42 U.S.C. § 1395ww
whichever is less;
plus the amount, if any, provided under paragraph (2), except that in no case may the amount payable under this subchapter (other than on the basis of a DRG prospective payment rate determined under subsection (d)) with respect to operating costs of inpatient hospital services exceed the maximum amount payable with respect to such costs pursuant to subsection (a).
increased (in a compounded manner) for each succeeding fiscal year (through the fiscal year involved) by the market basket percentage increase for the fiscal year.
increased by the applicable percentage increase under subparagraph (B) for that particular cost reporting period.
The application of this clause may result in the applicable percentage increase described in clause (i) being less than 0.0 for a fiscal year, and may result in payment rates under this section for a fiscal year being less than such payment rates for the preceding fiscal year.
There shall be substituted for the base cost reporting period described in clause (i) a hospital's cost reporting period (if any) beginning during fiscal year 1987 if such substitution results in an increase in the target amount for the hospital.
There shall be substituted for the base cost reporting period described in clause (i) a hospital's cost reporting period (if any) beginning during fiscal year 1987 if such substitution results in an increase in the target amount for the hospital.
There shall be substituted for the base cost reporting period described in clause (i) a hospital's cost reporting period (if any) beginning during fiscal year 1987 if such substitution results in an increase in the target amount for the hospital.
The Secretary cannot deny the application of a State under this subsection on the ground that the State's hospital reimbursement control system is based on a payment methodology other than on the basis of a diagnosis-related group or on the ground that the amount of payments made under this subchapter under such system must be less than the amount of payments which would otherwise have been made under this subchapter not using such system. If the Secretary determines that the conditions described in subparagraph (C) are based on maintaining payment amounts at no more than a specified percentage increase above the payment amounts in a base period, the State has the option of applying such test (for inpatient hospital services under part A) on an aggregate payment basis or on the basis of the amount of payment per inpatient discharge or admission. If the Secretary determines that the conditions described in subparagraph (C) are based on maintaining aggregate payment amounts below a national average percentage increase in total payments under part A for inpatient hospital services, the Secretary cannot deny the application of a State under this subsection on the ground that the State's rate of increase in such payments for such services must be less than such national average rate of increase.
With respect to a State system described in this paragraph, the Secretary shall judge the effectiveness of such system on the basis of its rate of increase or inflation in inpatient hospital payments for individuals under this subchapter, as compared to the national rate of increase or inflation for such payments, with the State retaining the option to have the test applied on the basis of the aggregate payments under the State system as compared to aggregate payments which would have been made under the national system since October 1, 1984, to the most recent date for which annual data are available.
The Secretary shall respond to requests of States under this paragraph within 60 days of the date the request is submitted to the Secretary.
and, in accordance with regulations of the Secretary, does not include a psychiatric or rehabilitation unit of the hospital which is a distinct part of the hospital (as defined by the Secretary). A hospital that was classified by the Secretary on or before September 30, 1995, as a hospital described in clause (iv) (as in effect as of such date) shall continue to be so classified (or, in the case of a hospital described in clause (iv)(II), as so in effect, shall be classified under clause (vi) on and after the effective date of such clause (vi) and for cost reporting periods beginning on or after January 1, 2015, shall not be subject to subsection (m) as of the date of such classification) notwithstanding that it is located in the same building as, or on the same campus as, another hospital.
For purposes of this subsection, the term "region" means one of the nine census divisions, comprising the fifty States and the District of Columbia, established by the Bureau of the Census for statistical and reporting purposes; the term "urban area" means an area within a Metropolitan Statistical Area (as defined by the Office of Management and Budget) or within such similar area as the Secretary has recognized under subsection (a) by regulation; the term "large urban area" means, with respect to a fiscal year, such an urban area which the Secretary determines (in the publications described in subsection (e)(5) before the fiscal year) has a population of more than 1,000,000 (as determined by the Secretary based on the most recent available population data published by the Bureau of the Census); and the term "rural area" means any area outside such an area or similar area. A hospital located in a Metropolitan Statistical Area shall be deemed to be located in the region in which the largest number of the hospitals in the same Metropolitan Statistical Area are located, or, at the option of the Secretary, the region in which the majority of the inpatient discharges (with respect to which payments are made under this subchapter) from hospitals in the same Metropolitan Statistical Area are made.
The Secretary may from time to time revise (through addition or deletion of codes) the diagnosis codes selected under this clause so long as there are diagnosis codes associated with at least two conditions selected for discharges occurring during any fiscal year.
In the case of the first cost reporting period beginning on or after October 1, 1997, subclause (II) shall be applied by using the average for such period and the preceding cost reporting period.
whichever results in greater payment to the hospital.
A hospital located in a rural area and with 500 or more beds also "serves a significantly disproportionate number of low income patients" for a cost reporting period if the hospital has a disproportionate patient percentage (as defined in clause (vi)) for that period which equals or exceeds a percentage specified by the Secretary.
In determining under subclause (II) the number of the hospital's patient days for such period which consist of patients who (for such days) were eligible for medical assistance under a State plan approved under subchapter XIX, the Secretary may, to the extent and for the period the Secretary determines appropriate, include patient days of patients not so eligible but who are regarded as such because they receive benefits under a demonstration project approved under subchapter XI.
where "P" is the hospital's disproportionate patient percentage (as defined in clause (vi)).
where "P" is the hospital's disproportionate patient percentage (as defined in clause (vi)).
where "P" is the hospital's disproportionate patient percentage (as defined in clause (vi)).
where "P" is the hospital's disproportionate patient percentage (as defined in clause (vi)).
where "P" is the hospital's disproportionate patient percentage (as defined in clause (vi)).
Subclause (I)(bb) shall apply for purposes of payment under clause (ii) only for discharges of a hospital occurring on or after the effective date of a determination of medicare-dependent small rural hospital status made by the Secretary with respect to the hospital after February 9, 2018. For purposes of applying subclause (II) of paragraph (8)(E)(ii) under subclause (I)(bb), such subclause (II) shall be applied by inserting "as of January 1, 2018," after "such State" each place it appears.
Subparagraphs (C) and (D) shall not apply with respect to the application of subclause (I).
for such discharges, adjusted in the manner provided in paragraph (3)(E) for different area wage levels; and
As used in this section, the term "subsection (d) Puerto Rico hospital" means a hospital that is located in Puerto Rico and that would be a subsection (d) hospital (as defined in paragraph (1)(B)) if it were located in one of the 50 States.
are not greater or less than-
except that the adjustment made under this subparagraph shall apply only to subsection (d) hospitals and shall not apply for purposes of making computations under subsection (d)(2)(B)(ii) or subsection (d)(3)(A).
are not greater or less than-
are not greater or less than-
The Secretary shall include in the publication referred to in subparagraph (A) for a fiscal year the report of the Commission's recommendations submitted under paragraph (3) for that fiscal year. To the extent that the Secretary's recommendations under paragraph (4) differ from the Commission's recommendations for that fiscal year, the Secretary shall include in the publication referred to in subparagraph (A) an explanation of the Secretary's grounds for not following the Commission's recommendations.
Notwithstanding section 1395x(v) of this title, instead of any amounts that are otherwise payable under this subchapter with respect to the reasonable costs of hospitals for direct graduate medical education costs, the Secretary shall provide for payments for such costs in accordance with paragraph (3) of this subsection. In providing for such payments, the Secretary shall provide for an allocation of such payments between part A and part B (and the trust funds established under the respective parts) as reasonably reflects the proportion of direct graduate medical education costs of hospitals associated with the provision of services under each respective part.
The Secretary shall determine, for each hospital with an approved medical residency training program, an approved FTE resident amount for each cost reporting period beginning on or after July 1, 1985, as follows:
The Secretary shall determine, for the hospital's cost reporting period that began during fiscal year 1984, the average amount recognized as reasonable under this subchapter for direct graduate medical education costs of the hospital for each full-time-equivalent resident.
The Secretary shall update each average amount determined under subparagraph (A) by the percentage increase in the consumer price index during the 12-month cost reporting period described in such subparagraph.
The Secretary shall not perform an update under clause (i) in the case of a hospital if the hospital's reporting period, described in subparagraph (A), began on or after July 1, 1984, and before October 1, 1984.
For the first cost reporting period of the hospital beginning on or after July 1, 1985, the approved FTE resident amount for the hospital is equal to the amount determined under subparagraph (B) increased by 1 percent.
Except as provided in a subsequent clause, for each subsequent cost reporting period, the approved FTE resident amount for the hospital is equal to the approved FTE resident amount determined under this paragraph for the previous cost reporting period updated, through the midpoint of the period, by projecting the estimated percentage change in the consumer price index during the 12-month period ending at that midpoint, with appropriate adjustments to reflect previous under- or over-estimations under this subparagraph in the projected percentage change in the consumer price index.
For cost reporting periods beginning during fiscal year 1994 or fiscal year 1995, the approved FTE resident amount for a hospital shall not be updated under clause (i) for a resident who is not a primary care resident (as defined in paragraph (5)(H)) or a resident enrolled in an approved medical residency training program in obstetrics and gynecology.
The approved FTE resident amount for a hospital for the cost reporting period beginning during fiscal year 2001 shall not be less than 70 percent, and for the cost reporting period beginning during fiscal year 2002 shall not be less than 85 percent, of the locality adjusted national average per resident amount computed under subparagraph (E) for the hospital and period.
For a cost reporting period beginning during fiscal year 2001 or fiscal year 2002 or during the period beginning with fiscal year 2004 and ending with fiscal year 2013, if the approved FTE resident amount for a hospital for the preceding cost reporting period exceeds 140 percent of the locality adjusted national average per resident amount computed under subparagraph (E) for that hospital and period, subject to subclause (III), the approved FTE resident amount for the period involved shall be the same as the approved FTE resident amount for the hospital for such preceding cost reporting period.
For the cost reporting period beginning during fiscal year 2003, if the approved FTE resident amount for a hospital for the preceding cost reporting period exceeds 140 percent of the locality adjusted national average per resident amount computed under subparagraph (E) for that hospital and preceding period, the approved FTE resident amount for the period involved shall be updated in the manner described in subparagraph (D)(i) except that, subject to subclause (III), the consumer price index applied for a 12-month period shall be reduced (but not below zero) by 2 percentage points.
In no case shall subclause (I) or (II) reduce an approved FTE resident amount for a hospital for a cost reporting period below 140 percent of the locality adjusted national average per resident amount computed under subparagraph (E) for such hospital and period.
The Secretary shall determine a locality adjusted national average per resident amount with respect to a cost reporting period of a hospital beginning during a fiscal year as follows:
The Secretary shall compute for each hospital operating an approved graduate medical education program a single per resident amount equal to the average (weighted by number of full-time equivalent residents, as determined under paragraph (4)) of the primary care per resident amount and the non-primary care per resident amount computed under paragraph (2) for cost reporting periods ending during fiscal year 1997.
The Secretary shall compute a standardized per resident amount for each such hospital by dividing the single per resident amount computed under clause (i) by an average of the 3 geographic index values (weighted by the national average weight for each of the work, practice expense, and malpractice components) as applied under section 1395w-4(e) of this title for 1999 for the fee schedule area in which the hospital is located.
The Secretary shall compute the average of the standardized per resident amounts computed under clause (ii) for such hospitals, with the amount for each hospital weighted by the average number of full-time equivalent residents at such hospital (as determined under paragraph (4)).
The Secretary shall compute the national average per resident amount, for a hospital's cost reporting period that begins during fiscal year 2001, equal to the weighted average computed under clause (iii) increased by the estimated percentage increase in the consumer price index for all urban consumers during the period beginning with the month that represents the midpoint of the cost reporting periods described in clause (i) and ending with the midpoint of the hospital's cost reporting period that begins during fiscal year 2001.
The Secretary shall compute the product of-
The locality adjusted national per resident amount for a hospital for-
in lieu of such FTE resident amount the Secretary shall, in accordance with the methodology described in section 413.77(e) of title 42 of the Code of Federal Regulations (or any successor regulation), establish a new FTE resident amount if the hospital trains at least 1.0 full-time-equivalent resident (in the case of a hospital described in subclause (I)) or more than 3.0 full-time-equivalent residents (in the case of a hospital described in subclause (II)) in a cost reporting period beginning on or after such date and before the date that is 5 years after such date.
The payment amount, for a hospital cost reporting period beginning on or after July 1, 1985, is equal to the product of-
As used in subparagraph (A), the term "aggregate approved amount" means, for a hospital cost reporting period, the product of-
The Secretary shall reduce the aggregate approved amount to the extent payment is made under subsection (k) for residents included in the hospital's count of full-time equivalent residents.
As used in subparagraph (A), the term "medicare patient load" means, with respect to a hospital's cost reporting period, the fraction of the total number of inpatient-bed-days (as established by the Secretary) during the period which are attributable to patients with respect to whom payment may be made under part A.
For portions of cost reporting periods occurring on or after January 1, 1998, the Secretary shall provide for an additional payment amount under this subsection for services furnished to individuals who are enrolled under a risk-sharing contract with an eligible organization under section 1395mm of this title and who are entitled to part A or with a Medicare+Choice organization under part C. The amount of such a payment shall equal, subject to clause (iii), the applicable percentage of the product of-
For purposes of clause (i), the applicable percentage is-
The Secretary shall estimate a proportional adjustment in payments to all hospitals determined under clauses (i) and (ii) for portions of cost reporting periods beginning in a year (beginning with 2000) such that the proportional adjustment reduces payments in an amount for such year equal to the total additional payment amounts for nursing and allied health education determined under subsection (l) for portions of cost reporting periods occurring in that year. In applying the preceding sentence for each of 2010 through 2019, the Secretary shall not take into account any increase in the total amount of such additional payment amounts for such nursing and allied health education for portions of cost reporting periods occurring in the year pursuant to the application of paragraph (2)(B)(ii) of such subsection.
The Secretary shall establish rules for the application of this subparagraph to a hospital reimbursed under a reimbursement system authorized under section 1395f(b)(3) of this title in the same manner as it would apply to the hospital if it were not reimbursed under such section.
The Secretary shall establish rules consistent with this paragraph for the computation of the number of full-time-equivalent residents in an approved medical residency training program.
Such rules shall take into account individuals who serve as residents for only a portion of a period with a hospital or simultaneously with more than one hospital.
Subject to subparagraph (D), such rules shall provide, in calculating the number of full-time-equivalent residents in an approved residency program-
Except as provided in clause (ii), such rules shall provide that, in the case of an individual who is a foreign medical graduate (as defined in paragraph (5)(D)), the individual shall not be counted as a resident on or after July 1, 1986, unless-
On or after July 1, 1986, but before July 1, 1987, in the case of a foreign medical graduate who-
the individual shall be counted as a resident at a rate equal to one-half of the rate at which the individual would otherwise be counted.
Subject to subparagraphs (J) and (K), such rules shall provide that only time spent in activities relating to patient care shall be counted and that-
Any hospital claiming under this subparagraph for time spent in a nonprovider setting shall maintain and make available to the Secretary records regarding the amount of such time and such amount in comparison with amounts of such time in such base year as the Secretary shall specify.
Such rules shall provide that for purposes of a cost reporting period beginning on or after October 1, 1997, subject to paragraphs (7), (8), (9), and (10), the total number of full-time equivalent residents before application of weighting factors (as determined under this paragraph) with respect to a hospital's approved medical residency training program in the fields of allopathic medicine and osteopathic medicine may not exceed the number (or, 130 percent of such number in the case of a hospital located in a rural area) of such full-time equivalent residents for the hospital's most recent cost reporting period ending on or before December 31, 1996.
In determining the number of such full-time equivalent residents for a hospital's most recent cost reporting period ending on or before December 31, 1996, for purposes of clause (i), the Secretary shall count an individual to the extent that the individual would have been counted as a primary care resident for such period but for the fact that the individual, as determined by the Secretary, was on maternity or disability leave or a similar approved leave of absence.
The total number of individuals counted under subclause (I) for a hospital may not exceed 3 full-time equivalent residents.
For cost reporting periods beginning during fiscal years beginning on or after October 1, 1997, subject to the limit described in subparagraph (F), the total number of full-time equivalent residents for determining a hospital's graduate medical education payment shall equal the average of the actual full-time equivalent resident counts for the cost reporting period and the preceding two cost reporting periods.
If any cost reporting period beginning on or after October 1, 1997, is not equal to twelve months, the Secretary shall make appropriate modifications to ensure that the average full-time equivalent resident counts pursuant to clause (i) are based on the equivalent of full twelve-month cost reporting periods.
In the case of a hospital's first cost reporting period beginning on or after October 1, 1997, clause (i) shall be applied by using the average for such period and the preceding cost reporting period.
The Secretary may prescribe rules which allow institutions which are members of the same affiliated group (as defined by the Secretary) to elect to apply the limitation of subparagraph (F) on an aggregate basis.
The Secretary may require any entity that operates a medical residency training program and to which subparagraphs (F) and (G) apply to submit to the Secretary such additional information as the Secretary considers necessary to carry out such subparagraphs.
For cost reporting periods beginning before October 1, 2022, in the case of a hospital that is not located in a rural area but establishes separately accredited approved medical residency training programs (or rural tracks) in a rural area or has an accredited training program with an integrated rural track, the Secretary shall adjust the limitation under subparagraph (F) in an appropriate manner insofar as it applies to such programs in such rural areas in order to encourage the training of physicians in rural areas.
For cost reporting periods beginning on or after October 1, 2022, in the case of a hospital not located in a rural area that established or establishes a medical residency training program (or rural tracks) in a rural area or establishes an accredited program where greater than 50 percent of the program occurs in a rural area, the Secretary shall 11 consistent with the principles of subparagraphs (F) and (G) and subject to paragraphs (7) and (8), prescribe rules for the application of such subparagraphs with respect to such a program and, in accordance with such rules, adjust in an appropriate manner the limitation under subparagraph (F) for such hospital and each such hospital located in a rural area that participates in such a training.
If an entity enters into a provider agreement pursuant to section 1395cc(a) of this title to provide hospital services on the same physical site previously used by Medicare Provider No. 05-0578-
Subject to the succeeding provisions of this clause, the Secretary shall, by regulation, establish a process under which, in the case where a hospital (other than a hospital described in clause (v)) with an approved medical residency program closes on or after a date that is 2 years before March 23, 2010, the Secretary shall increase the otherwise applicable resident limit under this paragraph for other hospitals in accordance with this clause.
Subject to the succeeding provisions of this clause, in determining for which hospitals the increase in the otherwise applicable resident limit is provided under such process, the Secretary shall distribute the increase to hospitals in the following priority order (with preference given within each category to hospitals that are members of the same affiliated group (as defined by the Secretary under clause (ii)) as the closed hospital):
The Secretary may only increase the otherwise applicable resident limit of a hospital under such process if the Secretary determines the hospital has demonstrated a likelihood of filling the positions made available under this clause within 3 years.
The aggregate number of increases in the otherwise applicable resident limits for hospitals under this clause shall be equal to the number of resident positions in the approved medical residency programs that closed on or after the date described in subclause (I).
Chapter 35 of title 44 shall not apply to the implementation of this clause.
Such rules shall provide that all time spent by an intern or resident in an approved medical residency training program in a nonprovider setting that is primarily engaged in furnishing patient care (as defined in paragraph (5)(K)) in non-patient care activities, such as didactic conferences and seminars, but not including research not associated with the treatment or diagnosis of a particular patient, as such time and activities are defined by the Secretary, shall be counted toward the determination of full-time equivalency.
In determining the hospital's number of full-time equivalent residents for purposes of this subsection, all the time that is spent by an intern or resident in an approved medical residency training program on vacation, sick leave, or other approved leave, as such time is defined by the Secretary, and that does not prolong the total time the resident is participating in the approved program beyond the normal duration of the program shall be counted toward the determination of full-time equivalency.
As used in this subsection:
The term "approved medical residency training program" means a residency or other postgraduate medical training program participation in which may be counted toward certification in a specialty or subspecialty and includes formal postgraduate training programs in geriatric medicine approved by the Secretary.
The term "consumer price index" refers to the Consumer Price Index for All Urban Consumers (United States city average), as published by the Secretary of Commerce.
The term "direct graduate medical education costs" means direct costs of approved educational activities for approved medical residency training programs.
The term "foreign medical graduate" means a resident who is not a graduate of-
The term "FMGEMS examination" means parts I and II of the Foreign Medical Graduate Examination in the Medical Sciences or any successor examination recognized by the Secretary for this purpose.
The term "initial residency period" means the period of board eligibility, except that-
Subject to subparagraph (G)(v), the initial residency period shall be determined, with respect to a resident, as of the time the resident enters the residency training program.
Subject to clauses (ii), (iii), (iv), and (v), the term "period of board eligibility" means, for a resident, the minimum number of years of formal training necessary to satisfy the requirements for initial board eligibility in the particular specialty for which the resident is training.
Except as provided in clause (iii), the period of board eligibility shall be such period specified in the 1985-1986 Directory of Residency Training Programs published by the Accreditation Council on Graduate Medical Education.
On or after July 1, 1989, if the Accreditation Council on Graduate Medical Education, in its Directory of Residency Training Programs-
In the case of a resident enrolled in a child neurology residency training program, the period of board eligibility and the initial residency period shall be the period of board eligibility for pediatrics plus 2 years.
The term "primary care resident" means a resident enrolled in an approved medical residency training program in family medicine, general internal medicine, general pediatrics, preventive medicine, geriatric medicine, or osteopathic general practice.
The term "resident" includes an intern or other participant in an approved medical residency training program.
In the case of an approved medical residency training program (meeting the requirements of clause (ii)) of a hospital which received funds from the United States, a State, or a political subdivision of a State or an instrumentality of such a State or political subdivision (other than payments under this subchapter or a State plan under subchapter XIX) for the program during the cost reporting period that began during fiscal year 1984, the Secretary shall-
A hospital's approved medical residency program meets the requirements of this clause if-
The term "nonprovider setting that is primarily engaged in furnishing patient care" means a nonprovider setting in which the primary activity is the care and treatment of patients, as defined by the Secretary.
In the case of a voluntary residency reduction plan for which an application is approved under subparagraph (B), subject to subparagraph (F), each hospital which is part of the qualifying entity submitting the plan shall be paid an applicable hold harmless percentage (as specified in subparagraph (E)) of the sum of-
The determination of the amounts under clauses (i) and (ii) for any year shall be made on the basis of the provisions of this subchapter in effect on the application deadline date for the first calendar year to which the reduction plan applies.
The Secretary may not approve the application of an qualifying entity unless-
For purposes of this paragraph, any of the following may be a qualifying entity:
In the case of a qualifying entity described in subparagraph (C)(i), the number of full-time equivalent residents in all the approved medical residency training programs operated by or through the entity shall be reduced as follows:
In the case of a qualifying entity described in subparagraph (C)(ii), the number of full-time equivalent residents in the aggregate for all the approved medical residency training programs operated by or through the entity shall be reduced as follows:
In the case of a qualifying entity described in subparagraph (C)(iii), the number of full-time equivalent residents in the aggregate for all the approved medical residency training programs operated by or through the entity shall be reduced by a number equal to at least 20 percent of the base number.
The reductions specified under the preceding provisions of this subparagraph for a qualifying entity shall be below the base number of residents for that entity and shall be fully effective not later than the 5th residency training year in which the application under subparagraph (B) is effective.
An entity is described in this clause if-
If a qualifying entity fails to comply with the representation described in subclause (II) by the end of such 5th residency training year, the entity shall be subject to repayment of all amounts paid under this paragraph, in accordance with procedures established to carry out subparagraph (F).
For purposes of this paragraph, the term "base number of residents" means, with respect to a qualifying entity (or its participating hospitals) operating approved medical residency training programs, the number of full-time equivalent residents in such programs (before application of weighting factors) of the entity as of the most recent residency training year ending before June 30, 1997, or, if less, for any subsequent residency training year that ends before the date the entity makes application under this paragraph.
For purposes of subparagraph (A), the "applicable hold harmless percentage" for the-
No payment may be made under this paragraph to a hospital for a residency training year if the hospital has failed to reduce the number of full-time equivalent residents (in the manner required under subparagraph (D)) to the number agreed to by the Secretary and the qualifying entity in approving the application under this paragraph with respect to such year.
If payments are made under this paragraph to a hospital, and if the hospital increases the number of full-time equivalent residents above the number of such residents permitted under the reduction plan as of the completion of the plan, then, as specified by the Secretary, the entity is liable for repayment to the Secretary of the total amounts paid under this paragraph to the entity.
In applying this paragraph, the Secretary shall establish rules regarding the counting of residents who are assigned to institutions the medical residency training programs in which are not covered under approved applications under this paragraph.
Except as provided in subclause (II), if a hospital's reference resident level (specified in clause (ii)) is less than the otherwise applicable resident limit (as defined in subparagraph (C)(ii)), effective for portions of cost reporting periods occurring on or after July 1, 2005, the otherwise applicable resident limit shall be reduced by 75 percent of the difference between such otherwise applicable resident limit and such reference resident level.
This subparagraph shall not apply to a hospital located in a rural area (as defined in subsection (d)(2)(D)(ii)) with fewer than 250 acute care inpatient beds.
Except as otherwise provided in subclauses (II) and (III), the reference resident level specified in this clause for a hospital is the resident level for the most recent cost reporting period of the hospital ending on or before September 30, 2002, for which a cost report has been settled (or, if not, submitted (subject to audit)), as determined by the Secretary.
If a hospital submits a timely request to increase its resident level due to an expansion of an existing residency training program that is not reflected on the most recent settled cost report, after audit and subject to the discretion of the Secretary, the reference resident level for such hospital is the resident level for the cost reporting period that includes July 1, 2003, as determined by the Secretary.
Upon the timely request of a hospital, the Secretary shall adjust the reference resident level specified under subclause (I) or (II) to include the number of medical residents that were approved in an application for a medical residency training program that was approved by an appropriate accrediting organization (as determined by the Secretary) before January 1, 2002, but which was not in operation during the cost reporting period used under subclause (I) or (II), as the case may be, as determined by the Secretary.
The provisions of clause (i) shall be applied to hospitals which are members of the same affiliated group (as defined by the Secretary under paragraph (4)(H)(ii)) as of July 1, 2003.
The Secretary is authorized to increase the otherwise applicable resident limit for each qualifying hospital that submits a timely application under this subparagraph by such number as the Secretary may approve for portions of cost reporting periods occurring on or after July 1, 2005. The aggregate number of increases in the otherwise applicable resident limits under this subparagraph may not exceed the Secretary's estimate of the aggregate reduction in such limits attributable to subparagraph (A).
In determining for which hospitals the increase in the otherwise applicable resident limit is provided under clause (i), the Secretary shall take into account the demonstrated likelihood of the hospital filling the positions within the first 3 cost reporting periods beginning on or after July 1, 2005, made available under this subparagraph, as determined by the Secretary.
In determining for which hospitals and residency training programs an increase in the otherwise applicable resident limit is provided under clause (i), the Secretary shall distribute the increase to programs of hospitals located in the following priority order:
Increases of residency limits within the same priority category under this clause shall be determined by the Secretary.
In no case shall more than 25 full-time equivalent additional residency positions be made available under this subparagraph with respect to any hospital.
With respect to additional residency positions in a hospital attributable to the increase provided under this subparagraph, notwithstanding any other provision of this subsection, the approved FTE resident amount is deemed to be equal to the locality adjusted national average per resident amount computed under paragraph (4)(E) for that hospital.
Nothing in this subparagraph shall be construed as permitting the redistribution of reductions in residency positions attributable to voluntary reduction programs under paragraph (6), under a demonstration project approved as of October 31, 2003, under the authority of section 402 of Public Law 90-248, or as affecting the ability of a hospital to establish new medical residency training programs under paragraph (4)(H).
In this paragraph:
The term "resident level" means, with respect to a hospital, the total number of full-time equivalent residents, before the application of weighting factors (as determined under paragraph (4)), in the fields of allopathic and osteopathic medicine for the hospital.
The term "otherwise applicable resident limit" means, with respect to a hospital, the limit otherwise applicable under subparagraphs (F)(i) and (H) of paragraph (4) on the resident level for the hospital determined without regard to this paragraph.
In the case of a hospital with a dual accredited osteopathic and allopathic family practice program for which-
the Secretary shall apply subparagraph (A)(i)(I) using the higher resident reference level and make any necessary adjustments to such reduction. Any such necessary adjustments shall be effective for portions of cost reporting periods occurring on or after July 1, 2005.
There shall be no administrative or judicial review under section 1395ff of this title, 1395oo of this title, or otherwise, with respect to determinations made under this paragraph, paragraph (8),14 paragraph (10), clause (i), (ii), (iii), or (v) of paragraph (2)(F), or clause (i) or (vi) of paragraph (4)(H).
Except as provided in clause (ii), if a hospital's reference resident level (as defined in subparagraph (H)(i)) is less than the otherwise applicable resident limit (as defined in subparagraph (H)(iii)), effective for portions of cost reporting periods occurring on or after July 1, 2011, the otherwise applicable resident limit shall be reduced by 65 percent of the difference between such otherwise applicable resident limit and such reference resident level.
This subparagraph shall not apply to-
The Secretary shall increase the otherwise applicable resident limit for each qualifying hospital that submits an application under this subparagraph by such number as the Secretary may approve for portions of cost reporting periods occurring on or after July 1, 2011. The aggregate number of increases in the otherwise applicable resident limit under this subparagraph shall be equal to the aggregate reduction in such limits attributable to subparagraph (A) (as estimated by the Secretary).
Subject to clause (iii), a hospital that receives an increase in the otherwise applicable resident limit under this subparagraph shall ensure, during the 5-year period beginning on the date of such increase, that-
The Secretary may determine whether a hospital has met the requirements under this clause during such 5-year period in such manner and at such time as the Secretary determines appropriate, including at the end of such 5-year period.
In the case where the Secretary determines that a hospital described in clause (ii) does not meet either of the requirements under subclause (I) or (II) of such clause, the Secretary shall-
In determining for which hospitals the increase in the otherwise applicable resident limit is provided under subparagraph (B), the Secretary shall take into account-
In determining for which hospitals the increase in the otherwise applicable resident limit is provided under subparagraph (B), subject to subparagraph (E), the Secretary shall distribute the increase to hospitals based on the following factors:
Subject to clause (ii), the Secretary shall reserve the positions available for distribution under this paragraph as follows:
In the case where the Secretary does not distribute positions to hospitals in accordance with clause (i) by July 1, 2011, the Secretary shall distribute such positions to other hospitals in accordance with the considerations described in subparagraph (C) and the priority described in subparagraph (D).
A hospital may not receive more than 75 full-time equivalent additional residency positions under this paragraph.
With respect to additional residency positions in a hospital attributable to the increase provided under this paragraph, the approved FTE per resident amounts are deemed to be equal to the hospital per resident amounts for primary care and nonprimary care computed under paragraph (2)(D) for that hospital.
In this paragraph:
The term "reference resident level" means, with respect to a hospital, the highest resident level for any of the 3 most recent cost reporting periods (ending before March 23, 2010) of the hospital for which a cost report has been settled (or, if not, submitted (subject to audit)), as determined by the Secretary.
The term "resident level" has the meaning given such term in paragraph (7)(C)(i).
The term "otherwise applicable resident limit" means, with respect to a hospital, the limit otherwise applicable under subparagraphs (F)(i) and (H) of paragraph (4) on the resident level for the hospital determined without regard to this paragraph but taking into account paragraph (7)(A).
The provisions of this paragraph shall be applied to hospitals which are members of the same affiliated group (as defined by the Secretary under paragraph (4)(H)(ii)) and the reference resident level for each such hospital shall be the reference resident level with respect to the cost reporting period that results in the smallest difference between the reference resident level and the otherwise applicable resident limit.
For fiscal year 2023, and for each succeeding fiscal year until the aggregate number of full-time equivalent residency positions distributed under this paragraph is equal to the aggregate number of such positions made available (as specified in clause (ii)(I)), the Secretary shall, subject to the succeeding provisions of this paragraph, increase the otherwise applicable resident limit for each qualifying hospital (as defined in subparagraph (F)) that submits a timely application under this subparagraph by such number as the Secretary may approve effective beginning July 1 of the fiscal year of the increase.
The aggregate number of such positions made available under this paragraph shall be equal to 1,000.
The aggregate number of such positions so made available shall not exceed 200 for a fiscal year.
The Secretary shall initiate a separate round of applications for an increase under clause (i) for each fiscal year for which such an increase is to be provided.
The Secretary shall notify hospitals of the number of positions distributed to the hospital under this paragraph as a result of an increase in the otherwise applicable resident limit by January 31 of the fiscal year of the increase. Such increase shall be effective beginning July 1 of such fiscal year.
For purposes of providing an increase in the otherwise applicable resident limit under subparagraph (A), the following shall apply:
In determining for which qualifying hospitals such an increase is provided under subparagraph (A), the Secretary shall take into account the demonstrated likelihood of the hospital filling the positions made available under this paragraph within the first 5 training years beginning after the date the increase would be effective, as determined by the Secretary.
With respect to the aggregate number of such positions available for distribution under this paragraph, the Secretary shall distribute not less than 10 percent of such aggregate number to each of the following categories of hospitals:
A hospital may not receive more than 25 additional full-time equivalent residency positions under this paragraph.
No increase in the otherwise applicable resident limit of a hospital may be made under this paragraph unless such hospital agrees to increase the total number of full-time equivalent residency positions under the approved medical residency training program of such hospital by the number of such positions made available by such increase under this paragraph.
With respect to additional residency positions in a hospital attributable to the increase provided under this paragraph, the approved FTE per resident amounts are deemed to be equal to the hospital per resident amounts for primary care and nonprimary care computed under paragraph (2)(D) for that hospital.
The Secretary shall permit hospitals receiving additional residency positions attributable to the increase provided under this paragraph to, beginning in the fifth year after the effective date of such increase, apply such positions to the limitation amount under paragraph (4)(F) that may be aggregated pursuant to paragraph (4)(H) among members of the same affiliated group.
In this paragraph:
The term "otherwise applicable resident limit" means, with respect to a hospital, the limit otherwise applicable under subparagraphs (F)(i) and (H) of paragraph (4) on the resident level for the hospital determined without regard to this paragraph but taking into account paragraphs (7)(A), (7)(B), (8)(A), and (8)(B).
The term "qualifying hospital" means a hospital described in any of subclauses (I) through (IV) of subparagraph (B)(ii).
The term "reference resident level" means, with respect to a hospital, the resident level for the most recent cost reporting period of the hospital ending on or before December 27, 2020, for which a cost report has been settled (or, if not, submitted (subject to audit)), as determined by the Secretary.
The term "resident level" has the meaning given such term in paragraph (7)(C)(i).
For fiscal year 2026, the Secretary shall, subject to the succeeding provisions of this paragraph, increase the otherwise applicable resident limit for each qualifying hospital (as defined in subparagraph (F)) that submits a timely application under this subparagraph by such number as the Secretary may approve effective beginning July 1 of the fiscal year of the increase.
The aggregate number of such positions made available under this paragraph shall be equal to 200.
At least 100 of the positions made available under this paragraph shall be distributed for a psychiatry or psychiatry subspecialty residency (as defined in subparagraph (F)).
The Secretary shall notify hospitals of the number of positions distributed to the hospital under this paragraph as a result of an increase in the otherwise applicable resident limit by January 31 of the fiscal year of the increase. Such increase shall be effective beginning July 1 of such fiscal year.
For purposes of providing an increase in the otherwise applicable resident limit under subparagraph (A), the following shall apply:
In determining for which qualifying hospitals such an increase is provided under subparagraph (A), the Secretary shall take into account the demonstrated likelihood of the hospital filling the positions made available under this paragraph within the first 5 training years beginning after the date the increase would be effective, as determined by the Secretary.
With respect to the aggregate number of such positions available for distribution under this paragraph, the Secretary shall distribute not less than 10 percent of such aggregate number to each of the following categories of hospitals:
The Secretary shall ensure that each qualifying hospital that submits a timely application under subparagraph (A) receives at least 1 (or a fraction of 1) of the positions made available under this paragraph before any qualifying hospital receives more than 1 of such positions.
A hospital may not receive more than 10 additional full-time equivalent residency positions under this paragraph.
No increase in the otherwise applicable resident limit of a hospital may be made under this paragraph unless such hospital agrees to increase the total number of full-time equivalent residency positions under the approved medical residency training program of such hospital by the number of such positions made available by such increase under this paragraph.
If a hospital that receives an increase in the otherwise applicable resident limit under this paragraph would be eligible for an adjustment to the otherwise applicable resident limit for participation in a new medical residency training program under section 413.79(e)(3) of title 42, Code of Federal Regulations (or any successor regulation), the hospital shall ensure that any positions made available under this paragraph are used to expand an existing program of the hospital, and not for participation in a new medical residency training program.
With respect to additional residency positions in a hospital attributable to the increase provided under this paragraph, the approved FTE per resident amounts are deemed to be equal to the hospital per resident amounts for nonprimary care computed under paragraph (2)(D) for that hospital.
The Secretary shall permit hospitals receiving additional residency positions attributable to the increase provided under this paragraph to, beginning in the fifth year after the effective date of such increase, apply such positions to the limitation amount under paragraph (4)(F) that may be aggregated pursuant to paragraph (4)(H) among members of the same affiliated group.
In this paragraph:
The term "otherwise applicable resident limit" means, with respect to a hospital, the limit otherwise applicable under subparagraphs (F)(i) and (H) of paragraph (4) on the resident level for the hospital determined without regard to this paragraph but taking into account paragraphs (7)(A), (7)(B), (8)(A), (8)(B), and (9)(A).
The term "psychiatry or psychiatry subspecialty residency" means a residency in psychiatry as accredited by the Accreditation Council for Graduate Medical Education for the purpose of preventing, diagnosing, and treating mental health disorders.
The term "qualifying hospital" means a hospital described in any of subclauses (I) through (IV) of subparagraph (B)(ii).
The term "reference resident level" means, with respect to a hospital, the resident level for the most recent cost reporting period of the hospital ending on or before December 29, 2022, for which a cost report has been settled (or, if not, submitted (subject to audit)), as determined by the Secretary.
The term "resident level" has the meaning given such term in paragraph (7)(C)(i).
The Secretary shall reduce any payment amounts otherwise determined under this section to the extent necessary to avoid duplication of any payment made under section 4005(e) of the Omnibus Budget Reconciliation Act of 1987.
Notwithstanding section 1395f(b) of this title, but subject to the provisions of section 1395e of this title, the amount of the payment with respect to the operating and capital costs of inpatient hospital services of a rehabilitation hospital or a rehabilitation unit (in this subsection referred to as a "rehabilitation facility"), other than a facility making an election under subparagraph (F) in a cost reporting period beginning on or after October 1, 2000, and before October 1, 2002, is equal to the sum of-
Notwithstanding section 1395f(b) of this title, but subject to the provisions of section 1395e of this title, the amount of the payment with respect to the operating and capital costs of inpatient hospital services of a rehabilitation facility for a payment unit in a cost reporting period beginning on or after October 1, 2002, or, in the case of a facility making an election under subparagraph (F), for any cost reporting period described in such subparagraph, is equal to the per unit payment rate established under this subsection for the fiscal year in which the payment unit of service occurs.
For purposes of subparagraph (A), for a cost reporting period beginning-
For purposes of this subsection, the term "payment unit" means a discharge.
Nothing in this subsection shall be construed as preventing the Secretary from providing for an adjustment to payments to take into account the early transfer of a patient from a rehabilitation facility to another site of care.
A rehabilitation facility may elect, not later than 30 days before its first cost reporting period for which the payment methodology under this subsection applies to the facility, to have payment made to the facility under this subsection under the provisions of subparagraph (B) (rather than subparagraph (A)) for each cost reporting period to which such payment methodology applies.
The Secretary shall establish-
For each case mix group the Secretary shall assign an appropriate weighting which reflects the relative facility resources used with respect to patients classified within that group compared to patients classified within other groups.
The Secretary shall from time to time adjust the classifications and weighting factors established under this paragraph as appropriate to reflect changes in treatment patterns, technology, case mix, number of payment units for which payment is made under this subchapter, and other factors which may affect the relative use of resources. Such adjustments shall be made in a manner so that changes in aggregate payments under the classification system are a result of real changes and are not a result of changes in coding that are unrelated to real changes in case mix.
Insofar as the Secretary determines that such adjustments for a previous fiscal year (or estimates that such adjustments for a future fiscal year) did (or are likely to) result in a change in aggregate payments under the classification system during the fiscal year that are a result of changes in the coding or classification of patients that do not reflect real changes in case mix, the Secretary shall adjust the per payment unit payment rate for subsequent years so as to eliminate the effect of such coding or classification changes.
The Secretary is authorized to require rehabilitation facilities that provide inpatient hospital services to submit such data as the Secretary deems necessary to establish and administer the prospective payment system under this subsection.
The Secretary shall determine a prospective payment rate for each payment unit for which such rehabilitation facility is entitled to receive payment under this subchapter. Subject to subparagraph (B), such rate for payment units occurring during a fiscal year shall be based on the average payment per payment unit under this subchapter for inpatient operating and capital costs of rehabilitation facilities using the most recent data available (as estimated by the Secretary as of the date of establishment of the system) adjusted-
The Secretary shall establish the prospective payment amounts under this subsection for payment units during fiscal years 2001 and 2002 at levels such that, in the Secretary's estimation, the amount of total payments under this subsection for such fiscal years (including any payment adjustments pursuant to paragraphs (4) and (6) but not taking into account any payment adjustment resulting from an election permitted under paragraph (1)(F)) shall be equal to 98 percent for fiscal year 2001 and 100 percent for fiscal year 2002 of the amount of payments that would have been made under this subchapter during the fiscal years for operating and capital costs of rehabilitation facilities had this subsection not been enacted. In establishing such payment amounts, the Secretary shall consider the effects of the prospective payment system established under this subsection on the total number of payment units from rehabilitation facilities and other factors described in subparagraph (A).
For purposes of this subsection for payment units in each fiscal year (beginning with fiscal year 2001), the Secretary shall establish an increase factor subject to clauses (ii) and (iii). Such factor shall be based on an appropriate percentage increase in a market basket of goods and services comprising services for which payment is made under this subsection, which may be the market basket percentage increase described in subsection (b)(3)(B)(iii). The increase factor to be applied under this subparagraph for each of fiscal years 2008 and 2009 shall be 0 percent.
Subject to clause (iii), after establishing the increase factor described in clause (i) for a fiscal year, the Secretary shall reduce such increase factor-
The application of this clause may result in the increase factor under this subparagraph being less than 0.0 for a fiscal year, and may result in payment rates under this subsection for a fiscal year being less than such payment rates for the preceding fiscal year.
The increase factor to be applied under this subparagraph for fiscal year 2018, after the application of clause (ii), shall be 1 percent.
For purposes of subparagraph (C)(ii)(II), the other adjustment described in this subparagraph is-
The Secretary may provide for an additional payment to a rehabilitation facility for patients in a case mix group, based upon the patient being classified as an outlier based on an unusual length of stay, costs, or other factors specified by the Secretary.
The amount of such additional payment under clause (i) shall be determined by the Secretary and shall approximate the marginal cost of care beyond the cutoff point applicable under clause (i).
The total amount of the additional payments made under this subparagraph for payment units in a fiscal year may not exceed 5 percent of the total payments projected or estimated to be made based on prospective payment rates for payment units in that year.
The Secretary may provide for such adjustments to the payment amounts under this subsection as the Secretary deems appropriate to take into account the unique circumstances of rehabilitation facilities located in Alaska and Hawaii.
The Secretary shall provide for publication in the Federal Register, on or before August 1 before each fiscal year (beginning with fiscal year 2001), of the classification and weighting factors for case mix groups under paragraph (2) for such fiscal year and a description of the methodology and data used in computing the prospective payment rates under this subsection for that fiscal year.
The Secretary shall adjust the proportion (as estimated by the Secretary from time to time) of rehabilitation facilities' costs which are attributable to wages and wage-related costs, of the prospective payment rates computed under paragraph (3) for area differences in wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the rehabilitation facility compared to the national average wage level for such facilities. Not later than October 1, 2001 (and at least every 36 months thereafter), the Secretary shall update the factor under the preceding sentence on the basis of information available to the Secretary (and updated as appropriate) of the wages and wage-related costs incurred in furnishing rehabilitation services. Any adjustments or updates made under this paragraph for a fiscal year shall be made in a manner that assures that the aggregated payments under this subsection in the fiscal year are not greater or less than those that would have been made in the year without such adjustment.
For purposes of fiscal year 2014 and each subsequent fiscal year, in the case of a rehabilitation facility that does not submit data to the Secretary in accordance with subparagraphs (C) and (F) with respect to such a fiscal year, after determining the increase factor described in paragraph (3)(C), and after application of subparagraphs (C)(iii) and (D) of paragraph (3), the Secretary shall reduce such increase factor for payments for discharges occurring during such fiscal year by 2 percentage points.
The application of this subparagraph may result in the increase factor described in paragraph (3)(C) being less than 0.0 for a fiscal year, and may result in payment rates under this subsection for a fiscal year being less than such payment rates for the preceding fiscal year.
Any reduction under subparagraph (A) shall apply only with respect to the fiscal year involved and the Secretary shall not take into account such reduction in computing the payment amount under this subsection for a subsequent fiscal year.
Subject to subparagraph (G), for fiscal year 2014 and each subsequent fiscal year, each rehabilitation facility shall submit to the Secretary data on quality measures specified under subparagraph (D). Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this subparagraph.
Subject to clause (ii), any measure specified by the Secretary under this subparagraph must have been endorsed by the entity with a contract under section 1395aaa(a) of this title.
In the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1395aaa(a) of this title, the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary.
Not later than October 1, 2012, the Secretary shall publish the measures selected under this subparagraph that will be applicable with respect to fiscal year 2014.
The Secretary shall establish procedures for making data submitted under subparagraph (C) and subparagraph (F)(i) available to the public. Such procedures shall ensure that a rehabilitation facility has the opportunity to review the data that is to be made public with respect to the facility prior to such data being made public. The Secretary shall report quality measures that relate to services furnished in inpatient settings in rehabilitation facilities on the Internet website of the Centers for Medicare & Medicaid Services.
Beginning not later than 18 months after January 5, 2023, the Secretary shall make publicly available on such Internet website, in addition to the information required to be reported on such website under clause (i), a list of all rehabilitation innovation centers, and shall update such list on such website not less frequently than biennially.
For purposes of clause (ii), the term "rehabilitation innovation centers" means a rehabilitation facility that, as of the applicable date (as defined in clause (v)), is a rehabilitation facility described in clause (iv).
Subject to subclause (II), a rehabilitation facility described in this clause is a rehabilitation facility that-
The Secretary may, as determined appropriate, waive any of the requirements under items (aa) through (ee) of subclause (I).
For purposes of clauses (iii) and (iv), the term "applicable date" means-
Notwithstanding any other provision of law the Secretary may implement clauses (ii) through (v) by program instruction or otherwise.
Chapter 35 of title 44 shall not apply to data collected under clauses (ii) through (v).
For the fiscal year beginning on the specified application date (as defined in subsection (a)(2)(E) of section 1395lll of this title), as applicable with respect to inpatient rehabilitation facilities and quality measures under subsection (c)(1) of such section and measures under subsection (d)(1) of such section, and each subsequent fiscal year, in addition to such data on the quality measures described in subparagraph (C), each rehabilitation facility shall submit to the Secretary data on the quality measures under such subsection (c)(1) and any necessary data specified by the Secretary under such subsection (d)(1).
For fiscal year 2019 and each subsequent fiscal year, in addition to such data described in clause (i), each rehabilitation facility shall submit to the Secretary standardized patient assessment data required under subsection (b)(1) of section 1395lll of this title.
Such data shall be submitted in the form and manner, and at the time, specified by the Secretary for purposes of this subparagraph.
To the extent data submitted under subparagraph (F) duplicates other data required to be submitted under subparagraph (C), the submission of such data under subparagraph (F) shall be in lieu of the submission of such data under subparagraph (C). The previous sentence shall not apply insofar as the Secretary determines it is necessary to avoid a delay in the implementation of section 1395lll of this title, taking into account the different specified application dates under subsection (a)(2)(E) of such section.
There shall be no administrative or judicial review under section 1395ff of this title, 1395oo of this title, or otherwise of the establishment of-
For cost reporting periods beginning on or after October 1, 1997, the Secretary may establish rules for payment to qualified nonhospital providers for their direct costs of medical education, if those costs are incurred in the operation of an approved medical residency training program described in subsection (h). Such rules shall specify the amounts, form, and manner in which such payments will be made and the portion of such payments that will be made from each of the trust funds under this subchapter.
For purposes of this subsection, the term "qualified nonhospital providers" means-
For portions of cost reporting periods occurring in a year (beginning with 2000), the Secretary shall provide for an additional payment amount for any hospital that receives payments for the costs of approved educational activities for nurse and allied health professional training under section 1395x(v)(1) of this title.
The additional payment amount under this subsection for each hospital for portions of cost reporting periods occurring in a year shall be an amount specified by the Secretary in a manner consistent with the following:
The Secretary shall estimate the ratio of payments for all hospitals for portions of cost reporting periods occurring in the year under subsection (h)(3)(D) to total direct graduate medical education payments estimated for such portions of periods under subsection (h)(3).
Subject to clause (ii), such ratio shall be applied to the Secretary's estimate of total payments for nursing and allied health education determined under section 1395x(v) of this title for portions of cost reporting periods occurring in the year to determine a total amount of additional payments for nursing and allied health education to be distributed to hospitals under this subsection for portions of cost reporting periods occurring in the year; except that in no case shall such total amount exceed $60,000,000 in any year.
For each of 2010 through 2019, the limitation under clause (i) on the total amount of additional payments for nursing and allied health education to be distributed to hospitals under this subsection for portions of cost reporting periods occurring in the year shall not apply to such payments made in such year to those hospitals that, as of December 29, 2022, are operating a school of nursing, a school of allied health, or a school of nursing and allied health.
The amount of payment under this subsection to a hospital for portions of cost reporting periods occurring in a year is equal to the total amount of payments determined under subparagraph (B) for the year multiplied by the ratio of-
For provisions related to the establishment and implementation of a prospective payment system for payments under this subchapter for inpatient hospital services furnished by a long-term care hospital described in subsection (d)(1)(B)(iv), see section 123 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 and section 307(b) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000.
In implementing the system described in paragraph (1) for discharges occurring during the rate year ending in 2008 for a hospital, the base rate for such discharges for the hospital shall be the same as the base rate for discharges for the hospital occurring during the rate year ending in 2007.
Subject to subparagraph (C), in implementing the system described in paragraph (1) for rate year 2010 and each subsequent rate year, any annual update to a standard Federal rate for discharges for the hospital during the rate year, shall be reduced-
The application of this paragraph may result in such annual update being less than 0.0 for a rate year, and may result in payment rates under the system described in paragraph (1) for a rate year being less than such payment rates for the preceding rate year.
For fiscal year 2018, the annual update under subparagraph (A) for the fiscal year, after application of clauses (i) and (ii) of subparagraph (A), shall be 1 percent.
For purposes of paragraph (3)(A)(ii), the other adjustment described in this paragraph is-
Under the system described in paragraph (1), for rate year 2014 and each subsequent rate year, in the case of a long-term care hospital that does not submit data to the Secretary in accordance with subparagraphs (C) and (F) with respect to such a rate year, any annual update to a standard Federal rate for discharges for the hospital during the rate year, and after application of paragraph (3), shall be reduced by 2 percentage points.
The application of this subparagraph may result in such annual update being less than 0.0 for a rate year, and may result in payment rates under the system described in paragraph (1) for a rate year being less than such payment rates for the preceding rate year.
Any reduction under subparagraph (A) shall apply only with respect to the rate year involved and the Secretary shall not take into account such reduction in computing the payment amount under the system described in paragraph (1) for a subsequent rate year.
Subject to subparagraph (G), for rate year 2014 and each subsequent rate year, each long-term care hospital shall submit to the Secretary data on quality measures specified under subparagraph (D). Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this subparagraph.
Subject to clause (ii), any measure specified by the Secretary under this subparagraph must have been endorsed by the entity with a contract under section 1395aaa(a) of this title.
In the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1395aaa(a) of this title, the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary.
Not later than October 1, 2012, the Secretary shall publish the measures selected under this subparagraph that will be applicable with respect to rate year 2014.
Not later than October 1, 2015, the Secretary shall establish a functional status quality measure for change in mobility among inpatients requiring ventilator support.
The Secretary shall establish procedures for making data submitted under subparagraph (C) and subparagraph (F)(i) available to the public. Such procedures shall ensure that a long-term care hospital has the opportunity to review the data that is to be made public with respect to the hospital prior to such data being made public. The Secretary shall report quality measures that relate to services furnished in inpatient settings in long-term care hospitals on the Internet website of the Centers for Medicare & Medicaid Services.
For the rate year beginning on the specified application date (as defined in subsection (a)(2)(E) of section 1395lll of this title), as applicable with respect to long-term care hospitals and quality measures under subsection (c)(1) of such section and measures under subsection (d)(1) of such section, and each subsequent rate year, in addition to the data on the quality measures described in subparagraph (C), each long-term care hospital (other than a hospital classified under subsection (d)(1)(B)(vi)) shall submit to the Secretary data on the quality measures under such subsection (c)(1) and any necessary data specified by the Secretary under such subsection (d)(1).
For rate year 2019 and each subsequent rate year, in addition to such data described in clause (i), each long-term care hospital (other than a hospital classified under subsection (d)(1)(B)(vi)) shall submit to the Secretary standardized patient assessment data required under subsection (b)(1) of section 1395lll of this title.
Such data shall be submitted in the form and manner, and at the time, specified by the Secretary for purposes of this subparagraph.
To the extent data submitted under subparagraph (F) duplicates other data required to be submitted under subparagraph (C), the submission of such data under subparagraph (F) shall be in lieu of the submission of such data under subparagraph (C). The previous sentence shall not apply insofar as the Secretary determines it is necessary to avoid a delay in the implementation of section 1395lll of this title, taking into account the different specified application dates under subsection (a)(2)(E) of such section.
For a discharge in cost reporting periods beginning on or after October 1, 2015, except as provided in clause (ii) and subparagraphs (C), (E), (F), and (G), payment under this subchapter to a long-term care hospital for inpatient hospital services shall be made at the applicable site neutral payment rate (as defined in subparagraph (B)).
Clause (i) shall not apply (and payment shall be made to a long-term care hospital without regard to this paragraph) for a discharge if-
The criterion specified in this clause (in this paragraph referred to as the "ICU criterion"), for a discharge from a long-term care hospital, is that the stay in the long-term care hospital ending with such discharge was immediately preceded by a discharge from a stay in a subsection (d) hospital that included at least 3 days in an intensive care unit (ICU), as determined by the Secretary.
In determining intensive care unit days under subclause (I), the Secretary shall use data from revenue center codes 020x or 021x (or such successor codes as the Secretary may establish).
The criterion specified in this clause (in this paragraph referred to as the "ventilator criterion"), for a discharge from a long-term care hospital, is that-
In this paragraph, the term "applicable site neutral payment rate" means-
Subject to clause (iv), in this paragraph, the term "site neutral payment rate" means the lower of-
The blended payment rate specified in this clause, for a long-term care hospital for inpatient hospital services for a discharge, is comprised of-
For each of fiscal years 2018 through 2026, the amount that would otherwise apply under clause (ii)(I) for the year (determined without regard to this clause) shall be reduced by 4.6 percent.
For cost reporting periods beginning during or after fiscal year 2016, the Secretary shall inform each long-term care hospital of its LTCH discharge payment percentage (as defined in clause (iv)) for such period.
For cost reporting periods beginning during or after fiscal year 2020, if the Secretary determines for a long-term care hospital that its LTCH discharge payment percentage for the period is not at least 50 percent-
The Secretary shall establish a process whereby a long-term care hospital may seek to and have the provisions of subclause (II) of clause (ii) discontinued with respect to that hospital.
In this subparagraph, the term "LTCH discharge payment percentage" means, with respect to a long-term care hospital for a cost reporting period beginning during or after fiscal year 2020, the ratio (expressed as a percentage) of-
In this paragraph, any reference in this paragraph to a subsection (d) hospital shall be deemed to include a reference to a subsection (d) Puerto Rico hospital.
In the case of a discharge occurring prior to January 1, 2017, subparagraph (A)(i) shall not apply (and payment shall be made to a long-term care hospital without regard to this paragraph) if such discharge-
In this subparagraph, the term "severe wound" means a stage 3 wound, stage 4 wound, unstageable wound, non-healing surgical wound, infected wound, fistula, osteomyelitis, or wound with morbid obesity, as identified in the claim from the long-term care hospital.
For discharges in cost reporting periods beginning during fiscal years 2018 and 2019, subparagraph (A)(i) shall not apply (and payment shall be made to a long-term care hospital without regard to this paragraph) if such discharge is from a long-term care hospital that meets each of the following requirements:
The long-term care hospital was a not-for-profit long-term care hospital on June 1, 2014, as determined by cost report data.
Of the discharges in calendar year 2013 from the long-term care hospital for which payment was made under this section, at least 50 percent were classified under MS-LTCH-DRGs 28, 29, 52, 57, 551, 573, and 963.
The long-term care hospital discharged inpatients (including both individuals entitled to, or enrolled for, benefits under this subchapter and individuals not so entitled or enrolled) during fiscal year 2014 who had been admitted from at least 20 of the 50 States, determined by the States of residency of such inpatients and based on such data submitted by the hospital to the Secretary as the Secretary may require.
Notwithstanding any other provision of law, the Secretary may implement subclause (I) by program instruction or otherwise.
Chapter 35 of title 44 shall not apply to data collected under this clause.
For a discharge occurring in a cost reporting period beginning during fiscal year 2018, subparagraph (A)(i) shall not apply (and payment shall be made to a long-term care hospital without regard to this paragraph) if such discharge-
In this subparagraph, the term "severe wound" means a wound which is a stage 3 wound, stage 4 wound, unstageable wound, non-healing surgical wound, or fistula as identified in the claim from the long-term care hospital.
In this subparagraph, the term "wound" means an injury involving division of tissue or rupture of the integument or mucous membrane with exposure to the external environment.
Under the system described in paragraph (1), for fiscal years beginning on or after October 1, 2017, the Secretary shall reduce the standard Federal payment rate as if the estimated aggregate amount of high cost outlier payments for standard Federal payment rate discharges for each such fiscal year would be equal to 8 percent of estimated aggregate payments for standard Federal payment rate discharges for each such fiscal year.
Notwithstanding subparagraph (A), the Secretary shall set the fixed loss amount for high cost outlier payments such that the estimated aggregate amount of high cost outlier payments made for standard Federal payment rate discharges for fiscal years beginning on or after October 1, 2017, shall be equal to 99.6875 percent of 8 percent of estimated aggregate payments for standard Federal payment rate discharges for each such fiscal year.
Any reduction in payments resulting from the application of subparagraph (B) shall not be taken into account in applying any budget neutrality provision under such system.
This paragraph shall not apply with respect to the computation of the applicable site neutral payment rate under paragraph (6).
Subject to the succeeding provisions of this subsection, with respect to inpatient hospital services furnished by an eligible hospital during a payment year (as defined in paragraph (2)(G)), if the eligible hospital is a meaningful EHR user (as determined under paragraph (3)) for the EHR reporting period with respect to such year, in addition to the amount otherwise paid under this section, there also shall be paid to the eligible hospital, from the Federal Hospital Insurance Trust Fund established under section 1395i of this title, an amount equal to the applicable amount specified in paragraph (2)(A) for the hospital for such payment year.
Subject to the succeeding subparagraphs of this paragraph, the applicable amount specified in this subparagraph for an eligible hospital for a payment year is equal to the product of the following:
The sum of-
The Medicare share as specified in subparagraph (D) for the eligible hospital for a period selected by the Secretary with respect to such payment year.
The transition factor specified in subparagraph (E) for the eligible hospital for the payment year.
The base amount specified in this subparagraph is $2,000,000.
The discharge related amount specified in this subparagraph for a 12-month period selected by the Secretary shall be determined as the sum of the amount, estimated based upon total discharges for the eligible hospital (regardless of any source of payment) for the period, for each discharge up to the 23,000th discharge as follows:
The Medicare share specified under this subparagraph for an eligible hospital for a period selected by the Secretary for a payment year is equal to the fraction-
Insofar as the Secretary determines that data are not available on charity care necessary to calculate the portion of the formula specified in clause (ii)(II), the Secretary shall use data on uncompensated care and may adjust such data so as to be an appropriate proxy for charity care including a downward adjustment to eliminate bad debt data from uncompensated care data. In the absence of the data necessary, with respect to a hospital, for the Secretary to compute the amount described in clause (ii)(II), the amount under such clause shall be deemed to be 1. In the absence of data, with respect to a hospital, necessary to compute the amount described in clause (i)(II), the amount under such clause shall be deemed to be 0.
Subject to clause (ii), the transition factor specified in this subparagraph for an eligible hospital for a payment year is as follows:
If the first payment year for an eligible hospital is after 2013, then the transition factor specified in this subparagraph for a payment year for such hospital is the same as the amount specified in clause (i) for such payment year for an eligible hospital for which the first payment year is 2013. If the first payment year for an eligible hospital is after 2015 then the transition factor specified in this subparagraph for such hospital and for such year and any subsequent year shall be 0.
The payment under this subsection for a payment year may be in the form of a single consolidated payment or in the form of such periodic installments as the Secretary may specify.
For purposes of this subsection, the term "payment year" means a fiscal year beginning with fiscal year 2011.
The term "first payment year" means, with respect to inpatient hospital services furnished by an eligible hospital, the first fiscal year for which an incentive payment is made for such services under this subsection. The terms "second payment year", "third payment year", and "fourth payment year" mean, with respect to an eligible hospital, each successive year immediately following the first payment year for that hospital.
For purposes of paragraph (1), an eligible hospital shall be treated as a meaningful EHR user for an EHR reporting period for a payment year (or, for purposes of subsection (b)(3)(B)(ix), for an EHR reporting period under such subsection for a fiscal year) if each of the following requirements are met:
The eligible hospital demonstrates to the satisfaction of the Secretary, in accordance with subparagraph (C)(i), that during such period the hospital is using certified EHR technology in a meaningful manner.
The eligible hospital demonstrates to the satisfaction of the Secretary, in accordance with subparagraph (C)(i), that during such period such certified EHR technology is connected in a manner that provides, in accordance with law and standards applicable to the exchange of information, for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination, and the hospital demonstrates (through a process specified by the Secretary, such as the use of an attestation) that the hospital has not knowingly and willfully taken action (such as to disable functionality) to limit or restrict the compatibility or interoperability of the certified EHR technology.
Subject to subparagraph (B)(ii) and using such certified EHR technology, the eligible hospital submits information for such period, in a form and manner specified by the Secretary, on such clinical quality measures and such other measures as selected by the Secretary under subparagraph (B)(i).
The Secretary shall seek to improve the use of electronic health records and health care quality over time.
The Secretary shall select measures for purposes of subparagraph (A)(iii) but only consistent with the following:
The Secretary may not require the electronic reporting of information on clinical quality measures under subparagraph (A)(iii) unless the Secretary has the capacity to accept the information electronically, which may be on a pilot basis.
In selecting such measures, and in establishing the form and manner for reporting measures under subparagraph (A)(iii), the Secretary shall seek to avoid redundant or duplicative reporting with reporting otherwise required, including reporting under subsection (b)(3)(B)(viii).
An eligible hospital may satisfy the demonstration requirement of clauses (i) and (ii) of subparagraph (A) through means specified by the Secretary, which may include-
Notwithstanding sections 1395w-115(d)(2)(B) and 1395w-115(f)(2) of this title, the Secretary may use data regarding drug claims submitted for purposes of section 1395w-115 of this title that are necessary for purposes of subparagraph (A).
There shall be no administrative or judicial review under section 1395ff of this title, section 1395oo of this title, or otherwise, of-
The Secretary shall post on the Internet website of the Centers for Medicare & Medicaid Services, in an easily understandable format, a list of the names of the eligible hospitals that are meaningful EHR users under this subsection or subsection (b)(3)(B)(ix) (and a list of the names of critical access hospitals to which paragraph (3) or (4) of section 1395f(l) of this title applies), and other relevant data as determined appropriate by the Secretary. The Secretary shall ensure that an eligible hospital (or critical access hospital) has the opportunity to review the other relevant data that are to be made public with respect to the hospital (or critical access hospital) prior to such data being made public.
The term "certified EHR technology" has the meaning given such term in section 1395w-4(o)(4) of this title.
For purposes of this subsection:
The term "EHR reporting period" means, with respect to a payment year, any period (or periods) as specified by the Secretary.
The term "eligible hospital" means a hospital that is a subsection (d) hospital or a subsection (d) Puerto Rico hospital.
Subject to the succeeding provisions of this subsection, the Secretary shall establish a hospital value-based purchasing program (in this subsection referred to as the "Program") under which value-based incentive payments are made in a fiscal year to hospitals that meet the performance standards under paragraph (3) for the performance period for such fiscal year (as established under paragraph (4)).
The Program shall apply to payments for discharges occurring on or after October 1, 2012.
For purposes of this subsection, subject to clause (ii), the term "hospital" means a subsection (d) hospital (as defined in subsection (d)(1)(B)).
The term "hospital" shall not include, with respect to a fiscal year, a hospital-
For purposes of determining the minimum numbers under subclauses (III) and (IV) of clause (ii), the Secretary shall have conducted an independent analysis of what numbers are appropriate.
In the case of a hospital that is paid under section 1395f(b)(3) of this title, the Secretary may exempt such hospital from the application of this subsection if the State which is paid under such section submits an annual report to the Secretary describing how a similar program in the State for a participating hospital or hospitals achieves or surpasses the measured results in terms of patient health outcomes and cost savings established under this subsection.
The Secretary shall select measures, other than measures of readmissions, for purposes of the Program. Such measures shall be selected from the measures specified under subsection (b)(3)(B)(viii).
For value-based incentive payments made with respect to discharges occurring during fiscal year 2013, the Secretary shall ensure the following:
Measures are selected under subparagraph (A) that cover at least the following 5 specific conditions or procedures:
Measures selected under subparagraph (A) shall be related to the Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS).
For value-based incentive payments made with respect to discharges occurring during fiscal year 2014 or a subsequent fiscal year, the Secretary shall ensure that measures selected under subparagraph (A) include efficiency measures, including measures of "Medicare spending per beneficiary". Such measures shall be adjusted for factors such as age, sex, race, severity of illness, and other factors that the Secretary determines appropriate.
The Secretary may not include under subparagraph (A) a measure that is based on the questions appearing on the Hospital Consumer Assessment of Healthcare Providers and Systems survey in 2018 or 2019 about communication by hospital staff with an individual about the individual's pain.
The Secretary may not select a measure under subparagraph (A) for use under the Program with respect to a performance period for a fiscal year (as established under paragraph (4)) unless such measure has been specified under subsection (b)(3)(B)(viii) and included on the Hospital Compare Internet website for at least 1 year prior to the beginning of such performance period.
A measure selected under subparagraph (A) shall not apply to a hospital if such hospital does not furnish services appropriate to such measure.
Subclause (VI) of subsection (b)(3)(B)(viii) shall apply to measures selected under subparagraph (A) in the same manner as such subclause applies to measures selected under such subsection.
The Secretary shall establish performance standards with respect to measures selected under paragraph (2) for a performance period for a fiscal year (as established under paragraph (4)).
The performance standards established under subparagraph (A) shall include levels of achievement and improvement.
The Secretary shall establish and announce the performance standards under subparagraph (A) not later than 60 days prior to the beginning of the performance period for the fiscal year involved.
In establishing performance standards with respect to measures under this paragraph, the Secretary shall take into account appropriate factors, such as-
For purposes of the Program, the Secretary shall establish the performance period for a fiscal year. Such performance period shall begin and end prior to the beginning of such fiscal year.
Subject to subparagraph (B), the Secretary shall develop a methodology for assessing the total performance of each hospital based on performance standards with respect to the measures selected under paragraph (2) for a performance period (as established under paragraph (4)). Using such methodology, the Secretary shall provide for an assessment (in this subsection referred to as the "hospital performance score") for each hospital for each performance period.
The Secretary shall ensure that the application of the methodology developed under subparagraph (A) results in an appropriate distribution of value-based incentive payments under paragraph (6) among hospitals achieving different levels of hospital performance scores, with hospitals achieving the highest hospital performance scores receiving the largest value-based incentive payments.
The methodology developed under subparagraph (A) shall provide that the hospital performance score is determined using the higher of its achievement or improvement score for each measure.
The methodology developed under subparagraph (A) shall provide for the assignment of weights for categories of measures as the Secretary determines appropriate.
The Secretary shall not set a minimum performance standard in determining the hospital performance score for any hospital.
The hospital performance score for a hospital shall reflect the measures that apply to the hospital.
In the case of a hospital that the Secretary determines meets (or exceeds) the performance standards under paragraph (3) for the performance period for a fiscal year (as established under paragraph (4)), the Secretary shall increase the base operating DRG payment amount (as defined in paragraph (7)(D)), as determined after application of paragraph (7)(B)(i), for a hospital for each discharge occurring in such fiscal year by the value-based incentive payment amount.
The value-based incentive payment amount for each discharge of a hospital in a fiscal year shall be equal to the product of-
The Secretary shall specify a value-based incentive payment percentage for a hospital for a fiscal year.
In specifying the value-based incentive payment percentage for each hospital for a fiscal year under clause (i), the Secretary shall ensure that-
The total amount available for value-based incentive payments under paragraph (6) for all hospitals for a fiscal year shall be equal to the total amount of reduced payments for all hospitals under subparagraph (B) for such fiscal year, as estimated by the Secretary.
The Secretary shall reduce the base operating DRG payment amount (as defined in subparagraph (D)) for a hospital for each discharge in a fiscal year (beginning with fiscal year 2013) by an amount equal to the applicable percent (as defined in subparagraph (C)) of the base operating DRG payment amount for the discharge for the hospital for such fiscal year. The Secretary shall make such reductions for all hospitals in the fiscal year involved, regardless of whether or not the hospital has been determined by the Secretary to have earned a value-based incentive payment under paragraph (6) for such fiscal year.
Payments described in items (aa) and (bb) of subparagraph (D)(i)(II) for a hospital shall be determined as if this subsection had not been enacted.
For purposes of subparagraph (B), the term "applicable percent" means-
Except as provided in clause (ii), in this subsection, the term "base operating DRG payment amount" means, with respect to a hospital for a fiscal year-
In the case of a medicare-dependent, small rural hospital (with respect to discharges occurring during fiscal year 2012 and 2013) or a sole community hospital, in applying subparagraph (A)(i), the payment amount that would otherwise be made under subsection (d) shall be determined without regard to subparagraphs (I) and (L) of subsection (b)(3) and subparagraphs (D) and (G) of subsection (d)(5).
In the case of a hospital that is paid under section 1395f(b)(3) of this title, the term "base operating DRG payment amount" means the payment amount under such section.
Under the Program, the Secretary shall, not later than 60 days prior to the fiscal year involved, inform each hospital of the adjustments to payments to the hospital for discharges occurring in such fiscal year under paragraphs (6) and (7)(B)(i).
The value-based incentive payment under paragraph (6) and the payment reduction under paragraph (7)(B)(i) shall each apply only with respect to the fiscal year involved, and the Secretary shall not take into account such value-based incentive payment or payment reduction in making payments to a hospital under this section in a subsequent fiscal year.
The Secretary shall make information available to the public regarding the performance of individual hospitals under the Program, including-
The Secretary shall ensure that a hospital has the opportunity to review, and submit corrections for, the information to be made public with respect to the hospital under clause (i) prior to such information being made public.
Such information shall be posted on the Hospital Compare Internet website in an easily understandable format.
The Secretary shall periodically post on the Hospital Compare Internet website aggregate information on the Program, including-
The Secretary shall establish a process by which hospitals may appeal the calculation of a hospital's performance assessment with respect to the performance standards established under paragraph (3)(A) and the hospital performance score under paragraph (5). The Secretary shall ensure that such process provides for resolution of such appeals in a timely manner.
Except as provided in subparagraph (A), there shall be no administrative or judicial review under section 1395ff of this title, section 1395oo of this title, or otherwise of the following:
The Secretary shall consult with small rural and urban hospitals on the application of the Program to such hospitals.
The Secretary shall promulgate regulations to carry out the Program, including the selection of measures under paragraph (2), the methodology developed under paragraph (5) that is used to calculate hospital performance scores, and the methodology used to determine the amount of value-based incentive payments under paragraph (6).
In order to provide an incentive for applicable hospitals to reduce hospital acquired conditions under this subchapter, with respect to discharges from an applicable hospital occurring during fiscal year 2015 or a subsequent fiscal year, the amount of payment under this section or section 1395f(b)(3) of this title, as applicable, for such discharges during the fiscal year shall be equal to 99 percent of the amount of payment that would otherwise apply to such discharges under this section or section 1395f(b)(3) of this title (determined after the application of subsections (o) and (q) and section 1395f(l)(4) of this title but without regard to this subsection).
For purposes of this subsection, the term "applicable hospital" means a subsection (d) hospital that meets the criteria described in subparagraph (B).
The criteria described in this subparagraph, with respect to a subsection (d) hospital, is that the subsection (d) hospital is in the top quartile of all subsection (d) hospitals, relative to the national average, of hospital acquired conditions during the applicable period, as determined by the Secretary.
In carrying out clause (i), the Secretary shall establish and apply an appropriate risk adjustment methodology.
In the case of a hospital that is paid under section 1395f(b)(3) of this title, the Secretary may exempt such hospital from the application of this subsection if the State which is paid under such section submits an annual report to the Secretary describing how a similar program in the State for a participating hospital or hospitals achieves or surpasses the measured results in terms of patient health outcomes and cost savings established under this subsection.
For purposes of this subsection, the term "hospital acquired condition" means a condition identified for purposes of subsection (d)(4)(D)(iv) and any other condition determined appropriate by the Secretary that an individual acquires during a stay in an applicable hospital, as determined by the Secretary.
In this subsection, the term "applicable period" means, with respect to a fiscal year, a period specified by the Secretary.
Prior to fiscal year 2015 and each subsequent fiscal year, the Secretary shall provide confidential reports to applicable hospitals with respect to hospital acquired conditions of the applicable hospital during the applicable period.
The Secretary shall make information available to the public regarding hospital acquired conditions of each applicable hospital.
The Secretary shall ensure that an applicable hospital has the opportunity to review, and submit corrections for, the information to be made public with respect to the hospital under subparagraph (A) prior to such information being made public.
Such information shall be posted on the Hospital Compare Internet website in an easily understandable format.
There shall be no administrative or judicial review under section 1395ff of this title, section 1395oo of this title, or otherwise of the following:
With respect to payment for discharges from an applicable hospital (as defined in paragraph (5)(C)) occurring during a fiscal year beginning on or after October 1, 2012, in order to account for excess readmissions in the hospital, the Secretary shall make payments (in addition to the payments described in paragraph (2)(A)(ii)) for such a discharge to such hospital under subsection (d) (or section 1395f(b)(3) of this title, as the case may be) in an amount equal to the product of-
Except as provided in subparagraph (B), in this subsection, the term "base operating DRG payment amount" means, with respect to a hospital for a fiscal year-
In the case of a medicare-dependent, small rural hospital (with respect to discharges occurring during fiscal years 2012 and 2013) or a sole community hospital, in applying subparagraph (A)(i), the payment amount that would otherwise be made under subsection (d) shall be determined without regard to subparagraphs (I) and (L) of subsection (b)(3) and subparagraphs (D) and (G) of subsection (d)(5).
In the case of a hospital that is paid under section 1395f(b)(3) of this title, the Secretary may exempt such hospitals provided that States paid under such section submit an annual report to the Secretary describing how a similar program in the State for a participating hospital or hospitals achieves or surpasses the measured results in terms of patient health outcomes and cost savings established herein with respect to this section.
For purposes of paragraph (1), subject to subparagraph (D), the adjustment factor under this paragraph for an applicable hospital for a fiscal year is equal to the greater of-
The ratio described in this subparagraph for a hospital for an applicable period is equal to 1 minus the ratio of-
For purposes of subparagraph (A), the floor adjustment factor specified in this subparagraph for-
In determining a hospital's adjustment factor under this paragraph for purposes of making payments for discharges occurring during and after fiscal year 2019, and before the application of clause (i) of subparagraph (E), the Secretary shall assign hospitals to groups (as defined by the Secretary under clause (ii)) and apply the applicable provisions of this subsection using a methodology in a manner that allows for separate comparison of hospitals within each such group, as determined by the Secretary.
For purposes of this subparagraph, the Secretary shall define groups of hospitals, based on their overall proportion, of the inpatients who are entitled to, or enrolled for, benefits under part A, and who are full-benefit dual eligible individuals (as defined in section 1396u-5(c)(6) of this title). In defining groups, the Secretary shall consult the Medicare Payment Advisory Commission and may consider the analysis done by such Commission in preparing the portion of its report submitted to Congress in June 2013 relating to readmissions.
In carrying out this subparagraph, the Secretary shall not impose any additional reporting requirements on hospitals.
The Secretary shall design the methodology to implement this subparagraph so that the estimated total amount of reductions in payments under this subsection equals the estimated total amount of reductions in payments that would otherwise occur under this subsection if this subparagraph did not apply.
The Secretary may take into account the studies conducted and the recommendations made by the Secretary under section 2(d)(1) of the IMPACT Act of 2014 (Public Law 113-185; 42 U.S.C. 1395lll note) with respect to the application under this subsection of risk adjustment methodologies. Nothing in this clause shall be construed as precluding consideration of the use of groupings of hospitals.
In promulgating regulations to carry out this subsection with respect to discharges occurring after fiscal year 2018, the Secretary may consider the use of V or other ICD-related codes for removal of a readmission. The Secretary may consider modifying measures under this subsection to incorporate V or other ICD-related codes at the same time as other changes are being made under this subparagraph.
In promulgating regulations to carry out this subsection, with respect to discharges occurring after fiscal year 2018, the Secretary may consider removal as a readmission of an admission that is classified within one or more of the following: transplants, end-stage renal disease, burns, trauma, psychosis, or substance abuse. The Secretary may consider modifying measures under this subsection to remove readmissions at the same time as other changes are being made under this subparagraph.
For purposes of this subsection:
The term "aggregate payments for excess readmissions" means, for a hospital for an applicable period, the sum, for applicable conditions (as defined in paragraph (5)(A)), of the product, for each applicable condition, of-
The term "aggregate payments for all discharges" means, for a hospital for an applicable period, the sum of the base operating DRG payment amounts for all discharges for all conditions from such hospital for such applicable period.
Subject to clause (ii), the term "excess readmissions ratio" means, with respect to an applicable condition for a hospital for an applicable period, the ratio (but not less than 1.0) of-
For purposes of clause (i), with respect to a hospital, excess readmissions shall not include readmissions for an applicable condition for which there are fewer than a minimum number (as determined by the Secretary) of discharges for such applicable condition for the applicable period and such hospital.
For purposes of this subsection:
The term "applicable condition" means, subject to subparagraph (B), a condition or procedure selected by the Secretary among conditions and procedures for which-
Beginning with fiscal year 2015, the Secretary shall, to the extent practicable, expand the applicable conditions beyond the 3 conditions for which measures have been endorsed as described in subparagraph (A)(ii)(I) as of March 23, 2010, to the additional 4 conditions that have been identified by the Medicare Payment Advisory Commission in its report to Congress in June 2007 and to other conditions and procedures as determined appropriate by the Secretary. In expanding such applicable conditions, the Secretary shall seek the endorsement described in subparagraph (A)(ii)(I) but may apply such measures without such an endorsement in the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1395aaa(a) of this title as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary.
The term "applicable hospital" means a subsection (d) hospital or a hospital that is paid under section 1395f(b)(3) of this title, as the case may be.
The term "applicable period" means, with respect to a fiscal year, such period as the Secretary shall specify.
The term "readmission" means, in the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same or another applicable hospital within a time period specified by the Secretary from the date of such discharge. Insofar as the discharge relates to an applicable condition for which there is an endorsed measure described in subparagraph (A)(ii)(I), such time period (such as 30 days) shall be consistent with the time period specified for such measure.
The Secretary shall make information available to the public regarding readmission rates of each subsection (d) hospital under the program.
The Secretary shall ensure that a subsection (d) hospital has the opportunity to review, and submit corrections for, the information to be made public with respect to the hospital under subparagraph (A) prior to such information being made public.
Such information shall be posted on the Hospital Compare Internet website in an easily understandable format.
There shall be no administrative or judicial review under section 1395ff of this title, section 1395oo of this title, or otherwise of the following:
The Secretary shall calculate readmission rates for all patients (as defined in subparagraph (D)) for a specified hospital (as defined in subparagraph (D)(ii)) for an applicable condition (as defined in paragraph (5)(B)) and other conditions deemed appropriate by the Secretary for an applicable period (as defined in paragraph (5)(D)) in the same manner as used to calculate such readmission rates for hospitals with respect to this subchapter and posted on the CMS Hospital Compare website.
The Secretary shall make information on all patient readmission rates calculated under subparagraph (A) available on the CMS Hospital Compare website in a form and manner determined appropriate by the Secretary. The Secretary may also make other information determined appropriate by the Secretary available on such website.
For purposes of this paragraph:
For fiscal year 2014 and each subsequent fiscal year, instead of the amount of disproportionate share hospital payment that would otherwise be made under subsection (d)(5)(F) to a subsection (d) hospital for the fiscal year, the Secretary shall pay to the subsection (d) hospital 25 percent of such amount (which represents the empirically justified amount for such payment, as determined by the Medicare Payment Advisory Commission in its March 2007 Report to the Congress).
In addition to the payment made to a subsection (d) hospital under paragraph (1), for fiscal year 2014 and each subsequent fiscal year, the Secretary shall pay to such subsection (d) hospitals an additional amount equal to the product of the following factors:
A factor equal to the difference between-
For each of fiscal years 2014, 2015, 2016, and 2017, a factor equal to 1 minus the percent change in the percent of individuals under the age of 65 who are uninsured, as determined by comparing the percent of such individuals-
minus 0.1 percentage points for fiscal year 2014 and minus 0.2 percentage points for each of fiscal years 2015, 2016, and 2017.
For fiscal year 2018 and each subsequent fiscal year, a factor equal to 1 minus the percent change in the percent of individuals who are uninsured, as determined by comparing the percent of individuals-
minus 0.2 percentage points for each of fiscal years 2018 and 2019.
A factor equal to the percent, for each subsection (d) hospital, that represents the quotient of-
There shall be no administrative or judicial review under section 1395ff of this title, section 1395oo of this title, or otherwise of the following:
For provisions related to the establishment and implementation of a prospective payment system for payments under this subchapter for inpatient hospital services furnished by psychiatric hospitals (as described in clause (i) of subsection (d)(1)(B)) and psychiatric units (as described in the matter following clause (v) of such subsection), see section 124 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999.
In implementing the system described in paragraph (1) for the rate year beginning in 2010 and any subsequent rate year, any update to a base rate for days during the rate year for a psychiatric hospital or unit, respectively, shall be reduced-
The application of this paragraph may result in such update being less than 0.0 for a rate year, and may result in payment rates under the system described in paragraph (1) for a rate year being less than such payment rates for the preceding rate year.
For purposes of paragraph (2)(A)(ii), the other adjustment described in this paragraph is-
Under the system described in paragraph (1), for rate year 2014 and each subsequent rate year, in the case of a psychiatric hospital or psychiatric unit that does not submit data to the Secretary in accordance with subparagraphs (C) and (E) with respect to such a rate year, any annual update to a standard Federal rate for discharges for the hospital during the rate year, and after application of paragraph (2), shall be reduced by 2 percentage points.
The application of this subparagraph may result in such annual update being less than 0.0 for a rate year, and may result in payment rates under the system described in paragraph (1) for a rate year being less than such payment rates for the preceding rate year.
Any reduction under subparagraph (A) shall apply only with respect to the rate year involved and the Secretary shall not take into account such reduction in computing the payment amount under the system described in paragraph (1) for a subsequent rate year.
For rate year 2014 and each subsequent rate year, each psychiatric hospital and psychiatric unit shall submit to the Secretary data on quality measures specified under subparagraph (D). Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this subparagraph.
Subject to clause (ii), any measure specified by the Secretary under this subparagraph must have been endorsed by the entity with a contract under section 1395aaa(a) of this title.
In the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1395aaa(a) of this title, the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary.
Not later than October 1, 2012, the Secretary shall publish the measures selected under this subparagraph that will be applicable with respect to rate year 2014.
Not later than for rate year 2031, the quality measures specified under this subparagraph shall include a quality measure of patients' perspective on care.
For rate year 2028 and each subsequent rate year, in addition to such data on the quality measures described in subparagraph (C), each psychiatric hospital and psychiatric unit shall submit to the Secretary, through the use of a standardized assessment instrument implemented under clause (iii), the standardized patient assessment data described in clause (ii). Such data shall be submitted with respect to admission and discharge of an individual (and may be submitted more frequently as the Secretary determines appropriate).
For purposes of clause (i), the standardized patient assessment data described in this clause, with respect to a psychiatric hospital or psychiatric unit, is data with respect to the following categories:
For purposes of clause (i), the Secretary shall implement a standardized assessment instrument that provides for the submission of standardized patient assessment data under this subchapter with respect to psychiatric hospitals and psychiatric units which enables comparison of such assessment data across all such hospitals and units to which such data are applicable.
The Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1395i of this title to the Centers for Medicare & Medicaid Services Program Management Account, of $10,000,000 for purposes of carrying out subclause (I).
The Secretary shall establish procedures for making data submitted under subparagraphs (C) and (F) available to the public. Such procedures shall ensure that a psychiatric hospital and a psychiatric unit has the opportunity to review the data that is to be made public with respect to the hospital or unit prior to such data being made public. The Secretary shall report quality measures, including the quality measure of patients' perspective on care described in subparagraph (D)(iv), that relate to services furnished in inpatient settings in psychiatric hospitals and psychiatric units on the Internet website of the Centers for Medicare & Medicaid Services.
The Secretary shall collect data and information as the Secretary determines appropriate to revise payments under the system described in paragraph (1) for psychiatric hospitals and psychiatric units pursuant to subparagraph (D) and for other purposes as determined appropriate by the Secretary. The Secretary shall begin to collect such data by not later than October 1, 2023.
The data and information to be collected under subparagraph (A) may include-
The Secretary may collect the additional data and information under subparagraph (A) on cost reports, on claims, or otherwise.
Notwithstanding the preceding paragraphs of this subsection or section 124 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, for rate year 2025 (and for any subsequent rate year, if determined appropriate by the Secretary), the Secretary shall, by regulation, implement revisions to the methodology for determining the payment rates under the system described in paragraph (1) for psychiatric hospitals and psychiatric units, as the Secretary determines to be appropriate. Such revisions may be based on a review of data and information collected under subparagraph (A).
The Secretary may make revisions to the diagnosis-related group classifications, in accordance with subsection (d)(4)(C), to reflect nursing and staff resource use and costs involved in furnishing services at such hospitals and units, including considerations for patient complexity and prior admission to an inpatient psychiatric facility, which may be based on review of data and information collected under subparagraph (A), as the Secretary determines to be appropriate.
Revisions in payment implemented pursuant to clause (i) for a rate year shall result in the same estimated amount of aggregate expenditures under this subchapter for psychiatric hospitals and psychiatric units furnished in the rate year as would have been made under this subchapter for such care in such rate year if such revisions had not been implemented.
Notwithstanding the preceding paragraphs of this subsection (other than paragraph (5)) or section 124 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, beginning not later than rate year 2031, in addition to any revisions pursuant to paragraph (5), the Secretary shall, by regulation, implement revisions to the methodology for determining the payment rates under the system described in paragraph (1) for psychiatric hospitals and psychiatric units, as the Secretary determines to be appropriate, to take into account the patient assessment data described in paragraph (4)(E)(ii).
Revisions in payment implemented pursuant to subparagraph (A) for a rate year shall result in the same estimated amount of aggregate expenditures under this subchapter for psychiatric hospitals and psychiatric units furnished in the rate year as would have been made under this subchapter for such care in such rate year if such revisions had not been implemented.
Not later than January 1, 2018, the Secretary shall develop HCPCS versions for MS-DRGs that are similar to the ICD-10-PCS for such MS-DRGs such that, to the extent possible, the MS-DRG assignment shall be similar for a claim coded with the HCPCS version as an identical claim coded with a ICD-10-PCS code.
In carrying out paragraph (1), the Secretary shall develop HCPCS versions of MS-DRG codes for not fewer than 10 surgical MS-DRGs.
The Secretary shall develop a HCPCS MS-DRG definitions manual and software that is similar to the definitions manual and software for ICD-10-PCS codes for such MS-DRGs. The Secretary shall post the HCPCS MS-DRG definitions manual and software on the Internet website of the Centers for Medicare & Medicaid Services. The HCPCS MS-DRG definitions manual and software shall be in the public domain and available for use and redistribution without charge.
In developing the HCPCS MS-DRG definitions manual and software under subparagraph (A), the Secretary shall consult with the Medicare Payment Advisory Commission and shall consider the analysis done by such Commission in translating outpatient surgical claims into inpatient surgical MS-DRGs in preparing chapter 7 (relating to hospital short-stay policy issues) of its "Medicare and the Health Care Delivery System" report submitted to Congress in June 2015.
In this subsection:
The term "HCPCS" means, with respect to hospital items and services, the code under the Healthcare Common Procedure Coding System (HCPCS) (or a successor code) for such items and services.
The term "ICD-10-PCS" means the International Classification of Diseases, 10th Revision, Procedure Coding System, and includes any subsequent revision of such International Classification of Diseases, Procedure Coding System.
1 So in original. Probably should be followed by "percentage point".
2 So in original. The semicolon probably should be a comma.
3 So in original. The comma probably should not appear.
4 See References in Text note below.
5 So in original. Probably should be followed by a period.
6 So in original. Probably should be followed by "and".
7 So in original. Probably should be section "557(b)".
8 So in original. Probably should be "section".
9 So in original.
10 So in original. The semicolon probably should not appear.
11 So in original. Probably should be followed by a comma.
12 So in original. No subpar.
13 So in original. The comma probably should be a semicolon.
14 So in original. Probably should be followed by "paragraph (9),". See 2020 Amendment notes below.
15 So in original. Probably should not be capitalized.
16 So in original. Probably should be "(6)(A)".
42 U.S.C. § 1395ww
EDITORIAL NOTES
REFERENCES IN TEXTSection 5001(b) of the Deficit Reduction Act of 2005, referred to in subsec. (b)(3)(B)(viii)(I), is section 5001(b) of Pub. L. 109-171, which is set out below.The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, referred to in subsecs. (b)(3)(B)(viii)(IV) and (d)(2)(C)(i), is Pub. L. 108-173, 117 Stat. 2066. Section 238(b) of the Act is set out as a note under section 1395ll of this title. Section 402(a) of the Act, which amended this section, does not contain a par. (1). Section 403(a)(1) of the Act amended this section. For complete classification of this Act to the Code, see Short Title of 2003 Amendment note set out under section 1305 of this title and Tables.The Internal Revenue Code of 1986, referred to in subsec. (b)(6), is classified generally to Title 26, Internal Revenue Code.Section 222(a) of the Social Security Amendments of 1972, referred to in subsec. (c)(4)(B), is section 222(a) of Pub. L. 92-603, Oct. 30, 1972, 86 Stat. 1329, which is set out as a note under section 1395b-1 of this title.The effective date of such clause (vi), referred to in concluding provisions of subsec. (d)(1)(B), probably means the date of enactment of Pub. L. 114-255, which redesignated subcl. (II) of cl. (iv) of subsec. (d)(1)(B) as cl. (vi) of subsec. (d)(1)(B), and which was approved Dec. 13, 2016.Section 9104(a) of the Medicare and Medicaid Budget Reconciliation Amendments of 1985, referred to in subsec. (d)(2)(C)(i), is section 9104(a) of Pub. L. 99-272, which amended subsec. (d)(5)(B) of this section.Section 4621(a)(1) of the Balanced Budget Act of 1997, referred to in subsec. (d)(2)(C)(i), is section 4621(a)(1) of Pub. L. 105-33, which amended subsec. (d)(5)(B)(ii) of this section.Section 111 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, referred to in subsec. (d)(2)(C)(i), is section 1000(a)(6) [title I, §111] of Pub. L. 106-113, which amended this section and enacted provisions set out as a note under this section. Section 302 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, referred to in subsec. (d)(2)(C)(i), is section 1(a)(6) [title III, §302] of Pub. L. 106-554, which amended this section and enacted provisions set out as a note under this section. Section 6003(c) of the Omnibus Budget Reconciliation Act of 1989, referred to in subsec. (d)(2)(C)(iv), is section 6003(c) of Pub. L. 101-239, which amended this section and enacted provisions set out below. Section 4002(b) of the Omnibus Budget Reconciliation Act of 1990, referred to in subsec. (d)(2)(C)(iv), is section 4002(b) of Pub. L. 101-508, which amended this section and enacted provisions set out below. Section 303 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, referred to in subsec. (d)(2)(C)(iv), is section 1(a)(6) [title III, §303] of Pub. L. 106-554, which amended this section and enacted provisions set out as notes under this section. Section 9104 of the Medicare and Medicaid Budget Reconciliation Amendments of 1985, referred to in subsec. (d)(3)(C)(ii), is section 9104 of Pub. L. 99-272, which amended subsec. (d)(2)(C)(i), (3)(C), (D)(i)(I), (ii)(I), and (5)(B) of this section.Section 4003(a)(1) of the Omnibus Budget Reconciliation Act of 1987, referred to in subsec. (d)(3)(C)(ii), is section 4003(a)(1) of Pub. L. 100-203, which amended subsec. (d)(5)(B)(ii) of this section.The Omnibus Budget Reconciliation Act of 1990, referred to in subsec. (d)(3)(C)(ii), is Pub. L. 101-508, 104 Stat. 1388. For complete classification of this Act to the Code, see Tables.The Patient Protection and Affordable Care Act, referred to in subsecs. (d)(3)(E)(i) and (r)(2)(B)(i)(I), is Pub. L. 111-148, 124 Stat. 119. Section 10324(a)(1) of the Act amended this section. For complete classification of this Act to the Code, see Short Title note set out under section 18001 of this title and Tables. Section 9831(a) of the American Rescue Plan Act of 2021, referred to in subsec. (d)(3)(E)(i), is section 9831(a) of Pub. L. 117-2, which amended subsec. (d)(3)(E)(i), (iv) of this section.Section 9304 of the Omnibus Budget Reconciliation Act of 1986, referred to in subsec. (e)(1)(C)(ii), is section 9304 of Pub. L. 99-509, which enacted subsecs. (d)(9) and (e)(1)(C) of this section and amended subsec. (d)(5)(C)(i)(I), (ii) of this section.Section 4628 of the Balanced Budget Act of 1997, referred to in subsec. (h)(6)(C)(iii), is section 4628 of Pub. L. 105-33, which is set out as a note below.Section 402 of Public Law 90-248, referred to in subsec. (h)(7)(B)(vi), (8)(A)(ii)(II), is section 402 of Pub. L. 90-248, title IV, Jan. 2, 1968, 81 Stat. 930, which enacted section 1395b-1 of this title and amended section 1395ll of this title.Such section 332(a)(1)(A), referred to in subsec. (h)(8)(D)(ii)(I), probably means section 332(a)(1)(A) of the Public Health Service Act, which is classified to section 254e(a)(1)(A) of this title.Section 4005(e) of the Omnibus Budget Reconciliation Act of 1987, referred to in subsec. (i), is section 4005(e) of Pub. L. 100-203, which is set out below. Section 123 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, referred to in subsec. (m)(1), is section 1000(a)(6) [title I, §123] of Pub. L. 106-113, which enacted provisions set out as a note under this section.Section 307(b) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, referred to in subsec. (m)(1), is section 1(a)(6) [title III, §307(b)] of Pub. L. 106-554, which enacted provisions set out as a note under this section. The Health Care and Education Reconciliation Act of 2010, referred to in subsec. (r)(2)(B)(i)(I), is Pub. L. 111-152, 124 Stat. 1029. For complete classification of this Act to the Code, see Short Title of 2010 Amendment note set out under section 1305 of this title and Tables. Section 124 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, referred to in subsec. (s)(1), (5)(D)(i), (6)(A), is section 1000(a)(6) [title I, §124] of Pub. L. 106-113, which enacted provisions set out as a note under this section.
AMENDMENTS2024-Subsec. (b)(3)(D). Pub. L. 118-42, §307(b)(1)(A), substituted "January 1, 2025" for "October 1, 2024" in introductory provisions.Subsec. (b)(3)(D)(iv). Pub. L. 118-42, §307(b)(1)(B), inserted "and the portion of fiscal year 2025 beginning on October 1, 2024, and ending on December 31, 2024," after "fiscal year 2024".Subsec. (d)(5)(G)(i). Pub. L. 118-42, §307(a)(1), substituted "January 1, 2025" for "October 1, 2024" in introductory provisions.Subsec. (d)(5)(G)(ii)(II). Pub. L. 118-42, §307(a)(2), substituted "January 1, 2025" for "October 1, 2024". Subsec. (d)(12)(B). Pub. L. 118-42, §306(a)(1), substituted "during the portion of fiscal year 2025 beginning on January 1, 2025, and ending on September 30, 2025, and in fiscal year 2026 and subsequent fiscal years" for "in fiscal year 2025 and subsequent fiscal years" in introductory provisions.Subsec. (d)(12)(C)(i). Pub. L. 118-42, §306(a)(2)(A), inserted "or portion of a fiscal year" after "for a fiscal year" and "and the portion of fiscal year 2025 beginning on October 1, 2024, and ending on December 31, 2024" after "through 2024" in introductory provisions.Subsec. (d)(12)(C)(i)(III). Pub. L. 118-42, §306(a)(2)(B), inserted "and the portion of fiscal year 2025 beginning on October 1, 2024, and ending on December 31, 2024" after "through 2024".Subsec. (d)(12)(C)(i)(IV). Pub. L. 118-42, §306(a)(2)(C), substituted "the portion of fiscal year 2025 beginning on January 1, 2025, and ending on September 30, 2025, and fiscal year 2026" for "fiscal year 2025".Subsec. (d)(12)(D). Pub. L. 118-42, §306(a)(3)(A), inserted "or during the portion of fiscal year 2025 beginning on October 1, 2024, and ending on December 31, 2024" after "through 2024" in introductory provisions.Subsec. (d)(12)(D)(ii). Pub. L. 118-42, §306(a)(3)(B), inserted "and the portion of fiscal year 2025 beginning on October 1, 2024, and ending on December 31, 2024" after "through 2024".2023-Subsec. (j)(7)(E). Pub. L. 117-341 designated existing provisions as cl. (i), inserted heading, and added cls. (ii) to (vii).2022-Subsec. (b)(3)(D). Pub. L. 117-328, §4102(b)(1)(A), substituted "October 1, 2024" for "December 24, 2022" in introductory provisions. Pub. L. 117-229, §102(b)(1)(A), substituted "December 24, 2022" for "December 17, 2022" in introductory provisions. Pub. L. 117-180, §102(b)(1)(A), substituted "December 17, 2022" for "October 1, 2022" in introductory provisions. Subsec. (b)(3)(D)(iv). Pub. L. 117-328, §4102(b)(1)(B), substituted "fiscal year 2024" for "fiscal year 2022 and the portion of fiscal year 2023 beginning on October 1, 2022, and ending on December 23, 2022,". Pub. L. 117-229, §102(b)(1)(B), substituted "December 23, 2022" for "December 16, 2022,". Pub. L. 117-180, §102(b)(1)(B), inserted "and the portion of fiscal year 2023 beginning on October 1, 2022, and ending on December 16, 2022," after "through fiscal year 2022". Subsec. (d)(5)(B)(v). Pub. L. 117-328, §4122(b)(1), substituted "(h)(9), and (h)(10)" for "and (h)(9)".Subsec. (d)(5)(B)(xii). Pub. L. 117-328, §4122(b)(2), realigned margins. Subsec. (d)(5)(B)(xiii). Pub. L. 117-328, §4122(b)(3), added cl. (xiii). Subsec. (d)(5)(G)(i). Pub. L. 117-328, §4102(a)(1), substituted "October 1, 2024" for "December 24, 2022". Pub. L. 117-229, §102(a)(1), substituted "December 24, 2022" for "December 17, 2022". Pub. L. 117-180, §102(a)(1), substituted "December 17, 2022" for "October 1, 2022".Subsec. (d)(5)(G)(ii)(II). Pub. L. 117-328, §4102(a)(2), substituted "October 1, 2024" for "December 24, 2022". Pub. L. 117-229, §102(a)(2), substituted "December 24, 2022" for "December 17, 2022". Pub. L. 117-180, §102(a)(2), substituted "December 17, 2022" for "October 1, 2022". Subsec. (d)(12)(B). Pub. L. 117-328, §4101(a)(1), substituted "in fiscal year 2025" for "during the portion of fiscal year 2023 beginning on December 24, 2022, and ending on September 30, 2023, and in fiscal year 2024" in introductory provisions. Pub. L. 117-229, §101(a)(1), substituted "December 24, 2022" for "December 17, 2022" in introductory provisions. Pub. L. 117-180, §101(a)(1), substituted "during the portion of fiscal year 2023 beginning on December 17, 2022, and ending on September 30, 2023, and in fiscal year 2024 and subsequent fiscal years" for "in fiscal year 2023 and subsequent fiscal years" in introductory provisions.Subsec. (d)(12)(C)(i). Pub. L. 117-328, §4101(a)(2)(A) (ii), which directed the substitution of "through 2024" for "through 2022 and the portion of fiscal year 2023 beginning on October 1, 2022, and ending on December 23, 2022' " in introductory provisions, was executed by making the substitution for "through 2022 and the portion of fiscal year 2023 beginning on October 1, 2022, and ending on December 23, 2022", to reflect the probable intent of Congress. Pub. L. 117-328, §4101(a)(2)(A)(i), struck out "or portion of a fiscal year" after "for a fiscal year" in introductory provisions. Pub. L. 117-229, §101(a)(2)(A), substituted "December 23, 2022" for "December 16, 2022" in introductory provisions. Pub. L. 117-180, §101(a)(2)(A), inserted "or portion of a fiscal year" after "for a fiscal year" and "and the portion of fiscal year 2023 beginning on October 1, 2022, and ending on December 16, 2022" after "through 2022" in introductory provisions. Subsec. (d)(12)(C)(i)(III). Pub. L. 117-328, §4101(a)(2)(B), which directed the substitution of "through 2024" for "through 2022 and the portion of fiscal year 2023 beginning on October 1, 2022, and ending on December 23, 2022' ", was executed by making the substitution for "through 2022 and the portion of fiscal year 2023 beginning on October 1, 2022, and ending on December 23, 2022", to reflect the probable intent of Congress. Pub. L. 117-229, §101(a)(2)(B), which directed the substitution of "December 23, 2022" for "December 16, 2022' ", was executed by making the substitution for "December 16, 2022" to reflect the probable intent of Congress. Pub. L. 117-180, §101(a)(2)(B), inserted "and the portion of fiscal year 2023 beginning on October 1, 2022, and ending on December 16, 2022" after "through 2022".Subsec. (d)(12)(C)(i)(IV). Pub. L. 117-328, §4101(a)(2)(C), substituted "fiscal year 2025" for "the portion of fiscal year 2023 beginning on December 24, 2022, and ending on September 30, 2023, and fiscal year 2024". Pub. L. 117-229, §101(a)(2)(C), substituted "December 24, 2022" for "December 17, 2022". Pub. L. 117-180, §101(a)(2)(C), substituted "the portion of fiscal year 2023 beginning on December 17, 2022, and ending on September 30, 2023, and fiscal year 2024" for "fiscal year 2023". Subsec. (d)(12)(D). Pub. L. 117-328, §4101(a)(3)(A), which directed the substitution of "through 2024" for "through 2022 or during the portion of fiscal year 2023 beginning on October 1, 2022, and ending on December 23, 2022' " in introductory provisions, was executed by making the substitution for "through 2022 or during the portion of fiscal year 2023 beginning on October 1, 2022, and ending on December 23, 2022", to reflect the probable intent of Congress. Pub. L. 117-229, §101(a)(3)(A), which directed the substitution of "December 23, 2022" for "December 16, 2022' " in introductory provisions, was executed by making the substitution for "December 16, 2022" to reflect the probable intent of Congress. Pub. L. 117-180, §101(a)(3)(A), inserted "or during the portion of fiscal year 2023 beginning on October 1, 2022, and ending on December 16, 2022" after "through 2022" in introductory provisions.Subsec. (d)(12)(D)(ii). Pub. L. 117-328, §4101(a)(3)(B), which directed the substitution of "through 2024" for "through 2022 and the portion of fiscal year 2023 beginning on October 1, 2022, and ending on December 23, 2022' ", was executed by making the substitution for "through 2022 and the portion of fiscal year 2023 beginning on October 1, 2022, and ending on December 23, 2022", to reflect the probable intent of Congress. Pub. L. 117-229, §101(a)(3)(B), which directed the substitution of "December 23, 2022" for "December 16, 2022' ", was executed by making the substitution for "December 16, 2022" to reflect the probable intent of Congress. Pub. L. 117-180, §101(a)(3)(B), inserted "and the portion of fiscal year 2023 beginning on October 1, 2022, and ending on December 16, 2022" after "through 2022".Subsec. (h)(3)(D)(iii). Pub. L. 117-328, §4143(b), inserted at end "In applying the preceding sentence for each of 2010 through 2019, the Secretary shall not take into account any increase in the total amount of such additional payment amounts for such nursing and allied health education for portions of cost reporting periods occurring in the year pursuant to the application of paragraph (2)(B)(ii) of such subsection."Subsec. (h)(4)(F)(i). Pub. L. 117-328, §4122(a)(1), substituted "(9), and (10)" for "and (9)". Subsec. (h)(4)(H)(i)(I). Pub. L. 117-328, §4122(a)(2), substituted "(9), and (10)" for "and (9)". Subsec. (h)(7)(E). Pub. L. 117-328, §4122(c), inserted "paragraph (10)," after "paragraph (8),".Subsec. (h)(10). Pub. L. 117-328, §4122(a)(3), added par. (10).Subsec. (l)(2)(B). Pub. L. 117-328, §4143(a), designated existing provisions as cl. (i), inserted heading, substituted "Subject to clause (ii), such ratio" for "Such ratio", and added cl. (ii).Subsec. (s)(4)(A)(i). Pub. L. 117-328, §4125(b)(1)(A), substituted "subparagraphs (C) and (E)" for "subparagraph (C)".Subsec. (s)(4)(D)(iv). Pub. L. 117-328, §4125(c)(1), added cl. (iv).Subsec. (s)(4)(E). Pub. L. 117-328, §4125(b)(1)(C), added subpar. (E). Former subpar. (E) redesignated (F).Subsec. (s)(4)(F). Pub. L. 117-328, §4125(c)(2), which directed amendment of subpar. (E) by inserting ", including the quality measure of patients' perspective on care described in subparagraph (D)(iv)," after "shall report quality measures", was executed by making the insertion in subpar. (F) to reflect the probable intent of Congress and intervening amendment by Pub. L. 117-328, §4125(b)(1)(B) . See below. Pub. L. 117-328, §4125(b)(1)(B), (D), redesignated subpar. (E) as (F) and substituted "subparagraphs (C) and (F)" for "subparagraph (C)". Subsec. (s)(5). Pub. L. 117-328, §4125(a), added par. (5). Subsec. (s)(6). Pub. L. 117-328, §4125(b)(2), added par. (6). 2021-Subsec. (d)(3)(E)(i). Pub. L. 117-2, §9831(b), substituted ", the amendments" for "and the amendments" and inserted ", and the amendments made by section 9831(a) of the American Rescue Plan Act of 2021" after "the Patient Protection and Affordable Care Act". Pub. L. 117-2, §9831(a)(1), substituted ", (iii), or (iv)" for "or (iii)".Subsec. (d)(3)(E)(iv). Pub. L. 117-2, §9831(a)(2), added cl. (iv). 2020-Subsec. (d)(4)(C)(iv). Pub. L. 116-136 added cl. (iv).Subsec. (d)(5)(B)(v). Pub. L. 116-260, §126(b)(1), substituted "(h)(8), and (h)(9)" for "and (h)(8)".Subsec. (d)(5)(B)(viii). Pub. L. 116-260, §131(c)(1), substituted "paragraphs (2)(F)(iv) and (4)(H) of subsection (h)" for "subsection (h)(4)(H)". Subsec. (d)(5)(B)(x), (xi). Pub. L. 116-260, §126(b)(2), redesignated cl. (x), relating to determining the hospital's number of full-time equivalent residents, as (xi) and realigned margins. Subsec. (d)(5)(B)(xii). Pub. L. 116-260, §126(b)(3), added cl. (xii).Subsec. (h)(2)(F). Pub. L. 116-260, §131(a), designated existing provisions as cl. (i) and added cls. (ii) to (v). Subsec. (h)(4)(F)(i). Pub. L. 116-260, §126(a)(1), substituted "paragraphs (7), (8), and (9)" for "paragraphs (7) and (8)". Subsec. (h)(4)(H)(i). Pub. L. 116-260, §131(b), designated existing provisions as subcl. (I) and added subcls. (II) to (V). Pub. L. 116-260, §126(a)(2), substituted "paragraphs (7), (8), and (9)" for "paragraphs (7) and (8)".Subsec. (h)(4)(H)(iv). Pub. L. 116-260, §127, substituted "Training programs in rural areas" for "Nonrural hospitals operating training programs in rural areas" in heading, designated existing provisions as subcl. (I), inserted heading, and substituted "For cost reporting periods beginning before October 1, 2022, in the case of" for "In the case of", and added subcl. (II). Substitution in cl. (iv) heading was executed by striking "hospitals" instead of "hospital" as directed, to reflect the probable intent of Congress.Subsec. (h)(4)(H)(iv)(I). Pub. L. 116-260, §131(c)(2)(A), substituted "a rural area or has" for "an rural area or has".Subsec. (h)(7)(E). Pub. L. 116-260, §131(c)(2)(B), substituted "under this paragraph, paragraph (8), clause (i), (ii), (iii), or (v) of paragraph (2)(F), or clause (i) or (vi) of paragraph (4)(H)." for "under this this paragraph, paragraph (8), paragraph (9), or paragraph (4)(H)(vi)." Pub. L. 116-260, §126(a)(3), (c), which amended subpar. (E) identically by inserting "paragraph (9)," after "paragraph (8),", was effectively undone by the subsequent amendment made by Pub. L. 116-260, §131(c)(2)(B) . See above.Subsec. (h)(9). Pub. L. 116-260, §126(a)(4), added par. (9).2019-Subsec. (a)(4). Pub. L. 116-94, §108(1), in introductory provisions, inserted "for cost reporting periods beginning on or after October 1, 2020, costs related to hematopoietic stem cell acquisition for the purpose of an allogeneic hematopoietic stem cell transplant (as described in subsection (d)(5)(M))," after "October 1, 1987),".Subsec. (d)(4)(C)(iii). Pub. L. 116-94, §108(2)(A), inserted "or payments under paragraph (5)(M) (beginning with fiscal year 2021)" after "fiscal year 1991)" and "or payments under paragraph (5)(M)" before period at end.Subsec. (d)(5)(M). Pub. L. 116-94, §108(2)(B), added subpar. (M). 2018-Subsec. (b)(3)(B)(viii)(XII). Pub. L. 115-271, §6104(a), added subcl. (XII).Subsec. (b)(3)(D). Pub. L. 115-123, §50205(b)(1)(A), substituted "October 1, 2022" for "October 1, 2017" in introductory provisions.Subsec. (b)(3)(D)(iv). Pub. L. 115-123, §50205(b)(1)(B), substituted "through fiscal year 2022" for "through fiscal year 2017".Subsec. (d)(5)(G)(i). Pub. L. 115-123, §50205(a)(1), substituted "October 1, 2022" for "October 1, 2017". Subsec. (d)(5)(G)(ii)(II). Pub. L. 115-123, §50205(a)(2), substituted "October 1, 2022" for "October 1, 2017".Subsec. (d)(5)(G)(iv). Pub. L. 115-123, §50205(a)(4), inserted concluding provisions.Subsec. (d)(5)(G)(iv)(I). Pub. L. 115-123, §50205(a)(3), added subcl. (I) and struck out former subcl. (I) which read as follows: "located in a rural area,".Subsec. (d)(5)(J)(ii)(IV), (V). Pub. L. 115-123, §53109(a)(1), added subcl. (IV) and redesignated former subcl. (IV) as (V).Subsec. (d)(5)(J)(iv). Pub. L. 115-123, §53109(a)(2)(A), inserted "The Secretary shall include in the proposed rule published for fiscal year 2019, a description of the effect of clause (ii)(IV)." after "this subparagraph." in introductory provisions. Subsec. (d)(5)(J)(iv)(I). Pub. L. 115-123, §53109(a)(2)(B), substituted "(III), and, in the case of proposed and final rules for fiscal year 2019 and subsequent fiscal years, (IV)" for "and (III)". Subsec. (d)(12)(B). Pub. L. 115-123, §50204(a)(1), substituted "fiscal year 2023" for "fiscal year 2018" in introductory provisions. Subsec. (d)(12)(C)(i). Pub. L. 115-123, §50204(a)(2)(A), substituted "through 2022, 15 road miles) from another subsection (d) hospital and has-" for "through 2017, 15 road miles) from another subsection (d) hospital and has less than 800 discharges (or, with respect to fiscal years 2011 through 2017, 1,600 discharges of individuals entitled to, or enrolled for, benefits under part A) during the fiscal year or portion of fiscal year." and added subcls. (I) to (IV). Subsec. (d)(12)(C)(ii). Pub. L. 115-123, §50204(a)(2)(B), substituted "subparagraphs (B) and (D)" for "subparagraph (B)" and inserted "(except as provided in clause (i)(II) and subparagraph (D)(i))" after "regardless".Subsec. (d)(12)(C)(iii). Pub. L. 115-141 added cl. (iii).Subsec. (d)(12)(D). Pub. L. 115-123, §50204(a)(3), substituted "through 2022" for "through 2017", "hospitals- "(i) with respect to each of fiscal years 2011 through 2018, with 200 or fewer"for "hospitals with 200 or fewer", and "fiscal year or portion of fiscal year; and" for "fiscal year.", and added cl. (ii).Subsec. (m)(6)(B)(i)(I). Pub. L. 115-123, §51005(a)(1), substituted "fiscal years 2016 through 2019" for "fiscal year 2016 or fiscal year 2017". Subsec. (m)(6)(B)(i)(II). Pub. L. 115-123, §51005(a)(2), substituted "2020" for "2018".Subsec. (m)(6)(B)(ii). Pub. L. 115-123, §51005(b)(1), substituted "Subject to clause (iv), in this paragraph" for "In this paragraph" in introductory provisions. Subsec. (m)(6)(B)(iv). Pub. L. 115-123, §51005(b)(2), added cl. (iv).Subsec. (n)(3)(A). Pub. L. 115-123, §50413, struck out "by requiring more stringent measures of meaningful use selected under this paragraph" after "quality over time" in concluding provisions. Subsec. (o)(2)(B)(iii). Pub. L. 115-271, §6104(b), added cl. (iii).2016-Subsec. (b)(3)(B)(ix)(II). Pub. L. 114-255, §4002(b)(2), inserted after first sentence "The Secretary shall exempt an eligible hospital from the application of the payment adjustment under subclause (I) with respect to a fiscal year, subject to annual renewal, if the Secretary determines that compliance with the requirement for being a meaningful EHR user is not possible because the certified EHR technology used by such hospital is decertified under a program kept or recognized pursuant to section 300jj-11(c)(5) of this title." Subsec. (d)(1)(B). Pub. L. 114-255, §15008(b), in concluding provisions, inserted "(as in effect as of such date)" after "clause (iv)" and "(or, in the case of a hospital described in clause (iv)(II), as so in effect, shall be classified under clause (vi) on and after the effective date of such clause (vi) and for cost reporting periods beginning on or after January 1, 2015, shall not be subject to subsection (m) as of the date of such classification)" after "so classified".Subsec. (d)(1)(B)(iv). Pub. L. 114-255, §15008(a), struck out subcl. (I) designation before "a hospital" and redesignated subcl. (II) as cl. (vi). Subsec. (d)(1)(B)(vi). Pub. L. 114-255, §15008(a)(2), redesignated subcl. (II) of cl. (iv) as cl. (vi).Subsec. (m)(5)(F)(i), (ii). Pub. L. 114-255, §15008(d)(2), substituted "(d)(1)(B)(vi)" for "(d)(1)(B)(iv)(II)".Subsec. (m)(6)(A)(i). Pub. L. 114-255, §15010(a)(1), substituted "(F), and (G)" for "and (F)". Pub. L. 114-255, §15009(a)(1), substituted ", (E), and (F)" for "and (E)". Subsec. (m)(6)(E)(i)(I)(aa). Pub. L. 114-255, §15010(a)(2), substituted "the last sentence of subsection (d)(1)(B)" for "the amendment made by section 4417(a) of the Balanced Budget Act of 1997 (42 U.S.C. 1395ww note, Public Law 105-33)". Subsec. (m)(6)(F). Pub. L. 114-255, §15009(a)(2), added subpar. (F).Subsec. (m)(6)(G). Pub. L. 114-255, §15010(a)(3), added subpar. (G).Subsec. (m)(7). Pub. L. 114-255, §15004(b), added par. (7).Subsec. (q)(3)(A). Pub. L. 114-255, §15002(a)(1), inserted "subject to subparagraph (D)," after "purposes of paragraph (1),".Subsec. (q)(3)(D), (E). Pub. L. 114-255, §15002(a)(2), (b), added subpars. (D) and (E). Subsec. (t). Pub. L. 114-255, §15001, added subsec. (t). 2015-Subsec. (b)(3)(B)(ix)(I). Pub. L. 114-115, §4(b)(1), which directed substitution of "(n)(6)" for "(n)(6)(A)", was executed by making the substitution for "(n)(6)(B)" to reflect the probable intent of Congress and the intervening amendment by Pub. L. 114-113, §602(b)(1)(A) . See below. Pub. L. 114-113, §602(b)(1)(A), substituted "(n)(6)(B)" for "(n)(6)(A)". Subsec. (b)(3)(B)(ix)(II). Pub. L. 114-115, §4(b)(2), inserted "(and, with respect to the application of subclause (I) for fiscal year 2017, for categories of subsection (d) hospitals, as established by the Secretary and posted on the Internet website of the Centers for Medicare & Medicaid Services prior to December 15, 2015, an application for which must be submitted to the Secretary by not later than April 1, 2016)" after "case-by-case basis". Pub. L. 114-113, §602(b)(1)(B), substituted "an eligible hospital" for "a subsection (d) hospital". Subsec. (b)(3)(D). Pub. L. 114-10, §205(b)(1)(A), substituted "October 1, 2017" for "April 1, 2015" in introductory provisions. Subsec. (b)(3)(D)(iv). Pub. L. 114-10, §205(b)(1)(B), substituted "through fiscal year 2017" for "through fiscal year 2014 and the portion of fiscal year 2015 before April 1, 2015".Subsec. (d)(5)(G)(i). Pub. L. 114-10, §205(a)(1), substituted "October 1, 2017" for "April 1, 2015".Subsec. (d)(5)(G)(ii)(II). Pub. L. 114-10, §205(a)(2), substituted "October 1, 2017" for "April 1, 2015". Subsec. (d)(9)(E)(iv). Pub. L. 114-113, §601(2)(A), inserted "and before January 1, 2016," after "2004,". Subsec. (d)(9)(E)(v). Pub. L. 114-113, §601(1), (2)(B), (3), added cl. (v).Subsec. (d)(12)(B). Pub. L. 114-10, §204(1), substituted "in fiscal year 2018 and subsequent fiscal years" for "in fiscal year 2015 (beginning on April 1, 2015), fiscal year 2016, and subsequent fiscal years" in introductory provisions.Subsec. (d)(12)(C)(i). Pub. L. 114-10, §204(2), substituted "fiscal years 2011 through 2017," for "fiscal years 2011 through 2014 and fiscal year 2015 (before April 1, 2015)," in two places.Subsec. (d)(12)(D). Pub. L. 114-10, §204(3), substituted "fiscal years 2011 through 2017," for "fiscal years 2011 through 2014 and fiscal year 2015 (before April 1, 2015),". Subsec. (j)(3)(C)(i). Pub. L. 114-10, §411(b)(1)(A), substituted "clauses (ii) and (iii)" for "clause (ii)".Subsec. (j)(3)(C)(ii). Pub. L. 114-10, §411(b)(1)(B), substituted "Subject to clause (iii), after" for "After" in introductory provisions. Subsec. (j)(3)(C)(iii). Pub. L. 114-10, §411(b)(1)(C), added cl. (iii).Subsec. (j)(7)(A)(i). Pub. L. 114-10, §411(b)(2), substituted "subparagraphs (C)(iii) and (D) of paragraph (3)" for "paragraph (3)(D)".Subsec. (m)(3)(A). Pub. L. 114-10, §411(e)(1), substituted "Subject to subparagraph (C), in implementing" for "In implementing" in introductory provisions. Subsec. (m)(3)(C). Pub. L. 114-10, §411(e)(2), added subpar. (C).Subsec. (m)(6)(A)(i). Pub. L. 114-113, §231(1), substituted "subparagraphs (C) and (E)" for "subparagraph (C)". Subsec. (m)(6)(E). Pub. L. 114-113, §231(2), added subpar. (E).Subsec. (n)(3)(A)(ii). Pub. L. 114-10, §106(b)(2)(B), inserted before period at end ", and the hospital demonstrates (through a process specified by the Secretary, such as the use of an attestation) that the hospital has not knowingly and willfully taken action (such as to disable functionality) to limit or restrict the compatibility or interoperability of the certified EHR technology".Subsec. (n)(6)(B). Pub. L. 114-113, §602(a), substituted "hospital that is a subsection (d) hospital or a subsection (d) Puerto Rico hospital" for "subsection (d) hospital". 2014-Subsec. (b)(3)(D). Pub. L. 113-93, §106(b)(1)(A), substituted "April 1, 2015" for "April 1, 2014" in introductory provisions.Subsec. (b)(3)(D)(iv). Pub. L. 113-93, §106(b)(1)(B), substituted "through fiscal year 2014 and the portion of fiscal year 2015 before April 1, 2015" for "through fiscal year 2013 and the portion of fiscal year 2014 before April 1, 2014". Subsec. (d)(5)(G)(i). Pub. L. 113-93, §106(a)(1), substituted "April 1, 2015" for "April 1, 2014".Subsec. (d)(5)(G)(ii)(II). Pub. L. 113-93, §106(a)(2), substituted "April 1, 2015" for "April 1, 2014". Subsec. (d)(12)(B). Pub. L. 113-93, §105(1), substituted "in fiscal year 2015 (beginning on April 1, 2015), fiscal year 2016, and subsequent fiscal years" for "in the portion of fiscal year 2014 beginning on April 1, 2014, fiscal year 2015, and subsequent fiscal years" in introductory provisions.Subsec. (d)(12)(C)(i). Pub. L. 113-93, §105(2), substituted "fiscal years 2011 through 2014 and fiscal year 2015 (before April 1, 2015)," for "fiscal years 2011, 2012, and 2013, and the portion of fiscal year 2014 before" in two places. Subsec. (d)(12)(D). Pub. L. 113-93, §105(3), substituted "fiscal years 2011 through 2014 and fiscal year 2015 (before April 1, 2015)," for "fiscal years 2011, 2012, and 2013, and the portion of fiscal year 2014 before April 1, 2014,".Subsec. (j)(7)(A)(i). Pub. L. 113-185, §2(c)(2)(A), substituted "subparagraphs (C) and (F)" for "subparagraph (C)".Subsec. (j)(7)(C). Pub. L. 113-185, §2(c)(2)(B), substituted "Subject to subparagraph (G), for fiscal year 2014 and each subsequent fiscal year" for "For fiscal year 2014 and each subsequent rate year".Subsec. (j)(7)(E). Pub. L. 113-185, §2(c)(2)(C), inserted "and subparagraph (F)(i)" after "subparagraph (C)". Subsec. (j)(7)(F), (G). Pub. L. 113-185, §2(c)(2)(D), added subpars. (F) and (G).Subsec. (m)(5)(A)(i). Pub. L. 113-185, §2(c)(3)(A), substituted "subparagraphs (C) and (F)" for "subparagraph (C)".Subsec. (m)(5)(C). Pub. L. 113-185, §2(c)(3)(B), substituted "Subject to subparagraph (G), for rate year" for "For rate year".Subsec. (m)(5)(E). Pub. L. 113-185, §2(c)(3)(C), inserted "and subparagraph (F)(i)" after "subparagraph (C)". Subsec. (m)(5)(F), (G). Pub. L. 113-185, §2(c)(3)(D), added subpars. (F) and (G).Subsec. (m)(6)(C)(iv). Pub. L. 113-93, §112(a), substituted "Medicare fee-for-service discharges" for "discharges" in subcls. (I) and (II). 2013-Subsec. (b)(3)(D). Pub. L. 113-67, §1106(b)(1)(A), substituted "April 1, 2014" for "October 1, 2013" in introductory provisions. Pub. L. 112-240, §606(b)(1)(A), substituted "October 1, 2013" for "October 1, 2012" in introductory provisions.Subsec. (b)(3)(D)(iv). Pub. L. 113-67, §1106(b)(1)(B), inserted "and the portion of fiscal year 2014 before April 1, 2014" after "through fiscal year 2013". Pub. L. 112-240, §606(b)(1)(B), substituted "through fiscal year 2013" for "through fiscal year 2012".Subsec. (d)(5)(G)(i). Pub. L. 113-67, §1106(a)(1), substituted "April 1, 2014" for "October 1, 2013". Pub. L. 112-240, §606(a)(1), substituted "October 1, 2013" for "October 1, 2012".Subsec. (d)(5)(G)(ii)(II). Pub. L. 113-67, §1106(a)(2), substituted "April 1, 2014" for "October 1, 2013". Pub. L. 112-240, §606(a)(2), substituted "October 1, 2013" for "October 1, 2012".Subsec. (d)(12)(B). Pub. L. 113-67, §1105(1), substituted "the portion of fiscal year 2014 beginning on April 1, 2014, fiscal year 2015, and subsequent fiscal years" for "fiscal year 2014 and subsequent fiscal years" in introductory provisions. Pub. L. 112-240, §605(1), substituted "2014" for "2013" in introductory provisions.Subsec. (d)(12)(C)(i). Pub. L. 113-67, §1105(2), inserted "and the portion of fiscal year 2014 before" after "and 2013," in two places and "or portion of fiscal year" after "during the fiscal year". Pub. L. 112-240, §605(2), substituted ", 2012, and 2013" for "and 2012" in two places. Subsec. (d)(12)(D). Pub. L. 113-67, §1105(3)(B), which directed insertion of "or the portion of fiscal year" after "in the fiscal year", was executed by making the insertion after "in the fiscal year" both places appearing to reflect the probable intent of Congress. Pub. L. 113-67, §1105(3)(A), inserted "and the portion of fiscal year 2014 before April 1, 2014," after "and 2013,". Pub. L. 112-240, §605(3), substituted ", 2012, and 2013" for "and 2012". Subsec. (m)(5)(D)(iv). Pub. L. 113-67, §1206(c), added cl. (iv).Subsec. (m)(6). Pub. L. 113-67, §1206(a)(1), added par. (6).2011-Subsec. (f)(2). Pub. L. 112-40 substituted "quality improvement" for "utilization and quality control peer review" in introductory provisions.2010-Subsec. (a)(4). Pub. L. 111-192, §102(a)(1), inserted "In applying the first sentence of this paragraph, the term 'other services related to the admission' includes all services that are not diagnostic services (other than ambulance and maintenance renal dialysis services) for which payment may be made under this subchapter that are provided by a hospital (or an entity wholly owned or operated by the hospital) to a patient-" after "hemophilia." and added subpars. (A) and (B).Subsec. (b)(3)(B)(i)(XX). Pub. L. 111-148, §3401(a)(1), substituted "clauses (viii), (ix), (xi), and (xii)" for "clause (viii)".Subsec. (b)(3)(B)(viii)(I). Pub. L. 111-148, §3401(a)(2), inserted "of such applicable percentage increase (determined without regard to clause (ix), (xi), or (xii))" after "one-quarter". Subsec. (b)(3)(B)(viii)(II). Pub. L. 111-148, §3001(a)(2)(A), inserted at end "The Secretary may require hospitals to submit data on measures that are not used for the determination of value-based incentive payments under subsection (o)."Subsec. (b)(3)(B)(viii)(V). Pub. L. 111-148, §3001(a)(2)(B), substituted "for fiscal years 2008 through 2012" for "beginning with fiscal year 2008".Subsec. (b)(3)(B)(viii)(VII). Pub. L. 111-148, §3001(a)(2)(C), substituted "information regarding measures submitted" for "data submitted". Subsec. (b)(3)(B)(viii)(VIII) to (XI). Pub. L. 111-148, §3001(a)(2)(D), added subcls. (VIII) to (XI). Subsec. (b)(3)(B)(ix)(I). Pub. L. 111-148, §3401(a)(3), inserted "(determined without regard to clause (viii), (xi), or (xii))" after "otherwise applicable under clause (i)".Subsec. (b)(3)(B)(x). Pub. L. 111-148, §3001(a)(3), added cl. (x).Subsec. (b)(3)(B)(xi), (xii). Pub. L. 111-148, §3401(a)(4), added cls. (xi) and (xii). Subsec. (b)(3)(B)(xii)(I). Pub. L. 111-148, §10319(a)(1), struck out "and" at end.Subsec. (b)(3)(B)(xii)(II). Pub. L. 111-152, §1105(a)(1)(A), placed subcl. (II), which was directed to be added by Pub. L. 111-148, §10319(a)(3), after subcl. (I) and struck out "and" at end. See Amendment note below. Pub. L. 111-148, §10319(a)(3), which directed addition of subcl. (II) "after subclause (II)", could not be executed. See Amendment note above. Former subcl. (II) redesignated (III). Subsec. (b)(3)(B)(xii)(III). Pub. L. 111-152, §1105(a)(1)(B), added subcl. (III) and struck out former subcl. (III) which read "subject to clause (xiii), for each of fiscal years 2014 through 2019, by 0.2 percentage point." Pub. L. 111-148, §10319(a)(2), (4), redesignated subcl. (II) as (III) and substituted "2014" for "2012". Subsec. (b)(3)(B)(xii)(IV), (V). Pub. L. 111-152, §1105(a)(1)(B), added subcls. (IV) and (V). Subsec. (b)(3)(B)(xiii). Pub. L. 111-152, §1105(a)(2), struck out cl. (xiii) which read as follows: "Clause (xii) shall be applied with respect to any of fiscal years 2014 through 2019 by substituting '0.0 percentage points' for '0.2 percentage point', if for such fiscal year- "(I) the excess (if any) of- "(aa) the total percentage of the non-elderly insured population for the preceding fiscal year (based on the most recent estimates available from the Director of the Congressional Budget Office before a vote in either House on the Patient Protection and Affordable Care Act that, if determined in the affirmative, would clear such Act for enrollment); over"(bb) the total percentage of the non-elderly insured population for such preceding fiscal year (as estimated by the Secretary); exceeds"(II) 5 percentage points." Pub. L. 111-148, §3401(a)(4), added cl. (xiii).Subsec. (b)(3)(D). Pub. L. 111-148, §3124(b)(1)(A), substituted "October 1, 2012" for "October 1, 2011" in introductory provisions.Subsec. (b)(3)(D)(iv). Pub. L. 111-148, §3124(b)(1)(B), substituted "through fiscal year 2012" for "through fiscal year 2011".Subsec. (d)(3)(E)(i). Pub. L. 111-148, §10324(a)(2), which directed the amendment of the third sentence of subsec. (d)(3)(E) by inserting "and the amendments made by section 10324(a)(1) of the Patient Protection and Affordable Care Act" after "2003", was executed by making the insertion in the fifth sentence of cl. (i) to reflect the probable intent of Congress. Pub. L. 111-148, §10324(a)(1)(A), substituted "clause (ii) or (iii)" for "clause (ii)".Subsec. (d)(3)(E)(iii). Pub. L. 111-148, §10324(a)(1)(B), added cl. (iii). Subsec. (d)(5)(B)(iv). Pub. L. 111-148, §5504(b), designated existing provisions as subcl. (I), inserted ", and before July 1, 2010" after "1997", and added subcl. (II).Subsec. (d)(5)(B)(v). Pub. L. 111-148, §5506(b), which directed substitution of "subsections (h)(4)(H)(vi), (h)(7), and (h)(8)" for "subsections (h)(7) and (h)(8)" in second sentence, was executed by making the substitution in the third sentence to reflect the probable intent of Congress. Pub. L. 111-148, §5503(b)(1), which directed the substitution, in second sentence, of "subsections (h)(7) and (h)(8)" for "subsection (h)(7)" and "they apply" for "it applies", was executed by making the substitution in the third sentence to reflect the probable intent of Congress.Subsec. (d)(5)(B)(x). Pub. L. 111-148, §5505(b), added cl. (x) relating to determining the hospital's number of full-time equivalent residents. Pub. L. 111-148, §5503(b)(2), added cl. (x) relating to indirect teaching adjustment factor for additional payment amount attributable to resident positions.Subsec. (d)(5)(F)(i). Pub. L. 111-148, §3133(1), substituted "Subject to subsection (r), for" for "For" in introductory provisions.Subsec. (d)(5)(G)(i). Pub. L. 111-148, §3124(a)(1), substituted "October 1, 2012" for "October 1, 2011".Subsec. (d)(5)(G)(ii)(II). Pub. L. 111-148, §3124(a)(2), substituted "October 1, 2012" for "October 1, 2011".Subsec. (d)(7)(C). Pub. L. 111-192, §102(a)(2), added subpar. (C).Subsec. (d)(12)(A). Pub. L. 111-148, §3125(1), inserted "or (D)" after "subparagraph (B)". Subsec. (d)(12)(B). Pub. L. 111-148, §3125(2), substituted "For discharges occurring in fiscal years 2005 through 2010 and for discharges occurring in fiscal year 2013 and subsequent fiscal years, the Secretary" for "The Secretary" in introductory provisions.Subsec. (d)(12)(C)(i). Pub. L. 111-148, §10314(1), substituted "1,600 discharges" for "1,500 discharges". Pub. L. 111-148, §3125(3), inserted "(or, with respect to fiscal years 2011 and 2012, 15 road miles)" after "25 road miles" and "(or, with respect to fiscal years 2011 and 2012, 1,500 discharges of individuals entitled to, or enrolled for, benefits under part A)" after "800 discharges". Subsec. (d)(12)(D). Pub. L. 111-148, §10314(2), substituted "1,600 discharges" for "1,500 discharges". Pub. L. 111-148, §3125(4), added subpar. (D).Subsec. (h)(4)(E). Pub. L. 111-148, §5505(a)(1)(A), substituted "Subject to subparagraphs (J) and (K), such rules" for "Such rules" in introductory provisions. Pub. L. 111-148, §5504(a), substituted "shall be counted and that-" for "shall be counted and that all the time", inserted cl. (i) designation and "effective for cost reporting periods beginning before July 1, 2010, all the time;" before "so spent", substituted "; and" for period at end, added cl. (ii), and inserted concluding provisions.Subsec. (h)(4)(F)(i). Pub. L. 111-148, §5503(a)(1), substituted "paragraphs (7) and (8)" for "paragraph (7)".Subsec. (h)(4)(H)(i). Pub. L. 111-148, §5503(a)(2), substituted "paragraphs (7) and (8)" for "paragraph (7)". Subsec. (h)(4)(H)(vi). Pub. L. 111-148, §5506(a), added cl. (vi).Subsec. (h)(4)(J), (K). Pub. L. 111-148, §5505(a)(1)(B), added subpars. (J) and (K).Subsec. (h)(5)(K). Pub. L. 111-148, §5505(a)(2), added subpar. (K). Subsec. (h)(7)(E). Pub. L. 111-148, §5506(e), substituted "this paragraph, paragraph (8), or paragraph (4)(H)(vi)" for "paragraph or paragraph (8)". Pub. L. 111-148, §5503(a)(3), inserted "or paragraph (8)" before period at end.Subsec. (h)(8). Pub. L. 111-148, §5503(a)(4), added par. (8).Subsec. (h)(8)(I). Pub. L. 111-309 added subpar. (I).Subsec. (j)(3)(C). Pub. L. 111-148, §3401(d)(1), designated existing provisions as cl. (i), inserted heading and "subject to clause (ii)" after "establish an increase factor" in text, and added cl. (ii).Subsec. (j)(3)(D). Pub. L. 111-152, §1105(c)(3), struck out cl. (i) designation and heading, redesignated subcls. (I) to (V) of former cl. (i) as cls. (i) to (v), respectively, and realigned margins. Pub. L. 111-148, §3401(d)(2), added subpar. (D).Subsec. (j)(3)(D)(i)(I). Pub. L. 111-148, §10319(c)(1), struck out "and" at end.Subsec. (j)(3)(D)(i)(II). Pub. L. 111-152, §1105(c)(1)(A), placed subcl. (II), which was directed to be added by Pub. L. 111-148, §10319(c)(3), after subcl. (I) and struck out "and" at end. See Amendment note below. Pub. L. 111-148, §10319(c)(3), which directed addition of subcl. (II) "after subclause (II)", could not be executed. See Amendment note above. Former subcl. (II) redesignated (III).Subsec. (j)(3)(D)(i)(III). Pub. L. 111-152, §1105(c)(1)(B), added subcl. (III) and struck out former subcl. (III) which read as follows: "subject to clause (ii), for each of fiscal years 2014 through 2019, 0.2 percentage point." Pub. L. 111-148, §10319(c)(2), (4), redesignated subcl. (II) as (III) and substituted "2014" for "2012".Subsec. (j)(3)(D)(i)(IV), (V). Pub. L. 111-152, §1105(c)(1)(B), added subcls. (IV) and (V).Subsec. (j)(3)(D)(ii). Pub. L. 111-152, §1105(c)(2), struck out cl. (ii). Text read as follows: "Clause (i)(II) shall be applied with respect to any of fiscal years 2014 through 2019 by substituting '0.0 percentage points' for '0.2 percentage point', if for such fiscal year-"(I) the excess (if any) of- "(aa) the total percentage of the non-elderly insured population for the preceding fiscal year (based on the most recent estimates available from the Director of the Congressional Budget Office before a vote in either House on the Patient Protection and Affordable Care Act that, if determined in the affirmative, would clear such Act for enrollment); over"(bb) the total percentage of the non-elderly insured population for such preceding fiscal year (as estimated by the Secretary); exceeds"(II) 5 percentage points."Subsec. (j)(7), (8). Pub. L. 111-148, §3004(b), added par. (7) and redesignated former par. (7) as (8).Subsec. (m)(3), (4). Pub. L. 111-148, §3401(c), added pars. (3) and (4).Subsec. (m)(4)(A). Pub. L. 111-152, §1105(b)(3), struck out subpar. (A) designation and heading before "For purposes", redesignated cl. (i) as subpar. (A), and realigned margin. Subsec. (m)(4)(A)(i). Pub. L. 111-148, §10319(b)(1)(A), substituted "rate year 2010" for "each of rate years 2010 and 2011" and struck out "and" at end.Subsec. (m)(4)(A)(ii), (iii). Pub. L. 111-152, §1105(b)(3), redesignated cls. (ii) and (iii) as subpars. (B) and (C), respectively, and realigned margins. Pub. L. 111-148, §10319(b)(1), (C), added cls. (ii) and (iii). Former cl. (ii) redesignated (iv).Subsec. (m)(4)(A)(iv). Pub. L. 111-152, §1105(b)(3), redesignated cl. (iv) as subpar. (D) and realigned margin. Pub. L. 111-152, §1105(b)(1), added cl. (iv) and struck out former cl. (iv), which read as follows: "subject to subparagraph (B), for each of rate years 2014 through 2019, 0.2 percentage point." Pub. L. 111-148, §10319(b)(1)(B), (D), redesignated cl. (ii) as (iv) and substituted "2014" for "2012".Subsec. (m)(4)(A)(v), (vi). Pub. L. 111-152, §1105(b)(3), redesignated cls. (v) and (vi) as subpars. (E) and (F), respectively, and realigned margins. Pub. L. 111-152, §1105(b)(1)(B), added cls. (v) and (vi).Subsec. (m)(4)(B). Pub. L. 111-152, §1105(b)(3), redesignated cl. (ii) of former subpar. (A) as subpar. (B) and realigned margin. Pub. L. 111-152, §1105(b)(2), struck out subpar. (B). Prior to amendment, text read as follows: "Subparagraph (A)(iv) shall be applied with respect to any of rate years 2014 through 2019 by substituting '0.0 percentage points' for '0.2 percentage point', if for such rate year-"(i) the excess (if any) of-"(I) the total percentage of the non-elderly insured population for the preceding rate year (based on the most recent estimates available from the Director of the Congressional Budget Office before a vote in either House on the Patient Protection and Affordable Care Act that, if determined in the affirmative, would clear such Act for enrollment); over"(II) the total percentage of the non-elderly insured population for such preceding rate year (as estimated by the Secretary); exceeds"(ii) 5 percentage points." Pub. L. 111-148, §10319(b)(2), substituted "(A)(iv)" for "(A)(ii)" in introductory provisions.Subsec. (m)(4)(C) to (F). Pub. L. 111-152, §1105(b)(3), redesignated cls. (iii) to (vi) of former subpar. (A) as subpars. (C) to (F), respectively, and realigned margins.Subsec. (m)(5). Pub. L. 111-148, §3004(a), added par. (5).Subsec. (o). Pub. L. 111-148, §3001(a)(1), added subsec. (o).Subsec. (o)(2)(A). Pub. L. 111-148, §10335, inserted ", other than measures of readmissions," after "shall select measures".Subsec. (p). Pub. L. 111-148, §3008(a), added subsec. (p).Subsec. (q). Pub. L. 111-148, §3025(a), added subsec. (q). Subsec. (q)(1). Pub. L. 111-148, §10309, in introductory provisions, substituted "the Secretary shall make payments (in addition to the payments described in paragraph (2)(A)(ii)) for such a discharge to such hospital under subsection (d) (or section 1395f(b)(3) of this title, as the case may be) in an amount equal to the product of" for "the Secretary shall reduce the payments that would otherwise be made to such hospital under subsection (d) (or section 1395f(b)(3) of this title, as the case may be) for such a discharge by an amount equal to the product of". Subsec. (r). Pub. L. 111-148, §3133(2), added subsec. (r).Subsec. (r)(1). Pub. L. 111-152, §1104(1), substituted "2014" for "2015".Subsec. (r)(2). Pub. L. 111-152, §1104(2)(A), substituted "2014" for "2015" in introductory provisions.Subsec. (r)(2)(B)(i). Pub. L. 111-152, §1104(2)(B)(i), (ii), (iv), inserted "2014," after "years" in heading and "2014," after "each of fiscal years" in introductory provisions and substituted "minus 0.1 percentage points for fiscal year 2014 and minus 0.2 percentage points for each of fiscal years 2015, 2016, and 2017" for "minus 1.5 percentage points" in concluding provisions. Pub. L. 111-148, §10316(1)(A), (D), struck out "(divided by 100)" after "change" in introductory provisions and inserted concluding provisions. Subsec. (r)(2)(B)(i)(I). Pub. L. 111-152, §1104(2)(B) (iii), substituted "on the Health Care and Education Reconciliation Act of 2010" for "on such Act". Pub. L. 111-148, §10316(1)(B), substituted "2013" for "2012".Subsec. (r)(2)(B)(i)(II). Pub. L. 111-148, §10316(1)(C), substituted comma for period at end. Subsec. (r)(2)(B)(ii). Pub. L. 111-152, §1104(2)(C), substituted "minus 0.2 percentage points for each of fiscal years 2018 and 2019" for "and, for each of 2018 and 2019, minus 1.5 percentage points" in concluding provisions. Pub. L. 111-148, §10316(2), struck out "(divided by 100)" after "change" in introductory provisions, substituted "2013" for "2012" in subcl. (I), substituted comma for period at end of subcl. (II), and inserted concluding provisions.Subsec. (s). Pub. L. 111-148, §3401(f), added subsec. (s).Subsec. (s)(3). Pub. L. 111-152, §1105(d)(3), struck out subpar. (A) designation and heading, redesignated cls. (i) to (v) of former subpar. (A) as subpars. (A) to (E), respectively, and realigned margins.Subsec. (s)(3)(A)(i). Pub. L. 111-148, §10319(e)(1), struck out "and" at end.Subsec. (s)(3)(A)(ii). Pub. L. 111-152, §1105(d)(1)(A), placed cl. (ii), which was directed to be added by Pub. L. 111-148, §10319(e)(3), after cl. (i) and struck out "and" at end. See Amendment note below. Pub. L. 111-148, §10319(e)(3), which directed addition of cl. (ii) "after clause (ii)", could not be executed. See Amendment note above. Former cl. (ii) redesignated (iii). Subsec. (s)(3)(A)(iii). Pub. L. 111-152, §1105(d)(1)(B), added cl. (iii) and struck out former cl. (iii) which read as follows: "subject to subparagraph (B), for each of the rate years beginning in 2014 through 2019, 0.2 percentage point." Pub. L. 111-148, §10319(e)(2), (4), redesignated cl. (ii) as (iii) and substituted "2014" for "2012". Subsec. (s)(3)(A)(iv), (v). Pub. L. 111-152, §1105(d)(1)(B), added cls. (iv) and (v).Subsec. (s)(3)(B). Pub. L. 111-152, §1105(d)(2), struck out subpar. (B). Prior to amendment, text read as follows: "Subparagraph (A)(ii) shall be applied with respect to any of rate years 2014 through 2019 by substituting '0.0 percentage points' for '0.2 percentage point', if for such rate year- "(i) the excess (if any) of-"(I) the total percentage of the non-elderly insured population for the preceding rate year (based on the most recent estimates available from the Director of the Congressional Budget Office before a vote in either House on the Patient Protection and Affordable Care Act that, if determined in the affirmative, would clear such Act for enrollment); over"(II) the total percentage of the non-elderly insured population for such preceding rate year (as estimated by the Secretary); exceeds"(ii) 5 percentage points."Subsec. (s)(4). Pub. L. 111-148, §10322(a), added par. (4). 2009-Subsec. (b)(3)(B)(viii)(I). Pub. L. 111-5, §4102(b)(1)(A), inserted "(or, beginning with fiscal year 2015, by one-quarter)" after "2.0 percentage points".Subsec. (b)(3)(B)(ix). Pub. L. 111-5, §4102(b)(1)(B), added cl. (ix). Subsec. (n). Pub. L. 111-5, §4102(a)(1), added subsec. (n). 2008-Subsec. (b)(3)(C). Pub. L. 110-275, §122(b)(1), substituted "subparagraphs (I) and (L)" for "subparagraph (I)" in introductory provisions.Subsec. (b)(3)(I)(i). Pub. L. 110-275, §122(b)(2), substituted "Subject to subparagraph (L), for" for "For" in introductory provisions.Subsec. (b)(3)(L). Pub. L. 110-275, §122(a), added subpar. (L).2007-Subsec. (h)(4)(H)(v). Pub. L. 110-161, §225(a), added cl. (v). Subsec. (h)(7)(D), (E). Pub. L. 110-161, §225(b)(1), added subpar. (D) and redesignated former subpar. (D) as (E). Subsec. (j)(3)(C). Pub. L. 110-173, §115(a)(1), inserted at end "The increase factor to be applied under this subparagraph for each of fiscal years 2008 and 2009 shall be 0 percent."Subsec. (m). Pub. L. 110-173, §114(e)(1), added subsec. (m). 2006-Subsec. (b)(3)(B)(i)(XIX). Pub. L. 109-171, §5001(a)(1)(A), substituted "2006" for "2007".Subsec. (b)(3)(B)(i)(XX). Pub. L. 109-171, §5001(a)(1)(B), substituted "for each subsequent fiscal year, subject to clause (viii)," for "for fiscal year 2008 and each subsequent fiscal year,". Subsec. (b)(3)(B)(vii)(I). Pub. L. 109-171, §5001(a)(2)(A), substituted "for fiscal years 2005 and 2006" for "for each of fiscal years 2005 through 2007".Subsec. (b)(3)(B)(vii)(II). Pub. L. 109-171, §5001(a)(2)(B), substituted "For fiscal years 2005 and 2006, each" for "Each".Subsec. (b)(3)(B)(viii). Pub. L. 109-432, §205(b)(1), realigned margins. Pub. L. 109-171, §5001(a)(3), added cl. (viii).Subsec. (b)(3)(B)(viii)(III). Pub. L. 109-432, §109(a)(2), inserted "(including medication errors)" after "quality of care".Subsec. (b)(3)(D). Pub. L. 109-171, §5003(b)(1), inserted "subject to subparagraph (K)," after "(d)(5)(G))," in introductory provisions. Pub. L. 109-171, §5003(a)(2)(A)(i), substituted "occurring" for "beginning" and "October 1, 2011" for "October 1, 2006" in introductory provisions. Subsec. (b)(3)(D)(iv). Pub. L. 109-171, §5003(a)(2)(A) (ii), substituted "through fiscal year 2011" for "through fiscal year 2005".Subsec. (b)(3)(K). Pub. L. 109-171, §5003(b)(2), added subpar. (K).Subsec. (d)(4)(C)(iv). Pub. L. 109-432, §106(c)(1), struck out cl. (iv) which read as follows: "The Secretary shall include recommendations with respect to adjustments to weighting factors under clause (i) in the annual report to Congress required under subsection (e)(3)(B) of this section." Subsec. (d)(4)(D). Pub. L. 109-171, §5001(c)(1), added subpar. (D).Subsec. (d)(5)(F)(vi). Pub. L. 109-171, §5002(a), inserted concluding provisions.Subsec. (d)(5)(F)(xiv)(II). Pub. L. 109-171, §5003(d), inserted "or, in the case of discharges occurring on or after October 1, 2006, as a medicare-dependent, small rural hospital under subparagraph (G)(iv)" before period at end.Subsec. (d)(5)(G)(i). Pub. L. 109-171, §5003(a)(1)(A), substituted "October 1, 2011" for "October 1, 2006".Subsec. (d)(5)(G)(ii)(II). Pub. L. 109-171, §5003(c), inserted "(or 75 percent in the case of discharges occurring on or after October 1, 2006)" after "50 percent". Pub. L. 109-171, §5003(a)(1)(B), substituted "October 1, 2011" for "October 1, 2006" and inserted "or for discharges in the fiscal year" after "for the cost reporting period".Subsec. (d)(7)(B). Pub. L. 109-171, §5001(c)(2), inserted ", including the selection and revision of codes under paragraph (4)(D)" before period at end. Subsec. (e)(3). Pub. L. 109-432, §106(c)(2), struck out par. (3) which read as follows: "The Secretary, not later than April 1, 1987, for fiscal year 1988 and not later than March 1 before the beginning of each fiscal year (beginning with fiscal year 1989), shall report to the Congress the Secretary's initial estimate of the percentage change that the Secretary will recommend under paragraph (4) with respect to that fiscal year." 2003-Subsec. (b)(3)(B)(i)(XIX), (XX). Pub. L. 108-173, §501(a), added subcls. (XIX) and (XX) and struck out former subcl. (XIX) which read as follows: "for fiscal year 2004 and each subsequent fiscal year, the market basket percentage increase for hospitals in all areas." Subsec. (b)(3)(B)(vii). Pub. L. 108-173, §501(b), added cl. (vii).Subsec. (b)(3)(I)(i)(I). Pub. L. 108-173, §736(a)(9), substituted "the amount" for "the the amount". Subsec. (b)(3)(I)(iii). Pub. L. 108-173, §407(a), added cl. (iii).Subsec. (d)(2)(C)(i). Pub. L. 108-173, §502(b), substituted "1999," for "1999 or" and inserted ", or the Medicare Prescription Drug, Improvement, and Modernization Act of 2003" before comma at end.Subsec. (d)(2)(C)(iv). Pub. L. 108-173, §402(b)(2), struck out "or" before "the enactment of section 303" and inserted ", or the enactment of section 402(a)(1) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003" before period at end. Subsec. (d)(3). Pub. L. 108-173, §401(b)(2)(A), inserted ", for fiscal years before fiscal year 1997," before "a regional adjusted DRG prospective payment rate" in introductory provisions. Subsec. (d)(3)(A)(iii). Pub. L. 108-173, §401(b)(3), substituted "in an urban area" for "in an other urban area".Subsec. (d)(3)(A)(iv). Pub. L. 108-173, §401(a), designated existing provisions as subcl. (I), substituted "Subject to subclause (II), for discharges" for "For discharges", and added subcl. (II). Subsec. (d)(3)(D). Pub. L. 108-173, §401(b)(1)(A), (B), (2)(B), in heading, struck out "in different areas" after "hospitals" and, in introductory provisions, inserted ", for fiscal years before fiscal year 1997," before "a regional DRG prospective payment rate" and struck out ", each of" before "which is equal-".Subsec. (d)(3)(D)(i). Pub. L. 108-173, §401(b)(1)(C)(i), inserted "for fiscal years before fiscal year 2004," before "for hospitals" in introductory provisions.Subsec. (d)(3)(D)(i)(II). Pub. L. 108-173, §401(b)(1)(C) (ii), struck out "and" at end.Subsec. (d)(3)(D)(ii). Pub. L. 108-173, §401(b)(1)(D)(i), inserted "for fiscal years before fiscal year 2004," before "for hospitals" in introductory provisions.Subsec. (d)(3)(D)(ii)(II). Pub. L. 108-173, §401(b)(1)(D) (ii), substituted "; and" for period at end.Subsec. (d)(3)(D)(iii). Pub. L. 108-173, §401(b)(1)(E), added cl. (iii).Subsec. (d)(3)(E). Pub. L. 108-173, §403(a), designated existing provisions as cl. (i), inserted cl. heading, substituted "Except as provided in clause (ii), the Secretary" for "The Secretary", inserted at end "The Secretary shall apply the previous sentence for any period as if the amendments made by section 403(a)(1) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 had not been enacted.", and added cl. (ii).Subsec. (d)(5)(B)(ii). Pub. L. 108-173, §422(b)(1)(A), substituted "Subject to clause (ix), for discharges" for "For discharges" in introductory provisions. Subsec. (d)(5)(B)(ii)(VI). Pub. L. 108-173, §502(a)(1), struck out "and" at end.Subsec. (d)(5)(B)(ii)(VII). Pub. L. 108-173, §502(a)(2), inserted "and before April 1, 2004," after "on or after October 1, 2002," and substituted semicolon for period at end.Subsec. (d)(5)(B)(ii)(VIII) to (XII). Pub. L. 108-173, §502(a)(3), added subcls. (VIII) to (XII). Subsec. (d)(5)(B)(v). Pub. L. 108-173, §422(b)(1)(B), inserted at end "The provisions of subsection (h)(7) shall apply with respect to the first sentence of this clause in the same manner as it applies with respect to subsection (h)(4)(F)(i)."Subsec. (d)(5)(B)(ix). Pub. L. 108-173, §422(b)(1)(C), added cl. (ix). Subsec. (d)(5)(F)(iv)(II) to (VI). Pub. L. 108-173, §402(b)(1)(A), inserted "subject to clause (xiv) and" before "for discharges occurring". Subsec. (d)(5)(F)(viii). Pub. L. 108-173, §402(b)(1)(B), substituted "Subject to clause (xiv), the formula" for "The formula". Subsec. (d)(5)(F)(x) to (xiii). Pub. L. 108-173, §402(b)(1)(C), substituted "Subject to clause (xiv), for purposes" for "For purposes" in introductory provisions.Subsec. (d)(5)(F)(xiv). Pub. L. 108-173, §402(a), added cl. (xiv).Subsec. (d)(5)(K)(i). Pub. L. 108-173, §503(b)(2)(A), inserted at end "Such mechanism shall be modified to meet the requirements of clause (viii)." Subsec. (d)(5)(K)(ii)(I). Pub. L. 108-173, §503(b)(1), inserted "(applying a threshold specified by the Secretary that is the lesser of 75 percent of the standardized amount (increased to reflect the difference between cost and charges) or 75 percent of one standard deviation for the diagnosis-related group involved)" after "is inadequate". Subsec. (d)(5)(K)(ii)(III). Pub. L. 108-173, §503(d)(1), struck out "subject to paragraph (4)(C)(iii)," before "provide for additional payment". Subsec. (d)(5)(K)(vii). Pub. L. 108-173, §503(a), added cl. (vii).Subsec. (d)(5)(K)(viii). Pub. L. 108-173, §503(b)(2)(B), added cl. (viii).Subsec. (d)(5)(K)(ix). Pub. L. 108-173, §503(c), added cl. (ix).Subsec. (d)(7)(A). Pub. L. 108-173, §406(b), inserted "or the determination of the applicable percentage increase under paragraph (12)(A)(ii)" after "to subsection (e)(1)".Subsec. (d)(9)(A). Pub. L. 108-173, §401(c)(1)(B), added cl. (ii) and concluding provisions and struck out former cl. (ii) which read as follows: "for discharges beginning in a fiscal year beginning on or after October 1, 1997, 50 percent (and for discharges between October 1, 1987, and September 30, 1997, 25 percent) of the discharge-weighted average of-"(I) the national adjusted DRG prospective payment rate (determined under paragraph (3)(D)) for hospitals located in a large urban area,"(II) such rate for hospitals located in other urban areas, and"(III) such rate for hospitals located in a rural area,for such discharges, adjusted in the manner provided in paragraph (3)(E) for different area wage levels. As used in this section, the term 'subsection (d) Puerto Rico hospital' means a hospital that is located in Puerto Rico and that would be a subsection (d) hospital (as defined in paragraph (1)(B)) if it were located in one of the fifty States." Subsec. (d)(9)(A)(i). Pub. L. 108-173, §§401(c)(1)(A), 504 (1)(A), substituted "the applicable Puerto Rico percentage (specified in subparagraph (E))" for "for discharges beginning on or after October 1, 1997, 50 percent (and for discharges between October 1, 1987, and September 30, 1997, 75 percent)" and struck out "and" at end. Subsec. (d)(9)(A)(ii). Pub. L. 108-173, §504(1)(B), which directed the substitution of "the applicable Federal percentage (specified in subparagraph (E))" for "for discharges beginning in a fiscal year beginning on or after October 1, 1997, 50 percent (and for discharges between October 1, 1987, and September 30, 1997, 25 percent)", could not be executed because of the amendment by Pub. L. 108-173, §401(c)(1)(B) . See above. Subsec. (d)(9)(C)(i). Pub. L. 108-173, §401(c)(2)(A), designated existing provisions as subcl. (I), substituted "For discharges in a fiscal year after fiscal year 1988 and before fiscal year 2004, the Secretary" for "The Secretary", and added subcl. (II).Subsec. (d)(9)(C)(ii). Pub. L. 108-173, §401(c)(2)(B), inserted "(or for fiscal year 2004 and thereafter, the average standardized amount)" after "each of the average standardized amounts". Subsec. (d)(9)(C)(iii)(I). Pub. L. 108-173, §401(c)(2)(C), struck out "for hospitals located in an urban or rural area, respectively" after "reduced under clause (ii))". Subsec. (d)(9)(C)(iv). Pub. L. 108-173, §403(b), designated existing provisions as subcl. (I), substituted "paragraph (3)(E)(i)" for "paragraph (3)(E)", and added subcl. (II). Subsec. (d)(9)(E). Pub. L. 108-173, §504(2), added subpar. (E). Subsec. (d)(12). Pub. L. 108-173, §406(a), added par. (12).Subsec. (d)(13). Pub. L. 108-173, §505(a), added par. (13).Subsec. (g)(3)(B). Pub. L. 108-173, §736(a) (15), inserted closing parenthesis after "(as defined in subsection (d)(5)(D)(iii)".Subsec. (h)(2)(D)(iv)(I). Pub. L. 108-173, §711(1), in heading, inserted "and 2004 through 2013" after "and 2002" and, in text, inserted "or during the period beginning with fiscal year 2004 and ending with fiscal year 2013" after "during fiscal year 2001 or fiscal year 2002".Subsec. (h)(2)(D)(iv)(II). Pub. L. 108-173, §711(2), substituted "For the" for "For a" and struck out "fiscal year 2004, or fiscal year 2005," after "during fiscal year 2003,". Subsec. (h)(3)(D)(ii)(III). Pub. L. 108-173, §736(c)(6), struck out "and" at end.Subsec. (h)(4)(F)(i). Pub. L. 108-173, §422(a)(1), inserted "subject to paragraph (7)," after "October 1, 1997,". Subsec. (h)(4)(H)(i). Pub. L. 108-173, §422(a)(2), inserted "and subject to paragraph (7)" after "subparagraphs (F) and (G)". Subsec. (h)(7). Pub. L. 108-173, §422(a)(3), added par. (7). 2000-Subsec. (b)(3)(B)(i)(XVI). Pub. L. 106-554, §1(a)(6) [title III, §301(a)(1)], substituted "for hospitals in all areas," for "minus 1.1 percentage points for hospitals (other than sole community hospitals) in all areas, and the market basket percentage increase for sole community hospitals,". Subsec. (b)(3)(B)(i)(XVII). Pub. L. 106-554, §1(a)(6) [title III, §301(a)(2)(B)], struck out "and" at end. Pub. L. 106-554, §1(a)(6) [title III, §301(a)(2)(A)], which directed amendment of subcl. (XVII) by "striking 'minus 1.1 percentage points' and inserting 'minus 0.55 percentage points; and", was executed as if an end quotation mark for the inserted material followed "points", to reflect the probable intent of Congress.Subsec. (b)(3)(B)(i)(XVIII). Pub. L. 106-554, §1(a)(6) [title III, §301(a)(5)], added subcl. (XVIII). Former subcl. (XVIII) redesignated (XIX).Subsec. (b)(3)(B)(i)(XIX). Pub. L. 106-554, §1(a)(6) [title III, §301(a)(3), (4)], redesignated subcl. (XVIII) as (XIX) and substituted "fiscal year 2004" for "fiscal year 2003".Subsec. (b)(3)(H)(ii)(III). Pub. L. 106-554, §1(a)(6) [title III, §307(a)(1)(A)], inserted "subject to subparagraph (J)," after "2002,".Subsec. (b)(3)(I)(i). Pub. L. 106-554, §1(a)(6) [title II, §213(a)(1)], in introductory provisions, substituted "there shall be substituted for the amount otherwise determined under subsection (d)(5)(D)(i), if such substitution results in a greater amount of payment under this section for the hospital" for "that for its cost reporting period beginning during 1999 is paid on the basis of the target amount applicable to the hospital under subparagraph (C) and that elects (in a form and manner determined by the Secretary) this subparagraph to apply to the hospital, there shall be substituted for such target amount". Subsec. (b)(3)(I)(i)(I). Pub. L. 106-554, §1(a)(6) [title II, §213(a)(2)], substituted "the amount otherwise applicable to the hospital under subsection (d)(5)(D)(i) (referred to in this clause as the 'subsection (d)(5)(D)(i) amount')" for "target amount otherwise applicable to the hospital under subparagraph (C) (referred to in this clause as the 'subparagraph (C) target amount')". Subsec. (b)(3)(I)(i)(II), (III). Pub. L. 106-554, §1(a)(6) [title II, §213(a)(3)], substituted "subsection (d)(5)(D)(i) amount" for "subparagraph (C) target amount". Subsec. (b)(3)(J). Pub. L. 106-554, §1(a)(6) [title III, §307(a)(1)(B)], added subpar. (J).Subsec. (d)(1)(B)(v)(III). Pub. L. 106-554, §1(a)(4) [div. B, title I, §152(a)], added subcl. (III).Subsec. (d)(1)(E). Pub. L. 106-554, §1(a)(4) [div. B, title I, §152(b)], substituted "For purposes of subclauses (II) and (III) of subparagraph (B)(v)" for "For purposes of subparagraph (B)(v)(II)".Subsec. (d)(2)(C)(i). Pub. L. 106-554, §1(a)(6) [title III, §302(c)], inserted "or of section 302 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000" after "Balanced Budget Refinement Act of 1999".Subsec. (d)(2)(C)(iv). Pub. L. 106-554, §1(a)(6) [title III, §303(c)], substituted "1989," for "1989 or" and inserted ", or the enactment of section 303 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000" after "Omnibus Budget Reconciliation Act of 1990".Subsec. (d)(3)(A)(vi). Pub. L. 106-554, §1(a)(6) [title III, §301(e)(1)], added cl. (vi). Subsec. (d)(3)(E). Pub. L. 106-554, §1(a)(6) [title III, §304(c)(2)], in third sentence, substituted "Not less often than once every 3 years the Secretary (through such survey or otherwise) shall measure" for "To the extent determined feasible by the Secretary, such survey shall measure". Subsec. (d)(4)(C)(i). Pub. L. 106-554, §1(a)(6) [title V, §533(b)(3)], substituted "technology (including a new medical service or technology under paragraph (5)(K))," for "technology,". Subsec. (d)(5)(B). Pub. L. 106-554, §1(a)(6) [title III, §302(d)], realigned margins. Subsec. (d)(5)(B)(ii)(V). Pub. L. 106-554, §1(a)(6) [title III, §302(a)(1)], struck out "and" at end.Subsec. (d)(5)(B)(ii)(VI). Pub. L. 106-554, §1(a)(6) [title III, §302(a)(4)], added subcl. (VI). Former subcl. (VI) redesignated (VII).Subsec. (d)(5)(B)(ii)(VII). Pub. L. 106-554, §1(a)(6) [title III, §302(a)(2), (3)], redesignated subcl. (VI) as (VII) and substituted "2002" for "2001". Subsec. (d)(5)(F)(i). Pub. L. 106-554, §1(a)(6) [title III, §303(d)(1)], struck out "and before October 1, 1997," before "the Secretary shall provide" in introductory provisions.Subsec. (d)(5)(F)(iv)(II). Pub. L. 106-554, §1(a)(6) [title II, §211(b)(5)(A)], inserted "or, for discharges occurring on or after April 1, 2001, is equal to the percent determined in accordance with clause (xiii)" after "5 percent". Subsec. (d)(5)(F)(iv)(III). Pub. L. 106-554, §1(a)(6) [title II, §211(b)(3)(A)], inserted "or, for discharges occurring on or after April 1, 2001, is equal to the percent determined in accordance with clause (xii)" after "4 percent".Subsec. (d)(5)(F)(iv)(IV). Pub. L. 106-554, §1(a)(6) [title II, §211(b)(4)], inserted "or, for discharges occurring on or after April 1, 2001, the greater of the percentages determined under clause (x) or (xi)" after "clause (viii)". Subsec. (d)(5)(F)(iv)(V). Pub. L. 106-554, §1(a)(6) [title II, §211(b)(2)(A)], inserted "or, for discharges occurring on or after April 1, 2001, is equal to the percent determined in accordance with clause (xi)" after "clause (viii)".Subsec. (d)(5)(F)(iv)(VI). Pub. L. 106-554, §1(a)(6) [title II, §211(b)(1)(A)], inserted "or, for discharges occurring on or after April 1, 2001, is equal to the percent determined in accordance with clause (x)" after "10 percent". Subsec. (d)(5)(F)(v)(II). Pub. L. 106-554, §1(a)(6) [title II, §211(a)(1)], inserted "(or 15 percent, for discharges occurring on or after April 1, 2001)" after "30 percent". Subsec. (d)(5)(F)(v)(III). Pub. L. 106-554, §1(a)(6) [title II, §211(a)(2)], inserted "(or 15 percent, for discharges occurring on or after April 1, 2001)" after "40 percent".Subsec. (d)(5)(F)(v)(IV). Pub. L. 106-554, §1(a)(6) [title II, §211(a)(3)], inserted "(or 15 percent, for discharges occurring on or after April 1, 2001)" after "45 percent". Subsec. (d)(5)(F)(ix)(III). Pub. L. 106-554, §1(a)(6) [title III, §303(a)(1)], struck out "each of" after "during" and inserted "and 2 percent, respectively" after "3 percent". Subsec. (d)(5)(F)(ix)(IV). Pub. L. 106-554, §1(a)(6) [title III, §303(a)(2)], substituted "3 percent" for "4 percent". Subsec. (d)(5)(F)(x). Pub. L. 106-554, §1(a)(6) [title II, §211(b)(1)(B)], added cl. (x).Subsec. (d)(5)(F)(xi). Pub. L. 106-554, §1(a)(6) [title II, §211(b)(2)(B)], added cl. (xi).Subsec. (d)(5)(F)(xii). Pub. L. 106-554, §1(a)(6) [title II, §211(b)(3)(B)], added cl. (xii).Subsec. (d)(5)(F)(xiii). Pub. L. 106-554, §1(a)(6) [title II, §211(b)(5)(B)], added cl. (xiii).Subsec. (d)(5)(G)(iv)(IV). Pub. L. 106-554, §1(a)(6) [title II, §212(a)], inserted ", or two of the three most recently audited cost reporting periods for which the Secretary has a settled cost report," after "1987".Subsec. (d)(5)(K), (L). Pub. L. 106-554, §1(a)(6) [title V, §533(b)(1)], added subpars. (K) and (L).Subsec. (d)(10)(D)(v), (vi). Pub. L. 106-554, §1(a)(6) [title III, §304(a)], added cls. (v) and (vi). Subsec. (h)(2)(D)(iii). Pub. L. 106-554, §1(a)(6) [title V, §511], in heading substituted "for" for "in fiscal year 2001 at 70 percent of" and in text inserted ", and for the cost reporting period beginning during fiscal year 2002 shall not be less than 85 percent," after "70 percent".Subsec. (j)(1)(A). Pub. L. 106-554, §1(a)(6) [title III, §305(b)(1)(A)], inserted "other than a facility making an election under subparagraph (F)" before "in a cost reporting period" in introductory provisions.Subsec. (j)(1)(B). Pub. L. 106-554, §1(a)(6) [title III, §305(b)(1)(B)], inserted "or, in the case of a facility making an election under subparagraph (F), for any cost reporting period described in such subparagraph," after "2002,". Subsec. (j)(1)(F). Pub. L. 106-554, §1(a)(6) [title III, §305(b)(1)(C)], added subpar. (F). Subsec. (j)(3)(B). Pub. L. 106-554, §1(a)(6) [title III, §305(b)(2)], inserted "but not taking into account any payment adjustment resulting from an election permitted under paragraph (1)(F)" after "paragraphs (4) and (6)". Pub. L. 106-554, §1(a)(6) [title III, §305(a)], substituted "98 percent for fiscal year 2001 and 100 percent for fiscal year 2002" for "98 percent".Subsec. (l)(2)(C). Pub. L. 106-554, §1(a)(6) [title V, §512(a)], substituted "the ratio of-" and cls. (i) and (ii) for "the Secretary's estimate of the ratio of the amount of payments made under section 1395x(v) of this title to the hospital for nursing and allied health education activities for the hospital's cost reporting period ending in the second preceding fiscal year to the total of such amounts for all hospitals for such cost reporting periods."1999-Subsec. (b)(1). Pub. L. 106-113, §1000(a)(6) [title III, §321(k)(15)(A)], inserted a comma after "paragraph (2)" in concluding provisions. Subsec. (b)(2)(A). Pub. L. 106-113, §1000(a)(6) [title I, §122(1)], substituted "Except as provided in subparagraph (E), in addition to" for "In addition to".Subsec. (b)(2)(E). Pub. L. 106-113, §1000(a)(6) [title I, §122(2)], added subpar. (E). Subsec. (b)(3)(B)(i)(XVI) to (XVIII). Pub. L. 106-113, §1000(a)(6) [title IV, §406], added subcls. (XVI) and (XVII), redesignated former subcl. (XVII) as (XVIII), and struck out former subcl. (XVI) which read as follows: "for each of fiscal years 2001 and 2002, the market basket percentage increase minus 1.1 percentage point for hospitals in all areas, and".Subsec. (b)(3)(B)(ii)(VI). Pub. L. 106-113, §1000(a)(6) [title III, §321(k)(15)(B)(i)], substituted comma for semicolon at end.Subsec. (b)(3)(B)(ii)(VII). Pub. L. 106-113, §1000(a)(6) [title III, §321(k)(15)(B)(ii)], substituted "year," for "year;".Subsec. (b)(3)(C). Pub. L. 106-113, §1000(a)(6) [title IV, §405(1)], inserted "subject to subparagraph (I)," before "the term 'target amount' means" in introductory provisions.Subsec. (b)(3)(D). Pub. L. 106-113, §1000(a)(6) [title IV, §404(b)(1)(A)], substituted "and before October 1, 2006," for "and before October 1, 2001," in introductory provisions. Pub. L. 106-113, §1000(a)(6) [title III, §321(b)(2)], substituted "and for discharges beginning on or after October 1, 1997, and before October 1, 2001," for "and for cost reporting periods beginning on or after October 1, 1997, and before October 1, 2001," in introductory provisions.Subsec. (b)(3)(D)(iv). Pub. L. 106-113, §1000(a)(6) [title IV, §404(b)(1)(B)], substituted "fiscal year 2005" for "fiscal year 2000".Subsec. (b)(3)(H)(i) to (iii). Pub. L. 106-113, §1000(a)(6) [title I, §121(a)], added cl. (i), redesignated former cl. (i) as subcl. (I) of cl. (ii) and inserted ", as adjusted under clause (iii)" after "fiscal year 1996", redesignated former cl. (ii) as subcl. (II) of cl. (ii) and substituted "subclause (I)" for "clause (i)" and "such subclause" for "such clause", added cl. (iii), and redesignated former cl. (iii) as subcl. (III) of cl. (ii).Subsec. (b)(3)(I). Pub. L. 106-113, §1000(a)(6) [title IV, §405(2)], added subpar. (I).Subsec. (b)(4)(A)(i). Pub. L. 106-113, §1000(a)(6) [title III, §321(f)], struck out "or unit" after "(and in the case of a hospital". Subsec. (b)(7)(A)(i)(II). Pub. L. 106-113, §1000(a)(6) [title III, §321(h)], inserted "(as estimated by the Secretary)" after "median".Subsec. (d)(2)(C)(i). Pub. L. 106-113, §1000(a)(6) [title I, §111(c)], inserted "or any additional payments under such paragraph resulting from the application of section 111 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999" after "Balanced Budget Act of 1997".Subsec. (d)(5)(B)(ii)(V), (VI). Pub. L. 106-113, §1000(a)(6) [title I, §111(a)], added subcl. (V), redesignated former subcl. (V) as (VI), and substituted "2001" for "2000" in subcl. (VI).Subsec. (d)(5)(B)(v). Pub. L. 106-113, §1000(a)(6) [title IV, §407(b)(2)], inserted "(or, 130 percent of such number in the case of a hospital located in a rural area)" after "may not exceed the number". Pub. L. 106-113, §1000(a)(6) [title IV, §407(a)(2)], inserted at end "Rules similar to the rules of subsection (h)(4)(F)(ii) shall apply for purposes of this clause." Subsec. (d)(5)(F)(i). Pub. L. 106-113, §1000(a)(6) [title III, §321(k)(16)], inserted a comma after "1986" in introductory provisions.Subsec. (d)(5)(F)(ix)(III). Pub. L. 106-113, §1000(a)(6) [title I, §112(a)(1)], substituted "during each of fiscal years 2000 and 2001" for "during fiscal year 2000".Subsec. (d)(5)(F)(ix)(IV). Pub. L. 106-113, §1000(a)(6) [title I, §112(a)(2)-(4)], redesignated subcl. (V) as (IV), substituted "reduced by 4 percent" for "reduced by 5 percent", and struck out former subcl. (IV) which read as follows: "during fiscal year 2001, such additional payment amount shall be reduced by 4 percent;". Subsec. (d)(5)(F)(ix)(V), (VI). Pub. L. 106-113, §1000(a)(6) [title I, §112(a)(3)], redesignated subcl. (VI) as (V). Former subcl. (V) redesignated (IV). Subsec. (d)(5)(G)(i). Pub. L. 106-113, §1000(a)(6) [title IV, §404(a)(1)], substituted "October 1, 2006," for "October 1, 2001,". Pub. L. 106-113, §1000(a)(6) [title III, §321(b)(1)(A)], substituted "or discharges occurring on or after October 1, 1997, and before October 1, 2001," for "or beginning on or after October 1, 1997, and before October 1, 2001,".Subsec. (d)(5)(G)(ii)(II). Pub. L. 106-113, §1000(a)(6) [title IV, §404(a)(2)], substituted "October 1, 2006," for "October 1, 2001,". Pub. L. 106-113, §1000(a)(6) [title III, §321(b)(1)(B)], substituted "or discharges occurring on or after October 1, 1997, and before October 1, 2001," for "or beginning on or after October 1, 1997, and before October 1, 2001,". Subsec. (d)(8)(B). Pub. L. 106-113, §1000(a)(6) [title IV, §402(a)], designated existing provisions as cl. (i), substituted "described in clause (ii)" for "published in the Federal Register on January 3, 1980", and added cl. (ii). Subsec. (d)(8)(E). Pub. L. 106-113, §1000(a)(6) [title IV, §401(a)], added subpar. (E).Subsec. (d)(9)(A)(ii). Pub. L. 106-113, §1000(a)(6) [title III, §321(k)(17)], inserted a comma after "1987" in introductory provisions.Subsec. (g)(1)(A). Pub. L. 106-113, §1000(a)(6) [title III, §321(e)], substituted "October 1, 2002," for "September 30, 2002," in last sentence. Subsec. (h)(2)(D)(i). Pub. L. 106-113, §1000(a)(6) [title III, §311(a)(1), (b)(1)], inserted heading and substituted "a subsequent clause" for "clause (ii)" and "the approved FTE resident amount determined" for "the amount determined". Subsec. (h)(2)(D)(ii). Pub. L. 106-113, §1000(a)(6) [title III, §311(b)(2)], inserted heading and realigned margins.Subsec. (h)(2)(D)(iii), (iv). Pub. L. 106-113, §1000(a)(6) [title III, §311(a)(2)], added cls. (iii) and (iv).Subsec. (h)(2)(E), (F). Pub. L. 106-113, §1000(a)(6) [title III, §311(a)(3), (4)], added subpar. (E) and redesignated former subpar. (E) as (F).Subsec. (h)(3)(D)(i). Pub. L. 106-113, §1000(a)(6) [title V, §541(b)(1)], inserted ", subject to clause (iii)," after "shall equal" in introductory provisions. Subsec. (h)(3)(D)(iii), (iv). Pub. L. 106-113, §1000(a)(6) [title V, §541(b)(2), (3)], added cl. (iii) and redesignated former cl. (iii) as (iv).Subsec. (h)(4)(F). Pub. L. 106-113, §1000(a)(6) [title IV, §407(a)(1)], designated existing provisions as cl. (i), inserted heading, realigned margins, and added cl. (ii).Subsec. (h)(4)(F)(i). Pub. L. 106-113, §1000(a)(6) [title IV, §407(b)(1)], inserted "(or, 130 percent of such number in the case of a hospital located in a rural area)" after "may not exceed the number".Subsec. (h)(4)(H)(iv). Pub. L. 106-113, §1000(a)(6) [title IV, §407(c)(1)], added cl. (iv). Subsec. (h)(5)(F). Pub. L. 106-113, §1000(a)(6) [title III, §312(a)(1)], substituted "Subject to subparagraph (G)(v), the initial residency period" for "The initial residency period" in concluding provisions. Subsec. (h)(5)(G)(i). Pub. L. 106-113, §1000(a)(6) [title III, §312(a)(2)(A)], substituted "(iv), and (v)" for "and (iv)". Subsec. (h)(5)(G)(v). Pub. L. 106-113, §1000(a)(6) [title III, §312(a)(2)(B)], added cl. (v). Subsec. (j)(1)(D). Pub. L. 106-113, §1000(a)(6) [title I, §125(a)(1)], struck out ", day of inpatient hospital services, or other unit of payment defined by the Secretary" before period at end. Subsec. (j)(1)(E). Pub. L. 106-113, §1000(a)(6) [title I, §125(a)(3)], added subpar. (E).Subsec. (j)(2)(A)(i). Pub. L. 106-113, §1000(a)(6) [title I, §125(a)(2)], amended cl. (i) generally. Prior to amendment, cl. (i) read as follows: "classes of patients of rehabilitation facilities (each in this subsection referred to as a 'case mix group'), based on such factors as the Secretary deems appropriate, which may include impairment, age, related prior hospitalization, comorbidities, and functional capability of the patient; and". Subsec. (l). Pub. L. 106-113, §1000(a)(6) [title V, §541(a)], added subsec. (l).1997-Subsec. (b)(1). Pub. L. 105-33, §4421(b)(1), inserted "and other than a rehabilitation facility described in subsection (j)(1)" after "subsection (d)(1)(B)" in introductory provisions. Pub. L. 105-33, §4415(b)(1), inserted "plus the amount, if any, provided under paragraph (2)" before "except that in no case" in concluding provisions.Subsec. (b)(1)(A). Pub. L. 105-33, §4415(a), added cls. (i) and (ii) and concluding provisions and struck out former cls. (i) and (ii) and former concluding provisions which read as follows:"(i) 50 percent of the amount by which the target amount exceeds the amount of the operating costs, or"(ii) 5 percent of the target amount,whichever is less; or".Subsec. (b)(1)(B). Pub. L. 105-33, §4415(c)(3), added subpar. (B). Former subpar. (B) redesignated (C). Subsec. (b)(1)(C). Pub. L. 105-33, §4415(c)(1), (2), redesignated subpar. (B) as (C) and substituted "greater than 110 percent of the target amount" for "greater than the target amount" and "exceed 110 percent of the target amount" for "exceed the target amount".Subsec. (b)(2). Pub. L. 105-33, §4415(b)(2), added par. (2). Subsec. (b)(3)(A). Pub. L. 105-33, §§4413(a)(1), 4416 (2), in introductory provisions, substituted "subparagraph (C) and succeeding subparagraph," for "subparagraphs (C), (D), and (E)," and inserted "and in paragraph (7)(A)(ii)," before "for purposes of this subsection". Subsec. (b)(3)(B)(i). Pub. L. 105-33, §4421(b)(2), inserted "and subsection (j)" after "For purposes of subsection (d)" in introductory provisions.Subsec. (b)(3)(B)(i)(XIII) to (XVII). Pub. L. 105-33, §4401(a), added subcls. (XIII) to (XVII) and struck out former subcl. (XIII) which read as follows: "for fiscal year 1998 and each subsequent fiscal year, the market basket percentage increase for hospitals in all areas."Subsec. (b)(3)(B)(ii)(VI) to (VIII). Pub. L. 105-33, §4411(a)(1), added subcls. (VI) and (VII) and redesignated former subcl. (VI) as (VIII).Subsec. (b)(3)(B)(vi). Pub. L. 105-33, §4411(a)(2), added cl. (vi).Subsec. (b)(3)(D). Pub. L. 105-33, §4204(a)(2)(A), substituted "September 30, 1994, and for cost reporting periods beginning on or after October 1, 1997, and before October 1, 2001," for "September 30, 1994," in introductory provisions. Subsec. (b)(3)(D)(iv). Pub. L. 105-33, §4204(a)(2)(B) -(D), added cl. (iv). Subsec. (b)(3)(F), (G). Pub. L. 105-33, §4413(a)(2), (b), added subpars. (F) and (G).Subsec. (b)(3)(H). Pub. L. 105-33, §4414, added subpar. (H). Subsec. (b)(4)(A)(i). Pub. L. 105-33, §4419(a)(1), in first sentence, substituted "The Secretary shall provide for an exception and adjustment to (and in the case of a hospital or unit described in subsection (d)(1)(B)(iii), may provide an exemption from)" for "The Secretary shall provide for an exemption from, or an exception and adjustment to,". Subsec. (b)(4)(A)(ii). Pub. L. 105-33, §4411(b), inserted at end "In making such reductions, the Secretary shall treat the applicable update factor described in paragraph (3)(B)(vi) for a fiscal year as being equal to the market basket percentage for that year." Subsec. (b)(7). Pub. L. 105-33, §4416(1), added par. (7). Subsec. (d)(1)(B). Pub. L. 105-33, §4417(a)(1), inserted at end "A hospital that was classified by the Secretary on or before September 30, 1995, as a hospital described in clause (iv) shall continue to be so classified notwithstanding that it is located in the same building as, or on the same campus as, another hospital."Subsec. (d)(1)(B)(iv). Pub. L. 105-33, §4417(b)(1), designated existing provisions as subcl. (I) and added subcl. (II).Subsec. (d)(1)(B)(v). Pub. L. 105-33, §4418(a)(1), designated existing provisions as subcl. (I), substituted ", or" for semicolon at end, and added subcl. (II).Subsec. (d)(1)(E). Pub. L. 105-33, §4418(a)(2), added subpar. (E). Subsec. (d)(2)(C)(i). Pub. L. 105-33, §4621(a)(2), inserted at end "except that the Secretary shall not take into account any reduction in the amount of additional payments under paragraph (5)(B)(ii) resulting from the amendment made by section 4621(a)(1) of the Balanced Budget Act of 1997,". Subsec. (d)(5)(A)(ii). Pub. L. 105-33, §4405(c), substituted "exceed the sum of the applicable DRG prospective payment rate plus any amounts payable under subparagraphs (B) and (F)" for "exceed the applicable DRG prospective payment rate".Subsec. (d)(5)(B)(i)(I). Pub. L. 105-33, §4405(a), inserted ", for cases qualifying for additional payment under subparagraph (A)(i)," before "the amount paid to the hospital". Subsec. (d)(5)(B)(ii). Pub. L. 105-33, §4621(a)(1), amended cl. (ii) generally. Prior to amendment, cl. (ii) read as follows: "For purposes of clause (i)(II), the indirect teaching adjustment factor for discharges occurring on or after October 1, 1988, is equal to 1.89 x (((1 + r) to the nth power) -1), where 'r' is the ratio of the hospital's full-time equivalent interns and residents to beds and 'n' equals .405."Subsec. (d)(5)(B)(iv). Pub. L. 105-33, §4621(b)(2), amended cl. (iv) generally. Prior to amendment, cl. (iv) read as follows: "In determining such adjustment, the Secretary shall continue to count interns and residents assigned to outpatient services of the hospital or providing services at any entity receiving a grant under section 254c of this title that is under the ownership or control of the hospital (if the hospital incurs all, or substantially all, of the costs of the services furnished by such interns and residents) as part of the calculation of the full-time-equivalent number of interns and residents." Subsec. (d)(5)(B)(v) to (viii). Pub. L. 105-33, §4621(b)(1), added cls. (v) to (viii).Subsec. (d)(5)(D)(iii)(III). Pub. L. 105-33, §4201(c)(4)(A), inserted "as in effect on September 30, 1997" before period at end.Subsec. (d)(5)(D)(v). Pub. L. 105-33, §4201(c)(4)(B), inserted "as in effect on September 30, 1997" after "section 1395i-4(i)(1) of this title" and substituted "(as defined in section 1395i-4(d) of this title)" for "(as defined in section 1395i-4(g) of this title)".Subsec. (d)(5)(F)(i). Pub. L. 105-33, §4403(a)(1), inserted "and before October 1, 1997" after "May 1, 1986" in introductory provisions.Subsec. (d)(5)(F)(ii). Pub. L. 105-33, §4403(a)(2), substituted "Subject to clause (ix), the amount" for "The amount".Subsec. (d)(5)(F)(ii)(I). Pub. L. 105-33, §4405(b), inserted ", for cases qualifying for additional payment under subparagraph (A)(i)," before "the amount paid to the hospital". Subsec. (d)(5)(F)(ix). Pub. L. 105-33, §4403(a)(3), added cl. (ix). Subsec. (d)(5)(G)(i), (ii)(II). Pub. L. 105-33, §4204(a)(1), substituted "October 1, 1994, or beginning on or after October 1, 1997, and before October 1, 2001," for "October 1, 1994,". Subsec. (d)(5)(I)(ii). Pub. L. 105-33, §4407(1), inserted "not taking in account the effect of subparagraph (J)," after "in a fiscal year,". Subsec. (d)(5)(J). Pub. L. 105-33, §4407(2), added subpar. (J).Subsec. (d)(6). Pub. L. 105-33, §4644(a)(1), substituted "August 1" for "September 1". Subsec. (d)(9)(A). Pub. L. 105-33, §4406(1), struck out "in a fiscal year beginning on or after October 1, 1987," after "inpatient hospital discharges" in introductory provisions.Subsec. (d)(9)(A)(i). Pub. L. 105-33, §4406(2), substituted "for discharges beginning on or after October 1, 1997, 50 percent (and for discharges between October 1, 1987, and September 30, 1997, 75 percent)" for "75 percent". Subsec. (d)(9)(A)(ii). Pub. L. 105-33, §4406(3), substituted "for discharges beginning in a fiscal year beginning on or after October 1, 1997, 50 percent (and for discharges between October 1, 1987 and September 30, 1997, 25 percent)" for "25 percent".Subsec. (d)(10)(C)(ii). Pub. L. 105-33, §4644(c)(1), substituted "the first day of the 13-month period ending on September 30 of the preceding fiscal year." for "the first day of the preceding fiscal year."Subsec. (d)(10)(D)(iii), (iv). Pub. L. 105-33, §4202(a), added cl. (iii) and redesignated former cl. (iii) as (iv). Subsec. (d)(11). Pub. L. 105-33, §4622, added par. (11). Subsec. (e)(2). Pub. L. 105-33, §4022(b)(1)(A)(i), struck out par. (2) which related to appointment, composition, and responsibilities of the Prospective Payment Assessment Commission.Subsec. (e)(3). Pub. L. 105-33, §4022(b)(1)(A) (ii), redesignated subpar. (B) as par. (3) and struck out subpar. (A) which read as follows: "The Commission, not later than the March 1 before the beginning of each fiscal year (beginning with fiscal year 1986), shall report its recommendations to Congress on an appropriate change factor which should be used for inpatient hospital services for discharges in that fiscal year, together with its general recommendations under paragraph (2)(B) regarding the effectiveness and quality of health care delivery systems in the United States."Subsec. (e)(5)(A). Pub. L. 105-33, §4644(b)(1)(A), substituted "April 1" for "May 1". Subsec. (e)(5)(B). Pub. L. 105-33, §4644(b)(1)(B), substituted "August 1" for "September 1".Subsec. (e)(6). Pub. L. 105-33, §4022(b)(1)(A)(i), struck out par. (6) which related to appointments, membership, responsibilities, compensation, access to records and information, audits, and appropriations concerning the Prospective Payment Assessment Commission.Subsec. (g)(1)(A). Pub. L. 105-33, §4402, inserted at end "In addition to the reduction described in the preceding sentence, for discharges occurring on or after October 1, 1997, the Secretary shall apply the budget neutrality adjustment factor used to determine the Federal capital payment rate in effect on September 30, 1995 (as described in section 412.352 of title 42 of the Code of Federal Regulations), to (i) the unadjusted standard Federal capital payment rate (as described in section 412.308(c) of that title, as in effect on September 30, 1997), and (ii) the unadjusted hospital-specific rate (as described in section 412.328(e)(1) of that title, as in effect on September 30, 1997), and, for discharges occurring on or after October 1, 1997, and before September 30, 2002, reduce the rates described in clauses (i) and (ii) by 2.1 percent."Subsec. (g)(3)(B). Pub. L. 105-33, §4201(c)(1), substituted "critical access" for "rural primary care".Subsec. (g)(4). Pub. L. 105-33, §4412, added par. (4).Subsec. (h)(3)(B). Pub. L. 105-33, §4625(b), inserted concluding provisions. Subsec. (h)(3)(D). Pub. L. 105-33, §4624, added subpar. (D).Subsec. (h)(4)(F) to (H). Pub. L. 105-33, §4623, added subpars. (F) to (H).Subsec. (h)(5)(G). Pub. L. 105-33, §4627(a), substituted "Subject to clauses (ii), (iii), and (iv)" for "Subject to clauses (ii) and (iii)" in cl. (i) and added cl. (iv). Subsec. (h)(6). Pub. L. 105-33, §4626(a), added par. (6).Subsec. (j). Pub. L. 105-33, §4421(a), added subsec. (j).Subsec. (k). Pub. L. 105-33, §4625(a), added subsec. (k).1994-Subsec. (a)(4). Pub. L. 103-432, §110(a), inserted "(or, in the case of a hospital that is not a subsection (d) hospital, during the 1 day)" after "3 days". Subsec. (b)(3)(B)(iv)(II). Pub. L. 103-432, §105(b), substituted "(adjusted to exclude any portion of a cost reporting period beginning during fiscal year 1993 for which the applicable percentage increase is determined under subparagraph (I))" for "(taking into account any portion of the 12-month cost reporting period beginning during fiscal year 1993 that occurred during fiscal year 1994)".Subsec. (b)(3)(D). Pub. L. 103-432, §105(a)(2), substituted "September 30, 1994" for "March 31, 1993" in introductory provisions.Subsec. (d)(3)(A)(iii). Pub. L. 103-432, §101(c), inserted at end "For discharges occurring on or after October 1, 1994, the Secretary shall adjust the ratio of the labor portion to non-labor portion of each average standardized amount to equal such ratio for the national average of all standardized amounts."Subsec. (d)(5)(B)(ii). Pub. L. 103-432, §110(c), substituted "October 1, 1988" for "May 1, 1986".Subsec. (d)(5)(D)(iii)(III). Pub. L. 103-432, §102(b)(1)(B)(i), substituted "that is located in a rural area and designated" for "that is designated".Subsec. (d)(5)(D)(v). Pub. L. 103-432, §102(b)(1)(B) (ii), substituted "in the case of a hospital located in a rural area and designated" for "in the case of a hospital designated".Subsec. (d)(5)(G)(ii)(I). Pub. L. 103-432, §105(a)(1), substituted "the 36-month period beginning with the first day of the cost reporting period that begins" for "the first 3 12-month cost reporting periods that begin".Subsec. (d)(5)(I). Pub. L. 103-432, §109, designated existing provisions as cl. (i) and added cl. (ii). Subsec. (d)(8)(C)(iv). Pub. L. 103-432, §101(b)(1)(A), substituted "paragraph (10)" for "paragraph (1)". Subsec. (d)(8)(C)(v). Pub. L. 103-432, §101(b)(1)(B), added cl. (v).Subsec. (d)(10)(C)(i)(II). Pub. L. 103-432, §101(b)(2)(A), substituted "the factor used to adjust the DRG prospective payment rate for area differences in hospital wage levels that applies" for "the area wage index applicable". Subsec. (d)(10)(D)(i)(I). Pub. L. 103-432, §101(a)(1), inserted "(to the extent the Secretary determines appropriate)" after "taking into account".Subsec. (d)(10)(D)(ii), (iii). Pub. L. 103-432, §101(b)(2)(B), added cl. (ii) and redesignated former cl. (ii) as (iii).Subsec. (e)(6)(B). Pub. L. 103-432, §108, substituted "health facility management, reimbursement of health facilities or other providers of services which reflect the scope of the Commission's responsibilities" for "hospital reimbursement, hospital financial management".Subsec. (h)(5)(E). Pub. L. 103-432, §153(a), inserted "or any successor examination" after "Medical Sciences". 1993-Subsec. (b)(3)(B)(i)(IX). Pub. L. 103-66, §13501(a)(1)(A), substituted "percentage increase minus 2.5 percentage points for hospitals" for "percentage increase for hospitals" and "percentage increase minus 1.0 percentage point" for "percentage increase plus 1.5 percentage points".Subsec. (b)(3)(B)(i)(X). Pub. L. 103-66, §13501(a)(1)(B), substituted "percentage increase minus 2.5 percentage points for hospitals" for "percentage increase for hospitals" and struck out "and" at end.Subsec. (b)(3)(B)(i)(XI). Pub. L. 103-66, §13501(a)(1)(C), struck out "and each subsequent fiscal year" after "1996", inserted "minus 2.0 percentage points" after "percentage increase", and substituted a comma for period at end.Subsec. (b)(3)(B)(i)(XII), (XIII). Pub. L. 103-66, §13501(a)(1)(D), added subcls. (XII) and (XIII).Subsec. (b)(3)(B)(ii). Pub. L. 103-66, §13501(a)(2)(B)(i), struck out ", (C), (D)," after "subparagraphs (A)".Subsec. (b)(3)(B)(ii)(III) to (VI). Pub. L. 103-66, §13502(a)(1), struck out "and" at end of subcl. (III), in subcl. (IV), substituted "a subsequent fiscal year ending on or before September 30, 1993," for "subsequent fiscal years" and a comma for the period at end, and added subcls. (V) and (VI).Subsec. (b)(3)(B)(iv). Pub. L. 103-66, §13501(a)(2)(A), added cl. (iv).Subsec. (b)(3)(B)(v). Pub. L. 103-66, §13502(a)(2), added cl. (v).Subsec. (b)(3)(C)(i)(II). Pub. L. 103-66, §13501(a)(2)(B) (ii), struck out "or" at end.Subsec. (b)(3)(C)(ii). Pub. L. 103-66, §13501(a)(2)(B) (iii), substituted "period beginning before fiscal year 1994, the target" for "period, the target", "subparagraph (B)(iv)" for "subparagraph (B)(ii)", and a comma for period at end. Subsec. (b)(3)(C)(iii), (iv). Pub. L. 103-66, §13501(a)(2)(B) (iv), added cls. (iii) and (iv).Subsec. (b)(3)(D)(ii). Pub. L. 103-66, §13501(a)(2)(B)(v), substituted "period beginning before fiscal year 1994, the target" for "period, the target", "subparagraph (B)(iv)" for "subparagraph (B)(ii)", and ", and" for period at end.Subsec. (b)(3)(D)(iii). Pub. L. 103-66, §13501(a)(2)(B) (vi), added cl. (iii). Subsec. (b)(4)(A). Pub. L. 103-66, §13502(b), designated existing provisions as cl. (i) and added cl. (ii).Subsec. (d)(1)(A)(iii). Pub. L. 103-66, §13501(f), amended cl. (iii) generally. Prior to amendment, cl. (iii) read as follows: "beginning on or after April 1, 1988, and ending on September 30, 1993,, the sum of (I) 85 percent of the national adjusted DRG prospective payment rate determined under paragraph (3) for such discharges, and (II) 15 percent of the regional adjusted DRG prospective payment rate determined under such paragraph."Subsec. (d)(5)(A)(i). Pub. L. 103-66, §13501(c)(1), substituted "For discharges occurring during fiscal years ending on or before September 30, 1997, the Secretary" for "The Secretary".Subsec. (d)(5)(A)(ii). Pub. L. 103-66, §13501(c)(2), substituted ", or, for discharges in fiscal years beginning on or after October 1, 1994, exceed the applicable DRG prospective payment rate plus a fixed dollar amount determined by the Secretary." for period at end.Subsec. (d)(5)(A)(iii). Pub. L. 103-66, §13501(c)(3), substituted "shall (except as payments under clause (i) are required to be reduced to take into account the requirements of clause (v)) approximate" for "shall approximate".Subsec. (d)(5)(A)(v), (vi). Pub. L. 103-66, §13501(c)(4), added cls. (v) and (vi). Subsec. (d)(5)(B)(iv). Pub. L. 103-66, §13506, inserted "or providing services at any entity receiving a grant under section 254c of this title that is under the ownership or control of the hospital (if the hospital incurs all, or substantially all, of the costs of the services furnished by such interns and residents)" after "the hospital".Subsec. (d)(5)(G)(i). Pub. L. 103-66, §13501(e)(1)(A), which directed amendment of subsec. (d)(5)(G) in clause (i) in the matter preceding subclause (I), by striking "ending on or before March 31, 1993," and all that follows and inserting "before October 1, 1994, in the case of a subsection (d) hospital which is a medicare-dependent, small rural hospital, payment under paragraph (1)(A) shall be equal to the sum of the amount determined under clause (ii) and the amount determined under paragraph (1)(A)(iii).", was executed by substituting the new language for "ending on or before March 31, 1993, with respect to a subsection (d) hospital which is a medicare-dependent, small rural hospital, payment under paragraph (1)(A) shall be-"(I) an amount based on 100 percent of the hospital's target amount for the cost reporting period, as defined in subsection (b)(3)(D) of this section, or"(II) the amount determined under paragraph (1)(A)(iii),whichever results in the greater payment to the hospital." to reflect the probable intent of Congress. Subsec. (d)(5)(G)(ii) to (iv). Pub. L. 103-66, §13501(e)(1)(B), (C), added cl. (ii) and redesignated former cls. (ii) and (iii) as (iii) and (iv), respectively.Subsec. (d)(8)(C)(iv). Pub. L. 103-66, §13501(b)(1), added cl. (iv).Subsec. (g)(1)(A). Pub. L. 103-66, §13501(a)(3), inserted at end "For discharges occurring after September 30, 1993, the Secretary shall reduce by 7.4 percent the unadjusted standard Federal capital payment rate (as described in 42 CFR 412.308(c), as in effect on August 10, 1993) and shall (for hospital cost reporting periods beginning on or after October 1, 1993) redetermine which payment methodology is applied to the hospital under such system to take into account such reduction."Subsec. (h)(2)(D). Pub. L. 103-66, §13563(a)(1), designated existing provisions as cl. (i), substituted "Except as provided in clause (ii), for each" for "For each", and added cl. (ii).Subsec. (h)(5)(F). Pub. L. 103-66, §13563(b)(1)(A), struck out "plus one year" after "board eligibility" in introductory provisions.Subsec. (h)(5)(F)(ii). Pub. L. 103-66, §13563(b)(1)(B), inserted "or a preventive medicine residency or fellowship program" after "fellowship program".Subsec. (h)(5)(H), (I). Pub. L. 103-66, §13563(a)(2), added subpar. (H) and redesignated former subpar. (H) as (I).Subsec. (h)(5)(J). Pub. L. 103-66, §13563(c)(1), added subpar. (J). 1990-Subsec. (a)(4). Pub. L. 101-508, §4003(a), struck out period at end of first sentence and inserted ", and includes the costs of all services for which payment may be made under this subchapter that are provided by the hospital (or by an entity wholly owned or operated by the hospital) to the patient during the 3 days immediately preceding the date of the patient's admission if such services are diagnostic services (including clinical diagnostic laboratory tests) or are other services related to the admission (as defined by the Secretary)." Subsec. (b)(1)(B)(ii). Pub. L. 101-508, §4005(a)(1), added cl. (ii) and struck out former cl. (ii) which read as follows: "in the case of cost reporting periods beginning on or after October 1, 1982, and before October 1, 1984, 25 percent of the amount by which the amount of the operating costs exceeds the target amount;".Subsec. (b)(3)(B)(i)(V). Pub. L. 101-508, §4002(a)(1)(A), struck out "and" after semicolon at end. Subsec. (b)(3)(B)(i)(VI). Pub. L. 101-508, §4002(c)(1)(A), substituted "in a large urban or other urban area, and the market basket percentage increase minus 0.7 percentage point for hospitals located in a rural area" for "in all areas". Pub. L. 101-508, §4002(a)(1)(C), added subcl. (VI). Former subcl. (VI) redesignated (IX). Pub. L. 101-508, §4002(a)(1)(B)(i), substituted "1994" for "1991".Subsec. (b)(3)(B)(i)(VII). Pub. L. 101-508, §4002(c)(1)(B), substituted "in a large urban or other urban area, and the market basket percentage increase minus 0.6 percentage point for hospitals located in a rural area" for "in all areas". Pub. L. 101-508, §4002(a)(1)(C), added subcl. (VII).Subsec. (b)(3)(B)(i)(VIII). Pub. L. 101-508, §4002(c)(1)(C), substituted "in a large urban or other urban area, and the market basket percentage increase minus 0.55 for hospitals located in a rural area," for "in all areas, and". Pub. L. 101-508, §4002(a)(1)(C), added subcl. (VIII).Subsec. (b)(3)(B)(i)(IX). Pub. L. 101-508, §4002(c)(1)(E), added subcl. (IX). Former subcl. (IX) redesignated (XI). Pub. L. 101-508, §4002(c)(1)(D)(i), substituted "1996" for "1994". Pub. L. 101-508, §4002(a)(1)(B) (ii), redesignated subcl. (VI) as (IX). Subsec. (b)(3)(B)(i)(X). Pub. L. 101-508, §4002(c)(1)(E), added subcl. (X). Subsec. (b)(3)(B)(i)(XI). Pub. L. 101-508, §4002(c)(1)(D) (ii), redesignated subcl. (IX) as (XI).Subsec. (b)(3)(B)(ii). Pub. L. 101-508, §4002(c)(2)(A)(i), substituted "(A), (C), (D), and (E)," for "(A) and (E)," in introductory provisions. Subsec. (b)(3)(C)(ii), (D)(ii). Pub. L. 101-508, §4002(c)(2)(A) (ii), substituted "subparagraph (B)(ii)" for "subparagraph (B)(i)". Subsec. (b)(4)(A). Pub. L. 101-508, §4005(c)(1)(B), inserted at end "The Secretary shall announce a decision on any request for an exemption, exception, or adjustment under this paragraph not later than 180 days after receiving a completed application from the intermediary for such exemption, exception, or adjustment, and shall include in such decision a detailed explanation of the grounds on which such request was approved or denied." Subsec. (b)(4)(B), (C). Pub. L. 101-508, §4005(c)(2), added subpar. (B) and redesignated former subpar. (B) as (C). Subsec. (c)(4). Pub. L. 101-508, §4008(f)(1), substituted "payments under the State system as compared to aggregate payments which would have been made under the national system since" for "rate of increase from" in last sentence.Subsec. (d)(1)(A)(iii). Pub. L. 101-508, §4002(e)(1), substituted "beginning on or after April 1, 1988, and ending on September 30, 1993," for "beginning on or after October 1, 1987, is equal to the national adjusted DRG prospective payment rate determined under paragraph (3) for such discharges, or, if the average standardized amount (described in clause (i)(I) or clause (ii)(I) of paragraph (3)(D)) for hospitals within the region of, and in the same rural, large urban, or other urban area as, the hospital is greater than the average standardized amount (described in the respective clause) for hospitals within the United States in that type of area for discharges occurring during the period beginning on April 1, 1988, and ending on October 20, 1990". Pub. L. 101-508, §4002(c)(2)(B)(i), substituted "large urban or other area" for "rural, large urban, or other urban area" in text of cl. (iii)(II) as amended by Pub. L. 103-66, §13501(f) . See 1993 Amendment note above. Pub. L. 101-403 substituted "October 20, 1990" for "September 30, 1990". Subsec. (d)(2)(C)(iv). Pub. L. 101-508, §4002(b)(4)(B), substituted "1989 or the enactment of section 4002(b) of the Omnibus Budget Reconciliation Act of 1990." for "1989." Pub. L. 101-508, §4002(b)(4)(A), struck out period at end and inserted ", except that the Secretary shall not exclude additional payments under such paragraph made as a result of the enactment of section 6003(c) of the Omnibus Budget Reconciliation Act of 1989." Pub. L. 101-508, §4002(b)(3)(A), struck out "and before October 1, 1995," after "October 1, 1986,".Subsec. (d)(3)(A)(ii). Pub. L. 101-508, §4002(c)(2)(B) (ii)(I), substituted "and ending on or before September 30, 1994, the Secretary" for "the Secretary". Subsec. (d)(3)(A)(iii) to (v). Pub. L. 101-508, §4002(c)(2)(B) (ii)(II), (III), added cls. (iii) and (iv) and redesignated former cl. (iii) as (v).Subsec. (d)(3)(B). Pub. L. 101-508, §4002(c)(2)(B) (iii), substituted "by a factor equal to the proportion of payments under this subsection (as estimated by the Secretary) based on DRG prospective payment amounts which are additional payments described in paragraph (5)(A) (relating to outlier payments)." for "for hospitals located in an urban area and for hospitals located in a rural area by a proportion equal to the proportion (estimated by the Secretary) of the amount of payments under this subsection based on DRG prospective payment amounts which are additional payments described in paragraph (5)(A) (relating to outlier payments) for hospitals located in such respective area."Subsec. (d)(3)(C)(ii). Pub. L. 101-508, §4002(b)(3)(B)(B), substituted "occurring on or after October 1, 1986," through the end of cl. (ii) for "occurring-" and subcls. (I) and (II) which read as follows:"(I) on or after October 1, 1986, and before October 1, 1995, of an amount equal to the estimated reduction in the payment amounts under paragraph (5)(B) that would have resulted from the enactment of the amendments made by section 9104 of the Medicare and Medicaid Budget Reconciliation Amendments of 1985 and by section 4003(a)(1) of the Omnibus Budget Reconciliation Act of 1987 if the factor described in clause (ii)(II) of paragraph (5)(B) were applied for discharges occurring during such period instead of the factor described in clause (ii)(I) of that paragraph, and"(II) on or after October 1, 1995, of an amount equal to the estimated reduction in the payment amounts under paragraph (5)(B) for those discharges that has resulted from the enactment of the amendments made by section 9104 of the Medicare and Medicaid Budget Reconciliation Amendments of 1985 and by section 4003(a)(1) of the Omnibus Budget Reconciliation Act of 1987."Subsec. (d)(3)(D)(i). Pub. L. 101-508, §4002(c)(2)(B) (iv)(I), which directed amendment of cl. (i) by substituting "a large urban area" for "an urban area (or," and all that follows through "area)," was executed by making the substitution for "an urban area (or, for discharges occurring on or after April 1, 1988, in a large urban area or other urban area)" to reflect the probable intent of Congress. Subsec. (d)(3)(D)(i)(I). Pub. L. 101-508, §4002(c)(2)(B) (iv)(II), substituted "a large urban area" for "an urban area".Subsec. (d)(3)(D)(ii). Pub. L. 101-508, §4002(c)(2)(B)(v), substituted "other areas" for "a rural area" in introductory provisions and in subcl. (I). Subsec. (d)(4)(D). Pub. L. 101-508, §4002(g)(2)(A), struck out subpar. (D) which read as follows: "The Commission (established under subsection (e)(2) of this section) shall consult with and make recommendations to the Secretary with respect to the need for adjustments under subparagraph (C), based upon its evaluation of scientific evidence with respect to new practices, including the use of new technologies and treatment modalities. The Commission shall report to the Congress with respect to its evaluation of any adjustments made by the Secretary under subparagraph (C)."Subsec. (d)(5)(B)(ii). Pub. L. 101-508, §4002(b)(3)(B)(A), amended cl. (ii) generally. Prior to amendment, cl. (ii) read as follows: "For purposes of clause (i)(II), the indirect teaching adjustment factor for discharges occurring- "(I) on or after May 1, 1986, and before October 1, 1995, is equal to 1.89x((1+r).405-1), or"(II) on or after October 1, 1995, is equal to 1.43x((1+r).5795-1), where 'r' is the ratio of the hospital's full-time equivalent interns and residents to beds."Subsec. (d)(5)(D)(iii). Pub. L. 101-508, §4008(m)(2)(A), substituted "For purposes of this subchapter, the term" for "The term" at beginning.Subsec. (d)(5)(F)(i). Pub. L. 101-508, §4002(b)(3)(A), struck out "and before October 1, 1995," after "May 1, 1986,".Subsec. (d)(5)(F)(iii). Pub. L. 101-508, §4002(b)(2), substituted "35 percent" for "30 percent". Subsec. (d)(5)(F)(vii)(I). Pub. L. 101-508, §4002(b)(1)(A), substituted "greater than 20.2-" and subdivs. (a) to (d) for "greater than 20.2, (P-20.2)(.65)+5.62, or".Subsec. (d)(5)(F)(vii)(II). Pub. L. 101-508, §4002(b)(1)(B), substituted "hospital-" and subdivs. (a) to (c) for "hospital, (P-15)(.6)+2.5,".Subsec. (d)(8)(C)(i). Pub. L. 101-508, §4002(h)(1)(A)(i), substituted "area, or by treating hospitals located in one urban area as being located in another urban area-" for "area-".Subsec. (d)(8)(C)(i)(II). Pub. L. 101-508, §4002(h)(1)(A) (ii), amended subcl. (II) generally. Prior to amendment, subcl. (II) read as follows: "reduces the wage index for that urban area by more than 1 percentage point (as applied under this subsection), the Secretary shall calculate and apply such wage index under this subsection separately to hospitals located in such urban area (excluding all the hospitals so treated) and to the hospitals so treated (as if each affected rural county were a separate urban area)."Subsec. (d)(8)(C)(ii) to (iv). Pub. L. 101-508, §4002(h)(1)(A) (iii), (iv), redesignated cls. (iii) and (iv) as (ii) and (iii), respectively, and struck out former cl. (ii) which read as follows: "If the application of subparagraph (B) or a decision of the Medicare Geographic Classification Review Board or the Secretary under paragraph (10), by reclassifying a county from a rural to an urban area or by reclassifying an urban county from one urban area to another urban area-"(I) reduces the wage index for the urban area within which the county or counties is reclassified by 1 percentage point or less (as applied under this subsection), the Secretary, in calculating such wage index under this subsection, shall exclude those counties so reclassified, or "(II) reduces the wage index for the urban area within which the county or counties is reclassified by more than 1 percentage point (as applied under this subsection), the Secretary shall calculate and apply such wage index under this subsection separately to hospitals located in such urban area (excluding all the hospitals so reclassified) and to hospitals located in the counties so reclassified (as if each affected county were a separate area)."Subsec. (d)(8)(D). Pub. L. 101-508, §4002(c)(2)(B) (vi), struck out "for hospitals located in an urban area" after "determined under paragraph (3)" and struck out at end "The Secretary shall make such adjustment in payments under this section to hospitals located in rural areas as are necessary to assure that the aggregate of payments to rural hospitals not affected by subparagraphs (B) and (C) or a decision of the Medicare Geographic Classification Review Board or the Secretary under paragraph (10) are not changed as a result of the application of subparagraphs (B) and (C) or a decision of the Medicare Geographic Classification Review Board or the Secretary under paragraph (10)."Subsec. (d)(10)(A). Pub. L. 101-508, §4002(h)(2)(B)(i), substituted "Geographic" for "Geographical".Subsec. (d)(10)(B)(i). Pub. L. 101-508, §4002(h)(2)(B) (ii), substituted "representative" for "representatives" and struck out "1 member shall be a member of the Prospective Payment Assessment Commission, and at least" after "At least".Subsec. (d)(10)(B)(ii). Pub. L. 101-508, §4002(h)(2)(B) (iii), substituted "initial" for "all".Subsec. (d)(10)(C)(iii)(II). Pub. L. 101-508, §4002(h)(2)(B) (iv), substituted "Appeal of decisions of the Board shall be subject to the provisions of section 557b of title 5" for "A decision of the Board shall be final unless the unsuccessful applicant appeals such decision to the Secretary by not later than 15 days after the Board renders its decision. The Secretary in considering the appeal of an applicant shall receive no new evidence but shall consider the record as a whole as such record appeared before the Board" and substituted "after the date on which" for "after".Subsec. (e)(2). Pub. L. 101-508, §4002(g)(1), designated existing provisions as subpar. (A) and added subpars. (B) and (C).Subsec. (e)(2)(A). Pub. L. 101-508, §4002(g)(2)(B), substituted "The Commission" for "In addition to carrying out its functions under subsection (d)(4)(D) of this section, the Commission". Subsec. (e)(3)(A). Pub. L. 101-508, §4002(g)(2)(C), substituted "Congress" for "the Secretary" and inserted before period at end ", together with its general recommendations under paragraph (2)(B) regarding the effectiveness and quality of health care delivery systems in the United States".Subsec. (e)(4). Pub. L. 101-508, §4002(g)(2)(D), designated existing provisions as subpar. (A) and added subpar. (B). Subsec. (e)(5). Pub. L. 101-508, §4002(g)(2)(E), substituted "recommendations" for "recommendation" in subpars. (A) and (B) and inserted at end "To the extent that the Secretary's recommendations under paragraph (4) differ from the Commission's recommendations for that fiscal year, the Secretary shall include in the publication referred to in subparagraph (A) an explanation of the Secretary's grounds for not following the Commission's recommendations." Subsec. (e)(6)(G). Pub. L. 101-508, §4002(g)(2)(F), redesignated cls. (ii) and (iii) as (i) and (ii), respectively, and struck out former cl. (i) which read as follows: "The Office shall report annually to the Congress on the functioning and progress of the Commission and on the status of the assessment of medical procedures and services by the Commission." Subsec. (g)(1)(A). Pub. L. 101-508, §4001(b), inserted at end "Aggregate payments made under subsection (d) and this subsection during fiscal years 1992 through 1995 shall be reduced in a manner that results in a reduction (as estimated by the Secretary) in the amount of such payments equal to a 10 percent reduction in the amount of payments attributable to capital-related costs that would otherwise have been made during such fiscal year had the amount of such payments been based on reasonable costs (as defined in section 1395x(v) of this title)." Subsec. (g)(3)(A)(v). Pub. L. 101-508, §4001(a), substituted "September 30, 1991" for "September 30, 1990".Subsec. (g)(3)(B). Pub. L. 101-508, §4001(c), substituted "subsection (d)(5)(D)(iii) or a rural primary care hospital (as defined in section 1395x(mm)(1) of this title)" for "subsection (d)(5)(D)(iii))". 1989-Subsec. (a)(4). Pub. L. 101-239, §6011(a), struck out "or," after "equity capital," and substituted "October 1, 1987), or costs with respect to administering blood clotting factors to individuals with hemophilia" for "October 1, 1987)".Subsec. (b)(3)(A). Pub. L. 101-239, §6004(b)(1)(A), substituted "(C), (D), and (E)" for "(C) and (D)" in introductory provisions. Pub. L. 101-239, §6003(f)(2)(i), substituted "subparagraphs (C) and (D)" for "subparagraph (C)" in introductory provisions. Pub. L. 101-239, §6003(e)(1)(B)(i), substituted "(A) Except as provided in subparagraph (C), for purposes of this subsection" for "(A) For purposes of this subsection" in introductory provisions. Subsec. (b)(3)(B)(i)(V), (VI). Pub. L. 101-239, §6003(a)(1), added subcl. (V), redesignated former subcl. (V) as (VI), and substituted "fiscal year 1991" for "fiscal year 1990" in subcl. (VI).Subsec. (b)(3)(B)(ii). Pub. L. 101-239, §6004(b)(1)(B), substituted "For purposes of subparagraphs (A) and (E)" for "For purposes of subparagraph (A)" in introductory provisions. Subsec. (b)(3)(C). Pub. L. 101-239, §6003(e)(1)(B) (ii), added subpar. (C).Subsec. (b)(3)(D). Pub. L. 101-239, §6003(f)(2) (ii), added subpar. (D).Subsec. (b)(3)(E). Pub. L. 101-239, §6004(b)(1)(C), added subpar. (E). Subsec. (b)(4)(A). Pub. L. 101-239, §6015(a), substituted "deems appropriate, including the assignment of a new base period which is more representative, as determined by the Secretary, of the reasonable and necessary cost of inpatient services and" for "deems appropriate,". Subsec. (c)(4). Pub. L. 101-239, §6022, substituted "the aggregate rate of increase from October 1, 1984, to the most recent date for which annual data are available" for "the aggregate payment or payments per inpatient admission or discharge during the three cost reporting periods beginning on or after October 1, 1983, after which such test, at the option of the Secretary, shall no longer apply, and such State systems shall be treated in the same manner as under other waivers" in second sentence. Subsec. (d)(1)(B)(v). Pub. L. 101-239, §6004(a)(1), added cl. (v). Subsec. (d)(3)(E). Pub. L. 101-239, §6003(h)(6), substituted "October 1, 1990, and October 1, 1993 (and at least every 12 months thereafter)" for "October 1, 1990 (and at least every 36 months thereafter)" and inserted at end "Any adjustments or updates made under this subparagraph for a fiscal year (beginning with fiscal year 1991) shall be made in a manner that assures that the aggregate payments under this subsection in the fiscal year are not greater or less than those that would have been made in the year without such adjustment."Subsec. (d)(4)(C). Pub. L. 101-239, §6003(b), designated existing provisions as cl. (i) and added cls. (ii) to (iv).Subsec. (d)(5)(C). Pub. L. 101-239, §6003(e)(1)(A)(i), (ii), (iv), (2)(B), redesignated former cl. (i)(I) as cl. (i), redesignated former cl. (i)(II) as cl. (ii) and substituted "clause (i)" for "subclause (I)" in three places, and redesignated former cls. (ii), (iii), and (iv) as subpars. (D), (I), and (H), respectively. Subsec. (d)(5)(D). Pub. L. 101-239, §6003(e)(1)(A) (iv), amended former subpar. (C)(ii) generally, redesignating it as subpar. (D) and substituting cls. (i) to (iv) relating to payments to sole community hospitals for cost reporting periods beginning on or after Apr. 1, 1990, for former single paragraph relating to payments to such hospitals for cost reporting periods beginning on or after Oct. 1, 1984.Subsec. (d)(5)(D)(iii)(III). Pub. L. 101-239, §6003(g)(2)(A), added subcl. (III).Subsec. (d)(5)(D)(v). Pub. L. 101-239, §6003(g)(2)(B), added cl. (v).Subsec. (d)(5)(E). Pub. L. 101-239, §6003(e)(1)(A) (iii), redesignated subpar. (D) as (E).Subsec. (d)(5)(F)(iii). Pub. L. 101-239, §6003(c)(3), substituted "30 percent" for "25 percent". Subsec. (d)(5)(F)(iv)(I). Pub. L. 101-239, §6003(c)(1)(A), substituted "the applicable formula described in clause (vii)" for "the following formula: (P-15)(.5)+2.5, where 'P' is the hospital's disproportionate patient percentage (as defined in clause (vi))".Subsec. (d)(5)(F)(iv)(III). Pub. L. 101-239, §6003(c)(2)(A) (ii), inserted "in subclause (IV) or (V) or" after "described".Subsec. (d)(5)(F)(iv)(IV) to (VI). Pub. L. 101-239, §6003(c)(2)(A)(i), (iii), (iv), added subcls. (IV) to (VI). Subsec. (d)(5)(F)(v)(II) to (IV). Pub. L. 101-239, §6003(c)(2)(B), added subcl. (II), redesignated former subcls. (II) and (III) as (III) and (IV), respectively, and substituted "area and is not described in subclause (II)" for "area" in subcl. (IV). Subsec. (d)(5)(F)(vii). Pub. L. 101-239, §6003(c)(1)(B), added cl. (vii).Subsec. (d)(5)(F)(viii). Pub. L. 101-239, §6003(c)(2)(C), added cl. (viii). Subsec. (d)(5)(G). Pub. L. 101-239, §6003(f)(1), added subpar. (G).Subsec. (d)(5)(H). Pub. L. 101-239, §6003(e)(1)(A)(i), redesignated subpar. (C)(iv) as subpar. (H).Subsec. (d)(5)(I). Pub. L. 101-239, §6004(a)(2), struck out "(including exceptions and adjustments that may be appropriate with respect to hospitals involved extensively in treatment for and research on cancer)" after "deems appropriate". Pub. L. 101-239, §6003(e)(1)(A) (ii), redesignated subpar. (C)(iii) as subpar. (I).Subsec. (d)(8)(C). Pub. L. 101-239, §6003(h)(3), amended subpar. (C) generally. Prior to amendment, subpar. (C) read as follows:"(i) If the application of subparagraph (B) or a decision of the Medicare Geographic Classification Review Board or the Secretary under paragraph (10),, [sic] by treating hospitals located in a rural county or counties as being located in an urban area, reduces the wage index for that urban area (as applied under this subsection), the Secretary shall calculate and apply such wage index under this subsection separately to hospitals located in such urban area (excluding all the hospitals so treated) and to the hospitals so treated (as if each affected rural county were a separate urban area). If the application of subparagraph (B) or a decision of the Medicare Geographic Classification Review Board or the Secretary under paragraph (10),, [sic] by treating the hospitals located in a rural county or counties as not being located in the rural area in a State, reduces the wage index for that rural area (as applied under this subsection), the Secretary shall calculate and apply such wage index under this subsection as if the hospitals so treated had not been excluded from calculation of the wage index for that rural area."(ii) Clause (i) shall only apply to discharges occurring on or after October 1, 1989, and before October 1, 1991."Subsec. (d)(8)(C)(i). Pub. L. 101-239, §6003(h)(2), substituted "subparagraph (B) or a decision of the Medicare Geographic Classification Review Board or the Secretary under paragraph (10)," for "subparagraph (B)" in two places.Subsec. (d)(8)(C)(iv). Pub. L. 101-239, §6003(h)(4), added cl. (iv).Subsec. (d)(8)(D). Pub. L. 101-239, §6003(h)(2)(B), substituted "(B) and (C) or a decision of the Medicare Geographic Classification Review Board or the Secretary under paragraph (10)" for "(B) and (C)" in three places. Subsec. (d)(9)(B)(ii)(IV). Pub. L. 101-239, §6003(e)(2)(C), substituted "subparagraph (D)(iii)" for "subparagraph (D)(v)". Subsec. (d)(9)(D)(iii). Pub. L. 101-239, §6003(e)(2)(D) (ii), redesignated cl. (v) as (iii). Former cl. (iii) redesignated (iv). Subsec. (d)(9)(D)(iv). Pub. L. 101-239, §6003(e)(2)(D)(i), (ii), redesignated former cl. (iii) as (iv), substituted "Subparagraph (H)" for "Subparagraph (C)(iii)", and struck out former cl. (iv) which read as follows: "Subparagraph (E) (relating to payments for costs of certified registered nurse anesthetists)." Subsec. (d)(9)(D)(v). Pub. L. 101-239, §6003(e)(2)(D) (iii), redesignated cl. (v) as (iii). Subsec. (d)(10). Pub. L. 101-239, §6003(h)(1), added par. (10).Subsec. (g)(3)(A)(iv). Pub. L. 101-234, §301(b)(3), (c)(3), amended cl. (iv) identically, substituting "(as the case may be)" for "(as the case may) be".Subsec. (g)(3)(A)(v). Pub. L. 101-239, §6002, added cl. (v). Subsec. (g)(3)(B). Pub. L. 101-239, §6003(e)(2)(E), substituted "subsection (d)(5)(D)(iii)" for "subsection (d)(5)(C)(ii)". Subsec. (i). Pub. L. 101-239, §6003(g)(4), added subsec. (i). 1988-Subsec. (b)(3)(B)(i)(III). Pub. L. 100-485, §608(d)(18)(A), substituted "for hospitals" for "for for hospitals" before "located in other urban areas".Pub. L. 100-360, §411(b)(1)(A), substituted "for hospitals located in other urban areas" for "other hospitals".Subsec. (b)(3)(B)(i)(IV). Pub. L. 100-485, §608(d)(18)(A), substituted "for hospitals" for "for for hospitals" before "located in other urban areas".Pub. L. 100-360, §411(b)(1)(A), (B), substituted "percentage points" for "percent" in three places and "for hospitals located in other urban areas" for "other hospitals".Subsec. (b)(3)(B)(i)(V). Pub. L. 100-360, §411(b)(1)(C), inserted "increase" after "market basket percentage". Subsec. (d)(1)(A)(iii). Pub. L. 100-360, §411(b)(1)(G), substituted "if the average standardized amount (described in clause (i)(I) or clause (ii)(I) of paragraph (3)(D)) for hospitals within the region of, and in the same rural, large urban, or other urban area as, the hospital is greater than the average standardized amount (described in the respective clause) for hospitals within the United States in that type of area" for "if greater".Subsec. (d)(2)(C)(i). Pub. L. 100-647, §1018(r)(1), struck out Pub. L. 99-514, §1895(b)(1), (2). Previously, Pub. L. 99-509, §9307(c)(1)(A), struck out Pub. L. 99-514, §1895(b)(1)(A). See 1986 Amendment note below.Subsec. (d)(2)(C)(iv). Pub. L. 100-647, §8401, substituted "1995" for "1990".Pub. L. 100-647, §1018(r)(1), struck out Pub. L. 99-514, §1895(b)(1), (2). Previously, Pub. L. 99-509, §9307(c)(1)(B)(i), as amended by Pub. L. 100-203, §4009(j)(6)(A), struck out Pub. L. 99-514, §1895(b)(2)(A). See 1986 Amendment note below. Subsec. (d)(2)(D). Pub. L. 100-360, §411(b)(1)(D), substituted "the publications described in subsection (e)(5)" for "the publication described in subsection (e)(5)(B)" in second sentence.Pub. L. 100-360, §411(b)(1)(H)(i), struck out at end "For purposes of payment under this subsection, a hospital is considered to be located in an urban area or large urban area, respectively, if the hospital is paid under this subsection at the rate for hospitals located in such an area."Subsec. (d)(3)(A). Pub. L. 100-647, §1018(r)(1), struck out Pub. L. 99-514, §1895(b)(1), (2). Previously, Pub. L. 99-509, §9307(c)(1)(A), struck out Pub. L. 99-514, §1895(b)(1)(B). See 1986 Amendment note below. Subsec. (d)(3)(A)(i). Pub. L. 100-360, §411(b)(1)(E)(i), as added by Pub. L. 100-485, §608(d)(18)(B), substituted "occurring" for "occuring" in first sentence.Pub. L. 100-360, §411(b)(1)(E)(ii), formerly §411(b)(1)(E), as redesignated by Pub. L. 100-485, §608(d)(18)(B), made technical correction to Pub. L. 100-203, §4002(c)(1)(B)(iii), see 1987 Amendment note below.Subsec. (d)(3)(A)(ii). Pub. L. 100-360, §411(b)(1)(F), substituted "in other urban areas" for "in urban areas".Subsec. (d)(3)(C)(ii). Pub. L. 100-647, §1018(r)(1), struck out Pub. L. 99-514, §1895(b)(1), (2). Previously, Pub. L. 99-509, §9307(c)(1)(A), struck out Pub. L. 99-514, §1895(b)(1)(C). See 1986 Amendment note below.Subsec. (d)(3)(C)(ii)(I), (II). Pub. L. 100-647, §8401, substituted "1995" for "1990".Subsec. (d)(3)(C)(iii). Pub. L. 100-647, §1018(r)(1), struck out Pub. L. 99-514, §1895(b)(1), (2). Previously, Pub. L. 99-509, §9307(c)(1)(B)(i), as amended by Pub. L. 100-203, §4009(j)(6)(A), struck out Pub. L. 99-514, §1895(b)(2)(B). See 1986 Amendment note below.Subsec. (d)(5)(B)(ii)(I), (II). Pub. L. 100-647, §8401, substituted "1995" for "1990".Subsec. (d)(5)(F)(i). Pub. L. 100-647, §8401, substituted "1995" for "1990". Subsec. (d)(5)(F)(vi)(I). Pub. L. 100-647, §1018(r)(1), struck out Pub. L. 99-514, §1895(b)(1), (2). See 1986 Amendment note below. Subsec. (d)(8). Pub. L. 100-360, §411(b)(4)(C)(i), made technical correction to directory language of Pub. L. 100-203, §4005(a)(1)(D), see 1987 Amendment note below. Subsec. (d)(8)(B). Pub. L. 100-360, §411(b)(4)(A)(i), substituted "For purposes of this subsection, the Secretary" for "The Secretary". Pub. L. 100-360, §411(b)(4)(A)(ii), substituted "the rural county would otherwise be considered part of an urban area, under the standards for designating Metropolitan Statistical Areas (and for designating New England County Metropolitan Areas) published in the Federal Register on January 3, 1980, if the commuting rates used in determining outlying counties (or, for New England, similar recognized areas) were determined on the basis of the aggregate number of resident workers who commute to (and, if applicable under the standards, from) the central county or counties of all contiguous Metropolitan Statistical Areas (or New England County Metropolitan Areas)." for "-"(i) the rural county would otherwise be considered part of an urban area but for the fact that the rural county does not meet the standard relating to the rate of commutation between the rural county and the central county or counties of any adjacent urban area; and "(ii) either (I) the number of residents of the rural county who commute for employment to the central county or counties of any adjacent urban area is equal to at least 15 percent of the number of residents of the rural county who are employed, or (II) the sum of the number of residents of the rural county who commute for employment to the central county or counties of any adjacent urban area and the number of residents of any adjacent urban area who commute for employment to the rural county is at least equal to 20 percent of the number of residents of the rural county who are employed." Subsec. (d)(8)(C). Pub. L. 100-647, §8403(a)(2), added subpar. (C). Former subpar. (C) redesignated (D). Pub. L. 100-360, §411(b)(4)(B), substituted "standardized amounts" for "standardized amount".Subsec. (d)(8)(D). Pub. L. 100-647, §8403(a)(1), redesignated former subpar. (C) as (D) and substituted "subparagraphs (B) and (C)" for "subparagraph (B)" wherever appearing.Subsec. (d)(9)(C)(iv). Pub. L. 100-360, §411(b)(3), added Pub. L. 100-203, §4004(a)(2), see 1987 Amendment note below.Subsec. (e)(6)(B). Pub. L. 100-360, §411(b)(8)(B), amended Pub. L. 100-203, §4009(d)(1), see 1987 Amendment note below. Subsec. (f)(1)(A). Pub. L. 100-360, §411(b)(6)(B), added Pub. L. 100-203, §4007(b)(1)(A), (B), see 1987 Amendment note below. Subsec. (f)(1)(B). Pub. L. 100-360, §411(b)(6)(B), added Pub. L. 100-203, §4007(b)(1)(C), see 1987 Amendment note below. Subsec. (g)(3)(A)(ii) to (iv). Pub. L. 100-360, §411(b)(5)(B), made technical amendment to Pub. L. 100-203, §4006(a), see 1987 Amendment note below.Subsec. (g)(3)(A)(iv). Pub. L. 100-360, §411(b)(5)(A), inserted "for payments attributable" after "15 percent". 1987-Subsec. (a)(4). Pub. L. 100-203, §4009(j)(1), inserted a comma after "educational activities".Pub. L. 100-203, §4006(b)(2)(A), substituted "other capital-related costs (as defined by the Secretary for periods before October 1, 1987)" for "with respect to costs incurred in cost reporting periods beginning prior to October 1 of 1987 (or of such later year as the Secretary may, in his discretion, select), other capital-related costs, as defined by the Secretary".Subsec. (b)(3)(B)(i). Pub. L. 100-203, §4002(e)(1), struck out "subparagraph (A) for 12-month cost reporting periods beginning during a fiscal year and for purposes of" after "For purposes of".Subsec. (b)(3)(B)(i)(II). Pub. L. 100-203, §4002(a), struck out "and for fiscal year 1988, the market basket percentage increase (as defined in clause (ii)) minus 2.0 percentage points, and" after "1.15 percent,".Subsec. (b)(3)(B)(i)(III) to (V). Pub. L. 100-203, §4002(a), added subcls. (III) to (V) and struck out former subcl. (III) which read "for fiscal year 1989 and subsequent fiscal years, the percentage determined by the Secretary pursuant to subsection (e)(4) of this section."Subsec. (b)(3)(B)(ii), (iii). Pub. L. 100-203, §4002(e)(2), (3), added cl. (ii), redesignated former cl. (ii) as (iii), and substituted "For purposes of this subparagraph" for "For purposes of clause (i)".Subsec. (d)(1)(A)(iii). Pub. L. 100-203, §4002(d), inserted before period at end ", or, if greater for discharges occurring during the period beginning on April 1, 1988, and ending on September 30, 1990, the sum of (I) 85 percent of the national adjusted DRG prospective payment rate determined under paragraph (3) for such discharges, and (II) 15 percent of the regional adjusted DRG prospective payment rate determined under such paragraph".Subsec. (d)(2)(C)(iv). Pub. L. 100-203, §4009(j)(6)(A), made technical amendment to Pub. L. 99-509, §9307(c)(1)(B). See 1986 Amendment note below.Pub. L. 100-203, §4003(c), substituted "1990" for "1989". Subsec. (d)(2)(D). Pub. L. 100-203, §4002(f)(1)(A), inserted sentence at end providing that hospital is considered located in urban area or large urban area, respectively, if it is paid under this subsection at rate for hospitals located in such area.Pub. L. 100-203, §4002(b), in second sentence inserted definition of "large urban area".Subsec. (d)(3). Pub. L. 100-203, §4002(c)(1)(A), substituted "large urban, other urban, or rural areas" for "urban or rural areas" in second sentence.Subsec. (d)(3)(A)(i). Pub. L. 100-203, §4002(c)(1)(B), (C), as amended by Pub. L. 100-360, §411(b)(1)(E)(ii), designated existing provisions as cl. (i), substituted "For discharges occuring [sic] in a fiscal year beginning before October 1, 1987, the Secretary" for "The Secretary" and "the fiscal year involved" for "each of fiscal years 1985, 1986, 1987, and 1988", struck out ", and adjusted for subsequent fiscal years in accordance with the final determination of the Secretary under subsection (e)(4) of this section, and adjusted to reflect the most recent case-mix data available", and added cls. (ii) and (iii).Subsec. (d)(3)(C)(ii). Pub. L. 100-203, §4003(c), substituted "1990" for "1989" in subcls. (I) and (II). Pub. L. 100-203, §4003(a)(2), inserted "and by section 4003(a)(1) of the Omnibus Budget Reconciliation Act of 1987" after "Amendments of 1985" in subcls. (I) and (II).Subsec. (d)(3)(C)(iii). Pub. L. 100-203, §4009(j)(6)(A), made technical amendment to Pub. L. 99-509, §9307(c)(1)(B). See 1986 Amendment note below.Subsec. (d)(3)(D). Pub. L. 100-203, §4002(c)(1)(D)(i), substituted "hospitals in different areas" for "urban and rural hospitals" in heading. Subsec. (d)(3)(D)(i). Pub. L. 100-203, §4002(c)(1)(D)(ii), (iii), inserted "(or, for discharges occurring on or after April 1, 1988, in a large urban area or other urban area)" after first reference to "urban area", and in subcl. (I) inserted "such" before "an urban area".Subsec. (d)(3)(E). Pub. L. 100-203, §4004(a)(1), formerly §4004(a), as redesignated by Pub. L. 100-360, §411(b)(3), inserted at end "Not later than October 1, 1990 (and at least every 36 months thereafter), the Secretary shall update the factor under the preceding sentence on the basis of a survey conducted by the Secretary (and updated as appropriate) of the wages and wage-related costs of subsection (d) hospitals in the United States. To the extent determined feasible by the Secretary, such survey shall measure the earnings and paid hours of employment by occupational category and shall exclude data with respect to the wages and wage-related costs incurred in furnishing skilled nursing facility services."Subsec. (d)(5)(B)(ii). Pub. L. 100-203, §4003(c), substituted "1990" for "1989" in subcls. (I) and (II).Pub. L. 100-203, §4003(a)(1), substituted "1.89" for "2" in subcl. (I) and "1.43" for "1.5" in subcl. (II). Subsec. (d)(5)(C)(i)(I). Pub. L. 100-203, §4005(d)(1)(A), substituted "275" for "500".Subsec. (d)(5)(C)(i)(II). Pub. L. 100-203, §4009(j)(2), inserted "index" after "case mix" in two places. Subsec. (d)(5)(C)(ii). Pub. L. 100-203, §4005(c)(1), substituted "1990" for "1988" in second sentence and inserted after second sentence "A subsection (d) hospital that meets the criteria for classification as a sole community hospital and otherwise qualifies for the adjustment authorized by the preceding sentence may qualify for such an adjustment without regard to the formula by which payments are determined for the hospital under paragraph (1)(A)."Subsec. (d)(5)(F)(i). Pub. L. 100-203, §4003(c), substituted "1990" for "1989".Subsec. (d)(5)(F)(i)(II). Pub. L. 100-203, §4009(j)(3)(A), substituted "such net inpatient care revenues" for second reference to "such revenues".Subsec. (d)(5)(F)(iii). Pub. L. 100-203, §4003(b)(1), substituted "25 percent" for "15 percent". Subsec. (d)(5)(F)(iv)(I). Pub. L. 100-203, §4009(j)(3)(B), substituted "clause (v)" for "subclause (III)". Pub. L. 100-203, §4003(b)(2), struck out "the lesser of 15 percent, or" after "is equal to".Subsec. (d)(5)(F)(vi)(I). Pub. L. 100-203, §4009(j)(6)(A), made technical amendment to Pub. L. 99-509, §9307(c)(1)(B)(ii). See 1986 Amendment note below. Subsec. (d)(8). Pub. L. 100-203, §4005(a)(1), as amended by Pub. L. 100-360, §411(b)(4)(C)(i), designated existing provisions as subpar. (A), redesignated former subpar. (A) and cls. (i) and (ii) as cl. (i) and subcls. (I) and (II), respectively, redesignated former subpar. (B) and cls. (i) and (ii) as cl. (ii) and subcl. (I) and (II), respectively, and added subpars. (B) and (C).Subsec. (d)(9)(A)(ii). Pub. L. 100-203, §4002(c)(2), substituted "a large urban area," for "an urban area, and" in subcl. (I), added subcl. (II), and redesignated former subcl. (II) as (III). Subsec. (d)(9)(B). Pub. L. 100-203, §4009(j)(4), realigned margin of introductory provisions.Subsec. (d)(9)(C)(iv). Pub. L. 100-203, §4004(a)(2), as added by Pub. L. 100-360, §411(b)(3), inserted at end "The second and third sentences of paragraph (3)(E) shall apply to subsection (d) Puerto Rico hospitals under this clause in the same manner as they apply to subsection (d) hospitals under such paragraph and, for purposes of this clause, any reference in such paragraph to a subsection (d) hospital is deemed a reference to a subsection (d) Puerto Rico hospital."Subsec. (e)(3)(B). Pub. L. 100-203, §4002(f)(1)(B), struck out "or determine" after "recommend". Subsec. (e)(4). Pub. L. 100-203, §4002(f)(1)(C), substituted "for each fiscal year (beginning with fiscal year 1988)" for "for fiscal year 1988", struck out "and shall determine for each subsequent fiscal year the percentage change which will apply for purposes of this section as the applicable percentage increase (otherwise described in subsection (b)(3)(B) of this section) for discharges in that fiscal year, and" after "in that fiscal year", and amended last sentence generally. Prior to amendment, last sentence read as follows: "The percentage change shall be the same for all subsection (d) hospitals and subsection (d) Puerto Rico hospitals, but may be different from that for other hospitals (and units not included as such hospitals) and may vary among such other hospitals and units."Subsec. (e)(5). Pub. L. 100-203, §4009(j)(6)(B), amended Pub. L. 99-509, §9302(a)(2)(C). See 1986 Amendment note below.Pub. L. 100-203, §4002(f)(1)(D), struck out "or determination" after "recommendation" in subpars. (A) and (B).Subsec. (e)(6)(B). Pub. L. 100-203, §4009(d)(1), as amended by Pub. L. 100-360, §411(b)(8)(B), substituted "include individuals with national recognition for their expertise in health economics, hospital reimbursement, hospital financial management, and other related fields, who provide a mix of different professionals, broad geographic representation, and a balance between urban and rural representatives" for "provide expertise and experience in the provision and financing of health care", and struck out last sentence which required Director to seek nominations from wide range of groups, including specified types of national organizations.Subsec. (e)(6)(D). Pub. L. 100-203, §4083(b)(1), inserted at end "For purposes of pay (other than pay of members of the Commission) and employment benefits, rights, and privileges, all personnel of the Commission shall be treated as if they were employees of the United States Senate."Subsec. (f)(1)(A). Pub. L. 100-203, §4007(b)(1)(A), (B), as added by Pub. L. 100-360, §411(b)(6)(B), inserted subpar. (A) designation and struck out ", for a period ending not earlier than September 30, 1988," after "shall maintain".Subsec. (f)(1)(B). Pub. L. 100-203, §4007(b)(1)(C), as added by Pub. L. 100-360, §411(b)(6)(B), added subpar. (B).Subsec. (f)(3). Pub. L. 100-93 amended par. (3) generally. Prior to amendment, par. (3) read as follows: "The provisions of paragraphs (2), (3), and (4) of section 1395y(d) of this title shall apply to determinations under paragraph (2) of this subsection in the same manner as they apply to determinations made under section 1395y(d)(1) of this title."Subsec. (g)(1). Pub. L. 100-203, §4006(b)(1), amended par. (1) generally. Prior to amendment, par. (1) read as follows: "If the Congress does not enact legislation, after April 20, 1983, and before October 1, 1987, respecting the payment under this subchapter for capital-related costs for inpatient hospital services, no payment may be made under this subchapter for capital-related costs of capital expenditures (as defined in section 1320a-1(g) of this title and except as provided in section 1320a-1(j) of this title) for inpatient hospital services in a State, which expenditures are obligated after September 30, 1987, unless the State has an agreement with the Secretary under section 1320a-1(b) of this title and under the agreement the State has recommended approval of the capital expenditures."Subsec. (g)(3)(A)(ii) to (iv). Pub. L. 100-203, §4006(a), as amended by Pub. L. 100-360, §411(b)(5)(B), substituted "on or after October 1, 1987, and before January 1, 1988," for ", and", at end of cl. (ii), added cls. (iii) and (iv), and struck out former cl. (iii) which read as follows: "10 percent for payments attributable to portions of cost reporting periods or discharges (as the case may be) occurring during fiscal year 1989."Subsec. (g)(3)(C). Pub. L. 100-203, §4006(b)(2)(B), struck out subpar. (C) which read as follows: "If the Secretary provides, under subsection (a)(4) of this section, for the inclusion of other capital-related costs in operating costs of inpatient hospital services, the Secretary shall provide-"(i) notwithstanding any other provision of this subchapter, for the continuation of payment under the reasonable cost methodology described in section 1395x(v)(1) of this title with respect to capital-related costs of any hospital that is such a sole community hospital for cost reporting periods beginning before October 1, 1990, and"(ii) in the design of such payment system that the aggregate payment amounts under this subchapter for such other capital-related costs for payments attributable to portions of cost reporting periods occurring during fiscal year 1988 and fiscal year 1989 shall approximate the aggregate payment amount under this subchapter that would have been made (taking into account the provisions of subparagraphs (A) and (B)) during that fiscal year but for the inclusion of such costs by the Secretary." Subsec. (h)(4)(C). Pub. L. 100-203, §4009(j)(5), substituted "subparagraph (D)" for "subparagraph (E)". 1986-Subsec. (a)(4). Pub. L. 99-509, §9320(g)(1), struck out ", costs of anesthesia services provided by a certified registered nurse anesthetist," after "approved educational activities".Pub. L. 99-509, §9303(c), substituted "October 1 of 1987 (or of such later year as the Secretary may, in his discretion, select)" for "October 1, 1987". Pub. L. 99-349 substituted "1987" for "1986".Pub. L. 99-272, §9107(a)(2), inserted "a return on equity capital," after "anesthetist," and "other" before "capital-related costs". Subsec. (b)(3)(B). Pub. L. 99-272, §9101(b), amended subpar. (B) generally. Prior to amendment, subpar. (B) read as follows: "For purposes of subparagraph (A) and subsection (d) of this section and except as provided in subsection (e) of this section, the 'applicable percentage increase' for any 12-month cost reporting period or fiscal year shall be equal to one-quarter of 1 percentage point plus the percentage, estimated by the Secretary before the beginning of the period or year, by which the cost of the mix of goods and services (including personnel costs but excluding non-operating costs) comprising routine, ancillary, and special care unit inpatient hospital services, based on an index of appropriately weighted indicators of changes in wages and prices which are representative of the mix of goods and services included in such inpatient hospital services, for such cost reporting period or fiscal year will exceed the cost of such mix of goods and services for the preceding 12-month cost reporting period or fiscal year. In determining a percentage change under subsection (e)(4) of this section with respect to discharges occurring in any cost reporting period or fiscal year beginning on or after October 1, 1985, and before October 1, 1986, the Secretary may not establish a percentage increase which exceeds the applicable percentage increase otherwise determined for that period or fiscal year under the preceding sentence."Subsec. (b)(3)(B)(i)(II). Pub. L. 99-509, §9302(a)(1), amended subcl. (II) generally. Prior to amendment, subcl. (II) read as follows: "for fiscal years 1987 and 1988, a percentage determined by the Secretary pursuant to subsection (e)(4) of this section, but not to exceed the market basket percentage increase (as defined in clause (ii)), and".Subsec. (b)(6). Pub. L. 99-514, §2, substituted "Internal Revenue Code of 1986" for "Internal Revenue Code of 1954". Subsec. (c)(7). Pub. L. 99-272, §9109(a), added par. (7). Subsec. (d)(1)(A). Pub. L. 99-272, §9102(a), substituted "1987" for "1986" in cls. (ii) and (iii).Subsec. (d)(1)(C). Pub. L. 99-272, §9102(b), struck out ", or discharges occurring" after "periods beginning" in introductory provision, and "and" after "percent;" in cl. (ii), added cl. (iii), redesignated former cl. (iii) as (iv), and in cl. (iv) substituted "on or after October 1, 1986, and before October 1, 1987" for "on or after October 1, 1985, and before October 1, 1986". Subsec. (d)(1)(D). Pub. L. 99-272, §9102(c), struck out "cost reporting periods beginning, or" before "discharges occurring" in introductory provision, in cl. (i) substituted "1986" for "1985", and in cl. (ii) substituted "1986" and "1987" for "1985" and "1986", respectively. Subsec. (d)(2)(C)(i). Pub. L. 99-509, §9307(c)(1)(A), struck out Pub. L. 99-514, §1895(b)(1)(A), which had directed the striking out of "(taking into account, for discharges occurring after September 30, 1986, the amendments made by section 9104(a) of the Medicare and Medicaid Budget Reconciliation Amendments of 1985)" after "medical education costs".Pub. L. 99-272, §9104(b)(1), inserted "(taking into account, for discharges occurring after September 30, 1986, the amendments made by section 9104(a) of the Medicare and Medicaid Budget Reconciliation Amendments of 1985)" after "medical education costs".Subsec. (d)(2)(C)(iv). Pub. L. 99-509, §9306(c), substituted "1989" for "1988".Pub. L. 99-509, §9307(c)(1)(B)(i), as amended by Pub. L. 100-203, §4009(j)(6)(A), struck out Pub. L. 99-514, §1895(b)(2)(A), which had directed that cl. (iv) was to be struck out.Pub. L. 99-272, §9105(b), added cl. (iv).Subsec. (d)(3)(A). Pub. L. 99-509, §9302(a)(2)(A), (c), substituted "1986, 1987, and 1988" for "and 1986" and inserted provisions relating to the computation of urban and rural averages with respect to discharges occurring on or after October 1, 1987.Pub. L. 99-509, §9307(c)(1)(A), struck out Pub. L. 99-514, §1895(b)(1)(B), which had directed insertion of "If the formula under paragraph (5)(B) for determining payments for the indirect costs of medical education is changed for any fiscal year, the Secretary shall readjust the standardized amounts previously determined for each hospital to take into account the changes in that formula."Pub. L. 99-272, §9101(c)(1), substituted "for each of fiscal years 1985 and 1986" for "for fiscal year 1985". Subsec. (d)(3)(B). Pub. L. 99-509, §9302(b)(1), inserted "for hospitals located in an urban area and for hospitals located in a rural area" after "subparagraph (A)", and inserted before the period "for hospitals located in such respective area". Subsec. (d)(3)(C). Pub. L. 99-272, §9104(b)(2), inserted "for fiscal year 1985" after "neutrality" in heading, designated existing provision as cl. (i), substituted "For discharges occurring in fiscal year 1985, the Secretary" for "The Secretary", and added cl. (ii).Subsec. (d)(3)(C)(ii). Pub. L. 99-509, §9306(c), substituted "1989" for "1988" in subcls. (I) and (II).Pub. L. 99-509, §9307(c)(1)(A), struck out Pub. L. 99-514, §1895(b)(1)(C), which had directed a general amendment of cl. (ii) to read as follows: "The Secretary shall further reduce each of the average standardized amounts by a proportion equal to the proportion (estimated by the Secretary) of the amount of payments under this subsection based on DRG prospective payment amounts which is the difference between-"(I) the sum of the additional payment amounts under paragraph (5)(B) (relating to indirect costs of medical education) if the indirect teaching adjustment factor were equal to 1.159r (as 'r' is defined in paragraph (5)(B)(ii)), and"(II) that sum using the factor specified in paragraph (5)(B)(ii)(II)." Subsec. (d)(3)(C)(iii). Pub. L. 99-509, §9307(c)(1)(B)(i), as amended by Pub. L. 100-203, §4009(j)(6)(A), struck out Pub. L. 99-514, §1895(b)(2)(B), which had added cl. (iii) reading as follows: "The Secretary shall further reduce each of the average standardized amounts by reducing the standardized amount for each hospital (as previously determined without regard to this clause) by a proportion equal to the proportion (established by the Secretary) of the amount of payments under this subsection based on DRG prospective payment amounts which are additional payments described in paragraph (5)(F) (relating to disproportionate share payments) for subsection (d) hospitals."Subsec. (d)(3)(D)(i)(I), (ii)(I). Pub. L. 99-272, §9104(b)(3), inserted "or reduced" after "(B), and adjusted". Subsec. (d)(4)(C). Pub. L. 99-509, §9302(e)(1), substituted "in fiscal year 1988 and at least annually" for "in fiscal year 1986 and at least every four fiscal years".Subsec. (d)(5)(B). Pub. L. 99-272, §9104(a), amended subpar. (B) generally. Prior to amendment, subpar. (B) read as follows: "The Secretary shall provide for an additional payment amount for subsection (d) hospitals with indirect costs of medical education, in an amount computed in the same manner as the adjustment for such costs under regulations (in effect as of January 1, 1983) under subsection (a)(2) of this section, except that in the computation under this subparagraph the Secretary shall use an educational adjustment factor equal to twice the factor provided under such regulations. In determining such adjustment the Secretary shall not distinguish between those interns and residents who are employees of a hospital and those interns and residents who furnish services to a hospital but are not employees of such hospital."Subsec. (d)(5)(B)(ii). Pub. L. 99-509, §9306(c), substituted "1989" for "1988" in subcls. (I) and (II). Subsec. (d)(5)(C)(i). Pub. L. 99-509, §9302(d)(1)(A), designated existing provisions as subcl. (I) and added subcl. (II).Pub. L. 99-272, §9106(a), inserted "and which shall not require a rural osteopathic hospital to have more than 3,000 discharges in a year in order to be classified as a rural referral center" before the period in second sentence. Pub. L. 99-272, §9105(c), struck out ", and of public or other hospitals that serve a significantly disproportionate number of patients who have low income or are entitled to benefits under part A of this subchapter" after "in rural areas)".Subsec. (d)(5)(C)(i)(I). Pub. L. 99-509, §9304(b)(1), inserted "(other than under paragraph (9))" after "established under this subsection" in first sentence. Subsec. (d)(5)(C)(ii). Pub. L. 99-509, §9304(b)(2), inserted "(other than under paragraph (9))" after "this subsection" in second and third sentences.Pub. L. 99-509, §9302(e)(4), substituted "1988" for "1986".Pub. L. 99-272, §9111(a), inserted provision authorizing the Secretary to adjust amount of payments to sole community hospitals that realize a significant increase in operating costs in a cost reporting period attributable to addition of new inpatient facilities or services.Subsec. (d)(5)(E). Pub. L. 99-509, §9320(g)(2), struck out subpar. (E) which read as follows: "The Secretary shall provide for an additional payment amount for any subsection (d) hospital equal to the reasonable costs incurred by such hospital for anesthesia services provided by a certified registered nurse anesthetist. Payment under this subparagraph shall be the only payment made to such hospital with respect to such services."Subsec. (d)(5)(F). Pub. L. 99-272, §9105(a), added subpar. (F).Subsec. (d)(5)(F)(i). Pub. L. 99-509, §9306(c), substituted "1989" for "1988". Subsec. (d)(5)(F)(iv)(I). Pub. L. 99-509, §9306(b)(1), inserted "or is described in the second sentence of subclause (III)" after "100 or more beds".Subsec. (d)(5)(F)(iv)(III). Pub. L. 99-509, §9306(b)(2), inserted "and is not described in the second sentence of clause (v)" after "rural area". Subsec. (d)(5)(F)(v). Pub. L. 99-509, §9306(a), inserted at end "A hospital located in a rural area and with 500 or more beds also 'serves a significantly disproportionate number of low income patients' for a cost reporting period if the hospital has a disproportionate patient percentage (as defined in clause (vi)) for that period which equals or exceeds a percentage specified by the Secretary." Subsec. (d)(5)(F)(vi)(I). Pub. L. 99-514, §1895(b)(2)(A), formerly §1895(b)(2)(C), as amended by Pub. L. 99-509, §9307(c)(1)(B)(ii), as amended by Pub. L. 100-203, §4009(j)(6)(A), which directed the substitution of "supplemental" for "supplementary" and "period" for "fiscal year", was repealed by Pub. L. 100-647, §1018(r)(1).Subsec. (d)(9). Pub. L. 99-509, §9304(a), added par. (9).Subsec. (e)(1)(C). Pub. L. 99-509, §9304(c), added subpar. (C).Subsec. (e)(3). Pub. L. 99-509, §9302(e)(3), designated existing provisions as subpar. (A) and added subpar. (B). Pub. L. 99-272, §9101(c)(2), struck out "(instead of the applicable percentage increase described in subsection (b)(3)(B) of this section)" after "should be used". Subsec. (e)(3)(A). Pub. L. 99-509, §9321(e)(2)(A), substituted "March" for "April".Subsec. (e)(4). Pub. L. 99-509, §9302(a)(2)(B), (e)(2), substituted "recommend for fiscal year 1988 an appropriate change factor for inpatient hospital services for discharges in that fiscal year and shall determine for each subsequent fiscal year" for "determine for each fiscal year (beginning with fiscal year 1987) and inserted at end "The percentage change shall be the same for all subsection (d) hospitals and subsection (d) Puerto Rico hospitals, but may be different from that for other hospitals (and units not included as such hospitals) and may vary among such other hospitals and units." Pub. L. 99-272, §9101(c)(3), substituted "fiscal year 1987" for "fiscal year 1986".Subsec. (e)(5). Pub. L. 99-509, §9302(a)(2)(C), as amended by Pub. L. 100-203, §4009(j)(6)(B), inserted "recommendation or" before "determination" in subpars. (A) and (B). Subsec. (e)(5)(A). Pub. L. 99-509, §9321(e)(2)(B), substituted "May" for "June".Subsec. (e)(6)(A). Pub. L. 99-272, §9127(a), substituted "17 individuals" for "15 individuals".Subsec. (g)(1). Pub. L. 99-349 substituted "1987" for "1986" in two places. Subsec. (g)(2). Pub. L. 99-272, §9107(a)(1), designated existing provision as subpar. (A), inserted "the applicable percentage (described in subparagraph (B)) of", and added subpar. (B).Subsec. (g)(2)(B). Pub. L. 99-514, §1895(b)(3), realigned margins of subpar. (B).Subsec. (g)(3). Pub. L. 99-509, §9303(a), added par. (3).Subsec. (g)(3)(A). Pub. L. 99-509, §9303(b), inserted "and a subsection (d) Puerto Rico hospital" after "subsection (d) hospital".Subsec. (h). Pub. L. 99-272, §9202(a), added subsec. (h).Subsec. (h)(2)(C). Pub. L. 99-514, §1895(b)(9)(A), substituted "subparagraph (B)" for "paragraph (B)". Subsec. (h)(4)(D). Pub. L. 99-514, §1895(b)(9)(B), (C), redesignated subpar. (E) as (D) and in cl. (ii) inserted "but before July 1, 1987,".Subsec. (h)(4)(E). Pub. L. 99-509, §9314(a), added subpar. (E).Pub. L. 99-514, §1895(b)(9)(C), redesignated former subpar. (E) as (D). Subsec. (h)(5)(B). Pub. L. 99-514, §1895(b)(9)(D), substituted "The" for "As used in this paragraph, the". 1984-Subsec. (a)(2)(B). Pub. L. 98-369, §2354(b)(42), substituted "disproportionate" for "disportionate". Subsec. (a)(4). Pub. L. 98-369, §2312(b), temporarily inserted ", costs of anesthesia services provided by a certified registered nurse anesthetist" after "approved educational activities". See Effective and Termination Dates of 1984 Amendments note below.Subsec. (b)(3)(A)(ii). Pub. L. 98-369, §2354(b)(43), inserted "of" after "in the case".Subsec. (b)(3)(B). Pub. L. 98-369, §2310(a), substituted "one-quarter of 1 percentage point" for "1 percentage point" and inserted provision that in determining the percentage change under subsec. (e) of this section with respect to discharges occurring in any cost reporting period or fiscal year beginning on or after Oct. 1, 1985, and before Oct. 1, 1986, the Secretary may not establish a percentage increase which exceeds the applicable percentage increase otherwise determined for that period or fiscal year under the preceding sentence.Subsec. (c)(4)(A). Pub. L. 98-369, §2315(a), substituted "(D), and (E)" for "and (D)". Subsec. (d)(2)(D). Pub. L. 98-369, §2315(b), struck out "Standard" before "Metropolitan" in provision following cl. (ii). Pub. L. 98-369, §2311(b), inserted provision for determining the region a hospital located in a Metropolitan Statistical Area would be deemed to be located.Subsec. (d)(3)(D)(i)(I). Pub. L. 98-369, §2354(b)(44), substituted "(C))" for "(C),".Subsec. (d)(5)(B). Pub. L. 98-369, §2307(b)(1), inserted provision that in determining such adjustment the Secretary not distinguish between those interns and residents who are employees of a hospital and those who furnish services to a hospital but are not employees of such hospital.Subsec. (d)(5)(C)(i). Pub. L. 98-617 substituted "August 17, 1984" for "30 days after July 18, 1984" before "for implementation by".Pub. L. 98-369, §2311(a), inserted provisions permitting a hospital classified as a rural hospital to appeal to the Secretary for reclassification as a rural referral center on the basis of criteria established and published by the Secretary and requiring the Secretary to make a final determination with respect to such appeal within 60 days after the date the appeal was submitted.Subsec. (d)(5)(E). Pub. L. 98-369, §2312(a), temporarily added subpar. (E). See Effective and Termination Dates of 1984 Amendments note below.Subsec. (d)(8). Pub. L. 98-369, §2311(c), added par. (8).Subsec. (e)(2). Pub. L. 98-369, §2313(a), inserted "(without regard to the provisions of title 5 governing appointments in the competitive service)" after "appointed by the Director".Subsec. (e)(5). Pub. L. 98-369, §2315(c)(1), struck out "for public comment" after "have published" in provisions preceding subpar. (A).Subsec. (e)(5)(A). Pub. L. 98-369, §2315(c)(2), inserted "for public comment" after "that fiscal year". Subsec. (e)(6)(C). Pub. L. 98-369, §2313(b)(3), inserted provision that section 10(a)(1) of the Federal Advisory Committee Act not apply to any portion of a Commission meeting if the Commission, by majority vote, determines such portion of such meeting should be closed. Subsec. (e)(6)(C)(i). Pub. L. 98-369, §2313(b)(1), amended cl. (i) generally, substituting provision authorizing the Commission to employ and fix the compensation of an Executive Director, subject to the approval of the Director of the Office, and such other personnel, not to exceed 25, as necessary, without regard to the provisions of title 5 governing appointment in the competitive service, for provision authorizing the Commission to employ and fix the compensation of such personnel, not to exceed 25, as may be necessary to carry out its duties.Subsec. (e)(6)(C)(iii). Pub. L. 98-369, §2313(b)(2), inserted "(without regard to section 5 of title 41)" after "Commission".Subsec. (e)(6)(D). Pub. L. 98-369, §2313(b)(4), inserted provision relating to payment of physician comparability allowance in the same manner as provided under section 5948 of title 5 and providing that for such purpose subsec. (i) of such section apply to the Commission in the same manner as it applies to the Tennessee Valley Authority. Subsec. (e)(6)(J). Pub. L. 98-369, §2313(d), added subpar. (J).1983-Subsec. (a)(1)(D). Pub. L. 98-21, §601(a)(1), added subpar. (D).Subsec. (a)(4). Pub. L. 98-21, §601(a)(2), inserted provision that term "operating costs of inpatient hospital services" does not include costs of approved educational activities, or, with respect to costs incurred in cost reporting periods beginning prior to Oct. 1, 1986, capital-related costs, as defined by the Secretary. Pub. L. 97-448, §309(b)(13), substituted "as such costs are determined" for "and such costs are determined". Subsec. (b)(1). Pub. L. 98-21, §601(b)(1), (2), in provisions preceding subpar. (A), substituted "Notwithstanding section 1395f(b) of this title but subject to the provisions of section 1395e of this title" for "Notwithstanding section 1395f(b) of this title, but subject to the provisions of sections 1395e of this title" and inserted "(other than a subsection (d) hospital, as defined in subsection (d)(1)(B))" after "of a hospital". Pub. L. 98-21, §601(b)(3), inserted "(other than on the basis of a DRG prospective payment rate determined under subsection (d))" after "payable under this subchapter" in provisions following subpar. (B). Pub. L. 97-448, §309(b)(14), substituted "section 1395f(b) of this title," for "sections 1395f(b) of this title" in provisions preceding subpar. (A). Subsec. (b)(2). Pub. L. 98-21, §601(b)(4), struck out par. (2) which provided that par. (1) would not apply to cost reporting periods of hospitals beginning on or after Oct. 1, 1985. Subsec. (b)(3)(B). Pub. L. 98-21, §601(b)(5)-(8), inserted "and subsection (d) of this section and except as provided in subsection (e) of this section" after "subparagraph (A)", inserted "or fiscal year" after "cost reporting period" each place it appears, inserted "before the beginning of the period or year" after "estimated by the Secretary", and substituted "will exceed" for "exceeds". Subsec. (b)(6). Pub. L. 98-21, §601(b)(9), added par. (6) and repealed a prior par. (6) which directed the Secretary to provide for an adjustment under this paragraph in the amount of payment otherwise provided a hospital under this subsection in the case of a hospital which, as of Aug. 15, 1982, was subject to FICA taxes and which was not subject to such taxes for part or all of a cost reporting period beginning on or after Oct. 1, 1982, that in making such adjustment for a cost reporting period the Secretary was to estimate the amount of the operating costs of inpatient hospital services that would have resulted if the hospital was subject to the FICA taxes during that period, that in making such estimate the Secretary was to reduce the amount of such FICA taxes that would have been paid (but not below zero) by the amount of costs which the hospital demonstrated to the satisfaction of the Secretary were incurred in the period for pensions, health, and other fringe benefits for employees (and former employees and family members) comparable to, and in lieu of, the benefits provided under subchapter II of this chapter and this subchapter, that if a hospital's operating costs of inpatient hospital services estimated under subparagraph (B) was greater than the hospital's operating costs of inpatient hospital services determined without regard to this paragraph for a cost reporting period, then the Secretary was to reduce the amount otherwise paid the hospital (respecting operating costs of inpatient hospital services) under this subchapter (taking into account any limitation under subsection (a) of this section) for the period by the amount by which (i) the amount that would have been paid the hospital if (I) the amount of the operating costs of inpatient hospital services estimated under subparagraph (B) were treated as the amount of the operating costs of inpatient hospital services and (II) subsection (a) of this section did not apply to the determination, exceeded (ii) the amount that would otherwise have been paid the hospital if subsection (a) of this section (and this paragraph) did not apply, except that, in making such determination for cost reporting periods beginning on or after Oct. 1, 1984, clause (ii) of paragraph (1)(B) was to continue to apply.Subsec. (b)(6)(C). Pub. L. 97-448, §309(b)(15), substituted "under this subchapter (taking into account any limitation under subsection (a) of this section)" for "under this subsection" in provisions preceding cl. (i).Subsec. (c)(1). Pub. L. 98-21, §601(c)(1), added subpars. (D) and (E) and provisions following subpar. (E). Subsec. (c)(3)(A). Pub. L. 98-21, §601(c)(2)(A), substituted "meets the requirements of subparagraphs (A), (D), and (E) of paragraph (1) and, if applicable, the requirements of paragraph (5)," for "meets the requirement of paragraph (1)(A)". Subsec. (c)(3)(B). Pub. L. 98-21, §601(c)(2)(B), inserted "(or, if applicable, in paragraph (5))". Subsec. (c)(4) to (6). Pub. L. 98-21, §601(c)(3), added pars. (4) to (6). Subsec. (d). Pub. L. 98-21, §601(d)(2), (e), added subsec. (d) and redesignated former subsec. (d), relating to the elimination of lesser-of-cost-or-charges provisions, as subsec. (j) of section 1814 of act Aug. 14, 1935, which is classified to subsec. (j) of section 1395f of this title.Subsecs. (e) to (g). Pub. L. 98-21, §601(e), added subsecs. (e) to (g).1982-Subsec. (d). Pub. L. 97-248, §110, added subsec. (d).
STATUTORY NOTES AND RELATED SUBSIDIARIES
CHANGE OF NAME References to Medicare+Choice deemed to refer to Medicare Advantage or MA, subject to an appropriate transition provided by the Secretary of Health and Human Services in the use of those terms, see section 201 of Pub. L. 108-173, set out as a note under section 1395w-21 of this title.
EFFECTIVE DATE OF 2022 AMENDMENT Pub. L. 117-328, div. FF, title IV, §4143(c), Dec. 29, 2022, 136 Stat. 5931, provided that: "The amendments made by this section [amending this section] shall apply to payments made for portions of cost reporting periods occurring in 2010 through 2019."
EFFECTIVE DATE OF 2020 AMENDMENT Pub. L. 116-260, div. CC, title I, §131(d), Dec. 27, 2020, 134 Stat. 2976, provided that: "The amendments made by this section [amending this section] shall apply to payment under section 1886 of the Social Security Act (42 U.S.C. 1395ww) for cost reporting periods beginning on or after the date of the enactment of this Act [Dec. 27, 2020]."
EFFECTIVE DATE OF 2015 AMENDMENT Pub. L. 114-113, §602, 129 Stat. 3024, provided that: "The amendments made by this section [amending this section and section 1395w-23 of this title] shall apply as if included in the enactment of the American Recovery and Reinvestment Act of 2009 (Public Law 111-5), except that, in order to take into account delays in the implementation of this section, in applying subsections (b)(3)(B)(ix), (n)(2)(E)(ii), and (n)(2)(G)(i) of section 1886 of the Social Security Act [42 U.S.C. 1395ww], as amended by this section, any reference in such subsections to a particular year shall be treated with respect to a subsection (d) Puerto Rico hospital as a reference to the year that is 5 years after such particular year (or 7 years after such particular year in the case of applying subsection (b)(3)(B)(ix) of such section)."Amendment by section 106(b)(2)(B) of Pub. L. 114-10 applicable to meaningful EHR users as of the date that is one year after Apr. 16, 2015, see section 106(b)(2)(C) of Pub. L. 114-10, set out as a note under section 1395w-4 of this title.
EFFECTIVE DATE OF 2014 AMENDMENT Pub. L. 113-93, §112, 128 Stat. 1045, provided that: "The amendments made by this section [amending this section and provisions set out as notes under this section] are effective as of the date of the enactment of this Act [Apr. 1, 2014]."
EFFECTIVE DATE OF 2011 AMENDMENT Amendment by Pub. L. 112-40 applicable to contracts entered into or renewed on or after Jan. 1, 2012, see section 261(e) of Pub. L. 112-40, set out as a note under section 1320c of this title.
EFFECTIVE DATE OF 2010 AMENDMENT Pub. L. 111-309, §203, 124 Stat. 3289, provided that the amendment made by section 203 is effective as if included in the enactment of section 5503(a) of Pub. L. 111-148. Pub. L. 111-192, §102, 124 Stat. 1281, provided that: "The amendments made by subsection (a) [amending this section] shall apply to services furnished on or after the date of the enactment of this Act [June 25, 2010]." Pub. L. 111-148, §3401, 124 Stat. 488, provided that: "Notwithstanding the preceding provisions of this section [amending this section and sections 1395f, 1395l, 1395m, 1395u, 1395rr, 1395yy, and 1395fff of this title], the amendments made by subsections (a), (c), and (d) [amending this section] shall not apply to discharges occurring before April 1, 2010." Pub. L. 111-148, §5505, 124 Stat. 661, provided that: "(1) IN GENERAL.-Except as otherwise provided, the Secretary of Health and Human Services shall implement the amendments made by this section [amending this section] in a manner so as to apply to cost reporting periods beginning on or after January 1, 1983."(2) GME.-Section 1886(h)(4)(J) of the Social Security Act [42 U.S.C. 1395ww(h)(4)(J)], as added by subsection (a)(1)(B), shall apply to cost reporting periods beginning on or after July 1, 2009."(3) IME.-Section 1886(d)(5)(B)(x)(III) of the Social Security Act [42 U.S.C. 1395ww(d)(5)(B)(x)(III)], as added by subsection (b), shall apply to cost reporting periods beginning on or after October 1, 2001. Such section, as so added, shall not give rise to any inference as to how the law in effect prior to such date should be interpreted."
EFFECTIVE DATE OF 2007 AMENDMENT Pub. L. 110-173, §114, 121 Stat. 2505, provided that: "Subsection (m)(2) of section 1886 of the Social Security Act [42 U.S.C. 1395ww(m)(2)], as added by paragraph (1), shall not apply to discharges occurring on or after July 1, 2007, and before April 1, 2008." Pub. L. 110-173, §115, 121 Stat. 2506, provided that: "The amendment made by paragraph (1) [amending this section] shall not apply to payment units occurring before April 1, 2008." Pub. L. 110-161, §225, 121 Stat. 2189, provided that: "Subject to paragraph (3) [section 225(b) of title II of div. G of Pub. L. 110-161 does not contain a par. (3)], the amendments made by paragraph (1) [amending this section] shall take effect as if included in the enactment of section 422 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173)."
EFFECTIVE DATE OF 2006 AMENDMENT Amendment by section 109(a)(2) of Pub. L. 109-432 applicable to payment for services furnished on or after Jan. 1, 2009, see section 109(c) of Pub. L. 109-432, set out as a note under section 1395l of this title. Amendment by section 205(b)(1) of Pub. L. 109-432 effective as if included in the enactment of Pub. L. 109-171, see section 205(c) of Pub. L. 109-432, set out as a note under section 1395u of this title.
EFFECTIVE DATE OF 2003 AMENDMENT Pub. L. 108-173, §407, 117 Stat. 2270, provided that: "The amendment made by subsection (a) [amending this section] shall apply to cost reporting periods beginning on or after January 1, 2004." Pub. L. 108-173, §502, 117 Stat. 2291, provided that: "The amendments made by this section [amending this section] shall apply to discharges occurring on or after April 1, 2004." Pub. L. 108-173, §503, 117 Stat. 2292, provided that:"(1) IN GENERAL.-The Secretary [of Health and Human Services] shall implement the amendments made by this section [amending this section] so that they apply to classification for fiscal years beginning with fiscal year 2005."(2) RECONSIDERATIONS OF APPLICATIONS FOR FISCAL YEAR 2004 THAT ARE DENIED.-In the case of an application for a classification of a medical service or technology as a new medical service or technology under section 1886(d)(5)(K) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(K)) that was filed for fiscal year 2004 and that is denied-"(A) the Secretary shall automatically reconsider the application as an application for fiscal year 2005 under the amendments made by this section; and"(B) the maximum time period otherwise permitted for such classification of the service or technology shall be extended by 12 months." Pub. L. 108-173, §505, 117 Stat. 2294, provided that: "The amendments made by this section [amending this section and section 1395cc of this title] shall first apply to the wage index for discharges occurring on or after October 1, 2004. In initially implementing such amendments, the Secretary [of Health and Human Services] may modify the deadlines otherwise applicable under clauses (ii) and (iii)(I) of section 1886(d)(10)(C) of the Social Security Act (4 2 U.S.C. 1395ww(d)(10)(C) ), for submission of, and actions on, applications relating to changes in hospital geographic reclassification."
EFFECTIVE DATE OF 2000 AMENDMENT Pub. L. 106-554, §1(a)(6) [title II, §212(b)], Dec. 21, 2000, 114 Stat. 2763, 2763A-485, provided that: "The amendment made by this section [amending this section] shall apply with respect to cost reporting periods beginning on or after April 1, 2001." Pub. L. 106-554, §1(a)(6) [title II, §213(b)], Dec. 21, 2000, 114 Stat. 2763, 2763A-486, provided that: "The amendments made by this section [amending this section] shall take effect as if included in the enactment of section 405 of BBRA [Pub. L. 106-113, §1000(a)(6) [title IV, §405]] (113 Stat. 1501A-372)." Pub. L. 106-554, §1(a)(6) [title III, §301(e)(2)], Dec. 21, 2000, 114 Stat. 2763, 2763A-492, provided that: "The amendment made by paragraph (1) [amending this section] shall apply to discharges occurring on or after October 1, 2001." Pub. L. 106-554, §1(a)(6) [title III, §303(d)(2)], Dec. 21, 2000, 114 Stat. 2763, 2763A-494, provided that: "The amendment made by paragraph (1) [amending this section] is effective as if included in the enactment of BBA [Pub. L. 105-33]." Pub. L. 106-554, §1(a)(6) [title III, §305(c)], Dec. 21, 2000, 114 Stat. 2763, 2763A-496, provided that: "The amendments made by this section [amending this section] take effect as if included in the enactment of BBA [Pub. L. 105-33]." Pub. L. 106-554, §1(a)(6) [title V, §512(b)], Dec. 21, 2000, 114 Stat. 2763, 2763A-534, provided that: "The amendment made by subsection (a) [amending this section] shall apply to portions of cost reporting periods occurring on or after January 1, 2001."
EFFECTIVE DATE OF 1999 AMENDMENT Pub. L. 106-113, div. B, §1000(a)(6) [title I, §121(b)], Nov. 29, 1999, 113 Stat. 1536, 1501A-330, provided that: "The amendments made by subsection (a) [amending this section] apply to cost reporting periods beginning on or after October 1, 1999." Pub. L. 106-113, div. B, §1000(a)(6) [title I, §125(c)], Nov. 29, 1999, 113 Stat. 1536, 1501A-333, provided that: "The amendments made by subsection (a) [amending this section] are effective as if included in the enactment of section 4421(a) of BBA [the Balanced Budget Act of 1997, Pub. L. 105-33]." Pub. L. 106-113, div. B, §1000(a)(6) [title III, §312(b)], Nov. 29, 1999, 113 Stat. 1536, 1501A-365, provided that: "The amendments made by subsection (a) [amending this section] apply on and after July 1, 2000, to residency programs that began before, on, or after the date of the enactment of this Act [Nov. 29, 1999]."Amendment by section 1000(a)(6) [title III, §321(b), (e), (f), (h), (k)(15)-(17)] of Pub. L. 106-113 effective as if included in the enactment of the Balanced Budget Act of 1997, Pub. L. 105-33 except as otherwise provided, see section 1000(a)(6) [title III, §321(m)] of Pub. L. 106-113, set out as a note under section 1395d of this title. Amendment by section 1000(a)(6) [title IV, §401(a)] of Pub. L. 106-113 effective Jan. 1, 2000, see section 1000(a)(6) [title IV, §401(c)] of Pub. L. 106-113, set out as a note under section 1395i-4 of this title. Pub. L. 106-113, div. B, §1000(a)(6) [title IV, §402(b)], Nov. 29, 1999, 113 Stat. 1536, 1501A-370, provided that: "The amendments made by subsection (a) [amending this section] apply with respect to discharges occurring during cost reporting periods beginning on or after October 1, 1999." Pub. L. 106-113, div. B, §1000(a)(6) [title IV, §407(a)(3)], Nov. 29, 1999, 113 Stat. 1536, 1501A-373, provided that: "(A) DGME.-The amendments made by paragraph (1) [amending this section] apply to cost reporting periods that begin on or after the date of the enactment of this Act [Nov. 29, 1999]."(B) IME.-The amendment made by paragraph (2) [amending this section] applies to discharges occurring in cost reporting periods that begin on or after such date of enactment." Pub. L. 106-113, div. B, §1000(a)(6) [title IV, §407(b)(3)], Nov. 29, 1999, 113 Stat. 1536, 1501A-374, provided that: "(A) DGME.-The amendment made by paragraph (1) [amending this section] applies to cost reporting periods beginning on or after April 1, 2000. "(B) IME.-The amendment made by paragraph (2) [amending this section] applies to discharges occurring on or after April 1, 2000." Pub. L. 106-113, div. B, §1000(a)(6) [title IV, §407(c)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A-374, provided that: "The amendment made by paragraph (1) [amending this section] applies with respect to- "(A) payments to hospitals under section 1886(h) of the Social Security Act (42 U.S.C. 1395ww(h)) for cost reporting periods beginning on or after April 1, 2000; and"(B) payments to hospitals under section 1886(d)(5)(B)(v) of such Act (42 U.S.C. 1395ww(d)(5)(B)(v)) for discharges occurring on or after April 1, 2000."
EFFECTIVE DATE OF 1997 AMENDMENT Amendment by section 4022(b) of Pub. L. 105-33 effective Nov. 1, 1997, the date of termination of the Prospective Payment Assessment Commission and the Physician Payment Review Commission, see section 4022(c)(2) of Pub. L. 105-33, set out as an Effective Date; Transition; Transfer of Functions note under section 1395b-6 of this title.Amendment by section 4201(c)(1), (4) of Pub. L. 105-33 applicable to services furnished on or after Oct. 1, 1997, see section 4201(d) of Pub. L. 105-33, set out as a note under section 1395f of this title. Pub. L. 105-33, §4204, 111 Stat. 376, provided that: "The amendments made by subsection (a) [amending this section and provisions set out as a note below] shall apply with respect to discharges occurring on or after October 1, 1997." Pub. L. 105-33, §4405, 111 Stat. 400, provided that: "The amendments made by this section [amending this section] apply to discharges occurring after September 30, 1997." Pub. L. 105-33, §4415, 111 Stat. 407, provided that: "The amendments made by subsections (a) and (c) [amending this section] shall apply with respect to cost reporting periods beginning on or after October 1, 1997." Pub. L. 105-33, §4417, 111 Stat. 408, provided that: "The amendment made by paragraph (1) [amending this section] shall apply to discharges occurring on or after October 1, 1995." Pub. L. 105-33, §4417, 111 Stat. 408, provided that: "The amendment made by paragraph (1) [amending this section] shall apply to cost reporting periods beginning on or after the date of the enactment of this Act [Aug. 5, 1997]." Pub. L. 105-33, §4419, 111 Stat. 409, provided that: "The amendment made by paragraph (1) [amending this section] shall apply to hospitals or units that first qualify as a hospital or unit described in section 1886(d)(1)(B) (4 2 U.S.C. 1395ww(d)(1)(B) ) for cost reporting periods beginning on or after October 1, 1997." Pub. L. 105-33, §4421, 111 Stat. 413, provided that: "The amendments made by this section [amending this section] shall apply to cost reporting periods beginning on or after October 1, 2000, except that the Secretary of Health and Human Services may require the submission of data under section 1886(j)(2)(D) of the Social Security Act [42 U.S.C. 1395ww(j)(2)(D)] (as added by subsection (a)) on and after the date of the enactment of this section [Aug. 5, 1997]." Pub. L. 105-33, §4627, 111 Stat. 483, provided that: "The amendments made by subsection (a) [amending this section] apply to combined medical residency training programs in effect for residency years beginning on or after July 1, 1997."
EFFECTIVE DATE OF 1994 AMENDMENT Pub. L. 103-432, §101, 108 Stat. 4400, provided that: "The amendment made by paragraph (1) [amending this section] shall take effect as if included in the enactment of OBRA-1989 [Pub. L. 101-239]." Pub. L. 103-432, §153, 108 Stat. 4437, provided that: "The amendment made by subsection (a) [amending this section] shall apply as if included in the enactment of the Consolidated Omnibus Budget Reconciliation Act of 1985 (Public Law 99-272)."
EFFECTIVE DATE OF 1993 AMENDMENT Pub. L. 103-66, §13501, 107 Stat. 574, provided that: "The amendment made by paragraph (1) [amending this section] shall apply to discharges occurring on or after October 1, 1991." Pub. L. 103-66, §13563, 107 Stat. 605, provided that: "The amendments made by paragraphs (1)(A) and (1)(B) [amending this section] shall take effect on July 1, 1995, and the date of the enactment of this Act [Aug. 10, 1993], respectively." Pub. L. 103-66, §13563, 107 Stat. 606, provided that: "The amendment made by paragraph (1) [amending this section] shall apply to payments under section 1886(h) of the Social Security Act [42 U.S.C. 1395ww(h)] for cost reporting periods beginning on or after October 1, 1992."
EFFECTIVE DATE OF 1990 AMENDMENT Pub. L. 101-508, §4002, 104 Stat. 1388-32, provided that: "The amendments made by paragraph (1) [amending this section] shall apply to payments for discharges occurring on or after January 1, 1991." Pub. L. 101-508, §4002, 104 Stat. 1388-33, provided that: "The amendments made by paragraphs (1), (3), and (4)(B) [amending this section] shall apply to discharges occurring on or after January 1, 1991, the amendment made by paragraph (2) [amending this section] shall apply to discharges occurring on or after October 1, 1991, and the amendment made by paragraph (4)(A) [amending this section] shall take effect as if included in the enactment of the Omnibus Budget Reconciliation Act of 1989 [Pub. L. 101-239]." Pub. L. 101-508, §4002, 104 Stat. 1388-35, provided that: "The amendments made by paragraph (1) and paragraph (2)(A) [amending this section] shall apply to payments for discharges occurring on or after January 1, 1991, and the amendments made by paragraph (2)(B) [amending this section] shall take effect October 1, 1994." Pub. L. 101-508, §4002(e)(4) [(3)], Nov. 5, 1990, 104 Stat. 1388-36, provided that: "The amendment made by paragraph (1) [amending this section] shall apply to discharges occurring on or after October 1, 1990." Pub. L. 101-508, §4002, 104 Stat. 1388-37, provided that: "The amendments made by this subsection [amending this section and section 1395w-1 of this title] shall take effect on the date of the enactment of this Act [Nov. 5, 1990]." Pub. L. 101-508, §4002, 104 Stat. 1388-38, provided that: "The amendments made by subparagraph (A) [amending this section] shall apply to discharges occurring on or after January 1, 1991." Pub. L. 101-508, §4003, 104 Stat. 1388-39, provided that: "The amendment made by subsection (a) [amending this section] shall apply- "(1) in the case of any services provided during the day immediately preceding the date of a patient's admission (without regard to whether the services are related to the admission), to services furnished on or after the date of the enactment of this Act [Nov. 5, 1990] and before October 1, 1991;"(2) in the case of diagnostic services (including clinical diagnostic laboratory tests), to services furnished on or after January 1, 1991; and"(3) in the case of any other services, to services furnished on or after October 1, 1991." Pub. L. 101-508, §4005, 104 Stat. 1388-40, provided that: "The amendment made by paragraph (1) [amending this section] shall apply to cost reporting periods beginning on or after October 1, 1991." Pub. L. 101-508, §4005, 104 Stat. 1388-42, provided that: "The amendments made by paragraph (1) [amending this section and section 1395h of this title] shall take effect on the date of the enactment of this Act [Nov. 5, 1990], and the amendments made by paragraph (2) [amending this section] shall take effect as if included in the enactment of the Omnibus Budget Reconciliation Act of 1989 [Pub. L. 101-239]." Pub. L. 101-508, §4008, 104 Stat. 1388-45, provided that: "The amendment made by paragraph (1) [amending this section] shall take effect as if included in the enactment of the Omnibus Budget Reconciliation Act of 1989 [Pub. L. 101-239]."
EFFECTIVE DATE OF 1989 AMENDMENT Pub. L. 101-239, §6003, 103 Stat. 2140, provided that: "The amendments made by paragraph (1) [amending this section] shall apply to payments for discharges occurring on or after January 1, 1990." Pub. L. 101-239, §6003, 103 Stat. 2142, provided that: "The amendments made by this subsection [amending this section] shall apply with respect to discharges occurring on or after April 1, 1990." Pub. L. 101-239, §6003, 103 Stat. 2158, provided that: "The amendments made by paragraphs (3) and (4) [amending this section] shall apply to discharges occurring on or after April 1, 1990." Pub. L. 101-239, §6004, 103 Stat. 2159, provided that: "The amendments made by this subsection [amending this section] shall apply with respect to cost reporting periods beginning on or after October 1, 1989, except that-"(A) in the case of a hospital classified by the Secretary of Health and Human Services as a hospital involved extensively in treatment for or research on cancer under section 1886(d)(5)(I) of the Social Security Act [42 U.S.C. 1395ww(d)(5)(I)] (as redesignated by section 6003(e)(1)(A)) after the date of the enactment of this Act [Dec. 19, 1989], such amendments shall apply with respect to cost reporting periods beginning on or after the date of such classification,"(B) in the case of a hospital that is not described in subparagraph (A), such amendments shall apply with respect to portions of cost reporting periods or discharges occurring during and after fiscal year 1987 for purposes of section 1886(g) of the Social Security Act [42 U.S.C. 1395ww(g)], and "(C) such amendments shall take effect 30 days after the date of the enactment of this Act for purposes of determining the eligibility of a hospital to receive periodic interim payments under section 1815(e)(2) of the Social Security Act [42 U.S.C. 1395g(e)(2)] ." Pub. L. 101-239, §6004, 103 Stat. 2160, provided that: "The amendments made by paragraph (1) [amending this section] shall apply with respect to cost reporting periods beginning on or after April 1, 1989." Pub. L. 101-239, §6011, 103 Stat. 2161, as amended by Pub. L. 103-66, §13505, 107 Stat. 579; Pub. L. 105-33, §4452, 111 Stat. 425, provided that: "The amendments made by subsection (a) [amending this section] shall apply with respect to items furnished 6 months after the date of enactment of this Act [Dec. 19, 1989] and on or before September 30, 1994, and on or after October 1, 1997."[Pub. L. 103-66, §13505, 107 Stat. 579, provided in part that the amendment made by that section to section 6011(d) of Pub. L. 101-239, set out above, is effective as if included in the enactment of Pub. L. 101-239.] Pub. L. 101-239, §6015, 103 Stat. 2164, provided that: "The amendment made by subsection (a) [amending this section] shall become effective with respect to cost reporting periods beginning on or after April 1, 1990."
EFFECTIVE DATE OF 1988 AMENDMENT Amendment by section 1018(r)(1) of Pub. L. 100-647 effective, except as otherwise provided, as if included in the provision of the Tax Reform Act of 1986, Pub. L. 99-514, to which such amendment relates, see section 1019(a) of Pub. L. 100-647, set out as a note under section 1 of Title 26, Internal Revenue Code.Amendment by Pub. L. 100-485 effective as if included in the enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L. 100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note under section 704 of this title.Except as specifically provided in section 411 of Pub. L. 100-360, amendment by Pub. L. 100-360, as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203, effective as if included in the enactment of that provision in Pub. L. 100-203, see section 411(a) of Pub. L. 100-360, set out as a Reference to OBRA; Effective Date note under section 106 of Title 1, General Provisions.
EFFECTIVE DATE OF 1987 AMENDMENT Pub. L. 100-203, title IV, §4002(g), Dec. 22, 1987, 101 Stat. 1330-45, as amended by Pub. L. 100-360, title IV, §411(b)(1)(I), July 1, 1988, 102 Stat. 769, provided that:"(1) PPS HOSPITALS, DRG PORTION OF PAYMENT.-In the case of a subsection (d) hospital (as defined in paragraph (6))-"(A) the amendments made by subsections (a) and (c) [amending this section] shall apply to payments made under section 1886(d)(1)(A)(iii) of the Social Security Act [42 U.S.C. 1395ww(d)(1)(A)(iii)] on the basis of discharges occurring on or after April 1, 1988, and "(B) for discharges occurring on or after October 1, 1988, the applicable percentage increase (described in section 1886(b)(3)(B) of such Act [42 U.S.C. 1395ww(b)(3)(B)] ) for discharges occurring during fiscal year 1987 is deemed to have been such percentage increase as amended by subsection (a)."(2) PPS SOLE COMMUNITY HOSPITALS, HOSPITAL SPECIFIC PORTION OF PAYMENT.-In the case of a subsection (d) hospital which receives payments made under section 1886(d)(1)(A) of the Social Security Act [42 U.S.C. 1395ww(d)(1)(A)] because it is a sole community hospital- "(A) the amendment made by subsections (a) and (c) [amending this section] shall apply to payments under section 1886(d)(1)(A)(ii)(I) of the Social Security Act made on the basis of discharges occurring during a cost reporting period of a hospital, for the hospital's cost reporting period beginning on or after October 1, 1987;"(B) notwithstanding subparagraph (A), for cost reporting period beginning during fiscal year 1988, the applicable percentage increase (as defined in section 1886(b)(3)(B) of such Act [42 U.S.C. 1395ww(b)(3)(B)] ) for the-"(i) first 51 days of the cost reporting period shall be 0 percent,"(ii) next 132 days of such period shall be 2.7 percent, and"(iii) remainder of such period of the cost reporting period shall be the applicable percentage increase (as so defined, as amended by subsection (a)); and"(C) for cost reporting periods beginning on or after October 1, 1988, the applicable percentage increase (as so defined) with respect to the previous cost reporting period shall be deemed to have been the applicable percentage increase (as so defined, as amended by subsection (a))."(3) PPS-EXEMPT HOSPITALS.-In the case of a hospital that is not a subsection (d) hospital-"(A) the amendments made by subsection (e) [amending this section] shall apply to cost reporting periods beginning on or after October 1, 1987;"(B) notwithstanding subparagraph (A), for the hospital's cost reporting period beginning during fiscal year 1988, payment under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] shall be made as though the applicable percentage increase described in section 1886(b)(3)(B) of such Act [42 U.S.C. 1395ww(b)(3)(B)] were equal to the product of 2.7 percent and the ratio of 315 to 366; and"(C) for cost reporting periods beginning on or after October 1, 1988, the applicable percentage increase (as so defined) with respect to the cost reporting period beginning during fiscal year 1988 shall be deemed to have been 2.7 percent."(4) DEFINITION, REGIONAL FLOOR, AND TECHNICAL AND CONFORMING AMENDMENTS.-The amendments made by subsections (b) and (d) and paragraphs (1) and (2) of subsection (f) [amending this section and provisions set out as a note below] shall take effect on the date of the enactment of this Act [Dec. 22, 1987]."(5) TRANSITION FOR LARGE URBAN AREA RATES.-In computing the average standardized amount for hospitals located in a large urban area or other urban area under section 1886(d)(3)(A)(ii) of the Social Security Act [42 U.S.C. 1395ww(d)(3)(A)(ii)] (as amended by subsection (c)) for fiscal year 1988, the reference to 'the respective average standardized amount computed for the previous fiscal year under this subparagraph' is deemed a reference to the average standardized amount computed for hospitals located in an urban area for the 51-day period beginning on October 1, 1987."(6) DEFINITION.-In this subsection, the term 'subsection (d) hospital' has the meaning given such term in section 1886(d)(1)(B) of the Social Security Act [4 2 U.S.C. 1395ww(d)(1)(B) ]."Pub. L. 100-203, title IV, §4003(e), Dec. 22, 1987, 101 Stat. 1330-47, provided that: "The amendments made by this section [amending this section] shall apply to payments for discharges occurring on or after October 1, 1988."Pub. L. 100-203, title IV, §4005(a)(3), Dec. 22, 1987, 101 Stat. 1330-48, as amended by Pub. L. 100-360, title IV, §411(b)(4)(C)(ii), July 1, 1988, 102 Stat. 770, provided that: "This subsection [amending this section] shall apply to discharges occurring on or after October 1, 1988."Pub. L. 100-203, title IV, §4005(c)(2)(A), Dec. 22, 1987, 101 Stat. 1330-49, provided that: "The amendments made by paragraph (1) [amending this section] shall apply to cost reporting periods beginning on or after October 1, 1987[.]" Pub. L. 100-203, title IV, §4005(d)(1)(B), Dec. 22, 1987, 101 Stat. 1330-49, provided that: "The amendment made by subparagraph (A) [amending this section] shall apply to discharges occurring on or after April 1, 1988."Pub. L. 100-203, title IV, §4006(b)(3), Dec. 22, 1987, 101 Stat. 1330-53, provided that: "The amendment made by paragraph (1) [amending this section] shall take effect on October 1, 1987. The amendments made by paragraph (2) [amending this section] shall apply to cost reporting periods beginning on or after October 1, 1987."Pub. L. 100-203, title IV, §4007(b)(2), Dec. 22, 1987, 101 Stat. 1330-53, as amended by Pub. L. 100-360, title IV, §411(b)(6)(B), July 1, 1988, 102 Stat. 770, provided that: "The amendment made by paragraph (1)(C) [amending this section] shall apply to hospital cost reporting periods beginning on or after October 1, 1989." Pub. L. 100-203, title IV, §4009(d)(2), Dec. 22, 1987, 101 Stat. 1330-57, provided that: "The amendments made by paragraph (1) [amending this section] shall apply to appointments made after the date of the enactment of this Act [Dec. 22, 1987]."Pub. L. 100-203, title IV, §4009(j)(6), Dec. 22, 1987, 101 Stat. 1330-59, provided that the amendment made by that section is effective as if included in the enactment of Pub. L. 99-509.Pub. L. 100-203, title IV, §4083(b)(2), Dec. 22, 1987, 101 Stat. 1330-129, provided that: "The amendments made by paragraph (1) [amending this section] shall take effect on the date of the enactment of this Act [Dec. 22, 1987]."Amendment by Pub. L. 100-93 effective at end of fourteen-day period beginning Aug. 18, 1987, and inapplicable to administrative proceedings commenced before end of such period, see section 15(a) of Pub. L. 100-93, set out as a note under section 1320a-7 of this title.
EFFECTIVE DATE OF 1986 AMENDMENT Pub. L. 99-514, title XVIII, §1895(b)(1)(D), Oct. 22, 1986, 100 Stat. 2932, which provided for applicability of amendments to this section by section 1895(b)(1) of Pub. L. 99-514 to discharges occurring on or after Oct. 1, 1986, with certain exceptions, was repealed by Pub. L. 99-509, title IX, §9307(c)(1)(A), Oct. 21, 1986, 100 Stat. 1995, and by Pub. L. 100-647, title I, §1018(r)(1), Nov. 10, 1988, 102 Stat. 3586. Pub. L. 99-514, title XVIII, §1895(b)(2)(b), formerly §1895(b)(2)(D), Oct. 22, 1986, 100 Stat. 2932, as amended by Pub. L. 99-509, title IX, §9307(c)(1)(B)(iii), as amended by Pub. L. 100-203, title IV, §4009(j)(6)(A), Dec. 22, 1987, 101 Stat. 1330-59, which provided for applicability of amendments to this section by section 1895(b)(2)(A) of Pub. L. 99-514 to discharges occurring on or after May 1, 1986, was repealed by Pub. L. 100-647, title I, §1018(r)(1), Nov. 10, 1988, 102 Stat. 3586.Amendment by section 1895(b)(3), (9) of Pub. L. 99-514 effective, except as otherwise provided, as if included in enactment of the Consolidated Omnibus Budget Reconciliation Act of 1985, Pub. L. 99-272, see section 1895(e) of Pub. L. 99-514, set out as a note under section 162 of Title 26, Internal Revenue Code.Pub. L. 99-509, title IX, §9302(a)(3), Oct. 21, 1986, 100 Stat. 1982, provided that: "The amendment made by paragraph (1) [amending this section] shall apply to cost reporting periods beginning on or after October 1, 1986 and, for purposes of section 1886(d) of the Social Security Act [42 U.S.C. 1395ww(d)], for cost reporting periods beginning and discharges occurring on or after October 1, 1986." Pub. L. 99-509, title IX, §9302(b)(2), Oct. 21, 1986, 100 Stat. 1982, provided that: "The amendments made by paragraph (1) [amending this section] shall apply to discharges occurring on or after October 1, 1986." Pub. L. 99-509, title IX, §9302(d)(1)(B), Oct. 21, 1986, 100 Stat. 1983, provided that:"(i) Subject to clause (ii), the amendments made by subparagraph (A) [amending this section] shall apply to payments for discharges occurring on or after October 1, 1986. "(ii) An appeal for classification of a rural hospital as a regional referral center, pursuant to the amendments made by subparagraph (A), which is filed before January 1, 1987, and which is approved shall be effective with respect to discharges occurring on or after October 1, 1986." Pub. L. 99-509, title IX, §9303(b), Oct. 21, 1986, 100 Stat. 1985, provided that the amendment made by such section 9303(b) is effective for cost reporting periods beginning and discharges occurring (as the case may be) on or after Oct. 1, 1987.Pub. L. 99-509, title IX, §9304(d), Oct. 21, 1986, 100 Stat. 1988, provided that: "The amendments made by this section [amending this section] shall apply to discharges occurring on or after October 1, 1987."Pub. L. 99-509, title IX, §9306(d), Oct. 21, 1986, 100 Stat. 1995, provided that: "The amendments made by subsections (a) and (b) [amending this section] shall apply to discharges occurring on or after October 1, 1986." Pub. L. 99-509, title IX, §9307(c)(1), Oct. 21, 1986, 100 Stat. 1995, provided that the amendment made by such section 9307(c)(1) is effective as if included in the enactment of the Tax Reform Act of 1986 (Pub. L. 99-514), if H.Con.Res. 395, 99th Congress, 2d Session, is not adopted. H.Con.Res. 395 was not adopted.Pub. L. 99-509, title IX, §9314(b), Oct. 21, 1986, 100 Stat. 2005, provided that: "The amendments made by subsection (a) [amending this section] shall apply to payments for approved residency training programs as of July 1, 1987."Amendment by section 9320(g) of Pub. L. 99-509 applicable to services furnished on or after Jan. 1, 1989, with exceptions for hospitals located in rural areas which meet certain requirements related to certified registered nurse anesthetists, see section 9320(i), (k) of Pub. L. 99-509, as amended, set out as notes under section 1395k of this title.Pub. L. 99-509, title IX, §9321(e)(3)(B), Oct. 21, 1986, 100 Stat. 2018, provided that: "The amendments made by paragraph (2) [amending this section] shall take effect beginning with fiscal year 1989."Pub. L. 99-272, title IX, §9101(d), Apr. 7, 1986, 100 Stat. 154, provided that: "The amendment made by subsection (a) [amending section 5(c) of Pub. L. 99-107, set out below] shall take effect on March 15, 1986, and the amendments made by subsection (c) [amending this section] shall take effect on the date of the enactment of this Act [Apr. 7, 1986]." Pub. L. 99-272, title IX, §9101(e), Apr. 7, 1986, 100 Stat. 154, provided that: "(1) PPS HOSPITALS, DRG PORTION OF PAYMENT.-In the case of a subsection (d) hospital (as defined in paragraph (4))- "(A) the amendment made by subsection (b) [amending this section] shall apply to payments made under section 1886(d)(1)(A) of such Act [42 U.S.C. 1395ww(d)(1)(A)] made on the basis of discharges occurring on or after May 1, 1986; and"(B) for discharges occurring on or after October 1, 1986, the applicable percentage increase (described in section 1886(b)(3)(B) [42 U.S.C. 1395ww(b)(3)(B)] ) for discharges occurring during fiscal year 1986 shall be deemed to have been 1/2 percent."(2) PPS HOSPITALS, HOSPITAL SPECIFIC PORTION OF PAYMENT.-In the case of a subsection (d) hospital-"(A) the amendment made by subsection (b) [amending this section] shall apply to payments under section 1886(d)(1)(A) of the Social Security Act [42 U.S.C. 1395ww(d)(1)(A)] made on the basis of discharges occurring during a cost reporting period of a hospital, for the hospital's cost reporting periods beginning on or after October 1, 1985;"(B) notwithstanding subparagraph (A), for the cost reporting period beginning during fiscal year 1986, the applicable percentage increase (as defined in section 1886(b)(3)(B) of such Act [42 U.S.C. 1395ww(b)(3)(B)] ) for the-"(i) first 7 months of the cost reporting period shall be 0 percent, and"(ii) for the remaining 5 months of the cost reporting period shall be 1/2 percent; and"(C) for cost reporting periods beginning on or after October 1, 1986, the applicable percentage increase (as so defined) with respect to the previous cost reporting period shall be deemed to have been 1/2 percent."(3) PPS-EXEMPT HOSPITALS.-In the case of a hospital that is not a subsection (d) hospital-"(A) the amendment made by subsection (b) [amending this section] shall apply to cost reporting periods beginning on or after October 1, 1985;"(B) notwithstanding subparagraph (A), for the hospital's cost reporting period beginning during fiscal year 1986, payment under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] shall be made as though the applicable percentage increase described in section 1886(b)(3)(B) [42 U.S.C. 1395ww(b)(3)(B)] were equal to 5/24 of 1 percent; and"(C) for cost reporting periods beginning on or after October 1, 1986, the applicable percentage increase (as so defined) with respect to the cost reporting period beginning during fiscal year 1986 shall be deemed to have been 1/2 percent."(4) DEFINITION.-In this subsection, the term 'subsection (d) hospital' has the meaning given such term in section 1886(d)(1)(B) of the Social Security Act [42 U.S.C. 1395ww(d)(1)(B)] ."Pub. L. 99-272, title IX, §9102(d), Apr. 7, 1986, 100 Stat. 155, provided that:"(1) DELAY IN FINAL TRANSITION.-The amendment made by subsection (a) [amending this section] shall take effect on the date of the enactment of this Act [Apr. 7, 1986]." "(2) CHANGE IN HOSPITAL SPECIFIC PERCENTAGE.-The amendments made by subsection (b) [amending this section] shall apply-"(A) to cost reporting periods beginning on or after October 1, 1985, but "(B) notwithstanding subparagraph (A), for a hospital's cost reporting period beginning during fiscal year 1986, for purposes of section 1886(d)(1)(A) of the Social Security Act [42 U.S.C. 1395ww(d)(1)(A)] -"(i) during the first 7 months of the period the 'target percentage' is 50 percent and the 'DRG percentage' is 50 percent, and"(ii) during the remaining 5 months of the period the 'target percentage' is 45 percent and the 'DRG percentage' is 55 percent."(3) CHANGE IN BLENDED RATE.-The amendments made by subsection (c) [amending this section] shall apply to discharges occurring on or after May 1, 1986."(4) EXCEPTION.-"(A) Notwithstanding any other provision of this subsection, the amendments made by this section [amending this section] shall not apply to payments with respect to the operating costs of inpatient hospital services (as defined in section 1886(a)(4) of the Social Security Act [42 U.S.C. 1395ww(a)(4)] ) of a subsection (d) hospital (as defined in section 1886(d)(1)(B) of such Act [42 U.S.C. 1395ww(d)(1)(B)] ) located in the State of Oregon."(B) Notwithstanding any other provision of law, for a cost reporting period beginning during fiscal year 1986 of a subsection (d) hospital to which the amendments made by this section [amending this section] do not apply, for purposes of section 1886(d)(1)(A) of of [sic] Social Security Act [42 U.S.C. 1395ww(d)(1)(A)] -"(i) during the first 7 months of the period the 'target percentage' is 50 percent and the 'DRG percentage' is 50 percent, and"(ii) during the remaining 5 months of the period the 'target percentage' is 25 percent and the 'DRG percentage' is 75 percent."(C) Notwithstanding any other provision of law, for purposes of section 1886(d)(1)(D) of such Act [42 U.S.C. 1395ww(d)(1)(D)], the applicable combined adjusted DRG prospective payment rate for a subsection (d) hospital to which the amendments made by this section [amending this section] do not apply is, for discharges occurring on or after October 1, 1985, and before May 1, 1986, a combined rate consisting of 25 percent of the national adjusted DRG prospective payment rate and 75 percent of the regional adjusted DRG prospective payment rate for such discharges."Pub. L. 99-272, title IX, §9104(c), Apr. 7, 1986, 100 Stat. 158, provided that:"(1) Except as provided in paragraph (2), the amendments made by this section [amending this section] shall apply to discharges occurring on or after May 1, 1986. "(2) The amendments made by this section shall not first be applied to discharges occurring as of a date unless, for discharges occurring on that date, the amendments made by section 9105 [amending this section] are also being applied."Pub. L. 99-272, title IX, §9105(e), Apr. 7, 1986, 100 Stat. 160, provided that: "The amendments made by this section [amending this section] shall apply to discharges occurring on or after May 1, 1986."Pub. L. 99-272, title IX, §9106(b), Apr. 7, 1986, 100 Stat. 160, provided that: "The amendment made by subsection (a) [amending this section] shall apply to cost reporting periods beginning on or after January 1, 1986."Pub. L. 99-272, title IX, §9107(c)(1), Apr. 7, 1986, 100 Stat. 161, provided that: "The amendments made by subsection (a) [amending this section] shall apply to hospital cost reporting periods beginning on or after October 1, 1986."Pub. L. 99-272, title IX, §9109(b), Apr. 7, 1986, 100 Stat. 162, provided that: "The amendment made by subsection (a) [amending this section] shall take effect on the date of the enactment of this Act [Apr. 7, 1986]."Pub. L. 99-272, title IX, §9111(b), Apr. 7, 1986, 100 Stat. 162, provided that: "The amendment made by this section [amending this section] shall apply to payments for cost reporting periods beginning on or after October 1, 1983, and before October 1, 1989." Pub. L. 99-272, title IX, §9202(b), Apr. 7, 1986, 100 Stat. 175, provided that: "The amendment made by subsection (a) [amending this section] shall apply to hospital cost reporting periods beginning on or after July 1, 1985."
EFFECTIVE AND TERMINATION DATES OF 1984 AMENDMENTAmendment by Pub. L. 98-617 effective as if originally included in the Deficit Reduction Act of 1984, Pub. L. 98-369, see section 3(c) of Pub. L. 98-617, set out as a note under section 1395f of this title.Pub. L. 98-369, div. B, title III, §2307(b)(2), July 18, 1984, 98 Stat. 1074, provided that: "The amendment made by paragraph (1) [amending this section] shall apply to cost reporting periods beginning on or after October 1, 1984."Pub. L. 98-369, div. B, title III, §2310(b), July 18, 1984, 98 Stat. 1075, provided that: "The amendments made by this section [amending this section] shall apply to cost reporting periods beginning in, and discharges occurring in, fiscal year 1985 and thereafter."Pub. L. 98-369, div. B, title III, §2311(d), July 18, 1984, 98 Stat. 1077, provided that: "(1) Except as provided in paragraph (2), the amendments made by subsections (b) and (c) [amending this section] shall be effective with respect to cost reporting periods beginning on or after October 1, 1983, and the amendment made by subsection (a) [amending this section] shall be effective with respect to cost reporting periods beginning on or after October 1, 1984."(2) The amendment made by subsection (b) [amending this section] shall not apply so as to reduce any payment under section 1886(d) of the Social Security Act [42 U.S.C. 1395ww(d)] to a hospital the region of which is deemed to be changed pursuant to such amendment for discharges occurring in any cost reporting period beginning before October 1, 1984."Pub. L. 98-369, div. B, title III, §2312(c), July 18, 1984, 98 Stat. 1078, as amended by Pub. L. 99-509, title IX, §9320(a), Oct. 21, 1986, 100 Stat. 2013; Pub. L. 100-360, title IV, §411(p), July 1, 1988, as added by Pub. L. 100-485, title VI, §608(d)(29), Oct. 13, 1988, 102 Stat. 2424, provided that: "The amendments made by subsections (a) and (b) [amending this section] shall apply to cost reporting periods beginning on or after October 1, 1984, and before January 1, 1989. In the case of a cost reporting period that begins before January 1, 1989, but ends after such date, additional payments under the amendment made by subsection (a) shall be proportionately reduced to reflect the portion of the period occurring after such date."Amendment by section 2313(a), (b), (d) of Pub. L. 98-369 effective July 18, 1984, see section 2313(e) of Pub. L. 98-369, set out as an Effective Date of 1984 Amendment note under section 1395y of this title.Pub. L. 98-369, div. B, title III, §2315(g), July 18, 1984, 98 Stat. 1080, provided that: "The amendments made by this section [amending this section and sections 1395i-2 and 1395cc of this title and enacting and amending provisions set out as notes under this section] shall be effective as though they had been included in the enactment of the Social Security Amendments of 1983 (Public Law 98-21)."Amendment by section 2354(b)(42)-(44) of Pub. L. 98-369 effective July 18, 1984, but not to be construed as changing or affecting any right, liability, status, or interpretation which existed (under the provisions of law involved) before that date, see section 2354(e)(1) of Pub. L. 98-369, set out as an Effective Date of 1984 Amendment note under section 1320a-1 of this title.
EFFECTIVE DATE OF 1983 AMENDMENT Pub. L. 98-21, title VI, §601(b)(9), Apr. 20, 1983, 97 Stat. 150, provided that the repeal of subsec. (b)(6) of this section is effective with respect to cost reporting periods beginning on or after October 1, 1982, and that the enactment of a new subsec. (b)(6) of this section is effective with respect to cost reporting periods beginning on or after October 1, 1983.Pub. L. 98-21, title VI, §604, Apr. 20, 1983, 97 Stat. 168, as amended by Pub. L. 98-369, div. B, title III, §2315(f)(1), July 18, 1984, 98 Stat. 1080, provided that: "(a)(1) Except as provided in section 602(l) [amending section 1395cc of this title] and in paragraph (2), the amendments made by the preceding provisions of this title [amending this section and sections 1320c-2, 1395f, 1395n, 1395x, 1395y, 1395cc, 1395mm, 1395oo, 1395rr, and 1395xx of this title] apply to items and services furnished by or under arrangements with a hospital beginning with its first cost reporting period that begins on or after October 1, 1983. A change in a hospital's cost reporting period that has been made after November 1982 shall be recognized for purposes of this section only if the Secretary finds good cause for that change."(2) Section 1866(a)(1)(F) of the Social Security Act [42 U.S.C. 1395cc(a)(1)(F)] (as added by section 602(f)(1)(C) of this title), section 1862(a)(14) [42 U.S.C. 1395y(a)(14)] (as added by section 602(e)(3) of this title) and sections 1886(a)(1)(G) and (H) of such Act [probably should be section 1866(a)(1)(G) and (H), 42 U.S.C. 1395cc(a)(1)(G), (H)] (as added by section 602(f)(1)(C) of this title) take effect on October 1, 1983."(b) The Secretary shall make an appropriate reduction in the payment amount under section 1886(d) of the Social Security Act [42 U.S.C. 1395ww(d)] (as amended by this title) for any discharge, if the admission has occurred before a hospital's first cost reporting period that begins after September 1983, to take into account amounts payable under title XVIII of that Act [42 U.S.C. 1395 et seq.] (as in effect before the date of the enactment of this Act [Apr. 20, 1983]) for items and services furnished before that period."(c)(1) The Secretary shall cause to be published in the Federal Register a notice of the interim final DRG prospective payment rates established under subsection (d) of section 1886 of the Social Security Act [42 U.S.C. 1395ww(d)] (as amended by this title) no later than September 1, 1983, and allow for a period of public comment thereon. Payment on the basis of prospective rates shall become effective on October 1, 1983, without the necessity for consideration of comments received, but the Secretary shall, by notice published in the Federal Register, affirm or modify the amounts by December 31, 1983, after considering those comments."(2) A modification under paragraph (1) that reduces a prospective payment rate shall apply only to discharges occurring after 30 days after the date the notice of the modification is published in the Federal Register."(3) Rules to implement the amendments made by this title [amending this section and sections 1320a-1, 1320c-2, 1395f, 1395i-2, 1395n, 1395r, 1395v, 1395w, 1395x, 1395y, 1395cc, 1395mm, 1395oo, 1395rr, and 1395xx of this title, enacting provisions set out as notes under sections 1395r and 1395x of this title, and amending provisions set out as a note under section 1395x of this title] shall be established in accordance with the procedure described in this subsection."Amendment by Pub. L. 97-448 effective as if originally included as a part of this section as this section was added by the Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248, see section 309(c)(2) of Pub. L. 97-448, set out as a note under section 426-1 of this title.
EFFECTIVE DATEPub. L. 97-248, title I, §101(b)(1), Sept. 3, 1982, 96 Stat. 335, provided that: "The amendments made by subsection (a) [enacting this section and amending section 1395x of this title] shall apply to cost reporting periods beginning on or after October 1, 1982."
REGULATIONS Pub. L. 101-508, §4003, 104 Stat. 1388-39, provided that: "The Secretary of Health and Human Services shall issue such regulations (on an interim or other basis) as may be necessary to implement this section [amending this section and enacting provisions set out as a note above]." Pub. L. 98-369, div. B, title III, §2315(f)(2), July 18, 1984, 98 Stat. 1080, provided that: "Notwithstanding section 604(c) of the Social Security Amendments of 1983 [section 604(c) of Pub. L. 98-21, set out above], the Secretary of Health and Human Services shall cause to be published in the Federal Register proposed regulations to carry out subsection (c) of section 1886 of the Social Security Act [42 U.S.C. 1395ww(c)] not later than July 1, 1984, and allow for a period of 45 days for public comment thereon. After consideration of the comments received, the Secretary shall cause to be published in the Federal Register final regulations to carry out such subsection not later than October 1, 1984."Pub. L. 97-248, title I, §101(b)(2)(A), Sept. 3, 1982, 96 Stat. 335, provided that: "The Secretary of Health and Human Services shall first issue such final regulations (whether on an interim or other basis) before October 1, 1982, as may be necessary to implement such amendments [amendments by section 101(a) of Pub. L. 97-248, enacting this section and amending section 1395x of this title] on a timely basis. If such regulations are promulgated on an interim final basis, the Secretary shall take such steps as may be necessary to provide opportunity for public comment, and appropriate revision based thereon, so as to provide that such regulations are not on an interim basis later than March 31, 1983."
CONSTRUCTION OF 2010 AMENDMENT Pub. L. 111-192, §102, 124 Stat. 1282, provided that: "Nothing in the amendments made by this section [amending this section] shall be construed as changing the policy described in section 1886(a)(4) of the Social Security Act (42 U.S.C. 1395ww(a)(4)), as applied by the Secretary of Health and Human Services before the date of the enactment of this Act [June 25, 2010], with respect to diagnostic services." Pub. L. 111-148, §5504, 124 Stat. 660, provided that: "The amendments made by this section [amending this section] shall not be applied in a manner that requires reopening of any settled hospital cost reports as to which there is not a jurisdictionally proper appeal pending as of the date of the enactment of this Act [Mar. 23, 2010] on the issue of payment for indirect costs of medical education under section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct graduate medical education costs under section 1886(h) of such Act (42 U.S.C. 1395ww(h))." Pub. L. 111-148, §5505(d), title X, §10501(j), Mar. 23, 2010, 124 Stat. 999, provided that: "The amendments made by this section [amending this section] shall not be applied in a manner that requires reopening of any settled cost reports as to which there is not a jurisdictionally proper appeal pending as of the date of the enactment of this Act [Mar. 23, 2010] on the issue of payment for indirect costs of medical education under section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct graduate medical education costs under section 1886(h) of such Act (42 U.S.C. 1395ww(h))." Pub. L. 111-148, §5506, 124 Stat. 662, provided that: "The amendments made by this section [amending this section] shall not be applied in a manner that requires reopening of any settled hospital cost reports as to which there is not a jurisdictionally proper appeal pending as of the date of the enactment of this Act [Mar. 23, 2010] on the issue of payment for indirect costs of medical education under section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct graduate medical education costs under section 1886(h) of such Act (42 U.S.C. Section [sic] 1395ww(h))."
TRANSFER OF FUNCTIONS Prospective Payment Assessment Commission (ProPAC) was terminated and its assets and staff transferred to the Medicare Payment Advisory Commission (MedPAC) by section 4022(c)(2), (3) of Pub. L. 105-33, set out as a note under section 1395b-6 of this title. Section 4022(c)(2), (3) further provided that MedPAC was to be responsible for preparation and submission of reports required by law to be submitted by ProPAC, and that, for that purpose, any reference in law to ProPAC was to be deemed, after the appointment of MedPAC, to refer to MedPAC.
IMPLEMENTATION OF AMENDMENT BY PUB. L. 118-42 Pub. L. 118-42, §306, 138 Stat. 417, provided that: "Notwithstanding any other provision of law, the Secretary of Health and Human Services may implement the provisions of, including the amendments made by, this section [amending this section] by program instruction or otherwise."
IMPLEMENTATION OF AMENDMENT BY PUB. L. 117-328 Pub. L. 117-328, div. FF, title IV, §4101(b), Dec. 29, 2022, 136 Stat. 5896, provided that: "Notwithstanding any other provision of law, the Secretary of Health and Human Services may implement the provisions of, including the amendments made by, this section [amending this section] by program instruction or otherwise."
IMPLEMENTATION OF AMENDMENT BY PUB. L. 117-229 Pub. L. 117-229, §101, 136 Stat. 2310, provided that: "Notwithstanding any other provision of law, the Secretary of Health and Human Services may implement the provisions of, including the amendments made by, this section [amending this section] by program instruction or otherwise."
IMPLEMENTATION OF AMENDMENT BY PUB. L. 117-180 Pub. L. 117-180, §101, 136 Stat. 2134, provided that: "Notwithstanding any other provision of law, the Secretary of Health and Human Services may implement the provisions of, including the amendments made by, this section [amending this section] by program instruction or otherwise."
IMPLEMENTATION OF AMENDMENT BY PUB. L. 116-136 Pub. L. 116-136, §3710, 134 Stat. 422, provided that: "Notwithstanding any other provision of law, the Secretary [probably means Secretary of Health and Human Services] may implement the amendment made by subsection (a) [amending this section] by program instruction or otherwise."
INCREASING ACCESS TO POST-ACUTE CARE DURING EMERGENCY PERIOD Pub. L. 116-136, §3711, 134 Stat. 422, provided that:"(a) WAIVER OF IRF 3-HOUR RULE.-With respect to inpatient rehabilitation services furnished by a rehabilitation facility described in section 1886(j)(1) of the Social Security Act (42 U.S.C. 1395ww(j)(1)) during the emergency period described in section 1135(g)(1)(B) of the Social Security Act (42 U.S.C. 1320b-5(g)(1)(B)), the Secretary of Health and Human Services shall waive section 412.622(a)(3)(ii) of title 42, Code of Federal Regulations (or any successor regulations), relating to the requirement that patients of an inpatient rehabilitation facility receive at least 15 hours of therapy per week."(b) WAIVER OF SITE-NEUTRAL PAYMENT RATE PROVISIONS FOR LONG-TERM CARE HOSPITALS.-With respect to inpatient hospital services furnished by a long-term care hospital described in section 1886(d)(1)(B)(iv) of the Social Security Act (42 U.S.C. 1395ww(d)(1)(B)(iv)) during the emergency period described in section 1135(g)(1)(B) of the Social Security Act (42 U.S.C. 1320b-5(g)(1)(B)), the Secretary of Health and Human Services shall waive the following provisions of section 1886(m)(6) of such Act (42 U.S.C. 1395ww(m)(6)):"(1) LTCH 50-PERCENT RULE.-Subparagraph (C)(ii) of such section, relating to the payment adjustment for long-term care hospitals that do not have a discharge payment percentage for the period that is at least 50 percent."(2) SITE-NEUTRAL IPPS PAYMENT RATE.-Subparagraph (A)(i) of such section, relating to the application of the site-neutral payment rate (and payment shall be made to a long-term care hospital without regard to such section) for a discharge if the admission occurs during such emergency period and is in response to the public health emergency described in such section 1135(g)(1)(B)."
APPLICATION OF CHANGE IN MEDICARE CLASSIFICATION FOR CERTAIN HOSPITALS Pub. L. 114-255, §15008, 130 Stat. 1321, provided that: "(1) IN GENERAL.-For cost reporting periods beginning on or after January 1, 2015, in the case of an applicable hospital (as defined in paragraph (3) [sic, probably should be "paragraph (2)"]), the following shall apply:"(A) Payment for inpatient operating costs shall be made on a reasonable cost basis in the manner provided in section 412.526(c)(3) of title 42, Code of Federal Regulations (as in effect on January 1, 2015) and in any subsequent modifications."(B) Payment for capital costs shall be made in the manner provided by section 412.526(c)(4) of title 42, Code of Federal Regulations (as in effect on such date). "(C) Claims for payment for Medicare beneficiaries who are discharged on or after January 1, 2017, shall be processed as claims which are paid on a reasonable cost basis as described in section 412.526(c) of title 42, Code of Federal Regulations (as in effect on such date)."(2) APPLICABLE HOSPITAL DEFINED.-In this subsection, the term 'applicable hospital' means a hospital that is classified under clause (iv)(II) of section 1886(d)(1)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(1)(B)) on the day before the date of the enactment of this Act [Dec. 13, 2016] and which is classified under clause (vi) of such section, as redesignated and moved by subsection (a), on or after such date of enactment."
IMPLEMENTATION OF AMENDMENT BY PUB. L. 114-113 Pub. L. 114-113, §602, 129 Stat. 3024, provided that: "Notwithstanding any other provision of law, the Secretary of Health and Human Services may implement the amendments made by this section [amending this section and section 1395w-23 of this title] by program instruction or otherwise."
CALCULATION OF LENGTH OF STAY EXCLUDING CASES PAID ON A SITE NEUTRAL BASIS Pub. L. 113-67, §1206, 127 Stat. 1203, as amended by Pub. L. 113-93, §112, 128 Stat. 1045; Pub. L. 114-255, §15007, 130 Stat. 1320, provided that: "For discharges occurring in cost reporting periods beginning on or after October 1, 2015, in calculating the length of stay requirement applicable to a long-term care hospital or satellite facility under section 1886(d)(1)(B)(iv)(I) [now 1886(d)(1)(B)(iv)] of the Social Security Act (42 U.S.C. 1395ww(d)(1)(B)(iv)(I) [1395ww(d)(1)(B)(iv)]) and section 1861(ccc)(2) of such Act (42 U.S.C. 1395x(ccc)(2)), the Secretary of Health and Human Services shall exclude the following:"(A) SITE NEUTRAL PAYMENT.-Any patient for whom payment is made at the site neutral payment rate (as defined in section 1886(m)(6)(B)(ii) [42 U.S.C. 1395ww(m)(6)(B)(ii)) of such Act, as added by paragraph (1)). "(B) MEDICARE ADVANTAGE.-Any patient for whom payment is made under a Medicare Advantage plan under part C of title XVIII of such Act [42 U.S.C. 1395w-21 et seq.]."[Pub. L. 114-255, §15007, 130 Stat. 1320, provided that: "The amendments made by subsection (a) [amending section 1206(a)(3) of Pub. L. 113-67, set out above] shall be effective as if included in the enactment of section 1206(a)(3) of the Pathway for SGR Reform Act of 2013 ( division B of Public Law 113-67; 42 U.S.C. 1395ww note)."]
REVIEW OF TREATMENT OF CERTAIN LTCHS Pub. L. 113-67, §1206, 127 Stat. 1204, provided that:"(1) EVALUATION.-As part of the annual rulemaking for fiscal year 2015 or fiscal year 2016 to carry out the payment rates under subsection (d) of section 1886 of the Social Security Act (42 U.S.C. 1395ww), the Secretary shall evaluate both the payment rates and regulations governing hospitals which are classified under subclause (II) of subsection (d)(1)(B)(iv) of such section."(2) ADJUSTMENT AUTHORITY.-Based upon such evaluation, the Secretary may adjust payment rates under subsection (b)(3) of section 1886 of the Social Security Act (42 U.S.C. 1395ww) for a hospital so classified (such as payment based upon the TEFRA-payment model) and may adjust the regulations governing such hospitals, including applying the regulations governing hospitals which are classified under clause (I) of subsection (d)(1)(B) of such section."
SPECIAL RULE FOR FISCAL YEAR 2011 AND ADJUSTMENT FOR CERTAIN HOSPITALS IN FISCAL YEAR 2011 Pub. L. 111-309, §102, 124 Stat. 3286, provided that:"(2) SPECIAL RULE FOR FISCAL YEAR 2011.- "(A) IN GENERAL.-Subject to subparagraph (B), for purposes of implementation of the amendment made by paragraph (1) [amending section 106(a) of div. B of Pub. L. 109-432, set out as a note under this section], including (notwithstanding paragraph (3) of section 117(a) of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173) [set out as a note under this section], as amended by section 124(b) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275)) for purposes of the implementation of paragraph (2) of such section 117(a), during fiscal year 2011, the Secretary of Health and Human Services shall use the hospital wage index that was promulgated by the Secretary of Health and Human Services in the Federal Register on August 16, 2010 (75 Fed. Reg. 50042), and any subsequent corrections."(B) EXCEPTION.-Beginning on April 1, 2011, in determining the wage index applicable to hospitals that qualify for wage index reclassification, the Secretary shall include the average hourly wage data of hospitals whose reclassification was extended pursuant to the amendment made by paragraph (1) only if including such data results in a higher applicable reclassified wage index. Any revision to hospital wage indexes made as a result of this subparagraph shall not be effected in a budget neutral manner."(3) ADJUSTMENT FOR CERTAIN HOSPITALS IN FISCAL YEAR 2011.-"(A) IN GENERAL.-In the case of a subsection (d) hospital (as defined in subsection (d)(1)(B) of section 1886 of the Social Security Act (42 U.S.C. 1395ww)) with respect to which-"(i) a reclassification of its wage index for purposes of such section was extended pursuant to the amendment made by paragraph (1); and"(ii) the wage index applicable for such hospital for the period beginning on October 1, 2010, and ending on March 31, 2011, was lower than for the period beginning on April 1, 2011, and ending on September 30, 2011, by reason of the application of paragraph (2)(B);"the Secretary shall pay such hospital an additional payment that reflects the difference between the wage index for such periods."(B) TIMEFRAME FOR PAYMENTS.-The Secretary shall make payments required under subparagraph (A) by not later than December 31, 2011."Similar provisions were contained in Pub. L. 111-148, §3137(a)(2), (3), title X, §10317, Mar. 23, 2010, 124 Stat. 438, 947.
NO REOPENING OF PREVIOUSLY BUNDLED CLAIMS Pub. L. 111-192, §102, 124 Stat. 1281, provided that:"(1) IN GENERAL.-The Secretary of Health and Human Services may not reopen a claim, adjust a claim, or make a payment pursuant to any request for payment under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.], submitted by an entity (including a hospital or an entity wholly owned or operated by the hospital) for services described in paragraph (2) for purposes of treating, as unrelated to a patient's inpatient admission, services provided during the 3 days (or, in the case of a hospital that is not a subsection (d) hospital, during the 1 day) immediately preceding the date of the patient's inpatient admission. "(2) SERVICES DESCRIBED.-For purposes of paragraph (1), the services described in this paragraph are other services related to the admission (as described in section 1886(a)(4) of the Social Security Act (42 U.S.C. 1395ww(a)(4)), as amended by subsection (a)) which were previously included on a claim or request for payment submitted under part A of title XVIII of such Act [42 U.S.C. 1395c et seq.] for which a reopening, adjustment, or request for payment under part B of such title [42 U.S.C. 1395j et seq.], was not submitted prior to the date of the enactment of this Act [June 25, 2010]."
IMPLEMENTATION OF AMENDMENT BY PUB. L. 111-192 Pub. L. 111-192, §102, 124 Stat. 1281, provided that: "Notwithstanding any other provision of law, the Secretary of Health and Human Services may implement the provisions of this section [amending this section and enacting provisions set out as notes under this section] (and amendments made by this section) by program instruction or otherwise."
PAYMENT FOR QUALIFYING HOSPITALS Pub. L. 111-152, §1109, 124 Stat. 1051, provided that:"(a) IN GENERAL.-From the amount available under subsection (b), the Secretary of Health and Human Services shall provide for a payment to qualifying hospitals (as defined in subsection (d)) for fiscal years 2011 and 2012 of the amount determined under subsection (c). "(b) AMOUNTS AVAILABLE.-There shall be available from the Federal Hospital Insurance Trust Fund $400,000,000 for payments under this section for fiscal years 2011 and 2012."(c) PAYMENT AMOUNT.-The amount of payment under this section for a qualifying hospital shall be determined, in a manner consistent with the amount available under subsection (b), in proportion to the portion of the amount of the aggregate payments under section 1886(d) of the Social Security Act [42 U.S.C. 1395ww(d)] to the hospital for fiscal year 2009 bears to the sum of all such payments to all qualifying hospitals for such fiscal year."(d) QUALIFYING HOSPITAL DEFINED.-In this section, the term 'qualifying hospital' means a subsection (d) hospital (as defined for purposes of section 1886(d) of the Social Security Act) that is located in a county that ranks, based upon its ranking in age, sex, and race adjusted spending for benefits under parts A and B under title XVIII of such Act [42 U.S.C. 1395c et seq.; 42 U.S.C. 1395j et seq.] per enrollee, within the lowest quartile of such counties in the United States."
VALUE-BASED PURCHASING DEMONSTRATION PROGRAMS Pub. L. 111-148, §3001, 124 Stat. 362, provided that:"(1) VALUE-BASED PURCHASING DEMONSTRATION PROGRAM FOR INPATIENT CRITICAL ACCESS HOSPITALS.- "(A) ESTABLISHMENT.-"(i) IN GENERAL.-Not later than 2 years after the date of enactment of this Act [Mar. 23, 2010], the Secretary of Health and Human Services (in this subsection referred to as the 'Secretary') shall establish a demonstration program under which the Secretary establishes a value-based purchasing program under the Medicare program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] for critical access hospitals (as defined in paragraph (1) of section 1861(mm) of such Act (42 U.S.C. 1395x(mm))) with respect to inpatient critical access hospital services (as defined in paragraph (2) of such section) in order to test innovative methods of measuring and rewarding quality and efficient health care furnished by such hospitals."(ii) DURATION.-The demonstration program under this paragraph shall be conducted for a 3-year period."(iii) SITES.-The Secretary shall conduct the demonstration program under this paragraph at an appropriate number (as determined by the Secretary) of critical access hospitals. The Secretary shall ensure that such hospitals are representative of the spectrum of such hospitals that participate in the Medicare program."(B) WAIVER AUTHORITY.-The Secretary may waive such requirements of titles XI and XVIII of the Social Security Act [42 U.S.C. 1301 et seq., 1395 et seq.] as may be necessary to carry out the demonstration program under this paragraph."(C) BUDGET NEUTRALITY REQUIREMENT.-In conducting the demonstration program under this section [amending this section and enacting this note], the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented."(D) REPORT.-Not later than 18 months after the completion of the demonstration program under this paragraph, the Secretary shall submit to Congress a report on the demonstration program together with-"(i) recommendations on the establishment of a permanent value-based purchasing program under the Medicare program for critical access hospitals with respect to inpatient critical access hospital services; and"(ii) recommendations for such other legislation and administrative action as the Secretary determines appropriate."(2) VALUE-BASED PURCHASING DEMONSTRATION PROGRAM FOR HOSPITALS EXCLUDED FROM HOSPITAL VALUE-BASED PURCHASING PROGRAM AS A RESULT OF INSUFFICIENT NUMBERS OF MEASURES AND CASES.-"(A) ESTABLISHMENT.-"(i) IN GENERAL.-Not later than 2 years after the date of enactment of this Act [Mar. 23, 2010], the Secretary shall establish a demonstration program under which the Secretary establishes a value-based purchasing program under the Medicare program under title XVIII of the Social Security Act for applicable hospitals (as defined in clause (ii)) with respect to inpatient hospital services (as defined in section 1861(b) of the Social Security Act (42 U.S.C. 1395x(b))) in order to test innovative methods of measuring and rewarding quality and efficient health care furnished by such hospitals."(ii) APPLICABLE HOSPITAL DEFINED.-For purposes of this paragraph, the term 'applicable hospital' means a hospital described in subclause (III) or (IV) of section 1886(o)(1)(C)(ii) of the Social Security Act [42 U.S.C. 1395ww(o)(1)(C)(ii)], as added by subsection (a)(1)."(iii) DURATION.-The demonstration program under this paragraph shall be conducted for a 3-year period."(iv) SITES.-The Secretary shall conduct the demonstration program under this paragraph at an appropriate number (as determined by the Secretary) of applicable hospitals. The Secretary shall ensure that such hospitals are representative of the spectrum of such hospitals that participate in the Medicare program."(B) WAIVER AUTHORITY.-The Secretary may waive such requirements of titles XI and XVIII of the Social Security Act [4 2 U.S.C. 1301 et seq., 1395 et seq.] as may be necessary to carry out the demonstration program under this paragraph."(C) BUDGET NEUTRALITY REQUIREMENT.-In conducting the demonstration program under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented. "(D) REPORT.-Not later than 18 months after the completion of the demonstration program under this paragraph, the Secretary shall submit to Congress a report on the demonstration program together with- "(i) recommendations on the establishment of a permanent value-based purchasing program under the Medicare program for applicable hospitals with respect to inpatient hospital services; and"(ii) recommendations for such other legislation and administrative action as the Secretary determines appropriate."
REFORMING THE MEDICARE HOSPITAL WAGE INDEX SYSTEM Pub. L. 111-148, §3137, 124 Stat. 438, 439, provided that: "(b) PLAN FOR REFORMING THE MEDICARE HOSPITAL WAGE INDEX SYSTEM"(1) IN GENERAL.-Not later than December 31, 2011, the Secretary of Health and Human Services (in this section referred to as the 'Secretary') shall submit to Congress a report that includes a plan to reform the hospital wage index system under section 1886 of the Social Security Act [42 U.S.C. 1395ww] . "(2) DETAILS.-In developing the plan under paragraph (1), the Secretary shall take into account the goals for reforming such system set forth in the Medicare Payment Advisory Commission June 2007 report entitled 'Report to Congress: Promoting Greater Efficiency in Medicare', including establishing a new hospital compensation index system that-"(A) uses Bureau of Labor Statistics data, or other data or methodologies, to calculate relative wages for each geographic area involved;"(B) minimizes wage index adjustments between and within metropolitan statistical areas and statewide rural areas; "(C) includes methods to minimize the volatility of wage index adjustments that result from implementation of policy, while maintaining budget neutrality in applying such adjustments;"(D) takes into account the effect that implementation of the system would have on health care providers and on each region of the country;"(E) addresses issues related to occupational mix, such as staffing practices and ratios, and any evidence on the effect on quality of care or patient safety as a result of the implementation of the system; and"(F) provides for a transition."(3) CONSULTATION.-In developing the plan under paragraph (1), the Secretary shall consult with relevant affected parties."(c) USE OF PARTICULAR CRITERIA FOR DETERMINING RECLASSIFICATIONS.-Notwithstanding any other provision of law, in making decisions on applications for reclassification of a subsection (d) hospital (as defined in paragraph (1)(B) of section 1886(d) of the Social Security Act (4 2 U.S.C. 1395ww(d) )[)] for the purposes described in paragraph (10)(D)(v) of such section for fiscal year 2011 and each subsequent fiscal year (until the first fiscal year beginning on or after the date that is 1 year after the Secretary of Health and Human Services submits the report to Congress under subsection (b)), the Geographic Classification Review Board established under paragraph (10) of such section shall use the average hourly wage comparison criteria used in making such decisions as of September 30, 2008. The preceding sentence shall be effected in a budget neutral manner."
APPLICATION OF BUDGET NEUTRALITY ON A NATIONAL BASIS IN THE CALCULATION OF THE MEDICARE HOSPITAL WAGE INDEX FLOOR Pub. L. 111-148, §3141, 124 Stat. 441, provided that: "In the case of discharges occurring on or after October 1, 2010, for purposes of applying section 4410 of the Balanced Budget Act of 1997 [ section 4410 of Pub. L. 105-33, set out as a note under this section] (4 2 U.S.C. 1395ww note) and paragraph (h)(4) of section 412.64 of title 42, Code of Federal Regulations, the Secretary of Health and Human Services shall administer subsection (b) of such section 4410 and paragraph (e) of such section 412.64 in the same manner as the Secretary administered such subsection (b) and paragraph (e) for discharges occurring during fiscal year 2008 (through a uniform, national adjustment to the area wage index)."
EFFECT ON TEMPORARY FTE CAP ADJUSTMENTS Pub. L. 111-148, §5506, 124 Stat. 662, provided that: "The Secretary of Health and Human Services shall give consideration to the effect of the amendments made by this section [amending this section] on any temporary adjustment to a hospital's FTE cap under section 413.79(h) of title 42, Code of Federal Regulations (as in effect on the date of enactment of this Act [Mar. 23, 2010]) in order to ensure that there is no duplication of FTE slots. Such amendments shall not affect the application of section 1886(h)(4)(H)(v) of the Social Security Act (42 U.S.C. 1395ww(h)(4)(H)(v))."
GRADUATE NURSE EDUCATION DEMONSTRATION Pub. L. 111-148, §5509, 124 Stat. 674, provided that:"(a) IN GENERAL.- "(1) ESTABLISHMENT.-"(A) IN GENERAL.-The Secretary shall establish a graduate nurse education demonstration under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) under which an eligible hospital may receive payment for the hospital's reasonable costs (described in paragraph (2)) for the provision of qualified clinical training to advance practice nurses."(B) NUMBER.-The demonstration shall include up to 5 eligible hospitals."(C) WRITTEN AGREEMENTS.-Eligible hospitals selected to participate in the demonstration shall enter into written agreements pursuant to subsection (b) in order to reimburse the eligible partners of the hospital the share of the costs attributable to each partner."(2) COSTS DESCRIBED.-"(A) IN GENERAL.-Subject to subparagraph (B) and subsection (d), the costs described in this paragraph are the reasonable costs (as described in section 1861(v) of the Social Security Act (42 U.S.C. 1395x(v))) of each eligible hospital for the clinical training costs (as determined by the Secretary) that are attributable to providing advanced practice registered nurses with qualified training."(B) LIMITATION.-With respect to a year, the amount reimbursed under subparagraph (A) may not exceed the amount of costs described in subparagraph (A) that are attributable to an increase in the number of advanced practice registered nurses enrolled in a program that provides qualified training during the year and for which the hospital is being reimbursed under the demonstration, as compared to the average number of advanced practice registered nurses who graduated in each year during the period beginning on January 1, 2006, and ending on December 31, 2010 (as determined by the Secretary) from the graduate nursing education program operated by the applicable school of nursing that is an eligible partner of the hospital for purposes of the demonstration."(3) WAIVER AUTHORITY.-The Secretary may waive such requirements of titles XI and XVIII of the Social Security Act [42 U.S.C. 1301 et seq., 1395 et seq.] as may be necessary to carry out the demonstration."(4) ADMINISTRATION.-Chapter 35 of title 44, United States Code, shall not apply to the implementation of this section."(b) WRITTEN AGREEMENTS WITH ELIGIBLE PARTNERS.-No payment shall be made under this section to an eligible hospital unless such hospital has in effect a written agreement with the eligible partners of the hospital. Such written agreement shall describe, at a minimum-"(1) the obligations of the eligible partners with respect to the provision of qualified training; and"(2) the obligation of the eligible hospital to reimburse such eligible partners applicable (in a timely manner) for the costs of such qualified training attributable to partner."(c) EVALUATION.-Not later than October 17, 2017, the Secretary shall submit to Congress a report on the demonstration. Such report shall include an analysis of the following:"(1) The growth in the number of advanced practice registered nurses with respect to a specific base year as a result of the demonstration."(2) The growth for each of the specialties described in subparagraphs (A) through (D) of subsection (e)(1). "(3) The costs to the Medicare program under title XVIII of the Social Security Act as a result of the demonstration."(4) Other items the Secretary determines appropriate and relevant."(d) FUNDING.-"(1) IN GENERAL.-There is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $50,000,000 for each of fiscal years 2012 through 2015 to carry out this section, including the design, implementation, monitoring, and evaluation of the demonstration."(2) PRORATION.-If the aggregate payments to eligible hospitals under the demonstration exceed $50,000,000 for a fiscal year described in paragraph (1), the Secretary shall prorate the payment amounts to each eligible hospital in order to ensure that the aggregate payments do not exceed such amount."(3) WITHOUT FISCAL YEAR LIMITATION.-Amounts appropriated under this subsection shall remain available without fiscal year limitation."(e) DEFINITIONS.-In this section:"(1) ADVANCED PRACTICE REGISTERED NURSE.-The term 'advanced practice registered nurse' includes the following: "(A) A clinical nurse specialist (as defined in subsection (aa)(5) of section 1861 of the Social Security Act (42 U.S.C. 1395x)). "(B) A nurse practitioner (as defined in such subsection). "(C) A certified registered nurse anesthetist (as defined in subsection (bb)(2) of such section)."(D) A certified nurse-midwife (as defined in subsection (gg)(2) of such section). "(2) APPLICABLE NON-HOSPITAL COMMUNITY-BASED CARE SETTING.-The term 'applicable non-hospital community-based care setting' means a non-hospital community-based care setting which has entered into a written agreement (as described in subsection (b)) with the eligible hospital participating in the demonstration. Such settings include Federally qualified health centers, rural health clinics, and other non-hospital settings as determined appropriate by the Secretary."(3) APPLICABLE SCHOOL OF NURSING.-The term 'applicable school of nursing' means an accredited school of nursing (as defined in section 801 of the Public Health Service Act [42 U.S.C. 296] ) which has entered into a written agreement (as described in subsection (b)) with the eligible hospital participating in the demonstration."(4) DEMONSTRATION.-The term 'demonstration' means the graduate nurse education demonstration established under subsection (a)."(5) ELIGIBLE HOSPITAL.-The term 'eligible hospital' means a hospital (as defined in subsection (e) of section 1861 of the Social Security Act (42 U.S.C. 1395x)) or a critical access hospital (as defined in subsection (mm)(1) of such section) that has a written agreement in place with-"(A) 1 or more applicable schools of nursing; and"(B) 2 or more applicable non-hospital community-based care settings."(6) ELIGIBLE PARTNERS.-The term 'eligible partners' includes the following: "(A) An applicable non-hospital community-based care setting."(B) An applicable school of nursing. "(7) QUALIFIED TRAINING.-"(A) IN GENERAL.-The term 'qualified training' means training-"(i) that provides an advanced practice registered nurse with the clinical skills necessary to provide primary care, preventive care, transitional care, chronic care management, and other services appropriate for individuals entitled to, or enrolled for, benefits under part A of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq.], or enrolled under part B of such title [42 U.S.C. 1395j et seq.]; and"(ii) subject to subparagraph (B), at least half of which is provided in a non-hospital community-based care setting."(B) WAIVER OF REQUIREMENT HALF OF TRAINING BE PROVIDED IN NON-HOSPITAL COMMUNITY-BASED CARE SETTING IN CERTAIN AREAS.-The Secretary may waive the requirement under subparagraph (A)(ii) with respect to eligible hospitals located in rural or medically underserved areas. "(8) SECRETARY.-The term 'Secretary' means the Secretary of Health and Human Services."
PAYMENT FOR LONG-TERM CARE HOSPITAL SERVICES Pub. L. 110-173, §114, 121 Stat. 2502, as amended by Pub. L. 111-5, §4302, 123 Stat. 495; Pub. L. 111-148, §3106(a), title X, §10312(a), Mar. 23, 2010, 124 Stat. 418, 943; Pub. L. 113-67, §1206, 127 Stat. 1203; Pub. L. 114-255, §15006, 130 Stat. 1320, provided that: "(1) DELAY IN APPLICATION OF 25 PERCENT PATIENT THRESHOLD PAYMENT ADJUSTMENT.-The Secretary [of Health and Human Services] shall not apply, for cost reporting periods beginning on or after July 1, 2007,- [sic] "(A) through June 30, 2016, and for discharges occurring on or after October 1, 2016, and before October 1, 2017, section 412.536 of title 42, Code of Federal Regulations, or any similar provision, to freestanding long-term care hospitals or to a long-term care hospital, or satellite facility, that as of December 29, 2007, was co-located with an entity that is a provider-based, off-campus location of a subsection (d) hospital which did not provide services payable under section 1886(d) of the Social Security Act [42 U.S.C. 1395ww(d)] at the off-campus location; and "(B) such section or section 412.534 of title 42, Code of Federal Regulations, or any similar provisions, to a long-term care hospital identified by the amendment made by section 4417(a) of the Balanced Budget Act of 1997 (Public Law 105-33) [amending this section and enacting provisions set out as a note under this section]. "(2) PAYMENT FOR HOSPITALS-WITHIN-HOSPITALS.-"(A) IN GENERAL.-Payment to an applicable long-term care hospital or satellite facility which is located in a rural area or which is co-located with an urban single or MSA dominant hospital under paragraphs (d)(1), (e)(1), and (e)(4) of section 412.534 of title 42, Code of Federal Regulations, or any similar provision, shall not be subject to any payment adjustment under such section if no more than 75 percent of the hospital's Medicare discharges (other than discharges described in paragraph (d)(2) or (e)(3) of such section) are admitted from a co-located hospital."(B) CO-LOCATED LONG-TERM CARE HOSPITALS AND SATELLITE FACILITIES.-"(i) IN GENERAL.-Payment to an applicable long-term care hospital or satellite facility which is co-located with another hospital shall not be subject to any payment adjustment under section 412.534 of title 42, Code of Federal Regulations, or any similar provision, if no more than 50 percent of the hospital's Medicare discharges (other than discharges described in paragraph (c)(3) of such section) are admitted from a co-located hospital."(ii) APPLICABLE LONG-TERM CARE HOSPITAL OR SATELLITE FACILITY DEFINED.-In this paragraph, the term 'applicable long-term care hospital or satellite facility' means a hospital or satellite facility that is subject to the transition rules under section 412.534(g) of title 42, Code of Federal Regulations, or any similar provision, or that is described in section 412.22(h)(3)(i) of such title."(C) EFFECTIVE DATE.-Subparagraphs (A) and (B) shall apply to cost reporting periods beginning on or after October 1, 2007 (or July 1, 2007, in the case of a satellite facility described in section 412.22(h)(3)(i) of title 42, Code of Federal Regulations) through June 30, 2016, and for discharges occurring on or after October 1, 2016, and before October 1, 2017."(3) NO APPLICATION OF VERY SHORT-STAY OUTLIER POLICY.-The Secretary shall not apply, for the 5-year period beginning on the date of the enactment of this Act, the amendments finalized on May 11, 2007 (72 Federal Register 26904, 26992) made to the short-stay outlier payment provision for long-term care hospitals contained in section 412.529(c)(3)(i) of title 42, Code of Federal Regulations, or any similar provision. "(4) NO APPLICATION OF ONE-TIME ADJUSTMENT TO STANDARD AMOUNT.-The Secretary shall not, for the 5-year period beginning on the date of the enactment of this Act, make the one-time prospective adjustment to long-term care hospital prospective payment rates provided for in section 412.523(d)(3) of title 42, Code of Federal Regulations, or any similar provision." [Pub. L. 111-5, §4302, 123 Stat. 496, provided that: "The amendments made by this section [amending Pub. L. 110-173, §114(c), set out above, and Pub. L. 110-173, §114(d), set out below] shall be effective and apply as if included in the enactment of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173)."]
MORATORIUM ON THE ESTABLISHMENT OF LONG-TERM CARE HOSPITALS, LON