of such paragraph have been determined for such year.

“(B)  Limitation.—Except as provided for in subparagraph (A), there shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the following:

“(i) The methodology used to determine the amount of the MIPS adjustment factor under paragraph (6)(A) and the amount of the additional MIPS adjustment factor under paragraph (6)(C) and the determination of such amounts.

“(ii) The establishment of the performance standards under paragraph (3) and the performance period under paragraph (4).

“(iii) The identification of measures and activities specified under paragraph (2)(B) and information made public or posted on the Physician Compare Internet website of the Centers for Medicare & Medicaid Services under paragraph (9).

“(iv) The methodology developed under paragraph (5) that is used to calculate performance scores and the calculation of such scores, including the weighting of measures and activities under such methodology.”.

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