There is created within the Centers for Medicare & Medicaid Services a Center for Medicare and Medicaid Innovation (in this section referred to as the "CMI") to carry out the duties described in this section. The purpose of the CMI is to test innovative payment and service delivery models to reduce program expenditures under the applicable subchapters while preserving or enhancing the quality of care furnished to individuals under such subchapters. In selecting such models, the Secretary shall give preference to models that also improve the coordination, quality, and efficiency of health care services furnished to applicable individuals defined in paragraph (4)(A).
The Secretary shall ensure that the CMI is carrying out the duties described in this section by not later than January 1, 2011.
In carrying out the duties under this section, the CMI shall consult representatives of relevant Federal agencies, and clinical and analytical experts with expertise in medicine and health care management. The CMI shall use open door forums or other mechanisms to seek input from interested parties.
In this section:
The term "applicable individual" means-
The term "applicable subchapter" means subchapter XVIII, subchapter XIX, or both.
For purposes of testing payment and service delivery models under this section, the Secretary may elect to limit testing of a model to certain geographic areas.
The CMI shall test payment and service delivery models in accordance with selection criteria under paragraph (2) to determine the effect of applying such models under the applicable subchapter (as defined in subsection (a)(4)(B)) on program expenditures under such subchapters and the quality of care received by individuals receiving benefits under such subchapter.
The Secretary shall select models to be tested from models where the Secretary determines that there is evidence that the model addresses a defined population for which there are deficits in care leading to poor clinical outcomes or potentially avoidable expenditures. The Secretary shall focus on models expected to reduce program costs under the applicable subchapter while preserving or enhancing the quality of care received by individuals receiving benefits under such subchapter. The models selected under this subparagraph may include, but are not limited to, the models described in subparagraph (B).
The models described in this subparagraph are the following models:
In selecting models for testing under subparagraph (A), the CMI may consider the following additional factors:
The Secretary shall not require, as a condition for testing a model under paragraph (1), that the design of such model ensure that such model is budget neutral initially with respect to expenditures under the applicable subchapter.
The Secretary shall terminate or modify the design and implementation of a model unless the Secretary determines (and the Chief Actuary of the Centers for Medicare & Medicaid Services, with respect to program spending under the applicable subchapter, certifies), after testing has begun, that the model is expected to-
Such termination may occur at any time after such testing has begun and before completion of the testing.
The Secretary shall conduct an evaluation of each model tested under this subsection. Such evaluation shall include an analysis of-
The Secretary shall make the results of each evaluation under this paragraph available to the public in a timely fashion and may establish requirements for States and other entities participating in the testing of models under this section to collect and report information that the Secretary determines is necessary to monitor and evaluate such models.
To the extent feasible, the Secretary shall select measures under this paragraph that reflect national priorities for quality improvement and patient-centered care consistent with the measures described in 2 1395aaa(b)(7)(B) of this title.
Taking into account the evaluation under subsection (b)(4), the Secretary may, through rulemaking, expand (including implementation on a nationwide basis) the duration and the scope of a model that is being tested under subsection (b) or a demonstration project under section of this title, to the extent determined appropriate by the Secretary, if-
In determining which models or demonstration projects to expand under the preceding sentence, the Secretary shall focus on models and demonstration projects that improve the quality of patient care and reduce spending.
The Secretary may waive such requirements of subchapters XI and XVIII and of sections 1396a(a)(1), 1396a(a)(13), 1396b(m)(2)(A)(iii), and 1396u-4 (other than subsections (b)(1)(A) and (c)(5) of such section) of this title as may be necessary solely for purposes of carrying out this section with respect to testing models described in subsection (b).
There shall be no administrative or judicial review under sectionof this title, section of this title, or otherwise of-
Chapter 35 of title 44 shall not apply to the testing and evaluation of models or expansion of such models under this section.
The Center may carry out activities under this section with respect to subchapter XXI in the same manner as provided under this section with respect to the program under the applicable subchapters.
There are appropriated, from amounts in the Treasury not otherwise appropriated-
Amounts appropriated under the preceding sentence shall remain available until expended.
Out of amounts appropriated under subparagraphs (B) and (C) of paragraph (1), not less than $25,000,000 shall be made available each such fiscal year to design, implement, and evaluate models under subsection (b).
Beginning in 2012, and not less than once every other year thereafter, the Secretary shall submit to Congress a report on activities under this section. Each such report shall describe the models tested under subsection (b), including the number of individuals described in subsection (a)(4)(A)(i) and of individuals described in subsection (a)(4)(A)(ii) participating in such models and payments made under applicable subchapters for services on behalf of such individuals, any models chosen for expansion under subsection (c), and the results from evaluations under subsection (b)(4). In addition, each such report shall provide such recommendations as the Secretary determines are appropriate for legislative action to facilitate the development and expansion of successful payment models.
1 So in original. Probably should be "Promoting".
2 So in original. Probably should be "in section".
3 So in original. Probably should be preceded by "the".
42 U.S.C. § 1315a
REFERENCES IN TEXTSection 4016 of the Balanced Budget Act of 1997, referred to in subsec. (b)(2)(B)(xx), is section 4016 of Pub. L. 105-33 which is set out as a note under sectionof this title.
AMENDMENTS2018-Subsec. (b)(2)(B)(xxv). Pub. L. 115-271, §6001, added cl. (xxv).Subsec. (b)(2)(B)(xxvi), (xxvii). Pub. L. 115-271, §6085(a), added cls. (xxvi) and (xxvii). 2015-Subsec. (b)(2)(B)(xxi) to (xxiv). Pub. L. 114-10, §101(e)(4)(A), added cls. (xxi) to (xxiv).Subsec. (b)(2)(C)(viii). Pub. L. 114-10, §101(e)(4)(B), substituted "other public sector payers, private sector payers, or statewide payment models" for "other public sector or private sector payers". Subsec. (d)(1). Pub. L. 114-85 substituted "1396b(m)(2)(A)(iii), and 1396u-4 (other than subsections (b)(1)(A) and (c)(5) of such section)" for "and 1396b(m)(2)(A)(iii)". 2010-Subsec. (a)(5). Pub. L. 111-148, §10306(1), added par. (5). Subsec. (b)(2)(A). Pub. L. 111-148, §10306(2)(A), inserted "The Secretary shall focus on models expected to reduce program costs under the applicable subchapter while preserving or enhancing the quality of care received by individuals receiving benefits under such subchapter." after the first sentence and substituted "this subparagraph may include, but are not limited to," for "the preceding sentence may include". Subsec. (b)(2)(B)(xix), (xx). Pub. L. 111-148, §10306(2)(B), added cls. (xix) and (xx).Subsec. (b)(2)(C)(viii). Pub. L. 111-148, §10306(2)(C), added cl. (viii).Subsec. (b)(4)(C). Pub. L. 111-148, §10306(3), added subpar. (C). Subsec. (c). Pub. L. 111-148, §10306(4)(C), inserted concluding provisions.Subsec. (c)(1)(B). Pub. L. 111-148, §10306(4)(A), substituted "patient care without increasing spending;" for "care and reduce spending; and". Subsec. (c)(2). Pub. L. 111-148, §10306(4)(B), substituted "reduce (or would not result in any increase in) net program spending under applicable subchapters; and" for "reduce program spending under applicable subchapters."Subsec. (c)(3). Pub. L. 111-148, §10306(4)(C), added par. (3).
CONSTRUCTION REGARDING TELEHEALTH SERVICES Pub. L. 114-10, title I, §101(e)(5), Apr. 16, 2015, 129 Stat. 122, provided that: "Nothing in the provisions of, or amendments made by, this title [see Tables for classification] shall be construed as precluding an alternative payment model or a qualifying APM participant (as those terms are defined in section 1833(z) of the Social Security Act , as added by paragraph (1)) from furnishing a telehealth service for which payment is not made under section 1834(m) of the Social Security Act ( )."
MEDICAID GLOBAL PAYMENT SYSTEM DEMONSTRATION PROJECTPub. L. 111-148, title II, §27052705,, 124 Stat. 324, provided that: "(a) IN GENERAL.-The Secretary of Health and Human Services (referred to in this section as the 'Secretary') shall, in coordination with the Center for Medicare and Medicaid Innovation (as established under section 1115A of the Social Security Act [ ], as added by section 3021 of this Act), establish the Medicaid Global Payment System Demonstration Project under which a participating State shall adjust the payments made to an eligible safety net hospital system or network from a fee-for-service payment structure to a global capitated payment model."(b) DURATION AND SCOPE.-The demonstration project conducted under this section shall operate during a period of fiscal years 2010 through 2012. The Secretary shall select not more than 5 States to participate in the demonstration project. "(c) ELIGIBLE SAFETY NET HOSPITAL SYSTEM OR NETWORK.-For purposes of this section, the term 'eligible safety net hospital system or network' means a large, safety net hospital system or network (as defined by the Secretary) that operates within a State selected by the Secretary under subsection (b)."(d) EVALUATION.- "(1) TESTING.-The Innovation Center shall test and evaluate the demonstration project conducted under this section to examine any changes in health care quality outcomes and spending by the eligible safety net hospital systems or networks. "(2) BUDGET NEUTRALITY.-During the testing period under paragraph (1), any budget neutrality requirements under section 1115A(b)(3) of the Social Security Act [ ] (as so added) shall not be applicable. "(3) MODIFICATION.-During the testing period under paragraph (1), the Secretary may, in the Secretary's discretion, modify or terminate the demonstration project conducted under this section."(e) REPORT.-Not later than 12 months after the date of completion of the demonstration project under this section, the Secretary shall submit to Congress a report containing the results of the evaluation and testing conducted under subsection (d), together with recommendations for such legislation and administrative action as the Secretary determines appropriate."(f) AUTHORIZATION OF APPROPRIATIONS.-There are authorized to be appropriated such sums as are necessary to carry out this section."
- The term "Administrator" means the Administrator of General Services.
- The term "Secretary" means the Secretary of Housing and Urban Development.1 See References in Text note below.
- The term "person" means an individual, a trust or estate, a partnership, or a corporation.
- The term "practices" means design, financing, permitting, construction, commissioning, operation and maintenance, and other practices that contribute to achieving zero-net-energy buildings or facilities.
- The terms "federally assisted housing" and "project" mean-(A) a public housing project (as such term is defined in section 3(b) of the United States Housing Act of 1937 [ 42 U.S.C. 1437a(b) ]);(B) housing for which project-based assistance is provided under section 8 of the United States Housing Act of 1937 [ 42 U.S.C. 1437f ];(C) housing that is assisted under section 1701q of title 12;(D) housing that is assisted under section 1701q of title 12, as such section existed before November 28, 1990;(E) housing financed by a loan or mortgage insured under section 1715l(d)(3) of title 12 that bears interest at a rate determined under the proviso of section 1715l(d)(5) of title 12;(F) housing insured, assisted, or held by the Secretary or a State or State agency under section 1715z-1 of title 12;(G) housing constructed or substantially rehabilitated pursuant to assistance provided under section 8(b)(2) of the United States Housing Act of 1937 [ 42 U.S.C. 1437f(b)(2) ], as in effect before October 1, 1983, that is assisted under a contract for assistance under such section; and(H) housing that is assisted under section 8013 1 of this title.